Trauma

Traumatic injury is the most common cause for pediatric emergency department (ED) visits and is the leading cause of death among children aged 1 to 18 years in the United States. Firearm-related injuries and motor vehicle collisions are the most common causes of pediatric traumatic injury; other common causes of traumatic morbidity and mortality in the pediatric population include bicycle injuries, falls, drowning, fire- and burn-related injuries, and nonaccidental trauma.

(Source: Current Causes of Death in Children and Adolescents in the United States. N Engl J Med 2022.)

Resuscitation of the injured child in the ED focuses on both initial stabilization and on disposition planning. Clinicians caring for injured children in settings that do not routinely provide definitive surgical or critical care to children must understand both the algorithms for resuscitation of the injured child and the criteria for transfer to a designated pediatric trauma center.

This section covers the following topics:

• Initial Evaluation of the Injured Child

• Criteria for Transfer to a Pediatric Trauma Center

• Traumatic Head Injury

• Nonaccidental Trauma (NAT)

• Concussion

• Pediatric Extremity Fractures

Initial Evaluation of the Injured Child

The American College of Surgeons’ advanced trauma life support (ATLS) algorithm outlines a standardized method for evaluating trauma victims and highlights the primary and secondary surveys as essential tools for this initial assessment.

Primary Survey

The ABCDEs (Airway, Breathing, Circulation, Disability, Exposure) is a systematic approach for immediate assessment and treatment of trauma patients to help identify life-threatening injuries that require immediate intervention. A single clinician is usually designated as the “surveyor” during trauma resuscitation. The surveyor calls out findings of the primary and secondary survey to the rest of the care team (examples in parentheses below).

Secondary Survey

After completion of the primary survey, the surveyor systematically assesses for injury by performing a rapid head-to-toe examination of the injured child:

• Maintain cervical spine immobilization if there is concern for spinal or neck injury. Indications for cervical spine immobilization include:

  • concerning mechanism or anatomic predisposition to C-spine injury

  • Glasgow Coma Scale (GCS) <13 or intoxication

  • neck pain or torticollis

  • neurologic deficit

• Log-roll the patient at least once during the secondary survey to allow for evaluation of often-missed areas of injury, including back, axillae, and perineum.

During the secondary survey, the rest of the trauma team addresses the injuries uncovered by the surveyor (e.g., insertion of multiple large-bore intravenous [IV] catheters or intraosseous devices for fluid resuscitation, blood transfusion, or both; placement of direct pressure or tourniquets at sites of active bleeding if not already addressed; and deployment of binding or traction devices at sites of orthopedic injury).

The trauma survey is not a static assessment; changes in the clinical status of the patient warrant frequent reevaluation and may require repeat iterations of the survey as the resuscitation unfolds.

Criteria for Transfer to a Pediatric Trauma Center

Providers can use the modified Glasgow Coma Scale (GCS), Infant Coma Scale (ICS), and Pediatric Trauma Score (PTS) to guide disposition of an injured child and to determine whether a child should be transferred for definitive care to a dedicated pediatric trauma center. The PTS emphasizes the importance of patient size and ability to maintain the airway.

Indications for transfer to a pediatric trauma center include:

• GCS or ICS <12

• PTS <8

Traumatic Head Injury

Traumatic brain injury (TBI) is the leading cause of death and disability among children with traumatic injury. Computed tomography (CT) is the standard imaging modality used to diagnose intracranial hemorrhage and skull fractures following head injury. Given the radiation exposure associated with CT and the high frequency of head injuries in the pediatric population, pediatric emergency medicine researchers have developed a data-driven imaging guideline for head injuries in the pediatric population.

The Pediatric Emergency Care Applied Research Network (PECARN) Head Imaging Criteria

PECARN criteria were derived and validated in more than 42,000 patients. The algorithm helps identify children at low risk of clinically significant head injury who do not require imaging. Patients with acute head trauma who meet the guideline’s low-risk criteria are at very low risk (<0.02% for children <2 years and <0.05% for children aged 2 to 18 years) for clinically significant brain injury. Therefore, most low-risk patients can avoid CT imaging, and their injuries can be managed instead with a short period of observation.

(Reprinted from Identification of Children at Very Low Risk of Clinically-Important Brain Injuries after Head Trauma: A Prospective Cohort Study. The Lancet 2009, with permission from Elsevier.)

Injuries Causing Increased Intracranial Pressure (ICP)

The following is a short list of potentially life-threatening intracranial injuries that must be considered in cases of head trauma:

Epidural hematoma:

• mechanism: usually the result of a direct localized blow to the head leading to a skull fracture and laceration of epidural vessels

• signs/symptoms:

  • common: lethargy, vomiting, and headache

  • classic (but less common): brief initial loss of consciousness followed by “lucid interval”

• diagnosis: noncontrast head CT: look for a high-density, biconvex lesion adjacent to the skull

• management: immediate neurosurgical consultation and craniotomy with evacuation of blood contents

(Source: Traumatic Epidural Hematoma. N Engl J Med 2009.)

Subdural hematoma:

• mechanism: usually the result of shearing forces to the brain (e.g., rapid acceleration-deceleration from car accident or shaking during nonaccidental trauma) leading to tearing of bridging veins in subdural space

• signs/symptoms: depressed mental status, headache, vomiting, or seizures (with or without initial loss of consciousness at the time of injury)

• diagnosis: noncontrast head CT (look for a high-density crescentic lesion in the extra-axial space)

• management:

  • nonsevere (no significant mass effect): nonoperative management; supportive care

  • severe (mass effect): surgical evacuation

(Source: Subdural Hematoma. N Engl J Med 1997.)

Subarachnoid hemorrhage (SAH):

• mechanism:

  • either a severe direct blow, rupture of an aneurysm, or severe shearing forces that lead to tearing of small vessels in pia mater

  • SAH alone rarely causes increased ICP but can cause cerebral vasospasm, leading to cerebral hypoxia and diffuse brain swelling

• management:

  • nonsevere (no signs of increased ICP): nonoperative management, supportive care, close observation

  • severe (signs of increased ICP, herniation, focal neurological deficits): medical management of ICP first; may require surgical decompression or embolization/coiling of aneurysm

Nonaccidental Trauma (NAT)

One in eight children in the United States is the victim of physical abuse or neglect. One critical role of providers in the ED is to screen for nonaccidental injury and to provide support for families and children in high-risk situations. In young infants, evidence of physical maltreatment may be subtle, making careful screening imperative.

Risk Factors for Child Abuse

Child maltreatment does not discriminate by race, age, or socioeconomic status, but the following factors put families and children at risk:

• parent factors: single parent, young parent, substance abuse, intimate partner violence

• child factors: prematurity or chronic illness, intrauterine drug exposure; young age is the greatest risk factor, with infants at highest risk for fatal abuse

• environmental factors: poverty, social isolation, lower education, larger family size, nonrelated adult(s) in the home

Red Flags for Nonaccidental Trauma

• injuries that are not commensurate with the developmental age of the child (e.g., bruising in a nonambulatory child)

• multiple injuries or injuries at different stages of healing

• bruises over nonbony prominences in an ambulating child

• frenulum tears

• patterned injuries (e.g., bruises in the shape of a belt buckle or hand)

• injuries with severity that is not well explained by the history

• vague or changing history

• unexplained delay in seeking care

Imaging Recommendations

The American Academy of Pediatrics (AAP) recommends imaging in children with suspected NAT as follows:

• skeletal survey: all children <2 years with suspected NAT, especially:

  • <2 years with obvious abusive injuries

  • <2 years with suspicious injury, including bruising or oral injury in nonambulatory infants

    • TEN-4-FACESp is a useful mnemonic to describe a validated decision rule for identifying high-risk bruising patterns concerning for physical abuse in children younger than 4 years:

      • TEN-4: Torso, Ears, Neck, infants <4 months with any bruise

      • FACESp: Frenulum, Angle of the jaw, Cheeks, Eyelids, Subconjunctivae, patterned bruising

  • infants and young toddlers with unexplained intracranial injury

  • infant and toddler siblings of an abused child

• head imaging: required for all patients with suspected abusive head trauma

  • CT in the acute setting if depressed mental status or neurological deficit

  • MRI if normal mental status and nonfocal neurologic exam

Concussion

Concussion is a clinical syndrome of biomechanically induced brain dysfunction resulting from head injury without apparent radiographic injury. Concussions are most commonly caused by falls in young children and by sports-related injury in older children.

Signs and Symptoms

• confusion, headache, nausea with or without vomiting, dizziness, amnesia, difficulty concentrating

Diagnosis

• Diagnosis is clinical, based on history and physical exam, particularly vestibular function testing. Imaging is unnecessary unless there are concerning focal findings on exam.

• Most concussion assessment tools are not validated in children; however, the Centers for Disease Control and Prevention (CDC) Acute Concussion Evaluation (ACE) tool was modified for use in the pediatric ED and demonstrated improved patient follow-up and adherence to the discharge recommendations.

• Other useful clinical tools and resources for concussion can be found on the CDC HEADS UP website.

Management

• physical and cognitive rest followed by a graduated return to both school and sports

• patients with persistent symptoms may undergo vestibular therapy as part of this gradual return

Pediatric Extremity Fractures

The following is a brief overview of pediatric extremity fracture patterns. For more images of pediatric extremity fractures, see Commonly Missed Subtle Skeletal Injuries in Children: A Pictorial Review.

Torus (“buckle”) fractures:

• most commonly occur in distal radius, followed by distal tibia, fibula, and femur

• mechanism: axial compression (e.g., fall on outstretched hand)

• radiograph findings: usually a subtle irregularity or “buckling” in the contour of the cortex

• management: splinting vs. short-arm cast and nonurgent orthopedic or primary care follow-up

(Source: Buckle Fractures of the Distal Radius in Children. Can Med Assoc J 2016.)

Plastic deformation (“bowing”) fractures:

• most commonly occur in the midshaft of ulna, radius, and fibula

• longitudinal bowing of plastic long bones in young children

• can be difficult to identify on radiograph without comparison films of the contralateral side

• if <20% deformity, intervention rarely needed; otherwise, refer to orthopedics for closed reduction, with interim splinting

(Source: Commonly Missed Subtle Skeletal Injuries in Children: A Pictorial Review. Emerg Radiol 2008.)

Greenstick fractures:

• radiograph findings: bending of long bone with a fracture line that does not extend completely through shaft

• occur in prepubertal children with pliable bones

(Source: Greenstick Fracture. [Updated 2022 Aug 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022.) Image courtesy of S Bhimji, MD

Physeal fractures:

• involve the growth plate and therefore can affect growth and symmetry if not managed correctly

• Salter-Harris classification characterizes five types of physeal fractures

(Reprinted by permission from Springer Nature: Classifications in Brief: Salter-Harris Classification of Pediatric Physeal Fractures. Clin Orthop Relat Res 2016.)

• type I fracture: separation through the physis

• type II fracture: enters in the plane of the physis and exits through the metaphysis

• type III fracture: enters in the plane of the physis and exits through the epiphysis

• type IV fracture: crosses the physis, extending from the metaphysis to the epiphysis

• type V fracture: crush injury resulting in injury to the physis

(Source: NEJM Knowledge+)

Toddler’s fracture:

• nondisplaced spiral fracture of the distal tibia

• immediately after injury, plain films may be normal; in children with persistent refusal to ambulate, repeat plain films a week after initial injury will usually reveal the diagnosis

(Source: Commonly Missed Subtle Skeletal Injuries in Children: A Pictorial Review. Emerg Radiol 2008.)