Trauma is a leading cause of morbidity and mortality for children in the United States. Access to trauma care, injury burden, and outcomes following injury, are inequitable. There are many anatomic and physiologic differences between children and adults that affect injury patterns and necessary trauma treatment. The principles of advanced trauma life support (ATLS) should be used by clinicians in high-resource settings for the immediate in-hospital treatment of the injured child.
Key points
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Trauma is a leading cause of morbidity and mortality for children and adolescents in the United States.
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Access to trauma care, and outcomes following injury, are inequitable.
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There are key anatomic and physiologic differences between children and adults that affect injury patterns, which can help guide appropriate care.
Introduction and overview
Injury is the leading cause of morbidity and mortality for children and adolescents in the United States. Although reductions in deaths from some causes, such as motor vehicle collisions, have been realized over time, substantial and sustained increases have been seen in childhood mortality secondary to gun violence over the past decade. Gross inequities are seen with the burden of injury, injury distribution, access to trauma care, and outcomes following injury for children in this country. , Injury affects the immediate and future health and welfare of children and their families, as well as the economic development and security of the communities in which they live.
The purpose of this review is to provide an overview of pediatric trauma and general care considerations of the injured child for oral and maxillofacial care providers. This review discusses the epidemiology of injury in children and adolescents in the United States, outlines important anatomic and physiologic considerations in the injured child and how they may contribute to injury pattern and management, and delineates initial assessment and management strategies contained within the Advance Trauma Life Support (ATLS) model. It has an emphasis on initial hospital management within a well-resourced health system.
Epidemiology
Trauma is a leading cause of death and disability for children in the United States. The Centers for Disease Control and Prevention (CDC) reported that unintentional injury–including motor vehicle collisions and falls–was the primary category of death for children spanning the ages of one and fourteen years old between 2018 and 2021, resulting in approximately 4.9 deaths per 100,000 population. Assault by others was the 4th most common cause of death in this age group, followed by intentional self-harm. Firearm-related injury, which can fall within all of these categories, is rapidly rising and is currently the singular leading cause of death among children and adolescents in the United States. Children living in communities in urban settings, as well as those in communities with high levels of socioeconomic disadvantage, suffer a disproportionate burden of penetrating trauma. For every child that dies secondary to injury, there are approximately 25 children hospitalized and 925 treated in emergency departments.
Despite the high prevalence of morbidity and mortality from trauma for children, significant inequities exist in access to centers able to care for such injuries, injury burden, and outcomes resulting from physical trauma. , For example, children experience improved outcomes when treated for injury at pediatric trauma centers, but only 22.3% of injured children in the United States receive care at such facilities [Burdick]. Only half of the US pediatric population can reach a pediatric trauma center by ground transportation within the golden hour following injury, with disparate access seen when stratified by race, ethnicity, socioeconomic characteristics and rurality. , Understanding the systems, structures, actions, and behaviors that create and perpetuate these inequities is critical for trauma prevention and treatment of children with injuries.
Principles of initial in-hospital management with Advanced Trauma Life Support (ATLS)
The principles ATLS can be used by clinicians for the immediate in-hospital treatment of the injured child, allowing for rapid identification and treatment of life-threatening injuries. This includes prompt assessment of the patient’s condition, resuscitation, stabilization, and determination of the need for and facilitation of transfer based on patient status and facility resources. The principles of initial assessment and management from the 10th edition of ATLS, with the specific consideration of the care of children, are reviewed in the paragraphs to follow.
The primary survey
Initial assessment and resuscitation of the injured child with the identification of life-threatening conditions can be done via a prioritized sequence using a primary survey. This survey incorporates the ABCDEs of trauma care: airway, breathing, circulation, disability, and exposure:
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A irway: Establishing/maintaining airway patency, including cervical spine immobilization.
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Airway assessment can be done by evaluating the patient’s ability to speak or cry. It includes looking for signs of airway obstruction, identifying obvious facial, trachea or laryngeal fractures, and suctioning of blood or secretions from the oropharynx. This may require the establishment of a definitive airway. Cervical spine motion should be limited with the assumption that a cervical spine injury may exist.
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B reathing: Ensuring adequate oxygenation and ventilation.
Breathing can be assessed by looking at chest wall excursion, assessing jugular venous distension and tracheal position, listening to breath sounds, and through the ability of the patient to generate air movement to speak or cry. Life-threatening injuries impairing ventilation, such as a tension pneumothorax, open pneumothorax, or massive pneumothorax, will need to be identified and treated during this stage such as via thoracic decompression.
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C irculation: Establishing effective circulation, including hemorrhage control and vascular access.
Circulation can be assessed by feeling for pulses, evaluating skin perfusion through capillary refill and extremity warmth and color, and considering the level of consciousness as a measure of cerebral perfusion. Hemorrhage is the primary cause of preventable death following injury. Massive external hemorrhage can be controlled with direct pressure and at times cautious tourniquet use. Internal hemorrhage should be considered within the chest, abdomen, retroperitoneum, pelvis and long bones. Temporary management may include the placement of a pelvic stabilizing device or extremity splints. Vascular assess should be established, typically with two large bore IVs, blood samples sent, and volume resuscitation maintained.
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D isability: Assessing neurologic status, including spine immobilization.
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Disability can be reviewed by evaluating the level of consciousness and rapid neurologic evaluation. This can be done by looking at the pupillary size and reaction and using a tool such as the GCS (Glasgow Coma Scale) to determine the level of consciousness ( Table 1 ).
Table 1Pediatric glasgow coma scaleData from References ,Infants Children Score Eye Opening Open spontaneously Open spontaneously 4 Open to verbal stimuli Open to verbal stimuli 3 Open to pain Open to pain 2 No response No response 1 Verbal Response Coos, babbles Oriented, appropriate 5 Irritable cries Confused 4 Cries in response to pain Inappropriate words 3 Moans in response to pain Incomprehensible words or sounds 2 No response No response 1 Motor Response Moves spontaneously and purposefully Follows commands 6 Withdraws to touch Localizes to pain 5 Withdraws to pain Withdraws in response to pain 4 Flexor posturing to pain Flexor posturing to pain 3 Extensor posturing to pain Extensor posturing to pain 2 No response No response 1 - •
E xposure and Environment: Preparing for a full exam while maintaining warmth.
Exposure can be obtained through the removal of patient clothing while warmth can be preserved or supported through external warming devices such as blankets and heating lights to prevent hypothermia.
Adjuncts to the primary survey can include continuous electrocardiography, pulse oximetry, measurement of end tidal CO2, and arterial blood gas (ABG) measurements. X-rays of the chest and pelvis, focused the assessment of sonography for trauma (FAST), and diagnostic peritoneal lavage (DPL) can be obtained. Additional labs can be completed, and gastric and urinary catheters can be placed.
The need for immediate transfer or immediate operative intervention should also be determined during the primary survey.
The secondary survey
After the completion of the primary survey with improvement or normalization of vital signs and ongoing resuscitation, care providers can then move on to the secondary survey. The secondary survey is a complete examination of the patient, including a head-to-toe physical exam and determination of a history if possible. Depending on the patient’s age and injury status, the history may need to come from family members of the injured child. The pneumonic AMPLE can be used to elicit the patient’s medical history and details of injury.
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A llergies
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M edications
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P ast illness
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L ast meal
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E vents of the injury
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A complete, head-to-toe physical exam should be completed, including log-rolling the patient.
Adjuncts to the secondary survey can include additional radiographs, CT scans, contrast urography, angiography, ultrasonography, bronchoscopy, esophagoscopy, and additional labs. Continuous monitoring of vital signs ( Table 2 ) and urinary output in important, as is adequate pain management.
