The ongoing and worldwide challenge of pediatric trauma

There is sometimes a tendency among health care providers in the United States - where aging members of the populous “Baby Boomer” generation have shifted the country's demographic distribution toward the elderly, while injury prevention efforts encouraging automobile seat belt and bicycle helmet use have reduced some forms of accidental childhood injury - to think that pediatric trauma is a less important public health problem than it once was. However, this notion is quickly put to rest by the stark statistics of pediatric injuries, subsequent hospitalizations and related mortality. Accidental and intentional injuries account for more deaths (~10,000 annually) among adolescents and young children than all other causes combined, as well as there are more years of potential life lost under 18 years of age than for infectious diseases, cancer and sudden infant death syndrome combined.[1] Furthermore, each year more than 10 million children require emergency department care for the evaluation and treatment of traumatic injuries.[2] As a result of hospital and other ongoing costs related to lifelong disability and requisite skilled care in this sizeable cohort, the economic costs of pediatric trauma have been estimated at $14 billion in lifetime medical spending and $66 billion in present and future work losses.[3] In other words, it is a misconception to think that pediatric trauma is losing significance - pediatric injury is a major public health problem in the US.

As staggering as these US numbers are, pediatric trauma occurs worldwide and is becoming an increasing global health problem. The causes of this problem include the significant fraction (roughly half) of the worldwide population now younger than 25 years, the pace of economic and technologic development across the globe that has resulted in increased automobile traffic, and the ongoing presence of armed conflicts around the globe that increasingly involve children as both combatants and innocent victims of intentional trauma. As a result, the World Health Organization estimates that traumatic injuries result in almost 1 million deaths annually worldwide.[4] In response, a recent international panel of adolescent health experts recommended that injury prevention programs traditionally used in high-income countries to target adolescent behaviors that lead to injury should be expanded to lower- and middle-income countries, in an effort to impact the lifelong morbidity and mortality associated with accidental and intentional injury.[5] One such series of examples would be comprehensive driving laws, safe roads campaigns, and restrictions on peer passengers and night-time driving for new drivers, all of which have been associated with fewer automobile crashes.

Although such injury prevention strategies have a long-term potential to reduce the volume of pediatric trauma, the need remains for comprehensive trauma care systems that begin with appropriate pre-hospital care and transport, progress through safe and efficient hospital management, and end with rehabilitation and functional recovery. The global resources for such systems are highly variable, and are generally based upon the availability of adult trauma care services. What makes the acute, resuscitative, peri-operative, and critical care of pediatric trauma patients different from other clinical settings and populations, and therefore worthy of special emphasis in the current issue? Among many answers to this question, 2 deserve special mention - (1) the unique characteristics of pediatric (compared to adult) trauma patients, and (2) the more complex interdisciplinary approach to their clinical care.

First, both the age-dependent anatomy and cognitive variability in children create special considerations for injury patterns, diagnosis and treatment. As is commonly stated, children are not merely “small adults,” but rather unique and continually evolving systems with respect to anatomic size, anatomic shape, skeletal composition, cardiovascular performance, respiratory reserve, drug metabolism and excretion, cognitive understanding, verbal maturity, and psychological coping ability. For example, the toddler's small body mass and incompletely calcified skeleton allows blunt force energy to be more widely transmitted to multiple organs, more likely resulting in remote and/or multiple organ injuries than in adults, often in the absence of obvious bony fractures on radiographic examination. In particular, the relatively soft skull incompletely protects the brain from blunt injury, resulting in a high frequency of traumatic brain injuries-the most frequent cause of death among hospitalized pediatric trauma victims.[6] Similarly, the small child's fixed stroke volume makes cardiac output almost exclusively heart rate dependent, while their reduced functional residual capacity and increased basal oxygen consumption significantly reduce apneic oxygenation time and gas exchange efficiency in the presence of a lung injury. As a result of these 2 critical physiologic differences from adults, hemorrhagic shock and respiratory failure can present abruptly and be immediately life-threatening. Hepatic metabolism and/or renal excretion of anesthetic and analgesic medications in the very young child is frequently prolonged due to organ immaturity, resulting in increased drug potency, prolonged duration of action, and increased incidence of unwanted side effects. Lastly, the stress, pain, and perceived threat associated with accidental or intentional injury may induce regressive behaviors in children of all ages, and negatively impact cooperation with history taking, urgent diagnostic examinations, and therapeutic procedures. As a result, both diagnostic errors and delayed treatment are more likely to occur in children than in adults. Parental presence is often necessary to counter these regressive behaviors, and although this may enhance prompt diagnosis and management of the injured child, such presence may create additional communication challenges for the health care team.

Secondly, the interdisciplinary care of the pediatric trauma patient is even more complex than that of the adult trauma patient, in whom the “team” of health care professionals may already include pre-hospital basic life support (BLS) providers, pre-hospital advanced life support (ALS) providers, emergency medicine physicians, general and subspecialty surgeons, anesthesiologists, intensivists, diagnostic and interventional radiologists, and various nursing specialists. In the case of an injured child, additional team members include the pediatrician, pediatric subspecialists, pediatric psychologist, and most importantly, parents or other family members. Orchestrating the complementary skills of each team member in such a rapidly changing clinical setting requires clear communication, a mutual understanding of each individual's roles, and well-defined leadership strategies. The hospital setting most conducive to such collaboration is not clear, with various approaches used in the US, including pediatric trauma centers, adult trauma centers with pediatric emphasis, combined pediatric/adult trauma centers, adult trauma centers without pediatric emphasis, and even non−trauma-designated hospitals. Given these variable administrative and practice settings - some of which encounter injured children frequently while others do not - the development and use of specific pediatric trauma care guidelines may offer clinical benefit.[7,8]

The American Academy of Pediatrics recently published a series of general pediatric trauma management guidelines that emphasize such interdisciplinary collaboration for trauma system planning, education and training competencies, and outcome assessment.[9] Of the 10 recommendations in this guideline, 4 deserve emphasis for their relevance to the subsequent reports in this issue that provide clinical content and suggested management strategies - specifically in the topic areas of pre-hospital care, initial assessment and management, peri-operative management, traumatic brain injury, and procedural sedation - that support the stated goals of each guideline:

1. Pediatric surgical specialists and pediatric medical subspecialists should participate at all levels of planning for trauma, emergency and disaster care.

2. Every pediatric and emergency care-related health professional credentialing and certification body should define pediatric emergency and trauma care competencies and require practitioners to receive the appropriate level of initial and continuing education to achieve and maintain those competencies.

3. Efforts to define and maintain pediatric care competencies should target both out-of-hospital and hospital-based care providers.

4. National organizations with a special interest in pediatric trauma should collaborate to advocate for a higher and more consistent quality of care within the nation.

Lastly, recent efforts to critically assess the quality of pediatric trauma care should be noted for their potential to improve such care through evidence-based approaches. [10] With a preventable death rate among injured children as high as 32% reported in this study, it is clear that a greater focus on pediatric trauma care strategies such as those reported in this issue are needed in order to optimize our care of injured children. Key to these efforts are interdisciplinary groups like the recently formed Pediatric Trauma Society (http://pediatrictraumasociety.org/) whose mission is to improve the outcomes of injured children by enhancing pediatric trauma care, and whose vision is to be a global leader in the field of pediatric trauma through optimal care guidelines, education, research and advocacy. The networking, resource sharing and quality benchmarking capabilities of such groups complement the didactic education provided in this issue and elsewhere, and support the goal to improve pediatric trauma care regardless of where the injured children are cared for.