pediatric trauma update for trauma call surgeons

Pediatric Trauma UpdatePediatric Trauma Update

Robert W. Letton, Jr., MDRobert W. Letton, Jr., MD

Associate Professor of Pediatric SurgeryAssociate Professor of Pediatric Surgery

Oklahoma University Health Sciences Oklahoma University Health Sciences CenterCenter

GOALGOAL

Discuss difference in Discuss difference in adult verses pediatric adult verses pediatric primary surveyprimary survey

Discuss some common Discuss some common injury patternsinjury patterns

Recognize warning Recognize warning signs for child abusesigns for child abuse

PRIMARY SURVEY

Primary SurveyPrimary Survey

Airway, Breathing, and CirculationAirway, Breathing, and Circulation Separated into 3 distinct systems Separated into 3 distinct systems

for discussion onlyfor discussion only In reality, assessment must cover all In reality, assessment must cover all

3 together in real time3 together in real time Evaluate simultaneously, not in Evaluate simultaneously, not in

sequencesequence The “Golden Hour”The “Golden Hour”

AirwayAirway

Primary goal to provide effective Primary goal to provide effective oxygenation and ventilationoxygenation and ventilation

Provide cervical spine protectionProvide cervical spine protection Reduce increases in ICPReduce increases in ICP Any trauma victim is assumed to Any trauma victim is assumed to

have a cervical spine injury until have a cervical spine injury until proven otherwiseproven otherwise

AirwayAirway

Recognition of compromised airway Recognition of compromised airway can be difficultcan be difficult

Cardiopulmonary arrest usually due Cardiopulmonary arrest usually due to respiratory arrestto respiratory arrest

Progression from respiratory distress Progression from respiratory distress to failure occurs quicklyto failure occurs quickly

Oral and nasopharyngeal airways Oral and nasopharyngeal airways not as effectivenot as effective

AirwayAirway

Airway complications as high as 25% Airway complications as high as 25% with pediatric field intubationwith pediatric field intubation

No difference in survival with adequate No difference in survival with adequate mask ventilation verses intubationmask ventilation verses intubation– beware occluding airway with tonguebeware occluding airway with tongue

LMA may provide effective airway LMA may provide effective airway control in field until definitive airway control in field until definitive airway can be obtainedcan be obtained

AirwayAirway

Orotracheal intubation is the “Gold Orotracheal intubation is the “Gold Standard”Standard”

Nasotracheal intubation should not Nasotracheal intubation should not be attempted in childrenbe attempted in children

Current ATLS recommendations call Current ATLS recommendations call for a rapid sequence inductionfor a rapid sequence induction– especially with closed head injuryespecially with closed head injury

Don’t forget to pre-oxygenateDon’t forget to pre-oxygenate

The Great DebateThe Great Debate

Orotracheal intubation the Gold Orotracheal intubation the Gold StandardStandard

Numerous studies suggest intubated Numerous studies suggest intubated head injury patients had worse head injury patients had worse outcomeoutcome– Prolonged initial hypoxic period during RSIProlonged initial hypoxic period during RSI– Significant period of HYPOcarbia post Significant period of HYPOcarbia post

intubationintubation

– Must monitor both SaOMust monitor both SaO22 and ETCO and ETCO22

Rapid Sequence Rapid Sequence IntubationIntubation

Short Acting SedativesBarbiturates

Etomidate 0.2-0.4 mg/kg

Pentothal 2-4 mg/kg

Versed 0.01-0.02 mg/kg

Short Acting Paralytic Rocuronium 0.6-0.9 mg/kg

Vecuronium 0.1-0.2 mg/kg

Succinyl Choline 1-2 mg/kg

Vagolytic (Infants) Atropine 0.01-0.02 mg/kg

Avoid Propofol and Ketamine in head injury patients

Watch hypotension with sedatives and barbiturates

ETT SizeETT Size

Broselow TapeBroselow Tape ID estimated by: AGE/4 + 4ID estimated by: AGE/4 + 4 Middle phalanx on 5Middle phalanx on 5thth digit digit Depth of insertion: 3 x IDDepth of insertion: 3 x ID Needle cricothyroidotomy may be Needle cricothyroidotomy may be

life savinglife saving Fiberoptic techniques, LMAFiberoptic techniques, LMA

AirwayAirway

Confirm tube positionConfirm tube position– capnometercapnometer– listen to axillae bilaterallylisten to axillae bilaterally– chest wall excursionchest wall excursion– CXRCXR

Significant face and neck burns Significant face and neck burns require immediate airway require immediate airway assessment and controlassessment and control

Larynx TraumaLarynx Trauma

BreathingBreathing

Pliable thoracic cavity: occult injuries Pliable thoracic cavity: occult injuries commoncommon

Less protection of upper abdominal Less protection of upper abdominal organsorgans

Mobile mediastinumMobile mediastinum– less aortic disruptionless aortic disruption– more tracheobronchial injuriesmore tracheobronchial injuries– earlier compromise from tension earlier compromise from tension

pneumothoraxpneumothorax Pulmonary contusion commonPulmonary contusion common

Pulmonary ContusionPulmonary Contusion

Most common pediatric thoracic injuryMost common pediatric thoracic injury Often a lack of physical or radiologic Often a lack of physical or radiologic

abnormalitiesabnormalities– Suspect with any thoracic cavity bruising, Suspect with any thoracic cavity bruising,

abnormal breath sounds, rib fracturesabnormal breath sounds, rib fractures Blood gas abnormalities often precede Blood gas abnormalities often precede

clinical/radiographic signsclinical/radiographic signs

Pulmonary Contusion Pulmonary Contusion RxRx

Early recognition and oxygen Early recognition and oxygen therapytherapy

Analgesics and chest physiotherapyAnalgesics and chest physiotherapy May need early mechanical May need early mechanical

ventilationventilation Keep them wet or keep them dry?Keep them wet or keep them dry?

– Crystalloid vs colloidCrystalloid vs colloid

Tension PneumothoraxTension Pneumothorax Breath sounds and percussion may be Breath sounds and percussion may be

misleadingmisleading Hypotension, distended neck veins and Hypotension, distended neck veins and

tracheal deviation are reliable but late findingstracheal deviation are reliable but late findings Any child with acute loss of consciousness, Any child with acute loss of consciousness,

respiratory distress, and cardiopulmonary respiratory distress, and cardiopulmonary arrest should have emergent chest arrest should have emergent chest decompressiondecompression

Persistent massive air leak warrants Persistent massive air leak warrants investigation for tracheobronchial injuryinvestigation for tracheobronchial injury

PneumothoraxPneumothorax

BreathingBreathing

BEWARE GASTRIC DISTENSIONBEWARE GASTRIC DISTENSION Chest wall is thin: breath sounds transmit Chest wall is thin: breath sounds transmit

easilyeasily Open pneumothorax rare but easily Open pneumothorax rare but easily

recognizedrecognized– positive pressure ventilation, flap dressingpositive pressure ventilation, flap dressing

Flail chest may occur with less ribs involvedFlail chest may occur with less ribs involved– paradoxical movement more debilitating than paradoxical movement more debilitating than

adultadult– underlying lung injuryunderlying lung injury

Open PneumothoraxOpen Pneumothorax

With penetrating rib With penetrating rib injuryinjury

To hilum and RLLTo hilum and RLL

BreathingBreathing

Massive hemothorax rare in blunt traumaMassive hemothorax rare in blunt trauma Diaphragmatic herniaDiaphragmatic hernia Cardiac tamponade rareCardiac tamponade rare Myocardial contusionMyocardial contusion Torn thoracic aortaTorn thoracic aorta

– Extremely rare if younger than 12Extremely rare if younger than 12 ER Thoracotomy has absolutely no role in ER Thoracotomy has absolutely no role in

management of blunt pediatric traumamanagement of blunt pediatric trauma

Worrisome CXR???Worrisome CXR???

Torn AortaTorn Aorta

Torn aortaTorn aorta

Aortic TearAortic Tear

CirculationCirculation

After oxygenation and ventilation, After oxygenation and ventilation, assessing shock takes priorityassessing shock takes priority

Shock is the inadequate delivery of Shock is the inadequate delivery of oxygen to the tissue bedsoxygen to the tissue beds

NOTE: Blood pressure is not mentioned NOTE: Blood pressure is not mentioned in the definition of shock!!!!in the definition of shock!!!!

More difficult to recognize shock in More difficult to recognize shock in children than adultschildren than adults


Children adept at compensating for blood Children adept at compensating for blood lossloss

Tachycardia difficult to appreciateTachycardia difficult to appreciate Depressed mental status earliest signDepressed mental status earliest sign

– If they’re not screaming they’re in shock!If they’re not screaming they’re in shock! Perfusion and capillary refill best monitorPerfusion and capillary refill best monitor

– child with cool feet and thready pulses is in child with cool feet and thready pulses is in shock until proven otherwiseshock until proven otherwise

Hypotension a Hypotension a “LATE”“LATE” sign with imminent sign with imminent cardiovascular collapsecardiovascular collapse


Blood volume 70-80 cc/kgBlood volume 70-80 cc/kg What appears to be small amount What appears to be small amount

of blood loss adds up quicklyof blood loss adds up quickly CONTROL the bleeding!CONTROL the bleeding! 200 ml EBL in 10 kg child is 25% of 200 ml EBL in 10 kg child is 25% of

blood volumeblood volume


Higher body surface area to mass Higher body surface area to mass ratioratio

Increased insensible fluid losses = Increased insensible fluid losses = increased heat lossincreased heat loss

VERY susceptible to hypothermia and VERY susceptible to hypothermia and must be protected from thismust be protected from this– aggravates pulmonary hypertension, aggravates pulmonary hypertension,

acidosis, coagulation cascade, increases acidosis, coagulation cascade, increases oxygen consumptionoxygen consumption


Wide variation in normal vital signsWide variation in normal vital signs Normal SBP: 60-70 + 2(age)Normal SBP: 60-70 + 2(age) Hypotension an ominous finding!Hypotension an ominous finding! Goal is to establish presence of shock Goal is to establish presence of shock

before the vital signs changebefore the vital signs change No lab test or x-ray that can estimate No lab test or x-ray that can estimate

EBL and shockEBL and shock– best lab predictor of shock is base deficitbest lab predictor of shock is base deficit

Pediatric Vital SignsPediatric Vital Signs

AGE Weight(kg)

Heart Rate(beats/min)

Pressure*(mm Hg)

Respirations(breaths/min)

Urine Output(cc/kg/hr)

0-6 months 3-6 160-180 60-80 60 2

Infant 12 160 80 40 1.5

Preschool 16 120 90 30 1

Adolescent 35 100 100 20 0.5

Clinical Signs of ShockClinical Signs of Shock

System < 25% Blood Loss 25%-45% Blood Loss > 45% Blood Loss

Cardiac Weak, thready pulse; increased heart rate

Tachycardia Hypotension, tachycardia to bradycardia

CNS Lethargic, irritable, confused

Changing level of consciousness; dulled response to pain

Comatose

Skin Cool, clammy Cyanotic, decreased capillary refill, cold extremities

Pale, cold

Renal No decrease in output, increased specific gravity

Decreased urine output No urine output


Must establish I.V. access:Must establish I.V. access:– peripheral, percutaneous central, peripheral, percutaneous central,

intraosseous, peripheral cutdownintraosseous, peripheral cutdown Send blood for trauma panel, type and Send blood for trauma panel, type and

crosscross Short large bore peripheral catheter Short large bore peripheral catheter

better than long central linebetter than long central line If central route needed, femoral okay in If central route needed, femoral okay in

childrenchildren

Intraosseous LineIntraosseous Line

Less than 6 years of Less than 6 years of ageage

Fluids, blood Fluids, blood products, and drugs products, and drugs can be givencan be given

Proximal tibia or distal Proximal tibia or distal femur best locationfemur best location

Fracture of the bone Fracture of the bone only contraindicationonly contraindication

Obtain alternate Obtain alternate access ASAPaccess ASAP

Fluid ResuscitationFluid Resuscitation

Observe Operation

Consider Transfer

Further Evaluation

Hem odynam icsNORM AL

Observe Operation

Consider Transfer

Further Evaluation

NORM AL

Operation

ABNORM AL

10 cc/kg PRBC's

Consider Operation

Hem odynam icsABNORM AL

20 cc/kg bolus of NS or LRSURGICAL CONSULTATIO N

Repeat Bolus

Hypovolemic ShockHypovolemic Shock

If child acutely hypotensive: rule If child acutely hypotensive: rule out tension pneumothorax firstout tension pneumothorax first

Most shock in pediatric trauma is Most shock in pediatric trauma is hypovolemichypovolemic

Need to determine etiology of blood Need to determine etiology of blood lossloss

Only 5 potential sources of massive Only 5 potential sources of massive blood lossblood loss


Chest: rule out with CXRChest: rule out with CXR Pelvis: rule out with pelvic filmPelvis: rule out with pelvic film Long bone fractures: look at patientLong bone fractures: look at patient ““On the floor”: history and examOn the floor”: history and exam

– apply pressure, don’t forget scalp lac’sapply pressure, don’t forget scalp lac’s Abdomen: none of the aboveAbdomen: none of the above


Child in extremis with normal CXR, pelvis film and no long bone fractures or lacerations needs a trip to the OR to complete their

Primary Survey!

DisabilityDisability

Closed head injury leading cause of Closed head injury leading cause of deathdeath

Often occurs with cervical spine injuryOften occurs with cervical spine injury– High c-spine injury with respiratory High c-spine injury with respiratory

arrestarrest Hypoxic injury often worse than TBIHypoxic injury often worse than TBI Delay in treatment makes ICP more Delay in treatment makes ICP more

difficult to controldifficult to control Early Head CT to rule out mass lesionEarly Head CT to rule out mass lesion

Glasgow Coma ScoreGlasgow Coma ScoreCRITERIACRITERIA SCORSCOR

EEINFANTINFANT CHILDCHILD

Eye openingEye opening 44 SpontaneousSpontaneous SpontaneousSpontaneous

33 To loud noiseTo loud noise To verbal stimuliTo verbal stimuli

22 To painTo pain To painTo pain

11 No responseNo response No responseNo response

Verbal Verbal ResponseResponse

55 Smiles, coos, cries Smiles, coos, cries appropriatelyappropriately

Appropriate, orientedAppropriate, oriented

44 Cries but consolableCries but consolable ConfusedConfused

33 Persistently irritable, cryingPersistently irritable, crying InappropriateInappropriate

22 Grunts or moansGrunts or moans IncomprehensibleIncomprehensible

11 No responseNo response No responseNo response

Motor Motor ResponseResponse

66 SpontaneousSpontaneous Follows commandsFollows commands

55 Withdraws to touchWithdraws to touch Localizes painLocalizes pain

44 Withdraws to painWithdraws to pain Withdrawal to painWithdrawal to pain

33 Decorticate (flexion) Decorticate (flexion) posturingposturing

Decorticate (flexion) Decorticate (flexion) posturingposturing

22 Decerebrate (extensor) Decerebrate (extensor) posturingposturing

Decerebrate (extensor) Decerebrate (extensor) posturingposturing

11 No ResponseNo Response No responseNo response

DisabilityDisability

GCS 13-15 mild TBI; 9-12 moderate TBI; GCS 13-15 mild TBI; 9-12 moderate TBI; 3-8 severe TBI (70% mortality)3-8 severe TBI (70% mortality)

May have significant blood loss from May have significant blood loss from associated scalp lacerationassociated scalp laceration

Basilar skull fractureBasilar skull fracture– Raccon’s eyes, hemotympanum, otorrhea, Raccon’s eyes, hemotympanum, otorrhea,

rhinorrhearhinorrhea– Indicates significant force but not important Indicates significant force but not important

to immediate outcometo immediate outcome– No prophylactic antibioticsNo prophylactic antibiotics

Prevent Secondary Prevent Secondary InjuryInjury

Early intubation to avoid hypoxia, Early intubation to avoid hypoxia, hypercapneahypercapnea– Acute hyperventilation decreases CBFAcute hyperventilation decreases CBF

Evacuation of any mass lesionsEvacuation of any mass lesions Prevent and treat other systemic Prevent and treat other systemic

complicationscomplications– Tension PTX, significant hypovolemic shockTension PTX, significant hypovolemic shock

Maintain adequate cerebral perfusion Maintain adequate cerebral perfusion pressurepressure

Prevent Secondary Prevent Secondary InjuryInjury

Common treatable causes of Common treatable causes of secondary injurysecondary injury– HYPOXIA-HYPERCARBIA-HYPOXIA-HYPERCARBIA-

HYPERTHERMIA-HYPONATREMIAHYPERTHERMIA-HYPONATREMIA Isotonic fluids: avoid hypovolemiaIsotonic fluids: avoid hypovolemia

– Running them dry is old schoolRunning them dry is old school Ventilation and oxygenationVentilation and oxygenation

– Profound acute hyperventilation is Profound acute hyperventilation is just as bad as hypercarbiajust as bad as hypercarbia

Maintain Adequate Maintain Adequate Cerebral Perfusion Cerebral Perfusion PressurePressure

CPP= MAP – ICP (normal > 50 CPP= MAP – ICP (normal > 50 mmHg)mmHg)

ICP monitoring in ?? patients??ICP monitoring in ?? patients?? Want ICP < 20:Want ICP < 20:

– Raise HOB, pCO2 30-35, avoid Raise HOB, pCO2 30-35, avoid hyponatremia, mannitol, sedation, hyponatremia, mannitol, sedation, paralyisis, barbituatesparalyisis, barbituates

Want MAP > 60-70:Want MAP > 60-70:– Euvolemia, pressors after ruling out Euvolemia, pressors after ruling out

hypovolemic shock, r/o PTXhypovolemic shock, r/o PTX

SECONDARY SURVEY

Abdominal TraumaAbdominal Trauma

In the multiple injured trauma In the multiple injured trauma victim, evaluation of abdomen victim, evaluation of abdomen problematicproblematic

U/S not as well tested in childrenU/S not as well tested in children– less volume presentless volume present

DPL invasiveDPL invasive CT scan only if “metastable” and CT scan only if “metastable” and

well “protected” well “protected”

Abdominal TraumaAbdominal TraumaLab Data/RadiologyLab Data/Radiology

CBC, Electrolytes, Amylase, LFT’s, CBC, Electrolytes, Amylase, LFT’s, Coagulation profile, U/A, Type and CrossCoagulation profile, U/A, Type and Cross

Establish 2 large bore IV’s with one Establish 2 large bore IV’s with one above the diaphragmabove the diaphragm– peripheral, intraosseous, cut-down, peripheral, intraosseous, cut-down,

percutaneous CVCpercutaneous CVC Lateral C-spine, Chest, and Pelvis plain Lateral C-spine, Chest, and Pelvis plain

filmsfilms Place NG/OG, Foley Catheter Place NG/OG, Foley Catheter

Abdominal TraumaAbdominal TraumaImaging StudiesImaging Studies

CXR, pelvis filmsCXR, pelvis films CT ScanCT Scan: If there is evidence of injury : If there is evidence of injury

or unable to examine abdomenor unable to examine abdomen– Chest CT in teenagersChest CT in teenagers

Retrograde UrethrogramRetrograde Urethrogram if blood at if blood at urethral meatusurethral meatus

Abdominal UltrasoundAbdominal Ultrasound– to r/o hemoperitoneum in multiple injury to r/o hemoperitoneum in multiple injury

traumatrauma ArteriogramArteriogram: for pelvic injuries with : for pelvic injuries with

bleedingbleeding

Abdominal TraumaAbdominal TraumaCT ScanCT Scan

Used to evaluate Chest, Abdomen, Used to evaluate Chest, Abdomen, Pelvis and RetroperitoneumPelvis and Retroperitoneum

Shows free fluid wellShows free fluid well Shows solid organ injury wellShows solid organ injury well Shows viability of organs based on Shows viability of organs based on

perfusionperfusion Hemorrhage shown by Hemorrhage shown by

extravasation of contrastextravasation of contrast

Abdominal TraumaAbdominal Trauma

CT of the abdomen & pelvis is not effective for ruling out

hollow viscus injuries

Abdominal TraumaAbdominal TraumaDiagnostic Peritoneal Diagnostic Peritoneal LavageLavage

For bleeding/perforation in abdominal cavityFor bleeding/perforation in abdominal cavity Sensitivity >95% for injurySensitivity >95% for injury

– injuries more often stable in children than adultsinjuries more often stable in children than adults False positive blood due to pelvic fractureFalse positive blood due to pelvic fracture Misses retroperitoneal injuriesMisses retroperitoneal injuries FAST has essentially replaced DPL in EDFAST has essentially replaced DPL in ED Technically difficult to performTechnically difficult to perform Still has role in head injured patient to rule Still has role in head injured patient to rule

out bowel injuryout bowel injury

Abdominal InjuriesAbdominal Injuries

Blunt trauma in pediatrics has much Blunt trauma in pediatrics has much higher mortality than penetrating higher mortality than penetrating traumatrauma

Multiple organ injury is far more Multiple organ injury is far more common with blunt than with common with blunt than with penetrating traumapenetrating trauma– High mortality when several organ High mortality when several organ

systems are injuredsystems are injured– Hemorrhage, sepsis, renal failureHemorrhage, sepsis, renal failure

Solid Organ InjurySolid Organ Injury

Solid organs less Solid organs less protected than protected than adults due to pliable adults due to pliable rib cage rib cage

Grading system the Grading system the same as in adultssame as in adults

Most solid organ Most solid organ lacerations Grade III lacerations Grade III or less can be or less can be managed managed conservativelyconservatively

Solid Organ InjurySolid Organ Injury

Follow fluid resuscitation algorithm as beforeFollow fluid resuscitation algorithm as before OR if still in shock after 1st 10 cc/kg of PRBCOR if still in shock after 1st 10 cc/kg of PRBC

– or suspect associated bowel injuryor suspect associated bowel injury Bedrest and serial exam if stableBedrest and serial exam if stable

Pediatric Spleen Pediatric Spleen Injury:Injury: Retrospective Review Retrospective Review

I II III IV

% Admit ICU 55.0 54.3 72.3 85.4

Mean HospitalDays

4.3 5.3 7.1 7.6

% Transfused 1.8 5.2 10.1 26.6

% Laparotomy None 1.0 2.7 12.6

Mean restriction 5.1 wk 6.2 wk 7.5 wk 9.2 wk

Stylianos, et.al., JPS 35:164-9, 2000

Pediatric Spleen Pediatric Spleen Injury:Injury: Prospective Trial Prospective Trial

I II III IV

ICU (days) None None None 1 day

Hospital (days) 2 3 4 5

Pre-DC imaging None None None None

Post-DC imaging None None None None

Activity restriction 3 weeks 4 weeks 5 weeks 6 weeks

Stylianos, et.al., JPS 35:164-9, 2000

Pediatric Spleen InjuryPediatric Spleen Injury

Prospective study had almost 90% Prospective study had almost 90% compliance to previous guidelinescompliance to previous guidelines

Only 1.9% (6 out of 312) patients Only 1.9% (6 out of 312) patients with solid organ injury managed with solid organ injury managed with this protocol failedwith this protocol failed

Lead to reduced ICU and hospital Lead to reduced ICU and hospital staystay

Stylianos, S. J Ped Surgery 2002 Mar:37(3):453-6

Seat Belt StripeSeat Belt Stripe

Bowel injuries associated with seat belt Bowel injuries associated with seat belt stripestripe– 20% will have seat belt stripe20% will have seat belt stripe– 15-20% of these have significant intestinal injury15-20% of these have significant intestinal injury

Physical exam can be difficultPhysical exam can be difficult– abdominal wall bruising painfulabdominal wall bruising painful


CT sensitive and specific for solid CT sensitive and specific for solid organ injuryorgan injury– Not as sensitive or specific for bowel injuryNot as sensitive or specific for bowel injury– looking for secondary signs of injurylooking for secondary signs of injury

CT Scan and Bowel CT Scan and Bowel InjuryInjury

Free fluid without associated solid Free fluid without associated solid organ injuryorgan injury

Intraperitoneal or retroperitoneal airIntraperitoneal or retroperitoneal air Bowel wall thickeningBowel wall thickening

Admission 24 HR later Duodenum


Serial physical exam if no hard signs on CT scanSerial physical exam if no hard signs on CT scan Laparotomy for all seat belt stripes not Laparotomy for all seat belt stripes not

indicatedindicated Delay in laparotomy Delay in laparotomy NOTNOT associated with associated with

increased morbidityincreased morbidity

Post-Trauma Bowel Post-Trauma Bowel ObstructionObstruction

““Negative” laparotomy may be therapeuticNegative” laparotomy may be therapeutic Mesenteric defects can present as internal Mesenteric defects can present as internal

herniahernia Pancreas, bladder injury a possibility as wellPancreas, bladder injury a possibility as well

Bicycle Handlebar Bicycle Handlebar InjuryInjury

LUQ usual point of injuryLUQ usual point of injury Spleen, pancreas, bowel and kidney often Spleen, pancreas, bowel and kidney often

injuredinjured Persistent LUQ pain, especially if left Persistent LUQ pain, especially if left

“shoulder” pain, warrants investigation“shoulder” pain, warrants investigation

Pancreas InjuryPancreas Injury

Conservative management often Conservative management often successfulsuccessful

Complete transection best managed Complete transection best managed acutely with distal pancreatectomyacutely with distal pancreatectomy– pseudocyst formation common, pseudocyst formation common, morbidity morbidity

Abdominal TraumaAbdominal TraumaGenitourinary SystemGenitourinary System

10% of all abdominal injuries10% of all abdominal injuries Kidneys most commonly injuredKidneys most commonly injured Hematuria in 90% of children with Hematuria in 90% of children with

GU injuryGU injury– hematuria associated with increased hematuria associated with increased

risk for other intra-abdominal injuryrisk for other intra-abdominal injury CT scan with IV contrastCT scan with IV contrast

Abdominal TraumaAbdominal TraumaGenitourinary SystemGenitourinary System

Cystogram for gross hematuriaCystogram for gross hematuria– observe extraperitoneal rupture, repair intra-observe extraperitoneal rupture, repair intra-

peritonealperitoneal Straddle injuries or pelvic fracturesStraddle injuries or pelvic fractures Suspect urethral injuries, especially in Suspect urethral injuries, especially in

malesmales– blood at urethral meatusblood at urethral meatus– retrograde urethrogram prior to passing foleyretrograde urethrogram prior to passing foley– treat with suprapubic tube, delayed repairtreat with suprapubic tube, delayed repair

Child Abuse Child Abuse “RED”“RED” FlagsFlags

Discrepancies in Discrepancies in storystory

Changing historyChanging history Inappropriate Inappropriate

responseresponse– parents and childparents and child

Multiple injuries in Multiple injuries in pastpast

Classic abuse injuriesClassic abuse injuries Child’s developmentChild’s development Sexual abuseSexual abuse

Child Abuse: Physical Child Abuse: Physical ExamExam

Multiple SDH, retinal hemorrhageMultiple SDH, retinal hemorrhage Ruptured viscus without antecedent Ruptured viscus without antecedent

historyhistory Perianal, genital traumaPerianal, genital trauma Multiple scars, fractures of varying ageMultiple scars, fractures of varying age Long bone fractures less than 3 years oldLong bone fractures less than 3 years old Bizarre injuries: bites, cigarette burns, Bizarre injuries: bites, cigarette burns,

rope marksrope marks Sharply demarcated burnsSharply demarcated burns

pediatric trauma update for trauma call surgeons

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