29 PEDIATRIC TRAUMA

Trauma is the leading cause of death in children from 1 to 14 years of age. Approximately 20,000 children and adolescents die each year, with the majority of deaths in children less than 19 years old resulting from unintentional injury.¹ In addition, each year another 100,000 children have permanent disability from injury.² In fact, traumatic injury is the leading cause of childhood hospitalization—approximately 300,000 hospitalizations per year in the United States.³ The economic costs are staggering. Traumatic injuries are a major cause of medical spending for children ages 5 to 14 years with billions of dollars spent on caring for the pediatric trauma victim each year.³ But the impact of pediatric trauma extends far beyond statistics and is often seen in the tragedy that the family and society must endure. Therefore nurses must be able to recognize the patterns of pediatric injury and the appropriate treatment.

The purpose of this chapter is to explain the similarities and differences between critically ill children and adults and to bring the nurse up to date on the practical management of the pediatric trauma patient. This chapter describes in detail appropriate assessment and management strategies in caring for a critically injured pediatric patient through the resuscitation, critical care, and intermediate care/rehabilitation phases of care. Special emphasis is placed on nursing management considerations as they pertain to the child rather than on specific injury types.

Nurses often have the primary responsibility for recognizing and interpreting changes in the child’s condition. Therefore, the nurse needs to understand how the child’s normal circulating blood volume, cardiac output, thermoregulation, fluid and electrolyte requirements, and renal function are different from those of the adult. Small variations may cause significant changes in the child’s condition. These changes must be immediately recognized, and the nurse must act on them at once. The intent of this chapter is to provide a systematic framework that allows nurses to relate to the pediatric trauma patient on the basis of the unique physiologic and psychologic dynamics inherent in this age group.

EPIDEMIOLOGY/INCIDENCE

In the United States, children between the ages of 1 and 19 years are at greater risk of dying from injury than from all diseases combined. Injury in this population is also the leading cause of disability. The single largest cause of all trauma-related deaths is motor vehicle incidents. Other leading causes of traumatic injury in children include the following: burns, drownings, poisonings, firearms, falls, and abuse.

Two of three childhood traumatic incidents occur in males. The peak unintentional injury age range is between 4 and 12 years, with the highest incidence at 8 years. The reason for this peak is that children in this age group are starting school, and parents generally are allowing them to have some independence.

PATTERNS OF INJURY

The most common injuries seen in children are blunt as opposed to penetrating injuries. At least 80% of life-threatening injuries in children occur from blunt trauma.² Blunt injuries are associated with rapid deceleration, which can occur in automobile incidents or with direct blows resulting from child abuse or contact sports activities. Blunt trauma is commonly associated with multiple injuries, which can make management of a child injured by a nonpenetrating mechanism complicated. Penetrating injuries represent approximately 20% of pediatric trauma.²

The anatomy of children renders them especially vulnerable to traumatic injury. The head of the child is proportionately larger in relation to body mass compared with these proportions in an adult; therefore, the child’s head is especially vulnerable to injury. Head injury is the most common cause of traumatic death in children.

In pedestrian trauma, injuries to the left side of the patient are predominant, perhaps because vehicles are driven on the right side of the road in the United States. Skeletal injuries usually involve long bones, especially of the lower limbs.⁴ Chest injuries generally occur as a result of blunt trauma. Because of differences in the child’s compliant chest wall, rib fractures and flail chest are less common than in adults, but pulmonary contusions are more frequent.⁵ Injuries to the liver and spleen are the most common blunt abdominal injuries seen in children; other injury sites include the bowel and pancreas. Because the kidneys in children are less protected and more mobile than in an adult, genitourinary system injuries often involve the kidneys and, less frequently, the bladder and urethra.⁶

TRAUMA AND CHILD ABUSE

Child abuse and neglect are broadly defined as the maltreatment of children and adolescents by their parents, guardians, or other caretakers. Reports of child maltreatment in the United States continue to rise.⁷ The nurse has two main responsibilities in such cases: detecting and reporting. The laws on child abuse reporting are clear. In all states it is mandatory for nurses to report suspected cases of child abuse and neglect to the local protective service agency. The law protects health professionals from liability suits if suspicion proves to be wrong. Reluctance to report such information can lead to a recurrence of abuse and injury. The opportunity to help these children lies in the ability of the emergency department staff not only to appropriately treat the child but also to recognize the recurring nature of the underlying problem.

An important facet of the evaluation of pediatric trauma should be a careful examination of the child for other signs that might suggest the possibility of intentional or inflicted injury. Inconsistencies between the trauma history and the injuries sustained should alert the nurse to potential child abuse.⁸ Diagnostic signs of child abuse may include orbital ecchymosis in the absence of a clear causative factor. This is a serious concern because of the high incidence of subdural hematoma formation associated with vigorous shaking or jarring of an infant’s head. Skull fractures, particularly if out of magnitude with the history, should always alert the nurse to the possibility of inflicted injury. The general appearance and nutritional state of the child also may suggest neglect or maltreatment. Other diagnostic signs may include cigarette burns; unusual bruising, especially over the back or soft tissue areas of the body; and any situation in which the circumstances are not clearly defined as causative of the injury. Old fracture sites revealed on radiographic examination also should raise suspicion. Careful examination of the genitalia and anal areas always need to be part of the evaluation of the injured child. Any injury in these areas should raise suspicion of sexual abuse.

In addition to detecting and reporting, the nurse’s role is to give the child the necessary emergency treatment and protection while at the same time helping to alleviate the parents’ distress. Informing the parents of the need for the child’s treatment and protection and verbalizing an interest in helping the parents through the crisis are important roles for the nurse. This is a difficult task for nurses who are feeling anger toward the parents; therefore, it is imperative for nurses to explore and come to terms with their own feelings regarding child abuse before therapeutic intervention can be expected. A helping relationship needs to be established early with the family to lay the groundwork for future intervention. If intentional injury is raised as a legitimate consideration in the causation of the child’s injury, the child protection team must be alerted so that they can help clarify the circumstances surrounding the injury.

PREVENTION STRATEGIES

With the recognition that unintentional injury and death are major public health problems, nurses play a major role in injury prevention. On the basis of clinical experiences and the identification of patterns and trends related to pediatric trauma, nurses’ contributions are paramount in all multidisciplinary efforts to determine sound trauma prevention strategies.⁹

Most children who are killed or injured in automobile crashes are passengers. These casualties occur when an automobile collides with another vehicle or a fixed object. The use of restraints decreases fatalities from motor vehicle crush injuries by 13% to 46%.¹⁰ By communicating these facts, health professionals involved in the care of pediatric patients have been instrumental in promoting the passage of safety restraint laws in all states. Because nurses are frequently in teaching roles, they are instrumental in bringing the legislation to the user level by instructing parents in how to protect their children and how to use restraint devices correctly.

Bicycle injuries are a common cause of injury requiring treatment in an emergency department. The most effective way to make bicycle riding safer is to insist that riders wear helmets. Improved bicycle design also contributes to the reduction of injury rates and injury severity.

Drowning, the fourth leading cause of death in children, is most common in children under 4 years of age and in adolescent males 15 to 19 years of age.⁹ Prevention strategies to decrease the incidence of drowning include teaching parents never to leave an infant or young child alone during a bath, providing supervised swimming instruction for children, and installing safety fences around pools. Cardiopulmonary resuscitation (CPR) helps to decrease the number of deaths if initiated early and executed effectively; therefore, CPR education is paramount.

Falls by children are not uncommon, but, although many are minor, they account for a large number of injuries and deaths each year.¹¹ Deaths are often caused by falls from second-story windows by wandering toddlers. Nurses need to educate parents about the importance of constant adult supervision in and around the home, the installation of safety gates at the tops and bottoms of stairwells, and diligent use of window locks.

Playground safety is also an area that requires community education and awareness. Playground design should be in accordance with available safety standards. Standards include using wood chips instead of concrete on the ground, reducing the height of equipment, and replacing metal pieces with plastic or wood.

RESUSCITATION PHASE

The priorities of management for the pediatric trauma patient during the resuscitation phase are affected by a broad spectrum of factors. Immediate interventions depend on the severity of injuries and the critical nature of the patient’s responses. The primary and secondary surveys provide a structured and systematic approach to the physical assessment of the patient. Other factors that must be considered are the growth and development patterns of the child. In addition, the child’s family must be cared for as they face the traumatic experience with the child.

ASSESSMENT CONSIDERATIONS

Pediatric Trauma History

A thorough history is obtained during the early evaluation of a child who has sustained multiple injuries and is included as part of the nursing database. The purpose of the history is to determine and record the nature, location, and time of injury. The history of the injury is crucial to the child’s treatment and begins at the scene of the incident. The history includes events leading to the incident, mechanism and time of injury, clinical course after the injury, contamination of wound sites, previous history of chronic illness or injury, allergies, medications, and time of the last meal eaten before injury. The Emergency Nurses Association recommends taking a CIAMPEDS history ¹²:

P = Past medical history

E = Events surrounding the illness or injury

D = Diet

S = Symptoms associated with the illness or injury

The chief complaint is the reason for the child’s visit to the emergency department, which in this case is the traumatic incident. Immunizations include an evaluation of the child’s current immunization status. An allergy history is obtained in children, as with all patients. The parents are asked if the child is allergic to any medicines, adhesive tape, latex, or environmental substances. The nurse establishes whether the parents have given the child any medications recently and whether the child takes medication routinely for diabetes, seizures, lung disease, cardiac disorders, or other disease entities. Determination is made as to whether the child is under medical care for reasons other than routine well-child health care. Events surrounding the injury include mechanism, suspected injuries, prehospital assessment and treatment, and what led to the injury. Determination of when the child’s last meal was eaten is important if the child needs to be intubated, sedated, or requires surgery. Any symptoms and their progression since the time of injury are ascertained.¹²

Because of limitations in communication skills, (i.e., undeveloped speaking and writing abilities), neither the infant nor the very young child can give a complete history, but it is useful to obtain whatever information is possible from the child. Younger children are likely to remember recent events. Earlier events may be better remembered by a parent or caretaker, although their accuracy may be clouded by the emotional state after the injury. In general, once a child reaches school age, obtaining a history becomes considerably easier.

The nurse begins to establish a relationship with the family and the child during this information-gathering session. Serious consideration must be given to the fact that this crisis has disrupted the entire family unit and that fear and anxiety prevail. The family needs as much feedback from the medical and nursing professionals as possible on a continual basis. Establishing a supportive rapport with the family during this initial phase helps to foster a closer working relationship among the child, the parents, and the health care team members throughout the child’s hospitalization. Early interactions with family members and the information presented should be documented in the interdisciplinary notes. An assessment of the family’s initial reactions, responses, concerns, and coping abilities serves as a baseline for other nurses who continue to care for the patient and family.

Growth and Development

Physical Development.

The initial encounter with the child includes an assessment of the child’s growth and physical development, which helps to identify existing alterations that determine the approach used during the examination. This assessment is done quickly because of the critical nature of the child’s injury. An accurate estimate of the child’s size and weight (Table 29-1) is made as soon as possible so that therapy can be initiated. When time allows, however, an exact weight should be obtained because medical treatment that involves drug and fluid therapy, calculated on a perkilogram basis, must be accurately determined.

TABLE 29-1 Approximate Weights for Children

Age	Weight (kg)
Newborn	3
6 months	6
1 year	10
3 years	15
5 years	20
8 years	25
10 years	30
16 years	50

Age	Beats/Minute
Infants	120-160
Toddlers	90-140
Preschoolers	80-110
School-age children	75-100
Adolescents	60-90

The respiratory rate is also counted for a full minute. Tachypnea is an initial response to stress in children. If a stressed child does not hyperventilate, head injury, spinal cord injury, or other reasons such as a distended abdomen are considered and investigated. Table 29-4 provides normal respiratory rates for children.

TABLE 29-4 Normal Respiratory Rates in Children

Age	Breaths/Minute
Infants	30-60
Toddlers	24-40
Preschoolers	22-34
School-age children	18-30
Adolescents	12-16

Blood pressures should be obtained by using a cuff size that is no less than half and no more than two thirds the length of the upper arm. If pediatric cuffs are not available, an adult cuff can be used on the child’s thigh. In the field a palpable systolic blood pressure is adequate; precious time should not be wasted to obtain a diastolic reading. The normal systolic blood pressure for individuals from 1 to 20 years of age is 90 plus two times the age in years. The diastolic pressure should be approximately two thirds the normal systolic pressure. Table 29-5 provides the normal blood pressure ranges in children.

TABLE 29-5 Normal Pediatric Blood Pressure Ranges

Age	Systolic (mm Hg)	Diastolic (mm Hg)
Infants	74-100	50-70
Toddlers	80-112	50-80
Preschoolers	82-110	50-78
School-age children	84-120	54-80
Adolescents	94-140	62-88

Fear and distress can increase the child’s heart rate and respiratory rate. The nurse may have to differentiate between emotional stress and hypoxia or shock. In addition, referring to the medical history is important to provide insight into abnormal vital signs. For example, a pediatric trauma patient may have a congenital heart defect and normally be tachypneic; if that child has a normal respiratory rate, ventilatory assistance may be required.

Respiratory Reserve.

The infant has less respiratory reserve than the adult for several reasons: (1) the infant’s vital capacity is smaller, (2) the chest wall is soft because the ribs and sternum are cartilage, and (3) the ribs are horizontal with poorly developed intercostal muscles.

An infant whose lung capacity is decreased compensates by increasing the respiratory rate and using auxiliary respiratory muscles, as evidenced by retractions. Retractions are an early sign of respiratory difficulty and compromise the infant’s tidal volume. Most of the child’s normal respiratory activity is affected by abdominal movement until age 6 or 7 years, and there is very little intercostal motion. A child who has a paralytic ileus after blunt abdominal trauma may have respiratory distress because abdominal distention elevates the diaphragm and interferes with pulmonary function. As a result, children in respiratory distress who are spontaneously breathing should be treated in the semi-Fowler position when spinal injury has been ruled out.

Fluid and Electrolyte Balance.

The daily fluid requirement of a child is larger per kilogram of body weight than that of an adult because the child has greater insensible water losses per unit of body weight. This is because the child has a larger surface area and a higher metabolic rate than the adult. Even with these factors, the absolute amount of fluid required by a child is small. Nurses must carefully monitor the fluid volume administered to the child to avoid overhydration. The calculation of maintenance fluid requirements is shown in Table 29-6. If the child’s fluid intake is adequate, the urine volume should average 0.5 to 1 ml/kg per hour. The nurse keeps accurate records of all possible sources of fluid loss, including laboratory blood samples, blood loss from any source, gastric drainage, vomitus, and diarrhea.

TABLE 29-6 Calculation of Maintenance Fluids (per 24 Hours) in Children

Weight (kg)	Kilograms per Body Weight Formula
0–10	100-120 ml/kg
11–20	1,000 ml for the first 10 kg and 50 ml/kg for each kg over 10 kg
21–30	1,500 ml for the first 20 kg and 25 ml/kg for each kg over 20 kg

The child’s higher metabolic rate dictates a requirement for more calories per kilogram of body weight. The critically ill child, even if immobile, still requires most of the normal maintenance calories, if not more. This is discussed in more detail in the critical care phase.

Some forms of electrolyte imbalance are more likely to occur in children than in adults. Serum glucose, calcium, and potassium levels are monitored closely in the child. Infants have high glucose needs because of high metabolic rates and low glycogen stores; therefore, the infant can become hypoglycemic quickly during periods of stress. A 25% dextrose in water bolus (0.5 to 1.0 gm/kg) helps correct this. Changes in serum potassium concentration can occur with changes in acid-base status and diuretic administration. The critically ill child does not seem to be as sensitive to hypokalemia as the adult, so cardiac arrhythmias from hypokalemia are not often seen in pediatric patients until the serum potassium is less than 3 mEq/L.¹³ Ventricular fibrillation is rarely seen in pediatric patients but may result from severe hypokalemia or hyperkalemia.

The administration of citrate phosphate dextran blood produces precipitation of serum ionized calcium.¹⁴ An infant who requires frequent transfusions is at risk for development of hypocalcemia, a condition that can interrupt normal cardiovascular function. The ionized calcium levels are monitored closely so that calcium supplements can be administered as needed.

The child’s circulating blood volume (80 ml/kg) is larger per unit of body weight than the adult’s. The loss of a small amount of blood in a child, however, is proportionately more significant than in an adult because of the child’s smaller total blood volume. Small blood volume loss may potentially lead to hypovolemic shock. A closed fracture of the femur, for example, in a 10-year-old child may result in a loss of 300 or 400 ml of blood. The same amount of blood loss in an adult may not cause a significant problem, whereas in the child this may represent 15% to 25% of the total circulatory blood volume. The child’s total circulating blood volume is calculated on admission, and all blood lost as a result of hemorrhage or drawn for laboratory tests is accurately tabulated and recorded.

Body Temperature.

Major heat losses can occur in a young child who is unclothed for even a short time. Infants and young children have a large surface area and therefore lose more heat to the environment through radiation, conduction, convection, and evaporation. During resuscitation, children are often unclothed and exposed, losing much of their body heat and therefore experiencing a lowered core body temperature. Hypothermia hinders the resuscitation attempt by causing apnea, coagulopathies, progressive metabolic acidosis, decreased cardiac output, and ventricular arrhythmias. The nurse can minimize this stress by monitoring the child’s temperature, keeping the child covered as much as possible, using heat lamps and warming blankets, and warming all fluids before infusion.

Assessment in Head Trauma

Each year approximately 22,000 acutely brain-injured children in the United States die and another 29,000 are left with a permanent disability.¹⁵ In children the brain tissues are thinner, softer, and more flexible; the head size is greater in proportion to the body surface area; and a relatively larger proportion of the total blood volume is in the child’s head. Thus the child’s response to head injury differs significantly from that of an adult. Intracranial hypertension and cerebral hypoxia occur commonly in children, rendering them highly susceptible to secondary brain injury. Preventing secondary injury contributes to a significantly better outcome in the pediatric patient.¹⁶ Expandable fontanelles and open cranial sutures allow increased room for swelling, providing an advantage for the head-injured infant. The primary disadvantage in the evaluation of the head-injured child is the developmentally imposed limitation in verbal expression, which can complicate assessment endeavors.