The multiply injured child

Abstract

Multiple trauma (MT) is an injury to more than one body system or at least two serious injuries to one body system. In the developed world, trauma is the leading cause of death and acquired disability in the 1-45 years age groups with staggering burden of medical and societal costs. Moreover, more than 95 % of pediatric injury deaths occur in the developing world, where the magnitude of trauma toll is increasing with the trends of expanding urbanization and motorization. MT is a “systemic” disease, and is best approached according to the “two-hits hypothesis”: The initial injury causes organ and tissue damage (first hits), that activate the neuroendocrine and metabolic stress response and the systemic inflammatory response (SIRS), causing ‘second hits’ such as respiratory distress syndrome, reperfusion injury, compartment syndromes and infections. Exogenous ‘second hits’ include surgical interventions, hypothermia, massive transfusions, inadequate or delayed surgical or intensive care interventions and line infections. Thus, MT increases the probability of secondary damage-especially to the brain. MT complicates the clinical course and the patient’s management, makes clinical decision making far more complicated and requires different priority setting. Management issues discussed in this chapter include pertinent aspects of pre-hospital, emergency room and intensive care evaluation and treatment, imaging of the multiply injured child, the pivotal role of the intensivist in the ICU care, approach to the bleeding patient with hypothermia and acidosis (“Triad of Death”), the damage control paradigm, and management of the multiply injured child with abdominal and chest trauma.