PEDIATRIC TRAUMA (also see Chapter 63 )

Prenatal and Perinatal Injuries

Perinatal trauma is sustained by the fetus or newborn before, during, or immediately after birth. The most common prenatal injuries are due to maternal gunshot wounds and maternal blunt trauma. Fetal mortality in either case is greater than twice that of the mother,^[343] with fetal death attributable to maternal shock and fetal oxygen deprivation rather than direct injury. Birth injuries occur more commonly in large full-term infants and in infants with a breech presentation.^[344] Injuries to the head include linear or depressed skull fractures, cephalohematomas from subperiosteal hemorrhage, subdural or subarachnoid hematomas, and intraparenchymal or intraventricular hemorrhage. Intracranial injuries can lead to increased ICP, cerebral ischemia, neurologic injury, and death. Neck trauma can result in torticollis from injury to the sternocleidomastoid muscle and, rarely, cervical cord transection during a difficult breech extraction.^[345] This latter tragedy leads to lifelong quadriplegia. Less devastating nerve injuries, also resulting from cervical traction, are phrenic nerve paralysis and Erb's or Klumpke's palsy from brachial plexus injury.

Perinatal bone fractures occur commonly in the clavicles and humeri as a result of shoulder dystocia; femoral shaft fractures are more common in breech deliveries. Abdominal injuries to the liver, spleen, adrenal glands, and kidneys can produce life-threatening hemorrhage or thrombosis.^[345] Thrombosis can cause vaso-occlusion with distal tissue loss in the cerebral, coronary, or renal vascular beds. Finally, emergency instrumentation of the airway in the delivery room can lead to tracheal and esophageal perforation, particularly in a premature infant.