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Pediatric trauma - How to improve level of care


Devendra Gupta, Professor and Head,
Department of Pediatric Surgery
All India Institute of Medical Sciences, New Delhi, India


Pediatric trauma - a separate specialty amidst different subspecialties

Trauma in children requires meticulous care at all levels right from the time of injury. The paramedical staff involved in transport of the baby is equally responsible for the ultimate outcome following the insult due to the injury. In most developed nations, injury is the leading cause of death among children older than 1 year. Death from accidental injury may account for upto 65% of all injury deaths in children and adolescents. Thus, pediatric trauma continues to be one of the major threats to children. We outline the factors that affect the outcome of Pediatric trauma.

Trend in pediatric trauma

Upto 80-90% of pediatric trauma occurs as a result of blunt trauma, with penetrating injury accounting for 10-20%. However, the 2 mechanisms of injuries are interrelated in that blunt mechanical force can result in penetrating injury, such as that caused by sharp edges. In infants and toddlers, falls are a common cause of severe injury. Burns are more common in children aged 1-4 years. In school going children and adolescents, bicycle-related mishaps are most common. Male children younger than 18 years have higher injury and mortality rates, due to their more aggressive behaviour and exposure to contact sports like skiing. Upper limb fractures are more common in children aged 5-9 years, and lower limb fractures and traumatic brain injuries are more common in adolescents. It is surprising that upto 35% of significant injuries occur due to accidents in the domestic environment of the child. Caustic ingestion and burns occur mostly in the familiar environment of the child as accidents.

Need for pediatric trauma registry 

It has been realized that the implementation of a proper pediatric trauma registry is very important for the preventive aspect. Studying the trend and epidemiology helps in the immediate management of the cases based on experience. Astute surgeons can recognize pattern of injuries in their localities and common clinical scenarios. Also public awareness programs can be organized to educate the masses as far as preventive aspects are concerned. The bicycle helmets law started in Canada is an example of this.

Training of paramedics and nurses dealing first with the patient

The morbidity of children who sustain major or life-threatening trauma depends upon good prehospital care, appropriate triage, resuscitation by an experienced trauma team in an emergency center, and effective emergent surgery. Emergency Paramedical staff being the first medical contact to the children following an injury, must be trained in rapid pediatric cardiorespiratory assessment, prompt establishment of effective ventilation (airway), oxygenation (breathing), and perfusion (circulation), as well as in stabilization and transport of injured or ill children to a tertiary care facility. The resuscitation should be tailored to each child and should begin in the field so that vital points like hypovolumic shock and metabolic instability are recognized and treated well in time. Currently, trauma nursing education has also attained paramount interest. Basic concepts of primary/secondary survey, airway management, and fluid management for hypovolemic shock have been recognized as a high priority. In fact, in some studies, the Pediatric trauma nurse practitioners have been reported to provide equivalent care for injured children with significantly shorter hospital stay and higher patient satisfaction than even residents. The intent was to provide an experienced group of nurses, who could provide expert trauma care, identify and resolve issues in the trauma room. Through increased education, exposure, mentoring, and professional development, the trauma nurse leader role has become an essential part of the specialized pediatric trauma care in some centres.

Training of surgeons dealing with the patient

The working together of all sub specialties under one roof understanding one language is of utmost importance in the golden hour in pediatric trauma. The success of training courses like Advanced Trauma Life Support (ATLS) course is fast being recognized as the standard for the first hours of trauma care and it is high time that all surgeons dealing with pediatric trauma cases should get trained in such courses. These courses give a chance to all concerned to acquire the essential skills required to save lives and limbs from infancy through adolescence. Adequate knowledge of characteristic features of the growing skeleton is necessary for effective treatment of fractures in the pediatric population. Generally, the principles of therapy of pediatric polytrauma are similar to the management of trauma in adults (ATLS). Nonetheless, attention must be paid to anatomical and physiological differences especially between young children and adults. However, ATLS is designed primarily for adults, and one trained only in ATLS may not be able to handle severe pediatric trauma due to the differences in the epidemiology of children suffering traumatic injury. In children, vascular access can be difficult and time-consuming and they may not require aggressive fluid resuscitation. Intraosseous lines are a reliable and rapid tool for obtaining vascular access in emergency situations, particularly in absence of refined paediatric intravenous cannulation skills for children. ATLS course designed specifically for pediatricians can markedly improve pediatric trauma care. While advanced cardiac life support (ACLS) and advanced trauma life support (ATLS) courses have become accepted standards for physicians who care for the critically ill and injured patient, only recently have pediatric advanced life support (PALS) courses been developed, which is different from most other programs in that emphasis has been placed on pediatric trauma in addition to traditional cardiac (ACLS) resuscitation . This 20-hour program combines a modified ACLS curriculum with specific pediatric trauma lectures and laboratory sessions. It includes a canine surgical procedure laboratory and modified ATLS skill stations.

Efficacy of Pediatric Trauma Care

The level and efficacy of pediatric trauma care delivered in a dedicated pediatric hospital compared with that in an adult trauma centre is unclear. Certification in pediatric trauma and experience in the delivery of trauma care are key determining factors. It has been demonstrated that pediatric trauma mortality is significantly improved in a pediatric trauma centre or in an adult centre with pediatric trauma certification, compared with level I or II adult trauma centres.