Early Assessment and Management of Trauma

Injury Epidemiology

Several injury severity scales exist in practice and in the literature. The large number of injury severity scales arises from the markedly different perspectives used in the application of the scales. The Abbreviated Injury Scale (AIS), primarily an anatomical measure of injury severity, was the first widely implemented scale used in practice. Criticism of the AIS includes the inability to account for multiple injuries to the same body region and the poor correlation of the AIS with severity and survival. The Injury Severity Score (ISS), New Injury Severity Score (NISS), and Pediatric Trauma Score (PTS) are examples of scoring systems developed to overcome the issues described. Despite controversies regarding these scales, it is commonly accepted that injuries whose severity are a threat to life correspond to an ISS of 10 or higher or a PTS of 8 or lower.

The death rate from traumatic injury in children in 2015 was 54.6/100,000. However, population-based data indicating that approximately 80% of lethally injured children will die before hospital admission demonstrate the need for effective injury prevention and prehospital care.

Blunt injuries outnumber penetrating injuries in children by a ratio of 12:1, a ratio that has increased somewhat in recent years. While blunt injuries are more common, penetrating injuries are more lethal. However, despite the decline in penetrating injuries, firearm-related deaths continue as one of the top three causes of mortality in American youth. Most blunt trauma deaths in childhood are sustained unintentionally, but nearly 30% of fatal injuries are due to intentional physical assault (suicide 7.5% among children 5–14 years of age; homicide 22.5%, about half of the latter, due to physical abuse). Still, the leading cause of death in children is the motor vehicle, responsible for approximately 75% of all childhood deaths, which are evenly split between those due to pedestrian trauma and those resulting from occupant injuries ( Table 14.1 ).

Injury Risks

The lack of adequate supervision of children during play involving possible injury hazards is recognized as a major risk factor for unintentional injury in children. However, drug and alcohol use, obesity, poverty, and race also influence the frequency of injury. Toxicology screens are reportedly positive in 10–40% of injured adolescents, and obese children and adolescents appear to have more complications and require longer stays in the intensive care unit (ICU). Socioeconomic status also has been associated with increased hospitalization and mortality following major trauma, owing to a higher frequency and more lethal mechanisms of injury, as opposed to injury severity. Race and ethnicity affect injury risk independent of socioeconomic status, particularly among African-American children, whose rate of death from preventable injuries, head injuries, and child abuse is three to six times higher than that of white children. Improper use of restraints may contribute to the increased fatality rates observed in African-American children, who are half as likely to be restrained as white children when involved in motor vehicle crashes (MVCs) and one-third as likely to be placed in car seats during MVCs.

Analysis of the Crash Injury Research Engineering Network (CIREN) database has yielded valuable information about the pattern of childhood injuries after MVCs: (1) child victims in frontal crashes are more likely to suffer severe spine and musculoskeletal injuries; (2) those in lateral crashes are more likely to suffer head and chest injuries; (3) those in front seats sustain more injuries to the chest, abdomen, pelvis, and axial skeleton than those in the rear seats; (4) seat belts are especially protective against pelvic and musculoskeletal injuries; (5) children involved in high-severity, lateral-impact crashes typically sustain injuries characterized by higher ISS and lower Glasgow Coma Scale (GCS) scores. Restraint devices also have been subjected to careful analysis: (1) they do not appear to protect young victims of MVCs as well as older victims; (2) car seats may not significantly affect injury outcome; (3) improper application may predispose to abdominal injuries, even in low-severity crashes; (4) the presence of abdominal wall bruising in restrained children, although not commonly observed, is frequently indicative of intra-abdominal injury.

Injury Outcomes

In recent years, much effort has been devoted to outcomes research in pediatric trauma with the hope that benchmarking of treatment results may lead to better care for injured children. 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. No less important than survival outcome is functional outcome, for which numerous studies now indicate improved outcomes in hospitals that specialize in pediatric trauma care. However, these studies also suggest that whereas children may recover from injury more quickly than adults, physical function may not fully normalize. Even so, self-perceived long-term quality of life among seriously injured children may not be adversely affected, justifying an aggressive approach to their resuscitation.

Perhaps the most important recent developments for outcomes research in pediatric trauma have been the expansion of the National Trauma Data Bank (NTDB) of the American College of Surgeons (ACS) to include children, the development of the Pediatric Trauma Quality Improvement Program (Pediatric TQIP) by the ACS, and the founding of the Pediatric Trauma Society ( http://www.pediatrictraumasociety.org ). The NTDB was initially designed as a simple case repository; efforts continue to analyze cases submitted to the NTDB to provide population estimates of severe pediatric injury and develop quality benchmarks for pediatric trauma care. Preliminary data suggest that these benchmarks perform as well as existing measures. Similarly, Pediatric TQIP, which is available to Level I and II pediatric trauma centers verified by the ACS Committee on Trauma (COT), is now being used to develop quality benchmarks for pediatric trauma care. Finally, the Pediatric Trauma Society has provided a forum for investigators in the field of pediatric trauma to present their work to a wide audience of pediatric trauma professionals from all relevant health care disciplines.

Injury Prevention

Injuries are not accidents, but rather predictable events that respond to harm-reduction strategies similar to those applied for other diseases. The Haddon Factor Phase Matrix neatly depicts these in graphic form ( Fig. 14.1 ). Strategies to lessen the burden of injury are applied to the host, agent, and environment before, during, and after the traumatic event using enforcement, engineering, education, and economics as techniques to limit the adverse impact of each factor.

Effective injury-prevention programs are community-based and require extensive collaboration with civic leaders, governmental agencies, community-based organizations, and neighborhood coalitions. Programs such as the National Safe Kids Campaign ( http://www.safekids.org ) and the Injury Free Coalition for Kids ( http://www.injuryfree.org ) have proven highly successful in reducing the burden of childhood injury in many communities.

Injury Patterns

Injury mechanism is the main predictor of injury pattern. The body regions most frequently injured in major childhood trauma are the lower extremities, head and neck, and abdomen. In minor childhood injury, soft tissue and upper extremity injuries predominate. Motor vehicle versus pedestrian trauma may result in the Waddell triad of injuries to the head, torso, and lower extremity (pelvis, femur, or tibia; Fig. 14.2 ). Motor vehicle accidents may cause head, face, and neck injuries in unrestrained passengers. Cervical spine injuries, bowel disruption or hematoma, and Chance fractures occur in restrained passengers ( Fig. 14.3 ). Bicycle trauma results in head injury in unhelmeted riders as well as upper extremity and upper abdominal injuries, the latter the result of contact with the handlebar ( Fig. 14.4 and Table 14.2 ). Direct impact from a bicycle handlebar may be predictive of the need for operation.