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Between age 1 month and 18 years, one half of all deaths in children
are the result of a traumatic injury. Trauma accounts for more deaths
in children in this age range than all forms of cancer, heart disease,
and infections combined. The objectives of this chapter will be
to review the differences between adults and children in regard
to mechanism of injury and physiologic response; discuss pathophysiology
and the initial management of the trauma victim; and outline common
injuries involving various organ systems. If trauma were a disease
entity, its incidence would be considered to be epidemic, and major
resources would be put in play to prevent and treat traumatic injuries.1-16
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Most infants and children with traumatic injuries are seen in
the emergency department. In contrast, the significantly injured
child, from a motor vehicle accident or a burn victim, requires
evaluation and management skills that may not be available in every
emergency department, and caregivers may have less experience with
their care.
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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.
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A common language that describes injuries and their consequences
is very useful in the frenzied circumstances that are the norm in
the trauma management process. The Glasgow Coma Scale (GCS, see Chapter 104) and Injury Severity Scale (ISS)
have been mainstays in the assessment and subsequent review of outcomes
in pediatric trauma patients. The New Injury Severity Score (NISS)
has been shown to have an improved predictive value in adult trauma
victims compared to the ISS, but this superiority has not been corroborated
in children. Likewise, trauma scores specifically designed for children
have not been found to be superior to trauma ...