PAEDIATRIC TRAUMA

Dave Ellis November 2011

Objectives •  Define trauma

•  Describe the anatomical and physiological features in children that influence their response to trauma

•  Identify the phases of evaluation of the paediatric trauma patient

•  Review the management of specific organ trauma

Definition Injury to human tissue and organs resulting from the

transfer of energy from the environment

the goal of trauma management is to provide an

organized and systematic approach to the assessment

and care of the pediatric trauma patient

Facts •  Leading cause of death after 1 year

•  20-40% of deaths are preventable

•  3-500 major paediatric cases/year  

Children Aren’t Small Adults

Airway •  Airway more difficult to obtain/maintain

–  Young infants obligate nasal breathers –  Larger tongue relative to size of oropharynx –  Narrow pharyngeal space –  Smaller nares and mandible –  Relatively larger T+A’s –  Submandibular tissues softer, more compressible –  Larynx more pliable collapses with neck hyper-extension. flexion –  Relatively large occiput forces neck flexion –  Small diameter: secretions significantly increase resistance

•  Intubation more difficult –  Larynx is more anterior and higher –  Large, long, floppy epiglottis –  Vocal cords lower anterior attachment –  Narrowest point of larynx subglottic (funnel shaped <10 years) –  Airway passages shorter (RMB intubation)

Cardiovasular •  Wide variation in normal vital signs •  Relatively fixed stroke volume

– Reliant on HR to maintain cardiac output •  Tachycardia sensitive but not specific to shock •  Small absolute circulating volume

– Small volume loss large % of absolute total •  Children maintain BP until 25-30% CBV lost •  Bradycardia produces significant drop in CO •  Children relatively anaemic •  Pulses awkward to feel  

Cervical Spine •  Lax interspinous ligaments •  Shallow angled facet joints •  Underdeveloped spinous processes •  Physiologic anterior wedging of vertebral bodies •  Relatively large head, shorter neck •  Underdeveloped neck muscles •  Flat facet joints •  Large head to BSA •  Fulcrum C2-C3 in child, C5-C6in adult •  Incomplete ossification of odontoid process

Skeletal •  Growth plates weakest point •  Cortices of bones more porous •  Periosteum thicker more plastic •  Disability if growth plate involved •  Proportionately greater blood loss

•  Associations  femur  +  abdominal    humerus  +  thoracic  

Thorax •  Ribs more pliable

– Greater transfer of energy to thoracic organs – Rib fractures uncommon

•  Flexible mediastinum –  less vessel trauma – more visceral displacement

•  Higher O2 demand + hmetabolic rate –  more rapid development of hypoxemia

•  Less alveoli irespiratory reserve •  Immature respiratory muscles fatigue

faster

Head •  Larger head-to-body ratio

–  increased momentum with accel/decel •  Soft calvarium

–  Injury without fracture –  Energy transfer to brain

•  Large subarachnoid space – venous tearing •  Unmyelinated brain tissue more prone to shearing •  Higher brain water content -more prone to oedema •  Brain more prone to reactive hyperaemia •  Open fontanelles/sutures may mask signs of hICP

Abdomen

•  Ribs do not protect the upper abdomen •  Proportionately larger solid organs •  Closer proximity •  Less musculature and fat •  Liver & spleen anterior •  Bladder intra-abdominal •  Viscera more mobile •  Air swallowing splints the diaphragm

Trauma Management

Neurosurgeon

Resuscitation Team

Surgical Specialties

Medical Specialties

Nursing ICU AE

Anaesthesia

Orthopedic Surgeon

Trauma Surgeon

TRAUMA CENTER TRAUMA TEAM

AHP’s

 Pre-­‐arrival      Resource    iden7fica7on    and  alloca7on      

1o  Survey   2o  Survey  

Basic  Studies   Specialty  Studies  

Reevalua7on  

Resuscita7on  

1o  Therapy   Defini7ve  Therapy  

Trauma:  Ini7al  Management  Priori7es  

Components  of  Management  

Time  

Pediatric Assessment Triangle

Response Work of Breathing

Circulation to Skin

 

 

Primary Survey

Circulation: - assess - access - stop hemorrhage - resuscitate

Breathing: - assess - support

Airway: - assess - establish - maintain

“H”

Primary Survey •  Airway obstruction •  Tension pneumothorax •  Open pneumothorax •  Massive haemothorax •  Flail chest •  Cardiac tamponade. •  Shock (haemorrhagic or otherwise) •  Decompensating head injury

Airway and C-Spine Control •  Oxygen •  Suction •  Jaw thrust •  Oral guedel •  OGT/NGT •  Intubation

Manual  in  line  stabilisa7on  

C-Spine Immobilisation

•  Proper size collar – Doesn’t impair ventilation – Doesn’t obstruct jugular venous return – Too small results in flexion – Too large doesn’t immobolise

•  Blocks and tapes •  Board

Breathing

•  Oxygen

•  Effort efficacy effect

•  Look feel listen

Difficult intubation

•  Decreased LOC •  Head trauma •  Facial trauma •  Neck trauma •  Upper chest trauma •  Airway, facial burns

Indications for Intubation and Ventilation

•  Persistent/predicted airway obstruction •  Inability to adequately ventilate with B+M •  Persistent hypoxia despite O2/adjuncts •  Loss of airway reflexes (GCS<9) •  Apnoea •  Inadequate ventilatory effort or fatigue •  Disrupted ventilatory mechanism, flail chest •  Controlled ventilation for management of ICP •  Fluid resistant shock •  Suspected upper airway burn •  Facial burns •  Unstable midface fracture

Intuba7on  

•  Adequate pre-oxygenation •  Adequate monitoring •  Most experienced personnel •  Cricoid pressure •  RSI •  Confirm position

– ETCO 2 – Colour (yellow ok , purple misplaced) – CARDIAC ARREST

Circulation •  HR, pulse volume, temp

gradient •  Compromise-consider hypoxia •  Shock=hypovolaemia •  Venous access a priority

– peripheral –  IO – central – cut down

Venous Access

EZ-IO

Circulation

Disability •  Conscious level

– GCS: age appropriate – AVPU

•  Pupils – Symmetry – Size – Reactivity

•  Posture •  Manage suspected raised ICP

Expose and Examine

•  Look to find •  Find to treat •  Remove ALL clothing •  Cover patient with blanket when finished

Analgesia

•  Opiates, simple analgesics •  Splinting, immobilisation •  Regional blocks

Secondary  Survey  

•  Identify , treat non life threatening conditions •  History

– Event – Previous medical

•  Examination – Re-evaluation primary survey – Top to toe/front and back (log roll)

•  Blood work, radiology •  NGT/UC/invasive lines

Inves7ga7ons  

•  FBC, X-match/G+S •  Blood glucose •  Coagulation- severe trauma, HI •  Gas- pulmonary injury, shock •  Urinalysis •  X-rays, C-spine, chest, pelvis •  CT: head, c-spine, thorax, abdo, pelvis

–  haemodynamically stable –  able to deliver ongoing resuscitation, monitoring

C-­‐Spine  Injury  

Cervical Spine Trauma

•  Decreased level of consciousness •  Blunt injury above clavicle •  Multisystem trauma •  Sudden deceleration •  Ejection •  Altered neurology  

Cervical Spine Injury •  1-2% paediatric trauma •  80% traumatic paediatric spinal injuries •  Usually C1-C3 •  5% spinal injuries second nonadjacent ♯ •  8% missed or delayed diagnosis

– Critical injuries, hypotension , decreased GCS –  Increased secondary neurological injury

Immobilisation takes priority over clearance Consider steroids if confirmed injury < 8 24  

C-Spine Investigations •  Xrays

–  3 views: 94% sensitive if all normal –  Open mouth (odontoid) :17% ♯ missed if intubated –  Lateral (up to 15%♯ missed) –  AP

•  No benefit of flexion extension if all 3 normal –  Xrays cannot exclude ligamentous instability –  Normal anatomical variations mimic fracture

•  CT: boney injury, soft tisue •  MRI:ligaments, spinal cord

Spinal Cord Injury Without Radiological Abnormlities

•  16-50% SCI •  CT and C-Spine xrays normal •  Transient neuro symptoms (paraesthesias)

–  recur up to 4 days •  MRI

–  abnormal neuro exam –  distracting injuries –  altered LOC –  high risk mechanism irrespective of normal Xray/CT

Criteria for Clearing C-Spine

•  No midline cervical tenderness on palpation •  No focal neurological deficit •  Normal alertness •  No intoxication •  No painful distracting injuries

Viccellio  et  al  (2001)  Pediatrics  

Traumatic Head Injury

Traumatic Head Injury •  Commonest trauma death in children •  Aim to minimise secondary injury

–  Hypoxia –  Anaemia –  Hypotension –  hICP –  Pyrexia –  Glucose abnormalities –  Seizures

•  Scalp •  Haemorrhagic shock in infants

Suspect Head Injury

•  Mechanism of injury •  Penetrating injury •  Loss of conciousness •  Fluctuating GCS, GCS< 8 AVPU •  Seizures •  Focal neurological signs •  Significant facial trauma

To CT or not to CT… •  GCS < 8, GCS variable since injury •  Suspected/open depressed ♯ •  Basal skull ♯ •  Focal neurology •  Persistent vomiting •  Seizure •  Amnesia > 30 minutes •  Suspicion of non-accidental trauma •  Concerning MOI •  Children <2

CPP= MAP – ICP •  i cerebral metabolic rate

–  sedation analgesia normothermia anticonvulsants

•  Maintain fuel –  euglycaemia

•  hmean arterial pressure –  Volume pressors

•  Maintain oxygen content –  Ventilation –  PEEP

•  Reduce ICP –  Osmotherapy avoid

hyponatraemia –  Normocapnoea –  Head of bed 30 deg

head midline –  Remove hard-collar –  Fentanyl/lignocaine for

suction –  Rx seizures

Chest  Trauma  

Chest Trauma •  50% paediatric trauma •  2nd highest cause of death in trauma •  Usually part of multisystem injury •  90% blunt deceleration •  External signs often absent •  Non specific signs-suspect from MOI •  Major vascular injury uncommon •  Mobile mediastinum

– Poorly tolerant of tension pneumothorax

Chest  Trauma  

 6 Lethal Injuries •  Airway obstruction •  Open pneumothorax •  Tension pneumothorax •  Massive haemothorax •  Flail chest •  Cardiac tamponade

6 Hidden Injuries •  Pulmonary contusion •  Cardiac contusions •  Aortic disruption •  Tracheobronchial

disruption •  Oesophageal disruption •  Diaphragmatic tear

Tension Pneumothorax

•  Can occur after intubation and PPV •  Can occur with drains in situ •  Air in the pleural space without exit

–  Collapse of ipsilateral lung –  Compressed contralateral lung –  Mediastinal shift –  Decreased venous return –  Decreased cardiac output

•  Symptoms and signs can be misleading •  Rapid thoracentesis and chest drain insertion

Lethal Injuries •  Cardiac Tamponade

–  Beck’s triad •  iBP, JV distension, muffled HS

•  Haemothorax –  Consider auto-transfusion

•  Flail Chest –  Paradoxical chest movement –  High velocity impact –  Multiple fractures –  Major issue is underlying injury

•  Open Pneumothorax –  occlusive dressing sealed on 3 sides

Pulmonary Contusion •  Most common chest injury •  Usually blunt injury •  High assossciation with with other injuries •  50% lack external signs, symptoms initially

– VQ mismatch, reduced lung compliance – Onset over 48 hours – Distress, pain, haemoptysis, hypoxia

•  Serial CXR if severe MOI / rib fracture •  Oxygen, analgesia, physiotherapy, intubation

Immediate life threatening chest injuries can be managed successfully by any clinician capable of performing

•  needle thoracocentesis •  chest drain insertion •  intubation and ventilation •  pericardiocentesis

Abdominal  Trauma  

Abdominal Trauma •  3rd commonest trauma •  Usually blunt •  Solid organ (liver>spleen) > hollow organ •  High level of suspicion

–  MOI (handlebars, lap belt), RTA –  Head –  Skeletal –  Polytrauma

•  Challenging-minimal external signs –  up to 45% initial examination insignificant –  sequential examinations essential

•  Missed overlooked –  Significant other trauma –  Altered LOC –  Unco-operative

Management  

•  Priority to airway and breathing •  Immediate laparotomy

– Abdominal distention + >40ml/kg fluid •  Early laparotomy

– Peritonitis – Pneumoperitoneum – Bladder rupture – Penetrating injuries

•  Most solid organ injury conservative

Lap Belt Injury •  Up to 75% have abdominal injury

•  Solid •  Hollow viscus

•  Lumbar ♯ •  Iliac, pubic rami ♯

Investigations

•  CT is the modality of choice in stable patients – Does not exclude hollow viscous injury – Allows grading for visceral injury

•  Focused Abdominal Sonography for Trauma (FAST) – Unstable patients

•  DPL – Rarely needed in pediatric. – FP 5-14%

Renal Trauma •  Haematuria

– only 88% with known injury – no correlation with degree of injury – significant if other abdominal injuries – marker for injury to other organs

•  CT –  Persistent microscopic haematuria –  Gross haematuria –  Injury to other organs + >50RBC /HPF

•  IVP –  normal in 20% of major injuries –  urinary extravasation and non functioning kidney

Extremity Trauma •  Priorities ABC’s •  Life threatening injury

– Traumatic amputation – Crush injury pelvis/abdomen – Open long bone fracture – Multiple skeletal fractures

•  Limb threatening – Supracondylar humeral – Femur – Fracture dislocation ankle

Acute Compartment Syndrome

•  Iatrogenic – splints – MAST trousers – casts – tissued IO

•  Trauma – crush injuries – fractures – burns

Pain- worse on passive stretching Pallor

Paralysis Decreased sensation

Pulselessness

CONCLUSIONS CHILDREN ARE NOT SMALL ADULTS

HYPOXIA AND HYPOVOLAEMIA ARE THE MOST IMMEDIATE THREATS TO

CHILDREN WITH TRAUMA  

AN ORGANIZED AND SYSTEMATIC APPROACH TO THE ASSESSMENT AND

CARE OF THE PEDIATRIC TRAUMA PATIENT SAVES LIVES  

Always pass on what you have

learned

Glasgow  Coma  Scale