++
The often invoked axiom that children, and especially infants
and young children, are not small adults applies also to understanding
and treating traumatic injuries. The differences involve anatomical
and physical characteristics, physiological and psychological responses,
and even the very mechanisms by which trauma occurs. Adult practitioners
often need to be reminded that, for instance, children have greater surface
ratio of area to mass than do adolescents or adults. This results
in greater dissipation of heat and water, which may compound the
effects of other traumatic injuries. The child’s skeleton
exhibits greater elasticity than the adult’s and is therefore
more likely to allow compression and visceral injury without fractures.
A vast majority of childhood injuries are passive and result from
blunt trauma and thus tend to involve multiple organs. Yet, children tend
to experience better outcomes compared to the adult with the same
mechanism of injury because of factors such as the occurrence of
fewer bone fractures and the lack of comorbid disorders. Yet, it
is important to remember that, while a recovery of function and
quality of life after blunt injury is common, physical function
tends to remain lower than age-matched norms at 6 months postinjury,
and often the childhood trauma victim and his or her family bears
the consequence of that injury for a lifetime.
++
The evaluation and management of the injured child is best performed
using a standard protocol. The Advanced Trauma Life Support (ATLS)
protocol is widely used and establishes three sequential events:
the primary survey, the secondary survey, and a definitive care
phase.
++
The primary survey is performed in the first several minutes (eTable 116.1). Seminal to this phase is the
rapid assessment of vital functions followed by the appropriate
resuscitation measures.
++
++
The presumption that every patient may have suffered a cervical
spine injury has become integral to initial trauma management. Cervical stabilization
is thus one of the first steps of the stabilization and is continued
until cervical injury can be adequately excluded. Immobilization
of the cervical spine is usually carried out by prehospital personnel
and can be achieved with appropriately sized Philadelphia or Aspen collars
or by using sandbags on either side of the head and applying tape
over the sandbag and the forehead of the patient. A foam cervical collar
will not adequately stabilize the neck. A caregiver can stabilize
the cervical spine by holding both mastoids and mandibles in a manner
that prevents flexion-extension and lateral movements. If the child
is awake and cooperative, the absence of pain or other findings
upon careful full range mobilization of the neck is usually sufficient
to exclude injury. However, physical examination alone cannot exclude
a spinal injury in: (1) patients who are uncooperative or unresponsive;
(2) the young child unable to give a meaningful or reliable response
to questions; or (3) the patient with a significant distracting
painful injury elsewhere. Pain with neck movement, tenderness to
palpation of the cervical vertebrae, a detectable cervical spine deformity,
or a neurologic abnormality referable to the neck are all good reasons
to continue immobilization and protection of the cervical spine
and to obtain specialized imaging studies and neurosurgical consultation
if available.
+++
Assessment of
Vital Functions
++
In children inadequate oxygenation and ventilation are the more
common causes of arrest after trauma. For this reason, primary attention must
be directed toward assessing airway patency and the efficiency of
breathing effort. In every case, the mouth should be opened and the
pharynx examined for foreign material or loose teeth. Secretions
should be cleared and, if the child is unconscious, a jaw thrust
maneuver or insertion of an oral airway may be used to prevent upper
airway obstruction. Supplemental oxygen should be instituted. The
presence of persistent respiratory distress or insufficient respiratory
effort is usually an indication for tracheal intubation, which should
be performed by the most experienced individual. If it is difficult
to establish a patent airway, a needle cricothyroidotomy can provide
rapid stabilization. A tracheostomy attempted outside of the operating
room, particularly in a small child, can be a very difficult procedure, and
is not the treatment of choice in this situation. Bag and mask ventilation
can often provide adequate ventilation even in the most difficult
circumstances and is preferable to unskilled tracheal intubation,
particularly if laryngeal or tracheal injuries are suspected.6
++
If the patient has a suspected injury and no stridor but apparent
upper airway obstruction, after several unsuccessful attempts of
endotracheal intubation, a cricothyroidotomy is the next step. In
the circumstance where there is a suspected laryngeal crush injury
and stridor, consideration should be given to proceeding directly
to a cricothyroidotomy without attempted endotracheal intubation
because of the risk of creating a false passage in placing the airway
via an endotracheal route.
++
After airway patency is assured, attention should move to other
aspects of the breathing function (see Chapter 102). Palpation and auscultation are used to determine whether
the trachea is in the midline. If it is, breath sounds can be heard
well bilaterally. A tracheal shift or a decrease of breath sounds
on one side of the chest may indicate a pneumothorax or hemothorax
(the tracheal will deviate to the side opposite to the shift). If
the patient is stable, a chest radiograph should be obtained to
establish the origin of the findings.
++
If there is a tension pneumothorax, urgent treatment is indicated.
This can be carried out by simply placing a needle into the pleural space
through the second intercostal space at the midclavicular line.
This allows relief of the tension and provides an opportunity to
place a chest tube for continued evacuation of air. Chest tube placement
or tube thoracostomy is the appropriate treatment for a traumatic
accumulation of gas or liquid in the pleural space. In a small infant,
a 12 to 14 French chest tube is appropriate. In an older child,
an 18 to 24 French chest tube is preferable. A larger bore chest
tube is more appropriate if a hemothorax is suspected. Prior to
placing the chest tube, one should assess the level of the diaphragm on
that side of the chest to avoid injuring abdominal organs. If there
is no elevation of the diaphragm, placement of the chest tube in
the midaxillary line at the level of the sixth intercostal space
is done. The chest tube should be placed no further posterior than
the midaxillary line, to prevent the patient from lying on the tube.
Some chest tube sets come with a metal obturator with a very sharp,
pointed end, which should not be used, especially by less experienced
clinicians because of the high risk of injury to the lungs or vascular
organs.
++
A child with several contiguous rib fractures may have a flail
chest, a condition characterized by a paradoxic inward movement
of a portion of the chest during inspiration. This reduces both
the functional residual capacity and the tidal volume, almost always
requiring positive pressure ventilation. A sucking chest wound involves
a penetrating injury that allows air to enter the chest during inspiration. The
resulting pneumothorax can be prevented from becoming larger by
placing a flap valve dressing over the injury until a chest tube
can be inserted and the chest wall can be subsequently repaired.
++
An often overlooked reason for respiratory dysfunction after
trauma is equipment failure. Worsening respiratory function can
not infrequently be traced to kinking, disconnection or obstruction
of an endotracheal tube, or insufficient suction on a chest tube.
The importance of surveying the life support equipment frequently
and thoroughly cannot be overemphasized, especially when a child
experiences an unexplained worsening.
++
The next step in the primary survey is assessing the adequacy
of tissue perfusion (see Chapter 103). A number
of physical signs can reflect inadequate perfusion including tachycardia, pallor,
cool extremities, confusion, combativeness, or a decreased blood
pressure. After hemorrhage, blood pressure is usually maintained until
the child loses 20% of his or her blood volume; thus, hypotension
is a late manifestation of a significant injury. Checking the capillary refilling
time provides a quick assessment of perfusion, provided that the
patient is not cold.
++
Completion of the primary survey requires an assessment of neurologic
function. It is particularly important to establish at this point whether
the child has any lateralizing neurological signs that suggest an
intracranial space-occupying lesion or spinal cord injury.
++
Adequate venous access is essential for the treatment of traumatic
injuries. It has become the norm that any child with a significant
traumatic injury should have two intravenous lines. If there is
an injury involving the abdomen then at least one of the intravenous
lines should be in an upper extremity or neck. Attempts should first
be made to place intravenous lines percutaneously, although this
may be challenging in the young child, particularly if hypovolemic.
In such conditions, successful placement of a small bore intravenous
line may gain precious time for the initial resuscitation. A larger
gauge catheter can be inserted then under less pressing circumstances.
If peripheral intravenous access cannot be achieved within several
minutes, alternative methods of access should be attempted (see Chapter 107), including intraosseous access
and, if skilled personnel are available, insertion of a central venous
catheter either percutaneously or by surgical venotomy. Subclavian
vein access in the trauma patient, particularly in one who is hypotensive
or hypovolemic, can be particularly challenging if one has not had
significant experience in placing these lines. Additionally, it
carries the potential consequence of an iatrogenic pneumothorax
or hemothorax. Also, central venous pressure monitoring in the emergency
department is unnecessary in the vast majority of pediatric trauma
victims.
++
After vascular access is established, fluid resuscitation can
be initiated accompanied by frequent reassessment of hemodynamic
function (heart rate, blood pressure, state of alertness, capillary
refill). A urinary catheter should be placed in a major trauma patient.
++
The secondary survey includes a history and a complete head to
toe examination of the child with a focus on specific organ systems.
The mnemonic AMPLE stands for obtaining a history in regard to Allergies, Medications, Past illnesses, Last
meal, Events, and Environment involved
with the injury. In the secondary survey the evaluation, testing,
and interventions should be individualized for each patient. Every
part of the body should be palpated, the chest and abdomen should
be auscultated and the patient “log rolled” to
examine the back and to perform a rectal examination.
++
The assessment and management of acute neurological injuries
are discussed in Chapters 104 and 111. Inspection and palpation of the head focuses
on the detection of eye and ear injuries, and craniofacial fractures.
Crepitus usually indicates a communication between the sinuses and
the subcutaneous tissue through a facial bone fracture. Tenderness over
the maxilla, and mandible, and malocclusion also indicate facial
bone fractures. Rhinorrhea or otorrhea suggest a spinal fluid leak through
a base of the skull fracture.
++
Examination of the neck and cervical spine includes palpation
to identify tenderness, mobilization to assess range of motion,
a motor and sensory examination, evaluation of reflexes, and appropriate
imaging studies. Difficulty in carrying out this examination is
most commonly the result of an altered level of consciousness and/or
lack of ability to cooperate because of the patient’s age,
or the distracting effects of other injuries. Signs of airway obstruction,
hoarseness, stridor, crepitus, or significant soft tissue swelling
are alerts for a possible airway injury.
++
In patients who have undergone stabilization of the neck with
a collar, examination of the cervical spine requires the removal
of the collar. This may not be appropriate in patients who are unconscious
or uncooperative. After inspecting for injury, the cervical spine
is palpated. If there is pain on palpation or if there is a deformity
or swelling, the cervical collar is reapplied and an imaging study
should be performed. If no abnormality on examination is noted and
no pain elicited, the patient is asked to rotate the head and neck
to each side, move it laterally, and then flex and extend it. If
movement is limited or pain occurs, the collar is reapplied and
imaging studies are indicated. If again no pain or abnormality is
noted, the patient’s cervical spine has been “cleared” and
no diagnostic imaging is needed. The decision process is more difficult,
if for any reason, usually loss of consciousness or lack of cooperation,
the cervical spine cannot be “cleared” in this
manner. Computerized tomography (CT) examination provides a practical
method to assess for neck injuries in children. A combined head
and neck CT scan will, in the right circumstances, decrease the
number of studies that a child will eventually undergo. It is important
to recognize, however, that a normal neck CT scan does not eliminate
the need to perform a functional examination of the neck once it
is possible to obtain patient cooperation.
++
More than 80% of thoracic injuries in children are caused
by blunt trauma. The incidence decreases to slightly less than 60% in
adolescents. In the patient with blunt chest injuries, the most common
cause of death is a head injury; in patients with penetrating chest
injury, the death is most often caused by the chest injury itself.
++
The majority of thoracic injuries can be handled well with supplemental
oxygen, tube thoracostomy, and analgesia. Approximately 5% to 10% of
all blunt chest injuries may require a thoracotomy. Immediate life-threatening
conditions include complete airway obstruction, tension pneumothorax,
massive hemothorax, cardiac tamponade, and penetrating cardiac injury.
Also potentially life-threatening conditions include pulmonary contusion,
myocardial contusion, aortic disruption, diaphragmatic rupture, tracheobronchial
disruption, and esophageal perforation. Indications for emergency
thoracotomy include a penetrating wound to the heart or aorta, continued
significant intrathoracic bleeding from other source (≥ 3–4
mL/kg/hour), an imaging study indicating an injury
to the aorta or other large vessel, a pneumothorax with an open
chest wall injury, a large continuing air leak indicative of a bronchial
injury, cardiac tamponade, impalpable pulses with closed chest compression,
diaphragmatic rupture, and esophageal perforation.
++
The secondary survey of the abdomen includes inspection, palpation,
percussion, auscultation, and the use of imaging studies as needed.
Abdominal blunt trauma carries an increased risk of injuring multiple
organs. The presence of a “seat belt” sign, a
linear abdominal wall ecchymosis, is indicative of a rapid deceleration mechanism
of injury. This deceleration can often cause significant intra-abdominal
injuries. The combination of a seat belt injury and significant
tenderness on palpation should cause a high degree of suspicion
for injuries of the abdominal viscera.
++
The abdominal plain film may show evidence of inferior rib fractures,
vertebral anomalies, a pelvic fracture, and an abnormal bowel gas
pattern. A nasogastric tube should be placed to decompress the stomach
if distended. If there is any evidence of a mid-face fracture, the
tube should be placed via an orogastric route to avoid the possibility
of the tube being misplaced into the cranial cavity. Urethral injury
is common in males and should be suspected if there is blood in
the urethral meatus or a high riding prostate on rectal examination.
If there is a significant suspicion to a urethral injury, a retrograde
urethrogram should be performed before inserting a Foley catheter.
++
The presence of a pelvic fracture should raise suspicions of
a concomitant retroperitoneal or urethral injury. Contemporary evaluation
of the abdomen often includes an abdominal and pelvic computerized
tomography scan. With the new generation of helical scanners, a
full abdominal examination can be carried out in minutes. Radiological
assessment should only be performed, however, once the patient is
sufficiently stable. Peritoneal lavage is now used in very limited
circumstances, because the presence of free blood in the abdominal
cavity is no longer considered an automatic indication for surgery.
++
The spleen and the liver are two of the abdominal organs most
commonly injured. The conservative management of childhood splenic and
liver injuries is common practice today. A retrospective study of
440 patients from 17 pediatric trauma centers who had isolated splenic injuries
showed that only 4% required surgery.12 Large
multi-institutional studies have shown that children with isolated
splenic or hepatic injuries (Grades I–III) injuries typically do
not require admission to the intensive care unit (ICU), infrequently
require blood transfusion, and, in their majority, can be managed nonoperatively (eTable 116.2).Indications
for surgery include a persistently low hemoglobin unresponsive to
blood transfusion, or hemodynamic instability unresponsive to fluid
resuscitation.
++
++
Injuries to the pancreas are often the result of a blunt injury,
such as those caused by the handlebar of a bicycle, a rapid deceleration
injury in a motor vehicle accident, a fall, or intentional child
abuse. Because of the location of the pancreas, there are often
coexisting injuries to the stomach, duodenum, kidneys, or spine.
The diagnosis is made on the basis of laboratory studies (elevation
in amylase and lipase) and imaging studies (a CT scan demonstrating
pancreatic edema, hematoma, or disruption). A penetrating injury
of the abdomen with a pancreatic injury requires laparotomy. A blunt
injury with stable vital signs and no peritonitis can usually be
managed nonoperatively. The decision to operate is usually prompted
by the persistence of fever, pain, ileus, and hyperamylasemia. Treatment
otherwise consists of bowel rest, intravenous nutrition, and administration of
octreotide to decrease pancreatic exocrine secretions. A pancreatic
pseudocyst is a known complication of pancreatic trauma, often associated
with an elevation in lipase and amylase. The pseudocyst is initially
managed nonoperatively. Many of these will decrease spontaneously
in size and resolve. If the pseudocyst if still present for over
six weeks, consideration should be given to internal drainage, a
cystgastrostomy, or drainage into the bowel depending upon the location
of the pseudocyst (see Chapter 417).
++
Intestinal injuries can occur throughout the large or small bowel.
The ligament of Treitz and the ileocecal valve are the two most
vulnerable points because shear forces tend to tear the bowel at
its tethering points to the abdominal wall. The duodenum, on the
other hand, is often injured when compressed between the abdominal
wall and the spine. A duodenal hematoma can be diagnosed by an upper
GI contrast study or an abdominal CT scan. Management is nonoperative,
and in approximately 85% of cases the hematoma will resolve spontaneously.
++
The presence of microscopic hematuria may not require admission
if the CT scan of the abdomen shows no abnormalities. An algorithm for
management is shown in eFigure 116.1. If there
is microscopic hematuria and a normal CT scan outpatient follow-up
is reasonable. An abnormal CT scan or macroscopic hematuria provides
indication for hospital admission. If the CT scan shows a major
blood extravasation, or nonvisualization of renal flow, arteriography is
indicated. If the vasculature is normal, bed rest and observation
is reasonable. However, if there is disrupted vasculature, operative
intervention is required. Bladder rupture also requires operative
intervention.
++
++
This subject is covered more extensively in Section
4. However, in the evaluation of the trauma patient, the suspicion
of child abuse should be kept in mind. This is particularly true
if any or several of the following are noted: (1) a discrepancy
between the history and the degree of injury; (2) a prolonged interval from
injury to treatment; (3) a history of repeated similar injuries;
(4) an inappropriate parental response; or (5) a changing history given
by the caretaker.
++
In this phase of care, decisions are made regarding transfer
from the Emergency Department to the next site of care. This begins
with a reassessment of the patient, review of the need for medications
(antibiotics, analgesics, immunizations), further imaging studies,
monitoring, and consultation. A comprehensive outline of the status
of the patient and the injuries identified is given to the accepting
unit in the hospital.