Pediatric Trauma

Pediatric Trauma
(Not Just Small Adults)

Monday, Oct 29 2007
SURG GP.
425
Dr. Aayed Al-Qahtani

Ass. Professor & Consultant pediatric surgery
Outline :
Background .
Trauma scores .
Principles and Approach .
ABCs .
Specific injuries
Head, C-Spine, Chest, Abdominal, Burns
Abuse .
Background:
Leading cause of death in pediatric age.
< 5 years
highest risk.
Boys > girls.
Blunt > penetrating
Falls>MVA (Motor Vehicle Accident) >MPA>rec>abuse>drown>burns.
Regionalized peds trauma centers.
Improved mortality of severely injured child .
Basic ATLS concepts include:

Treat the greatest threat to life first.
The lack of a definitive diagnosis should never impede the application of an indicated treatment.
A detailed history is not an essential prerequisite to begin evaluating an acutely injured patient
(meaning detailed history is not initially required).
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Pediatric Trauma
Monday, Oct 29 2007
SURG GP.
425

Principles:
Improper resuscitation has been identified as a major cause of preventable pediatric death.
Common errors in resuscitation include failure to:
Open and maintain the airway.
Provide appropriate and adequate fluid resuscitation to head injured children.
Recognize and treat internal hemorrhage.
Trimodal distribution of death from injuries:

The first peak of death is within minutes of the injury usually due to:
Brain , brain stem, high spinal cord, heart, great vessels.
The second peak occurs within minutes to several hours of the injury
This is the period that ATLS (Advanced Trauma Life Support) focuses upon (*the most
important).
The third death peak occurs several days to weeks after the initial injury
Sepsis, MSOF .
Criteria for transfer to trauma centre :
Multi-system .
Unstable .
Axial skeleton bone .
Neurovascular injury .
Acute cord injury .
Complicated TBI .
Low trauma score .
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Pediatric Trauma
SURG GP.
425

Monday, Oct 29 2007

Trauma scores:
Pediatric Trauma Score (PTS)

Accurate predictor of injury severity.
-4 to 12, <8 increased mortality.
Revised Trauma Score (RTS)
Same as adults .
<12 increased mortality.
Injury Severity Score (ISS)
Cumbersome, underestimates survival.
Pediatric trauma score:

Size (kg)
SBP*
Airway
CNS
Open Wound
Fractures
+2
>20
>90
N
awake
none
none
+1
10-20
50-90
Secure
obtund
minor
Closed
-1
<10
<50
tenuous
coma
major
Open
*SBP=Systolic blood pressure

Score +12 to -4 (the range of the score).
0% mortality 8 (meaning: there will be no mortality if the trauma score is more than 8).
45% = 2
100% = 0 up to -4 (there will be 100% mortality if the trauma score is zero).
transfer to pediatric trauma center if PTS <8 .
Revised trauma score:

Glasgow Coma
Scale Score
13-15
9-12
6-8
4-5
3
Systolic Blood
Pressure (mm Hg)
>89
76-89
50-75
1-49
0
Respiratory Rate
(breaths/ min)
10 - 29
>29
6-9
1-5
0
Coded Value
10
3
2
1
0
*Glasgow coma scale is similar to that in adults but with BP and RR added to it in
pediatrics.
Approach:
ATLS (Advanced Trauma Life Support).
Vital Signs: plus, BP, temp, weight.
Broselow tape (a tape for measuring height and weight used when we can't carry the patient and
weigh him/her with a scale like in emergencies and gives the required drug doses according to that.)
ABCs, C-spine, NG tube.
Consent (incases of the patient's need for surgery).
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Pediatric Trauma
Monday, Oct 29 2007
SURG GP.
425

Principles :
Kids are really not just small adults and there

are differences between the two.
Airway and shock management are very
important.
Head injury: morbidity & mortality.
Forces over small area multi-systemic
injury.
Little or no external injury does not rule
anything out.
Kids die from hypoxia and respiratory arrest
(*very important, one of the commonest
causes).
Heat loss, glucose & fluid requirements
(hypothermia) very imp. in pediatric
trauma.
Psyche sequel.
Primary survey:
A = Airway maintenance with cervical spine control: (we know that airway is clear if the
patient was able to cry or talk if not then we intubate, and in this step it is
very important to protect the C-spine if injured by in-line immobilization
where we mobilize the spine without any significant flexion or extension).
B = Breathing and ventilation: (by checking the chest movements).
C = Circulation with hemorrhage control: (by checking the pulse and BP and
resuscitated by two IV access lines).
-when I'm able to palpate the radial pulse then the SBP is usually minimally 90.
-if radial pulse is not palpable and femoral pulse is then SBP is usually 80.
-if cannot be felt in femoral but is palpable in carotid then SBP is usually 60 (60 is very low and the
patient may go into an arrest).
D = Disability: neurologic status (AVPU= Alert, Verbal stimuli response, Painful stimuli response,
Unresponsive).
E = Exposure/ Environmental control: completely undress the patient, but prevent hypothermia .
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Pediatric Trauma
Monday, Oct 29 2007
SURG GP.
425

Airway :
2 x O2 demands (usually we put them on 100% oxygen to start with).

respiratory failure #1 cause of arrest .
no surgical airway < 10years i.e. trachiastomy (sometimes it is exeptable is pediatrics),
cricothyrodotomy (because in pediatrics the cricothyroid membrane is very small if we do this cut we
will injure the cricoids or the larynx), .
Endotracheal tube (ET tube) size: for calculation of the tube size we do the following formula: (16 +
age)/4 .
Laryngeal Mask Airway (LMA) as rescue if >4 feet tall (used for ventilation and to access the airway).
Anatomical airway issues in kids:
Big tongue, soft tissue obstruction.

Soft trachea no cuff (usually not used below 8 years old because it may cause tracheal damage
and ischemia due to compressing the vessels there).
Soft Vocal Cord no stylet used (stylet: is the tool sed for guiding the tube into the larynx, but if
used here may injure the larynx).
Anterior larynx.
short trachea .
narrowest part of trachea is at subglottis .
nose breathers < 6 months .
big occiput (so there may be a spinal injury)
big epiglottis that may obstruct the larynx while intubation so we use a straight blade to elevate
the epiglottis .
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Pediatric Trauma
Monday, Oct 29 2007
SURG GP.
425

Pediatric Airway
RSI: (the doctor didnt mention this subtitle)

Pre-treat atropine 0.02 mg/kg all < 6years .
no defasciculating dose < 5 years .
induction:
ketamine 1-2 mg/kg
midaz 0.2-0.3 mg/kg
propofol 2 mg/kg
thiopental 3-7 mg/kg
etomidate 0.3 mg/kg
sux 2 mg/kg
no evidence for lidocaine in kids .
Breathing :
Signs of respiratory distress: indrawing, tracheal tug, nasal flaring, tachycardiac, tachypnic, use of
accessory respiratory muscles.
infants:
Immature response to hypoxia (they dont tolerate it very well).
Diaphragm 1 respiratory muscle
Easily fatigued.
aerophagia displaces diaphragm.
Thoracic structures and mediastinum is mobile shift.
Chest trauma :
2nd leading cause of pediatric trauma death. (where head injury is the first cause.)
Compliant chest wall ()

rib bone uncommon
Significant injuries without external signs.
If the bone fracture is present, this indicates severe injury.
Mobility of mediasternal structures more sensitive to tension pneumothoraces and flail segments or
flail chest (when part of the chest is moving in the opposite direction while breathing due to negative
pressure causing sucking i.e. the chest moves inwards with inhalation and outwards with exhalation.
For example when there are at least 3 ribs broken on each side of the cage, they will be flail
segments.
Treat conservatively:
15% require more than chest tube.
Pulmonary contusion is most common, aortic injury is rare.
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Pediatric Trauma
Monday, Oct 29 2007
SURG GP.
425

Life threatening thoracic injuries:
Tension pneumothorax: is a pneumothorax causing heamodinamical instability (tachycardia,

hypotention, shifting of mediastinum).
Massive hemothorax
Cardiac tymponade: fluid in the pericardium.
Flail chest.
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Pediatric Trauma
Monday, Oct 29 2007
SURG GP.
425

Circulation:
Low BP is a LATE sign: kids compensate well but drop very quickly after that.
25% loss of blood volume in order to have BP problems.
Minimum acceptable BP: 70 + (2 x age).
Early Signs of shock: HR, RR, mottled )"!

( #, cool, pulses, altered LOC, cap refill > 2 sec (prolonged).
Scalp laceration can cause shock in pediatrics only and not in adults (due to high surface area in the
head and high blood supply).
Management by IV lines: antecubital, femoral, external jugular.
Attempt <90 sec, then intraosseous (a rigid needle that we pass to the bone marrow where we inject
the fluid or blood there then it goes to the system immediately).
Age limit?
Landmarks?
Fluids: crystalloid (normal saline because isotonic) 20cc/kg x 2, then 10cc/kg pRBC .
no role for MAST: mortality.
*NOTES:
-normal saline: NaCl (Na 154 m.mol, Cl 154 m.mol).
- Total blood volume: -adults 5 L.
-Children 80 -120 cc/kg.
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Pediatric Trauma
Monday, Oct 29 2007
SURG GP.
425

Figure: intraosseous
Secondary survey :
Begins once the primary survey (ABCs) is completed, resuscitation has commenced and the patients
ABCs have been reassessed.
X-rays are before 2nd survey, just after primary.
A head-to-toe evaluation including:
Vital signs, and complete history and physical examination.
AMPLE:
A = Allergies.
M = Medications.
P = Past illnesses.
L = Last meal time.
E = Events/ Environment related to the injury .
Head injury:
leading cause of death in peds trauma (80%) .

90 % minor.
Falls > MVA > MPA > bicycle > assault.
Few require surgery: 0.4 -1.5%.
No evidence in peds for early surgery.
4-6% with normal exam have ICH on CT
?significance
?long term sequel.
Head injury: Anatomic differences:

Protective
Fontanelles .
open sutures .
plasticity .
helps in expanding the skull.
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Pediatric Trauma
Monday, Oct 29 2007
SURG GP.
425

Susceptible
big head torque .

soft cranium injury without fracture .
less myelin more shearing forces .
prone to reactive hyperemia .
Head injury: Types of injury: (doctor didnt mention this)
Contusions, DAI, SAH, parenchymal.

Epidural: uncommon, <4 years, subtle presentation, minor trauma.
Subdural: common, poor outcome, <1 year.
SBS: vomit, FTT, LOC, seizure, retinal hemorrhages.
Head injury: Assessment: (doctor didnt mention this)
Pediatric GCS: not predictive in infants.

Signs of ICP in infants:
Full fontanelle, split sutures, alt. LOC, irritable, persistent emesis, setting sun sign .
Skull fracture: (doctor didnt mention this)
20 x risk ICH
50% of parietal bone, 75% of occipital bone.
Linear > depressed > basilar.
X-rays neither sensitive nor specific.
90% linear bones have overlying hematoma.
Growing skull bone:diastatic dural tear meninges herniate, prevents closure: NSx F/U .
depressed bone: may miss on CT .
Interpretation?
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Pediatric Trauma
Monday, Oct 29 2007
SURG GP.
425

Growing Skull Fracture
Quayle et al. J Neurosurg. 1990
alt LOC, focal deficit, palpable depression, basal skull #, seizure

.
all HI < 1 year .
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Pediatric Trauma
Monday, Oct 29 2007
SURG GP.
425

Who gets CT?

Children < 2 years .
hard to assess .
prone to ICH, skull bone .
asymptomatic ICH (4-19%) .
low threshold .
various algorithms, no consensus.
CT head algorithms :
Savitsky, Am J Emerg Med. 2000
Predictors of ICH :
Greene, Pediatrics 1999

Scalp hematoma most sensitive clinical predictor
Quayle, Pediatrics 1997

depressed LOC (OR=4), focal neuro (OR=8), skull bone, LOC > 5 min, seizure
(trend) .
Beni-Adani, J Trauma 1999
TINS score for EDH; not validated .
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Pediatric Trauma
SURG GP.
425

Monday, Oct 29 2007

AAP Guidelines:
Management: (the main principle is to maintain brain blood supply and decrease
intra cranial pressure)
MAP > 70 teen, 60 child, 45 infant .

hyperventilation: not in 1st 24 hr .
mannitol: no studies .
HTS: small studies .
Euglycemia: glucose worse neuro outcome .
prophylactic anticonvulsants: consider in moderate/severe HI, >1 seizure or prolonged .
prophylactic Abx for basil skull bone : no role .
Normothermia: temp > 38.5 worse neuro outcome .
Hypertonic Saline :
Simma et al. Crit Care Med 1998
prospective RCT, 35 TBI kids
RL vs. HTS
fewer interventions to keep ICP<15 HTS group.
shorter ICU stay with HTS (3 days) .
same survival and total hospital stay .
Khanna et al. Pediatrics 2000

10 kids with TBI, resistant to
conventional Rx
statistically sign ICP with HTS .
C-Spine Injuries :
Less common in kids, higher mortality .

Associated with Head Injury.
falls>MVA>sports (trampolines).
<8 years: 2/3 above C3 .
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Pediatric Trauma
Monday, Oct 29 2007
SURG GP.
425

C-Spine: Anatomic differences :
big head, less muscles torque, fulcrum C2-3 .

cartilage > bone, lax ligaments
injury without bone.
pseudosubluxation
C2-3, C3-4: 3-4 mm or 50% vertebral body width .
use Swischuks line .
prevertebral space: C2=7mm, C3=5, C7=2cm .
facets joints horizontal, anterior wedging vertebral bodies .
predental space 4-5 mm .
incomplete ossification, multiple centers .
C-Spine Imaging :
3-views : AP, Lateral, Open mouth .

94% sensitive - but SCIWORA
Flexion-extension?
Ralston Acad Emerg Med 2001
no added info if 3 views normal .
SCIWORA : (= Spinal Cord Injury WithOut Radiological Abnormalities)

-Normal X-ray in major injury e.g. in destruction of ligaments and tendons with normal x-ray.
16-50% SCI!!
< 9 years .
transient neuro symptoms (parasthesias) .
recur up to 4 days later .
bottom line:
CT/MRI if abn neck/neuro exam, distracting injuries, alt. LOC, high risk mech DESPITE normal 3views.
Case :
6- year-old girl fell off bike
Whats the abnormality?
14 | P a g e
Pediatric Trauma
Monday, Oct 29 2007
SURG GP.
425

Endotracheal intubaton :
ETT size?
cuffed?
depth of insertion?
- Broselow
- Age (years) + 4
4
- Uncuffed < 8 years old (exceptions)
- Depth of insertion (cm):
tube ID (mm) x 3
or age (years)/2 + 12
Failed intubation :
BMV with Sellick

LMA an option
No cricothyroidotomy under 8 years
In a pinch: Needle cric .
Pediatric trauma :
Usual ABCs (sugar) and C-spine

Use your Broselow
Weight can also be estimated:
< 8: (AGE x 2) + 8
> 8: AGE x 3
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Pediatric Trauma
Monday, Oct 29 2007
SURG GP.
425

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Pediatric Trauma
Monday, Oct 29 2007
SURG GP.
425

Abdominal trauma :
3rd leading cause of trauma death .

often occult fatal injury .
blunt: MVA, bikes, sports, assault .
Abdominal trauma: Anatomic issues :
In pediatrics there are larger solid organs and less musculature leading to compact torso, elastic
ribcage, liver & spleen anterior .
potential internal injury .
spleen>liver>kidney>pancreas>intestine .
bladder intra-abdominal more than adults .
10% have GU injury .
low BP late sign of shock .
mechanism
handlebars, seat belt .
Abdominal Trauma: Assessment :
low BP late sign of shock .

clinical findings unreliable .
shoulder tip pain, flank / lap ecchymosis .
U/A, N/G .
reassess, reassess, reassess .
mechanism
handlebars, lap belt
Abdominal imaging:
-C T :
most widely used .

stable pt only
strongly consider in Head Injury patient
25% with GCS <10
insensitive for hollow viscous (25% sens), pancreas (85% sens).
-Focused Ultrasound: quick abdominal U.S looking fro fluids.
Abdominal trauma: DPL :
Rarely needed in pediatric.

FP 5-14%
? solid organs, retroperitoneum, intestine .
+ve:
>100,000 RBC (blunt in adult, in pediatric it is controversial).
>5,000 (GSW).
use: unstable, going to OR anyway .
Abdominal trauma: Management:
spleen and liver:

90% conservative: admit, observe, Hct.
Why?
More fatal hemorrhage with liver injuries .
Lap in unstable after resus .
hematuria:
Gross or >20 RBC + unstable IVP (intravenous pylogram) in OR.
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Pediatric Trauma
Monday, Oct 29 2007
SURG GP.
425

>10 RBC + stable CT cysto.
Burns :
infants spills > intentional immersions .

older kids flames .
Rules of Nines doesnt work:
Lund & Brouder chart .
palm = 1%
mgt same as adults .
Child abuse :
1 million confirmed cases / year (US) .

high index of suspicion .
RF: poverty, single parent, substance abuse, <2 years, disability, low birth weight .
cutaneuos injuries most common .
death 2to head & abdominal trauma .
interview child & parent separately .
Child abuse: Clues :

History
story injuries .
history changing .
injury development .
delay seeking help .
inappropriate level of concern .
Physical Exam
multiple old and new bruises .

posterior rib bone, sternum bone, spiral bone < 3 .
immersion burns, cigarette .
Child abuse: Head injury :
blunt, acceleration/deceleration .
31% missed, 28% re-injured .
fractures:
bilateral, cross sutures, diastatic, non-parietal .
IC injuires:
SAH, subdural, ICH, edema .
CT if suspect .
Child abuse: Management :
Document .
full P/E (rectal, genital).
Photograph .
B/W: CBC, PT/PTT, LFTs, lipase, U/A .
skeletal survey .
CT head, abdominal prn
Child Protection.
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Pediatric Trauma
Monday, Oct 29 2007
SURG GP.
425

Abdominal trauma: FAST :
Murphy. Emerg Med J 2001: review

30-87% sensitive, 70-100% specifi
Loiselle. Annals Emerg Med 2001:
sens 55%, spec 83%, NPV 50%, PPV 86%
bottom line:
insensitive, too specific .
FF lap, no FF no sign organ injury .
may replace DPL in unstable pt.
To Get The Slides

http://faculty.ksu.edu.sa/qahtani
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Pediatric Trauma

(Not Just Small Adults)

Dr. Aayed Al-Qahtani

Basic ATLS concepts include:

Dr. Aayed Al-Qahtani

Trimodal distribution of death from injuries:

Criteria for transfer to trauma centre :

(Not Just Small Adults)

Dr. Aayed Al-Qahtani