Anatomic Differences

Anatomic differences in the pediatric skeleton are multiple and vary with age and maturity. These differences include the presence of preosseous cartilage, physes, and thicker, stronger periosteum that produces callus more rapidly and in greater amounts than in adults. Because of the effects of age and growth, children vary in body size and proportions.

The size of the child is important not only in the response to trauma but also in the severity and constellation of injuries. Being variably smaller, children sustain a different complex of injuries than adults in a similar traumatic situation as well as a higher frequency of polytrauma. An example is a pedestrian struck by a motor vehicle. In adults, injury to the tibia or knee is common because these structures are at the level of the automobile’s bumper. In children, depending on their height, the bumper usually causes a fracture of the femur or pelvis or, in toddlers, a chest or head injury. Because the mass of a child’s body is proportionately less, a child is much more likely to become a projectile when struck and may sustain further injuries caused by secondary contact with the ground or another object. A classic example is the Waddell triad, which consists of an ipsilateral femoral shaft fracture, chest contusion, and contralateral head injury ( Fig. 5-1 ). Because of their smaller size, children are also more likely to be trapped beneath a moving object such as a motor vehicle and sustain crush injuries, fractures, and soft tissue damage. Crush injuries are relatively common in children, and such injuries often result in severe soft tissue loss, which can produce a poorer prognosis.

Different injury patterns resulting from a similar car-versus-pedestrian mechanism. A , A typical Waddell triad in which the child sustains an ipsilateral femoral and chest injury from the initial impact of the car and is then thrown forward and strikes the contralateral side of the head on the ground. B , A smaller child being struck by the car and sustaining chest and head injuries from a direct blow on the bumper and then sustaining lower extremity crush injuries from being dragged underneath the car. C , An adolescent being struck, sustaining tibia or knee injuries from the bumper, and then being thrown forward and sustaining chest, head, and neck injuries from impact on the windshield.

A child’s body proportions, being quite different from those of an adult, can produce a different spectrum of injuries. A child’s head is larger in proportion to the body, and the younger the child, the more extreme this disproportion. This comparatively larger head size makes the head and neck much more vulnerable to injury, especially with falls from a height, because the weight of the head often causes it to strike the ground first. In contrast, adults are more likely to protect themselves with their extremities or try to land on their feet. The relative shortness of children’s extremities, especially the arms, and a lack of strength often prevent them from adequately protecting themselves during a fall. This theory is supported by the high incidence of head injuries sustained by young children as a result of falls ( Fig. 5-2 ). Demetriades and colleagues in a study of pedestrians injured by automobiles determined that the incidence of severe head and chest trauma increased with age and that femur fractures were more common in the pediatric age groups.

Anatomic differences predispose a child to injuries different from those of an adult. These differences include a disproportionately large head, pliable rib cage with exposed liver and spleen below its margin, unprotected large and small bowel, distended bladder above the pelvic brim, and open physes.

Biomechanical Differences

The material properties (i.e., composition) of bone in children are quite different from those of adult bone. Children, including those who are victims of multiple traumatic injuries, demonstrate unique fracture patterns. These patterns include compression (torus), incomplete tension–compression (greenstick), plastic or bend deformation, complete, and epiphyseal fractures. These fracture patterns result from the presence of the physes, the thicker periosteum, and the material properties of the bone itself. Complete fractures occur more commonly in children with multiple injuries from trauma because they are associated with high-velocity injuries. Biomechanically, the pediatric skeletal system responds differently to an applied force than the adult skeleton does. Pediatric bone has a lower ash content and increased porosity, which are properties indicative of less mineralization. Such bone composition results in increased plasticity and less energy needed for bone failure. This difference decreases with skeletal maturity.

Bending is the most common mode of failure in long bones. Stress on the tension side of a bone with a low-yield stress initiates a fracture that is followed by compression on the opposite side. As bending continues, the fracture line eventually travels the entire width of the bone. Although pediatric bone is biomechanically weaker, it has a greater capacity to undergo plastic deformation than adult bone. Because pediatric bone yields at a lower force, the stress in the bone is less and the energy to propagate the fracture is less. These factors account for the compression, greenstick, and plastic deformation fracture patterns. The increased porosity of pediatric bone, which was previously thought to play a major role in the different fracture patterns, is no longer accepted as a theory.

Ligaments frequently insert into the epiphyses. As a consequence, traumatic forces applied to an extremity may be transmitted to the physis. The strength of the physis is enhanced by the perichondrial ring and, in some cases, by interdigitating mammillary bodies. In spite of this enhanced strength, however, the physis is not as strong biomechanically as the ligaments or metaphyseal or diaphyseal bone. Consequently, physeal fractures are relatively common in multiply injured children, and ligamentous injuries are less common than in adults. Ligamentous injuries, however, do occur and are probably more frequent than previously reported.

Because pediatric bone is more deformable and fractures with less force, it also affords less protection to the internal organs and other structures. The plasticity of bones can allow internal injuries without obvious external trauma, as reflected in the increased incidence of cardiac and pulmonary injuries without apparent damage to the thoracic cage and a high incidence of abdominal injuries without significant injury to the pelvis, abdomen, or lower ribs. Injuries to the liver and spleen are more common in children because of less rib coverage of these structures, as well as the greater pliability of the ribs. Children also have less soft tissue coverage, including muscle mass and strength, to protect the skeletal system from trauma. The lower mass of soft tissue may contribute to injury to the internal organs.

Physiologic Differences

Children respond differently than adults to the metabolic and physiologic stress of trauma. Total blood volume is smaller, depending on the size of the child, so less blood loss can be tolerated; hypovolemia develops more rapidly because the smaller volumes lost represent a larger percentage of the total. The higher ratio of surface area to volume also makes children more vulnerable to hypothermia. Multisystem organ failure tends to occur early during hospitalization and resuscitation, affecting all organ systems at once. In adults, multisystem organ failure usually does not take place until 48 hours after injury and occurs in a sequential order starting with the lungs. The metabolic response is also significantly different between adults and children. Whereas adults have a significant increase in their metabolic rate from the stress of trauma, children have minimal or no change. This minimal response to stress is believed to be caused by the significantly higher baseline metabolic rate of children, which needs to be increased only a small amount to accommodate the increased metabolic demands. The accelerated metabolic rate, together with the ability to metabolize lipid stores, provides a possible explanation for the increased survival rates in children after severe trauma. Adults also appear to have a significant systemic inflammatory response to trauma that does not occur in children. Conversely, children have a robust local inflammatory response at the tissue level that helps not only with accelerated healing but also with minimizing the systemic insult.

Physiologically, pediatric fractures have the capacity to heal rapidly, remodel, overgrow, and become progressively deformed or shortened if the physis is injured. For these reasons, pediatric fractures secondary to severe trauma require careful management. Musculoskeletal morbidity is a common sequela of multiple traumatic injuries. The ultimate consequences of injury are often not known for many years, and long-term follow-up is therefore necessary.

Falls

Most pediatric injuries are caused by simple falls, which account for approximately half of all injuries. According to 2010 data from the Centers for Disease Control and Prevention, unintentional falls were the leading cause of nonfatal injury in all children younger than 15 years. However, they are not frequently the cause of fatality. Musemeche and associates showed that falls occur predominantly in the younger population; the mean age was 5 years, and there was a 68% male preponderance. Of the falls, 78% occurred from a height of two stories or less at or near the home. Most patients sustained a single major injury that usually involved the head or skeletal system, although the incidence and spectrum of injury may vary with age. Long bone fractures predominate in children, whereas the incidence of spinal injuries and the total number of fractures are increased in adolescents. Fortunately, children can survive falls from significant heights, although serious injuries do occur. As would be expected, morbidity and mortality rates increase with the height of the fall, of which the latter usually is related to falls of a distance exceeding 10 feet. Pitone and Attia showed that in routine falls, children 2 years or younger fell from a bed or chair and sustained head injuries, whereas those 5 to 12 years of age were likely to fall from playground equipment and fracture an upper extremity.

In the past, falls from windows were noted to be a particular problem in urban areas. Recently, Harris and colleagues demonstrated that there was a decrease in the overall national incidence of falls from windows since 1990, especially in those urban areas in which a prevention program such as “Children Can’t Fly” and “Kids Can’t Fly” had been implemented. Window-related falls are much more common in children younger than 4 years, who are also more likely to sustain serious injuries as a result of the fall. Risk factors for serious injury include young age, fall from a height greater than three stories, and hard landing surfaces.

Motor Vehicle Accidents

By far the most common cause of multiple injuries in children is motor vehicle accidents—accidents in which they are motor vehicle occupants, pedestrians, or cyclists. This fact is well documented in studies on multiply injured children. In a 1989 series of 376 multiply injured children, Kaufmann and colleagues reported that motor vehicle–related accidents accounted for 58% of the overall injuries and 76% of the severely injured children. Marcus and associates reported a 91% incidence of motor vehicle–related mechanisms of injury in their series. Although the mechanism of injury was not analyzed by age, the incidence of motor vehicle–related injuries increases with age. According to the Centers for Disease Control data from 1999–2005, deaths from motor vehicle accidents are lowest from birth to 14 years (3.6 to 4.4 per 100,000 population), and a peak occurs in the 15- to 24-year-old age group (25.9 to 28.2 per 100,000). Males in this age group have twice the mortality rate of females. Scheidler and colleagues demonstrated that being an unrestrained child or adolescent and being ejected from the vehicle tripled the risk of mortality and significantly increased injury severity scores. Brown and associates recently demonstrated differences in injury patterns based on the direction at the impact (frontal or lateral) and the position of the patient in the automobile. Lateral impact accidents are characterized by head and chest injuries, whereas front seat passengers had higher trauma scores.

Spinal Injuries

The presence of facial injuries, including lacerations, contusions, and fractures, has been shown to be associated with an increased incidence of cervical spine injury in both children and adults. The presence of a cervical spine fracture in a multiply injured patient is associated with a 10% increased incidence of a noncontiguous fracture at another level of the spine. Because children are more elastic than adults, the force of injury can be transmitted over multiple segments and result in multiple fractures. In addition, certain anatomic differences have an effect on the type of injury, such as the increased cartilage-to-bone ratio, the presence of secondary ossification centers, variations in the normal planes of the articular facet, and increased laxity. Thus any child seen with head, facial, or spinal injuries at any level should have a careful evaluation of the entire spinal column, especially a head-injured child who is either comatose or unable to cooperate in the examination. In a multiply injured child, a spinal injury must be assumed to be present until proven otherwise by physical examination and radiographic evaluation.

Rib Fractures

The pediatric thorax has a greater cartilage content and incomplete ossification, which makes fractures of the ribs and sternum uncommon. Severe thoracic injury to the heart, lungs, and great vessels can be present with little external sign of injury or apparent fractures on chest radiographs. Fractures of the first and second ribs as a marker for severe trauma in children is well documented. These are associated with a high incidence of other injuries, including those to the head, neck, spinal cord, lungs, and great vessels.

Multiple rib fractures are also a marker of severe trauma in pediatric patients. Garcia and associates reported a 42% mortality rate in pediatric patients with multiple rib fractures; the risk of mortality increases with the number of ribs fractured. They found that a head injury with multiple rib fractures signified an even worse prognosis: the mortality rate was 71%. Similar results were reported by Peclet and colleagues. Because head injuries are associated with a higher incidence of mortality and long-term disability, it is critical to recognize this relationship. Multiple rib fractures in a child younger than 3 years should also alert the physician to the possibility of child abuse; 63% of the patients in this age group in the series of Garcia and associates were victims of child abuse. Multiple fractures in different stages of healing are also a sign of child abuse and should raise the physician’s suspicion accordingly (see Chapter 18 ).

Pelvic Fractures

Pelvic fractures in children are uncommon and, as in adults, usually the result of high-velocity trauma. As opposed to adults, children have greater plasticity of the pelvic bones, thicker cartilage, and increased elasticity of the symphysis pubis and sacroiliac joints. Simple or isolated, nondisplaced pelvic fractures have low morbidity and mortality rates and tend not to be associated with other injuries ( Fig. 5-3 ). Silber and Flynn demonstrated that patients with open triradiate cartilages were more likely to sustain pubic rami and iliac wing fractures, whereas those with closed triradiate cartilages were more likely to sustain acetabular fractures and pubic or sacroiliac diastasis. This is secondary to the immaturity of the pelvis early on in life when the pelvic bones are weaker than the more elastic pelvic ligaments. After the triradiate cartilage closes, the bones of the pelvis become stronger than the ligaments. Fortunately, most pelvic injuries in children are simple nondisplaced fractures. Conversely, displaced pelvic fractures in children have the same high incidence of associated injuries as in adults. More severe fractures mandate a careful evaluation for other injuries because a great deal of energy is necessary to cause this type of fracture. Associated injuries include head injuries; other fractures, including open fractures; hemorrhage; genitourinary injuries; and abdominal injuries. A sacral fracture, which is common in pelvic fractures, may have associated neurologic deficits. The presence of severe pelvic fractures should alert the physician to possible injuries to the abdominal and pelvic contents, particularly genitourinary injuries such as urethral lacerations (especially in males) and bladder rupture. Abdominal injuries may include rectal lacerations, tears of the small or large intestine, and visceral rupture of the liver, spleen, and kidneys. Blood at the urethral meatus, a high-riding or nonpalpable prostate gland on rectal examination, and blood in the scrotum are indications of serious damage to the genitourinary system. Such genitourinary complications must be investigated further, usually with a retrograde urethrogram, before an attempt is made to insert a Foley catheter. Rectal or vaginal lacerations indicate that the pelvic fracture may be open. A diverting colostomy may be necessary for these individuals so that the risk of infection is decreased. If a pelvic fracture is diagnosed and if it is necessary to perform peritoneal lavage, a supraumbilical approach is recommended instead of the routine infraumbilical approach because the former approach may avoid false-positive findings secondary to pelvic bleeding. Unstable fractures, such as vertical shear or wide pelvic diastasis, are often associated with significant hemorrhaging and hypovolemic shock secondary to retroperitoneal bleeding (see Chapter 13 ). In general, however, significant hemorrhage requiring transfusion or angiography is rare in children, perhaps because of the ability of their vessels to readily vasoconstrict as well as the smaller caliber of their vessels that contributes to rapid vasoconstriction. Other sources of bleeding should be investigated.

A , Anteroposterior radiograph of a 4-year-old child demonstrating a nondisplaced stable fracture of the iliac wing (arrows) with no associated intrapelvic or intraabdominal injuries. B , Anteroposterior pelvic radiograph of a 5-year-old child who was run over by a truck and sustained multiple pelvic injuries (arrows) and multiple associated injuries, including proximal femoral fractures, degloving soft tissue injuries, rectal perforation, and bladder rupture.

Lap Belt Injuries

In an automobile accident, the use of a lap belt without shoulder restraint may produce a constellation of injuries referred to as the seat belt syndrome. These injuries in children include flexion–distraction injury to the lumbar spine (Chance fracture), small-bowel rupture, and traumatic pancreatitis. Ecchymosis in a lap belt distribution should alert the physician to search for these injuries. Head and extremity injuries in this circumstance are unusual. Age is a major predictor in elevated risk of abdominal injury in seat belt–restrained children. Children ages 4 to 8 years old are at the highest risk of severe abdominal trauma because they are transitioning from child seats to adult seat belts. As a result, the American Academy of Pediatrics and the National Highway Traffic Safety Administration recommend that these children be restrained in a booster seat until they are taller than 4 feet 9 inches. This provides a better fit of the adult seat belt lower on the child’s pelvis to help prevent these injuries. Booster seat legislation appears to be associated with a decrease in the mortality rate in children ages 4 to 7 years old involved in motor vehicle accidents. The unrestrained passenger, however, is subjected to devastating amounts of energy in the absence of the “ride down” effect afforded by restraints.

Other Injury Patterns

Understanding injury patterns and the types of associated injuries can be helpful in evaluating a multiply injured patient. However, almost any combination can occur in a child, and the injury patterns are most closely related to the mechanism, the total force applied, and the age of the patient. According to Peclet and colleagues, head injuries are most common in child abuse victims, occupants in vehicular accidents, and children sustaining falls; nearly 40% of abused children have injuries to the head and face. In their study, thoracic and abdominal injuries were most common in children with penetrating injuries (gunshot and stab wounds), whereas extremity injuries predominate in bicyclists and pedestrians. These investigators also showed that the types of injuries change with age: burns and foreign bodies account for most injuries to children ages 1 to 2 years compared with a median age of 7 years for pedestrian bicycle injuries and 12 years for gunshot and stab wounds. Falls and traffic-related injuries are most common in children 5 to 10 years of age. Children who sustained injuries from falls are significantly younger than those with traffic-related injuries. The pattern of injuries from falls also changes with age. Sawyer and associates found that adolescents sustain a greater number of vertebral fractures and total fractures per fall than do younger children, who have a greater number of long bone fractures. Because the mechanisms of injury change with age, injury patterns and associated injuries also vary accordingly.

Modified Injury Severity Scale

The MISS represents an adaptation of the Abbreviated Injury Scale (1980 revision), combined with the Glasgow Coma Scale for neurologic injuries. The pediatric MISS categorizes injuries into five body areas: (1) neurologic system, (2) face and neck, (3) chest, (4) abdomen and pelvic contents, and (5) extremities and pelvic girdle ( Table 5-1 ). The severity of each injury is rated on a scale of 1 to 5: one point for minor injury, two points for moderate injury, three points for severe but not life-threatening injury, four points for severe injury but with probable survival, and five points for critical injury with uncertain survival. The Glasgow Coma Scale is used for grading neurologic injuries. The usefulness of this scale has been well established in head injuries in both adult and pediatric populations. The verbal component of this score has been modified for children, especially for those younger than 36 months ( Table 5-2 ).

The MISS score is determined by the sum of the squares of the three most severely injured body areas. The MISS has been shown to be an accurate predictor of morbidity and mortality in pediatric trauma. Mayer and colleagues found that scores of 25 points or more were associated with an increased risk of permanent disability. A score of more than 40 points was usually predictive of death. In their initial study, a score of 25 points or more was associated with 40% mortality and 30% disability, whereas a score of 24 points or less was associated with no deaths and only a 1% disability rate. Their mean MISS score for death was 33.4 points; for permanent disability, it was 30.2 points.

Marcus and colleagues used the MISS in their series of 34 multiply injured children and showed a progressive increase in disability and mortality with increasing scores. The mean score was 22 points, with a range of 10 to 34 points. Children with scores of 25 points or less had a 30% incidence of impairment, children with scores of 26 to 40 points had a 33% incidence of impairment, and children with scores of more than 40 points had a 100% incidence of impairment. Contrary to the findings of Mayer and associates, children with scores over 40 were able to survive but not without significant disability.

Loder in 1987 also confirmed the relationship of increasing MISS scores with increasing mortality and morbidity in his series of 78 multiply injured children. He reported a mean MISS score of 28 points (range, 10 to 57 points). No deaths occurred in children with MISS scores of less than 40 points. The mortality rate for those with MISS scores above 40 points was 50%, and above 50 points it increased to 75%. Thus the effectiveness of the MISS score in predicting both morbidity and mortality is well documented in several studies, although the absolute percentages vary.

Garvin and colleagues in 1990 demonstrated the accuracy of the MISS in predicting morbidity and mortality after pediatric pelvic fractures. Disrupted pelvic fractures had a higher MISS score than did nondisrupted fractures, and the former were associated with an increased incidence of morbidity and mortality.

Yue and associates in 2000 used the MISS in comparing the extent of injuries and the results of nonoperative versus operative or rigid stabilization in the management of ipsilateral pediatric femur and tibia fractures (i.e., the floating knee). The scores were useful in comparing the severity of injuries in both groups of patients. Loder and associates in 2001 demonstrated an increasing rate of complications related to fracture immobilization in patients 8 years or older with MISS scores of 41 points or greater.

Pediatric Trauma Score

The PTS can also be used to predict injury severity and mortality in children. This score is based on six components: size, airway, systolic blood pressure, CNS injury, skeletal injury, and cutaneous injury. Each category is scored +2 (minimal or no injury), +1 (minor or potentially major injury), or −1 (major or immediately life-threatening injury), depending on severity, and these points are added ( Table 5-3 ). One major advantage of this system is that it is based on criteria that can be easily obtained either at the scene of the accident or in the emergency department, and it can thus be used for triage purposes. Tepas and associates in 1988 demonstrated an inverse relationship between the PTS and the Injury Severity Score, as well as mortality, and found that the PTS was an effective predictor of both morbidity and mortality. No deaths occurred in children with a PTS greater than 8 points; those with a PTS less than 0 had 100% mortality. The PTS has also been validated in other studies as a tool for predicting mortality in pediatric trauma patients. The PTS allows for rapid assessment of trauma severity in a multiply injured child, which assists in appropriate field triage, transport, and early emergency treatment of these patients. It is recommended that children with a PTS of 8 points or less be transported to a pediatric trauma center for management.

Mortality

Mortality rates in children vary greatly as a result of differences in the mechanism of injury, severity of injury, and age of the patient. Unlike adults, who have a trimodal distribution of mortality from trauma, children follow a bimodal curve. Peclet and colleagues in 1990 demonstrated that the majority of deaths in children occurred within the first hour after injury, and another peak occurred at approximately 48 hours. In their series, 74% of deaths occurred within the first 48 hours. Overall, the mortality rate was 2.2% for all patients admitted to the trauma service. Not all the patients in this series were multiply injured, thus explaining the low mortality rate. In series dealing only with multiply injured children, van der Sluis and colleagues, Wesson and colleagues, and Loder reported mortality rates of 20%, 13%, and 9%, respectively. This did not include children who were dead on arrival in the emergency department.

The fact that mortality rates are closely associated with the severity of injury is not surprising. The higher the MISS score or the lower the PTS, the greater the rate of mortality. In spite of obvious differences from adults, children tend to have similar outcomes from trauma when equivalent injuries are compared. This finding was supported by the work of Eichelberger and colleagues, who used a statistical method based on the Trauma Score, MISS, and age. These investigators were unable to show statistically significant differences between the various pediatric age groups and the adult population. Other studies have documented higher survival rates in severely injured children than in adults with a similar degree of injury. This concept is accepted by many but may not be true. Head injuries are consistently associated with higher mortality rates than are other types of injuries. Acierno and associates showed that children requiring emergent general or neurosurgical intervention were at increased risk of death. Recently, with the use of statistical modeling, Courville and colleagues found that the most powerful variables in predicting in-hospital mortality in pediatric trauma were a low Glasgow Coma Scale score and hypotension in the emergency department.

Morbidity

Unlike a child with an isolated injury, which is usually associated with rapid healing, good function, and minimal residual disability, a multiply injured child has a significantly higher risk of residual disability. Morbidity in children is usually related to injuries to the CNS and musculoskeletal system. At a 6-month follow-up in a study by Wesson and associates of severely injured children, 54% still had one or more functional limitations; of these, 4% were in a vegetative state, 11% were severely disabled, 32% were moderately disabled, and 53% were healthy. The cause of the disability at 6 months was head injury in 44% and musculoskeletal injury in 32%. These findings are consistent with other reported series. In the series by Marcus and associates, 10 of the 32 survivors had residual disabilities. Five were related to head injuries with residual seizures and spasticity. The remainder of the disabilities included musculoskeletal injuries associated with nonunion, malunion, and growth disturbances. Feickert and coauthors, in a series of severely head-injured children, reported that 39% still had severe neurologic impairment at the time of discharge. The incidence and severity of the residual disability increased with the severity of the overall injury, as reflected in a higher MISS score. In children, disability often occurs late and is progressive because of the fact that children are still growing and normal growth patterns have been disrupted. In a study looking at short- and long-term outcomes after trauma, van der Sluis and colleagues found that of 59 survivors 22% were disabled at 1 year primarily as a result of severe brain injury. At a 9-year follow-up, 42% of patients had cognitive impairments.

Field Management before Transport

Successful management of a multiply injured child requires rapid, systematic assessment, with early emphasis on the treatment of life-threatening conditions. Treatment is initiated in the field with advanced life support techniques. The importance of treatment in the field, or during the prehospital phase, is well documented. Because mortality follows a bimodal distribution in pediatric multiple-trauma patients, with most deaths occurring shortly after the accident, an efficient and effective system of prehospital care is mandatory. Delays in treatment can significantly increase mortality rates. Functional recovery is also improved with more rapid surgical care. A delay in diagnosis and treatment has been shown to be particularly detrimental to those with head injuries, and a severely injured child is particularly at risk of delays in diagnosis and treatment. The goal of field treatment is to evaluate the patient rapidly, stabilize life-threatening conditions, prepare the patient for transport by immobilizing injured areas, and deliver the patient to a center equipped for resuscitation and definitive treatment.

Early resuscitation plus stabilization of a pediatric trauma patient requires specialized equipment, including small-diameter airway tubes, small-bore intravenous needles, modified backboards, small cervical collars, and splints of appropriate size. As in adults, it is critical to immobilize the patient properly before transport to avoid further damage to injured parts, especially when dealing with spinal injuries and extremity fractures. Preventable deaths in multiply injured children are associated with the “golden hour” of trauma resuscitation and occur from such causes as respiratory failure, intracranial hematoma, and inadequately treated hemorrhage. Treatment of respiratory failure and hemorrhage can be initiated in the field. Optimal treatment of an intracranial hematoma, however, requires rapid field triage and transport for immediate surgical decompression. Regarding hematomas, a 50% incidence of preventable deaths occur, of which field treatment errors account for one third of cases and transport errors account for one fourth. The importance of appropriate field treatment cannot be overemphasized. The American Association of Pediatrics recommends ongoing education in pediatric trauma care for prehospital care providers.

The use of a pediatric air ambulance should be considered in certain circumstances because a patient’s outcome is directly related to the elapsed time between injury and definitive, specialized care.

Pediatric Trauma Centers

Because most children sustaining multiple injuries require specialized care, they should be rapidly transported to a center that is able to institute the necessary treatment. The ACS has set standards categorizing the level of trauma care that an institution can provide to both adult and pediatric trauma victims. These levels of care are categorized into pediatric trauma centers, adult trauma centers (level I, II, or III), and adult trauma centers with added qualifications to treat children. The ACS has also set guidelines regarding when a patient should be transferred to a pediatric trauma center ( Table 5-4 ). Transport of an injured child to a facility lacking the capability of adequately handling these injuries significantly delays appropriate treatment and may allow inappropriate treatment to be initiated by a well-intentioned but inexperienced physician or staff member. Improved outcomes for trauma victims treated at trauma centers are well documented in both the pediatric and adult literature. Additionally, it has been demonstrated that younger and more seriously injured children have better outcomes at trauma centers at a children’s hospital or at a hospital with integrated adult and pediatric services. Osler and colleagues reported that, although pediatric trauma centers have overall higher survival rates for multiply injured children than adult trauma centers do, the difference decreases when controlled for Injury Severity Score, PTS, age, mechanism, and ACS verification status.

Trauma Team

In a multiply injured child, the complexity and number of injuries mandate a team approach. A multidisciplinary approach with members of specialties working as equal partners usually allows optimal care. In most cases, the team leader should be a pediatric surgeon who specializes in the care of multiply injured children. This person should take primary responsibility for supervising the resuscitation effort, coordinating team members, and making critical decisions regarding treatment priorities. The members of the team are drawn from the pediatric surgical subspecialties and include a thoracic surgeon, cardiovascular surgeon, orthopaedic surgeon, neurosurgeon, urologist, pediatric anesthesiologist, and plastic surgeon. Additional members include emergency department physicians and nurses, pediatric intensive care physicians and nurses, respiratory therapists, and physicians and nurses from rehabilitation services. Social workers, psychologists, and counselors also have an important role in the treatment of these patients.

Primary Survey and Resuscitation

The principles of evaluation and stabilization of a pediatric trauma patient have been established as guidelines and protocols by the ACS for advanced trauma life support. Although these guidelines are similar to those for adults, pediatric patients require special consideration because of their unique anatomic, physiologic, and pathophysiologic differences. The initial treatment consists of basic resuscitative measures, and the major focus is on diagnosis and treatment of life-threatening injuries. This primary survey consists of the ABCDEs of the initial assessment: Airway, Breathing, Circulation, Disability (consisting of a rapid neurologic examination), and Exposure/Environmental (removing all clothing and then re-covering the patient to prevent hypothermia).

Airway and Breathing

Assessment of the airway is the first consideration in all trauma patients. Patency of the airway must be assessed from the oral pharynx to the trachea. Evaluation, treatment, and maintenance of the airway must be performed with control and stabilization of the neck because of an increased incidence of cervical spine injuries in these children. All patients should be considered to have a cervical spine injury until proven otherwise. Stabilization of the spine should be provided with a cervical collar and backboard. A modified backboard should be used for young children and infants because of the large size of the head relative to the trunk. Herzenberg and associates demonstrated that the neck is flexed when the child is placed on a standard backboard, thus potentially displacing an unstable cervical spine injury ( Fig. 5-4 ). A backboard with an occipital cutout or a pad under the trunk to elevate it is used to prevent flexion of the cervical spine. In-line traction is used in all patients when trying to establish the airway. Major head and facial injuries should increase the physician’s suspicion of potential cervical spine injuries.

Standard adult backboard. A , The enlarged occiput causes a child to flex the head forward. B and C , Appropriate positioning on a modified board with either the occipital area cut out or a pad under the thorax to prevent flexion of the cervical spine.

Children have considerable variation in the anatomy of the upper airway, depending on their size and age. The smaller the child, the greater the disproportion between the size of the cranium and the midface. This leads to a propensity of the posterior pharynx to buckle anteriorly as a result of passive flexion of the cervical spine secondary to a large occiput. An inch of padding should be placed beneath the child’s torso to improve alignment. In spite of age, the jaw thrust maneuver is best for restoring airway patency; debris can be cleared from the mouth manually or with suction, if available. The neck is stabilized with in-line cervical traction. The plane of the face should be kept parallel to the plane of the bed for optimization of the airway. It is important to realize that infants are obligate nasal breathers and that any injury that occludes the nasal passages also occludes the upper airway. These injuries include nasal fractures, foreign material in the nostrils, and bleeding within the nasal passages. Iatrogenically inserted tubes, such as nasogastric tubes, can also contribute to nasal occlusion. Thus in an infant, both the oral pharynx and the nasal passage need to be cleared to restore the airway.

If a patent airway cannot be guaranteed with these maneuvers, an airway must be established. Before an attempt is made to mechanically establish an airway, the child should be oxygenated, if possible. An oral airway is not recommended in conscious children because it can induce vomiting by the gag reflex.

Endotracheal Intubation

Endotracheal intubation is indicated in children with severe brain injuries requiring controlled ventilation, in children who cannot maintain an airway, in children exhibiting signs of ventilatory failure, or in children with significant hypovolemia that requires operative intervention. Orotracheal intubation is the most reliable means of a establishing an airway and ventilation in a child. Most trauma centers will have an emergency intubation protocol referred to as drug-assisted intubation (previously known as rapid sequence intubation). Algorithms are available based on the child’s weight, vital signs, and level of consciousness.

Because the trachea varies in length and diameter according to the child’s size and age, the diameter of the endotracheal tube also varies. A length-based resuscitation tape (Broselow Tape) can be used to determine the appropriate size. If this is not available, the size of the tube can be determined based on the size of the external nares or the size of the child’s little finger. A full complement of endotracheal tube sizes must be available for dealing with multiply injured children. As of the 9th edition of the Advanced Trauma Life Support manual, the ACS no longer puts a restriction on the use of cuffed endotracheal tubes in very young children. Because of improvements in cuff design, the concern about tracheal necrosis no longer exists. It is recommended that the cuff pressure be measured as soon as possible and should not exceed 30 mm Hg.

The shortness of the trachea in young children also increases the potential for bronchial intubation. Intubation should be confirmed by auscultation of breath sounds over both lungs and with a secondary confirmatory device such as capnography, end-tidal carbon dioxide detection, or an esophageal detection device. A chest x-ray film should be obtained to document the position of the tube.

Cricothyroidotomy

If the upper airway of a child is severely obstructed and ventilation cannot be accomplished either by bag valve mask or endotracheal intubation, a surgical airway must be urgently created. A needle cricothyroidotomy can be performed quickly and safely to establish a temporary airway and is the treatment of choice. A large-bore needle (14 or 16 gauge) can be directly inserted percutaneously into the trachea through the cricothyroid membrane to temporarily create an airway.

Considerations for emergency needle cricothyroidotomy include laryngeal fractures, major foreign bodies that cannot be removed manually, severe oropharyngeal bleeding prohibiting intubation, edema of the glottis, and facial or mandibular fractures. Because needle cricothyroidotomy with the use of jet insufflation is only a temporary airway, if it is deemed that an oral or nasal airway cannot be achieved rapidly, provision must be made to convert the needle cricothyroidotomy into a surgical cricothyroidotomy. The cricothyroidotomy should be performed in the operating room under controlled conditions to decrease the risk of subglottic tracheal stenosis secondary to damage of the cricoid cartilage. For this reason, surgical cricothyroidotomy is rarely indicated in children younger than 12 years.

Once an airway has been established, adequate ventilation needs to be maintained. The adequacy of ventilation is evaluated both clinically and with arterial blood gas values. A pulse oximeter is also a rapid, noninvasive, and effective means of monitoring ventilation. Symmetric movement of the chest, auscultation for symmetric breath sounds, and palpation for equal chest expansion are necessary to ensure adequate ventilation. A posteroanterior or anteroposterior (AP) radiograph of the chest needs to be obtained so that the position of the endotracheal tube can be evaluated and so that injuries to the thorax (rib fractures), heart, lungs, and great vessels can be assessed. Because the thoracic cage in children is very compliant, pediatric patients can have significant lung and cardiac injuries without obvious external damage to the chest and without rib fractures. The presence of a fracture of the first rib or multiple ribs indicates severe trauma and an increased risk of associated injuries.

Life-Threatening Ventilation Abnormalities

Injuries that may have a life-threatening effect on ventilation include tension pneumothorax, open pneumothorax, massive hemothorax, and flail chest. Because infants and small children ventilate primarily with the diaphragm, any injury or condition that compromises diaphragmatic excursion restricts ventilation. Potential injuries that affect diaphragmatic excursion include diaphragmatic rupture and intraabdominal injuries.

Gastric Distention

Severe gastric distention can decrease diaphragmatic excursion considerably. Gastric decompression should be performed in all children with signs of ventilatory compromise. Decompression can be achieved easily with the passage of a small nasogastric or orogastric tube. Because of particulate matter, a tube smaller than 10F cannot adequately aspirate the gastric fluid and stomach contents and should not be used.

Tension Pneumothorax

Children are more susceptible to pneumothorax secondary to the mobility of their mediastinal structures. A pneumothorax under pressure may initially be managed by the insertion of a large-caliber intravenous catheter, such as a 14- or 16-gauge catheter (Angiocath), just above the third rib in the midclavicular line. Such treatment relieves the pressure and converts it into a simple pneumothorax, which can be managed with the use of a chest tube. In infants and small children, care should be taken not to insert the catheter too deep because this may actually cause a pneumothorax. Large penetrating chest wounds are initially treated with an occlusive dressing and positive-pressure ventilation. A flail chest is diagnosed by the observation of paradoxical motion with respirations. A child who also exhibits signs of inadequate ventilation should be treated with endotracheal intubation and mechanical ventilation.

Circulation and Resuscitation

The key factors in the evaluation and management of circulation are recognition of shock, fluid resuscitation, blood replacement, venous access, recording of urine output, and thermoregulation.

Shock

It is critical to recognize and treat shock in the immediate phases of the primary survey. A child’s response to shock is different from that of an adult. A child is often able to maintain normal blood pressure by increasing the heart rate along with significant peripheral constriction while in the supine position. A decrease in blood pressure is not usually seen or is a very late finding; absence of hypotension, however, does not rule out shock. A child can often compensate for a 20% to 30% blood volume loss without a decline in blood pressure. Tachycardia and poor skin perfusion are usually the only signs of early shock. Other more subtle signs include progressive narrowing of pulse pressure, skin mottling, cool extremities, a decreased level of consciousness, and a decreased response to pain. A guide for normal blood pressure in children is a systolic pressure of 90 mm Hg plus twice the child’s age in years and a diastolic pressure that is two thirds the systolic pressure. Because infants are relatively incapable of increasing their cardiac stroke volume, their only way to increase cardiac output is by increasing the heart rate. Thus, the heart rate must be monitored closely. Normal vital signs by age are presented in Table 5-5 . Hypotension in a child represents a state of decompensated shock and severe blood loss. During this stage of shock, tachycardia may also be replaced by bradycardia.

TABLE 5-5

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