Beaumont Children’s Hospital

Pediatric Trauma: What's the difference?

Robert Morden, MDPediatric Trauma Medical Director

What’s the Difference? Pre-hospital

• Different Mechanisms: Things children do and their changing levels of maturity predispose them to different injury patterns.

• Different Injuries: When involved in the same kind of accident as adults, children suffer quite different injuries.

Epidemiology of Childhood Injury( the U.S. numbers)

9. 9.2 million medical visits

151,319 hospitalizations

16% with permanent disability

Pediatric Trauma Factors

• Sex- males 2x risk• Economic conditions• Ethnic group• Race• Geography

How are Children Different?

• Anatomically• Physiologically• Cognitively• Psychologically

Age and Injury Related Deaths

• < 1y/o: airway obstruction• 1 to 4: drowning and

transportation related• 5 to 9: MVA• 10 to 14: MVA

Injury Pyramid

Injury Fatality Rate

Haddon “Matrix” and Injury Prevention

• Injuries result from predictable events and thus offer an opportunity for systemic intervention

• Pre-event• Event• Post-event

Interventions

• Cross walk timers• Helmets • Seat belts• Child proofing• Smoke alarms

Trimodal Pattern of Trauma Mortality and Morbidity

I. Death at the scene ie CNS and central vasculature. (prevention)

II. Second peak minutes to hours after ie solid organ, CNS, Cardiothoracic. (focus of ATLS protocols) preventable deaths

III. Days or weeks ie complications, RDS, infection. Uncommon in children

The ABCDE of Pediatric Trauma

• Application of a systemic protocol designed to standardize diagnostic and treatment decisions so that individual variations in patterns of injury do not distract the caregivers from recognizing and treating injuries that can have a profound impact upon outcome.

The Difference: Pre-hospital

• Kids are more difficult to intubate-50% failure rate.

• IV access-50% failure.• Unfamiliar with pediatric

resuscitation; pediatric patients account for only 10% of paramedic transport volume.

• Emotional factors-terrified child, distraught parent.

Airway Priorities

• Ensure Oxygenation• Ensure Ventilation• Protect Spine• Protect Airway

Considerations

• When and When not to intubate. O2 Sat <95% =clinical hypoxia Assess airway (teeth, debris,blood)

• Neurologically intact and phonates normally, and ventilates without stridor then leave them alone and monitor only.

• Coma, combativeness, shock, or direct trauma then needs a tube.

Pediatric Intubation

• Children’s airways differ both anatomically and physiologically.

• The best trained should intubate.

• Have appropriate equipment and medication available for best results.

• Pediatric Airway Differences

• Subglottic –tube type and size affect

• Narrow oropharynx• Larynx—anterior and cephalad• Epiglottis—short, floppy, angled

acutely• Vocal Cords— difficult to

visualize and are fragile and easily torn

• Trachea Shorter—endobronchial intubation and dislodgement are more common in kids.

More Pediatric Airway Considerations

• Nose breather—first 4 to 6 months

• Large tongue—relative to adults (jaw lift)

• Large head—occiput flexes head forward (support neck for neutral position)

Video Laryngoscope

Breathing (the differences)

• Laryngeal Mask Airway– unsuccessful then

• Cricothyrotomy >10 and needle 16 or 18 gauge if <10

• Tracheostomy—ONLY IN OR• Impaired spontaneous ventilatory drive

– head injury• Impaired lung expansion

– thoracic injury• Mortality rate for thoracic trauma in children

is 25%

Breathing

• Pediatric mediastinum mobile– more susceptible to tension pneumo

• Compliant chest wall– more susceptible to injury to the cardiothoracic

structures. (severe lung contusions)

Circulation

Seriously injured children often have normal vital signs even with significantly decreased circulating volume as a result of a remarkable cardiovascular reserve.

Circulation

• In children, hypotension in the presence of blood loss = OMINOUS SIGN

• Child’s blood volume 80-90ml/kg vs adult 65-70ml/kg

• Fixed stroke volume infants. To increase cardiac output can only increase heart rate.

Circulation

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

Clinical Signs of Shock

Circulation

• Vascular access-2 lines (above and below)• Central lines (if experienced)• Cut downs (saphenous easiest)• Interosseous (<6, 14 or 16 gauge, IO needle

preferred)• Fluids 20ml/kg RL• If after 40ml/kg –give pRBC 10ml/kg(AB0)

Intraosseous Line

• Less than 6 years of age• Fluids, blood products, and drugs can be given• Proximal tibia or distal femur best location• Fracture of the bone only contraindication• Obtain alternate access ASAP

Circulation

Signs of adequate perfusion -Slowing HR (<100) -Increase in Pulse Pressure(>20)

-Normal skin color -Increase warmth of extremities

-Improving GCS

-Increase systolic BP (>80)

-Urinary output-1-2 infant/ 1 child

Circulation

If hemodynamic remains unstable• hemorrhage intraabdominal or pelvic• cardiac dysfunction • tension pneumothorax• CNS (atlantooccipital dissociation)• profound hypothermia

Disability

• A rapid CNS evaluation A—alert V—voice responsive P—pain responsive

U—unresponsive• Pupillary responsiveness and symmetry

Disability

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

• May have significant blood loss from associated scalp laceration

• Basilar skull fracture– Raccoon's eyes, hemotympanum, otorrhea,

rhinorrhea– Indicates significant force but not important

to immediate outcome– No prophylactic antibiotics

Disability

• Open sutures (the fontanelles) -Ant. Open age 12-18mo

-Post. Open 2mo• Thinner cranial bones• Head relatively larger -heat

loss -higher center of gravity-more head trauma

Exposure

• Relatively small size– greater likelihood of multiple organ injury

• Higher BMR and surface area– heat loss and increase oxygen consumption

• Increased glucose needs and low glycogen– small glycogen stores therefore monitor glucose levels.

Exposure

• Hypothermia effects– cognitive function– cardiac activity– coagulation

• Keep core temp 35 to 36 degrees Celsius

– warm room, bed, fluids, gases

Other thoughts

• Gastric dilatation-NG tube– respiratory compromise and vagal bradycardia.

Decreases risk of aspiration.– no if facial fx or rhinorhea

• Foley only after perineal assessment• ECG-rarely abnormal but if it is then multiple

possibilities.

CNS Injury

• Cause of 70% of the deaths.• <2 Non-Accidental Trauma (abuse) is the

most common cause.• >2 falls, MVA, bicycle, pedestrian.• Traumatic Brain Injury

-Primary or Secondary

Primary

• Structural derangement of cerebral architecture from direct mechanical impact-cellular and vascular disruption

-infarction

-tissue loss

-epidural hematoma(thin skull)

-subdural (less common)

Secondary

• Decreased cerebral perfusion after the event– brain swelling leads to impairment of O2 and substrate.

– treatment principle is to protect cerebral perfusion and is the difference between disaster and success.

CPP=MAP-ICP

Secondary

• Maintain ICP <20mmHg in all ages• CPP >45mmHg in <8 years• CPP>70 to 80 mmHg older than 8 years

– intubate and controlled hyperventilation

• Pco2 30 to 35, Po2>100,and PH 7.4 -ventriculostomy to optimize CPP-osmotherapy (Mannitol or 3%Saline)-mild to moderate hypertension

• Decompressive craniectomy when ICP refractory

Spinal Cord Injury

• C1 and C2 fx unlike adults C6/C7• Compression and flexion distraction

fx– (Chance)

• SCIWORA-Spinal cord injury without radiologic abnormality– 10-20% of SCI– a documented neurologic deficit that

may have changed or resolved• MRI

The Childs Chest

• Narrow airway-obstructs easier• Anterior/Superior glottis-difficult

intubation• Shorter trachea-endobronchial intubation• Diaphragmatic breathing-hypoxia with

abdominal distension• Compliant rib cage-retraction and injury• Mobile mediastinum-tension pnemo

Clinical Predictors of Chest Injury

• Hypotension• Increased respiratory rate• Abnormal physical exam of chest• Femur Fx• GCS<15

– 98% of proven chest injuries had 1 or more of these.

Thoracic Injuries

• Second leading cause of death• In absence of external signs of trauma

significant intrathoracic injury– pliable chest– mobile mediastinum

• >50% of rib fx in <3 year olds– abuse

Thoracic Injury

• Pneumothorax-blunt burst type injury usually• Not all need chest tubes. If <20% and O2 Sat OK.• 4th or 5th intercostal space• Newborn 12 –16F• Infant 16 –18 F• School age 18-24 F• Adolescent 28 –32 F

Pneumothorax

Tension Pneumothorax

(usually a major injury if seen)• Severe distress,trachea shift, neck vein

distension, collapsed lung with flattened diaphragm, reduced venous return to heart.

• Treatment immediate needle-catheter (without waiting for Xray) 2nd intercostal space anteriorly or lateral in 4th or 5th .

Hemothorax

• Most bleeding stops-low pressure pulmonary circulation

• Massive-laceration of vessel (intercostal commonest)

• Thoracotomy consider: -Initial blood 20-25% of EBV -4ml/kg/hr

-Increasing bleeding-If can’t get out clot

Pulmonary Contusion

• Commonest Injury• Rare to need ventilation• Rare to go on to ARDS• Differentiate from Aspiration• Most clear in 7 to 10 days.

Trachea and Bronchi

• Rare but often fatal• Presentation-Voice disturbance, cyanosis,

hemoptysis,• Massive sub Q air and mediastinal

emphysema• Large leak from chest tube.• ATLS and then OR unless stable

Heart and Pericardium

• Concussion –commotio cordis• Contusion-commonest and difficult to

diagnosis (rarely of clinical significance in children)

• Myocardial rupture-commonest cause of death in blunt trauma. (if survive may see tamponade.)

Pericardial Tamponade

• Suspect when-tachycardia, peripheral vasoconstriction, jugular venous distension, persistent hypotension despite fluids.

• Beck’s triad-elevated jugular venous pressure, systemic hypotension, muffled heart sounds (rarely seen in acute trauma)

• Diagnosis –FAST exam and transthoracic echo.

Traumatic Asphyxia

• Unique to Children• Compression of Chest and/or Abdomen against a

closed glottis• Increase in intrathoracic pressure leads to increase

in the SVC pressure and the veins from the upper body that drain into it.

• Extravasation of blood into skin, sclera, brain• Seizures, disorientation, petechiae of upper body

and conjunctivae• Most recover

Petechiae

Pediatric Abdomen Difference

• Thin musculature (particularly <2)• Ribs flexible-don’t protect or dissipate energy• Solid organs larger• Lower fat content• Elastic attachments• Higher bladder

The Abdomen Exam

• Abdominal wall bruising:– 74% of children with had major injury– 99% of children without had none

• Lower rib fracture:– associated with 31% splenic injury and 15%

hepatic injury

The FAST?

• Focused Assessment Sonography in Trauma• Useful – free fluid detection, pericardial +/-• Not useful-solid organ injury (does not determine

grade)• Limitations: user dependent, high false negative

results.• Conclusions: Get CT if suspicious.

Solid Organ Injury

Splenic Laceration Liver Laceration

Solid Organ Injury

• The non-operative management:– Universally successful and the standard of care

>90%– Yet: The operative rate is 4 to 6 times greater in

non-pediatric centers.• Operate when hemodynamic instability

unresponsive to crystalloid and blood transfusion

.

Lab studies and blunt abdominal trauma

• CBC,TandC• U/A• Transaminases : elevated AST and ALT

strong association alone with injury.• Pancreatic enzymes: controversial but

baseline importance.

Seat Belt Sign

Bowel Injuries

CT or not CT

• Glasgow coma scale 14 or >• No evidence of abdominal wall trauma• No abdominal tenderness• No complaints of abdominal pain• No vomiting• No thoracic wall trauma• No decreased breath sounds.

Case Study: KW

• 11 yo female presented 16 hours following fall on cement block

• CC epigastric pain, nausea and emesis

• PMH/PSH negligible

Case Study: KW

• Physical Exam

• Afebrile, HR 120, BP 90/50

• NAD, Pale, lethargic, dry mucous membranes

• Abdomen soft, ND, TTP epigastrium, abrasion across left subcostal extending across anterior chest

Pancreatic Injury

Pancreatic Injury

• Treated non-operatively• NPO/IVF/TPN• PTD 7, +Clears introduced• PTD 14 discharged home on TPN and clear diet• 10/2 ultrasound, no pseudocyst, diet advanced

Pediatric Renal Trauma

• Most commonly injured abdominal organ in blunt trauma.– Fetal lobulations predispose to renal seperation– Less protection by pliable thoracic cage and less

developed musculature– Higher incidence of pedicle injury

• 80 % with renal injury has associated non-renal injuries

Pediatric Renal Trauma

• Pre-existing renal abnormalities are 3-5 times more common in peds patients undergoing screening CT for trauma than in adults.

• Classically, congenital renal abnormality presents with hematuria disproportionate to severity of trauma

Organ Injury Scale

Case Study: BF

• 15 y/o male presents to OSH after he was hit with a line drive while playing indoor baseball

• C/O pain to R abdomen/rib/flank• Pain is getting progressively worse and

patient is now vomiting

Case Study BF: Exam

• No acute abdominal tenderness• Unilateral rib x-rays negative• Labs drawn-CBC, CMP, PT/PTT• Given Vicodin and Zofran for pain and

nausea• UA ordered and staff recognized gross

hematuria, A/P CT was ordered

Case Study BF: Diagnosis

• CT shows at least AAST grade III laceration involving the medial interpolar right kidney with moderate surrounding perinephric hematoma.

• Patient transferred to RO Beaumont for eval.

Case Study BF: Admit

• Admit to Peds Urology• q6hr Hgb • -strict bed rest • -IVF • -pain control • -PICU for monitoring • -Type and Cross

Case Study BF: Disposition

• Patient was treated non-operatively • He remained in Pediatric ICU for 2 days, and

was transferred to the peds floor for 4 more days.

• Was discharged on day 6; home care included bedrest for 1 month and no school

Case Study: GSW

• 3 year old boy found fathers 45 under mattress inserted in mouth and pulled the trigger. Presents with bleeding from mouth and exit wound below mandible on right.

• A: Unable to visualize cords (blood and swelling)

• B: Harsh breath sounds• C: BP normal, mild Tachycardia• D: Crying (Glasgow 15)

Case Study: GSW

• Discrepancies in story• Changing history• Inappropriate response

– parents and child• Multiple injuries in past• Classic abuse injuries• Child’s development• Sexual abuse

Child Abuse “Red Flags”

Injuries that would be suspicious for abuse

• Multiple SDH, retinal hemorrhage• Ruptured viscus without antecedent history• Perianal, genital trauma• Multiple scars, fractures of varying age• Long bone fractures less than 3 years old• Bizarre injuries: bites, cigarette burns, rope

marks• Sharply demarcated burns

Overview: What’s the difference

Characteristic• Large BSA• Poor neck musculature• Large blood volume in head• Decreased alveolar surface area• High metabolic rate• Small airway• Heart high in chest• Small pericardial sac• Compliant skeleton• Thin walled, small abdomen• Poorly developed renal function

Result• Hypothermia• Flex/extension injury• Cerebral edema• Rapid desats• Rapid desats• Inc airway resistance• Injury/tamponade• Injury/tamponade• Fracture less common• Organs not protected• Risk renal failure

Questions?