Acute Care of Multiple Trauma

Epidemiology

Injury is a leading cause of death and disability in children throughout the world (see Chapter 13 ). Deaths represent only a small fraction of the total trauma burden. Approximately 140,000 children were treated in U.S. trauma centers in 2016 for serious injury. Many survivors of trauma have permanent or temporary functional limitations. Motor vehicle–related injuries and falls rank among the top 15 causes of disability-adjusted life years in children worldwide.

Trauma is frequently classified according to the number of significantly injured body parts (≥1), the severity of injury (mild, moderate, or severe), and the mechanism of injury (blunt or penetrating). In childhood, blunt trauma predominates, accounting for the majority of injuries. In adolescence, penetrating trauma increases in frequency, accounting for approximately 15% of injuries, and penetrating trauma secondary to a firearm is associated with a high case fatality rate of 11%.

Regionalization and Trauma Teams

Mortality and morbidity rates have decreased in geographic regions with comprehensive, coordinated trauma systems. Treatment at designated trauma centers is associated with decreased mortality. At the scene of injury, paramedics should administer necessary advanced life support and perform triage ( Fig. 82.1 ). It is usually preferable to bypass local hospitals and rapidly transport a seriously injured child directly to a pediatric trauma center (or a trauma center with pediatric commitment). Children have lower mortality rates, lower complication rates, and less operative interventions after severe blunt trauma when they are treated in designated pediatric trauma centers or in hospitals with pediatric intensive care units.

When the receiving emergency department (ED) is notified before the child's arrival, the trauma team should also be mobilized in advance. Each member has defined tasks. A senior surgeon (surgical coordinator) or, sometimes initially, an emergency physician leads the team. Team compositions vary somewhat from hospital to hospital; Fig. 82.2 shows the model used at The Johns Hopkins Hospital Bloomberg Children's Center (Baltimore, MD). Consultants, especially neurosurgeons and orthopedic surgeons, must be promptly available; and the operating room staff should be alerted.

Physiologic status, anatomic locations, and/or mechanism of injury are used for field triage as well as to determine whether to activate the trauma team. More importance should be placed on physiologic compromise and less on mechanism of injury. Scoring scales such as the Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), Pediatric Trauma Score ( Table 82.1 ), and Revised Trauma Score use these parameters to predict patient outcome. The AIS and ISS are used together. First, the AIS is used numerically to score injuries—as 1 minor, 2 moderate, 3 serious, 4 severe, 5 critical, or 6 probably lethal—in each of 6 ISS body regions: head/neck, face, thorax, abdomen and pelvic contents, extremities and bony pelvis, and external. The ISS is the sum of the squares of the highest 3 AIS region scores.

Primary Survey

During the primary survey, the physician quickly assesses and treats any life-threatening injuries. The principal causes of death shortly after trauma are airway obstruction, respiratory insufficiency, shock from hemorrhage, and central nervous system (CNS) injury. The primary survey addresses the ABCDEs : Airway, Breathing, Circulation, neurologic Deficit, and Exposure of the patient and control of the Environment.