Pediatric Trauma Surgery
As with tumors, trauma is a rather broad topic and will be touched on briefly. As a child develops he or she is subject to various types of trauma primarily related to age and activity. These can be broken down into three large categories. These are injuries occurring at birth, during infancy and during childhood. Often the injuries are accidental or due to a failure in the protective environment we place the child in.
Multiple trauma has been defined as substantial injury to more than one organ system or life-threatening injury to a single organ system. The full impact of injury deaths in children and adolescents is reflected in the fact that injury surpasses all major disease groups as the leading cause of premature years of life lost in this country. A major consideration in dealing with injured children is the effect that injury may have on subsequent growth and development. We Care India partner Hospital is designated as a Level 1 trauma center caring for the most acutely injured children. Over 500 pediatric trauma patients are admitted on an annual basis. Ninety percent of these children sustain blunt trauma, e.g. falls, pedestrian-motor vehicle crashes. The remaining 10% sustain penetrating injury, e.g. gunshot wounds or stab wounds.
The Pediatric Trauma Service at the We Care India partner Hospital is an interdisciplinary program with special resources from throughout the institution that are dedicated to providing optimal care for the child who sustains a significant traumatic injury. Effective care of the injured child requires an inclusive approach which recognizes injury as a major pediatric health problem, identifies effective strategies for prevention, improves systems of care for children, and provides the most appropriate care available. As a Level 1 trauma center we have an emergency department specifically equipped for children, as well as a pediatric intensive care unit with appropriately trained surgical and pediatric specialists available to care for the injured child. In addition, the child protection service provides expert consultation on child abuse cases.
Injury prevention is another responsibility of the pediatric trauma program. A pediatric pedestrian safety study is currently identifying local environmental factors that contribute to childhood pedestrian injury events among those patients treated at our Pediatric Level 1 trauma center. This information will then be utilized to determine whether the environment can be modified to reduce the risk of childhood pedestrian injuries within our community.
There are many types of birth related injuries that lead to involvement of a neurosurgeon. Luckily most are fairly benign and do not require surgical treatment. Common problems are bleeding under the scalp or membranes of the skull bone and small fractures. These are best left alone and will heal spontaneously. Rarely there may be bleeding inside the head. This may cause seizures or irritability or some change in the baby's activity. Often the bleeding is trivial and will go away on its own. Very rarely does a surgeon need to operate to remove a blood clot from the brain. These babies will then usually be followed by both a neurologist and a neurosurgeon. The outlook for most children is excellent.
Another type of injury to the nervous system at birth is injury to the brachial plexus. These are nerves that arise from the spinal cord in the neck to supply strength and sensation to the arms. This injury arises from the stretching of the nerves as the baby is being delivered. The injury may range from subtle weakness to complete loss of use of the arm. The great majority improve spontaneously. Under rare circumstances surgery may be required if the arm function does not return.
The second category of injury are those that occur in infancy. By and large these are due to freak accidents or moments of distraction when a parent will turn their back for a second and somehow the baby will topple over or off of something like a kitchen counter or changing table. The types of injuries that babies get are primarily bruises and only rarely do fractures or bleeding occur. It is difficult to say when a physician should be notified but in the absence of obvious trauma to the head then you must use your best judgment. If the baby quickly returns to their normal activity then usually things are okay. If the child becomes irritable or unusually sleepy or starts to vomit or have seizures then certainly they must be evaluated promptly.
It is difficult to say how far a child must fall to injure themselves, but a general guideline is that falls of about four feet or less are tolerated well. Of course what is also important is the type of floor they hit and which part of the head that hits it. However, it is certainly possible to fall shorter distances and get bad injuries under unusual circumstances.
In addition to these accidental causes, a small number of injuries are due to child abuse. These injuries are often far more serious than the accidental injuries. When the nature of the injury seems inconsistent with the findings, than a concern for child abuse is raised. Child abuse is seen in all socioeconomic classes and needs to be identified as soon as possible to prevent further injury or death. Often parents are outraged that they are suspected of abusing their child; however, it must be understood that the health care system is the advocate of the baby and must do everything possible to prevent a tragedy. It is not the role of the child protective agencies to remove children from their homes, but rather to see that they are being well cared for.
One type of child abuse that is often spoken of but misunderstood by the public is "shaken baby syndrome". This usually serious injury to the brain cannot be caused by the typical bouncing of a baby on the knee or gently shaking. It is most often seen with a very violent and vigorous shaking which is concluded with throwing of the baby down onto a hard surface. Most children with this syndrome as with most child abuse are less then two to three years of age.
As children start to venture out into the world and start to ride bikes and play on swings and gym sets, the types of injuries they get are more like those of adults. These include skull fractures and bleeding into or around the brain.
Some require surgery and others can be followed without any need for an operation. The best advice for parents is to minimize the risk for these injuries. This includes bike helmets, seat belts, supervised play and good judgment. Still, kids are kids and accidents will happen. Warning signs of an injury are similar to infants: worsening headaches, vomiting, seizures, lethargy, or confusion. After a concussion it is not uncommon for children to have a period of around 24 hours with vomiting and irritability. While it looks frightening it usually goes away on its own and the children make good recoveries.
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