Pediatric trauma

EM 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
management
Differences
Implications

Small size
Less fat and con tissue
Proximity of organs
Pliable skeleton
High ratio of body
surface area to mass

Pliable ribs

Mobile mediastinum

Airway anatomic and

Intense force leads to

organ injury
Increase in sensible water
losses--hypothermia
Pulmonary contusions
more common than rib
fracture
Rapid cardiovascular
decompensation from
tension pneumothorax
Prone to obstruction

Advanced Trauma Life

Support (ATLS) Approach
Phase
Primary survey

Resuscitation
Secondary
survey

Goals
Recognize the life
threatening injury
Open airway &
support breathing
Maintain circulation
Monitoring
Medical history
Head-to-toe
evaluation

Primary survey
Mne
m

Evaluation Management

Airway

Airway patency, sniffing position,

rool under shoulder
(infant)/under occiput (children),
chin lift - jaw thrust, ET
intubation

Breathing

Oxygenation-ventilation,
SaO2>94%

Circulatio
n

Vascular access, fluid/volume

resuscitation

Disability

Neurologic status: GCS, pupillary

resp, localizing sign, paralysis

Secondary survey
After primary survey completed and
patient is stable
History (SAMPLE)
Physical examination (from head to toe)

The SAMPLE History

Mnemonic
Symptoms

History Points

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

Last meal
Events

Current symptoms, particularly pain

Preexisting physical or psychological

disabilities; a history of previous
trauma or a chronic condition;
immunization status, including
tetanus prophylaxis
When and what the last ate or drank
Events that led up to the ill/injury

Physical examination (1)

Region

Head

Sign

Suggestion

Bulging fontanella
Sunken fontanella

Increased ICP
Volume loss

Laceration, step-offs

Fracture

Raccon eyes
(periorbital
ecchymosis), Battles
sign (mastoid
echymosis)

Basilar fracture

Puppilary response,
sub conj bleeding,
extra ocular
movement
Rhinorrhoe

Leakage CSF
(Oral NGT !)

Physical examination (2)

Region

Sign

Suggestion

Deformity, tenderness fracture

Inequality breath
sound
Chest

Distant, muffled heart Pericardial

sounds
effusion
Tachycardia, narrow
pulse

Echymosis, presence
and quality of bowel
Abdomen
sound, tenderness,
rigidity
Back

Pneumothorax,
hematothorax

Deformities,
ecchymosis,
tenderness

Pericardial
tamponade

Physical examination (3)

Region

Sign

Perineal

Laceration and blood

at the urethral
meatus,
Tone and presence of
blood in the rectal
vault

Musculoskeletal

Inspected and
palpated to identify
fractures or
dislocation

Suggestion

Diagnostic evaluation of trauma

Type of
trauma
Any
Head
C-spine

Thoracic

Diagnostic study
Complete blood count, PT/PTT,
aspartate/ alanine amino
transferase, amylase, lipase,
urinalysis, CXR, C-spine/Pelvis XR
Head CT, MRI
C-spine radiographs:PA/L/Odontoid
view
C-spine CT/MRI
CXR, Chest CT/angiography, ECG,
Echo, Esophagram,
Bronchoscopy/graphy
Aspartate/alanine amino

Pediatric Trauma Score

Size (kg)
SBP
Airway
CNS
Open
wound
Fractures

+2
>20
>90

+1
10-20
50-90

-1
<10
<50
Tenuou
N
Secure
s
Awake Obtund Coma
None

Minor

Major

None

Closed

Open

Score +12 to
-6
8 = 0%
mortality
2 = 45%
0 = 100%
PTS <8 =
transfer to
pediatric
trauma center

Pediatric trauma

Head trauma
Cervical spine trauma
Chest trauma
Abdominal trauma
Musculoskeletal
trauma
The battered abuses
child

Head Trauma/Traumatic Brain Injury

Degree
Mild
Moderate
Severe

GCS
13-15
9-12
3-8

Modified Glasgow Coma Scale (James and Trauner, 1985)

Activity

Eye-opening

Verbal

Motor

>5 years

<5 years

Score

Spontaneous

Spontaneous

To voice

To voice

To pain

To pain

None

None

Orientated

Alert, babbles, coos

Confused

Irritable

Inappropriate words

Cries to pain

Incomprehensible sounds

Moans to pain

No response to pain

No response to pain

Obeys commands

Spontaneous movements

Localises to supraocular pain

Localises to supraocular pain)

Withdraws nailbed pressure

Withdraws nailbed pressure

Flexion to supraocular pain

Flexion to supraocular pain

Extension to supraocular pain

Extension to supraocular pain

No response

No response

Score 8 = Comatose; Score 9 = Non Comatose

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
17
Hemorrhage

Contusion
Usually frontal or temporal lobe; Small cortical vessels and neural
tissue damaged; Damaged vessels may thombose, leading to ischemia

Severe head injury

With 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 hemorrhage
Usually frontal or temporal lobe; Can be bilateral (contracoup injury)
Can act as mass lesions and cause intracranial hypertension

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

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 Pressure

Age group
Newborn
Infant
Children

mmHg
0.7-1.5
1.5-6.0
3.0-7.5

Note: ICP in hydrocephalic infant = 7.5-30 mmHg

(CPP=MAP-ICP)
Age group
Adult
Children
Infant

CPP (mmHg)
60-70
50-60
40-50

Brain Herniations

1. Temporal lobes
herniation
2. Uncal herniation
3. Diencephalic and
midbrain/ upper pontine
herniation
4. Lower pontine and
medullary herniation

Management of increased ICP

Head 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

Brain death
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

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

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

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

Musculoskeletal trauma
Fracture
Soft tissue (muscle, tendon, ligament)
and joint injury
Growth plate injury

Soft tissue (muscle, tendon,

ligament) and joint injury

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 bones
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.

Salter Harris
classification of growth
plate fractures

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 doesnt match the degree of injury
seen
The timing of injury dosent fit with the
time of presentation
The childs developmental stage is not
sync with the history
The history of injury changes over time
or from caretaker to caretaker 40
40

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