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Not Just Smaller Injuries:
Considerations in Pediatric Trauma
Carl P. Kaplan, MD
Assistant Professor of Pediatrics & Emergency Medicine
Stony Brook University School of Medicine
Goals
A taste of ATLS
Boards type patterns of injury
Considerations in pediatric patients
Do’s and Don’ts
“ If a disease were killing our children in the proportions that injuries are, people would be outraged and demand that this killer be stopped.”
C. Everett Koop, M.D.
Pediatric Trauma: Unintentional Injuries and Homicide
US Dept of Health and Human Service Report, 2010. (Data from 2007)
Leading Causes of Death among Children Aged 1-4, United States
Leading Causes of Death among Children Aged 5-14, United States
Children age 0-5 requiring medical attention
for injuries• 27,543 surveyed regarding the past year
• 10.4% (2,856) responded YES
• Approximately 2.5 million (extrapolated to 2007 population data)
2007 National Survey of Children’s Health
CASE
5 yo F pedestrian struck by SUV thrown 30ft
No LOC, crying intermittantly, c/o leg back and abdo pain, incontinent of stool
BIBEMS immobilized on board with 22G PIV
Trauma Room
AirwayTeam Leader
RN,Tech, or Physician
RNSecondary Physician
Primary Physician
Resp TherapistScribeCirculating RNRadiology TechSW
History
A – Allergies
M – Medications
P – Past Medical Hx
L – Last meal
E – Events surrounding injury
• May be unknown
• May need to come from multiple sources
Primary Survey
Airway: audible grunting, no secretions, no blood, NRB 15L in place
(c-spine immobilized)
Breathing: tachypneic mid 40s, SpO2 91%, intercostal retractions, equal BS, diffuse crackles
Circulation: HR 130s, BP 132/60 , warm extremities CR=3s, no open wounds, pain with palpation of pelvis, 22G PIV
Disability
Neurologic Exam.
GCSExposure:Remove all clothing
Avoid hypothermia!
Primary Survey (cont)
Disability: GCS 10 (V3, M4, E3), Pupils 4mm bilaterally reactive/sluggish, limited movement of shortened / externally rotated LLE, moving all extrems with pain.
Exposure: Abrasions to frontal scalp area, Left anterior pelvis, blood in vulva and on perineum, Warming lights on.
Family: At bedside , Fingerstick: 145
Lets Think for a Minute…
Anatomy/PhysiologyOverall smaller size, more compact organs
Proportionately larger head
Smaller, narrower, funnel-shaped upper airway
Flatter facets joints, more elastic cervical ligaments
Injury ResponseMultiple injuries more common
Higher frequency of head trauma
Higher frequency of soft-tissue obstruction
Greater propensity for spinal cord injury without radiologic abnormality (SCIWORA)
Lets Think for a Minute…
Anatomy/PhysiologyThinner chest wall, more flexible ribs
Horizontal ribs, weaker intercostals
More mobile mediastinum
Abdominal organs more anterior and less subcutaneous fat
Injury ResponseHigher frequency of pulmonary injury
Young children are diaphragm breathers
Tension pneumothorax poorly tolerated
Higher risk of intra-abdominal injury and bleeding
Lets Think for a Minute…
Anatomy/PhysiologySofter bones, thicker periosteum
Active, unfused bony growth plates
Compensatory vasoconstriction
Larger body surface area/mass ratio
Injury ResponseHigher frequency of incomplete fractures
Disturbed growth after growth plate fractures
Normal blood pressure with early shock
Greater heat loss from exposed body surfaces
Imaging considerations (more thinking)
Another lecture entirely…
• Clinical practice guidelines
Head – PECARN
Cervical Spine – PECARN, NEXUS
Abdomen/Pelvis – PECARN
• CXR +/- Pelvis XR
• FAST
• Serial exams/labs
Things to Remember…
Be safe (universal precautions, traffic, sharps)
Be quiet, but diligent and thorough
Don’t be distracted
Unsightly, non-life threatening injuries
Crying, screaming families
Beeping, metal crashing
Communicate with team leader
Keep the drama out of the trauma
Back to the patient…
ABCD next steps…
• Grunting, Tachypnea, Retractions, good BS w/ diffuse crackles, SpO2 91% w/ NRB 15L in place
• Rapid Sequence Intubation with inline
C-spine immobilization
ABCD next steps…
• Tachycardia, Hypertension, Abdominal tenderness, pelvic tenderness/blood PV, LLE deformity
• Second large bore IV or IO,
• 20-40cc/kg NS or LR then PRBCs
• Consider pelvic stabilization
• Traction of femur fracture
ABCD next steps…
GCS 10, moving all extremities
• Close observation for signs of herniation
• Maintain BP, ICP monitor for CPP
• Normocapnea
• Elevate head of bed 30deg prn
• Possible load with AEDs
Secondary survey
Check from head to toe
Rectal exam for gross blood and tone
Roll/remove BB with C-spine precaution
Maintain warm environment
eFAST
eFAST
Pneumothorax Pneumothorax
Pelvic FF
Morrison’s PouchPleural Effusion
Splenorenal fossaPleural Effusion
Pericardial effusion/ tamponade
Pediatric Trauma
• Family• In trauma room or private area, Updates, don’t
leave alone
• Foley (if blood at meatus -> retrograde urethrogram)
• Fever • consider pre-op ABX for procedures (cefazolin) • DTap, TIG, or Tdap as indicated
Pediatric Trauma
Non accidental injury• History is not c/w injury pattern
• History changes with repeated questioning
• History is unknown
• Injury is not c/w developmental abilities of pt• ie. 6 mo climbed up onto counter and fell
• History of repeated injuries/ED visits
Pediatric Trauma
Non accidental injuryHead/Facial injury very common (present in 60-70%)
SBS – SDH, Rib fractures, retinal (multilayer) hemorrhages
Spiral fractures, corner fractures, fractures in different stages of healing
Blunt abdominal trauma.
Pediatric Trauma
Burns
• May be associated with other blunt or penetrating injuries
• May be associated with airway burns
• May be associated with toxic exposures
life threatening = CarboxyHb, CN, HF
Patterns of injury
Waddell Triad (Pedestrian Struck)
• Head Injury
• Thoraco-abdominal Injury
• Lower Extremity Fracture
Waddell Triad
Patterns of injury
Handlebar Injury
Retroperitoneal injury
Pancreas
Duodenum
(+/- Liver or spleen)
Patterns of Injury
Handlebar
Pancreas
Duodenum
Liver Stomach
Lapbelt injury
Patterns of Injury
Patterns of Injury
Lapbelt(Dependent on placement)
• Chance Fracture (flexion/distraction, Lspine)
• Hollow viscous rupture (or mesenteric tear/bleed)
(+/- Liver/Spleen)
Patterns of Injury
LapbeltChance Fracture Upper or Middle L-Spine
Patterns of Injury
Seatbelt sign
(not redness, not superficial abrasion from friction)
Patterns of Injury
• SDH• Retinal
hemorrhages• Posterior rib
Fxs
Wrap up
ABCDEFs keep focus away from drama
Be mindful of patterns of injury and NAI
Involve parents
Try to limit imaging when possible
CASE
16 yo M BIBEMS s/p assault and LOC, with multiple head/facial injuries/bleeding, now alert and oriented x 3, c/o HA and nausea
HR 105 BP 130/75 RR 22 SpO2 100%
NRB in place, CC/BB, IV in place
• Primary survey decreased BS right
Exposure
1 cm laceration with bubbling right posterior axillary line T3
No other injuries identified
“My head is killing me!”
Actions
Second IV placed – crystalloids continued
Right Tube Thoracostomy for HPTX
IV Cefazolin
Tdap
CT Head - small SDH/SAH, parietal skull Fx non-displaced
Ann Emerg Med 2012
Lancet 2009
Ann Emerg Med 2010