Pediatric Trauma

Norman C. Christopher, MD

Approximately 2 million injured children are admitted to American

hospitals each year. Among these, more than 30,000 suffer
permanently disabling injuries, and more than 20,000 children die as
a result of trauma. It is alarming that 48% of all children who die
between the ages of 1 and 19, and 30% of those who die before the
age of 12 months, do so as a direct result of either accidental or
inflicted injury. One-quarter of pediatric trauma patients will require
surgery during the first 24 hours after injury, a statistic that
emphasizes the importance of accurate triage and prompt
intervention in this patient population.1

Of special importance is the changing nature of urban violence, which

increasingly has come to include children and adolescents among its
victims. The rise in gang-related violence, the propensity to carry
firearms, and the increase in drug-and alcohol-related crimes have
contributed to the changing epidemiology of traumatic injuries in
children. These trends have been accompanied by an increasing
incidence of penetrating injuries in a population in which blunt trauma
once firmly dominated the clinical landscape. In addition, the increase
in reported violence by caretakers against children has had a
significant effect on the presentation of young patients complaining of
psychological, sexual, or physical abuse. Despite these trends, it
should be stressed that it is still not clear if increased incidence of
child abuse is real, or whether the apparent rise in these activities is a
function of more efficient reporting.

Although many aspects of pediatric trauma management reflect

strategies based on advanced trauma life support (ATLS) protocols
that have proved successful in adult patients, many diagnostic and
therapeutic approaches to trauma care in the pediatric population are
specialized, having been tailored to the unique physiological and
clinical needs of infants and children. For example, the Pediatric
Trauma Score (PTS) has been developed to help identify injured
children whose outcomes can be optimized from concentrated care
within the framework of a regionalized trauma system.

Recent work also suggests that patients who require admission for
treatment of multi-system injury experience late physical, behavioral,
and psychosocial morbidityas well as financial hardshiplong after
their hospitalization.1 Given the significant consequences associated
with pediatric trauma, the ED physician must develop a consistent
and systematic approach to the injured child. With this in mind, this
report will review recent trends and advances in pediatric trauma
management, stressing pediatric-specific approaches that permit
timely identification of serious injuries and delivery of definitive
trauma care.

Triage

Minimizing morbidity and mortality in the seriously injured child

begins with appropriate triage decisions in the prehospital
environment and by emergency physicians providing initial hospital
care. It is well-documented that inappropriate delays in definitive
operative care significantly increases mortality for patients who have
sustained neurological trauma.2 One landmark study of patients with
traumatic subdural hematoma demonstrated that the mortality rate
was only 30% if surgery was performed within four hours after injury,
but increased to 90% if definitive surgical intervention was delayed by
90 minutes or more.2 This investigation emphasized the importance of
triaging children with life-threatening trauma to centers equipped to
manage such injuries. While many emergency departments (EDs) are
well-suited for providing initial resuscitative care of the seriously
injured child, definitive management of such patients is best
accomplished by early, appropriate referral within a regionalized
system of pediatric trauma care. Experience has shown that
concentrating resources and clinical experience within a framework of
regionalized trauma services improves care for critically injured
pediatric patients in three important ways: 1) resuscitation outcomes
of injured children are improved; 2) prehospital care is optimized for
infants and children; and 3) prehospital and interhospital
transportation networks are developed that facilitate triage decisions.

While some degree of overtriage to designated trauma centers is

necessary to ensure that all significantly injured children are identified
(increased sensitivity) and managed, unnecessary referral patients
with minor injuries (decreased specificity) can generate excessive,
unjustified costs of care and inefficient resource utilization. 3,4
Fortunately, several recent reviews suggest guidelines for referral that
can help minimize overtriage, while still maintaining sufficient
sensitivity to identify all those children who would benefit from
concentrated regional care.5-7 Although these studies do not consider
children exclusively, they present evidence suggesting that accuracy
of clinical judgments made by EMTs regarding severity of injuries
(mortality estimates)as well as the necessity for emergency
operative intervention-was equivalent to the application of published
scoring systems routinely used to guide prehospital triage. 8

These studies indicate that patients with the following injuries are
best treated when triaged to a facility dedicated to trauma and
pediatric critical care:

Multisystem injury or single system injury requiring

pediatric intensive care unit (PICU) monitoring or care.

Hemodynamic instability after an acute injury.

Fracture of the axial skeleton or any fracture associated

with neurovascular injury.

Multiple long bone fractures, amputation, or avulsion

of an extremity that has the potential for replantation.

Suspected or actual cord injury.

Complicated intracranial injury, including those associated with an

open or depressed skull fracture, CSF leak, facial or orbital fracture,
or requirement for intracranial pressure monitoring. 9

Trauma Scoring Instruments. Objective and reproducible

measures of injury severity must be assigned. For a trauma system to
conduct internal reviews of quality of care provided for their patient
population, and also, to compare specific methods, interventions, and
clinical outcomes with those of other regionalized trauma centers. A
number of scoring systems have been developed and evaluated in
adult patients.10-13 Fortunately, clinical experience with pediatric
injuries suggests a number of these scoring systemssometimes with
only minor modificationscan also be applied to the evaluation and
triage of injured children. Because mechanistic and anatomic criteria
are limited in their ability to predict the need for more intensive levels
of emergency care, physiologic parameters have become increasingly
important for the development of trauma scoring systems.

The Glasgow Coma Scale (GCS), for example, is a well-known and

easily applied assessment too] that reliably measures the degree of
neurologic deficit based on behavioral or reflex responses to external
stimulation.10 Widely applied during triage and for serial assessment of
brain-injured patients, the GCS may be less useful in very young
patients because of variable rates, levels, and patterns of speech
acquisition and social development. 11,12 More comprehensive in scope,
the Trauma Score (TS) is a derivation of the Triage Index, and is
based on the assessment of physiologic parameters, including those
reflecting cardiovascular (capillary refill, systolic blood pressure),
neurologic (GCS), and respiratory (respiratory rate and effort) status.
The maximum assigned score in this system is l6, which represents a
normal physiologic state. (See Table 1.)

Table 1. Modified (Pediatric) Glasgow Coma Scale

Infants Children
Eye Opening
Spontaneous 4 Spontaneous
To speech or sound 3 To speech
To painful stimulus 2 To pain
None 1 None
Best Verbal
Response
Cries appropriately,
Coos, babbles, smiles 5
oriented
Irritable cry, but
4 Confused
consolable
Inappropriate crying/
Cries/screams to pain 3
words
Grunts/groans to Grunts incomprehensible
2
pain words
None 1 None
Best Motor
Response
Spontaneous
6 Obeys commands
movement
Localizes pain 5 Localizes pain
 Withdrawal from pain 4 Withdrawal from pain
Flexion to pain Flexion to pain
3
(decorticate) (decorticate)
Extension to pain Extension to pain
2
(decerebrate) (decerebrate)
None 1 None

A simplified variation of the TS, the Revised Trauma Score (RTS), is

better suited for the prehospital setting and for use by clinicians at
the bedside.13 Using variables coded from 0 (worst) to 4 (normal), the
RTS is derived from the GCS, systolic blood pressure, and respiratory
rate. Each of these parameters is serially monitored and recorded in
the prehospital and ED resuscitative phases. The RTS has the
advantage of using parameters that are easily assessed and can be
accurately reproduced with good interobserver reliability. In contrast
with the RTS, the Pediatric Trauma Score (PTS) attempts to address
specific developmental, physiologic, and mechanistic variables that
can either influence or reflect outcomes in pediatric trauma victims;
the PTS correlates well with the Injury Severity Score (ISS) discussed
below.14,15 In addition to systolic BP, PTS parameters include body
habitus, airway patency, level of alertness, and the presence and
degree of skeletal and cutaneous injuries. This predictive instrument
is designed to generate a score ranging from 12 (normal) to -4 (most
severe injury). Studies evaluating the predictive value of the PTS
demonstrate zero mortality in children with a score of 8 or greater, a
45% mortality rate in patients with a PTS of 2, and a 100% mortality
rate in trauma victims with a score of zero or less.14,15 Although the
PTS appears capable of accurately predicting emergency resource
needs, some studies found the PTS had no significant advantage when
compared to TS or RTS measurement instruments.16,17 (See Table 2.)

Table 2. Pediatric Trauma Score

Score +2 +1 -1
Maintainable
Normal with
without
oral or nasal
Airway advanced Unmaintainable
airway
airway
positioning
intervention
Blood
> 90 mmHg 50-90 mmHg < 50 mmHg
Pressure
 Obtunded,
Level of
Awake,alert loss of Comatose
Consciousness
consciousness
Major or
Open Wound None Minor
penetrating
Single, Open or
Fractures None
simple multiple
Adapted from: Ramensofsky JL, Ramenofsky MB, Jurkovich
GJ et al. The predictive validity of the pediatric trauma
score. J Trauma 1988; 28:1038.

The most widely used of all clinical scoring systems, the Injury
Severity Score (ISS) is a summary of individual injury scores derived
from clinical application of the Abbreviated Injury Scale (AIS). AIS
scores (ranging from 1 to 6, which implies a fatal injury) are assigned
for each injury identified. The ISS is then derived by summing the
squares of the three highest AIS scores for three different body
regions. Any child with an injury to a body region resulting in an AIS
of 6 is assigned a total ISS score of 75, the maximum value allowed
on this scale, and one that predicts a fatal injury. One obvious
shortcoming of this methodology, especially when applied to young
children, is that it considers equal injuries of different body regions as
having an equal effect on survival, which is not always the case.
Moreover, the ISS only considers the effect of injury to the three most
severely involved body regions. Finally, when used alone, the ISS
may not accurately predict the resource needs of injured patients, 18
and has been shown to overestimate the group of injured children
considered to be nonsalvageable.19 Despite these limitations, the ISS
is still a valuable instrument for guiding triage decisions in children
who have sustained life-threatening traumatic injuries.

Finally, even with the best scoring instruments, the severity of a

childs clinical condition may not be readily apparent. Prehospital
providers must be trained to detect and manage patients with subtle
signs of decreased oxygenation, acidosis, and impaired ventilation
(i.e., pCO2 > 50).

Trauma Management

General Principles. Mortality associated with pediatric trauma

occurs at three distinct peaks: l) Upon impact; 2) within two hours of
the injury; and 3) from complications during the recovery period.
Approximately 50% of all deaths due to trauma occur at the time of
or within moments of impact. Improvements in medical management
will have little or no effect on survival in this patient population.
Consequently, prevention constitutes the only logical approach for
reducing mortality associated with injuries of this severity. In this
regard, a successful prevention program should be based on
improving public awareness through education and generating
prevention-oriented legislation.

The most common causes of death during the first peak include
laceration of major intrathoracic or intra-abdominal vessels, high
division of the cervical spine, rupture of cardiac chambers, and severe
brain injury. The second mortality peak, which accounts for
approximately 30% of all trauma-related deaths, occurs within the
first l-2 hours after impact. Death during this phase is usually
secondary to inadequate establishment, stabilization, or control of the
airway, uncontrolled hemorrhage associated with hemodynamic
collapse, respiratory failure (pulmonary hemorrhage or contusion,
extrapulmonary collections of air), or intracranial hemorrhage. Most of
these injuries are potentially amenable to corrective measures during
the so-called Golden Hour of trauma management, during which
prompt and appropriate interventions and triage decisions have the
greatest effect on survival. The final mortality peak, which accounts
for about 20% of deaths after trauma, is observed during the
convalescent or recovery period, and is usually due to such
complications such as sepsis, progressive pulmonary insufficiency, or
aspiration pneumonitis.

Emergency physicians should be aware of high-risk factors associated

with poor clinical outcomes in injured children. Compilation and
evaluation of data collected from the National Pediatric Trauma
Registry and other recent studies show that mortality in pediatric
trauma victims is most closely linked to the presence and severity of
head injury.20,21 These studies suggest mortality after neurologic
injury is greatest in children less than 5 years of age.21 Early
identification and management of head injurywith specific attention
to increases in intracranial pressureare critical to maximizing
outcomes.

Assessment Considerations. Initial assessment of the injured child

is complicated by a number of variables, including difficulties
communicating with a frightened and anxious child; developmental
differences among patients of various ages; barriers to obtaining an
objective history from the patient and witnesses; and failure to
identify occult injuries soon after impact, while the child is still able to
physiologically compensate for blood loss. The emergency physician
also should recognize the psychological and emotional needs of
injured children who frequently endure the stress of being removed
from the comfort of their family and subsequent transport to an ED,
where eventually they undergo invasive procedures in the absence of
parental emotional support.

Specific Management Principles. The most constructive

management approach to pediatric trauma care is based on principles
outlined by the American College of Surgeons Advanced Trauma Life
Support (ATLS) course. Widely used and integral to trauma
management, ATLS principles should be adapted, when necessary, to
accommodate clinically relevant anatomic and physiologic differences
between children and adults. The ATLS approach stresses repetition,
intervention, and protocols, and is designed to ensure that potentially
life-threatening injuries are not overlooked while more dramatic, but
less physiologically significant injuries receive attention.

Initial Evaluation. Initial evaluation of the pediatric trauma victim

consists of basic resuscitation combined with simultaneous attention
to diagnosis and management of life-threatening injuries and
complications. Assessment begins with the primary survey, a rapid,
orderly appraisal of the patients vital organ systems and physiological
processes. This survey, which should be interrupted only in the case
of complete airway obstruction, includes assessment and
management of the airway (with attention to possible cervical spine
injury), ensuring adequate oxygenation and ventilation, maintenance
of circulatory status (including control of hemorrhage and fluid
resuscitation), and evaluation of neurologic status. Immediate goals
of the primary survey include systematic identification of all life-
threatening, pathophysiological derangements and prioritization of
their management.

The secondary survey, which is directed at documenting specific

injuries, should be completed after major physiological instabilities
(airway, breathing, etc.) are recognized and treated during the
primary assessment phase. As part of the secondary survey, the child
should be completely undressed and examined for injuries that may
have been overlooked or otherwise not addressed during the primary
survey. Suspected skeletal injuries must be splinted and a
neurovascular examination documented. (See Figure 1.)

After the primary and secondary surveys are completed,

measurement of temperature and serum glucose is of special
importance in children. Failure to recognize and correct abnormalities
in either of these two vital signs can complicate resuscitation, and
may compromise clinical management. For example, hypoglycemia in
infants and young children results from inefficient glucose
homeostasis and suboptimal glucose storage, and when present,
causes depressed level of consciousness, apnea, seizures, and
refractory arrhythmias, including bradycardia or asystole. Significant
hypothermia can make the neurologic exam unreliable, and can
produce metabolic abnormalities, arrhythmias, systemic
catecholamine resistance, and myocardial depression. 22

The Pediatric Airway. In the setting of pediatric trauma, inadequate

airway management is the single most important cause of morbidity
and mortality in an otherwise salvageable patient. 20 Consequently,
practitioners caring for children with major injuries should be able to
secure an airway and achieve intravenous access in patients of all
ages and body types. Although generally not difficult for physicians
with experience in managing the pediatric airway, endotracheal
intubation can be associated with complications that must be
recognized and appropriately managed.23 Accordingly, standard (i.e.,
first-line) as well as alternative approaches to intubation should be
learned and practiced, and these skills should be maintained through
repetition.

Airway management begins with careful observation from a non-

threatening distance, an approach that is designed to reduce anxiety
in the alert and conscious child. All trauma victims should be assumed
to be oxygen-deficient, and provided with supplemental oxygen. The
most common etiologies for airway obstruction in children are
redundant soft tissues of the posterior pharynx and a relatively large
tongue in relation to the size of the oropharynx. As a result, the
airway should initially be opened with simple maneuvers before
attempting more invasive techniques. The use of an oral airway is
controversial. Although not well-tolerated in the awake child, an oral
airway is, perhaps, appropriate only in the patient who is ventilating
normally, but whose airway is at risk for obstruction due to an altered
level of consciousness. On the other hand, it should be pointed out
that patients who are tolerating an oral airway probably have no gag
reflex, and if this is the case, rapid sequence intubation (RSI) is
probably the most prudent course.

Eliminating impediments to ventilation and managing airway

complications are of special concern in the pediatric patient. For
example, significant gastric distension from crying or from assisted
ventilation can cause upward pressure on the diaphragm and, as a
result, may compromise respiratory excursion. When impingement of
respiratory motion is considered clinically significant placement of a
decompressing oral or nasogastric tube will often help increase the
effectiveness of spontaneous respirations, and in the process, will
reduce the risk of emesis and subsequent aspiration. Insertion of
these devices should be attempted only in patients in whom an airway
has been secured. While all children are at risk for emesis from
increased aerophagia, recent meals, and pain, the effectiveness of
gastric decompression is limited by the size of tube accepted by the
oropharynx and the proximal gastrointestinal tract. Although external
compression of the esophagus (Sellicks maneuver) is often useful and
may limit the risk of emesis and aspiration, this technique should be
used with caution in the very young child. Because patients in this age
group have a trachea that is extremely compliant, excessive pressure
to the esophageal region, on occasion, can result in airway
compression or tracheal injury. Of course, nasogastric intubation
should not be attempted in the child with midface injury, which
increases the risk of penetration through the cribriform plate.

The goals of endotracheal intubation include: 1) Securing an intact

airway; 2) protection of a jeopardized airway, and; 3) providing an
airway when none exists. The technique for oral endotracheal
intubation in children is basically the same as in adult patients, and
the same contraindications and precautions apply. RSI should be
considered in the child with significant neurologic injury who is
suspected of having increased intracranial pressure, or when the
clinical situation makes conscious intubation difficult. 24

Unique anatomic and physiologic characteristics of the pediatric

airway that influence airway management in this population include
the following:

Children younger than 6 months of age are obligate nose breathers,

and anything obstructing the nose (i.e., NG tube, tape, nasal prongs,
etc.) in a spontaneously breathing child may potentially obstruct the
airway.

The relatively large tongue, the redundant soft tissues of the

posterior pharynx, and adenoid and lymphatic hypertrophy often
contribute to upper airway obstruction in children.

Vocal cords are cartilaginous and pliable.

The larynx lies more anterior and more cephalad in children-the

glottis is at the level of C3 in infants, C4-5 in young adults-making
direct visualization more difficult for the inexperienced clinician.

The trachea is very short in infants (5 cm at birth, 7 cm at 10

months of age), making dislodgement and malpositioning of an
endotracheal airway more common in children.

The narrowest portion of the pediatric airway is in the subglottic

area, rather than at the level of the true cords as in an adult patient.
This feature has special implications for airway management in
children with medical indications for intubation (i.e., tracheitis, croup,
or epiglottitis), but may also complicate the intubation of the airway
in the injured child.

The presence of prevertebral edema or hematoma will affect

patency of the subglottic airway before obstruction can be visualized
at the level of the cords.

Several caveats concerning airway assessment and interventions in

children deserve mention. First, because of the anterior and cephalad
position of the glottis and the redundancy of the soft tissues of the
posterior pharynx, blind nasotracheal intubation is difficult in pediatric
patients. Therefore, this technique should be reserved for patients 8-
l0 years of age or older. Second, because tracheal rings are poorly
developed and more easily damaged in young children, cuffed
endotracheal tubes should not be used in patients less than 8 years of
age. The normal subglottic narrowing in the pediatric airway serves as
a physiologic cuff in younger children, helping to secure the
endotracheal tube and providing some protection from aspiration.

Although rarely used, retrograde intubation has been described in

adults and may be attempted in a child, but only if alternative
methods for securing an airway have been exhausted. This technique,
however, may be especially useful when trying to place an airway in a
patient who is being resuscitated at the scene of an injury, and in
whom positioning for direct visualization and intubation is difficult
(i.e., when the patient cannot be quickly extricated from a heavily
damaged vehicle). It should be stressed that surgical
cricothyroidotomy is contraindicated in children less than 12 years of
age, in whom the surgical airway of choice is needle-jet insufflation
through a large-bore catheter positioned through the cricothyroid
membrane. Although a large-bore catheter does not represent the
ideal approach for ventilation, adequate oxygenation can usually be
maintained until an emergency tracheostomy is performed.

Once an airway is obtained, monitoring and care of the airway,

including measurement of end-tidal CO2, is the responsibility of a
designated member of the resuscitation team. Assigning this function
to a specific individual is critical because loss of a previously-secured
airway is an all too frequent an occurrence in children, and may
produce rapid clinical deterioration. After securing an intact airway,
oxygenation and ventilation should be maximized, but with the
understanding that a patent airway does not always guarantee
adequate gas exchange. In this regard, transcutaneous pulse
oximetry provides a very useful indicator of systemic oxygenation,
although its limitations should be recognized. 25 Definitive evaluation of
oxygen saturation, adequacy of ventilation, and assessment of acid-
base status are best accomplished with arterial blood gases, which
should be obtained in all children with serious injuries.

Circulation. All pediatric patients who have sustained significant

trauma require immediate placement of two large-bore intravenous
(IV) lines. Priority sites in children include the antecubital and femoral
vessels. Internal jugular access can be difficult in children with short
and fat necks, and can be further complicated by cervical spine
immobilization. Some emergency physicians are comfortable with
subclavian access in very young children, but the complications
associated with this approach must always be considered, i.e., the
risk of pneumothorax and difficulty in achieving hemostasis if a major
arterial vessel is severed. Saphenous, femoral, and brachiocephalic
vein cutdowns also can be attempted, but these approaches are time-
consuming and, often difficult. When peripheral or central IV access
can not be achieved within a reasonable time, intraosseous access
represents a rapid and effective mechanism for providing fluid
resuscitation and administering medications to a child in extremis.
Techniques for placement of intraosseous lines are discussed in most
emergency medicine textbooks and in a recent review. 26

Once fluid resuscitation is started, ongoing blood loss must always be

prevented with application of direct pressure over exsanguinating
wounds. Other techniques, such as placement of tourniquets or
clamping and ligation of individual vessels are practices that generally
should be avoided. The indications for pneumatic antishock garments
(PASG or MAST trousers) in children are unclear. There are no studies
demonstrating increased survival with this procedure, which is
contraindicated in thoracic trauma. Although these devices are useful
for mechanical stabilization and tamponade of severe, displaced pelvic
fractures-as well as for stabilization of long bone fractures in the
lower extremities-great care should be taken not to impede
respiratory efficiency in the spontaneously breathing child by
overinflating the abdominal portion of the device. In this regard,
improperly fitting trousers can produce direct pressure over the lower
rib margins, causing restriction of chest expansion. The associated
increase in intra-abdominal pressure can further compromise
diaphragmatic excursion and reduce minute ventilation.
Contraindications to the use of PASG devices in children include
penetrating chest injury, suspicion that a major intrathoracic vessel
has been disrupted, congestive heart failure, and pulmonary edema.

The least acceptable blood pressure in a child may be estimated by

the formula: 70 + (2 x age in years). All patients who are hypotensive
or who show other, more subtle signs of hemodynamic compromise
(tachycardia, pallor, cold extremities, diminished pulses) must be
assumed to be volume deficient and treated accordingly. In general,
there is no role for the use of pressor agents in the initial
management of the pediatric trauma victim, unless vigorous volume
replacement has been shown to be ineffective. Because compensatory
mechanisms for intravascular volume depletion are extremely efficient
in children, hypotension should be considered a late, ominous, and
even a preterminal event in the setting of volume loss due to
traumatic hemorrhage. Consequently, in the pediatric patient,
tachycardia, delayed capillary refill, alterations in pulse volume and
pressure, and changes in mental status in the absence of significant
head injury are better early indicators of significant blood loss and,
therefore, demand immediate intervention.

In this regard, volume replacement in children should be aggressive

and initiated as soon as possible: 20 cc/kg of crystalloid represents
the standard, initial fluid challenge, and should be repeated as
necessary. A reasonable estimate of a childs total blood volume is
approximately 80 mL/kg of body weight. Nevertheless, replacing
blood loss equal to 25% of the total blood volume usually requires 60
mL/kg of crystalloid, since fluid shifts restrict the volume remaining in
the intravascular space. Blood replacement should be considered in
the child whose volume requirements are excessive and in patients
with continuing hemorrhage and/or hemodynamic compromise.
Hypertonic saline has been studied extensively in adult trauma, but its
use has not yet replaced more standard resuscitation fluids (i.e.,
normal saline) supplemented by colloids such as whole blood, packed
red blood cells, albumin, and dextran. As a result, the use of
hypertonic saline in children requires further study before firm
recommendations can be made.

Cervical Spine Trauma

Assessment. Thorough and precise evaluation of the pediatric

cervical spine in infants and children is complicated by developmental
(i.e., structural) factors, by inherent difficulties examining an anxious,
frightened patient, and, sometimes, by the presence of associated
injuries. Generally speaking, therefore, the clinician should assume
that cervical spine injury is present in any child who has sustained
injuries above the level of the clavicles, or, if the mechanism of injury
is consistent with axial loading or sudden acceleration or deceleration
forces. In other words, presumptive evidence of a normal cervical
spine is inadequate and, therefore, immobilization techniques
consistent with the patients size and age should be instituted and
maintained until cervical spine injury has been excluded with
confidence.

Special Considerations. Although skeletal injuries of the cervical

spine are uncommon in children, they usually involve the high cervical
vertebra and, therefore, are frequently life-threatening. This pattern
is different than that seen in adult patients, in whom injuries of the
middle or lower cervical vertebrae predominate. The evaluation of
cervical spine injuries in injured children can be problematic because
of unique anatomic and radiographic characteristics of the normal
pediatric spine. An understanding of these features will facilitate
appropriate management of patients with suspected cervical spine
injuries. They include:

The presence of redundant prevertebral soft tissues can

radiographically mimic soft tissue edema or hematoma. This
anatomical feature also can contribute to mechanical upper airway
obstruction, especially if the neck is improperly positioned during
immobilization.

Children younger than 8 years of age have an increased cartilage-

to-bone ratio, which is associated with increased ligamentous laxity of
the cervical spine.

Anterior wedging of the vertebral bodies, which results from

incomplete ossification, can radiographically simulate multiple
compression fractures; this finding may also contribute to the
radiographic phenomenon of pseudosubluxation at the level of C2-C3.

Fractures can be simulated radiographically in children by the

presence of ossification centers and epiphyseal lines in developing
cervical vertebrae.

The horizontal orientation of facet joints is exaggerated in pediatric

patients, making the spine more elastic and mobile and, therefore,
increasing susceptibility to serious injury even in the absence of a
documented fracture.

Ligamentous laxity contributes to the normally widened predental

space in children.

Pseudosubluxation of C2-C3 (up to 4-5 mm), which is present in

40% of children younger than 7 years of age, can sometimes mimic
cervical injury at this level.

The infants head is disproportionately large when compared to the

body, and is poorly supported by the developing musculature of the
neck and shoulders, making the cervical spine more susceptible to
injury during sudden and violent flexion, extension, or rotation of the
head and neck.

The fulcrum for flexion and extension of the childs neck is at the
C2-C3 level, lending greater mobility to the cervical spine, but also
predisposing to high cord lesions.

Spinal cord injury without radiographic abnormality (SCIWORA) is a

well-described phenomenon in children younger than 9 years of
age.27-29 This phenomenon underscores the importance of a
conservative approach to the management of pediatric trauma victims
who present with an abnormal physical examination or who report a
mechanism of injury known to produce spinal cord injury. Although
the reported incidence of SCIWORA varies greatly, a significant
percentage of pediatric cervical cord injuries occur in the absence of
radiographically detectable bone injury.29,30 Consequently, all children
with altered level of consciousness, head trauma, significant injury
above the level of the first rib and clavicle, an abnormal neurologic
examination, or high speed/impact mechanism of injury should be
suspected of having spinal cord injury, even in the absence of
conclusive radiographic abnormalities. When clinical indicators, i.e.,
neurologic dysfunction, suggest cervical spine injury in the presence
of a normal radiographic exam, MRI or CT scans can be useful in
delineating cervical abnormalities.

Intervention. Management of suspected cervical spine injury

includes immobilization of the entire spine (not just the head and
neck), and prompt orthopedic or neurosurgical referral in the event of
clinical or radiographic evidence of spinal cord injury. Supine kyphosis
anterior translation (SKAT) describes the anatomical changes of the
fractured cervical spine that can occur when young children are laid
supine on a backboard. Proper positioning for improved patency and
maintenance of an open airway requires placement of enough padding
to bring the patients shoulders in horizontal alignment with the
external auditory meatus of the ear. The beneficial role of
glucocorticoids in adult patients with acute spinal cord injury has been
clearly demonstrated.31-33 Unfortunately, these prospective studies
have systematically excluded patients younger than 13 years of age
from their protocols, and therefore, it is difficult to make definitive
recommendations for steroid use in this age group.

Chest Trauma

Background and Evaluation. Although severe chest trauma is less

common in children than adults, when signs of significant blunt or
penetrating injury to the chest are present, the physician can assume
that associated injuries are likely and that mortality rate in these
patients will be significant,34,35 with most of the increase in mortality
being secondary to associated injuries. With respect to chest trauma,
the most frequently reported mechanisms of injury are vehicle-
pedestrian impact, automobile crashes, child abuse and, in some
urban practice settings, penetrating thoracic injury. It should be
emphasized that chest injury in children is rarely an isolated event,
and when present in association with either abdominal or head
trauma, a poor outcome can be expected.34 In fact, one large study
reported a mortality rate of 71% among children younger than l5
years of age who had rib fractures in association with head injury. 34

In general, the presence of rib fractureswhich is unusual in children

even after significant impactis a particularly ominous sign, because
the bony thorax in the pediatric age group is usually more compliant.
Hence, not only are rib fractures uncommon but when they do occur
in infants or children, they usually signify severe trauma and
increased mortality. As is the case for adult patients, fractures of the
first thoracic rib should prompt a search for associated major vascular
injury.36 Myocardial contusion37 and papillary muscle rupture are
rarely seen in children, but when present are characterized by sinus
tachycardia, cardiac arrhythmias, and cardiovascular collapse
accompanied by congestive heart failure.

Identifying significant chest injury in children can be very difficult,

because vital signs are frequently normal initially, symptoms are often
delayed for several hours after injury, and because radiographic
abnormalities frequently are not evident until later in the patients
course.38 In addition, interpretation of plain radiographs of the chest
and mediastinum in young children may be complicated by an
enlarged thymic shadow (a normal variant) and by delayed
ossification of thoracic bony structures. Significant diagnostic
limitations associated with standard radiographs in patients with chest
trauma were confirmed by a study in which 38% of intrathoracic
injuries were missed by plain (supine) chest radiographs, but
subsequently identified during CT evaluation for suspected intra-
abdominal hemorrhage.39 The clinical significance of injuries missed
by plain chest radiography but detected by CT scan for other
indications is not known. Finally, such techniques as transthoracic and
transesophageal echocardiography, which have been shown useful as
screening tools in adult patients suspected of having major aortic or
blunt cardiac injury, have not yet been scientifically evaluated for use
in children.40,41

Complications and Interventions. The approach to life-threatening

intrathoracic injuries must be systematic. Appropriate interventions
should be initiated as early as possible, usually within the time frame
for establishing a patent airway and beginning volume resuscitation.
When cardiac arrest occurs after significant blunt or penetrating chest
trauma in the pediatric age group, the physician should suspect
catastrophic intrathoracic or intra-abdominal hemorrhage. Indications
for performing an emergency thoracotomy in children are the same as
those in adult patients.42 While studied less extensively in children,
the outcome in this age group when vital signs are absent on
presentation is poor.43

Consequently, the decision to perform emergent open thoracotomy in

the ED should be individualized and is based on the childs initial
presentation. Nevertheless, most pediatric trauma surgeons concur
that this procedure should be strongly considered in a child with
penetrating chest injuries and documented vital signs in the ED or
during the immediate prehospital resuscitation phase.

Chest injuries in pediatric patients most often involve air-containing

structures; pneumothorax, bronchial rupture, and esophageal
contusion are commonly reported complications. While they do occur,
myocardial contusion, tamponade, and aortic rupture are less
common in children than in adults. Tension pneumothorax is a
common and treatable cause of respiratory distress in children who
have sustained significant chest trauma. In addition to adversely
affecting oxygenation and ventilation, tension pneumothorax in a child
can produce dramatic shifts in mobile mediastinal structures and
impair venous return to the heart. Mediastinal compression associated
with tension pneumothorax can produce a decrease in cardiac output
if treatment is delayed. The diagnosis is suggested by the presence of
dyspnea, hyperexpansion and hyper-resonance on the affected side,
in conjunction with decreased breath sounds, impaired chest wall
movement, jugular venous distension, and a tracheal shift to the
contralateral side. It should be noted that findings mimicking those
seen in tension pneumothorax can also be observed in hemothorax
and pulmonary contusion, in which case plain radiographs of the chest
will help clarify the diagnosis.

Initially, the unstable patient with tension pneumothorax requires

placement of a large-gauge angiocatheter into the affected
hemithorax. Catheter entrance should be guided through the second
or third intercostal space at the level of the midclavicular line; a rush
of air and normalization of vital signs usually confirms the diagnosis.
Definitive therapy includes a tube thoracostomy with continuous
suction through an underwater seal.

Because the bony thorax is extremely compliant and rib fractures are
unusual, open pneumothorax and flail chest are uncommon in young
children after blunt injury. Positive pressure ventilation is beneficial in
both conditions, and should be initiated early in the symptomatic
patient. Open lesions of the chest wall should be covered with a
sterile dressing and secured on three sides to allow spontaneous
decompression of intrathoracic air while preventing ventilation
through the defect in the chest wall. Definitive management for both
flail chest and open pneumothorax includes placement of a tube
thoracostomy and surgical closure of the chest wall.

Abdominal Trauma
General Principles. Although the epidemiology of pediatric trauma
appears to be changing, most abdominal injuries in children are the
result of blunt impact. Most often, they are associated with
multisystem injury. Although motor vehicle accidents, falls, and
vehicle-pedestrian accidents account for most cases of pediatric blunt
trauma, infants and children who are the victims of assault (physical
abuse), those who sustain lap belt injuries, or are injured from being
thrown over the handlebars of a bicycle also are at high risk for
significant abdominal injury. Sadly, significant mortality occurs in
young children who are victims of intentional injury, because their
presentation is often intentionally delayed and the mechanism of
injury is frequently concealed by the parents or guardians during the
initial history.44 Because of the childs relatively compact torso, energy
from blunt trauma is dissipated over a small area, increasing the
potential for internal injury, which can occur without external
evidence of trauma. Finally, successful management of intra-
abdominal injuries requires a knowledge of anatomic and physiologic
differences between children and adults, a high index of suspicion,
and expedient intervention as dictated by the childs clinical
presentation.

Initial Assessment. Physical assessment of the injured child is often

difficult and can produce misleading information. Hence, the
importance of serial examinations that permit the clinician to monitor
a patients course cannot be overemphasized. For example, intra-
abdominal injury may occur in the absence of significant physical
findings. In this regard, mild-to-moderate localized tenderness during
palpation or percussion are important but inconsistent findings, even
with severe abdominal injury. Because abdominal injury is rarely
isolated in the child who has had blunt trauma, a diligent search must
always be made for other potentially treatable, life- threatening
injuries.

Clinical predictors for significant abdominal injury in adults include

hypotension, pelvic ring disruption,45 arterial base deficit of 6,46
abdominal wall contusion/abrasion, femoral fracture/hip dislocation,
Glasgow Coma Scale score of < 12, respiratory insufficiency, rib
fracture below the sixth intercostal space, and any intrathoracic
injury. Among patients with abdominal injury, 99% will have one or
more of these risk factors and/or abdominal pain/tenderness. 47 While
not studied specifically in pediatric patients, these markers for
potential intra-abdominal injury in adults also may help predict
significant injury in children.

The most dreaded complication of intra-abdominal injury is life-

threatening hemorrhage, whose clinical presentation consists of
tachycardia and signs of poor perfusion, including prolonged capillary
refill, decreased urine output, altered mentation, pallor, cool
extremities, and asymmetry between central and peripheral pulses.
Because children have extremely efficient compensatory mechanisms
for volume loss, the presence of hypotension suggests a significant
volume deficit or severe myocardial dysfunction. In addition, children
can experience respiratory compromise from aerophagia and
secondary abdominal distension. Acute gastric distension can also
impair venous return by compression of the vena cava, which can
cause a precipitous fall in right atrial filling pressure and cardiac
output. In addition to relieving gastric distension from swallowed air,
gastric intubation reduced the risk of aspiration of food content, while
facilitating serial abdominal examination. Naturally, the usual
precautions and contraindications (i.e., unsecured airway, absent gag
reflex, etc.) regarding placement of an oro- or nasogastric tube
should be observed.

Because immature skeletal structures have greater compliance,

significant abdominal and pelvic visceral injury in children, unlike
adults, may occur in the absence of fractures. For example, the
bladder is an intra-abdominal organ in infants and young children,
making it more susceptible to injury after blunt abdominal impact.
Placement of an appropriately sized urethral catheter will simplify
evaluation and management by relieving bladder distension and
enabling accurate measurement of urine output. The presence of
hematuria, while nonspecific, suggests possible intra-abdominal or
retroperitoneal injury. A urinary catheter should be placed only after
the rectum and genitalia have been examined and urethral injury has
been ruled out.

Diagnostic Evaluation. Plain radiographic evaluation can help

identify abdominal injuries, but its value is limited by the childs
supine position and by a paucity of specific findings.
Pneumoperitoneum suggests a ruptured viscus. The presence of
peritoneal fluid collections, paralytic ileus, sentinel loops of bowel, and
mucosal edema are nonspecific findings associated with blunt
abdominal injury. Splenic injury, in particular, should be suspected
when normal soft tissue silhouettes are obscured by free fluid or
blood. Other radiographic findings that increase the likelihood of
splenic injury include displacement of adjacent organs in the left
upper quadrant (stomach, left kidney, splenic flexure of the colon,
and left hemidiaphragm), pleural effusion or atelectasis in the left
lung base, and overlying rib fractures. Blunt liver injury, with or
without involvement of the biliary structures, may produce similar
findings in the right upper quadrant. Pancreatic, intestinal, and renal
injuries produce nonspecific findings on plain films, and when present,
require directed evaluation.

Diagnostic peritoneal lavage (DPL) is indicated in unstable patients

who: l) Demonstrate continued signs of hemodynamic instability; 2)
whose signs, symptoms, and physical findings strongly suggest intra-
abdominal hemorrhage; and, 3) in children with a mechanism of
injury strongly suggestive of intra-abdominal injury, but who require
urgent, operative intervention for another associated injury.

Computed tomography (CT) has been shown to be especially useful

for evaluating suspected blunt abdominal injuries in hemodynamically
stable children. In most centers, this modality has assumed a pivotal
role in triaging and managing pediatric trauma victims with suspected
intra-abdominal injury. One important study suggests that stable
pediatric patients at risk for serious intra-abdominal injury fi.e, based
on mechanism of injury, screening laboratory studies, and physical
examination) benefit from CT evaluation, as do patients who are
stable but for whom reliable serial examination of the abdomen is
impossible (i.e., patients with altered mentation due to head injury or
intoxication, patients who must undergo prolonged anesthesia for
other injuries, patients with neurologic injury capable of masking
physical findings, and very young infants or children). 48

Other investigations, however, suggest that although abdominal CT

may be extremely helpful in delineating the location and extent of
internal injury after blunt abdominal trauma, there is very little
correlation between the extent of injury demonstrated
radiographically and the need for laparotomy.49,50 Consequently, CT
scanning of the abdomenas an isolated diagnostic modalityis
probably not useful for guiding therapeutic decision-making with
respect to the need for laparotomy. Therefore, evidence of visceral
injury by computed tomography must be considered in the context of
the child's overall clinical condition, and supplemented with serial
examinations that have been proved useful for making triage
decisions and guiding definitive operative management.
The value of routine abdominal CT scanning in the setting of pediatric
head trauma deserves special mention. One recent prospective study
of children with severe head trauma reported on 65 consecutive
pediatric patients.43 Investigators observed that l5 of these cases
(23%) had positive findings on routine abdominal CT scan. Six of 27
low-risk patients (those patients who were hemodynamically stable
with no specific physical findings referable to the abdomen no
hematuria) had visceral injury on CT scan. Three of 26 patients (l
l.5%) with only isolated microscopic hematuria had evidence of
abdominal injury by CT scan (l renal, l hepatic, and l hepatosplenic
injury). Six patients (10%) had physical examination findings
suggestive of visceral injury (tenderness and/or distension), but had
normal abdominal CT scans. All five patients in this series who were
hemodynamically unstable had intra-abdominal injuries confirmed by
CT. According to this study, and as previously discussed, findings on
CT scan failed to predict the need for operative intervention. Finally,
there were no false-negative scans, (i.e., no deterioration was
observed in patients with an initially normal abdominal CT study).

Another study prospectively examined 482 head-injured pediatric

patients to determine precise indications for abdominal CT scans to
evaluate the risk for severe abdominal and chest injury. The children
were divided into two groups based on GCS (8 or > 8). In addition to
showing a significant increase in mortality in the neurologically
impaired group (24% vs 0.26%), there was also an increased risk for
serious intra-abdominal injury in patients with head trauma. However,
all children in this study with positive findings on abdominal CT had
evidence of underlying abdominal injury based on physical
examination. In contrast to the previous investigation, this group
concluded that abdominal CT is best reserved for children at
significant risk for abdominal injury based on mechanism of injury and
clinical presentation, and that neurologic impairment alone, without
specific evidence of abdominal injury, is a low-yield indicator for need
for CT scan. In summary, CT scanning of the abdomen is probably
indicated in any child who is hemodynamically stable, who has an
unreliable examination for any reason, and who is at risk for intra-
abdominal injury based on mechanism of injury or physical
examination.

CT scanning is also useful for identifying associated pelvic fractures

and hematoma, retroperitoneal hematoma, free air, and bowel
perforation.52 Chance fractures, genitourinary injury, and52,53 occult
chest injury also can be detected . As stressed previously,
management decisions must be based on clinical findings and serial
examination in conjunction with CT findings.

Some experts advocate measurement of liver enzymes as a screening

procedure in children at risk for hepatic injury. One group reported on
309 adult victims of blunt trauma, 52 (17%) of whom were shown to
have intra-abdominal injury.54 Fifty-nine patients (19% of the study
population) had SGOT and SGPT levels greater than 130 IU/L; 30 of
these patients had identifiable abdominal injury (l8 involving the liver,
either alone or in association with other visceral injury). No patient
with liver injury had enzyme levels less than 130 IU/L. The sensitivity
of the test for all intra-abdominal injuries was 58.8%, with a false
positive rate of 10.9%. Another group of investigators retrospectively
studied 43 hemodynamically stable children after blunt abdominal
trauma who underwent CT scanning of the abdomen.55 Nineteen
patients (44%) had AST levels > 450 IU/L and ALT levels > 250 IU/L;
l7 of these l9 patients had evidence of hepatic injury on CT scan.
Sensitivity and specificity for abdominal injuries were 100% and
92.3%, respectively. They concluded that elevated hepatic enzymes
in stable children at risk for intra-abdominal injury are likely to be
associated with hepatic contusion or laceration. In a prospective study
of children younger than l2 years of age, who were evaluated for
physical abuse and who had no physical signs of abdominal injury,
enzyme determinations also proved useful. 56 Of 49 children with these
risk factors, four (8%) had elevated hepatic transaminase levels,
three of whom had clinically occult liver lacerations documented by CT
scan. Only patients with abnormal transaminase values underwent
evaluation by CT scan in this study.

The value of hematuria as a marker for abdominal injury in 378

consecutive children undergoing abdominal computed tomography
after blunt trauma has also been evaluated.57 In this study population,
256 patients (66%) had hematuria (52 were dipstick positive but with
< 10 RBC/hpf, l68 had microscopic hematuria with > 10 RBC/hpf, and
36 had gross hematuria). The presence and degree of hematuria
correlated with renal and other abdominal (non-genitourinary) injuries
as documented by CT scan. Organs in most frequently injured in
children with hematuria were the spleen (37%) and the liver (33%);
renal injury was less common, occurring in only 26% of children with
hematuria. Fifty-three children had hematuria with a radiographically
normal genitourinary tract, 41 (77%) of whom had underlying
hepatic, splenic, or pancreatic injury. These investigators concluded
that, although hematuria after blunt abdominal injury is a marker for
potential genitourinary injury, it may also predict the presence of
associated or isolated non-genitourinary abdominal injury. Hence,
physical examination, mechanism of injury, and need for fluid
resuscitation remain the best predictors for potential abdominal
injury, although ancillary studies such as urinalysis and enzyme
determinations may be useful if properly applied.

Management. Patients with hepatic or splenic injury who are

hemodynamically stable may be selectively managed non-operatively
with admission to the pediatric ICU for careful monitoring and serial
examinations. All patients require IV access, gastric decompression,
and serial hematocrit determinations. Clinical deterioration manifested
by hemodynamic instability, development of peritoneal irritation, or
transfusion requirement of greater than 40 cc/kg PRBC is an
indication for immediate laparotomy. At most institutions equipped for
major pediatric trauma, the majority of patients can be managed non-
operatively, even with HCTs as low as 20%, as long as they are
hemodynamically stable, monitored closely in the PICU, and have an
pediatric surgeon in attendance. In keeping with the trend toward
nonoperative management for children who remain hemodynamically
stable, as many as 90% of children with blunt hepatic injury may be
successfully managed conservatively without operative intervention. 58
Recent studies suggest that splenic injuries are at least as likely as
hepatic injuries to resolve without operative intervention, due in part
to the support of the thicker and more compliant splenic capsule. 59 It
should be emphasized that the incidence and mortality associated
with overwhelming post-splenectomy infection is considerable.
Specifically, the incidence of infection by encapsulated organisms
after splenectomy is increased by approximately 60-fold, with a
mortality rate estimated to be between 50-70%.60-63 Consequently,
spleen-salvaging management approaches are indicated in all cases in
which the childs clinical condition permits. When this is not possible,
appropriate immunizations against encapsulated organisms should be
administered as soon as possible prior to operative removal of the
spleen.

Follow-up computed tomography is indicated 7-10 days following

trauma to monitor for resolution and healing of either splenic or
hepatic injury after nonoperative management. Ultrasound, although
not as sensitive as CT scan for initial evaluation of blunt abdominal
injury, is useful for long-term follow-up of injuries identified at the
time of hospital admission.64 Subcapsular hematoma has been
associated with delayed rupture, and in rare cases with hepatic
abscess; these sequelae underscore the importance of long-term
follow-up.

Summary

Evaluation and management of the injured pediatric patient can be

difficult and requires a systematic approach to assessment that
includes a primary and secondary survey, followed by specific
interventions directed at life-threatening injuries. Securing an airway
is of paramount importance during the initial resuscitation, as is
restoration of circulating blood volume. Following initial resuscitative
measures, a management plan should be formulated promptly and
should be based upon information culled from the physical
examination, the history (i.e., mechanism of injury), and diagnostic
modalities that include but are not limited to CT scanning, diagnostic
peritoneal lavage, serum enzyme determinations, CBC, and urinalysis.
Definitive operative intervention is always guided by the patients
clinical status.

Finally, the trauma team leader must be aware not only of the pitfalls
associated with pediatric trauma carediagnostic difficulties,
problems negotiating life-threatening procedures, and confusion
regarding proper drug dosing in pediatric patientsbut must also be
sensitive to the special needs of the child and his or her family during
and soon after the acute resuscitation.

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