Pediatric trauma

10 Pediatric Trauma

Paleerat Jariyakanjana, MDEmergency physician

29/12/58

most injured children have no hemodynamic abnormalities → rapidly deteriorate, and serious complications will develop

Unique Characteristics ofPediatric Patients

SIZE AND SHAPEsmaller body mass → greater force

applied per unit of body arealess fat, less connective tissue, and

closer proximity of multiple organshigh frequency of multiple injuries

seenhead is proportionately larger

higher frequency of blunt brain injuries

SKELETONincompletely calcified, contains

multiple active growth centers, and is more pliable

internal organ damage is often noted without overlying bony fracture

rib fractures in children are uncommon, but pulmonary contusion is not

SKELETONskull or rib fractures

massive amount of energy underlying organ injuries, such as traumatic

brain injury and pulmonary contusion, should be suspected

SURFACE AREAThe ratio of a child’s body surface

area to body volume is highest at birth and diminishes as the child matures.

thermal energy loss is a significant stress factor

LONG-TERM EFFECTSlong-term quality of life for children

who have sustained trauma is surprisingly robust

aggressive resuscitation attempts

EQUIPMENT

EQUIPMENT

Airway: Evaluation and Management

ANATOMYpassive flexion of the cervical spine

caused by the large occiputplane of the midface be maintained

parallel to the spine board in a neutral position

Placement of a 1-inch-thick layer of padding beneath the infant’s (<1 year of age) or toddler’s (1-3 years of age) entire torso

ANATOMY

ANATOMYsoft tissues in an infant’s oropharynx

relatively large visualization of the larynx difficult

A child’s larynx is funnel-shaped, allowing secretions to accumulate in the retropharyngeal area.

The larynx and vocal cords are more cephalad and anterior in the neck.

ANATOMYThe vocal cords are frequently more

difficult to visualize when the child’s head is in the normal, supine, anatomical position during intubation than when it is in the neutral position required for optimal cervical spine protection.

ETT: depth (cm) = 3 x size

MANAGEMENT

Oral Airwaypractice of inserting the airway

backward and rotating it 180 degrees is not recommended trauma with resultant hemorrhage into soft

tissue structures of the oropharynx

MANAGEMENT

Orotracheal Intubationcuffed endotracheal tubesSize

child’s external nares tip of the child’s small finger

one size larger and one size smaller than the predicted size

MANAGEMENT

Orotracheal IntubationNasotracheal intubation should not

be performed blind passage around a relatively acute angle

in the nasopharynx toward the anterosuperiorly located glottis, making intubation by this route difficult

MANAGEMENT

Cricothyroidotomybag-mask

ventilation or orotracheal intubation LMA, intubating LMA, or needle cricothyroidotomy

MANAGEMENT

CricothyroidotomyNeedle-jet insufflation via the

cricothyroid membrane is an appropriate, temporizing technique for oxygenation, but it does not provide adequate ventilation, and progressive hypercarbia will occur.

MANAGEMENT

CricothyroidotomySurgical cricothyroidotomy is rarely

indicated for infants or small children.

can be performed in older children in whom the cricothyroid membrane is easily palpable (usually by the age of 12 years)

Breathing: Evaluation andManagement

BREATHING AND VENTILATIONexcessive volume or pressure during

assisted ventilation substantially increases the potential for iatrogenic barotrauma fragile nature of the immature

tracheobronchial tree and alveolipediatric bag-mask: <30 kg

NEEDLE AND TUBE THORACOSTOMY

needle decompression: using 14-18G over-the-needle catheters

Chest tubes: tunneling thinner chest wall

Circulation and Shock: Evaluationand Management

RECOGNITION OF CIRCULATORY COMPROMISE

A child’s increased physiologic reserve allows for maintenance of systolic blood pressure in the normal range, even in the presence of shock.



Tachycardia and poor skin perfusion often are the only keys to early recognition of hypovolemia

early assessment by a surgeon



mean normal SBP = 90 + (2 x yr) lower limit of normal SBP = 70 + (2 x

yr) DBP = 2/3 x SBP



Hypotension decompensated shock severe blood loss >45%

DETERMINATION OF WEIGHT ANDCIRCULATING BLOOD VOLUME

EBW = (2 x age) + 10Shock: bolus of 20 mL/kg

VENOUS ACCESSpercutaneous access x 2 attempts

bone marrow needle (18G in infants, 15G in young children)

femoral venous line venous cutdown

FLUID RESUSCITATION

THERMOREGULATIONThe high ratio of body surface area to

body mass in children increases heat exchange with the environment

Increased metabolic rates, thin skin, and the lack of substantial subcutaneous tissue

overhead heat lamps, heaters, or thermal blankets may be necessary

Cardiopulmonary Resuscitation

Cardiopulmonary ResuscitationChildren receiving CPR for >15

minutes prior to arrival in an ED or with fixed pupils on arrival uniformly predict nonsurvival.

continued CPR of long duration, prolonged resuscitative efforts are typically not beneficial

Chest Trauma

Chest TraumaMobility of mediastinal structures

more susceptible to tension

pneumothorax

Abdominal Trauma

ASSESSMENTOrogastric tube decompression is

preferred in infants.

DIAGNOSTIC ADJUNCTS

Computed TomographyFatal cancers: 1/1,000 patients

DIAGNOSTIC ADJUNCTS

Focused Assessment Sonography in TraumaI/C operative management

not by the amount of intraperitoneal blood by hemodynamic abnormality and its

response to treatment

DIAGNOSTIC ADJUNCTS

Diagnostic Peritoneal Lavage10 mL/kg (up to 1000 mL)Only the surgeon who will care for

the child should perform the DPL because DPL may interfere with subsequent

abdominal examinations or imaging upon which the decision to operate may in part be based

NONOPERATIVE MANAGEMENTCT/FAST that is positive for blood

alone does not mandate a laparotomy in a child who is hemodynamically normal or who stabilizes rapidly with fluid resuscitation

Head Trauma

lose significant amounts of blood in the subgaleal, subdural, or intraventricular spaces

ASSESSMENTinfant who is not in a coma but who

has bulging fontanelles or suture diastases should be treated as having a more severe injury

ASSESSMENTVomiting and even amnesia do not

necessarily imply increased intracranial pressure

persistent vomiting or vomiting that becomes more frequent is a concern and mandates CT of the head

Impact seizures (seizures that occur shortly after brain injury) are more common in children and are usually self-limited.

ASSESSMENT

ASSESSMENTMedication

Phenobarbital, 10-20 mg/kg/dose Diazepam, 0.1-0.2 mg/kg/dose; slow IV bolus Phenytoin or fosphenytoin, 15-20 mg/kg,

administered at 0.5-1.5 mL/kg/min as a loading dose, then-7 mg/kg/day for maintenance

Hypertonic saline 3% (Brain Trauma Foundation guidelines) 3-5 mL/kg

Mannitol, 0.5-1.0 g/kg (rarely required)

Spinal Cord Injury

ANATOMIC DIFFERENCESInterspinous ligaments and joint

capsules are more flexible.Vertebral bodies are wedged

anteriorly and tend to slide forward with flexion.

The facet joints are flat.The child has a relatively large head

compared with the neck.

ANATOMIC DIFFERENCESthe angular momentum is greater,

and the fulcrum exists higher in the cervical spine, which accounts for more injuries at the level of the occiput-C3

RADIOLOGIC CONSIDERATIONSPseudosubluxation of the cervical

vertebraeTo correct this radiographic anomaly,

place the child’s head in a neutral position by placing a 1-inch-thick layer of padding beneath the entire body from shoulders to hips, but not the head, and repeat the x-ray.

True subluxation will not disappear with this maneuver and mandates further evaluation.

RADIOLOGIC CONSIDERATIONS“spinal cord

injury without radiographic abnormalities” (SCIWORA): more commonly than adults

Musculoskeletal Trauma

BLOOD LOSSBlood loss associated with long-bone and

pelvic fractures is proportionately less in children than in adults.

Blood loss related to an isolated closed femur fracture that is treated appropriately is associated with an average fall in hematocrit of 4 percentage points, which is not enough to cause shock.

Hemodynamic instability in the presence of an isolated femur fracture should prompt evaluation for other sources of blood loss

SPECIAL CONSIDERATIONS OF THE IMMATURE SKELETON

The immature, pliable nature of bones in children may lead to a so-called greenstick fracture.

The torus, or “buckle,” fracture, seen in small children, involves angulation due to cortical impaction with a radiolucent fracture line.

Child Maltreatment

a history and careful evaluation of the child in whom maltreatment is suspected is critically important to prevent eventual death, especially in children who are <2 years of age

suspect‒ A discrepancy exists between the history and

the degree of physical injury‒ A prolonged interval has passed between the

time of the injury and presentation for medical care.

‒ The history includes repeated trauma, treated in the same or different EDs.

‒ The history of injury changes or is different between parents or guardians.

suspect‒ There is a history of hospital or doctor

“shopping.”‒ Parents respond inappropriately to or do not

comply with medical advice‒ The mechanism of injury is implausible based

on the child’s developmental stage.

findings ‒ Multicolored bruises (bruises in different

stages of healing)‒ Evidence of frequent previous injuries,

typified by old scars or healed fractures on x-ray examination

‒ Perioral injuries ‒ Injuries to the genital or perianal area‒ Fractures of long bones in children <3 years

of age

findings‒ Ruptured internal viscera without antecedent

major blunt trauma‒ Multiple subdural hematomas, especially

without a fresh skull fracture‒ Retinal hemorrhages‒ Bizarre injuries, such as bites, cigarette

burns, or rope marks

findings‒ Sharply demarcated 2nd & 3rd-degree burns‒ Skull fractures or rib fractures seen in

children <24 months of age

Pediatric trauma

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