Original article 345
The Significance of Multiple Trauma in Children O. Paar, R. Kasperk Surgieal Clinie of the .\\edieallnstilule of H\\'TII-Aaehen (Director: Prof. Dr. \'. Sehumpeliek)
Accident-related injuries, mainly trafficconnected, are the most serious threat to health and mostfrequent cause of death in the pediatric age group. L'sually these are multi-system injuries. \\'hile the total number of accidenls has decreased O\'er the last 20 years, traffic accidenls ha\'e becomc more serious. Com'entional prognostic score~ are not applicable in children with multiple injuries because of their essential pathophyiologic differences \\ith adulls. The Pediatric Trauma Score closes this gap. II is simple to use and prO\'ide high reliability.
Key words \Iultiple trauma in children - PTS - Prognosi
Resume Les lesions consecutives aux accidenls et en particulier en relation avec les accidenls de la circulation sont la cause la plus frequente de sequelles et de dece a l'age pediatrique. De faGon generale, il s'agit de polytraumatismes. Le nombre total des accidents a diminue depuis ces 20 dernieres annee mais les accidenls observes sont devenus plus severes. Les cores pronostiques conventionnels ne sont pas utilisables chez l'enfant polytraumatise a cause des differences physiopathologiques essentielles avec les adultes. Le score de
The spectrum of injuries from traffic accidents ha ba ically changed over the la t few decades a a result of increased motorization of ociety. Traffic accidenls are the mo t common traumatic e\-enls in almost all age group . Combined injuries of e\'eralorgan ystems 01' regions of the body are e pecially eriou, for \\'hich the concept of multiple trauma \\'as coined (10). In the 60's and ,O's the current principles for treating multiply-injured patienls \\-ere de\'ised (30). Today the effecti\'eness of this concept i unque tioned, but it still remains Hecei\l'd Oetoher :20. IUHU Eur ) Ped,alr SlIr~ 2 (1\)\'2) JI5-Jli © Illppo!-.rale" \ crla~ Slllllgari \\a""ol1 Edilellr Pari"
traumatologie pediatrique comble celle lacune. II est facile d'utilisation et compOlte une tres bonne fiabilite.
\Iots-eles Polytraumatisme chez I'enfant - PTS - Pronostic
Zusammenfassung L'nfallbedingte \'erJetzungen, zumeist im Hahmen eines \·erkehrsunfalles. sind die bedeutendste ernste Ge und heils törung und häufigste Todesursache im Kindesund frühen Jugendalter. Zumeist handelt e sich um \-erletzungen mehrerer Organe bZ\\. Körperregionen im Sinne eine Pol.\trauma. Während insgesamt eine Abnahme der L'nfallzahlen in den \'ergangenen 20 Jahren zu \'erzeichnen ist, hat gleichzeitig eine Yerschiebung zugunsten der schweren \'erletzungen stattgefunden. Kom'entionelle prognostische Scores sind aufgrund wesenUicher Cnterschiede in den pathophysiologischen Abläufen bei polytraumatisierten Kindern nicht anwendbar. Der Pediatric Trauma Score schließt diese Lücke. Er zeichnet sich durch einfache Handhabung und hohe Zuverläs igkeit aus.
Schlüsselwörter Kindliches Polytrauma - PTS - Prognose
to be tested \\'hether this treatment approach is a effective in children a it i in adult patients. The follO\\ing analy is \\-iJI point out the numerical importance of multiple trauma in children, as \\'eJl as existing inadequacies in the care of these badly-injured children and starting poinls for impro\'emenls in pediatric trauma care.
Frequency of multiple trauma in childhood Only the numbers of traffic and school accidenls im'olving children up to the age of 16 years are a\'ailabJe for a statistically accurate analysis.
Downloaded by: Universite Laval. Copyrighted material.
Summary
O. Paar and R. Kasperk
EurJ Pediatr Surg 2 (J 992)
The data from the Federal Republic Office of Vital Statistics used in this study cover the time period from 1965 until 1987 (15). There has been a continuous drop in the nurnber of accidents over the last 20 years. The relative proportion of severely injured children, however, has clearly increased. The percentage of fatalities in children in the O\'er-all traffic accident mortality in 1987 was 9.1 %; in 1965 it had been 11.2 %. In addition it must be taken into account that during this time period the number of children in the Federal Republic dropped to 31.5 %. There was, then, a drop in the number of traffic fatalities in children of 39.4 %, but a decline in severely injured children of only 14.4 %. Every 10th se\'erelyinjured traffic \-iclim in 1987 \\'as younger than 16 years old. Expressed in absolute numbers, 387 children died in traffic accidents and 11649 \\'ere se\'erely injured. The German Federal Hepublic thus takes the lead in all of Europe. A break-down according to age groups shows that with increasing age of children the risk of accident increases. One-third of all children injured in traffic are bel\\'een 6 and 9 years, and 41 % were bet\\'een 10 and 15 years. Boys and gi rI are equal in the general population but three out of four injured under the age of 16 are boys. \ \ortality statistics bet\\'een the ages of one and fifteen are for accidents in general; between fiw and fifteen traffic accidents account for most (15).
Table 1
Age dlstnbutlon
In
68 multl,traumatlzed chlldren Portion
Age
1
7% 42% 34% 17 %
1- 5 6-10 11-15
Authors' series We analyzed our own series between 1/1/87 and 3/31/89. During this time period (27 months) 68 children under the age of 16 were admitted with the diagnosis of multiple trauma. The total number of multiple trauma admis ions O\'er this time period wa 249. 27 % of these patients were under 16. The sex ratio was 2 to I (45 boys and 23 girls), The most frequenUy invoh'ed age \\'as the 1-5 year age-group with 17 %, followed by the under one-year-old patients, with 7 %. Foul' of the children died in the ambulance (6 %), ages 1,2, 3 and 4 respectively (Table I). After primary stabilization of \-ital signs under the care of Accident Surgeon and Anesthesiologi ts in the Shock l'nit, depending on the general condition and injurypattern of the injured patient, the patient was transferred to an Intensive Care Cnit (surgical, neurosurgical, anesthesia, pediatric). In order to estimale the se\'erily of the injuries. lhe children \\'ere classified relrospecli\'ely according to lhe Pediatric Trauma Score (Ped TS) (14). In 8 cases the a\'ailable documentation \\'as insufficient for classifying. For the remaining children (n = 60) Figure 1 shO\\'s the score distribution, Children who died in the Emergency Room had Ped TS values of
Table 2 Mortallty In relation to Pedlatnc Trauma Score In 60 chlldren with multiple trauma. Number dled
Mortality %
1 2 3
1 1 2 1
~4
0
100% 100% 50% 17 % 0%
Ped TS 0
under 2. Five more children died in the hospital; their primary TS values were bet\\'een 0 and 3 (Table 2). Of the children who had Ped TS scores of more than 4 at the time of admission, none died. Cause of death \\'as in almost all cases cranio-cerebral trauma; in two older children (7 and 9 years old) thoracic trauma paltly accounted for their fataloutcomes.
Discussion ~e\\'er studies from the L'nited States (5) show lhe importance of multiple trauma in children. After extensive setting-up of regional trauma centers, in 1985, at anational conference, childhood multiple trauma \\'as stated to be a "distinct area of medical interest". The authors complained that although traumatology is fully recognized as a branch of surgery, there is no corresponding status for pediatric surgery in the treatment of injured children.
In the FederaI Republic of Germany traffic accident figures are the only source of exact documentation of accidents in childhood. Other accidents are only recorded if they cause the death of the child. The mortality statistics show the predominant role of traffic accidents in children and youths. If we consider the numbers of injured children, whether lighUy or severely, it is clear that accidental injuries are the greatest health problem in childhood! In our clinic almost 30 % of the total nurnber of multiply-injured patients are children or youths, which shows the importance of this disease picture. Nevertheless, it is surprising that multiple trauma in childhood is underreported in the specialized literature. A review of all relevant articles in the German surgical and specialized accidentliterature since 1980 produced less than 10 articles which even covered partial aspects of pediatric multiple trauma. The "subordinate" role of childhood multiple trauma is also shoWTI by a data bank search of more than 200000 tiUes on the subject of multiple injuries, or polytrauma, there ,vere only 50 literature citations limited to childhood injuries.
10
10
6
5
5
5 3
1
T
---l4_----l_L-.......L-_I--'_J.-
L -.L._T...L1
o
---"-_--->2
2
3
4
5
6
7
8
9
10 11 Ped TS
Fig. 1 Frequency dlstr'butlon of the Ped,atrlc Trauma Score In 60 chlldren wlth multiple trauma
Downloaded by: Universite Laval. Copyrighted material.
346
Eur J Pedialr Surg 2 (1992)
Tize Signijicance ofJlultiple Trauma in C1lildren The Pedlatrlc Trauma Score (Tepas and Ramenofsky).
IEvaluation pOints Body weight Respiration Systol ic blood pressure Levelof consclousness Skeletal mJury Soft tlssue InJury
+2
1+1
20-40 kg
1
normal over 90 awake
10- 20 kg borderlme
none
50-90 mmHg obtunded/ unconsCious closed fracture
none
sllght
I below 10 kg Intubation below 50 coma/extensor spasms open/multiple fractures extensive/ penetratmg
--------
In the United States O\'er lhe lasl few years following lhe known mulliple trauma classifications (ISS; TS, AIS) original scoring for pediatric mulliple trauma was developed and, in palt, prospeclively validaled (13). The Pedialric Trauma Score (Ped TS) pro\'ed lo be especiaJly reliable and praclical. This score is determined from 6 measurable or assessible parameters, \\'hich are the body \\'eight, systolic blood pressure, respiralOl'Y stalus and le\'el of consciousness as \\'ell as the severily of bone and soft-tissue injuries (Table 3), The Ped TS has demonstraled ils reliabilily as an initial assessmenl in regard lo prognosis. II prO\'ides lhe prerequisite for a comparison of lrealmenl outcomes between \'arious centers and aJlows a retrospecli\'e quality control, in \\'hich periodicaJly lhe scores obtained can be compared to the actual mortality rale (11, 12), Over and abO\'e thal, there is the possibilily of analyzing the case series from the stand point of a\'oiding lrauma-caused fatal ilies; a problem wh ich, according to the American literalure showing numbers of over 50 % preventable deaths, has up to now received loo little attention (1, 2, 9), We did a retrospective classification of our palients according to Pediatric Trauma Scores (Fig, 1), While the literature puls lhe so-called crilical triage point, above which lhere is 0 mortality, al a Ped TS-value of 8, in our series this boundary value was lower (14), All children whose Ped TS score was 4 or greater survived (Table 3), The Ped TS provides early and accurate identification of particularly badly-hurt children and facilitates timely concentration of therapeutic efforts on these patienls, The pediatric age-group shows characteristic differences in patho-physiologic clinical courses as compared lo adults, The anatomic-physiologic peculiarities, as, for example, the slight protective effect of the bony connective tissue, but al the same time more rapid healing of fractures, or the sensitivity lo disturbances of waler and electrol)1.e balance in the presence of diminished renal ability to concentrale urine, have been clearly demonstrated, Slill, these data on resulls in the early phase of the treatmenl of mulliple injuries ha\'e scarcely been critically analyzed in lhe literalure (4, 7, 8). FinaJly, there is practicaJly no informalion on lhe long-term sequelae of mulliple-lrauma in children. Here \\'e
are dealing with not just the restoration of single-organ functions, particularly the locomotor apparatus, but even more the tracing of physical, social and psychologic developmental sequelae for the injured child and the family environment. A recent study from Boston shows lhat 80 % of all multiply-injured children later needed special schooling (6), Almo t 213 of noninjured siblings developed aggressive personality changes and became problems in schoo!. Al 0 1hof the parents nOliced deteriorations in their marriage, These data show thal multipleinjuries in childhood contain a considerable "hidden morbid ily", which can show itself years after the accident. These problems can be beller e\'aluated by systematic obsen'ation of lhese pedialric palienls, For lhis purpose we sel up in our clinic a prolocol which classified lhe injured child starting \\ith necessary data for his Ped TS score on admission to the Shock 1Jnit, as also the course of his further hospital care and clinical course al home,
References Cales R. 7h/llkey D. Pre\'entable trauma deaths. .-\ re\ie\\ of trauma rare systems del·elopment. JA.\\A 251 (1985) 1059 2 Dykes E, Spence L, )Ol/lIg}: Prel'entable pediatric trauma dealhs in a metropolitan region. J Pediatr Surg 2c1 (1989) 107 3 Ecke H. \'erletzungen des knöchernen Skeletts beim Polytraumatisierlen. Chirurg 19 (1978) 727 1 Flach ...I: Dringlichkeitsfragen bei der Ersll'ersorgung kombiniel1er \'erletzungen im Kindesalter. Langenbecks .-\rch Chir 329 (1971) 72 5 Harns B: Pediatric trauma. J Pediatr Surg 22 (1987) I 6 Harns B, Sclzwaitzberg S, Semall T: The hidden morbidity of pediatric trauma. J Pediatr Surg 2c1 (1989) 103 7 Hoftllalln S: Pathophysiologische Heaktionen des kindlichen Organismus bei Mehrfachverlelzungen. Langenbecks Arch Chir 337 (1974) 195 8 Hüner H: i\lehrfachverlelzungen bei Kindern und ihre Prognose. Langenbecks Arch Chir 322 (1968) 328 9 McJ{oy C, Bell ,\1: Pre\'entable traumatic deaths in children. J Pediatr Surg 18 (1983) 505 10 Popp 11': Behandlungsstrategie beim kindlichen Polytrauma. Beitr Orthop Traumatol 36 (1989) 129 11 Ramelloßky ,11, LutermanA, Qzzindlell E: .\ laximum sUI'\'ival in pediatric trauma: The ideal system. J Trauma 24 (198c1) 818 12 Ramelloßky M, Ramelloßky MB, jurkoviclz B, Threadgill D: The predictive \alidity of the pediatric trauma score. J Trauma 28 (1988) 1038 13 Tepasj, ,\1ollitt D, Talbert}: The pediatric trauma score as a predictor of injury se\'erity in the injured child, J Pediatr Surg 22 (1987) I cl 11 Tepasj, Ramelloßky ,\1, ,\1ollitt D, Galls B: The pediatric trauma score as a predictor of injury se\'erity: An objecti\'e a sessment. J Trauma 28 (1988) -125 15 Statistisches Bundesamt Wiesbaden: Fachserie 8, I~eihe 3.3 und Fachserie 12, Reihe I (1988) 1
Prof Dr. O. Paar Surgiral Clinic of the \Iedical Institute of H\\'TH-Aachen Pau\\'elstrasse 1 D-51 00 Aachen
Downloaded by: Universite Laval. Copyrighted material.
Table 3
347
The Significance of Multiple Trauma in Children O. Paar, R. Kasperk Surgieal Clinie of the .\\edieallnstilule of H\\'TII-Aaehen (Director: Prof. Dr. \'. Sehumpeliek)
Accident-related injuries, mainly trafficconnected, are the most serious threat to health and mostfrequent cause of death in the pediatric age group. L'sually these are multi-system injuries. \\'hile the total number of accidenls has decreased O\'er the last 20 years, traffic accidenls ha\'e becomc more serious. Com'entional prognostic score~ are not applicable in children with multiple injuries because of their essential pathophyiologic differences \\ith adulls. The Pediatric Trauma Score closes this gap. II is simple to use and prO\'ide high reliability.
Key words \Iultiple trauma in children - PTS - Prognosi
Resume Les lesions consecutives aux accidenls et en particulier en relation avec les accidenls de la circulation sont la cause la plus frequente de sequelles et de dece a l'age pediatrique. De faGon generale, il s'agit de polytraumatismes. Le nombre total des accidents a diminue depuis ces 20 dernieres annee mais les accidenls observes sont devenus plus severes. Les cores pronostiques conventionnels ne sont pas utilisables chez l'enfant polytraumatise a cause des differences physiopathologiques essentielles avec les adultes. Le score de
The spectrum of injuries from traffic accidents ha ba ically changed over the la t few decades a a result of increased motorization of ociety. Traffic accidenls are the mo t common traumatic e\-enls in almost all age group . Combined injuries of e\'eralorgan ystems 01' regions of the body are e pecially eriou, for \\'hich the concept of multiple trauma \\'as coined (10). In the 60's and ,O's the current principles for treating multiply-injured patienls \\-ere de\'ised (30). Today the effecti\'eness of this concept i unque tioned, but it still remains Hecei\l'd Oetoher :20. IUHU Eur ) Ped,alr SlIr~ 2 (1\)\'2) JI5-Jli © Illppo!-.rale" \ crla~ Slllllgari \\a""ol1 Edilellr Pari"
traumatologie pediatrique comble celle lacune. II est facile d'utilisation et compOlte une tres bonne fiabilite.
\Iots-eles Polytraumatisme chez I'enfant - PTS - Pronostic
Zusammenfassung L'nfallbedingte \'erJetzungen, zumeist im Hahmen eines \·erkehrsunfalles. sind die bedeutendste ernste Ge und heils törung und häufigste Todesursache im Kindesund frühen Jugendalter. Zumeist handelt e sich um \-erletzungen mehrerer Organe bZ\\. Körperregionen im Sinne eine Pol.\trauma. Während insgesamt eine Abnahme der L'nfallzahlen in den \'ergangenen 20 Jahren zu \'erzeichnen ist, hat gleichzeitig eine Yerschiebung zugunsten der schweren \'erletzungen stattgefunden. Kom'entionelle prognostische Scores sind aufgrund wesenUicher Cnterschiede in den pathophysiologischen Abläufen bei polytraumatisierten Kindern nicht anwendbar. Der Pediatric Trauma Score schließt diese Lücke. Er zeichnet sich durch einfache Handhabung und hohe Zuverläs igkeit aus.
Schlüsselwörter Kindliches Polytrauma - PTS - Prognose
to be tested \\'hether this treatment approach is a effective in children a it i in adult patients. The follO\\ing analy is \\-iJI point out the numerical importance of multiple trauma in children, as \\'eJl as existing inadequacies in the care of these badly-injured children and starting poinls for impro\'emenls in pediatric trauma care.
Frequency of multiple trauma in childhood Only the numbers of traffic and school accidenls im'olving children up to the age of 16 years are a\'ailabJe for a statistically accurate analysis.
Downloaded by: Universite Laval. Copyrighted material.
Summary
O. Paar and R. Kasperk
EurJ Pediatr Surg 2 (J 992)
The data from the Federal Republic Office of Vital Statistics used in this study cover the time period from 1965 until 1987 (15). There has been a continuous drop in the nurnber of accidents over the last 20 years. The relative proportion of severely injured children, however, has clearly increased. The percentage of fatalities in children in the O\'er-all traffic accident mortality in 1987 was 9.1 %; in 1965 it had been 11.2 %. In addition it must be taken into account that during this time period the number of children in the Federal Republic dropped to 31.5 %. There was, then, a drop in the number of traffic fatalities in children of 39.4 %, but a decline in severely injured children of only 14.4 %. Every 10th se\'erelyinjured traffic \-iclim in 1987 \\'as younger than 16 years old. Expressed in absolute numbers, 387 children died in traffic accidents and 11649 \\'ere se\'erely injured. The German Federal Hepublic thus takes the lead in all of Europe. A break-down according to age groups shows that with increasing age of children the risk of accident increases. One-third of all children injured in traffic are bel\\'een 6 and 9 years, and 41 % were bet\\'een 10 and 15 years. Boys and gi rI are equal in the general population but three out of four injured under the age of 16 are boys. \ \ortality statistics bet\\'een the ages of one and fifteen are for accidents in general; between fiw and fifteen traffic accidents account for most (15).
Table 1
Age dlstnbutlon
In
68 multl,traumatlzed chlldren Portion
Age
1
7% 42% 34% 17 %
1- 5 6-10 11-15
Authors' series We analyzed our own series between 1/1/87 and 3/31/89. During this time period (27 months) 68 children under the age of 16 were admitted with the diagnosis of multiple trauma. The total number of multiple trauma admis ions O\'er this time period wa 249. 27 % of these patients were under 16. The sex ratio was 2 to I (45 boys and 23 girls), The most frequenUy invoh'ed age \\'as the 1-5 year age-group with 17 %, followed by the under one-year-old patients, with 7 %. Foul' of the children died in the ambulance (6 %), ages 1,2, 3 and 4 respectively (Table I). After primary stabilization of \-ital signs under the care of Accident Surgeon and Anesthesiologi ts in the Shock l'nit, depending on the general condition and injurypattern of the injured patient, the patient was transferred to an Intensive Care Cnit (surgical, neurosurgical, anesthesia, pediatric). In order to estimale the se\'erily of the injuries. lhe children \\'ere classified relrospecli\'ely according to lhe Pediatric Trauma Score (Ped TS) (14). In 8 cases the a\'ailable documentation \\'as insufficient for classifying. For the remaining children (n = 60) Figure 1 shO\\'s the score distribution, Children who died in the Emergency Room had Ped TS values of
Table 2 Mortallty In relation to Pedlatnc Trauma Score In 60 chlldren with multiple trauma. Number dled
Mortality %
1 2 3
1 1 2 1
~4
0
100% 100% 50% 17 % 0%
Ped TS 0
under 2. Five more children died in the hospital; their primary TS values were bet\\'een 0 and 3 (Table 2). Of the children who had Ped TS scores of more than 4 at the time of admission, none died. Cause of death \\'as in almost all cases cranio-cerebral trauma; in two older children (7 and 9 years old) thoracic trauma paltly accounted for their fataloutcomes.
Discussion ~e\\'er studies from the L'nited States (5) show lhe importance of multiple trauma in children. After extensive setting-up of regional trauma centers, in 1985, at anational conference, childhood multiple trauma \\'as stated to be a "distinct area of medical interest". The authors complained that although traumatology is fully recognized as a branch of surgery, there is no corresponding status for pediatric surgery in the treatment of injured children.
In the FederaI Republic of Germany traffic accident figures are the only source of exact documentation of accidents in childhood. Other accidents are only recorded if they cause the death of the child. The mortality statistics show the predominant role of traffic accidents in children and youths. If we consider the numbers of injured children, whether lighUy or severely, it is clear that accidental injuries are the greatest health problem in childhood! In our clinic almost 30 % of the total nurnber of multiply-injured patients are children or youths, which shows the importance of this disease picture. Nevertheless, it is surprising that multiple trauma in childhood is underreported in the specialized literature. A review of all relevant articles in the German surgical and specialized accidentliterature since 1980 produced less than 10 articles which even covered partial aspects of pediatric multiple trauma. The "subordinate" role of childhood multiple trauma is also shoWTI by a data bank search of more than 200000 tiUes on the subject of multiple injuries, or polytrauma, there ,vere only 50 literature citations limited to childhood injuries.
10
10
6
5
5
5 3
1
T
---l4_----l_L-.......L-_I--'_J.-
L -.L._T...L1
o
---"-_--->2
2
3
4
5
6
7
8
9
10 11 Ped TS
Fig. 1 Frequency dlstr'butlon of the Ped,atrlc Trauma Score In 60 chlldren wlth multiple trauma
Downloaded by: Universite Laval. Copyrighted material.
346
Eur J Pedialr Surg 2 (1992)
Tize Signijicance ofJlultiple Trauma in C1lildren The Pedlatrlc Trauma Score (Tepas and Ramenofsky).
IEvaluation pOints Body weight Respiration Systol ic blood pressure Levelof consclousness Skeletal mJury Soft tlssue InJury
+2
1+1
20-40 kg
1
normal over 90 awake
10- 20 kg borderlme
none
50-90 mmHg obtunded/ unconsCious closed fracture
none
sllght
I below 10 kg Intubation below 50 coma/extensor spasms open/multiple fractures extensive/ penetratmg
--------
In the United States O\'er lhe lasl few years following lhe known mulliple trauma classifications (ISS; TS, AIS) original scoring for pediatric mulliple trauma was developed and, in palt, prospeclively validaled (13). The Pedialric Trauma Score (Ped TS) pro\'ed lo be especiaJly reliable and praclical. This score is determined from 6 measurable or assessible parameters, \\'hich are the body \\'eight, systolic blood pressure, respiralOl'Y stalus and le\'el of consciousness as \\'ell as the severily of bone and soft-tissue injuries (Table 3), The Ped TS has demonstraled ils reliabilily as an initial assessmenl in regard lo prognosis. II prO\'ides lhe prerequisite for a comparison of lrealmenl outcomes between \'arious centers and aJlows a retrospecli\'e quality control, in \\'hich periodicaJly lhe scores obtained can be compared to the actual mortality rale (11, 12), Over and abO\'e thal, there is the possibilily of analyzing the case series from the stand point of a\'oiding lrauma-caused fatal ilies; a problem wh ich, according to the American literalure showing numbers of over 50 % preventable deaths, has up to now received loo little attention (1, 2, 9), We did a retrospective classification of our palients according to Pediatric Trauma Scores (Fig, 1), While the literature puls lhe so-called crilical triage point, above which lhere is 0 mortality, al a Ped TS-value of 8, in our series this boundary value was lower (14), All children whose Ped TS score was 4 or greater survived (Table 3), The Ped TS provides early and accurate identification of particularly badly-hurt children and facilitates timely concentration of therapeutic efforts on these patienls, The pediatric age-group shows characteristic differences in patho-physiologic clinical courses as compared lo adults, The anatomic-physiologic peculiarities, as, for example, the slight protective effect of the bony connective tissue, but al the same time more rapid healing of fractures, or the sensitivity lo disturbances of waler and electrol)1.e balance in the presence of diminished renal ability to concentrale urine, have been clearly demonstrated, Slill, these data on resulls in the early phase of the treatmenl of mulliple injuries ha\'e scarcely been critically analyzed in lhe literalure (4, 7, 8). FinaJly, there is practicaJly no informalion on lhe long-term sequelae of mulliple-lrauma in children. Here \\'e
are dealing with not just the restoration of single-organ functions, particularly the locomotor apparatus, but even more the tracing of physical, social and psychologic developmental sequelae for the injured child and the family environment. A recent study from Boston shows lhat 80 % of all multiply-injured children later needed special schooling (6), Almo t 213 of noninjured siblings developed aggressive personality changes and became problems in schoo!. Al 0 1hof the parents nOliced deteriorations in their marriage, These data show thal multipleinjuries in childhood contain a considerable "hidden morbid ily", which can show itself years after the accident. These problems can be beller e\'aluated by systematic obsen'ation of lhese pedialric palienls, For lhis purpose we sel up in our clinic a prolocol which classified lhe injured child starting \\ith necessary data for his Ped TS score on admission to the Shock 1Jnit, as also the course of his further hospital care and clinical course al home,
References Cales R. 7h/llkey D. Pre\'entable trauma deaths. .-\ re\ie\\ of trauma rare systems del·elopment. JA.\\A 251 (1985) 1059 2 Dykes E, Spence L, )Ol/lIg}: Prel'entable pediatric trauma dealhs in a metropolitan region. J Pediatr Surg 2c1 (1989) 107 3 Ecke H. \'erletzungen des knöchernen Skeletts beim Polytraumatisierlen. Chirurg 19 (1978) 727 1 Flach ...I: Dringlichkeitsfragen bei der Ersll'ersorgung kombiniel1er \'erletzungen im Kindesalter. Langenbecks .-\rch Chir 329 (1971) 72 5 Harns B: Pediatric trauma. J Pediatr Surg 22 (1987) I 6 Harns B, Sclzwaitzberg S, Semall T: The hidden morbidity of pediatric trauma. J Pediatr Surg 2c1 (1989) 103 7 Hoftllalln S: Pathophysiologische Heaktionen des kindlichen Organismus bei Mehrfachverlelzungen. Langenbecks Arch Chir 337 (1974) 195 8 Hüner H: i\lehrfachverlelzungen bei Kindern und ihre Prognose. Langenbecks Arch Chir 322 (1968) 328 9 McJ{oy C, Bell ,\1: Pre\'entable traumatic deaths in children. J Pediatr Surg 18 (1983) 505 10 Popp 11': Behandlungsstrategie beim kindlichen Polytrauma. Beitr Orthop Traumatol 36 (1989) 129 11 Ramelloßky ,11, LutermanA, Qzzindlell E: .\ laximum sUI'\'ival in pediatric trauma: The ideal system. J Trauma 24 (198c1) 818 12 Ramelloßky M, Ramelloßky MB, jurkoviclz B, Threadgill D: The predictive \alidity of the pediatric trauma score. J Trauma 28 (1988) 1038 13 Tepasj, ,\1ollitt D, Talbert}: The pediatric trauma score as a predictor of injury se\'erity in the injured child, J Pediatr Surg 22 (1987) I cl 11 Tepasj, Ramelloßky ,\1, ,\1ollitt D, Galls B: The pediatric trauma score as a predictor of injury se\'erity: An objecti\'e a sessment. J Trauma 28 (1988) -125 15 Statistisches Bundesamt Wiesbaden: Fachserie 8, I~eihe 3.3 und Fachserie 12, Reihe I (1988) 1
Prof Dr. O. Paar Surgiral Clinic of the \Iedical Institute of H\\'TH-Aachen Pau\\'elstrasse 1 D-51 00 Aachen
Downloaded by: Universite Laval. Copyrighted material.
Table 3
347
