Pediatric Trauma

Pediatric TraumaLecture Objectives

ƒ Highlight the differences between adult and pediatric trauma management

ƒ Recognize some of subtleties of pediatric trauma presentations

ƒ Use of the Pediatric Trauma Score

ƒ Recognize possible signs of child abuse

Pediatric TraumaEpidemiology

ƒ " After the first year of life, trauma is the most serious pediatric health problem in the U.S. "

ƒ 1/2 of pediatric deaths after the first year of life are due to trauma

ƒ 22 million children (one in every 3) in U.S. are injured each year

Pediatric TraumaMost Common Etiologies

ƒ Motor vehicle crashes*ƒ Falls*ƒ Child abuseƒ Firesƒ Penetrating trauma (higher

incidence in teenagers)

* Together account for 80 % of injuries

Pediatric Trauma : Unique Pediatric Anatomic Features Compared to Adults

ƒ Head is disproportionately largerƒ Smaller body mass ; results in

greater force applied per unit area & higher frequency of multiple organ injuries

ƒ Surface area to body weight ratio is higher ; results in faster heat loss & tendency toward hypothermia

Pediatric Trauma : Pediatric Anatomic Features Affecting Trauma (cont.)ƒ Child's skeleton is softer & less

calcified–Results in internal damage without overlying bone fracture–Presence of fractures implies higher energy transfer

ƒ Mentally less developed–Less able to understand questions & procedures

ƒ Liver, spleen, bladder, & kidneys less protected & more prone to injury

Pediatric Trauma : Airway Anatomic Differences Compared to Adults

ƒ When supine, relatively larger head tends to flex neck & obstruct the airway

ƒ Larynx is more anteriorƒ Trachea is relatively short in length

–5 cm. in infants–7 cm. by age 18 months

ƒ Narrowest portion of airway is subglottic region (this is why uncuffed endotracheal tubes are preferred in children < 6 to 8 years old)

ƒ Infants are obligate nose breathers, and manifest respiratory distress even if there is only partial nasal obstruction

Optimal pediatric airway positioning

Pediatric TraumaAirway Management Steps

ƒ Overall trauma care priorities are same as in adults

ƒ "Sniffing position" is best for airway maintenance

ƒ Start high flow oxygen earlyƒ Nasotracheal intubation usually should not be

done in children (because of the acute naso-pharyngeal angle, & likelihood of hitting enlarged adenoids)

ƒ Pass endotracheal tube only 2 cm. past vocal cords (under direct vision)

ƒ Ventilate gently to avoid lung overdistention and pneumothorax

ƒ Needle cricothyroidostomy preferred to emergent tracheostomy if possible

Pediatric TraumaSize Selection for Endotracheal Tubes

ƒ Simplest rule is to use tube of same diameter as patient's little (5th) finger

ƒ Or can use formula :–Tube inner diameter = ( 16 + age in years) divided by 4 (result is in mm.)

ƒ Use uncuffed tubes up to age 6 to 8 years

Pediatric TraumaRough Guidelines for Normal Vital Signs in Children

Age (years)

Resp. Rate (breaths per min.)

Heart Rate (beats per min.)

Blood Pressure ( mm Hg)

Urine Output ( ml. per hr.)

0 to 1 40 120 to 160 80 / 40 10

1 to 5 30 120 100 / 60 20

6 to 10 20 100 110 / 70 30

> 10 14 to 18 80 120 / 80 > 30

Pediatric TraumaSigns of Shock

ƒ Children tend to initially compensate for shock with tachycardia and often maintain their blood pressure until just preterminal

ƒ So hypotension in children can be a grave, late sign of shock (usually represents > 40 % blood volume loss)

ƒ Change from tachycardia to bradycardia may also be a grave, late sign

Pediatric TraumaSigns of Shock

ƒ Early signs can be :–Tachycardia ( can be > 180 to 200 beats / min.)–Lethargy–Irritability–Confusion–Combativeness–Dulled response to pain–Not paying attention to parents–Delayed capillary refill–Mottling of skin color

Pediatric TraumaBlood Volume Considerations

ƒ Normal child blood volume = 80 ml/kg–(8 % of body weight)

ƒ Shock ensues if 25 % of blood volume lost

ƒ So initial correction should be 25 % of 80 ml/kg = 20 ml/kg

ƒ Generally, systolic BP should be 80 + twice age in years

ƒ Diastolic BP generally = 2/3 of systolic BP

Pediatric TraumaTreatment of Shock

ƒ Start intraosseous line(s) if IV insertion difficult

ƒ Initial boluses X 1 or 2 of 20 cc/kg Lactated Ringers

ƒ Emergent transfusion initially with 10 cc/kg packed red cell boluses if shock does not respond to the Ringers, or if blood loss is ongoing

ƒ Important to warm IV fluids and blood to 37 to 39 degrees C before infusion (rapid infusion of room temperature fluids can induce hypothermia)

ƒ Frequent reassessment is imperative

Pediatric TraumaSigns of Correction of Shock

ƒ Heart rate slows to < 130 bpmƒ Pulse pressure increases to > 20 mm Hgƒ Limbs become warmer and / or less

mottledƒ Mental status / behavior improveƒ Urinary output increases to > 1 cc/kg/hrƒ Blood pressure increases to > 80 mm Hg

systolicƒ Failure to correct shock with rapid fluid

or blood boluses implies need for emergency surgery to control bleeding

Pediatric TraumaImportance of Temperature Control

ƒ Children are at much greater risk of developing hypothermia (body temp. < 35 degrees C)

ƒ Complications of hypothermia :–Decreased mental status / coma–Hypotension–Arrhythmias–Coagulopathy (often the worst complication)–Ineffectiveness of medications

Pediatric TraumaPrevention of Hypothermia

ƒ Warm the room ; keep room doors closed ; limit traffic in & out of room

ƒ Heating lampsƒ Heating blanketƒ Warm IV fluidsƒ Cover patient's scalp & as much of the

rest of the body as possible with warm blankets

ƒ Consider warm saline NG lavage if other measures not adequate

Pediatric TraumaHead Injury Considerations

ƒ Head injury :–Comprises 80 % of blunt trauma in children–Causes 80 to 90 % of trauma deaths–Requires surgical intervention in only 6 % of pediatric cases (30 % of adult cases)–Diffuse cerebral edema more common & focal intracranial hemorrhages less common–Key treatments are restoration of blood volume & prevention of hypoxia

Pediatric TraumaHead Injury Considerations (cont.)

ƒ Rarely infants can become hypotensive from the amount of blood loss into epidural or subgaleal space

ƒ Bulging fontanelle may signify severe head injury : almost always is indication for CT

ƒ Vomiting after head injury in children is common & does not always indicate increased ICP

ƒ Once cerebral edema is identified, fluids should be restricted (if the patient is not in shock from other injuries)

Pediatric TraumaModified Glasgow Coma Scale (GCS)

ƒ Motor (M) and Eye Opening (E) scores are same as for adults

ƒ Modified pediatric verbal (V) score :–Smiles, follows objects, coos 5–Cries but consolable 4–Irritable, uncooperative, screams 3–Lethargic, grunts 2–No verbal noises 1

Pediatric TraumaNeck Injury Considerations

ƒ Lax neck ligaments and larger proportional head size contribute to severity of neck injuries in children

ƒ Can have spinal cord injury without bony C-spine injury

ƒ Preverbal children cannot communicate presence of neck pain, so should have low threshold to get C-spine films

Pediatric TraumaUnique Cervical Spine X-ray Findings

ƒ Pseudosubluxation of C2 on C3 or C3 on C4–Anterior longitudinal line is offset, but line at base of spinous processes is not

ƒ Predental space may be up to 5 mm width (3 mm is upper limit of normal in adults)

ƒ Prevertebral space may falsely appear wide if film is taken in expiration

ƒ Spinous process epiphyses may rememble spinous process fractures

Pediatric TraumaChest and Abdominal Injuries

ƒ Diagnostic & treatment priorities are basically same as in adults

ƒ Rib fractures represent greater proportional degree of force to chest

ƒ Blunt aortic injuries are less common than in adults but still can happen

Pediatric TraumaPsychologic Considerations

ƒ Should routinely explain procedures to children and be honest about potential pain or discomfort

ƒ Should treat pain early once exam is completed

ƒ Should address child's fearsƒ If parents are mentally stable,

allow them to interact with child after resuscitation

Pediatric TraumaChild Abuse

ƒ Also termed non-accidental trauma (NAT) or "child battering"

ƒ Refers to any deliberate injury inflicted by child's caretaker

ƒ Recognition is important to prevent further abuse ; may save child from fatal future injury

ƒ Any suspected case must be reported to child protection authorities, & usually child must be admitted to hospital for protection

Pediatric Trauma : Historical Features That May Indicate Child Abuse

ƒ History not consistent with severity or type of injury

ƒ Delay between time of injury & presentation

ƒ History of multiple prior injuriesƒ Different history of injury from

caretaker(s) and / or childƒ Caretaker reacts inappropriately to

situationƒ Child is afraid of caretaker

Pediatric Trauma : Physical Exam Findings Indicating Probable Child Abuse

ƒ Retinal hemorrhages ("shaken baby syndrome")

ƒ Perioral, perineal, anal, or genital injuries

ƒ Bruises in different stages of development and in areas not over bony prominences

ƒ Bizarre injuries such as cigarette burns, bite or belt or rope marks

ƒ Sharply demarcated burns

Sharply demarcated inflicted scald burns

Pediatric Trauma : X-ray Findings Indicating Possible Child Abuse

ƒ Multiple fractures in different stages of healing

ƒ Multiple rib fracturesƒ "Bucket handle" metaphyseal

fracturesƒ Spiral fractures of long bones

Fractures caused by grabbing and twisting the child’s limb

Metaphyseal chip fracture of the radius caused by abuse

Multiple fractures due to abuse

Pediatric Trauma Score (PTS)

Weight > 20 kg 10 to 20 kg < 10 kg

Airway Normal Oral or Nasal Airway

Intubated

Systolic BloodPressure (mm Hg)

> 90 50 to 90 < 50

Level ofConsciousness

Completely awake Obtunded or Lossof consciousness

Comatose

Open Wound None Minor Major or penetrating

Fractures None Minor Open or multiple

SCORE : +2 +1 Minus 1

Total score < 8 implies need to refer patient to pediatric trauma center

Pediatric TraumaSummary

ƒ Follow same priorities as in adultsƒ Interpret vital signs carefullyƒ Adjust fluid boluses and medication

dosages to the patient's weightƒ Act early to prevent hypothermiaƒ Pay attention early to psychologic

considerationsƒ Be alert for child abuse as a cause for

injuriesƒ Assist in trauma prevention efforts for

children