Pediatric traumaEM K2-06
· USA : Trauma is the leading cause of death in children > 1 yrs of age
· Annualy 1.5 million pediatric injuries· 500.000 require hospitalization· 120.000 will have permanent
disability· 20.000 die
Cowley (1979) : The concept of “the golden hour” (first hour after injury)
In small children : The concept of “the platinum half-hour”
Physical difference in children that affect trauma
managementDifferences Implications· Small size· Less fat and con tissue· Proximity of organs· Pliable skeleton
Intense force leads to organ injury
· High ratio of body surface area to mass
Increase in sensible water losses--hypothermia
· Pliable ribsPulmonary contusions more common than rib fracture
· Mobile mediastinumRapid cardiovascular decompensation from tension pneumothorax
· Airway anatomic and size
Prone to obstruction
Advanced Trauma Life Support (ATLS) Approach
Phase Goals
Primary survey
· Recognize the life threatening injury
· Open airway & support breathing
Resuscitation· Maintain circulation· Monitoring
Secondary survey
· Medical history· Head-to-toe
evaluation
Primary surveyMnem
Evaluation Management
A Airway
Airway patency, sniffing position, rool under shoulder (infant)/under occiput (children), chin lift - jaw thrust, ET intubation
B BreathingOxygenation-ventilation, SaO2>94%
C Circulation
Vascular access, fluid/volume resuscitation
D DisabilityNeurologic status: GCS, pupillary resp, localizing sign, paralysis
E ExposureRemoval clothing, additional injury?, cover with warm blanket
Secondary survey
· After primary survey completed and patient is stable
· History (SAMPLE)· Physical examination (from head to toe)
The SAMPLE History Mnemonic History Points
Symptoms Current symptoms, particularly pain
Allergies Allergies to medications; food; materials, environmental, bee stings
Medications
List prescription and nonprescription medications takes regularly, including dosage regimen and time of the last dose
Past medical history
Preexisting physical or psychological disabilities; a history of previous trauma or a chronic condition; immunization status, including tetanus prophylaxis
Last meal When and what the last ate or drank
Events Events that led up to the ill/injury
Physical examination (1)Region Sign Suggestion
Head
Bulging fontanella Increased ICP
Sunken fontanella Volume loss
Laceration, step-offs Fracture
Raccon eyes (periorbital ecchymosis), Battle’s sign (mastoid echymosis)
Basilar fracture
Puppilary response, sub conj bleeding, extra ocular movement
RhinorrhoeLeakage CSF(Oral NGT !)
NeckTenderness, crepitus, carotid pulse, trachea?
Physical examination (2)Region Sign Suggestion
Chest
Deformity, tenderness fracture
Inequality breath sound
Pneumothorax, hematothorax
Distant, muffled heart sounds
Pericardial effusion
Tachycardia, narrow pulse
Pericardial tamponade
Abdomen
Echymosis, presence and quality of bowel sound, tenderness, rigidity
BackDeformities, ecchymosis, tenderness
Physical examination (3)Region Sign Suggestion
Perineal
Laceration and blood at the urethral meatus,Tone and presence of blood in the rectal vault
Musculo-skeletal
Inspected and palpated to identify fractures or dislocation
Type of trauma
Diagnostic study
Any
Complete blood count, PT/PTT, aspartate/ alanine amino transferase, amylase, lipase, urinalysis, CXR, C-spine/Pelvis XR
Head Head CT, MRI
C-spineC-spine radiographs:PA/L/Odontoid viewC-spine CT/MRI
ThoracicCXR, Chest CT/angiography, ECG, Echo, Esophagram, Bronchoscopy/graphy
Abdominal
Aspartate/alanine amino transferase, amylase, lipase, urinalysis, FAST, Abd CT, diagnostic peritoneal lavage
Diagnostic evaluation of trauma
Pediatric Trauma Score
+2 +1 -1
Size (kg) >20 10-20 <10SBP >90 50-90 <50
Airway N SecureTenuou
sCNS Awake Obtund ComaOpen wound
None Minor Major
Fractures None Closed Open
· Score +12 to -6
· 8 = 0% mortality
· 2 = 45% · 0 = 100% · PTS <8 =
transfer to pediatric trauma center
· Head trauma· Cervical spine trauma· Chest trauma· Abdominal trauma· Musculoskeletal
trauma· The battered abuses
child
Pediatric trauma
Head Trauma/Traumatic Brain Injury
Degree GCS
Mild 13-15
Moderate 9-12
Severe 3-8
Activity >5 years <5 years Score
Eye-opening
Spontaneous Spontaneous 4
To voice To voice 3
To pain To pain 2
None None 1
Verbal
Orientated Alert, babbles, coos 5
Confused Irritable 4
Inappropriate words Cries to pain 3
Incomprehensible sounds
Moans to pain 2
No response to pain No response to pain 1
Motor
Obeys commands Spontaneous movements 6
Localises to supraocular pain
Localises to supraocular pain)
5
Withdraws nailbed pressure
Withdraws nailbed pressure
4
Flexion to supraocular pain
Flexion to supraocular pain
3
Extension to supraocular pain
Extension to supraocular pain
2
No response No response 1
Modified Glasgow Coma Scale (James and Trauner, 1985)
Score ≤ 8 = Comatose; Score 9 = Non Comatose
17
Clinical features in head trauma· Scalp Injuries · Skull Fractures· Depressed Skull Fractures· Basilar Skull Fractures· Vascular Injuries· Penetrating Head Injury· Intracranial Hemorrhage
‐ Epidural Hematoma‐ Subdural Hematoma‐ Subarachnoid
Hemorrhage‐ Intracerebral
Hemorrhage
ContusionUsually frontal or temporal lobe; Small cortical vessels and neural tissue damaged; Damaged vessels may thombose, leading to ischemia
Severe head injuryWith basilar skull fracture, right temporal hematoma, cerebral edema, hydrocephalus, and pneumocephalus
Epidural hematoma● Usually arterial in origin● Between skull and dura, limited
by suture lines● Often from tear in middle
meningeal artery● Initial injury may seem minor,
followed by “lucid interval,” then neurologic deterioration
● May expand rapidly and require emergency craniotomy
Subdural hematoma● Usually venous bleeding
(bridging veins)● On surface of cortex, beneath
dura and outside arachnoid, not limited by suture lines.
● Typically requires greater force to produce than epidural hematoma
● Usually associated with severe parenchymal injury
Intracerebral hemorrhageUsually frontal or temporal lobe; Can be bilateral (contracoup injury)Can act as mass lesions and cause intracranial hypertension
● Reduced cerebral perfusion pressure (CPP = MAP-ICP)
● Brain herniation : ● uncal herniation; ● diencephalic and midbrain/upper
pontine herniation; ● temporal lobes herniation● lower pontine and medullary
herniation
Intracranial hypertension
Note :Central or uncal herniation through the tentorium is compatible with intact survival; Foramen magnum hernation is not compatible with intact survival.
Normal Intra Cranial PressureAge group mmHg
Newborn 0.7-1.5
Infant 1.5-6.0
Children 3.0-7.5Note: ICP in hydrocephalic infant = 7.5-30 mmHg
(CPP = MAP-ICP)Age group CPP (mmHg)
Adult 60-70
Children 50-60
Infant 40-50
1. Temporal lobes herniation
2. Uncal herniation3. Diencephalic and
midbrain/ upper pontine herniation
4. Lower pontine and medullary herniation
Brain Herniations
Management of increased ICPHead position ● Head elevated 30 degrees and
midline
Sedation and pain control
● Analgesic + anxiolytic : Fentanyl, morphine, or propofol plus a benzodiazepine
Seizure prophylaxis ● Phenytoin or phosphenytoin
Neuromuscular blockade
● Facilitates mechanical ventilation and control of pCO2; prevents shivering;
Temperature control ● Maintain temp<37.5 oC; scheduled acetaminophen, body exposure, cooling blanket
Osmotherapy with mannitol or NS 3%
● Scheduled if elevated ICP is persistent
● Follow serum osmolality and Na; hold mannitol if serum osm > 320 mOsm/l
Reftractory intracranial hypertension
● Barbiturate “coma”; Induced hypertension; Decompressive craniotomy; Hypothermia
Drainage of CSF ● Possible if ventricular catheter is in place
● Set at 20 cm H2O; CSF drains when ICP exceeds drainage pressure;
● The brain function ceased completely● Pulmonary and cardiac functions can still be
maintained artificially● Diagnosed clinically in the majority of
patients (negative brain stem reflex)● EEG : flat● Flow index of transcranial Doppler
ultrasound < 0.8 more than 2 hours : irreversible brain stem death
Brain death
Cervical Spine Injuries
· Uncommon in children· Mortality rate 15-20 %· Cervical injuries, C-spine
dislocation, Spinal cord injury· < 8 yrs: 2/3 above C3· < 9 yrs: 16-50% SCIWORA (Spinal
Cord Injury With-Out Radiographic Abnormality), SC stretching, transient neuro symptoms (parasthesias), recure up to 4 days later
Chest Trauma (1)· Blunt trauma· 2nd leading cause pediatric trauma
death (behind head trauma)· Mortality rate 5 %, increase to 25 %
when accompanied by head and abdominal trauma
· Compliant chest wall : rib fractures uncommon
Chest Trauma (2)· Higher risk for pulmonary contusions,
associated with hypoxemia, hypoventilation, perfusion mismatch, decresed pulmonary compliance, lung consolidation/edema, alveolar hemorrhage
· Initial diagnostic: CXR· Treat conservatively, 15% require
more than chest tube, avoidance fluid overload, give supplemental O2, analgesia, mechanical ventilator if required
Abdominal Trauma (1)· 3rd leading cause of trauma death· Blunt injury, often occult fatal injury· Spleen
Injury>liver>kidney>pancreas>intestine· Bladder intra-abdominal, 10% have GU injury· Clinical findings unreliable, low BP late sign of
shock· Physical finding: abd distension, abrasion,
contusion, lap belt ecchymoisis, focal/diffuse tenderness
· Hb<< susp abd hemorrhage· Amylase, lipase predictor pancreatic injury· Alanine aminotransferase > 131U plus abd
tenderness, predictive abd injury (sens 100 %)
· Abd CT detecting solid organ injuries
Abdominal Trauma (2)· Focus Abdominal Sonography for Trauma
(FAST), diagnostic peritoneal lavage are limited utility in pediatric patients
· Abdominal CT with IV contrast is the most sensitive detector of splenic and liver injury
· Pneumoperitoneum or extravasation of oral contrast may detected on abd CT of bowel injury
· Hemodynamically unstable patients require emergency resuscitation and laparotomy; hemodinamycally stable warrant further assessment
· Splenectomy in unrepairable spleen damage and hemodynamically unstable; most liver injuries may be managed without surgery
• Fracture• Soft tissue (muscle, tendon, ligament)
and joint injury• Growth plate injury
Musculoskeletal trauma
• Strains: muscular injuries caused by excessive stretching; SS: pain and swelling of the muscle
• Sprains: caused by overstretch and partial tearing of a ligament
• Subluxation : incomplete separation of a joint; there is still partial contact between each bone’s articular cartilage
• Dislocation: complete separation of joint; all contact is lost between articular surfaces.
• The majority of sprains and strains heal promptly with Rest, Ice, Compression, and Elevation (RICE).
• Rigorous physical activity should be avoided for 3 weeks.
Soft tissue (muscle, tendon, ligament) and joint injury
Salter Harris classification of growth
plate fractures
4040
Non-accidental trauma(The battered abuses child)
Suspicion of abuse should arise when :· The caretaker is unable to explain the
injuries or gives a mechanism of injury that doesn’t match the degree of injury seen
· The timing of injury dosen’t fit with the time of presentation
· The child’s developmental stage is not sync with the history
· The history of injury changes over time or from caretaker to caretaker
Shaken baby syndrome (SBS)
· The diagnosis is made in the presence of : Subdural hemorrhage, retinal hemorrhage, skeletal injury
· The clinical history is vague and is usually some history of altered mental status
· The child has no specific symptoms such as lethargy, poor feeding, and irritability or may have had a seizure like episode
· Differential diagnosis : sepsis, meningitis, new onset seizure, metabolic disorder