Chapter 22: Evaluation and Management of the Multiple Trauma Patient

High-Yield Facts

• Injury is the leading cause of death of children in the United States.

• Orotracheal intubation is the most reliable means of securing an airway.

• Hypovolemic shock is caused by blood loss, which makes up 8% to 9% of the body weight of a child. Determining the extent of volume depletion and shock requires evaluation of multiple parameters.

• Attempt vascular access en route.

• Intraosseous (IO) infusion should be used as a quick access for crystalloid infusion if attempts at intravenous (IV) cannulation are unsuccessful after 90 seconds.

• For shock, give an initial infusion of 20 mL/kg of crystalloid solution rapidly.

• Unique characteristics of the pediatric cervical spine (C-spine) predispose it to ligamentous disruption and dislocation injuries without radiographic evidence of bone injury.

Injury is the leading cause of deaths in children in the United States, representing almost 40% of all pediatric fatalities.¹ Overall, mortality from pediatric trauma is one-third of the rate of adult trauma deaths; however, pediatric case–fatality rates are higher when compared with adults who have similar injuries. Eighty percent of their trauma deaths occur either at the scene or prior to admission.

Mortality data alone does not reveal the profound impact of trauma. For children <19 years of age, injuries are the leading cause of visits to emergency departments (EDs), numbering 9 million, accounting for more than 225,000 admissions, and resulting in nearly $87 billion in health care and societal costs.¹ Even minor injuries can have lasting effects causing physical or cognitive functional impairment and affect quality of life years after the acute traumatic event. Therefore, physical, emotional, and psychological needs of the child and family must be considered.

Nature of Injuries and Unique Pediatric Aspects

The blunt trauma is the predominant mechanism in children, with only 10% to 20% suffering a penetrating injury. Boys are injured twice as frequently as girls. Motor vehicle crashes (MVCs) account for more than half of all childhood trauma deaths.¹ Other major causes of death are falls, drowning, poisoning, and fire-related injuries, with the relative incidence for each injury type varying by age group (Table 22-1).²

Children have anatomic, physiologic, and psychological responses to trauma that are different from those seen in adults, and an understanding of these differences is essential to provide appropriate expert care for children. Kinetic energy from injury is distributed over a smaller area ...