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 C L I N I C A L

Pediatric Emergency Medicine

Vol 11, No 1 March 2010
Editor
Steven E. Krug,
FAAP

Feinberg School of
Medicine,
MD,

Advances In Pediatric Trauma

Harold K. Simon, MD, MBA
Northwestern
University, Children’s Guest Editor
Memorial Hospital,
Chicago, IL

GUEST EDITOR’S PREFACE

1 . . . . . . . . . . . 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. Jiménez

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 Bay—Comfort 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 Evidence-
Based, Patient-Centered
Coordination and Care
By Harold K. Simon, MD, MBA
F 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 improve-
ment 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 incor-
porates perspectives from pediatric emergency
medicine physicians, emergency medical services
providers, and critical care physicians. It will
address present state of care, improvement strate-
gies, and potential areas that can help us not only
decrease mortality but do so in a cost-effective
manner cognizant of facility and manpower re-
source limitations. Unlike many previous antholo-
Departments of Pediatrics and Emergency Medicine, Emory
University School of Medicine, Children's Healthcare of Atlanta,
Atlanta, GA.
PEDIATRIC TRAUMA: A ROADMAP FOR COORDINATION AND CARE / SIMON • VOL. 11, NO. 1 1
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 consid-
ering 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 radia-
tion exposure. This issue will address topics such as
coordination of care between subspecialties, transi-
tions 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
2 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 regiona-
lized 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 sur-
geons 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 stan-
dards 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 communi-
ties 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 well-
coordinated regional systems to best transport, stabi-
lize, and definitively care for critically injured chil-
dren.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 establish-
ing 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 long-
term 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 popula-
tion, 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. Consid-
eration 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 there-
fore also address pain management of the pediatric
trauma patient, posttraumatic stress disorder rec-
ognition, 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 deve-
lopment 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. O’Connor 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 abdom-
inal 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.
 Abstract:
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 con-
troversy around how this concept
Golden Hour or
should be interpreted, especially for
pediatric trauma patients. Health
care providers should instead focus
Golden
on the “golden opportunity,” differ-
ent for each patient, to provide the
best care in the most appropriate
Opportunity:
environment for all injured children.

Keywords:
pediatric trauma; golden hour;
Early
pediatric emergency; trauma
systems; interfacility transport 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
Pediatrics and Emergency Medicine, Divi-
sion of Pediatric Emergency Medicine, three days or two weeks later—but some-
Emory University School of Medicine, Chil- thing has happened in your body that is
dren’s Healthcare of Atlanta, Atlanta, GA.
Reprint requests and correspondence: irreparable.” R Adams Cowley MD1
Wendalyn Little, MD, MPH, Pediatric Emer-
gency Medicine, 1645 Tullie Circle, Atlanta,
GA 30329.
wendalyn.little@choa.org

1522-8401/$ - see front matter

© 2010 Elsevier Inc. All rights reserved.

4 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 post-
injury.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 in-
creased 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 eva-
cuation 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 pro-
longed, and patients may benefit from stabiliza-
tion 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 sur-
vive their initial injuries but need specialized
care and rehabilitation to achieve maximum post-
injury 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.
6 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 free-
standing children's hospitals and others within
general/adult facilities. Pediatric trauma care con-
tinues to evolve as a distinct facet of trauma care
that recognizes the different anatomical, physiolog-
ic, 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 cardio-
pulmonary 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 inter-
preted 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 depart-
ments at these facilities must be capable of assessing
pediatric trauma patients and providing stabilizing
care (also see article “Pediatric Patients in the Adult
Trauma Bay—Comfort 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 depart-
ments.19,21 Surveys evaluating preparedness con-
tinue to show inadequate preparation in equipment
and training for pediatric patients.13,20,22 Nonpedia-
tric 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 atmo-
sphere in which recognition and treatment of life-
threatening shock and respiratory failure go unad-
dressed 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 ulti-
mate 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 Unfortu-
nately, studies of pediatric patients transferred to
pediatric centers describe deficiencies in the detec-
tion 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 prima-
ry survey focusing on airway, breathing, and
circulation should be undertaken and any life-
threatening conditions corrected. All patients
should be placed on supplemental oxygen. Ad-
vanced airway management in the form of endotra-
cheal 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 provi-
ders must keep in mind that the strong compensa-
tory 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 candi-
dates 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, nonop-
erative 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, pediat-
ric patients undergo fewer laparotomies and sple-
nectomies 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, necessi-
tating 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 stabi-
lized 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 facili-
ties to a pediatric trauma center by “general”
helicopter teams vs specialized pediatric teams.
8 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
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 immedi-
ately available pediatric trauma centers. These
facilities must be capable of evaluating and stabiliz-
ing 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 faci-
lities 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 await-
ing the arrival of specialized transport teams from
the receiving institution. In these situations, per-
sonnel 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
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? Fur-
thermore, 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-threat-
ening 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-estab-
lished and well-coordinated systems of regionalized
trauma care.
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2. Trauma.org. Trauma resuscitation. Available at: http://www.
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3. Lerner EB, Moscati RM. The golden hour: scientific fact of
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6. Sasser SM, Hunt RC, Sullivant EE, et al. Guidelines for field
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7. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national
evaluation of the effect of trauma-center care on mortality.
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8. Nathens AB, Jurkovich GJ, Rivara FP, et al. Effectiveness of
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http://www.traumafoundation.org/restricted/tinymce/
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jscripts/tinymce/plugins/filemanager/files/About%20Trauma
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12. Potoka DA, Schall LC, Ford HR. Improved functional
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trauma centers. J Trauma 2001;51:824-34.
13. Odetola FO, Miller WC, Davis MM, et al. The relationship
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14. Osler TM, Vane DW, Tepas JJ, et al. Do pediatric trauma
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J Trauma 2001;50:96-101.
15. Farrell LS, Hannan EL, Cooper A. Severity of injury and
mortality associated with pediatric blunt injuries: hospitals
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Pediatr Crit Care Med 2004;5:5-9.
16. Nakayam DK, Copes WS, Sacco W. Differences in trauma
care among pediatric and nonpediatric trauma centers.
J Pediatr Surg 1992;27:427-31.
17. 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.
18. 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. Pediat-
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19. 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. Guide-
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20. Nance ML, Carr BG, Branas CC. Access to pediatric trauma care
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22. Gausche M. Differences in the out-of-hospital care of children
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23. Kumar VR, Bachman DT, Kiskaddon RT. Children and adults
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24. Seidel JS, Hornbein M, Yoshiyama K, et al. Emergency
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25. Seidel JS. Emergency medical services and the pediatric
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26. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-
hospital pediatric endotracheal intubation on survival and
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283:783-90.
27. Larson JT, Dietrich AM, Abdessalam SF, Werman HA.
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28. Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric preparedness
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29. Aaland MO, Smith K. Delayed diagnosis in a rural trauma
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31. Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of
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32. Carcillo JA, Kuch BA, Han YY, et al. Mortality and functional
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33. Zebrack M, Dandoy C, Hansen K, et al. Early resuscitation of
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34. Orr RA, Felmet KA, Han Y, et al. Pediatric specialized
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35. American Heart Association. PALS provider manual. Dallas
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37. Davis DH, Localio AR, Stafford PW, et al. Trends in operative
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38. Mooney DP, Rothstein DH, Forbes PW. Variation in the
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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
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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 Medi-
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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.
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 Children’s
Hospital, 6621 Fannin Street, MC
1-1481, Houston, TX 77030.
mxshah@texaschildrens.org
1522-8401/$ - see front matter
© 2010 Elsevier Inc. All rights reserved.
10 VOL. 11, NO. 1 • PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH
Prehospital
Management of
Pediatric Trauma
Manish I. Shah, MD
R
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 compo-
nents 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 infrastruc-
ture involves initiating high-quality prehospital care that uses
preestablished protocols. These protocols must then be applied by
skilled emergency medical technicians (EMTs) with the assis-
tance 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
 PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH • VOL. 11, NO. 1 11
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, identi-
fying 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 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 significant-
ly 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
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 impor-
tant. 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 para-
meters 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
12 VOL. 11, NO. 1 • PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH
ventilation via endotracheal intubation (ETI) or bag-
valve-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 find-
ings 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 prehospi-
tal 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 dis-
tance increased, such that the 95% CI included an
OR of 1 for transport distances greater than 20
miles. Intubated patients transported by helicop-
ter, 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 trau-
ma. The subgroup of child maltreatment patients
demonstrated improved survival with BVM com-
pared 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 differ-
ences of the pediatric airway relative to an adult,
and the limited pediatric continuing education for
prehospital providers make pediatric ETI a chal-
lenging 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.
 PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH • VOL. 11, NO. 1 13
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 on-
scene 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 on-
scene 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 place-
ment 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 trans-
port 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 profes-
sionals is to immobilize the cervical spine of a
patient who has had a traumatic injury. Once these
patients arrive at the hospital, the cervical immo-
bilization device might be removed based on
clinical criteria, or the patient might undergo
further imaging. The National Emergency X-Radi-
ography 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 evalua-
tion.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
14 VOL. 11, NO. 1 • PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH
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 prehos-
pital 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 age-
adjusted 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 vomit-
ing, 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 be-
cause 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 recom-
mendations 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 cogni-
tive 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 satu-
ration, 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
 PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH • VOL. 11, NO. 1 15

blood pressure should be monitored with an

appropriately sized pediatric cuff and prevented
TABLE 1. Comparison of pediatric GCS with
by giving boluses of 20 mL/kg of isotonic
standard GCS crystalloid (Table 2).31,35
Prehospital providers should determine the GCS
GCS Pediatric GCS and pupil size after airway, breathing, and circula-
tion have been assessed and stabilized. The most
Eye opening Eye opening
Spontaneous 4 Spontaneous 4 appropriate airway should be established in patients
Speech 3 Speech 3 with severe TBI, defined as a GCS less than 9.35
Pain 2 Pain 2 Also, because hypoglycemia can result after TBI,
None 1 None 1 blood glucose should be checked and treated when
Verbal response Verbal response serum glucose is less than 80 mg/dL.31
Oriented 5 Coos, babbles 5 Prehospital providers should directly transport
Confused 4 Irritable cries 4 children with severe TBI to a pediatric trauma
Inappropriate 3 Cries to pain 3 center or an adult trauma center with added
Incomprehensible 2 Moans to pain 2 qualifications to treat children.35 Because nonacci-
None 1 None 1 dental head injury is also a common cause of death
Motor response Motor response
in infants, prehospital providers should thoroughly
Obeys command 6 Normal, spontaneous 6
Localizes pain 5 Withdraws to touch 5 document findings at the scene and report unclear
Flexor withdrawal 4 Withdraws to pain 4 or implausible mechanisms to law enforcement,
Flexor posturing 3 Abnormal flexion 3 child protective services, and ED personnel, while
Extensor posturing 2 Abnormal extension 2 being cautious to maintain scene safety.31
None 1 None 1

Data from Badjatia.35

PAIN ASSESSMENT AND MANAGEMENT
Pain assessment and management in trauma is
important for patient comfort and potentially for
Children with suspected TBI should have their patient healing. In a retrospective chart review of
cervical spine (C-spine) immobilized in the field 696 pediatric trauma patients, prehospital person-
due to risk for concurrent injury.31 If ETI is going to nel documented a pain assessment in 81% of cases,
be attempted, manual C-spine stabilization is but only 0.1% actually used a pain assessment tool.
necessary to prevent secondary injury. For EMS Of the 64% of patients with documented pain, only
agencies that use RSI medications for intubation, 15% received some sort of intervention to address
premedication with 1.5 mg/kg of lidocaine followed their pain. For all patients, both pharmacologic and
by 0.3 mg/kg of etomidate for sedation and either nonpharmacologic interventions were used equally
1.5 mg/kg of succinylcholine or 1 mg/kg of vecur- in 13.4% of cases.40
onium are preferred to protect against increases in Because pain does not necessarily correlate with
intracranial pressure. Otherwise, the decision to injury severity, pain assessment should occur in all
intubate should be made in consultation with online children in the prehospital setting with a traumatic
medical control if these RSI medications are not injury. In addition, parental report of pain is often
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 TABLE 2. Definition of pediatric hypotension
monitor blood pressure, oxygenation, and end-tidal by age
CO2 (ETCO2). Patients should be maintained with
normal breathing rates (ETCO2 = 35-40 mm Hg), Age SBP
and hyperventilation (ETCO2 b 35 mm Hg) should
be avoided unless there are signs of cerebral 0-28 days b60 mm Hg
herniation. The evidence for the latter, however, is 1-12 months b70 mm Hg
lacking in pediatrics, and this recommendation has 1-10 years b70 + (2 × age in years)
been extrapolated from adult data.35 N10 years b90 mm Hg
Because hypotension with TBI in pediatric
patients has been associated with poor outcomes, Data from Badjatia.35
16 VOL. 11, NO. 1 • PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH
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 prehospi-
tal professionals is more likely to lead to manage-
ment 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-of-
hospital 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 con-
siderations of concussions among intercollegiate athletes.
Appl Neuropsychol 2003;10:12-22.
 PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH • VOL. 11, NO. 1 17
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 clinically-
important 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 Concus-
sion 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 routi-
nely 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
Reprint requests and correspondence:
Jeffrey F. Linzer Sr MD, Departments of
Pediatrics and Emergency Medicine,
Emory University School of Medicine,
Children’s Healthcare of Atlanta, GA
30322.
1522-8401/$ - see front matter
© 2010 Elsevier Inc. All rights reserved.
18 VOL. 11, NO. 1 • LABORATORY TESTS IN PEDIATRIC TRAUMA CARE / LINZER
Do Routine
Laboratory Tests
Add to the Care
of the Pediatric
Trauma Patient?
Jeffrey F. Linzer Sr, MD
L
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
 LABORATORY TESTS IN PEDIATRIC TRAUMA CARE / LINZER • VOL. 11, NO. 1 19
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 Gear-
hart,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 hematu-
ria 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 judg-
ment 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, high-
speed 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
20 VOL. 11, NO. 1 • LABORATORY TESTS IN PEDIATRIC TRAUMA CARE / LINZER
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 eleva-
tion 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
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.
When compared to other coagulation studies
(activated partial thromboplastin time [PTT],
thrombin time, bleeding time, platelet count,
fibrinogen, fibrin degradation products, and hemat-
ocrit), Hymel et al20 found that prolongation of the
prothrombin time (PT) was associated with paren-
chymal brain injury. In the review by Vavilala et
al,22 a fibrin degradation product of more than 1000
μg/mL was associated with a poor outcome in
children with a GCS between 7 and 12.
Holmes and colleagues25 ascertained that chil-
dren 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 coagu-
lation 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. Transa-
minases, pancreatic enzymes, and UA are not
TABLE 1. Laboratory charges.
CBC without differential $12.77
Hematocrit $4.67
Basic metabolic profile $16.70
Comprehensive metabolic profile $20.86
Hepatic function profile $16.12
AST $10.20
ALT $10.44
Amylase $12.79
Lipase $13.59
PT $7.75
PTT $11.84
Urinalysis (dip) $6.25
UA (automated with microbiology) $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/s00068-009-
9034-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 implica-
tions. 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 disposi-
tion 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 brain-
injured 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
Radiographic
patient. There is a substantially
increased dose of ionizing radiation
associated with CT compared to
Evaluation of the
plain radiography. Multiple studies
have demonstrated that the younger
the patient at the time of exposure,
Pediatric Trauma
the higher the radiation dose to the
organs. Higher organ radiation doses
have been linked with an increased
cancer risk. The indiscriminate use of
Patient and
CT in the evaluation of the pediatric
trauma patient is therefore
associated with an increased risk for
Ionizing
cancer in this population. This
article's objective is to review the
relative risks and benefits
Radiation
associated with this
radiographic modality. Exposure
Keywords:
CT scan; pediatric trauma;
radiation risk
Ricardo R. Jiménez, MD

Reprint requests and correspondence:
Ricardo R. Jiménez, 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.
“S
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 life-
threatening 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%

22 VOL. 11, NO. 1 • RADIOGRAPHIC EVALUATION AND IONIZING RADIATION EXPOSURE / JIMÉNEZ
 RADIOGRAPHIC EVALUATION AND IONIZING RADIATION EXPOSURE / JIMÉNEZ • VOL. 11, NO. 1 23
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. Diag-
nostic 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 replicat-
ing 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 short-
term 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 inju-
ries.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 x-
rays 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
24 VOL. 11, NO. 1 • RADIOGRAPHIC EVALUATION AND IONIZING RADIATION EXPOSURE / JIMÉNEZ
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 milli-
ampere 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 conscious-
ness less than 5 seconds, nonsevere injury mecha-
nism, 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. Be-
cause CSIs are very hard to evaluate clinically,
radiographic evaluation has been an integral part of
the traumatic cervical spine evaluation. Conven-
tional 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 clear-
ing 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
 RADIOGRAPHIC EVALUATION AND IONIZING RADIATION EXPOSURE / JIMÉNEZ • VOL. 11, NO. 1 25
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 phys-
iologic 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 anthro-
pomorphic 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 x-
ray, 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 concer-
ning 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 asso-
ciation 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 ap-
proach for the evaluation of pediatric blunt abdom-
inal 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. Recent-
ly, 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 inju-
ry.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 esti-
mated 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 pa-
tient.35,36 The American College of Emergency
26 VOL. 11, NO. 1 • RADIOGRAPHIC EVALUATION AND IONIZING RADIATION EXPOSURE / JIMÉNEZ
Physician has issued guidelines that strongly en-
courage the availability and use of FAST in the
evaluation of the trauma patient.36,37 It is under-
standable that FAST could decrease the use of
abdominal CT, reducing the organ radiation expo-
sure. 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 evalua-
tion 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.
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36. American College of Emergency Physicians. Use of ultra-
sound 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 normo-
tensive children with blunt abdominal trauma. J Pediatr Surg
2001;36:968-73.
 Abstract:
The acutely injured child poses un-
ique clinical challenges in many
respects. Our understanding of these
unique characteristic differences and
ability to care for pediatric trauma
Analgesia for the
Pediatric Trauma
patients has greatly improved over
recent decades; however, one area in
pediatric trauma care continues to
suffer from relative neglect in re-
search and shows few signs of
improvement in clinical practice: an-
algesia. Studies of analgesia prac-
Patient: Primum
tices continue to describe pervasive
undertreatment of pain in the pedia-
tric trauma patient. A growing body of
Non Nocere?
evidence suggests that poorly con-
trolled acute pain (oligoanalgesia) not
only causes suffering but may lead to
both immediate complications that Michael Greenwald, MD
worsen outcomes as well as debili-

tating chronic pain syndromes that
are often refractory to available treat-
ments. This article will provide a
review of pain in injured children with
respect to its pathophysiology, clin-
ical ramifications, and patterns of
analgesia practices. Impediments to
analgesia are examined regarding
multiple providers of care for the
acutely injured child including pre-
hospital personnel, nurses, and phy-
sicians. Finally, the article will provide
analgesia recommendations with an
approach to pain relief and sedation
for the injured pediatric patient.
Keywords:
oligoanalgesia; pain; pediatric; trauma
E
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 vulner-
able 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 pain-
related issues include visceral vs somatic pain, the stress
response, hypersensitivity vs habituation, central nervous system
(CNS) plasticity, hyperalgesia, and central sensitization.

Pediatrics and Emergency Medicine, Em- KEY CONCEPTS OF PAIN PATHOPHYSIOLOGY

ory University School of Medicine, Chil-
dren’s 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.
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

28 VOL. 11, NO. 1 • ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
 ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD • VOL. 11, NO. 1 29
by 2 sets of nerves: vagal and spinal nerves or pelvic
and spinal nerves. Most internal organs are inner-
vated 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 localiza-
tion as input is typically distributed over several
spinal segments. This leads to similar pain sensa-
tions 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
The Stress Response
Acute pain results in a stress response that
manifests in physiologic, biochemical, and behav-
ioral changes associated with hemodynamic insta-
bility and poor wound healing. Infants are
particularly vulnerable to changes in intracranial
pressures related to fluctuations in systemic vascu-
lar 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 respira-
tory 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
investigators found that the control group demon-
strated higher levels of stress hormones (eg,
hyperglycemia, lactic acidemia), greater incidence
of sepsis and disseminated intravascular coagulo-
pathy, and had a 27% mortality rate. The interven-
tion (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, bio-
chemical, 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.
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 chal-
lenging 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 non–life-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 recog-
nize the source of the pain as something that has a
30 VOL. 11, NO. 1 • ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
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 explana-
tions 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
γ-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 activat-
ing 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 character-
istics. 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 demon-
strate 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 oligoa-
nalgesia 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 research-
ers 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 connec-
tions and hyperinnnervation. Clinically, these
changes result in allodynia and other features of
neuropathic pain.10
Repetitive pain also appears to accelerate apo-
ptosis. 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 contrib-
ute 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 inflam-
matory markers, sensitization of neurons proximal
 ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD • VOL. 11, NO. 1 31
to and surrounding damaged nerves, and sympa-
thetically mediated pain.
After an injury, inflammatory mediators are re-
leased that may cause the pain response to increase
even in the absence of additional injury. This
sensitization of nociceptors results in primary hyper-
algesia 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 sponta-
neous 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 allody-
nia. 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
Summary of Neurophysiologic Reponses to Pain
Pain responses appear heightened in younger
patients whose CNS is more vulnerable to physiolog-
ic 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,
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 approximate-
ly 50% of the weight-based equivalent of analge-
sics.16-18 Furthermore, the milligram per kilogram
dosing of analgesics is generally directly related to
age, that is, younger patients receive lower milli-
gram per kilogram dosing regardless of clinical
situation.19 In 1996, Broome et al20 reported that
younger children received inconsistent pain assess-
ment and management and that institutional
standards regarding pain control were often ig-
nored. 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
32 VOL. 11, NO. 1 • ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
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 dis-
charge 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 includ-
ed 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.
Analgesia in Trauma
Research on analgesia practice for trauma
patients reveals similar patterns of undertreatment,
particularly for children. Friedland et al28 com-
pared analgesia provided for 215 children present-
ing 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%
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 musculoskel-
etal 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 com-
pared 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 trans-
ports 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
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 as-
sessment 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
 ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD • VOL. 11, NO. 1 33
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 frequent-
ly (78%) withheld to assist diagnosis.40 Most provi-
ders in this study believed that analgesics should be
withheld in cases of abdominal or multisystem
injury; however, 75% reported that they had inade-
quate 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 seri-
ous 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. Budu-
han 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. Ninety-
five percent of housestaff and 81% of nurses reported
adequate analgesia provided for patients who simul-
taneously 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 com-
pared 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. Fifty-
three 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
34 VOL. 11, NO. 1 • ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
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.
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 consider-
able 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 man-
agement relies first on the skilled use of nonphar-
macologic 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, Wong-
Baker 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,
TABLE 1. Pain assessment scales.
Patient Recommended Scoring
Description Scale Range
Infants NIPS: Neonatal 0-21
Infant Pain Scale
Preschool Wong-Baker Faces Scale 0-5
School age—
adolescent Visual Analog Scale 0-10
Intubated/
noncommunicative Comfort Scale 8-40
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, hemody-
namic changes are not always reliable markers in
painful settings. Vagal responses to pain may
decrease heart rate, whereas some patients demon-
strate 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 invalidat-
ing 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.
 ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD • VOL. 11, NO. 1 35
Keys to an optimal rapport with your patient
include honesty, clarity, and empowerment. Give
them choices wherever possible. The key is recog-
nizing 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 mem-
bers 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 describ-
ing 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 under-
standing 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.
Pharmacologic Interventions
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 understand-
ing 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
complete review of both pharmacologic and com-
plementary 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 admin-
istered. A secondary goal in acute pain manage-
ment is the prevention of chronic pain. Through
the careful titration of medication and attention to
nonpainful stressors that worsen painful experi-
ences, 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 (nau-
sea, 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-naïve 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-naïve patient in
severe pain is safely and effectively treated with an
initial dose of 2 to 3 μg/kg of fentanyl. A continuous
infusion can sustain therapeutic levels and allow
36 VOL. 11, NO. 1 • ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
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 μg/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
μg/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 exacerba-
tions 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 μg/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 de-
creased platelet function and gastritis, the role for
regular use of nonsteroidal antiinflammatory med-
ications 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 swell-
ing. 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 differ-
ent 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 (previ-
ously 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
 ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD • VOL. 11, NO. 1 37
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 require-
ment will be low (eg, laceration repair) or high (eg,
reducing a fracture). Next, determine if the proce-
dure 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 pro-
ceed 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 famil-
iarity with administration. Contraindications
against sedation with nitrous oxide include first
trimester pregnancy, pneumothorax, chronic respi-
ratory 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
TABLE 2. Treatment options for procedural sedation of the trauma patient. a
Analgesia Need Duration
Mild-moderate Short (b5 min)
Mild-moderate Long (N5 min)
(eg, long laceration repair)
Moderate-severe Short (b5 min)
Moderate-severe Long (N5 min)
a
Local or regional blocks with anesthetics are recommended where possible to decrease the requirement for systemic medications. IV
indicates intravenous; IN, intranasal.
Ketamine tends to increase secretions and has a
positive chronotropic and inotropic effect that can
result in an increase in systemic pressures. Keta-
mine administration is associated with increased
intracranial pressure; however, this effect is atten-
uated with benzodiazepine administration or hy-
perventilation. 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 prob-
lem, 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
Recommendation Alternatives
Fentanyl (IV, IN) Nitrous oxide (when anxiety N pain)
Fentanyl (IV, IN) + propofol Fentanyl infusion; Fentanyl + midazolam,
etomidate, OR methohexital
Ketamine
Ketamine + propofol Ketamine infusion; ketamine + midazolam,
etomidate, OR methohexital
38 VOL. 11, NO. 1 • ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
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 addi-
tional 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 contra-
indicated 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 Canna-
boid 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 require-
ments 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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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 manage-
ment: 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 depart-
ment.” 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 depart-
ment. 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
When There
unit admission in the ED. Emergency
department personnel are
experienced in the rapid assessment
Are No Inpatient
of trauma patients but may be less
prepared or comfortable with
providing ongoing management of
Beds: Providing
trauma patients, especially critically
injured pediatric patients. This
article reviews management
principles of traumatic brain injury,
Pediatric Critical
mechanical ventilation, and shock in
the pediatric trauma patient and is
intended to guide ED management
Care for Trauma
of these patients until they can be
transferred to an appropriate level of
inpatient care.
Patients in the
Keywords:
pediatric critical care; traumatic
Emergency
brain injury; shock; trauma;
mechanical ventilation Department
Toni Petrillo-Albarano, MD, FAAP*,
*Division of Pediatric Critical Care,
Wendalyn K. Little, MD, MPH†
Emory University School of Medicine,

Children’s Healthcare of Atlanta, Atlanta,
GA; †Division of Pediatric Emergency
Medicine, Emory University School of
Medicine, Children’s 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.
I
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 communi-
ties.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

PROVIDING PEDIATRIC CRITICAL CARE FOR TRAUMA PATIENTS IN THE ED / PETRILLO-ALBARANO AND LITTLE • VOL. 11, NO. 1 41
42 VOL. 11, NO. 1 • PROVIDING PEDIATRIC CRITICAL CARE FOR TRAUMA PATIENTS IN THE ED / PETRILLO-ALBARANO AND LITTLE
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 supplemen-
tal 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 main-
tain a partial pressure of carbon dioxide (PCO2)
within normal limits (35-45 mm Hg). Both hyper-
and hypoventilation may be deleterious to patients
with TBI. Hypoventilation may increase cerebral
blood flow, leading to increased intracranial pres-
sure (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 medi-
cal 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 intrave-
nous (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 ade-
quate intravascular volume is important for main-
taining 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 imme-
diately 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 persis-
tently elevated ICP, vasopressor agents such as
dopamine or norepinephrine may be needed to
maintain a normal to high-normal MAP and ade-
quate 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
 PROVIDING PEDIATRIC CRITICAL CARE FOR TRAUMA PATIENTS IN THE ED / PETRILLO-ALBARANO AND LITTLE • VOL. 11, NO. 1 43
treating patients with TBI involve decreasing cere-
bral 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 Maintain-
ing a normal body temperature is also important in
the management of TBI. Hyperthermia may in-
crease 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 blood-
brain 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. Intu-
bation 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. Al-
though multiple models of mechanical ventilators
exist, with multiple modalities for delivering mechan-
ical 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 para-
meters 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 volume-
control 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. Ventila-
tion 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 consider-
ation 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
44 VOL. 11, NO. 1 • PROVIDING PEDIATRIC CRITICAL CARE FOR TRAUMA PATIENTS IN THE ED / PETRILLO-ALBARANO AND LITTLE
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 decreas-
ing systemic blood pressure. This effect can often
be overcome by the provision of additional intra-
vascular 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 expira-
tion. 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, auto-
nomic reflex mechanisms are activated to maintain
vital organ perfusion. These include massive cate-
cholamine release, leading to increased heart rate
and systemic vascular resistance. These compensa-
tory mechanisms are particularly active in previ-
ously 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 progres-
sive 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 hypovole-
mic, 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. Trau-
ma 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 lead-
ing 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 morbid-
ity 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. Tachy-
cardia 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
 PROVIDING PEDIATRIC CRITICAL CARE FOR TRAUMA PATIENTS IN THE ED / PETRILLO-ALBARANO AND LITTLE • VOL. 11, NO. 1 45
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 hemor-
rhage, 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 prog-
ress 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 breath-
ing. All patients should be placed on supplemental
oxygen, preferably by high flow, non-rebreather
mask. Patients with a patent airway and spontane-
ous respirations may still benefit from early intuba-
tion 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, large-
caliber 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 trans-
fused and repeated as needed. Type-specific cross-
matched blood is preferred; however, type O
negative blood may be used in emergency circum-
stances until cross-matched blood is available.
Patients exhibiting signs of shock should have
emergent consultation by a trauma surgeon be-
cause they may require exploration to identify and
correct ongoing hemorrhage.13,25
Treatment of obstructive shock requires identifi-
cation and specific therapy for the type of obstruc-
tion. Pericardial tamponade may present with
muffled heart sounds, diminished pulses, and dis-
tended 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 treat-
ment. 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, di-
minished 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 norepi-
nephrine may be needed. The α-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
46 VOL. 11, NO. 1 • PROVIDING PEDIATRIC CRITICAL CARE FOR TRAUMA PATIENTS IN THE ED / PETRILLO-ALBARANO AND LITTLE
volume resuscitation with improvement of tachy-
cardia, capillary refill, or blood pressure, only to
return to an unstable shock state if they are
experiencing ongoing hemorrhage. The often men-
tioned “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 hemo-
globin and hematocrit may aid in recognizing
ongoing hemorrhage and identifying patients need-
ing emergent surgical intervention. Patients requir-
ing massive or ongoing volume resuscitation may
develop coagulopathy from consumption and dilu-
tion 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. Tradi-
tionally, 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 estab-
lished, 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 condi-
tions 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 bag-
mask ventilation, tracheal intubation, and even
ventilator management for patients who may re-
main 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 adminis-
tration of multiple medications. The most common-
ly 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 place-
ment does not require removal of the cervical collar
in trauma patients or interfere with airway manip-
ulation. 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 conscious-
ness, 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
 PROVIDING PEDIATRIC CRITICAL CARE FOR TRAUMA PATIENTS IN THE ED / PETRILLO-ALBARANO AND LITTLE • VOL. 11, NO. 1 47
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 consulta-
tion 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 depart-
ment 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. Neuro-
surgery 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 hyperten-
sion. 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 considera-
tions. Crit Care Med 2004;32:S591-594.
29. Buck MI, Wiggins BS, Sesler JM. Intraosseous drug adminis-
tration 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 speci-
alty training and in facilities that may
not be used to caring for children.
Pediatric Patients
Children have different physiologic
and psychologic responses to injury
than adults. Children have different
in the Adult
service and evaluative needs.
Several studies have shown that
pediatric trauma patients have
Trauma Bay—
improved outcomes with lower
mortality, fewer operations, and
improved function when cared for in
pediatric facilities or adult trauma
Comfort Level
centers with pediatric expertise.
Differences between injured adults
and injured children need to be
and Challenges
understood, recognized, and acted
upon by care providers to optimize
treatment for injured children.
Limitations in the availability of Kimberly P. Stone, MD, MS, MA,
pediatric specialists require that all
hospitals be prepared to effectively
George A. Woodward, MD, MBA

and successfully treat pediatric
trauma patients.
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.
C
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

48 VOL. 11, NO. 1 • PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD
 PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD • VOL. 11, NO. 1 49
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 non–pediatric-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. Knowl-
edge 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 hemor-
rhagic 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. Car-
diovascular 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 sec-
ondary 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
50 VOL. 11, NO. 1 • PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD

pediatric training or significant ongoing experience may be less familiar with the subtleties of weight-
in caring for children but are vital to be recognized based dosing and the complex calculations that may
by anyone caring for a pediatric trauma patient. be required. Providers caring for pediatric trauma
patients should seek to improve hospital-wide
systems to decrease pediatric medication errors as
Equipment part of a comprehensive pediatric patient safety
Children come in different ages and sizes, and
program.11 Establishing a weight in kilograms for all
therefore, the equipment needed to treat them (and
pediatric patients and the use of precalculated
sometimes the skills required) also need to come in
weight-based dosing tools will assist in the reduction
different sizes. Several recent studies have identified
of medication errors for all pediatric patients.12
that few nonpediatric hospitals are fully equipped
with all the necessary equipment to handle pediatric
emergencies.1 In its review of the emergency care
Evaluation Tools
system for children, the Institute of Medicine noted
The diagnostic tools used to evaluate intraabdom-
that only 6% of EDs in the United States had all the
inal injuries in pediatric trauma patients differ from
supplies deemed essential by the American Acade-
those used for adult trauma patients. For pediatric
my of Pediatrics and American College of Emergency
trauma patients, abdominal computed tomography
Physicians to handle pediatric emergencies. Only
(CT) remains the standard for evaluating suspected
half of the hospitals had at least 85% of the essential
abdominal injury in the hemodynamically stable
equipment.6 A similar study in Canada also found
child.14-17 The accepted standard for a hemody-
essential pediatric equipment unavailable in most of
namically unstable child, however, remains in
Canadian EDs.9 The materials most likely to be
evolution with decreasing use of diagnostic perito-
missing are equipment and supplies needed for
neal lavage (DPL), increasing use of focused abdom-
neonates and young infants. A 2003 survey of EDs
inal sonography for trauma (FAST), and continued
by Gausche-Hill and colleagues10 found similar
reliance on initial and serial physical examinations.
levels of readiness compared to published guidelines.
In hemodynamically unstable adults, DPL
Children's hospitals were predictably the best
remains a tool used to determine intraperitoneal
prepared, though hospitals with inpatient pediatric
hemorrhage or a ruptured hollow viscus.18,19
care resources and larger pediatric patient ED
However, DPL is now rarely used or recommended
volumes were typically better prepared. Regardless
in children because of its invasive nature and
of hospital size, the presence of a physician and/or
unacceptably high rate of nontherapeutic laparot-
nurse coordinator for pediatric emergency care was
omy.14,16,17 In addition, because most solid organ
predictive of a higher level of preparedness.10
injuries are managed nonoperatively, the presence
A recently updated reference for recommended
of blood may not determine therapeutic interven-
equipment (as well as other resources) for all EDs
tions. DPL in pediatric trauma patients should be
caring for pediatric patients can be found in the 2009
reserved for critically ill children with concerning
joint American Academy of Pediatrics, American
CT findings, in whom initial and serial physical
College of Emergency Physicians, and Emergency
examination is unreliable and for whom laparoto-
Nurses Association policy statement, Guidelines for
my poses substantial risk14 and for patients who
Care of Children in the Emergency Department.1
require immediate surgical interventions for non-
Any ED caring for pediatric trauma patients should
abdominal issues where a subtle or latent injury
make it a priority to have the appropriate range and
could prove problematic.
spectrum of equipment outlined.
In the adult trauma population, FAST examina-
tions have been well studied and are now routinely
Medications and Errors used to identify hemoperitoneum in unstable
Just as the equipment size needs to be scaled patients.16,20,21 Studies on FAST examinations in
down to child proportions, so too do the medication pediatric trauma populations have been mixed with
dosages. The need for weight-based dosing and lack high specificity (as high as 95%-100%)16,22 but wider
of standardized dosing for children leads to in- ranges of sensitivity (from 30% to 100%).16,20,22 The
creased medication errors in children as compared FAST examinations have the distinct advantage of
to adults.11,12 Medication errors in children are most being a bedside tool that can rapidly identify
associated with intravenous fluids,11 and pain and hemopericardium and hemoperitoneum in an un-
sedative medications,13 medications frequently stable trauma patient. However, children have a
used in pediatric trauma patients. Providers not higher incidence of solid organ injury without free
routinely administering medications to children fluid making a negative FAST examination less
 PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD • VOL. 11, NO. 1 51
predictive in this population. More recent studies
have found FAST examinations, when combined
with laboratory assessments23 or physical examina-
tion,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. Al-
though 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 intraab-
dominal organs.26-28 Familiarity and comfort with
examining pediatric patients and interpreting pedi-
atric 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 radio-
logic 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 chil-
dren.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 decision-
making 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 assess-
ment (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 decision-
support 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 pediat-
ric 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
52 VOL. 11, NO. 1 • PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD
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, inju-
ries with suspicious etiologies, or incidents blamed
on unlikely perpetrators.
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 family-
centered 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 resuscita-
tions. 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 resus-
citation, 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
felt that their presence was helpful to both them-
selves and their child.
Family involvement is a crucial element in pro-
viding well-rounded, sensitive care to injured chil-
dren. 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
Environment and Interactions
Hospitals and EDs, in particular, can be fear-
provoking 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 evalua-
tions and interventions. Pediatric EDs and chil-
dren'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 child-
friendly artwork all geared toward making children
and their parents feel more comfortable.
In addition to child-friendly environments, in-
jured 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 environ-
ments 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 conse-
quences 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
 PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD • VOL. 11, NO. 1 53
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 commit-
ment 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 non-
physician 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 imple-
ment such programs to improve performance and
patient safety.1,8,48
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 recommen-
dations are available through the American Acade-
my of Pediatrics, Committee on Injury and Poison
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 uninten-
tional 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 com-
pared 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 control-
ling for injury severity scores. The Kids' Inpatient
Database does not include trauma hospital designa-
tion so additional information based on trauma
designation is not available.
The findings of Densmore and colleagues com-
plement the findings in a 2000 study by Potoka and
colleagues.52 They retrospectively analyzed more
than 13,000 injured children from the Pennsylva-
nia 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
54 VOL. 11, NO. 1 • PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD
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%, respec-
tively). 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 nonopera-
tive 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.
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 dem-
onstrated 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 qualifica-
tions.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
adult trauma patients. Access to pediatric specialty
care in the form of pediatric emergency medicine
physicians, pediatric surgeons, pediatric anesthesiol-
ogists, pediatric critical care specialists, pediatric
nurses, child life specialists, pediatric rehabilitation
specialists, and pediatric social workers is critical in
the assessment, stabilization, treatment, and rehabil-
itation 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 nonspecia-
lized 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 continu-
ing education in pediatric critical care contributed to
the differences between nonspecialized and special-
ized 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 whenev-
er 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. Non-
pediatric trauma centers should partner with local/
regional pediatric specialists and identify physician
and nurse coordinators for pediatric emergency
medicine to create pediatric-specific trauma proto-
cols and pediatric provider resources where need-
ed.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 commit-
ment to pediatric excellence.60
SUMMARY
Trauma remains the leading cause of mortality in
children. Most injured children are treated in adult
 PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD • VOL. 11, NO. 1 55
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 success-
fully treat pediatric patients.
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58. Potoka DA, Schall LC, Ford HR. Improved functional
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Abstract:
Psychological issues are common
overlays with all forms of illness and
injury, but the extent to which these
problems are associated with trau-
ma 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 our-
selves to the best of our abilities if
we are to be successful in facing this
challenge. This article offers sug-
gestions 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.
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 Children’s 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.
Mental Health
Consequences of
Trauma: The
Unseen Scars
Michael Finn Ziegler, MD
T
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.
MENTAL HEALTH CONSEQUENCES OF TRAUMA / ZIEGLER • VOL. 11, NO. 1 57
58 VOL. 11, NO. 1 • MENTAL HEALTH CONSEQUENCES OF TRAUMA / ZIEGLER
BACKGROUND
For the sake of discussion, this article will focus
primarily on acute and prolonged posttraumatic
stress disorders (PTSDs) and subsyndromal presen-
tations, but it should be understood that depression,
anxiety, and other psychologic problems are also
associated with acute traumatic events. An under-
standing 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 reac-
tion” 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, investiga-
tors 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 reexperien-
cing, 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 coexis-
tence),15 or the avoidance symptoms are missed
because they are more difficult to assess in
children.16 Reexperiencing symptoms includes re-
current and intrusive thoughts often displayed
through playacting, intrusive distressing dreams of
the events, and intense psychological and physio-
logical distress at reminders of the events. Avoid-
ance symptoms include efforts to avoid thoughts or
activities that arouse memories, apparent amnesia
to events, withdrawal, and a sense of a foreshor-
tened future. Hyperarousal symptoms are often the
most easily identified and include insomnia, emo-
tional lability, poor concentration, hypervigilance,
and exaggerated startle response.14 These symp-
toms and subsequent somatizations are often what
bring children and their families back to the ED.
Other diagnostic challenges include the depen-
dence 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 recog-
nizes 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 under-
standing of the risks associated with its develop-
ment.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 full-
fledged 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
 MENTAL HEALTH CONSEQUENCES OF TRAUMA / ZIEGLER • VOL. 11, NO. 1 59
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 symp-
toms 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 circum-
stances. Injury or threat leads to neurohormonal
adaptive responses that provide emotional, behav-
ioral, cognitive, and physiologic changes necessary
for survival.28 Unfortunately, sometimes these
adaptive responses “lock” neurochemical and
microarchitectural organization and function lead-
ing to a lack of return to preevent homeostasis and
possibly to a clinical disorder such as PTSD.29
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 post-
traumatic stress is associated with children devel-
oping PTSD.30 This is likely due to parents being
less emotionally available to the child and them-
selves 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 provi-
ders 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 disor-
ders 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 overconsolida-
tion of traumatic memory with subsequent release
of stress hormones and catecholamines linked to
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.
ASSESSING RISK
The mental health community is actively pursu-
ing 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
60 VOL. 11, NO. 1 • MENTAL HEALTH CONSEQUENCES OF TRAUMA / ZIEGLER

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, sub-
stance 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 interven-
tions, education, anticipatory guidance, and follow-
up 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
 MENTAL HEALTH CONSEQUENCES OF TRAUMA / ZIEGLER • VOL. 11, NO. 1 61
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 prob-
lematic 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 penal-
ized 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.
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 intro-
duction 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
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 distinc-
tions 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 likeli-
hood 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 stress-
related 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 interven-
tions.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 pur-
pose of follow-up assessments through primary care
62 VOL. 11, NO. 1 • MENTAL HEALTH CONSEQUENCES OF TRAUMA / ZIEGLER
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 interven-
tions, 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
PSYCHOLOGICAL FIRST AID
The American Red Cross has proposed psycho-
logical 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, mini-
mizing patient separation from family members,
minimizing pain, and emphasizing positive coping
strategies and communication.
ADVOCACY
I propose that the knowledge and understanding
gained from caring for injured children and their
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 indicat-
ed. 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 short-
term 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.
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