Trauma in Children

The leading causes of death in children 1 to 14 years of age are accidents and trauma.^[346] The nature of the trauma is different from that in adults; children are usually victims of drops or falls, drowning, near-drowning, motor vehicle accidents (pedestrian), ingestions, and burns. The types of body damage a child experiences also differ. Head injuries are more common, especially in younger children, who have disproportionately large heads with relatively poor neck muscle support.^[347] Children are less likely to be victims of penetrating injury caused by gunshot or knife attacks; instead, blunt injuries are more usual. Blunt trauma to the abdomen causes solid organ injury (liver and spleen) rather than a perforated viscus.^[348] Hypothermia is more frequently encountered

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Similar to adult trauma, management of pediatric trauma requires an organized approach that combines diagnosis and treatment. Most preventable deaths in pediatric trauma are a result of airway obstruction, pneumothorax, shock secondary to inadequately treated bleeding, or secondary brain injury from an expanding intracranial hematoma.^[349] The American College of Surgeons recommends a four-step approach: (1) primary survey, (2) resuscitation, (3) secondary survey, and (4) definitive care.^[350] The primary survey requires rapid assessment of the airway, breathing, and circulation (ABCs). A disproportionately large tongue in relation to a narrow oropharynx easily obstructs the airway in an unconscious child. A patent airway can often be established by proper jaw positioning to enable bag-and-mask ventilation until intubation can be accomplished. Cervical spine injuries are less common in children surviving injuries than in their adult counterparts, but the neck of these patients should be immobilized until spinal damage is excluded.^[351] After establishment of an airway, adequacy of respiration should be verified by observation of symmetric chest wall movement, auscultation of normal and equal breath sounds, and an early chest radiograph. Tension hemopneumothorax can be diagnosed clinically and treated by needle aspiration at the second thoracic interspace in the midclavicular line to alleviate the tension and permit stabilization until a chest tube can be placed. The circulation can be quickly assessed in children. Hypovolemia is manifested first by tachycardia, poor peripheral perfusion, and weak peripheral pulses and, finally, by hypotension, which may not occur until the child has lost more than 25% of circulating blood volume.^[352] A severely hypovolemic child requires venous access quickly. If a peripheral venous catheter cannot be placed expeditiously, an IO cannula should be placed until central venous access is established.^[353] The degree of volume resuscitation is dictated by the clinical condition of the child and the estimated volume of blood or plasma loss.

During the secondary survey, a thorough head-to-toe examination is performed, and a plan of definitive treatment is developed. Diagnostic measures in a pediatric trauma patient are similar to those in an adult patient, but with consideration of special problems. Because of the higher incidence of solid organ injury and a more conservative approach to management, diagnostic peritoneal lavage is less helpful in children. Most intra-abdominal injuries that require laparotomy are recognized clinically because they produce peritonitis or involve increasing abdominal girth.^[354] Diagnostic peritoneal lavage may be helpful in children who are hemodynamically unstable despite fluid resuscitation with greater than 40 mL/kg of blood. It can be used to locate the site of occult bleeding in a child too unstable to undergo CT, or it can be used to evaluate abdominal injury in a child about to undergo emergency nonabdominal surgery. Indications for surgical intervention for abdominal trauma include free peritoneal air, evidence of a ruptured viscus, and acute uncontrolled bleeding greater than 40 mL/kg. A ruptured spleen or liver laceration is not an indication for surgery; the preferred treatment is supportive therapy with aggressive blood volume replacement.^[355]

A careful head and neurologic examination yields rapid information regarding intracranial trauma. The most important indicator of intracranial bleeding is a decrease in the level of consciousness. Rapid diagnosis and treatment of intracranial mass lesions can reduce ICP and may prevent secondary brain injury.