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of deaths. Mortality rates also vary according to the severity of injury.
For instance, closed head injury (CHI) is common, present in a high
percentage of injured children admitted to hospital. Most of CHIs are
due to falls, resulting in 82 % mild CHI, 14 % moderate to severe
CHI and 5 % overall mortality.
Severe CHI reveals a high mortality rate of 30%. It is also important
to be considered that 75-90% of the children who die after trauma,
have a CHI as the primary cause of death.
On the other hand only 38-48% of the adults who die after trauma,
have CHI as the primary cause of death.
Abdominal traumas in childhood cause about 15% of childhood
trauma deaths. The overall mortality rate in adults after abdominal
trauma is about 6.6%, while for children it is 2.4%.
The rate of death from CHI is 10.4% in adults, 2.5% in children. The
rate of mortality for severe CHI is more than 45%.
According to multiple studies conducted in taumatology, the injury
and the death rates for boys are twice higher than for girls.
These alarming rates of deaths in childhood due to trauma are causing
residual disability and economic losses in a high level. Trauma is the
second cause of morbidity in childhood after infection. Over one third
of the multiply injured children have residual abnormalities for a long
period after discharge.
Children sustained severe CHI (GCS < 8), 33 % of them survived with
good recovery. Even in cases of isolated mild CHI or multiple injury
without CHI, there are frequently behavioural disturbances resulting in
dysfunction and or use of special school programmes. The effects of
childhood trauma can be devastating to families, marital discord increases,
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the financial burden is significant and siblings are at risk of developing
behavioural problems. Economic losses are compounded by parents
leaving work temporarily or permanently to care for the child.
I. PREVENTION OF PEDIATRIC INJURY.
STRUCTURE AND PHYSIOLOGY IN CHILDREN.
The prevention of childhood trauma is the first important and practical
step to reduce and minimize the morbidity and mortality of pediatric
injury.
As a general rule children tolerate severe degrees of trauma with some
limitations better than adults could usually do.
Children and especially young children have usually marked microstructural and physiological differences in comparison with adults.
Children have their own developmental and psychosocial vulnerabilities.
Pediatric trauma events are usually predictable and should be amenable
to preventive measures. The prevention includes the education of parents
and children about risks and risk-control measures.
The development of pediatric trauma systems and pediatric intensive
care units leaded to the improvement in childhood mortality by
improving the delivery and effectiveness of trauma care to injured
children. Improved product measures include seat belts and airbags in
cars, window bars in apartments above the second story and fencing
directly around pools and other bodies of water.
There are several important differences between adults and children
which make it essential that providers of pediatric trauma care should
be familiar with children.
The most obvious difference is the smaller size of the child. The
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metabolism and psychology related to the normal development and
growth of a child have an impact on injury response and treatment.
The wide range of sizes in pediatric patients requires that a wide range
of sizes in urinary catheters, endotracheal and nasogastric tubes,
intravenous catheters and devices for immobilization should be
immediately available.
The other side has weight-based drug dosages.
The head of the child is large and heavy in relation to the rest of his
body.
This fact makes it susceptible to trauma, the head of a child is often
the first point of impact, especially in falls, motor vehicle crashes and
recreational injuries.
Mortality data in traumatic brain injury show the highest rate of death
in children less than 2 years of age.
This may be a reflection of injury mechanisms rather than an indicator
of physiological tolerance.
The relatively large weight of the head contributes to the vulnerability
of the pediatric cervical spine to injury as the cervical spine tethers
the head to the body. Additionally, the neck muscles are weak, the
ligaments are lax and the bones are immature in both strength and
architecture.
This contributes to an injury found more commonly in children than
In adults, in which cervical cord injuries are sustained without any
cervical spine fractures. Cervical cord and spine injuries are not
common in children who arrive alive in the emergency department.
The airway of the pediatric patient is significantly different from the
adult airway. The tongue is relatively larger and more likely to
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obstruct the airway of a supine patient by falling backwards into the
oropharynx.
The epiglottis of the pediatric patient is curved and flops posteriorly
into the pharynx, due to softness of the cartilage and to the short
distance between the thyroid cartilage and hyoid bone, resulting in
less soft tissue tension to hold the epiglottis erect. The larynx is
relatively shorter, and lies more anterior and more cephalad than in
adults.
The infant or young child has a very soft and complaint airway which
can be occluded by flexion or extension of the neck. This action must
be avoided during the management of the trauma victim with a
potential cervical spine injury.
Long-term airway complications due to iatrogenic cricoid injury can
be severe and cricothyroidotomy should not be performed in children
less than 8 years of age. The carina is at T4 in adulthood but in the
infant it is only at T2, increasing the risk of mainstem bronchus
intubation.
Finally, the mucosa and submucosal soft tissues below the glottis are
loose and subject to oedema.
The thorax in children is different also in comparison with adults.
The ribs are porous like other bones of the child and relatively
compliant, with a large cartilaginous component. Because of these
facts children have marked flexibility of the pediatric rib cage. As a
result of that, rib fractures in children are less frequent than in adults.
Pulmonary or cardiac contusions can occur without rib fractures and
must therefore be suspected in any child with chest wall contusions or
abrasions or with a significant mechanism of injury e.g. a road traffic
accident or a pedestrian struck by a motor vehicle.
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Although severe chest injuries are not common in children, they
contribute significantly to the mortality rate in injured children with
thoracic component. Chest injury also increases the mortality rate for
pediatric patients with head injury. Children with thoracic trauma are
much more likely to have multisystem injuries, which increase the
mortality rate.
Thoracic trauma is the only area where pediatric mortality is probably
greater than adult mortality, due to the facts that the soft tissues absorb
the force and multisystem injury is common.
The heart in a child makes up a greater percentage of the anterior
chest contents than in adults.
The lungs are smaller and immature. The alveoli continue to develop
in form and number until the age of 8 years. This means that a young
child has less pulmonary reserve than an old child or young adult.
The mediastinum of the child is more mobile than in an adult.
Therefore pneumothorax in relatively less common in children. The
abdominal organs of the child are anatomically and structurally at
increased risk of injury. The upper abdominal viscera and kidneys are
less covered by the rib case and therefore they are vulnerable.
The liver and the spleen are larger in size in relation to the size of
the child and therefore at additional risk to trauma.
The kidneys are also larger than in adults. The liver is the most
commonly injured intra-abdominal organ followed by the spleen and
the kidneys.
The abdominal wall of the child is thinner with less subcutaneous
tissue and less well developed musculature, affording less protection
to abdominal organs.
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Intra-abdominal injury has been found in about 6% of all children
admitted due to blunt trauma and in 33% of seriously injured children.
The mortality rate in children with abdominal injury is at 14%. The
bones of the child have a porous cortex, a high cartilage content
including growth plates and a thicker periosteum.
This physiological and growing condition makes the bones of
children relatively soft and compliant and therefore both weaker and
resilient than mature bones.
Additionally the ligaments in children are stronger than the bones.
This means that children are prone to fractures at the growth plates
and that joint dislocations are rare without concomitant fractures.
Children are also prone to greenstick and buckle fractures, which are
unusual in adults.
The brain, heart and kidneys of the child have commonly marked
clear physiological differences in comparison to adults.
The pediatric brain has the advantages of the plasticity of the very
young nervous system with its ability to learn and the ability of uninjured
neural tissue to assume some of the roles of dead or injured cells.
This plasticity diminishes with increasing age.
The pediatric brain is more tolerant of injury than the adult brain. This
is especially true in children less than 10 years old, approximately 50 %
of them show good functional recoveries after severe head trauma.
The mortality after head trauma in children between 2 and 15 years of
age is markedly less than it is in adults.
The infant heart has less ventricular compliance and relative inability
to alter stroke volumes in response to hypovolaemia. The young infant
has poor ability to conduct peripheral vasoconstriction in response to
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volume looses, because of the relatively immature sympathetic
innervation.
The older child has tremendous physiological reserve and can
compensate for hypoxia by increasing cardiac output with an increase
in stroke volume and only a slight increase in heart rate, or for
hypovolaemia with intense vasoconstriction and slight to moderate
increase in heart rate.
Because of this physiological reserve, vital signs of injured children
do not show evidence of haemodynamic decompensation until
dangerously late in the course of their deterioration.
There is a high correlation with increased intracranial pressure (ICP)
in children who die because of severe head injuries. This indicates that
proper and accurate measures to control ICP by decreasing the volume
of intracranial contents are very important. Hypotension and prolonged
resuscitation have been shown to have a very bad influence on head
injury outcome.
Therefore the child must have good mean arterial pressure and
oxygenation to maintain adequate perfusion and prevent cerebral
hypoxia.
A good maintained blood pressure helps to decrease cerebral blood
volume by vasoconstriction.
Brain volume could be reduced by minimizing oedema.
Large haematomas need to be promptly evacuated surgically.
The developmental and psychosocial vulnerabilities of the children
have an impact on the behavioral condition and reaction on both the
type of trauma sustained and the optimum approach to care in the
emergency centre.
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A child below one year of age is completely dependent. This child is
receiver of trauma by abuse or neglect. In the emergency centre this
child needs comforting, soothing and pain control.
Children between 1 and 3 years of age are learning to distinguish self
from others.
Above 3 years of age children have good receptive language ability
and can benefit from verbal reassurance and explanations. Frequent
reassurances as well as explanations of needed medical examinations
could be used in alleviating some of the child s anxiety.
Pain control is very important when dealing with pediatric injury. The
school age child has usually reasonable motor competence and has
become aware of his vulnerability. They are commonly pedestrian or
bicycling victims who are struck by motor vehicles after school.
These children are relatively mature and can do well with explanations
of injury, disease and treatment needed.
II. MANAGEMENT OF PEDIATRIC TRAUMA.
The management of pediatric trauma patient consists of the same
priorities as for adults but most incorporate the special physical and
psychological needs and vulnerabilities of children and their carers.
Traumas remain by far the biggest contributor to pediatric morbidity
and mortality.
Although modern treatment has improved the survival and brought
significantly better responses, the biggest impact on reducing these
numbers will be from improvements in preventing pediatric traumas.
Children with minor traumas can be managed properly in the emergency
department and discharged with appropriate follow up instructions.
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The management of children with major traumas is more complex
and requires the active involvement of prehospital and hospital teams
including an adequate transport and enough and sufficient facilities
offering an immediate and appropriate response.
Control of airway, breathing and bleeding followed by resuscitation
and treatment or triage are the priorities in the emergency department.
III. MANGEMENT OF MINOR TRAUMAS.
The majority of the children presented to the emergency department
have minor injuries, e.g. contusions, lacerations, or an isolated extremity
fracture. These injuries are the results of low energy events such as
blows, short falls, or misuse of a sharp object.
Careful judgment of congruency between injury and history is required
to detect abuse or neglect. Parents should be well informed about the
expected course of recovery and any further necessary follow up later.
Active bleeding could be always controlled by direct pressure over the
wound with a sterile gauze. Wounds without active bleeding should be
covered with sterile dressings to prevent infections. A thorough proper
examination must be done to assess the injured child and especially
the local areas around the wounds and to evaluate other injuries.
Verbal interactions and reassurances and also eye contacts are quite
helpful and needed when dealing with injured children. In many cases
an explanation of procedures and examinations is in order prior to
performance. Local anesthesia is used in wounds and lacerations.
Abrasions should be thoroughly scrubbed to prevent tattooing from
embedded particles, and treated like burns.
Contusions and sprains can be treated with elevation and retention.
Tetanus prophylaxis must be performed when indicated.
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IV. MANGEMENT OF SERIOUS TRAUMAS.
The management of a seriously injured child is within the same usual
principles and guidelines as for adults. The majority of injuries to
children are due to blunt traumas. The treating team must consider the
structural and metabolic and psychological differences of children and
their developmental stages. The treatment of the injured child as a
whole must be considered. Obviously and life-threatening injuries e.g.
limb- or organ injuries have first priority.
Verbal and eye contacts with the child and also reassurances are very
important to inform the injured child and prepare him for useful
cooperation.
The trauma team must continuously reassess the injured to conduct
the management in a correct and proper way.
The child should be covered well with a warm blanket,
All resuscitation fluids and inspired gases must be controlled.
The majority of injuries to children are blunt traumas and this means
that the energy is dissipated over a broad area, not confined to a
missile track or stab wound. Multiple system injuries and injury
complexes must anticipated.
The management starts with the initial assessment as a continuous
process of closed accurate control and treatment according to the
trauma treatment protocol that adapted from the guidelines of the
Advanced Trauma Life Support (ATLS).
V. TRAUMA TREATMENT PROTOCOL:
A. Primary survey.
1. Airway and cervical spine control.
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