AB van As, TF Lutz, AJ Millar, H Rode

Trauma Unit, Child Accident Prevention Foundation of Southern Africa, Department of Paediatric Surgery, Institute of Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, South Africa


Introduction Despite many efforts in accident prevention during recent years, trauma remains the leading cause of death in the paediatric age group. Although the adult shock syndrome has been described in detail, little is known about traumatic shock in children.

Aim To study prognostic indicators in all children presenting to our trauma unit with clinical signs or symptoms of shock.

Materials and methods A retrospective study was conducted from the 1st of January 1997 till the 1st of January 2000. (36 month period) The records of 57 patients were analysed. Information was gathered regarding age, sex, weight, initial vital signs, pre-hospital management, type of injury, in-hospital management, urine output, blood investigations and outcome.

Results The majority of patients were involved in a motor vehicle accident (65%), other causes were gunshots (12%), fire burns (9%) and non-fire burns (5%). The outcome of 45% of all patients was good, while in 32% the shock was fatal. 21% recovered, but was left with permanent neurological dysfunction, while 2% suffered permanent orthopaedic deficits. Mortality was the highest amongst the very young (47% amongst the children younger than 2 years versus only 16% amongst the 9-12 years old) and the very small (55% amongst the children lower than 10 kg versus 29% amongst the children from 21-30 kg). Mortality was 68% from the children presenting with an initial blood pressure of less than 50 mmHG (mean arterial pressure) versus 14% from the children with a blood pressure of more than 50 mmHg. Mortality was the highest in children presenting with fire burns (90%), less in gunshots (42%) and motor vehicle accidents (24%), while no child presenting with non-fire burn died. All children with cardiopulmonary resuscitation in progress or children that received pre-hospital atropine or adrenaline, died. 66% of all children with an Hemoglobin level of less than 7 (mg/dl) died versus only 10% of children with a level of more than 10 (mg/dl). From all children with a base excess of less than 7, 44% died, while 80% died of all children with a base excess of more than 12. All children (100%) who received less than 10 ml/kg resuscitation fluid in the first hour died, while only 13% died if fluid resuscitation was between 10 and 80 ml/kg in the first hour.

Conclusion Specific bad prognostic indicators in paediatric traumatic shock are: low age, weight, pre-hospital adrenaline or atropine, low blood pressure on arrival, cardiopulmonary resuscitation in progress on arrival and fire burns, as well as under-resuscitation in the first hour after arriving in the hospital. Early aggressive fluid resuscitation should take priority in all children presenting with traumatic shock, especially the very young and very small.