ORIGINAL ARTICLE Pediatric Polytrauma Management Robert M. Kay, MD and David L. Skaggs, MD Abstract: Appropriate care of pediatric polytrauma patients requires GENERAL APPROACH TO the knowledge and expertise of a variety of subspecialists. Though POLYTRAUMA PATIENTS most of pediatric polytrauma patients survive, long-term sequelae The philosophy behind trauma centers resulted from the are common. The most common causes of long-term functional de- wartime experience showing that injured soldiers who were ficits after pediatric polytrauma involve injuries to the central ner- rapidly mobilized and transported for acute, emergency care vous and musculoskeletal systems. Orthopaedic care of polytrauma fared better than did those treated locally by less sophisticated patients is important to facilitate early mobilization and care of these teams and facilities. There is some evidence that care at children, as well as to minimize late impairment. pediatric trauma centers may result in lower mortality than at community hospitals,6 though the high costs of such centers Key Words: pediatric, polytrauma, orthopaedics and geographic realities have limited the number of such (J Pediatr Orthop 2006;26:268Y277) centers. Partly due to the limited number of pediatric trauma centers, adult trauma centers are often used to care for chil- dren who sustain polytrauma. Initial stabilization of the child is carried out by emer- rauma remains the leading cause of death in children over gency medical technicians in the field and is comparable to T1 year of age. This is true throughout the world, even in that for adults. The child is rapidly stabilized, fractures are societies with the most advanced medical systems, including often splinted, and the child is brought as quickly as possible state-of-the-art pediatric trauma centers. to a trauma facility. Immediate establishment of an airway Common sites of injury in polytrauma patients include may mean the difference between life and death in the case of the head, chest, abdomen, and genitourinary and musculoskele- severe injury. tal systems. Recent series report death in 3% to 27% of children Cervical spine stabilization is performed at the scene if after polytrauma, with death most frequently correlating with the child is unconscious or has neck pain. Due to the large the severity of the traumatic brain injury.1Y5 In the survivors, head size of young children, a special board with an occipital some injuries to the various organ systems may not be detected cut-out is used for children under 6 years. Use of an adult for days to weeks after injury. Obviously, traumatic brain backboard will result in neck flexion and put the child at injuries make the assessment of many trauma victims quite increased risk of iatrogenic neurologic injury.7 challenging. Many young children have difficulty sufficiently communicating with medical personnel, especially in the PATIENT EVALUATION AND TREATMENT frightening emergency situation. Upon arrival to the hospital, the ABCs of trauma care Though rarely life-threatening, orthopaedic injuries ac- (Airway, Breathing, Circulation) are performed by the emer- count for a high proportion of injuries in polytrauma patients gency physicians and/or trauma staff. Primary and second- and may result in significant long-term impairment. The con- ary surveys are performed and appropriate subspecialists cept of early fracture fixation has carried over from adult to consulted. pediatric trauma victims, though there is less supporting evi- Many trauma scoring systems have been used to assess dence for such a mandate in children. children after polytrauma. It does not appear that specialized Though the management of pediatric trauma victims has pediatric trauma scores are necessary. The Injury Severity Score similarities to the management of adult trauma victims, studies is reproducible and is useful in pediatric trauma patients.8 suggest that the care of such populations isVand should Acidosis, hypothermia, and coagulopathyVthe Btriad beVsomewhat different. Fortunately, children generally have of death[Vmay occur in trauma patients due to hypovolemia far greater potential for recovery than do adults, in regard to and the systemic response to trauma.9 Blood pressure and both musculoskeletal and other system injuries. organ perfusion must be maintained, because death may occur if hypovolemia is not quickly reversed. Because most pediatric polytrauma results from blunt trauma, bleeding From University of Southern California Keck School of Medicine, Children’s most commonly is internal (due to visceral injuries and/or Orthopaedic Center, Children’s Hospital Los Angeles, Los Angeles, CA. fractures), and the amount of ongoing bleeding may be Study conducted at Children’s Hospital Los Angeles, Los Angeles, CA. underestimated. Monitoring of vital signs and the use of a None of the authors received financial support for this study. Reprints: David L. Skaggs, MD, 4650 Sunset Blvd., MS # 69, Los Angeles, urinary catheter are helpful in this assessment. Care needs CA 90027 (e-mail: [email protected]). to be exercised when hydrating children with head injuries Copyright * 2006 by Lippincott Williams & Wilkins to avoid overhydration and cerebral edema. 268 J Pediatr Orthop & Volume 26, Number 2, March/April 2006 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. J Pediatr Orthop & Volume 26, Number 2, March/April 2006 Pediatric Polytrauma Management Initial fluid resuscitation is with crystalloid solution. If long-term disability in children after polytrauma.3,4 However, venous access is difficult to obtain, intraosseous infusion with children can make remarkable progress after significant head large-bore catheters is effective. This is most often performed injuries, and children must be assumed capable of full re- in the proximal tibial apophysis, at least one fingerbreadth covery, thus necessitating the appropriate management of below the tibial tuberosity to make certain the physis is fractures to avoid the sequelae of malunion. avoided. A bone marrow needle with a stylet is used to pre- Acute management of children with head injuries often vent a bone plug from blocking inflow. This has been shown to includes elevation of the head of the bed, hyperventilation of be effective clinically10 and also to be safe for the bone and the intubated patient, and fluid restriction. In addition, frac- physis in a rabbit model.11 ture stabilization (temporary, as with a splint, as well as ulti- A thorough orthopaedic evaluation includes assessment mate fracture fixation) is necessary to minimize potentially of the spine, pelvis, and extremities. In the unconscious, intu- deleterious rises in intracranial pressure after brain injury.17 bated patient, the only signs may be swelling, ecchymosis, Letts et al reported residual neurologic impairment in and/or crepitus with manipulation of the injured extremity. 13% of 149 pediatric trauma patients at an average of 1 year Screening pelvis and spine x-rays are obtained routinely and of follow-up.1 At a mean of 4.2 years of follow-up, Schalamon extremity films are ordered as indicated. Fractured extremities et al reported a 10% rate of late neurologic sequelae, which are splinted to facilitate transport throughout the facility for was due to the severity of the initial head trauma.3 The same additional workup and to minimize pain while moving and authors noted that of 11 children with late deficits after transporting the injured child. Minimizing such discomfort not polytrauma, the deficits followed severe head trauma in only is humane but is also important in the setting of head injury 8 children (73%).3 to avoid increasing intracranial pressure and worsening the cerebral insult. Abdominal Injuries The physician and family need to understand that late 1 18 Abdominal injuries are reported in 8% to 27% of diagnosis of injuries in polytrauma patients is common. Letts pediatric polytrauma patients. Because children are generally et al reported that injuries were initially missed in 9% of 149 otherwise healthy, with good physiologic reserve, they may pediatric trauma patients.1 Such diagnoses are often not made initially remain stable clinically despite significant injuries. for weeks after injury and can include additional fractures (fre- Abdominal visceral injuries may often not be appreciated quently of the upper extremities, but also including those of until CT scans are obtained in polytrauma patients. the pelvis and spine) as well as visceral injuries. The patient’s Abdominal wall ecchymosis often indicates serious vis- and family’s help can be enlisted in the ongoing search for 19,20 ceral or spine injury but is often absent in many children such injuries by informing them of the high incidence of late with such injuries. Forty-eight percent of children (22/46) with diagnosis and asking them to communicate any previously such ecchymosis in one series required abdominal exploration, undetected sources of pain in the days and weeks after injury. and 23% of children (14/61) with such ecchymosis in another series were noted to have spine fractures.20 MECHANISM OF INJURY CT scan is generally the study of choice to assess for The two most common cause of polytrauma in children intra-abdominal pathology. In addition to being better than remain falls from height and motor vehicle accidents. Public ultrasound for assessing intra-abdominal pathology, CT scan awareness of these problems and legislation has made limited also allows the team