Chapter-28 Pediatric Trauma

BOOK TITLE: Principles and Practice of Trauma Care

1. Arora M
Publishing Year
Author Affiliations
1. Army Research and Referral Hospital, Delhi Cantt, New Delhi, India, Army Base Hospital, New Delhi, India
Chapter keywords
pediatric trauma, blunt injuries, penetrating injuries, head injury , spinal cord injury, chest trauma, abdominal trauma, resuscitation , primary survey , secondary survey, diagnosis, assessment, nonoperative, operative management.


Traumatic injuries are the cause of more than half the deaths among children aged 1 to 14 years and are the second leading cause of emergency room visits after infections. Blunt trauma accounts for more than 60% of childhood injuries. Head trauma is most common, but the most severely injured children have multi-system injuries. In children aged 2 years or younger, physical abuse is the most common cause of serious head injury. Shaken baby syndrome (SBS) is characterized by retinal hemorrhage, subdural or subarachnoid hemorrhage, and little evidence of external trauma. In children aged 3 years and older, falls and motor vehicle, bicycle, and pedestrian accidents are responsible for most traumatic brain injuries. Children tend to sustain injuries that produce diffuse edema rather than those that cause focal space-occupying lesions. Hypotension and hypoxia should be aggressively avoided and are known to produce secondary injury. The treatment goals were as follows: ICP less than 20 mmHg, CPP greater than 40 mmHg, normovolemia, normotension, normoventilation, and sedation as needed. Albumin and packed red blood cell transfusion were used to promote colloid osmotic pressure and to ensure adequate cerebral oxygenation. Spinal cord injury without radiologic abnormality (SCIWORA) syndrome is a problem unique to the pediatric population. MRI evaluation of SCIWORA is important in determining a prognosis but is not useful in determining stability of the spine. Thoracic injury is the second leading cause of death in pediatric trauma. Thoracic injury occurs in about 5% of children hospitalized for trauma. Pulmonary contusion, pneumothorax, and rib fractures are the most common injuries. Hemothorax and pneumothorax are the most common thoracic injuries from penetrating trauma. Chest exploration is indicated for an immediate return of 20% of the patient\'s estimated blood volume or a continued output of 2 mL/kg/h. Children\'s small, pliable rib cages and undeveloped abdominal muscles provide little protection of major organs. Solid organs (spleen, liver, kidneys) are vulnerable to injury. Nonoperative management is considered the standard of care for most children with blunt solid organ injury who are clinically stable. A key distinction between adult and pediatric nonoperative management of solid organ injury is that adults are more prone to late failure (e.g., >5 d), whereas 98% of pediatric failure is within 72 hours. Emergency medical team must be trained in rapid pediatric cardio-respiratory assessment, prompt establishment of effective ventilation (airway), oxygenation (breathing), and perfusion (circulation), as well as in stabilization and transport of injured or ill children to the treatment facility. The primary survey or initial phase of resuscitation should address life-threatening injuries that compromise oxygenation and circulation. Initial fluid resuscitation should consist of warm isotonic crystalloid solution (Ringer lactate or isotonic sodium chloride solution) at a bolus of 20 ml/kg.

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