Pediatric Care

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COURSE #206 - 15 HOURS EXPIRATION EXPIRATIO N DATE: 09/30/2004 CATEGORY: CATEGOR Y: PEDIATRICS Pediatric Trauma Care Take Test Release Date: 10/1/2001 Expiration Date: 9/30/2004   Faculty:   Category: Audience:

  Online Price: Accreditations:

Susan Engman Lazear RN, MN, CEN, CFRN Pediatrics This course is designed for all pediatric, neonatal and staff nurses. $35 CME Resource is accredited as a  provider  provi der of continu continuing ing nursing nursing education by the American Nurses Credentialing Center's (ANCC) Commission on Accreditation. CME Resource is approved as a  provider  provi der of continu continuing ing education education in nursing by the American Association of Critical-Care Nurses (AACN) Certification Corporation. Provider  #11156.

  Designations of Credit:

CME Resource designates this continuing education activity for 15 ANCC contact hour(s). This program has been approved by an AACNprovider Certification Corporationapproved #11156 under 

 

established AACN Certification Corporation guidelines for 15 contact hours, CERP Category A.   Individual State Nursing In addition to states that accept Accreditations:  ANCC, CME Resource is accredited as a provider of continuing education in nursing by: Alabama, ABNP0353; California, CEP9784; Florida, NCE 2862; Iowa, #295; Kentucky, 7-0054; Texas, ANCC/Type I Provider.   Additionall Approvals: Additiona Approvals: AST Category 3. (AST approval expires 9/30/2004)   About the Sponsor

The purpose of CME Resource is to provide challenging curricula to assist physicians, nurses, dentists, psychologists, and allied healthcare professionals to raise their level of professional expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare. Our contributing faculty members have taken care to ensure e nsure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of   publication  public ation.. The The publisher publisher disclaims disclaims any liabilit liability, y, loss or or damage damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice. Copyright © 1991-2003 CME Resource. All world rights reserved. All CME Resource brands, trade dress, and product names are trademarks or registered trademarks of CME Resource. All other marks are the property of their respective owners. Disclosure Statement Statement

 

It is the policy of CME C ME Resource not to accept commercial support. Table of Contents 1.

INTRODUCTION

2. 3.

BIOMECHANICS OF PEDIATRIC TRAUMA TRAUMA TO THE HEAD AND FACE TRAUMA TO THE SPINE AND SPINAL CORD CARDIOTHORACIC TRAUMA ABDOMINAL AND GENITOURINARY TRAUMA MEDICAL SEQUELAE OF PEDIATRIC TRAUMA TRAUMA CARE OF THE FUTURE SUMMARY WORKS CITED

4. 5. 6. 7. 8. 9. 10.

INTRODUCTION Trauma is the primary cause of mortality and morbidity in the  pediatric  pediat ric population. population. Although Although the numbe numberr of motor vehicle vehicle related injuries continues to fall, the overall incidence of pediatric trauma remains fairly stable. As the baby boomer generation continues to have children, the sheer volume of pediatric trauma is expected to climb as these children enter early e arly childhood and adolescence.

Unintentional injury and death in children have reached epidemic  proportions. Pediatric  proportions. Pediatric trauma trauma should should be consider considered ed a preventable preventable disease and not an "accident." Injury prevention measures, such as bicycle helmets, can significantly reduce the incidence of death and injury in children. It is estimated es timated that each year 20,000 children between the ages of 1 and 19 years will die due to injury. For each child who dies, an additional 40 will be hospitalized, and another 1120 will be treated in the emergency department and  be released released to home. home. Fifty thousand thousand of these these su survivi rviving ng childre children n will suffer permanent disability, primarily as a result of trauma to the head and spinal column [44].

 

During the past two decades, the leading causes of death in children aged 1 to 19 years has changed. Motor vehicle accidents (MVAs) remain at the top of the t he list, however, homicide and suicide now hold the second spot [44]. With the increasing incidence of childhood violence in America, the fear is that by the year 2005 homicide deaths will exceed MVAs as the leading cause of death in children in this country. 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. With rapid field resuscitation and early transport to a center  specializing in pediatric trauma care, the mortality rate is approximately 3% [44]. In caring for the injured child it is imperative that the health care provider consider the unique anatomic and physiologic parameters of children. These factors  predispose the child  predispose child to unique unique patterns patterns of injury as well 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. Additionally, emerging theories regarding trauma care will be discussed.   BIOMECHANICS BIOMECHA NICS OF PEDIATRIC TRAUMA

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. injury. The The majorit majority y of these injuries injuries may may not not be survivable; 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 twenty-three hours. The child who has sustained s ustained trauma to major   body organs organs and has ongoin ongoing g hemorr hemorrhage hage may not survive survive this this  period.. Additio  period Additionally, nally, significant significant head injury can cause cause massive massive swelling and subsequent herniation and death. It is during this

 

time period that aggressive resuscitation efforts can positively impact the child's outcome. Optimistically, the child will survive this first 24 hours; however, astute assessment and interventions continue to be required to reduce the sequelae of trauma, t rauma, including multiple organ failure and post-traumatic respiratory distress syndrome. The risk of  death and disability remains at a high level during the first firs t two weeks after injury. Although the child may survive this two week   period,, there  period there are pattern patternss of of injury injury in which which children children sustain sustain delayed onset of complications (greater than two weeks postinjury), which carry a high risk of death should these injuries develop. There are a number of factors that impact the pattern of injuries identified. Age, sex, behavior and locale all influence the types of  injuries sustained. The child with the statistically highest risk of  o f  sustaining injury is an eight-year-old male. This child is at risk  ri sk  for trauma due to a number of factors, including behavior  (bravado), level of activity, and the perception that he can "take care of himself." The injuries sustained at this age will differ from those occurring during infancy as well as adolescence. Infants (ages 1 month - 1 year) are at risk ri sk for sustaining injury in the home environment. Falls, choking and strangulation are leading causes of injury and death. Falls can occur from furniture, stairs, or while in walkers. Recent studies have noted the mortality associated with child carriers (such as portable car  seats) when a child is left le ft unattended and inadvertently tips the carrier either falling off an elevated surface or, as in one reported case, where a child in a carrier flipped the carrier while on a waterbed and subsequently suffocated when trapped between the carrier and the mattress [39]. Children at this age may be unrestrained in a motor vehicle crash and suffer significant multisystem injury. Child abuse is also prevalent at this age and is considered a form of trauma.

 

Toddlers (ages 1 - 3 years) and preschoolers pres choolers (ages 3 - 6 years) sustain motor vehicle trauma, both as passengers and as  pedestrians.  pedestr ians. Many bicycle bicycle deaths deaths in this this age group occur when a small child is struck by a car or truck because their small stature  prevents  preven ts them them from being seen by rearvi rearview ew mirror mirrors. s. T The he inquisitive nature of children in this age group increases the risk  of injury. Falls, poisonings, burns and drownings occur when children are unattended and encounter danger that they cannot defend themselves against nor comprehend. The toddler and  preschooler  presch ooler are also also victims victims of abuse abuse and homic homicides. ides. The largest risk of injury occurs during the school-age years (ages 7 - 12 years). 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 "lapbelt complex" in which the child sustains injury secondary to the lapbelt restraint. (This will be discussed in-depth under the discussion of abdominal trauma.) 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 despite the fact that statistics statis tics have shown that the use of a bi bicycle cycle helmet can reduce brain injury by as much as 88% [47]. Other patterns of injuries in the 7 to 12 1 2 year old child include falls, poisonings and drownings. The incidence of personal violence increases, and the number of suicides in this age group are increasing annually. The incidence of school ground trauma is  becoming  becom ing an almost almost daily part of American American newscasts. newscasts. Many of  these children are innocent bystanders bys tanders who are becoming victims of isolated outbursts among their peers. Many teenagers (ages 13 - 19 years) are injured in automobiles. As these children age, the risk of both driver and occupant injuries is prevalent. Recent studies have shown the incidence of  injury increases with the number of peers in an automobile, thus

 

reigniting the debate regarding driving privileges of young, newly licensed drivers. Many socioeconomic and cultural influences impact the type and incidence of trauma. Urban children have a higher hi gher 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 r ace of the child; young African-American African-American males in the 15 - 19 year ye ar age group have the highest proportion of  homicide deaths, frequently precipitated by firearms [6]. Suicide rates in teenage individuals have increased many times over during the last three decades. Five thousand adolescents take their own lives annually. Caucasian teenage males have the highest rate for suicide deaths, and for each fatality there are 31 nonfatal attempts [25]. Alcohol and drug use increases during this age, and the impact of  impaired behavior will influence injury and death rates. rates . Younger  teens are experimenting with inhalants; huffing or sniffing s niffing volatile agents will increase the risk of "sudden sniffing sni ffing death (SSD)." It is estimated that there are currently over 1400 agents available over the counter that can be legally purchased by young teens as a method of getting high [35]. A new and emerging area of research in trauma epidemiology is studying 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/or musculoskeletal injuries. Football, soccer,  baseball,  basebal l, and and skateboa skateboarding rding are just a few of th thee spo sports rts which which 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  pediat ric patients patients is less than than in adult trauma trauma victims, victims, the number  number  of gun and knife injuries is increasing. While penetrating trauma can be more easily recognized and diagnosed, it is no less life threatening than blunt injuries.

 

Blunt injuries present the challenge of recognition of injury and appropriate diagnosis. Missed injuries secondary to blunt trauma t rauma  pose a risk, especially especially in the the pediatri pediatricc patient. patient. Many of the the mi missed ssed injuries are thought to be related to the level of consciousness of  the child; however, a recent study showed that the inability to communicate was not associated with an increased increase d incidence of  missed injury. This same study noted that the number of missed injuries was significant, as high as 20% [37]. It is imperative that the health care provider caring for the pediatric victim be aware of this risk and pay close attention at tention to the assessment of the young trauma victim. SPECIFIC MECHANISMS OF INJURY

When the report of a traumatized child is obtained, one of the first questions to be answered is "How was the child injured?" As  previously discussed,  previously discussed, the patterns patterns of injury are influe influenced nced by a number of factors. Once the mechanisms of injury are identified, the diagnosis of the injuries is much easier. Most children injured in motor vehicle accidents are passengers, either restrained or unrestrained [8]. Unrestrained children suffer  numerous injuries when a motor vehicle crash occurs; oc curs; 60% of  children who die in an MVA are unrestrained. At the time of the crash, the unrestrained child becomes a projectile and is either  thrown around the interior of the car, impacting with the hard frame, or is ejected, e jected, suffering multiple injuries upon impact with the ground. The incidence of head injury increases by over 300% when the passenger is unrestrained. Children riding in cars equipped with airbags are known to be at increased risk of injury secondary to the impact of the airbags against their small body frames. It is recommended that all children less than 12 years of age be b e placed in the back seat of an automobile equipped with front passenger side airbags. The first airbags were designed to protect a 70 kg male riding in the  passengerr seat. The airbag was discha  passenge discharged rged at a speed of over over 20 200 0 miles per hour and was aimed at the thorax of this male [44]. For 

 

a child sitting in this same seat, the direction of the airbag impact is at the head he ad and neck of the child. Over 66 children have died secondary to airbag injuries, primarily trauma to the head and neck. New generation "smart" airbags are being installed in new model cars; these bags are able to detect de tect the weight of the  passengerr and the speed  passenge speed of the the impact impact and can can be released released at at a lower velocity. Regardless, the recommendation to reduce the risk  of injury and death remains placement of the child in the rear  seat. It must be noted, however, that passengers in this rear  compartment are also at risk for injury. New side impact airbags that are installed on the rear side s ide windows have caused death and injury to children who have inadvertently fallen asleep against the door and are injured when the airbag is deployed, causing lateral disruption of their cervical spine. Seat belt restraint devices can also be the cause of an injury. As noted previously, lap-belt complex occurs when a restraining res training device is improperly utilized. In older vehicles that are equipped with a single lap belt (the (t he shoulder harness device was only added on later model automobiles), the child can sustain injury if the device is not fastened low and tight across the pelvis. pe lvis. Two types of injuries are noted; the first is lap belt complex in which injury occurs to the liver and/or spleen when the belt is riding high on the child's abdomen and is suddenly retracted during a crash. Additionally, the bowel can rupture, causing spillage of bowel contents into the abdominal cavity. The second type of injury occurs when the lap belt is loosely applied around the abdomen of  a small child. In a high-speed hig h-speed crash, the child slips under the belt and catches the chin on the belt, causing causi ng a hangman type fracture of the second cervical vertebrae. This type of injury is known as submarining, as the child slips under the belt. Car seats for infants and small children have significantly reduced death rates of children in automobile crashes. Since their use has  been mandated, mandated, the number number of fataliti fatalities es has dropped dropped 7 71%. 1%. However, statistics demonstrate that 80% of car seats are incorrectly or inadequately are over different carinstalled seat designs, 40 types ofsecured. seatbe ltsThere seatbelts and 300 types100 of 

 

cars in which these seats are installed. It is no wonder that there is disparity in how well the seat is secured. Currently Canada and many European countries have a universal system syst em for installation; this universal locking mechanism will be required in all vehicles sold in the United States by September 2002. An additional type of vehicular trauma in pediatric patients occurs in school-age children riding on school buses. Statistics show that there are nine deaths and 8500 injuries a year in school age children. Those children who die are directly in line with the crash forces. An additional 26 children die annually as  pedestrians  pedestr ians when either leaving leaving or boarding boarding the the bus. bus. These These children are frequently the victims of drivers who try to illegally  pass a school bus when when the red red lights lights are flashin flashing g [15]. [15]. Recently Recently the National Transportation Safety Board (NTSB) reviewed school bus related injuries and deaths and decided to not require seatbelts in school buses. Further work is being done to expand on the concept of compartmentalization, compartmentalization, the method in which the school bus seats are designed. Currently the seats are small, s mall, high backed and closely closely spaced, spaced, with with tthe he in intent tent of keeping keeping the children children in their "compartment" in the event of a crash. During the teenage years, an additional type of injury that occurs as a result of an automobile occurs when a teen is "car  surfing"[38]. Car surfing can take one of two forms; in the first instance the child is riding either on the hood or the top of the  passenge  passenger r compartme comp artment nt in the a surfing surfi ng istype tythrown pe stance. stance. When the car  accelerates or decelerates, child to the ground, which is most often asphalt and a hard surface, and sustains major  head trauma. Additionally, if the child is thrown off the automobile, the driver may be unaware of this fall and continue to drive, possibly driving over the victim, vi ctim, crushing them to the ground. The second activity occurs when either a bicyclist or  skater holds either the door handles or the bumpers of the car, and is pulled by the car (this is known as bumper hitching). This child may also be run over when they inadvertently slip and fall under  the wheels.the Ininherent most instances, thethese victims (and drivers) do not recognize danger in thes e activities. The common

 

remark after such trauma is "I wasn't going very fast." Many victims of pediatric trauma do not comprehend the consequences of their activities until it is too late. Bicycles pose a number of hazards to children. Small children on three wheeled bikes and trikes may not be seen in a rearview mirror and can be run over by a car or truck, most commonly in their own driveway. Older school-age children are frequently injured on bikes. A landmark study conducted in the Seattle area found that bike helmets have the potential of making the difference between life and death in a bike accident. The helmet can reduce the risk of head injury by 85% and the risk of brain b rain injury by 88% [47]. However, an important part of this added safety is that the helmet fit correctly so that it is not dislodged during a fall. Many helmets are too loose. A chinstrap should be tight enough to allow only a finger to be slipped s lipped between the strap and the chin. Bicyclists sustain a number of injuries, with head injuries having the greatest risk of death and disability. Many bicyclists are hit by moving vehicles and can be thrown under the tires of the car or  truck. The child can sustain multiple orthopedic injuries as well as surface injury secondary to skidding across an uneven, rocky surface. Another form of recreational activity that is being studied for its trauma producing risk is the use of small wheel skates, such as inline skates, roller skates and skateboards. s kateboards. The majority of injuries sustained during this activity include trauma to the upper  extremities; the most common major injury is a distal forearm fracture. Studies have shown that only 25% of skaters utilize  protective  protec tive equipment. equipment. Wrist guards guards can reduce the inciden incidence ce of  forearm fracture by 23% [36]. All children who participate in organized sports are at risk for  certain types of injuries. In the United States, the sport with the highest incidence of mild traumatic brain injury is football, followed by wrestling and girls' soccer. There are over 62,000

 

cases of mild traumatic brain injury per year in high school-age athletes; the most common type of injury is a concussion [40]. The American Academy of Neurology has set guidelines for   player evaluation evaluation and return to play; play; unfor unfortunate tunately, ly, these guidelines are sometimes overlooked, and a player is returned to  play sooner than would be prudent prudent [2]. Football has always been perceived as a sport with risk, and it is not uncommon for injuries to occur while on the field. Of those children who die during a football game, 87% are secondary to a subdural hematoma. However, it is important to point out that 35% of head trauma sustained during football games ga mes involves no impact to the head; rather, the injury is related to an an acceleration/deceleration type of injury [10]. Football players who have suffered two or more concussions demonstrated de monstrated reduced cognitive skills and compromised functioning, with this loss of function averaging five days or even longer in some children [11]. Soccer is the most popular sport in the world, and the number of  children participating in organized soccer leagues is increasing by leaps and bounds. Many parents proclaim soccer to be a "safe" sport when compared to football and direct their children to this arena. Over 6 million children in the United States play organized soccer, and the injury rate is twice as high in females as in males. The vast majority of the injuries sustained occur in the lower  extremities theinjury most common reason se eking seeking medical attention is aand knee [32]. A study of for s occer soccer players demonstrated lower mental function test scores in the soccer   playerss as opposed  player opposed to to the the control control subjects subjects which which were swimmers swimmers and track participants. The median number of headers (subconcussive blows to the head from impacts with the soccer   ball) the players players utilize utilize during during a game game is 8.5. It is thought thought th that at this this type of play is harmful to the brain of the child; further studies are underway to elucidate this correlation [30]. One of the fastest fas test growing winter recreational activities, which is especially popular among teens, is snowboarding. Studies have

 

shown that snowboarding is twice as dangerous as skiing. The injuries sustained differ from ski injuries; snowboarders sustain ankle injuries and compression injuries to the lower spine. Twisting knee injuries, as seen in skiers, skier s, are rare as both feet are fixed together on the board [46]. Mechanism of injury patterns are also being be ing recognized in other  activities in which children participate. parti cipate. Personal watercraft (PWC) related injuries are being studied st udied and have shown that there are 8.5 times more injuries sustained on a PWC as occurring from a motorboat [4]. Extreme forms of trauma are being seen s een in the pediatric population, as more teenagers te enagers than ever before are trying extreme activities such as bungee jumping. With new forms of recreation come new mechanisms of injury, and it is the health care provider's responsibility to keep up with these advances in injury recognition so that the next time a  pediatric patient  pediatric patient sustains sustains trauma, trauma, the potenti potential al and and real real in injuries juries can be recognized without delay. PEDIATRIC TRAUMA RESUSCITATION RESUSCITATION

Resuscitation of the pediatric trauma t rauma patient requires not only hands-on care, but also recognition of the multitude of intricacies that the pediatric patient brings to the resuscitation. Anatomic and  physiologic  physiol ogic differences differences between between childr children en and and adults adults require require that that interventions be altered to take these differences into account. Preparing the emergency department for the pediatric trauma victim requires pediatric specific equipment and personnel trained in pediatric advanced life support s upport measures. Instituting the  primary  primar y and and seconda secondary ry survey survey must be done done with with these these conditions conditions in mind. Finally, adequacy of resuscitation must be monitored with consideration of the child's normal level of functioning. Controversies in pediatric resuscitation continue. Current therapies are, and should be, evaluated on a regular basis as a method of improving future care. ANATOMIC ANATOM IC AND PHYSIOLOGIC PHYSIOLOGIC DIFFERENCES DIFFERENCES

 

Trauma resuscitation of the pediatric patient requires that the  practitioner  practit ioner be cogniza cognizant nt of of the uniqueness uniqueness of childre children's n's anatom anatomy y and their physiologic needs. Comparison of the child's anatomic and physiologic parameters to those of an adult patient demonstrates that "children are not small adults" and interventions must be varied to meet these subtle differences. Children have large heads that are frequently injured in trauma. Proportionately, there is a larger volume of blood in the head, leading to the rapid onset of cerebral edema and increased intracranial pressure. Very young children, less than 2 years of  age, may have soft bones and cranial suture lines which are not completely fused, leading to what is known as a diastatic fracture, a separation of the cranial bones at the suture s uture line. Injuries to the neck and spinal column of a child occur for two reasons: (1) the head is heavy; and (2) muscular support of the neck is poor thus leading to flexion and/or extension injuries. Often the child will  present with neurologic neurologic deficits deficits withou withoutt ra radiolo diologic gic abnormali abnormalities, ties, defined as SCIWORA (spinal cord injury without radiologic abnormality). Stabilization and management of the child's airway is more difficult because the larynx is more cephalad and anterior than an adult's, resulting in vocal cords which are more difficult to visualize during an intubation attempt. In addition, the child's airway diameter is narrow, leading to the rapid onset of airway loss with only mildresistance edema formation. formation, airway increases,With thus the theonset child of hasedema a more difficult time maintaining an adequate gas exchange. e xchange. The respiratory system of a child is small, with less alveolar  surface area for gas exchange, as well as fewer collateral ventilatory pathways. Parenchymal injury (such as a pulmonary contusion) leads to severe se vere rapid compromise if oxygen and ventilatory support are not provided early during the t he resuscitation. The anatomic variables in a child's chest include ribs and diaphragm which are horizontal, sternum and ribs which are more cartilaginous, a thin chest wall, and a thin diaphragm. A

 

child may sustain massive soft tissue injury to the chest ches t without signs of external trauma, e.g. rib fractures, sternal fracture, etc. An increased susceptibility to both vagal and sympathetic stimuli leads to wide ranges in the child's pulse rate. In addition, children are tachycardic for a number of reasons, including pain, fear, and agitation, so that the assessment assess ment of tachycardia is less beneficial. The heart of a child lies higher in the chest cavity and has a tthin hin heart wall and small pericardial sac; therefore, it is more prone to  blunt injury injury to the chest. The developmen developmentt of cardia cardiacc tamponad tamponadee is rapid and severe, leading to early cardiac arrest if not identified and treated expeditiously. A thin-walled abdomen without musculature to protect the abdominal organs leads to frequent rupture of these organs. In addition, the horizontal diaphragm does little to protect the liver  and the spleen from injury. With fewer fat deposits around the abdominal and retroperitoneal organs, the organs are at risk for  developing tears of the major vessels supplying these organs. Once injury has occurred, bowel sounds are of little value as  bowel function function is labile labile and and bowel bowel tones are frequently frequently absent regardless of the extent of injury. The size of the t he abdominal organs is proportionately larger, with the exception e xception of the stomach, which is small with a small capacity; thus stomach distention leads to upward displacement dis placement of the diaphragm, causing respiratory distress. Musculoskeletal injuries account for a large proportion of the traumatic injuries seen in children due to the fact that the bones are soft and pliable, leading to multiple fracture types. Healing of  fractures occurs rapidly secondary to the thick and highly vascular periosteum. The incidence of dislocations is reduced, as ligaments are strong. Renal function is not well developed, and functional reserve is decreased, causing the child to produce dilute urine and be at risk  for acute renal failure. The genitourinary (GU) organs sit high in

 

the intraabdominal cavity, outside the pelvic ring, thus increasing the risk of injury to these organs. Other unique parameters in children include the large l arge body surface area to body mass, leading to an increased risk of  hypothermia at the time of injury as well as during the resuscitation. Children have irregularly functioning sweat glands, increasing the susceptibility to temperature variations. The immune system is not completely developed, putting the child at risk for infection. The proportion of body water to body weight decreases as a child grows, causing the small child to be at risk  for developing dehydration. Vital signs vary by age, and it is important to know the "normals" for each individual child. This basic knowledge of the child will allow the nurse managing the pediatric patient to recognize changes in the child's status although a lthough it should be noted that vital sign changes alone are misleading and can lead to delayed interventions. Finally, when assessing the injured child, growth and developmental characteristics must be considered. These capabilities will depend upon extrinsic factors such as older  siblings, school attendance, etc. As a child develops, growth  proceedss from  proceed from a head to toe, toe, proxim proximal al to distal, distal, and gross to fine fine direction. However, many of the child's capabilities will regress when the child is ill or injured. In summary, it is imperative to consider the unique parameters of  children when resuscitating and stabilizing the injured. Interventions may require alteration from standard trauma  protocols  protoc ols to to adjust adjust to the individual individual child's needs. To review review some of the important variances of children and the significance to trauma care, refer to Table 1. UNIQUE PEDIATRIC PARAMETERS AND SIGNIFICANCE Variable TO TRAUMA CARESignificance

 

Largee volu Larg volume me of bl bloo ood d in head head Poor Po or musc muscul ular ar su supp ppor ortt in neck neck Deccreas De reased ed alv alveo eola larr surf surfac acee area area Less alveolar surface area Hea eart rt lie iess hi higher gher in ches chestt cav cavit ity y

Cere Cerebr bral al edem edemaa deve develo lops ps ra rapi pidl dly y Flex Flexio ion/ n/ex exte tens nsio ion n inju injuri ries es occu occur  r  Incr Increa ease sed d airw airway ay res resis ista tanc ncee Injury leads to rapid compromise Pron Pronee tto o inj injur ury y

Thin-walled, sma small abdomen Bones are soft and pliable

Organs not well protected Fractures are less common but still occur  Renal functio function n not well well developed developed Develop Develop acute acute renal failure failure easily Larg La rgee body body surfa surface ce to to body body mass mass Pron Pronee to hypo hypoth ther ermi miaa Source: Compiled by author Table 1 LEVELS OF PEDIATRIC TRAUMA CARE

Most children injured are local t reated treated first by paramedics the field when who a callare goes int o the into 911 center. A child is in then transported to a definitive health care facility for resuscitation and stabilization. Pediatric trauma systems have been developed de veloped throughout the United States to ensure that the pediatric trauma victim is receiving the optimal care available. Studies have shown that the level of care provided at sophisticated trauma centers reduced the risk of death in seriously injured children. A differentiation is made between pediatric trauma centers and trauma centers with pediatric commitment; the  pediatric  pediat ric trauma trauma center center is capable capable of not not only only provid providing ing tertiary tertiary medical care but also support services that are designed specifically for the pediatric patient. In adult trauma centers with  pediatric  pediat ric commitmen commitment, t, the special special needs of childre children n may may or or ma may y not be met at the same s ame level as they are at pediatric trauma centers. However, the availability of these centers is limited; there are fewer than 30 pediatric trauma centers in only 21 states. Thus, the vast majority of pediatric trauma victims are cared for in hospitals with or without designated des ignated trauma care [44]. One important determinant in the outcome of children with traumatic injuries is the training of health care providers in

 

 pediatric trauma  pediatric trauma care care managem management. ent. Those facilities facilities with ongoing ongoing continuing education and a commitment to current trauma therapeutics demonstrate better outcomes for children when compared to a general hospital emergency e mergency department. Anoth Another  er  interesting statistic showed that only 5% to 21% of children with  blunt spleen and liver trauma trauma cared cared for by p pediatr ediatric ic trauma trauma surgeons undergo laparotomy. When compared to children cared for by adult trauma tr auma surgeons, the incidence of laparotomy increased to as high as 53% to 58% [42]. Despite the trend towards non-operative management of these injuries, there remains a significant disparity in how pediatric patients are currently managed. Other methods that are utilized to determine the level of care required by the pediatric trauma victim include scoring s coring systems. These systems are designed des igned to improve triage, organize trauma care, predict mortality and morbidity, and assure quality care. No ideal scoring system exists, yet many facilities will use these scores as determinants of pediatric care. One of the most widely utilized scoring systems in the prehospital setting is the Pediat  Pediatric ric Trauma Score, which assists the prehospital care provider in determining when a child should be transported to a hospital with a high level of sophisticated equipment. Other scores that analyze severity of injury, such as the Abbrev  Abbreviated iated Injury Scale and the  Injury Severity Severity Score Score, may be utilized to identify children at high risk for adverse outcomes. Knowledge of availability of resources for pediatric trauma tr auma victims is an important aspect of managing the injured pediatric  patient. Facilities Facilities must be willing willing to conduc conductt self self-exa -examina minations tions to determine their level of commitment and transfer those patients pati ents who cannot be cared for within the constraints of their facility. Managing the pediatric trauma victim with minimal resources increases the risk of death and disability. Prevention of this mortality and morbidity should be foremost in the minds of health care providers in determining appropriate care for the injured child.

 

PREPARING THE EMERGENCY PREPARING EMERGENCY DEPAR DEPARTMENT TMENT FOR A PEDIATRIC TRAUMA PATIENT

Readiness for resuscitation of the pediatric trauma victim requires a number of steps. Not only must the physical requirements of the child be met, but the emotional, psychological and social demands should also be weighed. The care providers must be able to intervene in all these realms rea lms to ensure family-centered care. Physically the department should be prepared with the appropriate size equipment to meet the special requirements of  the patient being admitted. Often the report from the prehospital  personnel  personn el will will provid providee the the age of the the child, child, which allows allows an estimation of the size and weight of the child. Although formulas for estimation exist, the use of the Broselow tape is now recommended to ensure age- and weight-appropriate interventions. Weighing the child upon admission is not important in the case of the trauma patient, and appropriate estimation can be achieved utilizing this method. Personnel trained in pediatric trauma resuscitation should be notified and present at the bedside upon arrival of the patient in the emergency department. A pediatric resuscitation cart should  be readily readily available available to provide provide appropriat appropriatee size equipment equipment for the the  patient. A cart cart that is color color coded coded to match match the Broselo Broselow w Resuscitation tape can be helpful in expediting equipment acquisition. Social workers, clergy or other personnel offering emotional and  psychologic  psycho logical al support support to the the family family memb members ers of the the ped pediatric iatric trauma patient can provide a tremendous advantage to the resuscitation. These individuals should be trained in providing general information on what is being done for the patient and how long it may be before the family members can visit with the child. Specific information regarding injuries and outcomes should be  provided  provid ed at at the discretion discretion of the the attending attending physic physician; ian; however, however, availability of general information will go a long way in helping the family adjust to the situation at hand.

 

The medical, nursing, and ancillary staff must be prepared to deal with the psychological impact of caring for the pediatric trauma  patient. Many times these children children are are injured injured in ways ways that that the the staff does not condone (lack of seatbelt use, abusive injuries, lack  of supervision), and these feelings of frustration and anger must  be held held in check while resuscitatin resuscitating g the the child child and dealin dealing g with with tthe he family. If an extremely emotional case occurs in the department,  post resusci resuscitation tation debriefing debriefing may benefit benefit al alll those those who who cared cared for  the patient. PRIMARY SURVEY

Immediate measures in trauma resuscitation for a patient patie nt of any age is management of the airway, breathing and circulation (ABC) while simultaneously determining if the child has sustained any life-threatening injuries. In the child, these steps take on even more importance, since the loss of the airway in a child can be rapid and result in devastating de vastating consequences. As the ABCs are stabilized, the primary survey includes assessment of  the level of disability and requires exposing the child for rapid identification of any underlying injuries. The primary survey should take no longer than 5 to 10 minutes for assessment ass essment and stabilization. Airway management of the child is critical and must be obtained as rapidly as possible. The limited size of the pediatric airway increases the risk of rapid deterioration and subsequent difficulties in managing the airway. Although the incidence of  spinal cord injury is rare in children, all pediatric pe diatric trauma patients should be managed as if a spinal cord injury exists. e xists. This requires utilizing the jaw-thrust maneuver to open the airway while maintaining alignment of the cervical spine. Once positioned, the airway should be examined for debris, such as loose teeth, blood, or saliva, which can be mechanically removed. For the child who is unable to maintain a patent airway, endotracheal intubation via the orotracheal approach should be instituted. The appropriate size tube should be utilized; an

 

uncuffed tube is preferred in children less than 8 years of age. age . Anatomic differences between adult and pediatric airways make endotracheal intubation more challenging in the child. During trauma resuscitation, the care provider with the most experience at pediatric intubations should be assigned the responsibility of  securing the airway. Those with less experience should defer this responsibility. This is not the appropriate time to be practicing intubation techniques. Rapid sequence intubation (RSI) has become a recommended adjunct to airway management of the child considered at highrisk of complications secondary to intubation. RSI involves the t he administration of sedative and paralytic agents to t o improve the success of intubation, while at the same time reducing the risk of  intubation increasing intracranial pressure. The methods of RSI vary slightly, and different trauma programs may choose different drug combinations; however, the end results are the same [31]. Table 2 lists the steps in securing the child's airway utilizing rapid sequence intubation techniques. RAPID SEQUENCE INTUBATION PROTOCOL 1. Preparation   1. Ensure adequate IV access 2. Test suction and oxygen 3. Prep Prepar aree Endo Endotr trac ache heal al tube tube (E (ETT TT)) (che (check ck cuff  cuff   patency)  patenc y) 4. Assemble equipment 5. Init Initia iate te puls pulsee oxim oximet etry ry,, if not not al alre read ady y do done ne 2. Preoxygenation   1. Appl Apply y 10 100% oxy oxygen gen for for 5 minut inutes es of norm normal al  breathing  breath ing 2. If tim time do does not not per perm mit it,, adm admiinist nister er 3 v vit ital al capacity breaths (maximum volume patient can take) with 100% oxygen 3. Premedicate   1. Atropine 0.01 mg/kg IV 2. Cons Consid ider er Lido Lidoca cain inee 1 to 1.5 1.5 mg mg/k /kg g IV in pati patien ents ts

 

4.

with severe reactive airway disease, or those patients with increased ICP Paralysis   1. Afte Afterr 2 min minut utes es of la last st prem remedic edican antt dru drug, g, administer sedative/anesthetic and Anectine (succinylcholine) 2. Sedat edativ ive/ e/an anes esth thet etic ic choic hoices es may may incl includ ude: e: (usually only one is administered) Etomidate 0.2 to 0.4 mg/kg Midazolam (Versed) 0.1 to 0.3 mg/kg Fentanyl 2 µg/kg 3. Adm Admini inister ster suc succinyl inylccholi holine ne 1.5 1.5 tto o 2 mg/kg g/kg 4. As pati patien entt lose losess cons consci ciou ousn snes ess, s, assi assist stan antt shou should ld  perform  perfo rm Sellick Sellick maneuv maneuver er and and mainta maintain in this this position position until ETT is in place and cuff is inflated Placement   1. Appr Approx oxim imat atel ely y 45 seco second ndss aaft fter er ad admi mini nist stra rati tion on of Anectine, proceed with intubation 





5.

2. Check tube tube placement, sec ecu ure tube Source: Adapted from [50]

Table 2

One technique that can improve success and decrease the risk of  complications during intubation is performance of the Sellick  maneuver. To perform this maneuver, the assistant places his/her  fingers over the trachea at the level of the cricoid ring and places firm pressure in an anteroposterior direction. This will displace the trachea posteriorally, closing off the opening to the esophagus. The individual who is performing the intubation will  be able able to better visualize visualize the vocal vocal cords, cords, thus improving improving the chances for a successful first attempt intubation. Additionally, by closing off the esophagus, the risk of aspiration is decreased should the patient regurgitate during the intubation attempt. It is critical that the individual performing this Sellick maneuver not  place too much much pressure pressure on the airway, airway, as the trachea trachea is collapsible and devastating loss of airway can occur [31].

 

Injuries that may complicate airway management include those of  the face, including facial fractures, mandibular fractures and fractures of the maxilla. These injuries produce rapid swelling and the visual loss of anatomic anat omic structures. Although needle cricothyrotomy is avoided in most cases, these injured children (Note: may require securing the airway utilizing method.on surgical cricothyrotomy should not be this performed children.) Emergency tracheotomies should only be performed pe rformed in the operating room under controlled conditions. Field and emergency department management of the airway should s hould first include intubation with RSI, and, if unsuccessful, laryngeal mask  airway placement or needle cricothyrotomy.

After securing the airway, ventilatory efforts must be ensured and supported as necessary. The child's rapid respiratory rate requires the care provider to ventilate the child at a faster rate than would  be utilized utilized in the the adult adult trauma trauma patient. patient. Choosin Choosing g the the appropri appropriate ate size resuscitation bag (ambu bag) is critical to prevent overdistention of fragile lung tissue. Tidal volumes in children are calculated on a weight basis: 5 - 10 cc per kilogram of body weight. Supplemental oxygen should be utilized, as children have high oxygen demands and become hypoxic quite quickly. As soon as  possiblee a pulse oximeter  possibl oximeter probe probe should be applied, applied, and monitoring of the child's oxygen saturations should be instituted. Oxygen desaturation can be a sign of developing respiratory failure and is helpful in providing real time iinformation nformation regarding the patient's oxygenation status. Circulatory support is the next step in the resuscitation res uscitation process. Assessment of circulation in children involves assessment of the  pulse rate, pulse strength, strength, skin color and capill capillary ary refill time. Assessment of blood pressure should be obtained; however, it is important to remember that children have an exceptional e xceptional ability to maintain normal vital signs in the face of significant si gnificant volume loss.

 

Control of ongoing hemorrhage must be the first step in circulatory support; subsequently, vascular access should be initiated. Obtaining vascular access is often difficult in the small child; venous cannulation should be attempted as soon as possible for improved success. The longer the cannulation is delayed, the greater the incidence failure. O ptimally, Optimally, the child who is hemorrhaging shouldof have two large bore lines placed, preferably in the antecubital fossa. If IV line placement is unsuccessful in small children less than 4 years of age, intraosseous (IO) line placement should be obtained. Intraosseous lines can provide rapid access to the central circulation; large amounts of fluid and/or blood b lood products can be administered, and all medications are safe to administer via this route. The most common complications of IO line placement are the development of a local abscess or cellulitis at the insertion site and osteomyletis. Both complications may be treated with antibiotics. Volume replacement in children is based on a milliliter per  kilogram basis; initial resuscitation is started at 10 - 20 ml/kg with warmed IV fluid. This fluid is administered rapidly and the child monitored for adequacy of resuscitation. In the child with ongoing blood loss, IV fluids can be increased to 50 - 60 ml/kg; however, at this point, blood b lood administration should be considered. Whole blood is administered at 20 ml/kg, while packed red blood cells can be administered at 10 ml/kg diluted with an equal amount of normal saline. The choice of IV fluids is somewhat s omewhat controversial. controversial. Both lactated Ringer's (LR) solution and normal saline (NS) solution can be administered as the initial crystalloid for resuscitation. Additionally, children will require the administration of a dextrose containing solution, preferably D5 0.25% NS, to prevent hypoglycemia and acidosis development. This dextrose containing solution is commonly referred to as maintenance fluids and is administered in children less than 8 years of age on a ml/kg basis. Table 3 presents the formula for maintenance fluid

 

administration. MAINTENANCE FLUID ADMINISTRATION Control of ongoing hemorrhage must be the first step in circulatory support; subsequently, vascular access should be •





100 cc/kg for 1st 10 kgs. 50 cc/kg for 2nd 10 kgs. 20 cc/kg for each kg over 20.

Example: 20 kg child •



Total:

1000 cc for first 10 kgs 500 cc for second 10 kgs 1500 cc/24 hours

Rate of  62 ml/hour  administration: D5 0.25% Normal Saline Fluid of choice: Source: Compiled by Author

Table 3

Throughout the resuscitation, efforts at maintaining normothermia and normal blood glucose levels should be undertaken. Resuscitation requires a team approach with individuals assigned specific tasks to support the child during this critical time period. Although discussed as a step-by-step sequence, simultaneous stabilization is mandatory. Once the ABCs are stabilized s tabilized and ongoing resuscitation efforts are secured, the child must be assessed for the level le vel of disability. A rapid method of disability evaluation is to utilize the AVPU  mnemonic. A is for alert, V indicates the child responds to verbal stimuli, P indicates response to pain, U is for the unconscious  patient.

 

Prior to initiating the secondary survey, the child must be completely undressed and all body surfaces exposed to allow for  identification of underlying injuries. SECONDARY SURVEY

The secondary survey is a systematic head to toe assessment ass essment of  the traumatic injuries sustained. Ecchymosis and other signs s igns of  underlying injury should be identified. Mechanisms of injury can direct the practitioner in identifying potential injuries although it is important to remember that not all traumatic injuries are clearcut and initially obvious. Beginning at the head of the child, the scalp is palpated and assessed for lacerations and irregularities in the shape of the skull. In infants, the fontanelles should be palpated for fullness and/or  widening. structures should be for assessed forbodies integrity instability.The Thefacial eyes should be examined foreign or  or  other structural deformities. Drainage of cerebral spinal fluid (CSF) from the nose and ears should be identified. The mouth should be inspected for lost or loose teeth, teet h, bleeding and secretions.  Neurologic assessment  Neurologic assessment should should include include the patient's patient's level level of  consciousness, Glasgow Coma Scale score, and pupillary response. Intact brain stem reflexes indicate an intact brain stem. Evaluation of the corneal and gag reflex should be obtained as  part of the the neurolo neurologic gic assessment. assessment. Motor Motor and and sensory sensory func function tion should be evaluated. Further discussion of weakness and paralysis is included in the section se ction on Trauma to the Spine and Spinal Cord. The neck should have been secured in a hard collar by prehospital  personnel.  personn el. At this this point point the the ccollar ollar can be be rem removed oved while an additional person ensures neck alignment. The neck is assessed for deformity, swelling and pain. Range of motion should not be assessed until a clear cervical cer vical spine x-ray has been obtained.

 

The chest is evaluated for bilateral, symmetrical chest movements with ventilation. Auscultation should include assessment of   breath and heart heart sounds. sounds. Should Shoulder er harness harness ecchymosis ecchymosis should be recognized if the mechanism of injury suggests this pattern of  injury. Although pediatric rib fractures are rare, integrity i ntegrity of the rib must of be rib determined. Once the child reaches adolescence, the cage incidence fractures increases. The abdomen must be palpated. Any obvious injury should s hould be assessed last. Beginning the assessment assess ment in a nonpainful area will ensure better cooperation from the child. Increasing abdominal distention is an early sign of underlying injury in a child and should be documented and followed as care progresses. The extremities should be assessed for proper alignment and range of motion. Any obviously injured part should be left alone, and distal pulses should be obtained to ensure e nsure adequate distal circulation. While at times it is difficult to assess ass ess children's extremities, by comparing the injured side to the uninjured side, one can improve the ability to recognize injuries. Once the anterior torso and extremities have been fully assessed, the child should be logrolled so that the back b ack and buttocks can be evaluated. Bruising over the flank area is an early sign of renal re nal trauma and can only be identified if the child is evaluated both front and back. Throughout this assessment the child should s hould be continually monitored for response to therapy. Oxygenation and ventilatory status should be of prime importance. Vital sign assessment should be obtained and interventional changes based base d upon findings. Cardiac monitoring, nasogastric tube, and foley catheter   placement  placem ent can be initiated initiated as appropri appropriate. ate. Once injuries injuries have have been been identified, laboratory and radiology studies can be instituted. Specific studies are identified in the following discussions of  system trauma. A final step in the resuscitative r esuscitative process should be the institution of pain control and anxiety-reduction measures. Many physicians

 

 prefer to delay delay admin administerin istering g narcot narcotics ics until until the seconda secondary ry survey survey is complete and all injuries have been identified. At this point, the child can be administered morphine (0.1 mg/kg) or fentanyl (1 µg/kg) and midazolam (0.05 - 0.1 mg/kg) as needed. Assessment of the effectiveness of these pain control measures should be  perfor  performed. med. If should the the child child cinstituted. ontinues es to complain complain of pain, pain, additional additional interventions becontinu After all injuries have been identified and stabilized, a decision regarding further intervention must be made. The severity of  injury may require that the child go directly to the operating room for further stabilization measures. Many pediatric traumatic injuries are managed non-operatively, thus the child is admitted to the intensive care unit. Depending upon the capabilities of the institution that is stabilizing the child, the appropriate disposition may be to transfer the child to a more sophisticated facility with  pediatric  pediat ric trauma trauma teams teams to to further further care for the cchild. hild. Arranging Arranging for  this transfer should be initiated as early ea rly as possible, and air  transport may be considered to limit the out of hospital time to which the child is subjected. CONTROVERSIES IN PEDIATRIC SHOCK TRAUMA CONTROVERSIES MANAGEMENT

Many of the controversies in trauma t rauma management are identified in adult and animal models. Most of the information obtained in these is then into the pediatric model. Thus, populations the information wepostulated have regarding controversial interventions may or may not be of consequence in the pediatric trauma patient; only time and experience will tell. Aggressive fluid resuscitation has been the protocol for many years, first being supported s upported by the American College of Surgeons in the Advanced Trauma Life Support courses. However, over the last few years, there has been bee n interest in what is known as "minimal volume, delayed resuscitation" in a specific group of   patients.  patient s. The The rationa rationale le for for this this new new resusci resuscitation tation technique technique is that that maximum fluid resuscitation will increase bleeding, prevent clot

 

formation or dislodge forming clots. The use of this type of  resuscitation is supported in patients with ruptured abdominal aortic aneurysms (a very rare injury in children) and in patients with penetrating truncal trauma (as seen see n in gunshot wounds). Once the injuries have been stabilized and bleeding has been controlled, aggressive volume resuscitation is then initiated initiate d to restore normal he movolemia. hemovolemia. The use of minimal volume, delayed resuscitation philosophy is at odds with the new standards of care for the patient pati ent with a head injury who requires an adequate blood pressure to ensure adequate cerebral circulation (this concept is discussed in depth in the Trauma to the Head and Face section). In addition, this method of resuscitation is not recommended in the rural setting with long transport times because in this setting the patient may exsanguinate prior to reaching sophisticated trauma care. As the incidence of penetrating truncal trauma increases in the  pediatric  pediat ric population population secondary secondary to the the increasing increasing incidence incidence of  gunshot wounds, the use of minimal volume, delayed resuscitation will be further evaluated. Because of small circulating volume, the pediatric patient may not benefit be nefit from this type of resuscitation in the same way as the t he adult trauma victim. Further study must take place to interpret the effects of this type of therapy. At the present time, resuscitation with aggressive fluid infusion is currently recommended for management of pediatric trauma. An additional area of debate in trauma resuscitation is how to best measure the effectiveness of resuscitation efforts. All patients should be monitored for adequate urine output, stable vital signs and acceptable respiratory function. As these measurements are assessments of global functioning, the need to look at organ specific endpoints has gained tremendous focus in the past couple of years. One of the difficulties in assessing assess ing end organ function is how to  best measure measure these parameters. parameters. High tech interventio interventions ns have have been

 

developed, but high tech often equates e quates with expensive care. Nearinfrared spectroscopy, fiberoptic oxygen probes and phosphorous magnetic reasonance spectroscopy have been developed to give us more detailed information on organ function [26]. With this information has come the need to develop methods of  manipulating end function regulating  perfus  perfusion ion at this ththe is level. lev el.organ We We must mu st then then and determi determine ne whattissue parameters parameters are acceptable in terms of adequacy of resuscitation. Each time a new piece of information is obtained, it opens the door to additional areas of study. Organ specific monitoring has focused a great deal of attention upon the gastric system. The splanchnic bed is the area first firs t affected by loss of volume and one of the last areas to regain adequate function once resuscitation is instituted. ins tituted. Measuring the gastric mucosal pH has been performed as an indicator of  hypoperfusion. The technique is simple, and the calculations are easy to perform. In patients with low gastric pH, the incidence of  multiple organ dysfunction syndrome was increased and the mortality of critically ill patients was higher [17]. We must refine methods of assessing gastric pH, learn how to manipulate the gastric pH and determine what levels of pH are acceptable as goals of resuscitation. There is much work to be done in this area, are a,  but it is an area of tremend tremendous ous excitement excitement as we obtain new information on how to assure adequate resuscitation and thus improved outcomes of trauma victims of all ages. age s. Despite the development of new techniques and interventions, i nterventions, the ultimate goal of resuscitation is to match energy production with energy demand at the cellular level. If global measurements (such as urine output) are the only measurements available, these should be followed and the child stabilized to meet the needs already identified.   TRAUMA TO THE HEAD AND FACE

 

The most life-threatening of all traumatic injuries in the pediatric  population  popula tion are those those that occur to the the head head and and fac face. e. Trauma Traumatic tic  brain injury injury is a major major cause of death death and disabil disability. ity. More than 600,000 children are temporarily incapacitated as a direct di rect result of head injury, and 22,000 die annually [7]. Head injury remains the leading cause of death in children over 1 year of age. Trauma to the head and face can cause injury to the scalp, s calp, skull, facial structures, and brain although a lthough 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 motor vehicle accidents and falls. Motor vehicle versus pedestrian injuries are common in school-age s chool-age children while child abuse is a major cause of brain b rain injury in children less than one year of age. Additional mechanisms of injury include  bicyclee injuries  bicycl injuries and assaults. assaults. Boys Boys have have a higher higher incide incidence nce of  trauma to the head than girls. Traumatic injuries to the head can 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 unique patterns of injuries seen in children, followedand by the an in-depth discussion of the treatment and outcomes following both minor and major brain injury. When the head is injured, it is important i mportant to remember that two types of injury can occur, primary and secondary. Primary injury is that injury to the head and brain that occurs at the time of  trauma. We have little control regarding rega rding the development of this type of injury, with the t he exception of education regarding  prevention.  preven tion. Secondary Secondary injuries injuries occur occur as a result result of trauma; trauma; 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 directed at preventi preventing ng or contro controlling lling the develo developmen pmentt of  secondary injury. The most apparent head injury is a scalp laceration. Blunt force applied to the head will cause tissue tis sue disruption, leading to hemorrhage. In small children, uncontrolled hemorrhage can cause exsanguination attributable to the high density of vascular   beds in the scalp. In most most patient patientss pressure pressure dressings dressings applied applied to the injury can 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 tre ated with observation and follow-up until resolution is achieved, which may require several se veral weeks. However, it is critical that during this recovery period assessments are  performed  perfor med faithfully faithfully to rule rule out out any any delayed delayed onset of trauma traumatic tic  brain injury. injury. Skull fractures can be described by their type: linear, depressed, compound, basilar, ping-pong ball and "growing." Seventy-five  percen  percent pediatric pediat ricIfskull fractures fractures are are linear linear fractures, fractures, simple simple cracks tinofthe bone. no underlying injury develops, theorchild will have complete resolution of the fracture site. Over time this fracture line may completely disappear from x-ray as remodeling re modeling 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 CT scan or possibly MRI scan 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 diagnosis because multiple bony b ony fragments must be evaluated. Each fracture segment seg ment 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 non-accidental trauma (such as child abuse)this should cons ideration when caring for  consideration the child sustaining type be of ainjury. Basilar fractures occur at the base of the skull s kull and may be easily diagnosed by specific, characteristic signs and a nd symptoms. The child with a basilar skull fracture may exhibit CSF leakage from the nose (rhinorrhea) or ears (otorrhea), raccoon eyes, and hemotympanium. A delayed but diagnostic sign is bruising (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 accomp accompanied anied by injury injury to the ocular, ocular, cochlea cochlear, r, and and facial facial nerves, leading to concomitant loss of vision, hearing or facial 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 t he segment is depressed but no fracture lines are evident on x-ray. The ping-pong ball designation was coined when someone s omeone 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 s mall children, generally less than 2 years of age, on account of the minimal mineralization of the skull tissue. The inherent risk of this depressed segment is the underlying damage to the cranial tissue. The depressed segment is commonly surgically elevated to reduce this 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 produc producing ing brain tissue compressio compression. n. Obscuring Obscuring the diagnosis is the inabilityresonance to visualize vis ualize the dura on best plainmethod skull for  radiographs. Magnetic imaging is the dural integrity evaluation although availability and cost issues often make this modality less than optimal. Patients with a higher  risk of dural tears and subsequent subse quent cyst formation are those with a diastasis of 3 mm or greater and a young age. Currently the trend in some institutions is to utilize ultrasound to diagnose these tears. Normally ultrasound beams do not penetrate an intact skull,  but an opening opening (fractu (fracture) re) will allow these beams to pass pass through, through, and the practitioner can examine the integrity of the dura [13]. Injury to the neural tissue can vary in severity s everity from a concussion, the mildest form, to a contusion, or to a diffuse axonal injury,  producing  produc ing severe, profound profound coma. A concussi concussion on produc produces es a temporary disruption of cerebral function, generally lasting less than one day. Recently the term "mild traumatic brain injury" has  been suggested suggested as as a replacement replacement for the term term concus concussion; sion; further  further  discussion of this type of injury will follow. 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  prolon ged periods periods of time, and recovery recovery outcomes outcomes may be unpredictable at the time of initial evaluation. Often contusions are referred to as "coup-contrecoup" injuries. This injury emerges during rapid acceleration and deceleration of the head as occurs in a motor vehicle crash. The "coup" injury occurs when the brain impacts the interior of the skull, leading to injury of the brain b rain tissue at the site si te of impact. The "contrecoup" lesion can be of  greater consequence; this lesion occurs on the brain at the side opposite initial impact. othergwords, thetobrain is r of   bounc  bouncing ingfrom around arounthe d inside insi de the skull, skull,Incausing causin damage damage a number numbe of 

 

areas in the brain. The greater the damage to the neural tissue, ti ssue, the greater the risk of severe brain injury. Diffuse axonal injury (DAI) 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 de velops 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 intracerebral 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 s ubdural develops within 2 weeks of injury and is defined by a progressing decrease in level of consciousness during this time frame. A chronic subdural is commonly diagnosed months later when a child chi ld is evaluated for changes in personality, pe rsonality, behavior and/or cognition or  new-onset seizures. The actual cranial insult may have been forgotten by the time of diagnosis. An epidural when bloodassociated accumulates between the skull andhematoma dura and isoccurs most commonly 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 present as asymptomatic. Neurologic deterioration occurs over time, thus compounding diagnosis. An epidural bleed is easily diagnosed by head CT scan; the blood accumulation is said to be "egg-shaped" "egg -shaped" or lenticular.

 

Subarachnoid hemorrhage occurs occurs when blood is deposited  between  betwee n the the arachnoi arachnoid d and and meninge meningeal al layers. layers. Violent Violent shaking 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, puncture should be in thebepatient pati ent with an epidurallumbar or subdural s ubdural hematoma andavoided should only performed when these types of intracranial hemorrhages have been first ruled out. Intracerebral hemorrhage can occur at the direct site sit e of impact where blood aggregates in the parenchymal tissue. The size of the hemorrhage directly impacts 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 since over time the blood will be reabsorbed by the cranial tissue. Evaluation of the child with a suspected or confirmed traumatic injury to the head requires astute observation of the child's level of functioning and any changes in the level of functioning. As mentioned earlier, brain injuries are classified classi fied as mild (minor), moderate, or severe based upon the child's Glasgow Coma Scale (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 bee n developed (Table 4). MODIFIED GLASGOW COMA SCALE FOR CHILDREN Eye Opening >1-Year-Old <1-Year-Old Score Spontaneous Spontaneous 4 To speech To Shout 3 To pain To pain 2  No respons responsee No respons responsee 1

 

Best Motor Response >1-Year-Old <1-Year-Old Obeys Spontaneous Localizes pain Localizes pain Flexion withdrawal Flexion withdrawal

Abnormal flexion (decorticate) Abnormal extension (decerebrate)  No respons responsee >5-Year-Old

Abnormal flexion (decorticate) Abnormal extension (decerebrate) No respons responsee Best Verbal Response 2-5-Year- Old

Score 6 5 4

3 2 1

0-23 months

Sco re

Appropriate words Smiles, coos 5 and phrases appropriately Disoriented, Inappropriate Cries, consolable 4 converses words Inappropriate Persistent, Persistent cries 3 words inappropriate cries Incomprehensible Grunts, agitated or  Grunts 2 sounds restless 1  No respons responsee No respon response se No respon response se TOTAL SCORE: 15 Source: Adapted from [7] Table 4 Oriented, converses

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 C T scans and MRIs. Unfortunately, no purely clinical indicators, eitherbrain aloneinjury. or in combination, have been found to detect structural

 

Imaging recommendations have been developed to afford a fford the healthcare provider with an organized strategy in determining when a child is a candidate for imaging studies. The liberal liber al use of  these studies can place undue burden upon the financial resources of the family and the health care system, while the underuse of  these studies can to lead to an of missed injuries,  possibl  possibly y leading leading death death orincreased perman permanent entrisk disability disabil ity 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 [45]. Children greater 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 with post-traumatic amnesia, CT scanning should be considered [45]. If no scanner is available, overnight hospitalization with astute assessment may be indicated. For the child with overt signs si gns of neurologic compromise, CT scanning should be utilized to rule out underlying cranial injury. Children less than two years of age are more difficult to assess ass ess for  a number of reasons. Verbal and motor skills may not be adequately developed to allow for accurate assessment as the sequelae of head injury are different. Infants may develop scalp hematomas in conjunction with a skull fracture. The liberal use of  neuroimaging and skull radiographs should be considered appropriate after injury in this age group [49]. Mild traumatic brain injury is the most difficult of the syndromes to accurately assess. A child who is profoundly comatose is recognized as a child who has sustained major injury. The Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine adopted the following criteria to define mild traumatic brain injury (TBI):

 

Mild TBI may or may not be associated with a brief  loss of consciousness that lasts a few seconds to no longer  than 30 minutes.  No abnorm abnormal al radiograph radiographic ic finding findingss and and no focal neurologic findings are present on initial clinical evaluation. •





Patients are neurologically intact with a GCS score of  13 to 15. Patients with mild TBI may experience e xperience post-traumatic amnesia for minutes but not more than 24 hours after injury [49]. •

Should neuroimaging demonstrate no evidence of underlying  brain pathology, pathology, the child child may be conside considered red a candidat candidatee for  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 healthcare; distance and transportation to an appropriate facility must be investigated prior to discharging the child. A child who is discharged after sustaining a mild traumatic brain injury must be cared for by an individual who will comply with recommended discharge instructions. The importance of repeated observations cannot be overlooked; reiteration of these instructions will enhance care provider compliance. A child should be awakened every two hours. The child should be assessed for the ability to speak s peak 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 o f care. The care provider should notify the emergency e mergency department (or  appropriate healthcare provider) if the child demonstrates excessive sleepiness, if the child vomits more than twice, has unequal or abnormally shaped pupils, develops slurred speech, spee ch, complains of a headache that worsens, demonstrates change in ambulation, or if seizures develop. This child should be transported to the appropriate healthcare facility for further  f urther 

 

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  producee a Glasgo  produc Glasgow w Coma Scale score of less less than than 13. A GC GCS S score of 9-12 is classified as a moderate injury. 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. The most frequent 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 s evere 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 progress ing through the emergency department and into the critical care unit. unit . Hypotension in brain-injured children can be multifactorial. Children can sustain acute blood b lood loss from multiple traumatic injuries, and neurogenic hypotension can develop subsequent to secondary cerebral injury. Prehospital care providers must immediately control ongoing blood loss at the scene. Fluid resuscitation to prevent hypotension should be initiated init iated early. During isotonic, glucose-free fluids should be an given, althoughtransport, the amount and rate of administration remains area of  debate. Studies have shown that isolated hypotension in children can triple the mortality from pediatric brain injuries. Couple the hypotensive episode with hypoxemia, and the mortality rate can quadruple [33]. Preventing hypoxemia means obtaining rapid control of the airway and supporting ventilations 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 thei r long-term outcomes. The exception is the child who has sustained concomitant chest trauma, suchepisodes. as a pneumothorax, which can lead to ongoing hypoxemic 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. Current theoretical management strategies aim at the management of cerebral perfusion pressure (CPP) rather than simply instituting therapies aimed at decreasing intracranial pressure (ICP). Mean arterial pressure (MAP) minus intracranial pressure equals cerebral perfusion pressure: CPP = MAP _ ICP. Thus, preventing hypotension and maintaining an adequate MAP will help ensure adequate cerebral perfusion. Many of the standard therapies for the management of the neurologically compromised patient are being challenged and replaced by newer, more aggressive management concepts. Elevation of the head of the bed was a standard treatment measure to decrease ICP. However, elevation will also decrease cerebral perfusion,are thus CPP. supine recommendations todecreasing keep the patient sCurrent upine unless contraindicated by other accompanying injuries. Hyperventilation was commonly instituted during the early days of management; the risk of cerebral ischemia with hyperventilation has challenged this approach, and currently children are maintained utilizing normoventilation patterns [26, 33]. Fluid management of the injured patient is aimed at preservation of blood volume and mean arterial pressure. pres sure. Many advances in the methods of volume management have been studied in adult  patients,  patient s, but but few few studies studies have been instituted instituted on pediatr pediatric ic

 

neurotrauma patients. In the adult patient, the use of hypertonic saline with accompanying control of osmolarity has been bee n successful in controlling cerebral swelling. These strategies are currently under study in children, and although controversy exists, many neurologists and neurosurgeons will recommend these child. measures in the management of the severely brain injured Other management strategies that are accepted include prevention of hyperthermia and hyperglycemia. The use of induced moderate hypothermia as a method of controlling intracranial pressure rises rise s has not met with great success in this country although in other   parts of the the world, world, including including Europe, Europe, induced induced hypothermi hypothermiaa is frequently instituted [48]. Hyperglycemic episodes following  brain injury injury have have been been found found to reduce reduce the inciden incidence ce of positive positive outcomes; hence 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 [45]. Post-traumatic seizures as early late. Early seizures develop within are the classified first 24 hours afterorinjury and have the potential to exacerbate secondary injury. Late post-traumatic seizures occur a week or more after the traumatic episode. The  prophylacti  prophy lacticc use of antiepil antiepileptic epticss is not recom recommend mended ed in in most most  patients.  patient s. Those Those who may benefit benefit from from this proph prophylaxi ylaxiss are those with cranial penetration or hemorrhage. For children with mild head injuries and normal imaging, post-traumatic seizure management can be safely done on an outpatient basis and does not warrant hospitalization [16].

 

Advances in neurotrauma care in the new millennium include  pharmacot  pharm acotherapy herapy to control control secondary secondary injury, injury, new new monito monitoring ring modalities and new imaging techniques. Neuroprotective drug agents have been hopeful. These drugs act on the neurochemical mediators of secondary injury, limiting long-term injury. Although hashas been some patients, globalof  acceptanceimprovement of these agents yetnoted to bein achieved. Monitoring  patientss is expanding  patient expanding beyond intracranial intracranial pressure pressure m monito onitors; rs; both global and local sensors have demonstrated usefulness in  providing  provid ing informati information on regarding regarding patients' patients' respons responses es to to therapie therapies. s. Imaging techniques now allow us to monitor injured brain, blood flow and metabolism, providing information on the exact location of compromise [26]. Although many of these advances are not yet included in standard practice, the future of neurotrauma care appears bright. Management of brain juries in children remains an area of  intensive research and study. Resuscitation of the brain of the injured child involves achieving a balance b alance between ICP reduction strategies and enhancing cerebral perfusion. Reduction of  secondary injury should be utmost in the minds of all healthcare  providers  provid ers caring caring for the child child with with injurie injuriess to their cranial cranial cavity. cavity. Accompanying, and often complicating, cranial injuries can be injuries to the face. Injuries that cause loss of facial integrity have the potential of preventing pre venting adequate airway management, leading to an increased risk ris k of hypoxemia. Maxillary fractures, also known as LeForte fractures, are classified as 1, 2, or 3. A LeForte 1 fracture is a transverse fracture through the alveolar process and involves the anterior teeth and nose. A LeForte 2 fracture is a  pyramidal  pyram idal fracture, fracture, including including fractures fractures of the the midfac midface, e, maxilla maxilla,, and nose. With a LeForte 2 fracture, the nose and upper dental arch move as a unit. LeForte 3 fractures are known as craniofacial separations and are the most life threatening of the three fracture types. All LeForte fractures can cause profuse bleeding, malocclusion of the teeth, and loss of the structural integrity of  the oral cavity. Managing the airway of the child with a LeForte

 

fracture is often difficult, if not impossible, requiring intubation and, in extreme cases, cases , cricothyrotomy. A fracture of the mandible requires extreme force for the break to occur. Mandibular fractures are accompanied by multiple mucosal and gingival lacerations leading to a high risk of  systemic infection. Maintenance of the airway with a bag-valvemask device is impossible as the seal between b etween the mask and the face is unattainable; thus, airway management presents as one of  the major challenges in patient management. Despite this dilemma, most children who can sit up, up , lean forward, and control secretions can be safely s afely transported to the operating room without requiring airway maneuvers. Fracture of the zygoma can occur in three places: the zygomatic arch, the infraorbital rim and across the zygomatic suture. Often the ocular muscles and nerve are trapped, leading to enopthalmus, diplopia and possible visual loss. Ocular nerve damage requires immediate intervention; surgical elevation of the depressed bone fragments can be done to relieve pressure on the neurovasculature. The keys to management of maxillofacial trauma are airway management and hemorrhage control. Interventions to reduce infection and maintaining a positive fluid balance are critical. Associated injuries must be recognized. re cognized. For example, blunt force to head and face can frequently cause simultaneous injury to thethe cervical spine. Ocular trauma can affect either the external eye socket or the eyeball or both. A new classification system of ocular trauma has  been developed developed to ensure ensure that ocular ocular trauma trauma is consistently consistently recognized and treated. One of the biggest problems in management of ocular trauma is the development de velopment of scar tissue and regenerative capabilities. The conjunctiva, lens, and eyelid all regenerate well while the optic nerve and retina have no regenerative capabilities.

 

Advances in spinal cord management have given hope to advances in optic nerve injury. i njury. Methylprednisolone Methylprednisolone is utilized after spinal cord injury to improve the chance of neurologic recovery (see following section on Trauma to the Spine and Spinal Cord). Although the results are not as promising in the outcome following nerve injury, methylprednisolone administered as a 30optic mg/kg bolus, followed by a continuousis infusion of 5.4 mg/kg/hr over 23 hours to any child with optic nerve damage. The child with trauma to the head and face requires aggressive management to reduce mortality and long-term sequelae. Outcomes in the pediatric population are better than for adult  patients;  patient s; howev however, er, there are many many children children who surviv survivee with with significant, life changing sequelae following trauma to the head and face. CASE STUDY

Alexis is a twenty month old child who refuses to be restrained res trained in a carseat. When the family was late for the movies, Alexis' mother did not want to deal with her temper tantrum and refusal to sit in her seat, so she decided to hold Alexis on her llap ap while her husband drove to the theater. While sitting at a stoplight, st oplight, a car   being pursued pursued by a police police officer officer in a high-speed high-speed chase ran the red light and hit Alexis' car head-on. he ad-on. Immediately Immediately prior to the moment Alexis' mother goimpact. of her daughter to put her handsofupimpact, t o protect to herself fromletthe Upon impact, Alexis was thrown to the floor and rolled under the passenger  side dashboard. The front end of the car was crushed accordionstyle; Alexis' parents both struck the windshield and were unconscious. Emergency Medical Service (EMS) responded to the scene and identified two victims, the parents. Utilization of the Jaws of Life was required to extricate them from the vehicle. As the car was  being pulled apart to remove remove Alexis' mother, mother, Alexis' body rolle rolled d down from under the dash where she was trapped. It was only at

 

this point that the EMS personnel were aware that they had a third victim. Alexis was unconscious and unresponsive at the scene. She was transported to the local pediatric hospital where she underwent immediate resuscitation. Upon evaluation she was noted to have a depressed skull fracture over the right temporal area and a  bulging  bulgin g fontanel fontanelle. le. An emerge emergent nt CT sca scan n was was perform performed ed and demonstrated an epidural bleed, an intraventricular hemorrhage and a subdural s ubdural hematoma, along with the depressed skull fracture. Alexis was admitted to the pediatric intensive care unit where she remained profoundly comatose. During the next two days efforts at supporting her neurologic status were performed, including optimizing her oxygenation status and ensuring ens uring adequate circulatory volume. She was on a ventilator and was paralyzed and sedated to ensure limited increases in intracranial pressure. press ure. Pharmacologic Pharmacologic agents administered included mannitol, decadron, and narcotics for  sedation. Despite these efforts, no change in Alexis' condition was noted. Her mother did not survive the automobile crash, and her father  remained comatose in the trauma intensive care unit at the trauma center 30 miles away. Her extended family was notified of her   poor prognosis, prognosis, and studies of brain brain function function were undertaken. undertaken. She was pronounced brainher dead and was disconnectedregarding from the ventilator. Prior to death, family was approached organ donation. As a consensus could not be reached, and her  father remained comatose, no organs were procured after her  death. Case Study Discussion

Although devastating, Alexis' injuries are not uncommon. Parents who do not restrain children in appropriate car seats run the risk  of these types of devastating injuries. The EMS personnel who arrived on the scene would have been able to find and treat Alexis had she been in her car seat. s eat. However, because she was trapped

 

under the dashboard, no resuscitation efforts were initiated for a long period of time. This delay in resuscitation may have contributed to her death although the extent of her injuries was severe and survival may not have been possible even with significant, aggressive resuscitation. The issue of organ donation was initiated with the family members. Whenever a trauma victim succumbs to injuries, organ donation should be a consideration. In this case, the child's  parentss were  parent were unable unable to particip participate ate in in the the decision decision regarding regarding donation; therefore, organs were not procured. Many adults have  becomee designat  becom designated ed organ donors; donors; howeve however, r, we do not have have such such  protocols  protoc ols for for childre children. n. The The belief belief is that that th thee parent parent will aalways lways be available to make these decisions; however, as is evident in this case study, this is not always true. Discussing organ donation for   both adults adults and children children should should be initiated initiated within family family units units  before such decisions decisions are are required. required.   TRAUMA TO THE SPINE AND SPINAL CORD

Although rare, pediatric spinal trauma can be a devastating and life threatening injury. 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 agedependent and are, to some extent, due to the anatomic changes that occur with aging. The majority of injuries sustained involve the cervical portion of the neck. Between infancy and 8 years of  age 75% of the injuries occur in this area. As the child ages, 60% of the injuries are cervical in location, and beyond 14 years of age the incidence of cervical injuries decreases and mimics the  patternss seen  pattern seen in adult patients patients [21]. [21]. The The majori majority ty of of spinal spinal injuries injuries that occur in children occur in males and in those over 12 years ye ars of  age. It is at this age that children begin participation in more risktaking activities.

 

Motor vehicle accidents are by far the most common mechanism of injury to the spinal column and cord in the pediatric  population.  popula tion. In addition addition to motor motor vehicle vehicle accident accidents, s, younge younger  r  children sustain injuries in falls, while school age and teenage te enage victims sustain injuries in sports-related activities. Other  documented mechanisms of injury to the spinal column and cord include diving injuries, falls on or off trampolines, pedestrian insults and child abuse injuries. In addition, the incidence of  gunshot wounds to the spinal column is increasing as the incidence of penetrating trauma of this nature proliferates. Compression and contusion injuries are more common than transection of the cord. The point of maximum mobility of the cervical region progresses caudad. Maximal mobility is between C1 and C3 in the child less than 8 years of age and be between tween 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 [21]. Age dependent variables can impact not only the level of injury  but the the type type of injury as well. well. Small Small children 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 spinal column and cord. The muscles of the neck are underdeveloped so that flexion and extension injuries, such as "whiplash," are common. This flexibility of the spinal s pinal column means that children have a lesser number of fractures and a higher incidence of compression injuries when compared to adult  patients.  patient s. Regardl Regardless ess of of this degree of movem movement, ent, it is vital to remember that the cord is fixed both distally and anteriorally. 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 is anchored, and it will either be stretched or compressed.

 

 Neck injuries injuries involv involvee more more than the spinal spinal cord and colum column n since since the ligaments, the vasculature and the airway can also be compromised. The most common finding upon physical exam in the child with a cervical spinal injury is midline cervical tenderness. Neurologic deficits can be deceiving and may be  present upon examinatio exami nation n oramay not develop develo p until until later later in the course of initial care. Any child with mechanism of injury suggestive of a spinal injury should be treated with full spinal s pinal  precautions.  precau tions. Other symptoms may include muscle spasms, limitation of neck  movement, and neurologic deficits. Paralyzed intercostal muscles may produce a "see-saw" respiratory pattern in which the t he 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  presencee of other associated  presenc associated traumatic traumatic injuries injuries should should be determined, with head trauma being the most frequently occurring concurrent injury. Testing neurologic function should begin as soon as possible after  ABC support has been secured. Testing should include both  pinprick  pinpri ck and llight ight touch as these these sensatio sensations ns are ccarried arried in different tracts of the cord (the anterior portion of the cord carries the pain fibers while light touch is carried in the t he posterior  columns.) The level of function can be rapidly assessed utilizing the chart in Table 5. It is essential es sential to remember that C4 innervation is necessary for respiration; patients with injury to C4 or above will most likely require ventilatory support. However, health care providers must remember that cord edema can  progress  progre ss both both proximall proximally y and distally, distally, and and it is importan importantt to assess ventilatory effort in any child with a cervical injury regardless of  its location. RAPID NEUROLOGIC ASSESSMENT OF SPINAL CORD INJURIES

 

Level of  Assessment Parameter Functi on Elbow flexion C5

Dorsiflexion of wrist Extension of the elbow Flexion of the middle  phalanx  phalan x of the middle middle finger  Abduction of the little finger  Flexion of the hip Extension of the knee Dorsiflexion of the ankle Dorsiflexion of the great toe Flexion of the ankle Bowel and bladder  function Source: Compiled by  Author 

C6 C7 C8 T1 L2 L3 L4 L5 S1 S2 - S4 Table 5

Many children suffer contusion and compression injuries, as mentioned earlier. This type of damage can lead to an incomplete injury, producing an identifiable pattern of function. Anterior  cord syndrome most commonly occurs secondary se condary to hyperflexion of the neck. This produces a pattern of complete motor paralysis  below the level level of injury. injury. Additional Additionally, ly, pain sensation sensation is lost lost,, but light touch remains intact. Central cord syndrome is common with a compression injury and produces a muscle weakness or   paralysis  paraly sis that that affects affects the upper upper extremities extremities to a much greater  degree than the lower extremities. e xtremities. Brown Sequard syndrome (also known as half-cord syndrome) occurs when half the cord is injured, producing paralysis and loss of proprioception and touch on the same side as the t he cord damage, while loss of pain and

 

temperature occurs on the side opposite of the cord lesion. These cord syndromes may or may not be reversible dependent upon the extent of damage and the subsequent degree of post-injury edema. Spinal cord injury without radiologic abnormality (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 spinal column is able to stretch st retch up to 2 inches, while the cord can only elongate e longate one-quarter of an inch without causing cord disruption [1]. If the spinal column is stretched within its limits, but beyond the limits of the cord, the cord will be b e compromised, producing neurologic symptoms despite the clear cervical spine x-ray. The physical findings of SCIWORA SC IWORA cannot cannot be ignored even though a cervical spine film is clear. Unfortunately, 44% of   patientss with  patient with SCIWO SCIWORA RA have a complete complete injury injury and and lifelong lifelong disability [1]. Tragically, studies have shown that up to 27% of  these patients may have a delayed onset of neurologic deficits. These patients may have complained or demonstrated de monstrated transient symptoms immediately after the injury, including paresthesia in the legs and hands, generalized weakness and/or a lightning (burning) sensation down the spine associated ass ociated with neck  movement. The delay in onset of symptoms ranges from 30 minutes to 4 days [21]. In many instances, the child may have  been discharged discharged to home, home, thus experiencin experiencing g these these defici deficits ts either  either  at home or school, s chool, 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 1-10 weeks after  the initial injury [21]. 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 children the most lethal occurs at C2 and and the is known as asmall hangman's fracture. The neckinjury is hyperextended cord

 

disrupted, leading to immediate loss of ventilatory drive and subsequent death. Trauma between C3 and C7 is difficult to diagnosis as most of these injuries are ligamentous li gamentous in nature. Patients with a C7 fracture commonly have an associated upper  rib fracture. Thoracic injuries are most commonly compression type injuries, often sustained in falls. The thoracic spine has strong s trong 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. injuries. A Chance Chance fracture fracture occur occurss when when a lap belt-on belt-only ly type type of restraint is utilized and in a high-speed deceleration the child flexes over the restraint device, thus stretching and displacing the vertebral column. Often these injuries are accompanied a ccompanied by internal abdominal injuries, producing the pattern of injury known as lap-belt complex. Lumbar fractures can 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 s tature as the child matures. Diagnosis of spinal injury includes positive findings during  physical  physic al assessmen assessment, t, radiologic radiologic evidence, 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 sensitivity of  this diagnostic tool. The series must include all seven se ven cervical vertebrae to allow for full evaluation. While x-rays remain the standard for rapid evaluation and gross screening of injury, magnetic resonance imaging (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. Confounding radiologic diagnosis are the differences in anatomic development of children at various ages. Up to 46% of children less 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 normal normally ly absent absent in children children up to 16 years years of age age [21]. [21]. In 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 pre vent flexion, extension and rotation. Hard cervical collars may not be available in the appropriate size, and utilizing a poor fitting collar  can actually do more harm than good. If an appropriate collar is not available, the neck can be stabilized with blankets, IV bags, and 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  betwee n the the child's child's shoulder shoulder blades, blades, thus establishing establishing alignment. 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 car ca r seat. Towels and blankets can 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  predisp oses them to loss loss of their ventilatory ventilatory drive. If required, required, intubation should be performed with minimal neck movement. The novice practitioner should not be attempting intubation in this patient.

 

Evaluation of concurrent injuries must be a priority. A child may survive the spinal insult only to die from a massive intracranial  bleed. Recognition Recognition of other other injuries injuries should should be systemati systematicall cally y evaluated utilizing the head to t o toe approach as re recommended commended 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 i njury at another  level. Improvement or deterioration of the patient's condition will  be quickly quickly recognized recognized utilizing utilizing this systematic systematic approach. approach. The use of steroids in the first eight hours after injury is now standard therapy for spinal injuries. Although the initial studies documenting the benefits of early steroid use did not include  pediatric  pediat ric patients, patients, admin administeri istering ng steroids steroids is recommend recommended. ed. The dosaging regimen requires a 30 mg/kg intravenous bolus of  methylprednisolone followed by a drip at 5.4 mg/kg per hour for  the subsequent 23 hours. It is important to remember that the  benefits  benefi ts of such therapy therapy will will only only be be achieved achieved if these these steroids steroids are initiated within 8 hours after the injury. Management of the child depends upon age, severity se verity level 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, s tabilized, halo stabilization becomes the mainstay of treatment [18]. Children with incomplete injuries have improved outcomes after  injury as compared to adult trauma patients. The health care providers must also address the emotional impact of these injuries. The potential loss of bodily b odily function is devastating, and patients may deny the consequences of such injuries. Additionally, the pediatric patient may have sustained injury pursuant to a risky behavior that they may have been instructed not to participate in. The guilt and anger that arise aris e in these patients is incredible, and early psychosocial counseling can favorably impact their long-term outcomes.

 

The future of spinal cord trauma management appears bright.  New drugs, new methods methods of of surgical surgical stabilization stabilization,, use use of  electrical stimulation, and efforts at cord regeneration are currently in the trial phases. GM1, a drug currently in phase three clinical trials, may hold one of the keys to improving recovery [21]. Surgical techniques, including fusion and posterior  instrumentation, currently utilized in adult spinal patients pat ients are  being successfull successfully y impleme implemented nted in younger younger and younge youngerr cchildre hildren n [41]. It is possible that the spinal s pinal cord has the ability to regenerate; however, after injury these regenerative properties are somehow compromised. Work 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 physio-psychological. CASE STUDY

Keith is a 14-year-old boy who was attending a birthday party at the local community pool. He is an excellent swimmer and has always been safe around ar ound pools. When he was swimming in the  pool, another another guest guest ran ran and and jumped jumped into the pool, pool, landin landing g on top of Keith. The force of the impact was directed at Keith's head and neck. Immediately, Keith sank to the bottom of the pool and had to be rescued by the pool lifeguard. After being brought to the surface, mouth-to-mouth resuscitation was initiated, and within moments Keith choked and started to breathe on his own. However, he was unable to move his extremities and felt no sensation below his shoulders. EMS personnel arrived on the scene and Keith was placed on a  backboard  backbo ard and put put in full spinal precaution precautionss prior prior to being being removed from the water. He continued to breathe on his own after 

 

the initial period of apnea. He was transported to the local emergency department for evaluation. Upon arrival at the emergency department, Keith continued to demonstrate flaccid paralysis of both his upper and lower  extremities. Neurologicbasis. assessments initiated continued on an every 15-minute Cervicalwere spinal x-raysand showed a fracture between C5 and C6. CT scan demonstrated diffuse swelling in this area with severe injury to the spinal cord. Within 30 minutes of his arrival and during his initial resuscitation, methylprednisolone was started at a 30 mg/kg  bolus. Despite this infusion, infusion, no improveme improvement nt in his neurologic neurologic status was noted. Supplemental oxygen was provided, a foley catheter was placed, and the neurosurgeon on call was notified. Subsequently, Keith was taken to the operating room for  stabilization of his cervical spine. He was placed in traction t raction in the operating room and transferred to the intensive inte nsive care unit. During his stay in the ICU, neurologic assessments were continued although no change was identified. During this time,  psychologic  psycho logical al counseli counseling ng was was initiated, initiated, as it was felt felt th that at the the injury Keith sustained was permanent, pe rmanent, rendering him quadriplegic. Initially Keith's frame of mind was good; he felt that he could overcome his injurytoand some be ableto toinsist walk that again. Despite counseling thewould contrary, heday continued he was going to get better. Within 2 weeks, Keith was ready to transfer to a spinal cord rehabilitation center. It was at this point that he realized the full extent of his hi s injury and became  profoundly  profo undly depressed. depressed. At times times he expressed expressed suicidal suicidal ideology ideology and received intensive counseling. During the next three months, Keith and his family learned to deal with his healthcare requirements. He was discharged to home with round-the-clock  nursing care. Case Study Discussion

 

Despite the fact that most spinal cord injuries occurring in swimming pools follow diving accidents, other mechanisms of  injury can be the cause. In this case cas e the victim was within the  boundss of safe swimming  bound swimming and was still still injured injured due tto o another  another  child's inattention to safety. s afety. Keith was immediately given mouthto-mouth resuscitation. Due to this prompt response, neardrowning was not a complication of this injury. The appropriate stabilization and resuscitation measures were undertaken without improvement in Keith's condition. The x-ray and CT scan demonstrated significant injury and the methylprednisolone was appropriately started as soon as possible after injury. In any patient suffering a spinal cord insult, this is considered appropriate treatment. The extent of injury and longterm effects are not easily identified at the time of injury, i njury, but the  patient should be given given the the benefit benefit of the the doubt doubt when when considerin considering g drug administration. The depression that Keith demonstrated is common in all patients suffering permanent spinal cord damage. Compounding this fact is that he is 14 years of age, and he has his hi s entire life ahead of  him. Adolescent depression is becoming increasingly common as children face new challenges. Caucasian teenage males have ha ve the highest incidence of suicide, and Keith required intensive counseling to work through the depression he developed.   CARDIOTHORACIC CARDIOTHO RACIC TRAUMA

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.. Many  present Many of these these injurie injuriess are are managed managed nonoperati nonoperatively vely unless accompanied by significant, persistent hemorrhage. Children's chest walls are very pliable, thus rib fractures are less les s common than in adults, while pulmonary contusions account for 

 

the majority of traumatic injuries to the chest. Children with  pulmonary  pulmo nary contusions contusions may or may may not not present present initially initially with with shortness of breath. The delay in symptom onset may be as long as 12 to 24 hours after injury. i njury. Bruising and tenderness over the chest wall may be the only presenting symptom that should cue the practitioner to the risk of pulmonary compromise. As the contusion develops, the child will develop increasing dyspnea, rales, hypoxemia and possibly hemoptysis. The child may be discharged to home if no other signs of trauma are present. The  primary  primar y care care provid provider er must must be be informed informed of these these d develo eveloping ping signs, and the child should return to the emergency department if  his/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 aggress ive 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. pe rcussion. 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 hemothorax is caused by an injury to the vascular system in the thoracic cavity causing blood accumulation. these the injuries in children are caused by blunt chestMany traumaofalthough

 

most life-threatening injuries follow penetrating trauma that causes direct injury to the thoracic vasculature. The lung is a low pressuree vascula  pressur vascularr system system that is capable capable of tampon tamponading ading many sources of bleeding, thus small injuries may be self-limiting. The risk in these cases occurs when a chest tube is placed for  drainage; this low pressure system is altered and the bleeding starts up again, leading to further blood loss and risk ris k of  cardiovascular collapse. Whenever a chest tube is inserted for  drainage of blood, the practitioner caring for the patient must monitor the blood loss as well as 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 s upport the circulating volume. Monitoring blood loss loss in the child is critical, as a 20 cc/kg loss is equal e qual to 20% to 25% of the child's blood volume. A tension pneumothorax can develop after crush injury to the chest in which a pneumothorax develops and fails to seal, causing air to accumulate in the thoracic cavity causing compression of  the lung tissue. As this pressure continues to build, the injured lung is deviated towards the uninjured side of the chest cavity. This causes a deviation of the trachea towards the unaffected side, severe respiratory distress, and cardiovascular compromise. The onset of symptoms is very rapid in small children due to the small s mall size of their thei r 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 ches t tube to water seal drainage. The child will also benefit b enefit from high flow oxygen therapy to improve their oxygenation status. Although rare, rib fractures and a flail chest can occur with significant to the rib in cage. flail chest develops when free two or more ribsforce are fractured twoAplaces and the ribs become be come

 

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 can 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 to improving oxygenation in the child is pain control measures. 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  perica rdial sac, which is nondisten nondistensible, sible, and compre compresses sses the heart. The severity of symptoms s ymptoms 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, thus only a small amount of blood can lead to significant compromise in the child. Children with tamponade will present with a weak, thready, rapid  pulse. Signs of shock shock may develop develop as the cardiovascu cardiovascular lar system  begins to fail. fail. Beck's Beck's triad of sympto symptoms, ms, late signs of  compromise, includes a decreased blood pressure with a narrow  pulse pressure, pressure, distended distended neck veins and distan distantt heart heart sounds. 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 e nsure 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 pressure and and tachycar tachycardia, dia, the initial initial resuscitativ resuscitativee effort effort is to  begin fluid resuscitati resuscitation on for for volum volumee support. support. In the the chil child d with with cardiac tamponade, this additional fluid may actually worsens the child's condition, as an increased volume of fluid is leaking 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 as piration of blood. The child should demonstrate immediate improvement after pericardiocentesis, as the heart is able to improve its pumping capabilities. Once the  blood has been been remov removed ed by by pericard pericardiocen iocentesis, tesis, the child child must must be 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. During the last few years there has been bee n increased interest in sudden cardiac death in children chi ldren (known as commodio cordis), especially during athletic competition or exertion. The incidence of sudden death is 1 in 200,000 athletes per year, which translates to between 1 and 5 deaths annually. Ninety percent of these deaths occur in males, and the sport with the highest incidence of  death is baseball. Some of these deaths occur when there is a sudden, blunt, modest  blow to the the mid-ch mid-chest. est. This can occur occur either as a bodily collisi collision on or a blow from an object, such as a baseball [20]. The patient has no evidence of cardiac damage or disease in most cases; 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. se cond. On autopsy those children who had no clinical signs of cardiac disease had evidence e vidence of  hypertrophic cardiomyopathy or a congenital coronary artery in anomaly. Only 10% of resuscitations are successful, s uccessful, however,

 

most cases of success, cardiopulmonary resuscitation was initiated within 20 seconds of the arrest [20]. To reduce the incidence of sudden death, it has been recommended by the American Heart Association that participant screening be performed prior to in high-risk hig h-risk sports. The screening done at present is participation inadequate and considered flawed. There are no specific s pecific training requirements to detect cardiovascular disease in children. Many athletes have a short evaluation performed by their family physician with inadequate training in evaluating for the risk factors associated with sudden death [29]. Additional measures to reduce death include inc lude the development of safer equipment, such as softer s ofter baseballs. In 1996 the Consumer Product Safety Commission recommended the use of soft baseballs; however, their use has not found acceptance in organized sports. 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 intraabdominal pressure that is transmitted to the t he diaphragm causing it to tear. This tear tea r most commonly develops develops in the left hemidiaphragm and can cause abdominal contents (most commonly the bowel and/or stomach) to enter the chest ches t cavity. This produces signs of respiratory distress as these organs compress the lung parenchyma. Other signs that may occur o ccur are signs of pneumothorax, bowel sounds in the chest and a nasogastric tube in the chest as seen s een 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  bronch  bronchus. us. not Tears be complet cofor mplete e or incomplete. incom plete.days Small Smal l incompl incinjury. omplete ete tears may be can evident up to three to four after

 

The child is admitted with significant dyspnea and hemoptysis, and intubation is often required to support the bronchial anatomy. 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 must be remembered that 12% of patients will have a concurrent cervical injury and must be placed in 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, thus pain control should be instituted early and continued throughout the course of care. CASE STUDY

Jim is an 8-year-old boy who was riding his bike when hit by a car. He was knocked to the ground and the subsequent car, which was unable to stop in time, ran over his chest wall. Jim's T-shirt showed tire marks across his anterior chest. However, immediately following being run over, Jim jumped up and started s tarted yelling at the driver who also damaged his new bicycle. Witnesses called 911 and emergency medical care personnel arrived within minutes of the accident. a ccident. Upon arrival Jim was walking around, expressing concern over his new bike. bike . He demonstrated no signs of injury other than the tire marks across his chest. Because of the mechanism of injury, the EMS  personnel  personn el insisted insisted that Jim be transpor transported ted to the the local local emergen emergency cy department (ED) for assessment and treatment, if neces necessary. sary. Upon arrival in the ED, Jim's vital signs were stable, s table, his oxygen saturation was 96%, and a chest x-ray was normal. His parents

 

were called and he was to be discharged di scharged to home. Prior to leaving, his parents were instructed to return to the ED if any signs of developing respiratory distress were evident. Case Study Discussion

Most children who are run over by an automobile will sustain multiple injuries; however, in this case, Jim sustained no identifiable trauma immediately following the accident. As is common in children, Jim's chest wall was very pliable, and the weight of the car crushed his chest wall without producing injury to the bony segments. The risk in this type t ype of trauma is that underlying pulmonary injury may develop, leading to significant respiratory distress. Upon admission to the ED, no respiratory distress was evident, his vital signs s igns were stable and his oxygen saturations were within normal limits. The most common delayed development in this case would be developing respiratory distress secondary to a pulmonary contusion. Prior to his discharge, the  parentss were  parent were instruc instructed ted in identif identifying ying signs of respirat respiratory ory distress distress and the requirement to return to the ED should these signs develop. In this case, Jim did very well and never required follow-up care. As for his T-shirt, he never washed it, and he keeps it on his wall as a reminder of the day he was run over by a car and walked away.   ABDOMINAL ABDOMINA L AND GENITOURINARY TRAUMA

Abdominal and genitourinary (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 non-operative, wait and see approach in children with solid organ injury. While

 

adults continue to have a high incidence of laparotomy, the incidence of invasive procedures in children has dropped significantly over the last decade. Children sustaining abdominal trauma demonstrate different injuries than seen in adult trauma patients. The solid sand olidmore organs (spleen, liverthose and kidneys) are proportionately larger  prone to direct direct injury. injury. Additio Additionally, nally, these organs organs are are not not wel welll  protected  protec ted by fat fat pads, pads, decreasin decreasing g the the risk risk of protection protection afforded afforded  by this this fatty fatty tissue. tissue. The organs organs are more more frequently frequently torn, especially from the pedicle. The adult's fat pads help to secure s ecure 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 since 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 injuries sustain sustained ed in automobile automobile crashes. crashes. The spleen 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 injurie injuriess occurs occurs when the lap-belt lap-belt portion portion of the the seat belt is improperly positioned; the belt sits up on the abdomen a bdomen of the child, and during a rapid deceleration the belt locks, compressing the abdominal organs. The injuries that are seen include small  bowel contusions contusions and/or and/or laceratio lacerations, ns, lumba lumbarr spine spine fractu fractures, res, mesenteric hematomas, renal trauma, fractured pelvis and ruptured bladder [42]. The second most common cause of abdominal trauma in children is pedestrian injury [42]. Additionally, a small number of children sustain abdominal trauma when falling from heights. In children less than 2 to 3 years of age, abusive injuries account for a significant portion of abdominal trauma. These injuries occur  when compressed following kick or can a punch. Whenthe theabdomen organs areiscompressed, bowel walla rupture occur,

 

leading to peritonitis and massive intra-abdominal bleeding. The children who survive these injuries should be reported to the local child protective services organization because other forms of  abuse may often be present. School-age children sustain abdominal trauma their   bicycl  bicycles es with with the the most most severe severe injuries injuries occurr oc curring ingwhen whenriding the cchild hild strikes the handlebars. Traumatic pancreatitis is the most common injury occurring with handlebar-related injuries. The mean delay to treatment in one study was 23 hours. Only after the children demonstrated signs and symptoms did their families seek s eek medical attention [42]. Penetrating injuries account for only a small amount of  abdominal injuries. However, with the increasing incidence of  gun violence, the incidence of penetrating pe netrating trauma has increased annually. This type of trauma is more commonly identified in children older than 12 years and is more common in males than females [42]. Evaluation of penetrating trauma is slightly s lightly 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. Most surgeons prefer that the child have a full abdominal workup prior to receiving pain medications. Obtaining diagnostic studies will assist the care providers in recognizing the presence and extent of injury in many children. Computed tomography (CT) scans are the diagnostic modality of  choice in stable patients pat ients sustaining blunt abdominal trauma [42]. 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, i ntravenously, can improve the diagnostic capabilities in a small group of 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 being 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 FAST (Focused Assessment with Sonography for Trauma) technique, which is useful in diagnosing hemoperitoneum and deciding who would  benefitt from  benefi from laparot laparotomy omy [3]. While While this this method method of evaluati evaluation on is common in adult abdominal trauma, its use is still being studied in pediatric patients with abdominal injuries. Diagnostic peritoneal lavage (DPL) can 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 can be a useful diagnostic tool, allowing for recognition re cognition of free blood within the abdominal cavity. The risks of DPL in children include  bowel perforatio perforation, n, injury to the the solid solid organs, organs, and v vascula ascularr injury. 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, lab values may be within normal limits during the initial admission screening. Following changes in hematocrit and hemoglobin (H & H) over time provides a good indication of ongoing blood loss. Obtaining a baseline H & H upon admission may be useful for later comparison. Liver  function (LFTs) arenot altered with although the valuestests obtained may clarify thehepatic extent trauma, of injury. Thus,

 

LFTs are commonly useful in diagnosing liver injury when CT scanning is not readily available [42]. Diagnosis of pancreatic injury is challenging with elevated amylase and lipase levels being common following many types of  abdominal injury. Although the extent of elevation is questionable, it is recommended that children with suspected mechanisms of 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  primar y concer concern n with with these these injuries injuries is the depth of injury injury and  potential  potent ial penetration penetration of the the peritone peritoneum. um. Currently, Currently, laparoscopy laparoscopy is  being studied as a method method of diagnosis diagnosis as well well as surgical surgical repair. repair. Liver, spleen and diaphragmatic tears can be sutured and repaired utilizing this method, preventing exploratory laparotomy. Future use of laparoscopy in trauma care is seen as one of the potential advances in the next decade of trauma management [19]. 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 [24]. The child with splenic injury i njury will complain of  upper abdominal pain over the left quadrant, left shoulder pain (Kehr's sign), and possibly left chest pain. Falling hematocrit and hemoglobin levels may indicate ongoing blood loss.  Non-operative  Non-operat ive managemen managementt of of spl splenic enic injuries injuries in children children has  been utilized utilized for for a number number of of years. years. The impetu impetuss for for this change change is that post-splenectomy sepsis carries a high mortality rate in this age group. The controversy regarding non-operative care is how to best manage the patient during the first few days post-injury. Some practitioners advocate 3 to 5 days of bed rest while most studies have found that bed rest does not improve success rates [24]. While everyone agrees that the child should be kept quiet,

 

constant monitoring in an intensive care unit may not be necessary for most children. Following the hematocrit in children will help to recognize potential problems. If the hematocrit falls, a repeat CT scan is generally obtained. A common splenic injury a hematoma. thick capsule surrounding the spleen canislimit bleeding The and protect the spleen from actual tissue disruption. The recommended re commended treatment treatment is nonoperative management; however, prior to returning to an active lifestyle, a repeat CT scan should be obtained at 6 to 8 weeks  post-injury  post-i njury [24]. If contact contact sports were to be initiated initiated prior to complete resolution, the risk of spontaneous rupture is high with an increased risk of hemorrhage and death. Currently, sonographers are evaluating the effectiveness of ultrasound diagnosis in these patients to reduce the high cost cos t associated with repeat CT scanning. The incidence of post-splenectomy sepsis has decreased during the last decade. The liberal use of antibiotics and the  pneumococ  pneum ococcal cal vaccine vaccine has signific significantly antly controlled controlled complicati complications. ons. Asplenic individuals are more at-risk for postoperative pos toperative  pneumonia,  pneum onia, infection, infection, abscess, and coagulo coagulopath pathies ies rather than  post-splenec  post-sp lenectomy tomy sepsis. Other sequelae sequelae to splenic injury include 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  promi nent location location of of the the liver. liver. Although Although splenic splenic injuries injuries are 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 the face of adequate volume replacement may indicate massive hemorrhage.

 

If the child is stable, s table, the trend in hepatic trauma management is to monitor the child and treat tre at the injury non-operatively. Patient selection for non-operative management is based primarily upon the hemodynamic stability of the patient, not the grade of injury. The impetus for non-operative management is the fact that tha t  patients who  patients who are are treated treated without without surgery surgery have a low lower er mortal mortality ity rate, require fewer transfusions, and have less risk of postoperative infection [24]. Delayed bleeding is rare after liver injury. Following the H & H will allow for identification of ongoing blood loss. For those  patientss with  patient with contin continued ued bleeding, bleeding, arterial arterial embolizatio embolization n to to con control trol  bleeding  bleedin g has has met with success. This method method of of stab stabiliza ilization tion  prevents  preven ts the the surgical surgical stress associated associated with explorator exploratory y laparotomy. Additional complications of liver trauma include bile leaks, the development of hemobilia, and disseminated dis seminated intravascular coagulation (DIC) [24]. Renal injuries in children are also treated non-operatively, especially grade I or II injuries (renal injuries are graded I to t o V as are splenic and hepatic 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's sign, a bruising over the flank area, is rapid to develop in children with vascular hemorrhage. Associated GU injuries include trauma to the ureters, urethra and bladder. 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 [43]. Delayed infection.complications of renal trauma include hypertension and

 

Bowel injuries in children are common with lap-belt complex. Rupture of the bowel leads to spillage of bowel contents into the  peritoneal  periton eal cavity. cavity. The The omentum omentum is not well developed developed in children children;; thus, free flowing contents spread easily e asily throughout the  peritoneum,  periton eum, leading leading to significant significant peritonitis. peritonitis. The jejunum jejunum is the most commonly injured segment of the bowel. Signs and symptoms of injury may be delayed up to 12 to 18 hours [43]. 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 e levated temperature, tachycardia and diminished urine output. Hematomas of the bowel can cause symptoms s ymptoms of obstruction, including pain, vomiting and distention. Pancreatic injuries are rare and difficult to diagnose. The pancreas is located in the retroperitoneal space, thus abdominal findings may not be present. prese nt. Dependent 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  pseudoc ysts are commo common n in the first first 3 to 7 days post-injury post-injury and large, symptomatic cysts may require percutaneous drainage. Other sequelae include the development de velopment of hypocalcemia, acidosis, and abscess or fistula formation. Penetrating trauma requires a different approach to management. Those injuries that penetrate pe netrate the peritoneum require surgical closure of this cavity. In unstable patients, the use of "damage control" surgery is now being considered. (This is also known as abbreviated laparotomy). Often the patient has other multi-system trauma, such as concomitant head or chest che st injuries, which  preclude  preclu de long long operat operative ive times. Damage Damage contro controll surgery surgery is a stepstepwise 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 s ubjected to a lengthy and often life-threatening initial surgery, and the bowel edema that develops post-operatively is allowed to resolve prior  to definitive repair [19]. One complication following abdominal injury, which has only  been recognized recognized in the the last few years, is the developmen developmentt of  abdominal compartment syndrome (ACS) [23]. Bowel edema and fluid sequestration increase the volume of the intra-abdominal cavity, thus increasing pressure within this cavity. As the intraabdominal pressure rises, there is an associated drop in venous return to the heart and subsequent decrease in cardiac output. The  patient then experiences experiences hemodynam hemodynamic ic compromis compromise. e.  Normal intra Normal intra-abdom abdominal inal pressure pressure ranges from 0 - 15 m mm m Hg. Hg. Intra-abdominal hypertension is defined as an intra-abdominal  pressuree greater  pressur greater than 15 - 20 mm mm Hg. Hg. As As the pressure pressure in increase creases, s, 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. Intraabdominal pressure (IAP) can be measured with IAP graded I to IV. A pressure of 35 mm Hg or greater signifies the development of cardiovascular collapse [27]. Management of ACS includes recognition and prevention with alternative surgical closure methods [27]. With high intraabdominal pressures, surgical decompression may be required to  preventt death  preven death of the the patient. patient. In the the operati operating ng room, room, decompression is preceded with volume resuscitation since opening the abdomen can cause a sudden shift of volume, leading to vascular collapse. Once the abdominal edema and fluid shifts have stabilized, the abdomen can be closed again with minimal risk of redevelopment. Advances in care of the child with abdominal trauma include early enteral feeding, new generation antibiotics, and new ne w closure techniques. Early enteral feeding has demonstrated a decrease in

 

 post-injury sepsis and multi post-injury multi-organ organ failure. failure. As As soo soon n as the ileus ileus resolves, tube feedings are initiated, and villus function in the  bowel is promoted promoted.. Liberal use of of antibioti antibiotics cs has has al also so decreased decreased the risk of post-operative infection, primarily the development of   peritonitis.  periton itis. New closure closure techniq techniques ues are are being being utilized, utilized, includ including ing single- and double-layer sutures as well as new absorbable sutures. With the development of new interventions and a reduction in operative procedures, the future of abdominal trauma in children will continue to evolve. Deciding how and for what length of  time a child who is treated non-operatively should be kept quiet will be an area of intensive inte nsive 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 prima primary ry goal of care. care. CASE STUDY

Emily is a 7-year-old girl who was riding in the center backseat of her automobile restrained by a lap-belt. The car was in a highspeed crash, causing Emily to be thrown forward over the top of  the lap-belt. The lap-belt kept her in her seat, se at, but her body was flexed over the belt, and her forehead impacted the back of the front seat. Immediately after the crash, Emily wasand s creaming screaming and crying. She was extremely upset by the crash, it was difficult to assess if she s he was merely upset or if she was indeed injured. Because of the mechanism of injury, Emily was placed on a  backboard  backbo ard in full full spinal spinal precautions precautions and transp transported orted to the the nearest nearest trauma center. Upon arrival in the ED, report was given as to the type and mechanism of injury. Emily had quieted down by this time and was only shaking her head yes or no when questioned about her injuries. As part of the head to toe assessment, the nurse in charge of Emily began palpating her lower abdomen, which caused Emily to scream and begin crying. Further assessment of 

 

her abdomen was deferred, as she s he was crying uncontrollably at this time, and information was difficult to ascertain. The head to toe assessment asses sment demonstrated a bump on her  forehead, ecchymosis over her abdomen below her umbilicus, and awas bruising overthat her Emily right flank. Due to the mechanism of injury, it suspected had sustained abdominal trauma,  possibly  possibl y a ruptured ruptured bowel bowel secondary secondary to seatbelt seatbelt compression. compression. Xrays and lab results were obtained and were all within normal limits. Eventually Emily quieted down, and she was transferred to the pediatric intensive care unit for further stabilization. During the first few hours in the PICU, Emily remained quiet and relatively pain free. The ecchymosis over her flank area increased in size, and her urine output fell to less than 1cc/kg/hr. A urinalysis was obtained that demonstrated de monstrated microscopic hematuria. hematuria. Renal trauma was suspected; however, the decision de cision was made to treat it non-operatively and continue to monitor her in the ICU. Her fluid intake was increased slightly in an effort to prevent acute tubular necrosis from developing. During the middle of the night shift, Emily sustained a respiratory arrest. All efforts at resuscitation were performed without results. Emily was pronounced dead 45 minutes after the onset of  resuscitative efforts. Case Study Discussion This case study demonstrates the type of injuries that can be sustained when children are restrained with only a simple lap belt. There is tremendou tremendouss effort effort underway underway to notify notify parents parents of the dangers of lap-belts and the benefits of booster seats for children less than 8 years of age. Had this type of restraint been utilized, the injuries to Emily may have been minimal, if occurring at all.

A number of omissions were made in Emily's assessment and resuscitation. The bruising over the flank area is a hallmark sign of renal trauma in children, and this should have been suspected much earlier in her course of care. The assumption that she

 

sustained seatbelt-induced injuries was correct, however, it focused the care provider's attention on her abdomen when other  injuries may have been present. prese nt. Another injury that can occur  secondary to seatbelt injury is injury to the lumbar spine. No studies were performed to rule out this injury. On autopsy, the cause of Emily's respiratory arrest was determined to be secondary to a large subdural hematoma that was not identified during her care. Because she was verbal and crying, it was assumed that she was neurologically intact. Her  quiet behavior may have been an indication of neurologic deterioration rather than that she was just "being a good girl." The  bump on her her forehea forehead d that that was was identifi identified ed in in the emergency emergency department should have alerted her care providers to the risk of  neurologic injury, and further studies should have been  performed.  performed. Because Emily did not survive, the extent of her injuries will never be known. What is known is that injuries were missed, and this played a direct role in her death. This case illustrates the horrible outcome that can occur when trauma care providers focus on one specific body system that is injured and overlook  other less obvious, yet life-threatening concurrent injuries. MUSCULOSKELETAL MUSCULO SKELETAL AND SOFT TISSUE TRAUMA

The majority of traumatic injuries b yadvantage by children are orthopedic injuries. Children have sustained the distinct of rapid  bone growth, growth, leading leading to faster faster healing. healing. The The thick thick periosteum 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/her  his /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 aand child is in pain. be instituted early repeated on anPain "as control needed"measures basis. Anshould evaluation of  neurovascular function is critical in order to help ensure viability of the injured area. The 5 P's of assessment provide a handy mnemonic for assessment: the patient should be assessed for  Pain, Pallor, Pulselessness, Parasthesia and/or Paralysis. When assessing a child, it is wise to begin on the uninjured side, working towards the injured extremity. Beginning assessment at the most distal point from the injury and working towards the suspected site of injury will allow for more in-depth assessment of the child. If a practitioner to startasatthe thechild pointwould of pain, further assessment would be were hampered, protect the injured area from further poking and prodding. Occasionally, assessment of the injured area can present an unclear picture; assessing the mirror image on the uninjured side can often allow for appraisal of the nuances of the child's skeletal s keletal system. Musculoskeletal trauma can take 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. hours . Those injuries that are limb- or life-threatening require immediate evaluation and stabilization to prevent pre vent untoward complications, including death and disability. Pediatric fractures are either open or closed. Open fractures are associated with a disruption in skin integrity over or near the fracture site. The child must be evaluated for other forms of lifethreatening trauma, including trauma to the head, neck, chest ches t and abdomen. Once stabilized, the fracture can be splinted prior to radiologic examination. The injured area should be radiographed in two planes; commonly the anteroposterior (AP) 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.  Neurovascula  Neurov ascularr status status should be assessed assessed frequently, frequently, as changes changes in vascular flow ominous must be readily identified. care should beare instituted asand appropriate. Utilizing topical Wound anesthetics can improve the quality of care since a comfortable, quiet child will allow a llow 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 as to the immunization status of the child. The most serious pediatric fractures are those that occur in the area of the epiphyseal plate, also known as the growth plate. These physeal injuries represent up to 18% of all pediatric fractures [14]. The Salter-Harris Classification system allows for  assessment of these injuries and is numbered I through V (Table 6). SALTER-HARRIS CLASSIFICATION SALTER-HARRIS CLASSIFICATION OF ORTHOPEDIC FRACTURES FRAC TURES IN CHILDREN Type Injured Area Outcome I Physis Excellent II Physis, bone Excellent Risk of long-term III Physis, bone, joint sequelae Physis, bone, transverses IV Growth abnormalities through joint Early closure, growth V Compression of physis retardation Source: Adapted from [14] Table 6  

A Salter-Harris Type I injury involves only the physis (plate). Often these injuries will appear normal on x-ray; however, the child complains of point tenderness over the physis. The Salter-Harris rris Type  prognosis  progno sis for for this this type type of injury injury is excellent. excellent. Salter-Ha II injuries involve the plate and the bone. This is the t he most

 

common type of epiphyseal injury and also has an excellent outcome. Salter-Ha Salter-Harris rris Type III injuries involve the plate, the  bone and the the joint. joint. It is imperativ imperativee that that these these injurie injuriess are reduced reduced and stabilized to prevent growth abnormalities and post-traumatic arthritis. Salter-Harris Type IV and V injuries are commonly associated with growth disturbances, even with good reduction and surgical repair. Salter-Har Salter-Harris ris Type IV injuries involve the bone and the  plate and traver traverses ses throug through h the the joint. joint. Compression Compression of the the physis physis is Salter-Harris is Type V injury, and frequently the classified as a Salter-Harr growth plate closes prematurely, leading to growth abnormalities, including differing lengths between extremities.

The most common fractures in children are fractures of the forearm and clavicle arm. [14].Fractures Both fractures when a child falls onto an outstretched of theoccur 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 require 4 to 6 weeks of casted caste d immobilization. A unique fracture of small s mall 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 (this is also known as plastic plas tic 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 preventing blood flow to the distal extremity can compromise the brachial artery. 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. st abilization. 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 s uspected and then treated if present [14]. Common lower extremity fractures include fractures of the tibia and fibula. These injuries can occur during sports-related activities (as seen in skiing s kiing and soccer), falls from heights, as well as pedestrian-motor vehicle collisions (most car bumpers strike the child's leg, causing fracture at the point of contact). conta ct). Limited weight bearing and crutch use is i s 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. Intermedullary 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 genitourinary 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. Future methods of bone healing may include advanced bone

 

grafting techniques and bioelectricity, which is being bei ng used to stimulate bone growth [5]. Due to the strong ligamenture of children, dislocations are not as commonly seen in children as in the adult population. The most common in afalls child is an shoulder occurringdislocation when a child onto theanterior shoulder area or dislocation, 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 e ntrapment does not occur during reduction. Follow-up assessment of neurovascular function is critical to ensure proper realignment. Children sustaining fractures and dislocations commonly have associated soft tissue tiss ue injuries. Open wounds require immediate assessment of the extent e xtent of injury. Neurovascular compromise requires immediate attention; hemostasis should be accomplished to control blood loss. After other major traumatic injuries have  been stabilized, stabilized, wound care should be institut instituted ed utilizin utilizing g irrigation and debridement as necessary. Wound closure can be accomplished using skin adhesives that are applied with 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 t raumatic 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  progno sis of of success success after after these these types of surgeri surgeries; es; thus, the lifelong disabilities associated with amputations can be negated. Care of traumatic amputations requires attention to a number of  issues. First and foremost, the child must be stabilized, lifethreatening injuries must be treated, and ongoing blood loss must  be control controlled. led. Once these priority priority injuri injuries es are are managed managed,, the the child child should be cleansed prepared The newly formed  be gently gently cleans ed and afor nd transport. pressur pressuree dressings dr essings applied applie d to stump contr control olshould

 

 bleeding. Debridem  bleeding. Debridement ent should not be undertaken undertaken without surgical consult. The part should be elevated to reduce swelling. If time permits, x-rays of the amputated part and the stump can be obtained; these will assist in decision de cision making prior to surgical reattachment. The amputated part should also be b e properly handled to prevent tissue destruction while awaiting surgical repair. The part should  be gently gently cleansed cleansed and and wrapped wrapped in slightly slightly moistened 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 plastic bag bag and the bag bag placed placed into a plastic plastic container, container, such as a urine cup or emesis basin. This plastic container should hence 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. These amputations produce a tremendous amount of   psychologic  psycho logical al impact impact on the the child child and and family family members. members. There is immense concern over long term outcomes, and grieving of these injuries begins early after injury. It is important that the staff  st aff  caring for this patient pat ient provide emotional and psychological support to all involved with this patient. For those children sustaining amputations without replantation, the long-term outcomes are often promising. Children adapt well to artificial limbs. The advances in design and use of these t hese artificial parts have progressed markedly during the last decade. Complications following musculoskeletal and surface trauma can  be limited limited with proper nursing nursing care. care. Wound Wound compli complicatio cations ns can can be minimized with early, thorough wound care. The development of   post-injury  post-i njury infections infections has decrea decreased sed drastically drastically over the last few few years as more judicious use of antibiotic therapy has been instituted. Closed 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  propor tion to the the extent extent of in injury. jury. Common Common pain managemen managementt techniques are inadequate to control the child's pain. Any pain that remains unresolved should be a clue to the possibi possibility lity of  increases in intracompartmental pressure. Neurovascular  compromise may be evident distal to the t he injury; however, the  presencee of pulses and adequate  presenc adequate capillary capillary refill does not guarantee that closed 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 is increasing in frequency freinjury. quencyAlthough is the development of tetanusthat following soft tissue 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 lifethreatening respiratory compromise and potential death can 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. CASE STUDY

Cody He is an 8-year-old boy protective who ctive was riding his skateboard inet. a city  park. was was not not wearing wearing prote gear, including inclu ding a helmet. helm

 

When a friend distracted his attention, he ran head-on into a  planter and was thrown thrown over over the the planter planter box onto the concr concrete, ete, landing on his left side. He immediately experienced pain in his left side, left wrist and abdomen. His left wrist was angulated and obviously broken. His friend responded to Cody's cries for help and called 911. EMS personnel responded to the scene, stabilized Cody's wrist, and transported Cody to the local emergency department for evaluation. A head to toe assessment asses sment of Cody demonstrates small, superficial scrapes on his forehead and left cheek. His facial structures st ructures appear to be intact. Neurologically he is normal with a GCS score of 14. He has no complaints of shortness of breath, and his chest ches t wall shows no obvious external injury. He complains of pain when the left upper quadrant of his abdomen is palpated. His  pelvis appears appear to be without without injury . His His and low lower er extremiti extremities es are are are  bruised and have hsave superficial superf icial injury. contusions contusions abrasio abrasions, ns, which contaminated with dirt and rocks. An x-ray of his left wrist shows a comminuted (splintered or crushed) fracture of his left radius and ulna. Cervical spine x-ray, laboratory results and urinalysis are all normal. At this time the focus of treatment is on his left le ft wrist and the pain in his abdomen. Abdominal CT scan was obtained and was normal, and liver injury was ruled out at this point in his care. Subsequently, Cody was taken to the t he operating room for  orthopedic repair of his left wrist. After surgery, Cody was admitted to the orthopedic floor with orders for pain medication as needed. He was to have repeat liver  function tests obtained on an every 6-hour basis. After being settled in bed, Cody appeared to be stable and enjoyed the attention that the injury had brought him. During the middle of the night, Cody awoke and complained of  severe pain in his left wrist. He was medicated with narcotics as ordered and appeared to drift off to sleep. Two later hewas was again awake and complaining of wrist pain. As hours the narcotic

 

ordered on an every four hour basis, the nurse had to obtain an order for additional narcotic, which she did. After this second dose of pain medication, Cody again drifted off to sleep. During the next day Cody had a number of visitors. He continued to of and painjoking in his with wristhis but,friends. when observed, was seen to complain be laughing The nursehe caring for  Cody asked him to rate his pain on a scale of 1 to 10 with a reply of 8. The nurse continued to observe Cody and had a hard time  believing  believ ing the pain pain was as as severe severe as as 8. Two hours later Cody again called the nurse, this time giving a pain score s core of 9, and he was medicated by another nurse. At this time the nurse medicating Cody checked his cast and found it to be tighter t ighter than it had been earlier in the day, and capillary refill in his left hand was slower  than on this right hand. She instructed Cody to keep the casted arm elevated on a pillow while visiting with his friends. Later that evening, Cody again complained of pain with a score of  9. He was again medicated and drifted off to sleep after a busy b usy day. During the middle of the night, Cody was crying and said that his hand hurt more than it ever had. His cast cas t was tight, and his left hand was cool to touch. t ouch. The orthopedic surgeon was notified by telephone, and the in-house physician evaluated Cody. The in-house physician recommended that Cody be returned to the OR for evaluation, e valuation, and the orthopedic surgeon arrived at the hospital within the hour. In the OR, Cody's hand was pale, with weak pulses and a significantly reduced range of motion. A diagnosis of  compartment syndrome was made, fasciotomy performed, and the wrist was placed in another cast that was bivalved. b ivalved. Eventually Cody's wrist healed, and he regained full range of motion after  intensive physical therapy. Case Study Discussion

The care Cody received in the initial stages after a fter his trauma was excellent. A complete assessment was performed, and all injuries,  both real and potenti potential, al, were identified. identified. The complicatio complications ns

 

developed post-surgery when he was admitted to the orthopedic ward. The frequent complaints of pain were incongruous with Cody's behavior and, therefore, not validated by the nurses caring for Cody. New guidelines for pain management stress the importance of including the patient in the assessment of their pain and believing the report provided by the patient. Just because the  patient's outwar  patient's outward d behavio behaviorr was was not what the nurse nurse expected, expected, it must be remembered that Cody may have been bee n utilizing his friends as a distraction to his pain pai n because he was not being adequately medicated. Cody's complaints of pain should also have alerted the staff to the development of potential problems. Once a patient's fracture has  been surgically surgically stabilized, stabilized, the pain pain should begin to resolve, resolve, not increase in intensity. With each complaint of pain, Cody should have had his pulsesdeteriorating and circulation checked, and have his cast evaluated. Cody's condition should been noted earlier, and surgical intervention could have been b een undertaken earlier rather than later. Cody was lucky in regaining full function after this complication. Children are generally more resilient resi lient than adults. Had this complication developed in an elderly individual, the results may not have been as fortunate.   MEDICAL SEQUELAE OF PEDIATRIC PEDIATRIC TRAUMA

Although most children respond to trauma treatment with good results, those children who are severely injured run the risk of  developing post-trauma sequelae, including post-traumatic respiratory distress, multi-organ dysfunction syndrome, and renal failure. With early recognition and aggressive therapies, these sequelae can be reversed and mortality lessened. Post-traumatic respiratory distress syndrome occurs following  pulmonary  pulmo nary injury, injury, leadin leading g to pulmonary pulmonary congestion. congestion. As the the disease progresses, there is increased mucus formation and a loss of surfactant. The syndrome four patinflammatory pathophysiologic hophysiologicresponse characteristics, including (1) has a systemic sys temic

 

with the release of mediators, (2) an alteration in alveolarcapillary membrane, (3) changes in airway diameter, and (4) a disruption in systemic oxygen transport and utilization. uti lization. The hallmark sign is persistent hypoxemia in the face of increasing oxygen delivery. The child will develop de velop a compensatory tachypnea, an increased shunt fraction, increased dead space s pace ventilation, a decreased static compliance, and pulmonary hypertension. Chest x-ray will demonstrate diffuse bilateral infiltrates i nfiltrates with normal lung next to severely injured lung. There will be no evidence of congestive heart failure as is seen see n 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 - 48 hours, x-ray the child be comes becomes and hypoxemic. Chest evidence willseverely develop dyspneic 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, compl complete ete resolution can take up to one year to complete. 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. Newer modes of ventilation are being utilized, including pressure support ventilation. The child will be  paralyzed  paraly zed and sedated to allow allow synchrony synchrony with the ventilator. ventilator. Although positive end expiratory pressure (PEEP) has shown no  prophylacti  prophy lacticc benefit, benefit, PEEP trials are institu instituted ted to help help improve improve the child's oxygenation status once the disease process is identified. The PEEP is increased in increments of 2.5 cm and limited to a maximum level of 15 cm. Whenever PEEP is being utilized, the child must be continually monitored for the detrimental effects of PEEP, including cardiovascular  compromise and neurologic deterioration.

 

Positioning the patient for the best gas exchange has been the focus of intensive study in the past few years. yea rs. The studies in adults have demonstrated that frequent position changes and  prone positioning positioning have beneficial beneficial effects effects upon upon the patient' patient'ss respiratory status. Positioning children with multiple injuries, multiple invasive lines, and stabilization devices requires forethought and ingenuity. It often seems that once the patient is finally settled into the new position, it is time to change position yet again. Other measures to improve patient status include i nclude administering  packed red blood blood cells to improv improvee oxygen oxygen delivery delivery at the cellular  cellular  level. This is instituted if the hemoglobin is low, as would be seen after occult hemorrhage. Pharmacologic agents may be utilized for cardiovascular support; these agents are generally reserved for  severe cases, with refractory interventions are being testedhypoxemia. in research Nonconventional institutions. Various methods of ventilatory support have been tried, including high frequency ventilation, inverse I:E ratio ventilation, and liquid ventilation. Pharmacologic support, including surfactant replacement, has been utilized, as has Interleukin-1. Until the  pathophysio  pathop hysiology logy of this this syndrom syndromee is completely completely understood, understood, various experimental measures will be utilized in an effort to support the failing child. Multiple organ dysfunction syndrome (MODS) is defined as  progressive  progre ssive deterioratio deterioration n of of two or more more organ system systemss over over a short time period. This organ failure is initiated by systemic inflammatory response syndrome (SIRS), which 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. Some of the etiologic factors in trauma include sepsis, persistent, prolonged hypovolemic shock, multiple transfusions, and extensive tissue damage. The defining characteristics of MODS are organ specific. Most commonly, pulmonary failure develops first and is characterized  by respirato respiratory ry failure failure with with a PaCO2 greater than 50 mm Hg, an

 

AaDO2 greater than 350 mm Hg, and ventilator dependence. de pendence. At day six or seven, hepatic failure begins to develop de velop and is defined  by a bilirubin bilirubin of greater greater than 6, a prothromb prothrombin in time of more more than 4 seconds over the control, and jaundice. If the bilirubin is greater  than 8, the syndrome carries a mortality of 90% or greater. Gastrointestinal (GI) failure is identified next; the child develops a paralytic ileus, and a GI bleed b leed 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 chi ld will require dialysis. Ultimately, neurologic and cardiovascular failures develop. The child becomes comatose with a Glasgow Coma Scale score of less than or equal e qual to 6 in the absence of ssedation. edation. 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 only one organ system involved, the mortality is approximately 40%. When two organs fail, the mortality increases to 60%, and with four or more organ systems involved, the mortality is approximately 100% [17]. The key to preventing this mortality is 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. As discussed previously, assessing the effectiveness of this volume resuscitation is controversial. Despite the debate regarding the optimal method of assessment, a ssessment, ensuring adequate resuscitation is critical. Depending De pending upon the capabilities of the facility, this may mean monitoring the base deficit and serum lactate levels, using us ing 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, fractures, and avoidi avoiding ng "missed "missed"" injuries. injuries. Once the patient is transferred to the trauma ICU, early nutritional support is instituted, antibiotics are ordered as appropriate, and  pharmacot  pharm acotherapy herapy for organ support support is provided. provided. Should Should the the  patient have sustained sustained a "missed" "missed" injury, injury, timely timely reoperative reoperative surgery is critical to prevent ongoing failure [17]. However, once 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 hospitalacquired 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 le vel to achieve  benefit.  benefi t. Having Having the child child sit up, cough and breath breathee deep deep will will improve pulmonary function. Suctioning is often required as  pulmonary  pulmo nary congestion congestion worsens. worsens. Blood Blood products products are also utilized utilized,, as with post-traumatic respiratory distress, to improve oxygen delivery. Coupling the increased oxygen supply with a decreased oxygen demand will help reverse the persistent hypoxemia. Decreasing the oxygen demand includes controlling anxiety and pain, administering analgesics and sedative agents, providing rest  periods,  period s, and and reducin reducing g the the developm development ent of hyperth hyperthermi ermiaa and and shivering. Providing the child with quiet, bedside activities will help provide a method of distraction; dis traction; however, it is imperative that these activities not excite the child chi ld further (an example would  be a Nintendo Nintendo GameBoyGameBoy- the excitem excitement ent generated generated may increase increase oxygen demands and defeat the purpose of the activity). Metabolic support is a critical partfunction of patient care management. Early feeding will improve tissue and provide energy for 

 

cellular activity. Tube feedings are being initiated in some  patientss as early as 24 hours after injury.  patient injury. At At this this point point an ileus has not yet developed, and early feeding may actually prevent its formation. The concentration of the feedings is increased i ncreased 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 pass age of gram-negative organism organismss into the vascular system that in turn precipitate mediator release. If this theory is valid, interventions inter ventions aimed at gut decontamination and control of gram negative sepsis may be a key to reversing the effects of this sequelae. At this point in i n 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. Other nonconventional measures include antiendotoxin therapy and agents to block mediator synthesis or their effect. However, there are more than twenty mediators that have been identified at various steps in syndrome development, and up to this point, none of the agents developed have been able to stop the development of the organ failure [17]. If, in the future, one or  more agents are developed to block b lock mediator action, outcomes will improve significantly. One of the more common and more easily easi ly treated sequelae of  trauma in children is the development of acute renal failure. Renal failure is classified as prerenal, intrarenal or postrenal failure [12]. The treatment of choice depends depe nds 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 the most common forms form s of renal failure following trauma and of 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 chi ld remains hypotensive for a long  period of time, time, intrare intrarenal nal failure failure is common. common. Postrenal Postrenal failure failure is less common; this type of failure develops as a result res ult of an obstruction in the drainage system. The majority of children who develop acute renal failure respond quickly to resuscitation and treatment. t reatment. Most children develop oliguric failure in which the urine output drops and the BUN and creatinine levels rise. (It is possible poss ible to have nonoliguric failure, also known as high-output failure, in which the urine output is high but creatinine clearance is low.) As the kidneys recover, the urine output increases and the t he urine becomes more concentrated. The of recovery is dependent upon the severity of damage to thedegree kidneys. The treatment goals include maintaining a normal circulating volume, maintaining normal electrolyte values, and maintaining 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 (Lasix) or  mannitol challenge may be administered to prevent acute tubular  t ubular  necrosis from developing during the oliguric phase. Hemodialysis has for many years been bee n 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. dialysis . This patient instability has lead to a renewed interest in other  methods of dialysizing the blood, which are now known as renal replacement therapies. 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 may advantageous forvolume the trauma patient, as the blood isdialysis dialyzed at abeslow rate without 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. The patient's blood pressure rather than a machine drives the dialysis system. This type of dialysis is i s good for the hemodynamically compromised patient although anticoagulation is required and may not be safe in certain trauma tra uma patients. The methods vary from arteriovenous to veno-venous type systems, dependent upon where the patient is cannulated for catheter   placement.  placem ent. Which Which method method of CRRT CRRT is best has yet 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 sequelae of injury and is i s 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. Health care ca re  providers  provid ers must must take take the time time to assess assess the the level 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 that narcotics and other medications will compromise the child's status. In fact, children can identify i dentify and describe the  pain and its its location. location. They can utilize utilize pain scales that have 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, non-steroidal 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. e xperiencing.

 

 Nonpharmacolo  Nonpharma cologic gic intervention interventionss for for pain pain can can also also be utilize utilized d with great success in many children. Positive reinforcement of  good behavior will yield desired des ired 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 that he or she will experience. e xperience. 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 se curity and will reduce fear and anxiety. It is imperative that health care providers aggressively pursue  pain control control options. options. While While not all measur measures es work work on al alll children, children,  providing  provid ing pain reduction reduction measures measures can can be achieved achieved through through trial and error.can Combining pharmacologic and nonpharmacologic therapies be performed with a high rate of success. Recently the State of California enacted legislation that requires all health care providers to assess pain and develop pain plans with patients, patie nts, including children. To neglect a child's pain in California could  bring legal consequenc consequences! es! 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 i nclude abdominal compartment syndrome and bone growth abnormalities, among many others. The pediatric trauma care practitioner must be aware of this multitude of sequelae and be constantly vigilant to their  impending development. The injured child can often respond  positively  positiv ely to the the treatmen treatments ts we we have have availabl availablee to us as long as they are instituted early in the course of development. de velopment.   TRAUMA CARE OF THE FUTURE

 

Further reducing death and disability from pediatric trauma will depend upon advances in trauma care management. Three areas of study include reduction of injuries, enhanced diagnosis of  injury, and improved interventional techniques. Injury prevention is an area of in-depth study. Since federally mandated seatbelt laws were instituted in 1981, we have seen a drastic reduction in motor vehicle injuries and fatalities in children. Despite this improvement, additional measures should  be undertak undertaken en to further further reduce reduce the the impact impact of motor motor vehicl vehiclee crashes. Reducing injuries in motor vehicle crashes requires  proper installation installation and use of of child child restrain restraintt devices. devices. Emphasis Emphasis on  properly  proper ly restraining restraining children children between between 4 and and 8 years of age age in  booster seats has recentl recently y come come to the forefront forefront of injury injury  prevention  preven tion programs. programs. In the future we may see automatic crash notification systems installed in all vehicles on our roadways. These systems include a number of technologies, including crash sensors, wireless location and global positioning systems, and a wireless telephone. When a crash occurs, information is immediately i mmediately transmitted to a communication center and provides information on the location and severity of the crash, the exact location of the vehicle, vehicle identification number and type, as well as information on the  precrash  precra sh speed speed and type type of impact impact (i.e., (i.e., frontal, frontal, side, rear or  rollover). A few car manufacturers have installed these systems in their new model vehicles, and these systems are being tested in a few cities within the United States. In future car models, this equipment may become standard if it proves effective e ffective in helping to manage the victims of automobile crashes [9]. Vehicular safety measures are in development that notify the driver of imminent danger. Crash avoidance systems include systems that notify the driver of road departure, lane change, intersection hazards, as well as location information. Driver  condition systems monitor the driver for attention. atte ntion. For example,  preventing an alcohol  preventing alcohol-- or drug-impai drug-impaired red driver driver from from startin starting ga vehicle is already developed and being utilized in the vehicles of 

 

repeated offenders of driving under the influence (DUI) laws. Also available are vision vis ion enhancement systems, which improve visibility during fog and low-light situations [9]. One of the injury prevention strategies that is extremely difficult to legislate and institute is protecting children from pedestrian injuries. Community efforts at reducing injury are required to  protectt children  protec children who are walkin walking g along along our our roads. roads. Protecting Protecting  pedestrian  pedestr ian children children from being struck by a motor vehicle vehicle is difficult. Installing barriers along the side of the road to keep cars from hitting children is not only cost-prohibitive but also difficult to implement. Preventing death and injury from firearms is an area of intense debate within our country. The incidence of firearm injuries is increasing exponentially while measures to protect children are debated in the news, on the television, in homes, and anywhere in our society, so it seems. see ms. Child safe gunlocks are readily available from gun manufacturers although their use is neither ne ither required nor  recommended by many gun owners. Safe storage of guns can help reduce death and injury i njury from firearms although this too is not legislated nor mandated. Reducing the time to diagnosis as well as the incidence of missed diagnoses is the focus of trauma research aimed at enhancing recognition of injury. Some of the newer methods of diagnosis have been previously discussed in this course (FAST ultrasound, transesophageal echocardiography). As these methods become cheaper and more commonplace, we will see children who are rapidly diagnosed and treated appropriately in a shorter time frame. To improve diagnosis even further, new technologies are currently being evaluated. A portable CT scanner has been developed and is currently being tested in a few trauma centers in the United States. This type of scanner can be moved to the  patients,  patient s, the whether whether theytoare inpatient, the ED, therisk OR, OR, ointra-f r the ICU. By  bringi  bringing ng scanner scanner the thein pat ient, the risk of of or int ra-facility acility

 

transport is reduced. The patient can be continually monitored with sophisticated systems, and immediate studies can be  performed  perfor med without without harm harm to the the patient patient [34]. Ultrasound assessment is being improved upon at a rapid rate. Trauma physicians are learning ultrasound diagnosis, thus reducing the delay in obtaining a diagnosis. New threedimensional sonograms are in development, allowing assessment in full dimensional views. These sonograms will prevent missed diagnoses when fluid or blood is sequestered behind an organ and thus missed by conventional, two dimensional systems. Technologic advances in interventions will soon seem s eem like something out of science fiction novels. Robotics is being utilized to augment skills, especially in surgical suites. suites . Hand-free surgery is no longer an intervention of the future; it has been utilized with success on a small number of patients. The ability to access body cavities with minimal incisional size will reduce the complications of surgical interventions [28].  New materials materials for wound healing healing and and managem management ent will be made made in test tubes. Artificial skin has been b een utilized for years to treat  patientss with  patient with large, large, full thickness thickness burns. burns. This technology technology can be be used on the trauma patient who has sustained large areas of open wounds. Bioelectricity is being studied as a method of speeding up tissue regeneration. The electricity passes through the tissue, enhancing cell growth [5]. Microinstrumentation is well developed de veloped and laparoscopy is growing in leaps and bounds. While the size of these instruments shrinks almost daily, the surgeon is able to access acces s areas of   bleeding  bleedin g and and cauterize cauterize or ligate ligate vessels without without openin opening g th thee body body cavity to exposure. Enhanced computer imaging allows the surgeon access to areas area s previously thought inaccessible without large field exposure. Patients who are treated with this type of  surgery do not have the post-operative complications seen in those patients with large surgical sites [22].

 

There are also many new drugs on the horizons. Pharmaceutical research and development groups are working around the clock to develop new drugs to manage head injuries, control multi-organ sepsis, promote nerve regeneration in spinal cord injuries, among others. As these drugs become available, the long-term sequelae of trauma may be a thing of the past. While these developments offer excitement for the future, the child who is injured today or tomorrow must be managed within the best of our capabilities. Each child must be offered the best be st of  current technology and advances to improve present day outcomes. If each child's case is studied st udied for its success and/or  failure, new information will be available to provide the missing link for obtaining 100% success rates.   SUMMARY

Rapidly assessing and managing children with multi-system injuries is critical to their successful s uccessful 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 secondary to trauma in children. Initially the tenets of trauma management include stabilization of the airway, breathing and circulation of the child. Once these are secured, a head to toe assessment as sessment to identify all  potential  potent ial and real real injuries injuries must be undertak undertaken. en. Throughout Throughout resuscitation, astute observation of the child's response to therapy must be performed; deterioration in the child's status is a poor   prognostic  progno stic sign. While in-depth discussion of trauma is beyond the scope of this course, a few of of the the sequelae major points were highlighted.

 

Reducing the long term consequences of these sequelae begin 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. Health care providers caring for pediatric trauma tr auma victims are well aware of the benefits be nefits of injury prevention strategies. Supporting  public awareness awareness and and educati education on regardi regarding ng these strategies 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 health care provider's education when working in the emergency and trauma care field. Instituting the measures presented in this course will enhance the care provided to victims of pediatric trauma. Take Test

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