Pediatric Trauma

It is a shocking fact that one in four children in the United States sustain an unintentional injury that requires medical care each year (Danesco et.al, 2000) and death due to injury surpasses all other causes of death in children and adolescents (Arias et.al, 2003). The cost implications of childhood trauma are tremendous with an estimated fourteen billion on lifetime medical spending, one billion on other resource costs and sixty six billion on present and future work losses (Miller et.al, 2000). Hence, it is important to recognize childhood injury as a National Public Health Problem.

Problems in Pediatric Trauma Management

The main problem in pediatric trauma management is that many health care organizations or hospitals are ill equipped with no sufficient pediatric resuscitation equipment or medications (Middleton et.al, 2006; Institute of Medicine, 2006) and there is significant variability in training and experience among the health care professionals in emergency departments (Yamamoto, 2007). Variation in the Management of Pediatric Trauma in the United States have been well documented and have serious implications for education, trauma triage and the establishment of practice guidelines (Mooney et.al, 2006). Insufficient training and a lack of expertise in the management of injured children have been identified as important factors contributing to disability and death in such children. Further, injury patterns and treatment algorithms differ from those recommended for adults (Vane et.al, 2002).  

For example, although the principles of resuscitation of injured children are similar to those for adults, there are important differences in cardiorespiratory variables, airway anatomy, response to blood loss and thermoregulation for successful initial resuscitation (Kissoon et.al, 1990). There is also a lack of concrete data supporting the best practices for pediatric resuscitation in fluid administration, cervical spine stabilization and airway management in children (AAP, 2008).

Recommended Practice Guidelines

Fluid management is an important aspect in the resuscitative care of the injured child and the ultimate goal of fluid resuscitation is restoration of tissue perfusion without compromising the body's natural compensatory mechanism. The timing, type, and amount of fluid administration during the resuscitative phase are often neglected during pediatric resuscitation. Fluid management has to always center on maintaining oxygen delivery in order to perfuse vital organs with oxygen and energy substrates to avoid tissue ischemia. Hemorrhage control, maintaining vascular access by peripheral intravenous, central venous, or intraosseous catheter are high priority nurse interventions (Schweer and Lynn, 2008).  Although Advanced Trauma Life Support (ATLS) is the standard for the first hours of trauma care, it is important to recognize the fact that ATLS has been designed primarily for adults. A study to investigate predictors of fluid resuscitation and to determine if all pediatric Level I trauma pediatric victims require two intravenous catheters has shown that there is no need for a second IV catheter and the pediatric trauma patient can be treated appropriately with one IV line taking us to the conclusion that ATLS guidelines may not always be appropriate for the management of pediatric trauma (Vella et.al, 2006).

Spinal injuries in children are challenging and more than half of pediatric spinal cord injuries occur in the cervical area (Brown et.al, 2001; Cirak et al, 2004; Eleraky et.al, 2000). Spinal cord injury can be classified as Complete and Incomplete Injury. Complete spinal cord injury results in total loss of sensation and movement below the level of the injury. Incomplete spinal cord injuries often fall into one of the following patterns namely, Anterior Cord Syndrome, Central Cord Syndrome, Brown-Sequard Syndrome, Spinal Concussion or Cauda Equina Syndrome (Schreiber, 2004). Flaccid extremities, Paralysis, Numbness or Paresthesias, Paresis or weakness, Priaprism, Incontinence of bowel or bladder and loss of rectal tone indicate spinal injury in children. Concomitant injuries at times, mask a spinal injury and hence, a high alert has to be maintained until an injury is identified or ruled out (Hayes et.al, 2005). Further damage can be prevented by immobilization and administration of high doses of steroids. Care should be taken to avoid prolonged immobilization as it causes problems related to hygiene, skin breakdown, and decubitus ulcer. Spinal Cord Injury without Radiographic Abnormality (SCIWORA) is common in pediatric trauma cases under eight years of age. Only an MRI and not Radiographs or Computerized Tomography films can detect SCIWORA (Hayes et.al, 2005).

Nonoperative management of blunt splenic trauma is the gold standard in pediatric trauma care. Nonoperative management with lower mortality, fewer complications, fewer blood transfusions and a decreased length of stay is the current standard of care for blunt splenic trauma in the pediatric patient (Houseknecht and Eileen, 2007). In case of grade 4 splenic injuries, the child usually becomes hemodynamically unstable within the first hours after arrival and remains so despite fluid resuscitation and transfusions. Splenic artery embolization can be performed as an alternative to laparotomy in such cases (Naess et.al, 2005). Although nonoperative management of pediatric traumas patients is widely accepted, other strategies are needed in hemodynamically unstable children. A recent study to examine the clinical factors that influence medical decision making in children with oropharyngeal trauma in a sample of one hundred and seven children with traumatic oropharyngeal injuries has shown that it is not possible to identify any clinical factors that would help predict high risk neurologic sequelae of oropharyngeal trauma in children (Soose et.al, 2006).  A study to investigate if Interventional Radiology (IVR) is useful in controlling massive Intra Abdominal Hemorrhage due to severe abdominal injury in children has shown that IVR is one of the most useful tools in trauma cases that show a response to the initial resuscitation further in need of a continuous blood transfusion for stability (Konosuke et.al, 2001). 

A recent study to review and evaluate the management of White-Eyed Blowout Fractures (WEBOF) in a retrospective chart review of consecutive cases of pediatric orbital blowout fracture requiring surgical repair at a large ophthalmologic referral center has shown that WEBOF is a clinical diagnosis consisting of vertical diplopia, gaze restriction and nausea or vomiting in the setting of peri-orbital trauma in the pediatric age group. Lack of external signs of trauma often leads to misdiagnosis or delay in treatment and a dedicated orbital CT is recommended (Lane et.al, 2007). Pelvic fractures in children are relatively uncommon and there is significant controversy regarding the appropriate approach toward the management of these injuries. There is also substantial variability in the orthopaedic management of pediatric pelvic fractures (Vitale, 2005). Femoral shaft fractures are the most common major pediatric injuries. Nonsurgical management is usually done with early spica cast application in younger children. Surgery is recommended for the school-age child and for patients with high-energy trauma. In the older child, traction followed by casting, external fixation, flexible intramedullary nails and plate fixation are the common interventions. Complications in such cases include shortening, angular and rotational deformity, delayed union, nonunion, compartment syndrome, overgrowth, infection, skin problems and scarring. Surgical complications include refracture after external fixator or plate removal, osteonecrosis after rigid antegrade intramedullary nail fixation and soft-tissue irritation caused by the ends of flexible nails (Flynnet.al, 2004).

Conclusion

It is important to recognize childhood injury as a National Public Health Problem due to the huge cost burden involved and there is a need for concrete data supporting the best practices for Pediatric Trauma Management with established practice guidelines.

Reference

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