14 Early Assessment and

Management of Trauma
ARTHUR COOPER

Trauma remains the leading cause of mortality and mor- children is the motor vehicle, responsible for approximately
bidity in the United States in children ages 1–14 years. In 75% of all childhood deaths, which are evenly split between
2015, it continued to result in more death and disability those due to pedestrian trauma and those resulting from
than all other childhood diseases combined, as nearly occupant injuries (Table 14.1). 
4000 pediatric patients died from trauma.1 Moreover, in
2010, the last year for which comprehensive national
data are available, trauma accounted for 8% of all pedi- Injury Risks
atric hospitalizations.2 Although recent data suggest that
it represents a decreasing share of pediatric intensive care The lack of adequate supervision of children during play
unit (PICU) admissions (7% in 2004 vs 13% in 1982 and involving possible injury hazards is recognized as a major
1995),3 trauma continues to constitute nearly 20% of risk factor for unintentional injury in children. However,
pediatric emergency department (ED) visits4 and nearly drug and alcohol use, obesity, poverty, and race also influ-
50% of pediatric ambulance transports.5 Death and dis- ence the frequency of injury. Toxicology screens are report-
ability from traumatic injuries are intimately related to edly positive in 10–40% of injured adolescents, and obese
mechanism of injury.6 children and adolescents appear to have more complica-
tions and require longer stays in the intensive care unit
(ICU).10–13 Socioeconomic status also has been associated
Injury Epidemiology with increased hospitalization and mortality following
major trauma, owing to a higher frequency and more lethal
Several injury severity scales exist in practice and in the mechanisms of injury, as opposed to injury severity.14
literature. The large number of injury severity scales arises Race and ethnicity affect injury risk independent of socio-
from the markedly different perspectives used in the appli- economic status, particularly among African-American
cation of the scales. The Abbreviated Injury Scale (AIS), children, whose rate of death from preventable injuries,
primarily an anatomical measure of injury severity, was head injuries, and child abuse is three to six times higher
the first widely implemented scale used in practice. Criti- than that of white children.15–18 Improper use of restraints
cism of the AIS includes the inability to account for multiple may contribute to the increased fatality rates observed in
injuries to the same body region and the poor correlation African-American children, who are half as likely to be
of the AIS with severity and survival. The Injury Severity restrained as white children when involved in motor vehi-
Score (ISS), New Injury Severity Score (NISS), and Pediat- cle crashes (MVCs) and one-third as likely to be placed in car
ric Trauma Score (PTS) are examples of scoring systems seats during MVCs.19
developed to overcome the issues described. Despite contro- Analysis of the Crash Injury Research Engineering Net-
versies regarding these scales, it is commonly accepted that work (CIREN) database has yielded valuable information
injuries whose severity are a threat to life correspond to an about the pattern of childhood injuries after MVCs: (1) child
ISS of 10 or higher or a PTS of 8 or lower.7 victims in frontal crashes are more likely to suffer severe spine
The death rate from traumatic injury in children in 2015 and musculoskeletal injuries; (2) those in lateral crashes are
was 54.6/100,000.8 However, population-based data indi- more likely to suffer head and chest injuries; (3) those in front
cating that approximately 80% of lethally injured children seats sustain more injuries to the chest, abdomen, pelvis, and
will die before hospital admission demonstrate the need for axial skeleton than those in the rear seats; (4) seat belts are
effective injury prevention and prehospital care.9 especially protective against pelvic and musculoskeletal inju-
Blunt injuries outnumber penetrating injuries in chil- ries; (5) children involved in high-severity, lateral-impact
dren by a ratio of 12:1, a ratio that has increased somewhat crashes typically sustain injuries characterized by higher ISS
in recent years. While blunt injuries are more common, and lower Glasgow Coma Scale (GCS) scores.20,21 Restraint
penetrating injuries are more lethal. However, despite the devices also have been subjected to careful analysis: (1)
decline in penetrating injuries, firearm-related deaths con- they do not appear to protect young victims of MVCs as well
tinue as one of the top three causes of mortality in American as older victims; (2) car seats may not significantly affect
youth. Most blunt trauma deaths in childhood are sustained injury outcome; (3) improper application may predispose
unintentionally, but nearly 30% of fatal injuries are due to to abdominal injuries, even in low-severity crashes; (4) the
intentional physical assault (suicide 7.5% among children presence of abdominal wall bruising in restrained children,
5–14 years of age; homicide 22.5%, about half of the latter, although not commonly observed, is frequently indicative of
due to physical abuse).8 Still, the leading cause of death in intra-abdominal injury.22–27 
211
212 Holcomb and Ashcraft’s Pediatric Surgery

Table 14.1  Incidence and Mortality From the Major

Economics
Education
Categories of Pediatric Trauma

Engineering
Enforcement
By Injury Mechanism Incidence (%) Mortality (%)
Host Agent Environment
Blunt 78.78
 Fall 34.11 1.46
 Motor vehicle traffic 23.70 3.19
 Struck by, against 9.84 1.35 Pre-event
 Transport, other 7.04 1.44 (primary
 Pedal cyclist, other 3.17 1.07 prevention)
 Pedestrian, other 0.50 4.09
 Machinery 0.42 0.68
Event
Penetrating 7.62
(secondary
 Firearm 4.40 11.19
prevention)
 Cut/pierce 3.22 1.56
Other 13.60
Post-event
Data from the American College of Surgeons, National Trauma Data Bank. (tertiary
2016 Pediatric Annual Report. prevention)

Injury Outcomes Fig. 14.1  The Haddon Factor Phase Matrix, as modified and refined
to include a third strategic dimension, integrates all phases of injury
control into a single system. (Adapted from Haddon W. Advances in the
In recent years, much effort has been devoted to outcomes epidemiology of injuries as a basis for public policy. Public Health Rep
research in pediatric trauma with the hope that benchmark- 1980;95:411–421; Runyan CW. Using the Haddon Matrix: Introducing the
ing of treatment results may lead to better care for injured chil- third dimension. Inj Prev 1998;4:302–307.)
dren. Both historical studies and contemporary investigations
indicate that children survive more frequently and recover
more fully in hospitals that specialize in pediatric trauma
than in other hospitals.28–44 No less important than survival applied for other diseases. The Haddon Factor Phase Matrix
outcome is functional outcome, for which numerous studies neatly depicts these in graphic form (Fig. 14.1).49 Strategies
now indicate improved outcomes in hospitals that special- to lessen the burden of injury are applied to the host, agent,
ize in pediatric trauma care.46–48 However, these studies also and environment before, during, and after the traumatic
suggest that whereas children may recover from injury more event using enforcement, engineering, education, and eco-
quickly than adults, physical function may not fully normal- nomics as techniques to limit the adverse impact of each
ize. Even so, self-perceived long-term quality of life among seri- factor.
ously injured children may not be adversely affected, justifying Effective injury-prevention programs are community-
an aggressive approach to their resuscitation.47 based and require extensive collaboration with civic leaders,
Perhaps the most important recent developments for out- governmental agencies, community-based organizations,
comes research in pediatric trauma have been the expan- and neighborhood coalitions. Programs such as the National
sion of the National Trauma Data Bank (NTDB) of the Safe Kids Campaign (http://www.safekids.org) and the
American College of Surgeons (ACS) to include children, Injury Free Coalition for Kids (http://www.injuryfree.org)
the development of the Pediatric Trauma Quality Improve- have proven highly successful in reducing the burden of
ment Program (Pediatric TQIP) by the ACS, and the found- childhood injury in many communities. 
ing of the Pediatric Trauma Society (http://www.pediatri
ctraumasociety.org). The NTDB was initially designed as
a simple case repository; efforts continue to analyze cases Injury Patterns
submitted to the NTDB to provide population estimates of
severe pediatric injury and develop quality benchmarks for Injury mechanism is the main predictor of injury pattern.
pediatric trauma care. Preliminary data suggest that these The body regions most frequently injured in major child-
benchmarks perform as well as existing measures.48 Sim- hood trauma are the lower extremities, head and neck,
ilarly, Pediatric TQIP, which is available to Level I and II and abdomen. In minor childhood injury, soft tissue and
pediatric trauma centers verified by the ACS Committee on upper extremity injuries predominate. Motor vehicle ver-
Trauma (COT), is now being used to develop quality bench- sus pedestrian trauma may result in the Waddell triad
marks for pediatric trauma care. Finally, the Pediatric of injuries to the head, torso, and lower extremity (pel-
Trauma Society has provided a forum for investigators in vis, femur, or tibia; Fig. 14.2). Motor vehicle accidents
the field of pediatric trauma to present their work to a wide may cause head, face, and neck injuries in unrestrained
audience of pediatric trauma professionals from all relevant passengers. Cervical spine injuries, bowel disruption or
health care disciplines.  hematoma, and Chance fractures occur in restrained pas-
sengers (Fig. 14.3). Bicycle trauma results in head injury
in unhelmeted riders as well as upper extremity and upper
Injury Prevention abdominal injuries, the latter the result of contact with
the handlebar (Fig. 14.4 and Table 14.2). Direct impact
Injuries are not accidents, but rather predictable events from a bicycle handlebar may be predictive of the need for
that respond to harm-reduction strategies similar to those operation.27
 14 • Early Assessment and Management of Trauma 213

Fig. 14.2 The Waddell Triad of injuries to head, torso, and lower

extremity is depicted. (From Foltin G, Tunik M, Cooper A, et al., editors.
Teaching Resource for Instructors of Prehospital Pediatrics. NYU School of
Medicine; 1998.)

%RZHOLQMXU\ Fig. 14.4  Children riding bicycles can sustain blunt abdominal trauma
after contact with handlebars or head trauma from falling off the bicy-
cle. (From Foltin G, Tunik M, Cooper A, et al., editors. Teaching Resource for
9HUWHEUDO Instructors of Prehospital Pediatrics. NYU School of Medicine; 1998.)
IUDFWXUH

Table 14.2  Common Injury Mechanisms and

Corresponding Injury Patterns in Childhood Trauma

/LYHUODFHUDWLRQ Injury Mechanism Injury Pattern

Motor vehicle injury: Unrestrained Head/neck injuries
Occupant Scalp/facial lacerations
Restrained Internal abdomen injuries
Lower spine fractures
Motor vehicle injury: Single Lower extremity fractures
Pedestrian
Multiple Head/neck injuries
Internal chest/abdomen
injuries
Lower extremity fractures
Fall from height Low Upper extremity fractures
Medium Head/neck injuries
Scalp/facial lacerations
Fig. 14.3  The mechanism for the development of intestinal and ver- Upper extremity fractures
tebral injuries from lap belts. (From Foltin G, Tunik M, Cooper A, et al., High Head/neck injuries
editors. Teaching Resource for Instructors of Prehospital Pediatrics. NYU Scalp/facial lacerations
School of Medicine; 1998.) Internal chest/abdomen
injuries
Upper/lower extremity
HEAD fractures
Fall from bicycle Unhelmeted Head/neck injuries
Head injuries are potentially more dangerous in children Scalp/facial lacerations
than in adults for several reasons. First, developing neu- Upper extremity fractures
Helmeted Upper extremity fractures
ral tissue is delicate, and the softer bones of the pediatric Handlebar Internal abdomen injuries
skull allow impact forces to be transmitted directly to the
underlying brain, especially at points of bony contact. Sec- From American College of Surgeons Committee on Trauma. Advanced
ond, intracranial bleeding in infants in whom the fonta- Trauma Life Support® ATLS® Student Course Manual. 9th ed. Chicago:
American College of Surgeons; 2012.
nelles and sutures remain open may, on rare occasions,
be severe enough to cause hypotensive shock. Third, the
proportionately larger size of the head, when coupled with (secondary insults). See Chapter 17 for more information
the injury mechanisms commonly observed in children, about head injuries. 
generally leads to head trauma with a loss of conscious-
ness. As a consequence, the voluntary muscles of the neck NECK
lose their tone, which can lead to soft tissue obstruction
in the upper airway and hypoxia. Hypoxia exacerbates Cervical spine injury is a relatively uncommon event in pedi-
and potentiates the initial traumatic injury to the brain atric trauma. It affects approximately 1.5% of all seriously
214 Holcomb and Ashcraft’s Pediatric Surgery

injured children and occurs at a rate of 1.8/100,000 popu- Table 14.3  Incidence and Mortality of Injuries to
lation, which is in contrast to closed-head injury, which Thoracic and Abdominal Organs
occurs at a rate of 185/100,000 population.50–52 The phy-
sician should also be aware of normal variants of cervical Organ Incidence (%) Mortality (%)
spine anatomy. The greater elasticity of the interspinous THORACIC
ligaments and the more horizontal apposition of the cervical Lung 52 18
vertebrae also give rise to a normal anatomic variant known Pneumothorax/hemothorax 42 17
as pseudosubluxation, which affects up to 40% of children Ribs/sternum 32 11
Heart 6 40
younger than age 7 years. The most common finding is a Diaphragm 4 16
short (2–3 mm) anterior displacement of C2 on C3, although Great vessels 2 51
anterior displacement of C3 on C4 can also occur. This pseu- Bronchi <1 20
dosubluxation is accentuated when the pediatric patient is Esophagus <1 43
placed in the supine position, which forces the cervical spine ABDOMINAL
of the young child into mild flexion because of the forward Liver 27 13
Spleen 27 11
displacement of the head by the more prominent occiput. Kidneys 25 13
The greater elasticity of the interspinous ligaments also is Gastrointestinal tract 21 11
responsible for the increased distance between the dens and Great vessels 5 47
the anterior arch of C1 that is found in up to 20% of children. Genitourinary tract 5 3
When an injury to the cervical spine does occur, it fre- Pancreas 4 7
Pelvis <1 7
quently occurs at C2, C1, and the occipitoatlantal junction.
These injuries are above the nerve roots that give rise to From Cooper A, Barlow B, DiScala C, et al. Mortality and truncal injury: The
diaphragmatic innervation (C4) and predispose the afflicted pediatric perspective. J Pediatric Surg 1994;29:33–38.
child to respiratory arrest as well as paralysis. The increased
angular momentum produced by movement of the propor-
tionately larger head, the greater elasticity of the interspi- upper abdominal viscera against the vertebral column, sud-
nous ligaments, and the more horizontal apposition of the den compression and bursting of the hollow upper abdomi-
cervical vertebrae are responsible for this spectrum of inju- nal viscera against the vertebral column, or shearing of the
ries. Subluxation without dislocation may cause spinal cord posterior attachments, including the vascular supply of
injury without radiographic abnormalities (SCIWORA). the upper abdominal viscera after rapid deceleration (see
SCIWORA accounts for up to 20% of pediatric spinal cord Table 14.3).56,58 Injuries to the liver (27%), spleen (27%),
injuries as well as a number of prehospital deaths that were kidneys (25%), and gastrointestinal tract (21%) occur most
previously attributed to head trauma.53–55  frequently and account for most of the deaths from intra-
abdominal injury. Injuries to the great vessels (5%), genito-
urinary tract (5%), pancreas (4%), and pelvis (<1%) occur
CHEST
less frequently and account for few of the deaths that result
Serious intrathoracic injuries occurred in 6% of pediatric from intra-abdominal injury. Most solid visceral injuries
blunt trauma victims in one study.56 Lung injuries, pneu- are successfully managed nonoperatively, especially those
mothorax and hemothorax, and rib and sternal fractures involving the kidneys (98%), the spleen (95%), and the liver
occur most frequently (Table 14.3). Injuries to the heart, (90%).60–62
diaphragm, great vessels, bronchi, and esophagus occur less The abdomen of the child is vulnerable to injury for sev-
frequently, but have higher mortality rates associated with eral reasons. Flexible ribs cover only the uppermost portion
them. Because blunt trauma is nearly 10 times more deadly of the abdomen. Thin layers of muscle, fat, and fascia pro-
when associated with major intrathoracic injury, thoracic vide little protection to the large solid viscera. The pelvis is
injury serves as a marker of injury severity, although it is shallow, lifting the bladder into the abdomen. Moreover,
the proximate cause of death <1% of all pediatric blunt the overall small size of the abdomen predisposes the child
trauma.57 Thus, nonoperative management will suffice for to multiple rather than single injuries as energy is dissipated
approximately 80% of patients and tube thoracostomy for from the impacting force. Finally, gastric dilatation due
most of the rest, with thoracotomy being needed in fewer to air swallowing (which often confounds the abdominal
than 5% of these patients.58,59 examination by simulating peritonitis) leads to ventilatory
The thorax of the child usually escapes major harm and circulatory compromise by limiting the diaphragmatic
because the pliable nature of the cartilage and ribs allows motion, increasing the risk of pulmonary aspiration of
the kinetic energy from forceful impacts to be absorbed gastric contents, and causing vagally mediated damping
without significant injury, either to the chest wall itself or to of the normal tachycardic response to hypoxia caused by
underlying structures. Pulmonary contusions are the typi- hypoventilation or hypovolemia. 
cal result, but are seldom life threatening. Pneumothorax
and hemothorax, due to lacerations of the lung paren- SKELETON
chyma and intercostal vessels, occur less frequently. 
Although they are the leading cause of disability, fractures
are rarely an immediate cause of death from blunt trauma.
ABDOMEN
They are reported to occur in 26% of serious blunt-injury
Serious intra-abdominal injuries occur in 10% of pediatric cases and constitute the principal anatomic diagnosis in
blunt trauma victims and are caused by crushing the solid 22%.9 Upper extremity fractures outnumber lower extremity
 14 • Early Assessment and Management of Trauma 215

fractures by 7:1, although in serious blunt trauma this ratio Table 14.4  Trauma Scores Commonly Used in Children
is 2:3. The most common long-bone fractures sustained dur-
ing pedestrian MVCs in children are fractures of the femur PEDIATRIC TRAUMA SCORE
and tibia. Falls are typically associated with both upper and +2 +1 −1
lower extremity fractures if the fall height is significant (from Size (kg) >20 10–20 <10
the window of a high-rise dwelling or the top of a bunk bed, Airway Normal Maintained Unmaintained
but not from falls from standard beds or down stairs).63–65 Systolic blood >90 50–90 <50
Because isolated long-bone and stable pelvic fractures are pressure (mmHg)
Central nervous Awake Obtunded Coma
infrequently associated with significant hemorrhage, a dili- system
gent search must be made for another source of bleeding if Open wound None Minor Major
signs of shock are observed.66,67 Unstable pelvic fractures are Skeletal trauma None Closed Open-multiple
an uncommon feature of childhood injury, but unilateral
(type III) or bilateral (type IV) anterior and posterior disrup- REVISED TRAUMA SCORE
tions are those most often associated with major hemorrhage Glasgow Coma Systolic Blood Respiratory Code Value
and must be recognized early and treated.68 Scale Pressure Rate (breaths/
(mmHg) min)
The child’s skeleton is susceptible to fractures because
cortical bone in childhood is highly porous, whereas the 13–15 >89 10–29 4
9–12 76–89 >29 3
periosteum is more resilient, elastic, and vascular. This 6–8 50–75 6–9 2
results in higher percentages both of incomplete (torus and 4–5 1–49 1–5 1
greenstick) fractures and complete, but nondisplaced frac- 3 0 0 0
tures. Long-term growth disturbances also may complicate
childhood fractures. Diaphyseal fractures of the long bones
cause significant overgrowth, whereas physeal (growth
plate) fractures cause significant undergrowth. Both result currently advocated by the ACS COT, based on the advice
in limb length discrepancies unless treated.  of an expert panel convened in 2011 by the Centers for Dis-
ease Control and Prevention (CDC).80 However, recent data
suggest that, with respect to injured children, application of
Prehospital Care these Guidelines, as well as their physiologic criteria alone as
defined in step 1 (vital signs and level of consciousness), both
Basic life support for the pediatric trauma patient consists of result in unacceptably high rates of undertriage and undesir-
oxygen administration, airway adjuncts, bleeding control, ably high rates of overtriage.81,82 
spine stabilization, and temperature maintenance. Assisted
ventilation and fracture immobilization should be provided
as needed. Spinal immobilization requires both neutral Emergency Care
positioning (which cannot be achieved without placing an
approximate 2.5 cm layer of padding beneath the torso from PRIMARY SURVEY
shoulders to hips) and careful strapping (because forced
vital capacity may be decreased by up to 60%).69,70 One Early management of childhood trauma begins in the field
study suggested that cervical spine immobilization can be and continues in the ED.83,84 A primary survey of the Airway,
safely avoided in most pediatric trauma patients with minor Breathing, Circulation (Box 14.1), and neurologic Disabilities
injuries, but caution was urged in view of the known risks (Box 14.2) should be completed to identify and correct deficits
of SCIWORA and atlanto-axial instability.71 Advanced life that pose an immediate threat to life. The primary survey con-
support of the pediatric trauma patient theoretically adds tinues with complete Exposure of the patient to ensure that
endotracheal intubation and volume resuscitation to this no injuries are missed, taking care to avoid hypothermia. The
armamentarium, but neither intervention has been shown placement of therapeutic adjuncts, such as a Foley (urinary)
to improve outcome.72–76 and Gastric catheter (unless contraindicated), is also com-
Field triage of pediatric trauma patients to pediatric trauma pleted during this initial survey. Diagnostic adjuncts, such
centers is now well established. Regional protocols should as pulse oximetry, radiographs, and Focused Assessment by
direct ambulance transports to such centers where available. Sonography in Trauma (FAST), facilitate the early recogni-
The use of scoring systems to assist in predicting the need tion and treatment of immediate threats to vital functions (Box
for specialty pediatric trauma care, such as the PTS and the 14.3). The complete “trauma series” of radiographs obtained
Revised Trauma Score (RTS), may reliably predict the need as an adjunct to the primary survey in adults may not always
for specialty pediatric trauma care, but neither is optimally be necessary in children because the lateral cervical spine
sensitive nor specific (Table 14.4).77,78 The most sensitive and radiograph will not detect SCIWORA and the screening pelvic
specific indicators for the need for specialty pediatric trauma radiograph seldom identifies a pelvic fracture. If a pelvic frac-
care are a score of 1 in best motor response in the calculation ture is suspected on physical examination, a computed tomog-
of the GCS or a selection of “unresponsive/unconscious” in raphy (CT) scan should be obtained.85,86 
the calculation of an alert, responsive to voice, responsive to
pain, unresponsive (AVPU) Score.79 Good results also have RESUSCITATION
been achieved by using guidelines to identify physiologic,
anatomical, mechanistic criteria rather than calculated Any child initially seen with major trauma should receive
scores. The Guidelines for Field Triage of Injured Patients are breathing support with high-concentration oxygen by the
216 Holcomb and Ashcraft’s Pediatric Surgery

respiratory distress (labored or inadequate work of breath-

Box 14.1  Primary Survey, Resuscitation, and ing), assisted ventilation via facemask or an endotracheal
Secondary Survey tube attached to a bag-valve device should be immediately
Primary Survey available. Endotracheal intubation with rapid-sequence
induction techniques is necessary in respiratory failure.
Airway: Clear and maintain, protect cervical spine
Breathing: Ventilate and oxygenate, fix chest wall The first step in management of the circulation is control
Circulation: Control bleeding, restore volume of bleeding. Direct pressure using sterile dressings is applied
Disability: Glasgow Coma Scale score and pupils, call the to all actively bleeding external wounds. Blind clamping is
neurosurgeon avoided, owing to the potential risk of injury to neurovascu-
Exposure: Disrobe, logroll, avoid hypothermia lar bundles. Military experience suggests that commercially
Foley catheter unless contraindicateda manufactured arterial tourniquets and topical hemostatic
Gastric tube unless contraindicatedb  agents, such as chitosan granules or powder, zeolite gran-
Secondary Survey ules, and kaolin clay, are effective in stopping major arterial
hemorrhage and massive arteriolar, venular, and capil-
History and physical: SAMPLE history, complete examination
lary oozing from large open wounds. Recent data suggest
Imaging studies: Plain radiographs,c special studiesd
equivalent effectiveness for tourniquets in children.87 How-
Data from American College of Surgeons Committee on Trauma. Advanced ever, because no reports of topical hemostatic agent use in
Trauma Life Support® ATLS® Student Course Manual. 9th ed. Chicago: children have been published to date, no evidence-based
American College of Surgeons; 2012. recommendation can be made regarding its applicability
aMeatal blood, scrotal hematoma, high-riding prostate.
bCSF otorhinorrhea, basilar skull fracture, midface instability.
in civilian pediatric trauma. Even so, most experts, includ-
cChest, pelvis, lateral cervical spine; others as indicated.
ing the ACS COT, now recommend both immediate atten-
dFAST, CT as indicated. tion to control of massive external hemorrhage, especially
CSF, cerebrospinal fluid; CT, computed tomography; GCS, Glasgow in cases of bleeding caused by active shooter events (ASEs)
Coma Scale; FAST, focused assessment by sonography in trauma. and improvised explosive devices (IEDs), using a stepwise
combination of direct pressure, and, if this fails, application
of a commercially manufactured arterial tourniquet and a
Box 14.2  Disability and Mental Status topical hemostatic agent if needed.88
The child with significant trauma will require volume
Pupils: Symmetry, reaction resuscitation if signs of hypovolemic shock are present.
LOC: GCS Intraosseous access should be used if conventional intrave-
Track and trend as a vital sign
nous access with peripheral large-bore catheters is not rap-
Significant change, 2 points
Intubate for coma, GCS ≤8
idly obtainable. Central venous catheter insertion, except
Motor: Strength, symmetry in cases when venous access cannot otherwise readily be
Abnormality/deterioration: Call neurosurgeon obtained, is not warranted. Simple hypovolemia usually
Traumatic brain injury responds to 20–40 mL/kg of warmed lactated Ringer’s
Mild (GCS 13–15): observe, consider CT for history of LOC solution. However, frank hypotension (defined clinically by
Moderate (GCS 9–12): Admit, obtain CT, repeat CT 12–24 hours a systolic blood pressure <70 mmHg plus twice the age in
Severe (GCS 3–8): intubate, ventilate, obtain CT, repeat CT years) typically requires 40–60 mL/kg of warmed lactated
12–24 hours Ringer’s solution followed by 10–20 mL/kg of warmed
packed red blood cells. To avoid the greater mortality asso-
Data from American College of Surgeons Committee on Trauma. Ad- ciated with coagulopathy and shock on hospital admission,
vanced Trauma Life Support® ATLS® Student Course Manual. 9th ed. a 1:1:1 or 2:1:1 ratio with fresh frozen plasma and platelet
Chicago: American College of Surgeons; 2012. concentrates has been used in adults and should be insti-
CT, computed tomography; GCS, Glasgow Coma Scale; LOC, loss of tuted when massive uncontrolled hemorrhage is present
consciousness. and a massive transfusion protocol is invoked, although
early results do not appear so promising in children as in
adults.89–92 Although evidence is limited in civilian pediatric
Box 14.3  Primary Survey Adjuncts trauma, tranexamic acid (TXA) use substantially decreased
Vital signs/pulse oximetry
mortality in pediatric trauma patients with massive hem-
Chest/pelvis/lateral cervical spine radiographs orrhage in a combat setting.93 Also, evidence extrapolated
Foley catheter/gastric tube from other conditions associated with major hemorrhage
Focused assessment by sonography in trauma/diagnostic in children led the Royal College of Paediatrics and Child
peritoneal lavage Health of England to recommend the use of TXA in pediat-
ric trauma patients using the following guidelines: loading
Data from American College of Surgeons Committee on Trauma. dose of 15 mg/kg, maximum 1 g, diluted in a convenient
Advanced Trauma Life Support® for Doctors Student Manual. 8th ed. volume of sodium chloride 0.9% or glucose 5%, given over
Chicago: American College of Surgeons; 2008. 10 minutes within 3 hours of injury; maintenance infusion
of 500 mg in 500 mL of sodium chloride 0.9% or glucose
most appropriate means. For the child with respiratory 5%, given at a rate of 2 mL/kg/h for at least 8 hours or until
distress (increased work of breathing), a nonrebreather bleeding stops.94 Urinary output should be measured in all
mask normally will suffice, provided the airway is open and seriously injured children as an indication of renal, and
breathing is spontaneous. For the child with significant hence tissue, perfusion. The minimum urinary output that
 14 • Early Assessment and Management of Trauma 217

indicates adequate tissue perfusion is 2 mL/kg/h in infants, Selective radiologic evaluation is another important part
1 mL/kg/h in children, and 0.5 mL/kg/h in adolescents. of the secondary survey. CT of the head (without contrast)
Due to the ability of a child’s blood vessels to compensate and abdomen (intravenous and oral, assuming hemody-
vigorously for hypovolemia by intense vasoconstriction, namic stability) should be obtained as indicated. However,
systolic hypotension is a late sign of shock and may not CT should be employed only when the short-term benefit of
develop until 30–35% of circulating blood volume is lost.95 accurate diagnosis is felt to outweigh the long-term risk of
Thus, any child who cannot be stabilized after infusing of late malignancy, particularly for body regions such as the
40–60 mL/kg of lactated Ringer’s solution and 10–20 mL/ cervical spine and the thorax for which conventional imag-
kg of packed red blood cells likely has internal bleeding and ing is typically adequate. The Pediatric Emergency Care
needs an operation. If a child initially is in shock, has no Applied Research Network (PECARN) has added immeasur-
signs of intrathoracic, intra-abdominal, or intrapelvic bleed- ably to our knowledge of pediatric trauma imaging through
ing, but fails to improve despite seemingly adequate volume its development of clinical decision rules, cited below with
resuscitation, other forms of shock (obstructive, cardio- an asterisk (*), that limit the use of CT in patients whose
genic, neurogenic) should be considered. Most children in findings indicate a low risk of clinically important injury.
hypotensive shock are victims of unrecognized hemorrhage When necessary, CT should be performed using radiation
that can be reversed only if promptly recognized and appro- doses “as low as reasonably achievable” (ALARA), consis-
priately treated by means of rapid blood transfusion and tent with the “Image Gently” protocols advocated by The
immediate intervention, particularly if major intrathoracic Alliance for Radiation Safety in Pediatric Imaging.108–114
or intra-abdominal vessels are injured.96–99  CT of the head should be performed whenever loss of
consciousness has occurred or if the GCS score is <15.115
It can be safely avoided* in children younger than 2 years
SECONDARY SURVEY
of age with (1) normal mental status, (2) no scalp hema-
Once the primary survey has been performed and the resus- toma except frontal, (3) no loss of consciousness or loss of
citation phase is ongoing, a secondary survey is under- consciousness for <5 seconds, (4) nonsevere injury mecha-
taken. This consists of a “SAMPLE” history (symptoms, nism, (5) no palpable skull fracture, and (6) normal activity
allergies, medications, past illnesses, last meal, events, and according to parents. Recommendations for not obtaining
environment) and a complete head-to-toe physical exami- a head CT in children 2 years of age and older include (1)
nation (including all body regions and organ systems). The normal mental status, (2) no loss of consciousness, (3) no
physician’s chief responsibility is to identify life-threatening vomiting, (4) nonsevere injury mechanism, (5) no signs of
injuries that may have been overlooked during the primary basilar skull fracture, and (6) no severe headache.116
survey, such as tension pneumothorax. Physical find- CT of the cervical spine may facilitate earlier identifica-
ings will also assist in determining other injuries that are tion of vertebral injury, but does so at the cost of increased
not readily apparent. For example, drainage from the nose radiation dose.117 In fact, it adds little more to the early
or ears, or any evidence of midface instability, suggests a management of trauma than what may be learned from
basilar skull fracture (which precludes passage of a naso- anteroposterior, lateral, and open mouth cervical spine
gastric tube) or an oromaxillofacial fracture (which may radiographs in a cooperative patient. Even these can
threaten the airway). All skeletal components should be be omitted, and the cervical spine “cleared” in children
palpated for evidence of instability or discontinuity, espe- younger than 3 years of age (those least able to cooperate
cially bony prominences such as the anterior superior iliac with plain radiographs), if a weighted point score developed
crests, which commonly are injured in major blunt trauma. by the American Association for the Surgery of Trauma
In the absence of obvious deformities, fractures should be (AAST) is <2 points (GCS score <14, 3 points; GCS best eye
suspected if bony point tenderness, hematoma, spasm of opening score = 1, 2 points; MVC, 2 points; age 2 years or
overlying muscles, an unstable pelvic girdle, or perineal older, 1 point).118 Thus, CT of the cervical spine should be
swelling or discoloration is found. considered* only if one or more of the following is present:
Selective laboratory evaluation is an integral part of the (1) altered mental status, (2) focal neurologic findings, (3)
secondary survey, although routine trauma laboratory neck pain, (4) torticollis, (5) substantial torso injury, (6)
panels are of limited utility owing to their relatively low conditions predisposing to cervical spine injury, (7) diving,
sensitivity and specificity.100–102 Although pulse oximetry or (8) high-risk MVC.119
(SpO2) provides reliable estimates of arterial oxygen satu- CT of the chest also adds little more to what is already
ration (SaO2), arterial blood gases are important in deter- known from the chest radiograph obtained during the primary
mining the adequacy of ventilation (PaCO2), oxygenation survey, because the incidental pulmonary contusions iden-
(PaO2), and perfusion (base deficit).103,104 However, the tified by CT of the chest do not correlate with increased fatal-
critically important determinant of blood oxygen content ity.120,121 Even so, it is both more sensitive and more specific
is the blood hemoglobin concentration. Serial hemoglobin in identification of small pneumothoraces and hemothoraces
values better reflect the extent of blood loss than does the that may be missed on the anteroposterior chest radiograph
initial value. Elevations in serum levels of transaminases obtained as part of the initial “trauma series” of films.
or amylase and lipase suggest injury to the liver or pan- CT of the abdomen should be obtained (1) in intubated
creas, but the infrequency of pancreatic injury makes the patients; (2) with signs of internal bleeding (abdominal
latter cost ineffective versus the former.105,106 Urine that is tenderness, distention, bruising, or gross hematuria), a his-
grossly bloody or is positive for blood by dipstick or micros- tory of hypotensive shock (which has responded to volume
copy (>50 red blood cells per high-power field) suggests a resuscitation), or a hematocrit <30%; (3) if a femur fracture
kidney injury.107 is evident; (4) if serum transaminase levels are elevated;
218 Holcomb and Ashcraft’s Pediatric Surgery

(5) if significant microscopic hematuria is present; or (6) if pain scales have now been validated.139 For patients who
the mechanism of injury is deemed significant.122,123 It can are not eating, nutritional support is recommended.140 In
safely be avoided in children with: (1) no evidence of abdom- children who have sustained injuries resulting in hema-
inal wall trauma or seatbelt sign; (2) GCS score 14 or 15; (3) tomas, low-grade fever may develop as these are resorbed.
no abdominal tenderness; (4) no evidence of thoracic wall However, high spiking fevers should prompt investigation
trauma; (5) no complaint of abdominal pain; (6) no absent for a source such as infected hematomas, effusions, or pel-
or decreased breath sounds; and (7) no vomiting.124 vic osteomyelitis. Children with chest tubes or long-term
Sonography serves an adjunctive role in the imaging of indwelling urinary catheters are at risk for systemic infec-
pediatric trauma. FAST itself is most useful in detecting intra- tion and should receive prophylactic or suppressive antibi-
abdominal blood but is not sufficiently reliable to exclude blunt otics as long as the tube or catheter is required. 
abdominal injury, although it does have the advantage that
such injuries can be detected by repeated examination.125–132 EMOTIONAL SUPPORT
Therefore, like its historical predecessor, diagnostic peritoneal
lavage, FAST adds relatively little to the management of pedi- Efforts must be made to attend to the emotional needs of
atric abdominal trauma, because unstable patients with pre- the child and family, especially for those families facing the
sumed intra-abdominal injuries need immediate operation, death of a child or a sibling.141 In addition to the loss of con-
whereas stable patients are managed nonoperatively without trol over their child’s destiny, parents of seriously injured
regard to the presence of intra-abdominal blood.133–137 How- children also may feel enormous guilt, whether or not these
ever, diagnostic sonography has been successfully used in feelings are warranted. The physician should attempt to
screening for intra-abdominal injuries when abdominal CT is create as normal an environment as possible for the child
unavailable or contraindicated.138  and allow the parents to participate meaningfully in postin-
jury care, because acute stress disorder symptoms in chil-
dren and parents are common after injury.142 In so doing,
Special Considerations in Trauma treatment interventions will be facilitated as the child per-
Care ceives that parents and staff are working together to ensure
an optimal recovery, with the added benefit that long-term
Definitive management of childhood trauma begins once psychological effects such as post-traumatic stress disorder
the primary survey and resuscitation phases have con- may be averted.143 Even so, depression is increasingly rec-
cluded. This care is the responsibility not of a single indi- ognized as a serious complication in adolescents after major
vidual or specialty, but from a multidisciplinary team of trauma. Risk factors for depression include high injury
professionals specializing in pediatric health care led by a severity, other family members injured, low socioeconomic
surgeon with experience in the care of both trauma and status, and suicidal ideation or attempt before the current
children. It begins with the secondary survey and reevalu- traumatic event.144 
ation of vital functions and progresses through the tertiary
survey (a scrupulous repetition of the primary and second-
NONACCIDENTAL TRAUMA
ary surveys conducted by the admitting team once the
patient is transferred to definitive care) to ensure no inju- Nonaccidental trauma (NAT) is the underlying cause of
ries have been missed. It persists throughout the duration 3–5% of significant traumatic injuries in childhood and is
of hospitalization and concludes with rehabilitation, fully a major cause of morbidity and mortality among children
encompassing the operative, critical, acute, and convales- referred to pediatric trauma centers.145 Although a detailed
cent phases of care. Avoidance of secondary injury (injury review of the mechanisms, patterns, presentations, and
due to persistent or recurrent hypoxia or hypoperfusion) is findings of NAT is beyond the scope of this chapter, NAT
a major goal of definitive management and mandates reli- should be suspected when (1) the injury remains unex-
ance on continuous monitoring of vital signs, GCS score, plained, (2) a lengthy delay occurs in obtaining treatment,
oxygen saturation, urinary output, and, when necessary, (3) the history is vague or otherwise incompatible with the
arterial and central venous pressure. observed physical findings, (4) the caretaker blames siblings
Definitive management of childhood trauma also or playmates or other third parties or protects other adults
depends on the type, extent, and severity of the injuries sus- rather than the child, (5) cutaneous bruises or skeletal frac-
tained. Any child requiring resuscitation should be admit- tures are found in multiple stages of healing or in unusual
ted to the hospital under the care of a surgeon experienced locations, (6) skeletal fractures are found in the diaphyses
in the management of childhood injuries. Further informa- of long bones in infants or children too young to walk, (7)
tion and details regarding the management and treatment scald or contact burns are found in unusual locations or
of traumatic injuries in children may found throughout patterns, or (8) unconsciousness is said to have occurred
this textbook, including vascular access (Chapter 8), burns in association with a low fall.146,147 As with unintentional
(Chapter 13), thoracic trauma (Chapter 15), abdominal trauma, traumatic brain injury is the leading cause of death
trauma (Chapter 16), traumatic brain injury (Chapter 17), in NAT. The term “shaken baby syndrome,” characterized
and orthopedic and spinal trauma (Chapter 18). by the classic triad of altered mental status, bilateral sub-
dural hematomas, and retinal hemorrhages, has largely
PHYSICAL SUPPORT been supplanted by the more inclusive term “abusive head
trauma,” because it is now recognized that this syndrome
The care of children with major traumatic injury also may be caused by shaking alone or shaking with impact,
involves assessment and treatment of somatic pain. Two which greatly magnifies the forces of acceleration and
 14 • Early Assessment and Management of Trauma 219

deceleration, and may result in hypoxic-ischemic encepha- comparable to those of pediatric trauma centers if pediat-
lopathy or cervical nerve disruption (or both), in addition to ric subspecialty and nursing support (pediatric emergency,
the classic triad described above.148–152 Although the initial acute care, and critical care medicine) are available.38–44
assessment and medical treatment of physical injuries is no Finally, an organized pediatric trauma service must be
different from that for any other mechanism of injury, the available within the regional pediatric trauma center that,
sociomedicolegal management of suspected cases of NAT in addition to exemplary patient care, provides education
requires a special approach. The crucial role played by the and research in pediatric trauma and leadership in pediatric
pediatric trauma service and the pediatric trauma registry trauma system coordination.161 
in early recognition and adequate documentation of poten-
tially abusive injuries is paramount.153,154 Reports of sus- TRAUMA SYSTEMS
pected NAT must be filed with local child protective services
in every North American state, province, and territory, as Pediatric patients, at significant risk for death from mul-
well as in most developed nations worldwide. Still, it must tiple and severe injuries, are best served by a fully inclusive
be emphasized that confrontation and accusation hinder trauma system that incorporates all appropriate health
treatment and rehabilitation and have no place in the man- care facilities and personnel to the level of their resources
agement of the potentially abused child, regardless of the and capabilities.161,162 Unfortunately, access to specialty
nature of the injury or the identity of the perpetrators.  pediatric trauma care, including pediatric intensive care,
remains highly variable.163,164 Moreover, collaboration
with local public health agencies (in programs for injury
PENETRATING TRAUMA
prevention and control), as well as local public health,
All penetrating wounds are contaminated and must be public safety, and emergency-management agencies (in
treated as infected. Accessible missile fragments should regional disaster-planning efforts), is necessary.161,162
be removed (once swelling has subsided) to prevent the Although the regional trauma center is at the hub of the
development of lead poisoning (especially those in contact system, area trauma centers may be needed in localities
with bone or joint fluid).155 Thoracotomy is usually not distant from the regional trauma center. All trauma cen-
required except for massive hemothorax (20 mL/kg) or ters, whether adult or pediatric, must be capable of the
ongoing hemorrhage (2–4 mL/kg/h) from the chest tube, initial management of the injured child or infant. This
persistent massive air leak, or food or salivary drainage requires the immediate availability of a resuscitation
from the chest tube. Laparotomy is nearly always required team trained and credentialed for the management of
for gunshot wounds as well as stab wounds associated with pediatric trauma, for which structured review and simu-
hemorrhagic shock, peritonitis, or evisceration, although lation training have been shown to improve team perfor-
nonoperative management may be employed in carefully mance, while family presence during resuscitation rarely
selected cases.156 Thoracoabdominal injury should be hinders it.165–170 All other hospitals in the region should
suspected whenever the torso is penetrated between the participate as they are able and must be fully capable of
nipple line and the costal margin. A diaphragmatic injury initial resuscitation, stabilization, and transfer of pediat-
should be suspected if peritoneal irritation develops after ric trauma patients. Finally, a regional trauma advisory
thoracic penetration, food or chyle is recovered from the committee should include pediatric representation that
chest tube, or if injury trajectory or imaging studies sug- has the authority to develop and implement guidelines
gest the possibility of diaphragmatic penetration. Tube for triage of pediatric trauma within the system to verified
thoracostomy, followed by laparotomy for repair of the pediatric-capable trauma centers.171,172 Mature systems
diaphragm and/or damaged organs, is mandated with should expect that seriously injured pediatric patients will
such signs, although laparoscopy is being used with be primarily transported to pediatric trauma centers.173 
increasing frequency.157–160 
AMBULANCE TRANSPORT
The Regional Pediatric Trauma Pediatric victims of multisystem trauma should undergo
direct primary transport from the injury scene to a
System pediatric-capable trauma center.28–48,80,161,162 If this is not
possible, additional secondary transport from the initial
TRAUMA CENTERS receiving hospital to the pediatric trauma center is needed.
Regional pediatric trauma centers should be located in Transport providers must be capable of critical pediatric
trauma hospitals with comprehensive pediatric services assessment and monitoring and skilled in the techniques
(a full-service general, university, or children’s hospital) of endotracheal intubation and vascular access, as well
that demonstrate an institutional commitment to pediat- as drug and fluid administration in children.174,175 Spe-
ric trauma care, including NAT.28–48,161 A regional pedi- cialized pediatric transport teams, staffed by physicians
atric trauma center should be directed by a surgeon with and nurses with advanced training in pediatric trauma
training and experience in both pediatrics and trauma, and critical care treatment and transport, should be used
ideally a pediatric surgeon with additional training and whenever possible. Complications related to endotracheal
experience in pediatric surgical critical care and staffed by intubation and vascular access are the leading causes of
pediatric surgeons and pediatric surgical and medical sub- adverse events during transport, which occur twice as
specialists with training and experience in both pediatrics often as in the PICU and 10 times more often without a
and trauma.161 Adult trauma centers can achieve results specialized team.176,177 
220 Holcomb and Ashcraft’s Pediatric Surgery

HOSPITAL PREPAREDNESS 12. Ehrlich PF, Drogonowski A, Swisher-McClure S, et  al. The impor-
tance of a preclinical trial: a selected intervention program for pedi-
Pediatric trauma centers, both regional (Level I) and area atric trauma centers. J Trauma. 2008;65:189–195.
(Level II), constitute the backbone of the regional health care 13. Brown CVR, Nevill AL, Salim A, et al. The impact of obesity on severely
injured children and adolescents. J Pediatr Surg. 2006;41:88–91.
system’s infrastructure for pediatric emergency and disaster 14. Marcin JP, Schembri MS, Jingsong H, et al. A population-based anal-
preparedness and response, owing to the breadth and depth ysis of socioeconomic status and insurance status and their relation-
of pediatric medical and surgical subspecialty support avail- ship with pediatric trauma hospitalization and mortality rates. Am J
able in such facilities. Because all natural disasters and nearly Publ Health. 2003;93:461–466.
15. Falcone RA, Brown RL, Garcia VF. The epidemiology of infant inju-
all human-made disasters involve physical trauma, pediatric ries and alarming health disparities. J Pediatr Surg. 2007;42:172–
trauma centers must take the lead in preparing their commu- 177.
nities for potential disasters, based on their local hazard vul- 16. Haider AH, Efron DT, Haut ER, et  al. Black children experience
nerability analyses. Worldwide experience has shown that worse clinical and functional outcomes after traumatic brain injury:
both natural and human-made disasters result in injuries an analysis of the National Pediatric Trauma Registry. J Trauma.
2007;62:1259–1263.
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trauma, and may therefore require up to three times the ICU head injury mortality, disparities exist between races. J Pediatr Surg.
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able to assist pediatric trauma centers in readying themselves 18. Falcone RA, Brown RL, Garcia VF. Disparities in child abuse mortality
are not explained by injury severity. J Pediatr Surg. 2007;42:1031–
and their communities for potential disasters.178–182 How- 1037.
ever, the most important element in pediatric emergency and 19. Rangel SJ, Martin CA, Brown RL, et  al. Alarming trends in the
disaster preparedness and response remains both the willing- improper use of motor vehicle restraints in children: implications
ness to recognize that a disaster can strike at any time and in for public policy and the development of race-based strategies for
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such events. atric car crash victims: crash injury research engineering network
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