Traumatic injuries are the leading cause of death, disability, and hospitalization among children in the United States. Each year, more than 20,000 children suffer traumatic deaths, resulting in more than 3 million years of potential life lost.¹ In addition, nonfatal injuries in individuals younger than 20 years lead to approximately 10 million emergency department visits, 10 million urgent care visits, and 300,000 hospitalizations each year.^2,3 The annual cost of unintentional injuries to children younger than 14 years is estimated to be $5 billion.⁴

Fatalities from traumatic injury are most commonly caused by head injuries; however, thoracic and abdominal injuries are the direct cause of death in 20% and 10% of pediatric trauma cases, respectively.³ The majority (85%) of injuries sustained by children and adolescents are from blunt trauma, many of which can be managed non-operatively.^5,6 Because of their anatomy, children are more vulnerable than adults to blunt trauma. For example, a child’s cranial vault is larger and heavier than an adult’s, predisposing the brain to injury. In addition, the pediatric brain is less myelinated, making it especially susceptible to shearing forces. The pediatric abdomen is also at high risk of injury secondary to the immature musculoskeletal system and body habitus.⁷ Solid organs in children are comparatively larger than in adults, and there is little fat or connective tissue to protect them from injury. Further, owing to a child’s smaller size, more force is applied per body surface area, resulting in a higher likelihood of internal injury than in adults.

Because many traumatic injuries in children are managed nonoperatively, it is imperative that the pediatric emergency physician, hospitalist, and intensivist understand the diagnostic approach and management of the most common pediatric injuries. This chapter reviews the most common injury patterns seen in children.

The approach to trauma victims is standardized, independent of age. The American College of Surgeons has created the ATLS (Advanced Trauma Life Support) program that outlines the medical and surgical management of trauma. The initial assessment of any trauma patient includes a primary survey, resuscitation, secondary survey, and triage. The goal of the primary survey is to assess the patient’s airway, breathing, and circulation (ABCs) while maintaining cervical spine immobilization until that injury can be ruled out. The secondary survey is a systematic assessment of the patient from head to toe to establish the presence of other injuries. Once the patient is stable, he or she may be triaged or transferred to the intensive care unit, general ward, or an outside institution. It is imperative that the receiving medical team perform its own secondary survey, regardless of the injuries found previously; nonlife-threatening injuries such as fractures and lacerations can be missed during the initial assessment.

Head trauma is the most common pediatric injury. Each year there are 600,000 emergency department visits, 95,000 hospitalizations, 7000 deaths, and 30,000 new permanent disabilities due to pediatric head trauma.^8,9 Causes of head trauma vary by age. In children younger than 2 years, the most common causes are falls (40%), followed by injuries suspicious for abuse.¹⁰ In older children, the most common causes are motor vehicle accidents, falls from bicycles, and athletic injuries.¹¹ Consequences of head injury include intracranial bleeding, cerebral contusion, diffuse axonal injury, skull fracture, concussion, cervical spine injury, and long-term neuropsychological sequelae. In this chapter, the discussion of head trauma is limited to minor head injuries and cervical spine injuries. See Chapter 159 for more details on moderate to severe head injuries.

MINOR HEAD INJURY

Minor closed head injury is defined by the American Academy of Pediatrics (AAP) as an injury in a previously healthy child aged 2 years or older with normal mental status, no abnormal neurologic findings, and no evidence of skull fracture.⁸ In children with minor head injury, the risk of intracranial injury is less than 1%; however, the risk of intracranial injury increases to 1% to 5% if the child also has a history of loss of consciousness, vomiting, or amnesia.¹² Children younger than 2 years have not been as well studied, but those with minor head injury are thought to have a risk of intracranial injury of 3% to 6%.¹³

Clinical Presentation

Children with minor head injury may present with temporary loss of consciousness (<1 minute), vomiting, seizure, headache, or lethargy. Seizures are present in approximately 10% of children with minor head injury, usually occurring at the time of injury. Seizures alone do not predict intracranial injury.^14-16 Skull fracture may also occur in patients with minor head injury; the incidence is highest in those younger than 2 years. Regardless of age, skull fractures are associated with a 15% to 30% risk of intracranial injury.⁹ The presence of scalp swelling or hematoma in a young child, especially parietal and temporal lesions, has been linked to the presence of an underlying skull fracture and to the presence of a intracranial bleed.^16,17

Diagnostic Evaluation

A recent multicenter study to address the question of which patients with a head injury are at low risk for a clinically significant intracranial process was completed.¹⁶ This rule can be applied to children either younger or older than age 2 and can be utilized to determine the actual risk for a clinically significant intracranial process (Figure 157-1).

Children younger than 2 years are at higher risk for intracranial injury. A CT should be obtained in any patient with altered mental status, palpable skull fracture, or depressed Glasgow Coma Scale (GCS) (Figure 157-1A). Signs and symptoms more concerning for intracranial injury include presence of a scalp hematoma (occipital, temporal, or parietal), history of loss of consciousness, severe mechanism, and behavior that is not normal per the parent. It is recommended that these children undergo observation or diagnostic imaging (computed tomography [CT] scan) based on other clinical factors and physician experience. This group also includes infants younger than 3 months with a history of head trauma.

Pediatric patients older than 2 years should undergo imaging with CT with altered mental status, depressed GCS, or signs of basilar skull fracture (Figure 157-1B). Children with the following constellation of signs or symptoms should be treated more cautiously: history of loss of consciousness, history of vomiting, severe mechanism of injury, or severe headache. Patients with these symptoms or signs should be observed or a computed tomography scan obtained on the basis of other factors including multiple findings, worsening symptoms or signs after observation, physician experience, and parental preference. Patients should be observed in the hospital until signs and symptoms such as amnesia, vomiting, and lethargy clear.

Low-risk patients have a normal neurologic examination, have a low-risk mechanism of injury, and meet low-risk criteria outlined in Figure 157-1. Low-risk patients can be safely discharged without imaging.^13,16

Management

Patients with a depressed skull fracture, intracranial blood, or cerebral contusion should be managed with the assistance of a neurosurgeon. Patients with amnesia or emesis despite normal imaging normally improve within 24 hours. Goals of inpatient admission are frequent neurologic examinations and hydration.

Consultation

Obtain a neurosurgical consultation for patients with abnormal CT findings, depressed skull fracture, depressed mental status, persistent emesis, or lethargy. Consult a general surgeon if the mechanism of injury is suspicious for occult thoracic or abdominal trauma.

Admission Criteria

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  Persistent amnesia, lethargy, irritability, or emesis

  
  
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  Inability to tolerate oral intake

  
  
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  Focal neurologic deficits

  
  
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  Abnormal CT findings

Discharge Criteria

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  Normal mental status

  
  
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  Normal neurologic examination

  
  
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  Ability to tolerate food or liquid by mouth

CERVICAL SPINE INJURIES

Cervical spine injuries are uncommon in children. They are found in only 1% to 2% of children who sustain blunt trauma.^18,19 Causes of cervical spine injuries vary by age. In younger children, they are most common after motor vehicle accidents or falls. In older children, sports injuries are the most common cause.^20,21

Clinical Presentation

Patients with cervical spine injuries often experience focal pain, muscle spasm, and decreased range of motion. Additionally, transient or persistent neurologic findings may be present.²² Children younger than 8 years are more susceptible to cervical spine injury than adults because of their proportionately larger and heavier heads compared to the rest of their bodies. In addition, young children have less muscle support and more elasticity of ligaments, resulting in more mobility of the upper cervical spine. This leads to the fulcrum of the spine being located at C2-C3 and predisposes children to higher cervical spine injuries.^22,23 Only 30% of cervical spine injuries in children are below C3. In addition, 25% to 50% of such injuries are spinal cord injuries without radiographic abnormalities (SCIWORA).^24,25

Diagnostic Evaluation

Any patient with focal findings or a concerning mechanism of injury should remain immobilized with a cervical collar and undergo radiographic evaluation. This evaluation should include three plain-film views of the cervical spine region: cross-table lateral, anteroposterior, and open-mouth odontoid. The ability of plain films to identify fractures varies by patient age, type of immobilization, and position. In the National Emergency X-Radiography Utilization Study, which evaluated the utility of plain radiography for identifying cervical fractures in adults and children, the three-view series was shown to be 89.4% sensitive.^26,27 The following findings are associated with a low likelihood of cervical fracture: no midline cervical tenderness, no focal neurologic findings, normal mental status, no distracting injury, and no intoxication. These criteria can be safely applied to children older than 8 years.²⁸ Patients who do not meet these low-risk criteria should undergo radiographic evaluation. Patients with persistent pain despite negative radiographs must remain immobilized and further imaging considered.

A recent study conducted through the Pediatric Emergency Care Applied Research Network identified the following eight criteria as associated with cervical spine injuries: (1) altered mental status, (2) focal neurologic deficits, (3) complaint of neck pain, (4) torticollis, (5) substantial injury to the torso, (6) predisposing condition, (7) high-risk motor vehicle crash, and (8) diving injury. Having one or more of these criteria had a sensitivity of 98% (95% CI 96% to 99%) and specificity of 26% (95% CI 23% to 29%) for identifying cervical spine injuries in children under age 16.²⁹

Management

If pain persists despite negative plain radiographs, CT or magnetic resonance imaging should be considered, along with pediatric neurosurgical consultation. The cervical spine can be cleared if the radiographs are negative and the patient is asymptomatic. Patients admitted with cervical immobilization can be cleared once the neurologic examination returns to baseline and they have no midline cervical tenderness and normal cervical radiographs.

Consultation

Neurosurgical consultation should be obtained for patients with abnormal plain radiographs, persistent cervical tenderness, or focal neurologic deficits.

Admission Criteria

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  Cervical fractures

  
  
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  Focal neurologic deficits

Children are less likely than adults to experience thoracic trauma. When they do, only a minority of injuries (15%) require surgical intervention beyond a chest tube.³⁰ Blunt trauma accounts for 85% of thoracic injuries, most commonly secondary to motor vehicle accidents, falls, crush injuries, contact sports, or child abuse.^31,32 Owing to differences in anatomy, children and adults are predisposed to different types of thoracic injuries. The pediatric chest wall has more elasticity and compliance than the adult thorax. Compressibility of the chest wall dissipates the force of impact; therefore significant force is required to cause rib fractures in children.³¹ However, this flexibility, along with the decreased anteroposterior diameter of the chest cavity, predisposes pediatric patients to pulmonary contusions.³³ The mediastinum in children is more flexible, thus reducing the incidence of major vessel and airway injury.³⁴

Holmes and coworkers identified several clinical predictors of thoracic trauma: abnormal respiratory rate, low systolic blood pressure, abnormal thoracic examination, abnormal chest auscultation, and Glasgow Coma Scale score less than 15 (Tables 157-1 and 157-2).³⁵ Plain radiographs of the chest are recommended for patients with any of these findings. Approximately 8% of children undergoing a chest radiograph in the Holmes study had a thoracic injury. The most common injuries were pulmonary contusions (70%), rib fractures (35%), pneumothorax (25%), and hemothorax (10%).³⁵