Trauma care in the general population has largely become protocol-driven, with an emphasis on fast and efficient treatment, good team communication at all levels of care including prehospital care, initial resuscitation, intensive care, and rehabilitation. Most available literature on trauma care has focused on adults, allowing the potential to apply concepts from adult care to pediatric care. But there remain issues that will always be specific to pediatric patients that may not translate from adults. Several new devices such as intraosseous (IO) needle systems and techniques such as ultrasonography to cannulate central and peripheral veins have become available for integration into our pre-existing trauma care system for children. This review will focus specifically on the latest techniques and evidence available for establishing intravenous access, rational approaches to fluid resuscitation, and blood product transfusion in the pediatric trauma patient.

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Pediatric burns comprise a major mechanism of injury, affecting millions of children worldwide, with causes including scald injury, fire injury, and child abuse. Burn injuries tend to be classified based on the total body surface area involved and the depth of injury. Large burn injuries have multisystemic manifestations, including injuries to all major organ systems, requiring close supportive and therapeutic measures. Management of burn injuries requires intensive medical therapy for multi-organ dysfunction/failure, and aggressive surgical therapy to prevent sepsis and secondary complications. In addition, pain management throughout this period is vital. Specialized burn centers, which care for these patients with multidisciplinary teams, may be the best places to treat children with major thermal injuries. This review highlights the major components of burn care, stressing the pathophysiologic consequences of burn injury, circulatory and respiratory care, surgical management, and pain management of these often critically ill patients.

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Decompressive craniectomy (DC) is a useful technique for the treatment of traumatic brain injuries (TBI) with intracranial hypertension (ICHT) resistant to medical treatment, increasing survival, although its role in the functional prognosis of patients is not defined. It is also a technique that is not without complications, and may increase the patient's morbidity and mortality. We report two cases of patients with TBI who required DC and suffered complications from the technique

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Injury is the leading cause of death and disability in children. Each year, almost one in six children in the United States require emergency department (ED) care for the treatment of injuries, and more than 10,000 children die from injuries. Severely injured children need to be transported to a facility that is staffed 24/7 by personnel experienced in the management of children, and that has all the appropriate equipment to diagnose and manage injuries in children. Anatomical, physiological, and emotional differences between adults and children mean that children are not just scaled-down adults. Facilities receiving injured children need to be child and family friendly, in order to minimize the psychological impact of injury on the child and their family/carers. Early recognition and treatment of life-threatening airway obstruction, inadequate breathing, and intra-abdominal and intra-cranial hemorrhage significantly increases survival rate after major trauma. The initial assessment and management of the injured child follows the same ATLS^; sequence as adults: primary survey and resuscitation, followed by secondary survey. A well-organized trauma team has a leader who designates roles to team members and facilitates clear, unambiguous communication between team members. The team leader stands where he/she can observe the entire team and monitor the "bigger picture." Working together as a cohesive team, the members perform the primary survey in just a few minutes. Life-threatening conditions are dealt with as soon as they are identified. Necessary imaging studies are obtained early. Constant reassessment ensures that any deterioration in the child's condition is picked up immediately. The secondary survey identifies other injuries, such as intra-abdominal injuries and long-bone fractures, which can result in significant hemorrhage. The relief of pain is an important part of the treatment of an injured child.

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Context: Though some studies have described traumatic brain injuries in tertiary care, urban hospitals in India, very limited information is available from rural settings. Aims: To evaluate and describe the epidemiological and clinical characteristics of patients with traumatic brain injury and their clinical outcomes following admission to a rural, tertiary care teaching hospital in India. Settings and Design: Retrospective, cross-sectional, hospital-based study from January 2007 to December 2009. Materials and Methods: Epidemiological and clinical data from all patients with traumatic brain injury (TBI) admitted to the neurosurgery service of a rural hospital in district Wardha, Maharashtra, India, from 2007 to 2009 were analyzed. The medical records of all eligible patients were reviewed and data collected on age, sex, place of residence, Glasgow Coma Scale (GCS) score, mechanism of injury, severity of injury, concurrent injuries, length of hospital stay, computed tomography (CT) scan results, type of management, indication and type of surgical intervention, and outcome. Statistical Analysis: Data analysis was performed using STATA version 11.0. Results: The medical records of 1,926 eligible patients with TBI were analyzed. The median age of the study population was 31 years (range <1 year to 98 years). The majority of TBI cases occurred in persons aged 21 - 30 years (535 or 27.7%), and in males (1,363 or 70.76%). Most patients resided in nearby rural areas and the most frequent external cause of injury was motor vehicle crash (56.3%). The overall TBI-related mortality during the study period was 6.4%. From 2007 to 2009, TBI-related mortality significantly decreased (P < 0.01) during each year (2007: 8.9%, 2008: 8.5%, and 2009: 4.9%). This decrease in mortality could be due to access and availability of better health care facilities. Conclusions: Road traffic crashes are the leading cause of TBI in rural Maharashtra ffecting mainly young adult males. At least 10% of survivors had moderate or more severe TBI-related disabilities. Future research should include prospective, population based studies to better elucidate the incidence, prevalence, and economic impact of TBI in rural India.

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The number of children requiring sedation and analgesia for diagnostic and therapeutic procedures has increased substantially in the last decade. Both anesthesiologist and non-anesthesiologists are involved in varying settings outside the operating room to provide safe and effective sedation and analgesia. Procedural sedation has become standard of care and its primary aim is managing acute anxiety, pain, and control of movement during painful or unpleasant procedures. There is enough evidence to suggest that poorly controlled acute pain causes suffering, worse outcome, as well as debilitating chronic pain syndromes that are often refractory to available treatment options. This article will provide strategies to provide safe and effective sedation and analgesia for pediatric trauma patients.

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Prehospital pediatric care is an important component in the treatment of the injured child, as the prehospital responders are the first medical providers performing life saving and directed medical care. Traumatic injuries are the leading cause of morbidity and mortality in the pediatric patient population. Nevertheless, for most prehospital provider it is a rare event to treat pediatric trauma patients and there is a still existing gap between the quality of care for pediatric patients compared to adults. To improve pediatric prehospital trauma care more provider need to be trained in identifying the specific differences between adult and pediatric patients.

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Pediatric trauma presents significant challenges to the anesthesia provider. This review describes the current trends in perioperative anesthetic management, including airway management, choice of anesthesia agents, and fluid administration. The review is based on the PubMed search of literature on perioperative care of severely injured children.

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Context: Mild traumatic brain injury (mTBI) represents a major health problem in civilian populations as well as among the military service members due to (1) lack of effective treatments, and (2) our incomplete understanding about the progression of secondary cell injury cascades resulting in neuronal cell death due to deficient cellular energy metabolism and damaged mitochondria. Aims: The aim of this study was to identify and delineate the mitochondrial targeted genes responsible for altered brain energy metabolism in the injured brain. Settings and Design: Rats were either grouped into naοve controls or received lateral fluid percussion brain injury (2-2.5 atm) and followed up for 7 days. Materials and Methods: Rats were either grouped into naοve controls or received lateral fluid percussion brain injury (2-2.5 atm) and followed for 7 days. The severity of brain injury was evaluated by the neurological severity scale-revised (NSS-R) at 3 and 5 days post TBI and immunohistochemical analyses at 7 days post TBI. The expression profiles of mitochondrial-targeted genes across the hippocampus from TBI and naÏe rats were also examined by oligo-DNA microarrays. Results: NSS-R scores of TBI rats (5.4 ± 0.5) in comparison to naÏe rats (3.9 ± 0.5) and H and E staining of brain sections suggested a mild brain injury. Bioinformatics and systems biology analyses showed 31 dysregulated genes, 10 affected canonical molecular pathways including a number of genes involved in mitochondrial enzymes for oxidative phosphorylation, mitogen-activated protein Kinase (MAP), peroxisome proliferator-activated protein (PPAP), apoptosis signaling, and genes responsible for long-term potentiation of Alzheimer's and Parkinson's diseases. Conclusions: Our results suggest that dysregulated mitochondrial-focused genes in injured brains may have a clinical utility for the development of future therapeutic strategies aimed at the treatment of TBI.

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Infrastructure, processes of care and outcome measurements are the cornerstone of quality care for pediatric trauma. This review aims to evaluate current evidence on system organization and concentration of pediatric expertise in the delivery of pediatric trauma care. It discusses key quality indicators for all phases of care, from pre-hospital to post-discharge recovery. In particular, it highlights the importance of measuring quality of life and psychosocial recovery for the injured child.

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Background: Injuries affect the lives of 10 - 30 million children and adolescents each year and have been acknowledged as the leading cause of mortality among young people in the age range of 15 - 19 years. Injury, as a research problem has been largely ignored in developing countries like Nigeria. Aims: This study was aimed at determining injury prevalence, external causes / mechanism of injury, various factors affecting injury occurrence, injury severity, type of treatment received, as well as the most common days and times of injury. Settings and Design: The study was conducted in the Agbor Metropolis of the oil-rich Niger delta region of Nigeria and adopted a cross-sectional study design. Materials and Methods: Semi-structured questionnaires were distributed to 386 subjects selected using a stratified and simple random technique. Analysis: Analysis was done using Social Science Statistical Package, with the level of significance taken at 0.05 Results: Injury prevalence was 284 (73.6%) with a mean frequency of 1.8 per child. About (221) 57.3% of the injuries sustained resulted in 1+ day's activity loss, with about 136 (35.2%) requiring medical attention. The top injury sites were street / road, 49 (12.69%) and school environment and sporting arena, 47 (12.18%), respectively, followed by home vicinity, 43 (11.14%). The key causes of injury were collision, 53 (13.73%), falling, 41 (10.62%), and cut / stabbing, 41 (7.51%). Most treatments were at the hospital, 136 (47.72%). Most injuries occurred in the afternoons, 108 (28%) and evenings, 89 (23.1%). Injury experience was associated with Respondents / Parents level of education, family type, alcohol consumption, and age (P < 0.05 for all). Conclusion: Injury experience was relatively high and varied with site, activity, age, family type, alcohol consumption, and parental educational status.

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Context: The use of imaging modalities is crucial in the diagnostic field of critical medicine. However, the ethical and economic use of these techniques has become a major concern especially in resource-poor settings. The Canadian computed tomography Head Rule (CCHR) is being increasingly used all over the world to evaluate the necessity of a Computer-assisted Tomography (CT) scan in patients with suspected head injury. Aim: The aim of the current study is to evaluate the efficacy of CCHR to predict the occurrence of head injury, as evidenced radiologically by a CT Head, at a government tertiary care clinical setting in south India. Setting and Design: The design was that of a hospital-based cross-sectional survey conducted at the Medical College Hospital, Thiruvananthapuram (Kerala, India). Materials and Methods: The study subjects were patients with suspected head injury evaluated at the Surgical Casualty Department of the study setting. Fifty consecutive patients with suspected head injury were enrolled in the study. Statistical Analysis: The Chi-square test was used to assess the statistical significance of association between the outcome variable and the exposure characteristics. The diagnostic ability of the Glasgow Coma Scale (GCS) and CCHR were expressed in terms of sensitivity and specificity by considering CT diagnosed Head injury as the gold standard diagnostic tool. Results: Clinical manifestations as measured by a GCS score < 13 failed to significantly predict a head injury in the CT scan. However, the same became statistically significant when the CCHR was added to the GCS score as a predictor (P value < 0.001). The sensitivity of the tool in predicting a head injury rose from 23.3 to 96.7%. Conclusion: The current study suggested that the CCHR could act as an excellent decision rule to indicate the need of a CT scan. The need of a decision rule was warranted in the context of the growth of newer diagnostic imaging facilities in India.

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