Pediatric Trauma Bartholomew J Tortella MTS, MD, MBA, FACS, FCCM 1.

Pediatric Trauma

Bartholomew J TortellaMTS, MD, MBA, FACS, FCCM

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Outline

• Background• Trauma scores• Principles and Approach• ABC’s• Specific injuries– Head, C-Spine, Chest, Abdominal, Burns

• Abuse

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Background• Leading cause of death > 1 yr• 50% of all childhood deaths• < 5 yr highest risk; boys > girls• 1.5M injures / 250k hospitalizations / 100k

permanent disabilities• 85% Blunt / 15% penetrating • Ped trauma ctr.– St. Christopher’s Hospital for Children– Children’s Hospital of Philadelphia

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Special Pediatric Considetions

• Smaller body size (larger force transfer/area)• Increased body surface area• Less subcutaneous fat• Head disproportionately large / C-spine• Bones have physes• Resp = leading cause of arrest• BP changes VERY late

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Airway

• Respiratory #1 cause of arrest• Twice O2 demands

• ET tube size: Age/4 + 4• Uncuffed ET tube

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Anatomical airway issues in kids

• Big tongue, soft tissue obstruction• Anterior larynx• Big epiglottis straight blade (Miller / Wisconsin)• Short trachea• narrowest at subglottis (uncuffed tube)• Big occiput forces airway shut when on back board

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Rapid Sequence Intubation

• Pre-treat atropine 0.02 mg/kg all < 6yr• Induction: Etomidate 0.3 mg/kg

• Paralytic: Succinylcholine 1.5 mg/kg• Post intubation• Morphine (0.05mg/kg)• Midazolam • Vecuronium (0.3 mg/kg)

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Breathing

• Signs of distress: retractions, tracheal tug, nasal flaring

• Infants: Diaphragm 1° muscle resp & easily fatigued

• Thoracic structures mobile shift• Rib Fx uncommon so beware the Tension PTx

without rib fractures

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Circulation

• Hypotension LATE sign: kids compensate well– 25% loss of blood volume– Minimum acceptable BP: 70 + (2 x age)

• Shock: HR, RR, mottled, cool, pulses, altered LOC, cap refill < 2 sec, narrow Pulse pressure

• Note: scalp laceration can cause shock

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Circulation

• IV’s: antecubital / femoral• Attempts >90 sec: intraosseous• Fluids– Ringer’s Lactate 20mL/kg x 2– pRBC 10mL/kg– FFP / Platelets

• No role for MAST: mortality• Surgery for continued instablility

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Disability Pediatric Glasgow Coma Scale1 2 3 4 5 6

Eyes Does not open eyes

Opens eyes in response to painful stimuli

Opens eyes in response to speech

Opens eyes spontaneously

Verbal No verbal response

Inconsolable agitated

Inconsistent inconsolable Moaning

Cries but consolable

Inapp’prate interactions

Smiles, orients to sounds, follows objects, interacts

Motor No motor response

Extension to pain (decerebrate response)

Abnormal flexion to pain for an infant (decorticate response)

Infant withdraws from pain

Infant withdraws from touch

Infant moves spontaneously or purposefully

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Exposure

• Thorough exam then COVER• Trauma X:– Multiple bruises in different stages of healing– Usual fractures (torque)– Cigarette / cigar burns– Changing / unrealistic history

• Legal duty to report (criminal liability for physician)

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Secondary Survery

• Head to toe examination• History from EMS / Care giver / Patient

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Laboratories & Intervenions

• Blood Bank Sample• PT / PTT (coagulopathy = higher mortality)• Others– Hemogram– Lytes

• Orogastric tube• Foley catheter

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Imaging

• FAST• Chest X-Ray• Obvious fractures• CT Scan

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Head Injury

• Leading cause of death in peds trauma (80%)• 90 % “minor”• Falls > MVC > MPC > bicycle > assault• Few require surgery: 0.5 -1.5%• 4-6% with normal exam have ICH on CT

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Head Injury: Anatomic differences

Protective• Fontanelles• Open sutures• Plasticity

Susceptible• Big head torque• Soft cranium injury w/o

fracture• Less myelin more shearing

forces• Prone to reactive hyperemia

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Head Injury: Types of injury

• Contusions, DAI, SAH, parenchymal• Subdural: common, poor outcome, <1 yr• Epidural: uncommon, <4 yr, subtle

presentation, minor trauma

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Skull Fracture

• 20 x risk ICH• Linear > depressed > basilar• X-rays not sensitive nor specific• 90% linear have overlying hematoma• “Growing skull”:diastatic dural tear meninges

herniate, prevents closure: NSx F/U

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Interpretation? 20

Growing Skull Fracture21

C-Spine Injuries

• Less common in kids BUT higher mortality• <8 yr: 2/3 above C3

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C-Spine• Less common in kids BUT higher mortality• <8 yr: 2/3 above C3• Big head, less muscles torque, fulcrum C2-3• Cartilage & lax ligaments injury w/o fracture• Pseudosubluxation

C2-3, C3-4: 3-4 mm or 50% vertebral body width• Prevertebral space: C2=7mm, C3=5mm, C6=14mm• Predental space 4-5 mm• Watch out for ncomplete ossification, multiple centres

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SCIWORA

• 16-50% SCI!!• < 9 years• Transient neuro symptoms (parasthesias)• Recur up to 4 days later• bottom line: – CT/MRI if abn neck/neuro exam, distracting

injuries, alt. LOC, high risk mech DESPITE normal 3-views

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Chest Trauma

• 2ND leading cause pediatric trauma death• Compliant chest wall rib fracture uncommon– Significant injuries w/o external signs– If fracture present, severe injury

• Treat non-operatively• PTx: 15% require more than chest tube• Pulmonary contusion most common, aortic

injury rare

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Chest Trauma

• Traumatic asphyxia– Sudden compression elastic chest wall against closed glottis

intrathoracic pressureobstruction of SVC/IVC capillary extravasation

– Petechiae face, neck ,chest– Periorbital edema– Retinal hemorrhages– Resp distress / hemoptysis, pulmonary/cardiac contusions,

liver injuries, pneumothorax

• Treat: chest tube prn, ventilate, PEEP, elevate head

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Abdominal Trauma: Anatomic issues

• Larger solid organs, less musculature, compact torso, elastic ribcage, liver & spleen anterior– Potential internal injury– Most solid organ – Spleen>liver>kidney>pancreas>intestine

• Bladder intra-abdominal (10% GU injury)

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Abdominal Trauma: Assessment

• Clinical findings unreliable• Shoulder tip pain, flank / lap ecchymosis• Feassess, reassess, reassess • Mechanism classics: handlebars, lap belt

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Abdominal Imaging: CT

• FAST not as reliable as adults• Stable pt only• ID’s injuries, retroperitoneum• Insensitive for hollow viscous (25% sens),

pancreas (85% sens)

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Abdominal Trauma: Management

• Spleen and liver:– 90% Non-operative: admit, observe, Hct– Fatal hemorrhage with liver injuries

• Pancreas:– Observation– Drain

• Hematuria:– gross or >20 RBC + unstable OR– >10 RBC + stable CT cysto

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Child Abuse: Clues

History• story injuries• history changing• injury development• delay seeking help• inappropriate level of

concern

Physical Exam• multiple old and new

bruises• posterior rib #, sternum

#, spiral # < 3• immersion burns,

cigarette

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Child Abuse

• 1 million confirmed cases / year (US)• high index of suspicion• RF: poverty, single parent, substance abuse,

<2 yr, disability, low birth wt• cutaneuos injuries most common• death 2° head & abd trauma• interview child & parent separately

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Child Abuse: Head Injury

• blunt, acceleration/decceleration • 31% missed, 28% re-injured• fractures:– bilateral, cross sutures, diastatic, non-parietal

• IC injuires:– SAH, subdural, ICH, edema

• CT if suspect

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Child Abuse: Management

• DOCUMENT• full P/E (rectal, genital)• photograph• B/W: CBC, PT/PTT, LFTs, lipase, U/A• skeletal survey• CT head, abd prn• Child Protection

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Bottom Lines

• NOT just little adults BUT resuscitation remains the same

• Severely injured do better at trauma centre• Metabolic requirements differ• Multisystem injury is RULE• Occult injuries are common• Head injuries: high mortality, assoc injuries• be aware of potential abuse

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