Peds0813 Motor Vehicle Trauma

Diagnosis And Management
Of Motor Vehicle Trauma In

Children: An Evidence-Based
Review
Abstract
Director, Central New York

Poison Control Center, Golisano
Adam E. Vella, MD, FAAP
Children's Hospital, Syracuse, NY
Associate Professor of Emergency
Medicine, Pediatrics, and Medical Ilene Claudius, MD
Associate Professor of Emergency
Education, Director Of Pediatric
Medicine, Keck School of Medicine
Emergency Medicine, Icahn
of the University of Southern
School of Medicine at Mount Sinai,
California, Los Angeles, CA
New York, NY
Cohen, MD
Associate Editor-in-Chief Ari
Chief of Pediatric Emergency
Vincent J. Wang, MD, MHA
Medicine Services, Massachusetts
Associate Professor of Pediatrics,
General Hospital; Instructor in
Keck School of Medicine of the
Pediatrics, Harvard Medical
University of Southern California;
School, Boston, MA
Associate Division Head,
T. Kent Denmark, MD, FAAP,
Division of Emergency Medicine,
FACEP
Children's Hospital Los Angeles,
Medical Director, Medical
Los Angeles, CA
Simulation Center, Professor,
Emergency Medicine, Pediatrics,
AAP Sponsor
and Basic Science, Loma Linda
Martin I. Herman, MD, FAAP, FACEP
University School of Medicine,
Professor of Pediatrics, Attending
Loma Linda, CA
Physician, Emergency Medicine
Marianne Gausche-Hill, MD,
Department, Sacred Heart
Childrens Hospital, Pensacola, FL FACEP, FAAP
Professor of Clinical Medicine,
Editorial Board
David Geffen School of Medicine
at the University of California at
Jeffrey R. Avner, MD, FAAP
Los Angeles; Vice Chair and Chief,
Professor of Clinical Pediatrics
Division of Pediatric Emergency
and Chief of Pediatric Emergency
Medicine, Harbor-UCLA Medical
Medicine, Albert Einstein College
Center, Los Angeles, CA
of Medicine, Childrens Hospital at
Montefiore, Bronx, NY
Richard M. Cantor, MD, FAAP,
FACEP
Professor of Emergency Medicine
and Pediatrics, Director, Pediatric
Emergency Department, Medical
Volume 10, Number 8

Authors
Saranya Srinivasan, MD
Fellow in Pediatric Emergency Medicine, Division of Emergency
Medicine and Transport, Childrens Hospital Los Angeles, Los
Angeles, CA
Todd Chang, MD
Associate Fellowship Director, Pediatric Emergency Medicine,
Childrens Hospital Los Angeles; Assistant Professor of
Pediatrics, University of Southern California, Los Angeles, CA
Peer Reviewers
Injuries from motor vehicle crashes are the leading cause of mortality
in children aged 5 years and older in the United States. This review
discusses common injuries in children after motor vehicle trauma
and examines the evidence regarding the evaluation and treatment
of pediatric patients involved in motor vehicle crashes. Both prehospital and emergency department care are discussed along with a
differential diagnosis of the injuries most commonly seen in motor
vehicle crashes. The various options for imaging modalities are also
discussed in this review. A critical appraisal of the existing guidelines for the management of motor vehicle trauma and for the use of
appropriate child-safety restraints is presented. Emergency clinicians
will be able to use the patients history and physical examination
findings along with knowledge of common injuries to determine the
most appropriate workup and treatment of pediatric patients who
present with motor vehicle trauma.
Editor-in-Chief
August 2013
Goryeb Children's Hospital,

Morristown Medical Center,
Morristown, NJ
Lois Lee, MD, MPH

Attending Physician, Division of Emergency Medicine, Boston
Childrens Hospital, Assistant Professor of Pediatrics, Harvard
Medical School, Boston, MA
Lara Zibners, MD
Honorary Consultant, Paediatric Emergency Medicine, St
Marys Hospital, Imperial College Trust; Emergency Medicine
Representative, Steering Group ATLS-UK, Royal College of
Surgeons, London, England
CME Objectives
Upon completion of this article, you should be able to:
1.
Describe the epidemiology of MVCs in the pediatric
population.
2. Describe common patterns of injury in children after motor
vehicle trauma and the differential diagnosis of these
injuries.
3. Perform an evidence-based diagnostic workup and
choose the most appropriate imaging modalities for a
pediatric patient after motor vehicle trauma.
Prior to beginning this activity, see the back page for faculty
disclosures and CME accreditation information.
Children's Hospitals and Clinics of
Minnesota, Minneapolis, MN
Physician, Connecticut Children's

Medical Center, Hartford, CT
Tommy Y. Kim, MD, FAAP, FACEP

Ran D. Goldman, MD
Assistant Professor of Emergency
Professor, Department of Pediatrics,
Medicine and Pediatrics, Loma
University of British Columbia;
Linda Medical Center and Childrens
Co-Lead, Division of Translational
Hospital, Loma Linda, CA
Therapeutics; Research Director,
Brent R. King, MD, FACEP, FAAP,
Pediatric Emergency Medicine, BC
FAAEM
Children's Hospital, Vancouver, BC, Professor of Emergency Medicine
Canada
and Pediatrics; Chairman,
Mark A. Hostetler, MD, MPH
Department of Emergency
Clinical Professor of Pediatrics
Medicine, The University of
and Emergency Medicine,
Texas Houston Medical School,
University of Arizona Childrens
Houston, TX
Hospital Division of Emergency
Robert Luten, MD
Medicine, Phoenix, AZ
Professor, Pediatrics and
Ghazala Q. Sharieff, MD, FAAP,

FACEP, FAAEM
Clinical Professor, Childrens
Hospital and Health Center/
University of California; Director
of Pediatric Emergency Medicine,
California Emergency Physicians,
San Diego, CA
Gary R. Strange, MD, MA, FACEP
Professor and Head, Department
of Emergency Medicine, University
of Illinois, Chicago, IL
Christopher Strother, MD
Assistant Professor, Director,
Undergraduate and Emergency
Emergency Medicine, University of
Simulation, Mount Sinai School of
Florida, Jacksonville, FL
Medicine, New York, NY
Alson S. Inaba, MD, FAAP

Associate Professor of Pediatrics,
University of Hawaii at Mnoa
Garth Meckler, MD, MSHS
John A. Burns School of Medicine, Associate Professor of Pediatrics,
Division Head of Pediatric
University of British Columbia;
Emergency Medicine, Kapiolani
Division Head, Pediatric
Medical Center for Women and
Emergency Medicine, BC
Children, Honolulu, HI
Children's Hospital, Vancouver,
Madeline Matar Joseph, MD, FAAP,
BC, Canada
FACEP
Joshua Nagler, MD
Professor of Emergency Medicine Assistant Professor of Pediatrics,
and Pediatrics, Chief and Medical
Harvard Medical School;
Director, Pediatric Emergency
Fellowship Director, Division of
Medicine Division, University
Emergency Medicine, Boston
of
Florida
Medical
SchoolMichael J. Gerardi, MD, FAAP,
Children's Hospital, Boston, MA
Jacksonville, Jacksonville, FL
FACEP
Steven Rogers, MD
Associate Professor of Emergency Anupam Kharbanda, MD, MS
Clinical Professor, University of
Medicine, Icahn School of
Research Director, Associate
Connecticut School of Medicine,
Medicine at Mount Sinai; Director,
Fellowship Director, Department
Attending Emergency Medicine
Pediatric Emergency Medicine,
of Pediatric Emergency Medicine,
International Editor
Lara Zibners, MD, FAAP
Honorary Consultant, Paediatric
Emergency Medicine, St Mary's
Hospital, Imperial College Trust;
EM representative, Steering Group
ATLS-UK, Royal College of
Surgeons, London, England
Pharmacology Editor
James Damilini, PharmD, MS,
BCPS
Clinical Pharmacy Specialist,
Emergency Medicine, St.
Joseph's Hospital and Medical
Center, Phoenix, AZ
Case Presentations
You receive a call that an 8-year-old child who was in a
motor vehicle crash will be arriving by air transport in
8 minutes. The child was the unrestrained passenger in
the back seat of a sport utility vehicle that was involved
in a high-speed collision on a busy freeway. The child was
ejected from the vehicle. When EMS arrived on scene, the
child was lying on the side of the road and was moaning
in pain. He was noted to have abrasions on his abdomen
and swelling of his left thigh. En route to the hospital, the
childs heart rate was 115 beats/min, respiratory rate was
24 breaths/min, and blood pressure was 90/42 mm Hg.
While you are waiting in the trauma bay for the patient,
you consider the injuries for which he is at risk and the
interventions, laboratory studies, and radiographic studies he may require.

A 14-year-old girl is brought in by ambulance after a
motor vehicle crash. She was a restrained passenger in the
front seat of a car driven by her mother. When the car in
front of them stopped suddenly, the patients car slammed
into it and was then rear-ended by the car behind theirs.
She was wearing both her lap and shoulder restraints, and
there was no airbag deployment, passenger space intrusion, or damage to the windshield or windows. The girl
denied any head injury or loss of consciousness. The girl
was ambulatory at the scene, but when EMS arrived, she
was placed in a cervical collar, positioned on a backboard,
and brought to the ED. On arrival, she is alert and oriented but is complaining of neck and back pain. She has
no other associated injuries. You wonder whether the patients cervical collar and backboard can be safely removed
and what, if any, radiographic studies you should order.

An ambulance arrives with a 3-year-old girl who
was involved in a pedestrian-versus-automobile accident.
The child was playing in the front yard of her familys
home when the ball she was playing with rolled onto
the driveway. She ran out to grab the ball just as her
father was backing his car out of the driveway; he felt a
thump as he backed over her. He immediately got out
of the car and found his daughter lying on the driveway
underneath the car between the front and rear wheels,
crying. An ambulance was called, and the child was
placed in a cervical collar and positioned on a backboard
and brought to the ED. On arrival, the child is alert and
awake with a Glasgow Coma Scale score of 15. Her head
and neck examination is within normal limits, but she
appears to have some abdominal tenderness and bruising
on the lower portion of her abdomen. As you complete the
remainder of your examination, you consider the injuries
for which this patient is at risk, based on her mechanism
of injury, and decide which imaging studies to order.
Introduction

Motor vehicle crashes (MVCs) are the leading cause
of morbidity and mortality among children in the
United States, and they often present a diagnostic
Pediatric Emergency Medicine Practice 2013 2
challenge for emergency clinicians, given the variety

of injuries that may be sustained. In these situations, the emergency clinician must determine the
most likely injuries and decide upon the appropriate workup for each patient. Given that a variety of
laboratory and radiographic studies can be used to
evaluate these injuries, determining the most appropriate workup for each patient is often a challenge.
This issue of Pediatric Emergency Medicine Practice focuses on the evaluation and management of children
injured in MVCs, using the best available evidence
from the literature.
Critical Appraisal Of The Literature

A PubMed search for articles pertaining to children
aged < 18 years published since 1980 was performed
using the search terms motor vehicle crash, motor
vehicle injury, motor vehicle accident, motor vehicle
trauma, motor vehicle collision, traffic accident, road
traffic accident, traffic injury, automobile accident, automobile injury, pedestrian, pedestrian injury, pedestrianversus-automobile, pedestrian accidents, car accident,
blunt abdominal trauma, head injury, and cervical spinal
injury. More than 2200 articles were identified, and a
total of 166 resources relevant to the topic of motor
vehicle trauma are included in this review. Although
several large prospective studies were included, the
majority of studies are retrospective. No randomized controlled trials were identified. A search of the
Cochrane Database of Systematic Reviews did not
produce any reviews addressing the specific patterns
of injury seen in MVCs or the workup and management of these patients.
Epidemiology And Risk Factors For Injury

In the United States, unintentional injuries are the
leading cause of death among children aged 1 to 19
years, and they accounted for nearly 9000 deaths in
the year 2010 alone.1-3 MVCs (including pedestrian
injuries) account for more than 50% of these deaths,
resulting in 5 deaths per 100,000 children annually.3

Although driver factors, environmental factors,
and seating position all play a role, improper use
of child passenger safety restraints is associated
with the greatest risk of injury.4,5 Automobile seat
belts were first introduced in the United States in
the 1960s, and they have significantly reduced the
incidence and severity of injury from MVCs.6-11
Compared to restrained children, unrestrained
children are at a significantly increased risk for
head injury, thoracic injury, intra-abdominal
injury, fractures, open wounds, spine and spinal
cord injury, and hospitalization.12-14 The relative
risk of head injury is 4.2 for unrestrained children
compared to restrained children.13 Reported rates
of improper restraint use are subject to incomplete
www.ebmedicine.net August 2013
parental disclosure and have the potential for

inaccuracy, but in the 1980s, rates as high as 50%
to 70% were reported.14,15 More recently, there has
been an increase in the use of child-safety restraints;
however, there remains significant variability in
reported rates of usage, from a low of 2% to a high
of 52%.6,16 Younger children (particularly those aged
< 1 y) are more likely to be appropriately restrained
than older children.7 Inappropriate child-safety
restraint use is most common among children
aged 4 to 8 years.17,18 Hispanic and black children
are more likely to be inappropriately restrained or
unrestrained than children of other ethnicities or
races, and they have higher mortality rates.4,19,20

Restrained drivers are associated with a higher
likelihood of child passenger restraint use and, as
a result, a decreased risk of child passenger injury.5
Driver fatality, on the other hand, is associated with
increased child passenger injury severity.8 Concerning mechanisms of injury include ejection from a
motor vehicle and pedestrian-versus-automobile accidents.21-23 Although ejection from a motor vehicle
is rare (0.7% of all MVCs), it is associated with both
a higher fatality rate and increased overall injury severity.22,24,25 Reported fatality rates in motor vehicle
ejection range from 15% (in children) to 27% percent
(in adults).24-26 Up to 88% of patients ejected from a
vehicle were either improperly restrained or unrestrained.22,25,26 When restraints are properly utilized,
they can significantly reduce both injury severity
and mortality.

Pedestrian-versus-automobile accidents (including back-over or driveway injuries) are another
mechanism that can result in significant and serious
injury, particularly in children.21,27 Despite the fact
that they tend to occur at lower vehicular speeds,
pedestrian-versus-automobile accidents have some
of the highest morbidity and mortality rates among
MVCs, accounting for more than 50% of hospitalizations for pediatric trauma.21,27-33 Emergency clinicians must be particularly vigilant when caring for
children with this mechanism of injury, given the
evidence suggesting increased injury severity.
cerebral edema, and concussions. The precise incidence of each of these injury types is unknown, but
all must be considered when evaluating a patient in
the emergency department (ED).

Skull Fracture
MVC patients who have sustained skull fractures
(such as linear skull fractures or depressed skull
fractures) typically present with large scalp hematomas, palpable step-offs, or bony deformities. Basilar
skull fractures, on the other hand, often present with
characteristic physical examination findings such
as Battle sign (the presence of posterior auricular or
mastoid hematomas), hemotympanum or bleeding
from the ear canal, cerebrospinal fluid otorrhea or
rhinorrhea, periorbital ecchymoses ("raccoon eyes"),
or cranial nerve palsies.36-39 However, given that
these are late findings, their absence does not rule
out a basilar skull fracture. Unlike other types of
skull fractures, basilar skull fractures are frequently
associated with intracranial injury even in patients
with a GCS score of 15 and a normal neurologic
examination.36 Although the precise incidence of
basilar skull fractures in pediatric patients involved
in MVCs is unknown, both MVCs and pedestrianversus-automobile accidents are common mechanisms of injury for these types of fractures.37
Intracranial Injury
Intracranial injuries can be divided into 2 primary
categories: (1) focal lesions such as epidural, subdural, or intraparenchymal hematomas, and (2) diffuse
injuries such as cerebral edema or diffuse axonal
injury.40 Physical examination findings concerning
for intracranial hemorrhage include altered level
of consciousness on arrival or any focal neurologic
findings on examination.36,40 Although the prevalence of these injuries is low in a child with a normal
neurologic examination (including a GCS score of 14
or 15), the consequences can be devastating if they
are missed. Diffuse axonal injury is a generalized
intracranial injury that occurs primarily as a result
of acceleration and deceleration forces. Although the
precise incidence of diffuse axonal injury in pediatric
MVCs is unknown, previous studies have estimated
that it occurs in up to 40% of children with severe
traumatic brain injury. With increasing use of magnetic resonance imaging (MRI), these injuries can
now be more accurately diagnosed, whereas they
may have been missed in the past.36,41

Differential Diagnosis
Head Injury
Head trauma is the most common injury in MVCs,

and traumatic brain injury is the leading cause of both
morbidity and mortality.25,29,34,35 Compared to older
children, younger children have large heads relative
to the rest of their bodies, and their skulls are thinner
and not yet fully ossified. These factors increase the
risk of both head injury and traumatic brain injury,
particularly in younger children.25,29 The differential
diagnosis for head injuries in children includes skull
fractures, intracranial hemorrhage (including subdural and epidural hematomas), cerebral contusions,
August 2013 www.ebmedicine.net
Spine And Spinal Cord Injury
Cervical Spine Injury

MVCs are the most common cause of cervical spine
injury in children.42-44 Cervical spine injuries in
children are relatively rare, occurring in < 1% of
children presenting for evaluation after trauma.45-47
Despite their relative rarity, the pediatric anatomy
3
Pediatric Emergency Medicine Practice 2013
predisposes children to injuries of the cervical spine.

Young children have relatively larger heads than
bodies, weaker cervical musculature, increased
ligamentous laxity, and immature vertebral joints
with horizontal articular facets, all factors that result
in greater mobility of the upper cervical spine.52
Consistent with these anatomical features, younger
children are more likely to sustain injuries to the
upper cervical spine, while adults and children aged
> 8 years are more likely to injure the lower cervical
spine.42,47,49-51 In general, injury to the cervical spine
is rare in children aged < 2 years and is most common in children aged 8 years.45,48,50 Certain medical conditions, such as Down syndrome, Klippel-Feil
syndrome, and specific mucopolysaccharidoses, are
associated with an increased risk of cervical spinal
injury in children.52
Thoracolumbar Spine Injury
Pediatric patients involved in MVCs are also at risk
for injuries to the thoracolumbar spine. Although the
incidence of thoracolumbar spinal injuries in children is low, both lumbar compression fractures and
Chance fractures may occur in children and have
been described as part of the seat-belt syndrome
(which also includes abdominal ecchymoses and
intra-abdominal injury).53 Chance fractures, which
are caused by flexion-distraction injuries resulting in
rupture of the posterior spinal ligaments, are transverse fractures of the spinous processes, pedicles,
and vertebral bodies. These fractures occur either
when the lap portion of the seat belt rides up onto
the abdomen or when the lap belt is worn alone.53

Spinal Cord Injury Without Radiographic
Abnormality
Children who are involved in MVCs are also at risk
for spinal cord injury without radiographic abnormality (SCIWORA). SCIWORA refers to spinal cord
injuries that occur in the absence of identifiable bony
or ligamentous injury on adequate plain radiographs or computed tomography (CT) scans. Clinical manifestations of SCIWORA include vital sign
abnormalities, neck pain, back pain, or focal neurologic deficits such as numbness, tingling, sensory
deficits, weakness, or paralysis.54,55 Even transient
deficits or those that resolve completely in the ED
may be indicative of SCIWORA.55 The same anatomic features that predispose children to cervical spine
injury also predispose them to SCIWORA.56 The
majority of cases of SCIWORA occur in the cervical
region and are the result of hyperextension injury,
hyperflexion injury, longitudinal distraction injury,
or spinal cord infarction.56 The true incidence of SCIWORA in children with spinal cord injuries remains
unknown, with rates ranging from 4.5% to 35%
reported.44,47,50,57 Contrary to what is suggested by
the name, the majority of children with SCIWORA
have abnormalities on MRI, sparking debate regarding whether these patients should truly be classified
as having SCIWORA.43,58 Children with clinical
findings concerning for SCIWORA should undergo
imaging with MRI. MRI can also be used to identify
ligamentous injuries in patients with continued pain
or persistent neurologic symptoms.
Abdominal Injury
MVCs and pedestrian-versus-automobile accidents

are the most common causes of blunt abdominal
trauma in children.59-61 As with head injuries, the
pediatric anatomy predisposes children to intra-abdominal injuries secondary to blunt trauma. Young
children, in particular, have poorly developed
abdominal musculature and protuberant abdomens
that provide relatively less protection for their
larger solid intra-abdominal organs. Additionally,
children have less intra-abdominal fat surrounding their organs, and the organs are in a smaller
space, which increases the risk of solid organ injury
as well as multiple organ injury.59 The differential
diagnosis for blunt abdominal trauma in children is
broad but can be classified into 3 major categories:
(1) solid organ injuries, (2) hollow viscus injuries,
and (3) injuries to the abdominal vasculature.
Injuries to the solid organs are most common,
followed by injuries to the hollow viscus.59,60 The
most commonly injured organs in blunt trauma
are the spleen and the liver, followed by the kidneys.63,64,66 In children, the larger size of the liver in
conjunction with a more flexible rib cage results in
an increased risk of hepatic injury.59,61,63
Hepatic Injury
The liver is one of the most commonly injured solid
organs in blunt abdominal trauma, and it is the
greatest source of mortality due to blunt abdominal trauma.64,65 Children with hepatic injuries have
significant potential for hemorrhage because of the
livers dual blood supply and close proximity to the
inferior vena cava.66 Liver injuries that occur in blunt
abdominal trauma include liver hematomas, lacerations, and vascular injuries. These injuries are categorized into grades of severity ranging from I to VI per
guidelines set forth by the American Association for
the Surgery of Trauma.67 (See Figure 1 on page 5.)
Hepatic injuries of grade III or higher are associated
both with increased mortality and an increased need
for interventional radiology or surgical interventions.64,65 Children with hepatic injuries may present with abdominal bruising (as part of the seat-belt
syndrome), abdominal pain, tenderness, abdominal
distension, or pain radiating to the shoulders.64,66
Spleen Injury
Splenic injuries, including lacerations and hematomas, are also commonly seen in blunt abdominal
trauma. The severity of splenic injuries is classified into grades ranging from I to V based on the
American Association for the Surgery of Trauma
guidelines.65,67 (See Figure 1.) As with hepatic injury,
mortality increases with increasing grades of splenic
injury.65 Classic physical examination findings
include diffuse or left upper quadrant abdominal
pain and the presence of the Kehr sign, which is left
shoulder pain caused by irritation of the diaphragm
from free intra-abdominal fluid.64,66

Renal Injury
Renal injury is the third most common solid organ
injury in children after blunt abdominal trauma,
with motor vehicle trauma as the most common
cause of renal injury. Children are more susceptible
to renal trauma than adults because of their weaker
abdominal musculature, more compliant rib cage,
and decreased perirenal fat.68,69 Common renal injuries after blunt trauma include contusions, lacerations, and hematomas, which are graded from I to V
based on severity.65 (See Figure 1.) Increasing grades
of injury severity are associated with increasing mortality.65 Characteristic physical examination findings
in renal trauma overlap with those of hepatic and
splenic injuries and include abdominal tenderness
and hematuria.68-70
to sit across the pelvis, so the lap belt ends up across

their abdomen. Additionally, children have smaller
pelvises that are unable to properly anchor the lap
portion of the seat belt. During a MVC, sudden
deceleration can result in flexion over the lap portion of the seat belt, resulting in the constellation of
symptoms seen in the seat-belt syndrome.53,72

Several studies have demonstrated that the
presence of a seat-belt sign on examination is associated with an increased risk of intra-abdominal
injury.71 In a large-scale 2004 retrospective study,
the seat-belt sign on physical examination was
associated with a 232 times higher odds of intraabdominal injury.74 Similarly, a prospective study
from 2005 compared the relative risk of intraabdominal injury in patients with a seat-belt sign
to those without and found that presence of the
seat-belt sign carried a relative risk of 2.9 for intraabdominal injury and a relative risk of 12.8 for
gastrointestinal injury.75 A more-recent prospective
study of 12,044 children found that the presence
of a seat-belt sign or evidence of abdominal wall
trauma on examination was significantly associated
with intra-abdominal injury requiring intervention.76 Although the presence of a seat-belt sign has
been associated with intra-abdominal injury, the
patients overall clinical picture must be taken into
consideration when determining the risk of intraabdominal injury.
Clinical Implications Of Abdominal Wall Ecchymoses

One particular physical examination finding that increases concern for intra-abdominal injuries (including both solid organ and hollow viscus injuries) is
the presence of a seat-belt sign, which is a term used
to describe a well-defined linear area of abdominal
wall ecchymosis caused by a lap belt worn during a
MVC.71 The seat-belt sign was first described in 1962
as part of the seat-belt syndrome, which is a constellation of findings including vertebral Chance fractures, abdominal wall bruising, and intra-abdominal
injury.71-73 These injuries are caused by improper use
of the lap belt, which is more common in children
aged 4 to 12 years. When worn properly, the lap
belt should be anchored over the pelvis; however,
young children are not tall enough for the lap belt
Thoracic Injury
Although thoracic injuries in children are relatively

rare when compared to head and abdominal injuries, they carry with them a significant risk of mortality. MVCs are the most common cause of blunt
thoracic trauma in children. Children, in particular,
are at increased risk of thoracic injury from pedestrian-versus-automobile accidents because their thorax
is often situated at the height of a car bumper. They
are also at risk for thoracic trauma in MVCs from
improperly fitted restraints.77 The differential diagnosis of thoracic injuries in children can be divided
into 3 major categories: (1) pulmonary pathology, (2)
chest wall injuries, and, rarely, (3) cardiac injury.
Pulmonary Injury
The differential diagnosis for pulmonary injuries
following motor vehicle trauma includes pulmonary contusions, pulmonary lacerations, hemothoraces, pneumothoraces, and disruption of the
tracheobronchial tree. Of these injuries, pulmonary
contusions are the most common.78-81 Pulmonary
contusions are the result of direct high-energy
trauma applied to the lung parenchyma, and they
typically present with hypoxemia, hypoventilation,
and consolidation on chest radiography. Unlike
adults, children have relatively elastic chest walls
and incompletely ossified ribs, so pulmonary
Figure 1. The American Association For The

Surgery of Trauma Injury Scoring Scale
Scan the QR code above with your smartphone or go to:

http://www.aast.org/Library/TraumaTools/InjuryScoringScales.aspx
contusions may occur either with or without the

presence of concurrent rib fractures.77,82-84
Rib Fractures
Though less common in children than in adults
(because of the increased compliance of the pediatric
rib cage), rib fractures still account for the second
most common thoracic injury in pediatric blunt
trauma.78,79 Because of the force required to cause
rib fractures in children, the presence of rib fractures
(in particular, fractures of the first rib) is indicative
of a significant mechanism of injury and has been
associated with the occurrence of hemothoraces.77,85

Pneumothoraces, Hemothoraces, And Other
Thoracic Injury
Following pulmonary contusions and rib fractures,
pneumothoraces and hemothoraces are the most
commonly seen injuries in children with blunt thoracic trauma.78,80 Presenting features of pneumothoraces and hemothoraces include decreased or absent
breath sounds. Hypotension may also be present,
particularly in the setting of a tension pneumothorax
or massive hemothorax. Although the aforementioned injuries are most common, other rare thoracic
injuries that can occur in the setting of blunt thoracic
trauma include disruption of the tracheobronchial
tree, cardiac contusions or rupture, disruption of the
great vessels, flail chest, or rupture of the diaphragm
or esophagus.78,81,83 Cardiac tamponade may also occur, but it is extremely rare and did not occur in any
of the studies reviewed.78-80,83

Because thoracic trauma may be difficult to
diagnose in children, a 2002 study set out to create a
decision rule by which children with thoracic trauma could be identified. The presence of tachypnea,
a GCS score < 15, abnormal findings on thoracic
examination, abnormal chest auscultation findings,
hypotension, or a femur fracture were all predictive
of thoracic injury.79 Although a GCS score of < 15
was found to be predictive of thoracic injury, we do
not recommend thoracic CT scanning of all patients
meeting this criterion. Rather, we recommend that
patients with an abnormal respiratory rate or oxygen
saturation, abnormal findings on cardiac or respiratory examinations, or a high-intensity mechanism of
injury undergo an evaluation for thoracic trauma.
Prehospital Care
Prehospital providers play an essential role in the
management of pediatric trauma and can have a
significant impact on the outcomes of these patients.
The primary goals of the prehospital provider are:
(1) to identify the patients with the most severe injuries and injuries with the potential to result in rapid
decompensation of the patient, and (2) to transport
these patients safely and quickly to the nearest
hospital capable of caring for these injuries. In order

to accomplish this task, the Advanced Trauma Life
Support (ATLS) guidelines set forth by the American College of Surgeons are often utilized for the
evaluation of individual patients.86

When assessing a patient in the field, the first
task that must be completed is an assessment of the
patients airway, breathing, and circulation (ABCs).
Basic maneuvers such as a jaw thrust, placement of
an oral airway, and bag-mask ventilation in patients
with respiratory failure are indicated to assure patency of the airway and adequate ventilation. Airway
maneuvers performed on a trauma patient must be
done with simultaneous protection of the cervical
spine with manual inline stabilization, which should
be performed by a separate provider. In contrast to
adult trauma patients, endotracheal intubation in the
field for pediatric patients does not improve mortality
rates; rather, complications are increased (compared
to bag-mask ventilation or other airway adjuncts,
such as laryngeal mask airways).87-90

Once assessment of the airway and breathing
are complete, the prehospital provider must assess
for adequate circulation and attempt to identify any
uncontrolled sources of hemorrhage. For pediatric
trauma patients without evidence of spontaneous
circulation, cardiopulmonary resuscitation (CPR)
and Pediatric Advanced Life Support (PALS) algorithms should be initiated. If uncontrolled external
hemorrhage is present, direct pressure should be applied to stop the hemorrhage. Although assessment
of airway, breathing, and circulation and stabilization of the spine are all crucial tasks that should be
performed prior to transport, the ultimate goal of
the prehospital provider is to transport the patient
as safely and as quickly as possible to the nearest
hospital capable of caring for the patient. Both the
cervical collar and backboard should remain in place
until the patient is safely transported to an ED or
trauma center. Multiple studies have demonstrated
increased mortality and morbidity with longer
transport times, so every effort should be made to
minimize field and transport time.91-93
Emergency Department Evaluation

Upon arrival to the ED, evaluation of a motor vehicle trauma patient should be done in a systematic
fashion, in accordance with the ATLS guidelines.
The ATLS guidelines can be divided into 2 primary
sections: (1) the primary survey, and (2) the secondary survey; both are discussed in detail as part of the
ATLS course.87 The primary survey can be summarized with the mnemonic ABCDE: Airway, Breathing, Circulation, Disability (neurologic status), and
Exposure. The goal of the primary survey is to assess
each of these components in a sequential manner
and to perform any life-saving interventions prior
this imaging technique is less well studied for hemothoraces.98-100 Performance of the eFAST should
not delay needle decompression if the patient has a
critical presentation.

As with the assessment of circulation in the
field, patients without evidence of spontaneous
circulation should be managed utilizing PALS algorithms, while patients with uncontrolled external
hemorrhage will require temporizing measures such
as application of direct pressure or a tourniquet to
stop the bleeding. Patients with uncontrolled internal hemorrhage who cannot be stabilized may require immediate surgical intervention. A GCS score
should be calculated as part of the assessment of
disability, and the patient should be fully exposed,
with clothing removed to facilitate the secondary
survey. The child should be covered with sheets or
blankets as soon as possible to prevent hypothermia.
This entire process should be performed with a rigid
cervical collar and triple immobilization or with
manual inline immobilization of the cervical spine
while the patient remains on the backboard.
to moving on to the next component. The secondary

survey, which should be performed only after the
primary survey has been completed, is a systematic
head-to-toe examination of the patient, along with a
brief history of how the event occurred.

Primary Survey
As part of the primary survey, the airway, breathing, and circulation should be thoroughly assessed.
The first step in the evaluation of any patient is to
assess the patency of the airway and to secure the
airway as soon as possible, if necessary. As with
patients in the field, basic airway maneuvers (such
as a jaw-thrust maneuver and ventilation with a bag
mask) should always be attempted on patients with
evidence of airway compromise before moving on to
more advanced airway techniques. Patients without
airway compromise should be given supplemental
oxygen. A definitive airway (such as a cuffed endotracheal tube) should be placed as soon as possible
in patients requiring such an intervention while
maintaining inline cervical immobilization. The position of the endotracheal tube should be confirmed
by auscultation of bilateral breath sounds and endtidal carbon dioxide (ETCO2) tracing.

In some trauma patients (such as those with significant facial trauma), endotracheal intubation may
not be possible. In these patients, airway adjuncts
such as intubation with a video laryngoscope or
placement of laryngeal-mask airway may be required as a temporizing measure prior to insertion
of a definitive airway. If none of these maneuvers
are successful, a needle cricothyroidotomy may be
required for oxygenation until a more definitive
airway can be established. A surgical cricothyroidotomy should generally not be performed in children under 10 to 12 years of age because of the risk
of damaging the cricoid cartilage and surrounding
structures and potentially causing further airway
compromise.94,95 In prepubescent children, the tracheal cartilages are very soft and pliable and provide
minimal support to the upper airway. As a result,
the cricoid cartilage is the only circumferential support for the trachea, and it is the primary structure
responsible for maintaining airway patency.95 Additionally, children who undergo surgical cricothyroidotomy are at increased risk for the development
of subglottic stenosis as they grow older.96,97

Once an airway is established, the presence of
equal bilateral breath sounds should be confirmed.
In patients with diminished or absent breath sounds,
the possibility of either a tension pneumothorax or
a massive hemothorax should be considered, and,
if confirmed, needle decompression and/or placement of a chest tube should be performed. Diagnosis
of a pneumothorax can be confirmed with bedside
ultrasound in the form of the extended focused abdominal sonography for trauma (eFAST), although
Secondary Survey
Once the primary survey has been completed and

all life-threatening conditions stabilized, a secondary
survey should be performed and additional history
about the event should be obtained. While there is
little controversy regarding how to manage severely
injured patients requiring urgent operative intervention or patients with only minor injuries, it is often
the patients with intermediate injury severities that
are the most difficult to manage. For these patients,
the secondary survey provides the best opportunity
to assess for more subtlebut still potentially seriousinjuries requiring intervention.
Head And Neck
The secondary survey should begin with an examination of the head and neck, including a thorough
inspection for any lacerations, abrasions, skull
depressions, and contusions. Because the scalp is extremely vascular in nature, direct pressure should be
applied to any large lacerations or open wounds until they can be closed with either staples or sutures.
The pupils should be inspected and the facial bones
palpated. The eyes should be examined for conjunctival hemorrhages, penetrating injury, lens dislocation, and ocular entrapment. Visual acuity should be
checked, and contact lenses should be removed before edema develops. Signs of basilar skull fracture
such as hemotympanum, raccoon eyes, and Battle
sign should be noted, although these are late findings and their absence should not falsely reassure
the emergency clinician. The ear canals, the nasal
passages, and the oropharynx should be thoroughly
inspected. The neck should be palpated (while the
cervical spine remains immobilized) to assess for
7
crepitus, which could be indicative of perforation of

the aerodigestive tract or laryngeal injury and could
lead to airway compromise. Examination of the neck
should also include assessment for signs of vascular
injury such as the presence of hematomas, ecchymoses, bruits, or palpable thrills.
Cardiac And Respiratory Systems
Cardiovascular examination should include an
assessment of vital signs as well as heart sounds.
Muffled heart sounds, distended neck veins, or
precordial bruising may be signs of cardiac tamponade. The respiratory examination should include
an assessment for equal breath sounds in all areas.
Decreased or absent breath sounds should prompt
concern for either a pneumothorax or hemothorax.
Abdominal And Genitourinary Systems
Careful inspection and palpation of the abdomen
should be performed to assess for distension or
tenderness and the presence of bowel sounds. The
presence and pattern of bruising should be noted.
The pelvis should be examined once (preferably by
the managing orthopedist) with gentle palpation
and application of downward-medial pressure to the
pelvic ring and inspection for any overlying ecchymoses. Pressure should not be applied in patients in
shock or in patients with obvious pelvic fractures.34
An external genitourinary examination should be
performed to assess for blood at the urethral meatus
or vaginal opening as this may be indicative of vesicoureteral, pelvic, or intra-abdominal injury. Though
conventional teaching was that a digital rectal examination is required in all trauma patients, it may
not be beneficial in the pediatric population.101,102
Musculoskeletal
Visual inspection, palpation of the extremities, and
range of motion of the joints should be carefully
performed to identify any obvious deformities that
may indicate underlying fractures. The extremities
should be inspected for contusions and evidence of
compartment syndrome. Peripheral pulses should
also be assessed.
Neurologic
Although an initial neurologic assessment is conducted as part of the primary survey, a more thorough neurologic examination should be performed
as part of the secondary survey. The patients mental
status, gross motor function, and sensation should
be assessed. The mnemonic AVPU (Awake, Verbal,
Pain response, Unresponsive) is a quick method to
assess mental status. Each patient should also be logrolled (with inline stabilization of the cervical spine)
so that the back can be thoroughly examined. The
presence of midline spinal tenderness or step-offs
should be noted, as these signs may be indicative of
fractures or spinal cord injury.
Clinical History
As part of the secondary survey, additional history

about the inciting event should be obtained. One
helpful mnemonic for obtaining a fast and focused
history is AMPLE: Allergies, Medications, Past
medical history, Last oral intake, Events or environmental factors leading up to the event.86 Good
communication with prehospital providers is crucial
to obtaining a complete and accurate history. Prehospital providers will often have the most information regarding the circumstances surrounding
the trauma. Information should be obtained on the
mechanism of injury, the circumstances of the MVC,
the use of restraints, the position of the patient, the
condition of the patient on scene, the condition of
other individuals in the vehicle, and the condition
of the vehicle, as these are all factors that may affect
the types of injuries for which the patient is at risk.
Examples of questions that should be asked include
the following:
1. Mechanism of injury: Was this a pedestrianversus-automobile injury or was this a collision
between 2 vehicles? Was the pedestrian on a
bicycle or skateboard, and, if so, was he wearing a helmet? Was the patient ejected from the
vehicle?
2. Specific circumstances of the accident: How
fast was/were the vehicle(s) moving? Where
was the site of impact on the vehicle? Was there
compartment intrusion? Did the airbags deploy?
Was there any damage to the windshield or
windows? Was the car able to be driven away
from the scene?
3. Restraints: Was the child restrained during the
crash? What type of restraint system was used?
Was the restraint system age appropriate for
the child? Was it utilized correctly (ie, forwardfacing or rear-facing child-safety seat)?
4. Passenger position: Where was the child seated
in the car? Was the child in the front seat or rear
seat at the time of impact? Was the child seated
on the side of impact?
5. Condition of the patient: What was the GCS score
of the patient on scene? Was the patient ambulatory on scene? Did the patient have any specific
complaints, including loss of consciousness?
6. Condition of other individuals: What is the
condition of the other passengers in the car?
Were there any fatalities? Did any individuals
require extrication from the vehicle?

While these questions may appear to be quite
detailed, many of these features are associated with
increased injury severity and/or specific patterns of
injury, and the information can be extremely valuable in the evaluation of these patients.
Diagnostic Studies
for intra-abdominal injuries, although the AST and

ALT cutoffs varied from study to study.109-111 A 2013
study by Holmes et al derived a clinical decision
rule to identify children at very low risk for intraabdominal injuries; this particular decision rule did
not employ laboratory studies, although the authors
recommended use of laboratory studies to further
risk stratify patients meeting some, but not all, lowrisk criteria.76

Additionally, recent review articles support obtaining liver function studies when there is a high
clinical suspicion for intra-abdominal injury.61,71
Urinalysis is another laboratory test that may aid
in the diagnosis of intra-abdominal injury, specifically renal injury. Children with 50 red blood
cells/high-powered field, gross hematuria, vertical
deceleration injuries, or physical examination findings concerning for renal injury (such as flank pain
or ecchymoses) should undergo CT of the abdomen
and pelvis (with intravenous contrast) to identify
renal injuries.112,113
One of the challenges in evaluating pediatric patients presenting after motor vehicle trauma is determining the most appropriate laboratory and radiologic workup. Although a variety of laboratory and
radiologic studies exist, it is important to undertake
this workup in a methodical fashion such that all
clinically significant injuries are identified without
unnecessary laboratory or radiographic testing.
Laboratory Studies
Although many pediatric patients undergo laboratory testing on arrival to the ED, a standardized
trauma panel does not exist, and the use of one is
not recommended. Instead, a variety of laboratory
studies are often ordered, depending on the institution where the patient is receiving care. Among
the tests that are frequently ordered are a complete
blood count (CBC), a blood type and crossmatch,
serum aspartate aminotransferase (AST) and serum
alanine aminotransferase (ALT), urinalysis, prothrombin time (PT), and partial thromboplastin
time (PTT).103

Detection Of Occult Hemorrhage
The preferred diagnostic study for the detection of
hemorrhage or other forms of occult injury is serial
hematocrits. Although there is minimal pediatric
literature on the subject, the utility of serial hematocrits has been demonstrated in adult populations. Serial hematocrits are a reliable indicator
for ongoing blood loss and major injury, although
the absence of a hematocrit drop cannot be used
to exclude major injury.104-106 Based on these data
in adults, serial hematocrits may be helpful in the
detection of internal hemorrhage in children. A type
and crossmatch should also be ordered in patients
with hemorrhage in whom a blood transfusion may
be required. Critically hemorrhaging children can always receive O-negative blood products, but proper
crossmatching may minimize overuse of the local
O-negative supply.

Detection Of Intra-Abdominal Injury
Identification of intra-abdominal injury in children
who have sustained blunt abdominal trauma has
remained a challenge for emergency clinicians. Studies have been performed to determine the utility of
specific features of the history and physical examination, along with laboratory studies, as predictors
for intra-abdominal injury. The presence of abdominal tenderness, gross or microscopic hematuria,
abdominal wall bruising, abnormal liver function
studies, pelvic fracture, or a history concerning for
assault or abuse have all been shown to be associated with intra-abdominal injury.61,66,107,108 Prior
studies have demonstrated that elevated AST and
ALT values can be used to identify children at risk
Trauma-Induced Coagulopathy
Trauma-induced coagulopathy is a well-known
phenomenon that occurs in trauma patients, particularly those with traumatic brain injury, and it is often
associated with a poor prognosis.114-117 The preferred
laboratory studies for the identification of traumainduced coagulopathy are coagulation studies such
as PT, PTT, and a platelet count. While the precise
etiology of this coagulopathy is unknown, it is likely
multifactorial in origin and related to tissue hypoxia
and acidosis, consumption of coagulation factors
and platelets, increased fibrinolysis, and dysfunction
of the platelet and coagulation system.114,118-121 In the
pediatric population, reported rates of coagulopathy after traumatic brain injury range from 37.9% to
77%.117,122,123 Risk factors for coagulopathy in children after traumatic brain injury include evidence of
significant multisystem trauma, injury severity score
16, the presence of cerebral edema on CT scan, the
presence of chest and/or abdominal injury, and a
low GCS score.122,123 Based on these data, children
who are suspected to have intracranial injury based
on their mechanism of injury, GCS score on arrival,
or physical examination findings should have a
platelet count and coagulation panel drawn as part
of their initial evaluation.
Radiographic Evaluation
Radiographic studies are frequently utilized in the

evaluation of motor vehicle trauma. Although a variety of modalities may be utilized, plain radiographs,
ultrasound, and CT scanning are the most common.
The modality selected is dependent on the region
that is injured, injury severity, the presenting history,
and the resources available at a given institution.
Imaging Of The Head

CT scanning of the brain is the preferred imaging
modality when there is suspicion for intracranial
injury. Although skull fractures may be visible on
plain radiographs, plain radiographs provide no
information about underlying intracranial injuries.36
When there is a mechanism of injury or a physical
examination finding concerning for head injury,
CT scanning of the head is the diagnostic test of
choice. In order to reduce the use of unnecessary
CT scanning and excessive radiation exposure,
clinical prediction rules have been developed to
aid the emergency clinician in decision making
regarding the use of CT in the evaluation of head
trauma.40,124,125 Findings that have been associated
with intracranial injury include severe mechanism
of injury, abnormal GCS score, loss of consciousness,
persistent vomiting, signs of a basilar skull fracture,
or focal neurologic deficit.40,124,125 The largest derivation study was conducted by Kupperman et al and
the Pediatric Emergency Care Applied Research
Network (PECARN). Published in 2009, it was a prospective cohort study of 42,412 children presenting
to the ED with head trauma.40 The study found that
children aged < 2 years with normal mental status,
loss of consciousness for < 5 seconds (or no loss of
consciousness), nonsevere mechanism of injury, only
frontal scalp hematomas (or no hematoma at all), no
palpable skull fractures, and those acting normally
(per their parents' report) were at extremely low
risk for traumatic brain injuries and did not require
evaluation with a CT scan. In children aged > 2
years, the presence of a normal mental status, no loss
of consciousness, no severe headache, no vomiting,
a nonsevere mechanism of injury, and no signs of
basilar skull fracture on examination were all associated with a very low risk of traumatic brain injuries;
children aged > 2 years meeting all of these criteria
do not routinely require evaluation with a CT scan.40
The clinical prediction rule for children aged < 2
years had a sensitivity of 100% and a specificity of
53.7%, while the sensitivity was 96.8% and the specificity was 59.8% for children aged > 2 years.40 Given
the lethal malignancy risks secondary to exposure to
ionizing radiation from CT scan, a period of observation may be a preferred management strategy to
decrease CT use.126-129
Imaging Of The Cervical Spine
Several studies have been conducted to identify risk
factors associated with cervical spinal injury after
blunt trauma, and 3 primary decision rules have
been created: the PECARN rules, the National Emergency X-Radiography Utilization Study (NEXUS)
low-risk criteria, and the Canadian Cervical Spine
rules.45,130-132 Of these 3 rules, only the PECARN and
NEXUS criteria have been studied in children.45,47
Factors that were associated with cervical spinal
injury in these studies were: the presence of altered
mental status, inability to ambulate, substantial torso

injury, focal neurologic deficits, complaint of neck
pain or torticollis, midline cervical tenderness, or
a high-risk mechanism such as a serious MVC or a
diving accident. (See Tables 1 and 2.)

One area of controversy that remains is the
radiographic evaluation of the pediatric cervical
spine. Two potential imaging modalities exist for
imaging of the cervical spine: plain radiographs and
CT. Although CT is the preferred imaging modality and is the definitive method of diagnosing bony
injuries to the cervical spine, the amount of ionizing
radiation exposure for CT is 30 times higher than
for plain radiographs.46 This is a particular concern
for the pediatric population, given that children are
more sensitive to ionizing radiation than adults and
are at increased risk for malignancies.126-128 Plain
radiographs have a sensitivity of 90% for identifying injuries of the cervical spine and are often the
most appropriate initial study.46,133 A CT of the
cervical spine should be considered in patients with
abnormal physical examination findings, abnormal
radiographs, inadequate cervical spine radiographs,
inconclusive plain radiographs, or normal radiographs with persistent pain.134 If a patient has neurologic symptoms with a normal cervical spine x-ray
and CT, an MRI should be considered for further
evaluation of the spine and spinal cord.

Which children require cervical spine radiographs? Several studies have set out to answer
this question.45,47 The first of these studies, which
evaluated the NEXUS low-risk criteria in pediatric
trauma patients, found that the presence of all criteria was associated with a low risk of cervical spinal
injury.47 (See Table 2.) However, the primary limitation of this study is that very few children aged
< 8 years were included and no children aged < 2
years were included, thus limiting the use of these
criteria to children aged 8 years. A second casecontrol study from 2012 found that the presence
of focal neurologic findings, altered mental status,
neck pain, torticollis, substantial injury to the torso,
history of a diving accident, history of a high-risk
MVC, or history of a condition predisposing to
cervical spine injury significantly increased the risk
of cervical spine injury.46 The presence of 1 or more
of these risk factors had a sensitivity of 98% and a
specificity of 26% for cervical spine injury.45 Unlike
the NEXUS study, this study included more children aged < 8 years and is applicable to children of
all ages, but it has yet to be validated.
Controversies In Management: Clinical Clearance Of
The Pediatric Cervical Spine: Despite the volume
of research that has been conducted on cervical

spinal injuries in children, there remains significant
controversy over whether or not the cervical spine
can be clinically cleared in children, particularly
in young children who are nonverbal. Consensus
guidelines have been created for the evaluation of

cervical spinal injuries in children.135 According
to these consensus guidelines, pediatric patients
can be divided into 2 subgroups: (1) those with
reliable physical examinations (awake, alert, and
cooperative, with a GCS score of 15), and (2) those
with unreliable physical examinations. The protocol
for patients with reliable physical examinations
utilizes a combination of the NEXUS criteria and
the Canadian Cervical Spine rules to clinically
clear the cervical spine.135 In children with reliable
physical examinations in whom the cervical spine
cannot be clinically cleared, further evaluation with
radiographic studies such as plain radiographs, CT
of the cervical spine, or MRI of the cervical spine is
recommended. In children with unreliable physical
examinations (eg, those who are unconscious or
have an altered level of consciousness with a GCS
score < 15), a separate protocol exists and essentially
requires imaging in the form of either radiographs
or a CT scan in order to clear the cervical spine.135

Even with the existence of these algorithms,
significant caution should be used when applying
them to children aged < 2 years. Based on the
evidence available, it is possible to clinically clear
the pediatric cervical spine in children with reliable
physical examinations.
Imaging Of The Abdomen
When evaluating injuries of the abdomen, the primary imaging modalities available are ultrasonography and abdominal CT. The primary ultrasonographic technique used in the assessment of trauma
patients is the FAST examination. The purpose of
the FAST examination is to identify free fluid within
the abdomen; however, it cannot be reliably used
to identify hollow viscus or solid organ injuries.
A 2007 meta-analysis examined the performance
of abdominal ultrasonography for the detection
of intra-abdominal injuries in children and found
a sensitivity between 66% and 80%, depending
on which studies were included.136 A prospective
observational study from 2011 found similar (but
somewhat less promising) results with a sensitivity of only 52% but a specificity of 96%.137 Based on
these data, it can be concluded that while a positive
FAST examination is suggestive of intra-abdominal
injury, a negative FAST examination does not aid
in decision making.137 Two recent review articles
concluded that, because of the variable sensitivity
of the FAST examination, it is most useful when
utilized in select patient populations such as hemodynamically unstable patients in whom a quick
bedside assessment is required.71,138 Hemodynamically unstable patients with a positive FAST examination should be taken to the operating room for
an exploratory laparotomy to identify the source of
free intra-abdominal fluid, although patients with a
negative FAST examination may also require operative intervention. Although FAST examination may
be a helpful adjunct in specific patient populations,
ultimately, the results of a FAST examination should
be interpreted in the context of the patients overall
clinical picture.

CT is the diagnostic modality of choice for the
evaluation of abdominal trauma, although it is much
less sensitive for the identification of hollow viscus
injuries compared to solid organ injuries.71,138,139
Abdominal CT scanning can also be used to identify
both hemorrhage and free fluid within the peritoneum as well as associated bony injury.138 Along with
providing helpful diagnostic information, abdominal CT scans can be used to guide nonoperative
management decisions, length of hospitalization,
and follow-up.71

The primary risk associated with CT scanning,
aside from the additional cost, is the increased
radiation exposure. Several studies have demon-
Table 1. PECARN Predictors Of Cervical

Spine Injury In Children

Altered mental status

Focal neurologic deficit
Complaint of neck pain
Torticollis
Predisposing medical condition
Substantial injury to the torso
Diving accident
High-risk motor vehicle crash
Presence of 1 or more factors is 98% sensitive and 26% specific for

cervical spine injury.
Abbreviation: PECARN, Pediatric Emergency Care Applied Research
Network.
Reprinted from Annals of Emergency Medicine, Volume 58, Issue 2.
Julie C. Leonard, Nathan Kupperman, Cody Olsen, et al. Factors associated with cervical spine injury in children after blunt trauma. Pages
145-155. Copyright 2011, with permission from Elsevier.
Table 2. NEXUS Low-Risk Criteria

Normal level of alertness

No midline cervical tenderness
No focal neurologic deficit
No painful, distracting injury
No intoxication
Patients must meet all 5 criteria to be classified as low risk for cervical
spine injury. This decision rule has a sensitivity of 99% and a specificity of 12.9%.
Abbreviation: NEXUS, National Emergency X-Radiography Utilization
Study.
Reprinted from Annals of Emergency Medicine, Volume 32, Issue 4.
Jerome R. Hoffman, Allan B. Wolfson, Knox Todd, et al. Selective cervical spine radiography in blunt trauma: methodology of the National
Emergency X-Radiography Utilization Study (NEXUS). Pages 461-469.
Copyright 1998, with permission from Elsevier.
11
strated that exposure to ionizing radiation from CT

scans may increase a childs lifetime risk of malignancy.126-128 A recent study by the PECARN network
from 2013 derived a clinical decision rule to identify
children at very low risk for intra-abdominal injuries
in whom an abdominal CT would be unnecessary.
The study found 7 history and physical examination characteristics that were associated with a very
low risk of intra-abdominal injury. (See Table 3.)
Children who met all 7 criteria had a 0.1% risk of
intra-abdominal injury requiring intervention, which
is less than the risk of radiation-induced malignancy
from a single abdominal CT scan. This prediction
rule has a sensitivity of 97% and a specificity of
42.5%.76 Several other clinical prediction rules aimed
at reducing the rate of CT scanning have been derived; however, these studies have yet to be prospectively validated.62,140
Utility Of Plain Radiographs In The

Evaluation Of Motor Vehicle Trauma
Although CT is the preferred imaging modality

for intracranial, intra-abdominal, and cervical
spinal injury, plain radiographs play an important
role in the evaluation of motor vehicle trauma.
Plain radiographs are the preferred imaging
modality for the evaluation of the thorax, pelvis,
spine, and extremities; chest and pelvic radiographs are considered adjuncts to the primary
survey per the ATLS guidelines.86,141 Chest radiography is the preferred initial imaging modality
for the evaluation of pediatric thoracic trauma
and can be used to diagnose a variety of conditions, including pneumothoraces, hemothoraces,
pulmonary contusions, pneumomediastinum,
pneumopericardium, and bony injuries such as
rib fractures.141-144 Although CT scanning of the
thorax may be required to further evaluate these
injuries, chest radiography is the most appropriate
and cost-effective initial screening study and may
Table 3. PECARN Clinical Prediction Rule To

Identify Children At Very Low Risk Of IntraAbdominal Injury79
No evidence of abdominal wall trauma or presence of a
seat-belt sign
GCS score > 13
No abdominal tenderness
No thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds
No vomiting
Patients must meet all 7 criteria to be classified as very low risk (0.1%
risk of intra-abdominal injury requiring intervention).
Abbreviation: PECARN, Pediatric Emergency Care Applied Research
Network.
be a better predictor of clinical outcome than chest

CTs.143 In terms of pelvic imaging, radiographs are
the screening study recommended by the ATLS
guidelines; however, the utility of pelvic radiographs in children with blunt abdominal trauma
has been debated, particularly since the sensitivity
of pelvic radiographs in children is lacking and
pelvic fractures in children are rare.145,146 Pelvic radiographs are most useful in patients with clinical
indicators concerning for a pelvic fracture such as
pelvic contusions and abrasions, pelvic or abdominal pain, or visible deformities on examination.147
Treatment
The first goal of treatment in the ED is to identify
and treat conditions that will lead to rapid deterioration of the patient, such as airway obstruction,
respiratory failure, tension pneumothoraces, massive hemothoraces, cardiac tamponade, or uncontrolled hemorrhage.148 All of these conditions require
emergent procedural interventions (such as endotracheal intubation, needle cricothyroidotomy, needle
decompression, tube thoracostomy, or pericardiocentesis), and they should be identified and initially
managed during the primary survey.148,149

While the primary survey is being performed,
it is crucial that reliable vascular access in the form
of an intravenous line, intraosseous line, or central
venous catheter is obtained for the administration
of intravenous fluids, blood products, and medications. Peripheral intravenous lines and intraosseous
lines are preferred over central venous catheters,
given the time it takes to place a central venous
catheter. In a hemodynamically unstable child, an
intraosseous line should be placed after 2 unsuccessful intravenous attempts. Rapid administration
of intravenous fluid in the form of warmed normal
saline or lactated Ringer's solution should be given
to all patients with evidence of shock after blunt
trauma. A total of 3 crystalloid boluses of 20 mL/
kg each should be given, and the patients response
to the fluids should be assessed after each bolus. In
general, children will require a volume of crystalloid fluid equivalent to 3 times the estimated blood
loss.86 While tachycardia is an early sign of hemorrhage, hypotension may not develop until 30% to
45% of blood volume has been lost. Transfusion of
blood products is indicated for patients who only
transiently improve with crystalloid infusions and
should be considered in pediatric patients requiring a third bolus of crystalloids.86

Once these initial steps in the stabilization of
the patient have been completed, whether or not
the patient requires immediate operative intervention must be determined. In the past, many solid
organ injuries to the liver and spleen were managed
operatively. Today, the standard of care for nearly
all solid organ injuries in children is nonoperative

management; however, exceptions to this management strategy do exist.63,71,150 For example, children
who are hemodynamically unstable after blunt
abdominal trauma, those with signs of peritonitis
on examination, those with penetrating abdominal
injuries, and those with radiographic evidence of
pneumoperitoneum should be taken to the operating room for emergent laparotomy.63,150,150 Although
these guidelines exist, the decision about whether
or not a child requires urgent operative intervention
should be made on a case-by-case basis in consultation with the managing surgeon.
Although these redesigned second-generation airbags have resulted in decreased fatality and injury
rates when compared to first-generation airbags,
they still remain a significant source of injury. The
most recent airbag safety standards require that all
airbags be tested for all sizes of occupants, including
children, and airbag redesign efforts remain ongoing. Until airbags can be redesigned to assure child
safety, the American Academy of Pediatrics strongly
recommends that all children aged < 13 years should
sit in the rear seats of vehicles. When this is not possible, as in the case of vehicles with a single row of
seats (such as pick-up trucks), front airbags should
be deactivated or turned off.7
Disposition
Motor Vehicle Accidents Complicated By

Drowning Or Hypothermia
For patients who do not require emergent operative

intervention, it must be determined whether or not
they should be admitted to the hospital for observation, monitoring of vital signs, and serial physical
examinations and laboratory studies or whether they
can be safely discharged home from the ED. In some
circumstances, this decision is clear. For example,
patients with altered mental status, documented intracranial, intra-abdominal, or significant orthopedic
injuries, hemodynamic compromise, or respiratory
compromise must be admitted to the hospital. However, in a child with normal vital signs and normal
imaging studies without evidence of intracranial and
intra-abdominal injury, discharge home with specific
return precautions may be appropriate.40,151 Despite
this, many trauma centers still admit these patients
for observation and serial abdominal and laboratory
examinations.71 Ultimately, this decision is made on
a case-by-case and a center-by-center basis.
Although most MVCs occur on roads or highways,

in rare cases, MVCs may be complicated by submersion in a body of water. It has been estimated that
submerged motor vehicles are responsible for 400
deaths per year in North America.156,157 There are
minimal data regarding the management of these
patients.156 What is known is that in these circumstances, mortality is often related to drowning rather
than injuries from the MVC itself.157 Additionally,
these patients are at significant risk of accidental hypothermia.158 Resuscitation of these patients requires
rewarming in addition to the usual measures undertaken during resuscitation.158 Cardiopulmonary
resuscitation should be continued in these patients
until rewarming is complete and the core body temperature has been restored to a normal range.
Injury Prevention Strategies
Although the emergency clinicians primary focus

is often on the medical management of patients, it
is equally important to dedicate time to learning
about and teaching injury prevention strategies.
Though there is not a single intervention that can
prevent MVCs from occurring, there are several
strategies that can be used to decrease injury
severity. These include: (1) improving the driving
environment with lighting, guardrails, and crash
barrels to mitigate crash forces; and (2) redesigning
motor vehicles with improved safety features such
that the impact from a vehicle collision is minimized. Legislative strategies include: (1) graduated
drivers licensing laws, (2) elderly driver laws, (3)
strict blood alcohol level laws, (4) primary and
secondary seat belt enforcement laws (with primary enforcement, a driver can be pulled over just
for not wearing a seat belt), and (5) child passenger
safety laws for car seat use by children. Use of an
age-appropriate child-safety restraint has been
consistently proven to decrease injury severity and
fatalities in children.7,8,159
Special Circumstances
Airbag-Related Injuries In Children
Airbag-related injuries in the pediatric population

were first well described in 1995 in a report published by the Centers for Disease Control and Prevention.152 In this report, 8 cases were described in
which children who were in relatively minor MVCs
died of cervical spine and intracranial injuries as a
result of airbag deployment. All 8 of these children
would have survived had it not been for the deployment of the airbags.152 Since the publication of this
report, a myriad of other injuries related to frontal
airbag deployment have been described, including
brain, skull, cervical spine, ocular, and extremity injuries.152-155 New airbag safety standards were enacted in 1998 by the National Highway Transportation
Safety Administration (NHTSA), which resulted in
airbag redesign. The redesigned airbags are no longer inflated by a gas-generating propellant, and the
volume and extent of the airbags has been decreased
(though not necessarily based on passenger weight).
(Continued on page 19)
13
Clinical Pathway For Evaluation Of Head Injury

After Motor Vehicle Trauma In Children Aged < 2 Years
Does the patient have any of the following?
GCS score 14
Altered level of consciousness
Palpable skull fracture
YES
Head CT (Class I)
YES
Observation for several hours versus head CT (Class I)
NO

Nonfrontal scalp hematoma
Loss of consciousness 5 sec
Severe mechanism of injury*
Not acting normally (per parent)
NO
Head CT not recommended (Class I)
*Severe mechanisms of injury include the following: rollover accident, ejection from a motor vehicle, death of another passenger, or pedestrian or bicyclist without helmet struck by motor vehicle.
Abbreviations: CT, computed tomography; GCS, Glasgow Coma Scale.
Adapted and reprinted from The Lancet, Volume 374. Nathan Kupperman, James F. Holmes, Peter S. Dayan, et al. Identification of children at very low
risk of clinically important brain injuries after head trauma: a prospective cohort study. Pages 1160-1170. Copyright 2009, with permission from Elsevier.
Class Of Evidence Definitions

Each action in the clinical pathway section of Pediatric Emergency Medicine Practice receives a score based on the following definitions.
Class I
Always acceptable, safe
Definitely useful
Proven in both efficacy and
effectiveness
Level of Evidence:
One or more large prospective
studies are present (with rare
exceptions)
High-quality meta-analyses
Study results consistently positive and compelling
Class II
Safe, acceptable
Probably useful
Level of Evidence:
Generally higher levels of
evidence
Non-randomized or retrospective studies: historic, cohort, or
case control studies
Less robust randomized controlled trials
Results consistently positive
Class III
May be acceptable
Possibly useful
Considered optional or alternative treatments
Level of Evidence:
Generally lower or intermediate
levels of evidence
Case series, animal studies,
consensus panels
Occasionally positive results
Indeterminate
Continuing area of research
No recommendations until
further research
Level of Evidence:
Evidence not available
Higher studies in progress
Results inconsistent, contradictory
Results not compelling
Significantly modified from: The
Emergency Cardiovascular Care
Committees of the American
Heart Association and repre-
sentatives from the resuscitation

councils of ILCOR: How to Develop Evidence-Based Guidelines
for Emergency Cardiac Care:
Quality of Evidence and Classes
of Recommendations; also:
Anonymous. Guidelines for cardiopulmonary resuscitation and
emergency cardiac care. Emergency Cardiac Care Committee
and Subcommittees, American
Heart Association. Part IX. Ensuring effectiveness of communitywide emergency cardiac care.
JAMA. 1992;268(16):2289-2295.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patients individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2013 EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Medicine.
Clinical Pathway For Evaluation Of Head Injury

After Motor Vehicle Trauma In Children Aged > 2 Years
GCS score 14
Altered level of consciousness
Signs of basilar skull fracture
YES
Head CT (Class I)
YES
Observation for several hours versus head CT (Class I)
NO

Loss of consciousness
Severe mechanism of injury*
History of vomiting
Severe headache
NO
Head CT not recommended (Class I)
*Severe mechanisms of injury include the following: rollover accident, ejection from a motor vehicle, death of another passenger, or pedestrian or bicyclist without helmet struck by motor vehicle.
Abbreviations: CT, computed tomography; GCS, Glasgow Coma Scale.
Adapted and reprinted from The Lancet, Volume 374. Nathan Kupperman, James F. Holmes, Peter S. Dayan, et al. Identification of children at very low
risk of clinically important brain injuries after head trauma: a prospective cohort study. Pages 1160-1170. Copyright 2009, with permission from Elsevier.
See class of evidence definitions on page 14.
15
Clinical Pathway For Evaluation Of The Cervical Spine

In Children With A Reliable Clinical Examination136
Is the patient alert and awake with a
GCS score of 15?
NO
Go to pathway for unreliable clinical

examination (page 17)
NO
MRI of cervical spine (Class II)
NO
CT cervical spine (Class II)
YES
Reliable clinical examination
Clinically clear;
discontinue cervical collar (Class II)
YES
Does the patient meet these criteria?

No focal neurological deficits
Normal level of alertness
No midline cervical spine tenderness
No intoxication
No painful or distracting injuries
Moves head in flexion and extension
without pain
Rotates head 45 without pain
NO
Normal neurological examination?

YES
Cooperative: anteroposterior/lateral/
odontoid x-rays
Uncooperative: anteroposterior/lateral
x-rays
X-rays normal and adequate?

YES
Age > 8 years?

NO
YES
Clinically clear;
discontinue cervical collar
(Class II)
YES
Is repeat examination
normal?
NO
Plan for head CT?
NO
YES
CT head down to C3 to
rule out injuries to upper
cervical spine (Class II)
MRI of cervical spine

(Class II)
Abbreviations: CT, computed tomography; GCS, Glasgow Coma Scale; MRI, magnetic resonance imaging.
Clinical Pathway For Evaluation Of The Cervical Spine

In Children With An Unreliable Clinical Examination136
Is the patient alert and awake with a GCS score of 15?
YES
Go to pathway for reliable clinical examination (page 16) (Class II)
NO
MRI of cervical spine (Class II)
NO
Unreliable clinical examination
Neurological examination normal?

YES
Anteroposterior and lateral cervical spine x-rays

Consider CT of cervical spine
ABNORMAL
Consult spine service

Consider MRI
(Class II)
NORMAL
Reassess level of consciousness in first 24-48 h
LEVEL OF
CONSCIOUSNESS
IMPROVING
If patient alert and cooperative, go to pathway

for reliable clinical examination (page 16)
(Class II)
LEVEL OF CONSCIOUSNESS NOT IMPROVING
Consult spine service

Consider MRI
(Class II)
Abbreviations: CT, computed tomography; GCS, Glasgow Coma Scale; MRI, magnetic resonance imaging.
17
Clinical Pathway For Evaluation Of Pediatric Blunt Abdominal Trauma76
Is the patient hemodynamically unstable

or hypotensive?
YES
NO
Does the patient have either of the

following?
Evidence of abdominal wall trauma/
seat-belt sign
GCS score < 14 with blunt abdominal
trauma
FAST examination (Class III)
To operating room
for exploratory laparotomy
(Class I)
POSITIVE
NEGATIVE
Consider operating room for exploratory laparotomy versus further

workup and treatment of hypotension
Stabilize and treat hypotension
YES
CT abdomen/pelvis (Class II)
NO
Does the patient have

abdominal tenderness?
YES
Check laboratory tests: AST/ALT
NO
AST > 200 U/L
or
ALT > 125 U/L
Does the patient have any of the
following?
Thoracic wall trauma
Abdominal pain
Decreased breath sounds
Emesis
CT abdomen/pelvis (Class II)
YES
NO
AST 200 U/L

or
ALT 125 U/L
Consider admission for

serial examinations (Class II)
Consider checking AST/ALT results

versus admission for serial examinations (Class III)
Discharge home versus observation in

the ED (very low risk for intra-abdominal
injury requiring intervention: 0.1%)
(Class I)
Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; CT, computed tomography; ED, emergency department; FAST, focused
assessment with sonography in trauma.
Please see class of evidence definitions on page 14.
ize their injuries. As such, emergency clinicians must

rely on history and physical examination findings to
guide both workup and treatment. Details regarding
the circumstances of the MVC such as collision speed
and direction, fatalities and injuries among other passengers, and patient restraint use are all factors that
can aid in medical decision-making. Knowledge of
specific patterns of injury associated with particular
mechanisms and characteristic physical examination
findings can further guide evaluation and treatment
of these patients.
(Continued from page 13)

The American Academy of Pediatrics has released a policy statement on child passenger safety
detailing the appropriate child-safety restraint for
each age group.7 (See Table 4.) The height and
weight restrictions for each child-safety restraint
are indicated on the individual manufacturers
label along with an expiration date for the device.
Although the benefits of child-safety restraints are
well established, there remain several barriers to
use. They are often costly, challenging to install,
and require parental education to ensure proper
usage. To help alleviate this problem, national
programs have been created to provide education
regarding appropriate child-safety seat use along
with providing actual car safety seats to families.160-163 These programs have been demonstrated
to both improve knowledge about car safety seats
and to increase rates of compliance; despite this,
child passenger safety remains a significant problem in the United States.164-166 As physicians, we
have the opportunity to counsel families regarding
child passenger safety, even in the ED setting.
Case Conclusions
All 3 children are at risk for specific injury types based on
their presenting histories and complaints. Of the 3 patients,
the 8-year-old and the 3-year-old are at greatest risk for
severe injuries based on their mechanisms of injury: ejection from a motor vehicle and pedestrian-versus-automobile
injury in the form of a driveway injury, respectively.

The 8-year-old was hypotensive and tachycardic on
arrival, with abdominal abrasions and swelling of his left
thigh. These findings are concerning for intra-abdominal
injury along with a left femur fracture. Although the
childs airway was patent, he was moaning incoherently
and his GCS was 8 on arrival, so you made the decision
to intubate him with an endotracheal tube. A chest x-ray
and ETCO2 monitoring confirmed position of the endotracheal tube and breath sounds were equal bilaterally.
An emergent head CT did not demonstrate any intracranial hemorrhage. At this point, the childs hypotension
and tachycardia worsened, and you determined that the
most immediate potential threat to life was compromised
circulation secondary to hemorrhage from an intraabdominal injury. A FAST examination was performed,
which demonstrated significant intra-abdominal free
fluid. An unstable intra-abdominal bleed was suspected,
and he was taken immediately to the operating room for
further management.

The 14-year-old girl was complaining of neck and back
pain after a low-speed MVC. Her GCS score on scene was
15, and she was ambulatory. Based on her mechanism of
injury, she was at risk for injuries to the neck and spine.
Her primary survey was within normal limits. Her secondary survey did not demonstrate any tenderness to palpation
of the thoracic or lumbar spine and no step-offs were noted,
so she was removed from the backboard. Her cervical collar
was left in place. Because her mental status was at baseline,
she was not intoxicated, and she did not have any painful
or distracting injuries on your initial examination, she was
a candidate for clinical clearance of the cervical spine. On
your examination, she had no midline cervical tenderness,
had no focal neurologic deficits, and was able to move her
head in flexion, extension, and lateral rotation without
pain, so you were able to clinically clear her cervical spine.
You gave her a dose of ibuprofen for pain and discharged
her home from the ED with instructions to return for new
or worsening symptoms.
Summary
MVCs are a leading cause of morbidity and mortality
among children in the United States. Because of their
unique anatomic considerations and stature, children
are particularly vulnerable to specific injury types
and patterns when involved in MVCs. Unlike adults,
children have relatively large heads, more pliable
thoracic cavities, larger intra-abdominal solid organs,
and less intra-abdominal fat and musculature, all of
which are factors that increase their risk for injury.
One additional issue that arises when treating very
young children is their diminished ability to local-
Table 4. American Academy of Pediatrics

Child Passenger Safety Recommendations7
Age
Recommended Child Passenger

Restraint
< 2 years
Rear-facing car safety seat until weight

limit is reached
2 years
Forward-facing car safety seat until

weight limit is reached
2 years and heavier

than weight limit for
car safety seat
Belt-positioning booster seat until child

reaches 57 inches in height
Children taller than 57

inches and aged
< 13 years
Lap and shoulder restraint in rear seat
Children taller than 57

inches and aged
13 years
Lap and shoulder restraint
19
Risk Management Pitfalls For Motor Vehicle Trauma In Children

1. There were no rib fractures on chest film, so his
chest must be fine.
Pediatric rib cages are pliable and, as a result,
significant pulmonary injury in the form of
pulmonary contusions or hemothoraces can
occur without overlying rib fractures. Emergency
clinicians should consider pulmonary injuries in
children with tachypnea, hypoxemia, or bruising
of the thorax even in the absence of rib fractures.
6. She was backed over in her driveway at a very

low speed, so her injuries probably arent severe.
Although back-over or driveway injuries occur at
a low vehicular speed, they are associated with
a significantly greater injury severity than other
types of MVCs or pedestrian-versus-automobile
accidents. Emergency clinicians must maintain a
high index of suspicion for occult injuries with this
mechanism of injury.
2. She had a femur fracture on examination, but I

didnt see any other injuries, so I didnt get any
further imaging.
The presence of a femur fracture is often
indicative of a serious mechanism of injury.
Even when an obvious femur fracture is seen, a
full evaluation for other injuries should still be
performed.
7. His FAST examination was negative, so he cant

have a serious intra-abdominal injury.
Although the utility of the FAST examination
has been demonstrated in adults, its utility in the
pediatric population remains unclear, given its low
sensitivity. While a positive FAST examination can
be helpful in decision-making, a negative FAST
examination is of minimal utility and cannot be
used to rule out intra-abdominal injury.
3. The child wasnt hypotensive, so he couldnt

have lost that much blood.
Hypotension is a late finding in children with
significant hemorrhage. Unlike adults, children can
often effectively compensate for hemorrhage until
30% to 45% of the blood volume has been lost.
4. He was wearing a lap and shoulder belt, so his
injuries probably arent severe.
Because of their stature, young children are at
increased risk for injuries from seat belts. Without
a booster seat, the lap belt often rides up onto
the abdomen and the shoulder belt often rides
up onto the neck, increasing the risk for intraabdominal injuries, thoracolumbar spinal injuries,
and injuries to the neck.
5. Shes younger than 2 years of age, so she must
have been in a car seat.
Although the American Academy of Pediatrics
recommends that children aged < 2 years be
restrained in a rear-facing car safety seat, rates of
unrestrained and improperly restrained children
in the United States remain high, putting these
children at increased risk for injury.
8. We removed her cervical collar while we were

intubating her, since there was no risk of her
moving on her own.
In patients who are unconscious or chemically
paralyzed, it is crucial to either leave the cervical
collar in place during intubation or to maintain
inline stabilization of the cervical spine during
intubation. Although the patient is unable to move,
passive movements that occur during intubation
could cause further damage to the spinal cord.
9. His abdominal CT showed a splenic laceration;
he will definitely need a splenectomy.
Although, historically, both splenic and hepatic
lacerations were managed operatively, the current
standard of care for most pediatric solid organ
injuries is nonoperative management. Only
patients who are hemodynamically unstable
require urgent operative intervention.
10. Hes just a child. We cant clinically clear his
cervical spine.
Although it may be challenging to obtain a
reliable physical examination in some children, it
is possible to clinically clear the cervical spine in
many pediatric patients. Particular caution should
be exercised, however, in children aged < 2 years.

The 3-year-old who was brought to the ED after a
pedestrian-versus-automobile accident was complaining of abdominal pain. Her vital signs on arrival to the
ED were stable. You noted that she was maintaining her
airway and had equal breath sounds bilaterally, so you
decided to closely monitor her respiratory status and provide supplemental oxygen but to not intervene further at
that time. Her secondary survey demonstrated abdominal
tenderness and lower abdominal bruising in the setting of

stable vital signs. You obtained an abdominal CT, and it
demonstrated a grade III hepatic laceration. You consulted
pediatric trauma surgery, and she was admitted for nonoperative management.
References
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are
equally robust. The findings of a large, prospective,
randomized, and blinded trial should carry more
weight than a case report.

To help the reader judge the strength of each
reference, pertinent information about the study,
such as the type of study and the number of patients
in the study will be included in bold type following
the references, where available. The most informative references cited in this paper, as determined by
the author, will be noted by an asterisk (*) next to
the number of the reference.
Time- And Cost-Effective

Strategies
1. Use your clinical history and physical examination to guide the workup.
Using the information from your initial
evaluation to guide the workup allows the
workup to remain efficient and focused. Not
every patient will require every diagnostic
study. In most cases, a careful history and
physical examination will determine which tests
will be highest yield.
1.
2. Approach the workup of motor vehicle trauma

in a step-wise fashion.
Although a patient may require laboratory
examinations, an ultrasound, and a CT scan
during the course of his evaluation, not all of
these tests need to be performed simultaneously.
Instead, by proceeding in a logical, stepwise fashion, the number of unnecessary or
redundant studies that are ordered can be
minimized.
2.
3.
4.
3. Choose the simplest study that will provide

the necessary information before moving on to
more complex diagnostics.
Often, a simple study such as a plain radiograph
may provide the necessary diagnostic
information, and a CT scan may not be required.
By starting with the simplest examination,
risks and costs from unnecessary studies can be
minimized.
5.
6.
7.
4. Prioritize the workup.

In the workup of a trauma patient, not every test
carries the same weight. Certain studies may be
more important than others and more likely to
provide useful clinical data; these studies should
be prioritized.
8.
9.
5. Do not be afraid to rely on your clinical judgment.

Not every trauma patient will require a
laboratory or radiographic study during the
course of their evaluation. In some cases, a
thorough history and physical examination are
the only diagnostic tests required.
Web-based Injury Statistics Query and Reporting System

(WISQARS) 2013; http://www.cdc.gov/injury/wisqars.
Accessed June 27, 2013. (Government website statistics)
Ten Leading Causes of Death and Injury Injury Prevention &

Control: Data & Statistics [Website ]. 2010; http://www.cdc.
gov/injury/wisqars/leadingcauses.html. Accessed April 6,
2013. (Government website statistics)
Fatal Injury Reports, National and Regional, 1999 - 2010.
Web-based Injury Statistics Query and Reporting System
2010; http://webappa.cdc.gov/sasweb/ncipc/mortrate10_
us.html. Accessed April 6, 2013. (Government website
statistics)
Angulo-Vazquez V, De Santis JP. Booster seat or seat belt?
Motor vehicle injuries and child restraint laws in preschool and early school-age children. J Spec Pediatr Nurs.
2005;10(4):183-190. (Systematic review)
Olsen CS, Cook LJ, Keenan HT, et al. Driver seat belt use indicates decreased risk for child passengers in a motor vehicle
crash. Accid Anal Prev. 2010;42(2):771-777. (Retrospective
cohort study; 40,708 patients)
Durbin DR, Chen I, Smith R, et al. Effects of seating position
and appropriate restraint use on the risk of injury to children
in motor vehicle crashes. Pediatrics. 2005;115(3):e305-e309.
(Cross-sectional study; 17,980 patients)
Durbin DR, Committee on Injury, Violence, and Poison Prevention. Child passenger safety. Pediatrics. 2011;127(4):788793. (American Academy of Pediatrics Policy Statement)
Winston FK, Kallan MJ, Senserrick TM, et al. Risk factors
for death among older child and teenaged motor vehicle
passengers. Arch Pediatr Adolesc Med. 2008;162(3):253-260.
(Retrospective cohort study; 45,560 patients)
Watson EA, Monteiro MJ. Advise use of rear facing child car
seats for children under 4 years old. BMJ. 2009;338:b1994.
(Systematic review)
10. Nance ML, Lutz N, Arbogast KB, et al. Optimal restraint

reduces the risk of abdominal injury in children involved in
motor vehicle crashes. Ann Surg. 2004;239(1):127-131. (Crosssectional study; 17,132 patients)
11. Ma X, Layde P, Zhu S. Association between child restraint
systems use and injury in motor vehicle crashes. Acad Emerg
21
Med. 2012;19(8):916-923. (Cross-sectional study; 7633 patients)
12. Chan L, Reilly KM, Telfer J. Odds of critical injuries in unrestrained pediatric victims of motor vehicle collision. Pediatr
Emerg Care. 2006;22(9):626-629. (Retrospective review; 336
patients)
(Cross-sectional study; 388 patients)
29. Ivarsson BJ, Crandall JR, Okamoto M. Influence of age-related stature on the frequency of body region injury and overall
injury severity in child pedestrian casualties. Traffic Inj Prev.
2006;7(3):290-298. (Retrospective study; 1590 patients)
13. Barraco RD, Cheng JD, Bromberg WJ, et al. Child passenger
safety: an evidence-based review. J Trauma. 2010;69(6):15881590. (Systematic review)
30. Kong LB, Lekawa M, Navarro RA, et al. Pedestrian-motor

vehicle trauma: an analysis of injury profiles by age. J Am
Coll Surg. 1996;182(1):17-23. (Retrospective study; 273 patients)
15. Agran PF, Dunkle DE, Winn DG. Motor vehicle accident
trauma and restraint usage patterns in children less than
4 years of age. Pediatrics. 1985;76(3):382-386. (Prospective
study; 494 patients)
32. Fenton SJ, Scaife ER, Meyers RL, et al. The prevalence of
driveway back-over injuries in the era of sports utility
vehicles. J Pediatr Surg. 2005;40(12):1964-1968. (Retrospective
14. Agran PF, Castillo DN, Winn DG. Comparison of motor

vehicle occupant injuries in restrained and unrestrained 4- to
14-year-olds. Accid Anal Prev. 1992;24(4):349-355. (Observational study; 649 patients)
16. Berg MD, Cook L, Corneli HM, et al. Effect of seating position and restraint use on injuries to children in motor vehicle
crashes. Pediatrics. 2000;105(4 Pt 1):831-835. (Retrospective
17. Centers for Disease Control and Prevention. Nonfatal injuries and restraint use among child passengers--United States,
2004. MMWR Morb Mortal Wkly Rep. 2006;55(22):624-627.
(Government publication)
18. Durbin DR, Kallan MJ, Winston FK. Trends in booster
seat use among young children in crashes. Pediatrics.
2001;108(6):E109. (Retrospective study; 53,834 patients)
19. Baker SP, Braver ER, Chen LH, et al. Motor vehicle occupant
deaths among Hispanic and black children and teenagers.
Arch Pediatr Adolesc Med. 1998;152(12):1209-1212. (Analysis
of data from National Center for Health Statistics and the
Nationwide Personal Transportation Survey)
20. Vaca F, Anderson CL, Agran P, et al. Child safety seat
knowledge among parents utilizing emergency services in
a level I trauma center in Southern California. Pediatrics.
2002;110(5):e61. (Prospective study; 655 patients)
21. Brainard BJ, Slauterbeck J, Benjamin JB. Fracture patterns

and mechanisms in pedestrian motor-vehicle trauma: the
ipsilateral dyad. J Orthop Trauma. 1992;6(3):279-282. (Retrospective study; 115 patients)
22. Gongora E, Acosta JA, Wang DS, et al. Analysis of motor
vehicle ejection victims admitted to a level I trauma center.
J Trauma. 2001;51(5):854-859. (Retrospective study; 6909
patients)
23. Palanca S, Taylor DM, Bailey M, et al. Mechanisms of motor

vehicle accidents that predict major injury. Emerg Med (Fremantle). 2003;15(5-6):423-428. (Retrospective analysis; 2298
patients)
24. Traffic Safety Facts 2010 Washington D.C. 2010. (Data from
the National Highway Traffic Safety Administration)
25. Scheidler MG, Shultz BL, Schall L, et al. Risk factors and
predictors of mortality in children after ejection from motor
vehicle crashes. J Trauma. 2000;49(5):864-868. (Retrospective
analysis; 2298 patients)
26. McCoy GF, Johnstone RA, Nelson IW, et al. Incidence and
consequences of ejection in motor vehicle accidents. BMJ.
1988;297(6658):1244-1245. (Prospective observational study;
1550 patients)
27. DiMaggio C, Durkin M. Child pedestrian injury in an
urban setting: descriptive epidemiology. Acad Emerg Med.
2002;9(1):54-62. (Retrospective descriptive study; 100,261
patients)
28. Henary BY, Crandall J, Bhalla K, et al. Child and adult

pedestrian impact: the influence of vehicle type on injury
severity. Annu Proc Assoc Adv Automot Med. 2003;47:105-126.
31. Partrick DA, Bensard DD, Moore EE, et al. Driveway

crush injuries in young children: a highly lethal, devastating, and potentially preventable event. J Pediatr Surg.
33. Holland AJ, Liang RW, Singh SJ, et al. Driveway motor
vehicle injuries in children. Med J Aust. 2000;173(4):192-195.
(Retrospective case series; 42 patients)
34. Al-Jazaeri A, Zamakhshary M, Al-Omair A, et al. The role

of seating position in determining the injury pattern among
unrestrained children involved in motor vehicle collisions presenting to a level I trauma center. Ann Saudi Med.
35. Demetriades D, Murray J, Martin M, et al. Pedestrians injured by automobiles: relationship of age to injury type and
severity. J Am Coll Surg. 2004;199(3):382-387. (Retrospective
36. Schunk JE, Schutzman SA. Pediatric head injury. Pediatr Rev.
37. Kadish HA, Schunk JE. Pediatric basilar skull fracture: do

children with normal neurologic findings and no intracranial
injury require hospitalization? Ann Emerg Med. 1995;26(1):3741. (Retrospective study; 239 patients)
38. Tubbs RS, Shoja MM, Loukas M, et al. William Henry Battle
and Battles sign: mastoid ecchymosis as an indicator of basilar skull fracture. J Neurosurg. 2010;112(1):186-188. (Historical review)
39. Watanabe K, Kida W. Images in clinical medicine. Battles
sign. N Engl J Med. 2012;367(12):1135. (Case report)
40.* Kuppermann N, Holmes JF, Dayan PS, et al. Identification

of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet.
2009;374(9696):1160-1170. (Prospective cohort study; 42,412
patients)
41. Tong KA, Ashwal S, Holshouser BA, et al. Diffuse axonal
injury in children: clinical correlation with hemorrhagic
lesions. Ann Neurol. 2004;56(1):36-50. (Cohort study; 40
patients)
42. Patel JC, Tepas JJ 3rd, Mollitt DL, et al. Pediatric cervical spine injuries: defining the disease. J Pediatr Surg.
2001;36(2):373-376. (Retrospective database study; 1098
patients)
43. Gore PA, Chang S, Theodore N. Cervical spine injuries in

children: attention to radiographic differences and stability
compared to those in the adult patient. Semin Pediatr Neurol.
44. Polk-Williams A, Carr BG, Blinman TA, et al. Cervical spine
injury in young children: a National Trauma Data Bank
review. J Pediatr Surg. 2008;43(9):1718-1721. (Retrospective
database study; 95,654 patients)
45.* Leonard JC, Kuppermann N, Olsen C, et al. Factors associated with cervical spine injury in children after blunt trauma.
Ann Emerg Med. 2011;58(2):145-155. (Case-control study; 540
children)
46. Nigrovic LE, Rogers AJ, Adelgais KM, et al. Utility of plain
radiographs in detecting traumatic injuries of the cervical
spine in children. Pediatr Emerg Care. 2012;28(5):426-432.
(Retrospective cohort study; 206 patients)
in infants and children: prompt identification and early

management of serious and life-threatening injuries. Part
II: specific injuries and ED management. Pediatr Emerg Care.
47.* Viccellio P, Simon H, Pressman BD, et al. A prospective

multicenter study of cervical spine injury in children. Pediatrics. 2001;108(2):E20. (Prospective multicenter study; 3065
patients)
65. Tinkoff G, Esposito TJ, Reed J, et al. American Association

for the Surgery of Trauma Organ Injury Scale I: spleen, liver,
and kidney, validation based on the National Trauma Data
Bank. J Am Coll Surg. 2008;207(5):646-655. (Retrospective
study; 54,148 patients)
48. Easter JS, Barkin R, Rosen CL, et al. Cervical spine injuries in
children, part I: mechanism of injury, clinical presentation,
and imaging. J Emerg Med. 2011;41(2):142-150. (Systematic
review)
66. Gaines BA, Ford HR. Abdominal and pelvic trauma in children. Crit Care Med. 2002;30(11 Suppl):S416-423. (Systematic
review)
49. Sun PP, Poffenbarger GJ, Durham S, et al. Spectrum of

occipitoatlantoaxial injury in young children. J Neurosurg.
2000;93(1 Suppl):28-39. (Retrospective study; 71 patients))
67. Moore EE, Shackford SR, Pachter HL, et al. Organ injury
scaling: spleen, liver, and kidney. J Trauma. 1989;29(12):16641666. (American Association for the Surgery of Trauma
Organ Injury Grading Scale)
50. Brown RL, Brunn MA, Garcia VF. Cervical spine injuries
in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center. J Pediatr Surg.
68. Nerli RB, Metgud T, Patil S, et al. Severe renal injuries

in children following blunt abdominal trauma: selective
management and outcome. Pediatr Surg Int. 2011;27(11):12131216. (Retrospective study; 43 patients)
51. Mohseni S, Talving P, Branco BC, et al. Effect of age on cervical spine injury in pediatric population: a National Trauma
Data Bank review. J Pediatr Surg. 2011;46(9):1771-1776. (Retrospective study; 240,647 patients)
69. Raz O, Haifler M, Copel L, et al. Use of adult criteria for

slice imaging may limit unnecessary radiation exposure in
children presenting with hematuria and blunt abdominal
trauma. Urology. 2011;77(1):187-190. (Retrospective study; 46
patients)
52. Herman MJ, Pizzutillo PD. Cervical spine disorders in children. Orthop Clin North Am. 1999;30(3):457-466. (Systematic
review)
70. Wessel LM, Scholz S, Jester I, et al. Management of kidney

injuries in children with blunt abdominal trauma. J Pediatr
Surg. 2000;35(9):1326-1330. (Retrospective study; 308 patients)
53. Durbin DR, Arbogast KB, Moll EK. Seat belt syndrome in
children: a case report and review of the literature. Pediatr
Emerg Care. 2001;17(6):474-477. (Case report and review of
the literature)
71.* Schonfeld D, Lee LK. Blunt abdominal trauma in children.

Curr Opin Pediatr. 2012;24(3):314-318. (Systematic review)
54. Shah LM, Zollinger LV. Congenital craniocervical anomalies pose a vulnerability to spinal cord injury without
radiographic abnormality (SCIWORA). Emerg Radiol.
2011;18(4):353-356. (Case report)
72. Muniz AE, Haynes JH. Delayed abdominal aortic rupture

in a child with a seat-belt sign and review of the literature. J
Trauma. 2004;56(1):194-197. (Case report and review of the
literature)
55. Ergun A, Oder W. Pediatric care report of spinal cord injury

without radiographic abnormality (SCIWORA): case report
and literature review. Spinal Cord. 2003;41(4):249-253. (Case
report and literature review)
73. Paris C, Brindamour M, Ouimet A, et al. Predictive indicators for bowel injury in pediatric patients who present with
a positive seat belt sign after motor vehicle collision. J Pediatr
56. Pang D. Spinal cord injury without radiographic abnormality in children, 2 decades later. Neurosurgery. 2004;55(6):13251342; discussion 1342-1323. (Systematic review)
74.* Lutz N, Nance ML, Kallan MJ, et al. Incidence and clinical significance of abdominal wall bruising in restrained
children involved in motor vehicle crashes. J Pediatr Surg.
2004;39(6):972-975. (Retrospective study; 147,985 patients)
57. Martin BW, Dykes E, Lecky FE. Patterns and risks in spinal
trauma. Arch Dis Child. 2004;89(9):860-865. (Retrospective
75. Sokolove PE, Kuppermann N, Holmes JF. Association

between the seat belt sign and intra-abdominal injury
in children with blunt torso trauma. Acad Emerg Med.
2005;12(9):808-813. (Prospective observational study; 390
patients)
58. Yucesoy K, Yuksel KZ. SCIWORA in MRI era. Clin Neurol

Neurosurg. 2008;110(5):429-433. (Systematic review)
59. Rothrock SG, Green SM, Morgan R. Abdominal trauma

in infants and children: prompt identification and early
management of serious and life-threatening injuries. Part I:
injury patterns and initial assessment. Pediatr Emerg Care.
76.* Holmes JF, Lillis K, Monroe D, et al. Identifying children

at very low risk of clinically important blunt abdominal
injuries. Ann Emerg Med. 2013 Jan 29. [Epub ahead of print]
(Prospective observational study; 12,044 patients)
60. Pariset JM, Feldman KW, Paris C. The pace of signs and
symptoms of blunt abdominal trauma to children. Clin
Pediatr (Phila). 2010;49(1):24-28. (Retrospective study; 77
patients)
77. Tovar JA, Vazquez JJ. Management of chest trauma in

children. Paediatr Respir Rev. 2013. 14(2):86-91. (Systematic
review)
61. Rance CH, Singh SJ, Kimble R. Blunt abdominal trauma in

children. J Paediatr Child Health. 2000;36(1):2-6. (Systematic
review)
78. Balci AE, Kazez A, Eren S, et al. Blunt thoracic trauma

in children: review of 137 cases. Eur J Cardiothorac Surg.
63.* Gaines BA. Intra-abdominal solid organ injury in children:

diagnosis and treatment. J Trauma. 2009;67(2 Suppl):S135S139. (Systematic review)
80. Ceran S, Sunam GS, Aribas OK, et al. Chest trauma in children. Eur J Cardiothorac Surg. 2002;21(1):57-59. (Retrospective
62. Karam O, Sanchez O, Chardot C, et al. Blunt abdominal

trauma in children: a score to predict the absence of organ
injury. J Pediatr. 2009;154(6):912-917. (Prospective study; 147
patients)
79. Holmes JF, Sokolove PE, Brant WE, et al. A clinical decision
rule for identifying children with thoracic injuries after blunt
torso trauma. Ann Emerg Med. 2002;39(5):492-499. (Prospective observational study; 986 patients)
64. Rothrock SG, Green SM, Morgan R. Abdominal trauma
81. Jamal-Eddine H, Ayed AK, Peric M, et al. Injuries to the
23
major airway after blunt thoracic trauma in children: review

of 2 cases. J Pediatr Surg. 2007;42(4):719-721. (Case report and
discussion of the literature)
82. Moore MA, Wallace EC, Westra SJ. Chest trauma in children:
current imaging guidelines and techniques. Radiol Clin North
Am. 2011;49(5):949-968. Systematic review)
83. Deng X, Yang Y, Deng Z, et al. Experiences in severe chest
trauma of children in 20 years. Interact Cardiovasc Thorac
84. Hamrick MC, Duhn RD, Carney DE, et al. Pulmonary contusion in the pediatric population. Am Surg. 2010;76(7):721-724.
(Retrospective study; 376 patients)
85. Haxhija EQ, Nores H, Schober P, et al. Lung contusion-lacerations after blunt thoracic trauma in children. Pediatr Surg
Int. 2004;20(6):412-414. (Retrospective study; 41 patients)
86. Advanced Trauma Life Support Student Manual. 9th ed:

American College of Surgeons Committee on Trauma 2012.
(Advanced Trauma Life Support Student Manual, 9th Edition)
87. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-ofhospital pediatric endotracheal intubation on survival and
neurological outcome: a controlled clinical trial. JAMA.
2000;283(6):783-790. (Controlled clinical trial; 830 patients)
88. Chen L, Hsiao AL. Randomized trial of endotracheal tube

versus laryngeal mask airway in simulated prehospital pediatric arrest. Pediatrics. 2008;122(2):e294-e297. (Randomized
crossover study; 52 subjects)
89. Ritter SC, Guyette FX. Prehospital pediatric King LT-D use: a
pilot study. Prehosp Emerg Care. 2011;15(3):401-404. (Prospective study; 45 subjects)
90. Youngquist S, Gausche-Hill M, Burbulys D. Alternative airway devices for use in children requiring prehospital airway
management: update and case discussion. Pediatr Emerg
Care. 2007;23(4):250-258. (Systematic review)
91. Gonzalez RP, Cummings GR, Phelan HA, et al. Does increased emergency medical services prehospital time affect
patient mortality in rural motor vehicle crashes? A statewide
analysis. Am J Surg. 2009;197(1):30-34. (Retrospective analysis; 45,763 police crash reports)
92. McCoy CE, Menchine M, Sampson S, et al. Emergency

medical services out-of-hospital scene and transport times
and their association with mortality in trauma patients
presenting to an urban level I trauma center. Ann Emerg Med.
2013;61(2):167-174. (Secondary analysis, prospective cohort
93. Feero S, Hedges JR, Simmons E, et al. Does out-of-hospital EMS time affect trauma survival? Am J Emerg Med.
1995;13(2):133-135. (Retrospective study; 848 cases)
94. Dorges V. Airway management in emergency situations.

Best Pract Res Clin Anaesthesiol. 2005;19(4):699-715. (Systematic review)
99. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound

and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Acad Emerg
Med. 2010;17(1):11-17. (Systematic review)
100. Brooks A, Davies B, Smethhurst M, et al. Emergency ultrasound in the acute assessment of haemothorax. Emerg Med J.
2004;21(1):44-46. (Prospective study; 61 patients)
101. Kristinsson G, Wall SP, Crain EF. The digital rectal examination in pediatric trauma: a pilot study. J Emerg Med.
2007;32(1):59-62. (Prospective study; 135 patients)
102. Shlamovitz GZ, Mower WR, Bergman J, et al. Lack of

evidence to support routine digital rectal examination in
pediatric trauma patients. Pediatr Emerg Care. 2007;23(8):537543. (Retrospective study; 213 patients)
103. Fenton SJ, Peterson DN, Connors RC, et al. A standard
pediatric trauma laboratory panel: a plea for a minimalist
approach. J Trauma. 2009;66(3):703-706. (Prospective observational study)
104. Thorson CM, Ryan ML, Van Haren RM, et al. Change in
hematocrit during trauma assessment predicts bleeding even
with ongoing fluid resuscitation. Am Surg. 2013;79(4):398406. (Prospective observational study; 232 patients)
105. Zehtabchi S, Sinert R, Goldman M, et al. Diagnostic performance of serial haematocrit measurements in identifying
major injury in adult trauma patients. Injury. 2006;37(1):4652. (Prospective observational study; 494 patients)
106. Goldman M, Kapitanyan R, Zehtabchi S, et al. Operating characteristics of serial hematocrit measurements
in detecting major injury after trauma. Ann Emerg Med.
2004;44(4):S128. (Retrospective review; 478 patients)
107. Holmes JF, Mao A, Awasthi S, et al. Validation of a prediction rule for the identification of children with intraabdominal injuries after blunt torso trauma. Ann Emerg Med.
2009;54(4):528-533. (Prospective observational study; 1324
patients)
108. Holmes JF, Sokolove PE, Brant WE, et al. Identification of
children with intra-abdominal injuries after blunt trauma.
Ann Emerg Med. 2002;39(5):500-509. (Prospective observational study; 1095 patients)
109. Karaduman D, Sarioglu-Buke A, Kilic I, et al. The role of

elevated liver transaminase levels in children with blunt
abdominal trauma. Injury. 2003;34(4):249-252. (Prospective
study; 87 patients)
110. Capraro AJ, Mooney D, Waltzman ML. The use of routine

laboratory studies as screening tools in pediatric abdominal
trauma. Pediatr Emerg Care. 2006;22(7):480-484. (Retrospective study; 382 patients)
111. Cotton BA, Beckert BW, Smith MK, et al. The utility of clinical and laboratory data for predicting intraabdominal injury
among children. J Trauma. 2004;56(5):1068-1074. (Retrospective study; 42 patients)
95. Scrase I, Woollard M. Needle vs surgical cricothyroidotomy: a short cut to effective ventilation. Anaesthesia.
112. Santucci RA, Langenburg SE, Zachareas MJ. Traumatic

hematuria in children can be evaluated as in adults. J Urol.
2004;171(2 Pt 1):822-825. (Retrospective review; 720 patients)
97. Sise MJ, Shackford SR, Cruickshank JC, et al. Cricothyroidotomy for long-term tracheal access. A prospective
analysis of morbidity and mortality in 76 patients. Ann Surg.
1984;200(1):13-17. (Prospective sutdy; 76 patients)
114. Maegele M. Coagulopathy after traumatic brain injury:

incidence, pathogenesis, and treatment options. Transfusion.
2013;53 Suppl 1:28S-37S. (Systematic review)
96. Schroeder AA. Cricothyroidotomy: when, why, and why

not? Am J Otolaryngol. 2000;21(3):195-201. (Systematic review)
98. Dulchavsky SA, Schwarz KL, Kirkpatrick AW, et al. Prospective evaluation of thoracic ultrasound in the detection of
pneumothorax. J Trauma. 2001;50(2):201-205. (Prospective
113. Santucci RA, Wessells H, Bartsch G, et al. Evaluation and

management of renal injuries: consensus statement of the
renal trauma subcommittee. BJU Int. 2004;93(7):937-954.
(Consensus statement)
115. Greuters S, van den Berg A, Franschman G, et al. Acute

and delayed mild coagulopathy are related to outcome
in patients with isolated traumatic brain injury. Crit Care.
2011;15(1):R2. (Retrospective study; 247 patients)
116. Van Beek JG, Mushkudiani NA, Steyerberg EW, et al. Prognostic value of admission laboratory parameters in traumatic
brain injury: results from the IMPACT study. J Neurotrauma.
2007;24(2):315-328. (Retrospective database analysis)
raphy Utilization Study Group. N Engl J Med. 2000;343(2):9499. (Prospective observational study; 21 centers, 818
patients)
133. Mower WR, Hoffman JR, Pollack CV Jr., et al. Use of plain
radiography to screen for cervical spine injuries. Ann Emerg
Med. 2001;38(1):1-7. (Prospective observational study; 34,069
patients)
117. Whittaker B, Christiaans SC, Altice JL, et al. Early coagulopathy is an independent predictor of mortality in children after
severe trauma. Shock. 2013;39(5):421-426.
118. Genet GF, Johansson PI, Meyer MA, et al. Trauma-induced
coagulopathy: standard coagulation tests, biomarkers of
coagulopathy, and endothelial damage in patients with
traumatic brain injury. J Neurotrauma. 2013;30(4):301-306.
(Prospective observational cohort study; 80 patients)
134. Caviness AC. Evaluation of cervical spine injuries in children

and adolescents. UpToDate [online journal]. Accessed April
1, 2013.
135.* Chung S, Mikrogianakis A, Wales PW, et al. Trauma association of Canada Pediatric Subcommittee National Pediatric
Cervical Spine Evaluation Pathway: consensus guidelines. J
Trauma. 2011;70(4):873-884. (Consensus guideline)
119. Zhang J, Jiang R, Liu L, et al. Traumatic brain injury-associated coagulopathy. J Neurotrauma. 2012;29(17):2597-2605.
(Systematic review)
136. Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a
meta-analysis. J Pediatr Surg. 2007;42(9):1588-1594. (Metaanalysis; 25 articles)
120. Laroche M, Kutcher ME, Huang MC, et al. Coagulopathy

after traumatic brain injury. Neurosurgery. 2012;70(6):13341345. (Systematic review)
121. Ward KR. The microcirculation: linking trauma and coagulopathy. Transfusion. 2013;53 Suppl 1:38S-47S. (Systematic
review)
137. Fox JC, Boysen M, Gharahbaghian L, et al. Test characteristics of focused assessment of sonography for trauma for
clinically significant abdominal free fluid in pediatric blunt
abdominal trauma. Acad Emerg Med. 2011;18(5):477-482.
(Prospective observational study; 431 patients)
122. Talving P, Lustenberger T, Lam L, et al. Coagulopathy after

isolated severe traumatic brain injury in children. J Trauma.
138. Sivit CJ. Imaging children with abdominal trauma. AJR Am J

Roentgenol. 2009;192(5):1179-1189. (Systematic review)
123. Affonseca CA, Carvalho LF, Guerra SD, et al. Coagulation disorder in children and adolescents with moderate to
severe traumatic brain injury. J Pediatr (Rio J). 2007;83(3):274282. (Cross-sectional study; 301 patients)
139. Bhagvan S, Turai M, Holden A, et al. Predicting hollow

viscus injury in blunt abdominal trauma with computed
tomography. World J Surg. 2013;37(1):123-126. (Retrospective
124. Osmond MH, Klassen TP, Wells GA, et al. CATCH: a clinical decision rule for the use of computed tomography in
children with minor head injury. CMAJ. 2010;182(4):341-348.
(Multicenter cohort study; 3866 patients)
140. Streck CJ, Jr., Jewett BM, Wahlquist AH, et al. Evaluation for
intra-abdominal injury in children after blunt torso trauma:
can we reduce unnecessary abdominal computed tomography by utilizing a clinical prediction model? J Trauma Acute
Care Surg. 2012;73(2):371-376. (Retrospective study; 125
patients)
125.* Dunning J, Daly JP, Lomas JP, et al. Derivation of the childrens head injury algorithm for the prediction of important
clinical events decision rule for head injury in children. Arch
Dis Child. 2006;91(11):885-891. (Prospective multicenter
141. Kool DR, Blickman JG. Advanced trauma life support.

ABCDE from a radiological point of view. Emerg Radiol.
126. Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med.
142. Sivit CJ. Pediatric thoracic trauma: imaging considerations.

Emerg Radiol. 2002;9(1):21-25. (Systematic review)
127. Pearce MS, Salotti JA, Little MP, et al. Radiation exposure
from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. The
Lancet. 2012;380(9840):499-505. (Retrospective cohort study;
178,604 patients)
143. Hammer MR, Dillman JR, Chong ST, et al. Imaging of pediatric thoracic trauma. Semin Roentgenol. 2012;47(2):135-146.
(Systematic review)
144. Chimutengwende-Gordon M, Khan WS, Sidhu J, et al. Advanced trauma life support radiographic trauma series: part
2--the chest radiograph. J Perioper Pract. 2010;20(12):430-435.
(Case studies with review of the literature)
128. Miglioretti DL, Johnson E, Williams A, et al. The Use of

Computed Tomography in Pediatrics and the Associated
Radiation Exposure and Estimated Cancer Risk. JAMA Pediatr. 2013:1-8. (Retrospective observational study; 4,857,736
child-years of observation)
145. Guillamondegui OD, Mahboubi S, Stafford PW, et al. The

utility of the pelvic radiograph in the assessment of pediatric
pelvic fractures. J Trauma. 2003;55(2):236-239. (Retrospective
129. Nigrovic LE, Schunk JE, Foerster A, et al. The effect of

observation on cranial computed tomography utilization for
children after blunt head trauma. Pediatrics. 2011;127(6):10671073. (Subanalysis of a prospective multicenter observational study; 42,412 children)
146. Rees MJ, Aickin R, Kolbe A, et al. The screening pelvic radiograph in pediatric trauma. Pediatr Radiol. 2001;31(7):497-500.
147. Ramirez DW, Schuette JJ, Knight V, et al. Necessity of routine pelvic radiograph in the pediatric blunt trauma patient.
Clin Pediatr (Phila). 2008;47(9):935-940. (Retrospective, casecontrol study; 33 patients)
130.* Hoffman JR, Wolfson AB, Todd K, et al. Selective cervical spine radiography in blunt trauma: methodology of
the National Emergency X-Radiography Utilization Study
(NEXUS). Ann Emerg Med. 1998;32(4):461-469. (Multicenter
prospective study)
148. McFadyen JG, Ramaiah R, Bhananker SM. Initial assessment

and management of pediatric trauma patients. Int J Crit Illn
Inj Sci. 2012;2(3):121-127. (Systematic review)
131.* Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian
C-spine rule for radiography in alert and stable trauma
patients. JAMA. 2001;286(15):1841-1848. (Prospective cohort
149. Avarello JT, Cantor RM. Pediatric major trauma: an approach to evaluation and management. Emerg Med Clin
North Am. 2007;25(3):803-836. (Systematic review)
132.* Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set
of clinical criteria to rule out injury to the cervical spine in
patients with blunt trauma. National Emergency X-Radiog-
150.* Stassen NA, Bhullar I, Cheng JD, et al. Selective nonoperative management of blunt splenic injury: an Eastern Associa-
25
tion for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S294-S300.
(Clinical practice management guideline and systematic
review; 125 articles)
151.* Kerrey BT, Rogers AJ, Lee LK, et al. A multicenter study of
the risk of intra-abdominal injury in children after normal abdominal computed tomography scan results in the
emergency department. Ann Emerg Med. 2013 Apr 25. [Epub
ahead of print] (Prospective study; 12,044 patients)
152. Centers for Disease Control and Prevention. Air-bag-associated fatal injuries to infants and children riding in front
passenger seats--United States. MMWR Morb Mortal Wkly
Rep. 1995;44(45):845-847. (Government publication)
153. Barnes SS, Wong W Jr, Affeldt JC. A case of severe airbag
related ocular alkali injury. Hawaii J Med Public Health.
2012;71(8):229-231. (Case report)
CME Questions
Take This Test Online!
Current subscribers receive CME credit absolutely free
by completing the following test. Each issue includes
4 AMA PRA Category 1 CreditsTM, 4 ACEP Category I
credits, 4 AAP Prescribed credits, and 4 AOA category
Take This Test Online!
2A or 2B credits. Monthly online testing is now available for current and archived issues. To receive your
free CME credits for this issue, scan the QR code below
or visit www.ebmedicine.net/P0813.
154. Cunningham K, Brown TD, Gradwell E, et al. Airbag-associated fatal head injury: case report and review of the literature on airbag injuries. J Accid Emerg Med. 2000;17(2):139-142.
(Case report and review of the literature)
155. Okamoto K, Takemoto M, Okada Y. Airbag-mediated craniocervical injury in a child restrained with safety device. J
Trauma. 2002;52(3):587-590. (Case report)
156. Giesbrecht GG, McDonald GK. My car is sinking: automobile submersion, lessons in vehicle escape. Aviat Space Environ Med. 2010;81(8):779-784. (Simulation of motor vehicle
submersions)
157. Wintemute GJ, Kraus JF, Teret SP, et al. Death resulting
from motor vehicle immersions: the nature of the injuries,
personal and environmental contributing factors, and potential interventions. Am J Public Health. 1990;80(9):1068-1070.
158. Friberg H, Rundgren M. Submersion, accidental hypothermia and cardiac arrest, mechanical chest compressions as a
bridge to final treatment: a case report. Scand J Trauma Resusc
Emerg Med. 2009;17:7. (Case report)
159.* Mannix R, Fleegler E, Meehan WP, 3rd, et al. Booster seat
laws and fatalities in children 4 to 7 years of age. Pediatrics.
2012;130(6):996-1002. (Retrospective longitudinal analysis)
160. Palmer KG, Mowery B. Injury prevention: role of the

hospital-based Child Passenger Safety Program (CPSP). J Ark
Med Soc. 2010;107(7):135-138. (Review)
161. Weiss-Laxer NS, Mello MJ, Nolan PA. Evaluating the educational component of a hospital-based child passenger safety
program. J Trauma. 2009;67(1 Suppl):S30-33. (Telephone
survey; 79 patients)
162. Colletti RB. A statewide hospital-based program to improve
child passenger safety. Health Educ Q. 1984;11(2):207-213.
(Discussion of a hospital-based child passenger safety
program)
163. Colletti RB. Longitudinal evaluation of a statewide network

of hospital programs to improve child passenger safety. Pediatrics. 1986;77(4):523-529. (Discussion)
164. Letourneau RJ, Crump CE, Bowling JM, et al. Ride Safe: a
child passenger safety program for American Indian/Alaska
Native children. Matern Child Health J. 2008;12 Suppl 1:5563. (Evaluation of a child passenger safety program; 3500
patients)
165. Duchossois GP, Nance ML, Wiebe DJ. Evaluation of
child safety seat checkpoint events. Accid Anal Prev.
2008;40(6):1908-1912. (Evaluation of a child safety seat
program; 42 participants)
1. When compared to properly restrained children, unrestrained children are at increased

risk for which of the following:
a. Head injury
b. Intra-abdominal injury
c. Musculoskeletal injury
d. Thoracic injury
e. All of the above
2. Which of the following mechanisms of injury
is NOT associated with SCIWORA?
a. Acceleration-deceleration injury
b. Hyperextension injury
c. Hyperflexion injury
d. Longitudinal distraction injuries
3. A 6-year-old restrained passenger is brought to
the ED after a high-speed MVC. She is noted to
have abdominal wall bruising and distension.
Which other injury is most likely to be present
in this patient?
a. Intracranial injury
b. Intra-abdominal injury
c. Cervical spine injury
d. Pulmonary contusion
4. Which of the following is the most appropriate
initial diagnostic study for a patient in whom
an intracranial injury is suspected?
a. Plain radiographs of the skull
b. Head CT with contrast
c. Head CT without contrast
d. Coagulation studies
166. Herring AB, Jones C, Nunez C. Evaluating the impact of

child safety seat check-up events on parental knowledge.
J Ark Med Soc. 2002;99(6):187-190. (Prospective study; 101
patients)
5. Which of the following patients with a closed

head injury does NOT require a head CT?
a. A 14-year-old with an initial GCS score of 14
b. An 18-month-old with a palpable skull
fracture
c. A 12-year-old with left hemotympanum and

a mastoid ecchymosis
d. A 15-month-old with 2 episodes of emesis

after a fall
Want 3 FREE issues added

to your subscription?
Receiving a FREE 3-issue
extension on your Pediatric
Emergency Medicine Practice
subscription is easy!
6. Plain radiographs are the preferred imaging

modality for all of the following regions EXCEPT:
a. Pelvis
b. Head
c. Chest
d. Extremities
Simply recommend Pediatric Emergency

Medicine Practice to a colleague
and ask them to mention your name when they
subscribe. Well automatically add 3 FREE issues
to your subscription for every new subscriber you
refer. And theres no limit on the number of people
you can refer!
7. A 15-year-old girl is brought to the ED in a

cervical collar after being rear-ended in a car.
She complains of neck and back pain on arrival, but her GCS score is 15. On examination,
she has no midline tenderness, has no focal
neurologic deficits, has no other associated
injuries, is not intoxicated, and is able to fully
flex, extend, and rotate her neck without pain.
Which of the following is the most appropriate
next step?
a. Clinically clear the cervical spine
b. Radiographs of the cervical spine
c. CT scan of the cervical spine
d. MRI of the cervical spine
Your colleagues can subscribe by calling

1-800-249-5770 and mentioning your name or by
visiting: www.ebmedicine.net/subscribe (Ask
them to enter Promotion Code: REFERRALP and
enter your name in the Comments box.) With this
exclusive promotion code, theyll save $100 off
the regular subscription price!
8. Which of the following is responsible for the

greatest decrease in pediatric morbidity after a
MVC?
a. Presence of airbags
b. Proper usage of child-safety restraints
c. Graduated drivers licensing programs
d. Improved motor vehicle design
Subscribe now to Pediatric

Emergency Medicine Practice
They can also use the order form below and mail
a check for $199 (a $100 savings) to:
EB Medicine
5550 Triangle Pkwy Ste 150
Norcross, GA 30092.
Start referring today!
Subscribe now for just $199 a $100 savings for a full year (12
issues) of Pediatric Emergency Medicine Practice
and well give the colleague who referred you 3 free issues! In
addition to your monthly print issues, youll have full online access
to evidence-based articles and over 100 CME credits!
Check enclosed (payable to EB Medicine)
9. An 18-month-old boy is brought to the ED after

a minor MVC that happened on the day prior
to presentation. His mother asks about child
passenger safety restraints. Which of the following is the most appropriate child passenger
safety restraint for this patient?
a. Belt-positioning booster seat
b. Forward-facing car safety seat
c. Rear-facing car safety seat
d. Lap and shoulder restraint
Charge my:

Visa
MC
AmEx: _____________________ ___ Exp: _____
Signature: _______________________________________________
Bill me
Promotion Code: REFERRALP
Name of new subscriber:____________________________________

Address Line 1: ___________________________________________
Address Line 2: ___________________________________________
City, State, Zip: ___________________________________________
Email: __________________________________________________
Colleagues name who referred you: ___________________________
Send to: EB Medicine / 5550 Triangle Pkwy, Ste 150 /

Norcross, GA 30092. Or fax to: 770-500-1316.
Or visit: www.ebmedicine.net/subscribe and enter
Promo Code REFERRALP. Or call: 1-800-249-5770 or
678-366-7933.
27
Physician CME Information
Pediatric Emergency
Medicine Practice has
been accepted for
indexing on PubMed
Date of Original Release: August 1, 2013. Date of most recent review: July 15,
2013. Termination date: August 1, 2016.
Accreditation: EB Medicine is accredited by the Accreditation Council for
Continuing Medical Education (ACCME) to provide continuing medical
education for physicians. This activity has been planned and implemented in
accordance with the Essential Areas and Policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a
maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only
the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved
by the American College of Emergency Physicians for 48 hours of ACEP
Category I credit per annual subscription.
AAP Accreditation: This continuing medical education activity has been
reviewed by the American Academy of Pediatrics and is acceptable for a
maximum of 48 AAP credits per year. These credits can be applied toward
the AAP CME/CPD Award available to Fellows and Candidate Fellows of the
American Academy of Pediatrics.
AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to
48 American Osteopathic Association Category 2A or 2B credit hours per year.
Needs Assessment: The need for this educational activity was determined by a
survey of medical staff, including the editorial board of this publication; review
of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and
evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine
physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate
medical decision-making based on the strongest clinical evidence; (2) costeffectively diagnose and treat the most critical ED presentations; and (3)
describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the newsletter, faculty
may be presenting investigational information about pharmaceutical products
that is outside Food and Drug Administration approved labeling. Information
presented as part of this activity is intended solely as continuing medical
education and is not intended to promote off-label use of any pharmaceutical
product.
Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance,
independence, transparency, and scientific rigor in all CME-sponsored
educational activities. All faculty participating in the planning or implementation
of a sponsored activity are expected to disclose to the audience any relevant
financial relationships and to assist in resolving any conflict of interest that
may arise from the relationship. Presenters must also make a meaningful
disclosure to the audience of their discussions of unlabeled or unapproved
drugs or devices. In compliance with all ACCME Essentials, Standards, and
Guidelines, all faculty for this CME activity were asked to complete a full
disclosure statement. The information received is as follows: Dr. Srinivasan, Dr.
Chang, Dr. Lee, Dr. Zibners, Dr. Vella, Dr. Wang, Dr. Damilini, and their related
parties report no significant financial interest or other relationship with the
manufacturer(s) of any commercial product(s) discussed in this educational
presentation.
Commercial Support: This issue of Pediatric Emergency Medicine Practice did
not receive any commercial support.
Method of Participation:
Print Semester Program: Paid subscribers who read all CME articles
during each Pediatric Emergency Medicine Practice 6-month testing period,
complete the CME Answer And Evaluation Form distributed with the June
and December issues, and return it according to the published instructions
are eligible for up to 4 hours of CME credit for each issue.
Online Single-Issue Program: Current, paid subscribers who read this
Pediatric Emergency Medicine Practice CME article and complete the test
and evaluation at www.ebmedicine.net/CME are eligible for up to 4 hours of
CME credit for each issue. Hints will be provided for each missed question,
and participants must score 100% to receive credit.
Hardware/Software Requirements: You will need a Macintosh or PC with
internet capabilities to access the website.
Additional Policies: For additional policies, including our statement of conflict of
interest, source of funding, statement of informed consent, and statement of
human and animal rights, visit http://www.ebmedicine.net/policies.
We at EB Medicine are proud to announce

that our publication, Pediatric Emergency
Medicine Practice, has been accepted
by the National Library of Medicine for
MEDLINE indexing. This means that
all 2013 and future issues of Pediatric
Emergency Medicine Practice will be
indexed on PubMed. This is an important
breakthrough for our publication, and we
are extremely pleased to have received
this recognition.
To read a letter from Dr. Adam Vella, Editorin-Chief, about this exciting achievement,
please visit
www.ebmedicine.net/MEDLINEPEMP.
All of our readers have played an
instrumental role in ensuring this
publications high quality, and we
greatly appreciate your support.
THE EB MEDICINE TEAM
CEO & Publisher: Stephanie Williford Managing Editor: Dorothy Whisenhunt Scientific Content Editor: Kelli Miller, ELS Assistant Editor: Kay LeGree
Director of Member Services: Liz Alvarez Member Services Representative: Kiana Collier
Marketing Manager: Robin Williford Senior Marketing Specialist: Angela Hammond
Direct all questions to:
EB Medicine
Phone: 1-800-249-5770 or 678-366-7933

Fax: 1-770-500-1316
5550 Triangle Parkway, Suite 150
Norcross, GA 30092
E-mail: ebm@ebmedicine.net
Website: EBMedicine.net
To write a letter to the editor, email: vellaadam@gmail.com
Subscription Information:
1 year (12 issues) including evidence-based print issues;
48 AMA PRA Category 1 CreditsTM, 48 ACEP Category 1 Credits, 48 AAP
Prescribed credits, and 48 AOA Category 2A or 2B credit; and full online access
to searchable archives and additional free CME: $299
(Call 1-800-249-5770 or go to www.ebmedicine.net/subscribe to order)
Single issues with CME may be purchased at
www.ebmedicine.net/PEMPissues
Pediatric Emergency Medicine Practice (ISSN Print: 1549-9650, ISSN Online: 1549-9669, ACID-FREE) is published monthly (12 times per year) by EB Medicine. 5550 Triangle Parkway, Suite 150, Norcross,
GA 30092. Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is intended as a general guide and is intended
to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used for making specific medical decisions. The materials contained herein
are not intended to establish policy, procedure, or standard of care. Pediatric Emergency Medicine Practice is a trademark of EB Medicine. Copyright 2013 EB Medicine All rights reserved. No part of this
publication may be reproduced in any format without written consent of EB Medicine. This publication is intended for the use of the individual subscriber only, and may not be copied in whole or in part or
redistributed in any way without the publishers prior written permission including reproduction for educational purposes or for internal distribution within a hospital, library, group practice, or other entity.

Peds0813 Motor Vehicle Trauma

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Peds0813 Motor Vehicle Trauma

Uploaded by

Copyright:

Available Formats

Diagnosis And Management

Of Motor Vehicle Trauma In

Director, Central New York

Volume 10, Number 8

Goryeb Children's Hospital,

Lois Lee, MD, MPH

Physician, Connecticut Children's

Tommy Y. Kim, MD, FAAP, FACEP

Ghazala Q. Sharieff, MD, FAAP,

Alson S. Inaba, MD, FAAP

challenge for emergency clinicians, given the variety

Critical Appraisal Of The Literature

Epidemiology And Risk Factors For Injury

parental disclosure and have the potential for

Head trauma is the most common injury in MVCs,

Spine And Spinal Cord Injury

Cervical Spine Injury

Pediatric Emergency Medicine Practice 2013

predisposes children to injuries of the cervical spine.

MVCs and pedestrian-versus-automobile accidents

to sit across the pelvis, so the lap belt ends up across

Clinical Implications Of Abdominal Wall Ecchymoses

Although thoracic injuries in children are relatively

Figure 1. The American Association For The

Scan the QR code above with your smartphone or go to:

August 2013 www.ebmedicine.net

Pediatric Emergency Medicine Practice 2013

contusions may occur either with or without the

hospital capable of caring for these injuries. In order

Emergency Department Evaluation

to moving on to the next component. The secondary

Once the primary survey has been completed and

Pediatric Emergency Medicine Practice 2013

crepitus, which could be indicative of perforation of

As part of the secondary survey, additional history

www.ebmedicine.net August 2013

for intra-abdominal injuries, although the AST and

Radiographic studies are frequently utilized in the

Pediatric Emergency Medicine Practice 2013

Imaging Of The Head

mental status, inability to ambulate, substantial torso

of research that has been conducted on cervical

guidelines have been created for the evaluation of

or a CT scan in order to clear the cervical spine.135

Table 1. PECARN Predictors Of Cervical

Altered mental status

Presence of 1 or more factors is 98% sensitive and 26% specific for

Table 2. NEXUS Low-Risk Criteria

Normal level of alertness

August 2013 www.ebmedicine.net

Pediatric Emergency Medicine Practice 2013

strated that exposure to ionizing radiation from CT

Utility Of Plain Radiographs In The

Although CT is the preferred imaging modality

Table 3. PECARN Clinical Prediction Rule To

Pediatric Emergency Medicine Practice 2013 12

be a better predictor of clinical outcome than chest

all solid organ injuries in children is nonoperative

Motor Vehicle Accidents Complicated By

For patients who do not require emergent operative

Although most MVCs occur on roads or highways,

Injury Prevention Strategies

Although the emergency clinicians primary focus

Airbag-related injuries in the pediatric population