Matthew Hansen
EPIDEMIOLOGY
Trauma is the most common cause of death and disability in children 1 year of age and older; motor vehicle crash is the leading mechanism of injury in these children.
Head injury is the most frequent cause of death.
PATHOPHYSIOLOGY
Differences in anatomy, physiology, and psychology mandate modifications to trauma evaluation and management in children.
CLINICAL FEATURES
Airway management in children can be challenging due to anatomic differences including a large occiput, large tongue, and cephalad location of the larynx.
Infants younger than 6 months are nose breathers, and facial trauma may cause respiratory distress. Tachypnea is often the first sign of dyspnea.
Children with compensated shock from hemorrhage have normal blood pressure and tachycardia. Other signs of shock include prolonged cap refill, cool extremities, weak peripheral pulses, and altered mental status. Hypotension is a pre-arrest finding.
Age-dependent adaptation of the traditional Glasgow Coma Scale (GCS) score should be used.
The ratio of surface area to mass is greater in children, increasing risk of hypothermia.
DIAGNOSIS AND DIFFERENTIAL
Infants and neonates are at the highest risk of intracranial injury, especially those with altered mental status, >1 minute loss of consciousness, vomiting, and/or seizures. Noncontrast computed tomography (CT) is the imaging modality of choice for head trauma.
Scalp injuries, particularly in neonates, may result in significant blood loss and shock.
The increased flexibility of the spine in preadolescent children is responsible for the relatively lower incidence of spinal fracture in this group. As a result, children with spinal cord injuries frequently do not have fractures and have symptoms concerning for spinal cord injury without radiographic abnormality (SCIWORA).
“Clearing the cervical spine” in children is challenging as there is little evidence to guide practice. Multisystem trauma or head trauma are general indications for neck immobilization and cervical spine imaging. Due to the low incidence of spine fractures in younger children and the need to lower ionizing radiation, plain radiographs of the cervical spine remain a useful tool (Table 159-1).
In blunt chest trauma, considerable force may be transmitted to intrathoracic structures, causing serious injury with a paucity of external signs. Rib fractures require a significant mechanism of injury.
The physical examination in children has been shown to be unreliable in determining the severity of injury in up to 45% of pediatric trauma patients.
CT imaging of the abdomen is indicated in patients with a suspicious mechanism of injury, tenderness, seatbelt sign, distention, or vomiting.
Identification of a pelvic fracture, particularly an anterior ring fracture, should prompt investigation for associated urethral or bladder injury.
Suspect nonaccidental trauma (child abuse) when evaluating pediatric trauma patients, especially when the described mechanism of injury is inconsistent with the injuries sustained in infants and neonates.
Other markers for child abuse include the presence of an injury not consistent with the child’s developmental status such as bruising in nonambulatory children.
TABLE 159-1 Considerations for Cervical Spine Imaging in Children
Moderate- or high-risk head injury
Multiple trauma
Signs or symptoms of spinal injury
Direct mechanism for spinal injury
Altered mental status or focal neurologic findings
Distracting painful injury
Agitation with possible mechanism for spinal injury
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Complete an organized primary and secondary survey for all pediatric patients with significant mechanism of injury. Many problems are managed in a fashion similar to that used in adult patients.
Initially administer all patients with 100% oxygen. With difficult bagging, consider two-person mask technique and placement of an oral airway.
Orotracheal intubation is indicated for airway management. The following formula is used to estimate endotracheal tube size: size = 4 + (age/4). Cuffed or uncuffed endotracheal tubes can be used. However, the appropriate cuffed tube size is ½ size smaller than what is calculated using the formula above.
Rapid sequence intubation using pretreatment with 100% oxygen, appropriate sedation, and paralysis is indicated for a patient with an unstable airway.
Obtain intraosseous cannulation in unstable patients if intravenous access cannot be promptly established.
Administer resuscitative fluids in 20 mL/kg boluses of isotonic crystalloid. If there is no response to 2 to 3 boluses, then infuse 10 mL/kg boluses of packed red blood cells.
Resuscitate burn patients according to a standard burn formula, such as the Parkland formula.
For pain control, fentanyl 1 microgram/kg or morphine 0.05 to 0.1 milligram/kg are appropriate.
If a head-injured patient has signs of impending herniation, the Paco2 should be maintained at 30 to 35 mm Hg, blood pressure optimized with IV fluids, the head of the bed elevated to 30 degrees, the head and neck positioned at neutral, and mannitol 1 gram/kg administered.
Spinal immobilization must be achieved in infants and younger children with allowance for their relatively larger head by placement of padding behind the shoulders.
Admit children with skull fractures, intracranial hemorrhage, spinal trauma, significant chest trauma, abdominal trauma with internal organ injury, significant burns, or other concerning injuries. Guidelines for referral to a pediatric trauma center are mechanisms of injury: injury from motor vehicle, fall from a height, motor vehicle collision with prolonged extrication, and motor vehicle collision with death of another vehicle occupant; and anatomic injury:multiple severe trauma, more than three long-bone fractures, spinal fractures or spinal cord injury, amputations, severe head or facial trauma, and penetrating head, chest, or abdominal trauma.
Social service consultation and reporting to child protective services are indicated if there is any suspicion of nonaccidental trauma.
For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 251, “Trauma in Children,” by William E. Hauda II.