Trauma management: Approach to the unstable child
- Lois K Lee, MD, MPH
Lois K Lee, MD, MPH
- Assistant Professor of Pediatrics
- Harvard Medical School
- Gary R Fleisher, MD
Gary R Fleisher, MD
- Editor-in-Chief — Adult and Pediatric Emergency Medicine
- Section Editor — Pediatric Signs and Symptoms
- Egan Family Foundation Professor
- Harvard Medical School
- Section Editor
- Richard G Bachur, MD
Richard G Bachur, MD
- Section Editor — Pediatric Trauma
- Professor of Pediatrics and Emergency Medicine
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
In the United States, over 12,000 children and adolescents die annually of unintentional and intentional injuries, making trauma the leading cause of death for this population . Injury and poisoning is also the leading cause of emergency department (ED) visits, accounting for over 7 million ED visits in 2010, which is over one quarter of the 25.5 million ED visits for children less than 18 years of age .
Blunt injury accounts for approximately 90 percent of all pediatric trauma. When blunt force is applied to a child's small body, multisystem trauma occurs frequently. Although the majority of injuries are mild to moderate in severity, the clinician caring for children should be prepared to rapidly evaluate and manage those patients with serious and life threatening trauma. In addition, children have differing anatomy and physiology from adults that require specific attention during advanced trauma care. (See "Trauma management: Unique pediatric considerations".)
The initial approach to the management of the unstable child with major traumatic injuries is presented here. The approach to the initially stable child with traumatic injury and the classification of trauma in the injured child are discussed separately. (See "Approach to the initially stable child with blunt or penetrating injury" and "Classification of trauma in children".)
A standardized approach to the initial management of trauma patients has been disseminated by the American College of Surgeons through the Advanced Trauma Life Support (ATLS) program (figure 1 and table 1). The ATLS protocols are based on the concept of the Trimodal Death Distribution :
●The first peak of death occurs in the seconds to minutes immediately after injury and only prevention can impact this mortality.
- http://www.cdc.gov/ncipc/wisqars (Accessed on August 11, 2016).
- Wier LM (Truven Health Analytics), Hao Y (RAND), Owens P (AHRQ), Washington R (AHRQ). Overview of Children in the Emergency Department, 2010. HCUP Statistical Brief #157. June 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb157.pdf (Accessed on August 18, 2016).
- American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 9th ed, American College of Surgeons, Chicago 2012.
- Lavoie M, Nance ML. Approach to the injured child. In: Fleisher and Ludwig's Textbook of Pediatric Emergency Medicine, 7th ed, Shaw KN, Bachur RG. (Eds), Lippincott Williams & Wilkins, Philadelphia 2016. p.9.
- Perno JF, Schunk JE, Hansen KW, Furnival RA. Significant reduction in delayed diagnosis of injury with implementation of a pediatric trauma service. Pediatr Emerg Care 2005; 21:367.
- Stafford PW, Blinman TA, Nance ML. Practical points in evaluation and resuscitation of the injured child. Surg Clin North Am 2002; 82:273.
- Waltzman ML, Mooney DP. Major trauma. In: Textbook of Pediatric Emergency Medicine, 5th, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.1349.
- Cantor RM, Leaming JM. Evaluation and management of pediatric major trauma. Emerg Med Clin North Am 1998; 16:229.
- Management of shock. In: Pediatric Advanced Life Support Provider Manual, Chameides L, Samson RA, Schexnayder SM, Hazinski MF (Eds), American Heart Association, Subcommittee on Pediatric Resuscitation, Dallas 2011. p.85.
- Eckert MJ, Wertin TM, Tyner SD, et al. Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg 2014; 77:852.
- Chidester SJ, Williams N, Wang W, Groner JI. A pediatric massive transfusion protocol. J Trauma Acute Care Surg 2012; 73:1273.
- Neff LP, Cannon JW, Morrison JJ, et al. Clearly defining pediatric massive transfusion: cutting through the fog and friction with combat data. J Trauma Acute Care Surg 2015; 78:22.
- Hendrickson JE, Shaz BH, Pereira G, et al. Coagulopathy is prevalent and associated with adverse outcomes in transfused pediatric trauma patients. J Pediatr 2012; 160:204.
- Strumwasser A, Speer AL, Inaba K, et al. The impact of acute coagulopathy on mortality in pediatric trauma patients. J Trauma Acute Care Surg 2016; 81:312.
- Lee LK, Fleisher G. An approach to the injured child. In: Textbook of Pediatric Emergency Medicine, 6th, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2010. p.1233.
- Holmes JF, Palchak MJ, MacFarlane T, Kuppermann N. Performance of the pediatric glasgow coma scale in children with blunt head trauma. Acad Emerg Med 2005; 12:814.
- Schonfeld D, Lee LK. Blunt abdominal trauma in children. Curr Opin Pediatr 2012; 24:314.
- Holmes JF, Sokolove PE, Brant WE, et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med 2002; 39:500.
- Melniker LA, Leibner E, McKenney MG, et al. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Ann Emerg Med 2006; 48:227.
- Menaker J, Blumberg S, Wisner DH, et al. Use of the focused assessment with sonography for trauma (FAST) examination and its impact on abdominal computed tomography use in hemodynamically stable children with blunt torso trauma. J Trauma Acute Care Surg 2014; 77:427.
- Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg 2007; 42:1588.
- Holmes JF, Brant WE, Bond WF, et al. Emergency department ultrasonography in the evaluation of hypotensive and normotensive children with blunt abdominal trauma. J Pediatr Surg 2001; 36:968.
- Levy JA, Bachur RG. Bedside ultrasound in the pediatric emergency department. Curr Opin Pediatr 2008; 20:235.
- Slack SE, Clancy MJ. Clearing the cervical spine of paediatric trauma patients. Emerg Med J 2004; 21:189.
- Shlamovitz GZ, Mower WR, Bergman J, et al. Poor test characteristics for the digital rectal examination in trauma patients. Ann Emerg Med 2007; 50:25.
- Shlamovitz GZ, Mower WR, Bergman J, et al. Lack of evidence to support routine digital rectal examination in pediatric trauma patients. Pediatr Emerg Care 2007; 23:537.
- Cervical spine immobilization before admission to the hospital. Neurosurgery 2002; 50:S7.
- Feliz A, Shultz B, McKenna C, Gaines BA. Diagnostic and therapeutic laparoscopy in pediatric abdominal trauma. J Pediatr Surg 2006; 41:72.
- Thompson RW, Kim YJ, Lee LK. Musculoskeletal trauma. In: Fleisher and Ludwig's Textbook of Pediatric Emergency Medicine, 7th ed, Shaw KN, Bachur RG. (Eds), Lippincott Williams & Wilkins, Philadelphia 2016. p.1195.
- Bowman SM, Zimmerman FJ, Christakis DA, et al. Hospital characteristics associated with the management of pediatric splenic injuries. JAMA 2005; 294:2611.
- Mooney DP, Rothstein DH, Forbes PW. Variation in the management of pediatric splenic injuries in the United States. J Trauma 2006; 61:330.
- COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, COUNCIL ON INJURY, VIOLENCE, AND POISON PREVENTION, SECTION ON CRITICAL CARE, SECTION ON ORTHOPAEDICS, SECTION ON SURGERY, SECTION ON TRANSPORT MEDICINE, PEDIATRIC TRAUMA SOCIETY, AND SOCIETY OF TRAUMA NURSES PEDIATRIC COMMITTEE. Management of Pediatric Trauma. Pediatrics 2016; 138.
- Webman RB, Carter EA, Mittal S, et al. Association Between Trauma Center Type and Mortality Among Injured Adolescent Patients. JAMA Pediatr 2016; 170:780.
- Sathya C, Alali AS, Wales PW, et al. Mortality Among Injured Children Treated at Different Trauma Center Types. JAMA Surg 2015; 150:874.
- Sasser SM, Hunt RC, Sullivent EE, et al. Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage. MMWR Recomm Rep 2009; 58:1.
- INJURY CLASSIFICATION
- Injury extent
- Injury type
- Injury severity
- INITIAL APPROACH
- PRIMARY SURVEY
- - Hemorrhage control
- Persistent hemorrhage
- - IV access
- - Fluid resuscitation
- Blood products
- - Massive transfusion protocol
- - Controlled hypotension
- - Vasoactive pressor medications
- - Advanced procedures
- - Neurologic assessment
- - Disability management
- Exposure and environment
- Adjuncts to the primary survey
- - Laboratory studies
- - Screening radiographs
- - FAST (Focused Assessment with Sonography for Trauma)
- - Urinary catheter
- - Gastric tube
- SECONDARY SURVEY
- Physical examination and management
- - Head
- - Cervical spine and neck
- - Chest
- - Abdomen
- - Perineum
- - Musculoskeletal
- - Neurologic
- Adjuncts to the secondary survey
- - Radiographs
- - Head CT
- - Neck CT
- - Abdominal CT
- - Laparoscopy
- - Orthopedic management
- Definitive care
- SUMMARY AND RECOMMENDATIONS