01 Clinical Pediatric Emergenc

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Pediatric Emergency MedicineC L I N I C A L

EditorSteven E. Krug, MD,FAAP

Feinberg School ofMedicine,NorthwesternUniversity, Children’sMemorial Hospital,Chicago, IL

Vol 11, No 1 March 2010

Advances In Pediatric TraumaHarold K. Simon, MD, MBA

Guest Editor

GUEST EDITOR’S PREFACEPediatric Trauma: A Roadmap for Evidence-Based, Patient-Centered Coordination and CareHarold K. Simon

Golden Hour or Golden Opportunity: Early Management of Pediatric TraumaWendalyn K. Little

Prehospital Management of Pediatric TraumaManish I. Shah

Do Routine Laboratory Tests Add to the Care of the Pediatric Trauma Patient?Jeffrey F. Linzer Sr

Radiographic Evaluation of the Pediatric Trauma Patient and the Risk for IonizationRadiation ExposureRicardo R. Jiménez

Analgesia for the Pediatric Trauma Patient: Primum Non Nocere?Michael Greenwald

When There Are no Inpatient Beds: Pediatric Intensive Care Level Management ofTrauma Patients in the Emergency DepartmentToni Petrillo-Albarano and Wendalyn K. Little

Pediatric Patients in the Adult Trauma Bay—Comfort Level and ChallengesKimberly P. Stone and George A. Woodward

Mental Health Consequences of Trauma: The Unseen ScarsMichael Finn Ziegler

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57 . . . . . . . . .W.B. Saunders

www.clinpedemergencymed.org

GUEST EDITOR'S PREFACE

Pediatric Trauma: ARoadmap for Evidence-Based, Patient-CenteredCoordination and Care

Departments of Pediatrics and Emergency Medicine,University School of Medicine, Children's Healthcare of AAtlanta, GA.

PEDIATRIC TRAUM

By Harold K. Simon, MD, MBA

For children younger than 14 years, there hasbeen a dramatic and steady decline over the past

2 decades in injury-related mortality from 9427deaths in 1986 (age-adjusted rate of 18.04/100 000)to 6530 in 2006 (age-adjusted rate of 10.59/100 000).1 Many factors contribute to this improve-ment including injury prevention strategies as wellas treatment and aftercare of trauma patients.Although tremendous strides have been made,injury remains a leading cause of morbidity andmortality in the United States and is especiallyconcerning within the pediatric population wheretrauma can rob years of happiness and productivity.

This issue of Clinical Pediatric Emergency Medicinefocuses on the complete spectrum of pediatrictrauma care, beginning with the initial “goldenhour,” emergency medical services care at thescene, through critical care management. It incor-porates perspectives from pediatric emergencymedicine physicians, emergency medical servicesproviders, and critical care physicians. It willaddress present state of care, improvement strate-gies, and potential areas that can help us not onlydecrease mortality but do so in a cost-effectivemanner cognizant of facility and manpower re-source limitations. Unlike many previous antholo-

Emorytlanta,

A: A ROADM

gies on the subject, it will also take into perspectivea more patient-centered approach to what can bedone with new and emerging technologies, takinginto account long-term implications when consid-ering what interventions are most beneficial to thepatient in the immediate care situation. It will lookat questions such as the risk vs benefits ofcomputed tomographic scanning in light of radia-tion exposure. This issue will address topics such ascoordination of care between subspecialties, transi-tions of care, and care of pediatric trauma patientsin adult-based centers. It will, however, go beyondthe traditional bounds and will touch on the moreholistic approach to care that can and should bepart of our broader perspective on pediatric traumamanagement. This will include sections on paincontrol as well as posttraumatic stress disorderrecognition and prevention.

Trauma care has emerged from its infancy in thelatter part of the 21st century as a focus of modernmedicine. Military experiences have helped pushthe envelope of trauma care and continues to helpus mold our perspectives, knowledge, and treatmentof trauma.2,3 Trauma centers have been proven tohave a positive impact on patient management,ultimately leading to decreased mortality.4 Pediatrictrauma care has, however, as is the case in mostareas of pediatric medicine, taken a backseat tomuch of the initial focus that has been adult patientbased. It was not until the development of the

AP FOR COORDINATION AND CARE / SIMON • VOL. 11, NO. 1 1

2 VOL. 11, NO. 1 • PEDIATRIC TRAUMA: A ROADMAP FOR COORDINATION AND CARE / SIMON

Emergency Medical Services for Children programin 1984 and the Institute of Medicine report onEmergency Medical Services for Children thatpediatric trauma care began to separate itself outas a functionally distinct discipline.5,6

Evidence has mounted over the years that regiona-lized centers with pediatric equipment, personnel, andexpertise have contributed to the overall improvementin pediatric trauma management.7-9 In addition,coordinated aftercare in centers with pediatric sur-geons and pediatric critical care physicians hasimproved outcomes. Differences in operative vssupportive treatment of the pediatric patient ascompared with the adult trauma patient, especiallyfor blunt abdominal trauma, and comfort levels andexpertise with the pediatric patient may contribute tothese effects.10 Consensus opinion and present stan-dards for field triage of pediatric trauma patientssupport the direction of those childrenmeeting traumacriteria to a pediatric capable trauma center.11

Many communities do not have the volume ofpatients or resources required to support designatedpediatric trauma centers. Facilities within communi-ties that do have this volume are often stretchedbeyond their functional capacity given the prevalenceof emergency department overcrowding and the use ofemergency departments as the safety net for medicalcare for many underserved populations.12,13 Thesefactors, along with the shear cost of keeping traumacenters available 24/7 in communities that may nothave the required resources, make it even moreimportant to develop trauma centers within well-coordinated regional systems to best transport, stabi-lize, and definitively care for critically injured chil-dren.11,14 However, today, fewer than 200 pediatrictrauma centers exist in the United States; and morethan 28% of children younger than 15 years are morethan 1 hour from such centers by ground or by airtransport. This disparity is even greater in rural areas,where 77% of children aremore than 1 hour from suchcenters.15 Given the critical importance of stabilizationwithin the “golden opportunity” for care, we have along way to go in coordinating such care and establish-ing centers capable of providing optimal managementto this vulnerable population. This points to a need toexpand access to pediatric trauma care for greaternumbers of children and to continue to grow andenhance the networks available. Those centers that doexist need to fully coordinate careover large catchmentareas with the necessary support systems and transferprotocols to best serve the children throughout theirregions. These items will be among those addressed inthis series of articles and are some of the mostchallenging issues faced as we seek to continue toexpand and enhance pediatric trauma networks.

Even when we are fortunate enough to have anabundance of resources or tertiary care pediatricfacilities in a region, wemust also determine if we areusing our resources appropriately and, in doing so,delivering evidence-based, highest-quality care.Technology simply for technology's sake may notalways lead to the best outcomes. We must thereforecritically evaluate the sensitivities and specificitiesof such “advancements” as well as balance the long-term effects and costs (financial and even adversemedical) that can come from their usage. Examplessuch as focused assessment sonography in traumaexaminations and their use in the pediatric popula-tion, screening laboratories, and radiologic studiesmust all be critically evaluated.16-20 The presentstate of knowledge and risks vs benefits of each willbe addressed.

Lastly, patient- and family-centered care needs tobe at the forefront of what distinguishes themanagement of pediatric trauma.21 Having theproper equipment and personnel for the basictrauma needs of children of all ages remainsessential. However, recognition of the need to treatboth patients and their families can help bring amore holistic approach to meeting the needs of ourmost vulnerable patients and their families. Consid-eration of the entire child and his or her family, andnot just the injury (eg, “the fracture in room one”),remains a crucial part of the challenge set forth inpediatric trauma care. Health care providers tend tounderrecognize, undertreat, and fail to prevent painand anxiety in children, and limit the impact of thesestressors related to trauma.21 This issue will there-fore also address pain management of the pediatrictrauma patient, posttraumatic stress disorder rec-ognition, and prevention strategies. Although we stillhave a long way to go to optimize the care of injuredchildren, this series should act as a roadmap for thebroad range of care providers treating pediatrictrauma patients.

REFERENCES1. National Center for Injury Prevention and Control. WISQARS

Injury Mortality Reports, 1999 - 2006. Available at: http://webapp.cdc.gov/sasweb/ncipc/mortrate10_sy.html. Accessed1/15/10.

2. Mullins RJ. A historical perspective of trauma system deve-lopment in the United States. J Trauma 1999;47(Suppl 3):S8-S14.

3. Berger E. Lessons from Afghanistan and Iraq: the costlybenefits from the battlefield for emergency medicine.Ann Emerg Med 2007;49:486-8.

4. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A nationalevaluation of the effect of trauma center care on mortality.N Engl J Med 2006;354:366-78.

PEDIATRIC TRAUMA: A ROADMAP FOR COORDINATION AND CARE / SIMON • VOL. 11, NO. 1 3

5. The Preventive Health Amendments of 1984, Pub. L. 98-555§ 7, 98 Stat. 2854, 2856 (1984) (codified as amended at 42 U.S.C. § 300w-9).

6. Institute of Medicine Committee on Pediatric EmergencyMedical Services. In: Durch JS, Lohr KN, editors. Emergencymedical services for children. Washington, DC: NationalAcademy Press; 1993.

7. Hall JR, ReyesHM,Meller JT, et al. Outcome for blunt trauma isbest at a pediatric trauma center. J Pediatr Surg 1996;31:72-7.

8. Potoka DA, Schall LC, Ford HR. Improved functionaloutcome for severely injured children treated at pediatrictrauma centers. J Trauma 2001;51:824-34.

9. Bensard DD, McIntyre RC, Moore EE, et al. A critical analysisof acutely injured childrenmanaged in an adult level I traumacenter. J Pediatr Surg 1994;29:11-8.

10. Farrell LS, Hannan EL, Cooper A. Severity of injury andmortality associated with pediatric blunt injuries: hospitalswith pediatric intensive care units vs. other hospitals. PediatrCrit Care Med 2004;5:5-9.

11. Centers for Disease Control and Prevention. Guidelines forfield triage of injured patients: recommendations of thenational expert panel on field triage. MMWR 2009;58:RR-1.

12. O’Connor RE. Specialty coverage at non-tertiary carecenters. Prehosp Emerg Care 2006;10:343-6.

13. Millin MG, Hedges JR, Bass RR. The effect of ambulancediversions on the development of trauma systems. PrehospEmerg Care 2006;10:351-4.

14. Taheri PA, Butz DA, Lottenberg L, et al. The cost of traumacenter readiness. Am J Surg 2004;187:7-13.

15. Nance ML, Carr BG, Branas CC. Access to pediatric traumacare in the United States. Arch Pediatr Adolesc Med 2009;163:512-8.

16. Holmes JF, Gladman A, Chang CH. Performance of abdom-inal ultrasonography in pediatric blunt trauma patients: ameta-analysis. J Pediatr Surg 2007;42:1588-94.

17. Holmes JF, Mao A, Awasthi S, et al. Validation of a predictionrule for the identification of children with intra-abdominalinjuries after blunt torso trauma. Ann Emerg Med 2009;54:528-33.

18. Blackwell CD, Gorelick M, Holmes JF, et al. Pediatric headtrauma: changed tomography in emergency departments inthe United States over time. Ann Emerg Med 2007;49:320-4.

19. Brenner DJ, Hall EJ. Computed tomography - an increasingsource of radiation exposure. New Engl J Med 2007;357:2277-84.

20. Jimenez RR, DeGuzman MA, Shiran S, et al. CT versus plainradiographs for evaluation of c-spine injury in youngchildren: do benefits outweigh risks? Pediatr Radiol 2008;38:635-44.

21. Ziegler M, Grenwald MH, DeGuzman MA, et al. Posttraumaticstress responses in children: awareness and practice among asample of pediatric emergency care providers. Pediatrics2005;115:1261-7.

Abstract:The concept of a “golden hour” is afixture in trauma care. There is adearth of scientific proof for thisconcept but an abundance of con-troversy around how this conceptshould be interpreted, especially forpediatric trauma patients. Healthcare providers should instead focuson the “golden opportunity,” differ-ent for each patient, to provide thebest care in the most appropriateenvironment for all injured children.

Keywords:pediatric trauma; golden hour;pediatric emergency; traumasystems; interfacility transport

Pediatrics and Emergency Medicine, Divi-

sion of Pediatric Emergency Medicine,

Emory University School of Medicine, Chil-

dren’s Healthcare of Atlanta, Atlanta, GA.

Reprint requests and correspondence:Wendalyn Little, MD, MPH, Pediatric Emer-gency Medicine, 1645 Tullie Circle, Atlanta,GA [email protected]

1522-8401/$ - see front matter© 2010 Elsevier Inc. All rights reserved.

4 VOL. 11, NO. 1 • GOLDEN HOUR OR GOLDEN OPP

Golden Hour orGolden

Opportunity:Early

Management ofPediatric Trauma

ORTUNITY / LITTLE

Wendalyn K. Little, MD, MPH

“There is a golden hour between life and

death. If you are critically injured you

have less than 60 minutes to survive.

You might not die right then; it may be

three days or two weeks later—but some-

thing has happened in your body that is

irreparable.” R Adams Cowley MD1

GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE • VOL. 11, NO. 1 5

THE GOLDEN HOURThe term golden hour is a fixture in the lexicon of

trauma care. The phrase refers to a critical periodin the care of trauma patients during whichappropriate care may limit morbidity and increasesurvival. The origin of this term is difficult to trace.It may have evolved from an early description of therelationship between survival and time from injuryto treatment on the battlefields of World War I.This analysis of French military data showed adecrease in mortality from battle wounds from 10%within 1 hour of treatment to 75% at 8 hours post-injury.2 More recent medical literature oftenattributes the phrase “golden hour” to traumasurgeon R. Adams Cowley, MD, one of the earlychampions of organized trauma care. Dr Cowleyconducted trauma research and wrote and spokeextensively on the subject of trauma care, and thecoining of the term golden hour is often attributed tohis speeches, yet none of his publications mentionsor tests the theory of a golden hour in traumacare.2,3 Modern support for the golden hour conceptbegan in the 1960s when trauma care in the UnitedStates was in its infancy and civilian traumasystems were nonexistent. Military data from eachof the world wars, the Korean Conflict and the warin Vietnam, show decreased combat mortality withthe development of faster, more organized systemsfor the transport of injured troops from thebattlefield to medical care facilities.3,4 This in-creased survival was attributed in part to fasterevacuation of wounded soldiers from the battlefieldto the hospital by way of helicopter transport.4 The1960s and 1970s saw an increased interest incivilian trauma care. Federal legislation led theway for funding emergency medical services (EMS)standards and training. The American College ofSurgeons published the first of many guidelines fortrauma care in 1976.4 Pioneers such as Dr Cowleychampioned trauma care as a specialty with itsroots in general surgery.5 Helicopter transportbegan to be seen as a means of quickly movinginjured patients to hospitals; some hospitals beganto devote specialized resources and teams to carefor trauma victims, and the concept of regionalizedtrauma systems gained support from health careproviders and governing bodies.4,6

TRAUMA SYSTEMS AND TRANSPORT TOTRAUMA CENTERS

Early studies of trauma patients appeared toshow increased survival with the development ofthese early trauma systems and continue to show

improved outcomes for severely injured patientscared for in dedicated trauma centers.7,8 A coreprincipal in many of these systems is the belief thatcritically injured patients are best cared for indesignated trauma centers, even if transport fromthe field to these centers bypasses closer medicalfacilities. The combination of the concepts of thegolden hour and the importance of trauma centershas been the impetus for the development of EMSpolicies such as rapid scene triage, minimization ofon-scene treatment interventions in favor of rapidtransport to emergency departments, and air eva-cuation of severely injured patients directly fromthe site of injury to designated trauma centers.These practices are not without cost, in money forequipment and staffing of helicopter transport andEMS resources. They are also not without risk toEMS teams, patients, and bystanders when priorityis placed on rapid transport, sometimes acrossgreat distances.9 A common debate in traumasystem development centers on whether patientsshould be transferred longer distances to traumacenters or to the closest available facility, whereinitial stabilization may be performed, and thenthose patients determined to need further specialtycare are then transferred to a trauma center. Muchof the current literature supports a varied approachbased on geographic location. In urban areas, wherelevel I trauma centers are often readily available,it may make sense to bypass closer facilities toreach the trauma facility, as differences in transporttimes are likely to be minor. In rural areas, however,transport times to trauma centers may be pro-longed, and patients may benefit from stabiliza-tion in a closer facility followed by transfer to atrauma center after initial stabilization. Effectivetrauma systems must therefore take into accountthe location and capabilities of the facilities within ageographic catchment area, as well as any traffic orgeographical features that may impact transporttimes. This approach to establishing effectivetrauma systems is perhaps best characterized bythe “3R” rule attributed to pioneering traumasurgeon Dr Donald Trunkey of getting the “rightpatient to the right place at the right time.”10 Somepatients may have only minutes to survive withoutappropriate intervention, whereas some may sur-vive their initial injuries but need specializedcare and rehabilitation to achieve maximum post-injury function. This concept might well be thebest guiding principle of trauma management, andthe immediate postinjury period might best bethought of as a “golden opportunity” to ensureprompt, appropriate treatment for each and everyinjured patient.

6 VOL. 11, NO. 1 • GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE

PEDIATRIC TRAUMA ANDTRAUMA CENTERS

If the concept of a golden hour and its relationshipto trauma systems is controversial and unproven inadults, it is even more so for pediatric traumapatients. The development of pediatric emergencymedicine as a specialty has promoted the creation ofpediatric trauma centers, some as part of free-standing children's hospitals and others withingeneral/adult facilities. Pediatric trauma care con-tinues to evolve as a distinct facet of trauma carethat recognizes the different anatomical, physiolog-ic, and developmental realities of pediatric patientsas well as the different injury patterns seen in thesepatients. The development and concentration ofpediatric expertise has improved the managementof injured children, with patients cared for inpediatric trauma centers appearing to have equalor better outcomes overall when compared topediatric patients cared for in general or adulttrauma centers.11-17 Many factors likely contributeto this positive effect including the availability ofappropriately sized equipment and monitoringcapabilities for pediatric patients, health careproviders capable of recognizing and treating theearly, often subtle, signs of shock in pediatricpatients, and management strategies unique topediatric injuries.

Despite evidence to suggest better outcomes forpediatric trauma victims treated in pediatric traumacenters, most pediatric trauma victims are caredfor, at least initially, in nonpediatric centers, as thenumber and geographic location of dedicatedpediatric centers leaves many children out ofreach for immediate care.12,13 The question thattherefore arises is not only does a golden hour existfor the treatment of pediatric trauma patients, butalso, what should occur during that initial timeframe. One aspect of this debate centers on whetherpediatric trauma patients should be transporteddirectly to pediatric centers, possibly bypassingother emergency facilities or trauma centers onthe way to specialized pediatric care, or should theybe stabilized at the closest capable facility and thentransferred to specialized pediatric centers if theircondition warrants. It is worrisome that pediatricpatients may be subjected to longer transport times,possibly bypassing “adult” trauma facilities to reachpediatric centers, as EMS providers often do nothave great familiarity or experience with critically illor injured children. The EMS pediatric volumes areoften quoted as around 10% of EMS calls, with lessthan 1% of these patients meeting the definition ofcritically ill. The EMS personnel may have difficulty

performing procedures such as intravenous access,endotracheal intubation, and appropriate cardio-pulmonary resuscitation on pediatric patients.14,15

There is literature to suggest similar outcomes forpediatric patients ventilated by means of bagginginstead of endotracheal intubation in cases ofrespiratory failure, suggesting that intubationshould not be attempted in the field for pediatricpatients in urban locations where transport times tohospital emergency departments is fairly short.15

Another study examining the effectiveness ofpediatric helicopter transport showed no benefitfor patients transported directly from the scene ofinjury to a pediatric trauma center as comparedwith those initially stabilized at the closest medicalfacility.17 All of this information could be inter-preted that time spent in EMS transport of criticallyill and injured children should be minimized, andthese patients should be transported to the closestfacility able to provide stabilizing, if not definitive,care.

EMERGENCY DEPARTMENT READINESSFOR CHILDREN

If pediatric patients are to be transported to non–pediatric-specific hospitals, the emergency depart-ments at these facilities must be capable of assessingpediatric trauma patients and providing stabilizingcare (also see article “Pediatric Patients in the AdultTrauma Bay—Comfort Level and Challenges,” inthis issue). Although most emergency departmentvisits in the United States involving children occurin nonpediatric facilities, many of these facilities areunderprepared to deal with critically ill or injuredchildren. In 2001, the American Academy ofPediatrics and the American College of EmergencyPhysicians established a set of guidelines forpediatric emergency department preparedness.18

These guidelines, which were recently updated in2009, address equipment, training, and qualityreview for pediatric care in emergency depart-ments.19,21 Surveys evaluating preparedness con-tinue to show inadequate preparation in equipmentand training for pediatric patients.13,20,22 Nonpedia-tric centers often transfer seriously ill or injuredpatients to pediatric centers for definitive care. Thepresence of a seriously injured child may engender asense of anxiety in the emergency department andhas the potential to create a stress-laden atmo-sphere in which recognition and treatment of life-threatening shock and respiratory failure go unad-dressed and untreated in attempts to get the patientout of the facility and enroute to a pediatric

GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE • VOL. 11, NO. 1 7

specialty center as quickly as possible. Missedinjuries on an initial trauma survey are a commonproblem, and there is some evidence from adultstudies that seriously injured patients transferredfrom rural hospitals to trauma centers frequentlyhave unrecognized injuries.23,24 This suggests thatpatients may have injuries overlooked in favor ofrapid transport to a trauma center. This problemmay be even more widespread for pediatric patientsin similar situations. Recent literature supportsearly recognition and treatment of shock andrespiratory failure as important in improving ulti-mate survival and outcome of critically ill or injuredpatients, both adult and pediatric.25,26 Similarly,neurologic outcome has been shown to improvewith early appropriate resuscitation and monitoringof children with traumatic brain injury.27 Unfortu-nately, studies of pediatric patients transferred topediatric centers describe deficiencies in the detec-tion and treatment of shock, hypotension, andrespiratory failure before transfer.18,25,26

INITIAL STABILIZATION OFINJURED CHILDREN

So what should be the scope of the evaluation andstabilization of pediatric trauma patients in generaltrauma facilities or community hospitals? A prima-ry survey focusing on airway, breathing, andcirculation should be undertaken and any life-threatening conditions corrected. All patientsshould be placed on supplemental oxygen. Ad-vanced airway management in the form of endotra-cheal intubation may be needed in patients withsevere traumatic brain injury, thoracic injuries, orshock. Adequate oxygenation and ventilation shouldbe ensured. A portable chest radiograph to evaluatefor pneumothorax may be helpful. Placement of athoracostomy tube should be pursued for most casesof pneumothorax. Close attention should be paid tothe child's hemodynamic status. Health care provi-ders must keep in mind that the strong compensa-tory mechanisms in children and teenagers allowthem to increase their systemic vascular resistanceand maintain blood pressure until a substantialamount of blood is lost.19,28 Early signs of shocksuch as tachycardia, mental status, and capillaryrefill time are more sensitive and should bemonitored closely. An initial fluid bolus of isotonicsaline should be administered and repeated asneeded. Blood component transfusion should beconsidered for patients not responding to crystalloidresuscitation or for those with evidence of ongoinghemorrhage.27 Patients with immediately life-

threatening hemorrhage would seem to be candi-dates for immediate transfer to a trauma center withpediatric surgeons and a pediatric intensive careunit but at times may require the services of ageneral surgeon, if available, to control hemorrhagebefore transport. Most pediatric trauma is caused byblunt mechanism of injury such as falls, motorvehicle collisions, assault, and sporting activities.Most patients will not require emergent surgicalintervention. Pediatric trauma specialists have ledthe development of protocols for expectant, nonop-erative management of some conditions, namelyliver and splenic injuries. In adult-oriented systems,these injuries are generally treated surgically,whereas children cared for in pediatric centers areusually managed nonoperatively. Therefore, pediat-ric patients undergo fewer laparotomies and sple-nectomies than do adult patients.29,30 The goldenhour for these patients might best be spent ensuringadequate oxygenation and ventilation, securing anairway if needed, obtaining vascular access, andproviding initial fluid resuscitation if needed.Patients with traumatic brain injury must becarefully monitored, and hypotension and hypoxiaavoided as both of these states have been found to beindependent predictors of increased mortality inpatients with traumatic brain injury. Pediatricpatients with isolated brain injuries may best bestabilized at the closest medical facility in whichthese conditions may be recognized and correctedas needed. Transport could then be undertaken in acontrolled fashion and preferably with a specializedpediatric critical care transport team. Time shouldnot be spent obtaining computerized tomographyand other extensive imaging studies if the facilitylacks the surgical capabilities to provide definitivecare for injuries detected on imaging or if obtainingscans will delay transport. Scans may inadvertentlyfail to be transported with the patient or, in the caseof digital images, transferred by compact disk,inaccessible at the receiving facility, thus, necessi-tating repeat imaging with increased costs andunnecessary radiation exposure to the patient. Infact, one study found that almost all radiographsperformed at referring facilities were later repeatedwhen patients arrived to the trauma center.31

Once critically ill or injured children are stabi-lized and the decision is made to transfer to apediatric trauma center, attention must then beturned to the best mode of transfer. One recentstudy showed significantly more complications anddeaths (23% mortality vs 9% mortality) amongpediatric patients transferred from referring facili-ties to a pediatric trauma center by “general”helicopter teams vs specialized pediatric teams.

8 VOL. 11, NO. 1 • GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE

This remained true even when corrected for patientmix and the greater average time from referral toarrival in the pediatric center among patientstransported by the specialty teams. The authorsspeculate that despite overall longer transporttimes, the patients transported by the specializedteam actually benefited from an overall longerperiod in the care of pediatric specialists.18 Thisconcept of “bringing the hospital to the patient”mayin fact be a critical piece of care that is currentlylacking in many trauma systems. Several studieshave shown that transport by specialty-trained“mobile intensive care unit” teams is associatedwith improved outcomes, even if such transportdelays ultimate patient arrival at the tertiary carecenter.18,19,28-44

THE GOLDEN OPPORTUNITYSo what is the best care for pediatric trauma

patients? How can a system capitalize on the“golden opportunity” to provide the right care inthe right place at the right time? Creation ofregionalized trauma systems to ensure timely accessto basic evaluation and stabilization for all patientsis vital.45 This may require initial transport ofpediatric trauma patients to general emergencyfacilities, especially in rural areas without immedi-ately available pediatric trauma centers. Thesefacilities must be capable of evaluating and stabiliz-ing pediatric trauma patients. Appropriately sizedequipment and monitoring capabilities must bepresent. Staff must have skills in the assessmentand stabilization of pediatric patients, especially inthe management of shock and real or impendingrespiratory failure. Pediatric patients with severeor life-threatening injuries, especially those inneed of intensive care unit-level care, should thenbe transferred to appropriate pediatric trauma faci-lities as rapidly as possible after initial stabilizationof any immediately life-threatening conditions. Thecriteria for transfer and mechanisms for referraland transfer must be put in place and maintained.Transfer agreements between general and pediatrictrauma centers must be well designed with prompt,easily accessed communication readily availablebetween facilities to expedite transfers. Carefulconsideration should be given to the mode oftransfer and composition of the transport team.For many pediatric patients, this may mean await-ing the arrival of specialized transport teams fromthe receiving institution. In these situations, per-sonnel at the referring facility must be capable andremain committed to caring for the patient untilthe team arrives. They must adopt a mentality of

ongoing treatment vs “awaiting transfer” and becapable of recognizing and responding to evolvingclinical changes in pediatric patients.

SUMMARYCertainly, no one would argue that timely care is

best for critically ill and injured persons. However,the exact meaning and significance of a golden hourin trauma care is the subject of debate andcontroversy. So is there a golden hour? If there is,then what should occur during this time? Shouldthis time be spent transferring a patient from thescene to a major trauma center, even if it is not theclosest facility? Or should patients be stabilized atthe closest medical facility before transfer? Fur-thermore, how do the concepts of a golden hour andtrauma system care apply to pediatric patients?Perhaps, the answers lie somewhere in between,and rather than a golden hour, health careproviders should focus on the “golden opportunity”to provide stabilization of immediately life-threat-ening conditions at the closest appropriate facilityfollowed by safe transfer when needed for definitivecare. True realization of this opportunity forpediatric trauma patients requires individualizedconsideration for each patient within well-estab-lished and well-coordinated systems of regionalizedtrauma care.

REFERENCES1. www.umm.edu/shocktrauma/history.htm. Accessed Decem-

ber 10, 2009.2. Trauma.org. Trauma resuscitation. Available at: http://www.

trauma.org/archive/history/resuscitation.html. AccessedAugust 11, 2009.

3. Lerner EB, Moscati RM. The golden hour: scientific fact ofmedical “urban legend”. Acad Emerg Med 2001;8:758-60.

4. Mackersie RC. History of trauma field triage development andthe American College of Surgeons criteria. Prehosp EmergCare 2006;10:287-94.

5. Cowley RA. Accidental death and disability: the neglecteddisease of modern society—where is the fifth component.Ann Emerg Med 1982;11:582-5.

6. Sasser SM, Hunt RC, Sullivant EE, et al. Guidelines for fieldtriage of injured patients. MMWR 2009;58:1-35.

7. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A nationalevaluation of the effect of trauma-center care on mortality.N Engl J Med 2006;354:366-78.

8. Nathens AB, Jurkovich GJ, Rivara FP, et al. Effectiveness ofstate trauma systems in reducing injury-related mortality: anational evaluation. J Trauma 2000;48:25-31.

9. Larson JT, Dietrich AM, Abdessalam SF, et al. Effective use ofthe air ambulance for pediatric trauma. J Trauma 2004;56:89-93.

10. Traumafoundation.org. Trauma's golden hour. Available at:http://www.traumafoundation.org/restricted/tinymce/

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jscripts/tinymce/plugins/filemanager/files/About%20Trauma%20Care_Golden%20hour.pdf. Accessed 10/27/2009.

11. Potoka DA, Schall LC, Gardner MJ, et al. Impact of pediatrictrauma centers on mortality in a statewide system. J Trauma2000;4:237-45.

12. Potoka DA, Schall LC, Ford HR. Improved functionaloutcome for severely injured children treated at pediatrictrauma centers. J Trauma 2001;51:824-34.

13. Odetola FO, Miller WC, Davis MM, et al. The relationshipbetween the location of pediatric intensive care unit facilitiesand child death from trauma: a county-level ecologic study.J Pediatr 2005;147:74-7.

14. Osler TM, Vane DW, Tepas JJ, et al. Do pediatric traumacenters have better survival rates than adult trauma centers?An examination of the national pediatric trauma registry.J Trauma 2001;50:96-101.

15. Farrell LS, Hannan EL, Cooper A. Severity of injury andmortality associated with pediatric blunt injuries: hospitalswith pediatric intensive care units versus other hospitals.Pediatr Crit Care Med 2004;5:5-9.

16. Nakayam DK, Copes WS, Sacco W. Differences in traumacare among pediatric and nonpediatric trauma centers.J Pediatr Surg 1992;27:427-31.

17. Hall JR, Reyes HM, Meller JL, et al. The outcome for childrenwith blunt trauma is best at a pediatric trauma center. JPediatr Surg 1996;31:72-7.

18. American Academy of Pediatrics, Committee on PediatricEmergency Medicine, American College of EmergencyPhysicians, Pediatric Committee. Care of children in theemergency department: guidelines for preparedness. Pediat-rics 2001;107:777-81.

19. Gausche-Hill M, Krug SE, American Academy of PediatricsCommittee on Pediatric Emergency Medicine AmericanCollege of Emergency Physicians Pediatric Committee,Emergency Nurses Association, Pediatric Committee. Guide-lines for the children in the emergency department.Pediatrics 2009;124:1233-43.

20. NanceML,CarrBG,BranasCC.Access to pediatric traumacarein theUnitedStates. ArchPediatr AdolescMed2009;163:512-8.

21. Athey J, Dean M, Ball J, et al. Ability of hospitals to care forpediatric emergency patients. Pediatr Emerg Care 2001;17:170-4.

22. Gausche M. Differences in the out-of-hospital care of childrenand adults: more questions than answers. Ann Emerg Med1997;29:776-9.

23. Kumar VR, Bachman DT, Kiskaddon RT. Children and adultsin cardiopulmonary arrest: are advanced life support guide-lines followed in the prehospital setting. Ann Emerg Med1997;29:743-7.

24. Seidel JS, Hornbein M, Yoshiyama K, et al. Emergencymedical services and the pediatric patient: are the needsbeing met. Pediatrics 1984;73:769-72.

25. Seidel JS. Emergency medical services and the pediatricpatient: are the needs being met? II. Training and equippingemergency medical services providers for pediatric emer-gencies. Pediatrics 1986;78:808-12.

26. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival andneurological outcome: a controlled clinical trial. JAMA 2000;283:783-90.

27. Larson JT, Dietrich AM, Abdessalam SF, Werman HA.Effective use of the air ambulance for pediatric trauma. JTrauma 2004;56:89-93.

28. Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric preparednessof US emergency departments: a 2003 survey. Pediatrics2007;120:1229-37.

29. Aaland MO, Smith K. Delayed diagnosis in a rural traumacenter. Surgery 1996;120:774-9.

30. Robertson R, Mattox R, Collins T, et al. Missed injuries in arural area trauma center. Am J Surg 1998;12:564-8.

31. Han YY, Carcillo JA, Dragotta MA, et al. Early reversal ofpediatric-neonatal septic shock by community physicians isassociated with improved outcome. Pediatrics 2003;112:793-9.

32. Carcillo JA, Kuch BA, Han YY, et al. Mortality and functionalmorbidity after use of PALS/APLS by community physicians.Pediatrics 2009;124:500-8.

33. Zebrack M, Dandoy C, Hansen K, et al. Early resuscitation ofchildren with moderate-to-severe traumatic brain injury.Pediatrics 2009;124:56-64.

34. Orr RA, Felmet KA, Han Y, et al. Pediatric specializedtransport teams are associated with improved outcomes.Pediatrics 2009;124:40-8.

35. American Heart Association. PALS provider manual. Dallas(Tex): American Heart Association; 2002.

36. American College of Surgeons. Advanced Trauma LifeSupport for Doctors. 7th ed. Chicago (Ill): American Collegeof Surgeons; 2004.

37. Davis DH, Localio AR, Stafford PW, et al. Trends in operativemanagement of pediatric splenic injury in a regional traumasystem. Pediatrics 2005;115:89-94.

38. Mooney DP, Rothstein DH, Forbes PW. Variation in themanagement of pediatric splenic injuries in the UnitedStates. J Trauma 2006;61:330-3.

39. Keller MS, Vane DW. Management of pediatric blunt splenicinjury: comparison of pediatric and adult trauma surgeons.J Pediatr Surg 1995;30:221-5.

40. Hall JR, Reyes HM, Meller JL, et al. The outcome for childrenwith blunt trauma is best at a pediatric trauma center.J Pediatr Surg 1996;31:72-7.

41. Thomas SH, Orf J, Peterson C, et al. Frequency and costs oflaboratory and radiograph repetition in trauma patientsundergoing interfacility transfer. Am J Emerg Med 2000;18:156-8.

42. Bellingan G, Oliver T, Batson S, Webb A. Comparison of aspecialist retrieval team with current United Kingdompractice for the transport of critically ill patients. IntensiveCare Med 2000;26:740-4.

43. Valenzuela TD, Criss EA, Copass MK, et al. Critical care airtransportation of the severely injured: does long distancetransport adversely affect survival. Ann Emerg Med 1990;19:169-72.

44. McPherson ML, Graf JM. Speed isn't everything in pediatricmedical transport. Pediatrics 2009;124:381-3.

45. Tuggle D, Krug SE, American Academy of Pediatrics, Sectionon Orthopedics, Committee on Pediatric Emergency Medi-cine, Section on Critical Care, Section on Surgery, Section onTransport Medicine, Pediatric Orthopedic Society of NorthAmerica. Management of pediatric trauma. Pediatrics 2008;121:849-54.

Abstract:A limited body of literature aboutpediatric prehospital trauma careexists to date. Topics that havebeen studied include delayingtransport to initiate treatmenton-scene, the use of advanced lifesupport or basic life supportresources, identifying high-riskpediatric trauma patients, optimalairway management, obtainingintravenous or intraosseous access,immobilization of the cervical spine,optimal management of traumaticbrain injury, and the assessmentand management of pain.Translating the best availableevidence into clinical practice isimportant to providing qualityprehospital pediatric trauma care.This article will review the literatureregarding the risks and benefits ofvarious aspects of pediatric traumacare in the prehospital setting.

Keywords:pediatric trauma; intravenous

access; intraosseous access;

cervical spine immobilization;

traumatic brain injury; prehospital

care; airway; emergency medical

services

Department of Pediatrics, Section of

Emergency Medicine, Baylor College of

Medicine, Houston, TX.

Reprint requests and correspondence:

Manish I. Shah, MD, Texas Children’s

Hospital, 6621 Fannin Street, MC

1-1481, Houston, TX 77030.

[email protected]

1522-8401/$ - see front matter

© 2010 Elsevier Inc. All rights reserved.

10 VOL. 11, NO. 1 • PREHOSPITAL MANAGEMENT O

PrehospitalManagement ofPediatric Trauma

F PEDIATRIC TRAUMA / SHAH

Manish I. Shah, MD

ecent estimates from the National Hospital AmbulatoryMedical Care Survey database note that 27% of all

patients transported via Emergency Medical Services (EMS) arechildren. Although the percentage of children who require EMS issmall relative to adults, the acuity of pediatric EMS patients isoften higher than that of adults. This is especially true withtrauma, in which 54% of pediatric trauma patients arrive to the EDvia EMS.1 As the EMS system in the United States was originallydesigned to meet the needs of adults, the integration of the uniqueneeds of children into the existing EMS infrastructure has beenone of the main goals of the federally funded Emergency MedicalServices for Children program for the past 25 years.2

Twenty years ago, Ramenofsky3 described essential compo-nents of an integrated pediatric trauma system that addressedsystem design, prevention, education, standards of care, researchand development, quality assurance, and funding. Successfullyintegrating the needs of children into the existing EMS infrastruc-ture involves initiating high-quality prehospital care that usespreestablished protocols. These protocols must then be applied byskilled emergency medical technicians (EMTs) with the assis-tance of online medical control until ultimate transport to anappropriate facility capable of providing definitive care.

Although much has been accomplished in each of these areasfor pediatric trauma, there are still many areas that have not beenadequately addressed. One of these is the incorporation ofevidence-based practices into prehospital care. This conceptwas highlighted in the recent Institute of Medicine (IOM) report,“The Future of Emergency Care,”which describes the importanceof extending evidence-based practices into prehospital care.4

Although the prehospital pediatric literature is limited to date,evaluating the literature for risks and benefits of various aspects ofpediatric trauma care in the prehospital setting is an important

PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH • VOL. 11, NO. 1 11

way to determine the value of certain decisions inthe field. These include delaying transport to initiatetreatment on-scene, the use of advanced life support(ALS) or basic life support (BLS) resources, identi-fying high-risk pediatric trauma patients, optimallymanaging the airway, obtaining intravenous (IV) orintraosseous (IO) access, immobilization of thecervical spine, optimal management of traumaticbrain injury, and the assessment and managementof pain. Each of these areas has been controversialin the management of pediatric trauma patients,and examination of the literature is important indetermining local protocols.

PREHOSPITAL CARE TIMESome literature suggests that prehospital care

time has a significant impact on survival in severelyinjured patients and is a major component of the“golden hour” of trauma care.5 Yet the impact ofresponse time intervals on morbidity and mortalityof all trauma patients is unclear.6 In a meta-analysisdesigned to describe average time intervals ofprehospital care, 4 time intervals were defined andanalyzed: (1) an activation time interval (ATI) in theprealarm period defined as the time from receivingthe call to the time of alarm, (2) a response timeinterval (RTI) defined as the time from alarm toarrival on-scene, (3) an on-scene time interval(OSTI) defined as the time from on-scene arrivalto departure, and (4) a transport time interval (TTI)defined as the time from scene departure to arrivalat a hospital. Average urban and suburban groundambulance time intervals were similar to each other(ATI = 1 minute; RTI = 5 minutes; OSTI = 14minutes; and TTI = 11 minutes) and significantlyshorter than those for rural ground ambulances(ATI = 3 minutes; RTI = 8 minutes; OSTI = 15minutes; and TTI = 17minutes). The average overallprehospital care time for urban/suburban settingswas 31 minutes compared to 43 minutes in the ruralsetting. Helicopter transport times were significant-ly longer than those for ground ambulances as awhole but were not compared by setting.7

Using these national averages as a benchmarkmaybe useful in evaluating the quality of pediatricprehospital trauma care. Although standards existfor time to definitive care for acute coronarysyndrome and stroke patients the impact of similarprehospital care time standards for trauma patientsis still unclear. The American College of Surgeonsdoes strongly encourage rapid transport to a traumacenter andminimization of on-scene time for traumapatients, and there is evidence to support improvedoutcomes with shorter on-scene times.5,8

PREHOSPITAL TRIAGE AND TRANSPORTRegionalizing trauma care has demonstrated

improved outcomes in pediatric trauma and hasbeen recommended by the IOM.4,9 Determiningwhich patients are at high risk for mortality or needspecialized treatment that can only be provided at atrauma center with pediatric capabilities is impor-tant. Using prehospital triage criteria that balancessensitivity and specificity to transport patients withthe most severe injuries to trauma centers, whiletransporting those with less severe injuries to theclosest hospital, is essential in regionalizing traumacare for children.

Engum et al10 performed a retrospective analysisof the predictive value of certain physiologic andanatomical criteria in determining pediatric traumapatients who subsequently died in the ED, wereadmitted to the pediatric intensive care unit, orrequired a major surgical procedure. Their findingsshowed that 5 criteria had a positive predictivevalue of 50% or higher, a systolic blood pressure(SBP) of less than 90 mm Hg (86%), Glasgow ComaScore (GCS) of 12 or less (78%), respiratory rate(RR) of less than 10/min or more than 29/min(73%), a second- or third-degree burn involvingmore than 15% total body surface area (79%), orparalysis (50%).

Yet this analysis did not take into account varyingnormal vital sign values by age group, thus drawingsome criticism on the utilization of SBP less than 90mm Hg and RR of more than 29/min as predictors ofpoor outcomes in young children. Newgard et al11

analyzed a retrospective cohort of injured childrenin the Oregon state trauma registry over a 6-yearperiod and included age-based physiologic para-meters to identify children at high risk for majornonorthopedic operative intervention, intensivecare unit stay of 2 days or longer, or in-hospitalmortality. They found that the GCS was the mostimportant prehospital predictor followed by (inorder) airway intervention, RR, heart rate (HR),SBP, and shock index. Examining the findings ofNewgard et al11 in reference to those of Engumet al,10 a RR of more than 29/min had no predictivevalue in children younger than 5 years of age and HRwas significantly more predictive of poor outcomesin comparison to SBP or shock index.

Yet, Newgard et al12 performed a subsequentanalysis on pediatric patients using the AmericanCollege of Surgeons Committee on Trauma fielddecision criteria to develop a clinical decision rule toidentify high-risk injured children. The decision ruleplaced these criteria in the following order to identifyhigh-risk injured children: need for assistance with

12 VOL. 11, NO. 1 • PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH

ventilation via endotracheal intubation (ETI) or bag-valve-mask ventilation (BVM), GCS of less than 11,pulse oximetry of less than 95%, and SBP of morethan 96 mmHg. Of note, HR and RR did not prove tobe important predictors in the model. In addition,the finding of a high SBP associated with pooroutcomes may be plausible with traumatic braininjury but otherwise did not seem to be expected.Therefore, pediatric patients with prehospital find-ings of a low GCS, the need for airway interventions,hypoxia, and hypertension seem to be at high risk forpoor outcomes. These predictors should potentiallybe incorporated into decision-making protocols fortransport of pediatric patients to a trauma center.12

The use of ALS vs BLS for the transport of traumapatients in the prehospital setting has stirred debate,given the resource implications of using ALS foreach patient, the lack of adequate ALS staffing inrural areas, and the assumption that prehospitalALS decreases morbidity and mortality.13,14 Staffingan ALS unit compared to a BLS unit is estimated tocost an extra $94 928 per year per unit.15 Also,procedures performed by ALS units take additionaltime, which may delay ultimate transport todefinitive care.16 A meta-analysis evaluating 15studies, including patients of all ages, concludedthat ALS-treated trauma patients overall had anincreased odds of mortality over BLS-treatedpatients (odds ratio [OR], 2.92). Interpretation ofthe confidence intervals (CIs), however, revealedonly one study that favored ALS. The other studieshad CIs that included 1, therefore did not show asignificant difference.17 One study from Finlandreported slightly improved outcomes in ALS unitsstaffed by a physician, but this model is rare in theUnited States.18 Thus, it seems that there is nodifference in mortality between ALS and BLStrauma care when provided by EMTs, but thereare significant differences in cost with possiblebenefit only in situations of prolonged transporttimes or physician-staffed ALS units.

AIRWAY MANAGEMENTOne of the most controversial topics in prehospi-

tal care is the method of airway management thatreduces morbidity and mortality while optimizingsafety. This is also an issue in adult trauma care, anda retrospective cohort analysis of trauma patientsolder than 14 years demonstrated that prehospitalcare time for patients undergoing rapid sequenceintubation (RSI) was 10.7 minutes longer (95% CI,7.7-13.8) than patients who were not intubated.Also, prehospital care time for patients undergoingconventional ETI without induction medications

was still 5.2 minutes longer than that for patientswho were not intubated.19 Thus, intubation clearlyincreases on-scene time, which may result in pooreroutcomes for patients.

In a separate analysis of the same cohort,adjusting for the propensity to be intubated,prehospital ETI was associated with an increasedodds of mortality (OR, 2.70; 95% CI, 1.63-4.46)when ground transport distances were short (b10miles) compared to nonintubated patients. Thisrisk gradually declined as ground transport dis-tance increased, such that the 95% CI included anOR of 1 for transport distances greater than 20miles. Intubated patients transported by helicop-ter, however, had decreased mortality (OR, 0.36;95% CI, 0.24-0.56). This finding may be due to themore advanced airway management skills of airtransport providers, but the evidence suggests thatETI in adults by ground crews near a hospitalincreases mortality.20

In a controlled trial of pediatric patients in theurban setting who either received BVM or ETI forprehospital airway management, intention-to-treatanalysis revealed that there was no differencebetween the 2 interventions for both survival andneurologic outcome, even in the subgroup analysis ofvarious categories of trauma patients includingsubmersion injury, head injury, and multiple trau-ma. The subgroup of child maltreatment patientsdemonstrated improved survival with BVM com-pared to ETI (OR, 0.07; 95% CI, 0.01-0.58), but therewas no significant difference in neurologic outcome.This study, however, did not examine potentialeffect measuremodification by transport distance.21

Maintenance of the rarely encountered task ofprehospital pediatric ETI, the anatomical differ-ences of the pediatric airway relative to an adult,and the limited pediatric continuing education forprehospital providers make pediatric ETI a chal-lenging task for the prehospital provider, especiallyin the rural setting. In rural pediatric traumapatients, field intubation success rates by bothEMT-paramedics and flight registered nurses aresignificantly poorer (45%-70%) when compared torates by ED physicians and anesthesiologists attrauma centers (89%-100%).22

Therefore, the risk of increased on-scene timeand potential complications with ETI must beweighed against the benefit of rapid transport to anappropriate trauma center when deciding whetherto intubate or use less invasive means to manage theairway of a pediatric trauma patient. This may beespecially true for ground transport distances lessthan 10 miles, in which higher mortality has beendemonstrated in the adult population.

PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH • VOL. 11, NO. 1 13

INTRAVENOUS AND IO ACCESSAND INFUSIONS

Because many time intervals in prehospital careare system dependent, the most effective way todecrease prehospital times is to decrease the on-scene duration. Procedures in the field may increasethe likelihood of survival or may increase mortalityby delaying definitive care. In a retrospective reviewof IV placement in trauma patients of all ages, thisprocedure added an additional 5 minutes of on-scene time.16

Because this study did not include a subgroupanalysis of pediatric patients, however, the time toplace an IV in a child may actually be longer. Aretrospective chart review of prehospital IV place-ment in pediatric patients, with subgroup analysisfor trauma patients, showed a 57% success rate forIV placement in patients less than 6 years of age and74% success rate in age 6 years or higher. Averagetime to IV placement in trauma patients was 14minutes (range, 7-24 minutes) in age less than 6years and 12 minutes (range, 1-43 minutes) in agemore than 6 years.23 For some patients, decreasingon-scene time may be essential to survival, but forothers, the benefit of initiating IV access mayoutweigh the risks. Therefore, the determination ofwhether to place an IV needs to be based on theindividual patient with respect to expected trans-port time and anticipated time to complete theprocedure.

Although obtaining IV access in pediatricpatients may prolong on-scene time by up to 14minutes, placement of an IO needle may providemore timely access for trauma patients withhemorrhagic shock. In a prospective observationalstudy of paramedics after a brief training session onthe placement of IO needles, 28 (84%) of 33 of theattempted IO infusions were successfully started inless than 1 minute in a simulated ambulance settingat a speed of 25 to 35 miles per hour.24 In aretrospective cohort of pediatric trauma patients inwhom an IO was attempted for cardiopulmonaryarrest, hypovolemic shock, or neurologic insult,successful placement by prehospital professionalswas noted in 13 (93%) of 14 cases. These IO needleswere used both in the prehospital and emergencydepartment settings to successfully administer bothcolloid and crystalloid infusions and multiplepharmacologic agents in patients 3 months to10 years of age, with only one reported case ofminor tissue extravasation.25

Regardless of whether an IV or IO is placed,controversy exists about whether administration offluids in the prehospital setting actually improves

patient outcomes. Computer modeling to evaluatethe potential benefit of administering prehospitalfluids for major hemorrhage suggests that onlytrauma patients who had a bleeding rate of morethan 25 mL/min and prehospital time greater than30 minutes would benefit.26 Yet these findings havenot been validated in children in the prehospitalsetting. The only study evaluating the efficacy ofprehospital IV fluid administration to pediatrictrauma patients was a retrospective review inwhich it was inconsequential in 94% of patients,potentially beneficial in 4% of cases, and potentiallyharmful in 2% of cases.27

It seems evident that adult trauma protocols maynot be applicable to children, prehospital IVplacement prolongs on-scene time, and the benefitof prehospital fluid therapy in pediatric traumapatients is still unclear.28 Yet given the physiologicdifferences between children and adults, IV/IO fluidadministration for hemorrhage secondary to traumamay be warranted. For some patients, decreasingon-scene time may be essential to survival, but forothers, the benefit of initiating IV access mayoutweigh the risks. Therefore, the determination ofwhether to place an IV or IO needs to be based onthe individual patient with respect to expectedtransport time and anticipated time to completethe procedure.

CERVICAL SPINE IMMOBILIZATIONCommon practice among prehospital profes-

sionals is to immobilize the cervical spine of apatient who has had a traumatic injury. Once thesepatients arrive at the hospital, the cervical immo-bilization device might be removed based onclinical criteria, or the patient might undergofurther imaging. The National Emergency X-Radi-ography Utilization Study (NEXUS) derived andvalidated a decision rule to determine who cansafely have a cervical spine immobilization deviceremoved in the ED without radiographic evalua-tion.29 Although these data apply to patients whohave already been immobilized, it is plausible thatsome EMS agencies may attempt to apply thesefindings to the prehospital setting. To date, thereare no published studies that provide evidence thatprehospital professionals can forego cervical spineimmobilization using the NEXUS criteria. Becauseonly 10% of the patients in NEXUS were children,applying these findings to the prehospital care ofchildren would be even more difficult.29,30 Analysisof the NEXUS pediatric patient data demonstratesthat no cervical spine injury would have beenmissed if the NEXUS criteria had been applied to

14 VOL. 11, NO. 1 • PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH

this population.30 Yet due to the low cervical spineinjury rate of 0.98% in pediatric trauma patients inthis study, it would be difficult to safely apply thisrule to children in the ED setting, let alone theprehospital setting.30 Until this issue is studiedfurther, children with a significant mechanism ofinjury should have their cervical spine immobilizedusing age-appropriate equipment before transportto the hospital.

TRAUMATIC BRAIN INJURYTraumatic brain injury (TBI) in children results

from a variety of causes, including nonaccidentalinjury, falls, and motor vehicle collisions.31 In theyoung athlete, TBI occurs with activities such asfootball, soccer, cheerleading, basketball, and fieldhockey.32 Because athletic injuries and motorvehicle collisions are common causes of pediatricTBI, the prehospital professional must be equippedto manage these common mechanisms of injury.33

In addition, because 50% of the mortality due to TBIoccurs in the first 2 hours after injury, prehospitalassessment and management of TBI is crucial.34 Yetvariation exists in assessing and managing childrenwith TBI in the prehospital environment, and anevidence-based approach is necessary.31

Early correction of hypoxemia and hypotension,accurate assessment of the GCS and pupils, airwaymanagement, and appropriate transport decisionmaking is vital, according to the Brain TraumaFoundation's evidence-based guidelines on prehos-pital management of TBI. Most of these guidelinesare based on adult studies, however, due torelatively limited studies on pediatric TBI in theprehospital setting. Regardless, modifying the GCSfor a pediatric patient is essential due to differencesin preverbal children (Table 1).35

In addition, the assessment of potential TBIshould include asking the verbal child about arecent prior head injury and symptoms of aconcussion, such as headache, dizziness, nausea,and blurred vision. In addition, it is also importantto ask bystanders about loss of consciousness andthe mechanism of injury. Physical assessmentshould include evaluation of the face and scalp forhematomas, ecchymoses, or palpable skull fracture;drainage of blood from the ears or nose; and athorough neurologic examination, including an age-adjusted assessment of the GCS.31

In a recent analysis of a prospective cohort ofchildren with head injuries, patients 2 years orolder with altered mental status, any suspected orconfirmed loss of consciousness, history of vomit-ing, severe mechanism of injury (motor vehicle

collision with patient ejection, death of anotherpassenger or rollover, pedestrian or bicyclistwithout helmet struck by a motorized vehicle,falls of N5 feet, head struck by a high-impactobject), clinical signs of basilar skull fracture(posterior auricular or periorbital ecchymoses,hemotympanum, or cerebrospinal fluid otorrhea/rhinorrhea), or a severe headache were at risk fora clinically significant TBI, which may requireneurosurgical intervention or hospital admission.Patients younger than 2 years with altered mentalstatus, occipital/parietal/temporal scalp hematoma,loss of consciousness for 5 seconds or more,severe mechanism of injury, palpable or equivocalskull fracture, or abnormal behavior according tothe caregiver were also at risk for clinicallyimportant TBI.36

Being aware of what makes a pediatric patienthigh risk for complications from TBI is especiallyessential for EMS systems in which EMTs candetermine patient disposition in the prehospitalsetting. This is also true in the case of potentialnontransport of patients after sports injuries be-cause providers must be aware of the sequelae ofTBI and recommendations to return to play aftersports-related injuries.31

For example, sports-related TBI can result in aclinical entity called second impact syndrome, in whicha second concussion in a patient who is stillsymptomatic from a first concussion can result incerebral edema, brain herniation, coma, anddeath.37 To prevent second impact syndrome, theConcussion in Sport Group has published recom-mendations on short-term management and whento return to play. These recommendations state thatany player that shows symptoms of headache,dizziness, nausea, or double vision should refrainfrom the current sports activity, under medicalevaluation, and should only return to play whenasymptomatic with a normal neurologic and cogni-tive evaluation.38 Also, patients who experience aloss of consciousness should be transported to ahospital for further evaluation.39

The prehospital management of TBI focuses onminimizing secondary injury, essentially throughhandling the compromised airway and interveningto prevent hypotension. Hypoxemia (oxygen satu-ration, b90%) should be avoided by managing theairway by the most appropriate means, which maybe supplemental oxygen, BVM, ETI, or other airwayadjuncts.35 There is no evidence to support ETIover BVM in pediatric patients with TBI, however,and pediatric trauma patients as a whole may havefewer complications from BVM when comparedto ETI.21

TABLE 1. Comparison of pediatric GCS withstandard GCS

GCS Pediatric GCS

Eye opening Eye openingSpontaneous 4 Spontaneous 4Speech 3 Speech 3Pain 2 Pain 2None 1 None 1

Verbal response Verbal responseOriented 5 Coos, babbles 5Confused 4 Irritable cries 4Inappropriate 3 Cries to pain 3Incomprehensible 2 Moans to pain 2None 1 None 1

Motor response Motor responseObeys command 6 Normal, spontaneous 6Localizes pain 5 Withdraws to touch 5Flexor withdrawal 4 Withdraws to pain 4Flexor posturing 3 Abnormal flexion 3Extensor posturing 2 Abnormal extension 2None 1 None 1

Data from Badjatia.35

TABLE 2. Definition of pediatric hypotensionby age

Age SBP

0-28 days b60 mm Hg1-12 months b70 mm Hg1-10 years b70 + (2 × age in years)N10 years b90 mm Hg

Data from Badjatia.35

PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH • VOL. 11, NO. 1 15

Children with suspected TBI should have theircervical spine (C-spine) immobilized in the fielddue to risk for concurrent injury.31 If ETI is going tobe attempted, manual C-spine stabilization isnecessary to prevent secondary injury. For EMSagencies that use RSI medications for intubation,premedication with 1.5 mg/kg of lidocaine followedby 0.3 mg/kg of etomidate for sedation and either1.5 mg/kg of succinylcholine or 1 mg/kg of vecur-onium are preferred to protect against increases inintracranial pressure. Otherwise, the decision tointubate should be made in consultation with onlinemedical control if these RSI medications are notavailable for use in the prehospital setting. Signs ofincreased intracranial pressure are represented byCushing's triad of hypertension, bradycardia, andirregular breathing.31

The EMS systems that use RSI protocols shouldmonitor blood pressure, oxygenation, and end-tidalCO2 (ETCO2). Patients should be maintained withnormal breathing rates (ETCO2 = 35-40 mm Hg),and hyperventilation (ETCO2 b 35 mm Hg) shouldbe avoided unless there are signs of cerebralherniation. The evidence for the latter, however, islacking in pediatrics, and this recommendation hasbeen extrapolated from adult data.35

Because hypotension with TBI in pediatricpatients has been associated with poor outcomes,

blood pressure should be monitored with anappropriately sized pediatric cuff and preventedby giving boluses of 20 mL/kg of isotoniccrystalloid (Table 2).31,35

Prehospital providers should determine the GCSand pupil size after airway, breathing, and circula-tion have been assessed and stabilized. The mostappropriate airway should be established in patientswith severe TBI, defined as a GCS less than 9.35

Also, because hypoglycemia can result after TBI,blood glucose should be checked and treated whenserum glucose is less than 80 mg/dL.31

Prehospital providers should directly transportchildren with severe TBI to a pediatric traumacenter or an adult trauma center with addedqualifications to treat children.35 Because nonacci-dental head injury is also a common cause of deathin infants, prehospital providers should thoroughlydocument findings at the scene and report unclearor implausible mechanisms to law enforcement,child protective services, and ED personnel, whilebeing cautious to maintain scene safety.31

PAIN ASSESSMENT AND MANAGEMENTPain assessment and management in trauma is

important for patient comfort and potentially forpatient healing. In a retrospective chart review of696 pediatric trauma patients, prehospital person-nel documented a pain assessment in 81% of cases,but only 0.1% actually used a pain assessment tool.Of the 64% of patients with documented pain, only15% received some sort of intervention to addresstheir pain. For all patients, both pharmacologic andnonpharmacologic interventions were used equallyin 13.4% of cases.40

Because pain does not necessarily correlate withinjury severity, pain assessment should occur in allchildren in the prehospital setting with a traumaticinjury. In addition, parental report of pain is often

16 VOL. 11, NO. 1 • PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH

comparable to a child's report and should beincorporated into a pain assessment.41 Althoughpediatric pain scales that have been validated in thehospital setting have not been validated in theprehospital setting, the use of standardized andage-appropriate pain assessment tools by prehospi-tal professionals is more likely to lead to manage-ment of pain.42

SUMMARYPrehospital providers play an essential role in

the initial management of pediatric traumapatients by minimizing secondary injury andtransporting injured children to definitive care ina timely manner. As the IOM has recentlyrecommended, it is essential for the United Statesto have an EMS system that is regionalized andcoordinated to provide optimal care in a seamlessfashion along the continuum from the prehospitalto ED settings.4 Although the evidence base forpediatric prehospital trauma care is limited,translating the best available information intoclinical practice is important to providing qualitycare. In addition, conducting further research inprehospital pediatric trauma care will be vital toproviding the best care possible in the future.

REFERENCES1. Shah MN, Cushman JT, Davis CO, et al. The epidemiology of

emergency medical services use by children: an analysis ofthe National Hospital Ambulatory Medical Care Survey.Prehosp Emerg Care 2008;12:269-76.

2. Krug S, Kuppermann N. Twenty years of emergency medicalservices for children: a cause for celebration and a call foraction. Pediatrics 2005;115:1089-91.

3. Ramenofsky ML. Emergency medical services for childrenand pediatric trauma system components. J Pediatr Surg1989;24:153-5.

4. Institute of Medicine of the National Academies. Emergencymedical services: at the crossroads. Washington, DC: NationalAcademies Press; 2006.

5. Sampalis JS, Lavoie A, Williams JI, et al. Impact of on-sitecare, prehospital time, and level of in-hospital care on survivalin severely injured patients. J Trauma 1993;34:252-61.

6. Lerner EB, Moscati RM. The golden hour: scientific fact ormedical “urban legend”. Acad Emerg Med 2001;8:758-60.

7. Carr BG, Caplan JM, Pryor JP, et al. A meta-analysis ofprehospital care times for trauma. Prehosp Emerg Care 2006;10:198-206.

8. American College of Surgeons. Advanced trauma life supportfor doctors. 8th ed. Chicago (Ill): American College ofSurgeons; 2008.

9. Haller JA, Shorter N, Miller D, et al. Organization andfunction of a regional pediatric trauma center: does asystem management improve outcome. J Trauma 1983;23:691-6.

10. Engum SA, Mitchell MK, Scherer LR, et al. Prehospital triagein the injured pediatric patient. J Pediatr Surg 2000;35:82-7.

11. Newgard CD, Cudnik M, Warden CR, et al. The predictivevalue and appropriate ranges of prehospital physiologicalparameters for high-risk injured children. Pediatr EmergCare 2007;23:450-6.

12. Newgard CD, Rudser K, Atkins DL, et al. The availability anduse of out-of-hospital physiologic information to identifyhigh-risk injured children in a multisite, population-basedcohort. Prehosp Emerg Care 2009;13:420-31.

13. Trunkey DD. Is ALS necessary for pre-hospital trauma care.J Trauma 1984;24:86-7.

14. Lewis FR. Ineffective therapy and delayed transport. PrehospDisaster Med 1989;4:129-30.

15. Ornato JP, Racht EM, Fitch JJ, et al. The need for ALS in urbanand suburban EMS systems. Ann Emerg Med 1990;19:1469-70.

16. Carr BG, Brachet T, Guy D, et al. The time cost of prehospitalintubations and intravenous access in trauma patients.Prehosp Emerg Care 2008;12:327-32.

17. Liberman M, Mulder D, Sampalis J. Advanced or basic lifesupport for trauma: meta-analysis and critical review of theliterature. J Trauma 2000;49:584-99.

18. Suominen P, Baillie C, Kivioja A, et al. Prehospital care andsurvival of pediatric patients with blunt trauma. J PediatrSurg 1998;33:1388-92.

19. Cudnik MT, Newgard CD, Wang H, et al. Endotrachealintubation increases out-of-hospital time in trauma patients.Prehosp Emerg Care 2007;11:224-9.

20. Cudnik MT, Newgard CD, Wang H, et al. Distance impactsmortality in trauma patients with an intubation attempt.Prehosp Emerg Care 2008;12:459-66.

21. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival andneurologic outcome. JAMA 2000;283:783-90.

22. Ehrlich PF, Seidman PS, Atallah O, et al. Endotrachealintubations in rural pediatriac trauma patients. J Pediatr Surg2004;39:1376-80.

23. Lillis KA, Jaffe DM. Prehospital intravenous access inchildren. Ann Emerg Med 1992;21:1430-4.

24. Fuchs S, LaCovey D, Paris P. A prehospital model ofintraosseous infusion. Ann Emerg Med 1991;20:371-4.

25. Guy J, Haley K, Zuspan SJ. Use of intraosseous infusion in thepediatric trauma patient. J Pediatr Surg 1993;28:158-61.

26. Wears RL, Winton CN. Load and go versus stay and play:analysis of prehospital IV fluid therapy by computersimulation. Ann Emerg Med 1990;19:163-8.

27. Teach SJ, Antosia RE, Lund DP, et al. Prehospital fluidtherapy in pediatric trauma patients. Pediatr Emerg Care1995;11:5-8.

28. Sadow KB, Teach SJ. Prehospital intravenous fluid therapy inthe pediatric trauma patient. Clin Pediatr Emerg Med 2001;2:23-7.

29. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set ofclinical criteria to rule out injury to the cervical spine inpatients with blunt trauma. N Engl J Med 2000;343:94-9.

30. Viccellio P, Simon H, Pressman BD, et al. A prospectivemulticenter study of cervical spine injury in children.Pediatrics 2001;180:e20.

31. Atabaki SM. Prehospital evaluation and management oftraumatic brain injury in children. Clin Pediatr Emerg Med2006;7:94-104.

32. Covassin T, Swanik CB, Sachs ML. Epidemiological con-siderations of concussions among intercollegiate athletes.Appl Neuropsychol 2003;10:12-22.

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33. NCCSIR. Eighteenth Annual Report, Fall 1982-Spring 2000.Chapel Hill (NC): University of North Carolina; 2000.

34. Baxt WB, Moody P. The impact of advanced prehospital careon the mortality of severely brain-injured patients. J Trauma1987;27:365-9.

35. Badjatia N, Carney N, Crocco TJ, et al. Guidelines forprehospital management of traumatic brain injury, 2nd ed.Prehosp Emer Care 2007;12:S1-S52.

36. Kuppermann N, Holmes JF, Dayan PS, for the PediatricEmergency Care Applied Research Network (PECARN).Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospectivecohort study. Lancet 2009;374:1160-70.

37. Cantu R, Voy R. Second impact syndrome: a risk in any sport.Phys Sport Med 1995;23:27-36.

38. Aubry M, Cantu R, Dvorak J, et al. Summary and agreementstatement of the First International Symposium on Concus-sion in Sport. Vienna 2001. Phys Sport Med 2002;30:57-63.

39. Collins M, Stump J, Lovell MR. New developments in themanagement of sports concussion. Curr Opin Orthop 2004;15:100-7.

40. Izsak E, Moore JL, Stringfellow K, et al. Prehospital painassessment in pediatric trauma. Prehosp Emerg Care 2008;12:182-6.

41. Baxt C, Kassam-Adams N, Nance M, et al. Assessment of painafter injury in the pediatric patient: child and parentperceptions. J Pediatr Surg 2004;39:979-83.

42. Zempsky WT, Cravero JP. Relief of pain and anxiety inpediatric patients in emergency medical systems. Pediatrics2004;114:1348-56.

Abstract:Laboratory studies are often routi-nely obtained in the injured child.How broad a range of studies areneeded and do they impact on thechild's management? This articlereviews the literature and makesrecommendations for a simplified,cost-effective laboratory testingstrategy.

Keywords:pediatric trauma; laboratory studies;intraabdominal injury

Reprint requests and correspondence:

Jeffrey F. Linzer Sr MD, Departments of

Pediatrics and Emergency Medicine,

Emory University School of Medicine,

Children’s Healthcare of Atlanta, GA

30322.

1522-8401/$ - see front matter© 2010 Elsevier Inc. All rights reserved.

18 VOL. 11, NO. 1 • LABORATORY TESTS IN PEDIATR

Do RoutineLaboratory TestsAdd to the Careof the PediatricTrauma Patient?

IC TRAUMA CARE / LINZER

Jeffrey F. Linzer Sr, MD

aboratory tests are often obtained on children who havehad traumatic injuries. These tests range from a

urinalysis (UA). The primary purpose for obtaining these tests inthe emergency department is either to (1) manage and monitorthe unstable patient or (2) screen the stable patient to determinethe need for imaging studies.

In some circumstances, the indication for specific testing isstraightforward. For example, a type and cross match for bloodwould be indicated for the hemodynamically unstable patient. Thedecision to provide additional treatment or to obtain a computerizedtomographic (CT) study is often based on clinical evaluation and ismade before these laboratory results are made available.1,2

It is the patient who has had blunt trauma without obviousinjury, however, where the use of routine laboratory testingcomes into question. Screening laboratory tests are most oftenused in these patients to determine the need for CT imaging. Asthere is now greater recognition of the potential risks fromionizing radiation, especially in younger children, the question ofthe use of laboratory testing to determine who needs imaging hasbecome a larger issue. A review of the literature shows that thereis no simple answer as to what test(s) may be of benefit. Theroutine use of “trauma panels” in pediatric trauma victims doesnot appear to provide any significant clinical benefit.1-5

LABORATORY TESTS IN PEDIATRIC TRAUMA CARE / LINZER • VOL. 11, NO. 1 19

URINALYSIS

Although no test has been shown to be 100%sensitive and specific, the UA appears to have someuse in determining the presence of intraabdominalinjury (IAI) in blunt trauma. There is controversy,however, as to the quantity of blood that needs to bepresent to determine the need for a CT scan. Inadults who are not hypotensive and who have nothad a deceleration entry, imaging is only indicated ifthere is frank hematuria.

In a retrospective study by Quinlan and Gear-hart,6 frank hematuria along with a low hematocritcorrelated with severe renal injury. In a review byStein et al,7 any degree of hematuria was anindication for radiographic imaging. Isaacman andcolleagues8 found that there was a low prevalence oflaboratory abnormalities in children with mild tomoderate trauma. Using a cutoff of greater than 5red blood cells per high-power field (RBC/hpf), theyfound the physical examination, in a patient with aGlasgow Coma Score (GCS) of 12 or higher, alongwith the UA, had a sensitivity of 100%, specificity of64%, and a negative predictive value of 100% forIAI.8 In a prospective study of children with blunttrauma, Holmes et al9 also found an association ofIAI with a UA with more than 5 RBC/hpf (odds ratio,4.8; 95% confidence interval [CI], 2.7-8.4).

Taylor et al10 found an association betweenabdominal symptoms and a UA with greater than10 RBC/hpf, but noted that asymptomatic hematu-ria would have a low yield as an indicator for CT ofthe abdomen. Whereas Lieu and colleagues11 foundthat more than 20 RBC/hpf was associated withhigher yield intravenous pyelography, Abou-Jaoudeet al12 found that using that same value missed 28%of genitourinary tract injuries or anomalies. Bothgroups of investigators believed that clinical judg-ment was valuable in determining the need forradiographic imaging.

Several studies, however, have shown that abaseline of 50 RBC/hpf can be used to determinethe need for acute radiographic imaging to evaluatefor renal injury. Morey13 found that a CT scan wasnot indicated in patients with minor abdominaltrauma if there were less than 50 RBC/hpf. Thelikelihood of significant genitourinary injuries was2% in that group of patients. Perez-Brayfield et al14

also found that a CT was indicated in children withmore than 50 RBC/hpf, who were hypotensive orhad had a significant mechanism of injury (eg, high-speed deceleration injury). Stalker and colleagues15

found a direct relationship between the severity ofrenal injury and the degree of hematuria in that thehigher the grade of injury the more RBCs that were

seen in the UA. In that same study, children withblunt abdominal trauma who were not in shock andhad less than 50 RBC/hpf did not benefit fromradiographic imaging.

HEMATOLOGYA CBC, on the whole, provides little predictive

information regarding the trauma patient. Whiteblood cell elevation is often encountered, usuallydue to the stress of the injury.3 However, there is nocorrelation between elevation and the degree ofinjury. In one study, 1% of patients had plateletcounts less than 100 000/hpf, but none requiredplatelet transfusions.1 Monitoring platelet counts inhemodynamically unstable patients, especiallythose who are receiving massive transfusions, maybe of value.

A low initial hematocrit may warn of ongoinghemorrhage from an occult bleed. Holmes et al9

found an initial value of less than 30% to be apredictor of IAI, whereas Cotton et al5 found eachunit decrease resulted in an 11% increase risk forIAI. Although a low hematocrit may imply the needfor transfusion, patients will usually have signs ofhemodynamic instability such as tachycardia orhypotension.1 One must however keep in mind thathypotension is a late sign of shock in children. Serialhematocrits may help in the monitoring of solidorgan injuries.

SERUM CHEMISTRIESLiver transaminases (aspartate aminotransferase

[AST] and alanine aminotransferase [ALT]) areoften used as a screen for liver injury. Usingrecursive partitioning retrospective analysis, Cottonet al5 found that 88% of patients with IAI werecorrectly identified when they had an AST morethan 131 U/L with a hematocrit of less than 39%(sensitivity 100% [95% CI, 90%-100%] and specificityof 87% [95% CI, 83%-91%]). An ALT of more than105 U/L had similar findings. As other solid organinjury, such as kidney and pancreas, can alsoproduce elevated transaminases, Chu et al16 foundthat a higher value, AST of more than 200 U/L orALT of more than 125 U/L, were predictors of liverinjury. Holmes et al9,17 also identified these elevatedvalues as among the “high-risk” variables used in thedecision to image children for IAI.

Keller and colleagues1 found that children withelevated transaminases were more likely to haveliver injury compared to children with normal levels(elevated vs normal: AST 12% vs 0%, ALT 17% vs 0%;P b .05). However, he determined that only levels of

TABLE 1. Laboratory charges.

CBC without differential $12.77Hematocrit $4.67Basic metabolic profile $16.70Comprehensive metabolic profile $20.86Hepatic function profile $16.12AST $10.20ALT $10.44Amylase $12.79Lipase $13.59PT $7.75PTT $11.84Urinalysis (dip) $6.25UA (automated with microbiology) $6.25

Based on midpoint values published by Centers forMedicare and Medicaid Services, revised January 2009.26

20 VOL. 11, NO. 1 • LABORATORY TESTS IN PEDIATRIC TRAUMA CARE / LINZER

more than 400 U/L were predictive of liver injury.Because these levels were associated with patientswho had other indications for imaging (eg, physicalexamination), the value did not influence thedecision for imaging studies or other interventions.

In a review of various “trauma panel” studies,Capraro et al3 did not find either the AST or ALT tobe of any value in predicting IAI or in determiningthe need for CT imaging. They found that AST had asensitivity of 63% (95% CI, 51%-74%), a negativepredictive value of 71% (95% CI, 67%-82%), and apositive predictive value of 38% (95% CI, 29%-47%).Alanine aminotransaminase fared no better with asensitivity of 52% (95% CI, 41%-64%), a negativepredictive value of 75% (95% CI, 67%-82%), and apositive predictive value of 48% (95% CI 37-60%). Inthe study by Isaacman et al,8 elevated AST and ALTlevels did not make a significant contribution inpredicting the presence of IAI or in determining theneed for imaging.

The use of serum amylase and lipase for screeningof pancreatic injury in children appears to carrylittle use. Adamson et al18 found that although thesevalues were elevated in pancreatic injury, there wasno cost-benefit in using them as screening tests todetermine the need for CT scanning. Simon et al19

found that pancreatic enzyme screening was oflimited value in the initial assessment of bluntabdominal trauma. In addition, Namias et al2 did notfind any correlation between serum amylase eleva-tion and pancreatic injury.

Serum electrolytes also contribute very little inthe evaluation of the hemodynamically stablepatient. Although transient abnormalities mayoccur, they are not usually clinically relevant anddo not impact management.2,4,8

COAGULATION STUDIESCoagulopathy has been shown to be associated

with significant head injuries20 and is a predictor ofpoor outcome.21,22 In a meta-analysis, Harhangiand colleagues23 found that 1 in 3 patients withtraumatic brain injury was at risk for developing acoagulopathy and that the presence abnormalcoagulation studies was an independent predictorof prognosis (odds ratio of mortality 9.0 [95% CI,7.3-11.6] and unfavorable outcome 36.3 [95% CI,18.7-70.7]). Keller et al24 found that children witha GCS of less than 14 after traumatic brain injuryappeared to be at the greatest risk of developing acoagulopathy (7% for a GCS of 15 vs 67% for GCS14; P b .05). Keller et al24 also found an inverserelationship between decreasing GCS and the riskof coagulopathy.

When compared to other coagulation studies(activated partial thromboplastin time [PTT],thrombin time, bleeding time, platelet count,fibrinogen, fibrin degradation products, and hemat-ocrit), Hymel et al20 found that prolongation of theprothrombin time (PT) was associated with paren-chymal brain injury. In the review by Vavilala etal,22 a fibrin degradation product of more than 1000μg/mL was associated with a poor outcome inchildren with a GCS between 7 and 12.

Holmes and colleagues25 ascertained that chil-dren with a GCS of 13 or lower had an odds ratio of8.7 (95% CI, 4.3-17.7) of having an elevatedinternational normalized ratio (INR) of 1.5 or higheror a PTT of 40 seconds or more. Keller et al24 usedPT, INR, and PTT in finding that 43% of the childrenin his review with intracranial injuries had coagu-lation abnormalities.

COSTBased on the Centers for Medicare and Medicaid

Services 2009 median for laboratory test code feeschedules (Table 1), a “traditional” trauma panelconsisting of a CBC, comprehensive metabolic profile,amylase, lipase, PT (including INR), PTT, and UA(with microscopy) would cost $84.45.26 Hematocrit,AST, and UA would cost $21.12, whereas hematocritand UA alone would cost $10.92.

SUMMARY AND RECOMMENDATIONSIn the unstable trauma patient, hematocrit, type

and cross match, PT, INR, and PTT are useful testsin managing the critically injured patient. Transa-minases, pancreatic enzymes, and UA are not

LABORATORY TESTS IN PEDIATRIC TRAUMA CARE / LINZER • VOL. 11, NO. 1 21

necessary in determining the need for a CT scanbecause imaging decisions are typically based on thephysical status of the patient. Holding blood for lateruse (eg, blood samples obtained during vascularaccess) if the CT scan shows liver or pancreaticinjury is cost-effective and does not adversely affectpatient management.27

In the hemodynamically stable child, nolaboratory tests are needed to determine theneed for radiographic imaging if there are anyphysical findings of abdominal injury, includingtenderness and contusion, or a positive FocusedAssessment by Sonography in Trauma (FAST)examination. The physical examination alone isclearly the best determinant for the need for CTimaging for IAI.5,8,28

In the child with blunt trauma to the thoraxwithout any physical findings and a negative FAST, ahematocrit and UA should be obtained. It is notunreasonable to obtain an AST or ALT in thisscenario. Imaging is indicated if the hematocrit isless than 30%, UA has 50 RBC/hpf or more, AST ismore than 200 U/L, and/or ALT is more than 125 U/L. A pregnancy test (urine or serum) should beobtained on every female patient of reproductivepotential age. Prothrombin time, INR, and PTT havedemonstrated value in monitoring patients with aGCS of less than 14.

REFERENCES1. Keller MS, Coln CE, Trimble JA, et al. The utility of routine

trauma laboratories in pediatric trauma resuscitations. Am JSurg 2004;188:671-8.

2. Namias N, McKenney MG, Martin LC. Utility of admissionchemistry and coagulation profiles in trauma patients: areappraisal of traditional practice. J Trauma 1996;41:21-5.

3. Capraro AJ, Mooney D, Waltzman ML. The use of routinelaboratory studies as screening tools in pediatric abdominaltrauma. Pediatr Emerg Care 2006;22:480-4.

4. Tasse JL, Janzen ML, Ahmed NA, et al. Screening laboratoryand radiology panels for trauma patients have low utility andare not cost effective. J Trauma 2008;65:1114-6.

5. Cotton BA, Liao JG, Burd RS. The utility of clinical andlaboratory data for predicting intraabdominal injury amongchildren. J Trauma 2005;58:1306-7.

6. Quinlan D, Gearhart J. Blunt renal trauma in childhood.Features indicating severe injury. Br J Urol 1990;66:526-31.

7. Stein J, Kaji D, Eastham J, et al. Blunt trauma in the pediatricpopulation: indications for radiographic evaluation. Urology1994;44:406-10.

8. Isaacman DJ, Scarfone RJ, Kost SI, et al. Utility of routinelaboratory testing for detecting intra-abdominal injury in thepediatric trauma patient. Pediatrics 1993;92:691-4.

9. Holmes JF, Sokolove PE, Brant WE, et al. Identification ofchildren with intra-abdominal injuries after blunt trauma.Ann Emerg Med 2002;39:500-9.

10. Taylor GA, Eichelberger MR, Potter BM. Hematuria: a markerof abdominal injury in children after blunt trauma. Ann Surg1988;208:688-93.

11. Lieu TA, Fleisher GR, Mahboubi S, et al. Hematuria andclinical findings as indicators for intravenous pyelographyin pediatric blunt renal trauma. Pediatrics 1988;82:216-22.

12. Abou-JaoudeWA, Sugarman JM, Fallat ME, et al. Indicators ofgenitourinary tract injury or anomaly in cases of pediatricblunt trauma. J Pediatr Surg 1996;31:88-90.

13. Morey AF, Bruce JE, McAninch JW. Efficacy of radiographicimaging in pediatric blunt renal trauma. J Urol 1996;156:2014-8.

14. Perez-Brayfield MR, Gatti JM, Smith EA, et al. Blunt dramatichematuria and children. Is a simplified algorithm justified. JUrol 2002;167:2543-7.

15. Stalker HP, Kaufman RA, Stedje K. The significance ofhematuria and children after blunt abdominal trauma. Am JRoentgenol 1990;154:569-71.

16. Chu FY, Lin HJ, Guo HR, et al. A reliable screening testto predict liver injury in pediatric blunt torso trauma.Eur J Trauma Emerg Surg 2009; doi:10.1007/s00068-009-9034-z.

17. Holmes JF, Mao A, Awasthi S, et al. Validation of a predictionrule for the identification of children with intra-abdominalinjuries after blunt torso trauma. Ann Emerg Med 2009;54:528-33.

18. Adamson WT, Hebra A, Thomas PB, et al. Serum amylaseand lipase alone are not cost-effective screening methodsfor pediatric pancreatic trauma. J Pediatr Surg 2003;38:354-7.

19. Simon HK, Muehlberg A, Linakis JG. Serum amylasedeterminations in pediatric patients presenting to the EDwith acute abdominal pain or trauma. Am J Emerg Med 1994;12:292-5.

20. Hymel KP, Abshire TC, Luckey DW, et al. Coagulopathyin pediatric abusive head trauma. Pediatrics 1997;99:371-5.

21. Miner ME, Kaufman HH, Graham SH, et al. Disseminatedintravascular coagulation fibrinolytic syndrome followinghead injury in children: frequency and prognostic implica-tions. J Pediatr 1982;100:687-91.

22. Vavilala MS, Dunbar PJ, Rivara FP, et al. Coagulopathypredicts poor outcome following head injury in childrenless than 16 years of age. J Neurosurg Anesth 2001;13:13-8.

23. Harhangi BS, Kompanje EJ, Leebeek FW, et al. Coagulationdisorders after traumatic brain injury. Acta Neurochir 2008;150:165-75.

24. Keller MS, Fendya DG, Weber TR. Glasgow Coma Scalepredicts coagulopathy in pediatric trauma patients. SeminPediatr Surg 2001;10:12-6.

25. Holmes JF, Goodwin HC, Land C, et al. Coagulation testing inpediatric blunt traumapatients. Pediatr EmergCare 2001;17:324-8.

26. Centers for Medicare and Medicaid Services. Medicareclinical laboratory fee schedule (09CLAB.Zip). Available at:http://www.cms.hhs.gov/ClinicalLabFeeSched/02_clinlab.asp#TopOfPage. Accessed October 12, 2009.

27. Bryant MS, Tepas JJ, Talbert JL, et al. Impact of emergencyroom laboratory studies on the ultimate triage and disposi-tion of the injured child. Am Surg 1988;54:209-11.

28. Miller D, Garza J, Tuggle D, et al. Physical examination as areliable tool to predict intra-abdominal injuries in brain-injured children. Am J Surg 2006;192:738-42.

Abstract:With the introduction of fastercomputerized tomography (CT),this radiographic modality hasbecome widely used for theevaluation of the pediatric traumapatient. There is a substantiallyincreased dose of ionizing radiationassociated with CT compared toplain radiography. Multiple studieshave demonstrated that the youngerthe patient at the time of exposure,the higher the radiation dose to theorgans. Higher organ radiation doseshave been linked with an increasedcancer risk. The indiscriminate use ofCT in the evaluation of the pediatrictrauma patient is thereforeassociated with an increased risk forcancer in this population. Thisarticle's objective is to review therelative risks and benefitsassociated with thisradiographic modality.

Keywords:CT scan; pediatric trauma;

radiation risk

Reprint requests and correspondence:Ricardo R. Jiménez, MD, PediatricEmergency Medicine Attending,University of South Florida AffiliatedFaculty, All Children's Hospital, 801 6thSt South, Saint Petersburg, FL [email protected]

1522-8401/$ - see front matter© 2010 Elsevier Inc. All rights reserved.

22 VOL. 11, NO. 1 • RADIOGRAPHIC EVALUATION AN

RadiographicEvaluation of thePediatric Trauma

Patient andIonizingRadiationExposure

D IONIZING RADIATION EXPOSUR

Ricardo R. Jiménez, MD

can them until they glow” said the surgeryattending on my first trauma case during my

overuse of computerized tomography (CT) was acceptable. Butwhat about the glow part?

Trauma is a leading cause of death in the pediatric population.A systematic detailed evaluation is necessary in the managementof the pediatric trauma patient. The goal of the traumaevaluation is the accurate and early identification of life-threatening injuries while ensuring the safety of the patient. Alarge part of the trauma evaluation is imaging, and it hasrevolutionized the way we practice medicine. The imagingevaluation can range from plain radiography of an injuredextremity to a head, neck, and/or abdominopelvic CT scan. Inthe last decade, with the invention of faster CT technology andwith the widespread availability of CT in most hospitals, therehas been a substantial increase in its use as part of the traumaevaluation. In a recent study, the use of CT increased from 12.8%

E / JIMÉNEZ

RADIOGRAPHIC EVALUATION AND IONIZING RADIATION EXPOSURE / JIMÉNEZ • VOL. 11, NO. 1 23

to 22.4% from 1995 to 2003 in the evaluation ofhead trauma.1 Furthermore, 11.2% of the CTs donein the United States were on patients 0 to 15 yearsof age.2

However, radiographic evaluation is not aninnocuous procedure and bears some risk. Diag-nostic radiography carries an exposure to ionizingradiation, ranging from fairly low doses in plainradiography to much higher doses with CT.Exposure to high levels of ionizing radiation isproven to increase the risk for cancer developmentlater in life, especially leukemia, breast cancer, andthyroid cancer. Unfortunately, children are moresusceptible to radiation effects than adults.2-5

Chernobyl and Hiroshima survivor studies havedemonstrated an increase cancer risk in thepediatric population when compared to adults.6,7

Furthermore, an association has been shown withage at the time of exposure and cancer risk; theyounger the patient at exposure, the higher therisk.8 Consider this, actively replicating cell lineswill have a higher risk of mutation; this risk isincreased by ionizing radiation. It is important to beaware that the radiation dose to an organ is energydeposited divided by mass; therefore, the greaterthe mass, the lower the dose to the organ. Now, alsoconsider that the actual dose of radiation to anorgan is affected by the distance to the radiationsource, for example, if an organ is proximal to theradiation source, the dose will be higher; as thesource rotates and the organ is now distal and ispartially shielded by body tissue, the dose to thatorgan will be lower. Because children are stillundergoing development, they carry more replicat-ing cells lines than adults, and because children areoften thinner than their adult counterparts, it iseasy to understand why they have a higher riskassociated with ionizing radiation exposure.

In the past years, the main source of this radiationwas environmental, averaging 3 mSv annuallydepending on where the person lives. The typicalsingle CT radiation exposure ranges from 1 to 14mSv.9 With the increased use of imaging studies,medical diagnostic evaluation has become a majorsource with CT accounting for 67% of the diagnosticradiation exposure.2 Computed tomography hasbecome for many the imaging study of choice inthe evaluation of the pediatric trauma patient,taking the place of plain radiography in theevaluation of head and neck injuries and peritoneallavage in the evaluation on abdominal injuries.Although other modalities such as ultrasound andmagnetic resonance imaging carry no ionizingradiation exposure, their use in the evaluation ofthe pediatric trauma patient remains unclear.

Recently, there has been increased concernregarding the association of diagnostic radiationexposure and the risk for cancer. With the increaseduse of CT in the care of children, we have to ask ifthis risk outweighs the benefits and consider short-term benefits vs long-term effects. Lastly, is it reallynecessary to scan them until they glow?

HEAD INJURY EVALUATIONTrauma is a leading cause of death in the pediatric

population, and head trauma is the most commonreason for death or disability.10 According to theCenter for Disease Control and Prevention, thereare roughly 650 000 hospital visits, 3000 deaths, and50 000 hospitalizations associated with head inju-ries.11 Most head injuries are classified as mild. Inthe absence of validated clinical criteria that canidentify with 100% sensitivity those patients withintracranial injury (ICI), the trauma physician oftenrelies on imaging studies to assess the extent of thehead injury. Initially, skull radiography was used todetect fractures after a head injury, followed with aCT if the x-ray detected a fracture. The presence ofskull fractures in a skull radiograph is one of thestronger predictors of ICI.12 Skull x-rays have asensitivity of 65% and 83% negative predictive valueand are better for detecting horizontal fractures thatthe CT can miss. Unfortunately, skull x-rays cannotdetect underlining brain injury. Head CT hasbecome the test of choice for the evaluation ofhead injury, especially since the introduction ofhelical CT, which is much faster and minimizes theneed for sedation.

Computed tomography is clearly a better tool forthe evaluation of head injury, as it detects not onlyskull fractures but also ICI. Of course, it carries ahigher level of ionizing radiation exposure and anincrease in cancer risk. In the absence of a set ofvalidated criteria that could reliably identify thosepatients with very low risk for ICI, the use of headCT has increased dramatically for the past decade.The problem lies in the overuse of CT in those headinjured patients who have a very low risk for ICI,which some studies suggest range from 40% to 60%of patients with head trauma.13-16 When comparingionizing radiation exposure associated with skull x-rays vs CT, there is a noticeable difference withdoses from plain radiographs ranging from 0.02 to10 mGy and doses from CT ranging from 5 to 20mGy.5 To put this in perspective, we shouldremember that the annual background radiationexposure in the United States averages 3 mSv andthat 1 mSv = 1 mGy.9 Therefore, radiation exposure

24 VOL. 11, NO. 1 • RADIOGRAPHIC EVALUATION AND IONIZING RADIATION EXPOSURE / JIMÉNEZ

associated with head CT is not only higher but isalso additive to background radiation.

Brenner and colleagues3,4 have estimated organdoses associated with CT use; the dose is dependenton the actual milliampere setting used in thescanner. The relationship between dose and milli-ampere is linear. When the setting used was 200mAs, the organ radiation dose to the brain from onehead CT ranged from 15 to 65 mGy; the highest dosewas associated with the youngest patients. Theorgan dose remained the same after 15 years of ageand increased directly proportional to decreasingpatient age. Conversely, in a study by Jimenez etal17 where anthropomorphic phantoms were used toquantify the organ doses after head and neck CT,the pituitary organ radiation dose in the 1-year-oldphantom was 21.25 mGy, whereas in the 5-year-oldphantom, it was 33.8 mGy. It is important torecognize that there are data supporting an increasein individual cancer risk with these dose ranges.18

Brenner3 was able to extrapolate a lifetimeattributable cancer risk associated to the organdoses from a single head CT. The attributable riskwas estimated to be highest in those younger than 2years, with a one in 2000 risk for the development ofcancer associated with a single head CT. It isimportant to understand that radiation doses arecumulative and will increase with the number ofexposures, and also, the attributable risk is afunction of the scanner setting used (in this case200 mAs). When evaluating for the pediatric traumavictim for head injury, we need to ask if thediagnostic benefits of CT imaging outweigh theradiation risk. For those children with a mechanismof injury or clinical findings indicative of a higherrisk for ICI, the answer is “yes.”

As discussed earlier, 40% to 60% of the childrenwho receive a CT as part of the head injuryevaluation are considered minor trauma, and onlyabout 10% of these children will have a positivefinding. This large discrepancy in the large number ofCTs and the small number of positive findings inchildren with minor head trauma is associated withthe lack of validated criteria that will identify patientswith a very low risk for ICI. Recent data obtained bythe Pediatric Emergency Care Applied ResearchNetwork (PECARN) presented a very promisingprediction rule for identifying children at very lowrisk of ICI. This prospective cohort study analyzedmore than 42 000 children with minor head injurydividing them in 2 groups, younger than 2 years and 2to 18 years of age. PECARN investigators used aprediction rule to identify those with very low risk forICI. For those younger than 2 years, the rule includednormal mental status, no scalp hematoma except

frontal, no loss of consciousness or loss of conscious-ness less than 5 seconds, nonsevere injury mecha-nism, no palpable skull fracture, and acting normallyas per parents. In the 2 to 18 years group, thisdecision rule included normal mental status, no lossof consciousness, no vomiting, no severe headache,nonsevere injury mechanism, and no signs of basilarskull fracture. The younger-than-2-year-old rule hada negative predictive value and sensitivity of 100%and the 2- to 18-year-old rule had a negativepredictive value of 99.95% and sensitivity of96.8%.19 This is the largest and most comprehensivestudy evaluating minor head injury. The study wasable to validate a prediction rule that would serve toidentify those children at very low risk of ICI andthose for whom a head CT may be obviated for thetrauma evaluation as the risk for ionizing radiationwill outweigh the benefits.

NECK INJURY EVALUATIONThe evaluation of the cervical spine for cervical

spine injury (CSI) is an integral part of the pediatrictrauma patient evaluation. Cervical spine injuriescan have severe deleterious effects if left untreated,from permanent neurologic defects to death. Be-cause CSIs are very hard to evaluate clinically,radiographic evaluation has been an integral part ofthe traumatic cervical spine evaluation. Conven-tional 3-view (anteroposterior, lateral, odontoid)cervical spine plain radiographs are a standard partof the neck injury evaluation. Both adult andpediatric literature supports the use of neck CT forthe evaluation of CSI as it yields a higher detectionrate and is more cost-effective.20-23 Cervical CTalone has been shown to have a sensitivity of 98% forCSIs; in contrast, conventional radiography hasbeen shown to miss up to 57% of CSIs.24,25 Keenanet al22 and Blackmore et al23 both support the use ofcervical CT for the evaluation of high-risk patients,which include altered mental status or focalneurologic deficit. An increase in the use of CTand its use without the use of plain radiography hasbeen noted in the evaluation of CSIs.19,26

The adult literature recommendations for clear-ing the cervical spine after a traumatic injury seemto agree that those patients classified as high riskshould be evaluated with a cervical spine CT. Themost common criteria used in the adult literature toclassify a patient as high risk are focal neurologicdeficit and altered mental status. A pediatricliterature review by Slack and Clancy27 suggesteda similar approach in clearing the cervical spine inchildren as that in adults. Cervical spine injuries arerare in the pediatric trauma patient. The largest

RADIOGRAPHIC EVALUATION AND IONIZING RADIATION EXPOSURE / JIMÉNEZ • VOL. 11, NO. 1 25

study evaluating CSI in the pediatric population,The National Emergency X-ray Utilization Study(NEXUS) group,28 found a CSI incidence rate of0.98% in the pediatric population compared to2.54% in adults. The difference in prevalence ofCSI between the pediatric and adult population isprobably associated with the anatomical and phys-iologic differences that exist among them. Thesedifferences are more prominent in those youngerthan 8 years but persistent in those 8 to 12years.29,30 The NEXUS decision rule has beenshown to be 100% sensitive in the detection of CSIin the pediatric population. The decision rule usedby the NEXUS group includes changes in sensorium,intoxication, focal neurologic deficits, distractioninjury, and midline cervical tenderness. With thelow incidence of CSI in the pediatric population anda decision rule that can potentially identify thosepediatric patients at lower risk, is there a need to useCT as a screening tool to clear the cervical spine andif so what is the risk?

Once again, the risk has to be measured againstthe benefits. It has already been established thatthere is a substantial increase in ionizing radiationexposure associated with CT use. Jimenez et al17

studied the amount of radiation exposure betweenplain neck radiography and neck CT using anthro-pomorphic phantoms representing a 1-year-old anda 5-year-old. This study directly collected the dosereceived by certain organs in the neck, specificallythe thyroid which is recognized as one of the mostradiosensitive organs in the body. Jimenez andcolleagues17 found that in the 1-year phantom, theradiation received to the thyroid from a CT was385 times (59.28 mGy) that from a 3-view neck x-ray, and in the 5-year phantom, the neck CTprovided a dose 164 times greater (52.3 mGy) thanthat from conventional radiography.19 Again, itappears that the younger the patient, the higherthe radiation organ dose. Interestingly enough,Jimenez et al17 also found that the organ dose tothe thyroid from a head CT was higher than that ofa 3-view conventional neck x-ray, which is concer-ning as some patients receive both a head and neckCT as part of the trauma evaluation.19 Brenner3,4

has also confirmed that the organs that receivemost of the radiation secondary to a head CT arethe brain and thyroid.

Studies about Chernobyl and Hiroshima survivorshave reported an increase in thyroid cancer in thepediatric population with a significant linear asso-ciation between radiation dose and cancer risk.6,7,31

Furthermore, Ron32 reported that the age at time ofexposure was strongly linked to the risk for thyroidcancer, with those younger than 15 years having the

strongest association.33 With the increased use ofCT for the evaluation of neck injury, it is importantto evaluate the risk for thyroid cancer later in life forthose patients who are exposed. In the study byJimenez et al,17 the excess relative risk for thyroidcancer was calculated. Those younger than 5 yearsappear to have a higher risk of developing thyroidcancer, with those younger than 1 year doublingtheir cancer risk with only one CT.19

ABDOMINAL EVALUATIONBlunt trauma accounts for 90% of childhood

injuries, and although only 10% of these injuriesinvolve the abdomen, abdominal injuries are one ofthose most commonly missed.33 The general ap-proach for the evaluation of pediatric blunt abdom-inal trauma is based upon the clinical status of thepatient. Abdominal CT is well accepted as thestandard diagnostic tool for the evaluation ofabdominal injuries. This would signify that mostchildren evaluated for intra-abdominal injuries willundergo a CT, which of course is associated withradiation exposure to the abdominal organs. Recent-ly, a prediction rule for the identification of childrenwith intra-abdominal injury has been validated; itshowed good sensitivity but was unable to identify100% of the children with intra-abdominal inju-ry.34,35 In this same study, the authors estimatedthat when these 6 “high-risk” variable predictionrules were used appropriately, it would decrease thenumber of abdominal CTs by one third.34,35

Brenner3,4 evaluated the radiation exposureassociated with an abdominal CT and found thatthe organs that were most affected were the liverand the stomach. The doses ranged between 12 and25 mGy at 200 mAs. Once again, this relation islinear and can be scaled up or down depending onthe mAs used in a specific scanner/examination.The relationship between organ radiation dose andage were again inversely proportional, putting theyoungest children at highest risk. When the esti-mated risk for developing cancer was calculated, thedigestive organs were the most affected, and thecancer risk increased as the age at exposuredecreased. The estimated lifetime risk was foundto be small, ranging from 1/2000 to 1/1000 in theyoungest patients.3,4

In the last decade, the use of focused assessmentwith sonography for trauma (FAST) by emergencyphysicians for the evaluation for abdominal traumaof the adult patient has become more accepted. Theuse of FAST has been shown to shorten the time tothe operating room in the unstable trauma pa-tient.35,36 The American College of Emergency

26 VOL. 11, NO. 1 • RADIOGRAPHIC EVALUATION AND IONIZING RADIATION EXPOSURE / JIMÉNEZ

Physician has issued guidelines that strongly en-courage the availability and use of FAST in theevaluation of the trauma patient.36,37 It is under-standable that FAST could decrease the use ofabdominal CT, reducing the organ radiation expo-sure. However, the use of FAST for the evaluation ofthe pediatric trauma patient has not been widelyaccepted, and there are no clear guidelines for itsuse in children. The reported sensitivity of FAST inthe pediatric population ranges from 31% to 100%,and it appears to perform well in the detection offree fluid in the hypotensive patient.37-39 Morestudies are needed that support the use of FAST inthe pediatric trauma patient before guidelines canbe devised for its regular implementation in thepediatric population. This is a tool that willhopefully help reduce the use of abdominal CT,thus, reducing the risk for cancer.

SUMMARYComputed tomography has become one of the

most frequently used diagnostic tools in the evalua-tion of the pediatric trauma patient. There is aninherent risk associated with ionizing radiationexposure secondary to CT use, and children aremore susceptible than adults to the development ofradiation-induced cancer. Although the risk may below and the benefits may greatly outweigh the risk incertain cases, such as those children with moresevere injuries, it is important toweigh the risk vs thebenefit for every patient. Exposing a child to aradiation dose that increases the risk for cancerwithout a proven diagnostic advantage is no longeracceptable. This practice is also contrary to ALARA(as low as reasonably achievable) that acknowledgesthat no level of diagnostic radiation is without risks.“Scan them until they glow” violates the ALARAconcept and is not an appropriate approach to theevaluation of the pediatric trauma patient.

REFERENCES1. Blackwell CD, Gorelick M, Holmes JF, et al. Pediatric head

trauma: changes in use of computed tomography in emer-gency departments in the United States over time. AnnEmerg Med 2007;49:320-4.

2. Mettler FA, Wiest PW, Locken JA, et al. CT scanning: patternsof use and dose. [see comment] J Radiation Protect 2000;20:353-9.

3. Brenner DJ. Estimating cancer risks from pediatric CT: goingfrom the qualitative to the quantitative. Pediatr Radiol 2002;32:223-8 [discussion 242-224].

4. Brenner D, Elliston C, Hall E, et al. Estimated risksof radiation-induced fatal cancer from pediatric CT.[See comment] AJR Am J Roentgenol 2001;176:289-96.

5. Health risks from exposure to low levels of ionizing radiation:BEIR VII Phase 2. Washington, DC: The National AcademicPress; 2001.

6. American Academy of Pediatrics Committee on Environ-mental Health. Risk of ionizing radiation exposure tochildren: a subject review. Pediatrics 1998;101(4 Pt 1):717-9.

7. Kazakov VS, Demidchik EP, Astakhova LN. Thyroid cancerafter Chernobyl. Nature 1992;359:21.

8. Hernandez JA, Chupik C, Swischuk LE. Cervical spinetrauma in children under 5 years: productivity of CT.Emerg Radiol 2004;10:176-8.

9. Ionization radiation exposure of the population of the UnitedStates. Report no. 93: National Council on RadiationProtection and Measurements. Bethesda (Md): NationalCouncil on Radiation Protection and Measurements; 1987.

10. National Center For Injury Prevention and Control. Trau-matic Brain Injury in the United States: a report to Congress.Atlanta (Ga): Center for Disease Control and Prevention;1999.

11. Centers for Disease Control and Prevention. 2000 NationalAmbulatory Medical Care Survey, Emergency DepartmentFile 2002. Hyattsville (Md): National Center for HealthStatistics; 2002.

12. Schutzman SA, Barnes P, Duhaime AC. Evaluation andmanagement of children younger than two years old withapparently minor head trauma: proposed guidelines. Pediat-rics 2001;107:983-93.

13. Dunnings J, Daly JP, Lomas JP, et al. Derivation of thechildren's head injury algorithm for the prediction ofimportant clinical events decision rule for head injury inchildren. Arch Dis Child 2006;91:885-91.

14. Greenes DS, Schuztman SA. Clinical indicators of intracra-nial injury in head-injured infants. Pediatrics 1999;104:861-2.

15. Palchak MJ, Holmes JF, Vance GW, et al. A decision rule foridentifying children at low risk for low brain injuries afterblunt head trauma. Ann Emerg Med 2003;43:493-506.

16. Quayle KS, Jaffe DM, Kuppermann N, et al. Diagnostic testingfor acute head injury in children: when are computedtomography and skull radiographs indicated. Pediatrics1997;99:1-8.

17. Jimenez RR, DeGuzman MA, Shiran S, et al. CT versus plainradiographs for evaluation of c-spine injury in youngchildren: do benefits outweigh risks. Pediatr Radiol 2008;38:635-44.

18. Pierce DA, Shimizu Y, Preston DL, et al. Studies of themortality of atomic bomb survivors. Report 12, part 1.Cancer: 1950-1990. Radiol Res 1996;146:1-27.

19. Kupperman N, Holmes JF, Dayan PS, et al. Identification ofchildren at very low risk of clinically-important brain injuresafter head trauma: a prospective cohort study. Lancet 2009;374:1160-70.

20. Nuñez DB, Zuluaga A, Fuentes-Bernardo DA, et al. Cervicalspine trauma: howmuch more do we learn by routinely usinghelical CT. Radiographics 1996;16:1307-18.

21. Nuñez DB, Quencer RM. The role of helical CT in theassessment of cervical spine injuries. AJR Am J Roentgenol1998;171:951-7.

22. Keenan HT, Hollingshead MC, Chung CJ, et al. Using CTof the cervical spine for early evaluation of pediatricpatients with head trauma. AJR Am J Roentgenol 2001;177:1405-9.

23. Blackmore CC, Ramsey SD, Mann FA, et al. Cervical spinescreening with CT in trauma patients: a cost-effectivenessanalysis. Radiology 1999;212:117-25.

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24. Borock EC, Sheryl GA, Lenworth MJ, et al. A prospectiveanalysis of a two-year experience using computed tomogra-phy as an adjunct for cervical spine clearance. J Trauma1991;31:1001-6.

25. Nuñez BA, Adel A. Clearing the cervical spine in multipletrauma victim: a time-effective protocol using helicalcomputed tomography. Am Soc Emerg Radiol 1994;1:273-7.

26. Shiran S, Jimenez R, Altman D, et al. Evaluation of C-spineHRCT. Pediatr Radiol 2005 [abstr].

27. Slack SE, Clancy MJ. Clearing the cervical spine of paediatrictrauma patients. Emerg Radiol J 2004;21:273-7.

28. Viccellio P, Simon H, Pressman BD, et al. A prospectivemulticenter study of cervical spine injury in children.Pediatrics 2001;108:e20.

29. d'Amato C. Pediatric spinal trauma: injuries in very youngchildren. Clin Orthop Related Res 2005:34-40.

30. Fesmire FM, Luten RC. The pediatric cervical spine:developmental anatomy and clinical aspects. J Emerg Med1989;7:133-42.

31. Sadetzki S, Chetrit A, Lubina A, et al. Risk of thyroid cancerafter childhood exposure to ionizing radiation for tineacapitis. J Cli Endocrinol Metab 2006;91:4798-804.

32. Ron E. Let's not relive the past: a review of cancer risk afterdiagnostic or therapeutic irradiation. Pediatr Radiol 2002;32:739-44.

33. Saladino RA, Lund DP. Abdominal trauma. In: Fleisher GR,Ludwig S, eds. Textbook of pediatric emergency medicine,5th ed. Philadelphia (Pa): Lippincott Williams & Wilkins;2006. p. 1453-62.

34. Holmes JF, Mao A, Awasthi S, et al. Validation of aprediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Ann EmergMed 2009;54:528-33.

35. Rozycki GS, Feliciano DV, Schmidt JA. The role of surgeon-performed ultrasound in patients with possible cardiacwounds. Ann Surg 1996;223:737-46.

36. American College of Emergency Physicians. Use of ultra-sound imaging by emergency physicians. Ann Emerg Med2001;38:470-81.

37. Ma OJ, Mateer JR. Pediatric applications. In: Price DP,Peterson MA, eds. Emergency ultrasound, 2nd ed. Columbus(Ohio): McGraw-Hill Companies; 2003. p. 464-89.

38. Mutabagani KH, Coley BD, Zumberge N. Preliminaryexperience with focused abdominal sonography for trauma(FAST) in children is it useful. J Pediatr Surg 1999;34:48-52.

39. Holmes JF, Brant WE, Bond WF. Emergency departmentultrasonography in the evaluation of hypotensive and normo-tensive children with blunt abdominal trauma. J Pediatr Surg2001;36:968-73.

Abstract:The acutely injured child poses un-ique clinical challenges in manyrespects. Our understanding of theseunique characteristic differences andability to care for pediatric traumapatients has greatly improved overrecent decades; however, one area inpediatric trauma care continues tosuffer from relative neglect in re-search and shows few signs ofimprovement in clinical practice: an-algesia. Studies of analgesia prac-tices continue to describe pervasiveundertreatment of pain in the pedia-tric trauma patient. A growing body ofevidence suggests that poorly con-trolled acute pain (oligoanalgesia) notonly causes suffering but may lead toboth immediate complications thatworsen outcomes as well as debili-tating chronic pain syndromes thatare often refractory to available treat-ments. This article will provide areview of pain in injured children withrespect to its pathophysiology, clin-ical ramifications, and patterns ofanalgesia practices. Impediments toanalgesia are examined regardingmultiple providers of care for theacutely injured child including pre-hospital personnel, nurses, and phy-sicians. Finally, the article will provideanalgesia recommendations with anapproach to pain relief and sedationfor the injured pediatric patient.

Keywords:oligoanalgesia; pain; pediatric; trauma

Pediatrics and Emergency Medicine, Em-

ory University School of Medicine, Chil-

dren’s Health care of Atlanta, Atlanta, GA.

Reprint requests and correspondence:

Michael Greenwald, MD, 1604 Clifton Rd

NE, Atlanta, GA 30322.

[email protected]

1522-8401/$ - see front matter

© 2010 Published by Elsevier Inc.

28 VOL. 11, NO. 1 • ANALGESIA FOR THE PEDIATRIC

Analgesia for thePediatric TraumaPatient: PrimumNon Nocere?

TRAUMA PATIENT / GREENWALD

Michael Greenwald, MD

from acute (normal) to chronic (maladaptive) pain with persistentor repetitive exposure to injury-provoked pain. This is true forpatients of any age; however, children appear especially vulner-able to the harmful effects of oligoanalgesia. Understanding howboth acute and chronic pain occurs may help us better controland prevent the pain responses that can cause harmful changesafter injury. A comprehensive description of pain physiology inthe pediatric trauma patients is beyond the scope of this article.Instead, we will focus on select concepts of the pain response, howthe pediatric patient's response to injury and pain are unique, andhow chronic pain syndromes are thought to occur. These pain-related issues include visceral vs somatic pain, the stressresponse, hypersensitivity vs habituation, central nervous system(CNS) plasticity, hyperalgesia, and central sensitization.

KEY CONCEPTS OF PAIN PATHOPHYSIOLOGYIN THE INJURED CHILD

Visceral vs Somatic PainSomatic and visceral pain systems have distinct physiologic and

clinical features. Cutaneous somatic innervation is more denseand limited to a few spinal segments; therefore, cutaneous somaticpain is better localized and characterized by specific sensations.Deep somatic pain (muscles, joints) resembles visceral pain in itsdull nature and poor localization. Visceral organs are innervated

ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD • VOL. 11, NO. 1 29

by 2 sets of nerves: vagal and spinal nerves or pelvicand spinal nerves. Most internal organs are inner-vated by the vagus nerve; however, its role intransmitting pain signals is not yet clear. Mostvisceral afferent fibers are thinly myelinated orunmyelinated providing a dull and difficult todescribe sensation. Visceral pain has poor localiza-tion as input is typically distributed over severalspinal segments. This leads to similar pain sensa-tions from nociceptive activity in unrelated organs(eg, urinary bladder and colon, gall bladder andheart). Visceral nerves receive convergent somaticinput (skin, muscle) resulting in referred pain tounrelated sites (eg, retrosternal pain to the neck,cardiac ischemic pain to neck, shoulder, or jaw).The stronger emotional and autonomic reactionsseen with visceral pain may reflect the involvementof the anterior cingulated gyrus, amygdala, andinsular cortex. Last, visceral nociceptor activationcan occur even in the absence of tissue damage (eg,functional abdominal pain).1,2

The Stress ResponseAcute pain results in a stress response that

manifests in physiologic, biochemical, and behav-ioral changes associated with hemodynamic insta-bility and poor wound healing. Infants areparticularly vulnerable to changes in intracranialpressures related to fluctuations in systemic vascu-lar pressures because of an immature blood brainbarrier. Autonomic responses to acute pain lead tofluctuations in heart rate and blood pressure. Theseresponses may diminish with persistent pain and areoften not a reliable marker for the presence of pain.Pain is also associated with hypoventilation thatmay lead to hypoxia. This may explain theseemingly paradoxical effect of improving respira-tory function in critically ill patients when treatingtheir pain with effective doses of opioids.3,4

Persistent or severe pain is associated withelevated levels of “stress hormones” such ascatecholamines, glucagon, growth hormone, andlactate and ketones, whereas insulin levels aresuppressed. Neonatal catecholamine and metabolicresponses are 3 to 5 times greater than those inadults undergoing similar types of surgery. One ofthe most significant clinical studies on the harmfuleffects of poorly controlled acute pain was reportedby Anand and Hickey5 in 1992. At the time thestandard of care in anesthesia held that neonateswould experience worse outcomes if provided acomparable level of anesthesia during surgery.Anand and Hickey5conducted a trial with neonatesrequiring congenital heart disease repair. The

investigators found that the control group demon-strated higher levels of stress hormones (eg,hyperglycemia, lactic acidemia), greater incidenceof sepsis and disseminated intravascular coagulo-pathy, and had a 27% mortality rate. The interven-tion (medication) group had no increase inpulmonary or circulatory complications and nodeaths. The results starkly contradicted prevailingwisdom at the time and were so remarkable thestudy was ended prematurely as it was consideredtoo risky to continue practicing the standard of care.

Finally, behavioral changes seen in patients withpoorly controlled pain include crying, agitation, andsleep disturbance. In one study, children in a burnunit were found to have posttraumatic stressdisorder symptoms inversely related to the amountof morphine administered 6 months prior at theirinitial presentation.6 Thus, many physiologic, bio-chemical, and behavioral changes associated withpoorly controlled pain are the very consequences ofinjury we hope to prevent and control to facilitatehealing and prevent harmful outcomes.

Hypersensitivity vs HabituationOne of the clinical hallmarks of a healthy adult's

response to pain is the ability to habituate. That is,with repeated or prolonged exposure to a similarstimulus, the autonomic responses tend to lessen. Incontrast, younger patients tend to demonstrate justthe opposite. This is classically found with the heelprick of a neonate. With repeated exposures, theinfant exhibits a lower pain threshold (ie, more briskflexor response) and autonomic lability.7 Similarly,older children report increased perception of pain ifpreceded by repeated painful experiences.8

On a conceptual level, the reason why infants maydiffer in a pain experience lies in the difference inunderstanding and processing the meaning of apainful experience. This is one of the most chal-lenging areas to explore; it is unlikely we will everknow how infants perceive a painful experience.Pain experiences have both physical and emotionalcomponents that affect the reaction. Our cognitivematurity allows us to attenuate the emotional andneurophysiologic response of a non–life-threateninginjury. One example is the pain from a percutaneousneedle insertion. The pain experienced from traumaassociated with a needle insertion is likely similar onan anatomical level in different aged individuals.The pain stimulates the same nociceptors, results inthe release of similar neurotransmitters, and travelson the same neural pathways to similar areas of thebrain. A healthy, mature individual should recog-nize the source of the pain as something that has a

30 VOL. 11, NO. 1 • ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD

positive purpose (to improve health) and a limitedduration and intensity. Even the adult with needlephobia will recognize that the pain experienced willdissipate and not recur without warning. Infants andto a lesser extent children lack this perspective. Thismay also help explain why the stress response to thesame pain stimulus is more brisk and intense in lessmature or adaptive individuals.7

There are several possible physiologic explana-tions for this phenomenon. One of the importantcomponents of pain physiology is modulation. Painresponses are either amplified or attenuated atthe level of the dorsal horn of the spinal cordthrough the release of excitatory and inhibitoryneurotransmitters. Less mature patients have arelative deficiency of inhibitory neurotransmittersand some inhibitory neurotransmitters, such asγ-Aminobutyric acid (GABA), have an excitatoryeffect in the premature infant.7

Another explanation lies at higher levels in aprocess known as integration. When pain signalsascend to the brain, they are distributed to multiplesupraspinal centers including the reticular activat-ing system, olivary, paraventricular, and thalamicnuclei; limbic system; cingulate and postcentralgyrus; frontal and parieto-occipital areas. At theselevels, the pain signal is integrated and processed.Pain is identified by its localization and character-istics. The information is matched with memories ofpast experiences that in turn mediate levels ofarousal, attention, and sympathetic responses. Inlaboratory studies, less mature subjects demon-strate less inhibitory pathway activation comparedto more mature subjects. It is hypothesized thatrecognition of nonharmful painful stimuli can aid inblunting the pain signal. This ability logically relatesto experiences and age and is inherently deficient inyounger patients.9

Central Nervous System PlasticityOne of the greatest concerns regarding oligoa-

nalgesia in young patients is the potential foraltering the developing CNS. The plasticity of thenervous system is now recognized in all age groupsbut is thought to have a particularly profoundimpact on young children because they haverapidly developing nervous systems. Pain research-ers have demonstrated that poorly controlled andrepetitive exposure to pain has a unique and lastingnegative impact on the CNS of young patients andthat this effect is potentially more profound withless maturity.

In laboratory studies of rat pups, the repeatedexposure to pain results in morphologic changes at

the site of injury and the dorsal horn of the spinalcolumn. These changes may be temporary or longlasting. They are seen at a variety of levels includingchanges in protein phosphorylation, altered geneexpression, loss of neurons, formation of newsynapses, and loss of inhibitory interneurons.Local tissue damage in the early postnatal periodresults in profound and lasting sprouting of sensorynerve terminals (A & C fibers) and sprouting ofneighboring dorsal root ganglia cells in the spinalcord leading to inappropriate functional connec-tions and hyperinnnervation. Clinically, thesechanges result in allodynia and other features ofneuropathic pain.10

Repetitive pain also appears to accelerate apo-ptosis. This refers to the “pruning” of unused neuralpathways. Although this is a normal phenomenonduring infancy, it appears to be accelerated inlaboratory animals subjected to repeated painfulstimuli. Finally, pain is associated with activation ofN-methyl D-aspartate (NMDA) receptors located onneurons. The receptor is activated by glutamateresulting in an influx of Ca++ and Na+ activating aCa++–calmodulin complex. This leads to productionof heat shock proteins that causes lysosomedegranulation and necrosis of the nerve cell. Theactivation of NMDA receptors is thought to contrib-ute to the development of chronic pain syndromes.Interestingly, this process is inhibited with theadministration of opioids as well as “NMDA receptorantagonists” such as ketamine, methadone, andnitrous oxide.11,12

Clinical evidence of these changes is found in theassociation of chronic conditions with exposure topainful stimuli. Anand et al13 described howfunctional abdominal pain is seen in higher ratesin former premature infants who experiencedfrequent gastric suctioning. Studies using PETscans have revealed that the anterior cingulatecortex is particularly affected by pain. This area isassociated with control of emotion and attentionand may help explain why premature infants whoexperience more medical complications exhibit ahigher rate of psychosocial disorders such asattention deficit hyperactivity disorder (ADHD)and lower academic achievement compared tomatched controls.14

Pathways to Chronic Pain: Hyperalgesia, CentralSensitization, and Sympathetically Mediated Pain

Multiple pathways are described to explain thedevelopment of chronic pain after injury. Thesemechanisms include hyperalgesia from local inflam-matory markers, sensitization of neurons proximal

ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD • VOL. 11, NO. 1 31

to and surrounding damaged nerves, and sympa-thetically mediated pain.

After an injury, inflammatory mediators are re-leased that may cause the pain response to increaseeven in the absence of additional injury. Thissensitization of nociceptors results in primary hyper-algesia at the site or injury. Primary hyperalgesiamanifests clinically as a more intense pain responsethan expected from stimuli. Secondary hyperalgesiamay develop in the area surrounding the area of injuryas a result of sensitization of neurons in the CNS. Thiscentral sensitization occurs when receptors thatnormally conduct nonpain signals (eg, touch) nowtransmit pain signals.When nonpainful stimuli such astouch result in a pain response the condition is calledallodynia. Clinical examples of this include the severeand diffuse pain associated with burns (light touch),pharyngitis (swallowing), arthritis (movement), and inmore unusual conditions such as complex regionalpain syndrome (formerly reflex sympatheticdystrophy).15

Hyperalgesia may also result from damaged orsevered nerves. Instead of a diminished pain signal,Wallerian degeneration of the severed nerve mayresult in sensitization of nociceptors in adjacentnerves (primary hyperalgesia) and increase sponta-neous activity of adjacent nociceptors resulting incentral sensitization (secondary hyperalgesia). Thisparadoxical pain response manifests in the clinicalsyndrome of neuropathic pain. Symptoms includeintense burning and electrical sensations that areoften refractory to opioids in usual doses.15

As noted above, nociceptor stimulation is oftenassociated with a resulting increase in sympatheticactivity. In some circumstances, the reactionreverses: nociceptors may develop sensitivity tocatecholamines. This is known as sympatheticallymaintained pain. In these conditions, trauma (evenseemingly trivial trauma) provokes a pain responsethat features not only hyperalgesia but also allody-nia. The classic example is complex regional painsyndrome that, in the pediatric patient, typicallyinvolves the lower extremity of school-age girls andis often associated with edema and dramaticchanges in cutaneous perfusion.15

Summary of Neurophysiologic Reponses to PainPain responses appear heightened in younger

patients whose CNS is more vulnerable to physiolog-ic stress. Repetitive and persistent pain is associatedwith morphologic changes of the nervous system atmultiple levels. Analgesics have a neuroprotectiveeffect by decreasing exhibitory neurotransmitteractivity, increasing inhibitory neurotransmitters,

and stabilizing neurons. The clinical result mayinclude a lower incidence of sepsis, metabolicacidosis, disseminated intravascular coagulopathy,and death. Given this information, it appears thatpain control is important for all patients andparticularly the youngest. Ironically, studies of ourclinical practice reflect just the opposite.

ANALGESIC PRACTICE FORPEDIATRIC TRAUMA PATIENTS

Most of the information available regarding painmanagement for pediatric trauma patients focuseson isolated injuries and burns. There are morestudies addressing pain management for adulttrauma patients than for children. In general,studies on analgesia practice in medicine over thepast several decades reveal pervasive patterns ofapparent undertreatment. In this section, we willexamine the following aspects of clinical practice.What are the patterns of analgesia for pediatricpatients? What are the patterns of analgesia fortrauma patients? What are some of the impedimentsto providing analgesia for pediatric trauma patients?

Analgesia for ChildrenThis year marks a decade since the Joint

Commission on the Accreditation of HealthcareOrganizations cited inadequate analgesia as thefirst nondisease healthcare crisis in the UnitedStates. Its response to this problem includednumerous guidelines, resources, and requirementsto assess and treat pain. Despite this effort, it isunclear whether we have seen improvement in theclinical practice of pain management for children.Pain research since the 1970s describes howchildren are given analgesics less often than adultsfor similar conditions and prescribed approximate-ly 50% of the weight-based equivalent of analge-sics.16-18 Furthermore, the milligram per kilogramdosing of analgesics is generally directly related toage, that is, younger patients receive lower milli-gram per kilogram dosing regardless of clinicalsituation.19 In 1996, Broome et al20 reported thatyounger children received inconsistent pain assess-ment and management and that institutionalstandards regarding pain control were often ig-nored. That same year, Cummings et al21 reportedon children admitted to a Canadian hospital, notingthat 21% had uncontrolled pain and that childrenwere offered analgesics less than prescribed (ie, prnmedications available but not provided).

Interestingly, some studies have shown that thosewith pediatric subspecialty training may provide less

32 VOL. 11, NO. 1 • ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD

analgesia than their generalist counterparts. In 2004,Cimpello et al22 described this in a review of morethan 700 children with fractures seen in 3 emergencydepartments (EDs) for 2 years. In this study, generalemergency physicians prescribedmore analgesics andrecommended pain treatment and advice on dis-charge more often than their pediatric emergencymedicine-trained colleagues. Quinn23 described acomparison of the use of local anesthetic for lumbarpuncture in children and found an even more strikingcontrast between those with and without pediatricsubspecialty training. In this study of childrenpresenting to different EDs in Baltimore, 93% ofchildren treated by those without pediatric trainingreceived local lidocaine before lumbar puncture,whereas only 4.5% of children presenting to thechildren's hospital ED received lidocaine. At thepediatric institution, those receiving lidocaine includ-ed 0 of 168 infants, 1 of 18 toddlers, and only 8 of 12children older than 4 years. The treating physicianswere asked whether pain was experienced to the samedegree regardless of age and 51% agreed with thisstatement.23

In addition to the patterns found in pediatricpatients, studies of other specific demographic groupshave also demonstrated patterns of oligoanalgesia.Elderly patients (N70 years old) also receive lessanalgesia in the ED.24 Analgesia research by Todd etal25 has described significant ethnic and racialdisparities in the administration of analgesia. Hispanicpatients in Los Angeles with isolated long bonefractures were twice as likely to receive no analgesiacompared to non-Hispanic white patients, and blackpatients in Atlanta were less likely to receive adequateanalgesia compared with white patients.26 Finally,patterns of sex discrimination are reported withwomen often receiving less analgesia than men.27

The reasons for these patterns of disparities aredifficult to elucidate but important to examine; theyare addressed later in this article.

Analgesia in TraumaResearch on analgesia practice for trauma

patients reveals similar patterns of undertreatment,particularly for children. Friedland et al28 com-pared analgesia provided for 215 children present-ing to Cincinnati Children's Hospital (Ohio).Children with vaso-occlusive crisis from sickle celldisease received analgesics at 100% of visits, within52 minutes (mean), with 78% therapeutic dosing(average), and with analgesia guidance given ondischarge at 100% of visits. In comparison, childrenwith fractures received analgesics at 31% of visits, at1.5 hours (mean) after presentation, with 69%

therapeutic dosing, and with analgesic advicegiven at 74% of visits. Children with burns receivedanalgesics even less often (26% of visits), with 70%therapeutic dosing, and with only 27% receivinganalgesia instructions at discharge.28 O'Donnell29

found that 49% of 172 children with musculoskel-etal injuries presenting to an ED were providedanalgesics. Another 2002 study noted only 50% ofburn victims received adequate analgesia in EDs.30

Neighbor et al31 described opioid use for severelyinjured patients in a level I trauma center over thecourse of 1 year. Of more than 500 cases, only 48%received intravenous opioids within the first 3hours with the mean time to first dose of 95minutes. Risk factors for receiving less opioidincluded younger age (b10 years old), intubation,lower revised trauma score, or not requiringfracture manipulation.31

Studies of prehospital care demonstrate 2 patterns.In general, prehospital personnel tend to undertreatpain in trauma patients; however, when analgesia isprovided by prehospital personnel, it makes asignificant difference in the time to analgesia com-pared to patients who receive their first dose ofanalgesia by hospital personnel. A 2000 report onprehospital analgesia in more than 1000 patientsshowed that only 1.5% of patients received analgesiaafter an extremity injury.32 A 2002 study on trans-ports of patients with isolated lower extremity injuriesshowed analgesic use in just 18.3% of transports.33

Several studies on the use of prehospital analgesiaprotocols for injured patients have demonstratedsafety, effectiveness, and increased use of prehospitalopioid analgesia.34-38 In a 2005 review of emergencymedical services (EMS) transports by 20 different EMSagencies in Michigan, analgesia was provided by EMSfor 22% of children having fractures or burns; however,these children received their medications 1 hoursooner than those who had to wait for a dose providedby the ED.39

Impediments to AnalgesiaEfforts to understand the causes of oligoanalgesia

have revealed a wide array of possible explanations.Influences may come from the patient, family, andsociety as well as the medical profession. For healthcare professionals, these explanations include (1)fear of masking signs of serious injury or illness, (2)fear of causing or exacerbating hemodynamic orrespiratory insufficiency, (3) inadequate pain as-sessment skills or efforts, (4) lack of understandingabout pain and analgesics, and (5) concerns aboutcreating addictive behavior by providing analgesia.

One of the purported reasons for withholdinganalgesics in the trauma patient is the belief that

ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD • VOL. 11, NO. 1 33

pain relief achieved by analgesics could masksymptoms of an underlying pathologic condition.The implication is that outcomeswill worsen due to adelay in diagnosis and progression of symptoms. Astudy of 215 physicians and nurses in 9 Israelitrauma units reported that analgesics were frequent-ly (78%) withheld to assist diagnosis.40 Most provi-ders in this study believed that analgesics should bewithheld in cases of abdominal or multisysteminjury; however, 75% reported that they had inade-quate knowledge about pain management.40

Although seemingly logical, the paradigm thatanalgesia worsens outcomes is not substantiated inthe literature. The basis for this belief may lie in partwith a classic surgical text originally authored byCope, Early Diagnosis of the Acute Abdomen. The textstates that in the setting of acute abdominal pain ofunclear etiology analgesia will (1) mask signs andsymptoms of a surgical condition causing a (2) delayin diagnosis with resulting (3) increase morbidityand mortality. Although these assertions werereplicated in subsequent editions, they do not offersupporting evidence.41 In recent years, researchershave attempted to test this assumption with respectto the patient with possible acute appendicitis. Morethan a half dozen studies have examined the use ofmorphine (typically 5-mg doses) in patients withsigns of peritonitis.42,43 None of the studies revealeda delay in diagnosis or a negative outcome attributedto the morphine. One study demonstrated improvedlocalization of tenderness.44 Kim et al45 publishedthe first pediatric study on this issue and also foundno false-negative evaluations and no complicationsattributed to opioid used for children with an acuteabdomen.

Opioid use in trauma patients has received closeexamination in the literature. The 3 primary concernsin acute pain management are altered mental status(ie, masking disorders involving the CNS or CNSperfusion), respiratory depression, and masking seri-ous injuries by blocking the pain response. Althoughexcessive dosing of opioids can certainly cause CNS orrespiratory depression, research in clinical use ofopioids in trauma patients does not support thepresumption that analgesia worsens outcomes. Budu-han et al46studied more than 500 trauma patients andfound no correlation with opioid use and missedinjuries. Lazarus et al47 reported a study of adversedrug events in more than 4000 trauma patients andfound no serious events due to opioids. Finally, severallarge studies have demonstrated safety and efficacy offentanyl used by EMS for trauma patients 48 includingone pediatric study.49

Improving pain assessment is a primary focus forreducing oligoanalgesia. Whipple et al50called atten-

tion to this issue in a 1995 study that described astriking contrast in perceptions among patients withmultisystem injury in a critical care setting. Ninety-five percent of housestaff and 81% of nurses reportedadequate analgesia provided for patients who simul-taneously rated pain moderate or severe 74% of thetime. It is logical that improved pain assessmentwould lead to improved analgesia. In a 2004prospective study of 150 adult trauma patients, 60%of those with pain scores received analgesics com-pared to 33% without pain scores. The mean time toanalgesia was 68 minutes in this study.51 However, arecent pediatric study on pain assessment failed toshow a change in analgesia administration rates andtime to analgesia with improved documentation ofpain scores.52 Barriers to analgesia likely occur atmultiple steps beginning with pain assessment andthen the response to that information.

A study of 355 ED nurses revealed deficits inunderstanding pharmacologic analgesic principlesand concepts such as addiction, tolerance, anddependence.53 Scores correlated with educationlevel and improved after a 1-day seminar. Fifty-three percent of nurses cited the potential foranalgesics to mask signs of injury or illness as abarrier to providing treatment. Forty-eight percentreported inadequate pain assessment skills.53

In a 2004 study of prehospital personnel, Henneset al54 found significant differences in the comfortlevel of EMS providers in administering analgesicsdepending on a patient's condition. Of the subjects,93% to 95% reported feeling comfortable providinganalgesics to patients with pain from fractures,burns, or nonspecific chest pain if the patient wasolder than 17 years. Much fewer respondents feltcomfortable if similar patients were 7 to 17 yearsold (chest pain, 36%; extremity injury, 70%; burn,77%) and even less if younger than 7 years (chestpain, 24%; extremity injury, 38%; burn, 44%). Inthis study, respondents cited the following asbarriers to providing analgesia to pediatric patients:inability to assess pain (87%), difficult vascularaccess (80%), delay of transport (66%), fear ofcomplication (68%), record keeping (30%), andpossible drug seeking (65%).54

Although attention to pain in the adult medicalliterature has increased exponentially in recentyears, a focus on analgesia for children and traumapatients remains sparse. Much of the research inpediatric pain centers on animal models. Majorpediatrics and pediatric emergency medicine textsstill provide relatively little attention to pain. Theadvanced trauma life support course practicallyignores the subject. In previous editions of theadvanced trauma life support provider manual, pain

TABLE 1. Pain assessment scales.

PatientDescription

RecommendedScale

ScoringRange

Infants NIPS: NeonatalInfant Pain Scale

0-21

Preschool Wong-Baker Faces Scale 0-5

School age—adolescent Visual Analog Scale 0-10

Intubated/noncommunicative Comfort Scale 8-40

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wasbriefly addressed in aparagraph that followed thesection on the secondary survey.55 The most recenteditionhasomittedeventhisbriefmention.Theindexcites just 2 pages where pain is addressed in thecurrent manual: as part of C-spine evaluation andunder musculoskeletal trauma. In the latter section,the authors' guidance states “Whenever analgesics,muscle relaxants, or sedatives are administered to aninjured patient, the potential exists for respiratoryarrest.”56 In comparison, the Emergency NursesAssociation course, Advanced Trauma Nursing:A Conceptual Approach, has an entire chapter onpain in the trauma patient.57 This contrast highlightsthe differing emphasis on pain management seen inthe nursing andmedical professions.

RECOMMENDATIONS FOR ANALGESIA INTHE PEDIATRIC TRAUMA PATIENT

The dictum “First do no harm” seems to conflictwith efforts to effectively control pain; but asexplained in the preceding pages, there is consider-able harm inflicted by allowing pain to continueunchecked. This final section will cover selectmodalities for both pain and anxiety. Althoughthere is no panacea for traumatic pain, the treatingclinician will find success with anticipation ofanalgesia needs, an understanding of both thepatient and available treatments, and an approachof titrating to effect.

Pain Management Approach for the Injured ChildWhen treating pain, physicians often tend to think

only of medications (“when you have a hammer, allthe world's a nail”), however, effective pain man-agement relies first on the skilled use of nonphar-macologic approaches. The first key intervention ispain assessment and reassessment. Just as shock isoverlooked if capillary refill, heart rate, and bloodpressure measurements are neglected, untreatedpain usually occurs because it is not recognized. Thechallenge lies not only in finding effective tools tomeasure pain but simply paying attention to pain inthe clinical setting.

Using our most validated instruments (eg, Wong-Baker Faces scale), pain assessment is generallyconsidered to be unreliable in children younger than3 years and the visual analog scale is generally notuseful in children younger than 6 years (Table 1).Furthermore, acutely injured patients may requireintubation and therefore lose the ability to vocalizediscomfort. When a patient is unable to perform apain score, the clinician is left with secondaryassessment measures. Vocalizations such as crying,

grunting, or moaning may reflect pain; however,children with painful injuries may make no soundsimply because they fear that vocalizations willprompt an injection. Heart rate and blood pressureare often elevated in acute pain; however, hemody-namic changes are not always reliable markers inpainful settings. Vagal responses to pain maydecrease heart rate, whereas some patients demon-strate a more attenuated sympathetic response,particularly when pain is prolonged.When uncertainone should ask a simple rhetorical question: Is this apainful condition/situation? If so, examine the effectof a small dose of analgesia on vital signs, muscletone, respiratory effort, and overall affect.

Just as important as “doing the right thing” iscaution not to do the “wrong thing.” Anxiety andpain are magnified in children when they feel a lossof control and lack psychosocial support. This, ofcourse, is also true for adults; the difference lies inthe ability to recognize and express these feelings.How we speak with vulnerable children can make atremendous positive or negative impact on theirexperience and reaction to the care we provide.Children may be scared by either a poor choice ofwords (“we'll give this a shot”) or language theyeither do not understand or misunderstand. Makingunrealistic promises (“this won't hurt”) or invalidat-ing feelings (“that doesn't really hurt”) only servesto undermine your relationship with the patient.Painful treatments should never be used as threatsor punishments. Take care to keep needles orneedle/syringe images out of view when possible.When possible, keep the patient close to eye leveland let them sit up whenever feasible. Last, childrenare usually very concerned about losing blood.When they see their own blood, they may benefitfrom reassurance that the amount of blood loss isnot harmful to them.

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Keys to an optimal rapport with your patientinclude honesty, clarity, and empowerment. Givethem choices wherever possible. The key is recog-nizing which patient may benefit from detailedinformation and which patient copes better withdistraction. While many children are extremelyfrightened of needles, some have worse anxietywhen they cannot see what is happening to them.Distraction is a potentially powerful interventionand generally easier to implement at younger ages.Hypnosis, an advanced form of distraction, has along track record of effective pain control in manyacute and chronic pain situations.

There is considerable evidence in the literaturethat supports family presence in the medicalsetting. Researchers have found that with clearguidelines and support, patients and family mem-bers report greater preference for family presenceeven in critical situations. Clinicians in thesestudies report no increase in adverse outcomeswhen family members are present and experts inthe field report a lower medicolegal risk whenfamily members are present at end of life settings.The key to family presence is providing skilledpersonnel such as clergy, nurses, or child lifeservices to guide the family members about wherethey should be in a trauma room and under whatcircumstances they may be asked to leave. If yourinstitution does not already have a policy describ-ing how to provide safe and effective familypresence, there are multiple resources availableto develop such a policy.58-63

The concepts listed above do not require amedical license or sophisticated understanding ofpharmacology. Rather, they require a basic under-standing of child development and a willingness andability to pay attention to verbal and nonverbal cuesof distress. When practiced and performed well theycan make the difference between an optimalsituation and one that is unmanageable.

Pharmacologic InterventionsIn a sense, all analgesics are “nerve blocks.”

Whether a pain signal is interrupted by a local orgeneralized anesthetic, systemic opioid, or effectivedistraction, each intervention works by attenuatingthe pain signal at some level. The keys to safe andeffective use of medications include an understand-ing of the characteristics of the medications and awillingness to carefully titrate to effect. This sectionis not intended to provide an exhaustive list ofavailable treatments. Attention will focus ongeneral concepts with added detail about selectand commonly available medications. A more

complete review of both pharmacologic and com-plementary approaches to analgesia is found in thereferences cited.64-66

Acute PainThe immediate goal of acute pain management

is to get pain under control and then maintainthat control. Even when the former is achieved,we often end up “chasing” the pain when weneglect to reassess and treat until the patient isagain in severe distress. This results in bothineffective analgesia and more medication admin-istered. A secondary goal in acute pain manage-ment is the prevention of chronic pain. Throughthe careful titration of medication and attention tononpainful stressors that worsen painful experi-ences, clinicians can provide safe and effectivepain control in most patients.

Opioids are usually the central therapy formanaging severe acute pain. There is considerablevariability of opioid responsiveness in some patients,and they may require significantly higher dosing.Such patients may either have differences in opioidreceptors (often a familial pattern) or a highertolerance due to chronic exposure to opioids. Ofthe numerous potential side effects of opioids, themost common are gastrointestinal dysmotility (nau-sea, pain, and constipation), sedation, and tolerance/dependence. Proactive treatment of constipation isstrongly recommended for patients receiving regulardoses of opioids.

Morphine, the “gold standard” analgesic, has arelatively slow onset of action and a half-life of 2 to 3hours. It is typically dosed as 0.05 to 0.1 mg/kg forthe opioid-naïve patient in severe pain. Subsequentdosing of 0.02 to 0.05 mg/kg should take place every10 minutes to desired level of analgesia. Althoughmorphine is perhaps the most familiar opioid, it issometimes not the ideal medication for traumapatients. Disadvantages include a slower onset,higher incidence of allergic reactions due tohistamine release, more venodilation and risk ofhypotension, and greater effects on gastrointestinalmotility than other commonly used opioids.

For the acutely injured patient whose initialevaluation is still in progress, fentanyl offers anumber of advantages. Fentanyl is metabolized inthe liver to inactive compounds; however, this is notsignificantly altered in liver disease. Onset is within5 minutes and therapeutic levels are achieved for 20to 60 minutes. Typically, the opioid-naïve patient insevere pain is safely and effectively treated with aninitial dose of 2 to 3 μg/kg of fentanyl. A continuousinfusion can sustain therapeutic levels and allow

36 VOL. 11, NO. 1 • ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD

careful titration. In addition, the literature showsgrowing interest in intranasal administration offentanyl. This offers the obvious advantage ofanalgesia without intravenous access. Some studiessuggest that a dose of 1.7 μg/kg of intranasal fentanylis equivalent to 0.1 mg/kg of morphine.67 In thisauthor's experience, a higher dose of fentanyl (2-3μg/kg) is required for mild-moderate pain. Oraltransmucosal fentanyl is another option; however,effective doses by this route are associated with highrates (25%-50%) of nausea and vomiting.68 Finally,hydromorphone offers several potential advantagesto morphine and fentanyl including fewer allergicreactions, longer duration of action, and somewhatless tolerance when used for prolonged periods.

Opioids are ideally dosed to maintain a steadystate serum concentration and avoid peaks andtroughs. Once pain control is achieved, it isimportant to anticipate the need for boluses ofanalgesia. Even small movements, turning thepatient or inadvertently bumping a chest tube orendotracheal tube can cause significant exacerba-tions of pain. The patient with a femur fracture mayappear to have good pain control when lyingmotionless but quickly loses that control whenmoved. Before moving the patient for x-rays orother reasons, consider a small (1-2 μg/kg offentanyl) bolus administered several minutes inadvance of anticipated movement. If the patientseems excessively sedated fentanyl also has theadvantage of a relatively short half-life. If opioidreversal is necessary in a stable but excessivelysedated patient physicians should begin cautiouslywith small doses of naloxone (0.001 mg/kg per dose)to avoid excessive blockade of opioid and resultingsevere pain.

Although not commonly used in the ED setting,some pediatric EDs are using patient-controlledanalgesia (PCA) for select patients (eg, sickle cellpain crisis) with good results. In general, PCArequires a patient with at least a 5-year-olddevelopmental level. Although not all patients preferthis approach, many patients achieve greatercontrol with lower doses of opioid when they haveimmediate control of their analgesia with a PCA.Typically, a basal infusion of opioid is provided witha limited number of PCA doses programmed into thePCA pump.

Nonsteroidal antiinflammatory medications suchas ibuprofen and ketorolac are potentially usefultreatments either alone for mild pain or as adjunctsfor moderate pain. Efficacy studies comparingketorolac to morphine and acetaminophen haveyielded mixed results.69,70 Given the risk of de-creased platelet function and gastritis, the role for

regular use of nonsteroidal antiinflammatory med-ications in the acutely injured patient is thereforelimited to situations where the risk for surgery is lowand pain levels are not severe.

Finally, nerve blockade at the spinal cord canprovide effective analgesia with a fraction of thedose required for systemic treatment. Long-termuse of epidural analgesia is possible and can offerappropriate candidates unique benefits. Althoughcommonly used for labor pain, cesarean delivery,and thoracic and abdominal surgery in adults, manypediatric institutions do not yet routinely use thisapproach as it requires close observation from thosetrained in this procedure.

Sedation of the Trauma PatientSedation of the pediatric trauma patient poses

unique challenges due to the risk of shock fromblood loss and CNS injury due to altered cerebralperfusion pressures secondary to intracranial swell-ing. In addition, these patients often requireanalgesia for pain. Although multiple studies haveshown that preprocedural fasting times do notcorrelate with aspiration, the clinician shouldconsider the risks of nausea and vomiting in eachsituation.71 The ideal sedatives for the necessaryprocedure in an acutely injured pediatric patientinclude the following properties: analgesia, minimalalteration in systemic and intracranial perfusionpressures, and short acting or reversible. No singleagent offers the ideal combination of benefits for allsituations; therefore, clinicians must rely on differ-ent options often with a combination of agents.Expertise in a handful of modalities is a betterinvestment than marginal familiarity with a broadarray of treatments.

Before starting sedation, one should verify thatequipment, medications, and personnel are in placeto respond effectively to a sudden decrease inventilation or oxygenation, emesis, hypotension, orseizure. Have an airway technician immediatelyavailable if your intention is to provide moderate todeep sedation. Recall that in light sedation (previ-ously conscious sedation), the patient respondsappropriately to physical and verbal stimuli. Indeep sedation, the patient is not easily aroused, mayhave partial or complete loss of protective reflexes,and loses the ability to respond purposefully tophysical or verbal stimuli. Last, anticipate when youmight stop a procedure. Take for example a childwho appears deeply sedated when untouched butscreams during a painful orthopedic procedure. Theorthopedist is focused on completing the procedure.The physician in charge of sedation should decide

ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD • VOL. 11, NO. 1 37

whether it is reasonable to attempt or complete theprocedure or defer to another setting such as theoperating room with general anesthesia.

The following strategy may be helpful in choosingoptimal sedation medications for a given scenario orprocedure. These are general recommendations,and each case requires an individual assessment bya physician trained and experienced in sedatingchildren. First, determine if the analgesia require-ment will be low (eg, laceration repair) or high (eg,reducing a fracture). Next, determine if the proce-dure is likely to be less than or greater than 5minutes. The key is to provide effective sedation andanalgesia with the least amount of medication. In allcases, local or regional anesthetic is recommendedwhere possible to limit the dose and duration ofsystemic medications. Last, strongly consider anamnestic agent (eg, benzodiazepine) as an adjunctfor frightening situations/procedures. Do not pro-ceed with a painful procedure until assured that thepatient's sedation and analgesia is adequate.

For lower analgesia requirements, fentanyl ornitrous oxide is recommended. Advantages ofnitrous oxide include its rapid onset and recoverytime and excellent anxiolysis;72 fentanyl offerssuperior analgesia. Nitrous oxide requires specificapparatus including a scavenging system and famil-iarity with administration. Contraindicationsagainst sedation with nitrous oxide include firsttrimester pregnancy, pneumothorax, chronic respi-ratory disease, bowel obstruction, CNS injury ordepression, and shock.73

For more painful procedures, it is sometimeschallenging to find a safe therapeutic window withfentanyl. In these cases, ketamine is often a goodalternative as it can provide effective analgesia andsedation without loss of spontaneous respirations.74

TABLE 2. Treatment options for proced

Analgesia Need Duration Recomm

Mild-moderate Short (b5 min) Fentanyl (IV,

Mild-moderate(eg, long laceration repair)

Long (N5 min) Fentanyl (IV,

Moderate-severe Short (b5 min) Ketamine

Moderate-severe Long (N5 min) Ketamine +

a Local or regional blocks with anesthetics are recommended whereindicates intravenous; IN, intranasal.

Ketamine tends to increase secretions and has apositive chronotropic and inotropic effect that canresult in an increase in systemic pressures. Keta-mine administration is associated with increasedintracranial pressure; however, this effect is atten-uated with benzodiazepine administration or hy-perventilation. Interestingly, one study of patientswith traumatic brain injury found a decrease inintracranial pressure in patients given ketamine andpropofol.75 In addition, ketamine often causesemesis and dysphoria upon waking (“emergencereaction”). The former is associated with higherdosing and the latter with older children andadults.11 Therefore, it is prudent to premedicatewith atropine if increased secretions pose a prob-lem, consider an antiemetic such as ondansetronand warn the family of the possibility of anemergence reaction (estimated to occur in 50% ofolder children and adults). When a procedurerequires more than 5 minutes, propofol is a usefulagent.76 Propofol can provide deep sedation withoutloss of spontaneous respirations and wears off withinminutes of discontinuation. Side effects includenegative inotropy, so special attention should bepaid to the blood pressure in patients receivingfentanyl and propofol. Propofol is typically bolusedwith a starting dose of 1 to 3 mg/kg and thenmaintained with an infusion at 5 mg/kg per hourtitrated to effect. Contraindications to propofolinclude soy or egg allergy. Alternatives to propofolinclude midazolam, etomidate, or methohexital(Table 2).

Prolonged Acute PainManaging prolonged or chronic pain is quite

different than acute pain and generally not the

ural sedation of the trauma patient. a

endation Alternatives

IN) Nitrous oxide (when anxiety N pain)

IN) + propofol Fentanyl infusion; Fentanyl + midazolam,etomidate, OR methohexital

propofol Ketamine infusion; ketamine + midazolam,etomidate, OR methohexital

possible to decrease the requirement for systemic medications. IV

38 VOL. 11, NO. 1 • ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD

responsibility of those in the emergency or acutecare setting. As a result, acute care providers aregenerally less familiar with approaches to chronicpain. Nevertheless, the acute care provider will carefor patients having prolonged or chronic pain andwill need an understanding of these issues.

Usually, patients transition from intravenous tooral opioids within days after injury or surgery. Oralopioids are sometimes necessary for 1 to 2 addi-tional weeks. When patients have difficulty weaningfrom opioids one should consider the possiblecauses and alternative treatments. Opioid tolerancetypically develops within a week of continuous useof the same opioid. Patients will exhibit a decreasingeffect of similar doses of the medication. Althoughincreased dosing can address this temporarily, it isusually more effective (ie, better analgesia with lessmedication) to switch to another opioid. Patientswith increasing needs for boluses of analgesics(breakthrough pain) should be reassessed for boththe causes of the pain and effectiveness of the painplan. Although attention to the possibility ofevolving organ damage is the priority, there areother common causes of increased opioid use in thissetting. Sleep deprivation is often an overlookedsource of poorly controlled pain.77 Anxiety maybuild with repetitive painful procedures, greaterawareness of injuries, and a sense of lack of controlover the situation.

Assuming more aggressive analgesia is not contra-indicated one may consider changing the opioid.Frequent need for a short-acting opioid shouldprompt a consideration to add a long-acting opioidsuch as methadone or long-acting formulations ofmorphine, oxycodone, or hydromorphone. Theobjective is to find an effective dose and dosingschedule that minimizes the peaks and troughs ofmedication level and pain control. Any changes intreatment strategy for patients with chronic painmust involve the advice and ongoing care of aknowledgeable physician.

Nonopioid adjuncts may have an opioid-sparingeffect and control the development of chronic pain.Unfortunately, pediatric trials for most of theseadjuncts are lacking, particularly for pediatrictrauma patients. A wide array of anticonvulsantmedications have demonstrated effectiveness forvarious chronic pain syndromes. Gabapentin'spossible effectiveness for phantom limb pain andspinal cord injury pain in addition to its relativelybenign side effect profile make it a reasonableconsideration for some trauma patients.78 Canna-boid therapy may offer some analgesia in addition toeffectiveness as an anxiolytic and antiemetic.79

Ketamine is a potent NMDA receptor antagonist

that has demonstrated effectiveness in suppressingpostsurgical central sensitization and secondaryhyperalgesia after burns. It has also been usedeffectively in the treatment of postamputationstump pain and complex regional pain syndrome.80

Tricyclic antidepressants such as amitriptyline havea long track record of effectiveness in a variety ofchronic pain syndromes. Amitriptyline's sedativeeffects may also help treat insomnia. More recentserotonin selective reuptake inhibitors have alsoshown some effectiveness.81

SUMMARYAnalgesia for the pediatric trauma patient remains

a challenging and important area of research andclinical care. The relative infrequency of cases andmultidimensional nature of injuries makes clinicalresearch daunting. Undertreatment of these patientscontinues due to a variety of influences includingexcessive fears about adverse effects of analgesics, alack of attention to pain, and underappreciation ofthe harmful effects of poorly controlled pain. Medicaleducation and training still underserves the issue ofpain in the context of patient care. Numerousnational and institutional guidelines and require-ments have modest impact as the standards of carefor analgesia are usually locally based.

Fortunately, the tools to improve care arewithin our grasp. Common pharmacologic andnonpharmacologic interventions are safe andeffective if used in a judicious manner. Analgesiaprotocols for prehospital and hospital-based carecan improve the percentages of patients treated;ultimately, the attitudes and understanding ofproviders regarding analgesia must evolve toachieve significant improvements in pain control.The emergency physician's responsibility in caringfor a patient includes effective pain relief duringtheir care and until the patient is transferred to asubsequent physician. Once we recognize that thepotential harm in “primum non nocere” lies asmuch in undertreatment as in overtreatment ofpain, children having injury will receive moreeffective analgesia.

REFERENCES1. Bielefeldt K, Gebhart GF. Visceral pain: basic mechanisms.

In: McMahon SB, Koltzenburg M, editors. Wall and Melz-back's textbook of pain. 5th ed. Philadelphia (PA): Elsevier;2006. p. 721-36.

2. Schaible H. Basic mechanisms of deep somatic pain. In:McMahon SB, Koltzenburg M, editors. Wall and Melzback'stextbook of pain. 5th ed. Philadelphia (PA): Elsevier; 2006.p. 621-31.

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3. Pasero C, Portenoy RK, McCaffery M. Opioid analgesics. In:McCaffery M, Pasero C, editors. Pain clinical manual. 2nd ed.St Louis (MO): Mosby; 1990. p. 271-2.

4. Hedderich R, Ness TJ. Analgesia for trauma and burns. CritCare Clin 1999;15:167-84.

5. Anand KJS, Phil D, Hickey P. Halothane-morphine comparedwith high dose sufentanil for anesthesia and post operativeanalgesia in neonatal cardiac surgery. N Engl J Med 1992;326:1-9.

6. Saxe G, Stoddard F, Courtney D, et al. Relationship betweenacute morphine and the course of PTSD in children withburns. J Am Acad Adolesc Psychiatr 2001;40:915-21.

7. Beggs S, Fitzgerald M. Development of peripheral and spinalnociceptive systems. In: Anand KJS, Stevens BJ, McGrath PJ,editors. Pain in neonates and infants. 3rd ed. New York (NY):Elsevier; 2007. p. 11-24.

8. Schechter NL, Zeltzer LK. Pediatric pain: new directions froma developmental perspective. J Develop Behav Pediatr 1999;20:209-10.

9. Anand KJS, Al-Chaer ED, Bhutta AT, Hall RW. Developmentof suprapinal pain processing. In: Anand KJS, Stevens BJ,McGrath PJ, editors. Pain in neonates and infants. 3rd ed.New York (NY): Elsevier; 2007. p. 25-44.

10. Woolf CJ, Salter MW. Plasticity and pain: role of the dorsalhorn. In: McMahon SB, Koltzenburg M, editors. Wall andMelzback's textbook of pain. 5th ed. Philadelphia (PA):Elsevier; 2006. p. 91-105.

11. Kohrs R, Duriex M. Ketamine: teaching an old dog new tricks.Anesth Anal 1998;87:1186-93.

12. Fitzgerald M, de Lima J. Hyperalgesia and allodynia ininfants. In: Finley GA, McGrath PJ, editors. Acute andprocedural pain in infants and children. Seattle (WA): IASPPress. 2001. p. 1-12.

13. Anand KJS, Runeson B, Jacobson B, et al. Gastric suction atbirth associated with long term risk for functional intestinaldisorders in later life. J Pediatr 2004;144:449-54.

14. Grunau RE, Tu MT. Long-term consequences of pain inhuman neonates. In: Anand KJS, Stevens BJ, McGrath PJ,editors. Pain in neonates and infants. 3th ed. New York (NY):Elsevier; 2007. p. 45-55.

15. Meyer RA, Ringkamp M, Campbell JN, Raja SN. Peripheralmechanisms of cutaneous nociception. In: McMahon SB,Koltzenburg M, editors. Wall and Melzback's textbook of pain.5th. ed. Philadelphia (PA): Elsevier; 2006. p. 3-34.

16. Schechter NL. The under-treatment of pain in children: anoverview. Pediatr Clin North Am 1989;36:781-93.

17. Selbst SM. Analgesic use in the emergency department. AnnEmerg Med 1990;19:1010-3.

18. Petrack EM, Christopher NC, Kriwinsky J. Pain managementin the emergency department: patterns of utilization.Pediatrics 1997;99:711-4.

19. Friedland LR, Kulick RM. Emergency department analgesicuse in pediatric trauma victims with fractures. Ann EmergMed 1994;23:203-7.

20. Broome ME, Richtsmeier A, Maikler V, Alexander M.Pediatric pain practices: a national survey of health profes-sionals. J Pain Symptom Manage 1996;11:312-20.

21. Cummings EA, Reid GJ, Finley GA, et al. Prevalence andsource of pain in pediatric inpatients. Pain 1996;68:25-31.

22. Cimpello L, Khine H, Avner JR. Practice patterns of pediatricvs general emergency physicians for pain management offractures in pediatric patients. Pediatr Emerg Care 2004;20:228-32.

23. Quinn M, Carraccio C, Sacchetti A. Pain, punctures, andpediatricians. Pediatr Emerg Care 1993;9:12-4.

24. Jones JS, Johnson K, McNinch M. Age as a risk factor forinadequate emergency department. Am J Emerg Med 1996;14:157-60.

25. Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factorfor inadequate emergency department analgesia. JAMA 1993;269:1537-9.

26. Todd KH, Deaton C, D'Adamo AP, Goe L. Ethnicity andanalgesic practice. Ann Emerg Med 2000;35:11-6.

27. Michael GE, Sporer KA, Youngblood GM. Women are lesslikely than men to receive prehospital analgesia for isolatedextremity injuries. Am J Emerg Med 2007;25:901-6.

28. Friedland LR, Pancioli AM, Duncan KM. Pediatric emergencydepartment analgesic practice. Pediatr Emerg Care 1997;13:103-6.

29. O'Donnell J, Ferguson LP, Beattie TF. Use of analgesia in apaediatric accident and emergency department followinglimb trauma. Eur J Emerg Med 2002;9:5-8.

30. Singer AJ, Thode HC. National analgesia prescribing patternsin emergency department patients with burns. J Burn CareRehab 2002;23:361-5.

31. Neighbor MN, Honner S, Kohn MA. Factors affectingemergency department opioid administration to severelyinjured patients. Acad Emerg Med 2004;11:1290-6.

32. White LJ, Cooper JD, Chambers RM, Gradisek RE. Prehos-pital use of analgesia for suspected extremity fractures.Prehosp Emerg Care 2000;4:205-8.

33. McEachin CC, McDermott JT, Swor R. Few emergencymedical services patients with lower extremity fracturesreceive prehospital analgesia. Prehosp Emerg Care 2002;6:406-10.

34. Curtis KM, Henriques HF, Fanciullo G, et al. A fentanyl basedpain management protocol provides early analgesia for adulttrauma patients. J Trauma Inj Infect Crit Care 2007;63:819-26.

35. Fullerton-Gleason L, Crandall C, Sklar DP. Prehospitaladministration of morphine for isolated extremity injuries:a change in protocol reduces time to medication. PrehospEmerg Care 2002;6:411-6.

36. DeVellis P, Thomas SH, Wedel SK, et al. Prehospital fentanylanalgesia in air-transported pediatric trauma patients.Pediatr Emerg Care 1998;14:321-3.

37. Thomas SH, Rago O, Harrison T, et al. Fentanyl traumaanalgesia use in medical scene transports. J Emerg Med 2005;29:179-87.

38. Frakes MA, Lord WR, Kociszewski C, et al. Efficacy offentanyl analgesia for trauma in critical care transport. Am JEmerg Med 2006;24:286-9.

39. Swor R, McEachin CM, Seguin D, et al. Prehospital painmanagement in children suffering traumatic injury. PrehospEmerg Care 2005;9:40-3.

40. Zohar Z, Eitan A, Halperin P, et al. Pain relief in major traumapatients: an Israeli perspective. J Trauma 2001;51:767-72.

41. Silen W. Cope's early diagnosis of the acute abdomen. 19thed. New York (NY): Oxford University Press; 1996.

42. Attard AR, Corlett MJ, Kidner NJ, et al. Safety of early painrelief for acute abdominal pain. BMJ 1992;305:554-6.

43. Vermulean B, Morabia A, Unger PF, et al. Acute appendicitis:influence of early pain relief on the accuracy of clinical andUS findings in the decision to operate—a randomized trial.Radiology 1999;210:639-43.

44. LoVecchio F, Oster N, Sturmann K, et al. The use ofanalgesics in patients with acute abdominal pain. J EmergMed 1997;15:775-9.

45. Kim MK, Strait RT, Sato TT, et al. A Randomized clinical trialof analgesia in children with acute abdominal pain. AcadEmerg Med 2002;9:281-7.

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46. Buduhan G, McRitchie DI. Missed injuries in patients withmultiple trauma. J Trauma 2000;49:600-5.

47. Lazarus HM, Fox J, Evans RS, et al. Adverse drug reactions intrauma patients. J Trauma 2003;54:337-43.

48. Kanowitz A, Dunn TM, Kanowitz EM, et al. Safety andeffectiveness of fentanyl administration for prehospital painmanagement. Prehosp Emerg Care 2006;10:1-7.

49. Devellis P, Thomas SH, Wedel SK, et al. Prehospital analgesiain air-transported pediatric trauma patients. Pediatr EmergCare 1998;14:321-3.

50. Whipple JK, Lewis KS, Quebbeman EJ, et al. Analysis of painmanagement in critically ill patients. Pharmocotherapy1995;15:592-9.

51. Silka PA, Roth MM, Moreno G, et al. Pain scores improveanalgesic administration patterns for trauma patients inthe emergency department. Acad Emerg Med 2004;11:264-70.

52. Kaplan CP, Sison C, Platt SL. Does a pain scale improve painassessment in the pediatric emergency department. PediatrEmerg Care 2008;24:605-8.

53. Tanabe P, Buschmann M. Emergency nurses' knowledge ofpain management principles. J Emerg Nurs 2000;26:299-305.

54. Hennes H, Kim MK, Pirrallo RG. Pre-hospital pain manage-ment: a comparison of providers' perceptions and practices.Prehosp Emerg Care 2005;9:32-9.

55. American College of Surgeons. Advanced trauma life supportstudent manual. Chicago (Ill): American College of Surgeons2004. p. 27.

56. American College of Surgeons. Advanced trauma life supportstudent manual. Chicago (Ill): American College of Surgeons2008. p. 169, 200.

57. Emergency Nurses Association. Course in advanced traumanursing: a conceptual approach. Park Ridge (Ill): TheEmergency Nurses Association; 1995. p. 253-78.

58. Rominson SM, Mackenzie-Ross S, Campbel-Hewson GL, et al.Psychological effect of witnessed resuscitation on bereavedrelatives. The Lancet 1998;352:614-7.

59. Sacchetti A, Lichenstein R, Carraccio CA, et al. Familymember presence during pediatric emergency departmentprocedures. Pediatr Emerg Care 1996;12:268-71.

60. Meers T, Eichorn D, Guzzetta C. Do families want to bepresent during CPR? A retrospective study. J Emerg Nurs1998;24:400-5.

61. Boie E, Moore G, Brummett C, et al. Do parents want to bepresent during invasive procedures performed on theirchildren in the emergency department? A survey of 400parents. Ann Emerg Med 1999;34:70-4.

62. Powers K, Rubenstein J. Family presence during invasiveprocedures in the pediatric intensive care unit: a prospectivestudy. Arch Pediatr Adolesc Med 1999;153:955-8.

63. Sacchetti A, Paston C, Carraccio C. Family members do notdisrupt care when present during invasive procedures. AcadEmerg Med 2005;12:477-9.

64. Kennedy RM, Luhman J. The “ouchless emergency depart-ment.” Advances in decreasing distress during painfulprocedures in the emergency department. Pediatr ClinNorth Am 1999;46:1215-47.

65. Zepmsky WT, Cravero JP. Relief of pain and anxiety inemergency medical systems. Pediatrics 2004;114:1348-56.

66. EMSC Grant Panel (Writing Committee) on PharmacologicAgents Used in Pediatric Sedation and Analgesia in theEmergency Department. Clinical policy: evidenced basedapproach to pharmacologic agents in the emergency depart-ment. Ann Emerg Med 2004;44:342-77.

67. Borland M, Jacob I, King B, et al. A randomized controlledtrial comparing intranasal fentanyl to intravenous morphinefor managing acute pain in the emergency department. AnnEmerg Med 2007;49:335-40.

68. Sharar SR, Bratton SL, Carrougher GJ, et al. A comparison oforal trans-mucosal fentanyl citrate and oral hydromorphonefor inpatient pediatric burn wound care analgesia. J BurnCare Rehab 1998;19:516-21.

69. Rusy LM, Houck CS, Sullivan LJ, et al. A double-blindevaluation of ketorolac tromethamine versus acetaminophenin pediatric tonsillectomy: analgesia and bleeding. AnesthAnalag 1995;80:226-9.

70. Burd RS, Tobias JD. Ketorolac for pain management afterabdominal surgical procedures in infants. S Med J 2002;95:331-3.

71. Roback MG, Bajaj L, Wathen JE, et al. Pre-procedural fastingand adverse events in procedural sedation and analgesia in apediatric emergency department: are they related. AnnEmerg Med 2004;44:454-9.

72. Luhman J, Kennedy RM, Porter FL, et al. A randomizedclinical trial of continuous flow nitrous oxide and midazolamfor sedation of young children during laceration repair. AnnEmerg Med 2001;37:20-7.

73. Clark M, Brunick A. N2O and its interaction with the body.Handbook of nitrous oxide and oxygen sedation. 2nd ed. StLouis (MO): Mosby; 2003. p. 89-98.

74. Parker RI, Mahan RA, Giugliano D. Safety of intravenousmidazolam and ketamine as sedation in therapeutic anddiagnostic procedures in children. Pediatrics 1997;99:427-31.

75. Albanese J, Arnaud S, Rey M, et al. Ketamine decreasesintracranial pressure and electroencephalographic activity intraumatic brain injury patients during propofol sedation.Anesthesia 1997;87:1328-34.

76. Gottschling S, Meyer S, Krenn T. Propofol versus midazolam/ketamine for procedural sedation in pediatric oncology. JPediatr Hematol Oncol 2005;27:471-6.

77. Lamberg L. Patients in pain need round-the-clock care. JAMA1999;281:689-90.

78. Sang C, Hayes K. Anticonvulsant medications in neuropathicpain. In: McMahon SB, Koltzenburg M, editors. Wall andMelzback's textbook of pain. 5th ed. Philadelphia (Pa):Elsevier; 2006. p. 499-506.

79. Rice ASC. Cannabinoids. In: McMahon SB, Koltzenburg M,editors. Wall and Melzback's textbook of pain. 5th ed.Philadelphia (PA): Elsevier; 2006. p. 521-40.

80. Hill RG. Analgesic drugs in development. In: McMahon SB,Koltzenburg M, editors. Wall and Melzback's textbook of pain.5th ed. Philadelphia (PA): Elsevier; 2006. p. 544.

81. Peter C, Watson N, Chipman ML, et al. Antidepressantanalgesics: a systematic review and comparative study. In:McMahon SB, Koltzenburg M, editors. Wall and Melzback'stextbook of pain. 5th ed. Philadelphia (PA): Elsevier; 2006.p. 481-97.

Abstract:The continued growth in emergencydepartment (ED) use combined withlimited inpatient bed availabilityoften leads to boarding of patientsneeding inpatient or intensive careunit admission in the ED. Emergencydepartment personnel areexperienced in the rapid assessmentof trauma patients but may be lessprepared or comfortable withproviding ongoing management oftrauma patients, especially criticallyinjured pediatric patients. Thisarticle reviews managementprinciples of traumatic brain injury,mechanical ventilation, and shock inthe pediatric trauma patient and isintended to guide ED managementof these patients until they can betransferred to an appropriate level ofinpatient care.

Keywords:pediatric critical care; traumaticbrain injury; shock; trauma;mechanical ventilation

*Division of Pediatric Critical Care,

Emory University School of Medicine,

Children’s Healthcare of Atlanta, Atlanta,

GA; †Division of Pediatric Emergency

Medicine, Emory University School of

Medicine, Children’s Healthcare of

Atlanta, Atlanta, GA.

Reprint requests and correspondence:Wendalyn K. Little, MD, MPH, PediatricEmergency Medicine, 1645 Tullie Circle,Atlanta, GA [email protected],[email protected]

1522-8401/$ - see front matter© 2010 Elsevier Inc. All rights reserved.

PROVIDING PEDIATRIC CRITICAL CARE FOR TRA

When ThereAre No InpatientBeds: ProvidingPediatric CriticalCare for TraumaPatients in theEmergencyDepartment

UMA PATIENTS IN THE ED / PETR

Toni Petrillo-Albarano, MD, FAAP*,Wendalyn K. Little, MD, MPH†

n an ideal world, the emergency department (ED) would beeasily accessed by those truly needing emergency care.

needing surgery or hospital admission would move through theED expediently to their final destination. Unfortunately, thatideal rare, exists in today's ED. More than 100 millionAmericans, 30 million of them children, present to the EDeach year.1 A persistent rise in ED visits over the last severaldecades has led to an overcrowding crisis in many communi-ties.2,3 This increase is often attributed to overuse of the ED forminor illnesses, but there is also evidence that EDs are seeingsteadily increasing numbers of patients with serious illness andinjuries. Lack of available inpatient hospital beds, particularlyintensive care unit (ICU) beds, also contributes to ED crowding

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42 VOL. 11, NO. 1 • PROVIDING PEDIATRIC CRITICAL CARE FOR TRAUMA PATIENTS IN THE ED / PETRILLO-ALBARANO AND LITTLE

and extended ED length of stay.1 Emergencydepartment physicians and staff may be challengednot only with seeing large numbers of patients, butalso with providing care for extended periods oftime to seriously ill and injured patients awaitinginpatient or ICU admission.

Although ED care providers are trained to provideinitial assessment and stabilization for acutely illand injured patients, they may be underprepared, interms of training and resources, to provide ongoingcritical care management.4 Delay in transfer ofcritically ill patients to the ICU has been associatedwith increased hospital length of stay and mortalityrates.5 In an ideal world, patients needing ICU levelcare would be quickly evaluated and transferred toan ICU. When a critically ill patient cannot beimmediately transferred to an ICU, they must beprovided with appropriate care in an ED ortransport setting, in essence bringing the ICU tothe patient. The purpose of this article is to reviewsome of the more common elements of ICU leveltrauma care that may be required in the ED ortransport setting.

TRAUMATIC BRAIN INJURYTraumatic brain injury (TBI) is a leading cause of

morbidity and mortality for pediatric patients in theUnited States, accounting for more than 400 000 EDvisits and more than 2000 deaths annually.6

Through the years, many therapies have beenproposed for the treatment of TBI; few of thesehave been studied or proven in pediatric patients. In2003, a multidisciplinary group convened a set ofguidelines7 for the management of pediatric patientswith TBI.4 A major focus of these guidelines is goodsupportive care of the critically injured patient, withparticular attention to prevention and treatment ofshock and respiratory failure. Recent literaturecontinues to support these guidelines, with agrowing body of evidence demonstrating thathypotension and hypoxia, especially if unrecognizedand untreated, are independent predictors of pooroutcome in TBI.8-11

Careful attention should be paid to the ability tomaintain an airway and adequate oxygenation andventilation in patients with TBI. Hypoxia has beenshown to negatively affect morbidity and mortalityin this group.7,10 In cases of mild to moderateisolated TBI, patients may require only supplemen-tal oxygen. If a patient's ability to maintain anadequate airway and control of ventilation iscompromised, endotracheal intubation may berequired. Ventilation should be provided to main-tain a partial pressure of carbon dioxide (PCO2)

within normal limits (35-45 mm Hg). Both hyper-and hypoventilation may be deleterious to patientswith TBI. Hypoventilation may increase cerebralblood flow, leading to increased intracranial pres-sure (ICP) if cerebral autoregulation of blood flow isimpaired by injury. Hyperventilation lowers PCO2

and causes subsequent cerebral vasoconstriction,with the potential for ischemia and secondary insultto the already injured brain. Only in cases ofpersistently elevated ICP refractory to other medi-cal management should consideration be given tomaintaining a lower level of PCO2 (30-35 mm Hg).7

Further discussion of specific ventilation strategieswill be covered later in this article.

Careful attention to volume status and perfusion isimportant in the management of TBI. Medicalpersonnel sometimes worry about giving intrave-nous (IV) fluids to TBI patients; there is a myth thatthe administration of any IV volume may worsencerebral edema. Adequate blood pressure is requiredto maintain cerebral perfusion, and ensuring ade-quate intravascular volume is important for main-taining blood pressure and perfusion to the brain andother vital organs. Cerebral perfusion pressure(CPP) can be estimated by subtracting ICP fromthe mean arterial pressure (MAP). Ideal CPP ininfants and children has not been well established,but targeting a range between 40 (infants) and 65mm Hg (adults) seems reasonable.12 A normal MAPis age dependent and can be estimated by theformula (50 + 2× age in years) for any child olderthan 1 year.13 Often, ICP monitoring is not imme-diately available in the ED. It is therefore advisable toattempt to maintain normal to slightly high MAPs inpatients with TBI. If ICPmonitoring is available, CPPshould be targeted to stay in the range of 40 to 65mmHg. Hypotension, if present, should initially betreated with fluid resuscitation. If blood pressureremains low or low-normal in the setting of persis-tently elevated ICP, vasopressor agents such asdopamine or norepinephrine may be needed tomaintain a normal to high-normal MAP and ade-quate CPP.

In addition to ensuring adequate oxygenation,ventilation, and blood pressure, a few other basicprinciples should be observed in managing TBIpatients. The patient's head should be kept midlineand elevated to 30° if possible because this promotesvenous return andmay help control ICP. One caveatto remember is that patients with TBI may haveassociated spinal injuries, and any positioning of thehead must be done while maintaining strict spinalprecautions until an injury of the spine is excluded,but slight angulation of the entire bed, if possible,may be helpful. Other management strategies in

PROVIDING PEDIATRIC CRITICAL CARE FOR TRAUMA PATIENTS IN THE ED / PETRILLO-ALBARANO AND LITTLE • VOL. 11, NO. 1 43

treating patients with TBI involve decreasing cere-bral metabolic demands to help manage the elevatedICP, which often accompanies TBI. One of thesestrategies is to maintain adequate analgesia andsedation, particularly in patients with concomitantinjuries or those requiring mechanical ventilation.Although the ability to monitor and follow a patient'sneurologic examination is important, it must bebalanced with the benefits of ensuring adequateanalgesia and sedation. In cases of persistentlyelevated ICP, consideration should be given todeeper sedation, such as pentobarbital coma andeven the use of neuromuscular paralysis.7 Maintain-ing a normal body temperature is also important inthe management of TBI. Hyperthermia may in-crease cerebral metabolic demands and lead toincreased ICP. Although some studies support theuse of mild hypothermia in the management of TBI,there is currently no strong evidence to support itsroutine use.14-16 Finally, hyperosmolar fluid therapymay be used to manage elevated ICP. Both mannitoland hypertonic saline have been shown to beeffective in this regard.16,17-19 These agents workby altering the osmotic gradient across the blood-brain barrier, in effect, pulling fluid from theedematous brain.7,12 There have been no definitivecomparison studies of the 2 agents, and the choice ofwhich to use may be based on availability orphysician preference. Hypertonic (3%) saline maybe administered in 5 to 10 mL/kg aliquots as neededuntil a serum sodium of 170 mEq/dL or a serumosmolarity of 360 mOsm has been reached.19

Mannitol should be given in 0.5 to 1 g/kg aliquotsas needed until a maximum serum osmolarity of 320mOsm is reached.12

VENTILATOR MANAGEMENTMany pediatric trauma patients may be managed

without intubation and mechanical ventilation. Intu-bationmay be required for airway protection in casesof craniofacial injury or head injury with alteredmental status, to ensure oxygenation and ventilationwith thoracic injuries, or to enable adequate sedationand analgesia and to decrease metabolic demands forpatients with severe or multisystem trauma. Al-though multiple models of mechanical ventilatorsexist, withmultiplemodalities for deliveringmechan-ical ventilation, themost important considerations inthe mechanical ventilation of pediatric patients isclose attention to initial choice of ventilator settingsand close monitoring of the patient to ensureadequate oxygenation and ventilation.

Previously healthy trauma patients withoutthoracic or lung injury should have fairly compli-

ant lungs and be able to be maintained onrelatively low ventilator settings. Initial ventilatorsettings are based on normal physiologic para-meters for a healthy child of similar weight andage. A positive end-expiratory pressure (PEEP) of 5cm is a good starting point. Many ventilators aredesigned to deliver both pressure and volume-control modes of ventilation. Either may be used,with the goal of delivering a tidal volume (TV) of 6to 8 mL/kg. Target respiratory rate varies withpatient age. Good starting points are a rate of 30for infants, 20 for children, and 16 for olderchildren and teenagers. Inspiratory time (Ti)should be set between 0.5 and 1 second to targetan inspiratory/expiratory ratio of 1:3 and allowadequate time in the exhalation phase of therespiratory cycle for carbon dioxide elimination.Using these guidelines, initial ventilator settings fora previously healthy 5-year-old patient weighing 20kg should be TV of 160 mL (8 mL/kg), PEEP of 5cm, rate of 20, and inspiratory time of 1 second.Patients undergoing mechanical ventilation shouldbe monitored with continuous pulse oximetry. Ablood gas measurement should be obtained shortlyafter instituting mechanical ventilation and the pHand PCO2 values used to gauge the effectiveness ofventilation. After this measurement, end-tidalcarbon dioxide monitoring, if available, augmentedwith periodic blood gas measurements, may beused to monitor and adjust ventilation. Capillary orvenous blood gas measurements may be adequatefor monitoring pH and PCO2 in some patients, butplacement of an arterial line may also be necessaryfor frequent blood sampling and blood pressuremonitoring in critically ill patients.

Ventilator adjustment may be required to correctdifficulties with oxygenation or ventilation. Ventila-tion difficulties require an increase in minuteventilation to remove carbon dioxide. Minuteventilation (MV) is defined as TV times respiratoryrate (MV = TV × RR) and can be changed bymanipulating either of these parameters. Tidalvolume may be adjusted by increasing the TVsetting in volume-control mode or increasing thepeak inspiratory pressure in pressure control mode.An important point to remember is that the TVdelivered to the patient may differ from that set onthe ventilator if there is a large air leak around theendotracheal tube. Another important consider-ation is the potential for secondary lung injuryfrom positive-pressure ventilation. Althoughpatients with TBI may benefit from keeping PCO2

levels in a low-normal range for ICP control, traumapatients without TBI may be managed with astrategy of “permissive hypercapnea” in which

44 VOL. 11, NO. 1 • PROVIDING PEDIATRIC CRITICAL CARE FOR TRAUMA PATIENTS IN THE ED / PETRILLO-ALBARANO AND LITTLE

PCO2 levels are allowed to remain above normal aslong as an acceptable pH level (generally consideredpH N7.2) is maintained.20

Ventilator adjustment may also be necessary toimprove oxygenation. The easiest parameter tomanipulate is the fraction of inspired oxygen(FIO2). Delivery of FIO2 greater than 60% forprolonged periods has been associated with freeradical formation and secondary lung injury. Inpatients requiring more than 60% FIO2, or in thosedifficult to oxygenate on higher levels of FIO2,consideration should be given to increasing thePEEP delivered by the ventilator. Increasing PEEPincreases the functional residual capacity of thelungs and may serve to recruit additional alveoliand improve oxygenation. However, increasingPEEP may also have the deleterious effect ofdecreasing venous return to the heart and decreas-ing systemic blood pressure. This effect can oftenbe overcome by the provision of additional intra-vascular volume in the form of isotonic fluid orblood product administration. A final ventilatoradjustment that may be considered to improveoxygenation is lengthening the inspiratory time(Ti). In doing so, care must be taken to allowadequate time in the respiratory cycle for expira-tion. Failure to do this may compromise ventilationand lead to the development of respiratory acidosisfrom carbon dioxide retention.

MANAGEMENT AND RECOGNITIONOF SHOCK

Shock is a state of inadequate delivery of oxygenand substrate to tissues. Any serious injury or illnesscan cause a state of shock if circulatory function issignificantly impaired. In compensated shock, auto-nomic reflex mechanisms are activated to maintainvital organ perfusion. These include massive cate-cholamine release, leading to increased heart rateand systemic vascular resistance. These compensa-tory mechanisms are particularly active in previ-ously healthy children and young adults and maymake early phases of shock difficult to recognize inthis population. If unrecognized and untreated,these compensatory mechanisms are overwhelmed,cellular function deteriorates, and a state of progres-sive organ dysfunction and metabolic acidosisheralds the development of uncompensated shock.Finally, terminal or irreversible shock implies organdamage to a degree that death is inevitable.21-24

Shock may be broadly categorized as hypovole-mic, distributive, cardiogenic, or obstructive. In thetrauma patient, the most common cause is hypovo-

lemic shock in which acute blood loss leads to aninadequate circulating intravascular volume. Trau-ma patients may also experience obstructive shockin which cardiac output is mechanically obstructedby tension pneumothorax or by hemopericardiumleading to pericardial tamponade. Distributiveshock, characterized by systemic vasodilation lead-ing to functional or relative hypovolemia, may beseen after spinal cord injuries and is sometimestermed spinal shock. Finally, myocardial contusionmay cause myocardial dysfunction and causecardiogenic shock.

Rapid recognition of shock, especially early orcompensated shock, is crucial to limiting morbid-ity and mortality after trauma. Careful andrepeated physical examinations may give valuableinformation as to the nature and cause of shock.The physical examination should start with anobservation of the patient's mental status andresponsiveness to the surrounding environment.Agitation, restlessness, and inability to be consoledby known caregivers may be an early sign of shockin infants and children. Even more concerning isthe quiet, withdrawn child that does not make eyecontact or respond to painful stimuli. Closeattention should next be paid to airway andbreathing. Effortless tachypnea is an early sign ofshock as the patient attempts to compensate for anincreasing metabolic acidosis through respiratoryelimination of carbon dioxide.13,21,22

The next step in the rapid assessment of patientsin shock is to evaluate the circulatory status byassessing skin perfusion, temperature, and capillaryrefill time. Healthy patients in a warm environmentshould have pink, warm skin with brisk (b2 second)capillary refill time. An early sign of hypovolemicand cardiogenic shock is the presence of cool distalextremities and prolonged capillary refill time.Conversely, patients with early distributive shockmay have flushed skin and brisk capillary refill.Heart rate and pulse quality are other importantelements of the cardiovascular assessment. Tachy-cardia is one of the earliest signs of shock and mustalso be interpreted in context to age-specific normalvalues. Hypovolemic or cardiogenic shock leads tonarrow pulse pressure and weak “thready” pulses.In contrast, patients in early distributive shock mayhave widened pulse pressure with readily palpated“bounding” pulses.18,19,21,22 Urine output is asensitive indicator of renal perfusion and shouldbe monitored closely as an indicator of intravascularvolume status. Diminished urine output may be anearly sign of intravascular volume depletion andmay progress to a state of complete anuria inpatients with severe shock.18,21-25

PROVIDING PEDIATRIC CRITICAL CARE FOR TRAUMA PATIENTS IN THE ED / PETRILLO-ALBARANO AND LITTLE • VOL. 11, NO. 1 45

Blood pressure should also be measured as part ofthe cardiovascular assessment. Many referencesdifferentiate compensated vs uncompensatedshock by the presence or absence of hypotension.Overreliance on blood pressure measurement,however, may lead to missed cases of shock. Thisis especially true in previously healthy children andyoung adults with hypovolemic shock, in whomarterial blood pressure may be normal or evenslightly elevated during early stages of shock due tostrong compensatory responses. With acute hemor-rhage, blood pressure may be maintained in anormal range until approximately 30% of thecirculating blood volume has been lost, at whichpoint uncompensated shock ensues and may prog-ress rapidly to terminal shock unresponsive totherapy.13,25 Health care providers must thereforerealize that hypotension is a late and ominous signof shock in pediatric patients, and every effortshould be made to recognize and treat shock statesbefore such decompensation occurs.13,21,22,25

Certain principles apply regardless of the etiologyof shock and should be instituted immediately for allpatients presenting with signs of shock. Attentionshould first be directed toward airway and breath-ing. All patients should be placed on supplementaloxygen, preferably by high flow, non-rebreathermask. Patients with a patent airway and spontane-ous respirations may still benefit from early intuba-tion to reduce metabolic demand and assureadequate oxygenation and ventilation, especiallyin cases of severe or decompensated shock.26-28

Establishing vascular access is another earlypriority in the management of shock. This is bestaccomplished through the placement of as large acaliber peripheral IV catheter as is possible for thepatient's size. Severely injured patients shouldideally have at least 2 functioning IVs. Themaximum rate of flow through any given catheteris proportional to the diameter and inverselyproportional to the length; therefore, short, large-caliber catheters are preferred over long centralvenous lines for initial resuscitation.24,25 When IVaccess cannot be quickly established, considerationshould be given to placing an intraosseous (IO)access device.13,25 Historically, IO access waslimited to infants and young children. Newer IOdrill devices allow this route to be used in olderchildren and adults.29,30 Fluid therapy should beinitiated immediately after access is established.Initial fluid therapy should consist of a 20 mL/kgbolus of isotonic crystalloid fluid given as quicklyas possible. If heart rate, level of consciousness,and capillary refill do not improve, a second 20 mL/kg bolus should be rapidly administered. If system-

ic perfusion does not respond to administration of40 to 60 mL/kg of crystalloid in patients withsuspected hemorrhagic shock, 10 to 15 mL/kg ofpacked red blood cells (PRBCs) should be trans-fused and repeated as needed. Type-specific cross-matched blood is preferred; however, type Onegative blood may be used in emergency circum-stances until cross-matched blood is available.Patients exhibiting signs of shock should haveemergent consultation by a trauma surgeon be-cause they may require exploration to identify andcorrect ongoing hemorrhage.13,25

Treatment of obstructive shock requires identifi-cation and specific therapy for the type of obstruc-tion. Pericardial tamponade may present withmuffled heart sounds, diminished pulses, and dis-tended neck veins. Chest radiograph and bedsideultrasound,when available,maybehelpful inmakingthe diagnosis. If time permits, pericardial drainageunder ultrasound guidance is the preferred treat-ment. Inpatientswith severe shockor cardiovascularcollapse, emergent pericardiocentesis may be lifesaving and should be performed without delay.Tension pneumothorax is a common cause ofobstructiveshockintraumapatientsandmaypresentwith hypoxia, hypotension, diminished pulses, di-minished or absent breath sounds on the affectedside, and distended neck veins and/or trachealdeviation. Chest radiographs may be helpful inmaking the diagnosis but should not delay treatmentin critically ill traumapatients. Thesepatients shouldhaveimmediatedecompressionof thepneumothoraxby placement of an over-the-needle catheter inthe second intercostal space in the midclavicularline followed by tube thoracostomy.13,24,25,31

Distributive shock may be seen in acute spinal cordinjuries when loss of systemic vascular tone creates astate of relative vascular volume depletion. Initialtreatment of distributive shock is similar to that ofhypovolemic shock. Vascular access should beobtained and crystalloid boluses of 20 mL/kg shouldbe delivered until systemic perfusion improves. Ifsystemic perfusion does not improve after 2 to 3 suchboluses and occult hemorrhage has been excluded,vasoactive medications such as dopamine or norepi-nephrine may be needed. The α-adrenergic propertiesof these medications cause systemic vasoconstrictionand may improve perfusion in cases of distributiveshock. These infusions are ideally given through acentral venous catheter because extravasation maycause significant tissue necrosis.

Ongoing management of trauma patients involvesfrequent reassessment to gauge the adequacy ofresuscitation and to recognize any need for furtherintervention. Some patients may respond to initial

46 VOL. 11, NO. 1 • PROVIDING PEDIATRIC CRITICAL CARE FOR TRAUMA PATIENTS IN THE ED / PETRILLO-ALBARANO AND LITTLE

volume resuscitation with improvement of tachy-cardia, capillary refill, or blood pressure, only toreturn to an unstable shock state if they areexperiencing ongoing hemorrhage. The often men-tioned “lethal triad” of trauma refers to thedevelopment of hypothermia, metabolic acidosis,and coagulopathy that may develop in seriouslyinjured patients. Pediatric patients are particularlysusceptible to hypothermia given their relativelylarger surface to body mass ratio, as compared withadults. Warming measures such as heated blankets,removal of wet clothing and bedding, and warminglights should be instituted and body temperatureclosely monitored. Serial measures of serum hemo-globin and hematocrit may aid in recognizingongoing hemorrhage and identifying patients need-ing emergent surgical intervention. Patients requir-ing massive or ongoing volume resuscitation maydevelop coagulopathy from consumption and dilu-tion of clotting factors. This may manifest externallyas mucosal bleeding or oozing from skin sites suchas needlesticks and cutaneous wounds. Thesepatients may require transfusion of fresh frozenplasma and platelets in addition to PRBCs. Tradi-tionally, trauma patients were transfused withPRBCs alone until coagulopathy became manifestas either excessive bleeding or abnormalities inlaboratory values for platelet levels, prothrombintime, and activated partial thromboplastin time.Recent literature suggests that patients requiringmassive transfusion, usually defined as more than10 U of PRBCs for adult patients, should receivecloser to a 1:1:1 ratio of red blood cells, plasma, andplatelets.32-34 Evidence-based pediatric guidelinesfor massive transfusion have not been well estab-lished, but it seems prudent to provide plasma andplatelet replenishment in addition to PRBCs to anypatient requiring massive transfusion.

SUMMARY AND RECOMMENDATIONSOptimal early intervention has been shown to

improve patient outcomes in many medical condi-tions including trauma.28 Unfortunately, EDs areoften overcrowded and understaffed, and inpatientand intensive care beds are often in short or limitedsupply. As a consequence, increasing numbers ofcritically ill patients are boarded in EDs whileawaiting inpatient bed availability.2,3,5,31

Seriously injured pediatric trauma patients mustbe carefully monitored and frequently assessed,whether in the ED, the radiology department, thepediatric ICU, or in-transit between locations.Careful attention must be paid to the airway,breathing, and adequacy of oxygenation and venti-

lation. Caregivers should be comfortable with bag-mask ventilation, tracheal intubation, and evenventilator management for patients who may re-main in the ED awaiting an ICU bed or transfer to atertiary care center.

All patients should have adequate vascular access.Often, IV access can be difficult to obtain in infantsand small children. Equipment for intraosseousaccess should be readily available and caregiversfamiliar with their use. Central venous catheterplacement may also be needed, especially inpatients requiring vasopressor infusion or adminis-tration of multiple medications. The most common-ly used site for central line insertion in pediatricpatients is the femoral vein. This site is often chosendue to relative ease of access and because place-ment does not require removal of the cervical collarin trauma patients or interfere with airway manip-ulation. However, in patients with intra-abdominalhemorrhage, a femoral line may not be the bestchoice; in these patients, a subclavian line may be amore optimal choice.

Patients must be carefully monitored for thesubtle early signs of shock and every effort madeto reverse shock before compensatory mechanismsare overwhelmed. Placement of an arterial line maybe helpful for both blood pressure monitoring andfrequent laboratory draws; especially in smallchildren in whom central access is not established.Placement should be considered for any patient whois on vasopressors, has an ICP monitor in place, orhas persistent hypotension or other signs of clinicalinstability. If an appropriately sized arterial line kitis not available, a 24- or 22-gauge catheter may beplaced in the radial, dorsalis pedis, or posterior tibialartery. A single-lumen, 3 French, 5- or 8-cm-longcentral venous catheter may also be placed in thefemoral artery of infants or children.

Maintaining airway, breathing, and circulation arealways top priorities in the management of traumapatients. Control of pain and anxiety is anotherimportant component of trauma care that may beoverlooked in the critically injured pediatric patient.Small doses of opiates and/or benzodiazepines maybe given and repeated as needed, with constantmonitoring for the depression of level of conscious-ness, respiratory drive, and blood pressure that mayoccur with these medications. If the child isintubated, ensuring adequate sedation is paramountto maintaining control of the airway. Inadequatesedation may lead to a host of secondary issues fromairway edema to aspiration and may increase ICP inpatients with TBI. Intubated patients may benefitfrom continuous low-dose infusions of narcotics and/or benzodiazepines to maintain adequate levels of

PROVIDING PEDIATRIC CRITICAL CARE FOR TRAUMA PATIENTS IN THE ED / PETRILLO-ALBARANO AND LITTLE • VOL. 11, NO. 1 47

sedation. On occasion, it may also be necessary touse neuromuscular blocking agents (paralytics) toassist ventilation or control ICP. These medicationsmay be given as either intermittent doses orcontinuous infusions. It is vitally important tomaintain adequate sedation in patients receivingneuromuscular blockade. Close monitoring of bloodpressure and heart rate, especially changes inresponse to positioning, suctioning, or other noxiousstimuli, may provide valuable information about thepatient's level of sedation.

While awaiting transfer to an appropriate ICUsetting, every effort should be made to “bring theICU to the patient” by providing close monitoring,frequent reassessment, and rapid correction ofproblems as they arise. Emergency departmentpersonnel should also keep in mind that consulta-tion with colleagues in critical care medicine oranesthesia is often available to help guide patientmanagement, even if an ICU bed is not physicallyavailable for a critically injured patient.

REFERENCES1. American Academy of Pediatrics Committee on Pediatric

Emergency Medicine. Overcrowding crisis in our nation'semergency departments: is our safety net unraveling?Pediatrics 2004;144:878-88.

2. Richardson LD, BR Asplin BR, Lowe RA. Emergencycrowding as health policy issue: past development, futuredirection. Ann Emerg Med 2002;40:388-93.

3. Derlet R, Richards J, Kravitz F. Frequent overcrowding inU.S. emergency departments. Acad Emerg Med 2001;8:151-5.

4. Cowan RM, Treciak S. Clinical review: emergency depart-ment overcrowding and the impact on the critically ill. CritCare 2005;9:291-5.

5. Chalfin DB, Trzeciak S, Likourezos A, et al. Impact of delayedtransfer of critically ill patients from the emergency departmentto the intensive care unit. Crit Care Med 2007;35:1477-83.

6. Curry R, Hollingworth W, Ellbogen RG, et al. Incidence ofhypo- and hypercarbia in severe traumatic brain injurybefore and after 2003 pediatric guidelines. Pediatr Crit CareMed 2008;9:141-6.

7. Carney NA, Chestnut R, Kochanek P, et al. Guidelines for theacute medical management of severe traumatic brain injuryin infants, children, and adolescents. Pediatr Crit Care Med2003;4(Suppl):S1-S75.

8. Pigula FA, Wald SL, Shackfor SR, et al. The effect ofhypotension and hypoxemia on children with severe headinjury. J Pediatr Surg 1993;28:310-4.

9. Coates BM, Vavilala MS, Mack CD, et al. Influence ofdefinition and location of hypotension on outcome followingsevere pediatric traumatic brain injury. Crit Care Med 2005;33:2645-50.

10. Michaud LJ, Rivara FP, Grady MS, et al. Predictors of survivaland disability after severe brain injury in children. Neuro-surgery 1992;31:254-64.

11. Ong L, Selladurai BM, Dhillon MK, et al. The prognostic valueof the Glascow coma scale, hypoxia, and computerizedtomography in outcome prediction of pediatric head injury.Pediatr Neurosurg 1996;24:285-90.

12. Mansfield RT. Severe traumatic brain injuries in children.Clin Pediatr Emerg Med 2007;8:156-64.

13. American Heart Association. Pediatric advanced life supportprovider manual. Dallas (Tex): American Heart Association;2002.

14. Marion DW, Obrisr DW, Carlier PM, et al. The use of moderatetherapeutic hypothermia for patients with severe head injuries:a preliminary report. J Neurosurg 1993;79:354-62.

15. Biswas AK, Bruce DA, Sklar FH, et al. Treatment ofacute traumatic brain injury with moderate hypothermiaimproves intracranial hypertension. Crit Care Med 2002;30:2742-51.

16. Shiozaki T, Hisashi S, Taneda M, et al. Effect of mildhypothermia on uncontrollable intracranial hypertensionafter severe head injury. J Neurosurg 1993;79:363-8.

17. Muizelaar JP, Lutz HA, Becker DP. Effect of mannitol on ICPand CBP and correlation with pressure autoregulation inseveral head injured patients. J Neurosurg 1984;61:700-6.

18. Khanna S, Davis D, Peterson B, et al. Use of hypertonic salinesolutions in the treatment of cerebral edema and intracranialhypertension. Crit Care Med 2000;28:1144-51.

19. Qureshi AI, Suarez JI. Use of hypertonic saline solutions inthe treatment of cerebral edema and intracranial hyperten-sion. Crit Care Med 2000;28:3301-13.

20. Nathens AB, Johnson JL, Minei JP, et al. Guidelines formechanical ventilation of the trauma patient. J Trauma 2005;59:764-76.

21. McConnell MS, Perkin RM. Shock states. In: Zimmerman JJ,Furman BP, editors. Pediatric critical care. St Louis (Mo):Mosby; 1998. p. 293-306.

22. Vanore M, Perks D. Early recognition and treatment of shockin the pediatric patient. J Trauma Nurs 2006;13:18-21.

23. Hameed SM, Aird WC, Cohn SM. Oxygen delivery. Crit CareMed 2003;31:S658-67.

24. Cheatham ML, Block EJ, Smith HG, et al. Shock: an overview.In: Rippe JM, IrwinRS, editors. Irwin andRippe's intensive caremedicine. Philadelphia (Pa): Wolters Kluwar; 2007. p. 1831.

25. American College of Surgeons. Advanced trauma life supportfor doctors. 7th ed. Chicago (Ill): American College ofSurgeons; 2004.

26. Maar SP. Emergency care in pediatric septic shock. PediatrEmerg Care 2004;20:617-24.

27. Welch SB, Nadel S. Treatment of meningococcal infection.Arch Dis Child 2003;88:608-14.

28. Parker MM, Hazelzet JA, Carcillo JA. Pediatric considera-tions. Crit Care Med 2004;32:S591-594.

29. Buck MI, Wiggins BS, Sesler JM. Intraosseous drug adminis-tration in children and adults during cardiopulmonaryresuscitation. Ann Pharmacother 2007;41:1679-86.

30. Blumberg SM, Gorn M, Crain EF. Intraosseous infusion: areview of methods and novel devices. Pediatr Emerg Care2008;24:50-9.

31. Gregory JC, Marcin JP. Golden hours wasted: the human costof intensive care unit and emergency inefficiency. Crit CareMed 2007;35:1614-5.

32. Hess JR, Lawson JH. The coagulopathy of trauma versusdisseminated intravascular coagulation. J Trauma 2006;60:S12-9.

33. Borgman MA, Spinella PC, Perkins JG, et al. The ratio ofblood products transfused affects mortality in patientsreceiving massive transfusions at a combat support hospital.J Trauma 2007;63:805-13.

34. Ketchum L, Hess JR, Hiippala S. Indications for early freshfrozen plasma, cryoprecipitate, and platelet transfusion intrauma. J Trauma 2006;60:S51-8.

Abstract:Most pediatric trauma patients arecared for in non-children's hospitalsby providers without pediatric speci-alty training and in facilities that maynot be used to caring for children.Children have different physiologicand psychologic responses to injurythan adults. Children have differentservice and evaluative needs.Several studies have shown thatpediatric trauma patients haveimproved outcomes with lowermortality, fewer operations, andimproved function when cared for inpediatric facilities or adult traumacenters with pediatric expertise.Differences between injured adultsand injured children need to beunderstood, recognized, and actedupon by care providers to optimizetreatment for injured children.Limitations in the availability ofpediatric specialists require that allhospitals be prepared to effectivelyand successfully treat pediatrictrauma patients.

Keywords:pediatric trauma; injured children;trauma systems; outcomes

Reprint requests and correspondence:Kimberly P. Stone, MD, MS, MA,Department of Pediatrics, Division ofEmergency Medicine, Seattle Children'sHospital, 4800 Sand Point Way NE, M/SB-5520, Seattle, WA [email protected],[email protected]

1522-8401/$ - see front matter© 2010 Elsevier Inc. All rights reserved.

48 VOL. 11, NO. 1 • PEDIATRIC PATIENTS IN THE AD

Pediatric Patientsin the AdultTrauma Bay—Comfort Leveland Challenges

ULT TRAUMA BAY / STONE AND W

Kimberly P. Stone, MD, MS, MA,George A. Woodward, MD, MBA

hildren represent almost 20% of all emergencydepartment (ED) visits in the United States.1 In

injury.2 Of these 13.5 million visits, only 23% of childrenwill be treated by a pediatric emergency physician and only7% of pediatric patients will be treated in a separatepediatric ED.3

Despite not having a pediatric ED or inpatient pediatricresources, 76% of hospitals will admit children to their ownfacilities.2 A recent review of hospital discharges for injuredchildren identified that 15% of injured children were dischargedfrom hospitals with low pediatric trauma experience and lowoverall pediatric experience. Of those 15% of injured children, 6%had injury severity scores of 9 or higher indicating moderate tosevere injury.4 Almost half of all pediatric trauma-relateddischarges in the review by Segui-Gomez and colleagues5 werefrom nontrauma centers, even in states with pediatric traumadesignation systems in place.

Despite the recent proliferation of pediatric emergencymedicine specialists, most injured children are treated byproviders without pediatric specialty training and in facilitiesthat may not be used to caring for children.2,6-8 Tremendousvariability exists across the country with some geographic areashaving availability of pediatric EDs and pediatric trauma services,whereas other areas still do not. Emergency departments, both

OODWARD

PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD • VOL. 11, NO. 1 49

within trauma centers and nontrauma centers, needto be prepared to care for injured children.2,8 Thisarticle will discuss pediatric-specific challenges thatface all providers and review the literature regardinghow injured pediatric patients fare when cared for inthe non–pediatric-specific trauma system.

CHALLENGES POSED BY THE PEDIATRICTRAUMA PATIENT

By now everyone has heard the phrase, “childrenare not little adults.” However, how they differ andwhy it matters, especially as it pertains to trauma, isnot necessarily universally appreciated. Childrenhave different physiologic and psychologicresponses to injury. Children have different serviceand evaluative needs. These differences need to beunderstood, recognized, and acted upon by treatingproviders to provide optimal treatment.

Assessment of the Child and Recognition of InjuryThe first step in any treatment algorithm is the

skilled assessment of the patient. The assessment ofthe injured child is inherently different than that ofan adult. Pediatric patients may be nonverbal ordevelopmentally incapable of communicating theirnonapparent injuries to health care providers.Providers will need to use nonverbal cues in youngchildren to assess pain and injury sites. Pediatrictrauma patients (and their parents) will often bescared and anxious; this anxiety may affect vitalsigns and limit the overall assessment. Assessmentof vital signs requires knowledge of age-based normsand confounders that may not be as familiar tononpediatric providers. Rapid identification of earlysigns of shock both by vital signs and physicalexamination are crucial for optimal resuscitation ofseriously injured children.

Anatomical and Physiologic DifferencesAchild's body size andhabitus affect how traumatic

energy forces are absorbed and distributed. Knowl-edge of anatomical differences can lead to patternrecognition and aid in timely diagnosis of injuries. Athorough review of the anatomical differences inchildren is beyond the scope of this article, but a fewimportant variations are highlighted here:

• A child's body size is smaller and hasproportionally less body fat leading to energyforces being more widely dispersed thatresults in multiple injuries and potentiallyless visibility on physical examination.

• A child's airway is more anteriorly located andeasily obstructed by poor positioning. Theability to successfully manage a child's airwayrequires specific advanced airway skill.

• A child's proportionally larger tongue cancause upper airway obstruction.

• Children have large heads, especially ascompared to the remainder of their bodysize. Young children “lead with their head”during falls resulting in more head injuries.

• The expandable skull in young children(b1 year) with open fontanelles provides spaceto accommodate a large intracranial bleed. Ascompared to adults and older children, youngchildren can present with or develop hemor-rhagic shock from closed head trauma.

• Children have a higher fulcrum in the neckresulting in higher spinal cord injuries (aboveC4) in younger children. These injuries maynot be as obvious on x-rays due to the largeamount of cartilage present, but the effectscan be devastating.

• Laxity of the vertebral column along with thecartilage artifacts can result in spinal cordinjury without radiographic abnormality(SCIWORA).

• A child's chest wall is pliable, allowing moreinternal force with little to no external signs ofinjury. Children have fewer rib fractures, flailchest, and more pulmonary contusions. Car-diovascular injuries can be initially silent andchallenging to diagnose.

• Abdominal organs in children are less wellprotected by the bony rib cage allowing formore solid organ injury. The infant liver andspleen are palpable below the costal margin.The kidneys are also more vulnerable sec-ondary to decreased abdominal musculature.

• A child's growing bones result in vulnerablegrowth plates leading to a high incidence ofgrowth plate fractures.

• Children have proportionally larger skinsurface area allowing them to more easilybecome hypothermic with resultant acidosis.

• Children have an overall smaller total bloodvolume that increases the risk for rapid onsetof shock. They also have the ability toincrease their heart rate and stroke volumeto temporize for acute volume loss. Vitalsigns, and particularly blood pressure, maynot indicate the true level of volume loss inthese children.

These anatomical and physiologic differencesmay be less familiar to medical providers without

50 VOL. 11, NO. 1 • PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD

pediatric training or significant ongoing experiencein caring for children but are vital to be recognizedby anyone caring for a pediatric trauma patient.

EquipmentChildren come in different ages and sizes, and

therefore, the equipment needed to treat them (andsometimes the skills required) also need to come indifferent sizes. Several recent studies have identifiedthat few nonpediatric hospitals are fully equippedwith all the necessary equipment to handle pediatricemergencies.1 In its review of the emergency caresystem for children, the Institute of Medicine notedthat only 6% of EDs in the United States had all thesupplies deemed essential by the American Acade-my of Pediatrics andAmericanCollege of EmergencyPhysicians to handle pediatric emergencies. Onlyhalf of the hospitals had at least 85% of the essentialequipment.6 A similar study in Canada also foundessential pediatric equipment unavailable in most ofCanadian EDs.9 The materials most likely to bemissing are equipment and supplies needed forneonates and young infants. A 2003 survey of EDsby Gausche-Hill and colleagues10 found similarlevels of readiness compared to published guidelines.Children's hospitals were predictably the bestprepared, though hospitals with inpatient pediatriccare resources and larger pediatric patient EDvolumes were typically better prepared. Regardlessof hospital size, the presence of a physician and/ornurse coordinator for pediatric emergency care waspredictive of a higher level of preparedness.10

A recently updated reference for recommendedequipment (as well as other resources) for all EDscaring for pediatric patients can be found in the 2009joint American Academy of Pediatrics, AmericanCollege of Emergency Physicians, and EmergencyNurses Association policy statement, Guidelines forCare of Children in the Emergency Department.1

Any ED caring for pediatric trauma patients shouldmake it a priority to have the appropriate range andspectrum of equipment outlined.

Medications and ErrorsJust as the equipment size needs to be scaled

down to child proportions, so too do the medicationdosages. The need for weight-based dosing and lackof standardized dosing for children leads to in-creased medication errors in children as comparedto adults.11,12 Medication errors in children are mostassociated with intravenous fluids,11 and pain andsedative medications,13 medications frequentlyused in pediatric trauma patients. Providers notroutinely administering medications to children

may be less familiar with the subtleties of weight-based dosing and the complex calculations that maybe required. Providers caring for pediatric traumapatients should seek to improve hospital-widesystems to decrease pediatric medication errors aspart of a comprehensive pediatric patient safetyprogram.11 Establishing a weight in kilograms for allpediatric patients and the use of precalculatedweight-based dosing tools will assist in the reductionof medication errors for all pediatric patients.12

Evaluation ToolsThe diagnostic tools used to evaluate intraabdom-

inal injuries in pediatric trauma patients differ fromthose used for adult trauma patients. For pediatrictrauma patients, abdominal computed tomography(CT) remains the standard for evaluating suspectedabdominal injury in the hemodynamically stablechild.14-17 The accepted standard for a hemody-namically unstable child, however, remains inevolution with decreasing use of diagnostic perito-neal lavage (DPL), increasing use of focused abdom-inal sonography for trauma (FAST), and continuedreliance on initial and serial physical examinations.

In hemodynamically unstable adults, DPLremains a tool used to determine intraperitonealhemorrhage or a ruptured hollow viscus.18,19

However, DPL is now rarely used or recommendedin children because of its invasive nature andunacceptably high rate of nontherapeutic laparot-omy.14,16,17 In addition, because most solid organinjuries are managed nonoperatively, the presenceof blood may not determine therapeutic interven-tions. DPL in pediatric trauma patients should bereserved for critically ill children with concerningCT findings, in whom initial and serial physicalexamination is unreliable and for whom laparoto-my poses substantial risk14 and for patients whorequire immediate surgical interventions for non-abdominal issues where a subtle or latent injurycould prove problematic.

In the adult trauma population, FAST examina-tions have been well studied and are now routinelyused to identify hemoperitoneum in unstablepatients.16,20,21 Studies on FAST examinations inpediatric trauma populations have been mixed withhigh specificity (as high as 95%-100%)16,22 but widerranges of sensitivity (from 30% to 100%).16,20,22 TheFAST examinations have the distinct advantage ofbeing a bedside tool that can rapidly identifyhemopericardium and hemoperitoneum in an un-stable trauma patient. However, children have ahigher incidence of solid organ injury without freefluid making a negative FAST examination less

PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD • VOL. 11, NO. 1 51

predictive in this population. More recent studieshave found FAST examinations, when combinedwith laboratory assessments23 or physical examina-tion,24 have higher sensitivity and accuracy inpediatric trauma patients. Many adult traumacenters that rely on FAST examinations in theiradult trauma also use the FAST examination fortheir pediatric trauma patients.25 Providers need tounderstand the limitations of the FAST examinationin children to appropriately interpret the results andprovide optimal direction and care to pediatricblunt trauma patients.

The history, initial examination, and serialphysical examination of the pediatric traumapatient remain the cornerstone of diagnosis. Al-though children have classically been consideredunreliable with regard to physical examinationfindings, more recent studies have found that theinitial and subsequent physical examinations willmost often identify those pediatric trauma patientsrequiring operative intervention for their intraab-dominal organs.26-28 Familiarity and comfort withexamining pediatric patients and interpreting pedi-atric vital signs, combined with an understanding ofinjury mechanisms, is fundamental to relying onand trusting the physical examination as part of thediagnostic evaluation of a pediatric trauma patient.

Radiation ExposureTrauma evaluations often include diagnostic radio-

logic evaluation. Pediatric trauma patients requireadditional consideration regarding the total radiationdose when deciding upon radiologic assessment.Potential future risks of accumulated radiation areunknown and disproportionately affect youngerpediatric patients who have a longer lifespan duringwhich radiation-related cancers could evolve.29

One review of pediatric trauma patients admittedto a level I trauma center found that 78% of patientsunderwent at least one radiologic examination. In thisstudy, CT scans accounted for 97.5% of the totaleffective radiation dose experienced by these chil-dren.30 The recent concern about potential radiationrisk from CT scans led to a scientific review by Riceand colleagues.31 According to their review, there is apotential increased risk of cancer from low-levelradiation (such as with CT); the calculated risk maybe as high as 1 fatal cancer for every 1000 CT scansperformed in a young child.31 Appropriate decision-making regarding use of CT scan evaluation requiresan understanding of the traumatic event and risk forinjury, an awareness of the radiation risk, theavailability of alternate means of radiologic assess-ment (eg, ultrasound and magnetic resonance imag-

ing where appropriate), and competency withongoing clinical assessment of the pediatric traumapatient. Although one should not withhold criticaldiagnostic imaging for children with potentiallyserious injuries, consideration of radiation risksshould be included in protocol development.32 Therecently published decision rule by the PediatricEmergency Care Applied Research Network(PECARN) for the evaluation of pediatric head traumais a good example of an evidence-based decision-support tool that when used appropriately can limitunnecessary radiation exposure.33

When CT scans are indicated in the evaluation ofa pediatric trauma patient, steps should be taken tominimize the radiation exposure. The ALARA(as low as reasonably achievable) concept is aphilosophy of radiation dose management that isbeing promoted by the Society for PediatricRadiology32 and the National Cancer Institute34

and has been embraced by numerous professionalorganizations and many pediatric care facilities. Afirst step in reducing radiation exposure is todecrease the radiation setting for pediatric CTscans. Children will receive a higher dose than isnecessary for image quality when adult CT settingsare used. Radiation settings can be adjusted forpediatric size yet maintain reliability of the study.Radiologists and all care providers treating pediat-ric trauma patients need to be aware of theprinciples of ALARA and work toward minimizingradiation exposure.29,32,34

Nonaccidental TraumaChild abuse remains a leading cause of death and

morbidity, especially among young children. In2005, 353 children younger than 4 years died as aresult of injuries sustained from an assault, makingit the fourth leading national cause of mortality inthis age group.35 Far more children have seriousinjuries, as a result of their abuse, with an estimated1.3% to 15% of pediatric injuries resulting in EDvisits caused by abuse.36

Several factors can influence the identification ofpatients who have injuries from suspected childabuse. The diagnosis of child abuse is often missedon initial medical visits due to erroneous histories,variable physical examinations, and psychosocialissues.37 Identification and reporting of suspectedchild abuse is linked with provider education aboutchild abuse.38,39 Pediatric residency programs havebeen found to provide more training and resourcesfor child abuse education than general emergencymedicine and family medicine programs.40 Inaddition, nonchildren's hospitals have been found

52 VOL. 11, NO. 1 • PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD

to less frequently identify victims of potential childabuse.41 Providers caring for pediatric traumapatients must be diligent in considering childabuse in their differential diagnosis and be awareof injuries and patterns that are concerning forinflicted injury, including unexplained apnea, inju-ries with suspicious etiologies, or incidents blamedon unlikely perpetrators.

Family-Centered CareIn 2006, the American Academy of Pediatrics and

the American College of Emergency Physicianspublished a joint policy statement calling forpatient- and family-centered care when providingcare to children in EDs.42 Patient- and family-centered care recognizes the integral role of thefamily when treating an ill or injured child andencourages mutually beneficial collaboration amongthe patient, family, and providers.42

Although including families in the care of childrenhas long been understood and appreciated bypediatricians, this concept is relatively new intrauma, specifically with regard to trauma resuscita-tions. A survey of trauma surgeons' attitude towardfamily presence during trauma resuscitation foundthat although 38% of respondents knew about thepush toward family presence during trauma resus-citation, only 50% would ever allow their presence.43

Of those respondents who would allow familypresence, only 8% would permit it during the entireresuscitation.43 These results are similar to thosefound by Helmer et al44 who surveyed members ofthe Emergency Nurses Association (ENA) andAmerican Association for the Surgery of Trauma(AAST) regarding their opinions on family presenceduring trauma resuscitations. Almost 98% of AASTmembers felt that family presence during all phasesof trauma resuscitation was inappropriate, andmany believed that family presence interferedwith patient care and increased stress of traumateam members.44

Several recent studies of family presence duringpediatric trauma resuscitations disprove theseattitudes. Both O'Connell et al45 and Dudley et al46

performed prospective studies of family presenceduring pediatric trauma resuscitations and foundlittle to no negative impact on the care provided topediatric patients. O'Connell and colleagues45 foundmedical decision making, institution of care, teamcommunication, and communication to the familyto be the same or even easier with family presence.Dudley and Hansen46 found no clinically relevantdifference in time to CT or resuscitation time withand without family presence. In their study, families

felt that their presence was helpful to both them-selves and their child.

Family involvement is a crucial element in pro-viding well-rounded, sensitive care to injured chil-dren. Providers caring for injured children need tobe well-versed in pediatric and family-centered careand seek to improve communication. Involvement offamily members of pediatric patients will serve toimprove care quality and promote patient safety.12

Environment and InteractionsHospitals and EDs, in particular, can be fear-

provoking entities for any young child. The inherentanxiety with a chaotic, loud ED may be furthercompounded for an injured child by being strappedto a backboard, surrounded by strangers, separatedfrom caregivers, and subjected to painful evalua-tions and interventions. Pediatric EDs and chil-dren's hospitals are acutely aware of theenvironment's impact on a child's psychologicstress. Walk into any children's hospital and yousee the muted lighting, open spaces, and child-friendly artwork all geared toward making childrenand their parents feel more comfortable.

In addition to child-friendly environments, in-jured children need age-appropriate interaction andattention. Children reflect the emotions of theadults and caregivers around them. Care providersneed to be cognizant of their own potential stressand/or highly charged emotions when interactingwith pediatric trauma patients. Pediatric traumapatients and their families need calm reassuranceand positive attitudes. When appropriate, providerscaring for injured children need to create environ-ments and interactions that reduce a patient's fearand stress. Soft lights and quiet, calm providers andenvironments should be the rule.

Psychologic Impact on ChildrenPediatric trauma patients may suffer conse-

quences beyond what is visible from their physicalinjuries. Posttraumatic stress disorder (PTSD) ishigh among children who sustain even mild ormoderate traumatic injury. In their longitudinalstudy of pediatric trauma patients and PTSD,Schreier and colleagues47 found that 69% of thepatients they interviewed between the ages of 7 and17 had at least mild symptoms of PTSD immediatelyafter a traumatic injury. The presence of PTSDsymptoms was still present in 38% of the cohort 18months after the initial injury. Care providers forpediatric trauma patients need to be aware of thesehigh rates of PTSD symptoms after even mild andmoderate injury. Systems need to be in place to

PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD • VOL. 11, NO. 1 53

identify those children at risk and assist withmanaging the symptoms.

Learning OpportunitiesThe ability to stay current with pediatric trauma

patient evaluation and treatment requires a commit-ment to ongoing education and opportunities to learnnew skills and practice routine ones. Pediatrictrauma centers make this commitment with theirfocus on the assessment and treatment of pediatrictrauma patients. Because of their higher pediatricvolumes, providers in pediatric trauma centers areable to maintain their skills. In a survey of EDs byGausche-Hill and colleagues,10 50% of respondinghospitals provide care for less than 6 pediatricpatients per day in the ED. The median volume ofpediatric patients cared for by all respondents was3700 patients per year, with less than 25% ofresponding EDs caring for more than 7000 patientsper year. With relatively few pediatric patients seen,providers in those EDsmay simply not have adequateongoing exposure to critically ill or injured childrento maintain their assessment and resuscitationskills. With limited exposure, there is an evengreater need for additional ongoing learning andskill maintenance experiences, such as with medicalsimulation, case reviews, and other educationalsessions. Unfortunately, continuing education inpediatric resuscitation is infrequently required ofED staff in nonpediatric trauma centers and adulthospitals (i.e., general hospitals or nonpediatrichospitals).6 Such ongoing pediatric education isimportant not only for physicians but also for non-physician providers (nurses, medical assistants,support staff), who may be called upon to care forpediatric trauma patients.

In addition, trauma centers caring for childrenneed to learn from the pediatric patients they carefor with pediatric-specific quality improvementactivities. Pediatric trauma centers are required tohave processes in place to critically review pediatricmortality, morbidity, and functional outcome. Allproviders caring for injured children should imple-ment such programs to improve performance andpatient safety.1,8,48

Injury PreventionA discussion of pediatric trauma would not be

complete without mentioning the important role ofprevention. Injury prevention programs have beenproven to be effective in reducing childhoodinjuries,8,49 and numerous prevention recommen-dations are available through the American Acade-my of Pediatrics, Committee on Injury and Poison

Prevention.50 Despite widespread knowledge of theimportance of injury prevention, most pediatrictrauma remains preventable. In a recent review,Joffe and Lalani51 identified that 77% of uninten-tional injuries sustained by children in a pediatricintensive care unit were from a mechanism that hada proven strategy to reduce significant injury andwas therefore, preventable.

Medical providers involved in the care of pediatrictrauma patients have an opportunity and obligationto contribute to injury prevention through datacollection that seeks to understand the causes ofinjuries and by participation in educational andcommunity injury-prevention activities.8

EXPERIENCE AND OUTCOMESSeveral studies and comprehensive reviews have

attempted to answer the question “Do pediatrictrauma patients treated at pediatric hospitals oradult hospitals with pediatric specialty experiencehave better outcomes than those treated at adulthospitals?” Although no comprehensive study ofpediatric trauma centers vs adult trauma centers orpediatric hospital vs adult hospitals has yet beenperformed, there are individual studies, as below, thatbegin to address portions of this complicated question.

Mortality of Pediatric Trauma PatientsTwo separate studies using large databases have

found that injured children treated by pediatricspecialists, especially younger and more severelyinjured children, have improved mortality as com-pared to those treated by adult specialists.7,52

Densmore and colleagues7 used the 2000 Kids'Inpatient Database to review more than 79,000cases of pediatric injury treated at children'shospitals and adult hospitals. They found that 89%of injured children in this database were treatedoutside children's hospitals. Importantly, in-hospitalmortality, length of stay, and hospital charges wereall higher in the adult hospitals, even after control-ling for injury severity scores. The Kids' InpatientDatabase does not include trauma hospital designa-tion so additional information based on traumadesignation is not available.

The findings of Densmore and colleagues com-plement the findings in a 2000 study by Potoka andcolleagues.52 They retrospectively analyzed morethan 13,000 injured children from the Pennsylva-nia Trauma Outcome Study database to comparemortality data across trauma-designated hospitals.In their study, injured children who were treated ata pediatric trauma center or an adult trauma

54 VOL. 11, NO. 1 • PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD

center with added qualifications to treat childrenhad lower mortality rates (11.9% and 12.4%,respectively) as compared to level I and level IIadult trauma centers (21.6% and 16.2%, respec-tively). Similarly, more severely injured childrenhad the best overall outcomes when treated at apediatric trauma center.52

Blunt Trauma PatientsAn estimated 90% of trauma in pediatric patients

is blunt trauma.14,17,20,52 Less than 5% of allpediatric trauma patients with blunt abdominaltrauma require operative intervention.53 Severalstudies looking at the outcome of this large subset ofinjured children have identified improved outcomesand increased likelihood of successful nonoperativetreatment when children are treated by pediatricspecialists or at a pediatric trauma center.54-57

In a review at one Chicago pediatric traumacenter, Hall et al54 reviewed almost 1800 records ofinjured children and compared patient outcomes forthis institution to outcomes reported in the MajorTrauma Outcomes Study. Most children in thissample had blunt trauma (75%) and had improvedsurvival rates and increased successful nonopera-tive treatment of blunt abdominal injuries.

Splenectomy rates after spleen injuries have beenwell studied as a process of care measure forpediatric trauma patients. Several independentstudies have identified that injured children withblunt spleen injury are more likely to be managedsuccessfully in a nonoperative fashion when treatedby pediatric surgeons,56 pediatric specialists,55 or ina pediatric trauma center.54,57 This affects acutemanagement as well as potential lifetime morbidity.

Functional OutcomesA few studies have begun tomove beyondmortality

outcomes and evaluate functional outcomes inpediatric trauma patients. One such study, usingdata from the Pennsylvania Trauma Outcome Study,found that children treated in pediatric traumacenters had improved functional outcomes, as dem-onstrated by decreased dependence on feeding,locomotion, or transfer devices, when comparedwith injured children treated at adult trauma centerswith additional qualifications for treating childrenand adult trauma centers without the added qualifica-tions.58 Certainly, more studies evaluating quality oflife and functional outcomes are needed.

The improved outcomes of injured children whentreated by pediatric specialists should come as nosurprise. Pediatric trauma patients are different from

adult trauma patients. Access to pediatric specialtycare in the form of pediatric emergency medicinephysicians, pediatric surgeons, pediatric anesthesiol-ogists, pediatric critical care specialists, pediatricnurses, child life specialists, pediatric rehabilitationspecialists, and pediatric social workers is critical inthe assessment, stabilization, treatment, and rehabil-itation of pediatric trauma patients.8

The findings described above also mirror similarfindings in other fields. A recent study comparing thesurvival rates and morbidity of pediatric patientstransported between facilities by pediatric criticalcare specialized teams vs nonspecialized teamsidentified increased mortality and more unplannedevents among patients transported with nonspecia-lized teams, regardless of the severity of illness.59 Theauthors in this study hypothesized that limitedpediatric critical care experience, limited pediatricprocedural experience, and lack of ongoing continu-ing education in pediatric critical care contributed tothe differences between nonspecialized and special-ized teams.59 It is reasonable to assume that thesesame conclusions can be applied to adult hospitalswith limited pediatric exposure and few, if any,requirements for ongoing pediatric education.

IMPROVING QUALITY OF CARE TOPEDIATRIC TRAUMA PATIENTS

Pediatric trauma centers should be used whenev-er feasible for pediatric trauma patients. However,because of geographic limitations, nonpediatrictrauma centers may need to provide the initialcare to injured children.2,8 Standardized coursessuch as Pediatric Advanced Life Support (PALS),Advanced Pediatric Life Support (APLS), andAdvanced Trauma Life Support (ATLS) will expandnonpediatric providers' assessment, managementskills, and comfort with pediatric patients. Non-pediatric trauma centers should partner with local/regional pediatric specialists and identify physicianand nurse coordinators for pediatric emergencymedicine to create pediatric-specific trauma proto-cols and pediatric provider resources where need-ed.8 Ongoing educational activities focused onpediatric-specific trauma care should be providedto all members of the trauma team.8,48 Measurableimprovements in quality and outcomes are foundwhen nonpediatric trauma centers make a commit-ment to pediatric excellence.60

SUMMARYTrauma remains the leading cause of mortality in

children. Most injured children are treated in adult

PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD • VOL. 11, NO. 1 55

hospitals and adult trauma centers. Although notconclusive, several studies have identified thatinjured children have improved outcomes, withlower mortality, fewer operations, and improvedfunction, when treated by pediatric specialists.However, limitations in the availability of pediatrictrauma centers and pediatric specialists require thatall hospitals be prepared to effectively and success-fully treat pediatric patients.

REFERENCES1. Gausche-Hill M, Krug SE, American Academy of Pediatrics,

Committee on Pediatric Emergency Medicine, AmericanCollege of Emergency Physicians, Pediatric Committee,Emergency Nurses Association, Pediatric Committee. Guide-lines for care of children in the emergency department.Pediatrics 2009;124:1233-43.

2. American Academy of Pediatrics, Committee on PediatricEmergency Medicine and College of Emergency Physicians,Pediatric Committee, Care of Children in the EmergencyDepartment. Guidelines for Preparedness. Pediatrics 2001;107:777-81.

3. Prentiss KA, Vinci R. Children in emergency departments: whoshould provide their care? Arch Dis Child 2009;94:573-6.

4. Guice KS, Cassidy LD, Oldham KT. Traumatic injury andchildren: a national assessment. J Trauma 2007;63:S68-80.

5. Segui-Gomez M, Change DC, Paidas CN, et al. Pediatrictrauma care: an overview of pediatric trauma systems andtheir practices in 18 US states. J Pediatr Surg 2003;38:1162-9.

6. Institute of Medicine, Committee on the Future of EmergencyCare in the US Health System, Emergency Care for Children.Growing pains. Washington, DC: National Academies Press;2006.

7. Densmore JC, Lim HJ, Oldham KT, et al. Outcomes anddelivery of care in pediatric injury. J Pediatr Surg 2006;41:92-8.

8. Tuggle D, Krug SE, American Academy of Pediatrics, Sectionon Orthopaedics, Section on Critical Care, Section onSurgery, Section on Transport Medicine, Committee onPediatricEmergencyMedicine, PediatricOrthopaedicSocietyofNorthAmerica.Management of pediatric trauma. Pediatrics2008;121:849-54.

9. McGillivray D, Nijssen-Jordan C, Kramer MS, et al. Criticalpediatric equipment availability in Canadian hospital emer-gency departments. Ann Emerg Med 2001;37:371-6.

10. Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric preparednessof US emergency departments: a 2003 survey. Pediatrics2007;120:1229-37.

11. American Academy of Pediatrics, Committee on Drugs andCommittee on Hospital Care. Prevention of medication errorsin the pediatric inpatient setting. Pediatrics 2003;112:431-6.

12. Frush K, Krug S, American Academy of Pediatrics Committeeon Pediatric Emergency Medicine. Patient safety in thepediatric emergency care setting. Pediatrics 2007;120:1367-75.

13. Tzimenatos L, Bond GR, Pediatric Therapeutic Error StudyGroup. Severe injury or death in young children fromtherapeutic errors: a summary of 238 cases from theAmerican Academy of Poison Control Centers. Clin Toxicol2009;47:348-54.

14. Bruny JL, Bensard DD. Hollow viscus injury in the pediatricpatient. Semin Pediatr Surg 2004;13:112-8.

15. Keller MS. Blunt injury to solid abdominal organs. SeminPediatr Surg 2004;13:106-11.

16. Levy JA, Noble VE. Bedside ultrasound in pediatric emer-gency medicine. Pediatrics 2008;121:e1404-12.

17. Wise BV, Mudd SS, Wilson ME. Management of bluntabdominal trauma in children. J Trauma Nurs 2002;9:6-14.

18. Whitehouse JS, Weigelt JA. Diagnostic peritoneal lavage: areview of indications, technique, and interpretation. Scand JTrauma Resusc Emerg Med 2009;17:13-8.

19. Cha JY, Kashuk JL, Sarin EL, et al. Diagnostic peritoneallavage remains a valuable adjunct to modern imagingtechniques. J Trauma 2009;67:330-6.

20. Gharahbaghian L, Vigil V, Williams S, et al. Imaging inpediatric abdominal trauma; what test, and why? TraumaRep 2009;10:1-12.

21. Boulanger BR, Kearney PA, Brenneman FD, et al. Utilizationof FAST (Focused Assessment with Sonography for Trauma)in 1999: results of a survey of North American traumacenters. Am Surg 2000;66:1049-55.

22. Patel JC, Tepas JJ. The efficacy of focused abdominalsonography for trauma (FAST) as a screening tool in theassessment of injured children. J Pediatr Surg 1999;34:44-7.

23. Sola JE, Cheung MC, Yang R, et al. Pediatric FAST andelevated liver transaminases: an effective screening tool inblunt abdominal trauma. J Surg Res 2009;157:103-7.

24. Suthers SE, Albrecht F, Foley D, et al. Surgeon-directedultrasound for trauma is a predictor of intra-abdominal injuryin children. Am Surg 2004;70:164-8.

25. Scaife ER, Fenton SJ, Hansen KW, et al. Use of focusedabdominal sonography for trauma at pediatric and adulttrauma centers: a survey. J Pediatr Surg 2009;44:1746-9.

26. Miller D, Garza J, Tuggle D, et al. Physical examination as areliable tool to predict intra-abdominal injuries in brain-injured children. Am J Surg 2006;192:738-42.

27. Jerby BL, Attorri RJ, Morton D. Blunt intestinal injury inchildren: The role of the physical examination. J Pediatr Surg1997;32:580-4.

28. Holmes JF, Mao A, Awasthi S, et al. Validation of a predictionrule for the identification of children with intra-abdominalinjuries after blunt torso trauma. Ann Emerg Med 2009;54:528-33.

29. Shah NB, Platt SL. ALARA: is there a cause for alarm?Reducing radiation risks from computed tomography scan-ning in children. Curr Opin Pediatr 2008;20:243-7.

30. Kim PK, Zhu X, Houseknecht E, et al. Effective radiation dosefrom radiologic studies in pediatric trauma patients. World JSurg 2005;29:1557-62.

31. Rice HE, Frush DP, Farmer D, et al. Review of radiation risksfrom computed tomography: essentials for the pediatricsurgeon. J Pediatr Surg 2007;42:603-7.

32. The Society for Pediatric Radiology. The Alliance forRadiation Safety in Pediatric Imaging. Available at: http://www.pedrad.org/associations/5364/ig/. Accessed 11/16/09.

33. Kuppermann N, Holmes JF, Dayan PS, et al. Identification ofchildren at very low risk of clinically-important brain injuriesafter head trauma: a prospective cohort study. Lancet 2009;374:1160-70.

34. The National Cancer Institute. Radiation risks and pediatriccomputed tomography (CT): a guide for health careproviders. Available at: http://www.cancer.gov/cancertopics/causes/radiation-risks-pediatric-CT. Accessed 11/16/09.

35. Martin JA, Kung HC, Mathews TJ, et al. Annual summary ofvital statistics: 2006. Pediatrics 2008;121:788-801.

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36. Kellogg ND, American Academy of Pediatrics, Committee onChild Abuse and Neglect. Evaluation of suspected childphysical abuse. Pediatrics 2007;119:1232-41.

37. Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed casesof abusive head trauma. JAMA 1999;281:621-6.

38. Flaherty EG, Sege R, Mattson CL, et al. Assessment ofsuspicion of abuse in the primary care setting. Amb Pediatr2002;2:120-6.

39. Flaherty EG, Sege R, Binns HJ, et al. Health care providers'experience reporting child abuse in the primary care setting.Arch Pediatr Adolesc Med 2000;154:489-93.

40. Starling SP, Heisler KW, Paulson JF, et al. Child abusetraining and knowledge: a national survey of emergencymedicine, and pediatric residents and program directors.Pediatrics 2009;123:e595-e602.

41. Trokel M, Waddimba A, Griffith J, et al. Variation in thediagnosis of child abuse in severely injured infants. Pediatrics2006;117:722-8.

42. American Academy of Pediatrics, Committee on PediatricEmergency Medicine, American College of EmergencyPhysicians, Pediatric Emergency Medicine Committee. Pa-tient- and family-centered care and the role of the emergencyphysician providing care to a child in the emergencydepartment. Pediatrics 2006;118:2242-4.

43. Kirchhoff C, Stegmaier J, Buhmann S, et al. Trauma surgeons'attitude towards family presence during trauma resuscita-tion: a nationwide survey. Resuscitation 2007;75:267-75.

44. Helmer SD, Smith RS, Dort JM, et al. Family presenceduring trauma resuscitation: a survey of AAST and ENAmembers. J Trauma 2000;48:1015-24.

45. O'Connell KJ, Farah MM, Spandorfer P, et al. Family presenceduring pediatric trauma team activation: an assessment of astructured program. Pediatrics 2007;120:e565-74.

46. Dudley NC, Hansen KW, Furnival RA, et al. The effect offamily presence on the efficiency of pediatric traumaresuscitations. Ann Emerg Med 2009;53:777-84.

47. Schreier H, Ladakakos C, Morabito D, et al. Posttraumaticstress symptoms in children after mild to moderate pediatrictrauma: a longitudinal examination of symptom prevalence,correlates, and parent-child symptom reporting. J Trauma2005;58:353-63.

48. American College of Surgeons, Committee on Trauma.Pediatric trauma care, in Resources for Optimal Care of theInjured Patient. Chicago (Ill): American College of Surgeons;2006. p. 55-61.

49. Shields BJ, Smith GA. Success in the prevention of infantwalker-related injuries: an analysis of national data,1990-2001. Pediatrics 2006;117:e452-9.

50. American Academy of Pediatrics, Section on Injury, Violenceand Poison Prevention (SOIVPP). Policy statements. Avail-able at: http://www.aap.org/sections/ipp/Policy.cfm. Accessed11/16/09.

51. Joffe AR, Lalani A. Injury admissions to pediatricintensive care are predictable and preventable: a call toaction. J Intensive Care Med 2006;21:227-34.

52. Potoka DA, Schall LC, Gardner MJ, et al. Impact of pediatrictrauma centers on mortality in a statewide system. J Trauma2000;49:237-45.

53. Tataria M, Nance ML, Holmes JH, et al. Pediatric bluntabdominal injury: age is irrelevant and delayed operation isnot detrimental. J Trauma 2007;63:608-14.

54. Hall JR, Reyes HM, Meller JL, et al. The outcome forchildren with blunt trauma is best at a pediatric traumacenter. J Pediatr Surg 1996;31:72-7.

55. Mooney DP, Rothstein DH, Forbes PW. Variation in themanagement of pediatric splenic injuries in the UnitedStates. J Trauma 2006;61:330-3.

56. Sims CA, Wiebe DJ, Nance ML. Blunt solid organ injury:do adult and pediatric surgeons treat children differently.J Trauma 2008;65:698-703.

57. Davis DH, Localio AR, Stafford PW, et al. Trends in operativemanagement of pediatric splenic injury in a regional traumasystem. Pediatrics 2005;115:89-94.

58. Potoka DA, Schall LC, Ford HR. Improved functionaloutcome for severely injured children treated at pediatrictrauma centers. J Trauma 2001;51:824-34.

59. Orr RA, Felmet KA, Han Y, et al. Pediatric specializedtransport teams are associated with improved outcomes.Pediatrics 2009;124:40-8.

60. Partrick DA, Moore EE, Bensard DD, et al. Operativemanagement of injured children at an adult level 1 traumacenter. J Trauma 2000;48:894-901.

Abstract:Psychological issues are commonoverlays with all forms of illness andinjury, but the extent to which theseproblems are associated with trau-ma is becoming better understood.Emergency care providers will dealwith the causes and consequencesof these posttraumatic difficulties.The practice of medicine, such asillness itself, is dynamic and alwayschanging. We must prepare our-selves to the best of our abilities ifwe are to be successful in facing thischallenge. This article offers sug-gestions for physicians and otheracute care providers for ways toaccomplish this task by relying onskills we already possess as weincrease our level of understanding.

Keywords:posttraumatic stress disorder(PTSD); acute stress disorder (ASD);emergency medicine; trauma;pain management

Reprint requests and correspondence:Michael Finn Ziegler, MD, Department ofPediatrics and Emergency Medicine, EmoryUniversity Children’s Healthcare of Atlanta1405 Clifton Road NE Atlanta, GA [email protected]

1522-8401/$ - see front matter© 2010 Elsevier Inc. All rights reserved.

Mental HealthConsequences ofTrauma: TheUnseen Scars

MENTAL HEALTH CONSEQUEN

Michael Finn Ziegler, MD

it is life-changing and disrupting not only to the patient but foreveryone around them. As emergency medicine (EM) physicians,especially those taking care of children and families, we see theentire gamut. We do our best to provide interventions thatpreserve and improve the quality of that life. Upon the completionof emergency care, we make disposition decisions, turn the care ofinjured children over to someone else and wish them well. Wethen move on to see the next patient, a child with 6 months ofabdominal pain and poor school performance who has no primarycare physician. He has been very healthy with only one other visitto an emergency department (ED) last year after a car accident,but thankfully, he was not hurt as severely as his brother. Onemight pause to feel the frustration of another “nonemergency”wrongly presenting to an ED. Or, one might also wish they hadspent just a few more minutes talking with that last family aboutwhat happens after trauma.

A growing body of knowledge now exists that sheds light on ourunderstanding of the psychological consequences of trauma andillness in childhood. As our understanding grows, so does our needto address these sequelae through education, direct interventions,appropriate referrals, and advocacy. Many EM physicians may notbe excited when faced with still another responsibility in theincreasingly overcrowded and time and resource-constrained ED.However, rather than seeing this as a new skill set and knowledgebase to acquire, emergency care providers already have theexpertise as well as the opportunity to become effective advocatesfor children with mental health consequences of trauma.

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58 VOL. 11, NO. 1 • MENTAL HEALTH CONSEQUENCES OF TRAUMA / ZIEGLER

BACKGROUND

For the sake of discussion, this article will focusprimarily on acute and prolonged posttraumaticstress disorders (PTSDs) and subsyndromal presen-tations, but it should be understood that depression,anxiety, and other psychologic problems are alsoassociated with acute traumatic events. An under-standing of posttraumatic behavioral changes hasbeen around for a long time, at least in reference tomilitary conflict. During the American Civil War,soldiers were described as having “soldier's heart”or “irritable heart” when they displayed alteredbehavior after conflict. During World War I, theterms shell shock or the effort syndrome were used todescribe the same behaviors. “Combat stress reac-tion” was first described among veterans of WorldWar II. Posttraumatic stress disorder was formallydescribed and given diagnostic criteria in responseto behavioral problems experienced by veterans ofthe Vietnam War.1

During this same period, childhood trauma as apredictor of future psychological problems such asPTSD was first described.2-5 Eventually, investiga-tors turned their attention to acute stress disorder(ASD) and PTSD in the pediatric population andfound that children were more susceptible thanadults in developing these disorders after traumaticexperiences. Overall, prevalence rates for PTSD inadults is estimated to be 8% to 9%;6-8 however,depending on the type of stressors, studies inchildren demonstrate the prevalence rate to rangebetween 13% and 45%.9-13

Diagnostic dilemmas also exist in children thatmay miss subsyndromal presentations that still maylead to significant disability. The Diagnostic andStatistical Manual of Mental Disorders, Fourth Edition,14

requires coexisting symptom clusters of reexperien-cing, avoidance, and hyperarousal in conjunctionwith an inciting stressor or traumatic event anddisability for 1 month or more to meet diagnosticcriteria for PTSD. The same criteria with theaddition of dissociation for less than 1 month defineASD. It is difficult for children to meet these criteriabecause they often alternate symptom clusters ofreexperiencing and avoidance (ie, no coexis-tence),15 or the avoidance symptoms are missedbecause they are more difficult to assess inchildren.16 Reexperiencing symptoms includes re-current and intrusive thoughts often displayedthrough playacting, intrusive distressing dreams ofthe events, and intense psychological and physio-logical distress at reminders of the events. Avoid-ance symptoms include efforts to avoid thoughts oractivities that arouse memories, apparent amnesia

to events, withdrawal, and a sense of a foreshor-tened future. Hyperarousal symptoms are often themost easily identified and include insomnia, emo-tional lability, poor concentration, hypervigilance,and exaggerated startle response.14 These symp-toms and subsequent somatizations are often whatbring children and their families back to the ED.

Other diagnostic challenges include the depen-dence of young children on their caregivers toexpress their symptoms. Several studies have shownthat caregivers often minimize children's symptomsand rarely seek help for these problems unless theyare assisted by a medical professional who recog-nizes the symptom clusters.13,15,17-19 Surveys ofemergency care and primary care providers notonly show that physicians are aware of thistendency of caregivers to minimize symptoms butalso show that the same providers underestimatethe prevalence of the disorder and lack an under-standing of the risks associated with its develop-ment.20,21 The reason these diagnostic difficultiesare so important is exemplified by studies that showthat subsyndromal states of stress disorders havesimilar posttraumatic disabilities as those meetingfull spectrum.22 Therefore, a missed diagnosis is amissed opportunity to intervene and potentiallychange what could become a bad outcome.

SINGLE INCIDENT TRAUMAEarly literature about childhood stress reactions

considered inciting events such as communityviolence, physical and/or sexual abuse, wars, anddomestic violence, but more recent studies havefound significant rates of ASD and PTSD amongvictims of accidental single incident trauma as well.Children who sustain motor vehicle-related injurieshave a 27% to 36% chance of developing a full-fledged ASD or a clinically significant immediatestress reaction within days to weeks after theinjury.18,23,24 Similarly, children who have injuriesfrommotor vehicle-related incidents will have a 25%to 33% chance of developing full diagnostic criteriafor PTSD.17,23 Victims of single incident dog attackswere studied and found to have full diagnosticcriteria for PTSD in 5 of 22 children at 7 months andan additional 7 of 22 children had subsyndromalpresentations in the same time frame.25 A recentstudy looking at single incident orthopedic injuriesfound that 33% met full diagnostic criteria for PTSDat follow-up psychological testing.26

As many as 80% of children will develop at leastone symptom of an immediate stress reaction withinthe first month after a motor vehicle-relatedinjury.27 It is likely that similar high rates of isolated

MENTAL HEALTH CONSEQUENCES OF TRAUMA / ZIEGLER • VOL. 11, NO. 1 59

symptoms would exist after other accidentaltraumas. Do we need to worry about all of thesepatients? Actually, most affected children will seethese symptoms disappear or become part of theircoping strategy. These acute stress-related symp-toms might actually help children adjust to thetrauma. It has long been theorized that some aspectsof traumatic stress are adaptive. Single incidentadaptive learning is essential to survival by allowingus to generalize the lesson to other similar circum-stances. Injury or threat leads to neurohormonaladaptive responses that provide emotional, behav-ioral, cognitive, and physiologic changes necessaryfor survival.28 Unfortunately, sometimes theseadaptive responses “lock” neurochemical andmicroarchitectural organization and function lead-ing to a lack of return to preevent homeostasis andpossibly to a clinical disorder such as PTSD.29

UNDERSTANDING RISKIf these isolated symptoms are so prevalent, how

do we ascertain who is at risk for developingdisability and who is going to cope well andrecover? Understanding what risk factors existmay help us decide what level of interventionmay be necessary. It has been shown that the lossor injury of a loved one during a traumatic event ishighly associated with the risk of that individualdeveloping PTSD.17,19,27,29 Likewise, parental post-traumatic stress is associated with children devel-oping PTSD.30 This is likely due to parents beingless emotionally available to the child and them-selves unable to cope with the tragedy. Thissuggests that simple parental separation duringand after trauma may also be associated with therisk for PTSD. Demographic factors affecting riskinclude female sex; this has been consistently foundas a risk factor in most types of trauma exceptmotor vehicle-related injuries. In addition, aninverse relationship exists between age and therisk of developing PTSD.17,31

Especially important to emergency care provi-ders is the association between PTSD and painmanagement. Several studies and reviews point toinadequate pain control as an independent riskfactor for developing trauma-related stress disor-ders such as ASD and PTSD.32-37 Hyperadrenergicstates occur with pain and stress. These statesenhance memory,38,39 especially if occurring inconjunction with negative emotions.40 A positivefeedback mechanism exists where hyperadrenergicstates from trauma and pain lead to overconsolida-tion of traumatic memory with subsequent releaseof stress hormones and catecholamines linked to

the reexperiencing symptoms of PTSD.41 This isfurther supported by findings that elevated heartrates and urinary cortisol levels at the time ofprehospital transport and ED presentation fortraumatic injury are more likely to be found inpatients who later develop PTSD.42-44 Therefore,appropriate pain control is essential in taking careof the child with trauma.

Surprising to many is the lack of an associationbetween severity of injury and risk of developingPTSD.17,31,45 Perception of injury tends to be moreimportant to future psychiatric disability than theactual injury itself. This is important because failureto understand the patient's internal concerns couldwrongly assign risk to patients who may otherwisedo well. A lack of concern on the provider's parttoward children with minor injuries may missotherwise high-risk patients.

ASSESSING RISKThe mental health community is actively pursu-

ing better diagnostic standards to improve bothsensitivity and specificity of the diagnostic criteriafor PTSD.46 The new Diagnostic and Statistical Manualof Mental Disorders, Fifth Edition, is expected toinclude developmental considerations in childhoodPTSD and will acknowledge the difficulty inrecognizing avoidance symptoms, which shouldloosen the criteria for full diagnostic PTSD inchildren. Mental health professionals who work inconjunction with EDs have also developed andtested screening tools that could be used for rapidassessment of risk stratification in the ED setting.One such tool is the Screening Tool for EarlyPredictors of PTSD (STEPP)47 (Figure 1). This toolconsists of 4 brief questions addressed to parents ofchildren and an additional 4 questions for thechildren themselves. This tool also incorporatesdemographic data that could be obtained from therecord or the physician.

Using the STEPP, a score was assigned thatyielded a negative predictive value of 0.95 forchildren and 0.99 for parents.47 A subsequentstudy assessed the viability of the tool in an activeED and found that it was relatively well accepted bystaff and families.48 These findings indicate that theSTEPP is a potentially valuable screening tool forrisk assessment in traumatized children. Anothertool is the University of California Los Angeles PTSDReaction Index,49 which demonstrated a sensitivityof 0.93 and a specificity of 0.87 for detecting PTSD.The Reaction Index has been proposed as a rapidscreening tool for EDs and primary care offices. Itsgreatest use may be in identifying children with high

Figure 1. Screening Tool for Early Predictors of PTSD (STEPP). Instructions for completion were as follows: ask questions 1 to 4 of theparent and questions 5 to 8 of the child, and record answers to questions 9 to 12 from the acute care medical record. Circle 1 for yes and 0for no. Instructions for scoring were as follows: the child STEPP score is the sum of responses to questions 4 to 10 and 12. A child score of 4or higher indicates a positive screen. The parent STEPP score is the sum of responses to questions 1 to 4, 9, and 11. A parent score of 3 orhigher indicates a positive screen. ((C)2003, The Children's Hospital of Philadelphia. Reproduced with permission.)

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scores that are considered to be at high risk andtherefore may require close follow-up.

THE ROLE OF EMERGENCYCARE PROVIDERS

So, what does this have to do with emergencycare providers? Perhaps a review of the sequelae ofuntreated posttraumatic stress may help us tobetter understand why this is, in part, our problemto deal with. Affected children have a higherrelative risk for poor school performance andother functional impairments, somatization, sub-stance abuse, and suicide attempts.1,17,18,33,50-54

Many of these patients will present to EDs duringtheir sequelae, and we must understand that thesemorbidities carry not only an acute component, butadditionally, a risk of long-term disability and anadded burden on society in health care cost andresource use. There is also the loss of productivity

experienced by the patient and family members. Asis true for all aspects of emergency care, a primarygoal should be to limit morbidity and mortality.This is typically achieved with immediate interven-tions, education, anticipatory guidance, and follow-up plans. Why should we look at this particularproblem any differently?

Emergency health care providers may see stressdisorders as beyond the scope of their practice. Bydefinition, we may be unable to make thesediagnoses during a short-term encounter. Mentalhealth professionals who understand the diagnosticcriteria and who are highly skilled with interviewtechniques are best suited to do this. These sameprofessionals are also in a position to recommendand initiate successful treatment modalities such ascognitive therapy and pharmacotherapy.55-57 Aspreviously discussed, it may be difficult to identifythose at risk in an initial encounter. Yet we also donot want to overrefer these patients. The mostsensible course of action would be to encourage

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follow-up with the primary care or posttraumamental health care systems available to the patientwhere further evaluation and referral can occur.

Unfortunately, many of the patients receivingcare in the ED have limited or no access to a medicalhome.45,58 In addition, few mental health resourcesexist in many communities, making referrals prob-lematic even after stress disorders are identified.Just as disturbing is the lack of use of such resourceswhen concerted efforts are made to make themavailable to the patient.58 The emergency caresystem may be the only point of contact for manyof these patients. However, surveys of physicianknowledge and practice in both emergency andprimary care settings have shown that physiciansfeel time constrained in dealing with such issues, arepoorly reimbursed for their efforts, may be penal-ized in managed care systems for referring, and feelunprepared to handle these problems.20,21,59 Thesesame studies confirm that mental health resourcesare scarce in many communities. A disconnectclearly exists between what we are beginning tounderstand about posttraumatic stress and what weactually do. One cannot ignore concerns aboutbarriers to effective practice if we wish to provideoptimal care for our patients.

EMERGENCY MEDICINE SOLUTIONSThe first thing to realize is that no one is

suggesting that the ED is the only place to addressPTSD, but as the ED often represents the firstcontact for these children, we are in a uniqueposition to implement interventions that mightpositively affect outcomes and advocate for betterprimary and trauma care follow-up, as well as,support the improvement of access to mental heathresources. None of these tasks are beyond ourabilities, and in fact, we are already very skilled intheir application; even if we do not realize it.

COMPASSIONCompassion is defined as a feeling of deep

sympathy and sorrow for another who is strickenby misfortune, accompanied by a strong desire toalleviate the pain.60 Compassion is at the center ofwhat we do each and every day. Perhaps we canimprove our compassion for these children andtheir families through our understanding of theproblem. Nancy Kassam-Adams, PhD, in an intro-duction to a special issue on pediatric stress in theJournal of Pediatric Psychology reports that as healthcare professionals we have compassion fatigue andsecondary traumatic stress as a result of our

practice of caring for trauma patients.61 Sheencourages us to broaden our understanding ofthe problem both as a way not only to improve ourcompassion for patients but also for ourselves.Understanding may in and of itself increasecompassion for our patients leading to moreattention to pain management and other comfortissues during our initial evaluation. This has theadded benefit of helping us to check our own biasesabout mental health issues by better understandingthe physiologic basis for these problems andavoiding the false dichotomy of drawing distinc-tions between so-called organic vs nonorganicdisease. This helps us to advocate for the benefitof mental health follow-up when necessary. Theneed for compassion and understanding can beimparted to families by educating them aboutposttraumatic stress reactions including the likeli-hood they will resolve. We can encourage familiesto pay a little extra attention to their children bothas a form of anticipatory guidance and as therapy.Encouraging healthy habits such as good sleeppatterns, good eating patterns, and exercise cangive the family a regained sense of control afterfeeling a significant loss of control.57 I like to tellfamilies that this is a good time for a few extra hugsas a way to encourage their level of compassionboth for their children and themselves.

EDUCATION AND UNDERSTANDINGEducation both for our patients and ourselves is

likely to improve clinical outcomes. The ability toinform families about likely posttraumatic stress-related symptoms and their expected resolutionmight be comforting and can help avoid furtherstress for the family when such symptoms occur.Furthermore, this gives the family a framework inwhich to observe for more concerning or prolongedreactions. This is empowering and may increasethe likelihood they will seek professional help inthe future.62 There is even some evidence tosuggest that anticipatory guidance may help reducesymptoms,63 but further investigation needs tooccur to best understand and maximize the effectof such interventions.

Our own understanding can help us to risk stratifyinjured patients. Physicians have expressed desiresto learn more and be prepared for interven-tions.20,21,45 This interest, in conjunction withscreening tools, may allow us to target anticipatoryguidance provided during an ED encounter towardthose who may need it the most, offering neededreassurance and/or strongly emphasizing the pur-pose of follow-up assessments through primary care

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or trauma care follow-up systems. Advocating for thepresence of staff in the ED that are trained in mentalhealth and the use of screening tools can help tomake the process more efficient and effective. In asurvey of emergency care providers, only half couldidentify such staff within their institutions.20 As ourunderstanding of the mental health consequences oftrauma improves so too can our ability to do efficientscreening of affected patients. For this reason, weneed to advocate for further research into screeningtools and ED assessments.

PAIN AND ANXIETY REDUCTIONAnother area where emergency care providers

possess great experience is pain management.Multiple studies have shown that attention to painmanagement can reduce the risk for PTSD.32-37

Recognizing this, we should continue our efforts tobe aggressive in our control of pain and anxiety intrauma patients. Dr Michael Greenwald offersguidance on painmanagement in this issue ofClinicalPediatric Emergency Medicine that is well worthreviewing. In addition to pharmacologic interven-tions, numerous initiatives have begun within theEM community to promote family-centered care andparental presence whenever possible during painfulor stressful procedures as a way to further reducedistress and as a means to promote coping. Previouspublications suggest family presence to be helpful inthe secondary prevention of PTSD.56

PSYCHOLOGICAL FIRST AIDThe American Red Cross has proposed psycho-

logical first aid as a means to deal with mental healthissues that arise in the aftermath of a masscasualty.64 These recommendations could easilybe adapted and applied to individual events.Schonfeld and Gurwitch56 propose that emergencyproviders are uniquely skilled in supporting familiesand patients in these disasters who have emotionaland psychological problems related to their crisis.This psychological first aid includes providingappropriate information without overburdeningthe already stressed family, creating a calmingsupportive environment whenever possible, mini-mizing patient separation from family members,minimizing pain, and emphasizing positive copingstrategies and communication.

ADVOCACYI propose that the knowledge and understanding

gained from caring for injured children and their

families makes emergency care providers uniquelyequipped to advocate for our patients at the systemlevel. We should first advocate for an accessiblemedical home for all children, as this would offer allchildren timely follow-up after acute trauma careprovided in the ED and allow for further screeningfor mental health disorders and referral as indicat-ed. We should also advocate for improved mentalhealth resources and expanded insurance coverage.We might also advocate for EDs to have adequatestaffing both at the provider and ancillary staff levelsand for appropriate reimbursement when we takethe time to address the mental health concerns ofour patients in the ED. Mental health disordersshould receive just as much attention as any othermedical issue and without stigma. Further researchand continuing education designed to continuallyimprove the quality of emergency care should beencouraged through funding and academic support.

SUMMARYTrauma has consequences that are both short-

term and delayed. Some of these consequences arenot easily seen or understood. Mental healthsequelae of trauma will impact the well-being ofour patients and their families. Failure on our part torecognize these concerns, the risks that increasetheir likelihood, or failing to provide immediateinterventions designed to reduce these risks is amissed opportunity to improve the well-being of ourpatients and their families. To inadequately addressthese issues at the time of acute traumatic eventmay likely place a burden on our already overtaxedemergency medical resources in the future. Policystatements from both the American Academy ofPediatrics and the American College of EmergencyPhysicians charge us to be responsible for themental health needs of our patients.65-67 We canmeet this challenge with expertise, understanding,and compassion just like we meet a myriad ofchallenges every day. In this way, we truly serve theneeds of our patients and, maybe, ourselves.

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