Pediatric Trauma and Injury

Definition and Epidemiology

• Trauma is a leading cause of morbidity and mortality in pediatric patients
• Accounts for 40% of deaths in children under 18 years old
• In the US, approximately 10,000 children die and 100,000 are hospitalized annually due to traumatic injuries

Types of Trauma in Pediatrics

• Blunt trauma: most common type, caused by falls, motor vehicle accidents, and assault
• Penetrating trauma: caused by gunshot wounds, stabbings, and other piercing injuries
• Burn trauma: caused by thermal, electrical, or chemical burns

Physiological Response to Trauma in Children

• Hypovolemic shock: common in pediatric trauma, caused by blood loss and dehydration
• Hypothermia: common in pediatric trauma, caused by environmental exposure and blood loss
• Metabolic acidosis: caused by tissue hypoperfusion and anaerobic metabolism

Assessment and Management

• Primary survey: focuses on airway, breathing, and circulation (ABCs)
• Secondary survey: comprehensive physical examination to identify all injuries
• Imaging studies: used to diagnose injuries, including X-rays, CT scans, and ultrasounds
• Fluid resuscitation: used to treat hypovolemic shock
• Pain management: crucial in pediatric trauma, often using multimodal analgesia

Psychological Trauma in Pediatrics

• Acute stress disorder: common in pediatric trauma, characterized by symptoms of dissociation and anxiety
• Post-traumatic stress disorder (PTSD): can develop in pediatric trauma patients, especially those with a history of prior trauma
• Psychological support: crucial in pediatric trauma, including counseling and therapy

Special Considerations in Pediatric Trauma

• Non-accidental trauma (NAT): also known as child abuse, requires a high index of suspicion and specialized evaluation
• Trauma in special populations: pediatric patients with pre-existing medical conditions, such as congenital heart disease or developmental disabilities, require tailored care
• Family-centered care: essential in pediatric trauma, including support and counseling for families

Trauma in Pediatrics

• Trauma is a leading cause of morbidity and mortality in pediatric patients, accounting for 40% of deaths in children under 18 years old.
• In the US, approximately 10,000 children die and 100,000 are hospitalized annually due to traumatic injuries.

Types of Trauma

• Blunt trauma is the most common type, caused by falls, motor vehicle accidents, and assault.
• Penetrating trauma is caused by gunshot wounds, stabbings, and other piercing injuries.
• Burn trauma is caused by thermal, electrical, or chemical burns.

Physiological Response to Trauma

• Hypovolemic shock is common in pediatric trauma, caused by blood loss and dehydration.
• Hypothermia is common in pediatric trauma, caused by environmental exposure and blood loss.
• Metabolic acidosis is caused by tissue hypoperfusion and anaerobic metabolism.

Trauma Assessment and Management

• Primary survey focuses on airway, breathing, and circulation (ABCs).
• Secondary survey is a comprehensive physical examination to identify all injuries.
• Imaging studies are used to diagnose injuries, including X-rays, CT scans, and ultrasounds.
• Fluid resuscitation is used to treat hypovolemic shock.
• Pain management is crucial in pediatric trauma, often using multimodal analgesia.

Psychological Trauma

• Acute stress disorder is common in pediatric trauma, characterized by symptoms of dissociation and anxiety.
• Post-traumatic stress disorder (PTSD) can develop in pediatric trauma patients, especially those with a history of prior trauma.
• Psychological support is crucial in pediatric trauma, including counseling and therapy.

Special Considerations

• Non-accidental trauma (NAT) requires a high index of suspicion and specialized evaluation.
• Pediatric patients with pre-existing medical conditions require tailored care.
• Family-centered care is essential in pediatric trauma, including support and counseling for families.

Pain Management

• All patients should be reassessed at frequent intervals using a standardized age-appropriate pain scale.
• Redosing should be done if pain persists, but only if:
  • There is an increase in pain score.
  • Pain is likely to occur due to unavoidable movement (extrication).
  • The half-life of medication is reached and the effect starts to reduce.
  • Aliquots were used with initial administration and the full dose has not yet been administered (titrating to effect).

Importance of Pre-Hospital Analgesia

• Safely and effectively relieves suffering.
• Prompt analgesia might prevent long-term adverse effects, especially in very young children.
• Impacts on mood and mental health.
• Impacts on sleep.
• Impacts on cardiovascular health.
• Impacts on cognitive processes, brain function, and CNS.
• Impacts on sexual function.
• Impacts on quality of life and functionality.
• Mitigates elevations in heart rate and blood pressure that accompany pain.
• Might be misconstrued as another clinical process.
• Might impact negatively on certain disease processes, such as myocardial ischemia and head injury.
• Might improve clinical status by facilitating respiratory effort and increasing oxygenation (e.g., chest wall injuries, multiple rib fractures, or flail chest).
• Patient is overall easier to manage.

Pre-Hospital Analgesia in Trauma

• The management of acute traumatic pain is a crucial component of pre-hospital care.
• The assessment and administration of analgesia is highly variable, frequently suboptimal, and often determined by consensus-based protocols.
• All patients with acute traumatic pain should be considered candidates for analgesia, regardless of transport interval.
• Reassess all patients who have received analgesia using an age-appropriate scale every 5 minutes.

Types of Pain

• Chronic pain: long-lasting and usually does not reduce with most treatments (e.g., osteoarthritis or fibromyalgia).
• Acute pain: occurs suddenly but is temporary, associated with anxiety and emotional stress, and resolves as the injury heals (e.g., fracture).
• Nociceptive pain: due to an injury to the body tissue (skin, muscle, or bone), pain reduces once the injury heals.
  • Somatic: sharp, stabbing, well-localized to area of injury (e.g., skin, muscles, soft tissues).
  • Visceral: dull, heavy, aching pain over a wide area (e.g., internal organs).
• Neuropathic pain: due to dysfunction or damage to the nerves, spinal cord, or brain, characterized by a burning, tingling, or stabbing sensation.
  • Peripheral.
  • Central.
• Psychogenic pain: caused by psychological factors, physical pain due to tissue or nerve damage but increases and is prolonged because of stress, fear, anxiety, or depression.
• Inflammatory pain: caused by an inappropriate response from the immune system (e.g., gout or rheumatoid arthritis).

Adverse Effects of Pain

• Neuroendocrine:
  • Activation of stress response.
  • Poor wound healing.
  • Impaired immune function.
  • Hyperglycaemia.
  • Weight loss / muscle wasting.
• Musculoskeletal:
  • Spasms.
  • Impaired muscle mobility and function.
  • Immobility.
  • Weakness.
  • Fatigue.
• Psychological:
  • Anxiety.
  • Fear.
  • Sleep deprivation.
  • PTSD.
• Cardiovascular:
  • ↑ heart rate.
  • ↑ blood pressure.
  • ↑ myocardial oxygen demand.
  • Hypercoagulation.
  • Unstable angina.
  • Myocardial infarction.
  • Deep vein thrombosis.
  • Pulmonary embolism.
• Respiratory:
  • ↓ lung volumes.
  • ↓ cough.
  • Splinting.
  • Pneumonia.
  • Hypoxaemia.
  • Atelectasis.
• Gastrointestinal:
  • ↓ bowel motility.
  • ↓ gastric emptying.
  • Constipation.
  • Anorexia.

Pre-Hospital Analgesia

• Hastens the relief of discomfort rather than waiting for pain medication administration in EDs.
• Pain management is frequently based on the assessment of need by a provider, rather than the requirements of patients.
• Historically, only entonox and morphine have been available for pre-hospital pain management.
• Many new additions, such as Ketamine, are available.
• The availability of appropriate and effective treatment options remains a challenge.