Despite the reliance on an action by the individualsinvolved, some active strategies benefit from enforcement.Children wearing bicycle helmets experience a significantly lower incidence of traumatic brain injury and death. Enforcement of seatbelt laws increases seatbelt use and may decreaseinjuries.
Automatic strategies require no action on the part ofthe population and often change the environment (speedbumps) or involve engineering (child-resistant pill bottles, air bags). Automatic strategies have more consistentlyresulted in a significant reduction in injuries. The most successful approaches to preventing injury have combined strategies (education, environmental changes, and engineering changes focused on the host, agent, and environment in all three time phases).
The general goal of prehospital trauma care is rapid assessment, support of the ABCs, immobilization, and transportation. Outcomes of patients with major or life-threatening trauma are significantly improved in a pediatric trauma center or in an adult center with pediatric trauma certification compared with level I or II adult trauma centers.
Once the injured child arrives at the emergency department, the trauma team must initiate an organized and synchronized response. The initial assessment of a seriously injured child should involve a systematic approach, including a primary survey, resuscitation, secondary survey, postresuscitation monitoring, and definitive care. The primary survey focuses on the ABCDEs of emergency care, as modified for trauma from the ABCs of cardiopulmonary resuscitation (see Chapter 38). The assessment of the airway and breathing components should include meticulous control of the cervical spine (especially if the patient has an altered mental status), evaluation for anatomic injuries that could impair air entry or gas exchange, and consideration of the likelihood of a full stomach (risk of aspiration pneumonia). Circulation can be assessed via observation (heart rate, skin color, mental status) and palpation (pulse quality, capillary refill, skin temperature) and restored (via two large peripheral intravenous lines, when possible) while control of bleeding is accomplished through the use of direct pressure. Assessment for disabilities (D),including neurologic status, includes examination of pupil size and reactivity, a brief mental status assessment (AVPU—alert; responds to voice; responds to pain; unresponsive), and examination of extremity movement to assess for spinal cord injury. The Glasgow Coma Scale can direct decisions regarding the initiation of cerebral resuscitation in patients with suspected closed head injuries (Table 42-1). E, which stands for exposure,requires a full assessment of the patient by completely disrobing the child for a detailed examination of the entire body. The examiner should ensure a neutral thermal environment to prevent hypothermia.
On completion of the primary survey, a more detailed headto-toe examination (the secondary survey) should ensue along with efforts to obtain a more complete history. The purpose of this careful re-examination is to identify life-threatening and limb-threatening injuries as well as less serious injuries. Coincident with the secondary survey and depending, in part, on the assessed physiologic status of the patient, certain procedures and resuscitative measures are initiated. The prioritization of definitive care needs is determined by the injury findings collected from the primary and secondary surveys, the child’s physiologic response to resuscitation, and data from continuous monitoring. A tertiary survey, including repeat primary and secondary surveys along with review of laboratory tests and radiologic studies, should be performed within 24 hours.
SEE CHAPTER 41.
Screening laboratory studies during initial resuscitation often include the tests listed in Table 42-2. Radiographic studies are determined by the pattern of injuries. A head computed tomography (CT) scan should be obtained in patients with evidence of head trauma or a history of loss of consciousness. Patients with obvious injury to the thorax or abdomen or who have pulmonary or abdominal symptoms may benefit from a CT scan. The focused abdominal sonography for trauma is gaining popularity because of concerns about radiation exposure. Diagnostic peritoneal lavage has limited utility. A spiral