Trauma in children

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Trauma in children
Other namesPediatric trauma
Gunshot wonud to leg.JPG
A gunshot wound to the left thigh showing entry and exit wound of a 3 year old girl.
Specialty Emergency medicine

Trauma in children, also known as pediatric trauma, refers to a traumatic injury that happens to an infant, child or adolescent. Because of anatomical and physiological differences between children and adults the care and management of this population differs.

Contents

Anatomic and physiologic differences

There are significant anatomical and physiological differences between children and adults. For example, the internal organs are closer in proximity to each other in children than in adults; this places children at higher risk of traumatic injury. [1]

Children present a unique challenge in trauma care because they are so different from adults - anatomically, developmentally, physiologically and emotionally. A 2006 study concluded that the risk of death for injured children is lower when care is provided in pediatric trauma centers rather than in non-pediatric trauma centers. Yet about 10% of injured children are treated at pediatric trauma centers. The highest mortality rates occur in children who are treated in rural areas without access trauma centers. [2]

An important part of managing trauma in children is weight estimation. A number of methods to estimate weight exist, including the Broselow tape, Leffler formula, and Theron formula. [3] Of these three methods, the Broselow tape is the most accurate for weight estimation in children ≤25 kg, [3] while the Theron formula performs better with patients weighing >40 kg. [3]

Due to basic geometry, a child's weight to surface area ratio is lower than an adult's, children more readily lose their body heat through radiation and have a higher risk of becoming hypothermic. [4] [5] Smaller body size in children often makes them more prone to poly traumatic injury. [6]

Diagnosis

Pediatric Trauma Score

Several classification systems have been developed that use some combination of subjective and objective data in an effort to quantify the severity of trauma. Examples include the Injury Severity Score [7] [8] and a modified version of the Glasgow Coma Scale. [9] More complex classification systems, such as the Revised Trauma Score, APACHE II, [10] and SAPS II [11] add physiologic data to the equation in an attempt to more precisely define the severity, which can be useful in triaging casualties as well as in determining medical management and predicting prognosis.

Though useful, all of these measures have significant limitations when applied to pediatric patients. For this reason, health care providers often employ classification systems that have been modified or even specifically developed for use in the pediatric population. For example, the Pediatric Glasgow Coma Scale is a modification of the Glasgow Coma Scale that is useful in patients who have not yet developed language skills. [12]

Emphasizing the importance of body weight and airway diameter, the Pediatric Trauma Score (PTS) was developed to specifically reflect the vulnerability of children to traumatic injury. The minimal score is -6 and the maximum score is +12. There is a linear relationship between the decrease in PTS and the mortality risk (i.e. the lower the PTS, the higher the mortality risk). [12] Mortality is estimated at 9% with a PTS > 8, and at 100% with a PTS ≤ 0.[ citation needed ]

In most cases the severity of a pediatric trauma injury is determined by the pediatric trauma score [4] despite the fact that some research has shown there is no benefit between it and the revised trauma scale. [13]

Management

The management of pediatric trauma depends on a knowledge of the physiological, anatomical, and developmental differences in comparison to an adult patient, this requires expertise in this area. [14] In the pre-hospital setting issues may arise with the treatment of pediatric patients due to a lack of knowledge and resources involved in the treatment of these injuries. [15] Despite the fact there is only a slight variation in outcomes in adult trauma centers, definitive care is best reached at a pediatric trauma center. [16] [17]

Epidemiology

Most common causes of pediatric trauma Pediatric Trauma stats.svg
Most common causes of pediatric trauma

Based on the Centers for Disease Control and Prevention's (CDC) WISQARS database for the latest year of data (2010), serious injury kills nearly 10,000 children in America each year. [18]

Pediatric trauma accounted for 59.5% of all mortality for children under 18 in 2004. [1] [19] Injury is the leading cause of death in this age group in the United States—greater than all other causes combined. [20] It is also the leading cause of permanent paralysis for children. [21] [22] In the US approximately 16,000,000 children go to a hospital emergency room due to some kind of injury every year. [4] Male children are more frequently injured than female children by a ratio of two to one. [4] Some injuries, including chemical eye burns, are more common among young children than among their adult counterparts; these are largely due to cleaning supplies and similar chemicals commonly found around the home. [23] Similarly, penetrating injuries in children is because of writing utensils and other common household objects as many are readily available to children in the course of their day. [24]

See also

Related Research Articles

<span class="mw-page-title-main">Triage</span> Process of determining the priority of patients treatments based on the severity of their condition

In medicine, triage is a process by which care providers such as medical professionals and those with first aid knowledge determine the order of priority for providing treatment to injured individuals and/or inform the rationing of limited supplies so that they go to those who can most benefit from it. Triage is usually relied upon when there are more injured individuals than available care providers, or when there are more injured individuals than supplies to treat them.

<span class="mw-page-title-main">Head injury</span> Serious trauma to the cranium

A head injury is any injury that results in trauma to the skull or brain. The terms traumatic brain injury and head injury are often used interchangeably in the medical literature. Because head injuries cover such a broad scope of injuries, there are many causes—including accidents, falls, physical assault, or traffic accidents—that can cause head injuries.

The Glasgow Coma Scale (GCS) is a clinical scale used to reliably measure a person's level of consciousness after a brain injury.

A trauma center, or trauma centre, is a hospital equipped and staffed to provide care for patients suffering from major traumatic injuries such as falls, motor vehicle collisions, or gunshot wounds. A trauma center may also refer to an emergency department without the presence of specialized services to care for victims of major trauma.

<span class="mw-page-title-main">Concussion</span> Type of traumatic brain injury

A concussion, also known as a mild traumatic brain injury (mTBI), is a head injury that temporarily affects brain functioning. Symptoms may include loss of consciousness; memory loss; headaches; difficulty with thinking, concentration, or balance; nausea; blurred vision; dizziness; sleep disturbances, and mood changes. Any of these symptoms may begin immediately, or appear days after the injury. Concussion should be suspected if a person indirectly or directly hits their head and experiences any of the symptoms of concussion. Symptoms of a concussion may be delayed by 1-2 days after the accident. It is not unusual for symptoms to last 2 weeks in adults and 4 weeks in children. Fewer than 10% of sports-related concussions among children are associated with loss of consciousness.

<span class="mw-page-title-main">Acute respiratory distress syndrome</span> Human disease

Acute respiratory distress syndrome (ARDS) is a type of respiratory failure characterized by rapid onset of widespread inflammation in the lungs. Symptoms include shortness of breath (dyspnea), rapid breathing (tachypnea), and bluish skin coloration (cyanosis). For those who survive, a decreased quality of life is common.

<span class="mw-page-title-main">Internal bleeding</span> Medical condition

Internal bleeding is a loss of blood from a blood vessel that collects inside the body. Internal bleeding is usually not visible from the outside. It is a serious medical emergency but the extent of severity depends on bleeding rate and location of the bleeding. Severe internal bleeding into the chest, abdomen, retroperitoneal space, pelvis, and thighs can cause hemorrhagic shock or death if proper medical treatment is not received quickly. Internal bleeding is a medical emergency and should be treated immediately by medical professionals.

<span class="mw-page-title-main">Major trauma</span> Injury that could cause prolonged disability or death

Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma, blunt and penetrating, including falls, motor vehicle collisions, stabbing wounds, and gunshot wounds. Depending on the severity of injury, quickness of management, and transportation to an appropriate medical facility may be necessary to prevent loss of life or limb. The initial assessment is critical, and involves a physical evaluation and also may include the use of imaging tools to determine the types of injuries accurately and to formulate a course of treatment.

<span class="mw-page-title-main">Traumatic brain injury</span> Injury of the brain from an external source

A traumatic brain injury (TBI), also known as an intracranial injury, is an injury to the brain caused by an external force. TBI can be classified based on severity ranging from mild traumatic brain injury (mTBI/concussion) to severe traumatic brain injury. TBI can also be characterized based on mechanism or other features. Head injury is a broader category that may involve damage to other structures such as the scalp and skull. TBI can result in physical, cognitive, social, emotional and behavioral symptoms, and outcomes can range from complete recovery to permanent disability or death.

Closed-head injury is a type of traumatic brain injury in which the skull and dura mater remain intact. Closed-head injuries are the leading cause of death in children under 4 years old and the most common cause of physical disability and cognitive impairment in young people. Overall, closed-head injuries and other forms of mild traumatic brain injury account for about 75% of the estimated 1.7 million brain injuries that occur annually in the United States. Brain injuries such as closed-head injuries may result in lifelong physical, cognitive, or psychological impairment and, thus, are of utmost concern with regards to public health.

APACHE II is a severity-of-disease classification system, one of several ICU scoring systems. It is applied within 24 hours of admission of a patient to an intensive care unit (ICU): an integer score from 0 to 71 is computed based on several measurements; higher scores correspond to more severe disease and a higher risk of death. The first APACHE model was presented by Knaus et al. in 1981.

Abnormal posturing is an involuntary flexion or extension of the arms and legs, indicating severe brain injury. It occurs when one set of muscles becomes incapacitated while the opposing set is not, and an external stimulus such as pain causes the working set of muscles to contract. The posturing may also occur without a stimulus. Since posturing is an important indicator of the amount of damage that has occurred to the brain, it is used by medical professionals to measure the severity of a coma with the Glasgow Coma Scale and the Pediatric Glasgow Coma Scale.

The Injury Severity Score (ISS) is an established medical score to assess trauma severity. It correlates with mortality, morbidity and hospitalization time after trauma. It is used to define the term major trauma. A major trauma is defined as the Injury Severity Score being greater than 15. The AIS Committee of the Association for the Advancement of Automotive Medicine (AAAM) designed and improves upon the scale.

Post-traumatic seizures (PTS) are seizures that result from traumatic brain injury (TBI), brain damage caused by physical trauma. PTS may be a risk factor for post-traumatic epilepsy (PTE), but a person having a seizure or seizures due to traumatic brain injury does not necessarily have PTE, which is a form of epilepsy, a chronic condition in which seizures occur repeatedly. However, "PTS" and "PTE" may be used interchangeably in medical literature.

<span class="mw-page-title-main">Pulmonary contusion</span> Internal bruise of the lungs

A pulmonary contusion, also known as lung contusion, is a bruise of the lung, caused by chest trauma. As a result of damage to capillaries, blood and other fluids accumulate in the lung tissue. The excess fluid interferes with gas exchange, potentially leading to inadequate oxygen levels (hypoxia). Unlike pulmonary laceration, another type of lung injury, pulmonary contusion does not involve a cut or tear of the lung tissue.

<span class="mw-page-title-main">Geriatric trauma</span> Medical condition

Geriatric trauma refers to a traumatic injury that occurs to an elderly person. People around the world are living longer than ever. In developed and underdeveloped countries, the pace of population aging is increasing. By 2050, the world's population aged 60 years and older is expected to total 2 billion, up from 900 million in 2015. While this trend presents opportunities for productivity and additional experiences, it also comes with its own set of challenges for health systems. More so than ever, elderly populations are presenting to the Emergency Department following traumatic injury. In addition, given advances in the management of chronic illnesses, more elderly adults are living active lifestyles and are at risk of traumatic injury. In the United States, this population accounts for 14% of all traumatic injuries, of which a majority are just mainly from falls.

<span class="mw-page-title-main">Stab wound</span> Medical condition

A stab wound is a specific form of penetrating trauma to the skin that results from a knife or a similar pointed object. While stab wounds are typically known to be caused by knives, they can also occur from a variety of implements, including broken bottles and ice picks. Most stabbings occur because of intentional violence or through self-infliction. The treatment is dependent on many different variables such as the anatomical location and the severity of the injury. Even though stab wounds are inflicted at a much greater rate than gunshot wounds, they account for less than 10% of all penetrating trauma deaths.

The Trauma Quality Improvement Program (TQIP) was initiated in 2008 by the American College of Surgeons Committee on Trauma. Its aim is to provide risk-adjusted data for the purpose of reducing variability in adult trauma outcomes and offering best practice guidelines to improve trauma care. TQIP makes use of national data to allows hospitals to objectively evaluate their trauma centers' performance relative to other hospitals. TQIP's administrative costs are less than those of other programs, making it an accessible tool for assessing performance and enhancing quality of trauma care.

Renal angina is a clinical methodology to risk stratify patients for the development of persistent and severe acute kidney injury (AKI). The composite of risk factors and early signs of injury for AKI, renal angina is used as a clinical adjunct to help optimize the use of novel AKI biomarker testing. The term angina from Latin and from the Greek ankhone ("strangling") are utilized in the context of AKI to denote the development of injury and the choking off of kidney function. Unlike angina pectoris, commonly caused due to ischemia of the heart muscle secondary to coronary artery occlusion or vasospasm, renal angina carries no obvious physical symptomatology. Renal angina was derived as a conceptual framework to identify evolving AKI. Like acute coronary syndrome which precedes or is a sign of a heart attack, renal angina is used as a herald sign for a kidney attack. Detection of renal angina is performed by calculating the renal angina index.

A pediatric concussion, also known as pediatric mild traumatic brain injury (mTBI), is a head trauma that impacts the brain capacity. Concussion can affect functional, emotional, cognitive and physical factors and can occur in people of all ages. Symptoms following after the concussion vary and may include confusion, disorientation, lightheadedness, nausea, vomiting, blurred vision, loss of consciousness (LOC) and environment sensitivity. Concussion symptoms may vary based on the type, severity and location of the head injury. Concussion symptoms in infants, children, and adolescents often appear immediately after the injury, however, some symptoms may arise multiple days following the injury leading to a concussion. The majority of pediatric patients recover from the symptoms within one month following the injury. 10-30% of children and adolescents have a higher risk of a delayed recovery or of experiencing concussion symptoms that persist.

References

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  2. ↑ Petrosyan, Mikael; Guner, Yigit S. MD; Emami, Claudia N. MD; Ford, Henri R. MD (August 2009). "Disparities in the Delivery of Pediatric Trauma Care". The Journal of Trauma. 67 (2 Supplement (Injury, Infection, and Critical Care Issue)): S114–S119. doi:10.1097/TA.0b013e3181ad3251. PMID   19667843.
  3. 1 2 3 So TY, Farrington E, Absher RK (2009). "Evaluation of the accuracy of different methods used to estimate weights in the pediatric population". Pediatrics. 123 (6): e1045–51. doi:10.1542/peds.2008-1968. PMID   19482737. S2CID   6009482 . Retrieved 2010-11-07.
  4. 1 2 3 4 Peitzman AB, Rhodes M, Schwab CW, Yealy DM, Fabian TC, eds. (2008). "Pediatric Trauma". The Trauma Manual (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. pp. 499–514. ISBN   978-0-7817-6275-5.
  5. ↑ "Pediatric Trauma And Triage: Overview of the Problem and Necessary Care for Positive Outcomes" (powerpoint). Jim Morehead. Retrieved 2010-11-06.
  6. ↑ Ron Walls MD; John J. Ratey MD; Robert I. Simon MD (2009). Rosen's Emergency Medicine: Expert Consult Premium Edition - Enhanced Online Features and Print (Rosen's Emergency Medicine: Concepts & Clinical Practice (2v.)). St. Louis: Mosby. pp. 262–80. ISBN   978-0-323-05472-0.
  7. ↑ Baker SP, O'Neill B, Haddon W Jr, Long WB (1974). "The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care". The Journal of Trauma. 14 (3): 187–96. doi: 10.1097/00005373-197403000-00001 . PMID   4814394.
  8. ↑ Copes WS, Champion HR, Sacco WJ, Lawnick MM, Keast SL, Bain LW (1988). "The Injury Severity Score revisited". The Journal of Trauma. 28 (1): 69–77. doi: 10.1097/00005373-198801000-00010 . PMID   3123707.
  9. ↑ Teasdale G, Jennett B (1974). "Assessment of coma and impaired consciousness. A practical scale". The Lancet . 2 (7872): 81–4. doi:10.1016/S0140-6736(74)91639-0. PMID   4136544.
  10. ↑ Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985). "APACHE II: a severity of disease classification system". Critical Care Medicine . 13 (10): 818–29. doi:10.1097/00003246-198510000-00009. PMID   3928249.
  11. ↑ Le Gall JR, Lemeshow S, Saulnier F (1993). "A New Simplified Acute Physiology Score (SAPS II) Based on a European/North American Multicenter Study". Journal of the American Medical Association . 270 (24): 2957–63. doi:10.1001/jama.1993.03510240069035. PMID   8254858.
  12. 1 2 Campbell, John Creighton (2000). Basic trauma life support for paramedics and other advanced providers. Upper Saddle River, N.J: Brady/Prentice Hall Health. ISBN   978-0-13-084584-9.
  13. ↑ Kaufmann CR, Maier RV, Rivara FP, Carrico CJ (January 1990). "Evaluation of the Pediatric Trauma Score". JAMA. 263 (1): 69–72. doi:10.1001/jama.263.1.69. PMID   2293691.
  14. ↑ Little, Wendalyn K. (1 March 2010). "Golden Hour or Golden Opportunity: Early Management of Pediatric Trauma". Clinical Pediatric Emergency Medicine. 11 (1): 4–9. doi:10.1016/j.cpem.2009.12.005.
  15. ↑ Lohr, Kathleen N.; Durch, Jane (1993). Emergency medical services for children: Committee on Pediatric Emergency Medical Services. Washington, D.C: National Academy Press. ISBN   978-0-309-04888-0.
  16. ↑ Densmore JC, Lim HJ, Oldham KT, Guice KS (January 2006). "Outcomes and delivery of care in pediatric injury". J. Pediatr. Surg. 41 (1): 92–8, discussion 92–8. doi:10.1016/j.jpedsurg.2005.10.013. PMID   16410115.
  17. ↑ Deasy C, Gabbe B, Palmer C, et al. (October 2011). "Paediatric and adolescent trauma care within an integrated trauma system". Injury . 43 (12): 2006–2011. doi:10.1016/j.injury.2011.08.032. PMID   21978766.
  18. ↑ "CDC childhood injury report; patterns of unintentional injuries among 0-19 year olds in the United States, 2000-2006". stacks.cdc.gov.
  19. ↑ Krug SE, Tuggle DW (2008). "Management of pediatric trauma" (PDF). Pediatrics . 121 (4): 849–54. doi: 10.1542/peds.2008-0094 . PMID   18381551. S2CID   28319980 . Retrieved 2010-11-06.
  20. ↑ "Childress Institute for Pediatric Trauma" . Retrieved 2010-11-06.
  21. ↑ Aghababian, Richard (2010). Essentials of Emergency Medicine. Jones & Bartlett Learning. pp. 992–1000. ISBN   978-0-7637-6652-8.
  22. ↑ Moore, Ernest J; Feliciano, David V.; Mattox, Kenneth L. (2008). Trauma. McGraw-Hill Medical. pp. 993–1000. ISBN   978-0-07-146912-8.
  23. ↑ Haring RS, Sheffield ID, Channa R, Canner JK, Schneider EB (August 2016). "Epidemiologic trends of chemical ocular burns in the United States". JAMA Ophthalmology. 134 (10): 1119–1124. doi: 10.1001/jamaophthalmol.2016.2645 . PMID   27490908.
  24. ↑ Fisher, S. B.; Clifton, M. S.; Bhatia, A. M. (September 2011). "Pencils and pens: An under-recognized source of penetrating injuries in children". The American Surgeon. 77 (8): 1076–1080. doi: 10.1177/000313481107700831 . PMID   21944527. S2CID   24546416.

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