Paediatric Trauma Paediatric Trauma

Dr. Ashok Jaisingani Dr. Ashok Jaisingani

Introduction Introduction

►Trauma is leading cause of death in Trauma is leading cause of death in children and adolescence in western children and adolescence in western countries. countries.

►Many of these death are avoidable if Many of these death are avoidable if proper care and effective treatment is proper care and effective treatment is given. given.

Primary Survey Primary Survey

► Approached to the child with major injuries Approached to the child with major injuries advocated by “advance trauma life support” advocated by “advance trauma life support” (ATLS), program is essential. Primary survey (ATLS), program is essential. Primary survey focus on focus on a) a) AAirway irway b) b) CCervical spineervical spinec) c) BBreathing reathing d) d) CCirculationirculatione) e) CControl of bleeding ontrol of bleeding f) f) AAssessment of conscious level, ssessment of conscious level, g) g) PPupil size & reactivityupil size & reactivityh) h) RRapid overview of all injuries apid overview of all injuries

Resuscitation Resuscitation

► Give first priority of treating to life – threatening Give first priority of treating to life – threatening problems, identify during primary survey. problems, identify during primary survey.

► Pt with cardiorespiratory compromise should be Pt with cardiorespiratory compromise should be provided with high – flow oxygen provided with high – flow oxygen

► Endotracheal intubation and ventilation are require if Endotracheal intubation and ventilation are require if OO22 is inadequate in child with severe head injury or to is inadequate in child with severe head injury or to control flail chest.control flail chest.

► Pneumothorax & haemothorax are best treated by Pneumothorax & haemothorax are best treated by chest tube drainage. chest tube drainage.

► Two large peripheral IV canulae require in severely Two large peripheral IV canulae require in severely injured children. injured children.

► Central venous access should only be assess by Central venous access should only be assess by expert. expert.

Resuscitation Resuscitation

► Overextension of the neck during the maintenance of Overextension of the neck during the maintenance of airway result in respiratory compromisation (short airway result in respiratory compromisation (short neck and relatively larger tongue) neck and relatively larger tongue)

► Circulation is evaluated from vital signs, capillary refill Circulation is evaluated from vital signs, capillary refill time, skin color, temperature and mental status. time, skin color, temperature and mental status.

► Systolic BP is normal until 25% of circulatory volume Systolic BP is normal until 25% of circulatory volume has been lost. has been lost.

► Intraosseous vascular assess is helpful in children Intraosseous vascular assess is helpful in children ► Cervical spine injury can be present without Cervical spine injury can be present without

radiological signs, after major trauma cervical spine radiological signs, after major trauma cervical spine injury should be assumed until it can be excluded by injury should be assumed until it can be excluded by full neurological assessment, the neck must be full neurological assessment, the neck must be immobilized. immobilized.

Secondary Survey & Emergency Secondary Survey & Emergency Management Management

►When pt become stable, the secondary When pt become stable, the secondary survey attempt to identify all injuries survey attempt to identify all injuries in a systemic way by detailed clinical in a systemic way by detailed clinical examination and appropriate examination and appropriate investigation. investigation.

►Emergency treatment involveEmergency treatment involve1- Treatment of chest injuries 1- Treatment of chest injuries 2- Treatment of abdominal injuries. 2- Treatment of abdominal injuries.

Emergency Treatment Of Chest Emergency Treatment Of Chest Injuries Injuries

► Children have relatively elastic ribs, that fracture Children have relatively elastic ribs, that fracture rarely, despite that lungs contusion is common rarely, despite that lungs contusion is common without ribs fracture. without ribs fracture.

► Major thoracic injuries may coexist despite normal Major thoracic injuries may coexist despite normal radiographic findings are radiographic findings are 1) Tension pneumothorax 1) Tension pneumothorax 2) Massive Haemothorax 2) Massive Haemothorax 3) Cardiac Temponade 3) Cardiac Temponade

► In all cases airway should be secured, O2 is given In all cases airway should be secured, O2 is given and hypovolemia is corrected with IV – fluid and hypovolemia is corrected with IV – fluid

► Diaphragmatic rupture after blunt abdominal Diaphragmatic rupture after blunt abdominal trauma can be detected by chest x-ray or CT-scan, trauma can be detected by chest x-ray or CT-scan, surgical repair is undertaken once the pt become surgical repair is undertaken once the pt become stable stable

Emergency Treatment Of Emergency Treatment Of Tension Pneumothorax Tension Pneumothorax

►Tension pneumothorax require prompt Tension pneumothorax require prompt clinical diagnosis and immediate clinical diagnosis and immediate needle thoracocentesis.needle thoracocentesis.

►The needle should be inserted via The needle should be inserted via “second inercostal space”, “second inercostal space”, “midclavicular line”.“midclavicular line”.

►Thoracocentesis is followed by chest Thoracocentesis is followed by chest tube drainage. tube drainage.

Massive Haemothorax Massive Haemothorax

►Massive haemothorax is treated by Massive haemothorax is treated by chest tube drainage via “fifth chest tube drainage via “fifth intercostals space midaxillary line”. intercostals space midaxillary line”.

Cardiac Temponade Cardiac Temponade

►Cardiac temponade may follow blunt Cardiac temponade may follow blunt or penetrating chest injury. or penetrating chest injury.

► It require emergency needle It require emergency needle “pericardiocentesis”. “pericardiocentesis”.

Emergency Management Of Emergency Management Of Abdominal Trauma Abdominal Trauma

► Blunt abdominal trauma is generally more Blunt abdominal trauma is generally more common than penetrating injury. common than penetrating injury.

► In children more vulnerable organs are liver In children more vulnerable organs are liver and spleen because less protected by pliable and spleen because less protected by pliable rib cage. rib cage.

► Intra-abdominal or intra-thoracic bleeding is Intra-abdominal or intra-thoracic bleeding is likely in shock child with no obvious source of likely in shock child with no obvious source of hemorrhage. hemorrhage.

► The abdomen must be carefully inspected for The abdomen must be carefully inspected for sign of patterned bruising which indicate sign of patterned bruising which indicate forceful compression against rigid skeleton. forceful compression against rigid skeleton.

Investigations used In Investigations used In Abdominal Trauma Abdominal Trauma

► The definitive radiological investigation of The definitive radiological investigation of major abdominal trauma in haemodynamically major abdominal trauma in haemodynamically stable child is CT – scan with IV – contrast. stable child is CT – scan with IV – contrast.

► Expert ultrasound scanning is readily available Expert ultrasound scanning is readily available it can demonstrate free abdominal fluid and it can demonstrate free abdominal fluid and solid organ injuries but it is not valuable as CT solid organ injuries but it is not valuable as CT

►Diagnostic peritoneal lavage is obsolete in Diagnostic peritoneal lavage is obsolete in children because modern imaging is superior children because modern imaging is superior

► Laprotomy is indicated for bowl perforation Laprotomy is indicated for bowl perforation and penetrating trauma. and penetrating trauma.

Isolated Splenic Or Liver Isolated Splenic Or Liver Injury Injury

► Isolated splenic or liver injury can be Isolated splenic or liver injury can be safely managed non-operatively in safely managed non-operatively in majority of the child with blunt majority of the child with blunt abdominal trauma. abdominal trauma.

►Hemorrhage is frequently self limiting, Hemorrhage is frequently self limiting, so that unnecessary surgery and long so that unnecessary surgery and long term risk of splenectomy can be term risk of splenectomy can be avoided. avoided.

Non-operative Management Of Non-operative Management Of Isolated Splenic or Liver Injuries Isolated Splenic or Liver Injuries ►Haemodynamic stability after Haemodynamic stability after

resuscitation with fluid not more than resuscitation with fluid not more than 40 – 60 ml/kg.40 – 60 ml/kg.

►Good quality of CT-scan. Good quality of CT-scan. ►No evidences of hollow visceral injury. No evidences of hollow visceral injury. ►Frequent careful monitoring and Frequent careful monitoring and

immediate availability of necessary immediate availability of necessary surgical expertise. surgical expertise.

Children With Intra-abdominal Children With Intra-abdominal Bleeding Bleeding

►Child with ongoing intra-abdominal Child with ongoing intra-abdominal bleeding require laprotomy.bleeding require laprotomy.

►Preliminary angiography and arterial Preliminary angiography and arterial embolization can be useful in some embolization can be useful in some cases of hepatic trauma. cases of hepatic trauma.

►Bile leak is uncommon and managed Bile leak is uncommon and managed with radiological techniques with radiological techniques

Accidental Pattern Of Injury Accidental Pattern Of Injury

► Pattern of injury often reflect the mechanism as Pattern of injury often reflect the mechanism as ► Lap belt trauma from motor vehicle crush may Lap belt trauma from motor vehicle crush may

cause injury to duodenum or jejunum and cause injury to duodenum or jejunum and lumbar spine.lumbar spine.

► Bicycle handlebar injuries associated with liver Bicycle handlebar injuries associated with liver or pancreatic trauma. or pancreatic trauma.

► Straddle injuries may damage urethra and Straddle injuries may damage urethra and pelvis pelvis

► Runover injuries may cause severe crushing of Runover injuries may cause severe crushing of chest or abdomen. chest or abdomen.

Non-accidental Pattern Of Non-accidental Pattern Of Injury Injury

► Non-accidental injury must considered in following Non-accidental injury must considered in following casescases

► Multiple injuries at different stage of healing Multiple injuries at different stage of healing ► Different types of injuries such as Different types of injuries such as

a) Soft Tissuesa) Soft Tissuesb) Fracture b) Fracture c) Burn & Scald c) Burn & Scald d) Cut and bruised) Cut and bruise

► Significant delay between injury and seeking Significant delay between injury and seeking medical advice medical advice

► Inconsistent vague history or inappropriate parental Inconsistent vague history or inappropriate parental behavior. behavior.