Pediatric Trauma Overview

Christine Kennedy

Pediatric Emergency Fellow

July 29th, 2010

Objectives

1) Review the key differences between pediatric and adult trauma patients

2) Discuss the approach to Pediatric blunt trauma

• Thoracic• Abdominal• Head

3) Review Pediatric penetrating trauma cases

Special Considerations

• Mechanism of injury

Mechanism of Injury

• Blunt injury most common (85%)– head injury 55%– internal injuries 15%

• Be attentive for the possibility of non-accidental trauma (child abuse)

Special Considerations

• Size and shape

Size and shape• Smaller mass

– greater force applied per unit body area

• Larger head– prone to head injuries– major source of heat loss– prominent occiput– cranial bones thinner

Size and shape• Neck

– weak muscles– supports greater mass– short / fat

• Difficult to see trachea and neck veins

– cervical spine injuries not as common

• Larynx– more cephalad & ant

• Epiglottis– tilted at 45 & floppy

• Cricoid cartilage– narrowest part of airway

Size and shape• Thorax

– more pliable– ribs cartilaginous and

flexible– less overlying muscle

and fat– Mobile mediastinal

structures

contusions (common), fractures (rare)

blunt force transmitted to underlying tissues

Size and shape• Abdomen

– less protected by ribs and muscles

– organs less insulated by fat– spleen / liver more caudad and

anterior

small forces may cause significant injury

significant injuries with minimal external evidence

Size and shape• Abdomen

– Prone to gastric distension

may be difficult to ventilate

Skeleton

• Incompletely calcified– active growth centers– pliable

internal injuries without overlying bony injuries

Skeleton

• Growth plates– weakest area of bone– weaker than ligaments– common site of

fractures– potential impact on

growth

Special Considerations

• Surface area

Surface area• Body surface area / body volume ratio

– highest in infants– diminishes as child matures

• Thermal energy loss significant– hypothermia may develop quickly– good for head injured patients??

Recent study shows increase in harm with cooling

James Hutchison et al. N Engl J Med 2008; 358:2447-2456

– bad for hypotensive patients

Special Considerations

• Psychologic status

Psychologic status

• impaired ability to interact– unfamiliar individuals– strange environment– emotional instability– fear / pain / stress– parents often unavailable

• history taking and cooperation can be difficult (if not impossible!)

Strange environment?

Stranger environment?

Family involvement

• Not just “one patient”

• Advantages– availability of historical data– comfort to child

• Disadvantages– may be a distraction– may influence care of patient

Family presence

• Facilitate family presence whenever possible

• Important to have designated support person to stay with family at all times

• Encourage family member to talk to and touch child

• Primary survey should be completed prior to family’s arrival in resus room

Special Considerations

• Long-term effects

Long-term effects

• Children with severe multisystem trauma– 60% residual personality changes at 1 year– 50% show cognitive and physical handicaps

• Significant impact on family structure– personality and emotional disturbances in

2/3 of uninjured siblings– strain on marital relationship

Special Considerations

• Equipment

Equipment

• Multiple sizes of everything!!

Broselow Measuring Tape

Circulation

• What % decrease in circulating blood volume is required to change the vital signs?

• What are the key clinical signs?

• What is the lower limit of systolic BP?

Circulation

• What % decrease in circulating blood volume is required to change the vital signs?

• What are the key clinical signs?

• What is the lower limit of systolic BP?

Tachycardia

• Why is evaluation of HR so important?

Tachycardia

• Why is evaluation of HR so important?

CO = HR x SV

Circulation

• What % decrease in circulating blood volume is required to change the BP?

Circulation

• What % decrease in circulating blood volume is required to change the BP?

Circulation

• What is a child’s blood volume?

• How much blood does this equate to in a

5 year old child?

Circulation

• What is a child’s blood volume?

• How much blood does this equate to in a

5 year old child?– 5 year old 20 kg– 20 kg = 1600 mL

• So a 30% loss in blood volume=480ml (<2 cups!)

Circulation - Interventions

• Control hemorrhage

• Restore volume– warmed crystalloid solution– 20 mL/kg; repeat X 1 then consider blood– blood (10mL/kg packed RBCs)

Intravenous access

arm

leg

Intravenous access

scalp

external jugular

Intraosseous

• any IV drug / fluid– same dosing

• best spot - tibia– anteromedial surface– 2 cm below tibial

tuberosity

• Be sure to secure!!!• How do you know

when you’re in?

Circulation issues• unusual hemorrhage sites

– subgaleal

Assessing GCS

Assessing GCS

Assessing GCS

Level of consciousness

• “AVPU”

• A – alert

• V – voice

• P – pain

• U – unresponsive

in general GCS < 8

Level of consciousness

if the patient looks like “PU” . . .

. . . they probably can’t protect their airway!

Exposure

• remove all clothes– Look under collar!

• keep child warm!!!– warm blankets– warm fluids– overhead warmer– warm the room

Case 1

• 14 yr old male, 53kg

• Checked into boards playing hockey

• Skated off ice, complained of mid-back pain

• Went back onto ice, hit again, then complained of increasing back pain

• Emesis X1 on route to hospital

Case 1

• GCS 15, HR 63, RR 40, BP 141/72

• Sats 100% on O2 10L NRB

• Pale, diaphoretic

• Pluritic chest pain (L) and dyspnea

• No syncope

• What now?

Thoughts on diagnosis? Plan?

3 hours later pt arrives at ACH

RR 29, HR 60, BP 107/47 Sat 99% 2L– Decreased A/E to left lung base– Pale & diaphoretic, pain on inspiration

• What would you like to do?

Hb 122, plt 238, WBC 11.7

INR 1.2, PTT 27.8

Na 140, K 4.0, Cl 107, CO2 22

Cr 67, BUN 4.8, glc 5.9

Plan now?

CT Chest

Case 1

• Chest tube inserted

– Drains 800cc blood

• Patient admitted to surgery, but remains in ED

• 5 hours later drainage at 1365cc

• What would you like to do now?

Case 1

• Pt arrives at FMC– Chest tube drainage at 1655cc (8h after

insertion)– HR 64, RR 14, 110/47, 98% 3L– Hb 109– Has received total of 2200cc NS over 19hour

• What do you do now?

Thoracotomy-Indications

• Drainage of 1500mL with initial CT placement (20mL/kg in kids)

• >200mL/h for 4 hours (>3mL/kg/h in kids)

• Combination of the above with hemodynamic instability

Cause of Hemothorax

• Injury to an intrathoracic vascular structure

• Rib fractures– Bleeding from intercostal vessel or pulmonary

parenchymal injury

• Rate of hemothorax • 6.7% with no rib fractures• 24.9% with 1 or 2 rib fractures• 81.4% with >2 rib fractures

Transfuse or not?Need based on estimation of lost blood volume:• >40 percent loss (>2000 mL)

– RBC transfusion is required• 30 to 40 percent loss (1500 to 2000 mL)

– crystalloids or synthetic colloid; RBC’s will probably be required

• 15 to 30 percent loss (800 to 1500 mL)– crystalloids or synthetic colloids; need for RBC’s unlikely

unless the patient has pre-existing anemia, continuing blood loss, or reduced cardiovascular reserve

• Less than 15 percent blood loss (750 mL):– No need for transfusion unless volume loss is

superimposed on preexisting anemia, or when patient is unable to compensate due to severe cardiac or respiratory distress

Murphy, MF, et al. British Committee for Standards in Haematology, Blood Transfusion Task Force. Br J Haematol 2001; 113:24.

Chest Trauma-Summary

• 8% of injuries in children involve the chest– >2/3 of children with chest trauma have other organ

system injuries

• Blunt mechanism– Pulmonary contusions common– Rib fractures uncommon

• Mobile mediastinum– Inc risk of tension pneumo

• Rare– Diaphragm rupture– Ao transection– Cardiac contusions

Case 2

• 4 year old male

• Ran out into the street and was hit by car going through a school zone

• Code 77 called– What are you going to get prepared?

• HR 180, BP 84/58, RR 30, Sat 99%, T36.1

• Diffuse abdominal tenderness on exam– What now?

Diagnosis?

Plan?

What abdominal injuries do children get?

Abdominal Injuries

• Splenic Lacerations: #1 blunt abdo injury• Liver lacerations• Duodenal hematoma• Pancreatic injuries• Kidney contusions

• Small bowel perforation• Bladder rupture• Straddle injuries (fall on fence)

Abdominal wall bruising

• Indicates significant intraabdominal injury in restrained children– Kids with abdo bruises were 232X more likely

to have intraabdominal injury than those w/o bruising (95% CI, 76-710)

– Sensitivity 73.5%– Specificity 98.8%

Incidence and clinical significance of abdominal wall bruising in restrained children involved in motor vehicle crashes. J Pediatr Surg 2004 Jun;39(6):972-5.

Non operative management??

• Bleeding from spleen, liver, kidneys generally self-limited in children– If child can’t be hemodynamically stabilized

(ie >40cc/kg pRBC)-laparotomy• In 3 years at ACH, only 9 cases of abdominal

trauma went to the OR!

Splenic Laceration: Treatment

• Isolated Grade IV spleen or liver injuries – observe for 1d day in the ICU, total of 5d in

hospital

• Grade I, II & III spleen or liver injuries– Admit for 2, 3 & 4 days respectively

• Typical, age-appropriate activities should be restricted for 3, 4, 5 & 6 weeks for Grade I, II, III & IV injuries respectively

American Pediatric Surgery Association

Usefulness of Liver enzymes

• Elevated liver enzymes highly associated with intraabdominal injury following blunt trauma – AST >200 U/L– ALT >125 U/L

• adjusted OR 17.4; 95% CI 9.4 to 32.1

Identification of children with intra-abdominal injuries after blunt trauma.Ann Emerg Med 2002 May;39(5):500-9.

Usefulness of urine

• Gross hematuria– highly suggestive of serious renal injury– warrants radiologic investigation

• U/A with >20 RBC suggests intraabdominal injury after blunt trauma– warrants serial examinations & AST/ALT– abdominal CT if the patient develops

tenderness or has elevated LE

Identification of children with intra-abdominal injuries after blunt trauma.Ann Emerg Med 2002 May;39(5):500-9.

?Usefulness of FAST

• Prospective study of 744 children with blunt abdominal trauma.

• Sens & spec of free fluid on U/S to detect intraabdominal injury – Sensitivity 56%– Specificity 97%

• Bottom line: U/S lacks adequate sensitivity, so CT’s are performed in all patients in whom the initial ultrasound is normal

Blunt abdominal trauma in children: evaluation with emergency US.Radiology 2002 Mar;222(3):749-54.

The advancement of seatbelts

Name this abdominal trauma

Name this abdominal injury

Head Trauma

Case 3

• 5 yr male

• Kicked in the head by a horse, found a few feet away, unresponsive. GSC fluctuating for EMS.

• GCS 9, HR 140, RR 30, Sat 98%, BP 90/60

• What is your approach?

Describe the CT head findings

Case 3

• On reassessment, without sedation, – GCS 5 (E1, M3, V1). HR 70, BP 120/80

• What is your management at this time?

Head Trauma

• MVC’s, Falls, Bike accidents

• What are the 2 most important things for us to prevent??

• Hypotension & Hypoxia• Outcome better compared to adults*• Impact seizures common and self-limited

Impact Seizure?

• If the following criteria are met, admission not required– brief immediate post-traumatic seizure– minor head trauma– normal head CT – Normal neurological exam

• Observe for several hours in the ED

Do children require hospitalization after immediate posttraumatic seizures? Ann Emerg Med 2004 Jun;43(6):706-10.

Who needs a head CT?

CATCH study

• N =3 866– Inclusion:

• 0-16 years• Blunt head trauma with one of:

– LOC, disorientation, amnesia, persistent vomiting, irritability

• GCS 13-15

• Injury within the past 24h

– Outcomes: • Need for Neurologic intervention• lesion on CT (phone f/u at 14 days if no CT scan)

CATCH study

• High risk criteria (for neurologic intervention)– GCS <15 2hrs post injury– Suspected open or depressed skull fracture– Worsening headache– Irritability on examination

• Sensitivity: 100% (95% CI, 86-100)• Specificity: 70.2% (95% CI, 69-72)• CT rate: 30.2%

CATCH study

• Medium risk criteria (for acute brain injury on CT)– Signs of basilar skull fracture– Boggy scalp hematoma– Dangerous mechanism (Fall from >3 feet / 5 stairs, MVC,

fall from bike w/o helmet)

• Sensitivity: 98.1%• Specificity: 50.1%• CT scan rate: 52%

Emergent Management of Increased ICP

Therapy Dose Mechanism

Head elevation (30°)

- Lowers intracranial venous pressure

Head in midline - Prevents jugular vein compression

Hyperventilation pCO2 30-35 mmHg

Promptly decreases cerebral blood volume pressure

Mannitol 0.5-1g/kg IV Rapid osmotic diuresis (If serum osm <320)

Hypertonic saline

(3% saline)

3cc/kg Osmotic diuresis (If serum osm <360)

Penetrating Trauma

• On to Dr. Guilfoyle….