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Traumatic injuries, including motor vehicle crashes, falls, burns, and immersions, account for the greatest number of deaths among children older than 1 year; injury exceeds all other causes of death combined with motor vehicle accidents accounting for the majority of deaths. Blunt trauma is most common, with penetrating trauma occurring in only 10% of cases. Head and abdominal injuries are particularly common and important.
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A coordinated team approach to the severely injured child will optimize outcomes. A calm atmosphere in the receiving area will contribute to thoughtful care. Parents are often anxious, angry, or guilt-ridden, requiring ongoing support from staff, social workers, or child life workers (therapists knowledgeable about child development).
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To provide optimal multidisciplinary care, regional pediatric trauma centers provide dedicated teams of pediatric specialists in emergency pediatrics, trauma surgery, orthopedics, neurosurgery, and critical care. However, most children with severe injuries are not seen in these centers. Community providers must often provide initial assessment and stabilization of the child with life-threatening injuries before transport to a verified pediatric trauma center.
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Document the time of occurrence, the type of energy transfer (eg, hit by a car, fall from playground), secondary impacts (if the child was thrown by the initial impact), appearance of the child at the scene, interventions performed, and clinical condition during transport. The report of emergency service personnel is invaluable. Forward all of this information with the patient to the referral facility if secondary transport occurs.
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INITIAL ASSESSMENT & MANAGEMENT
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The vast majority of children who reach a hospital alive survive to discharge. As most deaths from trauma in children are due to head injuries, cerebral resuscitation must be the foremost consideration when treating children with serious injuries. Strict attention to the ABCs (see the previous section) ensures optimal oxygenation, ventilation, and perfusion, and ultimately, cerebral perfusion.
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The primary and secondary survey is a method for evaluating and treating injured patients in a systematic way that provides a rapid assessment and stabilization phase, followed by a head-to-toe examination and definitive care phase.
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The primary survey is designed to immediately identify and treat all physiologic derangements resulting from trauma. The mnemonic, ABCDE, is a simple way to remember the general steps of the primary survey: Airway, with cervical spine control; Breathing; Circulation, with hemorrhage control; Disability (neurologic deficit); Exposure (maintain a warm Environment, undress the patient completely, and Examine)
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If the patient is apneic or has agonal breaths, the sequence reverts to the CABs of PALS resuscitation (chest compressions, open the airway, provide two rescue breaths). Please refer to PALS guidelines for further information. Refer to preceding discussion regarding details of the ABC assessment. Modifications in the trauma setting are added as follows:
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Failure to manage the airway appropriately is the most common cause of preventable morbidity and death. Administer 100% high-flow oxygen to all patients. Initially, provide cervical spine protection by manual inline immobilization, not traction. A hard cervical spine collar is applied after the primary survey.
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Most ventilation problems are resolved adequately by the airway maneuvers described earlier and by positive-pressure ventilation. Sources of traumatic pulmonary compromise include pneumothorax, hemothorax, pulmonary contusion, flail chest, and central nervous system (CNS) depression. Asymmetric breath sounds, particularly with concurrent tracheal deviation, cyanosis, or bradycardia, suggest pneumothorax, possibly under tension. To evacuate a tension pneumothorax, insert a large-bore catheter-over-needle assembly attached to a syringe through the second intercostal space in the midclavicular line into the pleural cavity and withdraw air. If a pneumothorax or hemothorax is present (evident by the sound of hissing as the air is evacuated), place a chest tube in the fourth or fifth intercostal space in the anterior axillary line. Connect to water seal. Insertion should be over the rib to avoid the neurovascular bundle that runs below the rib margin. Open pneumothoraces can be treated temporarily by taping petrolatum-impregnated gauze on three sides over the wound, creating a flap valve.
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A child with a depressed level of consciousness (Glasgow Coma Scale [GCS] score < 9), a need for prolonged ventilation, severe head trauma, or an impending operative intervention requires endotracheal intubation after bag-mask preoxygenation. Orotracheal intubation is the route of choice and is possible without cervical spine manipulation. Nasotracheal intubation may be possible in children 12 years of age or older who have spontaneous respirations, if not contraindicated by midfacial injury.
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Supraglottic devices, such as the LMA, are being used with increasing frequency, in both the prehospital and hospital settings. The device consists of a flexible tube attached to an inflatable rubber mask (Figure 12–8). The LMA is inserted blindly into the hypopharynx and is seated over the larynx, occluding the esophagus. Advantages to its use include ease of insertion, lower potential for airway trauma, and higher success rates. Patients remain at higher risk for aspiration with LMA use compared with orotracheal intubation; therefore, the LMA should not be used for prolonged, definitive airway management. Rarely, if tracheal intubation cannot be accomplished, particularly in the setting of massive facial trauma, cricothyroidotomy may be necessary. Needle cricothyroidotomy using a large-bore catheter through the cricothyroid membrane is the procedure of choice in patients younger than 12 years.
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Evaluation for ongoing external or internal hemorrhage is important in the trauma evaluation. Large-bore IV access should be obtained early during the assessment, preferably at two sites. If peripheral access is not readily available, an intraosseus line, central line, or cutdown, or IO line is established. Determine hematocrit and urinalysis in all patients. Blood type and cross-match should be obtained in the hypotensive child unresponsive to isotonic fluid boluses or with known hemorrhage. Consider coagulation studies, chemistry panel, liver transaminases, lipase, and toxicologic screening as clinically indicated.
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External hemorrhage can be controlled by direct pressure. To avoid damage to adjacent neurovascular structures, avoid placing hemostats on vessels, except in the scalp. Determination of the site of internal hemorrhage can be challenging. Sites include the chest, abdomen, retroperitoneum, pelvis, and thighs. Bleeding into the intracranial vault rarely causes shock in children except in infants. Evaluation by an experienced clinician with adjunctive computed tomography (CT) or ultrasound will localize the site of internal bleeding.
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Suspect cardiac tamponade after penetrating or blunt injuries to the chest if shock, pulseless electrical activity, narrowed pulse pressure, distended neck veins, hepatomegaly, or muffled heart sounds are present. Ultrasound may be diagnostic if readily available. Diagnose and treat with pericardiocentesis and rapid volume infusion.
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Treat signs of poor perfusion vigorously: A tachycardic child with a capillary refill time of 3 seconds or more, or other evidence of diminished perfusion, is in shock and is sustaining vital organ insults. Recall that hypotension is a late finding. Volume replacement is accomplished initially by rapid infusion of normal saline or lactated Ringer solution at 20 mL/kg of body weight. If perfusion does not normalize after two crystalloid bolus infusions, 10 mL/kg of packed red blood cells is infused. Rapid reassessment must follow each bolus. If clinical signs of perfusion have not normalized, repeat the bolus. Lack of response or later or recurring signs of hypovolemia suggest the need for blood transfusion and possible surgical exploration.
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A common problem is the brain-injured child who is at risk for intracranial hypertension and who is also hypovolemic. In such cases, circulating volume must be restored to ensure adequate cerebral perfusion; therefore, fluid replacement is required until perfusion normalizes. Thereafter provide maintenance fluids with careful serial reassessments.
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Disability-Neurologic Deficit
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Assess pupillary size and reaction to light and the level of consciousness. The level of consciousness can be reproducibly characterized by the AVPU (alert, voice, pain, unresponsive) system (Table 12–3). Pediatric GCS assessments can be done as part of the secondary survey (Table 12–4).
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Exposure & Environment
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Significant injuries can be missed unless the child is completely undressed and examined fully, front and back. Any patient transported on a backboard should be removed as soon as possible, as pressure sores may develop on the buttocks and heels of an immobilized patient within hours.
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Because of their high ratio of surface area to body mass, infants and children cool rapidly. Hypothermia compromises outcome except with isolated head injuries; therefore, continuously monitor the body temperature and use warming techniques as necessary. Hyperthermia can adversely affect outcomes in children with acute brain injuries, so maintain normal body temperatures.
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Cardiopulmonary monitors, pulse oximetry, and end-tidal CO2 monitors should be put in place immediately. At the completion of the primary survey, additional “tubes” may be needed to be placed. See Table 12–1 for age/weight-appropriate equipment sizes.
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A. Nasogastric or Orogastric Tube
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Children’s stomachs should be assumed to be full so a nasogastric tube needs to be placed. Gastric distention from positive-pressure ventilation increases the chance of vomiting and aspiration. Of note, the nasogastric route should be avoided in patients with significant midface trauma.
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An indwelling urinary bladder catheter should be considered to monitor urine output. Contraindications are based on the risk of urethral transection; signs include blood at the meatus or in the scrotum or a displaced prostate detected on rectal examination. Urine should be tested for blood. After the initial flow of urine with catheter placement, the urine output should exceed 1 mL/kg/h.
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After the Primary Survey and resuscitation phase, a focused history and a head-to-toe examination should be performed to reveal all injuries and determine priorities for definitive care.
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Obtain a rapid, focused history from the patient (if possible), available family members or prehospital personnel. The AMPLE mnemonic is frequently used:
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Search for lacerations, hematomas, burns, swelling, and abrasions. Remove superficial foreign material and cleanse as necessary. Cutaneous findings may indicate underlying pathology (eg, a flank hematoma overlying a renal contusion), although surface signs may be absent even with significant internal injury. Do not remove penetrating foreign objects because vital respiratory components, vascular structures, or organs may be involved and require removal in a controlled environment by a surgeon. Make certain that the child’s tetanus immunization status is current. Consider tetanus immune globulin for incompletely immunized children.
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Check for hemotympanum and for clear or bloody cerebrospinal fluid leak from the nares. The “battle sign” (hematoma over the mastoid) and periorbital hematomas (“raccoon eyes”) are late signs of basilar skull fracture. Explore wounds, evaluating for foreign bodies and defects in galea or skull. CT scan of the head is an integral part of evaluation for altered level of consciousness, posttraumatic seizure, or focal neurologic findings (see section Head Injury, later). Pneumococcal vaccine may be considered for basilar skull fractures as a preventive measure for meningitis.
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Cervical spine injury must be excluded in all children. This can be done clinically in children older than 4 or 5 years with normal neurologic findings on examination who are able to deny midline neck pain or midline tenderness on palpation of the neck and who have no other painful distracting injuries that might obscure the pain of a cervical spine injury. If radiographs are indicated, a cross-table lateral neck view is obtained initially followed by anteroposterior, odontoid, and, in some cases, oblique views. Normal studies do not exclude significant injury, either bony or ligamentous, or involving the spinal cord itself. Therefore, an obtunded child should be maintained in cervical spine immobilization until the child has awakened and an appropriate neurologic examination can be performed. The entire thoracolumbar spine must be palpated and areas of pain or tenderness examined by radiography.
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Children may sustain significant internal injury without outward signs of trauma. The most common type of injuries sustained from blunt chest trauma is pulmonary contusions which may lead to hypoxemia. Pneumothoraces are detected and decompressed during the primary survey. Hemothoraces can occur with rib fractures or with injury to intercostal vessels, large pulmonary vessels, or lung parenchyma. Tracheobronchial disruption is suggested by large continued air leak despite chest tube decompression. Myocardial contusions and aortic injuries are unusual in children.
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Blunt abdominal injury is common in multisystem injuries. Significant injury may exist without cutaneous signs or instability of vital signs. Abdominal pain and tenderness coupled with a linear contusion across the abdomen (“seat belt sign”) increases the risk of intra-abdominal injury threefold. Tenderness, guarding, distention, diminished or absent bowel sounds, or poor perfusion mandate immediate evaluation by a pediatric trauma surgeon. Injury to solid viscera frequently can be managed nonoperatively in stable patients; however, intestinal perforation or hypotension necessitates operative treatment. Intra-abdominal injury is highly likely if the AST is greater than 200 U/L or the ALT greater than 125 U/L; however, elevated levels that are below these thresholds do not exclude significant injury if a significant mechanism has occurred. When measured serially, a hematocrit of less than 30% also may suggest intra-abdominal injury in blunt trauma patients. Coagulation studies are rarely beneficial if no concomitant head injury is present. There is no single test value that can reliably predict intraabdominal injury and therefore laboratory interpretation requires close clinical correlation. Laboratory studies are often most valuable in the nonverbal or obtunded patient, to increase the suspicion for injury and subsequent need for imaging.
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Trauma ultrasonography, or the FAST (focused assessment with sonography for trauma), is routinely used in the adult trauma population. The purpose of the four-view examination (Morison pouch, splenorenal pouch, pelvic retrovesical space, and subcostal view of the heart) is to detect free fluid or blood in dependent spaces. In adults, such detection indicates clinically significant injury likely to require surgery. Accuracy and indications in children are much less clear. This examination has a high specificity rate to rule in free abdominal fluid, but low sensitivity to rule out significant intra-abdominal injury. Solid-organ injuries are more frequently missed. Additionally, much of the pediatric trauma management is nonoperative and therefore detection of free fluid by ultrasound in children is less likely to lead to surgery or result in a change in management. At least one recent study showed no change in the rate of pediatric patients eventually undergoing abdominal CT regardless of FAST findings.
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Pelvic fractures are classically manifested by pain, crepitus, and abnormal motion. Significant blood loss into the pelvis may occur due to vascular injury, thus have a sign index of suspicion in the setting of unexplained tachycardia or hypotension. Pelvic fracture is a relative contraindication to urethral catheter insertion. Many providers perform a rectal examination, noting tone, tenderness, and in boys, prostate position. If this is done, stool should be tested for blood.
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G. Genitourinary System
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If urethral transection is suspected, perform a retrograde urethrogram before catheter placement. Diagnostic imaging of the child with hematuria less than 50 red blood cells per high-power (hpf) field often includes CT scan or occasionally, IV urograms. Management of kidney injury is largely nonoperative except for renal pedicle injuries.
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Long bone fractures are common but rarely life threatening. Test for pulses, perfusion, and sensation. Neurovascular compromise requires immediate orthopedic consultation. Treatment of open fractures includes antibiotics, tetanus prophylaxis, and orthopedic consultation.
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I. Central Nervous System
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Most deaths in children with multisystem trauma are from head injuries, so optimal neurointensive care is important. Significant injuries include diffuse axonal injury; cerebral edema; subdural, subarachnoid, and epidural hematomas; and parenchymal hemorrhages. Spinal cord injury occurs less commonly. Level of consciousness should be assessed serially. A full sensorimotor examination should be performed. Deficits require immediate neurosurgical consultation and should be considered for a patient with a GCS less than 12. Extensor or flexor posturing represents intracranial hypertension until proven otherwise. If accompanied by a fixed, dilated pupil, such posturing indicates that a herniation syndrome is present, and mannitol or 3% hypertonic saline should be given if perfusion is normal (see further discussion in next section). Treatment goals include aggressively treating hypotension to optimize cerebral perfusion, providing supplemental oxygen to keep saturations above 90%, achieving eucapnia (end-tidal CO2 35–40 mm Hg), avoiding hyperthermia, and minimizing painful stimuli. Early rapid sequence intubation, sedation, and paralysis should be considered. Mild prophylactic hyperventilation is no longer recommended, although brief periods of hyperventilation are still indicated in the setting of acute herniation. Seizure activity warrants exclusion of significant intracranial injury. In the trauma setting, seizures are frequently treated with fosphenytoin or levetiracetam. The use of high-dose corticosteroids for suspected spinal cord injury has not been prospectively evaluated in children and is not considered standard of care. Corticosteroids are not indicated for head trauma.
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