The emotional impact on children, parents, and society cannot be neglected. The initial evaluation and management of children in the trauma setting can often be traumatizing to both the staff and parents. Proper counseling, debriefing, and post-hospital care are essential when addressing the pediatric trauma patient. It is equally important to consider prevention strategies and effective injury prevention and control require a comprehensive and integrated system that can monitor and collect essential data as the ongoing data collection systems recommended by WHO [15].

The previously mentioned peculiarities of the pediatric trauma patient may lead to challenges in executing appropriate management in a timely fashion in this special population. Establishing initial differential diagnoses of the patient’s injuries depends to a great degree on an appropriate history and physical examination as well as pertinent laboratory and radiologic investigations. Obtaining an accurate and comprehensive history from pediatric patients can be a challenge due to patients’ inability to communicate or due to events that are unwitnessed. Collateral history from parents, when available, can be impaired by the stress and emotional impact of the situation on the parents [16–18]. Certain signs may raise the suspicion of child abuse [19, 20]; subsequently a new set of rules should be considered in obtaining the history as recently recommended by the American Academy of Pediatrics [21] that may include interviewing and examining the child without the parents’ presence. The physical exam of a pediatric trauma patient can vary significantly in reliability based on the experience of the examiner. That involves simple tasks such as assessing volume status [22] or even measuring the temperature [23]. For instance, reading chest X-ray in emergency room for children with suspected pneumonia is reported to have high degree of intra-observer variability [24]. More advanced investigation can be limited in children due to the invasive nature of the test, the need for sedation, the increased risk of radiation exposure, or the inability to get consent in a short time. Because of concerns over ionizing radiation in this age group ultrasound carries a particular value, as will be explained later. Reducing diagnostic errors in pediatric emergency department can be achieved by adopting some of the key principles such as the ones suggested by Croskerry and others [25–27]. Croskerry, who is specialized in Emergency Medicine, hypothesized that the diagnostic process in ED follows the so-called dual process theory. The theory suggests that two basic modes of thinking are in action to reach a diagnosis. Type 1 processes are fast, reflexive, and intuitive, and may operate at a subconscious level. In contrast, Type 2 processes are analytic, slow, and deliberate that require focused attention. Using checklists [28] with better utilization of system 2 (Table 18.3) and de-biasing and disengagement of the intuitive mode (Table 18.4) are among the key concepts [29] to avoid diagnostic errors in the ED and in decision making in general.

Different types of pediatric shock require fast diagnosis and management. Obstructive shock can be due to severe pulmonary hypertension that may occur as a response surge of inflammatory mediators typically in sepsis, massive blood transfusion, severe hypoxia, or acute lung injury. Pulmonary vasodilators should be considered in these cases. Common causes of obstructive shock can be diagnosed by bedside focused ECHO, particularly pericardial tamponade. The distributive shock due to sepsis progresses rapidly in pediatric patients, usually with peripheral vasoconstriction and poor perfusion and far less common (compared to adults) with peripheral vasodilation, or the so-called warm sepsis [30–32]. Therefore, the use of vasodilators (e.g., phentolamine) with inotropes (e.g., epinephrine) or milrinone may constitute a consideration in these cases [33]. Appropriate and prompt correction of glucose (hypoglycemia), acidosis (hydrogen ion abnormalities), and hypoxia is considered among the top “5 Hs” priorities in shocked/arrested child [34]. Calcium correction is particularly important in the pediatric population. In goal-directed therapy of pediatric shock, care should be given to calcium that interacts with many physiological functions particularly myocardial contraction and inotropy [35, 36]. Ca²⁺ facilitates both systolic contraction (inotropy) and diastolic relaxation (lusitropy). Depletion of Ca²⁺ stores, impaired uptake of Ca²⁺ by the sarcoplasmic reticulum (SR), or impairment of the Ca²⁺-regulating proteins, including SR-Ca²⁺-ATPase, sarcoplasmic-endoplasmic reticulum Ca²⁺ (SERCA), and phospholamban, can contribute to rapid deterioration of cardiac contraction and thus aggravate the shock state. Treatment of acidosis and other metabolic abnormalities require rapid correct diagnosis that can be facilitated by following a few rules in the interpretation of the blood gas. Table 18.5 provides ten rules of thumb for such conditions and can be used as a pocket card and is available as smartphone image for quick reference. As in adults, multiple doses of etomidate should be used with caution in children with shock conditions because of its potential effects on the hypothalamic–pituitary–adrenal axis [37].

The published reports [38–44] about the FAST (focused assessment with sonography in trauma) exam in children carried conflicting results but in general indicate low sensitivity. The physiological and anatomical differences that are explained earlier in this chapter may explain the difference in the FAST utility in children versus adults and may also explain the relatively less uptake of FAST in pediatric population. Despite the fact that a negative FAST exam does not have a useful rule-out value, a positive FAST exam is still very useful in stratifying the management of pediatric trauma cases.

Beyond the ultrasound role in the initial detection of abdominal fluid by FAST, ultrasound (US) recently gained an increasing role in stabilization of shocked patient in the ED. A new philosophy of US imaging recently emerged which is the “problem-based critical” ultrasound. This is a paradigm shift from being an organ-based, systematic, comprehensive diagnostic exam to a new concept of problem-based, goal-directed, focused multi-organ, time-dependent exam done by the treating physician. Based on this concept, the US exam is not just done for detection of fluid collection or for an organ or region (e.g., US for abdomen or chest) but rather done to enhance the management of a problem (US for hypotension, US for hypoxia, US for sepsis, etc.). Certain problem-based US exams can involve scanning of multiple organs to enhance the management of a certain patient’s problem. The US within this concept is not considered just as a diagnostic tool but rather as an integral part of ED management that involves diagnosis, tailored treatment, monitoring effects, goal-directed therapy, ruling out possible complications, and of course guiding most of the pediatric ED procedures [45]. If we consider the example of “ultrasound for hypotension,” a process of scanning of three organs (heart, inferior vena cava (IVC), and lung) will generate a “sonodymanic” pattern to enhance the management of hypotension as follows [46]: