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C L I N I C A L

Pediatric Emergency Medicine

Vol 11, No 1 Editor
Steven E. Krug,
FAAP MD,

March 2010

Feinberg School of Medicine, Northwestern University, Childrens Memorial Hospital, Chicago, IL

Advances In Pediatric Trauma

Harold K. Simon, MD, MBA Guest Editor

GUEST EDITORS PREFACE . . . . . . . . . . . Pediatric Trauma: A Roadmap for Evidence-Based, Patient-Centered Coordination and Care
Harold K. Simon

4 . . . . . . . . . . Golden Hour or Golden Opportunity: Early Management of Pediatric Trauma

Wendalyn K. Little

10 . . . . . . . . . Prehospital Management of Pediatric Trauma

Manish I. Shah

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

22 . . . . . . . . . Radiographic Evaluation of the Pediatric Trauma Patient and the Risk for Ionization
Radiation Exposure
Ricardo R. Jimnez

28 . . . . . . . . . Analgesia for the Pediatric Trauma Patient: Primum Non Nocere?

Michael Greenwald

41 . . . . . . . . . When There Are no Inpatient Beds: Pediatric Intensive Care Level Management of
Trauma Patients in the Emergency Department
Toni Petrillo-Albarano and Wendalyn K. Little

48 . . . . . . . . . Pediatric Patients in the Adult Trauma BayComfort Level and Challenges

Kimberly P. Stone and George A. Woodward

57 . . . . . . . . . Mental Health Consequences of Trauma: The Unseen Scars Michael Finn Ziegler
W.B. Saunders

www.clinpedemergencymed.org

GUEST EDITOR'S PREFACE

Pediatric Trauma: A Roadmap for EvidenceBased, Patient-Centered Coordination and Care

By Harold K. Simon, MD, MBA

or children younger than 14 years, there has been a dramatic and steady decline over the past 2 decades in injury-related mortality from 9427 deaths in 1986 (age-adjusted rate of 18.04/100 000) to 6530 in 2006 (age-adjusted rate of 10.59/ 100 000).1 Many factors contribute to this improvement including injury prevention strategies as well as treatment and aftercare of trauma patients. Although tremendous strides have been made, injury remains a leading cause of morbidity and mortality in the United States and is especially concerning within the pediatric population where trauma can rob years of happiness and productivity. This issue of Clinical Pediatric Emergency Medicine focuses on the complete spectrum of pediatric trauma care, beginning with the initial golden hour, emergency medical services care at the scene, through critical care management. It incorporates perspectives from pediatric emergency medicine physicians, emergency medical services providers, and critical care physicians. It will address present state of care, improvement strategies, and potential areas that can help us not only decrease mortality but do so in a cost-effective manner cognizant of facility and manpower resource limitations. Unlike many previous antholo-

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

gies on the subject, it will also take into perspective a more patient-centered approach to what can be done with new and emerging technologies, taking into account long-term implications when considering what interventions are most beneficial to the patient in the immediate care situation. It will look at questions such as the risk vs benefits of computed tomographic scanning in light of radiation exposure. This issue will address topics such as coordination of care between subspecialties, transitions of care, and care of pediatric trauma patients in adult-based centers. It will, however, go beyond the traditional bounds and will touch on the more holistic approach to care that can and should be part of our broader perspective on pediatric trauma management. This will include sections on pain control as well as posttraumatic stress disorder recognition and prevention. Trauma care has emerged from its infancy in the latter part of the 21st century as a focus of modern medicine. Military experiences have helped push the envelope of trauma care and continues to help us mold our perspectives, knowledge, and treatment of trauma.2,3 Trauma centers have been proven to have a positive impact on patient management, ultimately leading to decreased mortality.4 Pediatric trauma care has, however, as is the case in most areas of pediatric medicine, taken a backseat to much of the initial focus that has been adult patient based. It was not until the development of the

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

Emergency Medical Services for Children program in 1984 and the Institute of Medicine report on Emergency Medical Services for Children that pediatric trauma care began to separate itself out as a functionally distinct discipline.5,6 Evidence has mounted over the years that regionalized centers with pediatric equipment, personnel, and expertise have contributed to the overall improvement in pediatric trauma management.7-9 In addition, coordinated aftercare in centers with pediatric surgeons and pediatric critical care physicians has improved outcomes. Differences in operative vs supportive treatment of the pediatric patient as compared with the adult trauma patient, especially for blunt abdominal trauma, and comfort levels and expertise with the pediatric patient may contribute to these effects.10 Consensus opinion and present standards for field triage of pediatric trauma patients support the direction of those children meeting trauma criteria to a pediatric capable trauma center.11 Many communities do not have the volume of patients or resources required to support designated pediatric trauma centers. Facilities within communities that do have this volume are often stretched beyond their functional capacity given the prevalence of emergency department overcrowding and the use of emergency departments as the safety net for medical care for many underserved populations.12,13 These factors, along with the shear cost of keeping trauma centers available 24/7 in communities that may not have the required resources, make it even more important to develop trauma centers within wellcoordinated regional systems to best transport, stabilize, and definitively care for critically injured children.11,14 However, today, fewer than 200 pediatric trauma centers exist in the United States; and more than 28% of children younger than 15 years are more than 1 hour from such centers by ground or by air transport. This disparity is even greater in rural areas, where 77% of children are more than 1 hour from such centers.15 Given the critical importance of stabilization within the golden opportunity for care, we have a long way to go in coordinating such care and establishing centers capable of providing optimal management to this vulnerable population. This points to a need to expand access to pediatric trauma care for greater numbers of children and to continue to grow and enhance the networks available. Those centers that do exist need to fully coordinate care over large catchment areas with the necessary support systems and transfer protocols to best serve the children throughout their regions. These items will be among those addressed in this series of articles and are some of the most challenging issues faced as we seek to continue to expand and enhance pediatric trauma networks.

Even when we are fortunate enough to have an abundance of resources or tertiary care pediatric facilities in a region, we must also determine if we are using our resources appropriately and, in doing so, delivering evidence-based, highest-quality care. Technology simply for technology's sake may not always lead to the best outcomes. We must therefore critically evaluate the sensitivities and specificities of such advancements as well as balance the longterm effects and costs (financial and even adverse medical) that can come from their usage. Examples such as focused assessment sonography in trauma examinations and their use in the pediatric population, screening laboratories, and radiologic studies must all be critically evaluated.16-20 The present state of knowledge and risks vs benefits of each will be addressed. Lastly, patient- and family-centered care needs to be at the forefront of what distinguishes the management of pediatric trauma.21 Having the proper equipment and personnel for the basic trauma needs of children of all ages remains essential. However, recognition of the need to treat both patients and their families can help bring a more holistic approach to meeting the needs of our most vulnerable patients and their families. Consideration of the entire child and his or her family, and not just the injury (eg, the fracture in room one), remains a crucial part of the challenge set forth in pediatric trauma care. Health care providers tend to underrecognize, undertreat, and fail to prevent pain and anxiety in children, and limit the impact of these stressors related to trauma.21 This issue will therefore also address pain management of the pediatric trauma patient, posttraumatic stress disorder recognition, and prevention strategies. Although we still have a long way to go to optimize the care of injured children, this series should act as a roadmap for the broad range of care providers treating pediatric trauma patients.

REFERENCES
1. National Center for Injury Prevention and Control. WISQARS Injury Mortality Reports, 1999 - 2006. Available at: http:// webapp.cdc.gov/sasweb/ncipc/mortrate10_sy.html. Accessed 1/15/10. 2. Mullins RJ. A historical perspective of trauma system development in the United States. J Trauma 1999;47(Suppl 3): S8-S14. 3. Berger E. Lessons from Afghanistan and Iraq: the costly benefits from the battlefield for emergency medicine. Ann Emerg Med 2007;49:486-8. 4. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma center care on mortality. N Engl J Med 2006;354:366-78.

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

5. The Preventive Health Amendments of 1984, Pub. L. 98-555 7, 98 Stat. 2854, 2856 (1984) (codified as amended at 42 U. S.C. 300w-9). 6. Institute of Medicine Committee on Pediatric Emergency Medical Services. In: Durch JS, Lohr KN, editors. Emergency medical services for children. Washington, DC: National Academy Press; 1993. 7. Hall JR, Reyes HM, Meller JT, et al. Outcome for blunt trauma is best at a pediatric trauma center. J Pediatr Surg 1996;31:72-7. 8. Potoka DA, Schall LC, Ford HR. Improved functional outcome for severely injured children treated at pediatric trauma centers. J Trauma 2001;51:824-34. 9. Bensard DD, McIntyre RC, Moore EE, et al. A critical analysis of acutely injured children managed in an adult level I trauma center. J Pediatr Surg 1994;29:11-8. 10. Farrell LS, Hannan EL, Cooper A. Severity of injury and mortality associated with pediatric blunt injuries: hospitals with pediatric intensive care units vs. other hospitals. Pediatr Crit Care Med 2004;5:5-9. 11. Centers for Disease Control and Prevention. Guidelines for field triage of injured patients: recommendations of the national expert panel on field triage. MMWR 2009;58:RR-1. 12. OConnor RE. Specialty coverage at non-tertiary care centers. Prehosp Emerg Care 2006;10:343-6. 13. Millin MG, Hedges JR, Bass RR. The effect of ambulance diversions on the development of trauma systems. Prehosp Emerg Care 2006;10:351-4.

14. Taheri PA, Butz DA, Lottenberg L, et al. The cost of trauma center readiness. Am J Surg 2004;187:7-13. 15. Nance ML, Carr BG, Branas CC. Access to pediatric trauma care in the United States. Arch Pediatr Adolesc Med 2009; 163:512-8. 16. Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg 2007;42:1588-94. 17. Holmes JF, Mao A, Awasthi S, et al. Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Ann Emerg Med 2009;54: 528-33. 18. Blackwell CD, Gorelick M, Holmes JF, et al. Pediatric head trauma: changed tomography in emergency departments in the United States over time. Ann Emerg Med 2007;49: 320-4. 19. Brenner DJ, Hall EJ. Computed tomography - an increasing source of radiation exposure. New Engl J Med 2007;357: 2277-84. 20. Jimenez RR, DeGuzman MA, Shiran S, et al. CT versus plain radiographs for evaluation of c-spine injury in young children: do benefits outweigh risks? Pediatr Radiol 2008; 38:635-44. 21. Ziegler M, Grenwald MH, DeGuzman MA, et al. Posttraumatic stress responses in children: awareness and practice among a sample of pediatric emergency care providers. Pediatrics 2005;115:1261-7.

The concept of a golden hour is a fixture in trauma care. There is a dearth of scientific proof for this concept but an abundance of controversy around how this concept should be interpreted, especially for pediatric trauma patients. Health care providers should instead focus on the golden opportunity, different for each patient, to provide the best care in the most appropriate environment for all injured children.

Abstract:

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

Golden Hour or Golden Opportunity: Early Management of Pediatric Trauma

Wendalyn K. Little, MD, MPH

There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks laterbut something has happened in your body that is irreparable. R Adams Cowley MD1

Pediatrics and Emergency Medicine, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Childrens Healthcare of Atlanta, Atlanta, GA. Reprint requests and correspondence: Wendalyn Little, MD, MPH, Pediatric Emergency Medicine, 1645 Tullie Circle, Atlanta, GA 30329. wendalyn.little@choa.org
1522-8401/$ - see front matter 2010 Elsevier Inc. All rights reserved.

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

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

THE GOLDEN HOUR

The term golden hour is a fixture in the lexicon of trauma care. The phrase refers to a critical period in the care of trauma patients during which appropriate care may limit morbidity and increase survival. The origin of this term is difficult to trace. It may have evolved from an early description of the relationship between survival and time from injury to treatment on the battlefields of World War I. This analysis of French military data showed a decrease in mortality from battle wounds from 10% within 1 hour of treatment to 75% at 8 hours postinjury.2 More recent medical literature often attributes the phrase golden hour to trauma surgeon R. Adams Cowley, MD, one of the early champions of organized trauma care. Dr Cowley conducted trauma research and wrote and spoke extensively on the subject of trauma care, and the coining of the term golden hour is often attributed to his speeches, yet none of his publications mentions or tests the theory of a golden hour in trauma care.2,3 Modern support for the golden hour concept began in the 1960s when trauma care in the United States was in its infancy and civilian trauma systems were nonexistent. Military data from each of the world wars, the Korean Conflict and the war in Vietnam, show decreased combat mortality with the development of faster, more organized systems for the transport of injured troops from the battlefield to medical care facilities.3,4 This increased survival was attributed in part to faster evacuation of wounded soldiers from the battlefield to the hospital by way of helicopter transport.4 The 1960s and 1970s saw an increased interest in civilian trauma care. Federal legislation led the way for funding emergency medical services (EMS) standards and training. The American College of Surgeons published the first of many guidelines for trauma care in 1976.4 Pioneers such as Dr Cowley championed trauma care as a specialty with its roots in general surgery.5 Helicopter transport began to be seen as a means of quickly moving injured patients to hospitals; some hospitals began to devote specialized resources and teams to care for trauma victims, and the concept of regionalized trauma systems gained support from health care providers and governing bodies.4,6

TRAUMA SYSTEMS AND TRANSPORT TO TRAUMA CENTERS

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

improved outcomes for severely injured patients cared for in dedicated trauma centers.7,8 A core principal in many of these systems is the belief that critically injured patients are best cared for in designated trauma centers, even if transport from the field to these centers bypasses closer medical facilities. The combination of the concepts of the golden hour and the importance of trauma centers has been the impetus for the development of EMS policies such as rapid scene triage, minimization of on-scene treatment interventions in favor of rapid transport to emergency departments, and air evacuation of severely injured patients directly from the site of injury to designated trauma centers. These practices are not without cost, in money for equipment and staffing of helicopter transport and EMS resources. They are also not without risk to EMS teams, patients, and bystanders when priority is placed on rapid transport, sometimes across great distances.9 A common debate in trauma system development centers on whether patients should be transferred longer distances to trauma centers or to the closest available facility, where initial stabilization may be performed, and then those patients determined to need further specialty care are then transferred to a trauma center. Much of the current literature supports a varied approach based on geographic location. In urban areas, where level I trauma centers are often readily available, it may make sense to bypass closer facilities to reach the trauma facility, as differences in transport times are likely to be minor. In rural areas, however, transport times to trauma centers may be prolonged, and patients may benefit from stabilization in a closer facility followed by transfer to a trauma center after initial stabilization. Effective trauma systems must therefore take into account the location and capabilities of the facilities within a geographic catchment area, as well as any traffic or geographical features that may impact transport times. This approach to establishing effective trauma systems is perhaps best characterized by the 3R rule attributed to pioneering trauma surgeon Dr Donald Trunkey of getting the right patient to the right place at the right time.10 Some patients may have only minutes to survive without appropriate intervention, whereas some may survive their initial injuries but need specialized care and rehabilitation to achieve maximum postinjury function. This concept might well be the best guiding principle of trauma management, and the immediate postinjury period might best be thought of as a golden opportunity to ensure prompt, appropriate treatment for each and every injured patient.

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

PEDIATRIC TRAUMA AND TRAUMA CENTERS

If the concept of a golden hour and its relationship to trauma systems is controversial and unproven in adults, it is even more so for pediatric trauma patients. The development of pediatric emergency medicine as a specialty has promoted the creation of pediatric trauma centers, some as part of freestanding children's hospitals and others within general/adult facilities. Pediatric trauma care continues to evolve as a distinct facet of trauma care that recognizes the different anatomical, physiologic, and developmental realities of pediatric patients as well as the different injury patterns seen in these patients. The development and concentration of pediatric expertise has improved the management of injured children, with patients cared for in pediatric trauma centers appearing to have equal or better outcomes overall when compared to pediatric patients cared for in general or adult trauma centers.11-17 Many factors likely contribute to this positive effect including the availability of appropriately sized equipment and monitoring capabilities for pediatric patients, health care providers capable of recognizing and treating the early, often subtle, signs of shock in pediatric patients, and management strategies unique to pediatric injuries. Despite evidence to suggest better outcomes for pediatric trauma victims treated in pediatric trauma centers, most pediatric trauma victims are cared for, at least initially, in nonpediatric centers, as the number and geographic location of dedicated pediatric centers leaves many children out of reach for immediate care.12,13 The question that therefore arises is not only does a golden hour exist for the treatment of pediatric trauma patients, but also, what should occur during that initial time frame. One aspect of this debate centers on whether pediatric trauma patients should be transported directly to pediatric centers, possibly bypassing other emergency facilities or trauma centers on the way to specialized pediatric care, or should they be stabilized at the closest capable facility and then transferred to specialized pediatric centers if their condition warrants. It is worrisome that pediatric patients may be subjected to longer transport times, possibly bypassing adult trauma facilities to reach pediatric centers, as EMS providers often do not have great familiarity or experience with critically ill or injured children. The EMS pediatric volumes are often quoted as around 10% of EMS calls, with less than 1% of these patients meeting the definition of critically ill. The EMS personnel may have difficulty

performing procedures such as intravenous access, endotracheal intubation, and appropriate cardiopulmonary resuscitation on pediatric patients.14,15 There is literature to suggest similar outcomes for pediatric patients ventilated by means of bagging instead of endotracheal intubation in cases of respiratory failure, suggesting that intubation should not be attempted in the field for pediatric patients in urban locations where transport times to hospital emergency departments is fairly short.15 Another study examining the effectiveness of pediatric helicopter transport showed no benefit for patients transported directly from the scene of injury to a pediatric trauma center as compared with those initially stabilized at the closest medical facility.17 All of this information could be interpreted that time spent in EMS transport of critically ill and injured children should be minimized, and these patients should be transported to the closest facility able to provide stabilizing, if not definitive, care.

EMERGENCY DEPARTMENT READINESS FOR CHILDREN

If pediatric patients are to be transported to non pediatric-specific hospitals, the emergency departments at these facilities must be capable of assessing pediatric trauma patients and providing stabilizing care (also see article Pediatric Patients in the Adult Trauma BayComfort Level and Challenges, in this issue). Although most emergency department visits in the United States involving children occur in nonpediatric facilities, many of these facilities are underprepared to deal with critically ill or injured children. In 2001, the American Academy of Pediatrics and the American College of Emergency Physicians established a set of guidelines for pediatric emergency department preparedness.18 These guidelines, which were recently updated in 2009, address equipment, training, and quality review for pediatric care in emergency departments.19,21 Surveys evaluating preparedness continue to show inadequate preparation in equipment and training for pediatric patients.13,20,22 Nonpediatric centers often transfer seriously ill or injured patients to pediatric centers for definitive care. The presence of a seriously injured child may engender a sense of anxiety in the emergency department and has the potential to create a stress-laden atmosphere in which recognition and treatment of lifethreatening shock and respiratory failure go unaddressed and untreated in attempts to get the patient out of the facility and enroute to a pediatric

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

specialty center as quickly as possible. Missed injuries on an initial trauma survey are a common problem, and there is some evidence from adult studies that seriously injured patients transferred from rural hospitals to trauma centers frequently have unrecognized injuries.23,24 This suggests that patients may have injuries overlooked in favor of rapid transport to a trauma center. This problem may be even more widespread for pediatric patients in similar situations. Recent literature supports early recognition and treatment of shock and respiratory failure as important in improving ultimate survival and outcome of critically ill or injured patients, both adult and pediatric.25,26 Similarly, neurologic outcome has been shown to improve with early appropriate resuscitation and monitoring of children with traumatic brain injury.27 Unfortunately, studies of pediatric patients transferred to pediatric centers describe deficiencies in the detection and treatment of shock, hypotension, and respiratory failure before transfer.18,25,26

INITIAL STABILIZATION OF INJURED CHILDREN

So what should be the scope of the evaluation and stabilization of pediatric trauma patients in general trauma facilities or community hospitals? A primary survey focusing on airway, breathing, and circulation should be undertaken and any lifethreatening conditions corrected. All patients should be placed on supplemental oxygen. Advanced airway management in the form of endotracheal intubation may be needed in patients with severe traumatic brain injury, thoracic injuries, or shock. Adequate oxygenation and ventilation should be ensured. A portable chest radiograph to evaluate for pneumothorax may be helpful. Placement of a thoracostomy tube should be pursued for most cases of pneumothorax. Close attention should be paid to the child's hemodynamic status. Health care providers must keep in mind that the strong compensatory mechanisms in children and teenagers allow them to increase their systemic vascular resistance and maintain blood pressure until a substantial amount of blood is lost.19,28 Early signs of shock such as tachycardia, mental status, and capillary refill time are more sensitive and should be monitored closely. An initial fluid bolus of isotonic saline should be administered and repeated as needed. Blood component transfusion should be considered for patients not responding to crystalloid resuscitation or for those with evidence of ongoing hemorrhage.27 Patients with immediately life-

threatening hemorrhage would seem to be candidates for immediate transfer to a trauma center with pediatric surgeons and a pediatric intensive care unit but at times may require the services of a general surgeon, if available, to control hemorrhage before transport. Most pediatric trauma is caused by blunt mechanism of injury such as falls, motor vehicle collisions, assault, and sporting activities. Most patients will not require emergent surgical intervention. Pediatric trauma specialists have led the development of protocols for expectant, nonoperative management of some conditions, namely liver and splenic injuries. In adult-oriented systems, these injuries are generally treated surgically, whereas children cared for in pediatric centers are usually managed nonoperatively. Therefore, pediatric patients undergo fewer laparotomies and splenectomies than do adult patients.29,30 The golden hour for these patients might best be spent ensuring adequate oxygenation and ventilation, securing an airway if needed, obtaining vascular access, and providing initial fluid resuscitation if needed. Patients with traumatic brain injury must be carefully monitored, and hypotension and hypoxia avoided as both of these states have been found to be independent predictors of increased mortality in patients with traumatic brain injury. Pediatric patients with isolated brain injuries may best be stabilized at the closest medical facility in which these conditions may be recognized and corrected as needed. Transport could then be undertaken in a controlled fashion and preferably with a specialized pediatric critical care transport team. Time should not be spent obtaining computerized tomography and other extensive imaging studies if the facility lacks the surgical capabilities to provide definitive care for injuries detected on imaging or if obtaining scans will delay transport. Scans may inadvertently fail to be transported with the patient or, in the case of digital images, transferred by compact disk, inaccessible at the receiving facility, thus, necessitating repeat imaging with increased costs and unnecessary radiation exposure to the patient. In fact, one study found that almost all radiographs performed at referring facilities were later repeated when patients arrived to the trauma center.31 Once critically ill or injured children are stabilized and the decision is made to transfer to a pediatric trauma center, attention must then be turned to the best mode of transfer. One recent study showed significantly more complications and deaths (23% mortality vs 9% mortality) among pediatric patients transferred from referring facilities to a pediatric trauma center by general helicopter teams vs specialized pediatric teams.

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

This remained true even when corrected for patient mix and the greater average time from referral to arrival in the pediatric center among patients transported by the specialty teams. The authors speculate that despite overall longer transport times, the patients transported by the specialized team actually benefited from an overall longer period in the care of pediatric specialists.18 This concept of bringing the hospital to the patient may in fact be a critical piece of care that is currently lacking in many trauma systems. Several studies have shown that transport by specialty-trained mobile intensive care unit teams is associated with improved outcomes, even if such transport delays ultimate patient arrival at the tertiary care center.18,19 , 28-44

ongoing treatment vs awaiting transfer and be capable of recognizing and responding to evolving clinical changes in pediatric patients.

SUMMARY
Certainly, no one would argue that timely care is best for critically ill and injured persons. However, the exact meaning and significance of a golden hour in trauma care is the subject of debate and controversy. So is there a golden hour? If there is, then what should occur during this time? Should this time be spent transferring a patient from the scene to a major trauma center, even if it is not the closest facility? Or should patients be stabilized at the closest medical facility before transfer? Furthermore, how do the concepts of a golden hour and trauma system care apply to pediatric patients? Perhaps, the answers lie somewhere in between, and rather than a golden hour, health care providers should focus on the golden opportunity to provide stabilization of immediately life-threatening conditions at the closest appropriate facility followed by safe transfer when needed for definitive care. True realization of this opportunity for pediatric trauma patients requires individualized consideration for each patient within well-established and well-coordinated systems of regionalized trauma care.

THE GOLDEN OPPORTUNITY

So what is the best care for pediatric trauma patients? How can a system capitalize on the golden opportunity to provide the right care in the right place at the right time? Creation of regionalized trauma systems to ensure timely access to basic evaluation and stabilization for all patients is vital.45 This may require initial transport of pediatric trauma patients to general emergency facilities, especially in rural areas without immediately available pediatric trauma centers. These facilities must be capable of evaluating and stabilizing pediatric trauma patients. Appropriately sized equipment and monitoring capabilities must be present. Staff must have skills in the assessment and stabilization of pediatric patients, especially in the management of shock and real or impending respiratory failure. Pediatric patients with severe or life-threatening injuries, especially those in need of intensive care unit-level care, should then be transferred to appropriate pediatric trauma facilities as rapidly as possible after initial stabilization of any immediately life-threatening conditions. The criteria for transfer and mechanisms for referral and transfer must be put in place and maintained. Transfer agreements between general and pediatric trauma centers must be well designed with prompt, easily accessed communication readily available between facilities to expedite transfers. Careful consideration should be given to the mode of transfer and composition of the transport team. For many pediatric patients, this may mean awaiting the arrival of specialized transport teams from the receiving institution. In these situations, personnel at the referring facility must be capable and remain committed to caring for the patient until the team arrives. They must adopt a mentality of

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26.

jscripts/tinymce/plugins/filemanager/files/About%20Trauma %20Care_Golden%20hour.pdf. Accessed 10/27/2009. Potoka DA, Schall LC, Gardner MJ, et al. Impact of pediatric trauma centers on mortality in a statewide system. J Trauma 2000;4:237-45. Potoka DA, Schall LC, Ford HR. Improved functional outcome for severely injured children treated at pediatric trauma centers. J Trauma 2001;51:824-34. Odetola FO, Miller WC, Davis MM, et al. The relationship between the location of pediatric intensive care unit facilities and child death from trauma: a county-level ecologic study. J Pediatr 2005;147:74-7. Osler TM, Vane DW, Tepas JJ, et al. Do pediatric trauma centers have better survival rates than adult trauma centers? An examination of the national pediatric trauma registry. J Trauma 2001;50:96-101. Farrell LS, Hannan EL, Cooper A. Severity of injury and mortality associated with pediatric blunt injuries: hospitals with pediatric intensive care units versus other hospitals. Pediatr Crit Care Med 2004;5:5-9. Nakayam DK, Copes WS, Sacco W. Differences in trauma care among pediatric and nonpediatric trauma centers. J Pediatr Surg 1992;27:427-31. Hall JR, Reyes HM, Meller JL, et al. The outcome for children with blunt trauma is best at a pediatric trauma center. J Pediatr Surg 1996;31:72-7. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, American College of Emergency Physicians, Pediatric Committee. Care of children in the emergency department: guidelines for preparedness. Pediatrics 2001;107:777-81. Gausche-Hill M, Krug SE, American Academy of Pediatrics Committee on Pediatric Emergency Medicine American College of Emergency Physicians Pediatric Committee, Emergency Nurses Association, Pediatric Committee. Guidelines for the children in the emergency department. Pediatrics 2009;124:1233-43. Nance ML, Carr BG, Branas CC. Access to pediatric trauma care in the United States. Arch Pediatr Adolesc Med 2009;163:512-8. Athey J, Dean M, Ball J, et al. Ability of hospitals to care for pediatric emergency patients. Pediatr Emerg Care 2001;17: 170-4. Gausche M. Differences in the out-of-hospital care of children and adults: more questions than answers. Ann Emerg Med 1997;29:776-9. Kumar VR, Bachman DT, Kiskaddon RT. Children and adults in cardiopulmonary arrest: are advanced life support guidelines followed in the prehospital setting. Ann Emerg Med 1997;29:743-7. Seidel JS, Hornbein M, Yoshiyama K, et al. Emergency medical services and the pediatric patient: are the needs being met. Pediatrics 1984;73:769-72. Seidel JS. Emergency medical services and the pediatric patient: are the needs being met? II. Training and equipping emergency medical services providers for pediatric emergencies. Pediatrics 1986;78:808-12. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-ofhospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA 2000; 283:783-90.

27. Larson JT, Dietrich AM, Abdessalam SF, Werman HA. Effective use of the air ambulance for pediatric trauma. J Trauma 2004;56:89-93. 28. Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric preparedness of US emergency departments: a 2003 survey. Pediatrics 2007;120:1229-37. 29. Aaland MO, Smith K. Delayed diagnosis in a rural trauma center. Surgery 1996;120:774-9. 30. Robertson R, Mattox R, Collins T, et al. Missed injuries in a rural area trauma center. Am J Surg 1998;12:564-8. 31. Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics 2003;112: 793-9. 32. Carcillo JA, Kuch BA, Han YY, et al. Mortality and functional morbidity after use of PALS/APLS by community physicians. Pediatrics 2009;124:500-8. 33. Zebrack M, Dandoy C, Hansen K, et al. Early resuscitation of children with moderate-to-severe traumatic brain injury. Pediatrics 2009;124:56-64. 34. Orr RA, Felmet KA, Han Y, et al. Pediatric specialized transport teams are associated with improved outcomes. Pediatrics 2009;124:40-8. 35. American Heart Association. PALS provider manual. Dallas (Tex): American Heart Association; 2002. 36. American College of Surgeons. Advanced Trauma Life Support for Doctors. 7th ed. Chicago (Ill): American College of Surgeons; 2004. 37. Davis DH, Localio AR, Stafford PW, et al. Trends in operative management of pediatric splenic injury in a regional trauma system. Pediatrics 2005;115:89-94. 38. Mooney DP, Rothstein DH, Forbes PW. Variation in the management of pediatric splenic injuries in the United States. J Trauma 2006;61:330-3. 39. Keller MS, Vane DW. Management of pediatric blunt splenic injury: comparison of pediatric and adult trauma surgeons. J Pediatr Surg 1995;30:221-5. 40. Hall JR, Reyes HM, Meller JL, et al. The outcome for children with blunt trauma is best at a pediatric trauma center. J Pediatr Surg 1996;31:72-7. 41. Thomas SH, Orf J, Peterson C, et al. Frequency and costs of laboratory and radiograph repetition in trauma patients undergoing interfacility transfer. Am J Emerg Med 2000;18: 156-8. 42. Bellingan G, Oliver T, Batson S, Webb A. Comparison of a specialist retrieval team with current United Kingdom practice for the transport of critically ill patients. Intensive Care Med 2000;26:740-4. 43. Valenzuela TD, Criss EA, Copass MK, et al. Critical care air transportation of the severely injured: does long distance transport adversely affect survival. Ann Emerg Med 1990;19: 169-72. 44. McPherson ML, Graf JM. Speed isn't everything in pediatric medical transport. Pediatrics 2009;124:381-3. 45. Tuggle D, Krug SE, American Academy of Pediatrics, Section on Orthopedics, Committee on Pediatric Emergency Medicine, Section on Critical Care, Section on Surgery, Section on Transport Medicine, Pediatric Orthopedic Society of North America. Management of pediatric trauma. Pediatrics 2008; 121:849-54.

Abstract:
A limited body of literature about pediatric prehospital trauma care exists to date. Topics that have been studied include delaying transport to initiate treatment on-scene, the use of advanced life support or basic life support resources, identifying high-risk pediatric trauma patients, optimal airway management, obtaining intravenous or intraosseous access, immobilization of the cervical spine, optimal management of traumatic brain injury, and the assessment and management of pain. Translating the best available evidence into clinical practice is important to providing quality prehospital pediatric trauma care. This article will review the literature regarding the risks and benefits of various aspects of pediatric trauma care in the prehospital setting.

Prehospital Management of Pediatric Trauma

Manish I. Shah, MD
ecent estimates from the National Hospital Ambulatory Medical Care Survey database note that 27% of all emergency department (ED) visits in the United States are by children younger than 19 years, and 13% of all patients transported via Emergency Medical Services (EMS) are children. Although the percentage of children who require EMS is small relative to adults, the acuity of pediatric EMS patients is often higher than that of adults. This is especially true with trauma, in which 54% of pediatric trauma patients arrive to the ED via EMS.1 As the EMS system in the United States was originally designed to meet the needs of adults, the integration of the unique needs of children into the existing EMS infrastructure has been one of the main goals of the federally funded Emergency Medical Services for Children program for the past 25 years.2 Twenty years ago, Ramenofsky3 described essential components of an integrated pediatric trauma system that addressed system design, prevention, education, standards of care, research and development, quality assurance, and funding. Successfully integrating the needs of children into the existing EMS infrastructure involves initiating high-quality prehospital care that uses preestablished protocols. These protocols must then be applied by skilled emergency medical technicians (EMTs) with the assistance of online medical control until ultimate transport to an appropriate facility capable of providing definitive care. Although much has been accomplished in each of these areas for pediatric trauma, there are still many areas that have not been adequately addressed. One of these is the incorporation of evidence-based practices into prehospital care. This concept was highlighted in the recent Institute of Medicine (IOM) report, The Future of Emergency Care, which describes the importance of extending evidence-based practices into prehospital care.4 Although the prehospital pediatric literature is limited to date, evaluating the literature for risks and benefits of various aspects of pediatric trauma care in the prehospital setting is an important

Keywords:
pediatric trauma; intravenous access; intraosseous access; cervical spine immobilization; traumatic brain injury; prehospital care; airway; emergency medical services

Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine, Houston, TX. Reprint requests and correspondence: Manish I. Shah, MD, Texas Childrens Hospital, 6621 Fannin Street, MC 1-1481, Houston, TX 77030. mxshah@texaschildrens.org
1522-8401/$ - see front matter 2010 Elsevier Inc. All rights reserved.

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way to determine the value of certain decisions in the field. These include delaying transport to initiate treatment on-scene, the use of advanced life support (ALS) or basic life support (BLS) resources, identifying high-risk pediatric trauma patients, optimally managing the airway, obtaining intravenous (IV) or intraosseous (IO) access, immobilization of the cervical spine, optimal management of traumatic brain injury, and the assessment and management of pain. Each of these areas has been controversial in the management of pediatric trauma patients, and examination of the literature is important in determining local protocols.

PREHOSPITAL TRIAGE AND TRANSPORT

Regionalizing trauma care has demonstrated improved outcomes in pediatric trauma and has been recommended by the IOM.4,9 Determining which patients are at high risk for mortality or need specialized treatment that can only be provided at a trauma center with pediatric capabilities is important. Using prehospital triage criteria that balances sensitivity and specificity to transport patients with the most severe injuries to trauma centers, while transporting those with less severe injuries to the closest hospital, is essential in regionalizing trauma care for children. Engum et al10 performed a retrospective analysis of the predictive value of certain physiologic and anatomical criteria in determining pediatric trauma patients who subsequently died in the ED, were admitted to the pediatric intensive care unit, or required a major surgical procedure. Their findings showed that 5 criteria had a positive predictive value of 50% or higher, a systolic blood pressure (SBP) of less than 90 mm Hg (86%), Glasgow Coma Score (GCS) of 12 or less (78%), respiratory rate (RR) of less than 10/min or more than 29/min (73%), a second- or third-degree burn involving more than 15% total body surface area (79%), or paralysis (50%). Yet this analysis did not take into account varying normal vital sign values by age group, thus drawing some criticism on the utilization of SBP less than 90 mm Hg and RR of more than 29/min as predictors of poor outcomes in young children. Newgard et al11 analyzed a retrospective cohort of injured children in the Oregon state trauma registry over a 6-year period and included age-based physiologic parameters to identify children at high risk for major nonorthopedic operative intervention, intensive care unit stay of 2 days or longer, or in-hospital mortality. They found that the GCS was the most important prehospital predictor followed by (in order) airway intervention, RR, heart rate (HR), SBP, and shock index. Examining the findings of Newgard et al11 in reference to those of Engum et al,10 a RR of more than 29/min had no predictive value in children younger than 5 years of age and HR was significantly more predictive of poor outcomes in comparison to SBP or shock index. Yet, Newgard et al12 performed a subsequent analysis on pediatric patients using the American College of Surgeons Committee on Trauma field decision criteria to develop a clinical decision rule to identify high-risk injured children. The decision rule placed these criteria in the following order to identify high-risk injured children: need for assistance with

PREHOSPITAL CARE TIME

Some literature suggests that prehospital care time has a significant impact on survival in severely injured patients and is a major component of the golden hour of trauma care.5 Yet the impact of response time intervals on morbidity and mortality of all trauma patients is unclear.6 In a meta-analysis designed to describe average time intervals of prehospital care, 4 time intervals were defined and analyzed: (1) an activation time interval (ATI) in the prealarm period defined as the time from receiving the call to the time of alarm, (2) a response time interval (RTI) defined as the time from alarm to arrival on-scene, (3) an on-scene time interval (OSTI) defined as the time from on-scene arrival to departure, and (4) a transport time interval (TTI) defined as the time from scene departure to arrival at a hospital. Average urban and suburban ground ambulance time intervals were similar to each other (ATI = 1 minute; RTI = 5 minutes; OSTI = 14 minutes; and TTI = 11 minutes) and significantly shorter than those for rural ground ambulances (ATI = 3 minutes; RTI = 8 minutes; OSTI = 15 minutes; and TTI = 17 minutes). The average overall prehospital care time for urban/suburban settings was 31 minutes compared to 43 minutes in the rural setting. Helicopter transport times were significantly longer than those for ground ambulances as a whole but were not compared by setting.7 Using these national averages as a benchmark may be useful in evaluating the quality of pediatric prehospital trauma care. Although standards exist for time to definitive care for acute coronary syndrome and stroke patients the impact of similar prehospital care time standards for trauma patients is still unclear. The American College of Surgeons does strongly encourage rapid transport to a trauma center and minimization of on-scene time for trauma patients, and there is evidence to support improved outcomes with shorter on-scene times.5,8

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ventilation via endotracheal intubation (ETI) or bagvalve-mask ventilation (BVM), GCS of less than 11, pulse oximetry of less than 95%, and SBP of more than 96 mm Hg. Of note, HR and RR did not prove to be important predictors in the model. In addition, the finding of a high SBP associated with poor outcomes may be plausible with traumatic brain injury but otherwise did not seem to be expected. Therefore, pediatric patients with prehospital findings of a low GCS, the need for airway interventions, hypoxia, and hypertension seem to be at high risk for poor outcomes. These predictors should potentially be incorporated into decision-making protocols for transport of pediatric patients to a trauma center.12 The use of ALS vs BLS for the transport of trauma patients in the prehospital setting has stirred debate, given the resource implications of using ALS for each patient, the lack of adequate ALS staffing in rural areas, and the assumption that prehospital ALS decreases morbidity and mortality.13,14 Staffing an ALS unit compared to a BLS unit is estimated to cost an extra $94 928 per year per unit.15 Also, procedures performed by ALS units take additional time, which may delay ultimate transport to definitive care.16 A meta-analysis evaluating 15 studies, including patients of all ages, concluded that ALS-treated trauma patients overall had an increased odds of mortality over BLS-treated patients (odds ratio [OR], 2.92). Interpretation of the confidence intervals (CIs), however, revealed only one study that favored ALS. The other studies had CIs that included 1, therefore did not show a significant difference.17 One study from Finland reported slightly improved outcomes in ALS units staffed by a physician, but this model is rare in the United States.18 Thus, it seems that there is no difference in mortality between ALS and BLS trauma care when provided by EMTs, but there are significant differences in cost with possible benefit only in situations of prolonged transport times or physician-staffed ALS units.

AIRWAY MANAGEMENT
One of the most controversial topics in prehospital care is the method of airway management that reduces morbidity and mortality while optimizing safety. This is also an issue in adult trauma care, and a retrospective cohort analysis of trauma patients older than 14 years demonstrated that prehospital care time for patients undergoing rapid sequence intubation (RSI) was 10.7 minutes longer (95% CI, 7.7-13.8) than patients who were not intubated. Also, prehospital care time for patients undergoing conventional ETI without induction medications

was still 5.2 minutes longer than that for patients who were not intubated.19 Thus, intubation clearly increases on-scene time, which may result in poorer outcomes for patients. In a separate analysis of the same cohort, adjusting for the propensity to be intubated, prehospital ETI was associated with an increased odds of mortality (OR, 2.70; 95% CI, 1.63-4.46) when ground transport distances were short (b10 miles) compared to nonintubated patients. This risk gradually declined as ground transport distance increased, such that the 95% CI included an OR of 1 for transport distances greater than 20 miles. Intubated patients transported by helicopter, however, had decreased mortality (OR, 0.36; 95% CI, 0.24-0.56). This finding may be due to the more advanced airway management skills of air transport providers, but the evidence suggests that ETI in adults by ground crews near a hospital increases mortality.20 In a controlled trial of pediatric patients in the urban setting who either received BVM or ETI for prehospital airway management, intention-to-treat analysis revealed that there was no difference between the 2 interventions for both survival and neurologic outcome, even in the subgroup analysis of various categories of trauma patients including submersion injury, head injury, and multiple trauma. The subgroup of child maltreatment patients demonstrated improved survival with BVM compared to ETI (OR, 0.07; 95% CI, 0.01-0.58), but there was no significant difference in neurologic outcome. This study, however, did not examine potential effect measure modification by transport distance.21 Maintenance of the rarely encountered task of prehospital pediatric ETI, the anatomical differences of the pediatric airway relative to an adult, and the limited pediatric continuing education for prehospital providers make pediatric ETI a challenging task for the prehospital provider, especially in the rural setting. In rural pediatric trauma patients, field intubation success rates by both EMT-paramedics and flight registered nurses are significantly poorer (45%-70%) when compared to rates by ED physicians and anesthesiologists at trauma centers (89%-100%).22 Therefore, the risk of increased on-scene time and potential complications with ETI must be weighed against the benefit of rapid transport to an appropriate trauma center when deciding whether to intubate or use less invasive means to manage the airway of a pediatric trauma patient. This may be especially true for ground transport distances less than 10 miles, in which higher mortality has been demonstrated in the adult population.

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INTRAVENOUS AND IO ACCESS AND INFUSIONS

Because many time intervals in prehospital care are system dependent, the most effective way to decrease prehospital times is to decrease the onscene duration. Procedures in the field may increase the likelihood of survival or may increase mortality by delaying definitive care. In a retrospective review of IV placement in trauma patients of all ages, this procedure added an additional 5 minutes of onscene time.16 Because this study did not include a subgroup analysis of pediatric patients, however, the time to place an IV in a child may actually be longer. A retrospective chart review of prehospital IV placement in pediatric patients, with subgroup analysis for trauma patients, showed a 57% success rate for IV placement in patients less than 6 years of age and 74% success rate in age 6 years or higher. Average time to IV placement in trauma patients was 14 minutes (range, 7-24 minutes) in age less than 6 years and 12 minutes (range, 1-43 minutes) in age more than 6 years.23 For some patients, decreasing on-scene time may be essential to survival, but for others, the benefit of initiating IV access may outweigh the risks. Therefore, the determination of whether to place an IV needs to be based on the individual patient with respect to expected transport time and anticipated time to complete the procedure. Although obtaining IV access in pediatric patients may prolong on-scene time by up to 14 minutes, placement of an IO needle may provide more timely access for trauma patients with hemorrhagic shock. In a prospective observational study of paramedics after a brief training session on the placement of IO needles, 28 (84%) of 33 of the attempted IO infusions were successfully started in less than 1 minute in a simulated ambulance setting at a speed of 25 to 35 miles per hour.24 In a retrospective cohort of pediatric trauma patients in whom an IO was attempted for cardiopulmonary arrest, hypovolemic shock, or neurologic insult, successful placement by prehospital professionals was noted in 13 (93%) of 14 cases. These IO needles were used both in the prehospital and emergency department settings to successfully administer both colloid and crystalloid infusions and multiple pharmacologic agents in patients 3 months to 10 years of age, with only one reported case of minor tissue extravasation.25 Regardless of whether an IV or IO is placed, controversy exists about whether administration of fluids in the prehospital setting actually improves

patient outcomes. Computer modeling to evaluate the potential benefit of administering prehospital fluids for major hemorrhage suggests that only trauma patients who had a bleeding rate of more than 25 mL/min and prehospital time greater than 30 minutes would benefit.26 Yet these findings have not been validated in children in the prehospital setting. The only study evaluating the efficacy of prehospital IV fluid administration to pediatric trauma patients was a retrospective review in which it was inconsequential in 94% of patients, potentially beneficial in 4% of cases, and potentially harmful in 2% of cases.27 It seems evident that adult trauma protocols may not be applicable to children, prehospital IV placement prolongs on-scene time, and the benefit of prehospital fluid therapy in pediatric trauma patients is still unclear.28 Yet given the physiologic differences between children and adults, IV/IO fluid administration for hemorrhage secondary to trauma may be warranted. For some patients, decreasing on-scene time may be essential to survival, but for others, the benefit of initiating IV access may outweigh the risks. Therefore, the determination of whether to place an IV or IO needs to be based on the individual patient with respect to expected transport time and anticipated time to complete the procedure.

CERVICAL SPINE IMMOBILIZATION

Common practice among prehospital professionals is to immobilize the cervical spine of a patient who has had a traumatic injury. Once these patients arrive at the hospital, the cervical immobilization device might be removed based on clinical criteria, or the patient might undergo further imaging. The National Emergency X-Radiography Utilization Study (NEXUS) derived and validated a decision rule to determine who can safely have a cervical spine immobilization device removed in the ED without radiographic evaluation.29 Although these data apply to patients who have already been immobilized, it is plausible that some EMS agencies may attempt to apply these findings to the prehospital setting. To date, there are no published studies that provide evidence that prehospital professionals can forego cervical spine immobilization using the NEXUS criteria. Because only 10% of the patients in NEXUS were children, applying these findings to the prehospital care of children would be even more difficult.29,30 Analysis of the NEXUS pediatric patient data demonstrates that no cervical spine injury would have been missed if the NEXUS criteria had been applied to

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this population.30 Yet due to the low cervical spine injury rate of 0.98% in pediatric trauma patients in this study, it would be difficult to safely apply this rule to children in the ED setting, let alone the prehospital setting.30 Until this issue is studied further, children with a significant mechanism of injury should have their cervical spine immobilized using age-appropriate equipment before transport to the hospital.

TRAUMATIC BRAIN INJURY

Traumatic brain injury (TBI) in children results from a variety of causes, including nonaccidental injury, falls, and motor vehicle collisions.31 In the young athlete, TBI occurs with activities such as football, soccer, cheerleading, basketball, and field hockey. 32 Because athletic injuries and motor vehicle collisions are common causes of pediatric TBI, the prehospital professional must be equipped to manage these common mechanisms of injury.33 In addition, because 50% of the mortality due to TBI occurs in the first 2 hours after injury, prehospital assessment and management of TBI is crucial.34 Yet variation exists in assessing and managing children with TBI in the prehospital environment, and an evidence-based approach is necessary.31 Early correction of hypoxemia and hypotension, accurate assessment of the GCS and pupils, airway management, and appropriate transport decision making is vital, according to the Brain Trauma Foundation's evidence-based guidelines on prehospital management of TBI. Most of these guidelines are based on adult studies, however, due to relatively limited studies on pediatric TBI in the prehospital setting. Regardless, modifying the GCS for a pediatric patient is essential due to differences in preverbal children (Table 1).35 In addition, the assessment of potential TBI should include asking the verbal child about a recent prior head injury and symptoms of a concussion, such as headache, dizziness, nausea, and blurred vision. In addition, it is also important to ask bystanders about loss of consciousness and the mechanism of injury. Physical assessment should include evaluation of the face and scalp for hematomas, ecchymoses, or palpable skull fracture; drainage of blood from the ears or nose; and a thorough neurologic examination, including an ageadjusted assessment of the GCS.31 In a recent analysis of a prospective cohort of children with head injuries, patients 2 years or older with altered mental status, any suspected or confirmed loss of consciousness, history of vomiting, severe mechanism of injury (motor vehicle

collision with patient ejection, death of another passenger or rollover, pedestrian or bicyclist without helmet struck by a motorized vehicle, falls of N5 feet, head struck by a high-impact object), clinical signs of basilar skull fracture (posterior auricular or periorbital ecchymoses, hemotympanum, or cerebrospinal fluid otorrhea/ rhinorrhea), or a severe headache were at risk for a clinically significant TBI, which may require neurosurgical intervention or hospital admission. Patients younger than 2 years with altered mental status, occipital/parietal/temporal scalp hematoma, loss of consciousness for 5 seconds or more, severe mechanism of injury, palpable or equivocal skull fracture, or abnormal behavior according to the caregiver were also at risk for clinically important TBI.36 Being aware of what makes a pediatric patient high risk for complications from TBI is especially essential for EMS systems in which EMTs can determine patient disposition in the prehospital setting. This is also true in the case of potential nontransport of patients after sports injuries because providers must be aware of the sequelae of TBI and recommendations to return to play after sports-related injuries.31 For example, sports-related TBI can result in a clinical entity called second impact syndrome, in which a second concussion in a patient who is still symptomatic from a first concussion can result in cerebral edema, brain herniation, coma, and death.37 To prevent second impact syndrome, the Concussion in Sport Group has published recommendations on short-term management and when to return to play. These recommendations state that any player that shows symptoms of headache, dizziness, nausea, or double vision should refrain from the current sports activity, under medical evaluation, and should only return to play when asymptomatic with a normal neurologic and cognitive evaluation.38 Also, patients who experience a loss of consciousness should be transported to a hospital for further evaluation.39 The prehospital management of TBI focuses on minimizing secondary injury, essentially through handling the compromised airway and intervening to prevent hypotension. Hypoxemia (oxygen saturation, b90%) should be avoided by managing the airway by the most appropriate means, which may be supplemental oxygen, BVM, ETI, or other airway adjuncts.35 There is no evidence to support ETI over BVM in pediatric patients with TBI, however, and pediatric trauma patients as a whole may have fewer complications from BVM when compared to ETI. 21

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TABLE 1. Comparison of pediatric GCS with standard GCS

GCS Eye opening Spontaneous Speech Pain None Verbal response Oriented Confused Inappropriate Incomprehensible None Motor response Obeys command Localizes pain Flexor withdrawal Flexor posturing Extensor posturing None
Data from Badjatia.35

Pediatric GCS 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1 Eye opening Spontaneous Speech Pain None Verbal response Coos, babbles Irritable cries Cries to pain Moans to pain None Motor response Normal, spontaneous Withdraws to touch Withdraws to pain Abnormal flexion Abnormal extension None 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1

blood pressure should be monitored with an appropriately sized pediatric cuff and prevented by giving boluses of 20 mL/kg of isotonic crystalloid (Table 2).31,35 Prehospital providers should determine the GCS and pupil size after airway, breathing, and circulation have been assessed and stabilized. The most appropriate airway should be established in patients with severe TBI, defined as a GCS less than 9.35 Also, because hypoglycemia can result after TBI, blood glucose should be checked and treated when serum glucose is less than 80 mg/dL.31 Prehospital providers should directly transport children with severe TBI to a pediatric trauma center or an adult trauma center with added qualifications to treat children.35 Because nonaccidental head injury is also a common cause of death in infants, prehospital providers should thoroughly document findings at the scene and report unclear or implausible mechanisms to law enforcement, child protective services, and ED personnel, while being cautious to maintain scene safety.31

PAIN ASSESSMENT AND MANAGEMENT

Pain assessment and management in trauma is important for patient comfort and potentially for patient healing. In a retrospective chart review of 696 pediatric trauma patients, prehospital personnel documented a pain assessment in 81% of cases, but only 0.1% actually used a pain assessment tool. Of the 64% of patients with documented pain, only 15% received some sort of intervention to address their pain. For all patients, both pharmacologic and nonpharmacologic interventions were used equally in 13.4% of cases.40 Because pain does not necessarily correlate with injury severity, pain assessment should occur in all children in the prehospital setting with a traumatic injury. In addition, parental report of pain is often

Children with suspected TBI should have their cervical spine (C-spine) immobilized in the field due to risk for concurrent injury.31 If ETI is going to be attempted, manual C-spine stabilization is necessary to prevent secondary injury. For EMS agencies that use RSI medications for intubation, premedication with 1.5 mg/kg of lidocaine followed by 0.3 mg/kg of etomidate for sedation and either 1.5 mg/kg of succinylcholine or 1 mg/kg of vecuronium are preferred to protect against increases in intracranial pressure. Otherwise, the decision to intubate should be made in consultation with online medical control if these RSI medications are not available for use in the prehospital setting. Signs of increased intracranial pressure are represented by Cushing's triad of hypertension, bradycardia, and irregular breathing.31 The EMS systems that use RSI protocols should monitor blood pressure, oxygenation, and end-tidal CO2 (ETCO2). Patients should be maintained with normal breathing rates (ETCO2 = 35-40 mm Hg), and hyperventilation (ETCO2 b 35 mm Hg) should be avoided unless there are signs of cerebral herniation. The evidence for the latter, however, is lacking in pediatrics, and this recommendation has been extrapolated from adult data.35 Because hypotension with TBI in pediatric patients has been associated with poor outcomes,

TABLE 2. Definition of pediatric hypotension by age

Age 0-28 days 1-12 months 1-10 years N10 years
Data from Badjatia.35

SBP b60 b70 b70 b90 mm Hg mm Hg + (2 age in years) mm Hg

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comparable to a child's report and should be incorporated into a pain assessment.41 Although pediatric pain scales that have been validated in the hospital setting have not been validated in the prehospital setting, the use of standardized and age-appropriate pain assessment tools by prehospital professionals is more likely to lead to management of pain.42

SUMMARY
Prehospital providers play an essential role in the initial management of pediatric trauma patients by minimizing secondary injury and transporting injured children to definitive care in a timely manner. As the IOM has recently recommended, it is essential for the United States to have an EMS system that is regionalized and coordinated to provide optimal care in a seamless fashion along the continuum from the prehospital to ED settings.4 Although the evidence base for pediatric prehospital trauma care is limited, translating the best available information into clinical practice is important to providing quality care. In addition, conducting further research in prehospital pediatric trauma care will be vital to providing the best care possible in the future.

REFERENCES
1. Shah MN, Cushman JT, Davis CO, et al. The epidemiology of emergency medical services use by children: an analysis of the National Hospital Ambulatory Medical Care Survey. Prehosp Emerg Care 2008;12:269-76. 2. Krug S, Kuppermann N. Twenty years of emergency medical services for children: a cause for celebration and a call for action. Pediatrics 2005;115:1089-91. 3. Ramenofsky ML. Emergency medical services for children and pediatric trauma system components. J Pediatr Surg 1989;24:153-5. 4. Institute of Medicine of the National Academies. Emergency medical services: at the crossroads. Washington, DC: National Academies Press; 2006. 5. Sampalis JS, Lavoie A, Williams JI, et al. Impact of on-site care, prehospital time, and level of in-hospital care on survival in severely injured patients. J Trauma 1993;34:252-61. 6. Lerner EB, Moscati RM. The golden hour: scientific fact or medical urban legend. Acad Emerg Med 2001;8:758-60. 7. Carr BG, Caplan JM, Pryor JP, et al. A meta-analysis of prehospital care times for trauma. Prehosp Emerg Care 2006; 10:198-206. 8. American College of Surgeons. Advanced trauma life support for doctors. 8th ed. Chicago (Ill): American College of Surgeons; 2008. 9. Haller JA, Shorter N, Miller D, et al. Organization and function of a regional pediatric trauma center: does a system management improve outcome. J Trauma 1983;23: 691-6.

10. Engum SA, Mitchell MK, Scherer LR, et al. Prehospital triage in the injured pediatric patient. J Pediatr Surg 2000;35: 82-7. 11. Newgard CD, Cudnik M, Warden CR, et al. The predictive value and appropriate ranges of prehospital physiological parameters for high-risk injured children. Pediatr Emerg Care 2007;23:450-6. 12. Newgard CD, Rudser K, Atkins DL, et al. The availability and use of out-of-hospital physiologic information to identify high-risk injured children in a multisite, population-based cohort. Prehosp Emerg Care 2009;13:420-31. 13. Trunkey DD. Is ALS necessary for pre-hospital trauma care. J Trauma 1984;24:86-7. 14. Lewis FR. Ineffective therapy and delayed transport. Prehosp Disaster Med 1989;4:129-30. 15. Ornato JP, Racht EM, Fitch JJ, et al. The need for ALS in urban and suburban EMS systems. Ann Emerg Med 1990;19:1469-70. 16. Carr BG, Brachet T, Guy D, et al. The time cost of prehospital intubations and intravenous access in trauma patients. Prehosp Emerg Care 2008;12:327-32. 17. Liberman M, Mulder D, Sampalis J. Advanced or basic life support for trauma: meta-analysis and critical review of the literature. J Trauma 2000;49:584-99. 18. Suominen P, Baillie C, Kivioja A, et al. Prehospital care and survival of pediatric patients with blunt trauma. J Pediatr Surg 1998;33:1388-92. 19. Cudnik MT, Newgard CD, Wang H, et al. Endotracheal intubation increases out-of-hospital time in trauma patients. Prehosp Emerg Care 2007;11:224-9. 20. Cudnik MT, Newgard CD, Wang H, et al. Distance impacts mortality in trauma patients with an intubation attempt. Prehosp Emerg Care 2008;12:459-66. 21. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-ofhospital pediatric endotracheal intubation on survival and neurologic outcome. JAMA 2000;283:783-90. 22. Ehrlich PF, Seidman PS, Atallah O, et al. Endotracheal intubations in rural pediatriac trauma patients. J Pediatr Surg 2004;39:1376-80. 23. Lillis KA, Jaffe DM. Prehospital intravenous access in children. Ann Emerg Med 1992;21:1430-4. 24. Fuchs S, LaCovey D, Paris P. A prehospital model of intraosseous infusion. Ann Emerg Med 1991;20:371-4. 25. Guy J, Haley K, Zuspan SJ. Use of intraosseous infusion in the pediatric trauma patient. J Pediatr Surg 1993;28:158-61. 26. Wears RL, Winton CN. Load and go versus stay and play: analysis of prehospital IV fluid therapy by computer simulation. Ann Emerg Med 1990;19:163-8. 27. Teach SJ, Antosia RE, Lund DP, et al. Prehospital fluid therapy in pediatric trauma patients. Pediatr Emerg Care 1995;11:5-8. 28. Sadow KB, Teach SJ. Prehospital intravenous fluid therapy in the pediatric trauma patient. Clin Pediatr Emerg Med 2001;2: 23-7. 29. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000;343:94-9. 30. Viccellio P, Simon H, Pressman BD, et al. A prospective multicenter study of cervical spine injury in children. Pediatrics 2001;180:e20. 31. Atabaki SM. Prehospital evaluation and management of traumatic brain injury in children. Clin Pediatr Emerg Med 2006;7:94-104. 32. Covassin T, Swanik CB, Sachs ML. Epidemiological considerations of concussions among intercollegiate athletes. Appl Neuropsychol 2003;10:12-22.

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33. NCCSIR. Eighteenth Annual Report, Fall 1982-Spring 2000. Chapel Hill (NC): University of North Carolina; 2000. 34. Baxt WB, Moody P. The impact of advanced prehospital care on the mortality of severely brain-injured patients. J Trauma 1987;27:365-9. 35. Badjatia N, Carney N, Crocco TJ, et al. Guidelines for prehospital management of traumatic brain injury, 2nd ed. Prehosp Emer Care 2007;12:S1-S52. 36. Kuppermann N, Holmes JF, Dayan PS, for the Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinicallyimportant brain injuries after head trauma: a prospective cohort study. Lancet 2009;374:1160-70. 37. Cantu R, Voy R. Second impact syndrome: a risk in any sport. Phys Sport Med 1995;23:27-36.

38. Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the First International Symposium on Concussion in Sport. Vienna 2001. Phys Sport Med 2002;30:57-63. 39. Collins M, Stump J, Lovell MR. New developments in the management of sports concussion. Curr Opin Orthop 2004; 15:100-7. 40. Izsak E, Moore JL, Stringfellow K, et al. Prehospital pain assessment in pediatric trauma. Prehosp Emerg Care 2008;12: 182-6. 41. Baxt C, Kassam-Adams N, Nance M, et al. Assessment of pain after injury in the pediatric patient: child and parent perceptions. J Pediatr Surg 2004;39:979-83. 42. Zempsky WT, Cravero JP. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics 2004;114:1348-56.

Abstract:
Laboratory studies are often routinely obtained in the injured child. How broad a range of studies are needed and do they impact on the child's management? This article reviews the literature and makes recommendations for a simplified, cost-effective laboratory testing strategy.

Keywords:
pediatric trauma; laboratory studies; intraabdominal injury

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

L
Reprint requests and correspondence: Jeffrey F. Linzer Sr MD, Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine, Childrens Healthcare of Atlanta, GA 30322.
1522-8401/$ - see front matter 2010 Elsevier Inc. All rights reserved.

aboratory tests are often obtained on children who have had traumatic injuries. These tests range from a complete blood count (CBC) to serum chemistries, liver and pancreatic enzymes, coagulation studies, and urinalysis (UA). The primary purpose for obtaining these tests in the emergency department is either to (1) manage and monitor the unstable patient or (2) screen the stable patient to determine the need for imaging studies. In some circumstances, the indication for specific testing is straightforward. For example, a type and cross match for blood would be indicated for the hemodynamically unstable patient. The decision to provide additional treatment or to obtain a computerized tomographic (CT) study is often based on clinical evaluation and is made before these laboratory results are made available.1,2 It is the patient who has had blunt trauma without obvious injury, however, where the use of routine laboratory testing comes into question. Screening laboratory tests are most often used in these patients to determine the need for CT imaging. As there is now greater recognition of the potential risks from ionizing radiation, especially in younger children, the question of the use of laboratory testing to determine who needs imaging has become a larger issue. A review of the literature shows that there is no simple answer as to what test(s) may be of benefit. The routine use of trauma panels in pediatric trauma victims does not appear to provide any significant clinical benefit.1-5

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URINALYSIS
Although no test has been shown to be 100% sensitive and specific, the UA appears to have some use in determining the presence of intraabdominal injury (IAI) in blunt trauma. There is controversy, however, as to the quantity of blood that needs to be present to determine the need for a CT scan. In adults who are not hypotensive and who have not had a deceleration entry, imaging is only indicated if there is frank hematuria. In a retrospective study by Quinlan and Gearhart,6 frank hematuria along with a low hematocrit correlated with severe renal injury. In a review by Stein et al,7 any degree of hematuria was an indication for radiographic imaging. Isaacman and colleagues8 found that there was a low prevalence of laboratory abnormalities in children with mild to moderate trauma. Using a cutoff of greater than 5 red blood cells per high-power field (RBC/hpf), they found the physical examination, in a patient with a Glasgow Coma Score (GCS) of 12 or higher, along with the UA, had a sensitivity of 100%, specificity of 64%, and a negative predictive value of 100% for IAI.8 In a prospective study of children with blunt trauma, Holmes et al9 also found an association of IAI with a UA with more than 5 RBC/hpf (odds ratio, 4.8; 95% confidence interval [CI], 2.7-8.4). Taylor et al10 found an association between abdominal symptoms and a UA with greater than 10 RBC/hpf, but noted that asymptomatic hematuria would have a low yield as an indicator for CT of the abdomen. Whereas Lieu and colleagues11 found that more than 20 RBC/hpf was associated with higher yield intravenous pyelography, Abou-Jaoude et al12 found that using that same value missed 28% of genitourinary tract injuries or anomalies. Both groups of investigators believed that clinical judgment was valuable in determining the need for radiographic imaging. Several studies, however, have shown that a baseline of 50 RBC/hpf can be used to determine the need for acute radiographic imaging to evaluate for renal injury. Morey13 found that a CT scan was not indicated in patients with minor abdominal trauma if there were less than 50 RBC/hpf. The likelihood of significant genitourinary injuries was 2% in that group of patients. Perez-Brayfield et al14 also found that a CT was indicated in children with more than 50 RBC/hpf, who were hypotensive or had had a significant mechanism of injury (eg, highspeed deceleration injury). Stalker and colleagues15 found a direct relationship between the severity of renal injury and the degree of hematuria in that the higher the grade of injury the more RBCs that were

seen in the UA. In that same study, children with blunt abdominal trauma who were not in shock and had less than 50 RBC/hpf did not benefit from radiographic imaging.

HEMATOLOGY
A CBC, on the whole, provides little predictive information regarding the trauma patient. White blood cell elevation is often encountered, usually due to the stress of the injury.3 However, there is no correlation between elevation and the degree of injury. In one study, 1% of patients had platelet counts less than 100 000/hpf, but none required platelet transfusions.1 Monitoring platelet counts in hemodynamically unstable patients, especially those who are receiving massive transfusions, may be of value. A low initial hematocrit may warn of ongoing hemorrhage from an occult bleed. Holmes et al9 found an initial value of less than 30% to be a predictor of IAI, whereas Cotton et al5 found each unit decrease resulted in an 11% increase risk for IAI. Although a low hematocrit may imply the need for transfusion, patients will usually have signs of hemodynamic instability such as tachycardia or hypotension.1 One must however keep in mind that hypotension is a late sign of shock in children. Serial hematocrits may help in the monitoring of solid organ injuries.

SERUM CHEMISTRIES
Liver transaminases (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) are often used as a screen for liver injury. Using recursive partitioning retrospective analysis, Cotton et al5 found that 88% of patients with IAI were correctly identified when they had an AST more than 131 U/L with a hematocrit of less than 39% (sensitivity 100% [95% CI, 90%-100%] and specificity of 87% [95% CI, 83%-91%]). An ALT of more than 105 U/L had similar findings. As other solid organ injury, such as kidney and pancreas, can also produce elevated transaminases, Chu et al16 found that a higher value, AST of more than 200 U/L or ALT of more than 125 U/L, were predictors of liver injury. Holmes et al9,17 also identified these elevated values as among the high-risk variables used in the decision to image children for IAI. Keller and colleagues1 found that children with elevated transaminases were more likely to have liver injury compared to children with normal levels (elevated vs normal: AST 12% vs 0%, ALT 17% vs 0%; P b .05). However, he determined that only levels of

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more than 400 U/L were predictive of liver injury. Because these levels were associated with patients who had other indications for imaging (eg, physical examination), the value did not influence the decision for imaging studies or other interventions. In a review of various trauma panel studies, Capraro et al3 did not find either the AST or ALT to be of any value in predicting IAI or in determining the need for CT imaging. They found that AST had a sensitivity of 63% (95% CI, 51%-74%), a negative predictive value of 71% (95% CI, 67%-82%), and a positive predictive value of 38% (95% CI, 29%-47%). Alanine aminotransaminase fared no better with a sensitivity of 52% (95% CI, 41%-64%), a negative predictive value of 75% (95% CI, 67%-82%), and a positive predictive value of 48% (95% CI 37-60%). In the study by Isaacman et al,8 elevated AST and ALT levels did not make a significant contribution in predicting the presence of IAI or in determining the need for imaging. The use of serum amylase and lipase for screening of pancreatic injury in children appears to carry little use. Adamson et al18 found that although these values were elevated in pancreatic injury, there was no cost-benefit in using them as screening tests to determine the need for CT scanning. Simon et al19 found that pancreatic enzyme screening was of limited value in the initial assessment of blunt abdominal trauma. In addition, Namias et al2 did not find any correlation between serum amylase elevation and pancreatic injury. Serum electrolytes also contribute very little in the evaluation of the hemodynamically stable patient. Although transient abnormalities may occur, they are not usually clinically relevant and do not impact management.2,4,8

When compared to other coagulation studies (activated partial thromboplastin time [PTT], thrombin time, bleeding time, platelet count, fibrinogen, fibrin degradation products, and hematocrit), Hymel et al20 found that prolongation of the prothrombin time (PT) was associated with parenchymal brain injury. In the review by Vavilala et al,22 a fibrin degradation product of more than 1000 g/mL was associated with a poor outcome in children with a GCS between 7 and 12. Holmes and colleagues25 ascertained that children with a GCS of 13 or lower had an odds ratio of 8.7 (95% CI, 4.3-17.7) of having an elevated international normalized ratio (INR) of 1.5 or higher or a PTT of 40 seconds or more. Keller et al24 used PT, INR, and PTT in finding that 43% of the children in his review with intracranial injuries had coagulation abnormalities.

COST
Based on the Centers for Medicare and Medicaid Services 2009 median for laboratory test code fee schedules (Table 1), a traditional trauma panel consisting of a CBC, comprehensive metabolic profile, amylase, lipase, PT (including INR), PTT, and UA (with microscopy) would cost $84.45.26 Hematocrit, AST, and UA would cost $21.12, whereas hematocrit and UA alone would cost $10.92.

SUMMARY AND RECOMMENDATIONS

In the unstable trauma patient, hematocrit, type and cross match, PT, INR, and PTT are useful tests in managing the critically injured patient. Transaminases, pancreatic enzymes, and UA are not

COAGULATION STUDIES
Coagulopathy has been shown to be associated with significant head injuries20 and is a predictor of poor outcome.21,22 In a meta-analysis, Harhangi and colleagues23 found that 1 in 3 patients with traumatic brain injury was at risk for developing a coagulopathy and that the presence abnormal coagulation studies was an independent predictor of prognosis (odds ratio of mortality 9.0 [95% CI, 7.3-11.6] and unfavorable outcome 36.3 [95% CI, 18.7-70.7]). Keller et al24 found that children with a GCS of less than 14 after traumatic brain injury appeared to be at the greatest risk of developing a coagulopathy (7% for a GCS of 15 vs 67% for GCS 14; P b .05). Keller et al24 also found an inverse relationship between decreasing GCS and the risk of coagulopathy.

TABLE 1. Laboratory charges.

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

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

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

necessary in determining the need for a CT scan because imaging decisions are typically based on the physical status of the patient. Holding blood for later use (eg, blood samples obtained during vascular access) if the CT scan shows liver or pancreatic injury is cost-effective and does not adversely affect patient management.27 In the hemodynamically stable child, no laboratory tests are needed to determine the need for radiographic imaging if there are any physical findings of abdominal injury, including tenderness and contusion, or a positive Focused Assessment by Sonography in Trauma (FAST) examination. The physical examination alone is clearly the best determinant for the need for CT imaging for IAI.5,8,28 In the child with blunt trauma to the thorax without any physical findings and a negative FAST, a hematocrit and UA should be obtained. It is not unreasonable to obtain an AST or ALT in this scenario. Imaging is indicated if the hematocrit is less than 30%, UA has 50 RBC/hpf or more, AST is more than 200 U/L, and/or ALT is more than 125 U/ L. A pregnancy test (urine or serum) should be obtained on every female patient of reproductive potential age. Prothrombin time, INR, and PTT have demonstrated value in monitoring patients with a GCS of less than 14.

REFERENCES
1. Keller MS, Coln CE, Trimble JA, et al. The utility of routine trauma laboratories in pediatric trauma resuscitations. Am J Surg 2004;188:671-8. 2. Namias N, McKenney MG, Martin LC. Utility of admission chemistry and coagulation profiles in trauma patients: a reappraisal of traditional practice. J Trauma 1996;41:21-5. 3. Capraro AJ, Mooney D, Waltzman ML. The use of routine laboratory studies as screening tools in pediatric abdominal trauma. Pediatr Emerg Care 2006;22:480-4. 4. Tasse JL, Janzen ML, Ahmed NA, et al. Screening laboratory and radiology panels for trauma patients have low utility and are not cost effective. J Trauma 2008;65:1114-6. 5. Cotton BA, Liao JG, Burd RS. The utility of clinical and laboratory data for predicting intraabdominal injury among children. J Trauma 2005;58:1306-7. 6. Quinlan D, Gearhart J. Blunt renal trauma in childhood. Features indicating severe injury. Br J Urol 1990;66: 526-31. 7. Stein J, Kaji D, Eastham J, et al. Blunt trauma in the pediatric population: indications for radiographic evaluation. Urology 1994;44:406-10. 8. Isaacman DJ, Scarfone RJ, Kost SI, et al. Utility of routine laboratory testing for detecting intra-abdominal injury in the pediatric trauma patient. Pediatrics 1993;92:691-4. 9. Holmes JF, Sokolove PE, Brant WE, et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med 2002;39:500-9.

10. Taylor GA, Eichelberger MR, Potter BM. Hematuria: a marker of abdominal injury in children after blunt trauma. Ann Surg 1988;208:688-93. 11. Lieu TA, Fleisher GR, Mahboubi S, et al. Hematuria and clinical findings as indicators for intravenous pyelography in pediatric blunt renal trauma. Pediatrics 1988;82: 216-22. 12. Abou-Jaoude WA, Sugarman JM, Fallat ME, et al. Indicators of genitourinary tract injury or anomaly in cases of pediatric blunt trauma. J Pediatr Surg 1996;31:88-90. 13. Morey AF, Bruce JE, McAninch JW. Efficacy of radiographic imaging in pediatric blunt renal trauma. J Urol 1996;156: 2014-8. 14. Perez-Brayfield MR, Gatti JM, Smith EA, et al. Blunt dramatic hematuria and children. Is a simplified algorithm justified. J Urol 2002;167:2543-7. 15. Stalker HP, Kaufman RA, Stedje K. The significance of hematuria and children after blunt abdominal trauma. Am J Roentgenol 1990;154:569-71. 16. Chu FY, Lin HJ, Guo HR, et al. A reliable screening test to predict liver injury in pediatric blunt torso trauma. Eur J Trauma Emerg Surg 2009; doi:10.1007/s00068-0099034-z. 17. Holmes JF, Mao A, Awasthi S, et al. Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Ann Emerg Med 2009;54: 528-33. 18. Adamson WT, Hebra A, Thomas PB, et al. Serum amylase and lipase alone are not cost-effective screening methods for pediatric pancreatic trauma. J Pediatr Surg 2003;38: 354-7. 19. Simon HK, Muehlberg A, Linakis JG. Serum amylase determinations in pediatric patients presenting to the ED with acute abdominal pain or trauma. Am J Emerg Med 1994; 12:292-5. 20. Hymel KP, Abshire TC, Luckey DW, et al. Coagulopathy in pediatric abusive head trauma. Pediatrics 1997;99: 371-5. 21. Miner ME, Kaufman HH, Graham SH, et al. Disseminated intravascular coagulation fibrinolytic syndrome following head injury in children: frequency and prognostic implications. J Pediatr 1982;100:687-91. 22. Vavilala MS, Dunbar PJ, Rivara FP, et al. Coagulopathy predicts poor outcome following head injury in children less than 16 years of age. J Neurosurg Anesth 2001;13: 13-8. 23. Harhangi BS, Kompanje EJ, Leebeek FW, et al. Coagulation disorders after traumatic brain injury. Acta Neurochir 2008; 150:165-75. 24. Keller MS, Fendya DG, Weber TR. Glasgow Coma Scale predicts coagulopathy in pediatric trauma patients. Semin Pediatr Surg 2001;10:12-6. 25. Holmes JF, Goodwin HC, Land C, et al. Coagulation testing in pediatric blunt trauma patients. Pediatr Emerg Care 2001;17:324-8. 26. Centers for Medicare and Medicaid Services. Medicare clinical laboratory fee schedule (09CLAB.Zip). Available at: http://www.cms.hhs.gov/ClinicalLabFeeSched/02_clinlab. asp#TopOfPage. Accessed October 12, 2009. 27. Bryant MS, Tepas JJ, Talbert JL, et al. Impact of emergency room laboratory studies on the ultimate triage and disposition of the injured child. Am Surg 1988;54:209-11. 28. Miller D, Garza J, Tuggle D, et al. Physical examination as a reliable tool to predict intra-abdominal injuries in braininjured children. Am J Surg 2006;192:738-42.

Abstract:
With the introduction of faster computerized tomography (CT), this radiographic modality has become widely used for the evaluation of the pediatric trauma patient. There is a substantially increased dose of ionizing radiation associated with CT compared to plain radiography. Multiple studies have demonstrated that the younger the patient at the time of exposure, the higher the radiation dose to the organs. Higher organ radiation doses have been linked with an increased cancer risk. The indiscriminate use of CT in the evaluation of the pediatric trauma patient is therefore associated with an increased risk for cancer in this population. This article's objective is to review the relative risks and benefits associated with this radiographic modality.

Radiographic Evaluation of the Pediatric Trauma Patient and Ionizing Radiation Exposure
Ricardo R. Jimnez, MD

Keywords:
CT scan; pediatric trauma; radiation risk

S
Reprint requests and correspondence: Ricardo R. Jimnez, MD, Pediatric Emergency Medicine Attending, University of South Florida Affiliated Faculty, All Children's Hospital, 801 6th St South, Saint Petersburg, FL 33701. ricardo.jimenez@allkids.org
1522-8401/$ - see front matter 2010 Elsevier Inc. All rights reserved.

can them until they glow said the surgery attending on my first trauma case during my medical school surgery rotation. What he meant was that when dealing with a trauma patient, the overuse of computerized tomography (CT) was acceptable. But what about the glow part? Trauma is a leading cause of death in the pediatric population. A systematic detailed evaluation is necessary in the management of the pediatric trauma patient. The goal of the trauma evaluation is the accurate and early identification of lifethreatening injuries while ensuring the safety of the patient. A large part of the trauma evaluation is imaging, and it has revolutionized the way we practice medicine. The imaging evaluation can range from plain radiography of an injured extremity to a head, neck, and/or abdominopelvic CT scan. In the last decade, with the invention of faster CT technology and with the widespread availability of CT in most hospitals, there has been a substantial increase in its use as part of the trauma evaluation. In a recent study, the use of CT increased from 12.8%

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to 22.4% from 1995 to 2003 in the evaluation of head trauma.1 Furthermore, 11.2% of the CTs done in the United States were on patients 0 to 15 years of age.2 However, radiographic evaluation is not an innocuous procedure and bears some risk. Diagnostic radiography carries an exposure to ionizing radiation, ranging from fairly low doses in plain radiography to much higher doses with CT. Exposure to high levels of ionizing radiation is proven to increase the risk for cancer development later in life, especially leukemia, breast cancer, and thyroid cancer. Unfortunately, children are more susceptible to radiation effects than adults.2-5 Chernobyl and Hiroshima survivor studies have demonstrated an increase cancer risk in the pediatric population when compared to adults.6,7 Furthermore, an association has been shown with age at the time of exposure and cancer risk; the younger the patient at exposure, the higher the risk.8 Consider this, actively replicating cell lines will have a higher risk of mutation; this risk is increased by ionizing radiation. It is important to be aware that the radiation dose to an organ is energy deposited divided by mass; therefore, the greater the mass, the lower the dose to the organ. Now, also consider that the actual dose of radiation to an organ is affected by the distance to the radiation source, for example, if an organ is proximal to the radiation source, the dose will be higher; as the source rotates and the organ is now distal and is partially shielded by body tissue, the dose to that organ will be lower. Because children are still undergoing development, they carry more replicating cells lines than adults, and because children are often thinner than their adult counterparts, it is easy to understand why they have a higher risk associated with ionizing radiation exposure. In the past years, the main source of this radiation was environmental, averaging 3 mSv annually depending on where the person lives. The typical single CT radiation exposure ranges from 1 to 14 mSv.9 With the increased use of imaging studies, medical diagnostic evaluation has become a major source with CT accounting for 67% of the diagnostic radiation exposure.2 Computed tomography has become for many the imaging study of choice in the evaluation of the pediatric trauma patient, taking the place of plain radiography in the evaluation of head and neck injuries and peritoneal lavage in the evaluation on abdominal injuries. Although other modalities such as ultrasound and magnetic resonance imaging carry no ionizing radiation exposure, their use in the evaluation of the pediatric trauma patient remains unclear.

Recently, there has been increased concern regarding the association of diagnostic radiation exposure and the risk for cancer. With the increased use of CT in the care of children, we have to ask if this risk outweighs the benefits and consider shortterm benefits vs long-term effects. Lastly, is it really necessary to scan them until they glow?

HEAD INJURY EVALUATION

Trauma is a leading cause of death in the pediatric population, and head trauma is the most common reason for death or disability.10 According to the Center for Disease Control and Prevention, there are roughly 650 000 hospital visits, 3000 deaths, and 50 000 hospitalizations associated with head injuries.11 Most head injuries are classified as mild. In the absence of validated clinical criteria that can identify with 100% sensitivity those patients with intracranial injury (ICI), the trauma physician often relies on imaging studies to assess the extent of the head injury. Initially, skull radiography was used to detect fractures after a head injury, followed with a CT if the x-ray detected a fracture. The presence of skull fractures in a skull radiograph is one of the stronger predictors of ICI.12 Skull x-rays have a sensitivity of 65% and 83% negative predictive value and are better for detecting horizontal fractures that the CT can miss. Unfortunately, skull x-rays cannot detect underlining brain injury. Head CT has become the test of choice for the evaluation of head injury, especially since the introduction of helical CT, which is much faster and minimizes the need for sedation. Computed tomography is clearly a better tool for the evaluation of head injury, as it detects not only skull fractures but also ICI. Of course, it carries a higher level of ionizing radiation exposure and an increase in cancer risk. In the absence of a set of validated criteria that could reliably identify those patients with very low risk for ICI, the use of head CT has increased dramatically for the past decade. The problem lies in the overuse of CT in those head injured patients who have a very low risk for ICI, which some studies suggest range from 40% to 60% of patients with head trauma.13-16 When comparing ionizing radiation exposure associated with skull xrays vs CT, there is a noticeable difference with doses from plain radiographs ranging from 0.02 to 10 mGy and doses from CT ranging from 5 to 20 mGy.5 To put this in perspective, we should remember that the annual background radiation exposure in the United States averages 3 mSv and that 1 mSv = 1 mGy.9 Therefore, radiation exposure

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associated with head CT is not only higher but is also additive to background radiation. Brenner and colleagues3,4 have estimated organ doses associated with CT use; the dose is dependent on the actual milliampere setting used in the scanner. The relationship between dose and milliampere is linear. When the setting used was 200 mAs, the organ radiation dose to the brain from one head CT ranged from 15 to 65 mGy; the highest dose was associated with the youngest patients. The organ dose remained the same after 15 years of age and increased directly proportional to decreasing patient age. Conversely, in a study by Jimenez et al17 where anthropomorphic phantoms were used to quantify the organ doses after head and neck CT, the pituitary organ radiation dose in the 1-year-old phantom was 21.25 mGy, whereas in the 5-year-old phantom, it was 33.8 mGy. It is important to recognize that there are data supporting an increase in individual cancer risk with these dose ranges.18 Brenner3 was able to extrapolate a lifetime attributable cancer risk associated to the organ doses from a single head CT. The attributable risk was estimated to be highest in those younger than 2 years, with a one in 2000 risk for the development of cancer associated with a single head CT. It is important to understand that radiation doses are cumulative and will increase with the number of exposures, and also, the attributable risk is a function of the scanner setting used (in this case 200 mAs). When evaluating for the pediatric trauma victim for head injury, we need to ask if the diagnostic benefits of CT imaging outweigh the radiation risk. For those children with a mechanism of injury or clinical findings indicative of a higher risk for ICI, the answer is yes. As discussed earlier, 40% to 60% of the children who receive a CT as part of the head injury evaluation are considered minor trauma, and only about 10% of these children will have a positive finding. This large discrepancy in the large number of CTs and the small number of positive findings in children with minor head trauma is associated with the lack of validated criteria that will identify patients with a very low risk for ICI. Recent data obtained by the Pediatric Emergency Care Applied Research Network (PECARN) presented a very promising prediction rule for identifying children at very low risk of ICI. This prospective cohort study analyzed more than 42 000 children with minor head injury dividing them in 2 groups, younger than 2 years and 2 to 18 years of age. PECARN investigators used a prediction rule to identify those with very low risk for ICI. For those younger than 2 years, the rule included normal mental status, no scalp hematoma except

frontal, no loss of consciousness or loss of consciousness less than 5 seconds, nonsevere injury mechanism, no palpable skull fracture, and acting normally as per parents. In the 2 to 18 years group, this decision rule included normal mental status, no loss of consciousness, no vomiting, no severe headache, nonsevere injury mechanism, and no signs of basilar skull fracture. The younger-than-2-year-old rule had a negative predictive value and sensitivity of 100% and the 2- to 18-year-old rule had a negative predictive value of 99.95% and sensitivity of 96.8%.19 This is the largest and most comprehensive study evaluating minor head injury. The study was able to validate a prediction rule that would serve to identify those children at very low risk of ICI and those for whom a head CT may be obviated for the trauma evaluation as the risk for ionizing radiation will outweigh the benefits.

NECK INJURY EVALUATION

The evaluation of the cervical spine for cervical spine injury (CSI) is an integral part of the pediatric trauma patient evaluation. Cervical spine injuries can have severe deleterious effects if left untreated, from permanent neurologic defects to death. Because CSIs are very hard to evaluate clinically, radiographic evaluation has been an integral part of the traumatic cervical spine evaluation. Conventional 3-view (anteroposterior, lateral, odontoid) cervical spine plain radiographs are a standard part of the neck injury evaluation. Both adult and pediatric literature supports the use of neck CT for the evaluation of CSI as it yields a higher detection rate and is more cost-effective.20-23 Cervical CT alone has been shown to have a sensitivity of 98% for CSIs; in contrast, conventional radiography has been shown to miss up to 57% of CSIs.24,25 Keenan et al22 and Blackmore et al23 both support the use of cervical CT for the evaluation of high-risk patients, which include altered mental status or focal neurologic deficit. An increase in the use of CT and its use without the use of plain radiography has been noted in the evaluation of CSIs.19,26 The adult literature recommendations for clearing the cervical spine after a traumatic injury seem to agree that those patients classified as high risk should be evaluated with a cervical spine CT. The most common criteria used in the adult literature to classify a patient as high risk are focal neurologic deficit and altered mental status. A pediatric literature review by Slack and Clancy27 suggested a similar approach in clearing the cervical spine in children as that in adults. Cervical spine injuries are rare in the pediatric trauma patient. The largest

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study evaluating CSI in the pediatric population, The National Emergency X-ray Utilization Study (NEXUS) group,28 found a CSI incidence rate of 0.98% in the pediatric population compared to 2.54% in adults. The difference in prevalence of CSI between the pediatric and adult population is probably associated with the anatomical and physiologic differences that exist among them. These differences are more prominent in those younger than 8 years but persistent in those 8 to 12 years.29,30 The NEXUS decision rule has been shown to be 100% sensitive in the detection of CSI in the pediatric population. The decision rule used by the NEXUS group includes changes in sensorium, intoxication, focal neurologic deficits, distraction injury, and midline cervical tenderness. With the low incidence of CSI in the pediatric population and a decision rule that can potentially identify those pediatric patients at lower risk, is there a need to use CT as a screening tool to clear the cervical spine and if so what is the risk? Once again, the risk has to be measured against the benefits. It has already been established that there is a substantial increase in ionizing radiation exposure associated with CT use. Jimenez et al17 studied the amount of radiation exposure between plain neck radiography and neck CT using anthropomorphic phantoms representing a 1-year-old and a 5-year-old. This study directly collected the dose received by certain organs in the neck, specifically the thyroid which is recognized as one of the most radiosensitive organs in the body. Jimenez and colleagues17 found that in the 1-year phantom, the radiation received to the thyroid from a CT was 385 times (59.28 mGy) that from a 3-view neck xray, and in the 5-year phantom, the neck CT provided a dose 164 times greater (52.3 mGy) than that from conventional radiography.19 Again, it appears that the younger the patient, the higher the radiation organ dose. Interestingly enough, Jimenez et al17 also found that the organ dose to the thyroid from a head CT was higher than that of a 3-view conventional neck x-ray, which is concerning as some patients receive both a head and neck CT as part of the trauma evaluation.19 Brenner3,4 has also confirmed that the organs that receive most of the radiation secondary to a head CT are the brain and thyroid. Studies about Chernobyl and Hiroshima survivors have reported an increase in thyroid cancer in the pediatric population with a significant linear association between radiation dose and cancer risk.6,7,31 Furthermore, Ron32 reported that the age at time of exposure was strongly linked to the risk for thyroid cancer, with those younger than 15 years having the

strongest association.33 With the increased use of CT for the evaluation of neck injury, it is important to evaluate the risk for thyroid cancer later in life for those patients who are exposed. In the study by Jimenez et al,17 the excess relative risk for thyroid cancer was calculated. Those younger than 5 years appear to have a higher risk of developing thyroid cancer, with those younger than 1 year doubling their cancer risk with only one CT.19

ABDOMINAL EVALUATION
Blunt trauma accounts for 90% of childhood injuries, and although only 10% of these injuries involve the abdomen, abdominal injuries are one of those most commonly missed.33 The general approach for the evaluation of pediatric blunt abdominal trauma is based upon the clinical status of the patient. Abdominal CT is well accepted as the standard diagnostic tool for the evaluation of abdominal injuries. This would signify that most children evaluated for intra-abdominal injuries will undergo a CT, which of course is associated with radiation exposure to the abdominal organs. Recently, a prediction rule for the identification of children with intra-abdominal injury has been validated; it showed good sensitivity but was unable to identify 100% of the children with intra-abdominal injury.34,35 In this same study, the authors estimated that when these 6 high-risk variable prediction rules were used appropriately, it would decrease the number of abdominal CTs by one third.34,35 Brenner3,4 evaluated the radiation exposure associated with an abdominal CT and found that the organs that were most affected were the liver and the stomach. The doses ranged between 12 and 25 mGy at 200 mAs. Once again, this relation is linear and can be scaled up or down depending on the mAs used in a specific scanner/examination. The relationship between organ radiation dose and age were again inversely proportional, putting the youngest children at highest risk. When the estimated risk for developing cancer was calculated, the digestive organs were the most affected, and the cancer risk increased as the age at exposure decreased. The estimated lifetime risk was found to be small, ranging from 1/2000 to 1/1000 in the youngest patients.3,4 In the last decade, the use of focused assessment with sonography for trauma (FAST) by emergency physicians for the evaluation for abdominal trauma of the adult patient has become more accepted. The use of FAST has been shown to shorten the time to the operating room in the unstable trauma patient.35,36 The American College of Emergency

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Physician has issued guidelines that strongly encourage the availability and use of FAST in the evaluation of the trauma patient.36,37 It is understandable that FAST could decrease the use of abdominal CT, reducing the organ radiation exposure. However, the use of FAST for the evaluation of the pediatric trauma patient has not been widely accepted, and there are no clear guidelines for its use in children. The reported sensitivity of FAST in the pediatric population ranges from 31% to 100%, and it appears to perform well in the detection of free fluid in the hypotensive patient.37-39 More studies are needed that support the use of FAST in the pediatric trauma patient before guidelines can be devised for its regular implementation in the pediatric population. This is a tool that will hopefully help reduce the use of abdominal CT, thus, reducing the risk for cancer.

SUMMARY
Computed tomography has become one of the most frequently used diagnostic tools in the evaluation of the pediatric trauma patient. There is an inherent risk associated with ionizing radiation exposure secondary to CT use, and children are more susceptible than adults to the development of radiation-induced cancer. Although the risk may be low and the benefits may greatly outweigh the risk in certain cases, such as those children with more severe injuries, it is important to weigh the risk vs the benefit for every patient. Exposing a child to a radiation dose that increases the risk for cancer without a proven diagnostic advantage is no longer acceptable. This practice is also contrary to ALARA (as low as reasonably achievable) that acknowledges that no level of diagnostic radiation is without risks. Scan them until they glow violates the ALARA concept and is not an appropriate approach to the evaluation of the pediatric trauma patient.

REFERENCES
1. Blackwell CD, Gorelick M, Holmes JF, et al. Pediatric head trauma: changes in use of computed tomography in emergency departments in the United States over time. Ann Emerg Med 2007;49:320-4. 2. Mettler FA, Wiest PW, Locken JA, et al. CT scanning: patterns of use and dose. [see comment] J Radiation Protect 2000;20: 353-9. 3. Brenner DJ. Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative. Pediatr Radiol 2002; 32:223-8 [discussion 242-224]. 4. Brenner D, Elliston C, Hall E, et al. Estimated risks of radiation-induced fatal cancer from pediatric CT. [See comment] AJR Am J Roentgenol 2001;176:289-96.

5. Health risks from exposure to low levels of ionizing radiation: BEIR VII Phase 2. Washington, DC: The National Academic Press; 2001. 6. American Academy of Pediatrics Committee on Environmental Health. Risk of ionizing radiation exposure to children: a subject review. Pediatrics 1998;101(4 Pt 1):717-9. 7. Kazakov VS, Demidchik EP, Astakhova LN. Thyroid cancer after Chernobyl. Nature 1992;359:21. 8. Hernandez JA, Chupik C, Swischuk LE. Cervical spine trauma in children under 5 years: productivity of CT. Emerg Radiol 2004;10:176-8. 9. Ionization radiation exposure of the population of the United States. Report no. 93: National Council on Radiation Protection and Measurements. Bethesda (Md): National Council on Radiation Protection and Measurements; 1987. 10. National Center For Injury Prevention and Control. Traumatic Brain Injury in the United States: a report to Congress. Atlanta (Ga): Center for Disease Control and Prevention; 1999. 11. Centers for Disease Control and Prevention. 2000 National Ambulatory Medical Care Survey, Emergency Department File 2002. Hyattsville (Md): National Center for Health Statistics; 2002. 12. Schutzman SA, Barnes P, Duhaime AC. Evaluation and management of children younger than two years old with apparently minor head trauma: proposed guidelines. Pediatrics 2001;107:983-93. 13. Dunnings J, Daly JP, Lomas JP, et al. Derivation of the children's head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child 2006;91:885-91. 14. Greenes DS, Schuztman SA. Clinical indicators of intracranial injury in head-injured infants. Pediatrics 1999;104: 861-2. 15. Palchak MJ, Holmes JF, Vance GW, et al. A decision rule for identifying children at low risk for low brain injuries after blunt head trauma. Ann Emerg Med 2003;43:493-506. 16. Quayle KS, Jaffe DM, Kuppermann N, et al. Diagnostic testing for acute head injury in children: when are computed tomography and skull radiographs indicated. Pediatrics 1997;99:1-8. 17. Jimenez RR, DeGuzman MA, Shiran S, et al. CT versus plain radiographs for evaluation of c-spine injury in young children: do benefits outweigh risks. Pediatr Radiol 2008; 38:635-44. 18. Pierce DA, Shimizu Y, Preston DL, et al. Studies of the mortality of atomic bomb survivors. Report 12, part 1. Cancer: 1950-1990. Radiol Res 1996;146:1-27. 19. Kupperman N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injures after head trauma: a prospective cohort study. Lancet 2009; 374:1160-70. 20. Nuez DB, Zuluaga A, Fuentes-Bernardo DA, et al. Cervical spine trauma: how much more do we learn by routinely using helical CT. Radiographics 1996;16:1307-18. 21. Nuez DB, Quencer RM. The role of helical CT in the assessment of cervical spine injuries. AJR Am J Roentgenol 1998;171:951-7. 22. Keenan HT, Hollingshead MC, Chung CJ, et al. Using CT of the cervical spine for early evaluation of pediatric patients with head trauma. AJR Am J Roentgenol 2001; 177:1405-9. 23. Blackmore CC, Ramsey SD, Mann FA, et al. Cervical spine screening with CT in trauma patients: a cost-effectiveness analysis. Radiology 1999;212:117-25.

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24. Borock EC, Sheryl GA, Lenworth MJ, et al. A prospective analysis of a two-year experience using computed tomography as an adjunct for cervical spine clearance. J Trauma 1991;31:1001-6. 25. Nuez BA, Adel A. Clearing the cervical spine in multiple trauma victim: a time-effective protocol using helical computed tomography. Am Soc Emerg Radiol 1994;1:273-7. 26. Shiran S, Jimenez R, Altman D, et al. Evaluation of C-spine HRCT. Pediatr Radiol 2005 [abstr]. 27. Slack SE, Clancy MJ. Clearing the cervical spine of paediatric trauma patients. Emerg Radiol J 2004;21:273-7. 28. Viccellio P, Simon H, Pressman BD, et al. A prospective multicenter study of cervical spine injury in children. Pediatrics 2001;108:e20. 29. d'Amato C. Pediatric spinal trauma: injuries in very young children. Clin Orthop Related Res 2005:34-40. 30. Fesmire FM, Luten RC. The pediatric cervical spine: developmental anatomy and clinical aspects. J Emerg Med 1989;7:133-42. 31. Sadetzki S, Chetrit A, Lubina A, et al. Risk of thyroid cancer after childhood exposure to ionizing radiation for tinea capitis. J Cli Endocrinol Metab 2006;91:4798-804. 32. Ron E. Let's not relive the past: a review of cancer risk after diagnostic or therapeutic irradiation. Pediatr Radiol 2002;32: 739-44.

33. Saladino RA, Lund DP. Abdominal trauma. In: Fleisher GR, Ludwig S, eds. Textbook of pediatric emergency medicine, 5th ed. Philadelphia (Pa): Lippincott Williams & Wilkins; 2006. p. 1453-62. 34. Holmes JF, Mao A, Awasthi S, et al. Validation of a prediction rule for the identification of children with intraabdominal injuries after blunt torso trauma. Ann Emerg Med 2009;54:528-33. 35. Rozycki GS, Feliciano DV, Schmidt JA. The role of surgeonperformed ultrasound in patients with possible cardiac wounds. Ann Surg 1996;223:737-46. 36. American College of Emergency Physicians. Use of ultrasound imaging by emergency physicians. Ann Emerg Med 2001;38:470-81. 37. Ma OJ, Mateer JR. Pediatric applications. In: Price DP, Peterson MA, eds. Emergency ultrasound, 2nd ed. Columbus (Ohio): McGraw-Hill Companies; 2003. p. 464-89. 38. Mutabagani KH, Coley BD, Zumberge N. Preliminary experience with focused abdominal sonography for trauma (FAST) in children is it useful. J Pediatr Surg 1999;34: 48-52. 39. Holmes JF, Brant WE, Bond WF. Emergency department ultrasonography in the evaluation of hypotensive and normotensive children with blunt abdominal trauma. J Pediatr Surg 2001;36:968-73.

Abstract:
The acutely injured child poses unique clinical challenges in many respects. Our understanding of these unique characteristic differences and ability to care for pediatric trauma patients has greatly improved over recent decades; however, one area in pediatric trauma care continues to suffer from relative neglect in research and shows few signs of improvement in clinical practice: analgesia. Studies of analgesia practices continue to describe pervasive undertreatment of pain in the pediatric trauma patient. A growing body of evidence suggests that poorly controlled acute pain (oligoanalgesia) not only causes suffering but may lead to both immediate complications that worsen outcomes as well as debilitating chronic pain syndromes that are often refractory to available treatments. This article will provide a review of pain in injured children with respect to its pathophysiology, clinical ramifications, and patterns of analgesia practices. Impediments to analgesia are examined regarding multiple providers of care for the acutely injured child including prehospital personnel, nurses, and physicians. Finally, the article will provide analgesia recommendations with an approach to pain relief and sedation for the injured pediatric patient.

Analgesia for the Pediatric Trauma Patient: Primum Non Nocere?

Michael Greenwald, MD
valuating pain in the trauma patient poses unique challenges as it may simultaneously involve both somatic and visceral pain from a variety of origins. The pain response is a complicated process that may evolve from acute (normal) to chronic (maladaptive) pain with persistent or repetitive exposure to injury-provoked pain. This is true for patients of any age; however, children appear especially vulnerable to the harmful effects of oligoanalgesia. Understanding how both acute and chronic pain occurs may help us better control and prevent the pain responses that can cause harmful changes after injury. A comprehensive description of pain physiology in the pediatric trauma patients is beyond the scope of this article. Instead, we will focus on select concepts of the pain response, how the pediatric patient's response to injury and pain are unique, and how chronic pain syndromes are thought to occur. These painrelated issues include visceral vs somatic pain, the stress response, hypersensitivity vs habituation, central nervous system (CNS) plasticity, hyperalgesia, and central sensitization.

Keywords:
oligoanalgesia; pain; pediatric; trauma
Pediatrics and Emergency Medicine, Emory University School of Medicine, Childrens Health care of Atlanta, Atlanta, GA. Reprint requests and correspondence: Michael Greenwald, MD, 1604 Clifton Rd NE, Atlanta, GA 30322. mgreenw@emory.edu
1522-8401/$ - see front matter 2010 Published by Elsevier Inc.

KEY CONCEPTS OF PAIN PATHOPHYSIOLOGY IN THE INJURED CHILD

Visceral vs Somatic Pain
Somatic and visceral pain systems have distinct physiologic and clinical features. Cutaneous somatic innervation is more dense and limited to a few spinal segments; therefore, cutaneous somatic pain is better localized and characterized by specific sensations. Deep somatic pain (muscles, joints) resembles visceral pain in its dull nature and poor localization. Visceral organs are innervated

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by 2 sets of nerves: vagal and spinal nerves or pelvic and spinal nerves. Most internal organs are innervated by the vagus nerve; however, its role in transmitting pain signals is not yet clear. Most visceral afferent fibers are thinly myelinated or unmyelinated providing a dull and difficult to describe sensation. Visceral pain has poor localization as input is typically distributed over several spinal segments. This leads to similar pain sensations from nociceptive activity in unrelated organs (eg, urinary bladder and colon, gall bladder and heart). Visceral nerves receive convergent somatic input (skin, muscle) resulting in referred pain to unrelated sites (eg, retrosternal pain to the neck, cardiac ischemic pain to neck, shoulder, or jaw). The stronger emotional and autonomic reactions seen with visceral pain may reflect the involvement of the anterior cingulated gyrus, amygdala, and insular cortex. Last, visceral nociceptor activation can occur even in the absence of tissue damage (eg, functional abdominal pain).1,2

investigators found that the control group demonstrated higher levels of stress hormones (eg, hyperglycemia, lactic acidemia), greater incidence of sepsis and disseminated intravascular coagulopathy, and had a 27% mortality rate. The intervention (medication) group had no increase in pulmonary or circulatory complications and no deaths. The results starkly contradicted prevailing wisdom at the time and were so remarkable the study was ended prematurely as it was considered too risky to continue practicing the standard of care. Finally, behavioral changes seen in patients with poorly controlled pain include crying, agitation, and sleep disturbance. In one study, children in a burn unit were found to have posttraumatic stress disorder symptoms inversely related to the amount of morphine administered 6 months prior at their initial presentation.6 Thus, many physiologic, biochemical, and behavioral changes associated with poorly controlled pain are the very consequences of injury we hope to prevent and control to facilitate healing and prevent harmful outcomes.

The Stress Response

Acute pain results in a stress response that manifests in physiologic, biochemical, and behavioral changes associated with hemodynamic instability and poor wound healing. Infants are particularly vulnerable to changes in intracranial pressures related to fluctuations in systemic vascular pressures because of an immature blood brain barrier. Autonomic responses to acute pain lead to fluctuations in heart rate and blood pressure. These responses may diminish with persistent pain and are often not a reliable marker for the presence of pain. Pain is also associated with hypoventilation that may lead to hypoxia. This may explain the seemingly paradoxical effect of improving respiratory function in critically ill patients when treating their pain with effective doses of opioids.3,4 Persistent or severe pain is associated with elevated levels of stress hormones such as catecholamines, glucagon, growth hormone, and lactate and ketones, whereas insulin levels are suppressed. Neonatal catecholamine and metabolic responses are 3 to 5 times greater than those in adults undergoing similar types of surgery. One of the most significant clinical studies on the harmful effects of poorly controlled acute pain was reported by Anand and Hickey5 in 1992. At the time the standard of care in anesthesia held that neonates would experience worse outcomes if provided a comparable level of anesthesia during surgery. Anand and Hickey5conducted a trial with neonates requiring congenital heart disease repair. The

Hypersensitivity vs Habituation
One of the clinical hallmarks of a healthy adult's response to pain is the ability to habituate. That is, with repeated or prolonged exposure to a similar stimulus, the autonomic responses tend to lessen. In contrast, younger patients tend to demonstrate just the opposite. This is classically found with the heel prick of a neonate. With repeated exposures, the infant exhibits a lower pain threshold (ie, more brisk flexor response) and autonomic lability.7 Similarly, older children report increased perception of pain if preceded by repeated painful experiences.8 On a conceptual level, the reason why infants may differ in a pain experience lies in the difference in understanding and processing the meaning of a painful experience. This is one of the most challenging areas to explore; it is unlikely we will ever know how infants perceive a painful experience. Pain experiences have both physical and emotional components that affect the reaction. Our cognitive maturity allows us to attenuate the emotional and neurophysiologic response of a nonlife-threatening injury. One example is the pain from a percutaneous needle insertion. The pain experienced from trauma associated with a needle insertion is likely similar on an anatomical level in different aged individuals. The pain stimulates the same nociceptors, results in the release of similar neurotransmitters, and travels on the same neural pathways to similar areas of the brain. A healthy, mature individual should recognize the source of the pain as something that has a

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positive purpose (to improve health) and a limited duration and intensity. Even the adult with needle phobia will recognize that the pain experienced will dissipate and not recur without warning. Infants and to a lesser extent children lack this perspective. This may also help explain why the stress response to the same pain stimulus is more brisk and intense in less mature or adaptive individuals.7 There are several possible physiologic explanations for this phenomenon. One of the important components of pain physiology is modulation. Pain responses are either amplified or attenuated at the level of the dorsal horn of the spinal cord through the release of excitatory and inhibitory neurotransmitters. Less mature patients have a relative deficiency of inhibitory neurotransmitters and some inhibitory neurotransmitters, such as -Aminobutyric acid (GABA), have an excitatory effect in the premature infant.7 Another explanation lies at higher levels in a process known as integration. When pain signals ascend to the brain, they are distributed to multiple supraspinal centers including the reticular activating system, olivary, paraventricular, and thalamic nuclei; limbic system; cingulate and postcentral gyrus; frontal and parieto-occipital areas. At these levels, the pain signal is integrated and processed. Pain is identified by its localization and characteristics. The information is matched with memories of past experiences that in turn mediate levels of arousal, attention, and sympathetic responses. In laboratory studies, less mature subjects demonstrate less inhibitory pathway activation compared to more mature subjects. It is hypothesized that recognition of nonharmful painful stimuli can aid in blunting the pain signal. This ability logically relates to experiences and age and is inherently deficient in younger patients.9

Central Nervous System Plasticity

One of the greatest concerns regarding oligoanalgesia in young patients is the potential for altering the developing CNS. The plasticity of the nervous system is now recognized in all age groups but is thought to have a particularly profound impact on young children because they have rapidly developing nervous systems. Pain researchers have demonstrated that poorly controlled and repetitive exposure to pain has a unique and lasting negative impact on the CNS of young patients and that this effect is potentially more profound with less maturity. In laboratory studies of rat pups, the repeated exposure to pain results in morphologic changes at

the site of injury and the dorsal horn of the spinal column. These changes may be temporary or long lasting. They are seen at a variety of levels including changes in protein phosphorylation, altered gene expression, loss of neurons, formation of new synapses, and loss of inhibitory interneurons. Local tissue damage in the early postnatal period results in profound and lasting sprouting of sensory nerve terminals (A & C fibers) and sprouting of neighboring dorsal root ganglia cells in the spinal cord leading to inappropriate functional connections and hyperinnnervation. Clinically, these changes result in allodynia and other features of neuropathic pain.10 Repetitive pain also appears to accelerate apoptosis. This refers to the pruning of unused neural pathways. Although this is a normal phenomenon during infancy, it appears to be accelerated in laboratory animals subjected to repeated painful stimuli. Finally, pain is associated with activation of N-methyl D-aspartate (NMDA) receptors located on neurons. The receptor is activated by glutamate resulting in an influx of Ca++ and Na+ activating a Ca++calmodulin complex. This leads to production of heat shock proteins that causes lysosome degranulation and necrosis of the nerve cell. The activation of NMDA receptors is thought to contribute to the development of chronic pain syndromes. Interestingly, this process is inhibited with the administration of opioids as well as NMDA receptor antagonists such as ketamine, methadone, and nitrous oxide.11,12 Clinical evidence of these changes is found in the association of chronic conditions with exposure to painful stimuli. Anand et al13 described how functional abdominal pain is seen in higher rates in former premature infants who experienced frequent gastric suctioning. Studies using PET scans have revealed that the anterior cingulate cortex is particularly affected by pain. This area is associated with control of emotion and attention and may help explain why premature infants who experience more medical complications exhibit a higher rate of psychosocial disorders such as attention deficit hyperactivity disorder (ADHD) and lower academic achievement compared to matched controls.14

Pathways to Chronic Pain: Hyperalgesia, Central Sensitization, and Sympathetically Mediated Pain
Multiple pathways are described to explain the development of chronic pain after injury. These mechanisms include hyperalgesia from local inflammatory markers, sensitization of neurons proximal

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to and surrounding damaged nerves, and sympathetically mediated pain. After an injury, inflammatory mediators are released that may cause the pain response to increase even in the absence of additional injury. This sensitization of nociceptors results in primary hyperalgesia at the site or injury. Primary hyperalgesia manifests clinically as a more intense pain response than expected from stimuli. Secondary hyperalgesia may develop in the area surrounding the area of injury as a result of sensitization of neurons in the CNS. This central sensitization occurs when receptors that normally conduct nonpain signals (eg, touch) now transmit pain signals. When nonpainful stimuli such as touch result in a pain response the condition is called allodynia. Clinical examples of this include the severe and diffuse pain associated with burns (light touch), pharyngitis (swallowing), arthritis (movement), and in more unusual conditions such as complex regional pain syndrome (formerly reflex sympathetic dystrophy).15 Hyperalgesia may also result from damaged or severed nerves. Instead of a diminished pain signal, Wallerian degeneration of the severed nerve may result in sensitization of nociceptors in adjacent nerves (primary hyperalgesia) and increase spontaneous activity of adjacent nociceptors resulting in central sensitization (secondary hyperalgesia). This paradoxical pain response manifests in the clinical syndrome of neuropathic pain. Symptoms include intense burning and electrical sensations that are often refractory to opioids in usual doses.15 As noted above, nociceptor stimulation is often associated with a resulting increase in sympathetic activity. In some circumstances, the reaction reverses: nociceptors may develop sensitivity to catecholamines. This is known as sympathetically maintained pain. In these conditions, trauma (even seemingly trivial trauma) provokes a pain response that features not only hyperalgesia but also allodynia. The classic example is complex regional pain syndrome that, in the pediatric patient, typically involves the lower extremity of school-age girls and is often associated with edema and dramatic changes in cutaneous perfusion.15

and stabilizing neurons. The clinical result may include a lower incidence of sepsis, metabolic acidosis, disseminated intravascular coagulopathy, and death. Given this information, it appears that pain control is important for all patients and particularly the youngest. Ironically, studies of our clinical practice reflect just the opposite.

ANALGESIC PRACTICE FOR PEDIATRIC TRAUMA PATIENTS

Most of the information available regarding pain management for pediatric trauma patients focuses on isolated injuries and burns. There are more studies addressing pain management for adult trauma patients than for children. In general, studies on analgesia practice in medicine over the past several decades reveal pervasive patterns of apparent undertreatment. In this section, we will examine the following aspects of clinical practice. What are the patterns of analgesia for pediatric patients? What are the patterns of analgesia for trauma patients? What are some of the impediments to providing analgesia for pediatric trauma patients?

Analgesia for Children

This year marks a decade since the Joint Commission on the Accreditation of Healthcare Organizations cited inadequate analgesia as the first nondisease healthcare crisis in the United States. Its response to this problem included numerous guidelines, resources, and requirements to assess and treat pain. Despite this effort, it is unclear whether we have seen improvement in the clinical practice of pain management for children. Pain research since the 1970s describes how children are given analgesics less often than adults for similar conditions and prescribed approximately 50% of the weight-based equivalent of analgesics.16-18 Furthermore, the milligram per kilogram dosing of analgesics is generally directly related to age, that is, younger patients receive lower milligram per kilogram dosing regardless of clinical situation.19 In 1996, Broome et al20 reported that younger children received inconsistent pain assessment and management and that institutional standards regarding pain control were often ignored. That same year, Cummings et al21 reported on children admitted to a Canadian hospital, noting that 21% had uncontrolled pain and that children were offered analgesics less than prescribed (ie, prn medications available but not provided). Interestingly, some studies have shown that those with pediatric subspecialty training may provide less

Summary of Neurophysiologic Reponses to Pain

Pain responses appear heightened in younger patients whose CNS is more vulnerable to physiologic stress. Repetitive and persistent pain is associated with morphologic changes of the nervous system at multiple levels. Analgesics have a neuroprotective effect by decreasing exhibitory neurotransmitter activity, increasing inhibitory neurotransmitters,

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analgesia than their generalist counterparts. In 2004, Cimpello et al22 described this in a review of more than 700 children with fractures seen in 3 emergency departments (EDs) for 2 years. In this study, general emergency physicians prescribed more analgesics and recommended pain treatment and advice on discharge more often than their pediatric emergency medicine-trained colleagues. Quinn23 described a comparison of the use of local anesthetic for lumbar puncture in children and found an even more striking contrast between those with and without pediatric subspecialty training. In this study of children presenting to different EDs in Baltimore, 93% of children treated by those without pediatric training received local lidocaine before lumbar puncture, whereas only 4.5% of children presenting to the children's hospital ED received lidocaine. At the pediatric institution, those receiving lidocaine included 0 of 168 infants, 1 of 18 toddlers, and only 8 of 12 children older than 4 years. The treating physicians were asked whether pain was experienced to the same degree regardless of age and 51% agreed with this statement.23 In addition to the patterns found in pediatric patients, studies of other specific demographic groups have also demonstrated patterns of oligoanalgesia. Elderly patients (N70 years old) also receive less analgesia in the ED.24 Analgesia research by Todd et al25 has described significant ethnic and racial disparities in the administration of analgesia. Hispanic patients in Los Angeles with isolated long bone fractures were twice as likely to receive no analgesia compared to non-Hispanic white patients, and black patients in Atlanta were less likely to receive adequate analgesia compared with white patients.26 Finally, patterns of sex discrimination are reported with women often receiving less analgesia than men.27 The reasons for these patterns of disparities are difficult to elucidate but important to examine; they are addressed later in this article.

therapeutic dosing, and with analgesic advice given at 74% of visits. Children with burns received analgesics even less often (26% of visits), with 70% therapeutic dosing, and with only 27% receiving analgesia instructions at discharge.28 O'Donnell29 found that 49% of 172 children with musculoskeletal injuries presenting to an ED were provided analgesics. Another 2002 study noted only 50% of burn victims received adequate analgesia in EDs.30 Neighbor et al31 described opioid use for severely injured patients in a level I trauma center over the course of 1 year. Of more than 500 cases, only 48% received intravenous opioids within the first 3 hours with the mean time to first dose of 95 minutes. Risk factors for receiving less opioid included younger age (b10 years old), intubation, lower revised trauma score, or not requiring fracture manipulation.31 Studies of prehospital care demonstrate 2 patterns. In general, prehospital personnel tend to undertreat pain in trauma patients; however, when analgesia is provided by prehospital personnel, it makes a significant difference in the time to analgesia compared to patients who receive their first dose of analgesia by hospital personnel. A 2000 report on prehospital analgesia in more than 1000 patients showed that only 1.5% of patients received analgesia after an extremity injury.32 A 2002 study on transports of patients with isolated lower extremity injuries showed analgesic use in just 18.3% of transports.33 Several studies on the use of prehospital analgesia protocols for injured patients have demonstrated safety, effectiveness, and increased use of prehospital opioid analgesia.34-38 In a 2005 review of emergency medical services (EMS) transports by 20 different EMS agencies in Michigan, analgesia was provided by EMS for 22% of children having fractures or burns; however, these children received their medications 1 hour sooner than those who had to wait for a dose provided by the ED.39

Analgesia in Trauma
Research on analgesia practice for trauma patients reveals similar patterns of undertreatment, particularly for children. Friedland et al28 compared analgesia provided for 215 children presenting to Cincinnati Children's Hospital (Ohio). Children with vaso-occlusive crisis from sickle cell disease received analgesics at 100% of visits, within 52 minutes (mean), with 78% therapeutic dosing (average), and with analgesia guidance given on discharge at 100% of visits. In comparison, children with fractures received analgesics at 31% of visits, at 1.5 hours (mean) after presentation, with 69%

Impediments to Analgesia
Efforts to understand the causes of oligoanalgesia have revealed a wide array of possible explanations. Influences may come from the patient, family, and society as well as the medical profession. For health care professionals, these explanations include (1) fear of masking signs of serious injury or illness, (2) fear of causing or exacerbating hemodynamic or respiratory insufficiency, (3) inadequate pain assessment skills or efforts, (4) lack of understanding about pain and analgesics, and (5) concerns about creating addictive behavior by providing analgesia. One of the purported reasons for withholding analgesics in the trauma patient is the belief that

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pain relief achieved by analgesics could mask symptoms of an underlying pathologic condition. The implication is that outcomes will worsen due to a delay in diagnosis and progression of symptoms. A study of 215 physicians and nurses in 9 Israeli trauma units reported that analgesics were frequently (78%) withheld to assist diagnosis.40 Most providers in this study believed that analgesics should be withheld in cases of abdominal or multisystem injury; however, 75% reported that they had inadequate knowledge about pain management.40 Although seemingly logical, the paradigm that analgesia worsens outcomes is not substantiated in the literature. The basis for this belief may lie in part with a classic surgical text originally authored by Cope, Early Diagnosis of the Acute Abdomen. The text states that in the setting of acute abdominal pain of unclear etiology analgesia will (1) mask signs and symptoms of a surgical condition causing a (2) delay in diagnosis with resulting (3) increase morbidity and mortality. Although these assertions were replicated in subsequent editions, they do not offer supporting evidence.41 In recent years, researchers have attempted to test this assumption with respect to the patient with possible acute appendicitis. More than a half dozen studies have examined the use of morphine (typically 5-mg doses) in patients with signs of peritonitis.42,43 None of the studies revealed a delay in diagnosis or a negative outcome attributed to the morphine. One study demonstrated improved localization of tenderness.44 Kim et al45 published the first pediatric study on this issue and also found no false-negative evaluations and no complications attributed to opioid used for children with an acute abdomen. Opioid use in trauma patients has received close examination in the literature. The 3 primary concerns in acute pain management are altered mental status (ie, masking disorders involving the CNS or CNS perfusion), respiratory depression, and masking serious injuries by blocking the pain response. Although excessive dosing of opioids can certainly cause CNS or respiratory depression, research in clinical use of opioids in trauma patients does not support the presumption that analgesia worsens outcomes. Buduhan et al46studied more than 500 trauma patients and found no correlation with opioid use and missed injuries. Lazarus et al47 reported a study of adverse drug events in more than 4000 trauma patients and found no serious events due to opioids. Finally, several large studies have demonstrated safety and efficacy of fentanyl used by EMS for trauma patients 48 including one pediatric study.49 Improving pain assessment is a primary focus for reducing oligoanalgesia. Whipple et al50called atten-

tion to this issue in a 1995 study that described a striking contrast in perceptions among patients with multisystem injury in a critical care setting. Ninetyfive percent of housestaff and 81% of nurses reported adequate analgesia provided for patients who simultaneously rated pain moderate or severe 74% of the time. It is logical that improved pain assessment would lead to improved analgesia. In a 2004 prospective study of 150 adult trauma patients, 60% of those with pain scores received analgesics compared to 33% without pain scores. The mean time to analgesia was 68 minutes in this study.51 However, a recent pediatric study on pain assessment failed to show a change in analgesia administration rates and time to analgesia with improved documentation of pain scores.52 Barriers to analgesia likely occur at multiple steps beginning with pain assessment and then the response to that information. A study of 355 ED nurses revealed deficits in understanding pharmacologic analgesic principles and concepts such as addiction, tolerance, and dependence.53 Scores correlated with education level and improved after a 1-day seminar. Fiftythree percent of nurses cited the potential for analgesics to mask signs of injury or illness as a barrier to providing treatment. Forty-eight percent reported inadequate pain assessment skills.53 In a 2004 study of prehospital personnel, Hennes et al54 found significant differences in the comfort level of EMS providers in administering analgesics depending on a patient's condition. Of the subjects, 93% to 95% reported feeling comfortable providing analgesics to patients with pain from fractures, burns, or nonspecific chest pain if the patient was older than 17 years. Much fewer respondents felt comfortable if similar patients were 7 to 17 years old (chest pain, 36%; extremity injury, 70%; burn, 77%) and even less if younger than 7 years (chest pain, 24%; extremity injury, 38%; burn, 44%). In this study, respondents cited the following as barriers to providing analgesia to pediatric patients: inability to assess pain (87%), difficult vascular access (80%), delay of transport (66%), fear of complication (68%), record keeping (30%), and possible drug seeking (65%).54 Although attention to pain in the adult medical literature has increased exponentially in recent years, a focus on analgesia for children and trauma patients remains sparse. Much of the research in pediatric pain centers on animal models. Major pediatrics and pediatric emergency medicine texts still provide relatively little attention to pain. The advanced trauma life support course practically ignores the subject. In previous editions of the advanced trauma life support provider manual, pain

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was briefly addressed in a paragraph that followed the section on the secondary survey.55 The most recent edition has omitted even this brief mention. The index cites just 2 pages where pain is addressed in the current manual: as part of C-spine evaluation and under musculoskeletal trauma. In the latter section, the authors' guidance states Whenever analgesics, muscle relaxants, or sedatives are administered to an injured patient, the potential exists for respiratory arrest.56 In comparison, the Emergency Nurses Association course, Advanced Trauma Nursing: A Conceptual Approach, has an entire chapter on pain in the trauma patient.57 This contrast highlights the differing emphasis on pain management seen in the nursing and medical professions.

TABLE 1. Pain assessment scales.

Patient Description Infants Preschool School age adolescent Intubated/ noncommunicative Recommended Scale NIPS: Neonatal Infant Pain Scale Wong-Baker Faces Scale Visual Analog Scale Comfort Scale Scoring Range 0-21 0-5 0-10 8-40

RECOMMENDATIONS FOR ANALGESIA IN THE PEDIATRIC TRAUMA PATIENT

The dictum First do no harm seems to conflict with efforts to effectively control pain; but as explained in the preceding pages, there is considerable harm inflicted by allowing pain to continue unchecked. This final section will cover select modalities for both pain and anxiety. Although there is no panacea for traumatic pain, the treating clinician will find success with anticipation of analgesia needs, an understanding of both the patient and available treatments, and an approach of titrating to effect.

Pain Management Approach for the Injured Child

When treating pain, physicians often tend to think only of medications (when you have a hammer, all the world's a nail), however, effective pain management relies first on the skilled use of nonpharmacologic approaches. The first key intervention is pain assessment and reassessment. Just as shock is overlooked if capillary refill, heart rate, and blood pressure measurements are neglected, untreated pain usually occurs because it is not recognized. The challenge lies not only in finding effective tools to measure pain but simply paying attention to pain in the clinical setting. Using our most validated instruments (eg, WongBaker Faces scale), pain assessment is generally considered to be unreliable in children younger than 3 years and the visual analog scale is generally not useful in children younger than 6 years (Table 1). Furthermore, acutely injured patients may require intubation and therefore lose the ability to vocalize discomfort. When a patient is unable to perform a pain score, the clinician is left with secondary assessment measures. Vocalizations such as crying,

grunting, or moaning may reflect pain; however, children with painful injuries may make no sound simply because they fear that vocalizations will prompt an injection. Heart rate and blood pressure are often elevated in acute pain; however, hemodynamic changes are not always reliable markers in painful settings. Vagal responses to pain may decrease heart rate, whereas some patients demonstrate a more attenuated sympathetic response, particularly when pain is prolonged. When uncertain one should ask a simple rhetorical question: Is this a painful condition/situation? If so, examine the effect of a small dose of analgesia on vital signs, muscle tone, respiratory effort, and overall affect. Just as important as doing the right thing is caution not to do the wrong thing. Anxiety and pain are magnified in children when they feel a loss of control and lack psychosocial support. This, of course, is also true for adults; the difference lies in the ability to recognize and express these feelings. How we speak with vulnerable children can make a tremendous positive or negative impact on their experience and reaction to the care we provide. Children may be scared by either a poor choice of words (we'll give this a shot) or language they either do not understand or misunderstand. Making unrealistic promises (this won't hurt) or invalidating feelings (that doesn't really hurt) only serves to undermine your relationship with the patient. Painful treatments should never be used as threats or punishments. Take care to keep needles or needle/syringe images out of view when possible. When possible, keep the patient close to eye level and let them sit up whenever feasible. Last, children are usually very concerned about losing blood. When they see their own blood, they may benefit from reassurance that the amount of blood loss is not harmful to them.

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Keys to an optimal rapport with your patient include honesty, clarity, and empowerment. Give them choices wherever possible. The key is recognizing which patient may benefit from detailed information and which patient copes better with distraction. While many children are extremely frightened of needles, some have worse anxiety when they cannot see what is happening to them. Distraction is a potentially powerful intervention and generally easier to implement at younger ages. Hypnosis, an advanced form of distraction, has a long track record of effective pain control in many acute and chronic pain situations. There is considerable evidence in the literature that supports family presence in the medical setting. Researchers have found that with clear guidelines and support, patients and family members report greater preference for family presence even in critical situations. Clinicians in these studies report no increase in adverse outcomes when family members are present and experts in the field report a lower medicolegal risk when family members are present at end of life settings. The key to family presence is providing skilled personnel such as clergy, nurses, or child life services to guide the family members about where they should be in a trauma room and under what circumstances they may be asked to leave. If your institution does not already have a policy describing how to provide safe and effective family presence, there are multiple resources available to develop such a policy.58-63 The concepts listed above do not require a medical license or sophisticated understanding of pharmacology. Rather, they require a basic understanding of child development and a willingness and ability to pay attention to verbal and nonverbal cues of distress. When practiced and performed well they can make the difference between an optimal situation and one that is unmanageable.

complete review of both pharmacologic and complementary approaches to analgesia is found in the references cited.64-66

Acute Pain
The immediate goal of acute pain management is to get pain under control and then maintain that control. Even when the former is achieved, we often end up chasing the pain when we neglect to reassess and treat until the patient is again in severe distress. This results in both ineffective analgesia and more medication administered. A secondary goal in acute pain management is the prevention of chronic pain. Through the careful titration of medication and attention to nonpainful stressors that worsen painful experiences, clinicians can provide safe and effective pain control in most patients. Opioids are usually the central therapy for managing severe acute pain. There is considerable variability of opioid responsiveness in some patients, and they may require significantly higher dosing. Such patients may either have differences in opioid receptors (often a familial pattern) or a higher tolerance due to chronic exposure to opioids. Of the numerous potential side effects of opioids, the most common are gastrointestinal dysmotility (nausea, pain, and constipation), sedation, and tolerance/ dependence. Proactive treatment of constipation is strongly recommended for patients receiving regular doses of opioids. Morphine, the gold standard analgesic, has a relatively slow onset of action and a half-life of 2 to 3 hours. It is typically dosed as 0.05 to 0.1 mg/kg for the opioid-nave patient in severe pain. Subsequent dosing of 0.02 to 0.05 mg/kg should take place every 10 minutes to desired level of analgesia. Although morphine is perhaps the most familiar opioid, it is sometimes not the ideal medication for trauma patients. Disadvantages include a slower onset, higher incidence of allergic reactions due to histamine release, more venodilation and risk of hypotension, and greater effects on gastrointestinal motility than other commonly used opioids. For the acutely injured patient whose initial evaluation is still in progress, fentanyl offers a number of advantages. Fentanyl is metabolized in the liver to inactive compounds; however, this is not significantly altered in liver disease. Onset is within 5 minutes and therapeutic levels are achieved for 20 to 60 minutes. Typically, the opioid-nave patient in severe pain is safely and effectively treated with an initial dose of 2 to 3 g/kg of fentanyl. A continuous infusion can sustain therapeutic levels and allow

In a sense, all analgesics are nerve blocks. Whether a pain signal is interrupted by a local or generalized anesthetic, systemic opioid, or effective distraction, each intervention works by attenuating the pain signal at some level. The keys to safe and effective use of medications include an understanding of the characteristics of the medications and a willingness to carefully titrate to effect. This section is not intended to provide an exhaustive list of available treatments. Attention will focus on general concepts with added detail about select and commonly available medications. A more

Pharmacologic Interventions

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careful titration. In addition, the literature shows growing interest in intranasal administration of fentanyl. This offers the obvious advantage of analgesia without intravenous access. Some studies suggest that a dose of 1.7 g/kg of intranasal fentanyl is equivalent to 0.1 mg/kg of morphine.67 In this author's experience, a higher dose of fentanyl (2-3 g/kg) is required for mild-moderate pain. Oral transmucosal fentanyl is another option; however, effective doses by this route are associated with high rates (25%-50%) of nausea and vomiting.68 Finally, hydromorphone offers several potential advantages to morphine and fentanyl including fewer allergic reactions, longer duration of action, and somewhat less tolerance when used for prolonged periods. Opioids are ideally dosed to maintain a steady state serum concentration and avoid peaks and troughs. Once pain control is achieved, it is important to anticipate the need for boluses of analgesia. Even small movements, turning the patient or inadvertently bumping a chest tube or endotracheal tube can cause significant exacerbations of pain. The patient with a femur fracture may appear to have good pain control when lying motionless but quickly loses that control when moved. Before moving the patient for x-rays or other reasons, consider a small (1-2 g/kg of fentanyl) bolus administered several minutes in advance of anticipated movement. If the patient seems excessively sedated fentanyl also has the advantage of a relatively short half-life. If opioid reversal is necessary in a stable but excessively sedated patient physicians should begin cautiously with small doses of naloxone (0.001 mg/kg per dose) to avoid excessive blockade of opioid and resulting severe pain. Although not commonly used in the ED setting, some pediatric EDs are using patient-controlled analgesia (PCA) for select patients (eg, sickle cell pain crisis) with good results. In general, PCA requires a patient with at least a 5-year-old developmental level. Although not all patients prefer this approach, many patients achieve greater control with lower doses of opioid when they have immediate control of their analgesia with a PCA. Typically, a basal infusion of opioid is provided with a limited number of PCA doses programmed into the PCA pump. Nonsteroidal antiinflammatory medications such as ibuprofen and ketorolac are potentially useful treatments either alone for mild pain or as adjuncts for moderate pain. Efficacy studies comparing ketorolac to morphine and acetaminophen have yielded mixed results.69,70 Given the risk of decreased platelet function and gastritis, the role for

regular use of nonsteroidal antiinflammatory medications in the acutely injured patient is therefore limited to situations where the risk for surgery is low and pain levels are not severe. Finally, nerve blockade at the spinal cord can provide effective analgesia with a fraction of the dose required for systemic treatment. Long-term use of epidural analgesia is possible and can offer appropriate candidates unique benefits. Although commonly used for labor pain, cesarean delivery, and thoracic and abdominal surgery in adults, many pediatric institutions do not yet routinely use this approach as it requires close observation from those trained in this procedure.

Sedation of the Trauma Patient

Sedation of the pediatric trauma patient poses unique challenges due to the risk of shock from blood loss and CNS injury due to altered cerebral perfusion pressures secondary to intracranial swelling. In addition, these patients often require analgesia for pain. Although multiple studies have shown that preprocedural fasting times do not correlate with aspiration, the clinician should consider the risks of nausea and vomiting in each situation.71 The ideal sedatives for the necessary procedure in an acutely injured pediatric patient include the following properties: analgesia, minimal alteration in systemic and intracranial perfusion pressures, and short acting or reversible. No single agent offers the ideal combination of benefits for all situations; therefore, clinicians must rely on different options often with a combination of agents. Expertise in a handful of modalities is a better investment than marginal familiarity with a broad array of treatments. Before starting sedation, one should verify that equipment, medications, and personnel are in place to respond effectively to a sudden decrease in ventilation or oxygenation, emesis, hypotension, or seizure. Have an airway technician immediately available if your intention is to provide moderate to deep sedation. Recall that in light sedation (previously conscious sedation), the patient responds appropriately to physical and verbal stimuli. In deep sedation, the patient is not easily aroused, may have partial or complete loss of protective reflexes, and loses the ability to respond purposefully to physical or verbal stimuli. Last, anticipate when you might stop a procedure. Take for example a child who appears deeply sedated when untouched but screams during a painful orthopedic procedure. The orthopedist is focused on completing the procedure. The physician in charge of sedation should decide

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whether it is reasonable to attempt or complete the procedure or defer to another setting such as the operating room with general anesthesia. The following strategy may be helpful in choosing optimal sedation medications for a given scenario or procedure. These are general recommendations, and each case requires an individual assessment by a physician trained and experienced in sedating children. First, determine if the analgesia requirement will be low (eg, laceration repair) or high (eg, reducing a fracture). Next, determine if the procedure is likely to be less than or greater than 5 minutes. The key is to provide effective sedation and analgesia with the least amount of medication. In all cases, local or regional anesthetic is recommended where possible to limit the dose and duration of systemic medications. Last, strongly consider an amnestic agent (eg, benzodiazepine) as an adjunct for frightening situations/procedures. Do not proceed with a painful procedure until assured that the patient's sedation and analgesia is adequate. For lower analgesia requirements, fentanyl or nitrous oxide is recommended. Advantages of nitrous oxide include its rapid onset and recovery time and excellent anxiolysis;72 fentanyl offers superior analgesia. Nitrous oxide requires specific apparatus including a scavenging system and familiarity with administration. Contraindications against sedation with nitrous oxide include first trimester pregnancy, pneumothorax, chronic respiratory disease, bowel obstruction, CNS injury or depression, and shock.73 For more painful procedures, it is sometimes challenging to find a safe therapeutic window with fentanyl. In these cases, ketamine is often a good alternative as it can provide effective analgesia and sedation without loss of spontaneous respirations.74

Ketamine tends to increase secretions and has a positive chronotropic and inotropic effect that can result in an increase in systemic pressures. Ketamine administration is associated with increased intracranial pressure; however, this effect is attenuated with benzodiazepine administration or hyperventilation. Interestingly, one study of patients with traumatic brain injury found a decrease in intracranial pressure in patients given ketamine and propofol.75 In addition, ketamine often causes emesis and dysphoria upon waking (emergence reaction). The former is associated with higher dosing and the latter with older children and adults.11 Therefore, it is prudent to premedicate with atropine if increased secretions pose a problem, consider an antiemetic such as ondansetron and warn the family of the possibility of an emergence reaction (estimated to occur in 50% of older children and adults). When a procedure requires more than 5 minutes, propofol is a useful agent.76 Propofol can provide deep sedation without loss of spontaneous respirations and wears off within minutes of discontinuation. Side effects include negative inotropy, so special attention should be paid to the blood pressure in patients receiving fentanyl and propofol. Propofol is typically bolused with a starting dose of 1 to 3 mg/kg and then maintained with an infusion at 5 mg/kg per hour titrated to effect. Contraindications to propofol include soy or egg allergy. Alternatives to propofol include midazolam, etomidate, or methohexital (Table 2).

Prolonged Acute Pain

Managing prolonged or chronic pain is quite different than acute pain and generally not the

TABLE 2. Treatment options for procedural sedation of the trauma patient. a

Analgesia Need Mild-moderate Mild-moderate (eg, long laceration repair) Moderate-severe Moderate-severe Duration Short (b5 min) Long (N5 min) Short (b5 min) Long (N5 min) Recommendation Fentanyl (IV, IN) Fentanyl (IV, IN) + propofol Ketamine Ketamine + propofol Ketamine infusion; ketamine + midazolam, etomidate, OR methohexital Alternatives Nitrous oxide (when anxiety N pain) Fentanyl infusion; Fentanyl + midazolam, etomidate, OR methohexital

a Local or regional blocks with anesthetics are recommended where possible to decrease the requirement for systemic medications. IV indicates intravenous; IN, intranasal.

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responsibility of those in the emergency or acute care setting. As a result, acute care providers are generally less familiar with approaches to chronic pain. Nevertheless, the acute care provider will care for patients having prolonged or chronic pain and will need an understanding of these issues. Usually, patients transition from intravenous to oral opioids within days after injury or surgery. Oral opioids are sometimes necessary for 1 to 2 additional weeks. When patients have difficulty weaning from opioids one should consider the possible causes and alternative treatments. Opioid tolerance typically develops within a week of continuous use of the same opioid. Patients will exhibit a decreasing effect of similar doses of the medication. Although increased dosing can address this temporarily, it is usually more effective (ie, better analgesia with less medication) to switch to another opioid. Patients with increasing needs for boluses of analgesics (breakthrough pain) should be reassessed for both the causes of the pain and effectiveness of the pain plan. Although attention to the possibility of evolving organ damage is the priority, there are other common causes of increased opioid use in this setting. Sleep deprivation is often an overlooked source of poorly controlled pain.77 Anxiety may build with repetitive painful procedures, greater awareness of injuries, and a sense of lack of control over the situation. Assuming more aggressive analgesia is not contraindicated one may consider changing the opioid. Frequent need for a short-acting opioid should prompt a consideration to add a long-acting opioid such as methadone or long-acting formulations of morphine, oxycodone, or hydromorphone. The objective is to find an effective dose and dosing schedule that minimizes the peaks and troughs of medication level and pain control. Any changes in treatment strategy for patients with chronic pain must involve the advice and ongoing care of a knowledgeable physician. Nonopioid adjuncts may have an opioid-sparing effect and control the development of chronic pain. Unfortunately, pediatric trials for most of these adjuncts are lacking, particularly for pediatric trauma patients. A wide array of anticonvulsant medications have demonstrated effectiveness for various chronic pain syndromes. Gabapentin's possible effectiveness for phantom limb pain and spinal cord injury pain in addition to its relatively benign side effect profile make it a reasonable consideration for some trauma patients.78 Cannaboid therapy may offer some analgesia in addition to effectiveness as an anxiolytic and antiemetic.79 Ketamine is a potent NMDA receptor antagonist

that has demonstrated effectiveness in suppressing postsurgical central sensitization and secondary hyperalgesia after burns. It has also been used effectively in the treatment of postamputation stump pain and complex regional pain syndrome.80 Tricyclic antidepressants such as amitriptyline have a long track record of effectiveness in a variety of chronic pain syndromes. Amitriptyline's sedative effects may also help treat insomnia. More recent serotonin selective reuptake inhibitors have also shown some effectiveness.81

SUMMARY
Analgesia for the pediatric trauma patient remains a challenging and important area of research and clinical care. The relative infrequency of cases and multidimensional nature of injuries makes clinical research daunting. Undertreatment of these patients continues due to a variety of influences including excessive fears about adverse effects of analgesics, a lack of attention to pain, and underappreciation of the harmful effects of poorly controlled pain. Medical education and training still underserves the issue of pain in the context of patient care. Numerous national and institutional guidelines and requirements have modest impact as the standards of care for analgesia are usually locally based. Fortunately, the tools to improve care are within our grasp. Common pharmacologic and nonpharmacologic interventions are safe and effective if used in a judicious manner. Analgesia protocols for prehospital and hospital-based care can improve the percentages of patients treated; ultimately, the attitudes and understanding of providers regarding analgesia must evolve to achieve significant improvements in pain control. The emergency physician's responsibility in caring for a patient includes effective pain relief during their care and until the patient is transferred to a subsequent physician. Once we recognize that the potential harm in primum non nocere lies as much in undertreatment as in overtreatment of pain, children having injury will receive more effective analgesia.

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3. Pasero C, Portenoy RK, McCaffery M. Opioid analgesics. In: McCaffery M, Pasero C, editors. Pain clinical manual. 2nd ed. St Louis (MO): Mosby; 1990. p. 271-2. 4. Hedderich R, Ness TJ. Analgesia for trauma and burns. Crit Care Clin 1999;15:167-84. 5. Anand KJS, Phil D, Hickey P. Halothane-morphine compared with high dose sufentanil for anesthesia and post operative analgesia in neonatal cardiac surgery. N Engl J Med 1992;326: 1-9. 6. Saxe G, Stoddard F, Courtney D, et al. Relationship between acute morphine and the course of PTSD in children with burns. J Am Acad Adolesc Psychiatr 2001;40:915-21. 7. Beggs S, Fitzgerald M. Development of peripheral and spinal nociceptive systems. In: Anand KJS, Stevens BJ, McGrath PJ, editors. Pain in neonates and infants. 3rd ed. New York (NY): Elsevier; 2007. p. 11-24. 8. Schechter NL, Zeltzer LK. Pediatric pain: new directions from a developmental perspective. J Develop Behav Pediatr 1999; 20:209-10. 9. Anand KJS, Al-Chaer ED, Bhutta AT, Hall RW. Development of suprapinal pain processing. In: Anand KJS, Stevens BJ, McGrath PJ, editors. Pain in neonates and infants. 3rd ed. New York (NY): Elsevier; 2007. p. 25-44. 10. Woolf CJ, Salter MW. Plasticity and pain: role of the dorsal horn. In: McMahon SB, Koltzenburg M, editors. Wall and Melzback's textbook of pain. 5th ed. Philadelphia (PA): Elsevier; 2006. p. 91-105. 11. Kohrs R, Duriex M. Ketamine: teaching an old dog new tricks. Anesth Anal 1998;87:1186-93. 12. Fitzgerald M, de Lima J. Hyperalgesia and allodynia in infants. In: Finley GA, McGrath PJ, editors. Acute and procedural pain in infants and children. Seattle (WA): IASP Press. 2001. p. 1-12. 13. Anand KJS, Runeson B, Jacobson B, et al. Gastric suction at birth associated with long term risk for functional intestinal disorders in later life. J Pediatr 2004;144:449-54. 14. Grunau RE, Tu MT. Long-term consequences of pain in human neonates. In: Anand KJS, Stevens BJ, McGrath PJ, editors. Pain in neonates and infants. 3th ed. New York (NY): Elsevier; 2007. p. 45-55. 15. Meyer RA, Ringkamp M, Campbell JN, Raja SN. Peripheral mechanisms of cutaneous nociception. In: McMahon SB, Koltzenburg M, editors. Wall and Melzback's textbook of pain. 5th. ed. Philadelphia (PA): Elsevier; 2006. p. 3-34. 16. Schechter NL. The under-treatment of pain in children: an overview. Pediatr Clin North Am 1989;36:781-93. 17. Selbst SM. Analgesic use in the emergency department. Ann Emerg Med 1990;19:1010-3. 18. Petrack EM, Christopher NC, Kriwinsky J. Pain management in the emergency department: patterns of utilization. Pediatrics 1997;99:711-4. 19. Friedland LR, Kulick RM. Emergency department analgesic use in pediatric trauma victims with fractures. Ann Emerg Med 1994;23:203-7. 20. Broome ME, Richtsmeier A, Maikler V, Alexander M. Pediatric pain practices: a national survey of health professionals. J Pain Symptom Manage 1996;11:312-20. 21. Cummings EA, Reid GJ, Finley GA, et al. Prevalence and source of pain in pediatric inpatients. Pain 1996;68:25-31. 22. Cimpello L, Khine H, Avner JR. Practice patterns of pediatric vs general emergency physicians for pain management of fractures in pediatric patients. Pediatr Emerg Care 2004;20: 228-32. 23. Quinn M, Carraccio C, Sacchetti A. Pain, punctures, and pediatricians. Pediatr Emerg Care 1993;9:12-4.

24. Jones JS, Johnson K, McNinch M. Age as a risk factor for inadequate emergency department. Am J Emerg Med 1996; 14:157-60. 25. Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA 1993; 269:1537-9. 26. Todd KH, Deaton C, D'Adamo AP, Goe L. Ethnicity and analgesic practice. Ann Emerg Med 2000;35:11-6. 27. Michael GE, Sporer KA, Youngblood GM. Women are less likely than men to receive prehospital analgesia for isolated extremity injuries. Am J Emerg Med 2007;25:901-6. 28. Friedland LR, Pancioli AM, Duncan KM. Pediatric emergency department analgesic practice. Pediatr Emerg Care 1997;13: 103-6. 29. O'Donnell J, Ferguson LP, Beattie TF. Use of analgesia in a paediatric accident and emergency department following limb trauma. Eur J Emerg Med 2002;9:5-8. 30. Singer AJ, Thode HC. National analgesia prescribing patterns in emergency department patients with burns. J Burn Care Rehab 2002;23:361-5. 31. Neighbor MN, Honner S, Kohn MA. Factors affecting emergency department opioid administration to severely injured patients. Acad Emerg Med 2004;11:1290-6. 32. White LJ, Cooper JD, Chambers RM, Gradisek RE. Prehospital use of analgesia for suspected extremity fractures. Prehosp Emerg Care 2000;4:205-8. 33. McEachin CC, McDermott JT, Swor R. Few emergency medical services patients with lower extremity fractures receive prehospital analgesia. Prehosp Emerg Care 2002;6: 406-10. 34. Curtis KM, Henriques HF, Fanciullo G, et al. A fentanyl based pain management protocol provides early analgesia for adult trauma patients. J Trauma Inj Infect Crit Care 2007;63:819-26. 35. Fullerton-Gleason L, Crandall C, Sklar DP. Prehospital administration of morphine for isolated extremity injuries: a change in protocol reduces time to medication. Prehosp Emerg Care 2002;6:411-6. 36. DeVellis P, Thomas SH, Wedel SK, et al. Prehospital fentanyl analgesia in air-transported pediatric trauma patients. Pediatr Emerg Care 1998;14:321-3. 37. Thomas SH, Rago O, Harrison T, et al. Fentanyl trauma analgesia use in medical scene transports. J Emerg Med 2005; 29:179-87. 38. Frakes MA, Lord WR, Kociszewski C, et al. Efficacy of fentanyl analgesia for trauma in critical care transport. Am J Emerg Med 2006;24:286-9. 39. Swor R, McEachin CM, Seguin D, et al. Prehospital pain management in children suffering traumatic injury. Prehosp Emerg Care 2005;9:40-3. 40. Zohar Z, Eitan A, Halperin P, et al. Pain relief in major trauma patients: an Israeli perspective. J Trauma 2001;51:767-72. 41. Silen W. Cope's early diagnosis of the acute abdomen. 19th ed. New York (NY): Oxford University Press; 1996. 42. Attard AR, Corlett MJ, Kidner NJ, et al. Safety of early pain relief for acute abdominal pain. BMJ 1992;305:554-6. 43. Vermulean B, Morabia A, Unger PF, et al. Acute appendicitis: influence of early pain relief on the accuracy of clinical and US findings in the decision to operatea randomized trial. Radiology 1999;210:639-43. 44. LoVecchio F, Oster N, Sturmann K, et al. The use of analgesics in patients with acute abdominal pain. J Emerg Med 1997;15:775-9. 45. Kim MK, Strait RT, Sato TT, et al. A Randomized clinical trial of analgesia in children with acute abdominal pain. Acad Emerg Med 2002;9:281-7.

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46. Buduhan G, McRitchie DI. Missed injuries in patients with multiple trauma. J Trauma 2000;49:600-5. 47. Lazarus HM, Fox J, Evans RS, et al. Adverse drug reactions in trauma patients. J Trauma 2003;54:337-43. 48. Kanowitz A, Dunn TM, Kanowitz EM, et al. Safety and effectiveness of fentanyl administration for prehospital pain management. Prehosp Emerg Care 2006;10:1-7. 49. Devellis P, Thomas SH, Wedel SK, et al. Prehospital analgesia in air-transported pediatric trauma patients. Pediatr Emerg Care 1998;14:321-3. 50. Whipple JK, Lewis KS, Quebbeman EJ, et al. Analysis of pain management in critically ill patients. Pharmocotherapy 1995;15:592-9. 51. Silka PA, Roth MM, Moreno G, et al. Pain scores improve analgesic administration patterns for trauma patients in the emergency department. Acad Emerg Med 2004;11: 264-70. 52. Kaplan CP, Sison C, Platt SL. Does a pain scale improve pain assessment in the pediatric emergency department. Pediatr Emerg Care 2008;24:605-8. 53. Tanabe P, Buschmann M. Emergency nurses' knowledge of pain management principles. J Emerg Nurs 2000;26:299-305. 54. Hennes H, Kim MK, Pirrallo RG. Pre-hospital pain management: a comparison of providers' perceptions and practices. Prehosp Emerg Care 2005;9:32-9. 55. American College of Surgeons. Advanced trauma life support student manual. Chicago (Ill): American College of Surgeons 2004. p. 27. 56. American College of Surgeons. Advanced trauma life support student manual. Chicago (Ill): American College of Surgeons 2008. p. 169, 200. 57. Emergency Nurses Association. Course in advanced trauma nursing: a conceptual approach. Park Ridge (Ill): The Emergency Nurses Association; 1995. p. 253-78. 58. Rominson SM, Mackenzie-Ross S, Campbel-Hewson GL, et al. Psychological effect of witnessed resuscitation on bereaved relatives. The Lancet 1998;352:614-7. 59. Sacchetti A, Lichenstein R, Carraccio CA, et al. Family member presence during pediatric emergency department procedures. Pediatr Emerg Care 1996;12:268-71. 60. Meers T, Eichorn D, Guzzetta C. Do families want to be present during CPR? A retrospective study. J Emerg Nurs 1998;24:400-5. 61. Boie E, Moore G, Brummett C, et al. Do parents want to be present during invasive procedures performed on their children in the emergency department? A survey of 400 parents. Ann Emerg Med 1999;34:70-4. 62. Powers K, Rubenstein J. Family presence during invasive procedures in the pediatric intensive care unit: a prospective study. Arch Pediatr Adolesc Med 1999;153:955-8. 63. Sacchetti A, Paston C, Carraccio C. Family members do not disrupt care when present during invasive procedures. Acad Emerg Med 2005;12:477-9. 64. Kennedy RM, Luhman J. The ouchless emergency department. Advances in decreasing distress during painful procedures in the emergency department. Pediatr Clin North Am 1999;46:1215-47. 65. Zepmsky WT, Cravero JP. Relief of pain and anxiety in emergency medical systems. Pediatrics 2004;114:1348-56.

66. EMSC Grant Panel (Writing Committee) on Pharmacologic Agents Used in Pediatric Sedation and Analgesia in the Emergency Department. Clinical policy: evidenced based approach to pharmacologic agents in the emergency department. Ann Emerg Med 2004;44:342-77. 67. Borland M, Jacob I, King B, et al. A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in the emergency department. Ann Emerg Med 2007;49:335-40. 68. Sharar SR, Bratton SL, Carrougher GJ, et al. A comparison of oral trans-mucosal fentanyl citrate and oral hydromorphone for inpatient pediatric burn wound care analgesia. J Burn Care Rehab 1998;19:516-21. 69. Rusy LM, Houck CS, Sullivan LJ, et al. A double-blind evaluation of ketorolac tromethamine versus acetaminophen in pediatric tonsillectomy: analgesia and bleeding. Anesth Analag 1995;80:226-9. 70. Burd RS, Tobias JD. Ketorolac for pain management after abdominal surgical procedures in infants. S Med J 2002;95: 331-3. 71. Roback MG, Bajaj L, Wathen JE, et al. Pre-procedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: are they related. Ann Emerg Med 2004;44:454-9. 72. Luhman J, Kennedy RM, Porter FL, et al. A randomized clinical trial of continuous flow nitrous oxide and midazolam for sedation of young children during laceration repair. Ann Emerg Med 2001;37:20-7. 73. Clark M, Brunick A. N2O and its interaction with the body. Handbook of nitrous oxide and oxygen sedation. 2nd ed. St Louis (MO): Mosby; 2003. p. 89-98. 74. Parker RI, Mahan RA, Giugliano D. Safety of intravenous midazolam and ketamine as sedation in therapeutic and diagnostic procedures in children. Pediatrics 1997;99: 427-31. 75. Albanese J, Arnaud S, Rey M, et al. Ketamine decreases intracranial pressure and electroencephalographic activity in traumatic brain injury patients during propofol sedation. Anesthesia 1997;87:1328-34. 76. Gottschling S, Meyer S, Krenn T. Propofol versus midazolam/ ketamine for procedural sedation in pediatric oncology. J Pediatr Hematol Oncol 2005;27:471-6. 77. Lamberg L. Patients in pain need round-the-clock care. JAMA 1999;281:689-90. 78. Sang C, Hayes K. Anticonvulsant medications in neuropathic pain. In: McMahon SB, Koltzenburg M, editors. Wall and Melzback's textbook of pain. 5th ed. Philadelphia (Pa): Elsevier; 2006. p. 499-506. 79. Rice ASC. Cannabinoids. In: McMahon SB, Koltzenburg M, editors. Wall and Melzback's textbook of pain. 5th ed. Philadelphia (PA): Elsevier; 2006. p. 521-40. 80. Hill RG. Analgesic drugs in development. In: McMahon SB, Koltzenburg M, editors. Wall and Melzback's textbook of pain. 5th ed. Philadelphia (PA): Elsevier; 2006. p. 544. 81. Peter C, Watson N, Chipman ML, et al. Antidepressant analgesics: a systematic review and comparative study. In: McMahon SB, Koltzenburg M, editors. Wall and Melzback's textbook of pain. 5th ed. Philadelphia (PA): Elsevier; 2006. p. 481-97.

Abstract:
The continued growth in emergency department (ED) use combined with limited inpatient bed availability often leads to boarding of patients needing inpatient or intensive care unit admission in the ED. Emergency department personnel are experienced in the rapid assessment of trauma patients but may be less prepared or comfortable with providing ongoing management of trauma patients, especially critically injured pediatric patients. This article reviews management principles of traumatic brain injury, mechanical ventilation, and shock in the pediatric trauma patient and is intended to guide ED management of these patients until they can be transferred to an appropriate level of inpatient care.

Keywords:
pediatric critical care; traumatic brain injury; shock; trauma; mechanical ventilation

When There Are No Inpatient Beds: Providing Pediatric Critical Care for Trauma Patients in the Emergency Department
Toni Petrillo-Albarano, MD, FAAP*, Wendalyn K. Little, MD, MPH
n an ideal world, the emergency department (ED) would be easily accessed by those truly needing emergency care. Seriously injured and ill patients would arrive and be cared for rarely and dispositioned in a timely fashion. Patients needing surgery or hospital admission would move through the ED expediently to their final destination. Unfortunately, that ideal rare, exists in today's ED. More than 100 million Americans, 30 million of them children, present to the ED each year.1 A persistent rise in ED visits over the last several decades has led to an overcrowding crisis in many communities.2,3 This increase is often attributed to overuse of the ED for minor illnesses, but there is also evidence that EDs are seeing steadily increasing numbers of patients with serious illness and injuries. Lack of available inpatient hospital beds, particularly intensive care unit (ICU) beds, also contributes to ED crowding

*Division of Pediatric Critical Care, Emory University School of Medicine, Childrens Healthcare of Atlanta, Atlanta, GA; Division of Pediatric Emergency Medicine, Emory University School of Medicine, Childrens Healthcare of Atlanta, Atlanta, GA. Reprint requests and correspondence: Wendalyn K. Little, MD, MPH, Pediatric Emergency Medicine, 1645 Tullie Circle, Atlanta, GA 30329. toni.petrillo@choa.org, wendalyn.little@choa.org
1522-8401/$ - see front matter 2010 Elsevier Inc. All rights reserved.

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and extended ED length of stay.1 Emergency department physicians and staff may be challenged not only with seeing large numbers of patients, but also with providing care for extended periods of time to seriously ill and injured patients awaiting inpatient or ICU admission. Although ED care providers are trained to provide initial assessment and stabilization for acutely ill and injured patients, they may be underprepared, in terms of training and resources, to provide ongoing critical care management.4 Delay in transfer of critically ill patients to the ICU has been associated with increased hospital length of stay and mortality rates.5 In an ideal world, patients needing ICU level care would be quickly evaluated and transferred to an ICU. When a critically ill patient cannot be immediately transferred to an ICU, they must be provided with appropriate care in an ED or transport setting, in essence bringing the ICU to the patient. The purpose of this article is to review some of the more common elements of ICU level trauma care that may be required in the ED or transport setting.

TRAUMATIC BRAIN INJURY

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality for pediatric patients in the United States, accounting for more than 400 000 ED visits and more than 2000 deaths annually. 6 Through the years, many therapies have been proposed for the treatment of TBI; few of these have been studied or proven in pediatric patients. In 2003, a multidisciplinary group convened a set of guidelines7 for the management of pediatric patients with TBI.4 A major focus of these guidelines is good supportive care of the critically injured patient, with particular attention to prevention and treatment of shock and respiratory failure. Recent literature continues to support these guidelines, with a growing body of evidence demonstrating that hypotension and hypoxia, especially if unrecognized and untreated, are independent predictors of poor outcome in TBI.8-11 Careful attention should be paid to the ability to maintain an airway and adequate oxygenation and ventilation in patients with TBI. Hypoxia has been shown to negatively affect morbidity and mortality in this group.7,10 In cases of mild to moderate isolated TBI, patients may require only supplemental oxygen. If a patient's ability to maintain an adequate airway and control of ventilation is compromised, endotracheal intubation may be required. Ventilation should be provided to maintain a partial pressure of carbon dioxide (PCO2)

within normal limits (35-45 mm Hg). Both hyperand hypoventilation may be deleterious to patients with TBI. Hypoventilation may increase cerebral blood flow, leading to increased intracranial pressure (ICP) if cerebral autoregulation of blood flow is impaired by injury. Hyperventilation lowers PCO2 and causes subsequent cerebral vasoconstriction, with the potential for ischemia and secondary insult to the already injured brain. Only in cases of persistently elevated ICP refractory to other medical management should consideration be given to maintaining a lower level of PCO2 (30-35 mm Hg).7 Further discussion of specific ventilation strategies will be covered later in this article. Careful attention to volume status and perfusion is important in the management of TBI. Medical personnel sometimes worry about giving intravenous (IV) fluids to TBI patients; there is a myth that the administration of any IV volume may worsen cerebral edema. Adequate blood pressure is required to maintain cerebral perfusion, and ensuring adequate intravascular volume is important for maintaining blood pressure and perfusion to the brain and other vital organs. Cerebral perfusion pressure (CPP) can be estimated by subtracting ICP from the mean arterial pressure (MAP). Ideal CPP in infants and children has not been well established, but targeting a range between 40 (infants) and 65 mm Hg (adults) seems reasonable.12 A normal MAP is age dependent and can be estimated by the formula (50 + 2 age in years) for any child older than 1 year.13 Often, ICP monitoring is not immediately available in the ED. It is therefore advisable to attempt to maintain normal to slightly high MAPs in patients with TBI. If ICP monitoring is available, CPP should be targeted to stay in the range of 40 to 65 mm Hg. Hypotension, if present, should initially be treated with fluid resuscitation. If blood pressure remains low or low-normal in the setting of persistently elevated ICP, vasopressor agents such as dopamine or norepinephrine may be needed to maintain a normal to high-normal MAP and adequate CPP. In addition to ensuring adequate oxygenation, ventilation, and blood pressure, a few other basic principles should be observed in managing TBI patients. The patient's head should be kept midline and elevated to 30 if possible because this promotes venous return and may help control ICP. One caveat to remember is that patients with TBI may have associated spinal injuries, and any positioning of the head must be done while maintaining strict spinal precautions until an injury of the spine is excluded, but slight angulation of the entire bed, if possible, may be helpful. Other management strategies in

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treating patients with TBI involve decreasing cerebral metabolic demands to help manage the elevated ICP, which often accompanies TBI. One of these strategies is to maintain adequate analgesia and sedation, particularly in patients with concomitant injuries or those requiring mechanical ventilation. Although the ability to monitor and follow a patient's neurologic examination is important, it must be balanced with the benefits of ensuring adequate analgesia and sedation. In cases of persistently elevated ICP, consideration should be given to deeper sedation, such as pentobarbital coma and even the use of neuromuscular paralysis.7 Maintaining a normal body temperature is also important in the management of TBI. Hyperthermia may increase cerebral metabolic demands and lead to increased ICP. Although some studies support the use of mild hypothermia in the management of TBI, there is currently no strong evidence to support its routine use.14-16 Finally, hyperosmolar fluid therapy may be used to manage elevated ICP. Both mannitol and hypertonic saline have been shown to be effective in this regard.16,17-19 These agents work by altering the osmotic gradient across the bloodbrain barrier, in effect, pulling fluid from the edematous brain.7,12 There have been no definitive comparison studies of the 2 agents, and the choice of which to use may be based on availability or physician preference. Hypertonic (3%) saline may be administered in 5 to 10 mL/kg aliquots as needed until a serum sodium of 170 mEq/dL or a serum osmolarity of 360 mOsm has been reached.19 Mannitol should be given in 0.5 to 1 g/kg aliquots as needed until a maximum serum osmolarity of 320 mOsm is reached.12

VENTILATOR MANAGEMENT
Many pediatric trauma patients may be managed without intubation and mechanical ventilation. Intubation may be required for airway protection in cases of craniofacial injury or head injury with altered mental status, to ensure oxygenation and ventilation with thoracic injuries, or to enable adequate sedation and analgesia and to decrease metabolic demands for patients with severe or multisystem trauma. Although multiple models of mechanical ventilators exist, with multiple modalities for delivering mechanical ventilation, the most important considerations in the mechanical ventilation of pediatric patients is close attention to initial choice of ventilator settings and close monitoring of the patient to ensure adequate oxygenation and ventilation. Previously healthy trauma patients without thoracic or lung injury should have fairly compli-

ant lungs and be able to be maintained on relatively low ventilator settings. Initial ventilator settings are based on normal physiologic parameters for a healthy child of similar weight and age. A positive end-expiratory pressure (PEEP) of 5 cm is a good starting point. Many ventilators are designed to deliver both pressure and volumecontrol modes of ventilation. Either may be used, with the goal of delivering a tidal volume (TV) of 6 to 8 mL/kg. Target respiratory rate varies with patient age. Good starting points are a rate of 30 for infants, 20 for children, and 16 for older children and teenagers. Inspiratory time (Ti) should be set between 0.5 and 1 second to target an inspiratory/expiratory ratio of 1:3 and allow adequate time in the exhalation phase of the respiratory cycle for carbon dioxide elimination. Using these guidelines, initial ventilator settings for a previously healthy 5-year-old patient weighing 20 kg should be TV of 160 mL (8 mL/kg), PEEP of 5 cm, rate of 20, and inspiratory time of 1 second. Patients undergoing mechanical ventilation should be monitored with continuous pulse oximetry. A blood gas measurement should be obtained shortly after instituting mechanical ventilation and the pH and PCO2 values used to gauge the effectiveness of ventilation. After this measurement, end-tidal carbon dioxide monitoring, if available, augmented with periodic blood gas measurements, may be used to monitor and adjust ventilation. Capillary or venous blood gas measurements may be adequate for monitoring pH and PCO2 in some patients, but placement of an arterial line may also be necessary for frequent blood sampling and blood pressure monitoring in critically ill patients. Ventilator adjustment may be required to correct difficulties with oxygenation or ventilation. Ventilation difficulties require an increase in minute ventilation to remove carbon dioxide. Minute ventilation (MV) is defined as TV times respiratory rate (MV = TV RR) and can be changed by manipulating either of these parameters. Tidal volume may be adjusted by increasing the TV setting in volume-control mode or increasing the peak inspiratory pressure in pressure control mode. An important point to remember is that the TV delivered to the patient may differ from that set on the ventilator if there is a large air leak around the endotracheal tube. Another important consideration is the potential for secondary lung injury from positive-pressure ventilation. Although patients with TBI may benefit from keeping PCO2 levels in a low-normal range for ICP control, trauma patients without TBI may be managed with a strategy of permissive hypercapnea in which

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PCO2 levels are allowed to remain above normal as long as an acceptable pH level (generally considered pH N7.2) is maintained.20 Ventilator adjustment may also be necessary to improve oxygenation. The easiest parameter to manipulate is the fraction of inspired oxygen (FIO2). Delivery of FIO2 greater than 60% for prolonged periods has been associated with free radical formation and secondary lung injury. In patients requiring more than 60% FIO2, or in those difficult to oxygenate on higher levels of FIO2, consideration should be given to increasing the PEEP delivered by the ventilator. Increasing PEEP increases the functional residual capacity of the lungs and may serve to recruit additional alveoli and improve oxygenation. However, increasing PEEP may also have the deleterious effect of decreasing venous return to the heart and decreasing systemic blood pressure. This effect can often be overcome by the provision of additional intravascular volume in the form of isotonic fluid or blood product administration. A final ventilator adjustment that may be considered to improve oxygenation is lengthening the inspiratory time (Ti). In doing so, care must be taken to allow adequate time in the respiratory cycle for expiration. Failure to do this may compromise ventilation and lead to the development of respiratory acidosis from carbon dioxide retention.

MANAGEMENT AND RECOGNITION OF SHOCK

Shock is a state of inadequate delivery of oxygen and substrate to tissues. Any serious injury or illness can cause a state of shock if circulatory function is significantly impaired. In compensated shock, autonomic reflex mechanisms are activated to maintain vital organ perfusion. These include massive catecholamine release, leading to increased heart rate and systemic vascular resistance. These compensatory mechanisms are particularly active in previously healthy children and young adults and may make early phases of shock difficult to recognize in this population. If unrecognized and untreated, these compensatory mechanisms are overwhelmed, cellular function deteriorates, and a state of progressive organ dysfunction and metabolic acidosis heralds the development of uncompensated shock. Finally, terminal or irreversible shock implies organ damage to a degree that death is inevitable.21-24 Shock may be broadly categorized as hypovolemic, distributive, cardiogenic, or obstructive. In the trauma patient, the most common cause is hypovo-

lemic shock in which acute blood loss leads to an inadequate circulating intravascular volume. Trauma patients may also experience obstructive shock in which cardiac output is mechanically obstructed by tension pneumothorax or by hemopericardium leading to pericardial tamponade. Distributive shock, characterized by systemic vasodilation leading to functional or relative hypovolemia, may be seen after spinal cord injuries and is sometimes termed spinal shock. Finally, myocardial contusion may cause myocardial dysfunction and cause cardiogenic shock. Rapid recognition of shock, especially early or compensated shock, is crucial to limiting morbidity and mortality after trauma. Careful and repeated physical examinations may give valuable information as to the nature and cause of shock. The physical examination should start with an observation of the patient's mental status and responsiveness to the surrounding environment. Agitation, restlessness, and inability to be consoled by known caregivers may be an early sign of shock in infants and children. Even more concerning is the quiet, withdrawn child that does not make eye contact or respond to painful stimuli. Close attention should next be paid to airway and breathing. Effortless tachypnea is an early sign of shock as the patient attempts to compensate for an increasing metabolic acidosis through respiratory elimination of carbon dioxide.13,21,22 The next step in the rapid assessment of patients in shock is to evaluate the circulatory status by assessing skin perfusion, temperature, and capillary refill time. Healthy patients in a warm environment should have pink, warm skin with brisk (b2 second) capillary refill time. An early sign of hypovolemic and cardiogenic shock is the presence of cool distal extremities and prolonged capillary refill time. Conversely, patients with early distributive shock may have flushed skin and brisk capillary refill. Heart rate and pulse quality are other important elements of the cardiovascular assessment. Tachycardia is one of the earliest signs of shock and must also be interpreted in context to age-specific normal values. Hypovolemic or cardiogenic shock leads to narrow pulse pressure and weak thready pulses. In contrast, patients in early distributive shock may have widened pulse pressure with readily palpated bounding pulses.18,19,21,22 Urine output is a sensitive indicator of renal perfusion and should be monitored closely as an indicator of intravascular volume status. Diminished urine output may be an early sign of intravascular volume depletion and may progress to a state of complete anuria in patients with severe shock.18,21-25

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Blood pressure should also be measured as part of the cardiovascular assessment. Many references differentiate compensated vs uncompensated shock by the presence or absence of hypotension. Overreliance on blood pressure measurement, however, may lead to missed cases of shock. This is especially true in previously healthy children and young adults with hypovolemic shock, in whom arterial blood pressure may be normal or even slightly elevated during early stages of shock due to strong compensatory responses. With acute hemorrhage, blood pressure may be maintained in a normal range until approximately 30% of the circulating blood volume has been lost, at which point uncompensated shock ensues and may progress rapidly to terminal shock unresponsive to therapy.13,25 Health care providers must therefore realize that hypotension is a late and ominous sign of shock in pediatric patients, and every effort should be made to recognize and treat shock states before such decompensation occurs.13,21,22,25 Certain principles apply regardless of the etiology of shock and should be instituted immediately for all patients presenting with signs of shock. Attention should first be directed toward airway and breathing. All patients should be placed on supplemental oxygen, preferably by high flow, non-rebreather mask. Patients with a patent airway and spontaneous respirations may still benefit from early intubation to reduce metabolic demand and assure adequate oxygenation and ventilation, especially in cases of severe or decompensated shock.26-28 Establishing vascular access is another early priority in the management of shock. This is best accomplished through the placement of as large a caliber peripheral IV catheter as is possible for the patient's size. Severely injured patients should ideally have at least 2 functioning IVs. The maximum rate of flow through any given catheter is proportional to the diameter and inversely proportional to the length; therefore, short, largecaliber catheters are preferred over long central venous lines for initial resuscitation.24,25 When IV access cannot be quickly established, consideration should be given to placing an intraosseous (IO) access device.13,25 Historically, IO access was limited to infants and young children. Newer IO drill devices allow this route to be used in older children and adults.29,30 Fluid therapy should be initiated immediately after access is established. Initial fluid therapy should consist of a 20 mL/kg bolus of isotonic crystalloid fluid given as quickly as possible. If heart rate, level of consciousness, and capillary refill do not improve, a second 20 mL/ kg bolus should be rapidly administered. If system-

ic perfusion does not respond to administration of 40 to 60 mL/kg of crystalloid in patients with suspected hemorrhagic shock, 10 to 15 mL/kg of packed red blood cells (PRBCs) should be transfused and repeated as needed. Type-specific crossmatched blood is preferred; however, type O negative blood may be used in emergency circumstances until cross-matched blood is available. Patients exhibiting signs of shock should have emergent consultation by a trauma surgeon because they may require exploration to identify and correct ongoing hemorrhage.13,25 Treatment of obstructive shock requires identification and specific therapy for the type of obstruction. Pericardial tamponade may present with muffled heart sounds, diminished pulses, and distended neck veins. Chest radiograph and bedside ultrasound, when available, may be helpful in making the diagnosis. If time permits, pericardial drainage under ultrasound guidance is the preferred treatment. In patients with severe shock or cardiovascular collapse, emergent pericardiocentesis may be life saving and should be performed without delay. Tension pneumothorax is a common cause of obstructive shock in trauma patients and may present with hypoxia, hypotension, diminished pulses, diminished or absent breath sounds on the affected side, and distended neck veins and/or tracheal deviation. Chest radiographs may be helpful in making the diagnosis but should not delay treatment in critically ill trauma patients. These patients should have immediate decompression of the pneumothorax by placement of an over-the-needle catheter in the second intercostal space in the midclavicular line followed by tube thoracostomy.13,24,25,31 Distributive shock may be seen in acute spinal cord injuries when loss of systemic vascular tone creates a state of relative vascular volume depletion. Initial treatment of distributive shock is similar to that of hypovolemic shock. Vascular access should be obtained and crystalloid boluses of 20 mL/kg should be delivered until systemic perfusion improves. If systemic perfusion does not improve after 2 to 3 such boluses and occult hemorrhage has been excluded, vasoactive medications such as dopamine or norepinephrine may be needed. The -adrenergic properties of these medications cause systemic vasoconstriction and may improve perfusion in cases of distributive shock. These infusions are ideally given through a central venous catheter because extravasation may cause significant tissue necrosis. Ongoing management of trauma patients involves frequent reassessment to gauge the adequacy of resuscitation and to recognize any need for further intervention. Some patients may respond to initial

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volume resuscitation with improvement of tachycardia, capillary refill, or blood pressure, only to return to an unstable shock state if they are experiencing ongoing hemorrhage. The often mentioned lethal triad of trauma refers to the development of hypothermia, metabolic acidosis, and coagulopathy that may develop in seriously injured patients. Pediatric patients are particularly susceptible to hypothermia given their relatively larger surface to body mass ratio, as compared with adults. Warming measures such as heated blankets, removal of wet clothing and bedding, and warming lights should be instituted and body temperature closely monitored. Serial measures of serum hemoglobin and hematocrit may aid in recognizing ongoing hemorrhage and identifying patients needing emergent surgical intervention. Patients requiring massive or ongoing volume resuscitation may develop coagulopathy from consumption and dilution of clotting factors. This may manifest externally as mucosal bleeding or oozing from skin sites such as needlesticks and cutaneous wounds. These patients may require transfusion of fresh frozen plasma and platelets in addition to PRBCs. Traditionally, trauma patients were transfused with PRBCs alone until coagulopathy became manifest as either excessive bleeding or abnormalities in laboratory values for platelet levels, prothrombin time, and activated partial thromboplastin time. Recent literature suggests that patients requiring massive transfusion, usually defined as more than 10 U of PRBCs for adult patients, should receive closer to a 1:1:1 ratio of red blood cells, plasma, and platelets.32-34 Evidence-based pediatric guidelines for massive transfusion have not been well established, but it seems prudent to provide plasma and platelet replenishment in addition to PRBCs to any patient requiring massive transfusion.

SUMMARY AND RECOMMENDATIONS

Optimal early intervention has been shown to improve patient outcomes in many medical conditions including trauma.28 Unfortunately, EDs are often overcrowded and understaffed, and inpatient and intensive care beds are often in short or limited supply. As a consequence, increasing numbers of critically ill patients are boarded in EDs while awaiting inpatient bed availability.2,3,5,31 Seriously injured pediatric trauma patients must be carefully monitored and frequently assessed, whether in the ED, the radiology department, the pediatric ICU, or in-transit between locations. Careful attention must be paid to the airway, breathing, and adequacy of oxygenation and venti-

lation. Caregivers should be comfortable with bagmask ventilation, tracheal intubation, and even ventilator management for patients who may remain in the ED awaiting an ICU bed or transfer to a tertiary care center. All patients should have adequate vascular access. Often, IV access can be difficult to obtain in infants and small children. Equipment for intraosseous access should be readily available and caregivers familiar with their use. Central venous catheter placement may also be needed, especially in patients requiring vasopressor infusion or administration of multiple medications. The most commonly used site for central line insertion in pediatric patients is the femoral vein. This site is often chosen due to relative ease of access and because placement does not require removal of the cervical collar in trauma patients or interfere with airway manipulation. However, in patients with intra-abdominal hemorrhage, a femoral line may not be the best choice; in these patients, a subclavian line may be a more optimal choice. Patients must be carefully monitored for the subtle early signs of shock and every effort made to reverse shock before compensatory mechanisms are overwhelmed. Placement of an arterial line may be helpful for both blood pressure monitoring and frequent laboratory draws; especially in small children in whom central access is not established. Placement should be considered for any patient who is on vasopressors, has an ICP monitor in place, or has persistent hypotension or other signs of clinical instability. If an appropriately sized arterial line kit is not available, a 24- or 22-gauge catheter may be placed in the radial, dorsalis pedis, or posterior tibial artery. A single-lumen, 3 French, 5- or 8-cm-long central venous catheter may also be placed in the femoral artery of infants or children. Maintaining airway, breathing, and circulation are always top priorities in the management of trauma patients. Control of pain and anxiety is another important component of trauma care that may be overlooked in the critically injured pediatric patient. Small doses of opiates and/or benzodiazepines may be given and repeated as needed, with constant monitoring for the depression of level of consciousness, respiratory drive, and blood pressure that may occur with these medications. If the child is intubated, ensuring adequate sedation is paramount to maintaining control of the airway. Inadequate sedation may lead to a host of secondary issues from airway edema to aspiration and may increase ICP in patients with TBI. Intubated patients may benefit from continuous low-dose infusions of narcotics and/ or benzodiazepines to maintain adequate levels of

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sedation. On occasion, it may also be necessary to use neuromuscular blocking agents (paralytics) to assist ventilation or control ICP. These medications may be given as either intermittent doses or continuous infusions. It is vitally important to maintain adequate sedation in patients receiving neuromuscular blockade. Close monitoring of blood pressure and heart rate, especially changes in response to positioning, suctioning, or other noxious stimuli, may provide valuable information about the patient's level of sedation. While awaiting transfer to an appropriate ICU setting, every effort should be made to bring the ICU to the patient by providing close monitoring, frequent reassessment, and rapid correction of problems as they arise. Emergency department personnel should also keep in mind that consultation with colleagues in critical care medicine or anesthesia is often available to help guide patient management, even if an ICU bed is not physically available for a critically injured patient.

REFERENCES
1. American Academy of Pediatrics Committee on Pediatric Emergency Medicine. Overcrowding crisis in our nation's emergency departments: is our safety net unraveling? Pediatrics 2004;144:878-88. 2. Richardson LD, BR Asplin BR, Lowe RA. Emergency crowding as health policy issue: past development, future direction. Ann Emerg Med 2002;40:388-93. 3. Derlet R, Richards J, Kravitz F. Frequent overcrowding in U.S. emergency departments. Acad Emerg Med 2001;8:151-5. 4. Cowan RM, Treciak S. Clinical review: emergency department overcrowding and the impact on the critically ill. Crit Care 2005;9:291-5. 5. Chalfin DB, Trzeciak S, Likourezos A, et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med 2007;35:1477-83. 6. Curry R, Hollingworth W, Ellbogen RG, et al. Incidence of hypo- and hypercarbia in severe traumatic brain injury before and after 2003 pediatric guidelines. Pediatr Crit Care Med 2008;9:141-6. 7. Carney NA, Chestnut R, Kochanek P, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Pediatr Crit Care Med 2003;4(Suppl):S1-S75. 8. Pigula FA, Wald SL, Shackfor SR, et al. The effect of hypotension and hypoxemia on children with severe head injury. J Pediatr Surg 1993;28:310-4. 9. Coates BM, Vavilala MS, Mack CD, et al. Influence of definition and location of hypotension on outcome following severe pediatric traumatic brain injury. Crit Care Med 2005; 33:2645-50. 10. Michaud LJ, Rivara FP, Grady MS, et al. Predictors of survival and disability after severe brain injury in children. Neurosurgery 1992;31:254-64. 11. Ong L, Selladurai BM, Dhillon MK, et al. The prognostic value of the Glascow coma scale, hypoxia, and computerized tomography in outcome prediction of pediatric head injury. Pediatr Neurosurg 1996;24:285-90.

12. Mansfield RT. Severe traumatic brain injuries in children. Clin Pediatr Emerg Med 2007;8:156-64. 13. American Heart Association. Pediatric advanced life support provider manual. Dallas (Tex): American Heart Association; 2002. 14. Marion DW, Obrisr DW, Carlier PM, et al. The use of moderate therapeutic hypothermia for patients with severe head injuries: a preliminary report. J Neurosurg 1993;79:354-62. 15. Biswas AK, Bruce DA, Sklar FH, et al. Treatment of acute traumatic brain injury with moderate hypothermia improves intracranial hypertension. Crit Care Med 2002;30: 2742-51. 16. Shiozaki T, Hisashi S, Taneda M, et al. Effect of mild hypothermia on uncontrollable intracranial hypertension after severe head injury. J Neurosurg 1993;79:363-8. 17. Muizelaar JP, Lutz HA, Becker DP. Effect of mannitol on ICP and CBP and correlation with pressure autoregulation in several head injured patients. J Neurosurg 1984;61:700-6. 18. Khanna S, Davis D, Peterson B, et al. Use of hypertonic saline solutions in the treatment of cerebral edema and intracranial hypertension. Crit Care Med 2000;28:1144-51. 19. Qureshi AI, Suarez JI. Use of hypertonic saline solutions in the treatment of cerebral edema and intracranial hypertension. Crit Care Med 2000;28:3301-13. 20. Nathens AB, Johnson JL, Minei JP, et al. Guidelines for mechanical ventilation of the trauma patient. J Trauma 2005; 59:764-76. 21. McConnell MS, Perkin RM. Shock states. In: Zimmerman JJ, Furman BP, editors. Pediatric critical care. St Louis (Mo): Mosby; 1998. p. 293-306. 22. Vanore M, Perks D. Early recognition and treatment of shock in the pediatric patient. J Trauma Nurs 2006;13:18-21. 23. Hameed SM, Aird WC, Cohn SM. Oxygen delivery. Crit Care Med 2003;31:S658-67. 24. Cheatham ML, Block EJ, Smith HG, et al. Shock: an overview. In: Rippe JM, Irwin RS, editors. Irwin and Rippe's intensive care medicine. Philadelphia (Pa): Wolters Kluwar; 2007. p. 1831. 25. American College of Surgeons. Advanced trauma life support for doctors. 7th ed. Chicago (Ill): American College of Surgeons; 2004. 26. Maar SP. Emergency care in pediatric septic shock. Pediatr Emerg Care 2004;20:617-24. 27. Welch SB, Nadel S. Treatment of meningococcal infection. Arch Dis Child 2003;88:608-14. 28. Parker MM, Hazelzet JA, Carcillo JA. Pediatric considerations. Crit Care Med 2004;32:S591-594. 29. Buck MI, Wiggins BS, Sesler JM. Intraosseous drug administration in children and adults during cardiopulmonary resuscitation. Ann Pharmacother 2007;41:1679-86. 30. Blumberg SM, Gorn M, Crain EF. Intraosseous infusion: a review of methods and novel devices. Pediatr Emerg Care 2008;24:50-9. 31. Gregory JC, Marcin JP. Golden hours wasted: the human cost of intensive care unit and emergency inefficiency. Crit Care Med 2007;35:1614-5. 32. Hess JR, Lawson JH. The coagulopathy of trauma versus disseminated intravascular coagulation. J Trauma 2006;60: S12-9. 33. Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007;63:805-13. 34. Ketchum L, Hess JR, Hiippala S. Indications for early fresh frozen plasma, cryoprecipitate, and platelet transfusion in trauma. J Trauma 2006;60:S51-8.

Abstract:
Most pediatric trauma patients are cared for in non-children's hospitals by providers without pediatric specialty training and in facilities that may not be used to caring for children. Children have different physiologic and psychologic responses to injury than adults. Children have different service and evaluative needs. Several studies have shown that pediatric trauma patients have improved outcomes with lower mortality, fewer operations, and improved function when cared for in pediatric facilities or adult trauma centers with pediatric expertise. Differences between injured adults and injured children need to be understood, recognized, and acted upon by care providers to optimize treatment for injured children. Limitations in the availability of pediatric specialists require that all hospitals be prepared to effectively and successfully treat pediatric trauma patients.

Pediatric Patients in the Adult Trauma Bay Comfort Level and Challenges
Kimberly P. Stone, MD, MS, MA, George A. Woodward, MD, MBA
hildren represent almost 20% of all emergency department (ED) visits in the United States.1 In any given year, an estimated 13.5 million pediatric ED visits are for intentional and unintentional injury.2 Of these 13.5 million visits, only 23% of children will be treated by a pediatric emergency physician and only 7% of pediatric patients will be treated in a separate pediatric ED.3 Despite not having a pediatric ED or inpatient pediatric resources, 76% of hospitals will admit children to their own facilities.2 A recent review of hospital discharges for injured children identified that 15% of injured children were discharged from hospitals with low pediatric trauma experience and low overall pediatric experience. Of those 15% of injured children, 6% had injury severity scores of 9 or higher indicating moderate to severe injury.4 Almost half of all pediatric trauma-related discharges in the review by Segui-Gomez and colleagues5 were from nontrauma centers, even in states with pediatric trauma designation systems in place. Despite the recent proliferation of pediatric emergency medicine specialists, most injured children are treated by providers without pediatric specialty training and in facilities that may not be used to caring for children.2,6-8 Tremendous variability exists across the country with some geographic areas having availability of pediatric EDs and pediatric trauma services, whereas other areas still do not. Emergency departments, both

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

Reprint requests and correspondence: Kimberly P. Stone, MD, MS, MA, Department of Pediatrics, Division of Emergency Medicine, Seattle Children's Hospital, 4800 Sand Point Way NE, M/S B-5520, Seattle, WA 98105. kimberly.stone@seattlechildrens.org, tony.woodward@seattlechildrens.org
1522-8401/$ - see front matter 2010 Elsevier Inc. All rights reserved.

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within trauma centers and nontrauma centers, need to be prepared to care for injured children.2,8 This article will discuss pediatric-specific challenges that face all providers and review the literature regarding how injured pediatric patients fare when cared for in the nonpediatric-specific trauma system.

CHALLENGES POSED BY THE PEDIATRIC TRAUMA PATIENT

By now everyone has heard the phrase, children are not little adults. However, how they differ and why it matters, especially as it pertains to trauma, is not necessarily universally appreciated. Children have different physiologic and psychologic responses to injury. Children have different service and evaluative needs. These differences need to be understood, recognized, and acted upon by treating providers to provide optimal treatment.

Assessment of the Child and Recognition of Injury

The first step in any treatment algorithm is the skilled assessment of the patient. The assessment of the injured child is inherently different than that of an adult. Pediatric patients may be nonverbal or developmentally incapable of communicating their nonapparent injuries to health care providers. Providers will need to use nonverbal cues in young children to assess pain and injury sites. Pediatric trauma patients (and their parents) will often be scared and anxious; this anxiety may affect vital signs and limit the overall assessment. Assessment of vital signs requires knowledge of age-based norms and confounders that may not be as familiar to nonpediatric providers. Rapid identification of early signs of shock both by vital signs and physical examination are crucial for optimal resuscitation of seriously injured children.

Anatomical and Physiologic Differences

A child's body size and habitus affect how traumatic energy forces are absorbed and distributed. Knowledge of anatomical differences can lead to pattern recognition and aid in timely diagnosis of injuries. A thorough review of the anatomical differences in children is beyond the scope of this article, but a few important variations are highlighted here: A child's body size is smaller and has proportionally less body fat leading to energy forces being more widely dispersed that results in multiple injuries and potentially less visibility on physical examination.

A child's airway is more anteriorly located and easily obstructed by poor positioning. The ability to successfully manage a child's airway requires specific advanced airway skill. A child's proportionally larger tongue can cause upper airway obstruction. Children have large heads, especially as compared to the remainder of their body size. Young children lead with their head during falls resulting in more head injuries. The expandable skull in young children (b1 year) with open fontanelles provides space to accommodate a large intracranial bleed. As compared to adults and older children, young children can present with or develop hemorrhagic shock from closed head trauma. Children have a higher fulcrum in the neck resulting in higher spinal cord injuries (above C4) in younger children. These injuries may not be as obvious on x-rays due to the large amount of cartilage present, but the effects can be devastating. Laxity of the vertebral column along with the cartilage artifacts can result in spinal cord injury without radiographic abnormality (SCIWORA). A child's chest wall is pliable, allowing more internal force with little to no external signs of injury. Children have fewer rib fractures, flail chest, and more pulmonary contusions. Cardiovascular injuries can be initially silent and challenging to diagnose. Abdominal organs in children are less well protected by the bony rib cage allowing for more solid organ injury. The infant liver and spleen are palpable below the costal margin. The kidneys are also more vulnerable secondary to decreased abdominal musculature. A child's growing bones result in vulnerable growth plates leading to a high incidence of growth plate fractures. Children have proportionally larger skin surface area allowing them to more easily become hypothermic with resultant acidosis. Children have an overall smaller total blood volume that increases the risk for rapid onset of shock. They also have the ability to increase their heart rate and stroke volume to temporize for acute volume loss. Vital signs, and particularly blood pressure, may not indicate the true level of volume loss in these children. These anatomical and physiologic differences may be less familiar to medical providers without

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pediatric training or significant ongoing experience in caring for children but are vital to be recognized by anyone caring for a pediatric trauma patient.

Equipment
Children come in different ages and sizes, and therefore, the equipment needed to treat them (and sometimes the skills required) also need to come in different sizes. Several recent studies have identified that few nonpediatric hospitals are fully equipped with all the necessary equipment to handle pediatric emergencies.1 In its review of the emergency care system for children, the Institute of Medicine noted that only 6% of EDs in the United States had all the supplies deemed essential by the American Academy of Pediatrics and American College of Emergency Physicians to handle pediatric emergencies. Only half of the hospitals had at least 85% of the essential equipment.6 A similar study in Canada also found essential pediatric equipment unavailable in most of Canadian EDs.9 The materials most likely to be missing are equipment and supplies needed for neonates and young infants. A 2003 survey of EDs by Gausche-Hill and colleagues10 found similar levels of readiness compared to published guidelines. Children's hospitals were predictably the best prepared, though hospitals with inpatient pediatric care resources and larger pediatric patient ED volumes were typically better prepared. Regardless of hospital size, the presence of a physician and/or nurse coordinator for pediatric emergency care was predictive of a higher level of preparedness.10 A recently updated reference for recommended equipment (as well as other resources) for all EDs caring for pediatric patients can be found in the 2009 joint American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association policy statement, Guidelines for Care of Children in the Emergency Department.1 Any ED caring for pediatric trauma patients should make it a priority to have the appropriate range and spectrum of equipment outlined.

may be less familiar with the subtleties of weightbased dosing and the complex calculations that may be required. Providers caring for pediatric trauma patients should seek to improve hospital-wide systems to decrease pediatric medication errors as part of a comprehensive pediatric patient safety program.11 Establishing a weight in kilograms for all pediatric patients and the use of precalculated weight-based dosing tools will assist in the reduction of medication errors for all pediatric patients.12

Evaluation Tools
The diagnostic tools used to evaluate intraabdominal injuries in pediatric trauma patients differ from those used for adult trauma patients. For pediatric trauma patients, abdominal computed tomography (CT) remains the standard for evaluating suspected abdominal injury in the hemodynamically stable child.14-17 The accepted standard for a hemodynamically unstable child, however, remains in evolution with decreasing use of diagnostic peritoneal lavage (DPL), increasing use of focused abdominal sonography for trauma (FAST), and continued reliance on initial and serial physical examinations. In hemodynamically unstable adults, DPL remains a tool used to determine intraperitoneal hemorrhage or a ruptured hollow viscus.18,19 However, DPL is now rarely used or recommended in children because of its invasive nature and unacceptably high rate of nontherapeutic laparotomy.14,16,17 In addition, because most solid organ injuries are managed nonoperatively, the presence of blood may not determine therapeutic interventions. DPL in pediatric trauma patients should be reserved for critically ill children with concerning CT findings, in whom initial and serial physical examination is unreliable and for whom laparotomy poses substantial risk14 and for patients who require immediate surgical interventions for nonabdominal issues where a subtle or latent injury could prove problematic. In the adult trauma population, FAST examinations have been well studied and are now routinely used to identify hemoperitoneum in unstable patients.16,20,21 Studies on FAST examinations in pediatric trauma populations have been mixed with high specificity (as high as 95%-100%)16,22 but wider ranges of sensitivity (from 30% to 100%).16,20,22 The FAST examinations have the distinct advantage of being a bedside tool that can rapidly identify hemopericardium and hemoperitoneum in an unstable trauma patient. However, children have a higher incidence of solid organ injury without free fluid making a negative FAST examination less

Medications and Errors

Just as the equipment size needs to be scaled down to child proportions, so too do the medication dosages. The need for weight-based dosing and lack of standardized dosing for children leads to increased medication errors in children as compared to adults.11,12 Medication errors in children are most associated with intravenous fluids,11 and pain and sedative medications,13 medications frequently used in pediatric trauma patients. Providers not routinely administering medications to children

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predictive in this population. More recent studies have found FAST examinations, when combined with laboratory assessments23 or physical examination,24 have higher sensitivity and accuracy in pediatric trauma patients. Many adult trauma centers that rely on FAST examinations in their adult trauma also use the FAST examination for their pediatric trauma patients.25 Providers need to understand the limitations of the FAST examination in children to appropriately interpret the results and provide optimal direction and care to pediatric blunt trauma patients. The history, initial examination, and serial physical examination of the pediatric trauma patient remain the cornerstone of diagnosis. Although children have classically been considered unreliable with regard to physical examination findings, more recent studies have found that the initial and subsequent physical examinations will most often identify those pediatric trauma patients requiring operative intervention for their intraabdominal organs.26-28 Familiarity and comfort with examining pediatric patients and interpreting pediatric vital signs, combined with an understanding of injury mechanisms, is fundamental to relying on and trusting the physical examination as part of the diagnostic evaluation of a pediatric trauma patient.

Radiation Exposure
Trauma evaluations often include diagnostic radiologic evaluation. Pediatric trauma patients require additional consideration regarding the total radiation dose when deciding upon radiologic assessment. Potential future risks of accumulated radiation are unknown and disproportionately affect younger pediatric patients who have a longer lifespan during which radiation-related cancers could evolve.29 One review of pediatric trauma patients admitted to a level I trauma center found that 78% of patients underwent at least one radiologic examination. In this study, CT scans accounted for 97.5% of the total effective radiation dose experienced by these children.30 The recent concern about potential radiation risk from CT scans led to a scientific review by Rice and colleagues.31 According to their review, there is a potential increased risk of cancer from low-level radiation (such as with CT); the calculated risk may be as high as 1 fatal cancer for every 1000 CT scans performed in a young child.31 Appropriate decisionmaking regarding use of CT scan evaluation requires an understanding of the traumatic event and risk for injury, an awareness of the radiation risk, the availability of alternate means of radiologic assessment (eg, ultrasound and magnetic resonance imag-

ing where appropriate), and competency with ongoing clinical assessment of the pediatric trauma patient. Although one should not withhold critical diagnostic imaging for children with potentially serious injuries, consideration of radiation risks should be included in protocol development.32 The recently published decision rule by the Pediatric Emergency Care Applied Research Network (PECARN) for the evaluation of pediatric head trauma is a good example of an evidence-based decisionsupport tool that when used appropriately can limit unnecessary radiation exposure.33 When CT scans are indicated in the evaluation of a pediatric trauma patient, steps should be taken to minimize the radiation exposure. The ALARA (as low as reasonably achievable) concept is a philosophy of radiation dose management that is being promoted by the Society for Pediatric Radiology32 and the National Cancer Institute34 and has been embraced by numerous professional organizations and many pediatric care facilities. A first step in reducing radiation exposure is to decrease the radiation setting for pediatric CT scans. Children will receive a higher dose than is necessary for image quality when adult CT settings are used. Radiation settings can be adjusted for pediatric size yet maintain reliability of the study. Radiologists and all care providers treating pediatric trauma patients need to be aware of the principles of ALARA and work toward minimizing radiation exposure.29,32,34

Nonaccidental Trauma
Child abuse remains a leading cause of death and morbidity, especially among young children. In 2005, 353 children younger than 4 years died as a result of injuries sustained from an assault, making it the fourth leading national cause of mortality in this age group.35 Far more children have serious injuries, as a result of their abuse, with an estimated 1.3% to 15% of pediatric injuries resulting in ED visits caused by abuse.36 Several factors can influence the identification of patients who have injuries from suspected child abuse. The diagnosis of child abuse is often missed on initial medical visits due to erroneous histories, variable physical examinations, and psychosocial issues.37 Identification and reporting of suspected child abuse is linked with provider education about child abuse.38,39 Pediatric residency programs have been found to provide more training and resources for child abuse education than general emergency medicine and family medicine programs.40 In addition, nonchildren's hospitals have been found

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to less frequently identify victims of potential child abuse.41 Providers caring for pediatric trauma patients must be diligent in considering child abuse in their differential diagnosis and be aware of injuries and patterns that are concerning for inflicted injury, including unexplained apnea, injuries with suspicious etiologies, or incidents blamed on unlikely perpetrators.

felt that their presence was helpful to both themselves and their child. Family involvement is a crucial element in providing well-rounded, sensitive care to injured children. Providers caring for injured children need to be well-versed in pediatric and family-centered care and seek to improve communication. Involvement of family members of pediatric patients will serve to improve care quality and promote patient safety.12

Family-Centered Care
In 2006, the American Academy of Pediatrics and the American College of Emergency Physicians published a joint policy statement calling for patient- and family-centered care when providing care to children in EDs.42 Patient- and familycentered care recognizes the integral role of the family when treating an ill or injured child and encourages mutually beneficial collaboration among the patient, family, and providers.42 Although including families in the care of children has long been understood and appreciated by pediatricians, this concept is relatively new in trauma, specifically with regard to trauma resuscitations. A survey of trauma surgeons' attitude toward family presence during trauma resuscitation found that although 38% of respondents knew about the push toward family presence during trauma resuscitation, only 50% would ever allow their presence.43 Of those respondents who would allow family presence, only 8% would permit it during the entire resuscitation.43 These results are similar to those found by Helmer et al44 who surveyed members of the Emergency Nurses Association (ENA) and American Association for the Surgery of Trauma (AAST) regarding their opinions on family presence during trauma resuscitations. Almost 98% of AAST members felt that family presence during all phases of trauma resuscitation was inappropriate, and many believed that family presence interfered with patient care and increased stress of trauma team members.44 Several recent studies of family presence during pediatric trauma resuscitations disprove these attitudes. Both O'Connell et al45 and Dudley et al46 performed prospective studies of family presence during pediatric trauma resuscitations and found little to no negative impact on the care provided to pediatric patients. O'Connell and colleagues45 found medical decision making, institution of care, team communication, and communication to the family to be the same or even easier with family presence. Dudley and Hansen46 found no clinically relevant difference in time to CT or resuscitation time with and without family presence. In their study, families

Environment and Interactions

Hospitals and EDs, in particular, can be fearprovoking entities for any young child. The inherent anxiety with a chaotic, loud ED may be further compounded for an injured child by being strapped to a backboard, surrounded by strangers, separated from caregivers, and subjected to painful evaluations and interventions. Pediatric EDs and children's hospitals are acutely aware of the environment's impact on a child's psychologic stress. Walk into any children's hospital and you see the muted lighting, open spaces, and childfriendly artwork all geared toward making children and their parents feel more comfortable. In addition to child-friendly environments, injured children need age-appropriate interaction and attention. Children reflect the emotions of the adults and caregivers around them. Care providers need to be cognizant of their own potential stress and/or highly charged emotions when interacting with pediatric trauma patients. Pediatric trauma patients and their families need calm reassurance and positive attitudes. When appropriate, providers caring for injured children need to create environments and interactions that reduce a patient's fear and stress. Soft lights and quiet, calm providers and environments should be the rule.

Psychologic Impact on Children

Pediatric trauma patients may suffer consequences beyond what is visible from their physical injuries. Posttraumatic stress disorder (PTSD) is high among children who sustain even mild or moderate traumatic injury. In their longitudinal study of pediatric trauma patients and PTSD, Schreier and colleagues47 found that 69% of the patients they interviewed between the ages of 7 and 17 had at least mild symptoms of PTSD immediately after a traumatic injury. The presence of PTSD symptoms was still present in 38% of the cohort 18 months after the initial injury. Care providers for pediatric trauma patients need to be aware of these high rates of PTSD symptoms after even mild and moderate injury. Systems need to be in place to

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identify those children at risk and assist with managing the symptoms.

Learning Opportunities
The ability to stay current with pediatric trauma patient evaluation and treatment requires a commitment to ongoing education and opportunities to learn new skills and practice routine ones. Pediatric trauma centers make this commitment with their focus on the assessment and treatment of pediatric trauma patients. Because of their higher pediatric volumes, providers in pediatric trauma centers are able to maintain their skills. In a survey of EDs by Gausche-Hill and colleagues,10 50% of responding hospitals provide care for less than 6 pediatric patients per day in the ED. The median volume of pediatric patients cared for by all respondents was 3700 patients per year, with less than 25% of responding EDs caring for more than 7000 patients per year. With relatively few pediatric patients seen, providers in those EDs may simply not have adequate ongoing exposure to critically ill or injured children to maintain their assessment and resuscitation skills. With limited exposure, there is an even greater need for additional ongoing learning and skill maintenance experiences, such as with medical simulation, case reviews, and other educational sessions. Unfortunately, continuing education in pediatric resuscitation is infrequently required of ED staff in nonpediatric trauma centers and adult hospitals (i.e., general hospitals or nonpediatric hospitals).6 Such ongoing pediatric education is important not only for physicians but also for nonphysician providers (nurses, medical assistants, support staff), who may be called upon to care for pediatric trauma patients. In addition, trauma centers caring for children need to learn from the pediatric patients they care for with pediatric-specific quality improvement activities. Pediatric trauma centers are required to have processes in place to critically review pediatric mortality, morbidity, and functional outcome. All providers caring for injured children should implement such programs to improve performance and patient safety.1,8,48

Prevention.50 Despite widespread knowledge of the importance of injury prevention, most pediatric trauma remains preventable. In a recent review, Joffe and Lalani51 identified that 77% of unintentional injuries sustained by children in a pediatric intensive care unit were from a mechanism that had a proven strategy to reduce significant injury and was therefore, preventable. Medical providers involved in the care of pediatric trauma patients have an opportunity and obligation to contribute to injury prevention through data collection that seeks to understand the causes of injuries and by participation in educational and community injury-prevention activities.8

EXPERIENCE AND OUTCOMES

Several studies and comprehensive reviews have attempted to answer the question Do pediatric trauma patients treated at pediatric hospitals or adult hospitals with pediatric specialty experience have better outcomes than those treated at adult hospitals? Although no comprehensive study of pediatric trauma centers vs adult trauma centers or pediatric hospital vs adult hospitals has yet been performed, there are individual studies, as below, that begin to address portions of this complicated question.

Mortality of Pediatric Trauma Patients

Two separate studies using large databases have found that injured children treated by pediatric specialists, especially younger and more severely injured children, have improved mortality as compared to those treated by adult specialists.7,52 Densmore and colleagues7 used the 2000 Kids' Inpatient Database to review more than 79,000 cases of pediatric injury treated at children's hospitals and adult hospitals. They found that 89% of injured children in this database were treated outside children's hospitals. Importantly, in-hospital mortality, length of stay, and hospital charges were all higher in the adult hospitals, even after controlling for injury severity scores. The Kids' Inpatient Database does not include trauma hospital designation so additional information based on trauma designation is not available. The findings of Densmore and colleagues complement the findings in a 2000 study by Potoka and colleagues.52 They retrospectively analyzed more than 13,000 injured children from the Pennsylvania Trauma Outcome Study database to compare mortality data across trauma-designated hospitals. In their study, injured children who were treated at a pediatric trauma center or an adult trauma

Injury Prevention
A discussion of pediatric trauma would not be complete without mentioning the important role of prevention. Injury prevention programs have been proven to be effective in reducing childhood injuries,8,49 and numerous prevention recommendations are available through the American Academy of Pediatrics, Committee on Injury and Poison

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center with added qualifications to treat children had lower mortality rates (11.9% and 12.4%, respectively) as compared to level I and level II adult trauma centers (21.6% and 16.2%, respectively). Similarly, more severely injured children had the best overall outcomes when treated at a pediatric trauma center.52

Blunt Trauma Patients

An estimated 90% of trauma in pediatric patients is blunt trauma.14,17,20,52 Less than 5% of all pediatric trauma patients with blunt abdominal trauma require operative intervention.53 Several studies looking at the outcome of this large subset of injured children have identified improved outcomes and increased likelihood of successful nonoperative treatment when children are treated by pediatric specialists or at a pediatric trauma center.54-57 In a review at one Chicago pediatric trauma center, Hall et al54 reviewed almost 1800 records of injured children and compared patient outcomes for this institution to outcomes reported in the Major Trauma Outcomes Study. Most children in this sample had blunt trauma (75%) and had improved survival rates and increased successful nonoperative treatment of blunt abdominal injuries. Splenectomy rates after spleen injuries have been well studied as a process of care measure for pediatric trauma patients. Several independent studies have identified that injured children with blunt spleen injury are more likely to be managed successfully in a nonoperative fashion when treated by pediatric surgeons,56 pediatric specialists,55 or in a pediatric trauma center.54,57 This affects acute management as well as potential lifetime morbidity.

adult trauma patients. Access to pediatric specialty care in the form of pediatric emergency medicine physicians, pediatric surgeons, pediatric anesthesiologists, pediatric critical care specialists, pediatric nurses, child life specialists, pediatric rehabilitation specialists, and pediatric social workers is critical in the assessment, stabilization, treatment, and rehabilitation of pediatric trauma patients.8 The findings described above also mirror similar findings in other fields. A recent study comparing the survival rates and morbidity of pediatric patients transported between facilities by pediatric critical care specialized teams vs nonspecialized teams identified increased mortality and more unplanned events among patients transported with nonspecialized teams, regardless of the severity of illness.59 The authors in this study hypothesized that limited pediatric critical care experience, limited pediatric procedural experience, and lack of ongoing continuing education in pediatric critical care contributed to the differences between nonspecialized and specialized teams.59 It is reasonable to assume that these same conclusions can be applied to adult hospitals with limited pediatric exposure and few, if any, requirements for ongoing pediatric education.

IMPROVING QUALITY OF CARE TO PEDIATRIC TRAUMA PATIENTS

Pediatric trauma centers should be used whenever feasible for pediatric trauma patients. However, because of geographic limitations, nonpediatric trauma centers may need to provide the initial care to injured children.2,8 Standardized courses such as Pediatric Advanced Life Support (PALS), Advanced Pediatric Life Support (APLS), and Advanced Trauma Life Support (ATLS) will expand nonpediatric providers' assessment, management skills, and comfort with pediatric patients. Nonpediatric trauma centers should partner with local/ regional pediatric specialists and identify physician and nurse coordinators for pediatric emergency medicine to create pediatric-specific trauma protocols and pediatric provider resources where needed.8 Ongoing educational activities focused on pediatric-specific trauma care should be provided to all members of the trauma team.8,48 Measurable improvements in quality and outcomes are found when nonpediatric trauma centers make a commitment to pediatric excellence.60

Functional Outcomes
A few studies have begun to move beyond mortality outcomes and evaluate functional outcomes in pediatric trauma patients. One such study, using data from the Pennsylvania Trauma Outcome Study, found that children treated in pediatric trauma centers had improved functional outcomes, as demonstrated by decreased dependence on feeding, locomotion, or transfer devices, when compared with injured children treated at adult trauma centers with additional qualifications for treating children and adult trauma centers without the added qualifications.58 Certainly, more studies evaluating quality of life and functional outcomes are needed. The improved outcomes of injured children when treated by pediatric specialists should come as no surprise. Pediatric trauma patients are different from

SUMMARY
Trauma remains the leading cause of mortality in children. Most injured children are treated in adult

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hospitals and adult trauma centers. Although not conclusive, several studies have identified that injured children have improved outcomes, with lower mortality, fewer operations, and improved function, when treated by pediatric specialists. However, limitations in the availability of pediatric trauma centers and pediatric specialists require that all hospitals be prepared to effectively and successfully treat pediatric patients.

REFERENCES
1. Gausche-Hill M, Krug SE, American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, American College of Emergency Physicians, Pediatric Committee, Emergency Nurses Association, Pediatric Committee. Guidelines for care of children in the emergency department. Pediatrics 2009;124:1233-43. 2. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine and College of Emergency Physicians, Pediatric Committee, Care of Children in the Emergency Department. Guidelines for Preparedness. Pediatrics 2001; 107:777-81. 3. Prentiss KA, Vinci R. Children in emergency departments: who should provide their care? Arch Dis Child 2009;94:573-6. 4. Guice KS, Cassidy LD, Oldham KT. Traumatic injury and children: a national assessment. J Trauma 2007;63:S68-80. 5. Segui-Gomez M, Change DC, Paidas CN, et al. Pediatric trauma care: an overview of pediatric trauma systems and their practices in 18 US states. J Pediatr Surg 2003;38: 1162-9. 6. Institute of Medicine, Committee on the Future of Emergency Care in the US Health System, Emergency Care for Children. Growing pains. Washington, DC: National Academies Press; 2006. 7. Densmore JC, Lim HJ, Oldham KT, et al. Outcomes and delivery of care in pediatric injury. J Pediatr Surg 2006;41: 92-8. 8. Tuggle D, Krug SE, American Academy of Pediatrics, Section on Orthopaedics, Section on Critical Care, Section on Surgery, Section on Transport Medicine, Committee on Pediatric Emergency Medicine, Pediatric Orthopaedic Society of North America. Management of pediatric trauma. Pediatrics 2008;121:849-54. 9. McGillivray D, Nijssen-Jordan C, Kramer MS, et al. Critical pediatric equipment availability in Canadian hospital emergency departments. Ann Emerg Med 2001;37:371-6. 10. Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric preparedness of US emergency departments: a 2003 survey. Pediatrics 2007;120:1229-37. 11. American Academy of Pediatrics, Committee on Drugs and Committee on Hospital Care. Prevention of medication errors in the pediatric inpatient setting. Pediatrics 2003;112:431-6. 12. Frush K, Krug S, American Academy of Pediatrics Committee on Pediatric Emergency Medicine. Patient safety in the pediatric emergency care setting. Pediatrics 2007;120: 1367-75. 13. Tzimenatos L, Bond GR, Pediatric Therapeutic Error Study Group. Severe injury or death in young children from therapeutic errors: a summary of 238 cases from the American Academy of Poison Control Centers. Clin Toxicol 2009;47:348-54.

14. Bruny JL, Bensard DD. Hollow viscus injury in the pediatric patient. Semin Pediatr Surg 2004;13:112-8. 15. Keller MS. Blunt injury to solid abdominal organs. Semin Pediatr Surg 2004;13:106-11. 16. Levy JA, Noble VE. Bedside ultrasound in pediatric emergency medicine. Pediatrics 2008;121:e1404-12. 17. Wise BV, Mudd SS, Wilson ME. Management of blunt abdominal trauma in children. J Trauma Nurs 2002;9:6-14. 18. Whitehouse JS, Weigelt JA. Diagnostic peritoneal lavage: a review of indications, technique, and interpretation. Scand J Trauma Resusc Emerg Med 2009;17:13-8. 19. Cha JY, Kashuk JL, Sarin EL, et al. Diagnostic peritoneal lavage remains a valuable adjunct to modern imaging techniques. J Trauma 2009;67:330-6. 20. Gharahbaghian L, Vigil V, Williams S, et al. Imaging in pediatric abdominal trauma; what test, and why? Trauma Rep 2009;10:1-12. 21. Boulanger BR, Kearney PA, Brenneman FD, et al. Utilization of FAST (Focused Assessment with Sonography for Trauma) in 1999: results of a survey of North American trauma centers. Am Surg 2000;66:1049-55. 22. Patel JC, Tepas JJ. The efficacy of focused abdominal sonography for trauma (FAST) as a screening tool in the assessment of injured children. J Pediatr Surg 1999;34:44-7. 23. Sola JE, Cheung MC, Yang R, et al. Pediatric FAST and elevated liver transaminases: an effective screening tool in blunt abdominal trauma. J Surg Res 2009;157:103-7. 24. Suthers SE, Albrecht F, Foley D, et al. Surgeon-directed ultrasound for trauma is a predictor of intra-abdominal injury in children. Am Surg 2004;70:164-8. 25. Scaife ER, Fenton SJ, Hansen KW, et al. Use of focused abdominal sonography for trauma at pediatric and adult trauma centers: a survey. J Pediatr Surg 2009;44:1746-9. 26. Miller D, Garza J, Tuggle D, et al. Physical examination as a reliable tool to predict intra-abdominal injuries in braininjured children. Am J Surg 2006;192:738-42. 27. Jerby BL, Attorri RJ, Morton D. Blunt intestinal injury in children: The role of the physical examination. J Pediatr Surg 1997;32:580-4. 28. Holmes JF, Mao A, Awasthi S, et al. Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Ann Emerg Med 2009;54: 528-33. 29. Shah NB, Platt SL. ALARA: is there a cause for alarm? Reducing radiation risks from computed tomography scanning in children. Curr Opin Pediatr 2008;20:243-7. 30. Kim PK, Zhu X, Houseknecht E, et al. Effective radiation dose from radiologic studies in pediatric trauma patients. World J Surg 2005;29:1557-62. 31. Rice HE, Frush DP, Farmer D, et al. Review of radiation risks from computed tomography: essentials for the pediatric surgeon. J Pediatr Surg 2007;42:603-7. 32. The Society for Pediatric Radiology. The Alliance for Radiation Safety in Pediatric Imaging. Available at: http:// www.pedrad.org/associations/5364/ig/. Accessed 11/16/09. 33. Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374:1160-70. 34. The National Cancer Institute. Radiation risks and pediatric computed tomography (CT): a guide for health care providers. Available at: http://www.cancer.gov/cancertopics/ causes/radiation-risks-pediatric-CT. Accessed 11/16/09. 35. Martin JA, Kung HC, Mathews TJ, et al. Annual summary of vital statistics: 2006. Pediatrics 2008;121:788-801.

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36. Kellogg ND, American Academy of Pediatrics, Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics 2007;119:1232-41. 37. Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA 1999;281:621-6. 38. Flaherty EG, Sege R, Mattson CL, et al. Assessment of suspicion of abuse in the primary care setting. Amb Pediatr 2002;2:120-6. 39. Flaherty EG, Sege R, Binns HJ, et al. Health care providers' experience reporting child abuse in the primary care setting. Arch Pediatr Adolesc Med 2000;154:489-93. 40. Starling SP, Heisler KW, Paulson JF, et al. Child abuse training and knowledge: a national survey of emergency medicine, and pediatric residents and program directors. Pediatrics 2009;123:e595-e602. 41. Trokel M, Waddimba A, Griffith J, et al. Variation in the diagnosis of child abuse in severely injured infants. Pediatrics 2006;117:722-8. 42. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, American College of Emergency Physicians, Pediatric Emergency Medicine Committee. Patient- and family-centered care and the role of the emergency physician providing care to a child in the emergency department. Pediatrics 2006;118:2242-4. 43. Kirchhoff C, Stegmaier J, Buhmann S, et al. Trauma surgeons' attitude towards family presence during trauma resuscitation: a nationwide survey. Resuscitation 2007;75:267-75. 44. Helmer SD, Smith RS, Dort JM, et al. Family presence during trauma resuscitation: a survey of AAST and ENA members. J Trauma 2000;48:1015-24. 45. O'Connell KJ, Farah MM, Spandorfer P, et al. Family presence during pediatric trauma team activation: an assessment of a structured program. Pediatrics 2007;120:e565-74. 46. Dudley NC, Hansen KW, Furnival RA, et al. The effect of family presence on the efficiency of pediatric trauma resuscitations. Ann Emerg Med 2009;53:777-84. 47. Schreier H, Ladakakos C, Morabito D, et al. Posttraumatic stress symptoms in children after mild to moderate pediatric trauma: a longitudinal examination of symptom prevalence, correlates, and parent-child symptom reporting. J Trauma 2005;58:353-63.

48. American College of Surgeons, Committee on Trauma. Pediatric trauma care, in Resources for Optimal Care of the Injured Patient. Chicago (Ill): American College of Surgeons; 2006. p. 55-61. 49. Shields BJ, Smith GA. Success in the prevention of infant walker-related injuries: an analysis of national data, 1990-2001. Pediatrics 2006;117:e452-9. 50. American Academy of Pediatrics, Section on Injury, Violence and Poison Prevention (SOIVPP). Policy statements. Available at: http://www.aap.org/sections/ipp/Policy.cfm. Accessed 11/16/09. 51. Joffe AR, Lalani A. Injury admissions to pediatric intensive care are predictable and preventable: a call to action. J Intensive Care Med 2006;21:227-34. 52. Potoka DA, Schall LC, Gardner MJ, et al. Impact of pediatric trauma centers on mortality in a statewide system. J Trauma 2000;49:237-45. 53. Tataria M, Nance ML, Holmes JH, et al. Pediatric blunt abdominal injury: age is irrelevant and delayed operation is not detrimental. J Trauma 2007;63:608-14. 54. Hall JR, Reyes HM, Meller JL, et al. The outcome for children with blunt trauma is best at a pediatric trauma center. J Pediatr Surg 1996;31:72-7. 55. Mooney DP, Rothstein DH, Forbes PW. Variation in the management of pediatric splenic injuries in the United States. J Trauma 2006;61:330-3. 56. Sims CA, Wiebe DJ, Nance ML. Blunt solid organ injury: do adult and pediatric surgeons treat children differently. J Trauma 2008;65:698-703. 57. Davis DH, Localio AR, Stafford PW, et al. Trends in operative management of pediatric splenic injury in a regional trauma system. Pediatrics 2005;115:89-94. 58. Potoka DA, Schall LC, Ford HR. Improved functional outcome for severely injured children treated at pediatric trauma centers. J Trauma 2001;51:824-34. 59. Orr RA, Felmet KA, Han Y, et al. Pediatric specialized transport teams are associated with improved outcomes. Pediatrics 2009;124:40-8. 60. Partrick DA, Moore EE, Bensard DD, et al. Operative management of injured children at an adult level 1 trauma center. J Trauma 2000;48:894-901.

Abstract:
Psychological issues are common overlays with all forms of illness and injury, but the extent to which these problems are associated with trauma is becoming better understood. Emergency care providers will deal with the causes and consequences of these posttraumatic difficulties. The practice of medicine, such as illness itself, is dynamic and always changing. We must prepare ourselves to the best of our abilities if we are to be successful in facing this challenge. This article offers suggestions for physicians and other acute care providers for ways to accomplish this task by relying on skills we already possess as we increase our level of understanding.

Mental Health Consequences of Trauma: The Unseen Scars

Michael Finn Ziegler, MD

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

Reprint requests and correspondence: Michael Finn Ziegler, MD, Department of Pediatrics and Emergency Medicine, Emory University Childrens Healthcare of Atlanta 1405 Clifton Road NE Atlanta, GA 30322. mike_ziegler@oz.ped.emory.edu
1522-8401/$ - see front matter 2010 Elsevier Inc. All rights reserved.

rauma happens; it is part of life. Injuries are very common in children and adolescents, almost a right of passage. In its most innocuous form, it is a whimsical story of remember the time, but in some instances, it is life-changing and disrupting not only to the patient but for everyone around them. As emergency medicine (EM) physicians, especially those taking care of children and families, we see the entire gamut. We do our best to provide interventions that preserve and improve the quality of that life. Upon the completion of emergency care, we make disposition decisions, turn the care of injured children over to someone else and wish them well. We then move on to see the next patient, a child with 6 months of abdominal pain and poor school performance who has no primary care physician. He has been very healthy with only one other visit to an emergency department (ED) last year after a car accident, but thankfully, he was not hurt as severely as his brother. One might pause to feel the frustration of another nonemergency wrongly presenting to an ED. Or, one might also wish they had spent just a few more minutes talking with that last family about what happens after trauma. A growing body of knowledge now exists that sheds light on our understanding of the psychological consequences of trauma and illness in childhood. As our understanding grows, so does our need to address these sequelae through education, direct interventions, appropriate referrals, and advocacy. Many EM physicians may not be excited when faced with still another responsibility in the increasingly overcrowded and time and resource-constrained ED. However, rather than seeing this as a new skill set and knowledge base to acquire, emergency care providers already have the expertise as well as the opportunity to become effective advocates for children with mental health consequences of trauma.
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BACKGROUND
For the sake of discussion, this article will focus primarily on acute and prolonged posttraumatic stress disorders (PTSDs) and subsyndromal presentations, but it should be understood that depression, anxiety, and other psychologic problems are also associated with acute traumatic events. An understanding of posttraumatic behavioral changes has been around for a long time, at least in reference to military conflict. During the American Civil War, soldiers were described as having soldier's heart or irritable heart when they displayed altered behavior after conflict. During World War I, the terms shell shock or the effort syndrome were used to describe the same behaviors. Combat stress reaction was first described among veterans of World War II. Posttraumatic stress disorder was formally described and given diagnostic criteria in response to behavioral problems experienced by veterans of the Vietnam War.1 During this same period, childhood trauma as a predictor of future psychological problems such as PTSD was first described.2-5 Eventually, investigators turned their attention to acute stress disorder (ASD) and PTSD in the pediatric population and found that children were more susceptible than adults in developing these disorders after traumatic experiences. Overall, prevalence rates for PTSD in adults is estimated to be 8% to 9%;6-8 however, depending on the type of stressors, studies in children demonstrate the prevalence rate to range between 13% and 45%.9-13 Diagnostic dilemmas also exist in children that may miss subsyndromal presentations that still may lead to significant disability. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,14 requires coexisting symptom clusters of reexperiencing, avoidance, and hyperarousal in conjunction with an inciting stressor or traumatic event and disability for 1 month or more to meet diagnostic criteria for PTSD. The same criteria with the addition of dissociation for less than 1 month define ASD. It is difficult for children to meet these criteria because they often alternate symptom clusters of reexperiencing and avoidance (ie, no coexistence),15 or the avoidance symptoms are missed because they are more difficult to assess in children.16 Reexperiencing symptoms includes recurrent and intrusive thoughts often displayed through playacting, intrusive distressing dreams of the events, and intense psychological and physiological distress at reminders of the events. Avoidance symptoms include efforts to avoid thoughts or activities that arouse memories, apparent amnesia

to events, withdrawal, and a sense of a foreshortened future. Hyperarousal symptoms are often the most easily identified and include insomnia, emotional lability, poor concentration, hypervigilance, and exaggerated startle response.14 These symptoms and subsequent somatizations are often what bring children and their families back to the ED. Other diagnostic challenges include the dependence of young children on their caregivers to express their symptoms. Several studies have shown that caregivers often minimize children's symptoms and rarely seek help for these problems unless they are assisted by a medical professional who recognizes the symptom clusters.13,15,17-19 Surveys of emergency care and primary care providers not only show that physicians are aware of this tendency of caregivers to minimize symptoms but also show that the same providers underestimate the prevalence of the disorder and lack an understanding of the risks associated with its development.20,21 The reason these diagnostic difficulties are so important is exemplified by studies that show that subsyndromal states of stress disorders have similar posttraumatic disabilities as those meeting full spectrum.22 Therefore, a missed diagnosis is a missed opportunity to intervene and potentially change what could become a bad outcome.

SINGLE INCIDENT TRAUMA

Early literature about childhood stress reactions considered inciting events such as community violence, physical and/or sexual abuse, wars, and domestic violence, but more recent studies have found significant rates of ASD and PTSD among victims of accidental single incident trauma as well. Children who sustain motor vehicle-related injuries have a 27% to 36% chance of developing a fullfledged ASD or a clinically significant immediate stress reaction within days to weeks after the injury.18,23,24 Similarly, children who have injuries from motor vehicle-related incidents will have a 25% to 33% chance of developing full diagnostic criteria for PTSD.17,23 Victims of single incident dog attacks were studied and found to have full diagnostic criteria for PTSD in 5 of 22 children at 7 months and an additional 7 of 22 children had subsyndromal presentations in the same time frame.25 A recent study looking at single incident orthopedic injuries found that 33% met full diagnostic criteria for PTSD at follow-up psychological testing.26 As many as 80% of children will develop at least one symptom of an immediate stress reaction within the first month after a motor vehicle-related injury.27 It is likely that similar high rates of isolated

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symptoms would exist after other accidental traumas. Do we need to worry about all of these patients? Actually, most affected children will see these symptoms disappear or become part of their coping strategy. These acute stress-related symptoms might actually help children adjust to the trauma. It has long been theorized that some aspects of traumatic stress are adaptive. Single incident adaptive learning is essential to survival by allowing us to generalize the lesson to other similar circumstances. Injury or threat leads to neurohormonal adaptive responses that provide emotional, behavioral, cognitive, and physiologic changes necessary for survival.28 Unfortunately, sometimes these adaptive responses lock neurochemical and microarchitectural organization and function leading to a lack of return to preevent homeostasis and possibly to a clinical disorder such as PTSD.29

the reexperiencing symptoms of PTSD.41 This is further supported by findings that elevated heart rates and urinary cortisol levels at the time of prehospital transport and ED presentation for traumatic injury are more likely to be found in patients who later develop PTSD.42-44 Therefore, appropriate pain control is essential in taking care of the child with trauma. Surprising to many is the lack of an association between severity of injury and risk of developing PTSD.17,31,45 Perception of injury tends to be more important to future psychiatric disability than the actual injury itself. This is important because failure to understand the patient's internal concerns could wrongly assign risk to patients who may otherwise do well. A lack of concern on the provider's part toward children with minor injuries may miss otherwise high-risk patients.

UNDERSTANDING RISK
If these isolated symptoms are so prevalent, how do we ascertain who is at risk for developing disability and who is going to cope well and recover? Understanding what risk factors exist may help us decide what level of intervention may be necessary. It has been shown that the loss or injury of a loved one during a traumatic event is highly associated with the risk of that individual developing PTSD.17,19,27,29 Likewise, parental posttraumatic stress is associated with children developing PTSD.30 This is likely due to parents being less emotionally available to the child and themselves unable to cope with the tragedy. This suggests that simple parental separation during and after trauma may also be associated with the risk for PTSD. Demographic factors affecting risk include female sex; this has been consistently found as a risk factor in most types of trauma except motor vehicle-related injuries. In addition, an inverse relationship exists between age and the risk of developing PTSD.17,31 Especially important to emergency care providers is the association between PTSD and pain management. Several studies and reviews point to inadequate pain control as an independent risk factor for developing trauma-related stress disorders such as ASD and PTSD.32-37 Hyperadrenergic states occur with pain and stress. These states enhance memory,38,39 especially if occurring in conjunction with negative emotions.40 A positive feedback mechanism exists where hyperadrenergic states from trauma and pain lead to overconsolidation of traumatic memory with subsequent release of stress hormones and catecholamines linked to

ASSESSING RISK
The mental health community is actively pursuing better diagnostic standards to improve both sensitivity and specificity of the diagnostic criteria for PTSD.46 The new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is expected to include developmental considerations in childhood PTSD and will acknowledge the difficulty in recognizing avoidance symptoms, which should loosen the criteria for full diagnostic PTSD in children. Mental health professionals who work in conjunction with EDs have also developed and tested screening tools that could be used for rapid assessment of risk stratification in the ED setting. One such tool is the Screening Tool for Early Predictors of PTSD (STEPP)47 (Figure 1). This tool consists of 4 brief questions addressed to parents of children and an additional 4 questions for the children themselves. This tool also incorporates demographic data that could be obtained from the record or the physician. Using the STEPP, a score was assigned that yielded a negative predictive value of 0.95 for children and 0.99 for parents.47 A subsequent study assessed the viability of the tool in an active ED and found that it was relatively well accepted by staff and families.48 These findings indicate that the STEPP is a potentially valuable screening tool for risk assessment in traumatized children. Another tool is the University of California Los Angeles PTSD Reaction Index,49 which demonstrated a sensitivity of 0.93 and a specificity of 0.87 for detecting PTSD. The Reaction Index has been proposed as a rapid screening tool for EDs and primary care offices. Its greatest use may be in identifying children with high

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Figure 1. Screening Tool for Early Predictors of PTSD (STEPP). Instructions for completion were as follows: ask questions 1 to 4 of the parent and questions 5 to 8 of the child, and record answers to questions 9 to 12 from the acute care medical record. Circle 1 for yes and 0 for no. Instructions for scoring were as follows: the child STEPP score is the sum of responses to questions 4 to 10 and 12. A child score of 4 or higher indicates a positive screen. The parent STEPP score is the sum of responses to questions 1 to 4, 9, and 11. A parent score of 3 or higher indicates a positive screen. ((C)2003, The Children's Hospital of Philadelphia. Reproduced with permission.)

scores that are considered to be at high risk and therefore may require close follow-up.

THE ROLE OF EMERGENCY CARE PROVIDERS

So, what does this have to do with emergency care providers? Perhaps a review of the sequelae of untreated posttraumatic stress may help us to better understand why this is, in part, our problem to deal with. Affected children have a higher relative risk for poor school performance and other functional impairments, somatization, substance abuse, and suicide attempts.1,17,18,33,50-54 Many of these patients will present to EDs during their sequelae, and we must understand that these morbidities carry not only an acute component, but additionally, a risk of long-term disability and an added burden on society in health care cost and resource use. There is also the loss of productivity

experienced by the patient and family members. As is true for all aspects of emergency care, a primary goal should be to limit morbidity and mortality. This is typically achieved with immediate interventions, education, anticipatory guidance, and followup plans. Why should we look at this particular problem any differently? Emergency health care providers may see stress disorders as beyond the scope of their practice. By definition, we may be unable to make these diagnoses during a short-term encounter. Mental health professionals who understand the diagnostic criteria and who are highly skilled with interview techniques are best suited to do this. These same professionals are also in a position to recommend and initiate successful treatment modalities such as cognitive therapy and pharmacotherapy.55-57 As previously discussed, it may be difficult to identify those at risk in an initial encounter. Yet we also do not want to overrefer these patients. The most sensible course of action would be to encourage

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follow-up with the primary care or posttrauma mental health care systems available to the patient where further evaluation and referral can occur. Unfortunately, many of the patients receiving care in the ED have limited or no access to a medical home.45,58 In addition, few mental health resources exist in many communities, making referrals problematic even after stress disorders are identified. Just as disturbing is the lack of use of such resources when concerted efforts are made to make them available to the patient.58 The emergency care system may be the only point of contact for many of these patients. However, surveys of physician knowledge and practice in both emergency and primary care settings have shown that physicians feel time constrained in dealing with such issues, are poorly reimbursed for their efforts, may be penalized in managed care systems for referring, and feel unprepared to handle these problems.20,21,59 These same studies confirm that mental health resources are scarce in many communities. A disconnect clearly exists between what we are beginning to understand about posttraumatic stress and what we actually do. One cannot ignore concerns about barriers to effective practice if we wish to provide optimal care for our patients.

EMERGENCY MEDICINE SOLUTIONS

The first thing to realize is that no one is suggesting that the ED is the only place to address PTSD, but as the ED often represents the first contact for these children, we are in a unique position to implement interventions that might positively affect outcomes and advocate for better primary and trauma care follow-up, as well as, support the improvement of access to mental heath resources. None of these tasks are beyond our abilities, and in fact, we are already very skilled in their application; even if we do not realize it.

practice of caring for trauma patients.61 She encourages us to broaden our understanding of the problem both as a way not only to improve our compassion for patients but also for ourselves. Understanding may in and of itself increase compassion for our patients leading to more attention to pain management and other comfort issues during our initial evaluation. This has the added benefit of helping us to check our own biases about mental health issues by better understanding the physiologic basis for these problems and avoiding the false dichotomy of drawing distinctions between so-called organic vs nonorganic disease. This helps us to advocate for the benefit of mental health follow-up when necessary. The need for compassion and understanding can be imparted to families by educating them about posttraumatic stress reactions including the likelihood they will resolve. We can encourage families to pay a little extra attention to their children both as a form of anticipatory guidance and as therapy. Encouraging healthy habits such as good sleep patterns, good eating patterns, and exercise can give the family a regained sense of control after feeling a significant loss of control.57 I like to tell families that this is a good time for a few extra hugs as a way to encourage their level of compassion both for their children and themselves.

EDUCATION AND UNDERSTANDING

Education both for our patients and ourselves is likely to improve clinical outcomes. The ability to inform families about likely posttraumatic stressrelated symptoms and their expected resolution might be comforting and can help avoid further stress for the family when such symptoms occur. Furthermore, this gives the family a framework in which to observe for more concerning or prolonged reactions. This is empowering and may increase the likelihood they will seek professional help in the future.62 There is even some evidence to suggest that anticipatory guidance may help reduce symptoms,63 but further investigation needs to occur to best understand and maximize the effect of such interventions. Our own understanding can help us to risk stratify injured patients. Physicians have expressed desires to learn more and be prepared for interventions.20,21,45 This interest, in conjunction with screening tools, may allow us to target anticipatory guidance provided during an ED encounter toward those who may need it the most, offering needed reassurance and/or strongly emphasizing the purpose of follow-up assessments through primary care

COMPASSION
Compassion is defined as a feeling of deep sympathy and sorrow for another who is stricken by misfortune, accompanied by a strong desire to alleviate the pain.60 Compassion is at the center of what we do each and every day. Perhaps we can improve our compassion for these children and their families through our understanding of the problem. Nancy Kassam-Adams, PhD, in an introduction to a special issue on pediatric stress in the Journal of Pediatric Psychology reports that as health care professionals we have compassion fatigue and secondary traumatic stress as a result of our

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or trauma care follow-up systems. Advocating for the presence of staff in the ED that are trained in mental health and the use of screening tools can help to make the process more efficient and effective. In a survey of emergency care providers, only half could identify such staff within their institutions.20 As our understanding of the mental health consequences of trauma improves so too can our ability to do efficient screening of affected patients. For this reason, we need to advocate for further research into screening tools and ED assessments.

PAIN AND ANXIETY REDUCTION

Another area where emergency care providers possess great experience is pain management. Multiple studies have shown that attention to pain management can reduce the risk for PTSD.32-37 Recognizing this, we should continue our efforts to be aggressive in our control of pain and anxiety in trauma patients. Dr Michael Greenwald offers guidance on pain management in this issue of Clinical Pediatric Emergency Medicine that is well worth reviewing. In addition to pharmacologic interventions, numerous initiatives have begun within the EM community to promote family-centered care and parental presence whenever possible during painful or stressful procedures as a way to further reduce distress and as a means to promote coping. Previous publications suggest family presence to be helpful in the secondary prevention of PTSD.56

families makes emergency care providers uniquely equipped to advocate for our patients at the system level. We should first advocate for an accessible medical home for all children, as this would offer all children timely follow-up after acute trauma care provided in the ED and allow for further screening for mental health disorders and referral as indicated. We should also advocate for improved mental health resources and expanded insurance coverage. We might also advocate for EDs to have adequate staffing both at the provider and ancillary staff levels and for appropriate reimbursement when we take the time to address the mental health concerns of our patients in the ED. Mental health disorders should receive just as much attention as any other medical issue and without stigma. Further research and continuing education designed to continually improve the quality of emergency care should be encouraged through funding and academic support.

SUMMARY
Trauma has consequences that are both shortterm and delayed. Some of these consequences are not easily seen or understood. Mental health sequelae of trauma will impact the well-being of our patients and their families. Failure on our part to recognize these concerns, the risks that increase their likelihood, or failing to provide immediate interventions designed to reduce these risks is a missed opportunity to improve the well-being of our patients and their families. To inadequately address these issues at the time of acute traumatic event may likely place a burden on our already overtaxed emergency medical resources in the future. Policy statements from both the American Academy of Pediatrics and the American College of Emergency Physicians charge us to be responsible for the mental health needs of our patients.65-67 We can meet this challenge with expertise, understanding, and compassion just like we meet a myriad of challenges every day. In this way, we truly serve the needs of our patients and, maybe, ourselves.

PSYCHOLOGICAL FIRST AID

The American Red Cross has proposed psychological first aid as a means to deal with mental health issues that arise in the aftermath of a mass casualty.64 These recommendations could easily be adapted and applied to individual events. Schonfeld and Gurwitch56 propose that emergency providers are uniquely skilled in supporting families and patients in these disasters who have emotional and psychological problems related to their crisis. This psychological first aid includes providing appropriate information without overburdening the already stressed family, creating a calming supportive environment whenever possible, minimizing patient separation from family members, minimizing pain, and emphasizing positive coping strategies and communication.

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ADVOCACY
I propose that the knowledge and understanding gained from caring for injured children and their

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