Chapter 110: Pediatric Trauma

INTRODUCTION AND EPIDEMIOLOGY

Pediatric trauma is a leading cause of morbidity, mortality, and disability for children. More than 9143 children died in the United States due to trauma-related injuries in 2010.¹ For each childhood death associated with injury, more than 1000 children received medical attention for nonfatal injuries.² According to the American College of Surgeons National Databank 2013 Pediatric Report, 152,884 patients younger than 19 years of age were admitted to 803 facilities across the United States and Canada with 2834 fatalities. Trauma is the leading cause of death in children over age 1 and exceeds all other causes of death combined.³

Unintentional injury death rates are high in some subgroups including newborns and infants less than 1 year of age and teenagers age 15 to 19 years old.⁴ Gun-related injuries in this population lead to 8.87 hospitalizations per 100,000 persons <20 years of age in 2009, with 6.1% dying in the hospital (35.1% fatality from suicide).⁵ In 2010, gun-related injuries accounted for 6570 deaths of children and young people (1 to 24 years of age).⁶

BEHAVIORAL CONSIDERATIONS

In general, a child's developmental stage dictates the expected behavioral response to injury. An infant should be appropriately curious and interactive or afraid of strangers, while an older child should respond with fear to invasive procedures. Understanding normal child development helps identify alterations of the sensorium, which may be the result of traumatic brain injury, hypoperfusion, or hypoxemia.

Family presence during trauma care is extremely important, not only to help assess the child's mental status, but also to support the injured child. Studies repeatedly demonstrate that parental presence is beneficial for both the patient's and parent's psychological well-being, does not interfere with medical efforts or increase stress in the healthcare team for the most part, and does not result in increased medicolegal issues. Family presence during resuscitation is an important standard practice in pediatric care.^7,8,9

ED PREPAREDNESS

Children require age- and size-based medication and equipment, so EDs should prepare an appropriate pediatric resuscitation area, provide personnel with adequate training in the care of children, and stock appropriately sized pediatric resuscitation equipment.¹⁰ In 2013, the American Academy of Pediatrics, the American College of Emergency Physicians, the Emergency Nurses Association, and the Emergency Medical Services for Children developed the Pediatric Readiness Project¹¹ to improve care for children in the ED, to provide a quality improvement process following the Guidelines for Care of Children in the Emergency Department,¹² and to measure ED improvements over time. Approximately 5000 EDs with a response rate of over 80% were involved, resulting in one of the most successful assessments to date.¹³

PEDIATRIC ANATOMY

The pediatric head has a larger surface area that is prone to significant bleeding either from open scalp wounds with brisk arterial bleeding or in the form of cephalohematomas or subgaleal hematomas that ...