The evolution of the management of traumatically injured children has paralleled the practice of pediatric surgery since its inception with Dr. Ladd in the early 20th century. On December 6th, 1917, during the height of World War I, the SS Mont-Blanc , a French cargo ship transporting wartime munitions, collided with a Norwegian vessel, the SS Imo , in the waters of Halifax, Nova Scotia. The resultant blast injured over 9000 individuals including scores of children. These children suffered various injuries including thermal, penetrating, and blast injuries from the shock wave that destroyed countless houses and businesses. Dr. Ladd, along with other healthcare professionals, traveled from Boston to assist with the mass casualty event. ^, While this event, despite the legends attached to it, may not have served as the official birth of the specialty of pediatric surgery, it underscores the importance of understanding the intricacies of managing injured children and why pediatric surgeons should be the standard-bearers for pediatric trauma. Over the next century, pediatric surgeons have remained instrumental in the treatment of children who have sustained traumatic injuries.

Trauma is a leading cause of morbidity and mortality in the pediatric population. In fact, unintentional injury is the leading cause of death in all age groups of children from 1 to 19 years of age in the United States: in 2020, injury accounted for 7373 deaths. Falls tend to be the most common mechanism of injury seen in children under the age of 10 years, while motor vehicle collisions become more frequent after the age of 10 years. Unfortunately, children also are frequently injured due to intentional injury with assault or homicide. This was the third leading cause of death in children 1–4 years of age (311 deaths) and second leading cause of death in adolescents aged 15–19 in 2020 (2572 deaths). Intentional self-harm or suicide is the second leading cause of death in children 10–14 years and third leading cause of death in adolescents aged 15–19. To put this in perspective, more children age 10–19 years died from suicide than from malignant neoplasms in 2020, underscoring the importance of preventive efforts in the community (Table 13.1 ). This results in a significant burden on medical resources as trauma accounted for 8% of all pediatric hospitalizations in 2010. From 2010 to 2019, the rate of deaths due to unintentional injury decreased by 11%; however, this remains a significant cause of mortality, and more than 7000 children died because of unintentional injury in 2019 and 2020. This is an average of about 20 deaths per day. Mortality rates were highest in males, those under 1 year of age or between the ages of 15 and 19, and with American Indian, Alaska Native, or Black ethnicity.

Most of these deaths occur within the first 24 hours after injury, emphasizing the need for appropriate care in the emergency room and the importance of initial management. ^{, ,} Compared with adult trauma patients, children are more likely to die in the emergency room following a traumatic injury, reinforcing the need for all pediatric healthcare providers, especially emergency room providers and surgeons, to be trained in the management of traumatically injured children. ^, The last decade has seen a focused effort to ensure all emergency rooms have appropriate equipment and training to care for pediatric emergencies. A study of the Pediatric Hospital Information Systems database shows an increased utilization of the emergency room for trauma-related injuries over the decade beginning in 2010. The number of trauma-related emergency room visits increased by 30% over the decade after 2010. Interestingly, the institutional hospitalization rates among these hospitals decreased over this same period.

Evaluation of trends has led to research focused on disparity in access to care and trauma outcomes. Rates of death due to unintentional injury are higher in children who live in rural areas when compared with urban or metropolitan areas. ^{, , ,} There are also disparities related to racial and ethnic background. Disparity by race and ethnicity has been previously shown in rates of drowning. In 2019, drowning was the leading cause of injury-related death in children under 5. Drowning rates were 2.6 times higher in Black children aged 5–9 years and 3.6 times higher in those aged 10–14 years compared with White children of the same age. Deaths due to motor vehicle collisions decreased by 24% in White children from 2010 to 2019 but increased in Black children by 9% during this period, potentially due to variation in seatbelt use. ^{, ,} Deaths due to poisoning increased by 50% in Hispanic children from 2010 to 2019 and by 37% among Black children but decreased by 24% among White children. Disparities are seen with exposure to other chemicals, such as pesticides, that may have long-lasting medical effects. Focused efforts are needed to better understand the underlying factors that drive these disparities.

Use of the term “injury” rather than “accident” when discussing trauma is purposeful. While accidents typically are unavoidable, research has shown that traumatic injuries can be avoided through evidenced-based guidelines and preventive measures. ^, Appropriate use of seatbelts and booster seats is a perfect example of safety measures proven to improve survival in motor vehicle collisions. Unintentional injury is the leading cause of death in children. It is felt that 80% of injuries could have been prevented with simple measures instituted in the home or the community. Due to the success of injury prevention programs, the American College of Surgeons (ACS) requires that trauma centers participate in injury prevention and community outreach as part of the trauma center accreditation. The ACS notes that an effective injury prevention program has certain key elements (see Box 13.1 ).

The work of Dr. Joyce Pressley at Harlem Hospital in New York City is a prime example of a successful injury prevention program. The program identified the ABCDE’s of injury prevention, noting that the prevention requires a multifaceted, systemic injury prevention approach. These are similar to those of the ACS (see Box 13.2 ). The results of this program are staggering, with a reported decline in traffic injuries by 36%, pedestrian injuries by 45%, and violent injuries due to firearms and assaults by 46% compared with preintervention rates. The success of these efforts has resulted in the national Injury Free Coalition for Kids ( https://www.injuryfree.org/index.cfm ). Another organization focused on injury prevention is Safe Kids Worldwide ( www.safekids.org ), previously known as the National SAFE KIDS campaign.

Providers caring for traumatically injured children should have a basic understanding of injury patterns. These patterns may be based upon age of the patient or mechanism of injury (Table 13.2 ). This knowledge allows the provider to not only approach the trauma patient systematically, but it also allows focused prevention efforts. Injury mechanism is the main predictor of injury pattern in children. Blunt trauma is the leading mechanism of injury in pediatric patients across all ages. ^, As children become older, penetrating injuries become more common, although blunt mechanisms still account for most traumatic injuries. As noted previously in this chapter, firearm-related injuries have become the leading cause of death in children; however, it is important to note that motor vehicle collisions remain the leading mechanism of injury in all children. ^,

The head, neck, abdomen, and lower extremities are common body regions affected by major pediatric trauma based upon the prevalence of falls and motor vehicle collisions as leading mechanisms. Minor pediatric trauma typically affects the soft tissue and upper extremities. Motor vehicle collisions may cause injury to the head, face, and neck in an improperly restrained or unrestrained passenger. In children who are properly restrained, injuries to the cervical spine, chest wall, and abdomen may be present due to the presence of the restraining device. A Chance fracture, sometimes referred to as a seatbelt fracture, results from excessive flexion of the spine, typically at the thoracolumbar region. This injury implies a significant amount of force and may have an associated small bowel or mesenteric injury as well as a potential pancreatic injury (Fig. 13.1 ). Children may also sustain severe traumatic injury as a pedestrian struck by a motor vehicle. The lower extremity is commonly injured from the front bumper of a stopping vehicle. Waddell’s triad is the combination of a lower extremity injury with a chest/torso injury and subsequent head injury. This occurs from the initial impact of the car on the lower extremity followed by the torso being struck, with the head striking the car or subsequently striking the ground after being thrown from the force of impact (Fig. 13.2 ).

The mechanism for the development of intestinal and vertebral injuries from lab belts.

The Waddell triad of injuries to the head, torso, and lower extremity.

All-terrain vehicle, dirt bike/motorcycle, and bicycle injuries occur frequently in the pediatric population. Proper use of helmets while ensuring appropriate fit is paramount to injury prevention, as severe traumatic brain injury (TBI) may be seen in the unhelmeted patient. Bicycle injuries may result in extremity injuries as well abdominal injuries from the handlebar. A focal area of ecchymosis from a handlebar injury in a patient with abdominal pain and tenderness is concerning for underlying duodenal injury or pancreatic injury and should be observed closely to ensure operative intervention is not required (Fig. 13.3 ). Dog bite injuries typically affect the extremities. When the face is involved the lip, cheek, and nose are the predominant site of injury, leaving potential long-term cosmetic concerns. Burn injuries that are patterned may be concerning for nonaccidental trauma or child abuse, especially with immersion injuries that are typically uniform in depth with sharp, well-demarcated margins. Intentional burns typically affect the trunk and perineum. Children who fall from a significant height and land on their feet may be at risk for thoracolumbar injuries and should also be evaluated for associated lower extremity fractures, such as a calcaneal fracture (Fig. 13.4 ). Similarly, children may sustain traumatic cervical injuries from diving headfirst into a shallow pool or other body of water.

Illustration of mechanism of injury from a child riding a bicycle.

Lumbar fractures and tibial fractures in an adolescent who jumped out of a window.

The prehospital phase of trauma management is an integral part of the spectrum of care that traumatically injured patients receive. This care is essential to the rapid diagnosis and management of trauma patients. It is imperative that any trauma system have open lines of communication with the emergency medical services that provide prehospital care. The medical care provided in the prehospital phase emphasizes the principles of the primary survey of Advanced Trauma Life Support (ATLS). Focus should be on maintenance, or establishment, of an airway along with ensuring adequate oxygenation while providing hemorrhage control.

Several methods exist for establishment of an advanced airway; however, in a patient who is maintaining their own airway a delay in transport to establish an airway should not occur. Perhaps even more importantly, care should be taken to avoid loss of a patent airway through failed attempts at intubation. ^, Direct pressure can be useful for the management of exsanguinating hemorrhage. Field-expedient tourniquets are being more commonly utilized in the prehospital setting, and their use and time of application should be annotated in the record and conveyed to the accepting trauma team. ^, Immobilization of the patient on a backboard and using an appropriately sized cervical collar assists with stabilization of fractures and prevents further injury during transport. If an appropriate cervical collar is not available, place the patient in a neutral position and use rolled up towels or sandbags to secure the cervical spine. Fluid resuscitation by placement of intravenous lines or intraosseous devices can also be started in the prehospital setting. Some centers are now beginning blood transfusion along with tranexamic acid (TXA) in the field, depending upon severity of injury and length of transport to the nearest trauma center. ^, Tourniquets are also being used more frequently for the management of hemorrhage in the setting of an extremity injury. Proper planning with prehospital services ensures that providers have appropriately sized devices for airway management, cervical collar immobilization, intravenous lines, and intraosseus needles to care for pediatric patients of all ages and sizes.

A major component of the prehospital management of any trauma patient is open communication with the receiving hospital regarding the mechanism of injury, age, and size of the patient, known injuries, and management strategies that have already been employed. Prehospital providers can also provide information regarding other injured patients, mortalities at the scene, and known history, which can assist in the management of the patient in the hospital setting. This information is vital to prepare for the pediatric patient and ensure a rapid seamless turnover to the hospital team. Constructive feedback should be provided to the prehospital provider to improve care. This can be accomplished through a regularly scheduled multidisciplinary review that is part of the trauma center’s quality initiative program.

The primary survey is the mainstay of the initial trauma evaluation and resuscitation for any injured patient. This brief, focused examination allows the provider to identify and treat life-threatening injuries in a systematic fashion. Preparation for the initial management of the patient begins prior to the arrival, with identification of roles for all team members. Upon arrival, patients should have immediate vital signs obtained, supplemental oxygen can be provided, and intravenous access should be obtained. Once intravenous (IV) access is established, fluid resuscitation can begin along with obtaining initial laboratory draws.

There are significant anatomic and physiologic differences that must be considered when caring for the injured child. These will be discussed in the context of their effect on the initial management of the pediatric patient and primary survey.

The secondary survey is a complete head-to-toe physical examination of the patient along with a complete history from either the patient, family members/caregivers, or other witnesses to the event. It is important to remember that the secondary survey does not begin until the primary survey is complete and the patient is stabilized. If the patient begins to deteriorate during the secondary survey, a return to the primary survey is required. A thorough secondary examination can be made more difficult in the noncommunicative patient due to age, TBI, underlying medical condition, or simply anxiety in the child. Obvious injuries such as an open fracture or amputation can also divert focus from more subtle injuries that may still have significant long-term consequences. The potential for missing an injury can be quite high. While the old trauma adage “a finger or tube in every orifice” is no longer applicable, it does serve as a reminder of how thorough the secondary survey needs to be to ensure all injuries are diagnosed and adequately addressed. The AMPLE (allergies, medications, past medical history, last meal, events) mnemonic can be used to ensure an adequate history is obtained. The secondary survey is also the time that further imaging can be obtained that focuses on specific findings on the physical exam or from the history. Efforts to reduce radiation have resulted in decreased use of computed tomography for trauma imaging including that of the cervical spine and head.

The abdomen and skeleton are two anatomic areas of substantial morbidity and mortality and should be thoroughly assessed during the secondary survey. The abdominal viscera tend to be less well protected due to a relatively thin abdominal wall and less abdominal wall musculature. The rib cage covers only the upper portion of the abdomen and is flexible, allowing transmission of force to the underlying solid organs. Bruising or a “seatbelt” sign should raise concern, and providers should have a high index of suspicion for intraabdominal injury. Injuries to the liver, spleen, kidneys, and gastrointestinal tract occur most frequently and account for most of the deaths from intraabdominal injury. Injuries to the great vessels, genitourinary tract, pancreas, and pelvis are less frequent and result in fewer deaths. Most solid visceral injuries are successfully managed nonoperatively, especially those involving the kidneys, the spleen, and the liver.

While frequently seen in pediatric trauma and potentially a significant cause of morbidity, skeletal injury is not usually an immediate cause of death. The pediatric provider should not be lulled into a false sense of security, as these injuries may suggest a significant amount of force and should prompt a thorough examination. They are reported to occur in 26% of serious blunt-injury cases and constitute the principal anatomic diagnosis in 22%. Upper extremity fractures outnumber lower extremity fractures by 7:1, although in serious blunt trauma this ratio is 2:3. The most common long-bone fractures sustained during pedestrians struck by a motor vehicle in children are fractures of the femur and tibia. Falls are typically associated with both upper and lower extremity fractures if the fall height is from a window or the top of a bunk bed, but not from falls from standard beds or down stairs. Substantial injuries from low-height falls should prompt consideration of nonaccidental trauma. Because isolated long-bone and stable pelvic fractures are infrequently associated with substantial hemorrhage, a diligent search must be made for another source of bleeding if signs of shock are observed. ^, Unstable pelvic fractures are an uncommon feature of childhood injury, but unilateral (type III) or bilateral (type IV) anterior and posterior disruptions are those most often associated with major hemorrhage and must be recognized early and treated.

All trauma patients require continual reevaluation to ensure that no injuries are missed, and this is especially important in patients with severe multisystem trauma with high injury severity scores. As life-threatening injuries are managed, other non–life-threatening injuries may become apparent. Injuries may also be more difficult to recognize initially due to altered mental status or the presence of other injuries. If left undiagnosed and untreated, these injuries may still have significant long-term consequences. These reassessments include thorough examinations like the secondary survey along with discussion with the patient about new areas of pain or discomfort. Nursing staff, physical therapy, and other providers may provide input that denotes a potential injury. For example, an improperly restrained child involved in an MVC may have an unrecognized pelvic fracture until the patient refuses to ambulate as part of a physical therapy assessment. A single institution retrospective review of 85 patients who underwent a tertiary trauma survey at a level 1 pediatric trauma center found 13 undiagnosed or undertreated injuries in 11 patients (12.9%). These injuries included cervical spine injuries, subdural hemorrhage, bowel injury, and solid organ injuries. A high index of suspicion is necessary in the management of any trauma patient to ensure all injuries are adequately addressed. Standardized templates for the tertiary survey can assist in the prompt detection of injuries and ensure appropriate treatment is received.

In recent years, much effort has been devoted to outcomes research in pediatric trauma with the hope that benchmarking of results may lead to better care for injured children. Research over the last several decades has routinely shown that children with traumatic injuries have better outcomes, including length of stay and survival, when treated in hospitals that specialize in pediatric trauma with outcomes comparable to adult level 1 trauma centers. Survival is not the only important outcome to be measured. Functional outcomes, particularly long term, are also important to assess following a traumatic injury in a child. Numerous studies also show improved functional outcomes when children are cared for at a pediatric trauma center. While children may recover from injury more quickly than adults, physical function may not fully return to normal. However, self-perceived long-term quality of life among seriously injured children may not be adversely affected, justifying an aggressive approach to their resuscitation.

Outcomes, in general, are related to the severity of the traumatic injury. Comparisons between injuries, mechanisms, and the effects of the traumatic event can be difficult, making outcomes research more complicated. Several injury severity scales exist, and this is due to the markedly different perspectives used in the application of the scales. The Abbreviated Injury Scale (AIS), primarily an anatomical measure of injury severity, was the first widely implemented scale used in practice. Criticism of the AIS includes the inability to account for multiple injuries to the same body region and the poor correlation of the AIS with physiologic severity and survival. The Injury Severity Score (ISS), New Injury Severity Score (NISS), and Pediatric Trauma Score (PTS) are examples of scoring systems developed to overcome the issues described. Despite controversies regarding these scales, it is commonly accepted that injuries whose severity is an ISS of 10 or higher or a PTS of 8 or lower are life-threatening.

Several databases have developed over the last several decades to focus on pediatric trauma. Notable is the expansion of the National Trauma Data Bank (NTDB) of the ACS to include children. The NTDB was initially designed as a simple case repository; efforts continue to analyze cases submitted to the NTDB to provide population estimates of severe pediatric injury and develop quality benchmarks for pediatric trauma care. Preliminary data suggest that these benchmarks perform as well as existing measures. Another data repository focused solely on the care of pediatric trauma patients is the Pediatric Trauma Quality Improvement Program by the ACS. Since 2016, this program—which is available to level I and II pediatric trauma centers verified by the ACS Committee on Trauma—allows for the development of quality benchmarks for pediatric trauma care. Numerous organizations have also developed or expanded focus to include caring for pediatric trauma patients. These organizations have robust websites that provide a variety of information including clinical practice guidelines and research updates. Several organizations are listed here (Table 13.3 ).

To improve outcomes in the treatment of hemorrhagic shock, mitigate coagulopathy, and overall blood use, utilization of a massive transfusion protocol (MTP), including consideration of whole blood as opposed to component therapy, has become more commonplace within the realm of pediatric trauma resuscitation. Five to fifteen percent of children suffering traumatic injury will require some form of transfusion therapy. Even fewer (well less than 1%) will require massive transfusion for life-threatening injuries according to the NTDB. The 28-day mortality rates for children requiring MTP in the setting of trauma range from 37% to 50%.

The definition of pediatric MTP is based on the volume of blood products transfused as a fraction of estimated total blood volume over time. This definition has been relatively arbitrary in both the adult and pediatric population. A weight-based definition has been recommended in pediatrics, due to the heterogeneity of the pediatric population. Recommendations from the Pediatric Trauma Society and others identify 40 mL/kg over 24 hours for all blood products given as a threshold, recognizing that blood volumes change with age. Children who suffer TBI may require specific attention in limiting shock, as they have a higher incidence of coagulopathy.

Despite its relative rarity, massive transfusion of blood products is an emergent process requiring “triggers” to initiate. There are several tools within the adult arena to predict the need for MTP initiation. There is no consensus algorithm for initiation of MTP in children The only validated scoring systems involve mortality prediction. Prehospital and emergency room age-adjusted pediatric shock index values are predictors of MTP requirement and mortality, with more accurate predictability in older children compared with the very young. For most pediatric centers, the activation of MTP is provider or institution specific.

Ratios of blood product transfusion have been challenged in the past. Most centers now incorporate a “balanced approach” of packed red bloods cells (pRBCs), fresh frozen plasma (FFP), and platelets (PLTs). The Pragmatic Randomized Optimal Platelet and FFP Ratios trial identified a decrease in death from exsanguination and an increased achievement in hemostasis with a balanced 1:1:1 resuscitation. The Prospective Observational Multicenter Major Trauma Transfusion trial showed a decrease in mortality for pediatric patients who received MTP.

TXA is a lysine analog that prevents fibrinolysis by counteracting the activation of plasminogen. It may serve as an adjunct to MTP. Military experience with this product occurred during Operation Enduring Freedom, evaluating its efficacy in children suffering penetrating or blast injuries. The PED-TRAX study evaluated pediatric patients (average age of 11 years) who sustained a traumatic injury due to the armed conflict in Afghanistan. Approximately 10% of patients received TXA, and it was found to be an independent predictor of decreased mortality. No adverse events were associated with its use.

To help guide of blood product administration, thromboelastography (TEG) and rotation thromboelastometry (ROTEM) provide near–real-time feedback in identification of fibrinolysis, clot formation, and coagulation factor dysfunction. For instance, development of hyperfibrinolysis may prompt the use of TXA. TEG and ROTEM parameters have been established for pediatric patients. Both of these tests are discussed in more detail below. Pathologists with expertise in blood banking may assist in the interpretation of these studies, and many institutions have cards or materials to assist interpretation readily available in trauma suites and intensive care units. Like any transfusion, complications of MTP include electrolyte disturbances, coagulopathy, immunological reactions related to ABO incompatibility, transfusion-related acute lung injury, and transfusion-associated circulatory overload.

The civilian use of whole-blood transfusion has been resurrected in both adult and pediatric arenas, including trauma resuscitation and MTP. Whole blood already possesses the ideal ratio of RBCs, FFP, and PLTs, thereby mitigating the requirement for multicomponent transfusion. Whole blood may decrease dilutional coagulopathy by decreasing the volume required to restore blood volume. The theoretical risk of allogeneic transfusion reactions related to ABO antibodies is minimized by using low-titer group O blood (LTOWB). With the limited supply of Rh-negative blood, many centers have turned to O-positive blood for routine whole-blood usage. There is a theoretical risk of alloimmunization by transfusing O-positive red blood cells to an O-negative recipient. Additionally, in female recipients of childbearing age, there remains a future risk of hemolytic disease of the fetus or neonate associated with anti-D alloimmunization. Fortunately, this risk is low, making transfusion of O-positive whole blood in the setting of hemorrhagic shock not only more practical but also safe.

The use of whole blood has been found to be safe and efficacious in the pediatric population, including small children (>1 year of age). Volumes of up to 40 mL/kg may be utilized prior to initiation of component therapy. Use of LTOWB is associated with faster resuscitation times compared with component therapy without an increased risk of hemolysis. Additionally, children receiving LTOWB benefit from faster resolution of shock, lower posttransfusion international normalized ratio (INR), and fewer overall blood products. Injured children requiring large volumes of whole blood may also enjoy a survival benefit. Whole blood is now part of MTP at many children’s centers, even outside the realm of trauma.

Nutritional support is an integral part of the management of any traumatically injured or critically ill patient. While surgical nutrition has been addressed earlier in this textbook ( Chapter 2 ), it is important to briefly mention it here as it may often be overlooked when managing a patient with multisystem trauma during a prolonged hospital stay. Appropriate nutrition allows for adequate calories to support the hypermetabolic phase seen in the recovery period for trauma and burn patients, prevents specific nutrient deficiencies, and ensures adequate protein for healing of injured tissues. Adequate nutritional support has a direct impact on the outcomes of any trauma patient. In children, a precise approach to the management of nutrition is paramount, as overfeeding may be as detrimental as underfeeding.

Cuthbertson and Tilston described two phases of injury in the adult phase: an “ebb” phase that lasts typically for 3–5 days and a “flow” phase. This flow phase is marked by a pronounced catabolism with breakdown and turnover of muscle protein. Fat and carbohydrate breakdown occurs, but the protein breakdown is the most important since no large available “protein store” exists (except organs and muscle), and children have a lower lean body mass relative to their body size. Significant protein loss may ultimately lead to fatal arrhythmias. ^, Goal-directed therapy with restoration of adequate perfusion along with appropriate surgical management of traumatic injuries can arrest the catabolic phase. Adequate early nutrition provides protein stores along with other essential nutrients to replenish losses and to provide a substrate for growth and healing, resulting in decreased time to recovery and prevention of wound breakdown and infection.

The timing of implementation of nutritional support is often a question posed in the intensive care unit or on the wards. Typically, nutritional support should be instituted once initial resuscitation has been completed. This usually is within the first 24–72 hours after initial injury. This early feeding has been associated with improved outcomes; in adult patients treated for severe TBI at 22 trauma centers in New York State, patients who were not fed within 5 and 7 days after TBI had a two- and four-fold increased likelihood of death, respectively. Data suggest similar findings in pediatric patients. A secondary analysis of the “Cool Kids Trial” (therapeutic hypothermia) showed initiation of nutritional support before 72 hours after TBI was associated with decreased mortality.

Questions typically arise regarding the implementation of enteral support in the patient on vasopressor therapy. Previously felt to be a contraindication, vasopressor therapy in and of itself is not a reason to withhold enteral support. Instead, an assessment of resuscitation status and hemodynamic stability should drive the decision whether to begin enteral support. Enteral nutrition may be started or reinitiated in a patient who is stable on pressor therapy and adequately resuscitated. ^, The focus should be on close monitoring to ensure tolerance of feeds with a slow advance from an initial trophic feed rate. Individual intuitional feeding protocols are beneficial to not only draw attention to the goal of early implementation of nutrition but to also provide recommended feeding advancement rates. ^,

Enteral nutrition is the goal for any trauma patient, providing a more efficient route for positive nitrogen balance compared with parenteral nutrition. Enteral nutrition also facilitates the preservation of the enterocytes, ensures mucosal and gut integrity, and helps to prevent translocation. Enteral nutrition can be provided through placement of a nasogastric or nasojejunal tube. Patients who may be candidates for long-term enteral support due to their underlying illness or severe TBI may benefit from placement of a gastrostomy tube. Parenteral nutrition is appropriate for those who will not tolerate enteral support or who cannot meet caloric requirement enterally.

Trauma-induced coagulopathy is the disruption of the normal coagulation cascade seen in patients with traumatic injury. This can range from a hypocoagulable state early in the posttraumatic hours that then develops into a hypercoagulable state. The pediatric trauma surgeon must understand this phenomenon, especially in the adolescent trauma patient. Several tools are available to direct treatment regimens and assist with management of the underlying coagulopathy. The main difference between ROTEM and TEG is the mechanics of the test: ROTEM spins the pin and TEG rotates the cup. Both are used to guide the management of trauma-induced coagulopathy.

TEG is an old tool to assess coagulation parameters that has made a resurgence in recent years, even within the realm of pediatric trauma. It is a viscoelastic analysis that requires only a small sample of clotting blood (300 μL) and is capable of assessing the coagulation profile and guiding specific interventions. The study can help identify issues with clot formation, clot strength, fibrinolysis, and deficiencies in fibrin or platelets. Traditional clotting analysis including coagulation profile or platelet count does not delineate between the various types of clotting dysfunction. Specifically, INR may be elevated in pediatric patients suffering either hyperfibrinolysis or fibrinolysis shutdown. Additionally, the turnaround time for traditional coagulation studies far exceeds TEG, limiting the usefulness of other modalities. Results from TEG are more rapid and are generally available within 20 minutes. TEG measures specific portions of clot formation including initiation, strength, stability, retraction, and lysis (see Table 13.4 and Box 13.6 ).

Table 13.4

Images of Thromboelastogram Findings and Treatment Options

Images obtained from https://en.wikipedia.org/wiki/Thromboelastography and made available for use under Creative Commons CC0 1.0 Universal Public Domain Dedication.

Condition	Image	Treatment
Normal (including parameters)		N/A
Prolonged R time		Fresh frozen plasma
Prolonged K time		Cryoprecipitate
Abnormal alpha angle		Platelet
Abnormal fibrinolysis		TXA or aminocaproic acid

Only gold members can continue reading. Log In or Register to continue

Share this:

• X
• Facebook

Related

Related posts:

1. Vascular Access
2. Burns
3. Nutritional Support for the Pediatric Patient
4. Ingested and Aspirated Foreign Bodies

Stay updated, free articles. Join our Telegram channel

Join