#92074: Care of the Pediatric Trauma Patient

Trauma is the primary cause of mortality and morbidity in the pediatric population [1,2]. Although great efforts have been made to educate the public on many safety issues, unintentional injury and death rates in children remain high. Pediatric trauma should be considered largely a preventable disease.

While the number of motor vehicle-related injuries continues to fall, the overall incidence of related pediatric trauma remains fairly stable. According to the Centers for Disease Control and Prevention (CDC), motor vehicle accidents (MVAs) are a leading cause of injury and death among children in the United States [2].

According to the CDC, MVAs and drowning are the two leading causes of death for children 1 to 14 years of age [3]. Other forms of intentional violence, poisonings, firearms, fire/burns, suffocation, sexual assault, and maltreatment are also common causes of trauma and fatality in the pediatric population [1,2,3]. The economic burden of injuries in children and adolescents is considerable and further exacerbated when factoring in the lifetime costs involved in treating and caring for these patients [3,4].

The pediatric population accounts for approximately 24.6 million visits to emergency departments each year [5]. Of the pediatric patients treated in hospitals, the mortality rates vary. One study found that pediatric units within adult hospitals had the highest mortality rate at 2.4%. The lowest mortality rates were found in pediatric centers, which had a 0.9% mortality rate. The length of hospital stays in these different facilities mirrored these findings [6]. According to a survey by the CDC, 87% of hospitals with 24-hour emergency departments admit pediatric patients but only 40% have wards specifically for these patients, have a pediatric intensive care unit, or are a children's hospital [7].

Although the statistics remain sobering, it is important to remember that pediatric trauma care has made a significant improvement in the outcomes of these injured children. Due to the implementation of rapid field resuscitation and early transport to a center specializing in pediatric trauma care, the overall mortality rate due to traumatic injury is approximately 8% (as of the last reporting from 2016) [8].

In caring for the injured child, it is imperative that the healthcare provider consider the unique anatomic and physiologic parameters of children. These factors predispose the child to unique patterns of injury as well as unique resuscitative requirements. This course will focus on the patterns of childhood trauma and measures to reduce the mortality and morbidity of these devastating injuries.

Most traumatic deaths occur during the first hour after injury. Interventions during this "golden hour" are aimed at preservation of blood volume and reduction of the effects of severe traumatic brain injury (TBI). The majority of these injuries may not be survivable; however, all efforts should be instituted to support the life of the child during this time.

Once stabilized, the risk of death remains high during the next 23 hours. The child who has sustained trauma to major body organs and has ongoing hemorrhage may not survive this period. Additionally, significant head injury may cause massive swelling and subsequent herniation and death. It is during this time period that aggressive resuscitation efforts may positively impact patient outcomes.

Optimistically, the child will survive this first 24 hours; however, astute assessment and interventions continue to be required to reduce the sequelae of trauma, including multiple organ failure and post-traumatic respiratory distress syndrome. The risk of death and disability remains high throughout the first two weeks after injury. Although the child may survive this two-week stretch, there are patterns of injury in which children sustain delayed onset of complications (greater than two weeks post-injury) that carry a high risk of death.

There are a number of factors that impact the pattern of injuries. Age, sex, behavior, and locale all influence the types of injuries sustained. Children with the statistically highest risk of sustaining injury are school-aged boys [4]. The injuries sustained at this age group will differ from those occurring during infancy or adolescence.

Infants (1 month to 1 year of age) are at risk for sustaining injury in the home environment. Falls and unintentional strikes are leading mechanisms of injury but are rarely a cause of death, while unintentional suffocation (i.e., choking, strangulation, asphyxiation) and homicide are leading causes of mortality in this age group [3]. Falls can occur from furniture, stairs, or while in walkers. Studies have noted the possibility of trauma associated with child carriers (such as portable car seats) when a child is not properly secured or is left unattended and inadvertently tips the carrier [9]. Children at this age may be unrestrained in a MVA and suffer significant multisystem injury. Fatal child abuse, particularly abusive head trauma, is also prevalent at this age.

Toddlers (1 to 3 years of age) and preschoolers (3 to 6 years of age) are most likely victims of drowning or motor vehicle trauma, both as passengers and as pedestrians [3]. Many bicycle deaths in this age group occur when a small child is struck by a car or truck because their small stature prevents them from being seen by rearview mirrors. Many vehicles now have rearview cameras and motion detectors to help prevent this type of accident. The inquisitive nature of children in this age group also increases the risk of injury. Falls, poisonings, and burns occur when children are unattended and encounter danger that they cannot defend themselves against nor comprehend. The toddler and preschooler may also be victims of abuse and homicide.

As noted, the largest risk of injury occurs during the school-age years (7 to 12 years of age). These children are developing a sense of independence and freedom, which predisposes them to new risks. Many school-age children are injured while riding in a motor vehicle. A unique injury in children is known as "lap belt complex," whereby the child sustains injury secondary to the lap belt restraint.

School-age children are the most likely age group to sustain injury while riding a bicycle. Although bicycle helmet laws exist in many states, the compliance with such laws remains low. It is important to note that the use of a bicycle helmet can reduce the risk of brain injury by as much as 63% to 88% [10]. Advances in helmet designs are further reducing the incidence of traumatic brain injury as a result of bicycle accidents [11].

Other types of injuries in children 7 to 12 years of age include falls, poisonings, and drowning. The incidence of personal violence increases, and the number of suicides in this age group is increasing annually [3]. The incidence of school-ground trauma has also become more prevalent.

Many teenagers (13 to 19 years of age) are injured in automobiles. As these children begin to drive, the risk of both driver and occupant injuries becomes more common. Studies have shown the incidence of injury increases with the number of peers in an automobile, thus reigniting the debate regarding restricting driving privileges of young, newly licensed drivers.

Many socioeconomic and cultural influences impact the type and incidence of trauma. Urban children have a higher incidence of violence; the presence of youth gangs, alcohol use, and drug use is highest in this environment. Patterns of behavior and injury are also impacted by the race of the child; young non-Hispanic Black individuals 20 to 24 years of age have the highest proportion of homicide deaths, frequently precipitated by firearms [12].

The suicide rate in teenage individuals increased threefold between 1950 and 1990; it began to decrease in the late 1990s, but since 2000 the incidence has increased annually [3,13]. Suicide is the second leading cause of death for children 10 to 14 years of age and the third leading cause of death for adolescents 15 to 24 years of age [3]. In 2021, adolescents and young adults 15 to 24 years of age had a suicide rate of 15.2%, with the highest rate (15.6%) among White youths [13]. Native American/Alaskan Native youths had the second highest rate for suicide deaths [13]. Hispanic youths are more likely to attempt suicide than non-Hispanic Black or White children.

Alcohol and drug use increases during this age, and the impact of impaired behavior will influence injury and death rates. Younger teens may experiment with inhalants; "huffing" or sniffing volatile agents will increase the risk of sudden sniffing death (SSD). It is estimated that there are more than 1,400 agents available over the counter that can be legally purchased by young teens as a method of getting high [14].

An emerging area of research in trauma epidemiology is the impact of sports-related activities on traumatic injury and death. Head injuries and sudden cardiac death are just two of the areas of study; sporting activities can also cause a multitude of orthopedic and musculoskeletal injuries. Football, soccer, baseball, and skateboarding are just a few of the sports that have been recognized as injury-producing activities.

Traumatic injuries can present as either penetrating or blunt injuries. Although the incidence of penetrating injuries in pediatric patients is less than in adult trauma victims, the number of gun and knife injuries is increasing [3]. While penetrating trauma can be more easily recognized and diagnosed, blunt injuries can be equally life threatening.

Blunt injuries present the challenge of recognition of injury and appropriate diagnosis. Missed injuries secondary to blunt trauma pose a risk, especially in the pediatric patient. Many missed injuries are thought to be related to the level of consciousness of the child; however, one study showed that the inability to communicate was not associated with an increased incidence of missed injury [15]. The prevalence of missed injuries among pediatric trauma patients has varied among studies, from 1% to 18% [16]. It is imperative that healthcare providers caring for pediatric victims be aware of this risk.

The most life-threatening of all traumatic injuries in the pediatric population are those that occur to the head and face. TBI is a major cause of death and disability. According to the CDC, there were 214,110 TBI-related hospitalizations in 2020 and 69,473 TBI-related deaths in 2021, representing more than 587 TBI-related hospitalizations and 190 TBI-related deaths per day [63]. In particular, treatment for sports- and recreation-related TBI has become more prevalent; the number of children and adolescents treated for nonfatal TBI resulting from sports or recreation activities increased significantly between 2001 and 2009, from 153,375 to 248,418, to an average of 283,000 during 2010–2016 [64,65]. However, the CDC has reported that sports and recreation TBIs decreased 32% between 2012 and 2018, likely due to a decline in football-related TBIs. It was noted that increased public awareness of sports-related TBIs resulted in decreased participation in tackle football among children and adolescents, as well as implementation of contact limitations [65]. While this information is promising, prevention efforts for sports- and recreation-related TBI should continue and these strategies should be implemented for other sports with a high risk.

Trauma to the head and face can cause injury to the scalp, skull, facial structures, and brain, although survival and outcomes are directly determined by the extent of injury to the brain. The focus of this section will be primarily on injuries to the brain, concluding with a brief discussion of injuries to the facial structures, including the ocular system.

The majority of traumatic injuries affecting the head and face are a direct result of MVAs, falls, and sports activities. Motor vehicle versus pedestrian injuries are common in school-age children, while child abuse is a major cause of brain injury in children younger than 1 year of age. Additional mechanisms of injury include bicycle injuries and assaults. Boys have a higher incidence of head trauma than girls [64].

HEAD TRAUMA

Traumatic injuries to the head may impact the skull, the neural tissue, and/or the cerebral vasculature. An extensive amount of research and study is directed at either mild (minor) or major, extensive brain injury. This section will focus first on the types of injuries and the unique patterns of injuries seen in children, followed by an in-depth discussion of the treatment and outcomes following both minor and major brain injury.

When the head is injured, it is important to remember that two types of injury are possible: primary and secondary. Primary injury is that injury to the head and brain that occurs at the time of trauma. Healthcare professionals have little control regarding the development of this type of injury, with the exception of education regarding prevention. Secondary injuries occur as a result of the trauma; examples include cerebral edema, bony fragments, and delayed vascular injury. Different portions of the brain demonstrate different responses to injury. For example, the area of primary trauma may exhibit vasospasm, while another area may develop vascular leak as a result of secondary injury. Trauma care of injuries to the head and brain is directed at preventing or controlling the development of secondary injury.

The most apparent head injury is a scalp laceration. Blunt force applied to the head will cause tissue disruption, leading to hemorrhage. In small children, uncontrolled hemorrhage may cause exsanguination attributable to the high density of the vascular bed in the scalp. In most patients, pressure dressings applied to the injury may slow or stop this loss of blood. In acute situations, hemostats and ligation or cautery of scalp vessels may be required to staunch the ongoing blood loss.

A pattern of injury that may be of concern to parents is the development of a cephalohematoma as the result of bleeding and swelling between the scalp and the skull. This form of injury, if isolated, is treated with observation and follow-up until resolution is achieved, which may require several weeks. However, it is critical that during this recovery period assessments are performed faithfully to rule out any delayed onset of TBI.

Skull fractures are described by their type: linear, depressed, compound, basilar, ping-pong ball, and growing. Seventy-five percent of pediatric skull fractures are linear fractures, or simple cracks in the bone[66]. If no underlying injury develops, the child will have complete resolution of the fracture site. Over time, this fracture line may completely disappear from x-ray as remodeling of the skull occurs.

Depressed fractures cause disruption of the integrity of the skull. The depth of the depressed segment correlates with the extent of injury; the deeper the depression, the greater the risk of underlying traumatic injury to the cranial contents. It is recommended that any child sustaining a depressed injury undergo a head computed tomography (CT) scan or possibly magnetic resonance imaging (MRI) to fully evaluate the extent of injury. A tear in the dura will increase the risk of infection and post-traumatic seizure development.

Compound fractures complicate the diagnostic process because multiple bony fragments must be evaluated. Each fracture segment must be assessed for depression and disruption of the dura mater. Creation of a compound fracture requires a tremendous application of external force to the skull. Suspecting nonaccidental trauma (such as child abuse) should be a consideration when caring for the child sustaining this type of injury.

Basilar fractures occur at the base of the skull and may be easily diagnosed by specific characteristic signs and symptoms. The child with a basilar skull fracture may exhibit CSF leakage from the nose (rhinorrhea) or ears (otorrhea), "raccoon eyes," and hemotympanum. A delayed but diagnostic sign is ecchymosis over the mastoid region behind the ear (Battle's sign), which may take up to 8 to 12 hours to appear. This ecchymosis is commonly associated with a fracture of the temporal bone. Any fracture occurring at the base of the skull can be accompanied by injury to the ocular, cochlear, and facial nerves, leading to concomitant loss of vision, hearing, or facial muscle function. Furthermore, these fractures are considered to be open, allowing introduction of organisms into the cranial vault with subsequent risk of meningitis development.

Two types of skull fractures are unique to the pediatric trauma victim. The "ping-pong ball" fracture is a dent in the skull; the segment is depressed but no fracture lines are evident on x-ray. The "ping-pong ball" designation was coined when someone noticed that the appearance of this type of fracture is similar to that of a ping-pong ball when it is indented. This type of fracture is only seen in small children, generally younger than 2 years of age, due to the minimal mineralization of the skull. The inherent risk of this depressed segment is the underlying damage to the cranial tissue. The depressed segment is commonly surgically elevated to reduce its impingement into the cranial vault and to prevent the formation of cosmetic deformities.

Another unique skull fracture in children is the growing fracture, also known as a leptomeningeal cyst. This type of fracture occurs when the dura is torn and there is accumulation of CSF in the extradural space. If this cyst develops, the fracture site appears to be growing as the cyst increases in volume. Over time, if not recognized and treated, the cyst can enlarge to the point of producing brain tissue compression. Obscuring the diagnosis is the inability to visualize the dura on plain skull radiographs. MRI is the best method for dural integrity evaluation, although availability and cost issues often make this modality less practical in some locations. Patients with a higher risk of dural tears and subsequent cyst formation are those with a diastasis of 3 mm or greater and a young age. Ultrasound is also used to diagnose these tears. Normally, ultrasound waves do not penetrate an intact skull, but an opening (fracture) will allow the beam to pass through, and the practitioner can examine the integrity of the dura[67].

Injury to the neural tissue can vary in severity from a concussion, the mildest form, to a contusion or a diffuse axonal injury, producing severe, profound coma. A concussion produces a temporary disruption of cerebral function, generally lasting less than one day. The term MTBI is often used interchangeably with the term concussion.

Contusion injuries of the brain cause a more prolonged compromise of cerebral function than a concussion. On examination, the brain tissue is edematous and may have signs of localized hemorrhage. Loss of consciousness may occur for prolonged periods of time, and recovery outcomes may be unpredictable at the time of initial evaluation. Often, contusions occur as "coup-contrecoup" injuries. This injury emerges during rapid acceleration and deceleration of the head as occurs in a MVA. The "coup" injury occurs when the brain impacts the interior of the skull, leading to injury of the brain tissue at the site of impact. The "contrecoup" lesion can be of greater consequence; this lesion occurs on the brain at the side opposite from the initial impact. In other words, the brain is bouncing around inside the skull, causing damage to a number of areas in the brain. The greater the damage to the neural tissue, the greater the risk of severe brain injury.

Diffuse axonal injury is due to severe, sudden deceleration, often accompanied by rotational forces. This injury is described as a shearing injury; the axons within the white matter are torn, leading to disruption of the connections between the cortex and the lower brainstem. The coma that develops is profound and deep; some children remain in a persistent vegetative state following this type of injury.

Disruption of the cerebral vasculature produces a cerebral hematoma or hemorrhage. Accumulation of blood between the dura and arachnoid layers produces a subdural hematoma, the most common type of intracranial hemorrhage in children. Subdural hematomas are generally venous in origin and are classified in three categories: acute, subacute, and chronic. The child with an acute subdural will present with immediate alterations in cerebral functioning. A subacute subdural hematoma develops within two weeks of injury and is defined by a progressing decrease in level of consciousness during this time frame. A chronic subdural hematoma is commonly diagnosed months later when a child is evaluated for changes in personality, behavior, and/or cognition or an onset of seizures. The actual cranial insult may have been forgotten by the time of diagnosis.

An epidural hematoma occurs when blood accumulates between the skull and dura and is most commonly associated with a tear of the middle meningeal artery. This child may demonstrate rapid deterioration of mental status, possibly leading to profound coma. However, unique to children is an epidural hematoma that is caused by a venous bleed. These children may initially be asymptomatic. Neurologic deterioration occurs over time, thus compounding the diagnosis. An epidural bleed is easily diagnosed by head CT scan; the blood accumulation is said to be egg-shaped or lenticular.

Subarachnoid hemorrhage occurs when blood is deposited between the arachnoid and meningeal layers. Violent shaking of a child, such as in abusive treatment, can produce this type of intracranial hemorrhage. If a subarachnoid hemorrhage is suspected, a lumbar puncture will provide confirmation. However, lumbar punctures should be avoided in patients with epidural or subdural hematomas and should only be performed when these types of intracranial hemorrhages have been first ruled out and there is no evidence of increased ICP.

Intracerebral hemorrhage can occur at the direct site of impact where blood aggregates in the parenchymal tissue. The size of the hemorrhage directly influences the treatment and subsequent outcome of the child. A large hemorrhage will require surgical evacuation to prevent development of mass effect and herniation syndromes. Smaller lesions may be treated conservatively, as the excess blood will be resorbed over time.

Evaluation of the child with a suspected or confirmed traumatic injury to the head requires astute observation of the child's initial level of function and any subsequent changes in this level. As mentioned earlier, brain injuries are classified as mild (minor), moderate, or severe based upon the child's GCS score. The difficulty in utilizing the GCS score is that the method of scoring does not take into consideration children at varying levels of developmental maturation; thus the Modified Glasgow Coma Scale for Children has been developed (Table 4).

PEDIATRIC GLASGOW COMA SCALE

Score	Responses by Age
Eyes Opening
	Patient >1 year of age		Patient <1 year of age
4	Spontaneously		Spontaneously
3	To verbal command		To shout
2	To pain		To pain
1	No response		No response
Motor Response
	Patient >1 year of age		Patient <1 year of age
6	Obeys		Spontaneous
5	Localizes pain		Localizes pain
4	Flexion-withdrawal		Flexion-withdrawal
3	Flexion-abnormal (e.g., decorticate rigidity)		Flexion-abnormal (e.g., decorticate rigidity)
2	To pain		To pain
1	No response		No response
Verbal Response
	Patient >5 years of age	Patient 2 to 5 years of age	Patient<23 months of age
5	Oriented and converses	Appropriate words or phrases	Smiles, coos, or cries appropriately
4	Disoriented and converses	Inappropriate words	Cries and consolable
3	Inappropriate words	Persistent cries and/or screams	Persistent inappropriate crying and/or screaming
2	Incomprehensible sounds	Grunts	Grunts or is agitated or restless
1	No response	No response	No response

Table 4

Source: [68]

According to the American College of Radiology, children 2 years of age and older who present with minor head injury (Glasgow Coma Scale score >13) without neurologic signs or high risk factors (e.g., altered mental status, clinical evidence of basilar skull fracture) do not require imaging studies. This recommendation excludes nonaccidental trauma.

(https://acsearch.acr.org/docs/3083021/Narrative Last Accessed: December 15, 2023)

Strength of Recommendation: 3 (Usually not appropriate)

One of the major areas of concern in treating the child with a head injury is recognition of the extent of injury. A child who is diagnosed with a mild head injury may be sent home but the risk of delayed complications is always of concern. Identification of the extent of injury includes assessment of the child over a period of time, recognition of symptoms that have a high incidence of delayed complications, and the use of diagnostic evaluation tools such as CT scans and MRIs. Unfortunately, no purely clinical indicators, either alone or in combination, have been found to detect structural brain injury.

Imaging recommendations have been developed to afford the healthcare provider with an organized strategy in determining when a child is a candidate for imaging studies. The liberal use of these studies can place undue burden upon the financial resources of the family and the healthcare system, while the underuse of these studies can lead to an increased risk of missed injuries, possibly leading to death or permanent disability in the child. One study demonstrated that 63% of scans in children with a GCS score of 13 or 14 were abnormal. These children had sustained injuries such as skull fractures, intracerebral hemorrhages, and cerebral contusions despite good neurologic function upon initial evaluation [69].

Children older than 2 years of age who present to the emergency department with a history of a mild head injury and who are neurologically normal and remain asymptomatic do not require imaging studies. If these children are symptomatic, with a history of loss of consciousness, vomiting, headache, drowsiness, irritability, or post-traumatic amnesia, CT scanning should be considered [69]. If obtaining a scan is not practical, overnight hospitalization with astute assessment may be indicated. For the child with overt signs of neurologic compromise, CT scanning should be utilized to rule out underlying cranial injury.

Children younger than 2 years of age are more difficult to assess for a number of reasons. Verbal and motor skills may not be adequately developed to allow for accurate assessment and the sequelae of the head injury may vary. Infants may develop scalp hematomas in conjunction with a skull fracture. The liberal use of neuroimaging and skull radiographs is considered appropriate after injury in this age group [70,71].

A child who is profoundly comatose is obviously one who has sustained major injury. However, MTBI is much more difficult to accurately assess. The CDC defines TBI severity as mild (MTBI or concussion), moderate, or severe, based on clinical presentation of a patient's neurologic signs and symptoms. A TBI can result in health effects that vary in intensity, length, and clinical manifestation. These health effects include disturbed cognition, headaches, fatigue, and sleep disturbances. A majority of patients, particularly those with MTBI, will generally experience one or more of these health effects for a short time following injury. Criteria used to classify MTBI include normal structural imaging, loss of consciousness less than 30 minutes, 0- to 1-day post traumatic amnesia, GCS score of 13–15, and an Abbreviated Injury Scale score of 1–2 [72].

If neuroimaging does not demonstrate evidence of underlying brain pathology, the child may be considered a candidate for discharge. Discharging the child to home is impacted by a number of issues, including medicolegal concerns and economic factors. Because the family must have access to proper care, distance and transportation to an appropriate facility must be investigated prior to discharging the child.

A child who is discharged after sustaining a MTBI must be cared for by an individual who will comply with recommended discharge instructions. The importance of frequent observation of the victim cannot be overlooked. Reiteration of the following instructions will enhance care provider compliance.

A child should be awakened every two hours. The child should be assessed for the ability to speak coherently and move his/her arms and legs. Pupils should be checked (the care provider should receive a demonstration on how to best check pupillary size and response). Any possible abnormal responses should be listed on the home care instructions, along with actions to take should these abnormal responses develop during the course of care. The care provider should notify the emergency department (or appropriate healthcare provider) if the child:

• Demonstrates excessive sleepiness

• Vomits more than twice

• Has unequal or abnormally shaped pupils

• Develops slurred speech

• Complains of a headache that worsens

• Demonstrates change in ambulation

• Develops seizures

If any of these signs are present, the child should be transported to the appropriate healthcare facility for further evaluation. The key to prevention of long-term sequelae is the early detection of patient deterioration.

Moderate and major traumatic brain injuries are those that produce a GCS score of less than 13. A GCS score of 9 to 12 is classified as a moderate injury [72].

A GCS score of 8 or less is an indicator of severe injury, and of these patients, 50% will die as a result of their injury [72]. The most frequent pathologic finding after severe head injury is diffuse brain swelling and edema, and this is two to five times more common in children than adults.

Signs and symptoms suggestive of moderate-to-severe brain injury include a loss, or decreasing level, of consciousness, focal neurologic abnormalities, and coma. Management of neurotrauma in this population is based upon two mainstays of treatment: controlling hypotension and controlling hypoxemia. Initial resuscitative efforts should be directed at preventing these two complications, beginning in the field and progressing through the emergency department and into the critical care unit.

Hypotension in brain-injured children can be multifactorial. Children can sustain acute blood loss from multiple traumatic injuries, and neurogenic hypotension can develop subsequent to the cerebral injury. Prehospital care providers must immediately control significant blood loss at the scene. Fluid resuscitation to prevent hypotension should be initiated early. During transport, isotonic, glucose-free fluids should be given, although the amount and rate of administration remains an area of debate. Studies have shown that isolated hypotension in children can triple the mortality from pediatric brain injuries [73]. Couple the hypotensive episode with hypoxemia, and the mortality rate can quadruple [74].

Preventing hypoxemia means obtaining rapid control of the airway and supporting ventilation in the brain-injured child. Rapid sequence intubation should be utilized to obtain endotracheal tube placement as quickly as possible. All advanced life support personnel should be trained in rapid intubation techniques of children; the need for early intubation is standard in head injury resuscitation guidelines. With rapid airway control, children can arrive in the emergency department adequately ventilated, with improvement in their long-term outcomes. The exception is the child who has sustained concomitant chest trauma, such as a pneumothorax, which can lead to ongoing hypoxemic episodes.

Monitoring the child with a severe head injury can be challenging in many adult critical care units; thus, these children require transport to a specialized pediatric center with neurologic monitoring capabilities. Management strategies tend to aim at the management of cerebral perfusion pressure (CPP) rather than simply instituting therapies aimed at decreasing ICP. Mean arterial pressure (MAP) minus ICP equals CPP: CPP = MAP – ICP. Thus, preventing hypotension and maintaining an adequate MAP will help ensure adequate cerebral perfusion. Although ideal CCP has not been identified and varies based on the patient, a threshold of 40 mm Hg for patients 0 to 5 years of age and 50 mm Hg for patients 6 to 17 years of age has been suggested [75,76].

The Brain Trauma Foundation recommends that bolus hypertonic saline (3%) be given to pediatric patients with intracranial hypertension. Recommended effective doses for acute use range between 2 and 5 mL/kg over 10 to 20 minutes.

(https://journals.lww.com/pccmjournal/fulltext/2019/03001/guidelines_for_the_management_of_pediatric_severe.1.aspx Last Accessed: December 15, 2023)

Level of Evidence: II (Based on a moderate-quality body of evidence)

Fluid management of the injured patient is aimed at preservation of blood volume and mean arterial pressure. Many advances in the methods of volume management have been studied in adult patients, but few studies have been instituted on pediatric neurotrauma patients [76]. In the adult patient, the use of hypertonic saline with accompanying control of osmolarity has been successful in controlling cerebral swelling. These strategies are currently being studied in children, and although controversy exists, many neurologists and neurosurgeons will recommend these measures for the management of intracranial hypertension in the severely brain-injured child.

Other management strategies that are accepted include prevention of hyperthermia and hyperglycemia. Although in other parts of the world, including Europe, induced hypothermia is frequently instituted in trauma management, the U.S. studies of induced moderate hypothermia to control increased ICP have not found the technique to be beneficial [77,78,79]. Hyperglycemic episodes following brain injury have been found to reduce the incidence of positive outcomes; therefore, hyperglycemic fluids are avoided in the resuscitative and critical care phases of care.

One of the more common sequelae to brain injuries in children is the development of post-traumatic seizures. The incidence ranges from 1% to 6%; the more severe the injury, the greater the risk of seizure development. The injuries with the highest risk of seizure development are those that penetrate the dura, cause intracranial hemorrhage, or produce prolonged (>12 hours) unconsciousness [69].

According to the American College of Radiology, children experiencing post-traumatic seizures should undergo MRI or CT scan of the head without contrast.

(https://acsearch.acr.org/docs/69441/Narrative Last Accessed: December 15, 2023)

Strength of Recommendation: 9 (Usually appropriate)

Post-traumatic seizures are classified as early or late. Early seizures develop within the first 24 hours after injury and have the potential to exacerbate secondary injury. Late post-traumatic seizures occur a week or more after the traumatic episode. The prophylactic use of antiepileptics is not recommended in most patients. Those who may benefit from this prophylaxis are those with cranial penetration or hemorrhage. For children with mild head injuries and normal imaging studies, post-traumatic seizure management can be safely done on an outpatient basis and does not warrant hospitalization [76,80].

Advances in neurotrauma care include pharmacotherapy to control secondary injury, new monitoring modalities, and improved imaging techniques. Neuroprotective drug agents may prove to be useful. These drugs act on the neurochemical mediators of secondary injury, limiting long-term injury. Although improvement has been noted in some patients, global acceptance of these agents has yet to be achieved. Monitoring of patients is expanding beyond ICP monitors; both global and local sensors have demonstrated usefulness in providing information regarding patients' responses to therapies. Imaging techniques allow monitoring of the injured brain, blood flow, oxygenation, and metabolism, providing information on the exact location of compromise [57].

Management of brain injuries in children remains an area of intensive research and study. Resuscitation of the brain of the injured child involves achieving a balance between ICP reduction strategies and enhancing cerebral perfusion. Reduction of secondary injury should be utmost in the minds of all healthcare providers caring for the child with head injuries.

Although rare, accounting for approximately 5% of all cases of spinal trauma, pediatric spinal trauma is a devastating and life-threatening injury[84]. The long-term sequelae and physical requirements are phenomenal; throughout the lifespan of the injured child, the medical, emotional, and economic impact can be immense.

The types of spinal trauma sustained by children are age-dependent and are, to some extent, due to the anatomic changes that occur with aging. Approximately 60% to 75% of injuries sustained involve the cervical portion of the neck[84,85].

MVAs are by far the most common mechanism of injury to the spine in the pediatric population[86]. In addition to MVAs, children sustain injuries in acts of violence, falls, and sports-related activities[86].

Compression and contusion injuries are more common than transection of the cord. The point of maximum mobility of the cervical region progresses caudad with age. Maximal mobility is between C1 and C3 in the child younger than 8 years of age and between C3 and C5 in children 8 to 12 years of age. By 14 years of age, the adult pattern of mobility is seen, with maximum mobility at the C5 to C6 level. This mobility pattern sets the stage for the type of injury sustained. The younger child is more likely to have a higher level of injury than the older child[85].

Age-dependent variables impact not only the level of injury but the type of injury as well. Small children have large heads and higher centers of gravity. In flexion injuries, the head will be the leading object, causing significant change in the shape of the vertebral column and cord. The muscles of the neck are underdeveloped, so flexion and extension injuries, such as "whiplash," are common. This flexibility of the spinal column means that children have a lesser number of fractures and a higher incidence of compression injuries when compared to adult patients. Regardless of this degree of movement, it is vital to remember that the cord is fixed both distally and anteriorly. The cord is anchored by the cauda equina at the termination of the cord and attached by the lumbar and brachial plexus at the anterior end. Thus, with movement, the cord will either be stretched or compressed.

Neck injuries involve more than the cord and vertebrae because the ligaments, the vasculature, and the airway may also be compromised. The most common finding upon physical examination in the child with a cervical spinal injury is midline cervical tenderness. Neurologic deficits may be present upon initial examination or may not develop until later in the course of care. Any child with a mechanism of injury suggestive of a spinal injury should be treated with full spinal precautions.

Other symptoms may include muscle spasms, limitation of neck movement, and neurologic deficits. Paralyzed intercostal muscles may produce a "see-saw" respiratory pattern whereby the chest retracts and the abdomen distends with inspiration. This indicates that the sole muscle responsible for respiration is the diaphragm, and ventilatory support should be readily available if needed. The presence of other associated traumatic injuries should be determined, with head trauma being the most frequently occurring concurrent injury.

Testing neurologic function should begin as soon as possible after CAB support has been secured. Testing should include both pinprick and light touch, as these sensations are carried in different tracts of the cord (the anterior portion of the cord carries the pain fibers, while light touch is carried in the posterior columns). The level of function may be rapidly assessed utilizing the chart inTable 5. It is essential to remember that C4 innervation is necessary for respiration; patients with injury to C4 or above will most likely require ventilatory support. However, healthcare providers must remember that cord edema can progress both proximally and distally, and it is important to assess ventilatory effort in any child with a cervical injury regardless of its location.

Many children suffer contusion and compression injuries, as mentioned. This type of damage may lead to an incomplete injury, producing an identifiable pattern of function. Anterior cord syndrome most commonly occurs secondary to hyperflexion of the neck. This produces a pattern of complete motor paralysis below the level of injury. Additionally, pain sensation is lost, but light touch remains intact. Central cord syndrome is common with a compression injury and produces a muscle weakness or paralysis that affects the upper extremities to a much greater degree than the lower extremities. Brown-Sequard syndrome (also known as half-cord syndrome) occurs when half of the cord is injured, producing paralysis and loss of proprioception and touch on the same side as the cord damage, while loss of pain and temperature occurs on the side opposite of the cord lesion [87]. These cord syndromes may or may not be reversible dependent upon the extent of damage and the subsequent degree of post-injury edema.

SCIWORA is a pattern of trauma that is unique to the pediatric population. The traumatized child will present to the emergency department with transient neurologic and/or motor deficits; however, radiologic examination demonstrates a normal spinal column. SCIWORA develops in children because the vertebral column is able to stretch up to 2 inches, while the cord can only elongate one-quarter of an inch without causing cord disruption [85]. If the vertebral column is stretched within its limits, but beyond the limits of the cord, the cord will be compromised, producing neurologic symptoms despite the normal cervical spine x-ray.

The physical findings of SCIWORA cannot be ignored even though a cervical spine film is normal. Unfortunately, many patients with SCIWORA have a complete injury and lifelong disability, and some patients may have a delayed onset of neurologic deficits [85]. Patients may complain of or demonstrate transient symptoms immediately after the injury, including paresthesia of the legs and hands, generalized weakness, and/or a lightning (burning) sensation down the spine associated with neck movement. The delay in onset of symptoms ranges from 30 minutes to four days [88]. In many instances, the child may have been discharged to home and experience these deficits either at home or school, away from medical care. Additionally, there appears to be a risk of developing a second, more severe spinal cord injury, often due to trivial trauma, between 1 to 10 weeks after the initial injury [88].

Although the focus of most pediatric trauma education is directed at recognition and treatment of cervical spine injuries, it must be remembered that injuries occur at all levels of the spinal column. In small children, the most lethal injury occurs at C2 and is known as a hangman's fracture. The neck is hyperextended and the cord disrupted, leading to immediate loss of ventilatory drive and subsequent death. Trauma between C3 and C7 is difficult to diagnose as most of these injuries are ligamentous in nature. Patients with a C7 fracture commonly have an associated upper rib fracture.

Thoracic spine injuries are most commonly compression type injuries, often sustained in falls. The thoracic spine has strong disks and end plates and obtains supplemental support from the rib cage. Compression injuries have relatively good outcomes when treated with symptomatic support and rest.

Fractures occurring in the thoracolumbar region are commonly burst injuries. A Chance fracture occurs when a lap-belt-only type of restraint is utilized. In a high-speed deceleration, the child flexes over the restraint device, stretching and displacing the vertebral column. These injuries are often accompanied by internal abdominal injuries, producing the pattern of injury known as lap belt complex.

Lumbar fractures may also be caused by lap belt use. Frequently, the disk is injured and may protrude between L3 and L5. Unstable fractures are frequently repaired surgically; the resultant kyphosis that may occur can lead to loss of stature as the child matures.

Diagnosis of spinal injury includes positive findings during physical assessment, radiologic evidence, and a high index of suspicion. A single lateral cervical x-ray is not adequate in many instances; however, three views (cross-table lateral, anteroposterior, and odontoid views) will improve the sensitivity of this diagnostic tool. The series must include all seven cervical vertebrae to allow for full evaluation.

The Congress of Neurological Surgeons does not recommend cervical spine imaging in children who are older than 3 years of age who have experienced trauma and who are alert, have no neurologic deficit, have no midline cervical tenderness, have no painful distracting injury, do not have unexplained hypotension, and are not intoxicated.

(https://www.cns.org/guidelines/browse-guidelines-detail/18-management-of-pediatric-cervical-spine-spinal-c Last Accessed: December 15, 2023)

Strength of Recommendation: II (Reflects moderate clinical certainty)

While x-rays remain the standard for rapid evaluation and gross screening of injury, MRI provides the practitioner with the most definitive information. MRIs allow for screening of soft tissue injuries, including edema and hematomas, and are considered the diagnostic method of choice for determination of cord injury [89].

Confounding radiologic diagnosis is the difference in anatomic development of children at various ages. Up to 46% of children younger than 8 years of age may demonstrate a pseudosubluxation of C2 on C3. Growth plate lines that are fusing may be interpreted as fractures. Lordosis, which is present in adult radiographs, may be normally absent in children up to 16 years of age [88]. In unclear cases, a radiologist specializing in reading pediatric spinal films should be consulted.

Immediate management of the child suspected of sustaining spinal trauma includes instituting full spinal precautions, securing the child to a backboard, and stabilizing the neck to prevent flexion, extension, and rotation. Hard cervical collars may not be available in the appropriate size, and utilizing a poor fitting collar may cause more harm than good. If an appropriate collar is not available, the neck may be stabilized with towels, blankets, IV bags, or even the child's shoes. It is important to assess the child once secured to the backboard. The large occiput of the head may normally push the head forward when resting on a hard surface. The child should be further stabilized to achieve neutral alignment. This can be achieved by placing a small towel roll between the child's shoulder blades, establishing alignment. The goal of alignment is that the external auditory meatus is in line with the shoulder in the coronal plane. An additional method of stabilization in the child weighing less than 40 pounds is to leave the child in his or her car seat. Towels and blankets may be secured about the head of the child to prevent movement.

Immediate evaluation of the airway, breathing, and circulatory status of the child must be undertaken, remembering that the increased incidence of high cervical injuries in small children predisposes them to lose their ventilatory drive. If required, intubation should be performed with minimal neck movement. Only practitioners with an appropriate level of experience should attempt intubation in this patient.

Evaluation of concurrent injuries must be a priority. A child may survive the spinal insult but may not survive the subsequent massive intracranial bleed. Recognition of other injuries should be systematically evaluated utilizing the head-to-toe approach, as recommended in trauma life support courses. Documentation of the level and type of neurologic findings should be instituted early and repeated on a frequent, regular basis. It is important to remember that the child may have a fracture at one level and disk injury at another level. Improvement or deterioration of the patient's condition will be quickly recognized utilizing this systematic approach.

The role of steroids after acute spinal injury is unclear. In 1990, the National Acute Spinal Cord Injury Study (NASCIS II) documented the benefits of early steroid utilization and indicated that a dosage regimen of 30 mg/kg IV bolus of methylprednisolone within 8 hours of injury, followed by a drip at 5.4 mg/kg per hour for the subsequent 23 hours (and up to 48 hours total) significantly improved motor neurologic and functional status outcomes in patients with acute spinal cord injury [90,91]. Although off-label, this was a standard in treatment until 2013, when the Congress of Neurological Surgeons found insufficient evidence of clinical efficacy and recommended against the routine use of methylprednisolone in the treatment of acute spinal cord [51,81]. Other studies have also recommended against this practice, including a meta-analysis of clinical studies published in 2019 that indicates that the use of methylprednisolone for acute spinal injury does not contribute to better neurologic recoveries but increases the risk of gastrointestinal hemorrhage and respiratory tract infection [92]. While practice has moved away from the routine use of methylprednisolone for acute spinal injury, controversy remains and more research is required to obtain a definitive recommendation.

Management of the child depends upon age, severity of injury, and the degree of neurologic compromise. Children with unstable fractures or those with worsening neurologic deficits are surgically managed. For those children not surgically stabilized, halo stabilization should be a part of treatment [85]. Children with cord injuries have more favorable outcomes after injury as compared to adult trauma patients.

Healthcare providers must also address the emotional impact of these injuries. The potential loss of bodily function is devastating, and patients may deny the consequences of such injuries. Additionally, pediatric patients may sustain injury pursuant to a risky behavior that they may have been instructed not to participate in. The guilt and anger that arise in these patients is incredible, and early psychosocial counseling may favorably impact their long-term outcomes.

The future of spinal cord trauma management is promising. Surgical techniques, including fusion and posterior instrumentation, utilized in adult spinal patients are being successfully implemented in children [85]. It is possible that the spinal cord has the ability to regenerate; however, these regenerative properties are somehow compromised after injury. Stem cell research may provide some answers to the problem. Work at unlocking the keys to these mysteries is paramount in reversing the devastating consequences of spinal cord trauma.

Spinal cord injury is a catastrophic injury. As changes in spinal cord management continue to develop, children will live longer, more productive lives after injury. Prevention of these injuries should continue to be a priority. Only with the reduction in the number of injuries can we be successful at reducing the tremendous costs, both monetary and physiopsychologic.

Trauma to the chest includes injuries to the pulmonary and cardiac systems. Thoracic injuries are the second leading cause of death in children after trauma to the neurologic system. Diagnosis is often challenging, as external signs of trauma are often not present. These injuries are generally managed nonoperatively unless accompanied by significant, persistent hemorrhage.

Children's chest walls are very pliable; therefore, rib fractures are less common than in adults. Pulmonary contusions account for the majority of traumatic injuries to the chest. Children with pulmonary contusions may or may not present initially with shortness of breath. The delay in symptom onset may be as long as 12 to 24 hours after injury. Bruising and tenderness over the chest wall may be the only presenting symptom and should cue the practitioner to the risk of pulmonary compromise. As the contusion develops, the child will experience increasing dyspnea, rales, hypoxemia, and possibly hemoptysis. The child may be discharged to home if none of these signs of trauma are present. The primary care provider must be informed of these developing signs, and the child should return to the emergency department if his or her condition deteriorates.

Management of developing pulmonary contusions depends upon the severity of symptoms. In severe cases, oxygen therapy and ventilatory support may be required, although this is quite rare in children. The most important intervention to prevent respiratory failure is aggressive pulmonary toilet to improve oxygenation. Unresolved contusions can lead to pneumonia and atelectasis if untreated.

A pneumothorax develops when air accumulates in the pleural space, leading to lung collapse. In children, the mechanism of injury is commonly blunt trauma to the chest, causing a burst type of injury of the lung tissue. The child will experience a sudden onset of chest pain with shortness of breath. Commonly, the pain associated with this injury will cause the child to take very shallow breaths; thus, auscultation of lung sounds is difficult. The area of the pneumothorax will have decreased or absent breath sounds and a hyperresonance to percussion. Definitive diagnosis is by chest x-ray. For pneumothoraces of greater than 20%, or those that cause significant respiratory distress, the intervention of choice is chest tube placement with water seal drainage until the lung re-expands.

A tension pneumothorax may develop after crush injury to the chest in which a pneumothorax develops and fails to seal, causing air to accumulate in the thoracic cavity and resultant compression of the lung tissue. As this pressure continues to build, the injured lung is deviated toward the uninjured side of the chest cavity. This causes a deviation of the trachea toward the unaffected side, severe respiratory distress, and cardiovascular compromise. The onset of symptoms is very rapid in small children due to the small size of their chest cavity. Immediate intervention requires efforts to release the pressure within the chest. The placement of a "flutter valve," a one-way valve (also known as needle thoracostomy), into the 2nd or 3rd intercostal space midclavicular line will allow pressure release. However, this is a temporizing measure, and definitive treatment requires placement of a chest tube to water seal drainage. Children will also benefit from high-flow oxygen therapy to improve their oxygenation status.

A hemothorax is caused by an injury to the vascular system in the thoracic cavity that results in blood accumulation. Many of these injuries in children are caused by blunt chest trauma, although the most life-threatening injuries follow penetrating trauma that causes direct injury to the thoracic vasculature. The lung has a low-pressure vascular system that is capable of tamponading many sources of bleeding; therefore, small injuries may be self-limiting. There is a risk in these cases when a chest tube is placed for drainage. This low pressure system is altered and the bleeding may start up again, leading to further blood loss and risk of cardiovascular collapse. Whenever a chest tube is inserted for drainage, the practitioner caring for the patient must monitor the blood loss and look for signs of deterioration immediately after chest tube placement.

In cases of massive hemothorax, the child will present with signs of hypovolemic shock, severe shortness of breath, and tachypnea. Blood replacement may be necessary to support the circulating volume. Monitoring blood loss in the child is critical, as a 20 cc/kg loss is equal to 20% to 25% of the child's blood volume.

Although rare, rib fractures and a flail chest can occur with significant force to the rib cage. A flail chest develops when two or more ribs are fractured in two places and the ribs become free floating. Fractures of the first two ribs may be associated with injury to either the brachial plexus or the subclavian artery. Fractures of ribs 9 through 12 may be associated with injury to either the liver or the spleen.

The hallmark symptom of fracture is the early onset of dyspnea associated with significant pain. This leads to ineffective ventilation patterns and worsening respiratory failure. The key to improving oxygenation in the child is adequate pain control. If the pain can be controlled, the child will cooperate with the respiratory exercises that are necessary to keep the lungs expanded. Measures of pain control include intercostal blocks and thoracic epidural analgesia with continuous infusions of narcotics and local anesthetics.

Trauma to the chest can also produce injury to the cardiovascular system. Pericardial tamponade and myocardial tissue damage can lead to cardiovascular collapse. Cardiac tamponade is most common after penetrating trauma to the chest; thus, it is more common in the adolescent than the younger child. Blood fills the pericardial sac, which is nondistensible, and compresses the heart. The severity of symptoms depends upon how rapidly the fluid accumulates; the faster the collection of blood, the more rapid the deterioration of the patient. The pericardial sac of the child is quite small, and a small amount of blood can lead to significant cardiac compromise.

Children with tamponade will present with a weak, thready, rapid pulse. Signs of shock may develop as the cardiovascular system begins to fail. Beck's triad of symptoms (late signs of compromise) includes a decreased blood pressure with a narrow pulse pressure, distended neck veins, and distant heart sounds. These symptoms are documented in only 10% to 30% of cases, although these signs are considered "classic" signs of tamponade.

Management of tamponade requires two steps. Initially, the cardiovascular system must be supported to ensure adequate cardiac output, and secondly, the cause of bleeding must be identified and controlled to prevent further blood accumulation. When the child presents to the emergency department with a low blood pressure and tachycardia, the initial resuscitative effort is to begin fluid resuscitation for volume support. In the child with cardiac tamponade, this additional fluid may actually worsen the child's condition if an increased volume of fluid leaks into the pericardial sac. If this develops, cardiac tamponade is suspected and fluids are slowed or discontinued until the source of bleeding can be identified and managed.

Removal of blood from the pericardial sac requires insertion of a needle into the sac and the aspiration of blood (pericardiocentesis). The child should demonstrate immediate improvement, as the heart is able to improve its pumping capabilities. Once the blood has been removed by pericardiocentesis, the child must be monitored for recurrence of blood accumulation. Until the source of bleeding is controlled, the risk of recurrence is high. Once resolved, the sequelae are minimal and long-term outcomes are normal.

There has been increased interest in sudden cardiac death in children (known as commotio cordis), especially during athletic competition or exertion. More than 90% of these deaths occur in male patients [93]. Some of these deaths occur when there is a sudden, blunt, modest blow to the mid-chest. Although this type of trauma occurs more frequently during sports, some occur during normal daily activities [93]. The patient has no evidence of cardiac damage or disease in most cases, and death is secondary to ventricular fibrillation. It is suspected that the impact occurs during repolarization of the cardiac cycle, a time window of less than 1/100 of a second. On autopsy, those children who had no clinical signs of cardiac disease had evidence of hypertrophic cardiomyopathy or a congenital coronary artery anomaly. Only 25% of resuscitations are successful [94].

To reduce the incidence of sudden death, it has been recommended by the American Heart Association that participant screening be performed prior to participation in high-risk sports. The screening done at present is inadequate and considered flawed in many instances. There are no specific training requirements to detect cardiovascular disease in children. Many athletes have a short evaluation performed by a physician with minimal training in evaluating for the risk factors associated with sudden death [95]. Additional measures to reduce death include the development of safer equipment.

In 1996, the Consumer Product Safety Commission recommended the use of soft baseballs. However, it has been found that softer, heavier baseballs, also referred to as reduction-in-force baseballs, do not reduce impact [94,95]. Lighter mass baseballs have been determined to be safer, especially when used in conjunction with effective chest protectors.

Other injuries occurring with trauma include diaphragmatic and tracheobronchial injuries. The diaphragm may tear with blunt force to the abdomen. This is caused by an increase in intra-abdominal pressure that is transmitted to the diaphragm, causing it to tear. This tear most commonly develops in the left hemidiaphragm and can cause abdominal contents (most commonly the bowel and/or stomach) to enter the chest cavity. This produces signs of respiratory distress as the organs compress the lung parenchyma. Other signs that may occur are evidence of pneumothorax, bowel sounds in the chest, and a nasogastric tube in the chest as seen on chest x-ray (although chest x-rays are only diagnostic 25% to 50% of the time). Repair of the diaphragm should be undertaken. While awaiting surgery, the child's respiratory status should be maximized to limit the developing hypoxemia.

Tracheobronchial injuries develop following a violent blunt force to the chest. Most injuries occur within 1 inch of the carina and are equally distributed between the right and left mainstem bronchus. Tears may be complete or incomplete. Small, incomplete tears may not be evident for up to three to four days after injury. The child is admitted with significant dyspnea and hemoptysis, and intubation is often required to support the child's respiratory effort. Tracheobronchial injuries should always be considered with a high index of suspicion when there is fracture of the upper five ribs and persistent pneumothorax with dyspnea. The overall mortality following these injuries is 20%, partially due to concomitant injury to the head, neck, spine, and chest. Large tears will require surgical repair while small tears are allowed to heal on their own.

When caring for the child with blunt thoracic trauma, it should be remembered that 12% of patients will have a concurrent cervical injury and should be treated with cervical spinal precautions. Although 85% of the injuries can be managed conservatively or with a chest tube, the goal of management is ventilatory support and improvement in the oxygenation status of the child. Without adequate pain control, these measures will be more difficult to attain; pain control should be instituted early and continued throughout the course of care.

Abdominal and GU trauma is the leading cause of unrecognized fatal injury in children. Although the incidence of death from these injuries remains low, a missed injury can have a devastating outcome. The majority of children who die after sustaining abdominal trauma expire from an associated injury, most commonly head injury. The focus of trauma care has changed from immediate surgical intervention to a nonoperative, wait-and-see approach in children with solid organ injury.

Children sustaining abdominal trauma demonstrate different injuries than those seen in adult trauma patients. The solid organs (spleen, liver, and kidneys) are proportionately larger and more prone to direct injury. Additionally, these organs are not well protected by fat pads, decreasing the protection afforded by fatty tissue. The organs are more frequently torn, especially from the pedicle. The adult's fat pads help to secure the organs in place. Without this support, the organs are suspended in the abdominal cavity and can sustain shearing injury with acceleration/deceleration forces. Abdominal trauma in children is also more difficult to assess as vital sign changes do not occur early, and signs of peritoneal irritation may be masked, altered, or delayed in children.

The majority of injuries to the abdominal and GU system are blunt injuries sustained in automobile crashes. The spleen and liver are most frequently injured, followed by the kidneys and gastrointestinal (GI) tract. A unique pattern of injury in small children (between 4 and 9 years of age) is lap belt complex. This pattern of injuries occurs when the lap belt portion of the seat belt is improperly positioned; the belt sits up on the abdomen of the child, and during a rapid deceleration the belt locks, compressing the abdominal organs. Associated injuries include small bowel contusions and/or lacerations, lumbar spine fractures, mesenteric hematomas, renal trauma, fractured pelvis, and ruptured bladder [40].

The second most common cause of abdominal trauma in children is pedestrian injury [40]. Additionally, a small number of children sustain abdominal trauma when falling from heights. In children younger than 2 to 3 years of age, abusive injuries account for a significant portion of abdominal trauma. These injuries occur when the abdomen is compressed following a kick or a punch. When the organs are compressed, bowel wall rupture can occur, leading to peritonitis and massive intra-abdominal bleeding. Children who survive these injuries should be reported to the local child protective services organization because other forms of abuse may often be present.

The American Urological Association recommends surgeons should perform scrotal exploration and debridement with tunical closure (when possible) or orchiectomy (when non-salvageable) in patients with suspected testicular rupture.

(https://www.auanet.org/guidelines-and-quality/guidelines/urotrauma-guideline Last Accessed: December 15, 2023)

Level of Evidence: B (Randomized controlled trials with some weaknesses of procedure or generalizability or generally strong observational studies with consistent findings)

School-age children sustain abdominal trauma when riding their bicycles, with the most severe injuries occurring when the child strikes the handlebars. Traumatic pancreatitis is a common injury occurring with handlebar-related injuries. The mean delay to treatment for traumatic pancreatitis in one study was 23 hours. Only after the children demonstrated signs and symptoms did their families seek medical attention [40].

Penetrating injuries account for only a small amount of abdominal injuries. However, with the increasing incidence of gun violence, the incidence of penetrating trauma has increased annually. This type of trauma is more commonly identified in children older than 12 years of age and is more common in male patients than female patients [40]. Evaluation of penetrating trauma is slightly different than for blunt injuries and will be discussed subsequently.

Assessment of abdominal trauma in children can be difficult. Preverbal children will not be able to accurately identify the location and extent of pain, while older children may guard their abdomen during assessment to reduce the risk of further pain. Furthermore, administration of pain medications can alter the exam. Therefore, most surgeons prefer that the child have a full abdominal workup prior to receiving pain medications. Obtaining diagnostic studies will assist care providers in recognizing the presence and extent of injury in many children.

CT scans are the diagnostic modality of choice in stable patients who have sustained blunt abdominal trauma [40]. With the increasing availability of CT scanners, the incidence of exploratory laparotomies has decreased significantly. CT scans allow for identification of many injuries, as well as grading the severity of injury. This information is utilized in making choices on how to best manage the patient. The disadvantage of CT scans is the decreased sensitivity and specificity in recognizing trauma to the pancreas, bowel, bladder, and mesentery. Utilization of contrast material, both orally and intravenously, can improve the diagnostic capabilities in some patients; however, the risk of aspiration following oral contrast administration is of concern. Patients sustaining penetrating trauma may benefit from a quick abdominal x-ray, allowing for identification of free air or foreign bodies.

In unstable patients, ultrasonography is utilized as a screening tool. It is fast, noninvasive, inexpensive, and interpreting ultrasound results has proven to be readily learned. Ultrasound assessment is performed utilizing the focused assessment with sonography for trauma (FAST) technique, which is useful in deciding who would benefit from laparotomy [96]. While this method of evaluation is common in adult abdominal trauma, its use is still being studied in pediatric patients with abdominal injuries [97,98]. The approval and introduction of specific ultrasonography contrast agents for contrast-enhanced ultrasound has enabled a better identification of traumatic organ injuries in the pediatric population [99,100]. One study found contrast-enhanced ultrasound to be more sensitive and accurate than baseline ultrasonography and nearly as sensitive as CT scan [101]. MRI has also been used to visualize soft tissue abdominal trauma.

Diagnostic peritoneal lavage (DPL) may be performed in children; however, due to the limited size of the abdominal cavity, the risk of complications is higher. With the advent of ultrasonography and CT scanning, DPL use is rapidly declining. However, in a rural setting without readily available CT scanning, DPL may be a useful diagnostic tool, allowing for recognition of free blood within the abdominal cavity. The risks of DPL in children include bowel perforation, injury to the solid organs, and vascular injury.

Laboratory evaluation of abdominal trauma may or may not be useful in the immediate situation. Changes in body chemistry are not always immediate; thus, laboratory values may be within normal limits during the initial admission screening. Following the changes in hematocrit and hemoglobin over time provides a good indication of ongoing blood loss. Obtaining a baseline hematocrit and hemoglobin upon admission may be useful for later comparison. Liver function tests (LFTs) are altered with hepatic trauma. Although the values obtained may not clarify the extent of injury, LFTs may be useful in diagnosing liver injury when CT scanning is not immediately available [40].

Diagnosis of pancreatic injury is challenging, as elevated amylase and lipase levels are common following many types of abdominal injury. Although the extent of elevation may be questionable, it is recommended that children with suspected injury to the pancreas have amylase levels measured initially and repeated as needed. The only other laboratory test that is useful during initial evaluation is a urinalysis, which demonstrates either gross or microscopic hematuria as an indicator of renal trauma.

Evaluation of penetrating trauma requires additional studies. The primary concern with these injuries is the depth of injury and potential penetration of the peritoneum. Laparoscopy has been shown to be a useful method of diagnosis as well as surgical repair [102]. Liver, spleen, and diaphragmatic tears may be sutured and repaired utilizing this method, preventing exploratory laparotomy. One retrospective review examined more than 16,000 pediatric trauma admissions that required surgical abdominal exploration. The authors found that laparoscopy reliably resolved diagnostic uncertainty in select cases. Furthermore, in a hemodynamically stable patient with a concerning exam and inconclusive imaging, laparoscopy provided sensitive diagnostic capability and opportunity for definitive repair with diminished surgical morbidity [103].

The spleen is the most commonly injured solid organ in abdominal trauma in children. Splenic injuries are graded on a scale of I to V. All children with a grade V injury undergo splenectomy [104]. The child with splenic injury will complain of upper abdominal pain over the left quadrant, left shoulder pain (Kehr sign), and possibly left chest pain. Falling hematocrit and hemoglobin levels may indicate ongoing blood loss.

Nonoperative management of splenic injuries in children has been utilized for a number of years. The impetus for this change is that post-splenectomy sepsis carries a high mortality rate in this age group. The controversy regarding nonoperative care is how to best manage the patient during the first few days post-injury. Some practitioners advocate three to five days of bed rest, but most studies have found that bed rest does not improve success rates [104,105]. While there is consensus that the child should be kept quiet, constant monitoring in an intensive care unit may not be necessary for most children. Following the hematocrit levels in children will help to recognize potential problems. If the hematocrit level falls, a repeat CT scan is generally obtained.

A common splenic injury is a hematoma. The thick capsule surrounding the spleen limits bleeding and protects the spleen from actual tissue disruption. The recommended treatment is nonoperative management; repeat CT scans or ultrasound should be obtained post-injury [106]. If contact sports were to be initiated prior to complete resolution, the risk of spontaneous rupture is high with an increased risk of hemorrhage and death. Nuclear medicine liver/spleen scans can also be used to follow these patients.

The incidence of post-splenectomy sepsis has decreased over the years. The liberal use of antibiotics and the pneumococcal vaccine have significantly controlled complications. Asplenic individuals are more at-risk for postoperative pneumonia, infection, abscess, and coagulopathies rather than post-splenectomy sepsis. Other sequelae to splenic injury include subphrenic abscess, pancreatitis formation, and embolic events when clots form secondary to the rebound elevation of thrombocytes.

Hepatic injuries are common in children due to the size and prominent location of the liver. Although splenic injuries are more common, hepatic injuries have the highest mortality. Liver injuries are similarly graded on a scale of I to V, with V being the most life-threatening injury associated with massive hemorrhage. The symptoms of liver injury include right upper quadrant pain and tenderness. Increasing abdominal girth in children may be an indicator of increasing intra-abdominal volume. Persistent hypovolemia in spite of adequate volume replacement may indicate massive hemorrhage.

If the child is stable, the trend in hepatic trauma management is to monitor the child and treat the injury nonoperatively. Patient selection for nonoperative management is based primarily upon the hemodynamic stability of the patient, not the grade of injury. The impetus for nonoperative management is the fact that patients who are treated without surgery have a lower mortality rate, require fewer transfusions, and have less risk of post-operative infection [107].

Delayed bleeding is rare after liver injury. Following the hematocrit and hemoglobin levels will allow for identification of ongoing blood loss. For those patients with continued bleeding, arterial embolization to control bleeding has met with success. This method of stabilization prevents the surgical stress associated with exploratory laparotomy.

Renal injuries are also graded I to V. Renal injuries in children are also treated nonoperatively, especially grade I or II injuries. Surgery is recommended for any child sustaining vascular injury, with the goal of surgery being salvation of the organ rather than removal. Hematuria, either gross or microscopic, is an indicator of renal trauma. Grey-Turner sign, a bruising over the umbilicus and the flank area, is rapid to develop in children with vascular hemorrhage. Associated GU injuries include trauma to the ureters, urethra, and bladder.

According to the American College of Radiology, hematuria is frequently found in the pediatric patient with blunt abdominal trauma. Macroscopic (gross) hematuria is a finding that necessitates a radiologic evaluation of the abdomen and pelvis.

(https://acsearch.acr.org/docs/69440/Narrative Last Accessed: December 15, 2023)

Level of Evidence: Analysis of the current literature and expert panel consensus

Bladder rupture is recognized by gross hematuria and lower abdominal pain. In infants and young children, the bladder is an intra-abdominal organ and signs of injury may not be initially evident. Other signs of rupture include an inability to void, little or no urine output after Foley catheter placement, and possibly an associated pelvic fracture. Bladder repair is undertaken with intraperitoneal ruptures and large extraperitoneal ruptures. Other small injuries can be treated with suprapubic drainage [108]. Delayed complications of renal trauma include hypertension and infection.

Bowel injuries in children are common with lap belt complex. Rupture of the bowel leads to spillage of bowel contents into the peritoneal cavity. The omentum is not well developed in children; thus, free flowing contents spread easily throughout the peritoneum, leading to significant peritonitis. The jejunum is the most commonly injured segment of the bowel. Signs and symptoms of injury may be delayed up to 12 to 18 hours [108]. Difficulty in diagnosis is complicated by the lack of external signs of trauma. Fifty-five percent of injuries caused by seatbelt compression have no evidence of external ecchymosis. Developing signs of bowel injury include peritonitis, elevated temperature, tachycardia, and diminished urine output. Hematomas of the bowel may cause symptoms of obstruction, including pain, vomiting, and distention.

As noted, pancreatic injuries are difficult to diagnose. The pancreas is located in the retroperitoneal space, so abdominal findings may not be present. Depending upon the extent of injury, simple nasogastric drainage and bowel rest may be adequate in the nonoperative management of these injuries. Those injuries in which the pancreas is transected require surgical repair. Pancreatic pseudocysts are common in the first three to seven days post-injury, and large, symptomatic cysts may require percutaneous drainage. Other sequelae include the development of hypocalcemia, acidosis, and abscess or fistula formation.

Penetrating trauma requires a different approach to management. Injuries that penetrate the peritoneum require surgical closure of this cavity. In unstable patients, the use of damage control surgery, or abbreviated laparotomy, should be considered. Often, the patient has other multi-system trauma, such as concomitant head or chest injuries, that preclude long operative times. Damage control surgery is a step-wise approach to repair. The initial operation is of short duration, with the goals of surgery to control hemorrhage and prevent further contamination leak. The patient is then transferred to the surgical intensive care unit for further resuscitation and stabilization. A planned reoperation is scheduled for 24 to 48 hours after injury to perform definitive repair. This method of repair has two distinct advantages: the patient is not subjected to a lengthy and often life-threatening initial surgery, and the bowel edema that develops postoperatively is allowed to resolve prior to definitive repair [109]. The laparoscope has been used with increasing frequency to diagnose and even repair intra-abdominal injuries. When it is used successfully, it results in fewer postoperative sequelae and shorter hospital stays [105,110,111].

Another complication possible following abdominal injury is the development of abdominal compartment syndrome [112]. Bowel edema and fluid sequestration increase the volume of the intra-abdominal cavity, which in turn increases pressure within this cavity. As the intra-abdominal pressure rises, there is an associated drop in venous return to the heart and subsequent decrease in cardiac output. The patient then experiences hemodynamic compromise.

Normal intra-abdominal pressure (IAP) ranges from 0–5 mm Hg, but it can be elevated up to 5–7 mm Hg in critically ill patients [113]. Intra-abdominal hypertension (IAH) is defined as an IAP greater than 12 mm Hg, but this is not synonymous with abdominal compartment syndrome, which can occur when IAP is greater than 20 mm Hg [113]. As the pressure increases, the abdomen becomes tensely distended and oliguria may develop. The systemic effects include compromise of the cardiac, respiratory, and renal systems, leading to systemic collapse. IAP can be measured using grades I to IV. A pressure greater than 20 mm Hg may signal the development of organ cardiovascular collapse; however, the beginning phases of organ dysfunction can occur before IAP reaches 20 mm Hg. The incidence of organ failure is highest in patients with grade IV IAP [113].

Management of abdominal compartment syndrome includes recognition and prevention with alternative surgical closure methods [114]. With high intra-abdominal pressures, surgical decompression may be required to prevent death of the patient. In the operating room, decompression is preceded with volume resuscitation, as opening the abdomen can cause a sudden shift of volume, leading to vascular collapse. When the abdominal edema and fluid shifts have stabilized, the abdomen may be closed again with minimal risk of a recurrence. Volume-controlled percutaneous catheter drainage has been found to be a minimally invasive and safe decompression method [115,116,117]. Choosing the appropriate intervention and its timing is determined by the etiology of the elevated IAP, the duration of increased IAP, and the degree of organ dysfunction. Not every patient will immediately need surgical decompression, as nonsurgical interventions can decrease intra-abdominal volume and ultimately improve IAP [113].

Advances in the care of the child with abdominal trauma include early enteral feeding, new generation antibiotics, and new closure techniques. Early enteral feeding has demonstrated a decrease in post-injury sepsis and multi-organ failure. As soon as the ileus resolves, tube feedings are initiated and villus function in the bowel is promoted. The use of antibiotics has also decreased the risk of post-operative infection, primarily the development of peritonitis.

With the development of new interventions and a reduction in operative procedures, the future of the management of abdominal trauma in children will continue to evolve. Deciding how and for what length of time a child who is treated nonoperatively should be kept quiet will be an area of intensive study over the next few years. The economic impact of keeping children hospitalized unnecessarily will be analyzed, with the early return to a pre-injury way of life being the primary goal of care.

The majority of traumatic injuries sustained by children are orthopedic injuries. Fortunately, children have the distinct advantage of rapid bone growth, leading to faster healing. The thick periosteum in children allows for less fracture displacement, fewer open fractures, and more stability of fractured extremities. Children also respond better to treatment, with post-casting joint stiffness and muscle atrophy being minimal.

The type of injury sustained is commonly identified by the mechanism of injury. Falls onto outstretched arms, such as falling off of monkey bars, cause fractures and/or dislocation of the upper extremities. Fractures of the lower extremities are associated with falls from heights (if the child lands on his or her legs) or are often sport-related fractures. Obtaining an accurate history of the mechanism of injury will prevent the practitioner from missing undetected injuries.

Accurate assessment of orthopedic trauma can be hampered when a child is in pain. Pain control measures should be instituted early and repeated on an as needed basis. An evaluation of neurovascular function is critical in order to help ensure viability of the injured area. The five Ps of assessment provide a useful mnemonic device for assessment. The patient should be assessed for:

When assessing a child, it is wise to begin on the uninjured side, working toward the injured extremity. Beginning assessment at the most distal point from the injury and working toward the suspected site of injury will allow for more in-depth assessment of the child. If a practitioner were to start at the point of pain, further assessment would be hampered, as the child would protect the injured area from further poking and prodding. Occasionally, assessment of the injured area may present an unclear picture; assessing the structures on the uninjured side often allows for appraisal of the nuances of the child's skeletal system.

Musculoskeletal trauma may present in many forms: fractures, dislocations, soft tissue injuries, or a combination of one or more of these injuries. The vast majority of orthopedic trauma sustained by children can be treated in the emergency department with follow-up orthopedic evaluation within 24 to 48 hours. Injuries that are limb- or life-threatening require immediate evaluation and stabilization to prevent untoward complications, including death and disability.

As in adults, pediatric fractures are either open (compound) or closed. The child must be evaluated for other forms of life-threatening trauma, including trauma to the head, neck, chest, and abdomen. Once stabilized, the fracture should be splinted prior to radiologic examination. The injured area should be radiographed in two planes; commonly, the anteroposterior and lateral views are adequate to visualize the majority of fractures in this group. All radiographs should include the joints above and below the area of injury.

Neurovascular status should be assessed frequently, as changes in vascular flow are ominous and must be readily identified. Wound care should be instituted as appropriate. Utilizing topical anesthetics can improve the quality of care as a comfortable, quiet child will allow for more thorough wound care than if the child is combative and in pain. The injured part should then be elevated, and tetanus immunization should be administered if there is a question about the immunization status of the child.

The most serious pediatric fractures are those that occur in the area of the physeal plate. These physeal injuries represent up to 30% of all pediatric fractures[118]. These fractures may lead to premature growth cessation or deformity[119,120].

The Salter-Harris classification system allows for the assessment of these injuries. The common types are numbered I through V and are summarized inTable 6.

The Salter-Harris type I injury is a transverse fracture through the hypertrophic zone of the physis resulting in a widening of the physis. The growth plate remains attached to the epiphysis, and there are usually no significant sequelae. The initial x-rays may only show a widening of the physis, but point tenderness at the epiphyseal plate suggests a type I injury is present. The prognosis for this type of injury is excellent.

Salter-Harris type II injuries include a fracture through the physis and metaphysis, but the epiphysis is uninvolved. It is the most common type of Salter-Harris fracture. On x-ray, the fracture line is seen through the metaphysis and may reach to the epiphyseal plate. The prognosis is usually excellent, although minimal shortening of the limb may occur in rare occasions. Type II represents 75% of cases [121].

Salter-Harris type III injuries involve a fracture through the physis and epiphysis, causing a disruption of the epiphysis. The fracture extends into the articular surface of the bone. It is uncommon for these fractures to result in permanent disability, and therefore, the prognosis is generally good; however, there is always a risk of long-term sequelae. The x-ray usually shows a well-demarcated fracture line through the physis, splitting the epiphysis and possibly extending to, but not disrupting, the metaphysis.

A type IV fracture is the second most common Salter-Harris fracture and occurs in approximately 10% to 12% of cases [121]. Salter-Harris type IV fractures involve the epiphysis, physis, and metaphysis. It can result in chronic disability and requires excellent reduction techniques. Because of the extensive damage, there is a strong probability of limb shortening and/or deformity of the joint. The x-ray shows a similar pattern to the type III injury with an obvious intra-articular fracture into the metaphysis.

Salter-Harris type V injuries are a compression or crush of the epiphyseal plate with no associated epiphyseal or metaphyseal fracture. Type V fractures are rare [121]. The clinical history usually includes an axial load injury. Because of the major damage to the growth plate, these injuries often result in early closure and growth retardation. The x-ray usually shows soft tissue swelling at the physis and narrowing in the region of the epiphyseal plate. In adolescents, this may be difficult to discern and the diagnosis is usually made after the early closure of the growth plate. However, a nuclear medicine bone scan may help determine if metabolic activity is still taking place in a previously injured epiphysis. Permanent limb shortening and/or deformity is common [121].

The most common fractures in children are fractures of the forearm and clavicle [122,123]. Both fractures occur when a child falls onto an outstretched arm. Fractures of the clavicle commonly occur in the distal third of the clavicle. Proximal fractures may be associated with an underlying subclavian artery injury and require more in-depth evaluation than distal fractures. Forearm fractures usually require four to six weeks of casted immobilization.

A unique fracture of small children is a "bowing" fracture, most commonly occurring in the forearm, although these injuries may also occur in the lower extremities. The bone is deformed and curved, like an archer's bow (also known as plastic deformity). This occurs in young children who have minimal mineralization of the extremities, allowing the bone to bend rather than break. The bowed extremity is casted in an anatomic straight position and will commonly remold to a normal shape.

Fractures involving the elbow require immediate assessment for neurovasculature function. The bony fragments may compromise the brachial artery, altering blood flow to the distal extremity. Most of these fractures are supracondylar, involving the distal humerus, and are common in children 3 to 10 years of age. An orthopedic surgeon should immediately evaluate any limb with signs of ischemia.

Humeral fractures of the proximal shaft should be assessed for epiphyseal injury. Early radiographs will demonstrate injury requiring orthopedic evaluation and stabilization. Compartment syndrome is a possible complication and can develop in less than 12 to 24 hours. If the child complains of unrelenting pain in the injured extremity, compartment syndrome should be suspected and treated if present [124].

Common lower extremity fractures include fractures of the tibia and fibula. These injuries can occur during sports-related activities (as seen in skiing and soccer), falls from heights, and pedestrian-motor vehicle collisions (most car bumpers strike the child's leg, causing fracture at the point of contact). Limited weight bearing and crutch use is recommended for a short period of time to allow for good bone growth and resolution.

Femur fractures require a tremendous amount of force. Children sustain these types of fractures most commonly in automobile accidents. The major concern following these injuries is the risk of hemorrhage associated with significant vascular injury. Unless stabilized, the child can exsanguinate following a femur fracture. Intramedullary rods and nailing are often used to stabilize the femur and allow the child early mobility.

Another life-threatening fracture is a pelvic fracture. Although rare in children, the risk of death with these injuries is high. Pelvic fractures in children are secondary to compression type forces, causing displacement of the pelvic ring and injury to surrounding organs and vasculature. Eighty percent of pelvic fractures that have multiple fracture sites have associated abdominal or GU trauma. Ruptured bladder is common, especially in the child who had a full bladder at the time of injury.

Advances in fracture management include early surgical stabilization and the rapid return to mobility. Most children sustaining fractures heal quickly without long-term sequelae. Methods of bone healing that continue to advance include bone grafting techniques, low-intensity ultrasonography, pulsed electromagnetic fields, distraction osteogenesis, and surgical therapy [125,126].

Due to the strong ligamenture of children, dislocations are not as common as in the adult population. The most common dislocation in a child is an anterior shoulder dislocation, occurring when a child falls onto the shoulder area or impacts the upper arm. Traction can frequently be utilized to reduce these types of dislocations, although care must be taken to ensure that nerve and vessel entrapment does not occur during reduction. Follow-up assessment of neurovascular function is critical and x-rays are necessary to ensure proper realignment.

Children sustaining fractures and dislocations commonly have associated soft tissue injuries. Open wounds require immediate assessment of the extent of injury. Neurovascular compromise requires immediate attention and hemostasis should be accomplished to control blood loss. After other major traumatic injuries have been stabilized, wound care should be instituted utilizing irrigation and debridement as necessary. Wound closure may be accomplished using skin adhesives, which have shown excellent results in children sustaining superficial lacerations.

Although rare, traumatic amputations can occur in children. Many of these injuries occur in rural locations, farming accidents being one of the leading causes. Any child who sustains a traumatic amputation should be stabilized and transported to a facility with microsurgical capabilities. Replantations of children's amputations are frequently performed. Children have a better prognosis of success after these types of surgeries, and the lifelong disabilities associated with amputations may possibly be eliminated.

Care of traumatic amputations requires attention to a number of issues. First and foremost, the child should be stabilized, life-threatening injuries must be treated, and ongoing blood loss must be controlled. After these priority injuries are managed, the child should be prepared for transport. The newly formed stump should be gently cleansed and pressure dressings applied to control bleeding. Debridement should not be undertaken without surgical consult. The stump should be elevated to reduce swelling. If time permits, x-rays of the amputated part and the stump can be obtained; this will assist in decision making prior to surgical reattachment.

The amputated part should also be properly handled to prevent tissue destruction while awaiting surgical repair. The part should be gently cleansed and wrapped in slightly moistened gauze. It is important to prevent the amputated part from becoming saturated, either with blood or serous drainage. The wrapped part should be placed in a plastic bag and the bag placed into a plastic container, such as a urine cup or emesis basin. This plastic container should then be placed on ice in an ice cooler. The part should not be buried in ice. If the part becomes too cold, frostbite can develop, rendering the part unacceptable for replantation.

Traumatic amputations produce a tremendous amount of psychologic impact on the child and family members. There is immense concern regarding long-term outcomes, and grieving of these injuries begins early after injury. It is important that the staff caring for this patient provide emotional and psychologic support to all involved.

For those children sustaining amputations without replantation, the long-term outcomes are often promising. Children adapt well to artificial limbs. The continuing advances in design and use of these artificial parts have made prostheses more practical [127].

Complications following musculoskeletal and surface trauma can be limited with proper medical care. Wound complications can be minimized with early, thorough wound care. The development of post-injury infection has decreased drastically as more judicious use of antibiotic therapy has been instituted.

As noted, compartment syndrome can occur in children, with rapid development of signs and symptoms. Most commonly this complication develops after fracture; however, soft tissue injuries, such as injury occurring to the leg after being kicked during a soccer match, can also precipitate this complication. A child with closed compartment syndrome will complain of pain that is out of proportion to the extent of injury. Common pain management techniques are inadequate to control the child's pain. Any pain that remains unresolved should be a clue to the possibility of increases in intracompartmental pressure. Neurovascular compromise may be evident distal to the injury; however, the presence of pulses and adequate capillary refill does not guarantee that compartment syndrome is not developing. Management of compartment syndrome requires surgical fasciotomy to relieve pressure. Delaying surgical intervention can lead to necrosis of the affected musculature and long-term functional disabilities.

Another complication that must be considered is the development of tetanus following soft tissue injury. Although the immunization status of many children is up to date, there are still a number of injured children whose tetanus status may be inadequate or nonexistent. At the time of stabilization, the child's immunization history should be obtained. If the child is found to have inadequate coverage, tetanus immunization should be administered. With this simple intervention, the risk of life-threatening respiratory compromise and potential death may be avoided.

Although musculoskeletal trauma occurs frequently, outcomes are generally quite good. The practitioner must be alert to the development of life-threatening injuries and complications. With astute assessment and stabilization, many of the sequelae can be averted. The goals of musculoskeletal trauma care should be stabilization and subsequent measures to reduce death and disability from these injuries.

Although most children respond to trauma treatment with good results, children who are severely injured run the risk of developing post-trauma sequelae, including post-traumatic respiratory distress, MODS, and renal failure. With early recognition and aggressive therapies, these sequelae can be reversed and the mortality rate can be minimized.

Post-traumatic respiratory distress syndrome occurs following pulmonary injury, leading to pulmonary congestion. As the disease progresses, there is increased mucus formation and a loss of surfactant. The syndrome has four pathophysiologic characteristics:

The hallmark sign is persistent hypoxemia in spite of increasing oxygen delivery. The child will develop a compensatory tachypnea, an increased shunt fraction, increased dead space ventilation, a decreased static compliance, and pulmonary hypertension.

Chest x-ray usually demonstrates diffuse bilateral infiltrates with a normal lung next to a severely injured lung. There will be no evidence of congestive heart failure as is seen with other respiratory distress syndromes. In the initial stages, the lungs are dry. The child is dyspneic and tachypneic, leading to a respiratory alkalotic state with a decreasing PaCO₂ level. Within 24 to 48 hours, the child becomes severely dyspneic and hypoxemic. Chest x-ray evidence will develop, and if recognized and treated early, resolution will occur. In severe cases, the child develops irreversible hypoxemia and death occurs within two weeks. For those children who survive this insult, the prognosis is good, with a return to normal pulmonary function; however, complete resolution can take up to one year.

Management of post-traumatic respiratory distress syndrome is aimed at supporting the hypoxemia and reducing the pulmonary congestion. If the syndrome progresses to the severe hypoxemic state, mechanical ventilatory support is necessary to provide adequate oxygenation. Continuous and bi-level positive airway pressure has been recommended to stabilize pediatric patients [91,128].

Positioning the patient for the best gas exchange has been the focus of intensive study. The studies in adults have demonstrated that frequent position changes and prone positioning have beneficial effects upon the patient's respiratory status. Positioning children with multiple injuries, multiple invasive lines, and stabilization devices requires forethought and ingenuity. It often seems that when the patient is finally settled into the new position, it is time to again change the position.

Other measures to improve patient status include administering packed red blood cells to improve oxygen delivery at the cellular level. This is instituted if the hemoglobin is low, as would be seen after hemorrhage. Pharmacologic agents may be utilized for cardiovascular support; these agents are generally reserved for severe cases with refractory hypoxemia. Until the pathophysiology of this syndrome is completely understood, various experimental measures will be utilized in an effort to support the failing child.

A full understanding of the epidemiology and outcome of MODS in children is limited by inconsistent definitions and populations studied, and recent research suggests that MODS be redefined to differentiate between organ injuries resulting from a common mechanism or mechanisms and organ injuries resulting from distinct mechanisms [129,130].

Since the 1970s, MODS has been defined as progressive deterioration of two or more organ systems over a short time period [131]. This organ failure is initiated by systemic inflammatory response syndrome (SIRS), which is a systemic response to a variety of insults, including trauma. SIRS causes the release of mediators that either facilitate cell-to-cell interaction or cause direct tissue damage. The etiologic factors in trauma include: sepsis; persistent, prolonged hypovolemic shock; multiple transfusions; and extensive tissue damage [131]. Descriptive scoring systems have been established for pediatric MODS based on severity of symptoms in five organ systems: cardiovascular (lactic acid), respiratory (PaCO₂/fraction inspired O₂ ratio), hepatic (bilirubin), hematologic (fibrinogen), and renal (blood urea nitrogen or BUN) [132].

The defining characteristics of MODS are organ specific [131]. Most commonly, pulmonary failure develops first and is characterized by respiratory failure with a PaCO₂ greater than 50 mm Hg, an alveolar-arterial oxygen difference (AaDO₂) gradient greater than 350 mm Hg, and ventilator dependence. At day six or seven, hepatic failure begins to develop and is defined by a bilirubin of greater than 6 mg/dL, a prothrombin time of more than four seconds greater than the control, and jaundice. If the bilirubin is greater than 8 mg/dL, the syndrome carries a mortality of 90% or greater.

GI failure is identified next; the child develops a paralytic ileus, and a GI bleed ensues. At two weeks, the kidneys begin to fail and the urine output drops while the BUN and creatinine begin to rise. At this point, the child will require dialysis. Ultimately, neurologic and cardiovascular failures develop. The child becomes comatose, with a GCS score of less than or equal to 6 in the absence of sedation. Cardiovascular failure is the terminal event; death occurs at two to four weeks after onset of organ dysfunction.

Mortality is dependent upon how many organ systems are involved. With two organ systems involved, the mortality rate is approximately 67% to 78% [133]. When four or more organs fail, mortality approaches 100% [133]. The keys to combating this mortality are prevention, early recognition, and controlling mediator release.

Prevention of multi-organ failure occurs during all phases of care. In the initial resuscitative period, aggressive volume resuscitation is imperative [131]. As discussed, assessing the effectiveness of volume resuscitation is controversial. Despite the debate regarding the optimal method of assessment, ensuring adequate resuscitation is critical. Depending upon the capabilities of the facility, this may mean monitoring the base deficit and serum lactate levels, using pulmonary artery catheters to measure central oxygenation and cardiac outputs, calculating oxygen delivery and consumption, and measuring the gastric pH.

Preventative measures undertaken during the operative phase of care include timely surgical intervention, thorough debridement of nonviable or infected tissue, early fixation of long bone and pelvic fractures, and avoiding "missed" injuries. After the patient is transferred to the trauma intensive care unit, early nutritional support is instituted, antibiotics are ordered as appropriate, and pharmacotherapy for organ support is provided. Should the patient have sustained a "missed" injury, timely reoperative surgery is critical to prevent ongoing failure [59].

However, after the organ failure begins, treatment is generally supportive. Controlling and treating infection is one goal of therapy. Antibiotics are initiated early, and IV lines are monitored frequently for signs of localized tissue reactions and are changed as needed. Aseptic technique is critical to prevent hospital-acquired infections from developing.

Increasing oxygen supply is critical to reducing organ failure and involves a number of interventions. Initially, the supplemental oxygen level is increased until it reaches 100%. Intubation and ventilatory support are required to achieve maximal oxygen delivery. However, oxygen must reach the tissue level to achieve benefit. Having the child sit up, cough, and breathe deeply will improve pulmonary function. Suctioning is often required as pulmonary congestion worsens. Blood products are also utilized, as with post-traumatic respiratory distress, to improve oxygen delivery.

Coupling the increased oxygen supply with a decreased oxygen demand will help reverse persistent hypoxemia. Decreasing the oxygen demand includes controlling anxiety and pain, administering analgesics and sedative agents, providing rest periods, and reducing the development of hyperthermia and shivering. Providing the child with quiet, bedside activities will help provide a method of distraction; however, it is imperative that these activities not excite the child further. The excitement generated may increase oxygen demands and defeat the purpose of the activity.

Metabolic support is a critical part of patient care management. Early feeding will improve tissue function and provide energy for cellular activity. Tube feedings are initiated in some patients as early as 24 hours after injury. At this point, an ileus has not yet developed and early feeding may actually prevent its formation. The concentration of the feedings is increased slowly until optimal caloric intake is achieved.

Much emphasis and research has focused on the action of the gut in the development of MODS. When the body is stressed, as in trauma, the integrity of the bowel mucosa may be compromised, allowing the passage of organisms into the blood stream. Much of the focus has been on the passage of gram-negative organisms into the vascular system, which in turn precipitates mediator release. If this theory is valid, interventions aimed at gut decontamination and control of gram-negative sepsis may be a key to reversing the effects of these sequelae. At this point in the research process, the results of gut decontamination are inconsistent. Despite this, antibiotic therapy for gram-negative organisms is utilized to reduce the risk of systemic sepsis.

One of the more common and more easily treated complications of trauma in children is the development of acute renal failure. Renal failure is classified as prerenal, intrarenal, or postrenal failure [134]. The treatment of choice depends upon the type of failure; thus, differentiating the cause of failure is critical to successful management.

Prerenal failure is caused by inadequate perfusion of the kidneys. This is one of the most common forms of renal failure following trauma and occurs secondary to the hypovolemia that develops with blood loss and fluid shifts. Intrarenal failure develops secondary to injury to the renal parenchyma and can be caused by either direct injury or, more commonly, injury that is secondary to prolonged ischemia. If the child remains hypotensive for a long period of time, intrarenal failure is common. Postrenal failure is less common; this type of failure develops as a result of an obstruction in the drainage system.

The majority of children who develop acute renal failure respond quickly to resuscitation and treatment. Most children develop oliguric failure, whereby the urine output drops and the BUN and creatinine levels rise. (It is possible to have nonoliguric failure, also known as high-output failure, whereby the urine output is high but creatinine clearance is low.) As the kidneys recover, the urine output increases and the urine becomes more concentrated. The degree of recovery is dependent upon the severity of damage to the kidneys.

The treatment goals include maintaining a normal circulating volume, normal electrolyte values, and vascular stability. In cases of prerenal failure, adequate fluid administration may be all that is necessary to reverse the impending failure. In some cases, a furosemide or mannitol challenge may be administered to prevent acute tubular necrosis from developing during the oliguric phase.

Hemodialysis has for many years been the treatment of choice for acute renal failure despite the fact that many patients do not tolerate the volume shifts that occur with this type of dialysis. Patient instability has led to a renewed interest in other methods of dialysizing the blood, now known as renal replacement therapies [135]. Trauma patients with unstable cardiovascular function cannot withstand further volume shifts that can occur with dialysis; thus, measures to limit these volume shifts have been instituted.

Peritoneal dialysis may be advantageous for the trauma patient, as the blood is dialyzed at a slow rate without volume shifts. However, in the trauma population, this method may not be able to be utilized if abdominal trauma is suspected or confirmed, as an intact peritoneal cavity is required.

Continuous renal replacement therapies (CRRT) are methods of circulating blood outside the body through a highly porous filter [136]. The patient's blood pressure, rather than a machine, drives the dialysis system. This type of dialysis is good for the hemodynamically compromised patient; however, anticoagulation is required and may not be safe in certain trauma patients. The methods vary from arteriovenous to veno-venous type systems, depending upon where the patient is cannulated for catheter placement. The best method of CRRT has yet to be determined; however, the use of CRRT is rapidly becoming a standard of therapy for the management of acute renal failure following trauma.

Pain is also considered a sequela of injury and is one complication that practitioners can proactively control. Studies have shown that many children treated for fractures in emergency departments do not receive adequate pain control. Physicians must take the time to assess the level of pain in a child and subsequently provide adequate medication for pain management.

Some of the common misconceptions in managing pain in children are that they cannot localize pain, they cannot use pain scales, and narcotics and other medications will compromise the child's status. In fact, children can identify and describe pain and its location. They can utilize pain scales that have been developed specifically for children, and narcotics are no more dangerous in children than they are in adults. Providing small, frequent doses of narcotics, nonsteroidal agents, and sedatives allows titration of drugs to the effect desired. Children should not suffer after injury. Once assessed, narcotics can be given to decrease the pain the child is experiencing.

Nonpharmacologic interventions for pain can also be utilized with great success in many children. Positive reinforcement of good behavior will yield desired rewards. Distraction will shift the child's attention away from the pain. Visiting with friends, watching television, and holding onto a parent will refocus the child's attention. The more the child is distracted, the less pain he or she will experience. Relaxation techniques in children can include deep breathing exercises. This will achieve two goals: relaxing the child and improving the child's gas exchange. Providing a child with a favorite toy or blanket provides the child with a sense of security and will reduce fear and anxiety.

It is imperative that healthcare providers aggressively pursue pain control options. While not all measures work on all children, providing pain reduction measures can be achieved through trial and error. Combining pharmacologic and nonpharmacologic therapies may be performed with a high rate of success. The State of California enacted legislation that requires all healthcare providers to assess pain and develop pain plans with patients, including children. To neglect a child's pain in California could bring legal consequences.

The sequelae of trauma presented here are only a few of the many complications that can beset the pediatric trauma victim. As children reach adolescence, the use of drugs and alcohol can be a factor in complication development and management. Other sequelae previously discussed include abdominal compartment syndrome and bone growth abnormalities, among many others. The pediatric trauma care practitioner must be aware of the multitude of sequelae and be constantly vigilant to their impending development. The injured child can often respond positively to treatments as long as they are instituted in a timely manner.

Healthcare professionals involved in the care of pediatric patients whose families have a limited proficiency in English are faced with many difficulties, both in the assessment of trauma victims and in making decision regarding care. When the patient and/or family members speak a language other than that of the clinician, a professional interpreter should be engaged. A systematic review of the literature has shown that the use of professional interpreters provides better clinical care than the use of "ad hoc" interpreters. Professional interpreters improve the quality of care for patients with limited English language skills to a level equal to that for patients with no language barriers [137]. Use of professional interpreters has been associated with improvements in communication (errors and comprehension), utilization, clinical outcomes, and satisfaction with care [137].

Rapidly assessing and managing children with multi-system injuries is critical to their successful recovery. While new drugs, interventions, and diagnostic tools are on the horizon, the basics of trauma resuscitation must be adhered to in order to prevent death and disability in children.

Children are at increased risk of multisystem injuries, as the traumatic forces are distributed over a smaller body mass. The risk of death increases with these multisystem injuries. Head injuries remain the leading cause of death due to trauma in children. Initially, the tenets of trauma management include stabilization of the airway, breathing, and circulation. After these are secured, a head-to-toe assessment to identify all potential injuries must be undertaken. Throughout resuscitation, astute observation of the child's response to therapy must be performed; deterioration in the child's status is a poor prognostic sign.

While in-depth discussion of the sequelae of trauma is beyond the scope of this review, a few of the major points were highlighted. Reducing the long-term consequences of these sequelae begins at the time of the injury and progress throughout all care areas. The incidence of sequelae can be limited with rapid, accurate identification of all injuries sustained and thorough stabilization of these injuries.

Healthcare providers caring for pediatric trauma victims are well aware of the benefits of injury prevention strategies. Supporting public awareness and education regarding these strategies whenever a child is seen can help further reduce death and disability from trauma in children.

Pediatric trauma care knowledge is a critical part of any healthcare provider's education when working in the emergency and trauma care fields. Instituting the measures presented in this course will enhance the care provided to victims of pediatric trauma.