INTRODUCTION AND EPIDEMIOLOGY
Traumatic injuries are the biggest killer of children in the developed world and can lead to significant disability and healthcare expenditure. On average, one child dies every hour from injuries or violence in the United States.1 Almost 14,000 children and adolescents died in 2016 in the United States from unintentional or violence-related injury, giving a crude death rate of almost 17 per 100,000; >60% of these deaths were unintentional.2 Additionally, an average of 22,200 children seek medical attention every day in U.S. EDs for nonfatal injuries.1 Although often referred to as “accidents,” most traumatic injuries in children represent discrete, potentially preventable events.
Pediatric trauma occurs in a bimodal age distribution, with peak incidences in toddlers and adolescents.1,3 Motor traffic–related injury is the number one cause of death in children >4 years old as well as adolescents. Other leading causes of unintentional injury include pedestrians and cyclists struck by vehicles, falls, and fires.2 Children are at greater risk of serious injury than adults when operating all-terrain vehicles and snowmobiles.4 Although blunt force trauma is far more common in children than penetrating injury, firearm-related mortality is one of the top four causes of mortality in American youth.2 Infants <1 year of age are at greatest risk of death from inflicted injury. Although the rate of pediatric homicides has decreased over the past two decades, death by suicide is on the rise in the adolescent population.1
The psychological ramifications of traumatic injuries and resuscitation in a busy trauma bay on the seriously injured child should not be underestimated. Behavioral regression is common due to pain, anxiety, and perceived threats in an unfamiliar environment. Making an effort to build a rapport and limit the number of providers in direct contact with the child is essential to gaining the child’s trust and cooperation. Understanding normal child development helps identify alterations of the sensorium, which may be the result of traumatic brain injury, hypoperfusion, or hypoxemia.
Family/caregiver presence during resuscitation is an important standard practice in pediatric care. This not only can help comfort the injured child but can also assist in assessing the child’s mental status. Studies repeatedly demonstrate that caregiver presence is beneficial for both the patient’s and caregiver’s psychological well-being, does not interfere with medical efforts, and does not result in increased medicolegal issues.5 Consider providing a designated support person to help family/caregivers cope.
Prearrival preparedness warrants special consideration when anticipating the arrival of a critically injured child: estimate the child’s weight beforehand, precalculate common sedation and intubation medications, and have the appropriate-size equipment readily available. Make sure ED personnel maintain pediatric trauma competency. When anticipating the arrival of a critically injured child, consider drawing up sedation and intubation drugs beforehand using the “3:2:1 rule”: fentanyl 3 micrograms/kg IV, ketamine 2 milligrams/kg IV, and rocuronium 1 milligram/kg.
Pediatric anatomy and physiology differences compared to adults are outlined in Table 110-1. The pediatric head has a ...