Traumatic injuries and accidents are a major cause of morbidity and mortality in children worldwide, with traffic accidents causing the majority of deaths due to trauma. When possible, children with injuries should be cared for at a dedicated trauma center, as outcomes have been shown to improve with the care of a specialized trauma team. General principles of management include a systematic, step by step approach beginning with the Pediatric Assessment Triangle. Once providers have performed a primary survey and stabilized the patient, more detailed secondary and tertiary surveys should be conducted. Specific treatments will vary depending on the nature of the injury. Public health initiatives in primary prevention to reduce the incidence of traumatic injuries and prevent injuries before they occur are also crucial.
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Injuries in children are a major public health problem worldwide. This is especially troubling in children under 5 years. According to various statistics, thousands of children die each year because of injuries, and millions of children suffer long-term consequences of non-fatal injuries. For this reason, the World Health Organization and many other international organizations have undertaken strategies to prevent the occurrence of injuries in all age groups, but with more emphasis on age groups most at risk, such as children and the elderly. In this sense, an injury is defined as “the physical damage that results when a human body is suddenly subjected to energy (this can be mechanical, thermal, chemical or radiated) in amounts that exceed the threshold of physiological tolerance – or else the result of a lack of one or more vital elements, such as oxygen”. 1 Injuries and violence are the leading causes of death in children worldwide, being responsible for about 950 000 deaths in children and youth. Unintentional injuries account for nearly 90% of these cases and are the leading cause of death for individuals from 10 to 19 years. 2
In an analysis of deaths from external injuries in children between 0 and 17 years in the United States, it was found that from 2000 to 2006, out of 884 medico-legal examinations there were 480 deaths due to external causes. In this study, male gender predominated. It was found that the most common mechanisms of injury resulting in death were: traffic accidents (40.2%), followed by suffocation (22.7%) and penetrating trauma (17.7%). This study showed that external causes remain a major cause of death in children.3 Another study examined the main severe injuries and intoxication in pediatric patients requiring intensive therapy in a regional trauma center. Eighty-six cases of pediatric patients were analyzed, where traffic accidents, falls, and burns were the 3 main categories and accounted for 57% of admissions in these pediatric intensive care units.4 On the other hand, it has been reported that around 3.8 million cases of traumatic brain injuries occur annually in the United States, most of them concussions. In this regard, it has been estimated that emergency departments annually receive about 173,000 children with concussions due to sports and recreational activities.5 According to statistics, about 53 million hospital days are used in the European Union each year to treat injured patients, which represent 9% of all hospital days. Likewise, it is estimated that about 40 million people have required hospital treatment for injuries each year, of which 5.7 million are admitted for serious injuries, representing at least 112,000 people a day. It has been observed that the risk of injury is higher for males compared to women in the younger ages. Also, children, adolescents and the elderly are at greater risk of injury.6
Investigations have shown that the care of children with injuries is better in a trauma center whether a general or children's hospital. The trauma center requires adequate infrastructure and trained personnel in pediatric emergency medicine, pediatric specialists, surgical specialists, and pediatric anesthesiologists, among others. It is important to note that special knowledge and skills are required to perform an accurate assessment of a child with acute injury. Children with serious damage or injury may be stable at first, which may lead providers to underestimate or ignore the seriousness of their condition upon arrival at the hospital. The general management of these children involves a pediatric assessment triangle (PAT) (first impression), primary ABCDE survey (Airway, Breathing and ventilation, Circulation, Disability, and Exposure), secondary survey (vital signs, focused history and detailed physical examination), and ongoing assessment (tertiary survey).7
In this sense, the template called the Pediatric Assessment Triangle (PAT) should be used for the evaluation of all children (Figure 1). The PAT is fast, simple, reproducible and useful for children of all ages, with all levels of disease and injury severity. For the critically ill or injured child, the determination of the primary physiological problem may be difficult or impossible since inadequate oxygenation may result in cardiopulmonary failure. The PAT brings together three key features of the overall pediatric cardiopulmonary assessment that are more accurate for initial evaluation than traditional vital signs: 1) appearance 2) work of breathing and, 3) circulation to the skin. It is based mainly upon astute, directed observation, and does not require a stethoscope, blood pressure cuff, cardiac monitor, pulse oximeter, or any other equipment or test. Because it entails simply observing a properly exposed child, the PAT can be completed in seconds. The main points to evaluate are: Appearance (tone, interactivity, speech/cry, consolability, and look/gaze); Work of breathing (abnormal breath sounds, abnormal positioning, retractions, and flaring); and Circulation (pallor, mottling, cyanosis, and bleeding). 8
After the first impression (PAT), children must be assessment and management simultaneously. In the primary survey (ABCDE assessment), the medical team must determine if ventilation is adequate, or if there is an obstruction, take further steps to establish the ventilation. After this, determine if there is an adequate gas exchange. With respect to the circulation, the goal is to assess the cardiovascular function and adequate blood supply to peripheral tissues as well as the control of any bleeding. In this sense, the heart rate, capillary refill time, pulse, and blood pressure are evaluated. Staff should ensure venous access in children, which can be challenging. Venous access can be placed in various anatomical sites, but the European Resuscitation Council recommends intraosseous puncture if peripheral venous access cannot be rapidly obtained. 9
The team has to assess for neurological disability and level of consciousness of patients using the AVPU (Alert, response to verbal stimulus, response to pain, unresponsive) scale or the pediatric Glasgow Coma Scale. (Table 1) As a general rule, a GCS score of less than eight indicates that intubation is warranted to protect the airway. Finally, expose the patient to assess for further injuries. After that, a secondary survey will be conducted with the evaluation of vital signs, clinical history, and a detailed physical examination. The secondary survey is done only after PAT and ABCDE are completed. Sometimes the secondary survey is performed after an operation or resuscitation for life-threatening injuries. Complete examination from head to toe should be done (head and neck, chest, abdomen, back, rectal and vaginal examinations, and musculoskeletal). A tertiary survey should always be performed semi-electively, according to the “Trauma Consultation” form. The purpose of this survey is to diagnose any occult or minor injuries. The medical team will reassess the patient at different times to determine the stability of the patient, detect less serious problems, and establish clinical diagnoses and laboratory tests and imaging. 9
The entire process of treatment and monitoring of children with trauma is complex and it will depend on the type of injury, severity, time of injury, patient age, patient gender, medical history and other factors. In this sense, reports have pointed to head trauma as the most common type of injury in children, while poisoning, cuts, bruises and fractures to the arms and legs are less frequent. Studies indicate that boys tend to have both more frequent and more severe injuries than girls. This difference may due to higher activity levels, more impulsive behavior, and or differences in socialization from girls.10
Worldwide, injuries in children should be prevented or controlled. In this sense, there are many and varied approaches to its prevention. This is because the causes of injury in children are multifactorial, and there is a close relationship between these factors. In general, three types of prevention are suggested: 1) primary prevention, which seeks a reduction in the occurrence of injuries; 2) secondary prevention, which seeks a reduction in the severity of the injuries; and 3) tertiary prevention, which focuses on decreasing the frequency and severity of the disability caused by an injury. In general, parental supervision is one of the most important aspects in the prevention of injuries. We also must establish and comply with local and international requirements for the prevention of accidents, among which may be mentioned: prohibition of the manufacture and sale of unsafe children's products; force drivers to slow their vehicles in urban areas, use of safety belts and child restraints in all vehicles, barriers or guards on doors, staircases, windows, wells, ponds; have first aid systems in homes and communities, among others. 2
Children are not little adults. They are a special group at high risk of injuries. Therefore, both government and non-government agencies must implement plans and programs in the community to prevent and respond appropriately to injuries in children. Likewise, extreme care should be taken by parents, relatives, and workers who are caring for children to prevent accidents. The community must have adequate systems of first aid, patient transportation, and hospital infrastructure for proper management of injured children.
Table 1. Pediatric Glasgow Coma Score. A score of 3 is the worst. A score of 15 is the best.
|6- Normal, spontaneous||5- Coos/Babbles/Oriented||4- Spontaneous|
|5- Withdraw to touch||4- Irritable/Confused||3- To Speech|
|4- Withdraw to pain||3- Cries of pain||2- To pain|
|3- Abnormal flexion to pain||2- Moans to pain||1- None|
|2- Abnormal extension to pain||1- None|
Figure 1. Pediatric Assessment Triangle.
 Baker SP, O'Neill B, Ginsburg MJ, Guohua Li MJ, Eds. The injury fact book, 2nd ed. Lexington,MA, Lexington Books, 1992.
 Peden M, et al. World report on child injury prevention. World Health Organization/UNICEF. 2008.
 Fraga AM, Fraga GP, Stanley C, Costantini TW, Coimbra R. Children at danger: injury fatalities among children in San DiegoCounty. Eur J Epidemiol. 2010; 25: 211-7.
 Hon KL, Leung TF, Cheung KL, Nip SY, Ng J, Fok TF, et al. Severe childhood injuries and poisoning in a densely populated city: where do they occur and what type? J Crit Care. 2010; 25: 175. e7-12.
 Centers for Disease Control and Prevention. Nonfatal traumatic brain injuries related to sports and recreation activities among persons aged ≤19 years—United States, 2001–2009. MMWR Morb Mortal Wkly Rep 2011; 60: 1337–42.
 EuroSafe, Injuries in the European Union, Report on injury statistics 2008-2010, Amsterdam, 2013.
 Corrales AY, Starr M. Assessment of the unwell child. Aust Fam Physician. 2010; 39: 270-5.
 American Academy of Pediatrics and the American College of Emergency Physicians. Textbook for APLS: The Pediatric Emergency Medicine Resource. 4th ed. Sudbury, MA. Jones and Bartlett Publishers. 2004.
 Biarent D, et al. European Resuscitation Council guidelines for resuscitation 2005. Section 6. Paediatric life support. Resuscitation 2005; 67(Suppl 1): S97–133.
 Spady DW et al. Patterns of injury in children: a population- based approach. Pediatrics, 2004, 113:522–529.
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