Chapter 43: The Pediatric Patient

INTRODUCTION

Early in the last century little distinction was made in the care of children from adults. William E. Ladd a general surgeon observed this first hand as he cared for severely burned children in the Halifax disaster of 1917. “Dr Ladd was distressed by the quality of surgical care offered to these small patients and was determined to improve it.”¹ He and Dr Robert E. Gross in the mid-20th century pioneered a new field of surgery specific to children, illuminating features of children that merited special attention. They and others recognized that although the care of children shared some similarities to that of the adult, there were distinctly different anatomic, physiologic characteristics, and surgical conditions in children that made them unique. In 1962 the first pediatric trauma unit was opened at the Kings County Hospital Center in Brooklyn. Yet, the lack of dedicated care and clinical protocols persisted in the United States until the early 1970s. The first designated pediatric shock trauma unit in the United States was opened at the Johns Hopkins Children’s Center and became incorporated into the statewide University of Maryland Institute of Emergency Medical Systems.² In the years that followed, the American College of Surgeons Committee on Trauma established the treatment of pediatric injury as an important component of all regional trauma centers, integrated pediatric trauma into the Advanced Trauma Life Support course, and established minimum requirements for pediatric trauma center designation. By 2010 the number of pediatric trauma centers in the United States grew to 43 but still far less than the 474 adult level I and II centers.

C. Everett Koop, a former pediatric surgeon and US Surgeon General declared, “If a disease were killing our children at the rate unintentional injuries are, the public would be outraged and demand that this killer be stopped.” Worldwide, every year nearly a million children are killed. Nonfatal injuries affect the lives of between 10 million and 30 million more. Each year in the United States, more than 12,000 children die from unintentional injuries and nearly a million children are treated in emergency departments for nonfatal injuries.³ The cost of unintentional injury can be measured in dollars, permanent disability, and potential lost years in productivity or life. Danseco reported that the estimated medical costs of unintentional childhood injuries in the United States were an astounding $347 billion per year. This estimate included $17 billion in medical costs, $72 billion in future work lost, and $257 billion in lost quality of life.⁴

Injuries are the leading cause of death in the United States for persons aged 1–19 years and the fifth leading cause of death for newborns and infants aged less than 1 year (Fig. 43-1). The death rate for males is almost two times the rate for females. Pediatric trauma patients demonstrate a lower mortality than adults. Similarly, injured children appear at lower risk of post-injury ...