Overview
Definition:
Road Traffic Accidents (RTAs) in children refer to injuries sustained by individuals under 18 years of age as a result of a collision or impact involving a motor vehicle
These incidents are a leading cause of morbidity and mortality in pediatric populations globally
RTAs encompass pedestrian accidents, cyclist accidents, and passenger vehicle occupants
The spectrum of injuries ranges from minor abrasions and contusions to life-threatening head injuries, spinal cord injuries, internal organ damage, and fractures.
Epidemiology:
Globally, RTAs are a significant public health concern, ranking as a major cause of death and disability among children and adolescents
In India, RTAs account for a substantial proportion of pediatric hospital admissions and mortality
Factors contributing to higher incidence include socioeconomic status, urbanization, road infrastructure, vehicle safety standards, and adherence to traffic laws
Young children and adolescents are particularly vulnerable due to developmental factors such as impulse control, risk perception, and physical fragility.
Clinical Significance:
Understanding the diagnosis and therapy of pediatric RTAs is crucial for pediatricians, emergency physicians, and surgeons
Prompt and accurate assessment, stabilization, and management can significantly reduce mortality, prevent long-term disability, and improve the quality of life for affected children
Knowledge of age-specific injury patterns and management protocols is essential for effective care
This topic is frequently tested in DNB and NEET SS examinations due to its high clinical relevance.
Clinical Presentation
Symptoms:
Presentation varies widely depending on the mechanism of injury and severity
Common symptoms include: Altered sensorium or loss of consciousness
Crying or inconsolable distress in younger children
Complains of pain at the site of injury
Difficulty breathing or shortness of breath
Vomiting
Visible deformities or bleeding from wounds
Inability to move limbs
Signs of shock: pallor, cold extremities, rapid pulse, decreased urine output.
Signs:
Vital sign abnormalities: Tachycardia, hypotension, tachypnea, hypothermia or hyperthermia
Neurological deficits: Glasgow Coma Scale (GCS) score, pupillary response, focal neurological deficits
Signs of external trauma: Lacerations, abrasions, contusions, deformities, impaled objects
Signs of internal trauma: Abdominal distension or tenderness, bruising over flanks or abdomen (seatbelt sign), crepitus over chest or limbs
Spinal tenderness or deformity
Signs of airway compromise: stridor, retractions, cyanosis.
Diagnostic Criteria:
There are no specific formal diagnostic criteria for RTA itself, as it is an event
Diagnosis of injuries is based on clinical assessment, physical examination findings, and investigations
Pediatric trauma scores (e.g., Pediatric Trauma Score, Injury Severity Score - Revised) may be used to stratify injury severity and guide management decisions
However, immediate resuscitation and management are guided by the Advanced Pediatric Life Support (APLS) or Pediatric Advanced Life Support (PALS) protocols, focusing on the ABCDE approach.
Diagnostic Approach
History Taking:
Obtain a detailed history from caregivers, witnesses, and emergency medical personnel
Key points include: Mechanism of injury (e.g., pedestrian vs
vehicle, speed, impact site, rollover)
Role of the child (driver, passenger, pedestrian, cyclist)
Use of restraints (seatbelts, car seats, helmets)
Nature of collision
Pre-hospital interventions
Child's pre-injury status (consciousness, symptoms)
Medical history: allergies, medications, previous surgeries, pre-existing conditions
Red flags: prolonged loss of consciousness, high-speed impact, ejection from vehicle, rollover, significant mechanism of head or abdominal trauma, suspected spinal injury.
Physical Examination:
Perform a rapid, systematic primary survey using the ABCDE approach: Airway with cervical spine immobilization
Breathing: chest expansion, auscultation, respiratory rate
Circulation: pulse rate and quality, blood pressure, capillary refill, skin color
Disability: neurological status (GCS, pupillary response)
Exposure: fully expose the child, assess for all injuries, prevent hypothermia
Secondary survey: Head-to-toe examination, including detailed examination of all systems, neurological assessment, musculoskeletal assessment, and rectal examination if indicated.
Investigations:
Laboratory tests: Complete blood count (CBC) for hemoglobin and hematocrit, coagulation profile (PT/INR, aPTT), electrolytes, blood urea nitrogen (BUN), creatinine, arterial blood gases (ABGs), lactate levels
Imaging modalities: Focused Assessment with Sonography for Trauma (FAST) scan for intra-abdominal or thoracic fluid
Chest X-ray for pneumothorax, hemothorax, rib fractures
Abdominal X-ray (limited utility but may show free air)
Pelvic X-ray for pelvic fractures
CT scan of head for suspected intracranial injury, CT abdomen/pelvis for solid organ injury, bowel injury, or vascular injury
CT scan of spine if high suspicion of spinal injury
Long bone X-rays for suspected fractures
Interpretation: Assess for signs of intracranial bleed (SDH, EDH, contusion), pneumothorax, hemothorax, solid organ lacerations (spleen, liver, kidney), bowel perforation, vascular injuries, and fractures
A negative FAST scan in a hemodynamically stable child generally excludes significant hemoperitoneum.
Differential Diagnosis:
The differential diagnosis for pediatric RTA injuries is broad and depends on the location and nature of the trauma
Considerations include: Head injuries (concussion, skull fractures, intracranial hemorrhage)
Spinal cord injuries
Thoracic injuries (pneumothorax, hemothorax, pulmonary contusion, cardiac contusion)
Abdominal injuries (solid organ lacerations, hollow viscus injury, mesenteric tear, pancreatic injury)
Musculoskeletal injuries (fractures, dislocations)
Burns
Soft tissue injuries
Poisoning or intoxication (if altered mental status is the primary issue, though RTA may be superimposed).
Management
Initial Management:
Immediate resuscitation and stabilization are paramount
Follow the ABCDE approach: Airway maintenance with cervical spine control (collar and log-rolling)
Assessment and support of breathing (oxygenation, ventilation)
Circulation support (IV access, fluid resuscitation with crystalloids like Ringer's lactate or normal saline, blood transfusion if needed, control external hemorrhage)
Assessment of neurological status (GCS)
Exposure and environmental control (keep the child warm)
Pain management
Rapid transport to a trauma center if not already there.
Medical Management:
Pharmacological management is primarily supportive and guided by specific injuries
Analgesia: Intravenous opioids (morphine, fentanyl) for severe pain
Sedation may be required for procedures or ventilation
Anticonvulsants: Intravenous levetiracetam or fosphenytoin for documented seizures or high risk of seizure (e.g., severe head injury)
Antibiotics: Prophylactic antibiotics may be considered for open fractures or penetrating injuries, guided by local protocols
Steroids are generally not recommended for traumatic brain injury
Antiemetics for nausea and vomiting.
Surgical Management:
Surgical intervention is dictated by the specific injuries identified
Indications include: Hemodynamic instability due to intra-abdominal hemorrhage requiring exploratory laparotomy
Significant intracranial hemorrhage with mass effect requiring neurosurgical intervention (craniotomy)
Tension pneumothorax requiring chest tube insertion and potential thoracotomy
Open fractures requiring debridement and stabilization
Limb-threatening injuries requiring orthopedic surgery
Vascular injuries requiring vascular repair.
Supportive Care:
Continuous monitoring of vital signs, neurological status, and urine output
Fluid management: Judicious use of fluids to maintain adequate perfusion without causing fluid overload
Nutritional support: Early enteral feeding once bowel function is established
Prevention of complications: Deep vein thrombosis (DVT) prophylaxis in older children with immobility, pressure area care, infection surveillance.
Complications
Early Complications:
Hemorrhagic shock
Airway obstruction
Respiratory failure
Cardiac arrest
Fat embolism syndrome (especially with long bone fractures)
Compartment syndrome
Acute kidney injury
Sepsis
Hypothermia.
Late Complications:
Post-traumatic epilepsy
Neurodevelopmental delay or cognitive deficits
Chronic pain
Growth disturbances or malunion of fractures
Post-traumatic stress disorder (PTSD)
Organ dysfunction
Amputations.
Prevention Strategies:
Strict enforcement of traffic laws and speed limits
Use of appropriate child restraint systems (car seats, booster seats) in vehicles
Mandatory use of helmets for cyclists and motorcyclists
Pedestrian safety education and improved road infrastructure (sidewalks, pedestrian crossings)
Public awareness campaigns on road safety
Vehicle safety standards and improvements.
Prognosis
Factors Affecting Prognosis:
Severity of injury (e.g., GCS score, presence of severe head injury, number of injured organs)
Age of the child (younger children may have better resilience but are more vulnerable)
Pre-existing medical conditions
Timeliness and quality of initial resuscitation and medical care
Presence of complications
Mechanism of injury.
Outcomes:
Outcomes vary significantly
Minor injuries typically have excellent recovery
Severe injuries, particularly head and spinal cord injuries, can lead to permanent disability, cognitive impairment, or even death
With prompt and appropriate management, many children can achieve good functional recovery
Long-term follow-up is essential to monitor for developmental and psychological sequelae.
Follow Up:
Follow-up care depends on the nature and severity of injuries
Children with significant head injuries require neurological and developmental assessments
Orthopedic follow-up is necessary for fractures
Psychological support and assessment for PTSD are crucial for all children who have experienced significant trauma
Regular check-ups with pediatricians and specialists as needed to ensure optimal recovery and address long-term issues.
Key Points
Exam Focus:
The ABCDE approach to pediatric trauma resuscitation is paramount
Understanding age-specific injury patterns and vulnerable populations is key
Recognition of shock and immediate management are critical
Principles of FAST scan and CT imaging in pediatric trauma
Indications for surgical intervention
Age-appropriate use of restraints.
Clinical Pearls:
Always maintain cervical spine precautions until ruled out
Do not underestimate the severity of injury based on initial appearance
a seemingly stable child can deteriorate rapidly
Use pediatric-specific resuscitation guidelines (APLS/PALS)
Involve a multidisciplinary team (surgeons, intensivists, nurses, allied health professionals) early
Reassess the child frequently after initial stabilization.
Common Mistakes:
Failure to maintain airway with cervical spine control
Inadequate fluid resuscitation leading to hypovolemic shock
Delayed recognition of occult injuries (e.g., abdominal, spinal)
Over-reliance on imaging without clinical correlation
Inappropriate management of head-injured children (e.g., routine steroid use)
Overlooking psychological impact on the child and family.