Cervical spine films Anteroposterior chest radiograph Radiographs of all apparent fractures Computed tomography scans where indicated for head, chest,
AST/ALT, Aspartate aminotransferase/alanine aminotransferase.
enhanced CT scan should be performed if there is concern about aortic injuries.
Head injuries and injuries to the limbs are the most common. Multiple organ involvement is also common, and penetrating trauma is becoming more frequent. After the initial evaluation and stabilization, the team focuses on the involved organ systems.
SEE CHAPTER 184.
Although spinal cord injury is not common in pediatric trauma patients, it is potentially devastating when it occurs. Cervical spine immobilization should be maintained until a spinal cord injury is ruled out. Cervical spine radiographs are not sufficient to rule out a spinal cord injury because the immature vertebral column in children may allow stretching of the cord or nerve roots with no radiologic abnormality (spinal cord injury without radiologic abnormality [SCIWORA]). SCIWORA may occur in a significant percentage of children with a spinal cord injury; when it is suspected, magnetic resonance imaging should be performed.
Thoracic injury is the second leading cause of trauma death. Pulmonary contusion, pneumothorax, and rib fractures occur most commonly, and patients may present without external signs of trauma. Patients with pulmonary parenchymal injury should receive supportive treatment to ensure adequate oxygenation and ventilation. Most pediatric blunt thoracic injuries can be managed without surgery. Injury to the heart and great vessels is rare but requires urgent diagnosis and treatment. Great vessel injury should be suspected if a widened mediastinum is seen on chest radiograph.
Injury to the abdomen occurs in approximately 8% of pediatric trauma patients and is the third leading cause of trauma death. The relative size and closer proximity of intra-abdominal organs in children increase the risk of significant injury after blunt trauma. Penetrating trauma may result in a child who is asymptomatic or who presents in hypovolemic shock.
Imaging studies such as abdominal CT and serial physical examinations are the primary methods of obtaining information on which to base decisions regarding operative intervention. Abdominal wall bruising is an important physical examination finding and is associated with significant intra-abdominal injury in more than 10% of patients. Operative intervention may be required in patients whose vital signs are persistently unstable in the face of aggressive fluid resuscitation, even in the absence of extravascular volume loss or an enlarging abdomen. The presence of peritoneal irritation or abdominal wall discoloration, together with signs of intravascular volume loss, indicates the need for laparotomy.
Most blunt solid organ injury is handled nonoperatively. Clinical observation is important, because most failures with nonoperative management occur in the first 12 hours.
Injury to the Spleen
The most frequently injured abdominal organ in children is the spleen. Suspicion of a splenic injury should be heightened if there are left upper quadrant abrasions or tenderness. A positive Kehr sign (pressure on the left upper quadrant eliciting left shoulder pain) is due to diaphragmatic irritation by the ruptured spleen and strongly suggests splenic injury. CT scans are used to identify and grade splenic injury.
Nonoperative management is the treatment of choice formost serious splenic injuries, unless there is continued largeblood loss or hemodynamic instability. If a splenectomy isperformed, patients should receive penicillin prophylaxis andshould receive pneumococcal and Haemophilus influenzaevaccines to decrease the increased risk of overwhelming sepsis.