By Santa J. Bartholomew M.D. FAAP, FCCM
In the US, approximately 12,000 children and adolescents under 18 die annually of accidental and non-accidental trauma. Traumatic injury is the leading cause of death for this collective population. Injuries and poisoning are also the leading causes of emergency department (ED) visits. There are more than 30 million ED visits by children each year, representing approximately 20% of children in the US.
The initial approach to all trauma care is built upon the ATLS (Advanced Trauma Life Support) protocols based on the Trimodal Death Distribution concept. This distribution states that the first group of patient deaths occur seconds to minutes after injury, and only prevention can impact this statistic. In other words, these patients die at the trauma scene or before reaching a hospital. The second group occurs in the minutes to hours after injury. During this “golden hour,” timely assessment and treatment decrease death rates and improve outcomes. Finally, the third group of deaths occur days to weeks after the initial injury because of secondary infection and organ system failure. This statistic suggests pediatric traumatic injuries that are not minor should always be managed in a tertiary care center, preferably a level I pediatric trauma center.
The initial approach to all trauma care is built upon the ATLS (Advanced Trauma Life Support) protocols based on the Trimodal Death Distribution concept.
Classification of injury severity helps care providers in the field communicate with those in EDs to assess several issues which can reduce the danger of complications or mortality. The extent, type, and severity of the injury must be evaluated. Sometimes the extent of injury may be evident; at other times, this may not be readily apparent, and the clinical picture may evolve. Injury severity differs based on whether they occur because of blunt or penetrating trauma. Assessment of the severity of the injury will dictate the initial management and disposition of the patient to a regional facility or a Trauma Center.
The initial goal of trauma management is to rapidly assess the initial trauma and stabilize the airway, confirm breathing by assisting with respirations if necessary, and lessen any blood or volume loss. Additionally, the patient’s mental status should be assessed rapidly. This is referred to as the “primary survey.” The “secondary survey” is more comprehensive care, including ongoing monitoring of vital functions when further resuscitation is needed.
Management of severely injured people relies on the idea that assessment and management occur concurrently during the primary survey. Any identified threat to life must be rapidly addressed before moving on to the secondary survey. If the patient’s condition worsens during the evaluation, the primary survey should be repeated, and any newly identified problems should be addressed before transporting. Although the priorities and methods of trauma care for children are the same as for adults, unique pediatric anatomy and physiology create specific differences in assessment and management.
Airway – Securing and managing the airway of a pediatric patient may be more difficult, especially in children <3 years of age. Small oral cavities and relatively large tongues and tonsils predispose to airway obstruction, especially in semiconscious or comatose patients. The rather large occiput in the infant or child naturally flexes the neck in the supine position, causing airway obstruction.
Head and brain – Head trauma and brain injury commonly occur after blunt injury. Infants and young children <8 years of age have heads that are relatively large compared to their bodies. As a result, head trauma often occurs following blunt injury and is the leading cause of death in pediatric trauma. Infants have skulls with open sutures, and their brains have a larger subarachnoid space and increased extracellular space. They tend to tolerate an expanding intracranial hematoma better than older children or adults. However, the infant’s brain is less myelinated, and the skull is thinner and easier to fracture. Because of this, mild forces may still result in skull fractures and significant injury. The possibility of abusive head injury in infants and young children should be considered, especially in the case of a substantial injury without a plausible mechanism.
Spinal cord/spine — Young children are at increased risk for spinal cord injury without radiographic abnormality (SCIWORA) because of anatomic flexibility that allows the cervical spine to flex (without apparent derangement) further than the spinal cord can tolerate. Many children will demonstrate abnormalities in their magnetic resonance imaging but none on x-ray. Despite this anatomic characteristic, SCIWORA rarely occurs in children.
Chest – Children are more prone to develop pulmonary contusions and tension pneumothoraces without fractures. Children have compliant chest walls, so rib fractures are less common, and pulmonary injury often presents without accompanying fractures. In addition, because of their mobile mediastinum, children are more likely to develop tension pneumothoraces than adults.
Abdomen – The liver and spleen in infants and toddlers are less protected by the rib cage and are more prone to injury.
Vascular system – Vascular access for fluid resuscitation is often more challenging. Intraosseous access is used more frequently than in adults.
Musculoskeletal System — Children have immature bones with growth plates that are more pliable than adults. These differences predispose children to fractures of the growth plates and greenstick and buckle fractures. For example, blood loss associated with an isolated fracture of the femur is less than that of adults and should not cause hemodynamic instability.
Vital signs – Normal vital signs change with age in children. Heart and respiratory rates are generally higher than in adults, and blood pressure is lower. The 5th percentile systolic blood pressure for age can be approximated by the formula for children aged 1 to 10: Systolic pressure = 70 mmHg + 2 X (age in years).
Breathing and ventilation – Infants and children become hypoxemic when ventilation is inadequate much more quickly than adults. Infants and young children also have smaller tidal volumes (6 to 8 mL/kg). They are at greater risk for barotrauma with overly aggressive artificial ventilation.
Metabolism – Children are prone to hypothermia and insensible fluid losses due to smaller fluid volumes and lack of body fat.
Signs of shock – Tachycardia and poor skin perfusion are the initial signs of circulatory failure in children, which should be recognized early and managed with fluid resuscitation and close monitoring. Children can maintain their blood pressure despite a loss of 30 to 45 percent of total blood volume. Hypotension with shock is a late and sudden finding that requires an immediate medical response. In infants, uncompensated shock with hypotension in the early stages is also accompanied by tachycardia, which may change to bradycardia if blood loss continues unchecked.
There are limited pediatric trauma centers with pediatric surgeons and specialists involved in trauma care. This may be why some ongoing disparities in the care of US children experiencing trauma. Injured children treated at accredited trauma centers do better than those treated at nonaccredited trauma centers and have improved overall outcomes. Appropriate triage systems are necessary to ensure that severely injured children are treated in pediatric trauma centers. Conversely, children with little chance of survival should not be transferred from their community long distances to pediatric trauma centers with the unfortunate task of informing parents that there is no hope of survival for their child. Because of the limited number and questionable decision-making, not all children receive the tertiary care they need. Trauma centers that treat injured children appreciate the child’s unique anatomic and physiological differences and incorporate them into appropriate treatment protocols.
References:
American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 10th ed, American College of Surgeons, Chicago, IL 2018.
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WISQARS™ — Web-based Injury Statistics Query and Reporting System https://www.cdc.gov/injury/wisqars/index.html (Accessed on June 13, 2023)
