Considerations in Pediatric Trauma

Updated: Nov 04, 2015
  • Author: Brian J Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Overview

Overview

Trauma is the most common cause of mortality and morbidity in the US pediatric population. Caring for the injured child requires special knowledge, precise management, and scrupulous attention to details. All clinicians who are responsible for the care of a pediatric trauma patient, including pediatricians, emergency room clinicians, pediatric emergency room clinicians, and trauma surgeons, must be familiar with every tenet of modern trauma care. The special considerations, characteristics, and unique needs of injured children must also be recognized.

In 1962, Peter Kottmeier established the first pediatric trauma unit at the Kings County Hospital Center in Brooklyn. In 1976, the publication of Resources for Optimal Care of the Injured Patient by the American College of Surgeons established requirements that should be met by a dedicated pediatric trauma center. Since 1985, the National Pediatric Trauma Registry (NPTR) has collected data concerning pediatric accidents. According to the American College of Surgeons, 81 accredited pediatric trauma programs are currently in the United States.

This article focuses on the special considerations that apply to pediatric trauma patients, provides the epidemiology of pediatric trauma, and briefly discusses the recent advances in the management of pediatric trauma.

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Epidemiology

Injury is the leading cause of death among children older than 1 year. In fact, for children, injury exceeds all other causes of death combined. Death from unintentional injury accounts for 65% of all injury deaths in children younger than 19 years. From 1972-1992, motor vehicle accidents (MVAs) were the leading cause of death in children aged 1-19 years, followed by homicide or suicide (predominantly with firearms) and drowning. Each year, approximately 20,000 children and teenagers die as a result of injury. Moreover, for every child who dies from an injury, 40 others are hospitalized and 1120 are treated in emergency departments. An estimated 50,000 children acquire permanent disabilities each year, most of which are the result of closed head injuries. Thus, pediatric trauma continues to be one of the major threats to the health and well-being of children.

Several factors influence childhood injuries, including age, sex, behavior, and environment. Of these, age and sex are the most important factors affecting the patterns of injury. Male children younger than 18 years have higher injury and mortality rates, perhaps in part because of their more aggressive behavior and exposure to contact sports. [1] In the infant and toddler age group, falls are a common cause of severe injury, whereas bicycle-related mishaps, with or without the interaction of motor vehicles, are the main culprits for injury of older children and adolescents. Use of helmets results in fewer head injuries and decreases the severity of them as well. Tragically, the home environment is the next most common scene of pediatric injury. Approximately 35% of significant injuries occur as the result of accidents in the very environment that should be the most sheltering and nurturing to children.

Most pediatric trauma occurs as a result of blunt trauma, with penetrating injury accounting for 10-20% of all pediatric trauma admissions at most centers. [2] Gunshot wounds are responsible for most penetrating injuries and carry a significantly higher mortality compared with blunt mechanism injuries. A rising incidence of pediatric penetrating trauma, particularly penetrating thoracic trauma, has occurred in recent years. Unfortunately, the proliferation of handguns and increased proclivity to urban violence in our society has increased the frequency of penetrating injury in children aged 13-18 years. Regardless of the classification, the 2 mechanisms of injuries are interrelated in that blunt mechanical force can result in penetrating injury, such as that caused by fender edges, door handles, or shrapnel. Thus, treating clinicians must be thorough and must proceed with a rational plan with scrupulous attention to detail.

A review by Guice and colleagues queried the Healthcare Cost and Utilization Project Kids’ Inpatient Database to define contemporary trends in pediatric trauma epidemiology. [3] Trauma remains the leading cause of death for children aged 1-17 years. The average age in this review was about 10 years, and, for every year, male gender was more prevalent than female gender. This disparity increases toward adolescence, with boys having a significantly higher incidence of traumatic injury. Burns were found to be most common in children aged 1-4 years, upper limb fractures were found to be common in children aged 5-9 years, and lower limb fractures and traumatic brain injuries were found to be more common in adolescents.

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Specific Injuries

Approach Considerations

Developmental milestones correlate with mechanisms of childhood injuries. Head injuries, either alone or in association with multiple system injuries, are the most severe and cause the most deaths. Head injuries also account for most disability in children. All factors considered, clinicians must become aware of the anatomic and physiologic characteristics that make children unique.

CNS Injuries

Among children, the CNS is the most commonly injured isolated system. Because CNS injury is the leading cause of death among injured children, it is the principal determinant of outcome. However, numerous observations have shown that patients from the pediatric population recover more frequently and more fully than similarly injured adults. Although this might be euphemistically ascribed to the "physiologic reserve" of the child, it suggests that injured children respond exceedingly well to preservation of cerebral oxygenation and perfusion. Therefore, management of the whole patient must focus on preservation of cerebral perfusion and elimination of potential detrimental effects of extracranial lesions to it.

In children aged 2 years or younger, physical abuse is the most common cause of serious head injury. Shaken baby syndrome (SBS) is characterized by retinal hemorrhage, subdural or subarachnoid hemorrhage, and little evidence of external trauma. In children aged 3 years and older, falls and motor vehicle, bicycle, and pedestrian accidents are responsible for most traumatic brain injuries.

Children tend to sustain injuries that produce diffuse edema rather than those that cause focal space-occupying lesions. For this reason, severely injured children who undergo early CT scanning may have minimal radiologic evidence of parenchyma injury. Follow-up studies may reveal much worse injury. MRI may reveal obscuring of the gray and white matter junction in the setting of cerebral edema. At this point, precise management makes the difference between disaster and success. Judicious fluid resuscitation, precise ventilatory care, and careful titration of cerebral perfusion pressure are the keys to success.

The Glasgow Coma Scale (GCS) score is the universal tool for the rapid assessment of the consciousness level of injured children. A modified verbal and motor version has been developed to aid in the evaluation of consciousness level in infants and young children. The GCS score and its modified version (with scores of 3-15) are based on children's best response in 3 areas: (1) motor activity, (2) verbal response, and (3) eye opening. Traumatic brain injury in children is classified as mild (GCS 13-15), moderate (GCS 9-12), or severe (GCS 3-8). Regardless of the GCS score, a head CT scan should be performed on any child with a history of trauma and loss of consciousness longer than 5 minutes or an altered level of consciousness.

Several factors predict mortality with head injury. A presenting GCS score of less than 8, unilateral dilated pupil, and transcranial gun shot wound are associated with mortality of almost 70-98%. Hypotension and hypoxia should be aggressively avoided and are known to produce secondary injury. This secondary injury, when present, is a substantial cause of morbidity, and aggressive protocols to prevent it should be in place. The Pediatric Risk of Mortality and the Pediatric Index of Mortality were developed to predict mortality of pediatric CNS injury. A review, provided by Haley et al, summarizes various outcome rating scores used for both hospital assessment and postdischarge assessment of injury severity and impact on quality of life. [4]

Metabolic Demand

Metabolic studies of children with multiple injuries and severe CNS trauma suggest that total body metabolic demand is significantly elevated; therefore, controlling seizures and fever is of utmost importance because both significantly increase metabolic demands of the brain. Initiation of good nutritional support within hours of definitive stabilization to meet the needs of increased metabolism and oxygen consumption is important. Enteric feeding is preferred.

Mild Head Injury

A concussion is defined by the American Academy of Neurology as "trauma-induced alteration in mental status that may or may not involve loss of consciousness."

Children with a mild head injury (GCS 14-15) with a history of transient loss of consciousness or amnesia of the events and normal findings on a head CT scan can be discharged and observed at home after at least 6 hours of uneventful observation in the pediatric emergency department. Caretakers should be provided with specific discharge instructions. Warn caretakers of a possible postconcussion syndrome, which includes the constellation of headaches, memory loss, behavior disturbances, and impaired concentration. This should prompt reevaluation and possibly a repeat head CT scan.

The postconcussive symptoms can last up to months after the injury but only rarely extend beyond 3 months. No specific treatment exists for these symptoms other than symptomatic support; however, with severe mood alteration, psychiatric treatment may be indicated.

Determining which pediatric patients with mild head injury need neuroimaging studies has been difficult. It has been reported that less than 5% of children with mild head injury (variably defined) have CT findings indicative of traumatic brain injury. Also, the concern for limiting radiation exposure has led to scrutiny of this practice. A meta-analysis of 16 studies, including over 20,000 children with mild head injury, defined associated risk factors for traumatic brain injury. Skull fracture (relative risk [RR], 6.1), focal neurologic signs (RR, 9.4), GCS less than 15 (RR, 5.5), and loss of consciousness (RR, 2.2) were all associated with traumatic brain injury. Headache (RR, 1.0) and vomiting (RR, 0.88) were not associated with traumatic brain injury with a presentation of mild head injury.

The very young child (< 2 y) with mild head injury is perhaps the most difficult evaluation. The limitations of the neurologic examination often present a decision-making dilemma as to the appropriate imaging studies. The key point to remember in this evaluation is that a higher index of suspicion is required in a young child as compared with an older child because there is a higher incidence of skull fracture and traumatic brain injury in a child younger than 2 years after mild head injury. Up to 30% of children younger than 2 years with a skull fracture may have traumatic brain injury demonstrable on CT scan.

The current American Academy of Pediatrics consensus guideline for CT evaluation of children younger than 2 years after mild head trauma include signs of depressed or basilar skull fracture, acute skull fracture, altered mental status, focal neurologic findings, bulging fontanel, loss of consciousness for 1 minute or longer, and multiple episodes of emesis; these findings are indications to proceed with CT scan. In the absence of these findings, plain skull radiographs are a reasonable evaluation method, with the finding of skull fracture prompting further evaluation with CT scan given the high association of underlying brain injury with skull fracture in this population.

A study by Königs et al investigated the impact of pediatric traumatic brain injury (TBI) on attention, a prerequisite for behavioral and neurocognitive functioning. The study concluded that lapses of attention represent a core attention deficit in children with mild TBI or moderate/severe TBI, and relate to daily life problems after pediatric TBI. [5, 6]

Severe Head Injury

The goal of initial resuscitation must be to limit or prevent secondary brain injury by maximizing cerebral perfusion and oxygen delivery while minimizing increased intracranial pressure (ICP). Hypoxia and hypotension should be aggressively treated. ICP monitoring is recommended in infants and children with a GCS score of 8 or less. Epidural hematoma occurs in about 2% of pediatric head trauma admissions. The characteristic lucid interval occurs in about 33%. A biconcave hyperdense lesion is seen on CT scan. Lesions associated with neurologic symptoms or mass effect should be evacuated. Intracranial hypertension can occur with open cranial sutures and does not alter this recommendation. Ventriculostomy catheters offer the benefit of allowing therapeutic cerebrospinal fluid (CSF) drainage, compared with Camino monitor.

An age dependent spectrum exists for cerebral perfusion pressure (CPP); in general, the CPP should be maintained above 40 mm Hg. CPP is the difference between mean arterial pressure (MAP) and ICP. ICP should be kept at less than 20 mm Hg. CPP is a predictor of outcome in pediatric severe head injury; however, whether this trend represents a marker of injury or a value that can alter the disease course is unclear. Current treatment of elevated ICP includes CSF drainage, sedation, neuromuscular blockade, mannitol, and hypertonic saline. Enthusiasm for hyperventilation therapy has waned with the finding of hypocapnic induced vasoconstriction further compromising cerebral blood flow. The only recommended role for hyperventilation is in the setting of acute herniation, to briefly assist, while definitive measures are being pursued. Another second tier therapy is hypothermia, which seems to be more efficacious in younger patients with traumatic brain injury.

Elevated ICP that is refractory to medical treatment may ultimately require decompressive craniectomy. The rationale for this treatment is founded on the Monro-Kellie doctrine, which allows for a stable intracranial volume via shifts in the amount of CSF, blood, or brain tissue. The Monro-Kellie doctrine defines ICP as a function of the relative composition of the 3 intracranial occupants: brain parenchyma, CSF, and blood. Decompressive craniectomy reduces the risk of death and unfavorable outcomes when maximal medical therapy fails to control ICP. Similar conclusions cannot be drawn from data on adults. Predictors of outcome after traumatic brain injury in the pediatric population have been noted to include initial GCS, pupillary reaction, and severity of findings on initial head CT scan.

Prospective data is limited in pediatric traumatic brain injury. One randomized trial of patients younger than 18 years examined 27 traumatic brain injuries. Findings supported improved outcome and less mortality with decompressive craniectomy in the pediatric population with refractory intracranial hypertension. Posttraumatic seizures may occur in up to 30%, and a lower GCS score portends a higher risk. There is insufficient data on prophylactic treatment in the pediatric population. When present, seizures should be treated to decrease metabolic demand and elevation of ICP that may extend an insult.

Adult literature supports the view that ICP management is more important than an absolute CPP threshold. The Lund concept–guided therapy has been validated in several clinical trails, in which this method of management improves outcomes and decreases mortality. It is designed as a treatment of vasogenic edema. This concept believes that systemic hypertension, in the setting of pathophysiology that may disrupt the blood-brain barrier and its autoregulation, increases intracapillary hydrostatic pressure, leading to accumulation of intracerebral water content. Thus, the emphasis is shifted to volume-targeted therapy, with judicious use of antihypertensive therapy to maintain normotension, in conjunction with aggressive maintenance of normovolemia.

The primary interventions used in the Lund concept–guided therapy are aggressive maintenance of normovolemia and reduction in ICP via manipulation of systemic arterial pressure. The Lund concept–guided therapy accepts a CPP of 40 mm Hg, in accordance with current pediatric guidelines. A recent review of the Lund concept–guided therapy toward children with severe traumatic brain injury by Whalstrom et al demonstrated favorable outcomes in 80% of patients and a survival rate of 93%. [7] The treatment goals were as follows: ICP less than 20 mm Hg, CPP greater than 40 mm Hg, normovolemia, normotension, normoventilation, and sedation as needed. Albumin and packed red blood cell transfusion were used to promote colloid osmotic pressure and to ensure adequate cerebral oxygenation. Larger prospective trials are needed to validate this therapy.

For a more detailed review of current therapeutic controversies and options, the reader is referred to the guidelines for treatment of traumatic brain injury published in the July 2003 issue of Pediatric Critical Care Medicine.

Spinal Cord Injury

Although spinal cord injury is relatively uncommon in the pediatric population, cervical spine injury must be presumed until proven otherwise. The most common cause of spinal cord injury (SCI) in the pediatric population is motor vehicle collision, accounting for about 40%. The common cervical fracture usually involves the first 2 vertebrae. If it remains undetected, cervical fracture can result in devastating injuries. Other common spinal fractures among pediatric patients with trauma are compression fractures and flexion-distraction (Chance) fractures of the lumbar spine, usually from inappropriate use of a lap seat belt.

Spinal cord injury without radiologic abnormality (SCIWORA) syndrome is a problem unique to the pediatric population. SCIWORA has been reported in 10-20% of children with SCI. The incompletely calcified vertebral column of the child may transiently deform and allow stretching of the cord or nerve roots with no residual anatomic evidence of injury. The hallmark of this syndrome is documented neurologic deficit that may have changed or resolved by the time the child has arrived in the emergency department. Immediate re-injury of the same area may produce permanent disability, so thorough neurosurgical evaluation is essential whenever reliable evidence of even a transient neurologic deficit is present.

MRI evaluation of SCIWORA is important in determining a prognosis but is not useful in determining stability of the spine. Radiologic evaluation should consider normal variants, such as C2-C3 pseudosubluxation occurring in 9% of children up to age 7 years. This is due to the elastic nature of the pediatric spine in that the ligaments and joint capsule can stretch without tearing. This and other factors that give the pediatric spine hypermobility account for the SCIWORA syndrome being unique in the pediatric population. The pediatric occiput is relatively larger and may cause passive flexion of the neck. Special attention should be given to ensure proper stabilization of the spine while undergoing evaluation.

Controversy exists regarding the use of methylprednisolone for children with SCI. They are not indicated for penetrating SCI. Bracken et al demonstrated a significant improvement with the use of methylprednisolone; however, only 15% of the study population was adolescent, and the study population included no one younger than 13 years. [8] A smaller population examined by Wang et al concluded no significant difference in neurologic improvement of pediatric SCI (mean age, 7.7 y) with blunt mechanism. [9]

Neck Injuries

Early airway control is paramount. Gross laryngotracheal injury, stridor, pulsatile bleeding, or expanding hematoma requires urgent operative treatment. Local exploration or probing of wounds is not recommended. In the absence of hemoptysis, hematemesis, dysphagia, subcutaneous emphysema, or the aforementioned urgent criteria, Zone 2 injury has been observed with success in some series. There are 3 horizontal zones of the neck for classification of injury location. Zone 1 extends from the sternal notch to the cricoid cartilage. Zone 2 extends from the cricoid cartilage to the angle of the mandible. Zone 3 extends from the angle of the mandible to the skull base. Angiography, endoscopy, and bronchoscopy are useful for a complete examination. Missed esophageal injury can be greatly minimized by endoscopy, esophagram, and careful physical examination.

A 5-year retrospective study of pediatric admissions with penetrating neck injury was conducted by Abjurama et al. [10] In this study, 31 children (mean age, 9.5 y) were examined. Most of these injuries (84%) were in zone 2. The 3 deaths had major findings on presentation and were characterized to be in extremis. A major physical examination finding was defined as shock, neurologic deficit, pulsatile hematoma, bruit/thrill, absence of pulses, or crepitus. Surgical exploration was conducted in 31% (8 patients), and all yielded negative findings. Use of studies, such as angiography and endoscopy, was limited. Although limited by size, this review emphasizes the importance of critical examination findings and the judicious use of ancillary studies.

Oropharyngeal injury represents a complex array of injury, and most are due to falls in the pediatric population. The generous blood supply to this area usually leads to excellent healing but also can result in copious bleeding from wounds. Laceration of the lip or the tongue is usually treated with primary repair with nonabsorbable sutures for the tongue and absorbable sutures for the lip. For optimal cosmesis, close attention should be given to approximation of the vermillion border of the lip. Recommendations vary for repair of a tongue laceration, but deformity from a significant, deep laceration should be prevented. Superficial facial laceration is treated with absorbable fine sutures and should be removed in 5-7 days to minimize scarring.

Treatment of dentoalveolar injuries is beyond the scope of this article and should be referred to a dentist.

Suspected injury to the parotid region should be evaluated with close attention to facial nerve function and ductal laceration. General wound care principles with irrigation and removal of foreign debris will suffice for most wounds in this region.

Ocular Trauma

Half of pediatric eye injuries occur during sporting events. Significant morbidity may result from pediatric eye trauma because of the continued development of the visual system up to age 9 years. (Similarly, the full adult complement of pulmonary alveoli is not present until about age 7 years.) If a rupture of the globe is suspected, the examination should cease; the eye should be covered with a protective device, and urgent ophthalmologic consultation is indicated.

In evaluation of a foreign body, topical anesthetic may be useful for a complete examination. The lid should be everted with a cotton swab for a thorough evaluation. Examination should include an assessment of visual acuity and extraocular motion. Eyelid lacerations deserve careful evaluation for lacrimal duct involvement. Orbital floor fractures may result in entrapment of extraocular muscles with complaints of diplopia. Corneal abrasions are assessed with fluorescein dye. Abnormal red reflex or leukocoria may indicate trauma to the lens.

Thoracic Injuries

Thoracic injury is the second leading cause of death in pediatric trauma. Thoracic injury occurs in about 5% of children hospitalized for trauma. Blunt trauma, particularly from MVAs, is responsible for most thoracic injuries. Not surprisingly, isolated thoracic injuries seen commonly in adults are relatively uncommon in children. The pediatric thorax has a greater cartilage content and incomplete ossification of the ribs. Due to the pliability of the pediatric rib cage and mediastinal mobility, significant intrathoracic injury may exist in the absence of external signs of trauma. Pulmonary contusion and pneumothorax are frequently present without rib fractures. Pulmonary contusion, pneumothorax, and rib fractures are the most common injuries. Hemothorax and pneumothorax are the most common thoracic injuries from penetrating trauma.

Chest exploration is indicated for an immediate return of 20% of the patient's estimated blood volume or a continued output of 2 mL/kg/h. Intercostal artery bleeding is commonly found in this setting. Helical chest CT scan can identify these injuries and may identify unsuspected injuries in up to 15% of children with normal chest x-ray film results. Physical examination of the traumatized pediatric thorax is notoriously unreliable and requires careful assessment.

Unfortunately, because of the variety of criteria used to diagnose pulmonary contusion and concomitant aspiration of gastric content in pediatric trauma, any radiographic evidence of pulmonary parenchymal injury must be treated aggressively to ensure adequate oxygenation and ventilation. Assessment of adequate ventilation can be determined with arterial blood gas (ABG) analysis and pulse oximetry. Approximately 90% of blunt pediatric thoracic injuries can be managed conservatively or with tube thoracostomy. Severe pulmonary injury may require mechanical ventilation. Epidural catheter may be useful to provide adequate analgesia while avoiding excessive sedation.

Over half of rib fractures in children younger than 3 years may be due to child abuse. Pain control and aggressive pulmonary toilet are the mainstays of treatment of rib fractures. Fixation of flail segments is rarely required. With pulmonary contusion, progressive inflammation may lead to edema, atelectasis, and consolidation. Hypoxemia, hypercarbia, and tachypnea may result. Radiographic findings are variable in appearance and time course. The initial chest x-ray film result is abnormal in up to 70% of patients, but a normal chest x-ray film result does not exclude the diagnosis. Most respond to supportive treatment and heal in 7-10 days.

Parenchymal cavitation from blunt trauma may cause pneumatocele. They may become infected or expand requiring surgical intervention, while most resolve slowly. Pulmonary laceration can be a source of persistent bleeding and air leak. Tube thoracostomy allows small lacerations to seal spontaneously, while larger lacerations require surgical treatment. Tracheobronchial injury usually occurs near the carina and is thought to stem from anterior-posterior compression of the pliable pediatric chest. Multiple findings may be present including pneumothorax, hemothorax, pneumomediastinum, subcutaneous emphysema, and hemorrhage. Persistent air leak is common. If the injury involves less than one third of the diameter of the bronchus, nonoperative therapy may be suitable; otherwise, most require open repair.

Great vessel injury is rare. The diagnosis is suggested by a finding of widened mediastinum on plain film. Most thoracic aortic injury occurs via blunt mechanism (eg, MVA, pedestrian, falls), in older children (mean age, 12 y), and at the ligamentum arteriosum (77-90%). This injury is highly morbid and requires rapid diagnosis and treatment. Preoperative blunt aortic injury management should include aggressive blood pressure control with beta blockade. Blunt cardiac injury is rare in children. Traumatic cardiac rupture is uniformly fatal. Traumatic cardiac contusion may result in arrhythmia, myocardial hypokinesis, and abnormal cardiac serum enzymes. In the adult trauma literature, Mattox has recommended eliminating cardiac contusion from the diagnostic lexicon. Numerous adult studies have yielded poor correlation between diagnostic findings and prognosis in the evaluation of cardiac contusion.

Traumatic diaphragmatic rupture occurs in about 1% of children with blunt chest trauma, with left-sided rupture being more common. Diagnosis is suggested with passage of a nasogastric tube noted to be in the chest on plain film. Laceration to the heart can be repaired with pledgeted 3-0 or 4-0 nonabsorbable monofilament sutures. Respiratory embarrassment from herniation of viscera into the thorax is commonly found. Early diagnosis usually results in repair via abdominal approach. Esophageal perforation from blunt trauma is rare in children. Primary repair is indicated if the perforation is diagnosed early. Evaluation with contrast esophagram and esophagoscopy is recommended.

Traumatic Asphyxia

Traumatic asphyxia is a unique injury in pediatric trauma because of the compliance of the chest wall. This injury is commonly the result of blunt compressing thoracic trauma, with sudden airway obstruction and abrupt retrograde high pressure in the superior vena cava. Patients with traumatic asphyxia have a dramatic physical presentation characterized by cervical and facial petechial hemorrhages or cyanosis associated with vascular engorgement and subconjunctival hemorrhage. Despite its dramatic presentation, this injury has a good prognosis. CNS injuries, pulmonary contusions, and intra-abdominal injuries are common associated injuries.

Abdominal Injuries

Anatomical differences in children make them more vulnerable to major abdominal injuries with very minor forces. In children, the abdomen begins at the level of the nipple. Children's small, pliable rib cages and undeveloped abdominal muscles provide little protection of major organs. Solid organs (eg, spleen, liver, kidneys) are vulnerable to injury.

Abdominal Wall Bruising

Bruising of the abdominal wall after a motor vehicle collision is an important finding. This is usually the result of a lap seat belt or a restraint device. A seat belt syndrome has been described as the concurrent findings of abdominal wall bruising, intra-abdominal injury, and vertebral fracture. [11] The sensitivity, specificity, positive predictive value, and negative predictive value for a significant intra-abdominal injury are 73.5%, 98.8%, 11.5%, and 99.9%, respectively. About 9 children with abdominal wall bruising need to be evaluated to diagnose one significant intra-abdominal injury (NNT=9).

The finding of fluid in the abdomen on CT scan without associated solid organ injury should raise suspicion for bowel injury. The most common intra-abdominal injury associated with abdominal wall bruising is a hollow viscus. In the setting of abdominal wall bruising and unexplained fluid in the abdomen, serial abdominal examination and further investigation are indicated.

Vertebral fracture is also highly associated with abdominal wall bruising and may be present in up to 50% of patients.

Stomach Injuries

The great majority of abdominal injuries are secondary to blunt trauma, and blunt injuries to the stomach occur more frequently in children than in adults. The injury is usually a blowout or perforation of the greater curvature. Children who are struck by a vehicle or who fall across bicycle handlebars shortly after eating a meal are at greater risk. Consider injury to the stomach if the child has peritoneal signs and/or bloody nasogastric drainage. Abdominal x-ray films may show pneumoperitoneum.

Penetrating Duodenal Injuries

These injuries are relatively uncommon in children compared to adults. Most pediatric duodenal injuries, such as intramural duodenal hematoma, are from blunt trauma and are often associated with child abuse. The diagnosis of intramural duodenal hematoma may be suggested by a coiled-spring appearance on contrast imaging. Other culprits include falls or mishaps with bicycles or go-carts.

Small Intestinal Injury

The most common intra-abdominal organs injured in restrained children involved in MVAs are hollow viscus type. Several mechanisms have been proposed for this type of injury. Rapid deceleration may cause the lap belt to compress the intestines against the spine. An increase in intraluminal pressure may lead to rupture or tear. This is the most common mechanism of injury to the pediatric duodenum. Duodenal hematoma may result and cause obstruction. Luminal stricture may present several weeks after blunt intestinal injury as persistent nausea and bilious emesis. Mesenteric hematoma or rent is also possible.

The incidence of intestinal injury in children with blunt trauma is estimated to be 1-15%. In comparison, colon injury from blunt trauma is rare.

As with adults, small intestinal injury in children occurs in the areas of fixation at the Treitz ligament or at the ileocecal valve. The most common site of the intestinal tract to be injured is the jejunum in the area of the Treitz ligament. Such injury occurs in association with lap seat belt use or rapid deceleration. Up to 50% of children with lap seat belt injuries have associated retroperitoneal injuries. Associated injuries, such as flexion-distraction lumbar spine injury, may also occur. Penetrating intestinal injury presents unique diagnostic and therapeutic challenges. If the peritoneum has been violated by such an injury, exploratory laparotomy is generally recommended.

With blunt or penetrating abdominal trauma, a high index of suspicion should be maintained for small intestine injury, because a delay in diagnosis or an unrecognized injury can result in substantial morbidity. Fewer than 50% of children with blunt intestinal perforation have peritonitis on initial examination. Abdominal tenderness is a consistent finding. Pneumoperitoneum or contrast extralumination on imaging study should prompt exploration as well. Close observation and serial examinations should guide unclear findings. In general, surgical treatment of perforation involving greater than 50% of circumference requires resection, whereas less than 50% can be repaired.

Although surgical management has generally been the standard of care for penetrating abdominal injuries, Cigdem et al assessed whether selective nonoperative management of such injuries is feasible in children. [12] Of 90 children (74 boys, 14 girls) with penetrating abdominal trauma (stab wounds, n = 60 [67%]; gun shot wounds, n = 30 [33%]), those with hemodynamic instability or signs of bowel perforation underwent immediate laparotomy (n = 39). The remaining children (n =51) were followed with serial clinical examinations, radiologic evaluation, and hemoglobin levels. [12]

The bowel was the most commonly injured organ (51.7%), with omentum/bowel evisceration through the wound in 7 patients, none of whom had organ injury. [12] Of the 39 children who were managed surgically, 6 (15.%) had no significant organ injury found during surgery; of the 51 patients who initially received conservative therapy, 2 children (3.9%) required surgery. The investigators concluded that in the absence of hemodynamic instability or signs of hollow viscus perforation, the majority of abdominal stab wounds and many gunshot wounds in children can initially be managed nonoperatively. [12]

Rectal Injuries

Except for the occasional straddle injury, child abuse or deviant sexual activity causes most isolated rectal injuries in children. Examine rectal injuries while the patient is under anesthesia because tissues are frequently painful. Examination under anesthesia also decreases the psychologic trauma of such an invasive examination. Rectal mucosal or superficial anal injuries usually resolve with conservative treatment, but full-thickness injuries or internal sphincteric injury may require surgical repair. If child abuse is a possibility, contact the appropriate agency.

Solid Organ Injury Management

Nonoperative management is considered the standard of care for most children with blunt solid organ injury who are clinically stable. This approach was pioneered in children and has led to a dramatic change in practice in adult patients regarding management of solid organ injury.

A recent review by Holmes et al sought to identify factors predicting failure of nonoperative management. [13] Data was collected from a 5-year multi-institutional review of 1,818 pediatric patients who sustained splenic, hepatic, pancreatic, or renal trauma. Overall incidence of nonoperative management failure was 5%. The reasons for declaration of failure were shock, peritonitis, persistent hemorrhage, pancreatic injury, hollow viscus injury, and ruptured diaphragm. Overall mortality for this cohort was 0.8%, with those patients in the failure group. Time to failure was 59% by 4 hours and 87% by 24 hours. A significantly increased risk of failure was associated with bicycle-related mechanism of injury, isolated pancreatic injury, and isolated grade 5 injury. Multiple solid organ injuries were associated with a higher risk of failure as well.

The data emphasize the importance of early vigilance in the care of the child with a solid organ injury. Those who will fail nonoperative management will likely do so early, within the first 12 hours. An important finding is that pancreatic injuries do not behave like other injured solid organs and are associated with a higher need for operative intervention. A key distinction between adult and pediatric nonoperative management of solid organ injury is that adults are more prone to late failure (eg, >5 d), whereas 98% of pediatric failure is within 72 hours.

For isolated liver or spleen injury, current recommendations for length of stay and observation are per Stylianos and the American Pediatric Surgical Association (APSA). [14] These recommendations are based on CT grade of injury. For grade 1 injury, no ICU stay, 2 total hospital days, and 3 weeks activity restriction. For grade 2 injury, no ICU stay, 3 total hospital days, and 4 weeks activity restriction. For grade 3 injury, no ICU stay, 4 total hospital days, and 5 weeks activity restriction. For grade 4 injury, 1 day of ICU stay, 5 total hospital days, and 6 weeks of activity restriction. These guidelines have been prospectively evaluated and demonstrate significant reduction in length of stay without adverse sequelae.

Splenic Injuries

Splenic injuries are relatively common in pediatric trauma. Successful conservative management of splenic injury was reported in 1968 by Upadhyaya et al. [15] Because of the risk of overwhelming sepsis following splenectomy (OPSS), the current philosophy is to manage splenic injuries conservatively unless the spleen is hemodynamically compromised. OPSS occurs slightly more frequently after splenectomy in the treatment of hematologic disease compared with the lower incidence after traumatic splenectomy. Age younger than 5 years at the time of splenectomy also increases the risk.

A child's spleen stops bleeding spontaneously; therefore, most patients with splenic injuries respond to nonoperative management. Perform CT scanning, ultrasound, or isotope imaging to define the site and the extent of injury in every child with splenic injury. Conservative treatment can be used, provided the child is in a pediatric intensive care unit for at least 48 hours, with an experienced surgical team who are prepared to intervene if needed, and adequate anesthesia and transfusion services are immediately available. In adults, the presence of a splenic arterial blush is a risk factor for failure of nonoperative management. Contrast blush is rare in children, and according to a small review by Cloutier et al, its presence does not predict nonoperative treatment failure. [16] A role for splenic artery embolization in the management of pediatric splenic injury has yet to be clarified.

Hepatic Injury

Isolated hepatic injury, without disruption of the portal vein, hepatic vein, or suprarenal inferior vena cava, behaves clinically like a splenic injury. Most patients with these injuries respond to nonoperative management. The same criteria for selecting nonoperative or operative treatment for patients with splenic injury are now being selectively used for patients with documented hepatic injuries. The success rate for nonoperative management of blunt hepatic injury is about 85-90%. The exception, of course, is for children with a massive hepatic injury or with perihepatic vascular involvement who are not hemodynamically stable and transfusion requirements of greater than 25-40 mL/kg/d.

The definition of the degree of hepatic injury from CT scan evaluation provides important prognostic information regarding the potential for complications, such as hematobilia or delayed rupture, as well as an indication of the expected speed of recovery. Delayed bleeding after liver injury may occur in 1-3%, and mortality from this injury has been reported as high as 18%. Delayed bleeding has been reported from 3 days to 6 weeks after injury. Hemodynamic instability should prompt surgical treatment; however, a role for angiographic embolization may exist.

A comparison of isolated hepatic injury, splenic injury, and combined hepatosplenic injury was performed by Paddock et al. [17] Hepatosplenic injury occurred in 2.9% of children registered in the NPTR database having sustained blunt abdominal injury. Mortality rate for isolated splenic injury was the lowest at 0.7%, followed by isolated hepatic injury at 2.5%, and hepatosplenic injury was the highest at 8.6%. Most deaths (89%) occurred during the first 48 hours after injury. Hemorrhage was the most common cause of death for each group. Clearly, combined hepatosplenic injury portends a higher risk and requires vigilance.

Pancreatic Injury

Blunt trauma causes most pancreatic injuries. A frequently cited mechanism involves falling into bicycle handlebars.

CT scanning is a useful diagnostic modality in evaluating most pancreatic trauma. It is insufficient to evaluate pancreatic ductal injury. Operative exploration may be required to fully evaluate pancreatic injury. Endoscopic retrograde pancreatography (ERP) can reliably evaluate pancreatic duct injury. A few reports have described using this technique to provide definitive treatment of pediatric blunt injury associated pancreatic ductal injury with ERP and stent placement. In most cases, diagnosis of pancreatic injury is suggested by an elevated amylase level. However, the amylase level has been demonstrated to be neither sensitive nor specific in the evaluation of pancreatic trauma. In the setting of major pancreatic ductal injury, the serum amylase level is usually elevated significantly. With severe ductal injury or pancreatic transaction, distal pancreatectomy may be indicated.

Timely diagnosis of major pancreatic injuries and prompt surgical treatment are essential to decrease mortality and morbidity rates in pediatric patients.

Renal Injury

Blunt abdominal trauma involves renal injury in 10-20% of cases. Renal trauma comprises 1.6% of total injuries, and 90% of these injuries are from a blunt mechanism of injury. The pediatric kidney is more susceptible to blunt injury due to the relative lack of perirenal fat and decreased protection from incompletely ossified ribs. Contusion is the most common renal injury encountered in children. Disruption of the ureteropelvic junction from transient axial torsion and parenchymal injury due to preexisting renal abnormalities are the next most common renal injuries. These lesions are commonly associated with direct blows to the back or flank.

The concept of nonoperative management has been expanded to include renal injuries as well. Conservative management is standard for low-grade renal injury (grades I-III). A treatment strategy adopted by some level I trauma centers includes bed rest for 24 hours, serial hematocrit, heart rate monitoring, and frequent physical examinations.

Management of high-grade renal injury is more controversial (grades IV-V). Absolute indications for renal exploration are an expanding or pulsatile renal hematoma. Relative indications include urinary extravasation, nonviable tissue, arterial injury, and the need for complete staging. The presence or absence of hematuria and the amount thereof do not correlate with the severity of renal injury. A recent experience reported by Rogers et al demonstrated successful management of most grade IV injuries with a blunt mechanism. [18] Management consisted of bedrest, catheter drainage, and documentation of the resolution of extravasation or urine leak via CT scan or ultrasound. A trial of ureteral stenting and catheter drainage should be used for urinary extravasation or renal fracture. All grade V injuries required operative management and only 30% achieved long-term renal salvage.

Vascular Injuries

Vascular injuries in children require early diagnosis and aggressive operative management to prevent serious sequelae. An injury to a major artery in a child's extremity can result in ischemia and growth retardation of that limb if not detected in a timely manner.

Most vascular injury is associated with orthopedic injuries, such as supracondylar fracture or long-bone fracture. The presence of hard signs mandates operative exploration and repair. These signs are pulsatile bleeding, expanding hematoma, absent pulses, cold limb, and bruit/thrill. If a vascular injury is thought to be present, objective studies (eg, Doppler studies, arteriography) may be required. The most important differential diagnosis in pediatric vascular trauma is between thrombosis and spasm of the injured vessel. Spasm usually lasts less than 3 hours. When the pulses remain absent longer than 6 hours, thrombosis or transection of the vessel must be excluded. A delay in diagnosing vascular injury could lead to prolonged ischemia, compartment syndrome, and Volkmann contractures, with consequent long-term disability.

Penetrating Injuries

The lethality of penetrating injuries is about 3 times that of blunt injury. Several factors having prognostic value have been identified. An arrival systolic blood pressure of less than 90 mm Hg and an initial core temperature of less than 34°C correlate with mortality of penetrating trauma patients. Specific injuries are discussed in other sections within this article. Impalement injuries are uncommon, and the recommendation is to leave them in place until they can be removed in the operating room because of the potential for hemorrhage. All potential gun shot wounds should be marked with radiopaque clips to allow estimation of trajectory on imaging study. Penetrating injury of the colon has been examined in the adult literature. The current trend is in preference of the primary repair of colon injuries.

Orthopedic Injuries

Approximately 30-45% of children with trauma have multiple injuries and at least 1 skeletal fracture. Careful evaluation of every extremity is essential, and the possibility of deformity or associated fracture must be excluded. Splint fractured limbs effectively to prevent ongoing hemorrhage and to reduce occurrence of fat emboli syndrome. Carefully assess every limb for the presence of distal pulses. Adequate documentation of intact sensation is critical. Pediatric bone is relatively soft and prone to incomplete fracture, such as greenstick type. Inappropriate use of a seat belt in children can also result in associated lumbar spine fractures (Chance fractures) and hollow visceral injuries, primarily of the small bowel. The clinician must be aware of associated injuries when lap seat belts are involved.

Air Bag Injuries

Air bags can save lives and prevent injuries when seat belts and car seats are used correctly. Failure to adhere to safety regulations can result in childhood fatalities. The American Academy of Pediatrics has recommended that children aged 12 years and younger ride in the back seat. Most pediatric injuries are a result of proximity to air bag deployment and unused or improperly used seat belts. A deploying air bag can reach speeds of more than 240 km/h (150 mph), so it is not surprising that internal organ injuries have been reported. In children facing forward, injuries include abrasions and friction burns to the face, neck, chest, inner arms, and upper thighs. As the child moves closer, more severe head and neck injuries can occur, such as basilar skull fractures and/or SCIWORA. The safest place for a child is in the middle of the back seat, either in a safety seat or in a 3-point restraint.

Child Abuse

Child abuse includes physical abuse, sexual abuse, emotional abuse, and child neglect. Child abuse involves children of all ages and crosses all socioeconomic boundaries, although poverty, a young single parent, and substance abuse contribute to the risk factors. Most abused children are younger than 3 years, with one third being younger than 6 months.

Because signs and symptoms of abuse can be subtle, maintain a high level of clinical awareness when evaluating these children. The history and mechanism of alleged trauma must be consistent. Infants and children younger than 2 years are more prone to present with closed-head trauma as a result of SBS. Older children, as they begin to explore their surroundings, are more likely to sustain physical abuse as a form of discipline, so abdominal trauma, skeletal trauma, and cutaneous injuries are more commonly observed. Prepubescent children and adolescents often experience sexual abuse and are less likely to report such assaults. Certain characteristic findings may suggest child abuse. Fundoscopic examination may reveal retinal hemorrhages suggesting SBS. Radiographic skeletal survey may demonstrate multiple fractures in various stages of healing.

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Acute Care

Prehospital Care

Emergency medical technicians (EMTs) must be trained in rapid pediatric cardiorespiratory assessment, prompt establishment of effective ventilation (airway), oxygenation (breathing), and perfusion (circulation), as well as in stabilization and transport of injured or ill children to a tertiary care facility. EMTs are the first medical contact (first responder) that children have following an injury. No objective studies compare the "scoop-and-run" philosophy to the "stay-and-play" philosophy in children, but resuscitation should be tailored to each child and should begin in the field. Dedicate time in the field to securing the airway. Do not extend the time with multiple attempts to establish intravenous access. If direct transport to a designated pediatric trauma facility is not possible because of great distance or a child's instability, take the child to the nearest emergency department for stabilization.

Initial Assessment and Resuscitation

The primary survey or initial phase of resuscitation should address life-threatening injuries that compromise oxygenation and circulation. Make evaluation of the child's ABCs, disability, and exposure the priority of this initial phase. The Broselow Pediatric Emergency Tape is a useful guide to the management of injured children (see the image below). However, a study of pediatric trauma patients presenting to a rural trauma unit in West Virginia suggests the Broselow tape may be an ineffective tool in rural populations. It failed to accurately predict the weight of more than 50% of 2358 pediatric patients. [19]

Considerations in pediatric trauma. For easy place Considerations in pediatric trauma. For easy placement, Broselow Pediatric Emergency Tape should be laminated or encased in rigid plastic.

Airway control is the first priority. Unlike in adults, the cause of childhood cardiac arrest is an initial respiratory arrest. A child's airway is anatomically different from an adult's. A child has a shorter neck, smaller and anterior larynx, floppy epiglottis, short trachea, and large tongue. If oral intubation is indicated, use the jaw-thrust maneuver to improve airway patency. All pediatric trauma patients must be assumed to have cervical spine injury until proven otherwise. Thus, if oral intubation is indicated, in-line cervical spine immobilization must be performed.

Estimate the size of the endotracheal tube by the child's fifth digit or by the formula (age + 16)/4. The subglottic trachea is the narrowest portion of the pediatric airway and provides a "physiologic cuff," so use uncuffed endotracheal tubes in children younger than 8 years in order to minimize tracheal trauma. Use a rapid-sequence intubation technique to facilitate successful intubation. If oral intubation is contraindicated in patients with severe maxillofacial or laryngotracheal trauma, then perform needle cricothyrotomy. Surgical cricothyroidotomy is rarely indicated in infants or small children because of the high association with secondary subglottic stenosis.

Once a patent airway is established, carefully assess the child's breathing. If respiration is inadequate, provide ventilatory assistance. Infants and small children are primarily diaphragmatic breathers; their ribs lack the rigidity and configuration present in adults. As a result, any compromise of diaphragmatic excursion significantly limits the child's ability to ventilate. Direct injury to the diaphragm, disruption and herniation of intra-abdominal contents, or gastric distension (aerophagia) can severely compromise the infant or small child's ability to breathe. The mediastinum of a child is very mobile; therefore, mediastinal structures can shift into the contralateral hemithorax as a result of a simple pneumothorax, hemothorax, or tension pneumothorax. The clinician must recognize these emergencies and intervene as needed.

Recognizing hypovolemic shock in pediatric trauma patients is essential to ensure a positive outcome. Tachycardia is usually the earliest measurable response to hypovolemia. In addition, mental status change, respiratory compromise, absence of peripheral pulses, delayed capillary refill, skin pallor, and hypothermia are all possible early signs of shock that must be immediately recognized. Children are known to have an amazing cardiovascular reserve, so the initial normal vital signs should not impart any sense of security with regard to the status of the child's circulating volume.

Table. Normal Vital Signs (Open Table in a new window)

  Pulse (beats/min) Systolic blood pressure (mm Hg) Respiration (breaths/min)
Newborn 95-145 60-90 30-60
Infant 125-170 75-100 30-60
Toddler 100-160 80-110 24-40
Preschool 70-110 80-110 22-34
School age 70-110 85-120 18-30
Adolescent 55-100 95-120 12-16

Obvious signs of shock, such as hypotension or a decrease in urinary output, may not occur until more than 30% of blood volume has been lost. Make vascular access the next priority once adequate ABCs are established. If possible, place 2 percutaneous intravenous catheters in the upper extremities. If peripheral venous access cannot be obtained after 3 attempts or in less than 90 seconds, establish intraosseous access in children younger than 6 years. A saphenous vein cutdown and cannulation of central veins are other options, but these techniques should be reserved for stable patients and skilled personnel.

Initial fluid resuscitation should consist of warm isotonic crystalloid solution (Ringer lactate or isotonic sodium chloride solution) at a bolus of 20 mL/kg. The goals of the initial resuscitation should be to achieve hemodynamic normality and to restore adequate tissue perfusion as soon as possible. Children with evidence of hemorrhagic shock who fail to response to fluid resuscitation should also receive blood (10 mL/kg) and be evaluated by a pediatric surgeon for possible operative intervention.

Estimation of blood loss and normal blood volume may guide component replacement. In general, younger patients have a higher fraction of their body weight as blood volume. Obese patients tend to have a lower fraction. To estimate blood volume, multiply 70 by the patient's weight in kilograms. For example, a 30-kg child would estimate 2100 mL of blood volume. Estimation of volume required to replace loss multiplies the estimated blood volume by the fractional change in hematocrit. For example, a 30-kg child with a hematocrit of 0.26, whose normal hematocrit is 0.36, would have a fractional change in hematocrit of 0.28 ([0.36-0.26]/0.36) and an estimated blood loss of 588 mL (0.28X2100).

Avoid accidental hypothermia during the initial phase of resuscitation. Hypothermia results in vasoconstriction, low-flow state, acidosis, and consumptive coagulopathy. To prevent hypothermia, use warm intravenous fluids. Once the patient is exposed, cover the patient with a warm blanket. Connective air rewarmers (eg, Bear Hugger) and warmed, humidified ventilation can help maintain core body temperature if hypothermia is detected (< 35°C/95°F). Peritoneal lavage with warm saline may assist with hypothermia refractory to prior measures. Reserve extracorporeal circulatory rewarming for patients with severe hypothermia (< 28°C/82°F) in association with ventricular fibrillation or arrest or with drowning in cold water.

Once the primary survey has been completed, address the issue of pain control. Manage pain on a case-by-case basis. Pain relief can be provided with morphine (0.1 mg/kg) or a combination of fentanyl (1 mcg/kg) and midazolam (0.5-0.1 mg/kg).

Definitive treatment can be accomplished safely once hypoxia, tachycardia, hypotension, and hypothermia have been managed. The secondary survey involves a more detailed systemic evaluation and initiation of diagnostic studies.

Early surgical evaluation is important for high risk patients. The NPTR database was examined by Tepas et al to evaluate the risk of death or disability from a significant injury that required surgical evaluation. [20] Patients (n=87,424) were identified as either not at risk or at risk of death by a GCS score of less than 15; a GCS score, motor component, of less than 5; systolic blood pressure of less than 90 mm Hg; or a discharge Injury Severity Scale (ISS) score of more than 10. Those at risk (n=28,645) had a mortality of 5.9% compared with 0.02% of those not at risk (n=58,779). Those at risk with a surgical diagnosis had mortality of 6.6% compared with 0.9% of those at risk without a surgical diagnosis. Of those at risk with a surgical diagnosis requiring operative procedure, mortality climbed to 12.1% compared with 5.1% of those requiring no operation. Surgical pathology is the major determinant of outcome in pediatric trauma.

The data emphasize the importance of early surgical evaluation of high-risk injured pediatric patients.

Diagnostic Modalities

As with adults, radiographic evaluation of the cervical spine, chest, and pelvis has become an integral part of assessment of injured children. Radiographic evaluation of the pediatric cervical spine can be challenging because of normal anatomical variants and should be performed by experienced personnel.

Clinical diagnosis of cervical spine injuries in children is difficult but diagnostic rates can be improved by knowing the factors associated with the injury. An analysis of cervical spine injury in children after blunt trauma suggests that having one or more of the following factors was 98% (95% CI, 96-99%) sensitive and 26% (95% CI, 23-29%) specific for cervical spine injury: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, diving, and high-risk motor vehicle crash. [21] These are preliminary results that require validation before general implementation. Additionally, the results of this study add little to the NEXUS and Canadian C-spine rules.

Once the initial trauma x-ray films (eg, cervical spine series, anteroposterior chest and pelvis series) have been cleared, perform further imaging studies (eg, CT scans of head, chest, abdomen, pelvis) on a case-by-case basis, depending on the mechanism of injury. Widespread use of CT has increased radiation exposure levels to children, with the thyroid gland at particular risk. [22] Focused examination should be the rule.

Assessment of Blunt Abdominal Trauma in Children

Blunt trauma is responsible for most intra-abdominal injuries. Injuries of solid organs predominate, particularly injuries of the spleen, followed by the liver and kidney. However, the mortality rate for children from severe blunt trauma is higher than the rate from penetrating injuries because of concurrent CNS, chest, and skeletal injuries. Fortunately, nonoperative management has a 90% success rate and has become the standard of care. In children who are hemodynamically stable with possible thoracoabdominal injury, CT scan is the preferred imaging technique.

However, concern regarding the use of CT scan and unnecessary radiation exposure has prompted a reevaluation of this practice. There is currently no level I evidence regarding the exact use of CT scan for the assessment of pediatric blunt abdominal trauma. Several recent trials have emphasized the efficacy of a physical examination, focused abdominal sonography for trauma (FAST) (see below), and the judicious use of laboratory data. In the hemodynamically stable patient with a negative FAST examination and a reassuring physical examination, the decision to order a CT scan must be guided by clinical judgment, as no clear decision rule exists. However, as noted below, a FAST examination can miss major solid organ injury. Inference of the mechanism of injury and clinical suspicion are key factors in this decision.

The most commonly used indications for an abdominal CT scan are abdominal bruising (ie, seat belt sign) and gross hematuria. Establishing a diagnosis of hollow viscus injury with CT scan is extremely challenging. Common findings when a bowel perforation has occurred or is severely contused are thickening of the bowel wall and collection of free fluid. Focal points of free air, mesenteric thickening or stranding, bowel dilatation, and focal hematoma are also suggestive of hollow viscus injury when encountered on an abdominal CT scan. At least 30% of children with hollow viscus injury will have no evidence of such on CT scan, thereby emphasizing the need for clinical vigilance.

Diagnostic peritoneal lavage (DPL) has a limited role in the assessment of intra-abdominal injury. Children are more likely to have solid organ injury without hemoperitoneum; therefore, a CT scan is preferable. DPL is indicated for children with coexisting injuries (eg, head or orthopedic injuries) requiring immediate surgical intervention and with no time for CT scanning.

FAST is slowly gaining acceptance as a reliable method to evaluate patients with trauma, particularly individuals who are hemodynamically unstable. FAST has several advantages over CT scan and DPL. FAST is portable and easy to use, and it can be performed in minutes. It is noninvasive, fairly accurate in identifying fluid in the peritoneal cavity or pericardial sac, and costs less than CT scan. A review of relevant pediatric literature performed by Murphy demonstrated the sensitivity of FAST examination to be 30-87.5% and the specificity to be 42-100%. [23] Adult series have reported a higher sensitivity with FAST examination for hemoperitoneum. As noted in a recent review, a FAST examination can miss significant spleen or liver injury. Up to 40% of low-grade liver and spleen injury and 11% of high-grade liver and spleen injury will be missed based on a negative FAST examination.

A role for laparoscopy, as both diagnostic and potentially therapeutic, has been suggested for the evaluation of blunt and penetrating abdominal injuries in hemodynamically stable patients. Proposed benefits include avoiding morbidity of a negative laparotomy, improved diagnostic accuracy, and shorter ICU and hospital length of stays. With local wound exploration demonstrating penetration of anterior abdominal fascia, a laparoscopic survey may be useful. Indications for laparoscopic evaluation in patients with blunt abdominal trauma include suspicious examination findings, such as abdominal wall contusions, peritonitis, and a declining hematocrit. The child with blunt abdominal trauma and free peritoneal fluid but no radiographic solid organ injury presents the greatest dilemma. Delayed diagnosis of a bowel injury in this setting would be a substantial cause of morbidity.

The role of emergent laparoscopy as a diagnostic and potentially therapeutic modality in pediatric abdominal trauma was assessed by Feliz et al. [24] All trauma admissions over a 5-year period were reviewed, 11.7% had internal organ injury and 1.8% required exploration. Of those explored, 28% had initial laparoscopy. Laparotomy was avoided in 56% of these cases, and 19% had a therapeutic intervention. ICU and hospital length of stay was significantly lower in the laparoscopy group as well.

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Pediatric Trauma Centers

The survival of children who sustain major or life-threatening trauma depends upon good prehospital care, appropriate triage, resuscitation by an experienced trauma team in an emergency center, and effective emergent surgery. Given the great numbers of childhood injuries occurring yearly in the United States, integrated echelons of care are needed that include regional pediatric trauma centers with pediatric commitment and emergency departments that are appropriate for children.

The efficacy of pediatric trauma care delivered in a dedicated pediatric hospital compared with that in an adult trauma center is unclear. It has been demonstrated that pediatric trauma mortality is significantly improved in a pediatric trauma center or in an adult center with pediatric trauma certification, compared with level I or II adult trauma centers. Certification in pediatric trauma and experience in the delivery of trauma care are key factors.

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Prevention

Evaluating outcome measures of an injury prevention program is complex. Significant financial and organizational barriers prevent the widespread application of these programs. An assessment and reporting tool for such activity was developed by Sise. [25] Identification of factors contributing to successful injury prevention programs may help guide public policy and use of resources.

Prevention includes the following:

  • Commitment by individuals to the pediatric trauma population, whether in a children's hospital or a trauma center
  • Public education regarding automobile safety (eg, Mothers Against Drunk Driving [MADD]), firearm safety, and burn prevention
  • Pediatric life-support courses for providers and prehospital contacts
  • Legislation regarding establishment and enforcement of seat belt laws, increased enforcement of drunk driving statutes, firearm registration, establishment of trauma registry
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Summary

Caring for pediatric patients with trauma is a complex and integrated process that requires knowledge of the special considerations of pediatric trauma patients and understanding of the pathophysiology and special requirements of the pediatric population. Providing this care is an exercise in psychomotor skill, surgical judgment, and intellectual reasoning. Approach the treatment of the injured child with a rational and meticulous plan of action that not only leads to expeditious diagnosis and therapeutic intervention but also provides efficient and effective care for the patient.

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