Management of pediatric polytrauma

Polytrauma involves multiple injuries, of which at least one carriesa serious prognosis. While the incidence is decreasing as a result ofpreventive measures, the expectations of the public continue to rise.Polytrauma remains the commonest cause of death in children afterthe age of one. Improvements in imaging techniques have improveddiagnosis, and together with rapid transport to hospital have greatlyimproved the management of these injured children. More accuratediagnosis has reduced the need for surgical exploration, althoughspeed in diagnosis and in any necessary surgery remains very important.Investigations must start with the most serious injuries,often with CT scanning of the head and neck, thorax and abdomen,and this is followed by examination of the limbs. Individual specialistsmust then agree on an order of priority for dealing with all thelesions, but this team must have a leader or coordinator. Braintrauma, predominantly contusions, affects eighty per cent of theseinjured children and this greatly influences the neurological prognosis.Urgent neuro-surgical operation is rarely indicated, except tointroduce catheters to monitor intra-cranial pressure, but many childrenwill require sedation to protect their brains. Thoracic injuriesrarely require open surgery and are primarily managed by insertionof a chest drain. Blunt abdominal trauma is also being treated conservatively,peritoneal lavage has been abandoned, and urgent laparotomyis rarely required. They have been replaced by clinical, ultrasonic and biological surveillance. The incidence of early orthopaedicsurgery seems to be increasing. The use of internal and externalfixation allows better imaging, early resuscitation, and mobilisation.Intramedullary elastic nailing seems particularly useful.The optimism of the 80’s with regard to sequelae has been marredby the neurological results, and this remains a largely unresolvedproblem. Overall improvements in the care of the polytraumatisedchild depend on improved resuscitation, transport, and establishmentof specialised reception centres, as well as continuing to developimproved methods of prevention, and of rehabilitation forthose left with brain damage.