Multiple Trauma Management in Pediatric Patients in the ED

Management of Multiply Injured Pediatric Trauma Patients in the Emergency Department

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Table of Contents
About This Issue

When children with multiple serious injuries present to the ED, how do you ensure that you identify and address all of their injuries? This issue provides a systematic approach to the management of pediatric patients with multiple traumatic injuries, with specific attention to commonly missed injuries and injuries that may cause significant morbidity or mortality. You will learn:

Recommendations for initial field management and evaluation that will aid in early recognition and stabilization of injuries

Critical elements of the primary survey that will help identify and address life-threatening injures

Which diagnostic imaging modalities are warranted, and which is the best choice, based on presentation

Evidence-based recommendations for a systematic approach to managing pediatric patients with multiple traumatic injuries

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Pathophysiology
    1. Common Mechanisms of Injury
    2. Difficulties in Assessing Pediatric Patients
    3. Commonly Missed Injuries
    4. Traumatic Brain Injuries
  6. Differential Diagnosis
  7. Prehospital Care
    1. Initial Stabilization and Communication With Field Emergency Medical Technicians
    2. Cervical Spine Immobilization
    3. Splinting Orthopedic Injuries
  8. Emergent Management
    1. History
    2. Physical Examination
      1. Primary Survey
        • Airway Management
        • Breathing
        • Circulation
        • Disability
        • Exposure and Environmental Control
    3. Evaluation
      1. Focused Assessment With Sonography in Trauma (FAST) Examination
    4. Primary Stabilization/Management
      1. Pediatric Airway Management
      2. Management of Closed Head Injuries
      3. Stabilization of Musculoskeletal Injuries
        • Open Fractures
        • Tetanus Vaccination
        • Compartment Syndrome
      4. Fluid Resuscitation
  9. Diagnostic Studies
    1. Radiographic Studies
    2. Computed Tomography
    3. Magnetic Resonance Imaging
    4. Laboratory Studies
  10. Treatment
  11. Special Populations
    1. Infants
    2. Pregnant Teenagers
  12. Controversies and Cutting Edge
    1. Closed Head Injury
      1. Severe Traumatic Brain Injury
    2. Transportation of Pediatric Trauma Patients
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls in the Management of Pediatric Patients With Multiple Injuries
  16. Case Conclusions
  17. Time and Cost-Effective Strategies
  18. Key Points
  19. Clinical Pathway for the Management of a Pediatric Patient With Multiple Traumatic Injuries
  20. Tables and Figures
    1. Table 1. Differential Diagnosis for Pediatric Trauma Patients
    2. Table 2. Pediatric Glasgow Coma Scale Scoring
    3. Figure 1. Primary Survey Evaluation for Trauma Patients
    4. Figure 2. Differences in the Pediatric Airway Compared to the Adult Airway
    5. Figure 3. AVPU System for Infant Neurologic Assessment
  21. References



Management of the child with multiple traumatic injuries can be challenging, and important injuries may not be readily recognized. Early recognition of serious injuries, initiation of appropriate diagnostic studies, and rapid stabilization of injuries are key to decreasing morbidity and mortality in the multiply injured pediatric trauma patient. The differential diagnosis for these patients is wide, and treatment is targeted to the specific injuries. In this issue, a systematic approach to the multiply injured pediatric patient will be reviewed, with specific attention to commonly missed injuries and those injuries that may cause significant morbidity or mortality.


Case Presentations

A 12-year-old previously healthy boy presents to the ED via EMS for a visible deformity of his right arm. His 18-year-old brother was pulling him around in an inner tube that was attached by a long rope to a truck traveling about 40 miles per hour through a lightly wooded area. His brother made a sharp turn, and the patient went flying off the inner tube and hit a tree. The brother said that the patient did not lose consciousness, but that he was “stunned” for a few seconds, then started complaining about his right arm. The patient said he was not wearing any personal protective equipment. He has multiple abrasions to his face, trunk, and extremities. He denies pain anywhere except in his arm. He requests to have his neck brace removed because it is “annoying.” He denies vomiting but reports feeling nauseous after receiving morphine from the paramedics en route to the hospital. Because this was a severe mechanism, though the patient appears to have an isolated injury, you begin to consider how much you should do. Should you “pan-scan” the patient and draw labs because of the mechanism? What other imaging studies do you need to obtain besides an x-ray of the arm? Is the patient at risk for internal bleeding due to this blunt impact? Should you consult the surgeons or just call the orthopedist to reduce the obvious fracture?

A 16-month-old previously healthy girl presents to the ED via EMS after a seemingly accidental fall out of a third-story apartment window. Onlookers said the girl fell into a bush and appeared stunned but did not lose consciousness. The mother says when she got downstairs, the child was crying but easily consoled. The girl has multiple abrasions all over her body and a bloody nose, but otherwise seems fine. She cries throughout the primary and secondary surveys. Is the crying merely developmentally appropriate stranger anxiety? Does this patient need labs drawn? What type of imaging is warranted? If no other injuries are identified, what is the appropriate disposition for this patient?



Trauma is the leading cause of morbidity and mortality in children aged > 1 year.1,2 When pediatric patients present with multiple traumatic injuries, life- or limb-threatening injuries in 2 or more organ systems are not uncommon;1,3,4 traumatic brain injuries (TBIs) and orthopedic/musculoskeletal injuries are frequent.5 Death occurs in up to 27% of pediatric patients with multiple traumatic injuries and is mainly dependent upon the severity of the TBI.4

Typically, major issues with airway, breathing, and circulation are recognized and stabilized in a timely fashion. Problems occur when TBIs and orthopedic injuries are not identified early, as they can lead to long-term disabilities in pediatric patients.2,6 In one study, 9% of injuries were initially missed in pediatric trauma patients, with 46% of those injuries being missed fractures. Earlier identification of these injuries can greatly decrease the rates of morbidity and mortality. Other organ systems in which certain missed injuries can lead to serious morbidity in multiple-trauma patients include the gastrointestinal and respiratory systems.6 Less common pathologies, such as abdominal compartment syndrome,3 if not recognized early, can lead to a decline in respiratory status and decreased cardiac output. Blunt chest trauma can cause morbidity primarily from lung contusions or hemothorax/pneumothorax or secondarily as a result of a systemic inflammatory response syndrome leading to acute lung injury.

This issue of Pediatric Emergency Medicine Practice will discuss evidence-based recommendations for early recognition of TBI during the primary survey, initiation of the proper imaging to diagnose injuries, expedient stabilization of injuries, and utilization of a systematic approach to manage pediatric patients with multiple trauma.


Critical Appraisal of the Literature

A literature search was performed in PubMed using the search terms: multiple traumapediatricsemergency roomtraumachildrenpolytraumaimagingFASTpermissive hypotensiontransfusionairwaytranexamic acid, and ATLS. A total of 193 articles from 1997 to the present were reviewed. The Cochrane Database of Systematic Reviews and the National Guideline Clearinghouse were searched for systematic reviews using the key term multiple trauma pediatrics. Approximately 70 articles were found, most of them being from the view of surgical management. The ninth edition of the Advanced Trauma Life Support (ATLS) guidelines,7 released by the American College of Surgeons Committee on Trauma, were also reviewed. While ATLS is not pediatric-specific, it is a system based on both best available evidence and expert consensus. These guidelines are widely considered the standard approach to all injured patients. Very few guidelines or policy statements were found specifically on pediatric trauma. The American Academy of Pediatrics (AAP) issued a policy statement in August 2016 that demonstrated the importance of a diverse trauma team when caring for pediatric trauma patients.8

The search of the literature revealed few case reports on multiple trauma in pediatric patients; there were also few studies on the emergency medical management of these cases. There were more studies that focused on the surgical management of multiple trauma patients, including emergency surgical procedures and early involvement of surgical specialties in resuscitation. The studies were retrospective, with very few prospective or randomized double-blinded studies.


Tables and Figures

Table 2. Pediatric Glasgow Coma Scale Scoring




Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

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  3. Letts M, Davidson D, Lapner P. Multiple trauma in children: predicting outcome and long-term results. Can J Surg. 2002;45(2):126-131. (Retrospective case series; 149 patients)
  4. Dereeper E, Ciardelli R, Vincent JL. Fatal outcome after polytrauma: multiple organ failure or cerebral damage? Resuscitation. 1998;36(1):15-18. (Retrospective review; 98 patients)
  5. van der Sluis CK, Kingma J, Eisma WH, et al. Pediatric polytrauma: short-term and long-term outcomes. J Trauma. 1997;43(3):501-506. (Retrospective study; 74 patients)
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  7. ATLS Subcommittee, American College of Surgeons' Committee on Trauma. Chapter 10: Pediatric Trauma. Advanced Trauma Life Support Student Course Manual. 9th ed: American College of Surgeons; 2013. (Textbook)
  8. 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, et al. Management of pediatric trauma. Pediatrics. 2016;138(2). (AAP policy statement)
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Publication Information

Andria Tatem, MD; Rupa Kapoor, MD, FAAP

Peer Reviewed By

Michelle Hughes, DO, FAAP; Lara Zibners, MD, MMEd

Publication Date

June 2, 2018

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