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INTRODUCTION  —  The initial approach to the management of the unstable child with major traumatic injuries is presented here. The approach to the initially stable child with traumatic injury and the classification of trauma in the injured child are discussed separately. (See "Approach to the initially stable child with blunt or penetrating injury" and "Classification of trauma in children" .)

EPIDEMIOLOGY  —  In the United States, over 12,000 children and adolescents 0 to 18 years old die annually of unintentional and intentional injuries, making trauma the leading cause of death for this population [ 1 ]. Injuries and poisoning are also the leading causes of emergency department (ED) visits [ 2 ], accounting for over 17 million ED visits in 2017, which is over one-third of the 48.5 million ED visits for children and youth <25 years old [ 3 ].

Blunt injury accounts for approximately 90 percent of all pediatric trauma. When blunt force is applied to a child's small body, multisystem trauma occurs frequently. Although the majority of injuries are mild to moderate in severity, the clinician caring for children should be prepared to rapidly evaluate and manage those patients with serious and life-threatening trauma. In addition, children have differing anatomy and physiology from adults, which requires specific attention during advanced trauma care. (See "Trauma management: Overview of unique pediatric considerations" .)

OVERVIEW  —  A standardized approach to the initial management of trauma patients has been disseminated by the American College of Surgeons through the Advanced Trauma Life Support (ATLS) program ( table 1 and table 2 ). The ATLS protocols are based on the concept of the Trimodal Death Distribution [ 4 ]:

● The first peak of death occurs in the seconds to minutes immediately after injury and only prevention can impact this mortality.

● The second peak occurs in the minutes to hours after injury. During this time, referred to as the "golden hour," rapid assessment and treatment decreases fatalities and improves outcomes.

● The third peak of death occurs days to weeks after the initial injury because of infection and multi-organ system failure. Definitive care in a center with pediatric expertise and resources mitigates this delayed mortality.

TERMINOLOGY  —  For this discussion, the unstable pediatric trauma patient refers to any child who has abnormal vital signs, disruption of vital functions (eg, airway, breathing, circulation, mental function), or apparent injuries of a critical nature. Knowledge of normal vital signs by age and awareness of the ability of children to sustain major hemorrhage without hypotension facilitates recognition of the critically injured child ( table 3 and table 4 ). (See "Trauma management: Overview of unique pediatric considerations" .)

INJURY CLASSIFICATION  —  Several methods for measuring severity of injury exist. In order to appropriately triage the management of the trauma patient, one useful method to categorize injuries uses the following parameters. (See "Classification of trauma in children" .)

Injury extent  —  Multiple trauma is defined by apparent injury to two or more body areas. Localized trauma involves only one anatomic region (eg, head and neck, chest and back, abdomen, extremities) of the body. Sometimes the extent of injury may be obvious; at other times this may not be readily apparent, and the clinical picture may evolve over time.

Injury type  —  The expected injuries differ based on whether they occur as a result of blunt trauma (eg, fall, motor vehicle collision [MVC]) or penetrating trauma (eg, gunshot, stabbing, shrapnel from explosion).

Injury severity  —  The mechanism of injury and physical examination findings are useful in the determination of severity. Assessment of severity will dictate the initial management and disposition [ 5 ]. High risk trauma mechanisms predict patients who are more likely to be unstable or become unstable and, along with vital signs and physical findings, are often used to guide prehospital transport decisions ( table 3 and table 5 and table 6 ). (See "Classification of trauma in children" .)

INITIAL APPROACH  —  The goals of initial trauma management in children, as in adults, are to rapidly assess the injuries, determine management priorities, and provide critical interventions. Achieving these goals requires a systematic and logical approach according to the tenets of Advanced Trauma Life Support (ATLS), presented below in an expanded format to emphasize the importance of performing specific procedures rapidly in the emergency department (ED) and the crucial need to continuously reassess vital functions ( table 1 ) [ 6 ]:

● Primary survey (rapid primary evaluation)

● Resuscitation of vital functions (eg, airway, breathing, circulation, mentation)

• Utilization of adjuncts to the primary survey and resuscitation

● Secondary survey (more comprehensive secondary assessment)

• Continued post resuscitation monitoring with further resuscitation as needed

• Utilization of adjuncts to the secondary survey

● Transition to definitive care

Management of seriously injured children relies on two key principles:

● Assessment and management occur simultaneously during the primary survey. Any identified physiologic threat to life must be rapidly treated before moving on to the evaluation of the next priority area.

● If there is any deterioration of the patient during the evaluation, the primary survey should be repeated and any newly identified problems addressed before proceeding with the definitive care of the patient [ 4,7 ].

Clinicians should incorporate ATLS guidelines into the management of the pediatric trauma patient but with the understanding that this offers only a general construct. In reality, particularly when multiple clinicians are involved, many steps typically occur simultaneously.

Organization of the medical response around the concept of a pediatric trauma team may provide more timely identification of injury and more rapid treatment with improved outcomes [ 8 ].

The next section will discuss each of the key elements of the primary survey as if they were distinct entities occurring in a strict sequence, even though in centers with optimal pediatric trauma resources these steps typically occur simultaneously.

PRIMARY SURVEY  —  The order of priority in the initial assessment and treatment in ATLS is called the "primary survey" and includes:

● A - Airway maintenance with cervical spine (C-spine) protection

● B - Breathing and ventilation

● C - Circulation with hemorrhage control

● D - Disability (evaluation of neurologic status)

● E - Exposure (complete visualization)/environmental control (prevention of hypothermia)

During the primary survey, clinicians must identify and promptly address life-threatening conditions ( table 1 ). Prior to the arrival of the patient, care providers should don eye protection, mask, gown, and gloves to prevent exposure to patient secretions (universal precautions). The care of the patient proceeds more effectively if participants know their role beforehand and if the leader of the resuscitation communicates clearly.

In trauma centers, advance notice to all participants and key units (eg, blood bank, operating room) facilitates collaborative and timely care of the critically injured child.

Upon arrival of the patient, clinicians should place the appropriate monitors, obtain vital signs (pulse, respirations, oxygen saturation, blood pressure, temperature), and provide supplemental oxygen. It is imperative for the trauma provider to assess pediatric vital signs in comparison to a readily available reference of normal values for age. (See 'Vital signs' below.)

The list below provides a brief overview of the approach and a more detailed discussion of each major category follows. Use of a trauma flow sheet with a dedicated recorder helps ensure that all aspects of assessment and care receive attention.

In the clinical setting, particularly when multiple clinicians are involved, many steps occur simultaneously. For example, intravenous (IV) access may precede chest tube placement, even though "breathing" comes before "circulation" in the algorithm. Also, clinical events will dictate the exact sequence of assessment and management. Some conditions are difficult to detect in young children based on physical findings (eg, cardiac tamponade), and others may evolve over time. For instance, a patient with initially symmetric breath sounds may become cyanotic from a tension pneumothorax in the middle of the secondary survey while receiving positive pressure ventilation and require an immediate thoracostomy tube.

Vital signs  —  Normal vital signs change with age in children ( table 4 ). In general, heart and respiratory rates are higher than in adults, and blood pressure is lower. For children, the 5 th percentile systolic blood pressure for age is defined by Pediatric Advanced Life Support as follows [ 9 ]:

● Term neonates (0 to 28 days): <60 mmHg

● Infants (1 to 12 months): <70 mmHg

● Children (1 to 10 years): <(70 mmHg + [child's age in years x 2])

● Children >10 years: <90 mmHg

Airway with cervical spine motion restriction

● Airway assessment – Airway obstruction with hypoxia and inadequate ventilation is the most common cause of pediatric cardiopulmonary arrest following trauma [ 10 ]. The clinician must rapidly determine airway patency, presence of foreign bodies in the mouth or pharynx, and evidence for facial/mandibular or tracheal/laryngeal fractures with potential for an unstable airway. Medical providers must remain alert for the potential loss of the airway. A patient who is able to cry or speak normally is unlikely to have impending airway obstruction, but should be reevaluated frequently [ 11 ]. (See "Basic airway management in children" and "Technique of emergency endotracheal intubation in children" .)

● Airway management – Clinicians should restrict motion of the cervical spine. During the initial management, the clinician must assume a cervical spine injury in the patient with multiple trauma, especially with head/neck injury or with an altered level of consciousness. Padding under the shoulder and back and use of the "sniffing position" is important to open the airway maximally and maintain a neutral cervical spine position in the infant or young child. Note that this positioning is markedly different from adults where padding under the head is frequently required to achieve neutral cervical spine position. (See "Pediatric cervical spinal motion restriction" .)

Indications for cervical spine motion restriction include (see "Evaluation and acute management of cervical spine injuries in children and adolescents" ):

• Mechanism concerning for potential C-spine injury (motor vehicle-pedestrian collision, motor vehicle-bicycle collision, fall from a considerable height, motor vehicle collision [MVC] with unrestrained passenger, diving) ( table 5 )

• Anatomic predisposition to neck injury (eg, Down syndrome), prior neck injury, or history of cervical spine surgery

• Altered mental status (GCS <15) or intoxication

• Neck pain, torticollis, and/or guarding of the neck

• Neurologic deficit

• Substantial trauma to the torso defined as the following:

- Observable injuries that appear to be life threatening, require surgical intervention, or warrant inpatient observation.

- Injuries of the clavicles, abdomen, flanks, back (including the spine), or the pelvis (eg, rib fractures, visceral or solid organ injury, pelvic fracture).

• Anatomically remote distracting injury that may mask cervical spine instability because of pain such as a femoral fracture. To qualify as a distracting injury, the trauma must be sufficiently severe as to make the otherwise alert, verbal child unaware of neck pain. One possible method of assessment is to forcibly pinch the child on the neck to see if there is a reaction.

Cervical spine motion restriction is usually addressed by the application of a rigid cervical collar. One-person, manual in-line techniques to restrict motion must be used if immobilizing devices need to be removed for endotracheal intubation or other airway procedures ( figure 1 ) [ 7 ]. (See "Pediatric cervical spinal motion restriction", section on 'Techniques' .)

Clinicians must establish an airway if the airway is inadequate. This may be accomplished by performing the following maneuvers/procedures in sequence. In most trauma patients, an inadequate airway means the patient requires rapid sequence intubation to manage or to prevent hypoxemia and hypercarbia and to prevent rapid respiratory decompensation. Establishing an airway, particularly in children <3 years of age may be challenging due to specific anatomical differences from adults (see "Basic airway management in children" and "Technique of emergency endotracheal intubation in children" and "Trauma management: Overview of unique pediatric considerations", section on 'Airway' ):

• Chin lift or jaw thrust

• Suctioning of secretions

• Oropharyngeal/nasopharyngeal airway as adjuncts to bag-valve-mask ventilation or temporary measures prior to endotracheal intubation (nasopharyngeal airway is contraindicated if cribriform plate fracture is suspected)

• Endotracheal intubation

• Laryngeal mask airway (LMA) (if endotracheal intubation fails or difficult airway is anticipated)

• Needle or surgical cricothyroidotomy

Common reasons for endotracheal intubation in injured patients include impending or potential airway compromise (eg, airway trauma, inhalation injury, prolonged seizures), pulmonary contusion with hypoxemia, flail chest with inadequate chest wall movement ( figure 2 ), hemorrhagic shock, and severe head injury (GCS <8) [ 4,10,11 ]. General indications for endotracheal intubation are discussed separately. (See "Technique of emergency endotracheal intubation in children" .)

Endotracheal intubation in severe head trauma requires judicious choice of medications to prevent the abrupt increase in intracranial pressure associated with laryngoscopy and intubation. (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management", section on 'Rapid sequence intubation' .)

● Breathing assessment – Assessment of breathing begins with inspection of the neck and thorax. Key findings include tracheal deviation, abnormal chest wall movement, the use of accessory muscles, and contusions or lacerations of the thorax or neck (see below). In addition the rate and depth of respirations should be determined and breath sounds auscultated ( table 4 ) [ 4 ]. If bedside ultrasound is available and its application will not cause any delays, this modality may be helpful in the diagnosis of a pneumothorax [ 12 ]. Certain life-threatening injuries, which may impair ventilation, often are associated with specific physical examination findings ( table 7 ):

• Tension pneumothorax may present with tracheal deviation, a hyperresonant chest, and unilateral decreased or absent breath sounds.

• Flail chest may present with an asymmetric rise and fall of the chest ( figure 2 ).

• Open pneumothorax may result from a large defect in the chest wall.

• Massive hemothorax may cause unilateral decreased breath sounds and dullness to percussion.

● Breathing management – Management principles should focus on improvement of vital signs with the following interventions:

• Administer a high concentration of oxygen.

• Deliver bag-valve-mask ventilation in cases of inadequate respiratory effort.

• Decompress tension pneumothorax either with a needle initially or by placing a thoracostomy tube. For a hemothorax, use a thoracostomy tube. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children" .)

• Seal open pneumothorax and immediately place a chest tube.

• In addition to treating respiratory compromise, apply end-tidal CO 2 monitoring and consider arterial or venous blood gas measurements [ 7 ]. (See "Thoracic trauma in children: Initial stabilization and evaluation" and "Continuous oxygen delivery systems for the acute care of infants, children, and adults" and "Basic airway management in children" and "Technique of emergency endotracheal intubation in children" .)

Circulation

● Circulatory assessment – Hypovolemia due to blood loss is the most common cause of shock in the pediatric trauma patient [ 7 ], and its early recognition and treatment are critical during trauma resuscitation. Compensated shock occurs when there has been significant blood loss, but the blood pressure has been maintained by tachycardia and vasoconstriction. Hypotensive shock manifests with hypotension in addition to tachycardia [ 13 ]. Cardiac tamponade is uncommon in children with trauma and difficult to diagnose on clinical examination. If bedside ultrasound is available and its application will not cause any delays, this modality may be helpful in identifying pericardial effusion [ 12 ].

Tachycardia is usually the first sign of hypovolemia in the child. Due to the physiologic reserve in children, blood pressure may be maintained despite a loss of up to 45 percent of the circulating blood volume. Therefore, the trauma patient who is cool and tachycardic should be considered to be in shock until proven otherwise. Other signs of shock include delayed capillary refill, narrowing of the pulse pressure to less than 20 mmHg, skin mottling, cool extremities, decreased level of consciousness, and dulled response to pain ( table 8 ) [ 11 ]. (See "Initial evaluation of shock in children" and "Trauma management: Overview of unique pediatric considerations" .)

The remainder of the assessment focuses on sources of bleeding and other causes of hemodynamic compromise:

• External bleeding (eg, large vessel injury, limb amputation, large scalp laceration)

• Significant chest trauma with possible tension pneumothorax, hemothorax, cardiac tamponade, or blunt cardiac injury (see 'Breathing' above and "Thoracic trauma in children: Initial stabilization and evaluation" and "Initial evaluation and management of blunt cardiac injury", section on 'Clinical features' )

• Abdominal tenderness suggesting internal hemorrhage (eg, liver laceration, splenic laceration)

• Pelvic pain and/or instability indicating fracture

• Open fractures of the long bones

• Spinal cord injury with shock (see "Acute traumatic spinal cord injury" )

● Circulation management – Hemorrhage control, IV access for administration of crystalloid or blood, and advanced procedures for persistent hemodynamic compromise constitute the primary management issues for the circulation phase of the primary survey.

Hemorrhage control  —  Sites of significant external hemorrhage require direct manual pressure to control bleeding ( figure 3 ). The presence of nerves near vascular bundles argues against blind clamping of bleeding vessels except in the scalp. In patients whose bleeding does not abate with direct pressure or who have a sharp foreign body at the site of bleeding or an amputation, compression at the nearest vascular pressure point provides an alternative means for hemorrhage control. Finally, the medical provider may employ a blood pressure tourniquet or Penrose drain tourniquet for severe bleeding that is poorly controlled despite direct pressure or compression of pressure points ( figure 4 ) [ 14 ].

Severe bleeding from a large scalp laceration often responds to rapid closure using a figure of eight suture, surgical staples, or scalp clips (Raney clips). A circumferential Penrose drain tourniquet can provide temporary control of scalp bleeding until repair is complete ( figure 5 ). (See "Closure of minor skin wounds with staples" .)

Reduction and splinting of long bone fractures may also provide hemostasis. (See "Basic techniques for splinting of musculoskeletal injuries" .)

For patients with a suspected pelvic fracture and hemodynamic instability, clinicians should carefully examine the perineum and rectum and then place a pelvic stabilization device over the greater trochanter (prefabricated pelvic binder or a bed sheet tied tightly around the pelvis) ( figure 6 ). External fixation devices are generally placed in the operating room because placement can be difficult and time consuming and may interfere with other components of resuscitation.

Persistent hemorrhage  —  Although limited evidence is available for children, studies in adult trauma victims suggest potential benefits from developing treatments for external hemorrhage that cannot be controlled by direct pressure and ongoing internal hemorrhage as follows:

● Uncontrolled external hemorrhage – A number of hemostatic products are being developed to control such bleeding, including chitosan dressing, kaolin-impregnated sponge powder, and fibrin sealant dressing. Although some of these products have been routinely used by military personnel in combat, few controlled studies with civilians have been performed, and it remains unclear how these products should be used by civilian emergency clinicians. No experience of their use in children has been reported. These agents are discussed separately. (See "Fibrin sealants" .)

● Ongoing internal hemorrhage – Antifibrinolytics, specifically aminocaproic acid , tranexamic acid , and aprotinin have all been shown to be safe and effective at reducing bleeding during elective surgery. Of these, tranexamic acid has undergone the most use in adult trauma patients and has been associated with a significant reduction in mortality when given within three hours of blunt or penetrating trauma but an increased risk of death from hemorrhage if administered after three hours. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient", section on 'Antifibrinolytic agents' .)

Preliminary evidence suggests that tranexamic acid may have similar benefits in severely injured children as well. As an example, in an observational study of 766 pediatric trauma patients younger than 18 years of age with combat injuries (73 percent with penetrating trauma), the 66 patients who received tranexamic acid had a significantly lower mortality compared with all other patients (adjusted odds ratio [OR] 0.3, 95% CI 0.09-0.89). Also, tranexamic acid significantly improved neurologic outcomes among patients who received tranexamic acid and large volume transfusions compared with large volume transfusions alone (Glasgow Coma Score [GCS] of 14 to 15 at discharge, 90 versus 69 percent, respectively) [ 15 ]. No thromboembolic complications were seen in the patients who received tranexamic acid. Further study of tranexamic acid therapy in pediatric trauma patients with significant hemorrhage are needed to determine its safety and efficacy [ 16 ].

IV access  —  Ideally, vascular access involves placement of two large bore IVs in the upper extremities within 60 to 90 seconds of arrival, realizing that in young children the lower extremities provide a reasonable alternative and that in many cases two large bore IVs cannot be inserted in a timely fashion.

The most common type of peripheral venous catheter used in children is the over-the-needle catheter. Catheter size necessary for fluid resuscitation varies by age: 22 to 24 gauge in newborns and infants, 18 to 20 gauge for older children. The size of the cannula used in resuscitation should be the largest that can be inserted reliably. In shock or severe hypovolemia, a smaller cannula may be used for initial fluid resuscitation until a larger vein can be cannulated. Butterfly needles should be avoided because they infiltrate easily. (See "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies" .)

If peripheral IV access is not rapidly achieved, the intraosseous (IO) route offers a rapid and easily obtainable alternative access. Percutaneous central access or venous cutdown are other options for establishing more permanent vascular access for ongoing care. Central access is accomplished more easily than a cutdown, which is rarely used. Among the sites for central access, the femoral vein is most frequently used and affords the lowest rate of complications in the short term [ 4,10,11 ] (see "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies" and "Intraosseous infusion" ). When available, ultrasound guidance should be used to facilitate central venous catheterization.

Fluid resuscitation  —  In patients with compensated shock after blunt trauma, a fluid bolus of 20 mL/kg of warmed normal saline or Lactated Ringer should be rapidly given over 10 to 15 minutes. Patients generally need to receive crystalloid volume that is three times the estimated blood loss in order to become hemodynamically stable. In children, three boluses or 60 mL/kg of normal saline or Lactated Ringer (maximum dose: 3 L total volume) would balance a blood loss of 20 mL/kg (approximately one-third of blood volume), assuming that bleeding is controlled. A transfusion of 10 mL/kg of packed red blood cells (PRBC) should be considered if there is inadequate clinical improvement after IV boluses of 40 to 60 mL/kg of normal saline [ 4 ]. (See "Shock in children in resource-abundant settings: Initial management" .)

There is some debate about whether NS or Lactated Ringer is the better initial resuscitation fluid. However, when limited to 60 mL/kg, it is unlikely there is a significant difference in outcome. Lactated Ringer should not be given with blood through the same venous access because it can cause clotting. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient", section on 'Intravenous fluid resuscitation' .)

Blood products  —  Blunt trauma patients with hypotension require rapid restoration of blood volume. These patients often require blood transfusion if they show little to no improvement with initial crystalloid infusions. Type specific or unmatched O negative packed red blood cells (PRBCs, initial volume 10 to 20 mL/kg up to 2 units) administered through a rapid infusion system with an inline warmer may be lifesaving in these patients.

Patients with compensated shock not responsive to initial crystalloid infusions should receive type and cross-matched blood (10 mL/kg up to 1 unit).

The role of other blood products, such as fresh frozen plasma (FFP), platelets, and recombinant activated factor VII (rFVIIa) for the treatment of severely traumatized patients who require massive transfusion is evolving. While replacement therapy with plasma, platelets, and red cells should not generally be based upon any set formula, results from a number of observational studies in adults suggest that patients with severe trauma, massive blood replacement, and coagulopathy have improved survival when the ratio of transfused FFP (units) to transfused platelets (units) to red cells (units) approaches 1:1:1. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient" .)

Massive transfusion protocol  —  In children, a massive transfusion protocol [ 17 ] is indicated for patients who have profound hemorrhage or ongoing bleeding with an anticipated need to replace total blood volume over 24 hours. Use of such a transfusion protocol has been associated with better outcomes in adults although evidence in children is limited [ 18,19 ]. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient", section on 'Management by clinical scenario' .)

● Estimated volume trigger – The optimal volume trigger for initiating a massive transfusion protocol in children is unknown but some experts use the following weight-based approach:

• <5 kg (neonate) – 55 mL/kg

• 5 to 25 kg (infant) – 50 mL/kg

• 25 to 50 kg (child) – 45 mL/kg

• >50 kg (adolescent) – 40 mL/kg or 6 units PRBC

In support of a trigger of 40 mL/kg, one retrospective observational study of over 1,100 children (median age, 10 years) who sustained combat injuries found that patients who received 40 mL/kg or more of total blood products in the first 24 hours were at significantly higher risk of early and in-hospital death than those received <40 mL/kg (5 versus 2 percent for early death and 15 versus 6 percent for in-hospital death, respectively) [ 20 ].

● Hemostatic resuscitation – In addition to estimated blood loss, the presence of coagulopathy in severely traumatized children undergoing blood transfusion is significantly associated with mortality and is also used as a criterion for initiating a massive transfusion protocol by some centers [ 17,21,22 ].

Patients with documented coagulopathy, especially those with significant head trauma, warrant FFP even in the absence of blood transfusion requirements and should also receive FFP if blood transfusion is necessary. Hemostatic resuscitation using blood component therapy resembling that of whole blood (PRBC:FFP:platelets in a 1:1:1 ratio) has been associated with improved outcomes. For example, in a retrospective cohort of over 1200 United States children undergoing massive transfusion and reported to a national pediatric trauma data registry, transfusion using a FFP:PRBC ratio of 1:1 compared with higher ratios (1:2, 1:3, and 1:3+) was associated with a significantly lower 24 hour mortality and lower PRBC transfusion requirements with no difference in complications [ 19 ].

Controlled hypotension  —  Questions remain whether reversal of hypovolemia or control of hemorrhage should take priority in some trauma patients. For example, controlled hypotension may be beneficial in patients with hemorrhagic shock due to torso injuries from gunshot or stab wounds. In this setting, titrating fluid resuscitation to regain a peripheral pulse but to maintain hypotension may allow lacerated blood vessels to spasm, form thrombi, and preserve blood volume prior to definitive surgical exploration and hemorrhage control. On the other hand, aggressive fluid administration prior to hemorrhage control in patients with penetrating trauma might, via augmentation of blood pressure, dilution of clotting factors, and production of hypothermia, disrupt thrombus formation and worsen bleeding. However, little data exists for this approach in children. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient", section on 'Delayed fluid resuscitation/controlled hypotension' .)

Of note, controlled hypotension may be detrimental to blunt trauma patients with brain injury, as hypotension reduces cerebral perfusion and increases mortality. For this reason, we do not recommend controlled hypotension for pediatric blunt trauma victims, especially those with head injury.

Vasoactive pressor medications  —  Vasoactive pressor infusions are not appropriate for the treatment of hypovolemic shock but may be necessary to treat shock secondary to spinal cord injury. (See "Acute traumatic spinal cord injury" .)

Refractory shock  —  Recalcitrant hypotension despite appropriate fluid therapy suggests massive hemorrhage or mechanical disruption of cardiac pumping ability.

Cardiac tamponade may manifest as Beck's triad (increased venous pressure [distended neck veins], muffled heart sounds, and hypotension), which may be absent with hypovolemia. Cardiac tamponade also may cause PEA (pulseless electrical activity) in the absence of hypovolemia and tension pneumothorax [ 4 ]. When available, bedside ultrasound reliably diagnoses or excludes significant cardiac tamponade and should be used, if time allows, prior to attempting pericardiocentesis. Pericardiocentesis, optimally performed with ultrasound guidance, may rapidly restore circulation, but thoracotomy will typically be required to control the source of bleeding. (See "Emergency pericardiocentesis" .)

Open thoracotomy, though rarely successful in preventing mortality, provides access to the pericardium, heart, pulmonary vessels, and aorta for procedures that may address pericardial tamponade, exsanguinating intrathoracic hemorrhage, penetrating cardiac injury, or large vessel abdominal bleeding. Potential indications include (see "Thoracic trauma in children: Initial stabilization and evaluation", section on 'Emergency thoracotomy' ):

• Patient had vital signs in the field but has cardiac arrest either on transport or while in the ED.

• Patient has thoracic trauma and is hemodynamically unstable despite appropriate fluid resuscitation.

• A thoracic or trauma surgeon is available within approximately 45 minutes.

Neurologic assessment  —  Rapid neurologic assessment encompasses determination of level of consciousness [ 11 ] using the Glasgow Coma Scale (GCS) or the pediatric GCS, a validated scale for children ≤2 years ( table 9 ). (See "Classification of trauma in children", section on 'Glasgow Coma Scale' .)

Trauma patients with a GCS ≤8 or who are unresponsive or only respond to pain have severe altered mental status and require rapid resuscitative efforts. (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management", section on 'Initial assessment' .)

Additional neurologic findings to elicit during the primary survey include pupillary responsiveness and brainstem reflexes (eg, gag reflex). Unequal or fixed and dilated pupils indicate cerebral herniation and the need for aggressive measures to counteract increased intracranial hypertension. (See 'Disability management' below and "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis" .)

Disability management  —  Patients with concerns for significant intracranial injury or increased intracranial pressure (ICP) must be managed appropriately to reduce the likelihood of secondary brain injury from hypoxia, ischemia, and cerebral edema [ 4,10,11 ]:

● The clinician should provide supplemental oxygen to keep saturation >95 percent.

● Head injured patients with compromised airway, inadequate breathing, or a GCS ≤8 require early endotracheal intubation and controlled ventilation ( table 9 ). Hyperventilation (PaCO 2 <35 mmHg) may cause cerebral ischemia as the result of decreased cerebral blood flow. Consequently, PaCO 2 should be maintained between 35 and 38 mmHg unless there are signs of impending herniation. (See "Elevated intracranial pressure (ICP) in children: Management", section on 'Breathing' .)

● Patients with hypotension require rapid fluid resuscitation to maintain cerebral perfusion. (See 'Circulation' above.)

● Patients with evidence of cerebral herniation should receive IV Mannitol 0.5 to 1 g per kg or IV hypertonic saline as 2 to 6 mL per kg of 3 percent NaCl (1 to 3 mEq per kg) to reduce ICP. Evidence is lacking regarding the best regimen for osmolar therapy in children with increased ICP. For most pediatric patients, osmolar therapy with either mannitol or hypertonic saline is initially effective. (See "Elevated intracranial pressure (ICP) in children: Management", section on 'Hyperosmolar therapy' .)

Hypertonic saline has a theoretical advantage over mannitol because it does not exacerbate hypovolemia due to an osmotic diuresis in patients with brain injury and hemorrhagic shock. (See "Elevated intracranial pressure (ICP) in children: Management", section on 'Hypertonic saline' .)

On the other hand, many experts prefer mannitol for treatment of acute herniation due to severe head trauma because it has a more rapid and sustained effect. (See "Elevated intracranial pressure (ICP) in children: Management", section on 'Mannitol' .)

Any child with a GCS ≤12 warrants consultation and evaluation by a neurosurgeon ( table 9 ). In addition, children with a GCS ≤8 deserve invasive monitoring of ICP. Specific therapies targeted at increased ICP are discussed separately. (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management" and "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis" .)

Exposure and environment  —  Completely undressing the patient during the primary survey facilitates rapid identification and treatment of multiple injuries. After advanced procedures are completed, the medical providers may log roll the patient while maintaining cervical spine immobilization in order to fully assess the back for injuries to the flank or spine. Many providers chose to perform a rectal examination while the patient is in a lateral position during the log roll to assess anal sphincter tone and presence of gross blood in the rectal vault. Alternatively, the patient may be log rolled as part of the secondary survey ( figure 7 ). (See 'Musculoskeletal' below.)

Pressure sores on the buttocks and heels can develop quickly (within hours) in immobilized patients. Backboards should be used only to transport patients with potentially unstable spinal injury and discontinued as soon as possible. (See "Acute traumatic spinal cord injury" .)

Hypothermia should be avoided with the use of increased ambient room temperature, radiant warmers, warmed IV fluids/blood, warm and humidified inspired oxygen, and covering the patient with warm blankets after full assessment [ 4,7 ].

Adjuncts to the primary survey

Laboratory studies  —  Hematologic studies, serum chemistries and urinalysis have low sensitivity for identifying serious injuries in children with blunt trauma. Clinicians should consider them adjuncts to diagnosis and not substitutes for clinical assessment of critically injured children [ 23 ]. Of the blood and urine studies typically obtained during the primary survey, the following have the greatest impact on patient management [ 11 ]:

● Type and cross – Type and cross for PRBC allows for rapid transition to blood product transfusion if crystalloid fluid resuscitation does not reverse shock. The emergency clinician should order a blood type and cross-match for any victim of significant trauma in anticipation of the need for transfusion. For the patient with a potentially life-threatening hemorrhage, the blood bank should be notified directly (ie, by telephone or in person) of the need for O negative uncross-matched blood and, when necessary, other blood products (eg, FFP, platelets, rVIIa) for immediate transfusion. (See 'Circulation' above.)

● Hematocrit – Hematocrit value <30 percent identifies low oxygen carrying capacity and may suggest intra-abdominal injury in blunt trauma patients [ 24 ]. The hematocrit can be useful as a baseline value in trauma patients. It must be interpreted in light of the clinical context, including the extent of hemorrhage, time since the injury, and the amount of exogenous fluid administration. As an example, the clinician should not be reassured by a normal hematocrit in the acute trauma victim with hypotension. The hematocrit is most helpful when measured serially to assess ongoing hemorrhage.

● Blood glucose – Rapid blood glucose diagnoses hypoglycemia in the patient with altered mental status. (See "Approach to hypoglycemia in infants and children" .)

● Liver enzyme studies – Elevated liver enzyme values (AST >200 international unit/L or ALT >125 international unit/L) are highly associated with intra-abdominal injury following blunt trauma in children although values below this level do not exclude a significant injury in patients with a severe mechanism [ 23 ]. (See "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'Liver transaminases' .)

● Urinalysis – Gross hematuria is highly suggestive of serious renal or urinary tract injury and warrants further investigation. Urinalysis demonstrating ≥50 red blood cells (RBCs) per high-powered field also suggests intra-abdominal injury after blunt trauma in children, which should be investigated with an abdominal computed tomography (CT) scan. Although some experts consider >5 to 50 RBCs to be abnormal, this finding would not mandate further imaging in otherwise well appearing children. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Pediatric considerations' .)

● Blood gas determination – Arterial blood gas or venous blood gas combined with pulse oximetry identifies hypoxemia. In addition, metabolic acidosis associated with inadequate perfusion is common in the unstable trauma patient. It is important to interpret blood gas findings in light of the patient's current clinical condition. Some values (eg, pH, base deficit) may lag behind clinical improvement after an aggressive resuscitation.

In addition to the above, the unstable pediatric trauma victim often undergoes the following testing:

● Complete blood count (CBC) with differential

● Prothrombin time (PT)

● Partial thromboplastin time (PTT)

● International normalized ratio (INR)

● Serum electrolytes

● Serum blood urea nitrogen (BUN) and creatinine

● Serum lipase or amylase

Although these tests do not usually assist in the identification of specific injuries [ 23 ], they do serve as baseline values for comparison in the course of trauma resuscitation. For example, electrolytes and renal function may become abnormal after osmotherapy for increased ICP (see "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis" ). Similarly, thrombocytopenia and coagulopathy may occur in patients who have head trauma or receive multiple transfusions.

Selected patients should also have measurement of blood ethanol level (adolescents), rapid urine pregnancy test (postmenarchal females), or urine screen for drugs of abuse (adolescents and children with suspected exposure) [ 4 ]. Although the results of these will not typically alter acute trauma management they may have important ramifications for care after initial resuscitation.

Screening radiographs  —  Cross-table lateral cervical spine (C-spine), anteroposterior (AP) chest, and, in selected patients, AP pelvis help identify immediately life-threatening injuries during the primary survey [ 11 ]:

● A cross-table lateral C-spine film identifies up to 80 percent of fractures, dislocations, and subluxations. However, a negative C-spine radiograph does not exclude the possibility of serious spinal cord injury. Cervical immobilization should continue until complete clinical assessment and additional studies, as needed, rule out serious C-spine fracture or spinal cord trauma. In severely injured or comatose patients with a concerning mechanism of injury, the trauma physician may elect to maintain cervical spine immobilization, even after a complete radiographic C-spine evaluation shows no abnormality. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Cervical spine imaging' .)

● An AP chest radiograph may demonstrate pneumothorax, hemothorax, aortic dissection, pulmonary contusion, pneumomediastinum, rib fractures, and/or hemopericardium. In addition, it provides visualization of endotracheal and gastric tube placement.

● The AP pelvis radiograph is most often helpful in victims of high energy blunt trauma who are hemodynamically unstable, display pelvic pain, or have pelvic instability on physical examination. Identification of fracture in these unstable patients allows the emergency practitioner to initiate pelvic binding in anticipation of hypogastric artery embolization or operative external pelvic fixation. However, the sensitivity of an AP radiograph for pelvic fractures in children is limited, especially in patients younger than two years of age. Patients with negative plain radiographs in whom pelvic fracture is suspected should undergo CT of the pelvis once they are stable or, if performed, along with an abdominal CT. (See "Pelvic trauma: Initial evaluation and management", section on 'Imaging studies and fracture types' and 'Circulation' above and "Pelvic trauma: Initial evaluation and management", section on 'Initial stabilization and approach' .)

e-FAST (extended focused assessment with sonography for trauma)  —  e-FAST is a rapid ultrasound examination of four abdominal locations: right upper quadrant, left upper quadrant, subxiphoid region, and pelvis; lungs; and heart [ 25 ]. The primary utility of this examination for the unstable trauma patient is the detection of intraperitoneal fluid secondary to intra-abdominal injury, pneumo- or hemothorax, and/or hemopericardium.

We suggest e-FAST examination in hemodynamically unstable pediatric trauma patients as a rapid means to identify an underlying etiology and to focus further management and for stable patients, if performance of ultrasound will not cause any delays [ 12,26 ]. For example, hemodynamically unstable children with positive abdominal findings on e-FAST may warrant operative intervention in lieu of abdominal CT [ 26 ]. e-FAST may also have utility in a neurologically unstable child who is multiply injured and requires emergency surgery for an epidural hematoma. In this instance, a positive FAST examination may support the need for a laparoscopy or laparotomy at the time of craniotomy when there may not be time for other advanced imaging.

Although evidence is limited in children, e-FAST may also permit more timely detection of pneumothorax, hemothorax, or cardiac tamponade with greater sensitivity but lower specificity than a supine chest radiograph. (See "Overview of intrathoracic injuries in children", section on 'Diagnosis' .)

The utility of e-FAST for the detection of intra-abdominal injury in hemodynamically stable children with blunt abdominal trauma and no other injury that requires emergency surgery is less clear:

● Although FAST has been associated with improved outcomes in adult trauma patients (see "Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Clinical studies' ), its use in the evaluation of children is not routine because the nature of pediatric injuries, primarily the common presence of solid organ lacerations, makes FAST an insensitive means for detecting important intra-abdominal injury [ 27 ]. As an example, in a metaanalysis of 25 studies (over 3800 injured children), FAST had a sensitivity of 66 percent and a specificity of 95 percent for the detection of hemoperitoneum using CT as the gold standard [ 28 ]. Given this low sensitivity, hemodynamically stable children with a moderate to high pretest probability for intra-abdominal injury warrant abdominal CT, regardless of findings on FAST.

● FAST may also not have an impact on potentially important clinical outcomes or resource use in hemodynamically stable children with a low clinical suspicion for intra-abdominal injury. For example, in an unblinded randomized trial of 925 hemodynamically stable children evaluated for blunt torso trauma at a single center, FAST was not associated with significant differences in missed intra-abdominal injury (0 to 0.2 percent), frequency of abdominal CT (52 to 55 percent), mean emergency department length of stay (six hours), and hospital charges compared with standard care without FAST [ 29,30 ]. Negative results on ultrasonography did lower the clinical suspicion for intra-abdominal injury by managing physician but did not decrease the use of abdominal CT. However, the study did not provide a specified approach to positive or negative FAST results and the sensitivity of FAST in this study (33 percent) was low compared with prior studies [ 31 ].

On the other hand, in a retrospective observational study of 354 children with blunt torso trauma (14 percent with intra-abdominal injury), e-FAST combined with physical examination had a sensitivity of 88 percent (95% CI, 76 to 96 percent) and a negative predictive value of 97 percent (95% CI, 95 to 99 percent) for intra-abdominal injury and a sensitivity of 100 percent (95% CI, 75 to 100 percent) and a negative predictive value of 100 percent for intra-abdominal injury requiring acute intervention [ 32 ]. Larger prospective studies are needed to confirm these findings.

Given the significant potential for false negative results, e-FAST alone should not be used to limit the use of abdominal CT in children with blunt abdominal trauma [ 33 ]. However, preliminary evidence suggests that e-FAST in combination with physical examination findings may provide useful information to guide clinical decisions.

Urinary catheter  —  A urinary catheter should be placed to monitor urinary output and to obtain urine for diagnostic testing. Patients with suspected urethral transection (blood at the urethral meatus, perineal ecchymosis, blood in the scrotum, or pelvic fracture) should undergo a retrograde urethrogram to evaluate urethral integrity before urinary catheterization is attempted. Alternatively, a suprapubic tube offers an option for emergent decompression of the bladder [ 4 ]. Retrograde urethrogram should be deferred when significant pelvic vascular injury is suspected as extravasated contrast dye from the retrograde urethrogram or cystogram may obscure computed tomography and angiography images thereby interfering with study interpretation and subsequent embolization attempts. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'History, examination, and approach to testing' .)

Gastric tube  —  Major trauma often results in gastroparesis and significant stomach enlargement. When this occurs, an orogastric or nasogastric tube should be placed for stomach decompression to reduce the risk of aspiration. Placement of a gastric tube may also facilitate endotracheal intubation.

Nasogastric insertion is contraindicated in patients with oromaxillary trauma and possible cribriform plate fracture, either diagnosed radiographically or if suspected on the basis of epistaxis, watery discharge from the nares, or mobility of the maxilla [ 11 ]. In this setting, the orogastric route is preferred.

SECONDARY SURVEY  —  The secondary survey is a systematic head-to-toe evaluation of the trauma patient, which must be performed after the primary survey has been completed and resuscitation begun, as needed, with the stabilization of vital functions. This part of the evaluation includes the patient history, comprehensive physical examination, and additional studies and procedures ( table 2 ) [ 4,7 ].

Although the goal of the secondary survey is to be complete, the need for rapid treatment requires a compromise in some cases. For instance, in a hypotensive child who has sustained multiple pelvic fractures due to a compression injury of the lower body, one would not ordinarily check visual acuity before moving on to interventional radiology.

When the physical examination is truncated due to patient condition, it is incumbent upon the team to ensure that the examination is completed after the necessary interventions or diagnostic studies are performed. If the patient is transferred to another service or hospital, the missing components of the examination should be specifically communicated.

History  —  The AMPLE mnemonic may be used to obtain a quick, focused history from prehospital personnel, patients, or family members [ 11 ]:

● A – Allergies

● M – Medications

● P – Past medical history/pregnancy

● L – Last meal

● E – Events/environment leading to the injury

Physical examination and management  —  The components of the physical examination that deserve special focus in the secondary survey are summarized below ( table 2 ).

Head  —  The scalp and head should be examined and palpated for lacerations, hematomas, or bony step-offs.

● Eyes – The eyes should be evaluated for pupillary size, conjunctival/fundal hemorrhage, penetrating injury, ocular mobility/entrapment, or periorbital ecchymosis (Raccoon's eyes). Contact lenses, if present, should be removed. Awake patients should have visual acuity assessed.

● Ears – Hemotympanum ( picture 1 ) or blood or clear drainage from the ear canal suggests basilar fracture with CSF leakage, as does retroauricular ecchymosis (Battle's sign). (See "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Basilar skull fracture' .)

● Maxillofacial – The emergency practitioner should inspect the nose for cerebrospinal fluid leakage or blood. When placing a gastric tube in patients with midface fractures, as indicated by deformity, tenderness, or mobility of the maxilla, the clinician should pass an orogastric rather than a nasogastric tube because of the risk of penetration of the cribriform plate with intracranial placement of the gastric tube. The mouth should be inspected for soft tissue lacerations, malocclusion, or loose teeth [ 4,7 ]. Jaw pain or deformity indicates possible jaw fracture. Significant maxillofacial injury is a marker for possible cervical spine injury.

Cervical spine and neck  —  Cervical spine protection and motion restriction should be maintained throughout the examination [ 7 ]. The neck should be inspected for tracheal deviation, contusions, hematomas, or penetrating injuries, which may affect the airway, the spinal cord, or major vessels. Palpation should assess for cervical spine tenderness (in the awake and cooperative patient), or stepoff that suggests vertebral fracture or dislocation. Crepitus indicates subcutaneous emphysema, which may result from laryngeal fracture, esophageal rupture, or pneumothorax [ 11 ]. (See "Evaluation and acute management of cervical spine injuries in children and adolescents" .)

Chest  —  Inspection and auscultation of the chest should be repeated as described previously. In addition, the entire chest, including the clavicles, sternum, and ribs, should be palpated for crepitus, step-offs, or tenderness. Children may sustain significant internal injury to the intrathoracic structures (eg, pulmonary or cardiac contusion) without evidence of skeletal trauma [ 4,11 ]. (See "Thoracic trauma in children: Initial stabilization and evaluation" and "Initial evaluation and management of blunt cardiac injury", section on 'Pediatric considerations' .)

Abdomen  —  Inspection, auscultation, and palpation of the abdomen with reevaluation is important for the pediatric trauma patient as examination findings may change over time. The physician should evaluate the abdomen for distention, ecchymosis, presence/quality of bowel sounds, abdominal tenderness, rebound, guarding, or palpable masses. (See "Pediatric blunt abdominal trauma: Initial evaluation and stabilization" .)

The presence of a "seat belt sign" (a linear contusion across the abdomen), especially when coupled with abdominal pain and tenderness, is associated with a substantially increased risk of intra-abdominal injury, specifically, gastrointestinal injury. (See "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'Seat belt sign' .)

Hollow viscus and retroperitoneal injuries, including to the pancreas, are often occult initially on a clinical basis, and a high index of suspicion based on the mechanism of injury is important for the identification of these injuries. (See "Hollow viscus blunt abdominal trauma in children", section on 'Lap seat belt injury' .)

Perineum  —  Inspection of the perineum is important for the identification of contusions, hematomas, lacerations, or urethral bleeding (in the male). Although the utility of the rectal examination in trauma patients has been questioned [ 34 ], we believe that it can add information regarding blood from the bowel lumen and sphincter tone in the unstable patient. In teenage or adult males a high-riding prostate suggesting transurethral transection may be palpated. In the female patient the vagina should be inspected for the presence of blood or lacerations [ 4 ]. Postpubertal women with pelvic fractures should undergo vaginal examination. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'History, examination, and approach to testing' .)

Musculoskeletal  —  The emergency provider should inspect the extremities for swelling or contusion and palpate for deformity, tenderness, presence/absence of pulses, and quality of pulses. Any potential fracture should undergo splinting. In addition, limbs with neurovascular compromise require rapid involvement of orthopedic and vascular subspecialists. (See 'Orthopedic management' below and "Basic techniques for splinting of musculoskeletal injuries" .)

Ecchymosis over the iliac wings, pubis, labia, or scrotum is suspicious for pelvic fractures. In the alert patient, pain on palpation of the pelvic ring suggests the presence of a fracture. In the unconscious patient, mobility of the pelvis in response to anterior-to-posterior pressure on both anterior iliac spines and symphysis pubis is suggestive of pelvic ring disruption. "Rocking" of the pelvis back and forth should be avoided as it may increase hemorrhage due to pelvic fracture. The patient must be rolled and the back inspected and palpated for tenderness or step-offs if not already performed during patient exposure. The axillae should also be examined [ 11 ].

Neurologic  —  A brief but thorough neurologic evaluation including motor and sensory function as well as reevaluation of the patient's level of consciousness and pupillary response to light must be performed as part of the secondary survey. If any spinal cord injury is suspected, the patient must be immobilized using cervical spine immobilization devices. (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management", section on 'Secondary survey' .)

Adjuncts to the secondary survey  —  After the pediatric trauma patient has been assessed, resuscitated, and stabilized, imaging can be performed to identify specific injuries not detected or fully characterized on the screening radiographs. Computed tomography (CT) is the modality of choice to identify intracranial and abdominal injuries when indicated by physical findings. (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management", section on 'Imaging' and "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'Indications' and "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'Neuroimaging' and "Minor blunt head trauma in children (≥2 years): Clinical features and evaluation", section on 'Neuroimaging' .)

CT may also be useful to evaluated selected children with suspected cervical spine injuries ( algorithm 1 and algorithm 2 ). (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Computed tomography' .)

To avoid excess radiation exposure with subsequent cancer risk, injury mechanism and clinical factors must be carefully considered when determining if a CT scan should be performed in the pediatric trauma patient. (See "Ischemic stroke in children: Clinical presentation, evaluation, and diagnosis", section on 'CT safety considerations' .)

Radiographs  —  After stabilization, the cervical spine radiographic series may be completed with AP and, in the older child, open mouth odontoid views. Due to the possibility of spinal cord injury without radiologic or CT evidence of trauma (SCIWORA or SCIWOCTET) in the pediatric population, trauma patients with brief or sustained sensory or motor deficits with no plain radiologic or CT abnormality and decreased level of consciousness must be assumed to have a cervical spine injury, and cervical spine protection and motion restriction must be maintained until proven otherwise. (See "Spinal cord injury without radiographic abnormality (SCIWORA) in children", section on 'Clinical features and diagnosis' .)

Based on physical examination findings, extremity radiographs should also be performed for the evaluation of suspected fractures. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Cervical spine imaging' .)

Head CT  —  Intracranial imaging should be performed for normotensive patients with GCS scores <14 ( table 9 ) or signs of a basilar skull fracture. In a hypotensive patient with depressed mental status, every effort should be made with fluid resuscitation to improve the hypotension, which may also improve mental status and obviate the need for a head CT [ 4 ]. (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management" .)

The indications for obtaining imaging for children with minor head trauma are discussed separately. (See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'Neuroimaging' and "Minor blunt head trauma in children (≥2 years): Clinical features and evaluation", section on 'Neuroimaging' .)

Neck CT  —  Although CT of the neck with sagittal and coronal three-dimensional (3D) reconstruction is highly sensitive and specific for cervical spine fractures, the radiation risk does not justify routine use of neck CT in pediatric trauma patients. Screening cervical spine radiographs, which identify most life-threatening cervical spine injuries, remain the initial imaging modality. An anatomically focused CT on the cervical spine level of concern should be obtained in any of the following circumstances (see "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Cervical spine imaging' ):

● Inadequate cervical spine radiographs (three-views)

● Suspicious plain radiographic findings

● Fracture/displacement seen on plain radiographs

● High clinical index of suspicion of injury despite normal radiographs

Chest CT  —  For children, chest CT is primarily indicated to identify vascular or tracheo-bronchial injury in hemodynamically stable patients with the following findings:

● Physical examination evidence of great vessel injury (asymmetric pulses, diminished pulses throughout with associated major chest trauma, paralysis, or large hemothorax with ongoing hemorrhage)

● Abnormal screening chest radiograph with findings that suggest great vessel injury (eg, wide mediastinum, obscured aortic knob, left apical cap, or large left hemothorax)

● Suspected tracheo-bronchial injury

Hemodynamically unstable patients with suspected aortic injury should undergo emergency surgical or endovascular repair rather than additional imaging. For children with suspected blunt aortic injury (BAI), the approach to diagnosis and treatment is similar to the approach in adults ( algorithm 3 ). (See "Overview of intrathoracic injuries in children", section on 'Traumatic aortic injury' .)

We restrict the use of chest CT to the above indications because a normal chest radiograph has a high negative predictive value for significant thoracic injury that requires intervention. Furthermore, the incidence of cardiac and great vessel injury in children is significantly lower than the risk of radiation exposure in children. The initial stabilization and evaluation of thoracic trauma is discussed in more detail separately. (See "Thoracic trauma in children: Initial stabilization and evaluation", section on 'Thoracic imaging' .)

Abdominal CT  —  Abdominal CT with intravenous contrast is the preferred diagnostic imaging modality to detect intra-abdominal injury in hemodynamically stable children who have sustained blunt abdominal trauma. CT is sensitive and specific in diagnosing liver, spleen, and retroperitoneal injuries, which may be managed nonoperatively. (See "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'Abdominal and pelvic CT' and "Liver, spleen, and pancreas injury in children with blunt abdominal trauma", section on 'Imaging' .)

CT with intravenous (IV) contrast alone is less sensitive in detecting injuries of the pancreas, intestinal tract, bladder, and lumbar spine. (See "Liver, spleen, and pancreas injury in children with blunt abdominal trauma", section on 'Imaging' and "Hollow viscus blunt abdominal trauma in children", section on 'Imaging' and "Blunt genitourinary trauma: Initial evaluation and management", section on 'CT scanning' .)

Patients with hypotension are also at high risk for intra-abdominal injury. Those children who do not respond to fluid resuscitation require direct operative intervention; a FAST examination may be helpful in characterizing the injury in this situation. Those who become hemodynamically stable after fluid repletion should have an abdominal CT performed. (See 'e-FAST (extended focused assessment with sonography for trauma)' above.)

A low-risk rule for intra-abdominal injury can identify children and adolescents who may undergo emergency department observation rather than abdominal and pelvic CT and is discussed in detail separately. (See "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'PECARN low-risk rule' .)

The accuracy of CT imaging may be increased with the use of oral or intravenous contrast. The routine use of oral contrast is controversial; it is rarely of benefit in the diagnosis of acute distal bowel injuries, but may be helpful in the diagnosis of duodenal and pancreatic injuries. The use of oral contrast media can increase scanning time and cause vomiting although low rates of aspiration have been documented in retrospective studies. In addition, oral contrast may inadequately penetrate the small or large bowel. For these reasons, many trauma centers no longer use oral contrast. (See "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'Abdominal and pelvic CT' .)

Laparoscopy  —  In patients with suspected bowel injury, who are hemodynamically stable, emergent laparoscopy may be considered as a diagnostic and therapeutic procedure. This may be useful for selected patients who have sustained blunt or penetrating abdominal injuries as an alternative to laparotomy [ 35 ]. (See "Hollow viscus blunt abdominal trauma in children", section on 'Suspected hollow viscus injury' .)

Orthopedic management  —  Fractures resulting in neurovascular compromise may be gently reduced and splinted while awaiting orthopedic consultation. If the pulses are present, the extremity may be maintained in the position in which it is found. Splints should be placed to immobilize the joint above and below the injury site, if possible. The neurovascular status of the extremity should be evaluated before and after splint placement. (See "Basic techniques for splinting of musculoskeletal injuries" .)

Pelvic fractures may be temporarily managed by wrapping a sheet around the pelvis at the level of the greater trochanter to reduce pelvic volume and control hemorrhage ( figure 6 ). (See 'Circulation' above.)

Open wounds should have appropriate wound care, and IV antibiotics should be given for open fractures. The choice of prophylactic antibiotics is derived from evidence in adults and depends upon the type of open fracture and the degree of contamination as described in the table ( table 10 ) and is discussed separately. (See "Osteomyelitis associated with open fractures in adults", section on 'Antibiotics after open fracture' .)

Tetanus immunization ( table 11 ) and pain control should also be addressed [ 11,36 ]. (See "Pain in children: Approach to pain assessment and overview of management principles" .)

Definitive care  —  Level 1 pediatric trauma centers (PTCs) have the greatest amount of personnel and resources devoted to the care of critically injured children ( table 12 ) and are the preferred sites for initial resuscitation and ongoing management of pediatric trauma patients [ 8,37 ]. When a level 1 PTC is not available, injured children should receive care at a hospital that has the highest level of pediatric trauma expertise and resources. Depending upon the region, this site may be a level II pediatric trauma center, an adult trauma center with pediatric capability sometimes called a combined trauma center (CTC), an adult trauma center (ATC), or a children's hospital without trauma verification. In the US, just over half of children had timely access (ie, ground or air transport time < 60 minutes) to a level 1 or 2 PTC by ground transport in 2020 [ 38 ].  

Experts have developed a field triage guideline that identifies those patients who warrant direct prehospital transportation to a US trauma center. This critical field transport decision requires evaluation of vital signs, level of consciousness, injury anatomy, injury mechanism, and special patient or local emergency medical systems considerations. This guidance recommends that children "should be triaged preferentially to pediatric-capable trauma centers" ( algorithm 4 ) [ 39 ].

For injured infants, children, and younger adolescents who require admission, treatment in a PTC is associated with better clinical outcomes than an ATC. For example, in a metanalysis of 34 studies that evaluated hospitalized pediatric trauma patients, treatment in a PTC for children < 14 years old was associated with lower mortality than in an ATC (23 studies; OR 0.59, 95% CI 0.46 to 0.76) or in an ATC with additional pediatric capability referred to as a combined trauma center (CTC, 11 studies; OR 0.73, 95% CI 0.53 to 0.99) [ 37 ]. Compared with an ATC, care of children with blunt trauma in a PTC was also associated with a lower likelihood of undergoing computed tomography or operative management for a blunt solid organ injury. There was significant heterogeneity in the metaanalyses, and the overall quality of the evidence was rated as low. In a separate large retrospective cohort study of over 88,000 children <18 years old treated in 146 US trauma centers, high ED pediatric readiness was independently associated with a lower risk of death at one year [ 40 ].  

SOCIETY GUIDELINE LINKS  —  Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pediatric trauma" .)

SUMMARY AND RECOMMENDATIONS

● Terminology – For this discussion, the unstable pediatric trauma patient refers to any child who has abnormal vital signs, disruption of vital functions, or apparent injuries of a critical nature. Knowledge of normal vital signs by age and awareness of the ability of children to sustain major hemorrhage without hypotension facilitates recognition of the critically injured child ( table 3 and table 4 ). (See 'Terminology' above and "Trauma management: Overview of unique pediatric considerations" .)

● Initial approach – The initial trauma management in the pediatric trauma patient are summarized in the tables provided ( table 1 and table 2 ). The phases of treatment are (see 'Initial approach' above):

• Primary survey (rapid primary evaluation) (see 'Primary survey' above) – Assessment and management occur simultaneously during the primary survey. Any identified physiologic threat to life must be rapidly addressed and treated before moving on to the evaluation of the next priority area including:

- Resuscitation of vital functions (eg, airway, breathing, circulation, mentation) (see 'Airway with cervical spine motion restriction' above and 'Breathing' above and 'Circulation' above and 'Disability' above and 'Exposure and environment' above)

- Utilization of adjuncts to the primary survey and resuscitation such as laboratory studies, screening radiographs, extended focused assessment with sonography for trauma (FAST or e-FAST), and placement of a urinary catheter and gastric tube (see 'Laboratory studies' above and 'Screening radiographs' above and 'e-FAST (extended focused assessment with sonography for trauma)' above and 'Urinary catheter' above and 'Gastric tube' above)

• Secondary survey (more comprehensive secondary assessment) (see 'Secondary survey' above) – The secondary survey is performed after the primary survey and consists of a head to toe physical examination with continued postresuscitation monitoring. Adjuncts to the secondary survey include completion of cervical spine imaging, more detailed imaging of the head and abdomen in stabilized patients, and laparoscopy. Key orthopedic interventions include external wrapping of pelvic fractures and splinting of fractures. (See 'Adjuncts to the secondary survey' above.)

If there is any deterioration of the patient during the evaluation, the primary survey should be repeated and any newly identified problems addressed before proceeding with the definitive care of the patient. (See 'Primary survey' above and 'Secondary survey' above.)

● Definitive care – Level 1 pediatric trauma centers have the greatest amount of personnel and resources devoted to the care of critically injured children ( table 12 ) and are the preferred sites for initial resuscitation and ongoing management of pediatric trauma patients. (See 'Definitive care' above.)

ACKNOWLEDGMENT  —  The UpToDate editorial staff acknowledges Gary R Fleisher, MD, who contributed to earlier versions of this topic review.

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• Maw G, Furyk C. Pediatric Massive Transfusion: A Systematic Review. Pediatr Emerg Care 2018; 34:594.
• Akl M, Anand T, Reina R, et al. Balanced hemostatic resuscitation for bleeding pediatric trauma patients: A nationwide quantitative analysis of outcomes. J Pediatr Surg 2022; 57:986.
• Neff LP, Cannon JW, Morrison JJ, et al. Clearly defining pediatric massive transfusion: cutting through the fog and friction with combat data. J Trauma Acute Care Surg 2015; 78:22.
• Chidester SJ, Williams N, Wang W, Groner JI. A pediatric massive transfusion protocol. J Trauma Acute Care Surg 2012; 73:1273.
• Strumwasser A, Speer AL, Inaba K, et al. The impact of acute coagulopathy on mortality in pediatric trauma patients. J Trauma Acute Care Surg 2016; 81:312.
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• v.43; 2019 Jul

Bilateral thoracic trauma; presentation and management, a case series

a Faculty of Medical Sciences, School of Medicine, Department Cardiothoracic and Vascular Surgery, University of Sulaimani, François Mitterrand Street, Sulaimani, Kurdistan Region, Iraq

Fahmi H. kakamad

b Kscien Organization for Scientific Research, Hamdi Street, Sulaimani, Kurdistan, Region, Iraq

Associated Data

Introduction.

Unilateral chest trauma has been perfectly described in the literature while bilateral chest trauma has never been specifically probed, the aim of this study is to highlight the specificities, presentations, the difference in the therapeutic algorithm and outcome of patients with bilateral thoracic trauma.

Patients and methods

A single center, prospective study was carried out in four years. The data were taken directly from the patients, patient's relatives and the medical records. All patients presenting with bilateral chest trauma, admitted to the hospital overnight, were included in this study. The patients were managed according to the Advanced Trauma Life Support (ATLS) protocol which consists of primary and secondary surveys. For those patients who diagnosed to have either haemo or pneumothorax or both, thoracostomy tube was inserted. Descriptive and analytical analyses were calculated.

The study included 107 patients. Bilateral blunt trauma was found in 72 (67.3%) cases while bilateral penetrating trauma was found in 35 (32.7%) patients. The most common mechanism of trauma was road traffic accidents (RTA) accounting for 68 (63.6%) victims. Overall 30-day mortality was 14.9%. In blunt trauma, 3 or more rib fracture, pulmonary contusion, intubation, and intensive care unit admission were among the predictors of increased risk of mortality.

Bilateral thoracic trauma has comparable patterns of presentation, choices of investigation, strategies of management, predictors of the outcome, morbidity and mortality with unilateral chest trauma.

• • Unilateral chest trauma has been perfectly described in the literature.
• • While bilateral chest trauma has never been specifically probed in the literature.
• • This study highlights the details of bilateral thoracic trauma.

1. Introduction

Trauma is regarded as the most common cause of death in young and middle age groups [ 1 ]. The most frequent body parts involved in serious injuries are the cranium (43%), chest (28%) and abdomen (19%) [ 2 ]. Rib fracture is the most common skeletal insult which can be found in 50% of cases with blunt chest trauma [ 3 ]. During the first hour in the hospital, the most common causes of death are thoracic and central nervous system injuries [ 2 ]. Despite the improved methods of management, chest trauma accounts for 25% of trauma deaths and it plays a major role in as many as a further 50% of in-hospital mortality [ 2 , 4 ]. The morbidity and mortality of trauma patients are significantly affected by the coincidence of chest trauma, which may result in pulmonary capillary leakage syndrome with subsequent interstitial edema, loss of compliance, ventilation/perfusion mismatching, intra-bronchial and intra-alveolar bleeding and an enhanced systemic inflammatory response [ 4 , 5 ]. In general, victims of thoracic trauma have about 10% mortality rate [ 2 ]. Mortality has been reported to be increased three folds (36.3%) when first rib fracture occurs [ 3 ]. From the pathophysiological point of view and impact of the injuries, chest trauma classically has been divided into penetrating and blunt chest trauma. The overall mortality rate of the former is 11.5% [ 2 , 6 ]. Blunt trauma has more variable clinical courses with different mortality rates in various reports ranging from 3% to 25% according to the severity of the trauma and the magnitude of the insult [ 6 , 7 ]. In spite of this, classification of chest trauma into unilateral and bilateral injuries has never been probed in the literature. The impact of the latter on the general health, its risks, strategies of management and outcome are not well understood. The aim of this study is to highlight the presentation, management and outcome of patients presenting with bilateral thoracic trauma.

2.1. Registration

The research registry record has been captured in accordance with the declaration of Helsinki – “Every research study involving human subjects must be registered in a publicly accessible database before recruitment of the first subject”. The study was registered in Chinese Clinical Trial Registry. The registration number was ChiCTR1900021262.

2.2. Study design

This is a single center prospective case series study. The participants were consecutive in order. The paper has been written in line with the PROCESS criteria [ 8 ].

2.3. Setting

The patients were managed in an academic practice setting which is located in Kurdistan-Iraq. The study lasted four years from 1/10/2015 to 1/10/2018. The data were taken directly from the patients, patient's relatives and the medical records. The patients were followed up for an average of two years ranging from 3 months to 4 years. Approval has been granted from the Ethical and Scientific Council of Kurdistan Board for Medical Specialties (KBMS).

2.3.1. Participants

All Patients presenting with bilateral chest trauma, admitted to the hospital overnight, were included in this study. The followings have been precluded from the study: (1) Any patient without bilateral chest trauma. (2) Patient with bilateral chest trauma but for which not admitted to the hospital. (3) Patient with bilateral chest trauma admitted to hospital but discharged within the 24 hours of admission.

2.3.2. Work up and management

The patients were managed according to the Advanced Trauma Life Support (ATLS) protocol consisting of primary and secondary surveys commencing from the airway, breathing, circulation, exposure. Chest-x-ray and eFAST were requested for every patient after stabilization. Chest Computed Tomography scan (CT scan) was taken for patients with suspected major intra-thoracic injuries and those cases with findings unexplained by the chest-x-ray and eFAST. For the patients suspected to have plural collections by clinical examination and/or radiological imaging, appropriate thoracostomy tube was inserted under local anesthesia in the safety triangle.

2.3.3. Who performed the procedures

A team consisting of a specialist, senior house office and nurses performed all the procedure. The first author was the team leader.

2.4. Post-intervention considerations

The patients were kept on intravenous antibiotics (1 g ceftriaxone 1 × 2), analgesic (paracetol bottle 1 × 2) and expectorant (solvodin ampule, 4 mg, 1 × 3) during the hospital stay, while they were advised to receive oral antibiotics (Ciprofloxacin 500 mg x 2) and analgesic (paracetol tablet 500 mg, 1 × 4) at least for the five days following discharge. The patients were followed up in a private clinic.

2.4.1. Statistical analysis

The data were collected and entered into an excel sheet, after coding, they were transferred to the Statistical Package for the Social Sciences (SPSS) software, version 22. Descriptive and analytical analyses were calculated. Relationship between the initial findings and subsequent morbidity and mortality were found using chi square test for nominal variables and T-test for quantitative variables.

The study included 107 patients. Seventy-three (68.2%) patients were male, 34 (31.8%) cases were female. The mean age was 34.98 years with a standard deviation of ±15.81 years, ranging from 7 to 74 years. Blunt trauma was found in 72 (67.3%) cases while penetrating trauma was found in 35 (32.7%) patients, Table 1 .

Basic characteristics of the patients according to the type of the trauma with comparison.

N/A: not applicable.

COPD: chronic obstructive airway disease.

The most common mechanism of trauma was RTA accounting for 68 (63.6%) victims (94% of the blunt thoracic trauma), followed by stab wounds (30, 28%), bullet injuries (5, 4.6%) and fall from height (FFH) (4, 3.7%).

Findings varied between the blunt and penetrating thoracic trauma. Pneumomediastinum occurred in 6 (5.6%) cases while pulmonary contusion was more common and it was found in 23 (21.5%) victims ( Fig. 1 ). Multiple rib fractures were observed in 66 (91.7%) cases (less than 3 ribs in 12 cases, 3–6 ribs in 27 cases, more than 6 ribs in 21 cases, associated sternal fracture in 3 cases and flail segment in 3 cases) ( Fig. 2 ). All of these three findings (pneumomediastinum, contusion and rib fracture) were exclusive to the blunt chest trauma ( Table 2 ).

Computed tomography scan of a 25-year-old male subjected to blunt chest trauma revealing bilateral pulmonary contusion.

Three-D reconstructed computed tomography scan of a young female presented with blunt chest trauma demonstrating multiple rib fractures with sternal fracture.

Findings in both bilateral blunt and penetrating trauma with comparison.

LOC: loss of consciousness.

One hundred and six patients (99.1%) underwent both chest-x-ray and eFAST. One patient (0.9%) died during the resuscitation precluding any sort of investigation. He was a 26-year-old male presented with the disturbed level of consciousness (Glasgow Coma Scale 4), multiple stab wounds to the both anterior chest wall. Myocardium was exposed. Resuscitation was performed including direct cardiac massage without response. Fifty-three (49.5%) patients had a chest CT scan. Overall 30-day mortality was 14.9% (16 cases died). The disturbed level of consciousness on presentation was the most frequent finding among the patients who died 30 days within the insult (10 (62.5%) in the dead group versus 2 (2.2%) in the alive group, P-value <0.001) ( Table 3 ).

Predictors of mortality in bilateral chest trauma.

ICU: intensive care unit.

4. Discussion

Chest trauma is regarded as an influential source of morbidity and mortality in various age groups [ 7 , 9 , 10 ]. Among 22613 cases of blunt chest trauma, Huber and colleagues reported a mean age of 46.1 years [ 10 ]. In the series of Cho et al., which included 130 cases of severe chest trauma, the mean age at the time of the presentation was around 50 years [ 3 ]. Even in the same study and the same geographical region with two different time periods, different age distribution has been reported. Edegbye and associates analyzed their 24-year registry of blunt chest trauma, they divided the participants into two time period, the first and the second dozens of years. The mean age of the cases in the first time period was 38.3 years while it was 56.4 years in the second half [ 9 ]. Regarding this report of bilateral chest trauma, the mean age was near 35 years, being older significantly in the blunt chest trauma (38.26 ± 17.6 years) and younger in the penetrating chest trauma (28.23 ± 7.9), p-value <0.001.

According to most of the reports, blunt thoracic trauma occurs more prevailingly and has a higher mortality rate than penetrating thoracic trauma. Penetrating thoracic trauma generally forms only one-third of the chest trauma patients [ 11 ]. In this regard, bilateral chest trauma may have the same picture as in the current study, two-third of the patients had blunt thoracic trauma and it is significantly associated with a higher risk of mortality (P-value 0.014).

A tattoo is a specific design drawn by inducing an exogenous dye or pigment into the dermis. Worldwide, in the recent few years, the number of persons having body tattoos has increased. Researchers think that it is more than merely a cultural and/or cosmetic habit. It may be a symbol for social rank, or member of a criminal and noncriminal groups, narrates an event, or reveals a personality [ 12 ]. Surprisingly, in this study, the number of patients having body tattoos was significantly higher in the penetrating trauma group than the blunt trauma groups (P-value <0.001). To best of our knowledge, there is no report supporting or rejecting this finding. Further studies are crucial to explain this result.

The most prevalent mechanism of thoracic trauma in this study was RTA, accounting for more than half of the total cases (63.6%) and 94% of the blunt chest trauma, this is in accordance with the international standard for the unilateral chest trauma [ 11 , [13] , [14] , [15] , [16] ]. Rib fracture is a frequent manifestation of blunt chest trauma. It comprises 10% of all trauma admission [ 14 , 16 , 17 ]. It is considered by some studies as a risk factor for increased mortality while others denied this correlation [ 3 , [18] , [19] , [20] , [21] ]. Analysis of a registry by Lien and colleagues which included 18856 patients with rib fracture showed that patients with six or more rib fracture were three times more in risk to die within 24 hours of hospitalization [ 22 ]. In the systematic review of Battle and associates, at least there were four studies which denied the relationship between rib fracture and increased risk of mortality [ 23 ]. In the current study, the rate of mortality significantly increased when there was ≥3 rib fracture.

Pulmonary contusion is another common finding in blunt chest trauma reaching about 30–70% in some reports. It is considered a predictor for the higher morbidity and mortality. This is because of impaired gas exchange, and development of acute respiratory distress syndrome due to systemic and local activation of the immune response [ 24 , 25 ]. The rate of pulmonary contusion found in this report (31.9% of the blunt trauma cases) is relatively lower than the international standard [ 9 , 24 ]. This may be explained by the fact that all patients in this study did not undergo chest CT scan and pulmonary contusion might be missed by plain chest-X-ray [ 25 ].

Pneumomediastinum which is sometime called mediastinal emphysema is defined as a collection of air surrounding the mediastinal contents. In less than 2% of the cases, the etiologies are related to the tracheaobronchial injures and very rarely due to the esophageal injuries while most of the time, the causes and the mechanisms are not known. Macklin effect is a three-step pathophysiological process which was proposed to explain pneumomediastinum in those cases without aero-digestive tract injuries. It includes first, pulmonary contusion with alveolar rupture, second, dissection of the air along the bronchovascular sheath, and lastly, spreading of the air into the mediastinum. However, macklin effect was only observed in 37% of the cases with mediastinal emphysema. Following blunt thoracic trauma, pneumomediastinum has been reported in 2.6%–10% of the cases [ 13 , 14 , 16 ]. According to Mucart and associates, in the absence of aerodigestive tract injuries, pneumomediastinum associated with chest trauma is a benign condition and does not predict increased mortality [ 16 ]. In the current report, pneumomediastinum was found in six (5.6%) of the participants. However, it was found more in those cases died (50%), and the difference was highly significant (P-Value <0.001). Again, this could be explained by the bias created by the omitting chest CT scan in the alive patients as almost all of the dead patients (93.8%) underwent CT Scan [ 14 ].

Securing the airway is the first and the most crucial step in the management of any trauma patient. Endotracheal intubation is an imminent strategy when an airway is about to collapse. However, intubation and subsequent ICU admission are well-recognized to be the two predictors of mortality in chest trauma [ 11 , 14 ]. This correlation was confirmed by the current study (both P-values were <0.001).

5. Conclusion

The patients with bilateral thoracic trauma have comparable patterns of presentation, investigation of choices, strategies of management, predictors of the outcome, morbidity and mortality with unilateral chest trauma. The overall outcome depends on the type of trauma and severity of the insult.

Ethical approval

Ethical approval was given by Ethical and Scientific Committee of Kurdistan Board for Medical Specialties. 28/10/2018. No. 545.

None is found.

Author contribution

Aram Baram: Surgeon supervising the management, revising the manuscript. Final approval of the manuscript.

Fahmi Hussien Kakamad: data collection, drafting the manuscript. Final approval of the manuscript.

Conflicts of interest

None to be declared.

Research registration unique identifying number (UIN)

ChiCTR1900021262 from Chinese Clinical Trial Registry.

Fahmi Hussein Kakamad.

Appendix A Supplementary data related to this article can be found at https://doi.org/10.1016/j.amsu.2019.05.006 .

Appendix A. Supplementary data

The following is the supplementary data related to this article:

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Trauma Management

Aug 21, 2014

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Trauma Management. By: Michael Putnam RN Adapted from ENA; TNCC. Overview. Trauma patients are treated very differently depending on the type hospital you are in People usually attend to the most graphic of injuries first This often lead to other more serious injuries being missed.

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Presentation Transcript

Trauma Management By: Michael Putnam RN Adapted from ENA; TNCC

Overview • Trauma patients are treated very differently depending on the type hospital you are in • People usually attend to the most graphic of injuries first • This often lead to other more serious injuries being missed

Overview con’t • The Emergency Nurses Association (ENA) established a set of evidence based practices that could be used internationally: Trauma Nursing Core Curriculum (TNCC) • In York Region most trauma is diverted to Sunnybrook based on the field trauma triage guidelines • Peads Trauma goes to Sick Kids

Patient Management • A – Airway • B – Breathing • C – Circulation • D – Disability • E – Expose/Environment • F – Five Interventions/Full Vitals • G – Give Comfort • H – History/Head to Toe • I – Inspect the Back

IMPORTANT Like all things they must be done in order. 1 comes before 2 and A comes before B

EMS History Taking MIVT format • Mechanism • Injuries Sustained • Vital Signs • Treatment Rendered

Airway • Assess • Patent? Obstruction? Vocalizing? • Interventions • Suction, Jaw Thrust, OPA, NPA, ETT, NTT, surgical airway. • C – Spine must be maintained!

Breathing • Assess • Breathing? (rate, rhythm) chest symmetry, integrity of chest, accessory muscle use, chest auscultation, trachea position, jugs • Interventions • O2 by NRB • BVM if necessary • Chest tube, chest seal, needle decompression if needed

Circulation • Assess • Pulse? Present? Skin condition, exsanguating trauma, BP (if enough people), heart sounds • Interventions • CPR • Control bleeding, elevate, • IV (2X 14G or 16G): Use warmed solutions when possible or central line? Blood or N/S • Labs • Thoracotomy

A Note on Fluid Resuscitation • Bigger is better…a 14 G peripheral line is better than a 3 Lumen Central Line. • Central Line options • 6 – 8.5F cordis, 2-3 lumen, 1-3 lumen slic • Crystalloid versus colloid • Saline versus Ringers • IV line choices • Gravity versus pump

Disability (mini-neuro) • A- Alert • V – Verbal • P – Painful • U – Unresponsive • Pupils: Size - Equal, Reactive to Light? • GCS… Sum of its parts more important than the total

Secondary • Identify most life threatening injuries by this point • Secondary assessment will identify other minor injuries

Expose/Environment • Removal of all clothing, board straps, etc. • Attempt to maintain warmth where possible • Warmed fluids, blankets

Five Interventions • Monitor with SpO2 and BP (12 lead) maintain SpO2  95% • Foley – Contraindicated? • N/G Tube – Contraindicated? • Labs (if not done in “C”) • Family

Give Comfort • Pain control • Verbal reassurance • Stimuli reduction

History • MIVT • Domestic Violence ? • PmHx, Meds, Allergies, LNMP • Tetanus Status

Head to Toe • Soft Tissue Injuries • Bony Deformities • Full Neuro exam • Eyes, Ears, Nose, Neck • Chest, Abdo, Pelvis, Extremities

Inspect • Roll Patient off Back Board inspect the back/posterior with Log Roll • Keep Neck Stable at all times!

Charting Example • Pt arrived to 14B @1432 CTAS 1 • M – 32 y/o female belted driver into concrete embankment at minimum 100km/h, no airbag, star pattern on windshield, 30 minute extrication time. • I - ? Closed head injury was initially conscious GCS 13 now GCS 3, ? # L femur • V – initially 138/70 HR 110 Resp 24 now 100/50 HR 130 Resp 6 • T – OPA, collar, board, assist resps with BVM, sager to L femur, IV 18 G to R Hand with N/S at KVO • A – clear, no vomit, no blood, no teeth OPA in place no apparent gag, intubation by MD lidocaine 100mg iv @ 1435 etomidate 20mg IV by MD @ 1436 Sux 80mg IV by MD @ 1437. Insert 8.0 ETT 23cm at teeth, positive bilateral breath sounds, and positive ETCO2. Easy to bag. • B – ventilate at 12/min chest clear, no trauma identified, chest stable no crepitus or deformity. • C – pulse 95/min strong and regular. Skin pale warm and dry, B/P 95/40. 2nd iv 14 G into L A/C with N/S at KVO labs drawn from reseal. • D – pupils L 4 R 6 non reactive.

Organ Donation… Salvation from tragedy…

Questions trauma.org

Take Home Points • A,B,C,D • Keep them warm • IV’s bigger the better • Only do what needs to be done to get them out, or does not delay transfer.

Summary • We don’t get much trauma • What we do get we can be better at • Think transfer early

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News & Info

Msc faculty brings further awareness to trauma and substance abuse at 2024 aca conference.

The 2024 American Counseling Association (ACA) conference included an eye-opening presentation by Dr. Sylvia Lindinger-Sternart from the University of Providence and Dr. Varinder Kaur from the University of Detroit Mercy on the intersection of trauma and substance use disorder. Their presentation, “Interrelatedness of Trauma and Substance Abuse,” offered a comprehensive dive into how unresolved traumas can leads to substance use disorders (SUD), and how holistic treatment approaches are so crucial in addressing both trauma and substance use disorders, especially in underserved communities.

Understanding the Connection

The link between trauma and substance abuse disorders (SUD) continues to be an area of important study in the mental health and addiction treatment fields. Trauma , or exposure to an incident or series of events that are emotionally disturbing or life-threatening, can have lasting adverse effects on mental health and can lead to adjacent mental health conditions. In many cases, those who experience significant traumas either in childhood or adulthood are diagnosed with Post-Traumatic Stress Disorder (PTSD) .

The National Center for PTSD estimates that approximately 6% of Americans are likely to experience trauma-related PTSD at some point in their lives. Substance use disorder, a primary derivative factor of trauma-related PTSD, has seen significant increases over the past 10-years. In 2021, an estimated 46.3 million people in the U.S. battled SUD, according to Substance Abuse and Mental Health Services Administration (SAMHSA) .

Ther correlation between trauma-related PTSD diagnosis and SUD is reported by the National Center for PTSD, which reported that 44.6% of individuals diagnosed with PTSD also meet criteria for SUD . This correlation further emphasizes why addressing both trauma-related PTSD and SUD within a dual treatment plan are important to ensuring a more wholistic and sustained recovery. This is especially true when considering the Social Determinants of Health (SDOH) and its impact on the recovery process.

ACA Presentation Focus Points

The presentation by Dr. Lindinger-Sternart and Dr. Kaur outlined a wholistic approach to addressing both trauma-related PTSD and substance use disorders “The presentation discussed the underlying reasons of drug abuse, an analysis on the enabling factor, the reinforcing factors of addiction and the synthesizing of the specific role of integrating cultural traditions into professional counseling through the lens of a holistic approach.” said Lindinger-Sternart, who has worked in both clinical and educational capacities with trauma, PTSD, substance abuse, rehabilitation, and holistic healing approaches.

The topics relevance and the importance of its study drew positive feedback from viewers “The audience was very engaged and provided some positive feedback such as expressing the importance of studying the contributing factors of addiction more in depth in underserved populations who use substances often as a kind of self-medication before they get addicted.” said Lindinger-Sternart.

Preparing Counselors Through Education

The education of future clinicians will play an important role in how these diagnoses are treated in tandem with one another. The University of Providence’s Master of Science in Clinical Mental Health Counseling program provides counseling students with a comprehensive understanding of these vital issues through courses offered in both the core Clinical Mental Health Counseling curriculum and in optional concentrations in Addiction Counseling and Clinical Rehabilitation Counseling.

“The program addresses the topic of unresolved trauma and interrelatedness to substance use disorders in the course of how to counsel the addicted client, crisis intervention, and clinical courses,” said Lindinger-Sternart.  As research and focus on the subject does, so will the need for a specialized course that focuses exclusively on trauma and its connection to SUD and other mental health problems, like depression, and anxiety.

Looking Ahead

The conversation around trauma and substance abuse will continue to grow as awareness of how traumatic experiences, especially in childhood, impact not just our minds but our bodies too. “Traumatic experiences, particularly adverse childhood experiences, impact not only the psychological health but also physiological systems such as heart variability, immune system, and brain development,” Lindinger-Sternart said. Understanding why people turn to substances as a coping mechanism, an oftentimes generational struggle, will help drive the future emphasis on trauma-informed care and a broader understanding of trauma’s ripple effects on health.

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Streamlining processes and standing up HR operations with PwC’s Total Workforce Management solution

From acquisition to autonomy: how a tech company transformed its workforce

• May 29, 2024

A regional tech company faced the challenge of establishing a new company after an acquisition, while also scaling its workforce. To avoid costly transition services agreements (TSAs) and preserve deal value, it needed a rapid HR system separation. The company worked with PwC to swiftly move its enterprise-wide HR operations to SAP and stand up its own system. The solution provides unprecedented visibility across the organization and empowers leadership to make data-driven decisions that improve employee experience.

Regional Tech Company

time and pay accuracy after converting enterprise data from legacy systems over to SAP

faster than industry standard timeline to implement SAP SuccessFactors and Fieldglass for 6,000+ employees and contractors

HR TSAs required post-divestiture, despite accounting for HR and tax nuances in 35 states and 25+ employee unions, which helped preserve deal value

A human-led, tech-powered workforce transformation enables transparency and helps build trust with stakeholders

PwC shares the path to operational efficiency

What was the challenge.

The challenge was managing rapid change amid a complex acquisition . The client needed to physically separate the HR, payroll and operations systems of its newly acquired company to avoid relying on the former owner’s tech infrastructure via costly TSAs.

Speed was key. The goal was to stand up the new systems as quickly as possible without a significant impact on either company’s daily operations, which span 35 states. Simultaneously, the team also had to onboard thousands of employees overnight, causing a rapid scaling of the HR organization.

Describe the solution delivered by the PwC community of solvers

PwC’s Total Workforce Management solution powered by SAP was chosen to streamline HR processes and manage all related operations. This comprehensive, cloud-based HR suite integrates modules like S/4HANA, SuccessFactors and Fieldglass to efficiently handle talent management, learning, recruitment, timekeeping, finance (including financial planning and analysis) and contractor management. The automation tools and data cleansing enabled a smooth transition under a tight deadline, along with accurate financial data posting and streamlined payment processing for both contractors and over 25 employee unions across the business.

Transitions of this magnitude typically take at least 12 to 15 months, but PwC did it in 9 months. The client now has great operational efficiency and workforce management capabilities.

How does the solution blend the strengths of technology and people?

Despite the time constraints, PwC quickly implemented Total Workforce Management and the Experience Suite framework . This is a digital SuccessFactors-driven solution that provides tools to enhance employee upskilling, labor sourcing and localized people management. The solution simplified governance, improved visibility and empowered smarter decisions as the organization grew. Within the Experience Suite, you could see exactly what the system build would look like via a test environment, incorporating standardized practices to meet the deadline as an independent company.

Where or how did innovation and unexpected ways of thinking come into play?

PwC’s Experience Suite framework provided a practical and efficient approach to setting up a new system. This included leading practices and pre-built models based on PwC’s extensive experience with SAP SuccessFactors and Fieldglass implementations. It streamlined project management, reduced decision-making time and minimized complexities. PwC’s fit-to-standard approach also helped provide a standard system setup and HR enhancements to simplify the implementation process. The team’s innovative solutions truly made a difference in the workforce transformation journey.

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Apple Hearing Study shares preliminary insights on tinnitus

Tinnitus Prevalence 

Management of Tinnitus  

Cause of Tinnitus

Characterizing Tinnitus

How Apple Products Can Help

Text of this article

May 28, 2024

Researchers from the University of Michigan release data from one of the largest surveys on tinnitus to date

The Apple Hearing Study is sharing new insights on tinnitus in one of the largest surveys to date.

Through the study, University of Michigan researchers reviewed a cohort of more than 160,000 participants who answered survey questions and completed app-based assessments to characterize their experience of tinnitus. This research aims to improve understanding of tinnitus characteristics and inform future research on potential treatments.

“Roughly 15 percent of our participants experience tinnitus daily,” said Rick Neitzel, University of Michigan School of Public Health’s professor of environmental health sciences. “Tinnitus is something that can have a large impact on a person’s life. The trends that we’re learning through the Apple Hearing Study about people’s experience with tinnitus can help us better understand the groups most at risk, which can in turn help guide efforts to reduce the impacts associated with it. The Apple Hearing Study gives us an opportunity that was not possible before to improve our understanding of tinnitus across demographics, aiding current scientific knowledge that can ultimately improve management of tinnitus.”

Tinnitus, or the perception of sound that others do not hear, can happen to many people in one or both ears. With tinnitus, the sounds can take many forms but are most commonly described as a ringing sound and can be momentary or occur over longer durations. The symptoms and experience of tinnitus can vary significantly from person to person and can change for an individual.

Tinnitus can impact a person’s overall quality of life, for example, disrupting a person’s sleep, concentration, or ability to hear clearly.

A first step toward advancing understanding of tinnitus is to learn more about who experiences it, how the experience differs between people and within an individual over time, the potential causes, and the methods for managing tinnitus and their perceived effectiveness.

The study found that 77.6 percent of participants have experienced tinnitus in their life, with the prevalence of daily tinnitus increasing with age among many. Those ages 55 and up were 3x more likely to hear tinnitus daily compared to those 18-34 years old. Additionally, 2.7 percent more male participants reported experiencing daily tinnitus compared to females. However, 4.8 percent more males stated they had never experienced tinnitus.

In the Apple Hearing Study, participants reported mainly trying three methods to ease their existing tinnitus: using noise machines (28 percent), listening to nature sounds (23.7 percent), and practicing meditation (12.2 percent). Less than 2.1 percent of participants chose cognitive and behavioral therapy to manage their tinnitus.

While there’s no guaranteed method to prevent tinnitus given its complex causes, practicing hearing protection and managing stress levels can lower the chances of tinnitus. In the study, participants cited “noise trauma,” or exposure to excessively high levels of noise, as the primary cause of tinnitus (20.3 percent), followed closely by stress (7.7 percent).

The majority of participants experience brief episodes of tinnitus, compared to 14.7 percent who reported constant tinnitus. The reported duration of tinnitus significantly increases with age among participants 55 and older: 35.8 percent of participants ages 55 and older constantly experience tinnitus. Male participants experience constant tinnitus nearly 6.8 percent more than females.

As for tinnitus levels, the majority found it to be faint, with 34.4 percent calling it noticeable compared to 8.8 percent who found it very loud or ultra loud. Ten percent of participants reported that their tinnitus has moderately or entirely interfered with their ability to hear clearly.

In addition to the survey questions, participants who experienced tinnitus also completed an app-based sound test to better characterize their experience of tinnitus, matching the type and quality of the sounds they experience.

The majority of participants described their tinnitus as either a pure tone (78.5 percent) or white noise (17.4 percent). Among those who described a pure tone, 90.8 percent reported a pitch at 4 kilohertz or above, similar to the tones in a songbird’s call. Additionally, for those who described a pure tone, 83.5 percent identified their tinnitus as a single tone and 16.5 percent identified it as a teakettle tone — a high-pitched, whistling sound.

For participants who matched their tinnitus to a white noise, 57.7 percent identified it as a static tone, 21.7 percent compared it to a cricket tone, 11.2 percent said it was an electric tone, and 9.4 percent identified it as a pulse tone.

The Apple Hearing Study is one of three landmark public health studies in the Research app on iPhone, which launched in 2019 and is ongoing.

Conducted in collaboration with the University of Michigan, the Apple Hearing Study advances the understanding of sound exposure and its impact on hearing health. Researchers have already collected about 400 million hours of calculated environmental sound levels supplemented with lifestyle surveys to analyze how sound exposure affects hearing, stress, and hearing-related aspects of health. Study data will also be shared with the World Health Organization as a contribution to its Make Listening Safe initiative.

Apple technology provides a number of features to support hearing health with just a tap.

Noise app : With the Noise app, Apple Watch users can enable notifications for when environmental noise levels might affect their hearing health. The Health app on iPhone keeps track of a user’s history of exposure to sound levels, and informs whether headphone audio levels or environmental sound levels have exceeded those recommended by World Health Organization standards.

Environmental sound reduction : Apple Watch users can see when the environmental sound level is reduced while they are wearing AirPods Pro and AirPods Max.

Active Noise Cancellation and Loud Sound Reduction mode : Active Noise Cancellation uses the microphone to detect external sounds, which AirPods Pro then counter with anti-noise, canceling the external sounds before a user hears them. For those looking to still enjoy surrounding sounds, Loud Sound Reduction with AirPods Pro (2nd generation) helps reduce loud noises while still keeping the fidelity of sound.

Reduce loud audio : To set a headphone volume limit, users can go into Settings, then tap Sounds & Haptics (on iPhone 7 and later) or Sounds (for earlier models). They’ll then tap Headphone Safety, where they can turn on Reduce Loud Audio and drag a slider to a preferred decibel level.

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