Frequency of Injuries

Although often preventable, injury continues to be the leading cause of death and disability for children older than 1 year.^3,17 Nearly 3000 children 0 to 14 years old die every year as the result of injuries—more deaths than all diseases combined.^45,47 Leading causes of injury death are falls, motor vehicle crashes, burn injuries, pedestrian injuries, and drowning.^45,47 For additional information, see Epidemiology and Incidence of Pediatric Trauma in the Chapter 19 Supplement on the Evolve Website.

Intentional (Inflicted) Versus Unintentional Injuries

Injuries in the child can be categorized as either intentional or unintentional.¹⁹ Intentional injuries are inflicted injuries (i.e., child abuse) or injuries that result from neglect (see Intentional Injuries/Inflicted Trauma, later in the chapter). Unintentional injuries, such as many burns, drowning, and traffic-related injuries are often preventable.

Eighty to ninety percent of life-threatening pediatric trauma is blunt injury, resulting from motor vehicle-related causes and falls^4,7; approximately half of motor vehicle-related injuries and fatalities are thought to be preventable with the use of age-appropriate safety restraints.^27,60 Children can also sustain motor vehicle-related injuries as pedestrians or on bicycles. Although bicycle riding is a common childhood activity, it can be dangerous. The most severe head injuries are sustained when children who are not wearing bicycle helmets collide with motor vehicles.^48,50,68 When a child is in a bicycle crash, a helmet will likely decrease the severity of head injuries.²⁷

Role of Nurses and Healthcare Providers in Injury Prevention

Prevention of unintentional injuries requires an understanding of risk factors at each child’s developmental stage, and knowledge of risk-reducing actions.^15,46,70 Nurses should use every “teachable moment” with families to increase parental awareness⁴⁹ of the risk of unintentional injuries and to promote the use of appropriate safety equipment. A teachable moment can occur during encounters such as a well-child checkup or a parent visit to the school,^20,35,60 but is probably not present when the child is in the PCCU after an injury occurred. Nurses will need to select the best opportunities and methods to teach injury prevention strategies. See the Chapter 19 Supplement on the Evolve Website, for information about injury prevention.

Airway and Ventilation

Cardiovascular Function and Circulating Blood Volume

Neurologic Function

The morbidity and mortality of pediatric head injury is lower than the morbidity and mortality of similar head injury in adults. Many children who survive head injury recover completely; however, severe head injury can be fatal or produce long-term disability.

Thermoregulation

Children have large surface area-to-volume ratios, so they lose more heat to the environment through evaporation, conduction, and convection than do adults. An injured child may experience a rapid fall in body temperature from exposure to a cold environment, submersion in cold water, or from evaporative losses when resuscitated in the out-of-hospital setting. Hypothermia, in turn, complicates resuscitation. Cold stress can be exacerbated by exposure in a cool emergency department (ED) or computed tomography (CT) scan room.

Every effort must be made to keep the injured child warm. Warm blankets and warming lights should be used if needed. In general, patient warming and rewarming should be performed with careful monitoring to prevent hyperthermia.

It may be necessary to warm intravenous (IV) fluids before they are administered to the child. Because microwave ovens warm fluids inconsistently, they should not be used to warm IV fluids.

Cold stress produces vasoconstriction that can mask the severity of blood loss; as the child is warmed, peripheral vasodilation may result in development or worsening of hypotension. Providers should anticipate the need for administration of additional fluid or blood during rewarming.

Fluid Administration

Field Triage and Scoring

Scoring systems have been developed to quantify injury severity and predict patient outcome. These scoring systems also provide objective criteria to determine the need to transfer the trauma victim to a pediatric trauma center. As a result the transport team must select an accepted triage scoring system and use it consistently.

The trauma score (TS) is designed for scoring injury severity in the field; it uses the GCS score and the scoring of four additional physiologic parameters: systolic blood pressure, capillary refill, respiratory rate, and respiratory effort. Each category is scored and then totalled.¹⁰

The revised trauma score (RTS) was created to identify patients for triage to a trauma center.¹¹ It requires evaluation of fewer physiologic parameters than the TS. To calculate the RTS, the provider assigns a coded value to the GCS score, the systolic blood pressure, and the respiratory rate and then adds these three values together (Table 19-1). A weighted version of the RTS is a predictor of mortality; an RTS of less than four is correlated with a probability of survival of less than 60%, and should prompt consideration for transfer to a trauma center.²

The pediatric trauma score (PTS) was developed to better identify the manifestations of injuries in children and better quantify their severity. The PTS evaluates the following six parameters: (1) patient size, (2) airway stability, (3) systolic blood pressure, (4) mental status, (5) wounds, and (6) skeletal injuries (Table 19-2).

In the PTS, large size and optimum status result in a score of 2 for each parameter; extremely small size or systemic dysfunction results in a score of −1 for each parameter. The highest possible score is a 12 and the lowest possible score is a −6.⁶⁷ Children with a PTS totaling 8 or less have the highest potential for preventable mortality and morbidity, and they should be transported to a facility with the resources necessary to provide optimal pediatric care (e.g., a pediatric trauma center).⁶⁷

The PTS is a conservative scoring system and will result in the triage of some children who have only moderate injuries; however, conservative triage is generally thought to be appropriate for injured children. The PTS has not been shown to be consistently superior to the RTS, so many centers continue to use the RTS for the triage of children and with good results. Because vital signs (e.g., particularly blood pressures) are often not evaluated in the field,^22,38 a simple scoring system that uses fewer vital signs (e.g., the RTS) can be used more consistently than one requiring evaluation of heart rate and respiratory rate in addition to blood pressure (i.e., the PTS).

In 2006, the National College of Surgeons Committee on Trauma convened a panel of national experts on trauma field triage to develop consensus trauma triage criteria for adults and children based on physiologic criteria (GCS score, systolic blood pressure, and respiratory rate), anatomy of the injury (e.g., penetrating trauma to the head, neck, or torso; flail chest; two or more long bone fractures; amputation; pelvic fractures; open or depressed skull fractures), the mechanism of injury (e.g., falls of 10 feet [3.048   m], or a distance of more than twice or threefold the child’s height, high risk auto crashes, motor vehicle vs. pedestrian crashes, motorcycle crashes), special patient or system considerations (e.g., children should be preferentially triaged to pediatric trauma centers; patients with associated anticoagulation or bleeding disorders; the EMS provider judges transport is indicated⁵⁹), and protocols.

The criteria contained in the National College of Surgeons Committee on Trauma guidelines are included in Box 19-1. A detailed explanation of these guidelines was published by the Centers for Disease Control and Prevention in 2009.⁵⁶ A link to this publication is available in Triage of Injured Patients in the Chapter 19 Supplement on the Evolve Website.

Team Approach to Management

Optimal trauma care requires organization of resources and personnel. The trauma team should have protocols in place that designate responsibilities for initial assessment and management of the injured child to specific members of the trauma team. Team composition can vary among institutions based on the number and skill level of personnel, but intervention priorities remain the same.

Emergency Department Stabilization and Transfer

The amount of care provided in the ED will be determined by the child’s clinical status and the distance between the ED and the definitive treatment center. Preferably, the child with major trauma will be transported from the ED directly to the PCCU in the same hospital. In this case, the time in the ED will be short. If the PCCU is located in a separate hospital, a more thorough evaluation should be performed in the ED to detect and stabilize major occult injuries before transfer. This evaluation requires a delicate balance between taking time to perform adequate evaluation and stabilization and the need to avoid excessive delay in transferring the child to the (definitive) trauma center. The child always should be stabilized before extensive diagnostic studies, such as CT scans, are performed. The radiology department is not the optimal location for the initiation of resuscitation.

General indications for transfer of the critically ill child to a trauma center with a PCCU include multisystem trauma, shock requiring multiple transfusions or vasoactive drug therapy, head injury accompanied by alteration in level of consciousness, multiple long bone fractures, rib fractures in the young child, penetrating injuries, traumatic amputations, significant burns, and anticipated need for prolonged mechanical ventilation (see Box 19-1).⁵⁶

Airway

Spine Stabilization

Spinal cord injuries are less common in children than in adults. When these injuries occur in children, they are generally associated with motor vehicle-related crashes, falls, and inflicted head trauma and can result in injuries of the upper or lower cervical spine (Fig. 19-1).⁴

Fig. 19-1 Cervical spine injury. Lateral cervical spine radiograph indicating cervical spine injury. A, Cervical spine radiograph of a toddler demonstrating wide separation between the first and second cervical vertebrae, consistent with complete cervical spine injury at the level of C1 to C2. Note the anterior displacement of the nasogastric tube (arrow) indicating anterior displacement of the esophagus (which should lie just anterior to the vertebrae) caused by edema at the site of the spinal cord injury. This child was intubated, but the endotracheal tube is not visible because it is not radiopaque. B, Normal anatomy of the cervical spine in a toddler. Note the horizontal articulation of the vertebrae, which increases the mobility of the upper cervical spine in this age group.

(A. Radiograph courtesy of John B. Pietsch, Nashville, TN. B. Illustration from Riviello JJ, et al: Delayed cervical central cord syndrome after trivial trauma. Pediatr Emerg Care 6:116, 1990. Williams and Wilkins.)

Spine stabilization and then immobilization is indicated after motor vehicle crashes, after pedestrian-related crashes, after crashes in which the child was unrestrained, for any unconscious trauma victim (because it is difficult to ascertain the extent of injury), and for any major trauma associated with head injury.² Manual stabilization is provided initially, and then a device is used to immobilize the cervical spine during transport and initial evaluation (Fig. 19-2).

Fig. 19-2 Cervical spine manual stabilization and immobilization. A, Preparation for intubation using a second person to stabilize cervical spine. This two-person technique may be necessary if a hard cervical collar of appropriate size is not available. No traction or force should be applied to the cervical spine, but movement is prevented. B, With a hard cervical collar in place, the patient’s torso is taped or strapped to the board, then the patient’s head and neck (with collar) are secured to the backboard. Linen rolls are used to prevent lateral movement of the head.

There are many acceptable methods for immobilizing the cervical spine. A semirigid collar (e.g., an extrication collar) immobilizes the cervical spine, but these collars are not recommended for use in children younger than 4 years.⁵ Foam collars can be applied easily and are available in small sizes, but they often provide no protection against head and neck movement. If an excessively large collar is applied, flexion of the neck may cause airway obstruction or hyperextension of the neck can result in the very movement and possible injury that the collar is designed to prevent.

Cervical spine immobilization in children requires a combination of a cervical collar (of the appropriate size) with a rigid spine board. The child’s head is supported in a neutral position on the board, using a board with head well or pads under the torso, and, foam blocks and straps. Towel rolls, and tape should be used to secure the torso and the head (see Fig. 19-2).^3,25,29

If the mechanism of injury suggests thoracic spine trauma, providers should avoid any flexion or torsion of the torso. If lap belt injuries are suspected (see Secondary Survey, Abdomen), providers should prevent movement of the lumbar spine until further examination.⁵⁵ The child should be log-rolled whenever turning is required until an injury to the spine is ruled out (i.e., the spine is cleared). If the child is sufficiently stable, the provider should evaluate and document movement and sensation of all extremities.

Airway Management

Oropharyngeal and nasopharyngeal airways can help to maintain a patent upper airway. Oral airways are reserved for the child with absent cough and gag reflex. Oral airways must be sized appropriately, because airways that are too small can push the tongue back into the oropharynx and those that are too long can obstruct the pharynx.⁵⁴ The length of the airway should equal the distance from the mouth to the angle of the mandible. Nasal airways can be inserted in the alert child or the unresponsive child who has no facial trauma; they may facilitate suctioning.

Breathing

Life-Threatening Thoracic Injuries

Not all thoracic injuries are immediately recognizable, and not all injuries are immediately life threatening. It is important to note that these complications often can be identified on the basis of clinical findings. When thoracic injuries or their complications (e.g., tension pneumothorax, severe hemorrhage) are life threatening and produce typical signs and symptoms, treatment should be initiated before a radiograph is obtained.

Injuries to the lung parenchyma or accumulation of intrathoracic air or fluid can impair oxygenation and ventilation and can produce cardiorespiratory failure. Injuries may be internal, external, or both. Common life-threatening thoracic injuries include tension pneumothorax, open pneumothorax (sucking chest wound), massive hemothorax, and cardiac tamponade. Additional injuries that are potentially life threatening include pneumothorax, tracheobronchial injuries, and pulmonary contusion. Fortunately, injuries resulting from penetrating trauma are relatively uncommon in children.⁷

Tension Pneumothorax

Tension pneumothorax develops from progressive air entry into the pleural space from the lung or airways; this air accumulation elevates intrapleural pressure, compresses the lung, and can compromise cardiovascular function. The lung on the side of the tension pneumothorax is partially collapsed, and severe hypoxemia develops (Fig. 19-3; see Fig. 10-7). Breath sounds and chest expansion on the side of the pneumothorax are decreased or absent.

Fig. 19-3 Chest radiograph showing tension pneumothorax. A, Right tension pneumothorax produces displacement of the mediastinum to the patient’s left side (arrow). Note the absence of rib fractures. This injury was sustained when the rear wheels of a car ran over the child’s right chest, and the tension pneumothorax was apparent on clinical examination. B, Reexpansion of the right lung is apparent after insertion of a chest tube. The mediastinum has shifted back to the midline. Opacification of the right lung is consistent with pulmonary contusion. The child is intubated and a nasogastric tube is in place. Note that the chest radiograph did not and should not delay thoracostomy.

(Chest radiographs courtesy of James Betts, Oakland, CA.)

A tension pneumothorax shifts the mediastinum away from the affected side. This shift reduces venous return to the heart and decreases cardiac output; neck vein distension may be observed. In addition, the point of maximal impulse and the trachea shift away from the tension pneumothorax,⁴ although the tracheal shift may be difficult to appreciate in infants and children. The resultant decrease in cardiac output and oxygen delivery are life threatening. The mediastinal shift can result in compression of the contralateral lung, further compromising oxygenation and ventilation.

A tension pneumothorax requires immediate needle decompression followed by tube thoracostomy. Needle decompression should be performed on the basis of clinical examination, and providers should not delay therapy to obtain a chest radiograph. A simple pneumothorax is treated with chest tube insertion.

To perform needle decompression, insert a large-bore (13, 16, or 18 gauge) angiocatheter on the affected side, into the second intercostal space at the midclavicular line.⁵⁴ The diagnosis of tension pneumothorax is confirmed when needle or tube thoracostomy results in evidence of air evacuation and immediate improvement in the patient’s condition. After initial air evacuation, the provider can use a stopcock to prevent entrainment of air into the chest. The provider can also attach the angiocatheter to tubing with the tubing tip placed 2 to 3   cm below the surface of a bottle of sterile water; this maintains an underwater seal until a chest tube is inserted.

Chest tubes are inserted to treat pneumothorax and hemothorax. Appropriate chest tube size is based on the age of the child (Table 19-4), and sizes can be predicted from length-based (e.g., Broselow) resuscitation tapes. Before the chest tube is inserted, the skin is prepared with a povidone iodine or chlorhexidine scrub, and the provider administers local anesthetic (e.g., lidocaine). A small stab wound is made in the skin and subcutaneous tissue along the long axis of the rib, in the fifth or sixth intercostal space at the midaxillary line. A curved hemostat followed by the chest tube is advanced through the chest wall and pleura, into the chest cavity (see Evolve Fig. 19-1 in the Chapter 19 Supplement on the Evolve Website for an illustration of chest tube insertion).

Table 19-4 Pediatric Chest Tube Sizes

Age	Chest Tube Size (French)
Full-term neonate (6 months)	10-12
Older infant (6-18 months)	12-14
Toddler (1-3 years)	14-16
Young school age (4-7 years)	16-20
Older school age (8-12 years)	20-24
Adolescent	24-32

Pulmonary Contusion

A pulmonary contusion is a bruise on the lung resulting from lung parenchymal injury. Although a pulmonary contusion can be asymptomatic and diagnosed only on CT scan, it can cause respiratory compromise following major blunt chest trauma.^13,44 A significant pulmonary contusion will cause hypoxemia, and opacification is visible on a chest radiograph or CT scan (see Figs. 19-3, B and 19-4).

Fig. 19-4 Pulmonary contusion on chest radiograph and computed tomography (CT) scan. A, Chest radiograph. Note the increased opacification in the patient’s right lower lung fields (arrows). Note the absence of rib fractures. B, CT scan from the same patient demonstrating opacification (white contusion is visible in the dark air density) of the right lower lung. The trachea is not visible in mediastinum, so opacification is below the area of bifurcation of the trachea into bronchi. This CT view is shot from below the area of contusion with a view in the cephalad direction. The patient’s right chest appears on the left side of this image, and the patient’s left chest is visible on the right side of this image. The front of the patient is the top of this image, and the patient’s back is at the bottom of this image; thus, the patient’s heart is anterior (visible as a white oval) and vertebral column is posterior.

An associated hemothorax typically suggests the presence of a more severe lung injury. Treatment includes supplementary oxygen and may require positive-pressure ventilation with oxygen support and positive end-expiratory pressure.

Circulation

Assessment and support of circulation includes: (1) assessment of systemic perfusion, including assessment for signs of hemorrhage; (2) control of external bleeding; and (3) treatment of hypovolemia and any other causes of inadequate systemic perfusion. The nurse should monitor the child’s heart rate and assess systemic perfusion frequently.

Cardiovascular compromise in the trauma patient generally is caused by hypovolemia, but it may also be caused by hypoxia or severe head injury. Even if effective cardiovascular function is present on arrival in the hospital, the trauma team should assess and reassess systemic perfusion to detect any signs of deterioration. These signs may be subtle in the child and include: tachycardia; weak peripheral pulses, mottled skin; cool, pale extremities; delayed capillary refill; and unusual irritability or lethargy (Box 19-4).

If the child has an ineffective or absent pulse in a central artery (e.g., carotid, femoral), or the infant has no brachial pulse, cardiopulmonary resuscitation is needed (see Chapter 6). Additional indications for the initiation of chest compressions include symptomatic bradycardia (a heart rate less than 60/min associated with signs of poor systemic perfusion) that is unresponsive to adequate oxygenation and ventilation.^26,54

The most common terminal (prearrest) cardiac rhythm in pediatric patients is a bradycardia that deteriorates to an agonal rhythm or asystole. Ventricular tachycardia and ventricular fibrillation are less common in children than in adults. For further information regarding cardiopulmonary resuscitation in children, see Chapter 6. Survival following prehospital cardiac arrest and cardiovascular collapse in pediatric victims of blunt trauma is poor.²⁶ To prevent arrest, providers must detect and treat signs of airway compromise, respiratory failure, and shock.

Treatment of Hypovolemia

Fluid resuscitation begins with a bolus of isotonic crystalloid solution (lactated Ringer’s solution or normal saline) administered in boluses of 20   mL/kg over 5 to 20 minutes.^2,54 If the child has signs of substantial blood loss or shock, the bolus should be administered as quickly as possible, typically over 5 to 10 minutes. The patient with trauma and hemorrhage also will require blood administration. Typically one bolus of packed red blood cells (RBCs) is administered after every two to three boluses of isotonic crystalloid (Fig. 19-5).

Fig. 19-5 Trauma fluid resuscitation.

Boluses (10-20   mL/kg) of type O, Rh-negative packed RBCs can be administered when type-specific blood is not available; type-specific whole blood can be administered if packed RBCs are not available. Rh-negative blood is typically reserved for young females and females of reproductive age, to reduce the incidence of Rh sensitization. Rh-positive blood can be used in prepubescent females if there is no alternative, although this predisposes them to developing antibodies that can complicate future pregnancies. Either Rh-positive or Rh-negative blood may be administered to males.

Both isotonic crystalloids and colloids are used for intravascular volume resuscitation, and a larger quantity of fluid will be administered than the estimated volume lost. As a result of the distribution and effects of IV crystalloids and colloids, usually a crystalloid-to-colloid ratio of 3:1 is administered to produce the same effects (the “3 to 1 rule”). Although both crystalloids and colloids are ultimately distributed throughout the extracellular space, colloids remain in the vascular space for a longer period of time and may enable restoration of circulating blood volume with fewer boluses. However, there is no evidence that colloids are superior to crystalloids for volume resuscitation.

If the blood pressure, capillary refill, and quality of peripheral pulses remain poor and tachycardia persists despite the administration of two or three fluid boluses, then substantial hemorrhage has likely occurred or a continuing source of blood loss is present.³¹ Surgical exploration should be considered if the child’s condition is still unstable despite administration of two boluses of packed RBCs (in addition to the isotonic crystalloids). Abdominal bleeding can result from a solid organ or major vessel injury, and the trauma team should look for occult retroperitoneal or pelvic bleeding.¹³ Additional causes of shock that is unresponsive to initial fluid resuscitation include cardiac tamponade, tension pneumothorax (discussed previously), and neurogenic shock.

Disability: Neurologic Function

Rapid neurologic evaluation is an essential component of the primary survey of the injured child. The initial neurologic examination consists of an assessment of pupil size and response to light, evaluation of responsiveness (GCS score or modified GCS score) and voluntary movement and sensation, and (in the infant) palpation of the fontanelle.

Signs of increased intracranial pressure include: deterioration in level of consciousness, pupil dilation (unilateral or bilateral), lack of response to a central painful stimulus, and, in the infant, a firm fontanelle. Late signs of increased intracranial pressure (often associated with impending brainstem herniation) include bradycardia, systolic hypertension with widening pulse pressure, and altered respiratory pattern, such as apnea (see Box 19-5).

Effective cerebral resuscitation in the pediatric trauma victim requires adequate shock resuscitation; cerebral perfusion will not be optimal if shock is present. The trauma team should provide shock resuscitation until systemic perfusion is effective. If signs of impending herniation develop (i.e., bradycardia, systolic hypertension, and altered respiratory pattern), it may be helpful to provide mild hyperventilation to reduce carbon dioxide levels and, thus, cerebral blood flow as a temporary emergency measure. Hyperventilation is not routinely performed unless signs of impending herniation are present. IV mannitol (0.25-0.5   g/kg) is given to shift water from the cellular to the extracellular (including intravascular) space; this rapidly decreases blood viscosity, leading to an increase in cerebral blood flow and tissue oxygen delivery. Hypertonic saline (3%-23.5%) may also be administered to produce an osmotic diuresis and improve cerebral perfusion; it may have other additional benefits. For further information, see Management of Increased Intracranial Pressure in Chapter 11.

Status epilepticus is uncommon, but must be identified and treated aggressively in the patient with increased intracranial pressure, because continuous seizures will increase cerebral metabolic oxygen consumption and will cause cerebral ischemia. Intermittent seizures will increase intracranial pressure transiently and are treated with diazepam (0.25   mg/kg).² A prophylactic anticonvulsant (i.e., phenytoin) is typically administered for 1 week to infants and children with moderate or severe head injury (GCS less than 12) who are thought to be at high risk for seizures.

Infants rarely lose a significant percentage of blood volume from intracranial hemorrhage, but bleeding from scalp wounds in infants or children can result in significant blood loss. After initial resuscitative efforts and treatment of the scalp wounds, persistent signs of shock are likely explained by other causes.

Exposure

Once the child’s condition is hemodynamically stable, the trauma team should remove the child’s clothes to inspect the entire body for injuries. Infants and small children can rapidly become hypothermic during transport and during resuscitation in cool rooms. Warm blankets or a radiant warming device should be available for all pediatric trauma victims. Throughout initial resuscitation and stabilization, the nurse should closely monitor the child’s skin and core body temperature.

Fever will increase metabolic rate and can contribute to worse outcome following resuscitation.^9a,38a Therefore, it is important to prevent or promptly treat fever.

Head

The most common head injury in children is closed head injury.⁵⁸ Closed head trauma is not always immediately recognizable. For this reason, the mechanism of injury and the initial response to therapy (or lack of response) should provide a high index of suspicion. The first priority of management is to maintain cerebral perfusion and treat increased intracranial pressure by performing intubation and providing adequate ventilation, oxygenation, shock resuscitation, osmotic diuresis, and analgesia and sedation if needed. Early identification of increased intracranial pressure is essential to reduce morbidity and mortality.

It is important to palpate the entire head carefully to identify fractures or wounds. In addition, the nose and ears are examined carefully for blood or cerebrospinal fluid drainage, which is indicative of maxillofacial fracture or basilar skull fracture with dural tear. If clear fluid drains from the nose or the ears, it should be tested for the presence of glucose; the presence of glucose suggests that the fluid is cerebrospinal fluid. An ocular examination should be performed to identify papilledema or lateralizing extraocular muscle paresis or eye injury.

Providers should evaluate cranial nerve function when possible and immediately report any absence of cranial nerve function to the trauma surgeon or the trauma team leader. The nurse can often correlate patient neurologic function with the site of central nervous system injury through careful assessment of signs of cranial nerve function and evaluation of any abnormal posturing or respiratory patterns (Table 19-6).

A CT scan will provide important information about the extent and severity of the head injury and potential causes of further deterioration, such as intraparenchymal, subdural, or epidural hemorrhage (Fig. 19-6). In addition, it will provide information about the need for surgical intervention. If a CT scan is performed to evaluate a head injury, the scan should include the upper cervical spine.²³ Magnetic resonance imaging (MRI) has been used more often in recent years because it provides better detail of head injuries and may be more useful to predict outcome (see the following discussion under Neck and Spine).²⁴

Fig. 19-6 Epidural hematoma in two CT scans taken 2   hours apart. These two images show the rapid progression of an epidural hematoma. A, This first scan was taken soon after the child’s arrival in the emergency department. The epidural hematoma (blood) is visible as a white density in the patient’s right temporal area (visible on the left side of this image). The lateral ventricles and third ventricles are partially visible as dark densities at the midline and on either side of the midline of this image. B, This second scan was obtained 2   hours later when the child’s level of consciousness deteriorated. The child’s right pupil dilated and reacted sluggishly to light. The image is at the same level as image A and now shows a much larger epidural hematoma (white density on patient’s right side). The lateral ventricles and third ventricle are almost completely obliterated as the result of compression from the expanding epidural hematoma.

This child required urgent surgical intervention. (Images courtesy of Thomas Abramo, Nashville, TN.)

Brain injury causes the release of biomarkers that can be measured in the blood, cerebral spinal fluid, and extracellular brain fluid. These biomarkers include inflammatory mediators (e.g., interleukins, tumor necrosis factor), nerve growth factor, and adhesion molecules to proteins. Monitoring levels of biomarkers may be useful in evaluating the severity of brain injury and response to therapy and in predicting outcome.^6,24

The trauma team and especially the bedside nurse should frequently assess the patient’s mental status. The use of a standardized scoring system will enable quantification of the patient’s progress and responsiveness and trends in the patient’s condition. The GCS or the modified (pediatric) GCS³⁶ will be helpful (Table 19-7). Frequent assessments are needed to detect subtle signs of deterioration.

Occasionally children with diffuse cerebral injury will demonstrate sudden deterioration several hours after injury; such deterioration must be immediately detected and treated. For further information regarding the assessment and management of the child with head injury and increased intracranial pressure, see Chapter 11.

If spine trauma is suspected, hypotension persists, and hypovolemia and pericardial tamponade have been ruled out, then neurogenic shock may be present. Neurogenic shock results from a spinal cord injury that produces loss of autonomic (sympathetic nervous system) tone and results in vasodilation and hypotension (see below).²⁵

The most consistent indicators of poor prognosis following closed head injury in children include flaccid paralysis and fixed, dilated pupils despite the restoration of satisfactory perfusion. Other poor prognostic indicators include the development of diabetes insipidus at or soon after admission (often indicates cessation of pituitary function), cardiovascular instability unrelated to hemorrhage, and disseminated intravascular coagulation. Brain injury results in the release of fibrinogen; severe head injury can result in substantial fibrinogen release and disseminated intravascular coagulation.³ Concentrations of some combinations of biomarkers of brain injury may predict poor outcome from head trauma, although research in this area continues to evolve.^6,24

If a devastating neurologic injury is present and brain death is diagnosed or imminent, the family should be asked about organ donation. The request should be made in accordance with local protocols, which can vary by jurisdiction. For further information, see Brain Death in Chapter 11; see also Chapter 3.

Neck and Spine

If the child has a mechanism of injury that is likely to cause spine injury or if the child has head or neck trauma, then providers should immobilize the cervical and thoracic spine as a precautionary measure. Once the child’s condition has been stabilized, further evaluation is warranted to determine whether spinal cord injury can be ruled out.

If the child has a mechanism of injury that is consistent with possible spinal cord injury, has neurologic signs of spinal cord injury, or is comatose or hypotensive without neurologic signs, then the extrication collar should remain in place until spinal cord injury is ruled out; this requires a combination of clinical assessment, cervical spine radiographs, CT scan, and possibly an MRI (Fig. 19-7).²³

Fig. 19-7 Computed tomography (CT) and magnetic resonance image (MRI) to detect cervical spine injury in a child. A, Coronal CT from a 4-year-old girl who was an unrestrained passenger in a motor vehicle crash shows widening of the bilateral atlantoaxial joints. B, Sagittal MRI short T1-weighted inversion recovery images show signal changes within the bilateral atlantoaxial joints (arrows) and within the right occipitoatlantal joint (arrows). MRI confirmed that the transverse ligament was intact (not shown).

(From Gore PA, Chang S, Theodore N: Cervical spine injuries in children: attention to radiographic differences and stability compared to those in the adult patient. Semin Pediatr Neurol 16:42-58, 2009.)

It is difficult to rule out cervical spinal cord injury solely on the basis of anteroposterior and lateral radiographs and CT scans, because many children experience spinal cord injuries that are not associated with abnormalities in standard radiographs and CT scans.^3,23,42a Historically, a complete radiographic cervical spine series includes anteroposterior and lateral cervical spine radiographs and oblique and odontoid views.^32,69

In adults, the CT scan has largely replaced radiographs for evaluation of the cervical spine, particularly in obtunded patients,³³ but similar comparison data have not been published for children.²³ Cervical spine subluxation or vertebral fracture can be identified with CT scan, and the combination of spine radiographs and limited CT scan of the occiput to the third cervical spine can increase identification of cervical spine injuries in obtunded or young children.^21,23

In many centers, a screening trauma CT scan (“traumagram”) can be performed in less than 10 minutes. This screening scan consists of a CT of the head, neck, chest, abdomen, and pelvis using a rapid scanner that requires no repositioning of the child or transport to different rooms in the radiology department. MRI also can be helpful, but is not feasible in the evaluation of the patient in an unstable condition; it will be performed if clinical findings suggest the presence of a cervical spine injury.

If the child is awake and oriented, the presence of neck or back pain is suggestive of vertebral injury.^23,69 The National Emergency X-Radiography Utilization Study Group developed a decision instrument of clinical criteria to rule out cervical spine injuries in patients with blunt trauma (Box 19-6)³² that performed well in a multicenter trial involving more than 3000 children. However, the study authors recommended caution in interpreting the results because there were fewer than 90 infants and toddlers in the study.⁶⁹

At some trauma centers, the extrication collar is left in place until the child is sufficiently awake to respond when providers check for tenderness during movement. If the child remains comatose for a long time, the cervical spine is screened using an MRI, and the collar is removed if the MRI is interpreted as normal. The child with no tenderness plus a normal MRI or a normal neurologic examination is unlikely to have a cervical spine injury and so is unlikely to produce a secondary injury with spontaneous movement.

If clinical findings or the mechanism of injury suggest the likelihood of a lower spine injury, then thoracic, lumbar, and sacral spinal films and CT scan are indicated. Lap belt bruising should raise the possibility of a Chance fracture, caused by flexion against the lap belt with resultant distraction injury to the lumbar spine (see Abdomen, below).

Chest

As noted previously, children have softer, more compliant rib cages than do adults. Therefore rib fractures are relatively uncommon, occurring in one third or less of children with blunt trauma. Severe intrathoracic injury may be present despite the absence of rib or sternal fractures or other manifestations of abnormality on external examination.^3,13 However, thorough chest inspection and palpation should reveal obvious signs of injury. The nurse may note chest asymmetry associated with respiratory effort or caused by rib fractures. Careful auscultation should identify localized alteration in the intensity or pitch of breath sounds; pulmonary edema may cause crackles and hypoxemia.

Chest radiographs, including anteroposterior and lateral films, should be performed on any child with severe injury to the chest or torso.¹³ CT scans may provide additional information and detail, particularly to evaluate airway abnormalities and fluid collections. A pulmonary contusion will produce localized opacification of the lung (see Fig. 19-4) and increased density on the CT scan.

Although rare, cardiac contusions may be present in any child with a history of blunt thoracic trauma. Clinical signs include chest pain, arrhythmias, and myocardial dysfunction. The child may have a new murmur or evidence of congestive heart failure, including systemic and pulmonary edema and a gallop rhythm. The diagnosis is made by evaluating cardiac isoenzymes, a 12-lead ECG, and an echocardiogram.⁴

The cardiac troponin complex consists of three troponins (C, I, and T) that are involved in the interaction of the actin and myosin filaments in cardiac muscle.³⁷ These troponins are normally present only in cardiac muscle, and their levels will rise with cardiac necrosis (death of heart muscle) and myocardial injury. In adults, concentrations of troponins I and T are monitored to determine the presence of an acute coronary syndrome; elevation of troponins I and T can be more sensitive indicators of myocardial injury than elevation of the creatinine kinase myocardial band (CK-MB).³⁷ Although troponin concentrations are normally negligible in children, they are often elevated after cardiac contusion. It is important to note that not all children with cardiac contusion demonstrate elevation of troponins, and troponins may be elevated by conditions other than cardiac contusions.³⁰

ECG signs of a cardiac contusion may include atrial or ventricular arrhythmias (uncommon) or S-T segment depression or elevation, which may be confused with myocardial ischemia. The echocardiogram may detect abnormalities of contraction and wall motion.

Treatment of cardiac contusion is primarily supportive and includes careful fluid titration to optimize cardiac preload, support of myocardial function with inotropes (e.g., dobutamine), and manipulation of afterload (e.g., using vasodilators or vasopressors). Providers should be alert for the sudden development of arrhythmias such as ventricular tachycardia or fibrillation, and they should be prepared to treat them.

Abdomen

Hemorrhage from thoracoabdominal injuries is a leading cause of traumatic death in pediatric victims, as are head injury and complications of airway and ventilation.^4,54a Children do not often have penetrating abdominal injuries; blunt abdominal trauma accounts for the vast majority of pediatric abdominal injuries.

Providers should examine the child carefully to identify both overt and subtle signs of intraabdominal injuries. Fifteen percent of injured children with negative abdominal examinations are subsequently found to have significant intraabdominal injuries, even in the presence of normal mental status and vital signs.^4,13

Signs of abdominal hemorrhage are difficult to detect in the comatose patient or one with spinal cord injury and loss of abdominal sensation. In these patients, additional evaluation and diagnostic studies are needed. Emergency ultrasound and FAST are now the diagnostic tools of choice for unstable (particularly those who are obtunded) patients, because they can be performed at the bedside as often as necessary, without radiation exposure or the need to transport the patient. With these devices, free fluid or blood (i.e., hemoperitoneum) appears black against the gray of organs.⁴² FAST scans have a higher specificity (i.e., when fluid is observed, the child has intraabdominal bleeding) than sensitivity (i.e., children can have organ injury without detection of free fluid or blood in the abdomen). Therefore FAST is often used in conjunction with the CT scan to detect intraabdominal bleeding in children with trauma and hypotension.⁴²

A CT scan will usually reveal the presence of significant injury (see below). As noted above, a screening trauma CT scan can be performed in many medical centers in less than 10 min. The CT series includes scans of the head, neck, chest, abdomen, and pelvis using a rapid scanner that requires no repositioning of the child or transport to different rooms in the radiology department. Peritoneal lavage is rarely used in children because it is not as accurate as the use of FAST or a CT scan. In addition, it will create a painful site that complicates later assessment of abdominal tenderness.⁴

Injuries resulting from improperly positioned lap belts frequently produce abdominal ecchymosis and bruising (Fig. 19-8). If the lap belt was positioned across the lower abdomen and not over the pelvis, the bruising may indicate the possibility of intestinal and lumbar spine injury (Fig. 19-9).^55,66

Fig. 19-8 Lap belt contusion. This contusion should raise suspicion of abdominal injury and lumbar spine injury (Chance fracture). This child had a small intestinal injury and a Chance fracture with resulting paraplegia.

(Courtesy John B. Pietsch, Nashville, TN.)

Fig. 19-9 Chance fracture of first lumbar vertebra. This fracture resulted from hyperflexion of the child over a lap belt during a high-speed automobile collision.

(Courtesy John B. Pietsch, Nashville, TN.)

Any visible bruising on the abdomen should raise the suspicion of an intraabdominal injury.⁴³ The bruise itself makes it more difficult to examine the conscious child, because the bruise will cause abdominal wall tenderness that is difficult to distinguish from tenderness associated with intraabdominal injury. Pain itself may be difficult to evaluate. The severity of pain does not necessarily correlate with the severity of abdominal injury.

Progressive abdominal distension is one of the first signs of major abdominal injury, so measurement of the abdominal girth, especially in infants and young children, may be helpful. Pain and abdominal distension will reduce the child’s effective tidal volume and ventilation, altering the child’s respiratory rate, respiratory effort, and chest expansion (Box 19-7). Unilateral splinting of respirations with or without evidence of rib fracture is an indication for liver and spleen scans.⁵⁸ Additional high-risk variables, in addition to abdominal tenderness and systolic hypotension, found to be sensitive for radiographically confirmed intraabdominal injury in children after blunt torso trauma include: femur fracture, elevated liver enzymes, microscopic hematuria, and an initial hematocrit less than 30% (see Box 19-7); however, these variables were not specific for intraabdominal injury.³⁴

Signs of splenic or hepatic injury include tachycardia, hypotension, and abdominal tenderness. The splenic injury will be apparent on a CT scan (Fig. 19-10). Splenic injury can cause a positive Kehr’s sign (referred pain to the left shoulder during compression of the left upper quadrant) and leukocytosis.¹³

Fig. 19-10 Splenic injury. A, Computed tomography scan reveals splenic laceration visible on the patient’s left side (white arrow on right side of the image). As in all CT scans, the view is from below and the patient’s right side is on the left of this image and the patient’s left side is on the right side of the image. The front of the patient’s abdomen is at the top of the image and the patient’s back is at the bottom of the image. B, Spleen after splenectomy in the operating room. Three large lacerations are visible, and a large contusion causes discoloration seen on the left side of the photograph.

(Courtesy John B. Pietsch, Nashville, TN.)

Hepatic trauma (Fig. 19-11) can cause referred right shoulder pain instead of Kehr’s sign or left shoulder pain.¹³ Most significant hepatic injury will result in elevation of the serum transaminases (aspartate aminotransferase greater than 200 International Units/L and alanine aminotransferase greater than 125 International Units/L).²⁸

Fig. 19-11 Computed tomography scan image of liver laceration showing disruption of the capsule of the right lobe. Bleeding from the liver injury (dark gray density) extends from the liver injury to the surface of the liver, separating the liver from the abdominal wall. As in all CT scans, the view is from below and the patient’s right side is on the left of this image and the patient’s left side is on the right of the image. The front of the patient’s abdomen is at the top of the image and the patient’s back is at the bottom of the image.

(Courtesy Thomas Abramo, Nashville, TN.)

Further evaluation for abdominal injury includes a thorough rectal examination to rule out the presence of blood within the rectum, to assess sphincter tone, and to ensure that there has been no disruption of the lower urinary tract. Absence of sphincter tone can indicate spinal cord injury.

The pediatric patient with a history of blunt trauma requires close observation. The nurse should obtain frequent vital signs and must be able to recognize signs of pain and subtle signs of deterioration in systemic perfusion. If the patient’s condition is unstable, continuous nursing care and medical supervision is necessary during all phases of transport and testing. Notify the physician or other on-call provider immediately if the patient’s condition deteriorates. Appropriate resuscitation equipment should always be readily available. Occasionally, a follow-up CT scan is useful if the initial scan is not diagnostic and the child is not improving (e.g., the child may have intestinal injury).

Conservative management of splenic, hepatic, or renal contusions and lacerations includes supportive care and close observation in a PCCU. Typically, bleeding from such lacerations has ceased by the time the child arrives at the hospital, and these organs often will heal without intervention.⁴ If conservative management is provided, the child’s systemic perfusion must be monitored closely.

Surgical intervention is required in the presence of ongoing hemorrhage, hemodynamic instability (including the need for excessive fluid administration to maintain blood pressure and perfusion), hollow viscous perforation, or catastrophic organ injury.³¹ In hemodynamically stable patients, surgical exploration can be accomplished through laprascopy.⁶⁴

When surgical intervention is required, the injured organ is often repaired rather than removed (see Evolve Fig. 19-3, A and B in the Chapter 19 Supplement on the Evolve Website for color surgical photographs of splenic injury and lap belt injury to the intestine). Removal of the injured spleen, liver lobe, or kidney usually is required only for devastating injury or if the organ is separated from its vascular supply.

Genitourinary Trauma

Genitourinary trauma is seldom life threatening. However, injured children are more prone to renal injuries than injured adults, because the kidneys are less well protected by muscle, ribs, and fat. Hematuria, abdominal pain, and flank hematomas are all signs of renal injury.¹³ The presence of threadlike clots in the urethra is a pathognomonic finding indicative of renal injury, and the amount of hematuria correlates well with the severity of renal trauma.⁶²

Although insertion of a urinary catheter is routine during trauma resuscitation, a catheter should not be inserted in the trauma victim if frank blood is observed in the urinary meatus. Such blood often is caused by urethral disruption and is a contraindication to urinary catheter insertion.⁴¹ The presence of blood in the urinary meatus indicates the need for a retrograde urethrogram and urologic consultation.^8a Severe renal injury with separation of the kidney from the urethra may not be associated with hematuria; these patients will demonstrate evidence of extravasation of urine that will be detected by a CT scan.

Bladder rupture should be suspected if any degree of hematuria is detected in the child with a pelvic fracture. A cystogram is indicated to rule out bladder injury.^8a

Extremities

Extremities should be observed for tenderness, deformity, swelling, pallor, coolness, and decreased peripheral pulses. Subtle fractures can be missed during initial resuscitative management, but they should be detected during the secondary survey.

Long bone fractures and pelvic fractures can produce significant blood loss, especially in older children. When a pelvic fracture is suspected, the trauma team should assess the integrity of other structures within the pelvis, including the urethra, bladder, and pelvic vessels. Disruption of pelvic vessels can cause rapid and severe blood loss.⁴

Skin

During initial stabilization of the trauma victim, visibility of some areas of skin will be compromised by pressure dressings. Once the primary survey and stabilization have been accomplished, the undressed pediatric patient should be examined carefully for the presence of other injuries, including contusions and burns. If burns are present, the trauma team should plan fluid resuscitation based on the estimated burn depth and extent. For information about burns, refer to Chapter 20.

Most fire-related deaths result from smoke inhalation, and the most common cause of death during the first hour after burn injury is respiratory failure.² A history of closed space confinement should lead to evaluation for the presence of carbon monoxide poisoning. The child should be inspected for (1) singed eyebrows and nose hair, (2) dark sputum, (3) carbon deposits and inflammatory changes in the mouth, (4) cyanosis and dyspnea, and (5) altered level of consciousness. Initial treatment includes oxygen administration and close observation for deteriorating respiratory status. Note that carboxyhemoglobin is not detected by a pulse oximeter, so pulse oximetry will be falsely high in the presence of carbon monoxide poisoning (see Pulmonary Injuries in Chapter 20).

Definition and Epidemiology

Intentional injuries are inflicted injuries (e.g., child abuse) or injuries that occur as a result of neglect. In the United States it is estimated that 1% or more of all children are abused or neglected, and approximately 4000 children die annually as victims of abuse.⁵⁷

The term child abuse applies to any maltreatment of a child, including infliction of physical injuries, sexual exploitation, infliction of emotional pain, or neglect. Child abuse usually is not a random, isolated act of violence, but rather a pattern of maladjusted behavior. The three components of the child abuse syndrome include the maladjusted adult, the vulnerable child, and the presence of situational stressors.⁶⁵ For more information, refer to Intentional Injury/Inflicted Trauma; Definition and Epidemiology in the Chapter 19 Supplement on the Evolve Website.

History of Injuries Suggesting Intentional Injuries (Inflicted Trauma)

It is estimated that as many as 10% of children younger than 5 years who are seen in EDs with traumatic injuries have inflicted injuries.⁵⁷ Healthcare workers must be vigilant in attempting to detect evidence of abuse and are obligated to report suspected abuse to the local child protective agency.⁹

Explanations for traumatic injuries that should be questioned include unknown injury, implausible sequence of events, self-inflicted injury, or sibling-inflicted injury. Any injury followed by a delay in seeking medical care is suspicious. Finally, when a child or a spouse names an adult as the cause of the injuries, the accusation usually is true.⁵⁷

Characteristics of Injuries Suggestive of Intentional Injury

Implausible injuries are those that are inconsistent with the history. For example, if a child allegedly sustained multiple bruises when falling down the stairs, bruises will most likely be located over bony prominences; bruises will rarely appear over soft tissues. If a head injury occurs when the child falls out of bed, usually a single lump is present, and the skull is not fractured. Although small linear skull fractures may occur with minor falls, loss of consciousness and multiple bruises are inconsistent with a simple fall.⁵⁷

Suspicious bruises are located on the buttocks, inside of the child’s legs, over the cheeks or flanks, near the upper lip or inside of the mouth, and around the neck. Any bruises or lacerations near the genitals should be examined carefully and investigated. Bilateral black eyes, retinal hemorrhages, detached retina, and traumatic cataracts usually are inflicted injuries.

The marks of injury can be characteristic of the method or instrument of injury. Human hand marks often can be identified, and bite marks can be used to confirm the identity of the abuser. Marks from belt buckles or hair brushes may be identifiable.

Inflicted burns may be splash burns, hot water immersion burns, or branding. Inflicted splash burns may be difficult to distinguish from unintentional burns. Hot water immersion burns usually have circumscribed borders. If the hands or feet are immersed, the burns may resemble the areas covered by gloves or socks, respectively. If the child’s buttocks are dunked in the water, a characteristic V burn will be associated with the water level on the back and thighs. Irregular margins consistent with splashing or movement by the child will be notably absent, indicating that the child was held in the water. Branding burns usually will reflect the shape of the hot object, which may include a pan, a hot radiator, a cigarette tip, or a cigarette lighter.

Subdural hematomas are among the most common results of inflicted head injury in children. Many subdural hematomas are associated with skull fracture, and some may be associated with retinal hemorrhage (the shaken baby syndrome). Scalp bruises and traumatic alopecia also may be observed in these victims.⁵⁷

Inflicted head trauma¹² (formerly called shaken baby syndrome) is the term used to encompass the spectrum of inflicted head injuries, including associated cerebral, spinal, and cranial injuries and their complications. The trauma can result from the combination of vigorous shaking of the child associated with the application of force (e.g., the child is shaken and struck or is shaken while being held against a mattress in bed). However, injuries can also result from blunt head trauma and may be associated with spinal cord injury or hypoxia.¹² These injuries include the primary injury as well as secondary injuries such as hypoxia, ischemia, increased intracranial pressure, and long-term complications including seizures, developmental delay, and other disabilities.¹²

Signs of inflicted head trauma include retinal hemorrhages and subarachnoid hemorrhage documented by cerebrospinal fluid examination and a CT scan. Additional injuries include brainstem and spinal cord hematoma, subdural hematoma or cerebral contusion, and spinal cord injuries.¹²

Intentional injuries should also be considered if the child has shock that does not respond to conventional therapy. For example, if the child exhibits shock and has a history of vomiting and diarrhea or a nonspecific history, and the child’s perfusion and level of consciousness do not improve with adequate hydration, then other causes of shock should be considered, such as intraabdominal injury (Fig. 19-12).

Fig. 19-12 Inflicted liver laceration. This standard computed tomography (CT) scan was obtained in a 21-month-old infant who was brought to the ED with a history of vomiting and diarrhea. He also had unusual bruising to his abdomen and abdominal distension. A standard abdominal CT with contrast confirmed the presence of liver and pancreatic injuries. The CT scan provides an image similar to that achieved by looking up at a cross-section of the abdomen, with the child’s liver on the patient’s right (but on the left side of this image). The front of the child’s abdomen is depicted at the top of the image, and the child’s back is depicted at the bottom of the image. The contrast appears white in the kidneys and the aorta. The dark grey, irregular shape on the outer edge of the liver is the liver laceration; the lighter grey density is the liver itself.

Additional views of the abdominal CT scan demonstrated free fluid in the abdomen and a linear pancreatic defect consistent with a pancreatic laceration. (Image courtesy of Cristina Estrada, Nashville, TN.)

Responsibilities of the Healthcare Team

The first priority in the care of the abused child is providing necessary resuscitation and support of cardiopulmonary function. In addition, the child must be protected from further abuse, and both the child and the family must receive compassionate emotional support. The parents may not have injured the child, but they are likely to feel guilty that they left the child in the care of someone who hurt the child.

The trauma team should carefully document the size, shape, and color of all injuries, but the recording should not interfere with or delay the resuscitation. If possible, color photographs of the child should be taken as soon as possible after the child’s arrival, but this should not delay the institution of appropriate care.

A thorough examination is required to identify all current injuries and evidence of healed injuries. A skeletal series of radiographs and possibly a bone scan will be performed to identify healed fractures. Levels of biologic markers of head injury can be determined from blood or cerebral spinal fluid and can assist in the identification of head injury when inflicted trauma is suggested in the child without neurologic symptoms.^,6 These markers can also be useful for monitoring the child’s response to therapy and for predicting outcome of the head injury.²⁴

Suspected abuse must be reported to the local child protective service agency, and nurses must be familiar with the hospital policy and the sequence. The child abuse team is often the first and best contact and can advise the nurse and the entire team regarding documentation. The report to the local child protective service agency ultimately must be in writing, although an initial telephone contact may be acceptable. The child protective agency usually will arrange that temporary custody of the child be awarded to the hospital or to the state. The healthcare team must be aware of this custody information, because the child’s custodian must provide permission for any elective surgery or procedures for the duration of the custody order.

If a child abuse team is present in the hospital, they should be consulted about the proper recording of injuries and documentation of parental statements. This team also is experienced in examining abused children and frequently will identify additional injuries that may be related to abuse.⁴⁰