Accidental Trauma of Infancy: Emergency Department Evaluation and Management - Trauma EXTRA Supplement

Table of Contents

 

About This Issue

Although the majority of injuries resulting from accidental trauma in infants are minor, accidental injuries still account for 5.5% of deaths in children aged <1 year. The mechanisms and types of accidental trauma most often seen in infants differ from those seen in older children, and emergency clinicians must be aware of the unique physiologic trauma response of infants. In infants with head trauma, the risks associated with radiographic exposure in childhood must be considered when making diagnostic decisions.

Which injury patterns are associated with common mechanisms of accidental injury in the infant?

What are the anatomic and physiologic considerations that inform the assessment of the injured infant?

How should the primary and secondary surveys be approached for the infant trauma patient?

What are the indications for adjunctive studies in injured infants?

What are the imaging recommendations for infants with minor head trauma?

Is there benefit to allowing family members to be present during resuscitation of an injured infant?

Does home safety education provided in the ED impact parent behavior?

What is the appropriate disposition for infants with accidental injury?

1. Abstract
2. Case Presentation
3. Introduction
4. Epidemiology and Pathophysiology
   1. Mechanisms of Injury
   2. Types of Injury
5. Differential Diagnosis
   1. Systemic Injury in Severe Trauma
   2. Head, Neck, and Central Nervous System Injury
   3. Skin and Soft-Tissue Injury
   4. Musculoskeletal Injury
   5. Thoracic Injury
   6. Abdominal Injury
6. Prehospital Care
7. Emergency Department Evaluation
   1. Primary Survey
      1. A: Airway and Cervical Spine Stabilization
      2. B: Breathing
      3. C: Circulation
      4. D: Disability
      5. E: Exposure
      6. F: Family
   2. Secondary Survey
      1. Neurologic Evaluation
      2. Cardiopulmonary Examination
      3. Abdominal Examination
      4. Musculoskeletal/Integumentary Examination
   3. Evaluation of Burn Injuries
8. Diagnostic Studies
   1. Laboratory Studies
   2. Imaging Studies
9. Treatment
   1. Airway and Cervical Spine Stabilization
   2. Breathing
   3. Circulation
   4. Disability
   5. Exposure
   6. Treatment of Burn Injuries
      1. Fluid Resuscitation
10. Special Circumstances
    1. Family Presence During Resuscitation
    2. Home Safety Education
11. Controversies and Cutting Edge
    1. Imaging in Head Injury
    2. Osmolar Therapy
12. Disposition
13. Summary
14. Time- and Cost-Effective Strategies
15. Risk Management Pitfalls for Accidental Trauma in Infancy
16. Case Conclusion
17. Clinical Pathway for the Primary Survey for Accidental Trauma in Infants
18. Tables and Figures
    1. Table 1. Guidelines Related to the Treatment of Carotid or Vertebral Artery Dissections
    2. Table 2. History of an Injured Infant in the Prehospital Setting
    3. Table 3. Glasgow Coma Scale Modified for Pediatric Patients
    4. Table 4. Lund and Browder Chart for Infants Aged =1 Year
    5. Table 5. Burn Center Referral Criteria
    6. Table 6. Recommendations for Family Presence During Pediatric Cardiopulmonary Resuscitation and Procedures
    7. Figure 1. Imaging Recommendations for Patients Aged <2 Years With Apparently Minor Head Trauma
19. References

Abstract

The common mechanisms and injury patterns of accidental trauma in infants differ from those of older children and adults, with falls representing the most common etiology. While the evaluation of traumatic injury in infants should follow an algorithm similar to that used for adults, the unique pediatric physiologic response to trauma must be taken into consideration. In addition, the utility of certain imaging studies in these patients is highly case specific, particularly with minor head injuries. This supplement reviews the evaluation and management of infants with accidental traumatic injury, including the most common circumstances and pathophysiology of injury, the differential diagnosis of the infant trauma victim, and the workup and management of accidental injuries in this patient population.

Case Presentation

A 4-month-old boy is brought to your ED by his mother, who is concerned about the effects after the baby fell...

• The mother reports that the infant fell when his unsecured changing pad slid off the table while she disposed of a soiled diaper during a late-night diaper change. She heard a “thud” that she presumed to be the baby’s head hitting the floor after he fell approximately 3 feet.
• The patient has no past medical history. Your initial impression is that his development seems to be appropriate for age. He is sucking on a pacifier and appears content in his mother’s arms.
• A quick once-over of the patient reveals no external signs of trauma. You wonder about the best approach to evaluate this nonverbal child for injury...

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Clinical Pathway for the Primary Survey for Accidental Trauma in Infants

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

7. Warrington SA, Wright CM, Team AS. Accidents and resulting injuries in premobile infants: data from the ALSPAC study. Arch Dis Child. 2001;85(2):104-107. (Retrospective; 11,466 patients) DOI: 10.1136/adc.85.2.104

13. Miglioretti DL, Johnson E, Williams A, et al. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr. 2013;167(8):700-707. (Retrospective observational study; 744 CT scans) DOI: 10.1001/jamapediatrics.2013.311

14. American Academy of Pediatrics. Ten Things Physicians and Patients Should Question. Accessed February 1, 2021. (Recommendations of the Choosing Wisely campaign)

15. Rui P, Kang K. National Hospital Ambulatory Medical Care Survey: 2015 Emergency Department Summary Tables. 2015. Accessed February 1, 2021. (Survey data)

21. United States Centers for Disease Control and Prevention - National Center for Injury Prevention and Control. 10 Leading Causes of Injury Deaths by Age Group Highlighting Unintentional Injury Deaths, United States - 2018. Accessed February 1, 2021. (Data from the National Center for Health Statistics, National Vital Statistics System)

28. Crompton EM, Lubomirova I, Cotlarciuc I, et al. Meta-analysis of therapeutic hypothermia for traumatic brain injury in adult and pediatric patients. Crit Care Med. 2017;45(4):575-583. (Database review) DOI: 10.1097/CCM.0000000000002205

73. Meltzer JA, Stone ME, Jr., Reddy SH, et al. Association of whole-body computed tomography with mortality risk in children with blunt trauma. JAMA Pediatr. 2018;172(6):542-549. (Retrospective multicenter cohort; 42,912 patients) DOI: 10.1001/jamapediatrics.2018.0109

89. Kendrick D, Barlow J, Hampshire A, et al. Parenting interventions for the prevention of unintentional injuries in childhood. Cochrane Database Syst Rev. 2007(4):CD006020. (Systematic review; 15 studies) DOI: 10.1002/14651858.CD006020.pub3

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Keywords: infant, accidental trauma infant, infant trauma, accidental trauma, accidental injury, safe sleep recommendations, infant head injury, infant falls, infant head trauma, infant burn injury, motor vehicle collision, primary survey, secondary survey, imaging head trauma, pediatric advanced life support, Glasgow Coma Scale, pediatric GCS, Lund Browder chart, pediatric endotracheal intubation, fluid resuscitation, wound care, family presence, home safety education