pediatric trauma jessica mills, md, frcsc assistant professor surgery, pediatric surgeon
TRANSCRIPT
Pediatric Trauma
Jessica Mills, MD, FRCSCAssistant Professor Surgery, Pediatric
Surgeon
Objectives
Epidemiology of Pediatric Trauma
Pediatric Injury Patterns
Imaging in Pediatric Trauma
Pediatric ABCDE’s and Pitfalls Clinical Decision Rules to guide Imaging choices
Pediatric Pain Assessment tools
Triage of Pediatric Trauma in NY State STAC 2014 Guidelines
The Scope of the Problem
Trauma most common cause of death > 1 yr
Causes almost half of deaths < 15 yrs 38% MVC 13% Homicide 13% Drowning 9% Fire/Burn 5% Suicide
In-hospital mortality low
20 children die every day
Burden of disability incalculable1/2 have social, affective and learning
disabilities2/3 siblings have emotional disturbancesFinancial/Employment troubles for parentsMarital strain
The Scope of the Problem
Why so Vulnerable?
Children put themselves at riskHigh curiosity + Low Judgement = Injury
Falls most common mechanism in younger children
Violence most common in older teens
Higher risk of significant injury
Why so Vulnerable?
Goal = Prevention
Reality = Minimizing morbidity and mortality
What can we do?
Pediatric Injury Patterns
Multitrauma is the Rule
Multitrauma is the Rule
Multitrauma is the Rule
Very difficult in conscious younger children
Invest time in starting slowlyChildren can smell fear!Develop rapportSoothe and cajole
Use parent as your allyControl personal emotions
Examine the Patient?
Scan the Patient?
CT Scan considered gold standard
Worry about missed injuries ? Increase in morbidity/mortality ? Legal concern
Increasing awareness of radiation risks Younger patient = More vulnerable
Bottleneck Resource Triage CT Scans in disaster scenario
Risk of Malignancy
Lifetime cancer mortality risks attributable to the radiation exposure from a CT in a 1-year-old are 0.18% (abdominal) and 0.07% (head)-
600,000 pediatric CT head/abdomen per year Estimate 500 deaths from cancer due to CT
radiation
Brenner D et al. Estimated risks of radiation-induced fatal cancer from pediatric CT. Am J Roentgeno. 2001;176(2):289-96.
Risk of Malignancy
Estimated effect of Pediatric CT radiation 50 mGy ?= 3 x risk of leukaemia 60 mGy ?= 3 x risk of brain cancer
Cumulative absolute risks are small In 10 yrs following radiation exposure under
10 yrs of age 1 leukemia/10,000 1 brain tumor/10,000 head CT
Pearce MS et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012 4;380(9840):499-505
So What?
If you are going to scan, make it the best scan possible Make sure IV contrast, PO contrast if
necessary Don’t turn down the radiation too much
Don’t decrease the radiation of the scan
Decrease the number of scans Use Clinical Decision Rules
Mild head injury Low/moderate suspicion abdominal injury
ABCDE’s of Pediatric Trauma
AAirway
Big tongue, Big occiputMost common cause of airway obstructionPositioning, oral airway
Much larger adenoidsDifficult viewBleeding with nasopharyngeal airway
attemptsAirway narrows with depth, sits anterior
Difficult view and intubationSensitive gag
Oral airway only if unconscious
Airway Pitfalls
Only if unconsciousCan help hold tongue forwardDO NOT place backward and flip in
oropharynxPlace directly under vision
tongue blade helpful
Oral Airway
PreOxygenateProtect the c-spineCorrect tube size + one up & one down
Cuffed tubes improve ventilationAvoid high cuff pressure
Confirm tracheal placementIf not sure: remove the tube and try
againRecheck with every move
Orotracheal Intubation
BBreathing
#2 cause of pediatric trauma deathNo obvious fracture = Coast is clear
Ribs flexiblePulmonary contusion without fracture
Fracture = Large amount of forceLook for the other injuries
Need high index of suspicionMechanism of injuryExternal signs of injury
Is there a chest injury?
Pitfalls
Overventilation> 1 year : 20 breaths per minute< 1 year: 30 breaths per minute
Breathe, Rest, Rest
Power of the CXR
CXR will find common injuriesRib fracturesPulmonary contusionsPneumothoraces
CXR will miss rare but deadly injuriesHeart and great vesselsTracheobronchial tree and esophagusDiaphragm
CT Chest
Efficient
Sensitive
BUT Radiation Risk ? Need for Anesthesia
Clinical Decision Rules
Type of Injury No.Frequency Among Patients With Thoracic Injuries (n=80), % (95% CI)
Frequency Among Total Population (n=986), % (95% CI)
Pulmonary contusion 57 71 (60-81) 5.8 (4.4-7.4)
Rib fracture 28 35 (25-46) 2.8 (1.9-4.1)
Isolated rib fracture 9 11 (5-20) 0.9 (0.4-1.7)
Pneumothorax 20 25 (16-36) 2.0 (1.2-3.1)
Hemothorax 9 11 (5-20) 0.9 (0.4-1.7)
Hemopneumothorax 5 6 (2-14) 0.5 (0.2-1.2)
Pneumomediastinum* 6 8 (3-16) 0.6 (0.2-1.3)
Cardiac 5 6 (2-14) 0.5 (0.2-1.3)
Aortic 2 3 (0-9) 0.2 (0.0-0.7)
Diaphragmatic injury 1 1 (0-7) 0.1 (0.0-0.6)
Sternal fracture 1 1 (0-7) 0.1 (0.0-0.6)
*Includes 2 patients with tracheal lacerations.
Holmes JF et al. A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma. Ann Emerg Med 2002; 39:492–499
Chest Trauma Decision Rule
Prospective study, n= 968
Predictors of thoracic injury Low systolic BP Elevated age-adjusted respiratory rate Abnormal thoracic exam Abnormal auscultation of lung fields Femur # GCS < 15
Decision Rule Performance
Identified 78 /80 patients with injury Sensitivity 98% Specificity 37% PPV 12% NPV 99%
2 missed injuries found on Abdominal CT Both observed No morbidity from missed diagnosis
CCirculation
Is there bleeding?
Vital signs can mislead
Tachycardia
Hypotension
30% Blood Loss
Blood Pressure
So How Will I know?
Subtle physical findings Skin mottling Cool extremities compared to the trunk Thready/weakening peripheral pulses Prolonged capillary refill > 2 seconds Decreased sensorium * dulled pain response
How Much Do I Give?
Weight based dosing Crystalloid Blood Drugs
Ask parent 2.2 pounds per kilogram
Broselow tape
Formula Weight (kg) = (2 x age) + 10
What and How Much?
Crystalloid 20 cc/kg WARMED saline/ LR Repeat x 1 Repeat x 2 think about blood
PRBC 10 cc/kg O negative WARMED PRBC
Have I Given Enough?
Improving tachycardia
Better peripheral pulses
Improved skin color and warmth
More active and responsive
Venous Access
Peripheral IV : 2 attempt max Antecubital fossa Saphenous veins at ankle
Intraosseous Anteromedial Tibia Distal Femur
? Intra-abdominal Injury
Physical Exam findings
Laboratory Evaluation
FAST
Clinical Decision Rules
CT Scan
Physical Exam
Sensitivity of Abdominal Pain and Tenderness
Strongly dependent on GCS GCS 15: Sensitivity 79% GCS 14: Sensitivity 50’s GCS 13: Sensitivity 30’s
Isolated abdominal pain/tenderness Rate of injury = 8% Rate of intervention = 1%
Adelgais KM et al. Accuracy of the abdominal examination for identifying children with blunt intra-abdominal injuries. J Pediatr. 2014 Dec;165(6).
Seat Belt Sign
Seat Belt Sign Worry about compression of organs against
vertebrae Injured organs related to location
How predictive of IAI?Sensitivity 25% Specificity 85%
Can we ignore it? Higher rate of IAI : hollow viscus, mesentery Only sign in 5% conscious asymptomatic
patients
Laboratory Evaluation
Transaminases Varying cutoffs Most useful in a clinical decision rule
Possible screening tool in suspected NAI Child with no abdominal bruising, tenderness,
or distention AST or ALT >80 IU/l Sensitivity = 77% Specificity = 82%
FAST
Focused sonography right upper quadrant left upper quadrant pelvis pericardial windows
Look for free peritoneal fluid Blood (bile, urine)
FAST
Prospective study, clinically important free fluid Sensitivity poor : 50% Specificity good: 96%
Positive scan suggests hemoperitoneum CT Scan or OR
Negative scan cannot rule out hemoperitoneum Need further imaging……..Fox JC et al. Test characteristics of focused assessment of sonography for
trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med 2011; 18:477–482.
FAST plus Labs
FAST plus elevated Transaminases AST/ALT > 100 IU/L
Sensitivity : 88%
Consider observation in patients with normal FAST and “normal” Transaminases
Sola JE et al. Pediatric FAST and elevated liver transaminases: an effective screening tool in blunt abdominal trauma. J Surg Res 2009; 157:103–107
Abdominal CT Scan
Good for solid organ injury Guide non-operative care
Not as good for hollow viscus peritoneal fluid without solid organ injury bowel wall enhancement and thickening extraluminal gas bowel wall discontinuity mesenteric stranding
Isolated free fluid serial exams
Identifying IAI
12,000 patients 46% had CT Scans 6.3% IAI 75% of patients with
IAI had Intraperitoneal fluid
Spleen (39%) Liver (37%) Kidney (19%) Gastrointestinal tract (15%) Adrenal gland (12%) Pancreas (7%) Intra-abdominal vascular
structure (2%) Urinary bladder (2%) Ureter (0.5%) Gallbladder (0.5%) Traumatic fascial defect
(0.5%).
Holmes JF et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med. 2013 Aug;62(2):107-116
Prediction Rule
Evidence of abdominal wall trauma or seat belt sign
GCS score less than 14
Abdominal tenderness
Evidence of thoracic wall trauma
Complaints of abdominal pain
Decreased breath sounds
Vomiting
Prediction Rule Performance
Sensitivity = 97%
Specificity = 42.5%
Use to reassure in low risk patients
NOT meant to indicate need for scan
DDisability
#1 organ system injury death
Large head to body ratioBrain less myelinatedSkull bones thinnerBrain more susceptible to secondary
injury• Main risk = hypovolemia
Always Worry about the Head
CDR for Mild Head Injury
CHASE vs CHALICE vs PECARN
PECARN only one with 100% sensitivity 2 age groups Only GCS 14 or 15: lower risk of TBI GCS </= 13 : 20% injury risk : CT scan
PECARN < 2 years old
GCS=14 Other signs of altered mental status Palpable skull fracture
Scalp hematoma-Occip/parietal/tempHistory of LOC ≥5 secSevere mechanism of injury Not acting normally per parent
CT Recommended
Observation versus CT• Physician experience• Multiple versus isolated findings• Worsening symptoms or signs after ED observation • Age <3 months• Parental preference
YES
YES
NO
NO
No CT Recommended
PECARN >/= 2 years old
GCS=14 Other signs of altered mental status Signs of basilar skull fracture
History of LOCHistory of vomitingSevere mechanism of injurySevere headache
CT Recommended
Observation versus CT• Physician experience• Multiple versus isolated findings• Worsening symptoms or signs after ED observation• Parental preference
YES
YES
NO
NO
No CT Recommended
Think C-spine
Pediatric spine injuries: C-spine
Pseudosubluxation
Physiologic misalignment occurring in normal children Disappears with age
40% < 7 yrs 20% < 16 yrs
Usually at C2-C3
Check spinous process line
SCIWORA
Usually C-spine injury 5 to 35% of spinal cord injuries
No signs of bony/ligamentous injury on plain film/CT 2/3 have MRI abnormality
Suspect if: Blunt trauma Early/transient defecits Neurologic findings on initial assessment
EExposure
Undress but Cover
Need to fully expose
Cover ASAP High BSA to Body Mass Cool very quickly Warm everything
Blankets Fluids Consider Bair Hugger
Pediatric Pain
Morbidity of Pain
Trauma #1 cause of acute pain in children
Effects wildly variable Anxiety Crying Regression Aggression
Not related to injury severity
Inadequate treatment longterm effects
Barriers to Pediatric Analgesia
Difficulty in rating pediatric pain
Variable provider training
Limited choice of agent/route
Assessing Pediatric Pain
Vital signs unreliable
Patient self report Teenagers can use 1-10 Pain Scale Younger children need different approach
Parent report Correlates well with child self report Good surrogate measure
Brieri Faces Pain Scale
Wong and Baker Pain Scale
Pediatric Pain Treatment
Pharmacologic Fentanyl 1 to 3 μ/kg ? Intranasal fentanyl
Non pharmacologic Splinting # Diversion and distraction
Triage of Pediatric Trauma
CDC Triage Guidelines
#1Vital Signs
Level of Consciousne
ss
#2Anatomy of
Injury
#3 Mechanism
of Injury
#4Special
Circumstances
Vitals and LOC
Glasgow Coma Scale </= 13
Systolic Blood Pressure <90mmHg
Respiratory Rate <10 or >29
or <20 in infant aged <1 year
or need for ventilatory support
Anatomy of Injury
All penetrating injuries to head, neck, torso, and extremities proximal to elbow or knee
Chest wall instability or deformity (e.g. flail chest)
Two or more proximal long-bone fractures
Crushed, degloved, mangled, or pulseless extremity
Amputation proximal to wrist or ankle
Pelvic fractures
Open or depressed skull fracture
Paralysis
Mechanism of Injury
Fall >10 feet or 2 – 3 x height of the child
High-risk auto crash Intrusion >12 inches occupant site; >18 inches any site
Ejection (partial or complete)
Death in same passenger compartment
Vehicle telemetry data indicates high risk of injury
Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact
Motorcycle crash > 20 mph
Special Circumstances
Older Adults
Children Triage preferentially to pediatric capable
trauma centers
Anticoagulants and bleeding disorders
Burns
Pregnancy >20 weeks
EMS provider judgment
NY StateSTAC Guidelines for Pediatric Trauma Patients
November 2014
Prehospital
Pediatric TraumaMeets CDC guidelines
Transport time </= 60 minutes
Level I or II Pediatric Trauma Center
Adult Trauma / Non Trauma Hospital
If CDC triage criteria still met
Level I or II Pediatric Trauma Center
Adult Trauma / Non Trauma Hospital
Transfer Early Decision to Transfer
Once the primary survey and resuscitation phases are initiated usually within 30 minutes of arrival
Initiation of Transfer Should be made immediately upon recognition of meeting
criteria for transfer usually within 15 minutes following initiation of the primary
survey
Transfer Should occur as soon as possible thereafter
ideally within 1 hour of arrival definitely within 2 hours of arrival.
Summary
Pediatric Trauma significant problem
Beware of Multitrauma and Pitfalls
Triage your CT Scans Consider Clinical Decision Rules
Optimize pediatric analgesia
Severely injured kids should go to Level I/II Pediatric Trauma Center