Pulmonary and respiratory complications of pediatric trauma.

Pediatric trauma management requires both operative and nonoperative (supportive) care. Fewer than 15% of pediatric trauma patients require surgery (Children's Hospital of Michigan Registry Data, excluding fractures), and the primacy of closed head injury and the multisystem nature of pediatric trauma dictate assessment and therapy. Complications arise at every level, including fluid resuscitation (too much or too little), antibiotics (too late), or pain control (inadequate). The institution of mechanical ventilation that is usually life-saving carries its own risks including those associated with intubation (perforation, aspiration, pro longed endotracheal intubation (stricture, pneumonia), and barotrauma (ventilator-induced lung injury). Minor procedures, such as thoracentesis, chest tube insertion, and pericardiocentesis, can all be complicated by perforation and hemorrhage. Major interventions, including laparotomy and thoracotomy, can result in hemorrhage, air leak, abdominal compartment syndrome, phrenic nerve and thoracic duct injury, postoperative abscess, and septicemia. Transfusion, cardiopulmonary bypass, and invasive monitoring can result in coagulopathy and vascular injury. Prolonged resuscitation and operative explorations can cause hypothermia and coagulopathy and initiate a cascade of multiorgan failure and ARDS. There is no doubt that rapid evacuation, prompt resuscitation, and organized systems of pediatric trauma care have reduced the overall mortality of childhood trauma. The higher velocity of travel and an increasingly chaotic urban environment have resulted in more multitrauma cases and in injuries of higher severity requiring more sophisticated and complicated diagnostic and therapeutic modalities. Our ability to identify life-threatening injuries, to provide expedited and definitive care, and to reduce and detect the complications predicted by these injuries and their treatment will result in long-term improvements in survival and significant reductions in morbidity.