Introduction

Care of the Pediatric Trauma Victim in the Field

Care of the Traumatically Injured Child in the ER or Trauma Center

Care of the Traumaically Injured Child in the ICU

Ethnic, Cultural, and Religious

References

Introduction

Traumatic injury is a common reason for a child to be admitted to an Emergency Department and/or to an Intensive Care Unit.  Pediatric injuries account for approximately One Million admission to hospitals and for over 25 Million Emergency Department visits each year (Micik and Walker, 1987).  All members of the team, including pre-hospital team members, need to be highly skilled in treating the child with a traumatic injury.  Unlike adults who possibly have health problems prior to the injury, the child is usually in good health prior to the trauma.  Because of this, a main focus (after immediate treatment) should be on returning the child (and the family) to as normal a lifestyle as possible.

The leading cause of death in the child between the ages of one and fourteen (22,000 to 25,000 children/year) is traumatic injury (Baker and Waller, 1989).  Additionally, the disabilities resulting from multisystem trauma are not only tragedies for the child and family, but also for society.  The long term cost to society of providing care for the child and resources to the family is one concern, but it is virtually impossible to measure the cost of the loss to society of the child’s talents and potential.  Many of the injuries to children are preventable.

Studies have shown that there is an increase in accidental injuries and in poisonings in children during a period of family crisis (Scheidt).  If the family is already in a time of crisis, and then a traumatic event occurs with one of the children, the crisis is worsened.  There may also be tremendous guilt attached to the event by one or both parents.  In addition to meeting the child’s immediate physical needs, skillful family crisis intervention will need to be provided.

The Emergency Medical System that was developed in this country is being expanded by developing a system within a system in order to better care for injured children.  It is estimated that one out of every five children in the United States is cared for in an Emergency Department each year for an accidental injury.  A total of 100,000 children suffer permanent disability and 8,500 children less than 14 years of age die each year from accidental injuries (Behrman, 1992).

Four areas lead the locations for accidental injuries to children.  They are:  the streets, the home, schools, and on the farm.  Motor vehicular accidents (MVA) primarily affect two groups:  teenager and infants.  One out of every fifty teenagers is injured in a Motor Vehicular Accident each year.  The use of alcohol is a factor in 50% of these accidents.  Ten percent of the drivers are under 20 years of age, but account for 18% of automobile fatalities.

Infants also have a particularly high injury rate (9.1/1,000,000/yr).  The infant being transported on the lap of an adult in the front seat is at highest risk because of the velocity of the infant’s body plus the crushing which occurs from the adult behind the infant (Behrman, 1992).  Since accidents most often occur without any prior warning, it is always best to have the infant restrained in an acceptable infant seat.  Other types of motor vehicular accidents involving children are bicycles, motorcycles, mopeds, motorbikes, and motor scooters.  Many accidents involving a bicycle or motorcycle also involve another vehicle.  It is estimated that one out of every eighty children between the ages of 6 – 12 are treated in a hospital every year for an injury from a bicycle accident. 

Many (70%) bicycle accidents involving young children seemed to occur when they were in violation of traffic laws.  They were frequently cited for such infractions as turning violations, riding facing traffic and failure to yield the right of way.  One has to ask whether children are being taught the proper way to ride the bicycle or if they are just unable to adjust quickly enough to rapidly changing traffic conditions.   About sixty percent of the fatalities from pedestrian vs. motor vehicle accidents each year involve a person less than 24 years of age.  Children involved in these accidents are usually unsupervised at the time of the accident and they usually dash out into traffic, often from behind an object which blocks them from the view of the unsuspecting motorist.

The most common type of accident occurring in the home occurs in the two to three year old.  These accidents are usually falls from various heights, either down stairs or against furniture or other objects.  The distance of the fall seems to be less important than the surface against which the child falls.  An unusually high number of children using walkers (one out of three) are inured, often from a fall down stairs.  Parents and caretakers need to “child-proof” their homes periodically to keep safety hazards for small children under control.  Parents also need to be aware of toy safety issues since this is another potential cause of childhood accidental injuries.  A toy purchased for an older sibling can be fatal if a younger brother or sister plays with it.

Physical Education activities at school are one of the leading causes of injuries occurring at schools.  Younger children are often injured in unorganized activities.  Shop and interscholastic sports activities are also involved in the accidents related to older children.  Thirty percent of the injuries happen to teenage males.  The surfaces upon which the activities are conducted play an important part of the severity of the injury.  This also includes the surfaces over which playground equipment is installed.  Any surface which is energy-absorbing is better than a surface such as asphalt or even hard-packed dirt.

The injury level for sports activities is significant.  One out of every fourteen teenagers is treated in a hospital every year for a sports related injury; most of which occur during practice, instead of during the actual competition.  The farm is also the scene of a significant number of injuries (20,000+) to children each year; most of which occur during planting and harvest times (Behrman, 1992).

While the types of accidents that happen to a child are related to their developmental level, they also seem to be related to the amount of adult supervision provided for the child.  As parents have increasingly busy schedules, they must be aware of the need to provide for the supervision and safety of their children and make the necessary provision.

Nurses must be aware of the development of the child as well as the developmental needs.  The physical development and age of the child has a bearing on what type of injury the child will have and the developmental needs will directly affect the care needed.  As an example, the toddler struck by the bumper of a car may sustain head and chest injuries, while a six year old struck by the same bumper may have lower leg injuries.  The toddler may need a parent at the bedside all of the time, while the six year old is verbal and may not need a parent all of the time.

Children are Different from Adults:

When judging the severity of specific injuries in a specific child, and in planning definitive treatment, consideration needs to be given to obvious injuries, but also to the following:

1.  In the child, blunt injury is more frequent than penetrating injury.  Because of the smallness of the space, the injury has a greater potential of being more severe.  In the adult, the blunt injury is spread over more space, thus dissipating the force of the injury.  In the child, it is more concentrated, thus often much more severe.
   
   
2.  Head injuries in the child are frequent, partly because the child becomes a projectile in an accident, hurling through the air, with the head being at the front of the projectile.  The severity of the injury has to do with the force plus the type of surface against which the child impacts.  The head injury in a child is usually more diffuse than in the adult.  In addition, subdural, intracranial and epidural bleeding is less common in the child than in the adult.
   
   Children who do survive a head injury usually recover more fully than the adult who sustains the same head injury (Tepas, 1990).  Seizures after a head injury are more likely to occur in the child than in the adult.  These can occur immediately or up to 48 hours after the injury.  The use of the Glascow Coma Scale is prevalent in Trauma Centers as a means of assessing mental status of the injured person.  This Scale is effective for adults, but it does not account for the developmental differences in young children.  A modified Glascow Coma Scale has been developed for the preverbal child or the child who is not easily following directions (Patterson, 1992).
   
   
3.  Spinal cord injuries in children amount to about five percent of all spinal cord injuries.  This is largely due to the greater elasticity of the child’s spine.  Children are less apt to have vertebral fractures than the adult, unless severe stress is put on the spine of the child.  Other bone structure is also less likely to fracture because the bones are more compliant than those of an adult.
   
   
4. The abdominal wall in children is less well developed in children than in adults; therefore, injuries to the abdomen can be very severe.  Vital organs are closer to the surface, so the child can more easily have internal injuries.
   
   
5. Additionally, because children have smaller airways they are more likely to go into respiratory distress.  One of the primary causes of death in children suffering trauma is airway compromise.  Children also have a proportionately larger head than adults and this makes positioning for needed procedures difficult (Reynolds, 1992).  Intubation is more difficult in the young child because of the angle and location of the larynx.  Intubation should be tried by only experienced staff and should be done prior to transport if continued bag-mask ventilation is not going to be possible.  Any interference which prevents diaphragm excursion in the child will impede the ventilator effort of the child because the intercostal muscles are not capable of elevating the chest wall to allow inspiration.  The child must depend upon the diaphragm to initiate inspiration.  Any interference may result in respiratory failure (Hazinski, 1992).
   
   
6. Blood pressure cannot be used as the only criteria for estimating blood loss.  Blood pressure can be maintained in children until 25 to 50% of their blood volume has been lost.  A slight increase in the diastolic pressure is usually an indication of impending shock in a pediatric patient.  Pulse rate will be rising in the child before the systolic blood pressure drops.  It is better to assess the circulatory effort by taking peripheral pulse rates, assessing for quality and strength as well as accurately counting the pulse rate.  Other signs to monitor for are:  capillary refill, skin color and temperature, urine output and EKG monitoring (Kitt and Kaiser, 1990).  A child has little reserve cardiac output because the child’s cardiac output and heart rate are near their maximum even when the child is at rest.  So if the child has increased oxygen needs or the delivery of the oxygen is compromise, the child’s condition may go downhill very quickly.  The absence of cyanosis is not a reliable indicator of the child’s oxygen saturation level.  A child can be circulating a significant amount of deoxygenated hemoglobin without showing any signs of cyanosis.  A child’s anxiety level may cause irregularities in pulse and respiratory rates.  It is important to count for one full minute when taking these vital signs to achieve the most accurate information in addition to attempting to alleviate the child’s anxiety.
   
   
7. Body temperature must be closely watched in the injured child.  Hypothermia will hamper resuscitative efforts.  Children lose more heat more quickly than adults because of their larger amount of surface area to volume ratio than adults.  Warm blankets, warming lights and warmed intravenous fluids should be used as much as possible.  The goal of re-warming should be about one degree centigrade per hour.
   
   
8. Fluid administration and urinary output must be carefully measured and calculated.  After vascular access is established, fluids must be administered very carefully.  The child will receive smaller amounts than the adult and excess fluid administration needs to be avoided.  An accurate recording of all output is also necessary.  Care should be taken to weigh diapers, pads, etc., to determine accurate output.  Urine output drops when more than 25% of the total blood volume is lost.  Keeping all of the above in mind, the earlier the child can be definitively treated, the better his/her potential outcome.  The first half hour is considered to be a critical time period in the treatment of pediatric trauma patients (Kitt and Kaiser, 1990).

Next: CARE OF THE PEDIATRIC TRAUMA VICTIM “IN THE FIELD”