Manual of pediatric trauma

Stroud, Michele M. Walsh, M. Pediatrics August ; 2 : e Children who sustain injuries with resulting disabilities incur significant costs not only for their health care but also for productivity lost to the economy. The families of children who survive childhood injury with disability face years of emotional and financial hardship, along with a significant societal burden.

The entire process of managing childhood injury is enormously complex and varies by region. Only the comprehensive cooperation of a broadly diverse trauma team will have a significant effect on improving the care of injured children. Unintentional and intentional injury and homicide cause more deaths in children and adolescents ages 1 to 18 years than all other causes combined.

It is estimated that 1 in 4 children sustain an unintentional injury requiring medical care each year. Improving outcomes for the injured child requires an approach that recognizes childhood injury as a significant public health problem. Additional topics related to the injured child can be found in other publications from the American Academy of Pediatrics AAP.

Children are injured in a wide variety of geographic locations, and the involvement of local and regional centers is paramount to optimizing care for injured children. A pediatric trauma system functions best as a part of the inclusive emergency medical services EMS , trauma system, and disaster response system at the local, regional, state, and national levels.

The inclusive trauma system is defined as one in which all EMS providers, physicians, other caregivers, and hospitals participate in the care of injured patients. Regional adult trauma centers and regional pediatric trauma centers are the central components of such a system. These systems allow for prompt communication, earlier recognition of critical injuries, and continuing education for trauma and emergency care providers.

An inclusive trauma system ranges from hospitals capable of initial stabilization to those that provide comprehensive trauma care. However, in many less populated states, the percentage of children living within 50 miles of a trauma center is much lower. Optimally, each trauma system will also define the age range of the pediatric patient on the basis of specific hospital and trauma team resources that are available.

When a regional pediatric referral center is available within the trauma system, the most severely injured children may be transported to a facility with a level I or II pediatric trauma designation. It has been recommended that a physician and nurse coordinator for pediatric emergency care be identified in each facility, with pediatric-specific policies, procedures, equipment, a quality-improvement process, and guidelines for care established.

Protocols for field and hospital triage, treatment, and transfer of victims of pediatric trauma are an important part of any trauma system. Benchmarking care by using risk-adjusted data is important for the ongoing improvement in pediatric care and system delivery models.

The outcomes for pediatric trauma patients can be compared with available benchmarks such as the National Trauma Data Bank, 21 and information shared with specific providers so that an optimal environment for quality improvement in pediatric trauma care is promoted. Prehospital providers may not be as familiar with effective pediatric emergency care as they are with the care provided to adults, 23 because most prehospital providers are infrequently exposed to critically ill or injured children.

Online and remote training may be an effective and reasonable alternative in largely rural states. No matter how continuing education is accomplished, mechanisms for assessing knowledge and skill retention and continuous evaluation of performance are crucial for prehospital personnel.

The method for maintaining skills may include continuous evaluation of performance or collaboration with a pediatric health care system that provides opportunities to maintain and expand on pediatric acute care knowledge and skills.

New projects that use simulation show promising results. This feedback can be provided by the receiving facility by using real-time reviews, case review presentations, or feedback to the referring prehospital agency.

There is a relative lack of data regarding the best practices for pediatric resuscitation in out-of-hospital traumatic cardiac arrest, including fluid administration, cervical spine stabilization, and airway management of children. The Broselow system does provide useful information for early resuscitation, and there are new recommendations for termination of resuscitation in the field.

Nurses with demonstrated competency in the care of pediatric trauma patients are an important aspect of care as well.

Management of the injured child requires special considerations. Issues that are unique to children include reducing diagnostic radiation exposure, family presence during resuscitation, 37 the availability of child life specialists, fluid and electrolyte management, and blood transfusions, to name a few.

Careful consideration of diagnostic radiation for trauma evaluation is always of primary importance because of the radiation dose that is often delivered. Specific guidelines for implementing and facilitating family presence during pediatric trauma care are useful to facilitate safety and efficacy of family presence within a hospital.

Competency and ability to provide a full range of pediatric pain strategies for children, including systemic analgesics, regional and local pain control options, and distraction techniques, are essential components for pediatric trauma care.

Continuing trauma education for hospital providers and trauma nurses is important and can be accomplished by current certification in the Advanced Trauma Life Support course from the ACS and courses in trauma nursing supported by the Society of Trauma Nurses and the Emergency Nurses Association. Thus, the most seriously injured children may need to be stabilized in regional referral centers and transported to tertiary facilities with these resources.

Pediatric critical care transport teams are often the best resource for such transfers. A well-equipped and staffed pediatric intensive care unit PICU is another essential component of a pediatric trauma center. PICUs offer a setting with the necessary monitoring devices, equipment, medications, and technology to support physiologic function and are staffed with professionals with the expertise to apply them to the pediatric patient.

Data show that the availability of PICU beds within a region may improve survival in pediatric trauma. In addition to critically injured children, stable patients with the potential for deterioration may also require the specialized services of a PICU. Pediatric trauma care specialists, especially those with critical care training, are in short supply and are distributed irregularly in the population, thus endangering the nationwide delivery of pediatric trauma care.

Moreover, pediatric trauma care continues on inpatient floors. It is the goal of a comprehensive trauma system to reintegrate the child into his or her community and to his or her primary care medical home. The availability of rehabilitation resources for pediatric patients is a vital component of pediatric trauma care.

Returning the child to full, age-appropriate function, with the ability to reach his or her maximum adult potential, is the ultimate goal after injury. Early rehabilitation is especially crucial for those children suffering neurologic injuries. Physical, occupational, cognitive, speech, and play therapy, as well as psychological and social support, are all essential elements of a comprehensive rehabilitation effort for the injured child and his or her family. It is important to address acute stress and posttraumatic stress reactions in trauma patients.

The presence of active and effective performance improvement committees, with issues focused toward pediatrics, is an integral component for trauma centers.

In any trauma center, these activities also include attention to patient safety. Periodic review of trauma care by the providers of that care is the process that is most likely to improve patient outcomes in any hospital.

Trauma care review is facilitated by a comprehensive trauma registry that has ties with national databases so that outcomes can be benchmarked for improved quality of care. Mandatory systematic child death review processes are recommended to identify emerging trends and higher level risk factors for which interventions can be developed and evaluated.

The ACS suggests that every facility that provides care for injured children have a quality-improvement process that leads to focused continuing education. Another unique aspect related to pediatric trauma care is the need for increased awareness for signs of potential child abuse. This is best accomplished by using a protocol or screening to detect child abuse in the ED that cares for children. It is the responsibility of all pediatric providers to be educated regarding the early detection, diagnosis, and management of inflicted injuries.

Community hospitals with limited pediatric services can identify resources for specialized child protection teams in their regional referral areas. Cooperation and collaboration between referring providers and hospital-based child protection teams are important for the management of cases of suspected abuse and neglect. Injury prevention is the cornerstone to any discussion concerning pediatric trauma. Injury-prevention initiatives do work. However, these initiatives are not promoted equally across the United States, often because of limited resources.

There are methods to identify and refine the approach to injury-prevention initiatives that are specific to individual regions. Injury-prevention activities can be identified by using local data and may focus on such things as fall prevention, alcohol and drug abuse recognition and intervention, child passenger safety, bike safety, water safety, and other regionally appropriate activities as endorsed by the Injury Free Coalition for Kids www.

Ideally EMS providers, hospitals, EDs, and trauma centers have injury-prevention content and information as well as activities incorporated into patient and staff education and as part of community-based injury-prevention programs. Primary care providers are encouraged to emphasize individual and community safety and injury-prevention programs such as The Injury Prevention Program from the AAP. Disaster preparedness in the United States has improved significantly in the years since Hurricane Katrina.

Hospital accreditation programs such as The Joint Commission have strengthened their disaster preparedness requirements. Children have unique needs for care in mass casualty incidents, especially if chemical, biological, or nuclear events occur. Along with physiologic considerations, triage, identification, decontamination, tracking, and reunification are all issues that must be considered during mass casualty events.

A process for recruiting pediatric health care professionals when a surge response is needed is often included in any disaster plan. One model includes a calling tree within the various departments and sections to recruit providers for a surge response.

States and regions facilitated by federal partners can review current emergency operations and devise appropriate plans to address the population-based needs of infants and children in large-scale disasters.

Ideally, attending to the psychological needs of injured children is considered in any such event. Although the needs of children in disasters can be anticipated, the capability of a trauma system to meet these needs will remain in question until the nation achieves an optimal level of emergency readiness for children on a daily basis.

The unique needs of injured children need to be integrated specifically into trauma systems and disaster planning at the local, state, regional, and national levels. Every state should identify appropriate facilities with the resources to care for injured children and establish continuous monitoring processes for care delivered to injured children.

These facilities are especially important for the youngest and most severely injured children. Evaluation and management of the injured child should begin with the providers at the bedside who have basic competency in pediatric trauma care. The receiving team needs to be familiar with airway devices used by pre-hospital personnel, as they may differ from those used in the hospital. Capnography is the gold standard to confirm ventilation of the lungs. Capnography does not rule out mainstem bronchial intubation, however.

Also, an ETT which is dislodged just proximal to the vocal cords could result in a waveform on the capnograph. If intubation is necessary, a quick assessment of the airway should be made prior to induction of anesthesia and administration of a neuromuscular blocking drug. A back-up plan should be in place in anticipation of a difficult or failed intubation.

A gum elastic bougie of appropriate size should be immediately available. Presume that the child's C-spine is injured until proven otherwise, especially in a child with a head injury. Techniques of immobilizing the C-spine include towel rolls, cervical collar, spinal board, and tape. For non-intubated patients arriving to the emergency room ER , it is vital to assess, re-assess, and keep re-assessing ABCs for adequacy until the patient is transferred to the definitive care place ICU or floor or the operating room.

Pediatric victims of polytrauma have near-normal vital signs even in the presence of significant blood loss, and can deteriorate rapidly. These children should be monitored with extra vigilance during transport to the CT scanner, in the CT scanner, and in the emergency room.

Patients who arrive to the ER intubated should be monitored for existing or developing complications such as barotrauma or endobronchial intubation, in addition to ensuring that their oxygenation and ventilation is adequate. If the child has confirmed or suspected head injury, and if ICP is monitored, mild hyperventilation may be needed for refractory increases in ICP.

Prophylactic hyperventilation is not recommended, and may be harmful, by causing cerebral vasoconstriction and ischemia. Pain has, historically, been undertreated in patients presenting to the ED. A recent meta-analysis found that the administration of opioids did not result in significant increase in management errors in patients presenting to the ED with abdominal pain. The three pediatric trials that were included actually showed a non-significant absolute decrease in management errors.

Another reason for withholding or under-dosing opioids is fear of side effects such as respiratory depression, hypotension, nausea and vomiting, and drowsiness. These side effects can be reduced or avoided by employing regional anesthesia techniques.

Epidurals, paravertebral blocks,[ 38 — 40 ] or even simple intercostal nerve blocks[ 41 ] can be extremely useful for children with rib fractures or flail chest. Femoral nerve block or fascia iliaca block can easily be performed in the ED to relieve pain from femoral fracture rapidly and effectively.

While femoral nerve block is common in some countries Australia[ 42 ] and UK[ 43 ] , it is uncommon in the emergency setting in North America. If a regional anesthetic technique is not possible, a multimodal analgesic technique combining acetaminophen and NSAIDs reduces the dose of opioids required to treat pain. IV patient-controlled analgesia PCA can be used in children above the age of about 5 years, and it allows the child to titrate opioid boluses according to the pain that they are experiencing.

All victims of major trauma should be considered to be at risk for hypothermia. Children are more prone to develop hypothermia than adults. Hypothermia can lead to arrhythmias, coagulation abnormalities, and acidosis. An initial core temperature measurement oral, rectal, or bladder should be done as a part of the primary survey. Passive rewarming, i. The child's head should be covered with a reflective hat.

All IV fluids and blood products should be warmed using fluid warmers. Active external rewarming with a convective air blanket e. Experiences with accidents, injuries, physical abuse, or hospitalization can leave a lasting impact on some children's minds. While some are able to cope with the experience and move on, some others and their families may benefit from psychosocial support and intervention. Medical facilities dealing with traumatized children should have a multidisciplinary team, comprised of social workers, psychiatrists, psychologists, etc.

Source of Support: Nil. Conflict of Interest: None declared. National Center for Biotechnology Information , U. Author information Copyright and License information Disclaimer. Address for correspondence: Dr. E-mail: gro. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles in PMC.

Abstract Injury is the leading cause of death and disability in children. Keywords: Initial assessment, injury, pain, pediatric, primary survey, trauma.

PRIMARY SURVEY The primary survey is presented in a sequential fashion, but in reality the trauma team, directed by a team leader, performs the components of the primary survey simultaneously, so that the entire process takes only a few minutes. AIRWAY The assessment of the airway simply involves determining the ability of air to pass unobstructed into the lungs. Anticipate respiratory failure if any of the following signs is present: an increased respiratory rate, particularly with signs of distress e.

Open in a separate window. Appendix 1. Every pediatric and emergency care-related health professional credentialing and certification body should define pediatric emergency and trauma care competencies and require practitioners to receive the appropriate level of initial and continuing education to achieve and maintain those competencies. Efforts to define and maintain pediatric care competencies should target both out-of-hospital and hospital-based care providers.

Evidence-based protocols for management of the injured child should be developed for every aspect of care, from prehospital to postdischarge. Research, including data collection for best practices in isolated trauma and mass-casualty events, should be supported. Pediatric injury management should include an integrated public health approach, from prevention through prehospital care, to emergency and acute hospital care, to rehabilitation and long-term follow-up.

National organizations with a special interest in pediatric trauma should collaborate to advocate for a higher and more consistent quality of care within the nation. National organizations with a special interest in pediatric trauma should collaborate to advocate for injury-prevention research and application of known prevention strategies into practice. State and federal financial support for trauma system development and maintenance must be provided. Steps should be taken to increase the number of trainees in specialties that care for injured children to address key subspecialty service shortages in pediatric trauma care.

Strategies should include increased funding for graduate medical education and appropriate reimbursement for trauma specialists. Krug, MD, Chairperson. Tuggle, MD. All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

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Close mobile search navigation Article navigation. Volume , Issue 4. Previous Article Next Article. Article Navigation. From the American Academy of Pediatrics April 01 This Site. Google Scholar. Pediatrics 4 : — Get Permissions. Cite Icon Cite. William L. Hennrikus, MD, Chairperson. John F. Paul W. Esposito, MD. Keith R. Gabriel, MD. Kenneth J. Guidera, MD. David P. Roye Jr, MD. Michael G. Vitale, MD. David D. Aronsson, MD, Past Chairperson.

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American Academy of Family Physicians. Dan Kavanaugh, MSW. December 17, History. An edition of The Hospital for Sick Children manual of pediatric trauma Written in English. Libraries near you: WorldCat. Edition Notes Includes bibliographical references and index. Genre Handbooks, manuals, etc. Other Titles Manual of pediatric trauma.

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