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