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