Introduction

Trauma continues to be the leading cause of morbidity and mortality in the paediatric population. In Victoria there are around 2,000 trauma related presentations to the Royal Children’s Hospital, the paediatric Major Trauma Service (MTS), each year either through direct admission or via inter-hospital transfer. Between 100 and 130 of admissions to the RCH are defined as major trauma. The RCH paediatric major trauma admissions encompasses about 85 per cent of all paediatric major traumas in Victoria. ^{2 3} The percentage of major trauma among paediatric (<16 years) patients remains low, at 4.5 %. ⁴

Children are vulnerable to injury for a variety of reasons. As they are developing they tend to be clumsy and can easily fall; they have poor judgement and little awareness of potential harms. Their ill-considered actions, such as reaching for a hot saucepan, can lead to injury. As children reach adolescence they may engage in risk-taking behaviour with little regard for the consequences of their actions.

Motor vehicle accidents account for almost half of the fatalities in children. Correctly fitted child restraints are key to avoiding injury in children. Reviewing how a child was restrained in a vehicle assists in identifying a potential injury pattern. Inappropriately restrained children should have a DHS notification made. For more information on correct child restraints see: http://www.kidsafe.com.au/crguidelines
Being aware of the differences between adult and paediatric patients is essential in managing paediatric major trauma. The sequence of concurrent assessment and actions are the same. The approach relates directly to the anatomical and physiological differences and the injury pattern that could be caused relative to the mechanism of injury.⁵ 
Children have a smaller body mass, therefore, for example, in a car accident, a greater force of energy is applied and transmitted to a body that has less fat, connective tissue and closer internal organs, leading to a high frequency of multiple injuries.⁶ The skeleton of a child is not mature and is less resilient, therefore it is more likely to transmit the kinetic forces applied during a traumatic event, leading to significant internal injuries without obvious external signs. Lack of fracture does not indicate absence of underlying injury. In addition, children have a higher relative body surface area the younger they are, meaning they can rapidly become hypothermic. This can in turn complicate physiological responses to concomitantly occurring metabolic derangements, leading to severe coagulopathy and cardiovascular collapse.⁷ It is also key to note that the relative size of the head in children must be considered in both airway and cervical spine management.
 

Clinicians working outside of the paediatric MTS are often not as familiar with paediatric emergency management as they may be with adults. This may lead to a delay in children receiving appropriate initial care. This interval can have an adverse effect on both morbidity and mortality. It has been shown that younger and more seriously injured children have better outcomes when they are managed at a specialist trauma facility within a children’s hospital.⁸ It is therefore encouraged that early engagement and specialist consultation is sought when faced with a paediatric trauma patient. In Victoria, the Paediatric Infant Perinatal Emergency Retrieval (PIPER) service is available to retrieve critically injured children from referral hospitals and provide safe, expert, emergency inter-hospital retrieval. The earlier contact is made with PIPER, the earlier a retrieval can be initiated to provide assistance.
All paediatric trauma patients must receive a rapid and systematic primary and secondary survey, just the same as in adult care. The main goal is to ensure optimum resuscitation in the emergency setting as well as activation of the retrieval network, with timely transfer to an appropriate facility.