Patient A is 20 months of age and refuses to be restrained in a car seat. The family is late for a movie, and her mother does not want to deal with a temper tantrum. So, she decides to hold Patient A on her lap while her husband drives to the theater. While sitting at a stoplight, their car is hit head-on by a car being pursued by a police officer in a high-speed chase. Immediately prior to the moment of impact, Patient A's mother had let go of her daughter to put her hands up to protect herself from the impact. Upon impact, the child is thrown to the floor and rolls under the passenger side dashboard. The front end of the car is crushed accordion-style; the parents both strike the windshield and are unconscious.

Emergency medical service (EMS) responds to the scene and identifies only two victims, the parents. Utilization of rescue tool 10, also referred to as the "Jaws of Life," is required to extricate them from the vehicle. As the car is being pulled apart to remove the mother, Patient A's body rolls down from under the dash where she was trapped. It is only at this point that the EMS personnel are aware that they have a third victim.

The child is unconscious and unresponsive at the scene. She is transported to the local pediatric hospital, where she undergoes immediate resuscitation. Upon evaluation she is noted to have a depressed skull fracture over the right temporal area and a bulging fontanelle. An emergency CT scan is performed and demonstrates an epidural bleed, an intraventricular hemorrhage, and a subdural hematoma, along with the depressed skull fracture. She is admitted to the pediatric intensive care unit, where she remains profoundly comatose.

During the next two days, efforts at supporting the patient's neurologic status are performed, including optimizing her oxygenation status and ensuring adequate circulatory volume. She is on a ventilator and is paralyzed and sedated to ensure limited increases in ICP. Pharmacologic agents administered include mannitol, dexamethasone, and narcotics for sedation. Despite these efforts, no change in her condition is noted.

The mother does not survive the automobile crash, and the father remains comatose in the trauma intensive care unit at the trauma center 30 miles away. Patient A's extended family is notified of her poor prognosis, and studies of brain function are undertaken. She is pronounced brain dead and is disconnected from the ventilator. Prior to death, her family is approached regarding organ donation. As a consensus cannot be reached and her father remains comatose, no organs are procured after her death.

Patient B is a boy, 14 years of age, attending a birthday party at the local community pool. He is an excellent swimmer and has always been safe around pools. When he is swimming in the pool, another guest runs and jumps into the pool, landing on top of Patient B. The force of the impact is directed at his head and neck. Immediately, he sinks to the bottom of the pool and is rescued by the pool lifeguard. After being brought to the surface, mouth-to-mouth resuscitation is initiated. Within moments, Patient B chokes and starts to breathe on his own. However, he is unable to move his extremities and feels no sensation below his shoulders.

EMS personnel arrive on the scene, and Patient B is placed on a backboard and put in full spinal precautions prior to being removed from the water. He continues to breathe on his own after the initial period of apnea. He is transported to the local emergency department for evaluation.

Upon arrival at the emergency department, the patient continues to demonstrate flaccid paralysis of both his upper and lower extremities. Neurologic assessments are initiated and continued on an every 15-minute basis. Cervical spinal x-rays show a fracture between C5 and C6. A CT scan demonstrates diffuse swelling in this area, with severe injury to the spinal cord. Supplemental oxygen is provided, a Foley catheter is placed, and the neurosurgeon on call is notified.

Subsequently, Patient B is taken to the operating room for stabilization of his cervical spine. He is placed in traction in the operating room and transferred to the intensive care unit. During his stay in the intensive care unit, neurologic assessments are continued although no change is identified. During this time, psychologic counseling is initiated, as it is felt that the injury sustained will be permanent, rendering the patient quadriplegic.

Initially, Patient B's frame of mind is good; he feels that he can overcome his injury and be able to walk again. Despite counseling to the contrary, he continues to insist that he is going to get better. Within two weeks, he is ready to transfer to a spinal cord rehabilitation center. It is at this point that he realizes the full extent of his injury and becomes profoundly depressed. At times he expresses suicidal ideology and receives intensive counseling. During the next three months, Patient B and his family learn to deal with his healthcare requirements. He is discharged to home with around-the-clock nursing care.

Patient C is a boy, 8 years of age, who is riding his bike when hit by a car. He is knocked to the ground and a subsequent car, which was unable to stop in time, runs over his chest wall. His t-shirt shows tire marks across his anterior chest. However, immediately following being run over, he jumps up and starts yelling at the driver, who also damaged his new bicycle. Witnesses call 911, and emergency medical care personnel arrive within minutes of the accident. Upon arrival, Patient C is walking around, expressing concern regarding his new bike. He demonstrates no signs of injury other than the tire marks across his chest. Because of the mechanism of injury, the EMS personnel insist that he be transported to the local emergency department for assessment and treatment, if necessary.

Upon arrival in the emergency department, his vital signs are stable, his oxygen saturation is 96%, and a chest x-ray is normal. His parents are called, and the patient is to be discharged to home. Prior to leaving, his parents are instructed to return to the emergency department if any signs of developing respiratory distress are evident.

Patient D is a girl, 7 years of age, who is riding in the center backseat of her automobile restrained by a lap belt. The car is in a high-speed crash, causing the patient to be thrown forward over the top of the lap belt. The lap belt keeps her in her seat, but her body is flexed over the belt, and her forehead impacts the back of the front seat.

Immediately after the crash, she is screaming and crying. She is extremely upset by the crash, and it is difficult to assess if she is merely upset or if she is indeed injured. Because of the mechanism of injury, she is placed on a backboard in full spinal precautions and transported to the nearest trauma center. Upon arrival in the emergency department, a report is given as to the type and mechanism of injury. She has quieted down by this time and is only shaking her head yes or no when questioned about her injuries. As part of the head-to-toe assessment, the nurse begins palpating her lower abdomen, which causes Patient D to scream and begin crying. Further assessment of her abdomen is deferred, as she is crying uncontrollably at this time and information is difficult to ascertain.

The head-to-toe assessment demonstrates a bump on the patient's forehead, ecchymosis over her abdomen below her umbilicus, and a bruising over her right flank. Due to the mechanism of injury, it is suspected that she has sustained abdominal trauma, possibly a ruptured bowel secondary to seatbelt compression. X-rays and lab results are obtained and all are within normal limits. Eventually, Patient D quiets down, and she is transferred to the pediatric intensive care unit for further stabilization.

During the first few hours in the pediatric intensive care unit, she remains quiet and relatively pain free. The ecchymosis over her flank area increases in size, and her urine output falls to less than 1 cc/kg/hr. A urinalysis is obtained and demonstrates microscopic hematuria. Renal trauma is suspected; however, the decision is made to treat it nonoperatively and continue to monitor the patient in the intensive care unit. Her fluid intake is increased slightly in an effort to prevent acute tubular necrosis from developing.

During the middle of the night shift, she sustains a respiratory arrest. All efforts at resuscitation are performed without success. Patient D is pronounced dead 45 minutes after the onset of resuscitative efforts.

Patient E is a boy, 8 years of age, who is riding his skateboard in a city park. He is not wearing protective gear, including a helmet. When a friend distracts his attention, he runs head-on into a planter and is thrown over the planter box onto the concrete, landing on his left side. He immediately experiences pain in his left side, left wrist, and abdomen. His left wrist is angulated and obviously broken. His friend responds to Patient E's cries for help and calls 911. EMS personnel respond to the scene, stabilize his wrist, and transport him to the local emergency department for evaluation.

A head-to-toe assessment demonstrates small, superficial scrapes on the patient's forehead and left cheek. His facial structures appear to be intact. Neurologically, he is normal, with a GCS score of 14. He has no complaints of shortness of breath, and his chest wall shows no obvious external injury. He complains of pain when the left upper quadrant of his abdomen is palpated. His pelvis appears to be without injury. His lower extremities are bruised and have superficial contusions and abrasions, which are contaminated with dirt and rocks. An x-ray of his left wrist shows a comminuted fracture of his left radius and ulna.

Cervical spine x-ray, laboratory results, and urinalysis are all normal. At this time, the focus of treatment is on his left wrist and the pain in his abdomen. Abdominal CT scan is obtained and is normal, and liver injury is ruled out. Subsequently, Patient E is taken to the operating room for orthopedic repair of his left wrist.

After surgery, he is admitted to the orthopedic floor with orders for pain medication as needed. Repeat liver function tests are obtained on an every six-hour basis. After being settled in bed, he appears to be stable and enjoys the attention that the injury has brought him.

During the middle of the night, the patient awakens and complains of severe pain in his left wrist. He is medicated with narcotics as ordered and appears to drift off to sleep. Two hours later, he is again awake and complaining of wrist pain. As the narcotic was ordered on an every four hour basis, the nurse must obtain an order for additional narcotic, which she does. After this second dose of pain medication, the patient again drifts off to sleep.

During the next day, he has a number of visitors. He continues to complain of pain in his wrist, but when observed, he is seen to be laughing and joking with his friends. The nurse caring for Patient E asks him to rate his pain on a scale of 1 to 10 with a reply of 8. The nurse continues to observe him and has a hard time believing the pain is as severe as 8. Two hours later, the patient again calls the nurse, this time giving a pain score of 9, and he is medicated by another nurse. The nurse medicating him checks his cast and finds it to be tighter than it had been earlier in the day, and capillary refill in his left hand is slower than on this right hand. She instructs him to keep the casted arm elevated on a pillow while visiting with his friends.

Later that evening, the patient again complains of pain with a score of 9. He is again medicated and drifts off to sleep after a busy day. During the middle of the night, he is crying and says that his hand hurts more than it ever has. His cast is tight, and his left hand is cool to touch. The orthopedic surgeon is notified by telephone, and the in-house physician evaluates Patient E. The in-house physician recommends that the patient be returned to the operating room for evaluation, and the orthopedic surgeon arrives at the hospital within the hour.

In the operating room, Patient E's hand is pale, with weak pulses and a significantly reduced range of motion. A diagnosis of compartment syndrome is made, fasciotomy is performed, and the wrist is placed in another cast that is bivalved. Eventually, the patient's wrist heals, and he regains full range of motion after intensive physical therapy.