Management Of Pediatric Trauma Research Articles

Management of Pediatric Trauma.

Injury is still the number 1 killer of children ages 1 to 18 years in the United States (http://www.cdc.gov/nchs/fastats/children.htm). Children who sustain injuries with resulting disabilities incur significant costs not only for their health care but also for productivity lost to the economy. The families of children who survive childhood injury with disability face years of emotional and financial hardship, along with a significant societal burden. The entire process of managing childhood injury is enormously complex and varies by region. Only the comprehensive cooperation of a broadly diverse trauma team will have a significant effect on improving the care of injured children.

Epidemiology of Pediatric Trauma and Its Patterns in Western Iran: A Hospital Based Experience.

Background and Objective:Trauma is a major cause of mortality in children aged 1 to 14 years old and its patterns differs from country to country. In this study we investigated the epidemiology and distribution of non-intentional trauma in the pediatric population.Materials and Methods:The archives of 304 children below 10 years old who presented to Taleghani trauma care center in Kermanshah, Iran from March to September 2008, were reviewed. Patients’ demographic and injury related information were registered. The participants were categorized into three age groups of 0-2, 3-6 and 7-10 years old and the data was compared among age groups and between both sexes.Findings:The most common cause for trauma was falling from heights (65.5%) and road traffic accidents (16.4%). The most common anatomical sites of injury were the upper limbs followed by the head and neck (36.8% and 31.2%, respectively). Injuries mostly occurred in homes (67.4%). The injuries were mostly related to the orthopedics and the neurosurgery division (84.1% and 13.1%, respectively). Accident rates peaked during the hours of 18-24 (41.3%). Male and female patients did display any difference regarding the variables. Children between the ages of 0-2 years old had the highest rate of injury to the head and neck area (40.3%) (p=0.024). Falls and road traffic accidents displayed increasing rates from the ages of 0-2 to 3-6 and decreasing rates to the ages of 7-10 years old (p=0.013). From the ages of 0-2 to 3-6 years old, street accidents increased and household traumas decreased. After that age household trauma rates increased and street accidents decreased (p=0.005). Children between the ages of 7-10 years old had the highest rate of orthopedic injury (p=0.029).Conclusion:Special planning and health policies are needed to prevent road accidents especially in children between the ages of 3-6 years old. Since homes were the place where children between the ages of 0-2 were mostly injured, parents should be educated about the correct safety measures that they need to take regarding their children’s environments. The orthopedics department needs to receive the most training and resources for the management of pediatric trauma.

Initial Management of Pediatric Trauma

Initial Management of Pediatric Trauma

Pattern and epidemiology of pediatric musculoskeletal injuries in Kashmir valley, a retrospective single-center study of 1467 patients.

This work aimed to study the pattern and epidemiology of pediatric musculoskeletal trauma and consequent morbidity in Kashmir Valley and compare the results with other studies and to formulate preventive measures and devise management strategies. This was a retrospective study of 1467 pediatric orthopedic trauma patients who presented to our hospital over a 3-year period between September 2005 and August 2008. Information was recorded in a prescribed proforma including the following: age, sex, mode of trauma, type of fracture/injury, radiological study, final diagnosis, intervention performed, and complications. The information was collected from the Medical Records Department of the hospital. The children's ages ranged from 0 to 16 years; there were 996 males and 471 females, with males outnumbering females in every age group (the overall male-to-female ratio was 2.12:1). Most fractures occurred in children aged 7-12 years [n=816 (53.96%)] and decreased in younger and older children beyond this age group. The left side was involved in 762 cases, 612 injuries involved the right side, 24 were bilateral, and 69 patients presented with multiple injuries. In children aged 0-6 years, the most common site of injury was the elbow, whereas in children aged 7-16 years, it was the forearm. In descending order, most injuries were sustained because of fall while playing (34.76%), fall from height (33.74%), road traffic accidents (14.92%), and fall from standing height (7.97%). The majority of injuries were caused by unintentional trauma (94.48 vs. 5.52%). The places where injury occurred were the home [603 (41.10%)], play field and orchards near the home [450 (30.67%)], roads [219 (14.92%)], school [183 (12.47%)], and unknown [12 (0.81%)]. The pattern and epidemiology of pediatric trauma differs from those in adults. The majority of musculoskeletal injuries are because of unintentional trauma in this young age group and hence preventable. Enhanced supervision at home and school is recommended. A safer environment and better playing conditions may decrease the high frequency of trauma in pediatric patients. Dedicated trauma centers with such facilities as orthopedics, neurosurgery, and plastic surgery need to be established for the proper management of pediatric trauma.

Damage Control Resuscitation

Evidence for changes in adult trauma management often precedes evidence for changes in pediatric trauma management. Many adult trauma centers have adopted damage-control resuscitation management strategies, which target the metabolic syndrome of acidosis, coagulopathy, and hypothermia often found in severe uncontrolled hemorrhage. Two key components of damage-control resuscitation are permissive hypotension, which is a fluid management strategy that targets a subnormal blood pressure, and hemostatic resuscitation, which is a transfusion strategy that targets coagulopathy with early blood product administration. Acceptance of damage-control resuscitation strategies is reflected in recent changes in the American College of Surgeons' Advanced Trauma Life Support curriculum; the most recent edition has decreased its initial fluid recommendation to 1 L from 2 L, and it now recommends early administration of blood products without specifying any specific ratio. These recommendations are not advocating permissive hypotension or hemostatic resuscitation directly but represent an initial step toward limiting fluid resuscitation and using blood products to treat coagulopathy earlier. Evidence for permissive hypotension exists in animal studies and few adult clinical trials. There is no evidence to support permissive hypotension strategies in pediatrics. Evidence for hemostatic resuscitation in adult trauma management is more comprehensive, and there are limited data to support its use in pediatric trauma patients with severe hemorrhage. Additional studies on the management of children with severe uncontrolled hemorrhage are needed.

Management of paediatric trauma in England and Wales

Management of paediatric trauma in England and Wales

Analgesia in the management of paediatric and adolescent trauma during the resuscitative phase: The role of the pediatric trauma centre

BackgroundThe objective of this study was to evaluate the use of analgesia in the resuscitative phase of severely injured children and adolescents. MethodsA retrospective cohort of paediatric (age<18 years), severely injured (ISS≥12) patients were identified from the London Health Sciences Centre's Trauma Registry from 2007 to 2010. Variables were compared between Analgesia and Non-analgesia groups with Pearson Chi-square and Mann–Whitney U tests. Resuscitative analgesia use was assessed through multivariable logistic regression controlling for age, gender, mechanism, arrival and Trauma Team Activation (TTA). ResultsAnalgesia was used in 32% of cases. Univariate analysis did not reveal any differences in gender, age, injury type, injury profile and arrival patterns. Significant differences were found with analgesia used more frequently in patients injured in a motor vehicle collision (58% vs. 42%, p=0.026) and having parents in the resuscitation room (17% vs. 6%, p=0.01). Analgesia patients were more injured (median ISS 22 vs. 17, p=0.027) and had 2.25 times more TTA (39% vs. 17%). Logistic regression revealed patients arriving directly to a trauma centre had a higher incidence of receiving analgesia (OR 2.01, 95% CI: 1.03–3.93), as did TTA (OR 2.18, 95% CI: 1.01–4.73) and having parents in resuscitation room (3.56, 95% CI: 1.23–10.33). Narcotics were most commonly used (85%), followed by benzodiazepines (16%), with 66% given during the primary survey. ConclusionUse of analgesia is important in the acute management of paediatric trauma. Direct presentation to a level I trauma centre, TTA and the presence of parents lead to higher appropriate use of analgesia in paediatric trauma resuscitation.

Anterior mediastinal teratoma in a child presenting as trauma

SummaryAn eight‐year‐old girl presented to the Emergency Department with chest pain and dyspnoea following a low impact chest injury. A large haemothorax secondary to trauma was initially suspected on the basis of a chest radiograph and ultrasound scan; insertion of a chest drain was considered but not performed. The child remained stable and was transferred to the local trauma unit, where a CT scan revealed an anterior mediastinal mature cystic teratoma. She went on to have a successful resection of the tumour and an uneventful recovery. This case highlights the requirement for a high index of suspicion in circumstances where mechanism of injury and pathology are not congruous. Effective communication within trauma networks is vital for the management of paediatric trauma presenting to district general hospitals.

Trauma Association of Canada Annual Scientific Meeting abstractsErythroopoietin resuscitated with normal saline, Ringer’s lactate and 7.5% hypertonic saline reduces small intestine injury in a hemorrhagic shock and resuscitation rat model.Analgesia in the management of pediatric trauma in the resuscitative phase: the role of the trauma centre.Multidisciplinary trauma team care in Kandahar, Afghanistan: current injury patterns and care practices.Does computed tomography

Trauma Association of Canada Annual Scientific Meeting abstractsErythroopoietin resuscitated with normal saline, Ringer’s lactate and 7.5% hypertonic saline reduces small intestine injury in a hemorrhagic shock and resuscitation rat model.Analgesia in the management of pediatric trauma in the resuscitative phase: the role of the trauma centre.Multidisciplinary trauma team care in Kandahar, Afghanistan: current injury patterns and care practices.Does computed tomography

Book and other media review

In the United States, trauma is the leading cause of death in children today. Managing pediatric trauma patients often causes high levels of anxiety, even in the most experienced of Emergency Physicians (EPs). One must recognize the unique physiologic and anatomical variations of children, as well as other special considerations in the pediatric patient. This book is an overview of the diagnosis and management of pediatric trauma. It is in no way a comprehensive review of pediatric trauma or its definitive surgical care, but a book focused on Emergency Department (ED) management.

Prehospital Management of Pediatric Trauma

A limited body of literature about pediatric prehospital trauma care exists to date. Topics that have been studied include delaying transport to initiate treatment on-scene, the use of advanced life support or basic life support resources, identifying high-risk pediatric trauma patients, optimal airway management, obtaining intravenous or intraosseous access, immobilization of the cervical spine, optimal management of traumatic brain injury, and the assessment and management of pain. Translating the best available evidence into clinical practice is important to providing quality prehospital pediatric trauma care. This article will review the literature regarding the risks and benefits of various aspects of pediatric trauma care in the prehospital setting.

Golden Hour or Golden Opportunity: Early Management of Pediatric Trauma

The concept of a “golden hour” is a fixture in trauma care. There is a dearth of scientific proof for this concept but an abundance of controversy around how this concept should be interpreted, especially for pediatric trauma patients. Health care providers should instead focus on the “golden opportunity,” different for each patient, to provide the best care in the most appropriate environment for all injured children.

Pediatric chest CT after trauma: impact on surgical and clinical management

Chest CT after pediatric trauma is frequently performed but its clinical impact, particularly with respect to surgical intervention, has not been adequately evaluated. To assess the impact of chest CT compared with chest radiography on pediatric trauma management. Two hundred thirty-five consecutive pediatric trauma patients who had both chest CT and radiography were identified. Images were reviewed and findings were categorized and correlated with subsequent chest interventions, blinded to final outcome and management. Of the 235 children, 38.3% (90/235) had an abnormal chest radiograph and 63.8% (150/235) had an abnormal chest CT (P < 0.0001). Chest interventions followed in 4.7% (11/235); of these, the findings could be made 1 cm above the dome of the liver in 91% (10/11). Findings requiring chest intervention included pneumothorax (PTX) and vertebral fractures. PTX was found on 2.1% (5/235) of chest radiographs and 20.0% (47/235) of chest CTs (P < 0.0001); 1.7% (4/235) of the children received a chest tube for PTX, 0.85% (2/235) seen on chest CT only. Vertebral fractures were present in 3.8% of the children (9/235) and 66.7% (6/9) of those cases were treated with spinal fusion or brace. There were no instances of mediastinal vascular injury. Most intrathoracic findings requiring surgical management in our population were identified in the lower chest and would be included in routine abdominopelvic CT exams; this information needs to be taken into consideration in the diagnostic algorithm of pediatric trauma patients.

Endovascular stenting of a penetrating axillary artery injury in a 14-year-old with 1-year follow-up

In the management of pediatric trauma, certain principles that are practiced in children who have sustained injuries more commonly seen in adults are extrapolated from the adult trauma literature. The increased use of computer tomography angiograms in the diagnosis of penetrating vascular trauma and endovascular therapy in treating vascular trauma in the adult population is being extended to the pediatric population. We present a case of a 14-year-old male with an axillary artery injury that was diagnosed by computer tomography angiogram and treated with an endovascular Stent graft with 1-year follow-up.

Treatment in Pediatric Renal Trauma: A Conservative Management Approach

Purpose: The management of pediatric trauma is substantially derived from the results of adult trauma patient. Despite the increasing of pediatric renal trauma, the management of them still remains controversial. The aim of this study is to evaluate our experience with the expectant conservative management of blunt trauma in children. Materials and Methods: We retrospectively studied 45 pediatric patients with renal trauma between 1995 and 2007. We reviewed medical records for clinical symptoms, mechanism of injury, assigned grade of renal injury, associated injuries, indication of surgery, and treatment outcomes. We graded renal injuries according to the American Association for the Surgery of Trauma Organ Injury Scale. Results: All patients of grade I, II, III, and IV were managed conservatively at beginning, if the hemodynamic state is stable. Among them, 2 patients of grade IV were done delayed operation. One patient underwent delayed renorrhaphy for persistent anemia and hypotension, and the other patient needed delayed nephrectomy because of persistent fever and worsening abdominal pain with significant urinary extravasation. All patients of grade V were undergone early nephrectomy. Conclusions: Except for persistent fever with significant extravasation and grade V injury, initial conservative management of blunt renal trauma in children is effective and recommendable at beginning, if the hemodynamic state is stable. Prospective larger randomized controlled trials will be needed. (Korean J Urol 2009;50:1125-1132) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Interventional radiology for paediatric trauma

Paediatric interventional radiology plays a cornerstone role in the management of paediatric trauma. In the acute setting, interventional radiology techniques allow minimally invasive control of haemorrhage or re-establishment of blood flow. Percutaneous stenting and drainage can allow disruptions in urinary or biliary systems to heal without the need for further surgery. Interventional radiology techniques also have a significant role in treating delayed complications of trauma, including embolization of arterial pseudoaneurysms and pulmonary embolism prophylaxis in individuals immobilized due to the trauma or its operative treatment.

Management of Pediatric Trauma

Injury is the number 1 killer of children in the United States. In 2004, injury accounted for 59.5% of all deaths in children younger than 18 years. The financial burden to society of children who survive childhood injury with disability continues to be enormous. The entire process of managing childhood injury is complex and varies by region. Only the comprehensive cooperation of a broadly diverse group of people will have a significant effect on improving the care and outcome of injured children. This statement has been endorsed by the American Association of Critical-Care Nurses, American College of Emergency Physicians, American College of Surgeons, American Pediatric Surgical Association, National Association of Children's Hospitals and Related Institutions, National Association of State EMS Officials, and Society of Critical Care Medicine.

Role of the Pediatric Intensivist in the Management of Pediatric Trauma

There is a substantial body of evidence supporting the importance of the intensivist, and the importance of active involvement of the intensivist in day-to-day management of patients, although there are much fewer data for pediatric trauma. Postoperative management of the pediatric trauma patient is complex and includes many nonsurgical areas of expertise, such as management of respiratory and renal failure, nutritional support, metabolic support, prevention and management of infection, and sepsis. Collaborative multidisciplinary care of these children should include the active and officially acknowledged involvement of pediatric intensivists side by side with their surgical colleagues.

Asistencia al paciente politraumatizado. Realidad actual desde la perspectiva de las unidades de cuidados intensivos

To study the epidemiology and management of pediatric trauma patients as well as the organizational, human and technical resources dedicated to these children from the perspective of the pediatric intensive care unit (PICU).A standardized data collection form was sent to 43 PICUs in Spain. Items inquired about the existence of training courses, trauma clinical practice guidelines and trauma registers, and which physician was in charge of trauma patients. Data on casuistics, the age of trauma patients, and the availability of human and technical resources, were also recorded.Twenty-four PICUs completed the questionnaire. The PICU physician was responsible for trauma patient care in 66% of the hospitals. No training courses were available in 59% of the hospitals. No trauma register was available in 62% of the hospitals. Trauma patients represented 11% of PICU admissions, and most patients were aged up to 14 years old. An anesthetist was always at the hospital in 100% of the hospitals. A radiologist and traumatologist were always at the hospital in 91%, a neurosurgeon in 66% and a pediatric surgeon in 50%. The remaining surgical and medical specialties were on call. Continuous intracranial pressure monitoring was available in 87% of the PICUs, jugular venous saturation monitoring in 54% and continuous electroencephalogram and transcranial Doppler ultrasound in 50%. Computed tomography and ultrasound were available at all times in all hospitals. Magnetic nuclear resonance and echocardiography were available at all times in 44% of the hospitals, and arteriography in 42%.In Spain, the organization of pediatric trauma management is based on pediatric teams under the supervision of a PICU physician. Some hospitals show a lack of technical and human resources. Therefore, the minimum criteria required to consider a hospital as a pediatric trauma center should be established. Trauma training courses are required.

Predictors of fluid resuscitation in pediatric trauma patients

Advanced Trauma Life Support (ATLS) is accepted as the standard for the first hours of trauma care. However, ATLS is designed primarily for adults. In children, vascular access can be difficult and time-consuming. Due to the differences in the epidemiology of children suffering traumatic injury, they may not require aggressive fluid resuscitation. The objective of the study was to establish predictors of fluid resuscitation, and to determine whether all pediatric Level I Trauma victims require two intravenous catheters. Medical charts of all patients aged < 18 years meeting Level I Trauma criteria who presented to Childrens Hospital Los Angeles (CHLA) between January 1 and December 31, 1999 were retrospectively reviewed. There were 152 patients reviewed with a median age of 6 years (range 4 months to 17 years); 64% were boys. The mechanism of injury was motor vehicle crash 49%, fall 37%, crush 8%, gunshot 5%, and knife 1%. Injuries included closed head 88%, penetrating abdomen/chest 6%, and other 6%. Vital signs over time showed no change in 59%, got better in 34%, and got worse in 7%. Fluid resuscitation included no bolus in 70%, 1 bolus in 20%, 2 boluses in 7%, > 2 boluses in 3%. The ICU admitted 23%, 12% were intubated, survival was 95%, and 59% received a prehospital i.v. The i.v. #1 site: antecubital 51%, hand 41%, foot 5%, femoral 1%. The i.v. #2 site: hand 30%, antecubital 20%, foot 2%, none 48%. T test showed no statistically significant differences in fluid resuscitation or second i.v. placement based on the mechanism of injury. T test for unequal variances showed a statistically significant difference in means with p < 0.001 for second i.v. placement as compared with only i.v. fluid amount, age, and Injury Severity Score (ISS). Revised Trauma Score was the only predictor of worsening of vital signs (logistic regression [LR], p < 0.001). Age was the only predictor of second i.v. placement (LR, p < 0.03). ISS was the only predictor of a bolus being given (LR, p < 0.01). In our study, blunt trauma occurred in 90% of children, with 10% requiring > 1 fluid bolus. ISS was the only predictor of the need for fluid resuscitation and is not likely to be helpful in the clinical setting. In our population, nearly 50% had no second i.v. This preliminary review of the nature of pediatric trauma suggests that ATLS guidelines may not always be appropriate for the management of pediatric trauma.