Polytrauma in Children—Epidemiology, Acute Diagnostic Evaluation, and Treatment

Abstract

Background: Inadequate clinical experience still causes uncertainty in the acute diagnostic evaluation and treatment of polytrauma in children (with or without coagulopathy). This review deals with the main aspects of the acute care of severely injured children in the light of current guidelines and other relevant literature, in particular airway control, volume and coagulation management, acute diagnostic imaging, and blood coagulation studies in the shock room.

Methods: This review is based on literature retrieved by a selective search in PubMed, Medline (OVIDSP), the Cochrane Central Register of Controlled Trials, and Epistemonikos covering the period January 2001 to August 2023. Review articles and the updated S2k clinical practice guideline on polytrauma management in childhood were considered.

Results: Most accidents in childhood occur at home and in the child's free time, with varying mechanisms and patterns of injury depending on age. The outcome of treatment depends largely on the presence or absence or traumatic brain injury, which affects 66% of children with polytrauma and is thus the most common type of injury in this group, and of hemorrhagic shock with or without coagulopathy. Acute care follows the ABCDE algorithms with attention to special features in children, including age-specific reference values. According to a registry study, coagulopathy and hypovolemic shock are associated with 22% and 17% mortality, respec - tively. Treatment in a pediatric trauma reference center of the trauma network is recommended. Computed tomography (CT) should be carried out in children in accordance with defined criteria (PECARN), as a team decision and with the use of age-specific low-dose CT protocols. In children as in adults, viscoelasticity-based point-of-care tests enable the prompt diagnosis of relevant coagulopathies and their treatment in consideration of age-specific target values. The administration of tranexamic acid remains controversial.

Conclusion: 4% of polytrauma patients are children. Because children differ from adults both anatomically and physiologically, the diagnostic evaluation and management of polytrauma in children presents a special challenge. The evidence base for pediatric polytrauma management is still inadequate; current recommendations are based on consensus, in consideration of the special features of children compared to adults.

Figure 1

Age-dependent distribution of injury pattern in pediatric polytrauma patients (German Trauma Registry DGU 2008–2022, 15 years [4]); basic patient population with primary admission to a TR-DGU-associated hospital; n = 18 028; 66% male, mean Injury Severity Score/ISS 16 points; 5% died; four age groups: <1 year, 1–4 years, 5–14 years and 15–17 years). All injuries with a severity of AIS 2+ or higher were counted for each body region. The body regions are determined by the first digit of the AIS code with additional division of the lower extremity into pelvis and legs. AIS, Abbreviated Injury Scale

Figure 2

BIG score: Formula for calculating the BIG score and estimating the individual mortality risk (adapted from 5, 11, 12) BE, base excess; GCS, Glasgow Coma Scale; INR, international normalized ratio. * Calculation formula: 1/(1 + e ^{– [0.2 × (BIG score) – 5.208])})

Figure 3. Pediatric transfusion protocol with hybrid approach*¹

*¹ Adapted from (31, 38) *² Low pulse amplitude (blood-pressure amplitude/pulse pressure) as the difference between systole and diastole or other signs of hypovolemia BV, blood volume (loss); RBCC, red blood cell concentrate; FFP, fresh frozen plasma; kg, kilogram; mg, milligram; mL, milliliter; ROTEM, rotational thromboelastometry; TEG, thromboelastometry; PC, platelet concentrate; TXA, tranexamic acid