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Chest x-ray showing multiple rib fractures from child abuse. Fractures of ribs 3, 4, and 10 on the right and ribs 8, 9, and 10 on the left. Image courtesy of Nancy Harper, MD Masonic Children's Hospital, Minneapolis, MN and Sonja Eddleman, RN, Driscoll Children's Hospital, Corpus Christi, TX.
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Trauma constitutes a significant cause of death and disability globally. The vast majority -about 95%, of the 5.8 million deaths each year, occur in low-and-middle-income countries (LMICs) 3–6. This includes almost 1 million children. The resource-adapted introduction of trauma care protocols, regionalized care and the growth specialized centers fo...
Citations
... This includes approximately 1 million children. Additional deleterious effects have been seen on children, international organizations such as the United Nations by the increase of global conflicts [34]. ...
Introduction: Trauma is a major problem which has a significant health, social, and economic impact. Particularly, pediatric trauma carries substantial mortality and morbidity. This is a great concern for subspecialized general and pediatric surgeons. Therefore, a global initiative for pediatric trauma care is warranted and should be initiated. Aim: The international association “Global Initiative for Children’s Surgery” (GICS) would like to propose and organize a children’s trauma care (CTC) initiative. This initiative should comprehensively address pediatric trauma management globally, especially in low- and middle-income countries (LMICs). The initiative seeks to achieve a structured cooperation and collaboration with respective sister organizations and local stakeholders. Methods: The initiative will address these relevant aspects: 1. first aid; 2. prehospital primary trauma care; 3. hospital primary trauma care; 4. advanced care (ATLS); 5. diagnostic facilities; 6. operation room (OR) equipment; 7. specialized surgical services; 8. rehabilitation; 9. registry, research, and auditing; 10. specialization in pediatric trauma; 11. capacity and confidence building in pediatric trauma; 12. prevention. The GICS CTC provided activities have been recorded and evaluated in a structured manner. This statement paper is based on data of a narrative review as well as expert opinions. Results: The Trauma Working Group of GICS provided specialized trauma prevention leaflets available for translation to different languages. A one-day children’s primary trauma course has been designed to be delivered at the physical GICS meetings. Exercising advocacy, the group addressed several meetings on prevention of pediatric trauma, which included the 75th United Nations General Assembly (UNGA) (2020), GICS IVth meeting in Johannesburg (2020), Norwich (UK) Joint SPRINT Symposium on Pediatric Surgery for Pediatricians (2021), the second online Pan African Pediatric Surgical Association (PAPSA) meeting (2021), the seventh World Congress of the World Federation of Associations of Pediatric Surgeons (WOFAPS) in Prague (2022), and GICS pediatric trauma webinar (2023). Additionally, the working group participated in the preparations of a pediatric trauma module for the World Health Organization (WHO) and published several related studies. The contents of the selected articles added relevant information to the categories stated above. Conclusions: The CTC initiative of GICS is proposed as a mean to address pediatric trauma comprehensively through a process of collaboration and advocacy with existing organizations to achieve awareness, health education, prevention, health, and training. Further, it will support the provision of suitable facilities to health institutions. The establishment of a specialization in pediatric trauma is encouraged. GICS CTC initiative aims to improve pediatric trauma care in LMICs by developing injury prevention strategies; optimizing the use of locally available resources; obtaining commitment by LMICs governments; improvement in all fields of hospital care; improvements in infrastructure, education and training, and attention to data registry and research.
... Noninvasive ICP monitoring methods include fluid dynamic methods like magnetic resonance imaging and transcranial doppler ultrasound, ophthalmologic methods like pupillometry and optic nerve ultrasound, otic methods, and electrophysiological methods [9,10]. In limited-resource settings, such as Uganda, invasive ICP monitoring techniques are often inadequate or unavailable due to the lack of infrastructure required for safe, routine use [11]. Currently, no noninvasive ICP monitoring devices are used clinically in Uganda, and more information is needed on existing monitoring methods. ...
... These concerns identified in this study could be related to barriers faced in the neurosurgical system in Uganda, including unreliable access to electricity, [35] difficulty with the maintenance of imported technology, [36,37] and limited health system funding [38]. Another concern identified in this study likely relates to the challenge of using pupillometry in LMICs, where alternative, invasive methods of ICP monitoring are often inadequate or unavailable [11]. While many providers in this study discussed the value of pupillometry to detect elevated ICP, some expressed concern that pupillometry could not be used to gain an exact, numerical estimate of ICP. ...
Introduction
Traumatic brain injury (TBI) accounts for the majority of Uganda’s neurosurgical disease burden; however, invasive intracranial pressure (ICP) monitoring is infrequently used. Noninvasive monitoring could change the care of patients in such a setting through quick detection of elevated ICP.
Purpose
Given the novelty of pupillometry in Uganda, this mixed methods study assessed the feasibility of pupillometry for noninvasive ICP monitoring for patients with TBI.
Methods
Twenty-two healthcare workers in Kampala, Uganda received education on pupillometry, practiced using the device on healthy volunteers, and completed interviews discussing pupillometry and its implementation. Interviews were assessed with qualitative analysis, while quantitative analysis evaluated learning time, measurement time, and accuracy of measurements by participants compared to a trainer’s measurements.
Results
Most participants (79%) reported a positive perception of pupillometry. Participants described the value of pupillometry in the care of patients during examination, monitoring, and intervention delivery. Commonly discussed concerns included pupillometry’s cost, understanding, and maintenance needs. Perceived implementation challenges included device availability and contraindications for use. Participants suggested offering continued education and engaging hospital leadership as implementation strategies. During training, the average learning time was 13.5 minutes (IQR 3.5), and the measurement time was 50.6 seconds (IQR 11.8). Paired t-tests to evaluate accuracy showed no statistically significant difference in comparison measurements.
Conclusion
Pupillometry was considered acceptable for noninvasive ICP monitoring of patients with TBI, and pupillometer use was shown to be feasible during training. However, key concerns would need to be addressed during implementation to aid device utilization.
... Statistics have shown an improvement in the survival rate in trauma patients in LRS, especially in head trauma patients. That is referred to as a merge of the continuity of CALS and ATLS training and the updated emergency protocols made specifically for low-resource institutions for pediatric patients [19]. ...
... Trauma remains a leading cause of child mortality in lowresource settings, urging the need for adapted trauma care protocols and specialized trauma centers [19]. The scarcity of resources and inadequate staffing levels contribute to delays in assessing and treating pediatric trauma cases, impacting outcomes significantly. ...
... However, initiatives like the Emergency Triage, Assessment, and Treatment Plus (ETAT +) training and locally developed trauma protocols have shown promise in improving the prioritization and management of pediatric emergency cases in low-resource settings, potentially enhancing outcomes. Organizations such as WHO and AFEM have offered adaptable guidelines for pediatric trauma care, accommodating local resource constraints and largely improving outcomes in various pediatric emergency centers [19]. ...
Purpose of Review
This review examines the state of pediatric emergency care in low-resource settings (LRS), highlighting significant gaps, particularly in resources and infrastructure.
Recent Findings
Recent assessments of pediatric emergency care in various low-resource settings reveal stark differences in resources and capabilities. For instance, the situation in Rwanda’s district hospitals illustrates disparities in numbers and resources. Similarly, Nigeria faces challenges stemming from institutional deficiencies, inadequate human resources, and insufficient training, necessitating urgent adjustments in training programs, resource allocation, and working conditions. In conflict-ridden Yemen, providing pediatric emergency care is further complicated by conflict-related obstacles, hindering prompt and efficient interventions. Despite these challenges, promising developments include improved metrics for pediatric emergency care services (PECS), strengthened emergency medical services (EMS), and advancements in healthcare professional training.
Summary
Addressing the ongoing challenges in pediatric emergency care in low-resource settings requires targeted strategies. These may include enhancing preparedness for emergencies, overcoming barriers to service provision, and providing comprehensive support and training to medical professionals. Recognizing these constraints and translating them into actionable recommendations are crucial for establishing a pathway towards sustainable long-term improvements in pediatric emergency care services within LRS.
... La mortalité varie en fonction de l'âge, avec des débats sur la mortalité la plus élevée chez les enfants de moins de 2 ans ou les enfants plus âgés [28]. Dans les pays à ressources limitées, les taux de mortalité sont plus élevés en raison de facteurs systémiques tels que l'hypotension, l'anémie et l'hyperthermie [1,29]. La prise en charge des TCP nécessite des ajustements locaux, notamment des soins préhospitaliers adaptés, une meilleure organisation des services d'urgence et une formation des soignants [1,29]. ...
... Dans les pays à ressources limitées, les taux de mortalité sont plus élevés en raison de facteurs systémiques tels que l'hypotension, l'anémie et l'hyperthermie [1,29]. La prise en charge des TCP nécessite des ajustements locaux, notamment des soins préhospitaliers adaptés, une meilleure organisation des services d'urgence et une formation des soignants [1,29]. L'absence de décès chez les enfants opérés souligne l'importance de maintenir des unités neurochirurgicales pour les traumatismes pédiatriques [30].Les rapports futurs devraient inclure des mesures à long terme des résultats pour évaluer les implications socio-économiques potentielles des déficits cognitifs subtils. ...
Objectif. Pediatric traumatic brain injury (PTBI) is the leading cause of death and a major source of morbidity in children worldwide. Despite their prevalence, our understanding of the epidemiological factors associated with these injuries remains incomplete. The aim of this study was to explore a variety of factors associated with these lesions, including mechanism, radiological diagnosis, neurosurgical management and outcome. Methods. This retrospective study, conducted over a 15- month period, focused on 270 cases of PTBI in children under 15 years of age admitted to the neurosurgical emergency department of Constantine University Hospital and who had received medical and surgical management for post-traumatic brain injuries. Results. A total of 270 patients were included in the study. The mean age was 3.5 years, with a sex ratio of 2.37. The main causes were falls (81.4%) and road traffic accidents (16.7%). The severity of the trauma was as follows: severe in 8,9% of cases, moderate in 26,3% and mild in 64,8%. The lesions identified on the CT scan were mainly cranial fractures (37,4%), epidural haematomas (32,2%) and depressed skull (14,8%). Surgery was required in 22.2% of cases, and mortality was 2,2%. Poor prognostic factors were a low Glasgow score and the severity of the injury. 14% underwent rehabilitation for minor sequelae. Conclusion. Falls and road traffic accidents are the main causes of head trauma in children. Most of these injuries are mild to moderate in severity, requiring CT imaging. To improve outcomes, it is imperative to devise an effective strategy to prevent falls and accidents in children.
... [29] However, even the Advanced Trauma Life Support (ATLS) course, the world's most successful trauma course offered in 86 countries, has only been completed by 6% of the world's physicians over the past 14 years. [30][31][32] Based on this scenario, we estimate that training four-member teams in every trauma center to treat the 60 million children who visit hospitals yearly [1,29,[33][34][35] could require an impossible investment of 1.2 billion US dollars in pediatric trauma education annually. ...
Purpose: Pediatric trauma is a leading cause of death and disability among children. While trauma education can improve these outcomes, it remains expensive and available only to a few providers worldwide. Innovative educational technologies like virtual reality (VR) can be key to democratizing trauma education. This study, therefore, evaluates the face and content validity of a VR platform designed to enhance pediatric trauma skills. Specifically, we seek to determine whether the platform effectively presents an injured child and comprehensively covers the essential tasks to successfully treat them within a trauma team.
Methods: Physicians were invited to test a VR platform simulating a child with blunt head and truncal trauma. After the simulation, they filled out surveys assessing the face and content validity of the scenario, including their opinions on the realism, interaction, ease of use, and the educational content of the platform. Additionally, they completed a cybersickness questionnaire. Demographic data were also collected, including age, gender, country of medical education, and previous experience with VR. A descriptive analysis was performed.
Results: Eleven physicians graduated from eight different countries tested the VR platform. Most (87%) found it valuable, and 81% preferred using it over high-fidelity mannequins for training purposes. The platform received more favorable evaluations for non-technical skills training (median: 5, IQR: 5.0 to 5.0) than for technical skills (median: 4, IQR: 3.0 to 5.0). Regarding cybersickness, 73% of the participants reported experiencing any or minimal discomfort during the simulation, and none needed to stop the test due to discomfort.
Conclusion: Our initial validation of a VR platform designed for pediatric trauma education was positive. Participants endorsed VR and its potential to enhance performance, particularly in non-technical skills. Encouraged by these results, we will proceed with feasibility and implementation studies, comparing VR to high-fidelity mannequins.
... Implementing professional interventions for violence prevention and child and family care in Buraydah, Al Qassim, is not without difficulties. Limited resources, such as financing and skilled personnel, can make these interventions unavailable and inaccessible (Kiragu et al., 2018;Schwab-Reese & Renner, 2018). To address this dilemma, government agencies, non-profit groups, and community leaders must work together to efficiently distribute resources and prioritize the well-being of children and families. ...
Addressing family violence in Al Qassim is critical for ensuring the well-being of children and encouraging stable households. This study explores effective professional interventions and innovative ways to protect and support families affected by violence, while considering the difficulties and critical aspects involved in their implementation. Family therapy, community education programs, trauma-informed care, and counseling services are described as useful interventions that improve communication, resolve problems, and create healthy relationships within families by the Osrah organization. Furthermore, technology-based therapies and arts-based therapy provide novel approaches to closing service gaps and promoting healing and resilience. Community empowerment, education programs, economic opportunities, and constant review are all part of long-term solutions. Al Qassim, specifically in Buraydah, may build a safer and more supportive environment by prioritizing the well-being of children and families and applying these techniques, fostering strong relationships within the community.
... While the fight against communicable diseases appears, to be succeeding due to the concerted effort by national governments, regional and global bodies in implementing and investing in actionable policies, particularly aimed at promoting preventive medicine and in strengthening primary health delivery and service, the same advances have not been achieved in childhood injuries (3). According to the World Health Organization (WHO), trauma accounted for 5 million deaths in 2016 (5) with an estimated 1 million child deaths (6,7). On average 100 children die from non-intentional injuries every hour (7,8). ...
... According to the World Health Organization (WHO), trauma accounted for 5 million deaths in 2016 (5) with an estimated 1 million child deaths (6,7). On average 100 children die from non-intentional injuries every hour (7,8). Disproportionately, 90-95% of these occur in children from LMICs (5,9). ...
... It is thus necessary that any adaptation of what could be presumed as the ideal should be pragmatic and its execution sustainable. This requires taking into consideration available human and material resources (7). The WHO has recommended the up-scaling of lay first responders in LMICs, as a prelude to a creating a robust pre-hospital emergency response system. ...
Trauma is rising as a cause of morbidity and mortality in lower-and middle-income countries (LMIC). This article describes the Epidemiology, Challenges, Management strategies and prevention of pediatric trauma in lower-and middle-income countries. The top five etiologies for non-intentional injuries leading to death are falls, road traffic injuries, burns, drowning and poisoning. The mortality rate in LMICs is twice that of High-Income Countries (HICs) even controlling for injury severity. The reasons for inadequate care include lack of facilities, transportation problems, lack of prehospital care, lack of resources and trained manpower to handle pediatric trauma. To overcome these challenges, attention to protocolized care and treatment adaptation based on resource availability is critical. Training in the management of trauma helps to reduce the mortality and morbidity in pediatric polytrauma cases. There is also a need for more collaborative research to prevent childhood trauma.
... The child injury death rate is 3.4 times higher in LMICs than in highincome countries [7], and pediatric injuries are a leading cause of morbidity and mortality in LMICs. While significant gains have been made in reducing child mortality toward the Sustainable Development Goals (SDGs) [8], this progress has focused primarily on infectious diseases and neglected the burden of injuries among children [9,10]. In order to close the gap on childhood survival, more emphasis needs to be placed on the growing problem of pediatric injury. ...
... The recovery of injured children in LMICs is often impeded by barriers in accessing and receiving timely and quality care at healthcare facilities. Healthcare providers in LMICs often face a variety of barriers when treating patients, such as resource limitations, inadequate staffing, large patient loads, lack of pre-hospital and transport services, financial difficulties for families, delayed presentation for illnesses and injuries, cultural differences, and a lack of specialist care [9,17,18]. Due to these challenges, it is important to investigate how these barriers impede quality of care for injured children. ...
... Few hospitals in LMICs have emergency medicine-trained specialists, and even fewer have pediatric emergency medicine specialists that have unique training in caring for acutely ill and seriously injured children. This leads to the majority of pediatric injury care being provided by healthcare providers with no specialized training in the management of pediatric trauma [9]. The lack of trained providers has been shown to have a significantly negative impact on outcomes [24]. ...
Pediatric injuries are a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). The recovery of injured children in LMICs is often impeded by barriers in accessing and receiving timely and quality care at healthcare facilities. The purpose of this study was to identify the barriers and the facilitators in pediatric injury care at Kilimanjaro Christian Medical Center (KCMC), a tertiary zonal referral hospital in Northern Tanzania. In this study, focus group discussions (FGDs) were conducted by trained interviewers who were fluent in English and Swahili in order to examine the barriers and facilitators in pediatric injury care. Five FGDs were completed from February 2021 to July 2021. Participants (n = 30) were healthcare providers from the emergency department, burn ward, surgical ward, and pediatric ward. De-identified transcripts were analyzed with team-based, applied thematic analysis using qualitative memo writing and consensus discussions. Our study found barriers that impeded pediatric injury care were: lack of pediatric-specific injury training and care guidelines, lack of appropriate pediatric-specific equipment, staffing shortages, lack of specialist care, and complexity of cases due to pre-hospital delays in patients presenting for care due to cultural and financial barriers. Facilitators that improved pediatric injury care were: team cooperation and commitment, strong priority and triage processes, benefits of a tertiary care facility, and flexibility of healthcare providers to provide specialized care if needed. The data highlights barriers and facilitators that could inform interventions to improve the care of pediatric injury patients in Northern Tanzania such as: increasing specialized provider training in pediatric injury management, the development of pediatric injury care guidelines, and improving access to pediatric-specific technologies and equipment.
... The point has been made those horizontal interventions, i.e., the ones that benefit several diseases at the same time may provide better services/care than vertical ones, such as strengthening surgery. That said, the provision of emergency trauma care in the country needs to be revisited, for instance, by making better use of some capacities locally available [29]. This could be extended to subnational level hospitals (different from the central ones). ...
Background:
Hospitals from resource-scarce countries encounter significant barriers to the provision of injury care, particularly for children. Shortages in material and human resources are seldom documented, not least in African settings. This study analyzed pediatric injury care resources in Mozambique hospital settings.
Methods:
We undertook a cross-sectional study, encompassing the country's four largest hospitals. Data was collected in November 2020 at the pediatric emergency units. Assessment of the resources available was made with standardized WHO emergency equipment and medication checklists, and direct observation of premises and procedures. The potential impact of unavailable equipment and medications in pediatric wards was assessed considering the provisions of injury care.
Results:
There were significant amounts of not available equipment and medications in all hospitals (ranging from 20% to 49%) and two central hospitals stood out in that regard. The top categories of not available equipment pertained to diagnosis and monitoring, safety for health care personnel, and airway management. Medications to treat infections and poisonings were those most frequently not available. There were several noteworthy and life-threatening shortcomings in how well the facilities were equipped for treating pediatric patients. The staff regarded lack of equipment and skills as the main obstacles to delivering quality injury care. Further, they prioritized the implementation of trauma courses and the establishment of trauma centers to strengthen pediatric injury care.
Conclusion:
The country's four largest hospitals had substantial quality-care threatening shortages due to lack of equipment and medications for pediatric injury care. All four hospitals face issues that put at risk staff safety and impede the implementation of essential care interventions for injured children. Staff wishes for better training, working environments adequately equipped and well-organized. The room for improvement is considerable, the study results may help to set priorities, to benefit better outcomes in child injuries.
... These data reinforce the importance and utility of trauma curricula in LMIC in improving trauma-related outcomes [2,6,13,14]. However, only half of studies reviewed here included paediatric content, emphasizing a gap in current LMIC educational practices that impact nearly 20% of the global trauma patient population [2,3]. ...
... Children are more prone to respiratory arrest causing cardiac arrest, altering how resuscitation methods are done [63]. Without an understanding of paediatric physiology and trauma management, providers lack the necessary tools to care for 20% of the global trauma population [2,3]. ...
... Current curricular reports describe high variability in content, making it difficult to transfer or evaluate educational efforts among diverse learner populations. This curricular deficiency also falls short of the training needs necessary for providers to care for children, who are 20% of the global trauma patient population and who have a 32% preventable death rate related to trauma injuries [2,3,25]. Further work is needed in curriculum assessment tools and paediatric-focused trauma education. ...
Background:
Trauma-specific training improves clinician comfort and reduces patient morbidity and mortality; however, curricular content, especially with regard to paediatric trauma, varies greatly by region and income status. We sought to understand how much paediatric education is included in trauma curricula taught in low- and middle-income countries (LMICs).
Methods:
We conducted a systematic literature review in October 2020 and in July 2022 based on PRISMA guidelines, utilizing seven databases: MEDLINE, Scopus, Web of Science, CINAHL, Cochrane Reviews, Cochrane Trials, and Global Index Medicus. Reports were limited to those from World Bank-designated LMICs. Key information reviewed included use of a trauma curriculum, patient-related outcomes, and provider/participant outcomes.
Results:
The search yielded 2008 reports, with 987 included for initial screening. Thirty-nine of these were selected for review based on inclusion criteria. Sixteen unique trauma curricula used in LMICs were identified, with only two being specific to paediatric trauma. Seven of the adult-focused trauma programmes included sections on paediatric trauma. Curricular content varied significantly in educational topics and skills assessed. Among the 39 included curricula, 33 were evaluated based on provider-based outcomes and six on patient-based outcomes. All provider-based outcome reports showed increased knowledge acquisition and comfort. Four of the five patient-based outcome reports showed reduction in trauma-related morbidity and mortality.
Conclusion:
Trauma curricula in LMICs positively impact provider knowledge and may decrease trauma-related morbidity and mortality; however, there is significant variability in existing trauma curricula regarding to paediatric-specific content. Trauma education in LMICs should expand paediatric-specific education, as this population appears to be underserved by most existing curricula.
