Acute Care of Multiple Trauma in Pediatrics

Introduction

Trauma remains a leading cause of morbidity and mortality in the pediatric population worldwide. The management of the multiply injured child requires a systematic, multidisciplinary approach that addresses the unique anatomical, physiological, and psychological characteristics of children. This document provides a comprehensive overview of the acute care of pediatric multiple trauma, emphasizing evidence-based strategies and best practices.

Pre-hospital Care

Effective pre-hospital care is critical in improving outcomes for pediatric trauma patients. Key considerations include:

Triage: Utilize validated pediatric triage tools (e.g., Pediatric Trauma Score) to identify severely injured children and transport to appropriate trauma centers.
Airway management: Recognize that children have proportionately larger occiputs; padding under the shoulders may be necessary to achieve neutral positioning.
Breathing: Be aware that children are predominantly diaphragmatic breathers; assess breath sounds bilaterally and watch for signs of respiratory fatigue.
Circulation: Tachycardia is often the earliest sign of shock in children; hypotension is a late and ominous finding.
Immobilization: Use age- and size-appropriate immobilization devices; avoid separating the child from the immobilization device unless absolutely necessary for assessment or procedures.
Pain management: Provide appropriate analgesia; untreated pain can contribute to physiological decompensation.

Initial Hospital Management

Primary Survey

Follow the ABCDE approach with life-threatening conditions addressed immediately:

A - Airway with cervical spine protection

Assess for airway patency while maintaining manual in-line stabilization of the cervical spine.
Clear the airway of debris, blood, or secretions; consider oropharyngeal or nasopharyngeal airways if no signs of basal skull fracture.
Be prepared for rapid sequence intubation (RSI) if there are signs of airway compromise.

B - Breathing and ventilation

Assess respiratory rate, effort, and symmetry.
Auscultate breath sounds and percuss the chest.
Provide supplemental oxygen and assist ventilation if needed.
Tension pneumothorax, open pneumothorax, massive hemothorax, and flail chest must be recognized and treated promptly.

C - Circulation with hemorrhage control

Assess heart rate, blood pressure, capillary refill time, and skin temperature.
Establish vascular access (two large-bore IVs or intraosseous line).
Begin fluid resuscitation with warmed isotonic crystalloids (20 mL/kg boluses), reassessing after each bolus.
Identify and control sources of external hemorrhage.
Be vigilant for signs of internal bleeding (abdomen, pelvis, long bones).

D - Disability (neurological status)

Assess pupillary size and reactivity.
Determine level of consciousness using the pediatric Glasgow Coma Scale (GCS) or AVPU (Alert, Voice, Pain, Unresponsive) scale.
Check for lateralizing signs and assess spinal cord integrity.

E - Exposure and environmental control

Remove all clothing for a thorough examination, then cover the child to prevent hypothermia.
Log-roll the patient, maintaining spinal precautions, to examine the back and buttocks.
Actively warm the patient and the resuscitation bay.

Adjuncts to Primary Survey

Continuous cardiac monitoring and pulse oximetry
Capnography if intubated
Urinary catheter (unless urethral injury is suspected)
Nasogastric or orogastric tube (use orogastric if basilar skull fracture is suspected)
Arterial and central venous catheters in severely injured children
Portable chest and pelvic radiographs
Focused Assessment with Sonography for Trauma (FAST) examination
Arterial blood gas analysis

Secondary Survey

Once immediately life-threatening conditions have been addressed and the patient is stabilized, a comprehensive head-to-toe examination is performed:

Head: Inspect and palpate for contusions, lacerations, and skull fractures. Reassess pupils and GCS.
Maxillofacial: Check for malocclusion, tooth loss, septal hematoma, cerebrospinal fluid rhinorrhea or otorrhea.
Neck: Palpate for step-offs or tracheal deviation, assess for JVD and subcutaneous emphysema.
Chest: Reinspect for asymmetrical movement, auscultate heart and lung sounds, palpate for crepitus or instability.
Abdomen: Observe for distension and bruising, palpate all four quadrants, assess for peritonitis.
Pelvis: Gently compress the iliac crests to assess stability, check perineum for blood.
Extremities: Evaluate pulses, motor and sensory function; look for deformities and open fractures.
Neurological: Perform a detailed assessment including cranial nerves and peripheral nervous system.

Diagnostic Imaging

Imaging studies should be judiciously chosen based on the mechanism of injury and clinical findings:

CT scan of the head for moderate to severe TBI or focal neurological deficits.
CT cervical spine for altered mental status, neck pain, or neurological symptoms.
Chest CT for suspected great vessel or cardiac injury.
Abdominal CT with IV contrast for suspected solid organ injury, especially with positive FAST or hemodynamic instability.
CT of the pelvis for suspected pelvic fractures.
Radiographs of extremities for suspected fractures.

Consider the risk of radiation exposure and use low-dose protocols when possible.

Damage Control Resuscitation

In severely injured children with hemorrhagic shock, damage control resuscitation principles should be applied:

Permissive hypotension (except in TBI) targeting a systolic blood pressure for age.
Balanced transfusion with 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets.
Limited use of crystalloids to avoid dilutional coagulopathy.
Early use of tranexamic acid within 3 hours of injury (15 mg/kg loading dose, then 2 mg/kg/hr infusion).
Aggressive correction of hypothermia, acidosis, and coagulopathy.
Early activation of massive transfusion protocol when indicated.

Traumatic Brain Injury (TBI) Management

TBI is a major cause of morbidity and mortality in pediatric trauma. Priorities in acute TBI management include:

Preventing secondary brain injury by maintaining adequate cerebral perfusion pressure.
Treating raised intracranial pressure (ICP):
- Elevation of the head to 30 degrees.
- Maintaining PaCO2 at 35-40 mmHg (unless signs of herniation).
- Osmotherapy with mannitol or hypertonic saline.
- Sedation and analgesia.
- Anticonvulsant prophylaxis in severe TBI.
- Consider early ICP monitoring for GCS ≤ 8.
Avoidance of hypotension and hypoxemia at all costs.
Early neurosurgical consultation for operative lesions (e.g., epidural hematoma, depressed skull fractures).

Thoracic Trauma

Although often managed non-operatively, thoracic injuries can be immediately life-threatening:

Tube thoracostomy for pneumothorax or hemothorax.
Pericardiocentesis or thoracotomy for cardiac tamponade.
Positive pressure ventilation for flail chest.
High index of suspicion for tracheobronchial or esophageal injuries.
ECG and cardiac enzymes to evaluate for blunt cardiac injury.

Abdominal Trauma

The management of pediatric abdominal trauma has shifted towards non-operative approaches in hemodynamically stable patients:

Serial clinical examinations and hemoglobin levels.
Angioembolization for selected solid organ injuries.
Emergent laparotomy for peritonitis or hemodynamic instability despite resuscitation.
Diagnostic laparoscopy may be considered for diaphragmatic or hollow viscus injury assessment.

Musculoskeletal Injuries

Fractures and dislocations require prompt attention to prevent complications:

Early reduction of fractures and dislocations with appropriate analgesia and sedation.
Splinting in anatomical position.
Compartment syndrome assessment, especially in unconscious patients.
Repeat neurovascular checks after any intervention.

Special Considerations

Child Abuse

Always consider non-accidental trauma, especially in infants and young children. Red flags include:

Inconsistent history
Patterned bruising
Injuries in various stages of healing
Delay in seeking medical attention

Pediatric Trauma Score (PTS)

The PTS can aid in triage and predict mortality. It assesses weight, airway, systolic BP, CNS status, open wounds, and skeletal injuries. A score ≤ 8 indicates the need for a pediatric trauma center.

Psychological Support

The acute care of pediatric trauma extends beyond physical injuries:

Allow family presence when appropriate.
Provide clear, honest, and age-appropriate communication.
Screen for acute stress reactions in both the child and family members.
Initiate early psychological support and follow-up.

Disposition

The appropriate level of care depends on injury severity and institutional resources:

Pediatric Intensive Care Unit (PICU) for severe injuries or those requiring close monitoring.
Inpatient ward for stable patients needing further care or observation.
Consider transfer to a pediatric trauma center if specialized care is not available locally.

Quality Improvement and Education

Continuous improvement in pediatric trauma care relies on:

Regular trauma team simulations and debriefings.
Ongoing education in pediatric-specific trauma care.
Participation in trauma registries and quality improvement initiatives.
Multidisciplinary trauma conferences to review cases and outcomes.