I. Components of the Trauma Assessment

A. Primary Survey

1. 1. The primary survey involves assessment of ABCDE: Airway, Breathing, Circulation, Disability, Exposure.¹
   1. a. Airway:
      1. (1) Can the patient maintain their own airway? Consider their neurologic status.
      2. (2) Is the airway patent? Is there an upper airway obstruction or stridor?
      3. (3) Do they have a head/neck injury that would make endotracheal intubation difficult? Will they need a surgical airway?
      4. (4) Ensure C-spine stability when assessing and managing a patient’s airway.
      5. (5) Have backup—call anesthesia or an intensivist for difficult airways.
   2. b. Breathing:
      1. (1) Does the patient have an intervenable process (e.g., hemorrhagic, obstructive, compressive) affecting oxygenation/ventilation that can be addressed with rapid procedural intervention (such as a medical airway, needle decompression, or a chest tube)?
      2. (2) If the patient is not breathing on their own, is the bag-valve-mask ventilation technique being optimized until a more secure airway is placed? Confirm a good mask seal, appropriate patient positioning, appropriate respiratory rate and volume for age/size, equal chest rise, and end-tidal CO₂ monitoring.
   3. c. Circulation:
      1. (1) Is the patient actively hemorrhaging? Identify and control external bleeding quickly.
      2. (2) Does the patient show signs of pericardial tamponade (e.g. distended neck veins, distant heart sounds, and decreased pulse pressure)?
      3. (3) Assess for shock: hypotension, tachycardia, altered mental status, and decreased urine output. Does the patient have access? Place two large-bore IVs. If intravenous access is difficult or limited, promptly consider intraosseous (IO) access.
      4. (4) Are pulses strong or thready? Check centrally (carotid, femoral, brachial) and distally (radial, pedal). Is their skin warm or cool? Assess capillary refill.
      5. (5) What are the vital signs? Tachycardia may be the only abnormal vital sign in early shock.
      6. (6) Consider the need for fluid resuscitation and/or blood product administration. Cases of severe hemorrhage may benefit from early activation of massive transfusion protocols.
      7. (7) Large-volume resuscitation is not a substitute for prompt control of external hemorrhage in the injured patient.
   4. d. Disability:
      1. (1) What is the patient’s neurologic status? Assess pupil size, symmetry, reactivity.
      2. (2) Calculate Glasgow Coma Score (see Chapter 1): “intubate when less than 8”; motor score may identify spinal cord injury.
      3. (3) What was the mechanism of the traumatic injury? (e.g., high-speed motor vehicle collision with traumatic brain injury or house fire with significant burns)
      4. (4) Does the patient need fast-acting pain control and/or sedation? Consider risk of respiratory depression with opioids. Confirm medical history and drug allergies when possible.
   5. e. Exposure:
      1. (1) Expose skin completely for thorough evaluation. Remove injurious debris and clothing.
      2. (2) Could there have been a medication overdose or drug intoxication associated with the trauma?
2. 2. Note: The Advanced Trauma Life Support algorithm developed by the American College of Surgeons continues to support prioritizing the rapid assessment and treatment of life-threatening airway and breathing problems ahead of circulation problems (ABC). For nontraumatic cardiorespiratory arrest, the circulation, airway, and breathing (CAB) sequence is currently in use by the American Heart Association as part of the Pediatric Advanced Life Support algorithm (see Chapter 1).

B. Secondary Survey (Fig. 2.1)

1. 1. Critical care labs: Hemoglobin, blood gas, lactate, glucose, electrolytes
2. 2. Coagulation studies (PT, aPTT, INR, fibrinogen): especially for operative planning
3. 3. Type and screen/cross: Preparing crossmatched blood is important for anticipated surgical intervention. Emergency blood release may be needed in cases of severe hemorrhage.
4. 4. Lactate: If level is elevated, consider poor tissue perfusion, organ/vascular injury, internal hemorrhage.
5. 5. Urinalysis: Hematuria may indicate kidney, urinary tract, or pelvic injury.
6. 6. Creatinine and BUN (acute kidney injury); liver transaminases (direct liver trauma or shock liver); lipase (traumatic pancreatitis)
7. 7. CBC: Initial hemoglobin can be normal in acute hemorrhage.
8. 8. Pregnancy test: Obtain for all females of child-bearing age.

II. Head and Neck Trauma

A. Head Imaging

1. 1. PECARN algorithm developed by the Pediatric Emergency Care Applied Research Network (Fig. 2.2)²
   1. a. A well-validated, pediatric clinical decision aid that predicts need for computed tomography (CT) head imaging after pediatric head injury by assessing risk factors
   2. b. Allows providers to identify pediatric patients at very low risk of clinically important traumatic brain injuries (ciTBI)
   3. c. CT imaging carries known risks of lethal radiation-induced malignancy, which is higher in children than adults (the risk decreases with age).
   4. d. Only applies to children with GCS scores ≥14.
2. 2. If signs of traumatic brain injury on CT, consider consultation with pediatric intensivists, neurosurgery, and/or trauma surgery.
   1. a. For management of increased intracranial pressure, see Chapter 1.

1. 1. There are currently no unified protocols or clinical guidelines for pediatric cervical spine clearance after blunt trauma.³
2. 2. Based on Pediatric Emergency Care Applied Research Network (PECARN) C-spine criteria,³ consider obtaining imaging if any of the following are present in a pediatric patient:
   1. a. Altered mental status
   2. b. Focal neurologic deficits
   3. c. Complaint of neck pain
   4. d. Torticollis
   5. e. Substantial injury to the torso
   6. f. Predisposing condition
   7. g. High-risk motor vehicle crash
   8. h. Diving accident
3. 3. Of note, many institutions alternatively or adjunctly use NEXUS criteria for clinical C-spine clearance, though it is not validated in children ≤8 years.³ The criteria state that if any of the below are present, imaging is indicated^4,5:
   1. a. Midline cervical tenderness
   2. b. Altered level of alertness
   3. c. Evidence of intoxication
   4. d. Neurologic deficit
   5. e. Presence of a painful distracting injury
4. 4. Unlike the NEXUS criteria, the PECARN criteria include consideration of mechanism of injury and suggest that cervical spine imaging should be considered even in those who cooperate and are pain free if a high-risk mechanism of injury exists.
5. 5. Recent guidelines by the Pediatric Cervical Spine Clearance Working Group Algorithm⁶ additionally highlight the following factors:
   1. a. When clinical C-spine clearance is not possible, the preferred imaging modality for children who are ≤3 years old is radiography (see Chapter 26).
   2. b. Clinical clearance can be done regardless of mechanism of injury in a child who is ≥3 years old if they are asymptomatic with normal mental status and normal physical examination.
   3. c. Clinical clearance cannot be performed if the child or their parent reports persistent neck pain, abnormal head posture, or difficulty in neck movement.
6. 6. Other clinical considerations⁷:
   1. a. Evaluate carefully children who display marking from seatbelt restraints in a motor vehicle collision, as this may indicate that extreme flexion of the cervical spine has occurred.
   2. b. It should be stressed that the subsequent development of neck tenderness is an important diagnostic sign. Parents should always be encouraged to return to care if pain develops later or the child develops reluctance to move their neck.

C. Specific Imaging Studies

1. 1. A C-spine x-ray with minimum of two views (lateral, anteroposterior, and/or odontoid views) has 90% sensitivity in identifying bony cervical spine injury.⁸
2. 2. Consider CT scan if there is high level of concern for a cervical vertebrae fracture and plain radiographs are inconclusive.⁹
3. 3. Consider magnetic resonance imaging (MRI) scan for further evaluation of ligamentous and cervical spinal cord injury.^9,10
4. 4. 30%–40% of children with traumatic myelopathy have SCIWORA (spinal cord injury without radiographic abnormality)—clinical symptoms of traumatic myelopathy with no radiographic or CT features of spinal fracture or instability. MRI should be considered in these cases.¹¹
   1. a. SCIWORA is most common in children 8 years of age and under.
5. 5. If signs of spinal column or vascular injury on imaging, consider consultation by trauma, vascular, spine, and/or head and neck surgeon.

III. Concussion

A. Concussion Evaluation

1. 1. Concussions can encompass a constellation of symptoms following traumatic head injury, thought to result from neurometabolic dysfunction rather than structural injury. They are typically associated with normal structural neuroimaging findings. Most concussion symptoms clinically resolve in 1 to 3 weeks.¹²
2. 2. Concussion symptoms can be physical, cognitive, emotional, or related to sleep:¹³
   1. a. Headache
   2. b. Feeling foggy, fatigued
   3. c. Confusion, difficulty focusing
   4. d. Photophobia, phonophobia
   5. e. Forgetfulness
   6. f. Nausea ± vomiting
3. 3. Patients with symptoms lasting more than 3 weeks, worsening symptoms, or history of multiple concussions may benefit from a more detailed, longitudinal assessment by a medical provider (pediatrician, neurologist, sports medicine specialist, concussion specialist).¹³
4. 4. The Centers for Disease Control and Prevention (CDC) HEADS UP website is a valuable resource center grounded in an education campaign focused on increasing awareness of concussion among children to prevent and reduce adverse outcomes.¹⁴
5. 5. The CDC’s Acute Concussion Evaluation (ACE) is a tool that can be used in multiple settings, including the clinic and emergency department. The form provides a thorough definition of what a concussion is and signs/symptoms for which to assess. There is also an ACE care plan for patients to help guide their recovery.¹⁴
6. 6. CDC’s HEADS UP resource links for patients and providers:
   1. a. General website: https://www.cdc.gov/headsup
   2. b. ACE Forms and Work/School Care Plans: https://www.cdc.gov/headsup/providers/tools.html

B. Return-to-School and Return-to-Play Guidelines (Table 2.1)

1. 1. The overarching goal is to allow healing from injury and prevent cumulative brain trauma.

IV. Intrathoracic, Abdominal, and Pelvic Trauma

Section references: 16

A. Assessment and Management Pearls

1. 1. See Fig. 2.1 for physical exam findings during the secondary survey.
2. 2. Tension pneumothorax or massive hemothorax
   1. a. Symptoms: Respiratory distress, unequal/abnormal breath sounds, hypotension, tachycardia, altered mental status
   2. b. Iatrogenic causes: Positive-pressure-related barotrauma, procedures (subclavian or internal jugular central line placement), following CPR
   3. c. Traumatic causes: Penetrating or blunt trauma, rib fractures
   4. d. Emergent treatment: Immediate needle decompression (tension pneumothorax), chest tube placement (pneumothorax, hemothorax), volume resuscitation/blood transfusion (hemothorax)
3. 3. Cardiac tamponade
   1. a. Symptoms: Chest pain, difficulty breathing, muffled/distant heart sounds, tachycardia, hypotension, altered mental status, electrical alternans on ECG/cardiac telemetry
   2. b. Emergent treatment: Pericardiocentesis, volume resuscitation
4. 4. Aortic dissection
   1. a. Symptoms: Severe chest/abdominal pain, shortness of breath, loss of consciousness, stroke symptoms, pulse differential between arms or between arms and legs, poor distal perfusion, leg pain, difficulty walking
   2. b. More stable patients can be considered for inotropy-reducing treatment (β-blockers) and endovascular repair.
   3. c. Transfer should be initiated to the nearest trauma center if indicated and possible.
   4. d. Hemodynamically unstable patients with concern for dissection should be taken to the operating room for laparotomy/thoracotomy.
5. 5. Rib fractures and flail chest
   1. a. Patients with multiple acute rib fractures typically warrant admission to a pediatric trauma center for:
      1. (1) Pain control to improve respiratory function
      2. (2) Age-appropriate pulmonary physiotherapy to prevent atelectasis
   2. b. Splinting rib fractures with external devices can worsen ventilatory compromise and should be avoided.
   3. c. Patients with rib fractures who require tube thoracostomy to relieve pneumo- or hemothorax should have tubes placed at sites separate from the areas of fracture.
   4. d. Children younger than 3 years of age with rib fractures and without a history of high-force trauma warrant evaluation for possible child abuse.
   5. e. Children with flail chest (which occurs when the chest wall loses stability as the result of multiple rib fractures) should receive respiratory support. Those with respiratory distress or failure should be intubated and receive positive-pressure ventilation for adequate oxygenation and ventilation as well as to optimally expand and internally splint the injured segments.
   6. f. Due to more compliant chest walls, more kinetic energy can be transmitted to the intrathoracic structures without thoracic bony injury in children. For this reason, pulmonary contusion without rib fracture occurs more often in children than adults. Significant force is required to produce thoracic bony injury in children.
6. 6. Abdominal injury (vascular, bowel or other organ) requiring surgery
   1. a. PECARN rule for blunt abdominal trauma
      1. (1) A pediatric patient with all of the below patient history and physical examination findings (without laboratory or ultrasonographic information) has a very low risk for intra-abdominal injury (IAI) requiring acute intervention (99% sensitivity in internal and external retrospective validation studies).^17,18
         1. (a) No evidence of abdominal wall trauma or seatbelt sign
         2. (b) Glasgow Coma Scale score greater than 13
         3. (c) No abdominal tenderness
         4. (d) No evidence of thoracic wall trauma
         5. (e) No complaints of abdominal pain
         6. (f) No decreased breath sounds
         7. (g) No vomiting
   2. b. Peritonitis (severe pain, abdominal wall guarding/rigidity, avoidance of motion, flexed hips to relieve abdominal wall tension, hypoactive-to-absent bowel sounds, distention) can indicate intra-abdominal vascular or organ/bowel injury.
      1. (1) Peritonitis due to intra-abdominal hemorrhage may take several hours to develop.
   3. c. “Seatbelt sign” (bruising/visible injury in the distribution of a seatbelt restraint) is a significant predictive factor for surgical abdominal injury after blunt trauma (sensitivity 70.6%, specificity 82.4%).¹⁹
   4. d. Emergency laparotomy is the accepted standard of care in patients with a penetrating torso injury who are hemodynamically unstable and have a clinical indication for exploratory laparotomy, such as evisceration or gastrointestinal bleeding.
7. 7. Unstable pelvic fracture
   1. a. Place a pelvic stabilization device.
   2. b. Can be associated with pelvic organ injury, internal bleeding, and/or urinary tract injury

B. Imaging Studies to Consider

1. 1. Ultrasound—FAST (focused assessment with sonography in trauma) exam
   1. a. May identify free fluid early and guide need for further imaging, observation, or surgery
   2. b. In a 2017 randomized trial of 925 hemodynamically stable children comparing standard trauma workup or standard workup plus FAST, there was no difference in the proportion obtaining CT, missed intra-abdominal injury (IAI), length of stay, or cost.²⁰
   3. c. In a 2021 systematic review and meta-analysis of hemodynamically stable pediatric patients presenting with blunt abdominal trauma, the FAST exam had a pooled sensitivity of 35% and specificity of 96% for IAI.²¹
      1. (1) A positive FAST examination result means that IAI is likely and could warrant CT imaging.
      2. (2) A negative examination result alone cannot preclude further diagnostic workup (e.g., CT scan, serial FAST exams).
      3. (3) See Fig. 2.3 for an algorithm that incorporates the FAST exam and other findings to identify patients at very low risk for IAI.²²
2. 2. Radiographs
   1. a. Chest x-ray: Evaluate for rib fracture, pneumothorax/hemothorax, pulmonary contusion, pneumomediastinum.
   2. b. Abdominal and pelvic x-rays: Evaluate for free air, fluid, pelvic fracture.
3. 3. Abdominal/pelvic CT with IV contrast:
   1. a. CT is the gold standard for diagnosis of IAI; however, radiographs should be obtained first if there is concern for additional injuries that would compromise clinical stability.
   2. b. CT is commonly used to rule out IAI in children, despite associated cost and radiation exposure. The Pediatric Surgery Research Collaborative developed a clinical prediction rule to identify children at very low risk for IAI after blunt abdominal trauma, for whom a CT scan of the abdomen could be avoided. (Fig. 2.3).²²
      1. (1) The algorithm includes 5 clinical factors associated with IAI in the order of availability: reported abdominal pain, abnormal abdominal exam, abnormal chest x-ray, AST >200 U/L, and abnormal pancreatic enzymes.
   3. c. In stable patients with blunt abdominal trauma, CT with routine oral contrast is not necessarily indicated, whereas IV contrast should be used to help to identify visceral, vascular, or bowel injury.
   4. d. For penetrating abdominal trauma (gunshot wounds, impalement, stab wounds), triple contrast (oral, rectal, IV) CT can be used to identify peritoneal penetration or intra-abdominal organ injury in stable patients.
   5. e. If gross hematuria or urinalysis with microscopic hematuria ≥50 RBCs per high-powered field, the patient may have genitourinary tract trauma. Consider CT pelvis with/without IV contrast or serial urinalyses/physical exams in consultation with surgery or urology.
4. 4. If any workup is positive for thoracic or abdominal trauma, immediate consultation with nearest pediatric trauma center/surgeon is indicated if not available on site.

V. Limb and Long Bone Trauma

Section references: 16

A. Assessment and Management Pearls

1. 1. See Fig. 2.1 for physical exam findings during the secondary assessment.
2. 2. Children are difficult to examine, especially when they are in pain. A painful orthopedic injury can distract from other internal injury.
3. 3. Neurovascular assessment:
   1. a. Choose motor/sensory tests that are easy to perform quickly.
   2. b. Use Doppler to aid in identifying pulses and monitoring for compartment syndrome.
4. 4. Bleeding
   1. a. Consider arterial bleed if absent pulses and cool extremity with bleeding.
   2. b. Consider venous bleed if persistent pulse with bleeding.
   3. c. Obtain time of tourniquet placement if done in prehospital setting.
5. 5. Compartment syndrome:
   1. a. Circumferential, constrictive swelling leads to vascular and nerve compromise.
   2. b. Can develop soon after significant trauma—especially in crush injuries, burns, animal bites/stings, vascular injuries of limbs, long bone fractures, limb gunshot wounds
   3. c. Symptoms include pain (especially out of proportion to apparent injury or with passive extension), paresthesias, pallor, pulselessness (if unable to palpate pulse, use Doppler), paresis
6. 6. If signs/symptoms of compartment syndrome or fracture, immediate consultation with an orthopedic surgeon is recommended.
7. 7. Consider need for tetanus prophylaxis. Refer to Chapter 16 for details.

B. Imaging

1. 1. Children’s bones are less densely calcified, have thickened periosteum, and have growth plates, all of which increase their vulnerability to fractures.
2. 2. Consider obtaining radiographs if bony point tenderness or deformity, decreased sensation, decreased range of motion, or overlying skin discoloration.
3. 3. Radiographs with anterior-posterior (AP) and lateral views ± oblique and including areas above and below the suspected area of injury are recommended.

C. Traumatic Fractures in Children

1. 1. Physeal or Salter-Harris fractures: Fractures involving growth plates (see Chapter 26)
2. 2. Plastic fractures: Pliability of bones in response to compressive and transverse forces
   1. a. Torus or buckle fracture: Compression injury with buckled cortex
   2. b. Greenstick fracture: Fracture on one side of the diaphysis with cortex intact on other side of diaphysis
   3. c. Bowing or bending fractures
3. 3. Avulsion fractures: Tendon or ligament dislodging a bone fragment-these are more common among adolescents participating in sports.
4. 4. Dislocations in children are relatively unusual, generally related to major trauma, and associated with fractures. This is due to stronger ligaments with comparatively less bony strength.
   1. a. Subluxation of the radial head or “nursemaid elbow” reduction can often be done by an emergency provider. Most other dislocations should be referred to orthopedic surgery.
5. 5. See Chapter 4 for basic splinting and musculoskeletal procedures.

D. Fractures Requiring Urgent Orthopedic Surgeon Consultation

1. 1. Open fractures
2. 2. Unacceptably displaced fractures
3. 3. Fractures with associated neurovascular compromise (consider emergent reduction to improve neurovascular status if orthopedic surgery is not available on site)
4. 4. Significant growth plate or joint injuries
5. 5. Complete or displaced fractures of the long bones of the extremities
6. 6. Pelvic fractures (other than minor avulsions)
7. 7. Spinal fractures
8. 8. Dislocations of major joints other than the shoulder

E. Fractures That Are Appropriate to Manage Acutely With Outpatient Referral to Orthopedics (Table 2.2)

VI. Dental Trauma

A. Components of a Tooth (Fig. 2.4)

1. 1. Primary teeth appear 6 months to 3 years of age, are relatively smaller, thinner, and whiter; the roots are shorter and the front teeth have a smooth biting surface.
2. 2. Permanent teeth appear 6 years to 21 years of age, relatively larger with a longer root; front teeth have a ridged biting surface.

C. Dental Injuries

1. 1. Avulsion²³
   1. a. Complete displacement of the tooth and its root from the bony alveolar socket
   2. b. If a primary tooth, reimplantation should not be attempted and outpatient dental follow-up is appropriate.
   3. c. If a permanent tooth, this is a dental emergency. If possible and safe, immediate reimplantation should occur within 60 minutes to maximize tooth and periodontal ligament viability.
      1. (1) Good prognosis is very much dependent on early actions and reimplantation at the place of accident or during emergency care management.
   4. d. For a permanent tooth, reimplantation should always be attempted. If reimplantation is not possible, place the tooth in a suitable storage medium (in descending order of preference: milk, Hank’s balanced salt solution, expectorated saliva, saline) and refer to a dentist emergently for reimplantation and splinting.
      1. (1) Situations when reimplantation is not indicated: primary tooth avulsion, severe caries or periodontal disease, an uncooperative patient, risk of choking, severe cognitive impairment, sedation, immunosuppression, severe cardiac conditions, unstable patient
   5. e. Reimplantation steps:
      1. (1) Pick up the avulsed tooth by the crown and avoid touching the root.
      2. (2) Wash the tooth and alveolar socket with sterile saline, removing clotted blood if necessary.
      3. (3) Administer local anesthesia (without a vasoconstrictor) into the gum if necessary.
      4. (4) Insert the root into the alveolar socket with concave part facing the tongue, and apply slight manual pressure.
      5. (5) Ask the patient to bite on gauze or cloth to hold it in position.
      6. (6) The patient should be seen by a dentist or dental professional emergently for splinting and follow-up care.
2. 2. Luxation²⁴
   1. a. Luxation injuries result from physical displacement of tooth within the alveolar socket itself. Luxation can be associated with tearing of the periodontal ligament or injury to the alveolar bone.
      1. (1) Luxation injuries are the most common traumatic dental injuries in the primary dentition.
   2. b. Primary tooth:
      1. (1) If tooth is loose and there is an increased risk of aspiration, the tooth may be extracted by using firm pressure with gauze.
      2. (2) If tooth is not loose, it may need repositioning and splinting.
      3. (3) In both situations, refer to a dentist for evaluation within 48 hours.
   3. c. Permanent tooth:
      1. (1) Immediate dental evaluation required if significant tooth mobility; otherwise, outpatient evaluation within 48 hours is appropriate
3. 3. Subluxation²⁴
   1. a. Subluxation is characterized by tooth injury with minor mobility but without displacement.
   2. b. Regardless of whether permanent or primary tooth, outpatient dental follow-up, ideally within 48 hours, is needed to rule out root fracture.
4. 4. Tooth fracture²⁴
   1. a. Classify the fracture per involvement of enamel, dentin, and pulp.
   2. b. For management guidelines, see Table 2.3.

D. Anticipatory Guidance Following Dental Trauma

1. 1. Avoid contact sports until cleared by a dentist
2. 2. Analgesics as needed for pain control (e.g., acetaminophen, ibuprofen, cold compresses)
3. 3. Soft diet
4. 4. Use a soft toothbrush, if able to brush teeth.
5. 5. Regular follow-up with a dentist

VII. Ophthalmologic Trauma

Section references: 16

A. Chemical Injury to the Eye

1. 1. Immediate and continued irrigation of eyes with water, isotonic saline, or lactated Ringer’s solution is necessary.
2. 2. Consult with Poison Control.
   1. a. Call (800) 222-1222—will route to local center.
   2. b. Available 24 hours a day
3. 3. Determine if substance is an acid or alkali. Alkali solutions tend to be more damaging because they penetrate more deeply.
   1. a. Obtain a baseline pH by touching Litmus paper to the conjunctiva. This is a crude but practical way to determine the type of substance if otherwise unknown.
      1. (1) Consider acidic substance if pH <7, and alkali if >7.4.
      2. (2) Continue irrigation for a minimum of 20 minutes or until 2 liters of fluid have been used to irrigate the eye(s).
      3. (3) Evert the eyelid and continue lavage.
      4. (4) Remeasure pH every 15 to 30 minutes until pH becomes neutral (7.0 to 7.4). Normalization of pH for most eye exposures typically takes 30 to 60 minutes.
4. 4. Measure and trend visual acuity if possible.
5. 5. Urgent ophthalmologic evaluation should be considered in cases with severe vision changes or vision loss, uncontrolled pain, significant mucosal injury, or persistent pH abnormality despite diligent irrigation.
6. 6. In the United States, injury from chemical ocular burns occurs most often in residential settings, with preschool-aged children being the most common victims.¹⁶

B. Ruptured Globe

1. 1. A ruptured globe is caused by laceration or puncture of the cornea and/or sclera following projectile or blunt trauma.
2. 2. Warrants emergent ophthalmology consultation.
3. 3. Key physical exam findings include teardrop-shaped pupil pointing toward perforation, hyphema (hemorrhage in the anterior chamber), subconjunctival hemorrhage, severe pain, decreased visual acuity, edema.
   1. a. When hyphema is present, sickle cell trait is a significant risk factor for complications including secondary hemorrhage, increased intraocular pressure, and permanent visual impairment in children.²⁵
4. 4. Stop the exam and place a rigid eye shield. Do not instill eye drops.
5. 5. Elevate the head of the bed.
6. 6. Keep patient as calm as possible and control symptoms (e.g., antiemetics and pain control) to avoid increased globe pressure and further extrusion of vitreous/aqueous humor.
7. 7. Administer appropriate antibiotics.

C. Corneal Abrasion

1. 1. Symptoms: Red eye with tearing, intense pain, resistance to eye opening, photophobia, foreign body sensation
2. 2. Consider application of topical anesthetic before examination, which can support diagnosis if providing immediate relief.
   1. a. Although topical anesthetic eye drops may be used during the initial examination, they should not be regularly used or prescribed for the treatment of corneal abrasion pain due to risk of patient misuse or complications. Repeat application of an ocular anesthetic can delay or compromise healing and increase infection risk.
3. 3. Evert eyelids to look for retained foreign body; irrigate eye if necessary.
4. 4. Apply fluorescein staining and examine with Wood’s lamp. Focal uptake indicates abrasion.
   1. a. Staining should be deferred until the eye examination is complete and an open globe is excluded.
5. 5. Treatment: Artificial tears and/or ophthalmic ointment for lubrication, topical ophthalmic antibiotic ointment, oral analgesics or ophthalmic NSAIDs, ophthalmologic follow-up as indicated, ± patching depending on severity or patient cooperation.
6. 6. Consider ophthalmologic consultation in the ED if concern for larger corneal abrasions associated with vision changes, corneal laceration, ulceration, embedded foreign body, or prolonged healing (i.e., symptoms not improving after several days).

D. Eyelid Glued Shut due to Cyanoacrylate (Superglue)

1. 1. Can consider trimming eyelashes as needed with blunt-tip scissors. Do not try to force eyes open.
2. 2. Consider ophthalmology consultation, especially in the case of glue bonding to the eye.
3. 3. The use of around-the-clock eye/mucosa-safe oil-based ointments can help accelerate dissolution of the glue bonds. Can cover eye with gauze or a patch to prevent the patient from touching it.
4. 4. Consider consultation with ophthalmology if a few days of ointment is unsuccessful.
5. 5. A 2017 report by physicians at the University of Alabama at Birmingham Hospital discusses the Jameson muscle hook technique, which has been successfully used there without complications to safely relieve eyelid adhesions due to cyanoacrylate glue without the use of general anesthesia in pediatric and adult patients.²⁶
   1. a. With this method, topical anesthetic is applied through an explored opening in the eye. Then, a Jameson muscle hook is inserted into an opening between the eyelids and pulled parallel to the lid margins through the site of adhesion, while counter pressure is applied against the direction of the hook.

E. Eyelid Laceration

1. 1. Do not initiate closure of an eyelid laceration prior to excluding injury to the globe or foreign body.
   1. a. Ocular injury (i.e., open globe, traumatic hyphema, corneal abrasion) may accompany eyelid laceration in up to two-thirds of cases.
2. 2. Consult with ophthalmology if full-thickness lacerations (exposed adipose tissue), laceration through the lid margin, lacerations involving lacrimal canaliculi (medial third of the upper/lower lids), ptosis (unequal lifting of lids with upward gaze would suggest this), or other concerning symptoms.
3. 3. Lacerations to the eyelid should be repaired within 24 hours of injury to prevent scarring and promote appropriate alignment of the eyelid tissues.
4. 4. Superficial, simple lacerations that are horizontal, follow the skin lines, and involve less than 25% of the lid will usually heal well without suturing. Providers can use antibiotic ointment or adhesive surgical tape (i.e., Steri-strips) to approximate wound edges.

F. Orbital Floor Fractures

1. 1. This injury is usually caused by blunt trauma. The weakest area of the orbital bones is the orbital floor/maxillary roof.
2. 2. For children, the most common mechanisms of orbital fracture injury are falls, being struck by a ball, and physical assaults.
3. 3. Key physical exam findings include eyelid swelling, ecchymosis, exophthalmos, ptosis, diplopia, anesthesia of the cheek (involvement of infraorbital nerve), and restricted extraocular eye movements (intraocular muscle entrapment).
4. 4. Often associated with significant traumatic injury. Evaluate for other globe injuries (including retinal trauma, ruptured globe, hyphema) and intracranial injuries/bleeds.
   1. a. Injury to the globe is commonly associated with an orbital fracture (29% to 50% of patients, depending upon the setting).
5. 5. In addition to ophthalmology, consider consultation with plastic surgery and/or head and neck surgery.
6. 6. CT imaging should be performed for a patient with periorbital trauma and any of the following findings:
   1. a. Evidence of a fracture on physical examination
   2. b. Limitation of extraocular movement
   3. c. Decreased visual acuity
   4. d. Severe pain
   5. e. Inadequate examination (usually because of soft tissue swelling)
   6. f. Altered mental status

G. Other Instances Requiring Ophthalmologic Consultation

1. 1. Traumatic iritis is associated with blunt trauma and may present as painful red eye, pupillary constriction, and photophobia, often with delayed presentation of symptoms (24 to 72 hours) after trauma.
2. 2. Sudden loss of vision could suggest retrobulbar hemorrhage or retinal detachment.

VIII. Animal Bites

Section references: 16

A. Risk of Infection and Antibiotic Prophylaxis

1. 1. Risk factors include:
   1. a. Underlying immunosuppression (including diabetes) or asplenia
   2. b. Bite involving the hand, foot, genitalia, or joint surface
   3. c. Bite in an extremity with underlying venous and/or lymphatic compromise
   4. d. Bite near or in a prosthetic joint or vascular graft
   5. e. Crush injury or puncture wound
   6. f. Cat bite (given propensity for deep puncture wounds)
   7. g. Human bite
   8. h. Delayed presentation (≥12 hours after a bite on the extremities and ≥24 hours after a bite on the face)
2. 2. Antibiotic prophylaxis is suggested for:
   1. a. Patients with risk factors above
   2. b. Lacerations undergoing primary closure
   3. c. Wounds requiring surgical repair
3. 3. Empiric antibiotic treatment (Table 2.4)
   1. a. Consider IV antibiotics if patient is critically ill or unable to tolerate PO intake.
   2. b. Tetanus postexposure prophylaxis: See Chapter 16.
   3. c. Rabies postexposure prophylaxis: See Chapter 16.

B. Physical Exam Assessment

1. 1. Evaluate wounds carefully for foreign material.
2. 2. Neurovascular assessment should be routinely performed in areas distal to the wounds.
3. 3. The median time to showing symptoms of infection following a dog bite is approximately 24 hours; the median time following a cat bite is typically shorter—approximately 12 hours.

C. Imaging

1. 1. Imaging is not necessary for most clinically uninfected, superficial bites.
2. 2. Deep bite wounds, including those near joints, warrant radiographs to evaluate for evidence of foreign bodies (such as embedded teeth), fracture, or joint disruption.

D. Decision to Suture and Infection Risk

1. 1. Avoidance of primary closure is generally preferred unless wound is present on the face (cosmetic importance and has a lower rate of infection relative to other areas).
2. 2. Wounds left open to heal by secondary intention should be debrided, irrigated copiously, dressed, and evaluated daily for signs of infection.
3. 3. Lacerations closed primarily should be clinically uninfected and ideally <24 hours old (facial lacerations) or <12 hours old (sites other than the face). Meticulous debridement and irrigation should be performed prior to closure.
4. 4. Bite wounds should not be closed with tissue adhesive glue (e.g., Dermabond) due to increased infection risk.
5. 5. Surgical consultation (i.e. plastic, orthopedic, otolaryngology, ophthalmology) warranted in:
   1. a. Large/complex wounds
   2. b. Wounds that involve tendons, joints, deep fascia, major vasculature, or bones
   3. c. Deep infection (abscess, necrotizing soft tissue infection, septic arthritis, osteomyelitis)
   4. d. Infection associated with neurovascular compromise
   5. e. Presence of crepitus
   6. f. Rapidly progressive infection

IX. Burns

Section references: 27,28

A. First Aid and Emergency Management

1. 1. See Fig. 2.6 for an algorithmic approach to burn evaluation in the emergency setting.
2. 2. Triaging burn severity
   1. a. Estimate of the total body surface area (TBSA) of burns (see Fig. 2.7 for modified Lund-Browder chart)
      1. (1) Only include partial- and full-thickness burns in this calculation (exclude superficial burns).
      2. (2) The hand of the person who is burned (palm and adducted 5 fingers) is approximately 1% of the TBSA; this can be an easier way to measure TBSA of burns in the emergent setting
   2. b. Determine the depth of the burn (see Table 2.5).
3. 3. Burns that should prompt consideration of elective/early intubation
   1. a. Signs of smoke inhalational injury (e.g., singed nasal hairs, soot at the nares, oropharyngeal erythema)
   2. b. Early onset stridor
   3. c. Severe burns of face and/or mouth
   4. d. Signs of worsening oxygenation/ventilation
4. 4. Fluids
   1. a. See Fig. 2.8 for fluid resuscitation guide in patients with burns.
      1. (1) Fluid resuscitation should be considered a dynamic process guided by frequent reassessments as opposed to an absolute volume, to prevent over- or under-resuscitation.
   2. b. Consider central venous access for burns greater than 25% TBSA.
   3. c. Withhold potassium from IV fluids for the first 48 hours (release of potassium from damaged tissues).
   4. d. Foley catheter placement is recommended to monitor urine output during fluid resuscitation phase.
5. 5. Analgesia
   1. a. Consider conscious/procedural sedation versus general anesthesia for cases requiring significant debridement.
   2. b. Children with major burns typically require opioid analgesics for pain relief.
   3. c. Most burn centers use morphine for wound care pain. Fentanyl may be a safer choice for initial pain management for patients whose cardiovascular status is unstable.
   4. d. Acetaminophen and NSAIDs alone or in combination with opioids for less severe burns.
6. 6. Indications for transfer to a burn center
   1. a. Partial-thickness (second-degree) burns ≥10% TBSA burn
   2. b. Any significant burn to the face, hands, feet, genitalia, perineum, or major joints
   3. c. Full-thickness (third-degree) burns
   4. d. Electrical burns, including lightning injury
   5. e. Chemical burns
   6. f. Inhalation injury
   7. g. Any child with burns and traumatic injury (i.e., fractures) in whom the burn injury poses the greatest risk of morbidity or mortality
   8. h. Burns in children with preexisting conditions that could complicate management, prolong recovery, or affect mortality.
      1. (1) Children requiring social, emotional, or rehabilitative factors
      2. (2) Burned children in hospitals without qualified personnel and equipment for the care of children
7. 7. Risk of shock
   1. a. Immediately following the burn injury, vasoactive mediators (cytokines, prostaglandins, oxygen radicals) are released from damaged tissue, causing increased capillary permeability and risk of distributive shock.
   2. b. Patients with large burns (≥15% TBSA for young children and ≥20% for older children and adolescents) often develop systemic inflammatory responses.
   3. c. Tissue damage and release of cell contents can cause electrolyte shifts and cardiac arrhythmia. For patients with 40% TBSA or more, myocardial depression can occur.
8. 8. Criteria for admission to a local hospital for observation, intravenous fluid administration, and pain management include:
   1. a. Children with 5%–10% TBSA burn (depending upon parental capability and social circumstances)
   2. b. Full thickness burn 2%–5% TBSA, if local pediatric surgical expertise is available
   3. c. Circumferential burn
   4. d. Medical problem predisposing to infection
   5. e. Concern for nonaccidental trauma or unsafe home environment
9. 9. Wound evaluation and care
   1. a. Debridement
      1. (1) Debridement of devitalized tissue (including ruptured blisters) decreases the risk of infection.
      2. (2) The depth of burn wounds can be determined with better accuracy when the wound bed is inspected directly.
      3. (3) Initial debridement can usually be accomplished with sterile saline-soaked gauze.
      4. (4) Experts generally recommend that large blisters and those that are painful (regardless of size) be removed.
   2. b. Wound dressing
      1. (1) For patients who are being rapidly transferred to a burn unit, burns should be covered with dry, sterile dressings. Moist dressings, ointments, or creams should not be applied because they can hinder initial wound assessment and care at the burn center.
      2. (2) Superficial burns (epidermal and superficial partial-thickness burns) are generally managed with topical antimicrobial agents with an overlying dressing.
         1. (a) A moist wound environment should be maintained for optimal healing.
         2. (b) For optimum effect and pain relief, the dressing should maintain maximum contact with the wound without adhering to it. It should be easy to apply and remove.
   3. c. Management of less severe burns (superficial and partial thickness)
      1. (1) Clean with warm saline or mild soap and water.
      2. (2) For superficial burns (including sunburns), application of nonperfumed moisturizing cream or ointment is typically all that is required, without need for a topical antibiotic or dressing.
      3. (3) Sloughed or necrotic skin, including ruptured blisters, should be debrided before applying a dressing.
      4. (4) For partial-thickness burns, apply topical antibacterial agent such as bacitracin (requires daily dressing changes) or silver-impregnated dressings (dressing can be left in place until follow-up) and cover with nonadherent dressing.
      5. (5) Follow-up inspections of burn wounds should occur the day after injury (to adjust pain medications and to assess the patient’s/family’s competence performing dressing changes). Subsequent follow-up can then be done on a weekly basis until wound epithelialization occurs.

1. 1. Circumferential burns rapidly begin to contract and can lead to compartment syndrome.
2. 2. Children involved in a house/building fire or fire in an enclosed space are at risk for carbon monoxide and cyanide poisoning; consider empiric use of appropriate therapy (e.g. hyperoxygenation or hydroxocobalamin).
3. 3. For patients with electrical burns from exposure to high voltage (>1000 V) or lightning:
   1. a. May have associated conditions such as cardiac arrhythmias—consider cardiac monitoring for 48 hours
   2. b. Risk of fractures, compartment syndromes, and rhabdomyolysis/myoglobinuria (with related renal injury)
   3. c. Increased risk of compression spine fractures or spinal cord injury due to tetany
4. 4. Household outlets are 120 to 240 V, and household electrical burns rarely cause serious injuries or cardiac arrhythmias.²⁷
   1. a. Mobile babies, toddlers, and young children can chew on or bite electrical cords that are plugged into an outlet. Electrical burn from this can lead to significant mouth/facial injury.
5. 5. Tetanus prophylaxis is warranted with burns. Refer to Chapter 16 for details.
6. 6. See Section X for signs of nonaccidental traumatic burns.

X. Nonaccidental Trauma

Section references: 16

A. Physical Abuse

1. 1. Red flags in history
   1. a. History is inconsistent with age, pattern, or severity of the injury.
   2. b. History is inconsistent with child’s physical or developmental capabilities.
   3. c. Inconsistent/incomplete/vague/changing explanations for significant injury
   4. d. Delay in presentation
   5. e. Different witnesses provide different explanations.
2. 2. Red flags in physical exam
   1. a. Bruises
      1. (1) In protected areas—chest, abdomen, back, buttocks
      2. (2) Multiple
      3. (3) In various stages of healing
      4. (4) Do not fit history or developmental stage of child
      5. (5) In unusual places (e.g., postauricular, neck, inner aspect of arms)
      6. (6) Consistent with slap of hand or pinch
   2. b. Burns
      1. (1) Scald burns that have a sharply demarcated edge
      2. (2) Burns in the distinct shape of an object
      3. (3) Small circular burns matching a cigarette or cigar tip
      4. (4) Burns on the perineal area with sparing of inguinal/flexural creases, matching a “dip-in” pattern (child dipped into scalding water)
      5. (5) Multiple burns in various places
      6. (6) Stocking/glove distribution burns
      7. (7) Symmetrically burned palms/soles, buttocks, and/or lower legs; mirror image burns of extremities
   3. c. Frenulum tears
   4. d. Loop marks from cord or cable
   5. e. Welts
   6. f. Bites
   7. g. See Figs. 2.9 through 2.12 (color plates) and ^{eFIGURE 2.1 eFIGURE 2.2 eFIGURE 2.3 eFIGURE 2.4} for examples.

1. 3. Imaging guidelines^{29, 30, 31}
   1. a. Skeletal survey
      1. (1) In children less than 2 years of age, use a skeletal survey to evaluate for bony injury. This includes frontal and lateral views of the skull, lateral views of the cervical spine and thoracolumbosacral spine, and single frontal views of the long bones, hands, feet, chest, and abdomen.
      2. (2) In children greater than 5 years of age, targeted imaging to the area(s) of suspected injury is usually appropriate. The utility of screening with skeletal survey diminishes after 5 years of age.
      3. (3) In children 2 to 5 years of age, decisions about type of imaging are open to clinical judgement.
      4. (4) Do not use “babygrams” (i.e., whole-body x-rays) because of the high rate of false negatives.
      5. (5) Follow-up skeletal survey approximately 2 weeks after the initial examination should be performed when abnormal or equivocal findings are found on initial study or to identify fractures missed on initial survey.
      6. (6) Fractures associated with child abuse include posterior rib fractures, bucket handle and metaphyseal corner fractures, spine and scapula fractures, and skull fractures.
   2. b. Head CT without contrast if:
      1. (1) Less than 6 months of age with suspected abuse
      2. (2) Neurological changes, altered mental status
      3. (3) Significant facial injuries concerning for abuse
   3. c. Additional imaging/consultation
      1. (1) Ophthalmologic evaluation for retinal hemorrhages
      2. (2) MRI may identify lesions/injury not detected by CT.
2. 4. What to do if child abuse is suspected:
   1. a. Medical stabilization is the immediate goal; prevention of further injuries is the long-term goal.
   2. b. All healthcare providers are mandated by law to report suspected child maltreatment to the local police and/or child welfare agency.
   3. c. The professional who makes a report is immune from any civil or criminal liability.
   4. d. Consider consultation of local child injury/abuse specialist.
   5. e. It is important to obtain a workup to rule out medical causes of injuries (bleeding disorder, osteogenesis imperfecta).
3. 5. Carefully and legibly document the following:
   1. a. Reported and suspected history and mechanisms of injury
   2. b. Any history given by the victim in their own words (use quotation marks)
   3. c. Information provided by other providers or services
   4. d. Physical examination findings, including photos or drawings of injuries and details of dimensions, color, shape, and texture. Consider early use of police crime laboratory photography to document injuries. If taking photos, start with full patient, then part of patient, then zoomed into wound, and then take a separate photo of wrist identification band.

B. Sexual Abuse³²

1. 1. What to do if sexual abuse is suspected:
   1. a. Sexual abuse evaluations are best performed in a nonemergency setting, such as a child abuse advocacy center.
   2. b. Urgent evaluation is necessary under the following circumstances and typically occurs in an emergency setting:
      1. (1) The alleged abuse occurred within 72 to 96 hours, depending upon jurisdiction.
      2. (2) There are genital or anal injuries that require treatment.
      3. (3) There is obvious forensic evidence on the patient’s clothes or body that must be collected.
      4. (4) There is danger of continued abuse or reprisal by the alleged perpetrator.
      5. (5) The victim has reported homicidal or suicidal ideation.
   3. c. Avoid re-traumatizing the patient with invasive exams unless medically necessary. Keep in mind that most genital examinations are normal in cases of sexual abuse.
2. 2. The medical evaluation of childhood sexual abuse has several immediate goals:
   1. a. Identify injuries or other conditions that require treatment.
   2. b. Screen for, empirically treat, and/or diagnose sexually transmitted infections (STIs).
   3. c. Evaluate for and, if possible/desired, reduce the risk of pregnancy.
   4. d. Document findings of potential forensic value.
3. 3. STI testing
   1. a. In adolescents, recommended for all patients presenting with concern for sexual abuse
   2. b. In prepubertal children presenting with concern for sexual abuse, consider testing if any of the below factors are met:
      1. (1) Penetration of the vagina or anus
      2. (2) Abuse by a stranger
      3. (3) Abuse by a perpetrator known to be infected with an STI or at high risk of being infected (IV drug use, sex trafficking concerns, multiple sexual partners)
      4. (4) Child with sibling or another household member with STI
      5. (5) Child living in an area with high rate of STI in the community
      6. (6) Signs/symptoms of an STI
      7. (7) Has already been diagnosed with one STI
   3. c. Tests include:
      1. (1) Serum: HIV, syphilis
      2. (2) Specimen cultures for gonorrhea/chlamydia/trichomonas, which can be collected from the penis, vagina, anus, and pharynx
   4. d. Consider the need for postexposure HIV prophylaxis (see Chapter 17).

Author(s)

Radhika Ghodasara, MD

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