David Slocum, MD Albany Medical Center Pediatric Trauma David Slocum, MD Albany Medical Center

Introduction Epidemiology Primary Survey Specific Injuries Orthopedic Injuries Abused Child Pitfalls

Pediatric Trauma Size Skeleton Surface Area Psychological Equipment

Broselow Tape

Pediatric Vitals Blood pressure Heart Rate Infant/child  70 + (2 x age) mmHg Adolescent  90 mmHg Heart Rate Age 1  90 to 150 Age 3  80 to 125 Age 5  70 to 115 Age >10 adult vital signs

Pediatric Trauma Unstable Patient Physical Findings Mechanism of Injury

Unstable Patient GCS < 13 Inadequate respiratory status Cap refill > 2 seconds Brady or Tachycardia

Physical Findings Penetrating injuries Combined system trauma 2 or more long bone fractures Suspected flail chest

Physical Findings Suspected spinal cord injury Amputation (not digits) Suspected pelvic fracture Suspected skull fracture

Mechanism of Injury Ejection from vehicle Death in same passenger compartment Extrication > 20 minutes 12 inches of vehicle intrusion

Mechanism of Injury Motorcycle > 20 MPH Fall > 10 feet Vehicle Rollover Vehicle vs. pedestrian or bicycle

Epidemiology Head injury MVA Leading cause of death Leading cause of injury 18% deaths 37% trauma deaths

Epidemiology Alcohol use by a driver Infants 25% crashes Suffocation Drowning, fire/burn, firearms

Epidemiology Gender Boys twice girls Economics Poor 2.6 times

Trauma Centers Trimodal distribution of death First Peak Second Peak Prehospital Second Peak Minutes to Hours Third Peak ICU

Resuscitation Primary Survey Secondary Survey Identify life threatening conditions Secondary Survey Set priorities

Lethal Problems Airway Obstruction Tension Pneumothorax Massive Hemorrhage Open Pneumothorax Flail Chest Cardiac Tamponade

Primary Survey Airway Breathing Circulation Disability – Neurological C-spine Breathing Circulation Hemorrhage control Disability – Neurological Exposure

Airway Foreign Bodies Fractures Chin-lift Nasal airway Two person technique

Pediatric Airway Most important step Anatomy – Funnel shaped Basic airway techniques Intubation Is it better than BLS airway?

Breathing Palpate and Auscultate Deviated trachea Crepitus Neck Chest Deviated trachea Crepitus Paradoxical Chest Movement Absent breath sounds

Breathing Sucking Chest Wound Tension Pneumothorax Hemopneumothorax Occlusive dressing Tension Pneumothorax Needle decompression Hemopneumothorax Large chest tube

Pediatric Breathing Oxygen Hypoxemia Ventilation Cyanosis, cap refill, bradycardia Ventilation Nasal flaring, grunting, retractions

Tension Pneumothorax Absent breath sounds Hypotension Jugular venous distention RX: Needle Decompression

Massive Hemothorax Absent breath sounds Dullness to percussion No JVD RX: Thoracostomy >15mL/kg to OR >4mL/kg per hour to OR

Open Pneumothorax Occlusion dressing 3-sided Prevent tension pneumothorax Asherman Chest Seal

Asherman Chest Seal

Circulation Level of consciousness Skin color Peripheral pulses 2 large bore IVs

Circulation Hypotension and Tachycardia Pulse Pressure Hemorrhagic Shock Assumed in hypotensive patient Crystalloids

Pediatric Circulation Shock Tachycardia Cool extremities AMS Low urine output Cap refill > 3 sec

Pediatric Circulation Resuscitation Crystalloid 20mL/kg times 3 PRBCs 10mL/kg

Cardiac Arrest Penetrating Trauma Blunt Trauma Thoracotomy Poor Outcomes

Cardiac Tamponade Beck’s Triad Hypotension Muffled Heart Sounds Jugular Venous Distention

Vascular Access Peripheral (2 attempts) Intraosseous (children < 6) Femoral Vein Venous cut down Avoid multiple sticks

Disability Level of Consciousness Pupils Motor Function GCS

Pediatric Disability Glascow Coma Scale AVPU system Pupils Motor strength

Exposure Fully disrobe patient Logroll to check back/spine

Pediatric Exposure Identify wounds Hypothermia Surface area to volume

Pediatric Head Trauma Incidence TBI 200/100,000 Approximately 400,000 ED visits a year Subarachnoid hemorrhage more common than epidural or subdural hematoma Hemorrhagic shock possible for ICH due to large head to body ratio

Pediatric Head Trauma Anatomy Neck ligamentous structure Larger head size Neck ligamentous structure Incomplete myelinated brain Open sutures

Symptoms Vomiting Headache Lethargy Coma

Physical Exam Level of consciousness Symmetry of movement Sensory function (pain withdrawal) Fontanel fullness

Increased Intracranial Pressure Mild hyperventilation PaCO2 30-34 mmHg Fluids Elevate HOB 20-30 degrees No steroids

CT Scan LOC Distal injury GCS 14 Amnesia to events

Pediatric Head Trauma 2043 children  1,271 CT scan  105 interventions 5 risk factors determined Headache Abnormal mental status Scalp hematoma Vomiting Clinical skull fracture Palchak et al. A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann E Med. 2003; 42: 492-506

Pediatric Spinal Trauma Uncommon Younger children Falls Older children MVA Sports

Pediatric Spinal Trauma Higher incidence of ligamentous and growth plate injuries in young children Children have big heads  difficult to immobilize Anatomical differences Upper C-spine more likely

Nexus Criteria No posterior midline tenderness No focal neurological deficits No intoxication No distracting injury

Nexus Study 3065 pediatric patients Age 8-17  2817 Children Age 2-8 817 Children Below age 2 88 Children C spine injuries in 1% (30 children) All 30 patients met criteria for imaging

Imaging X-rays AP Lateral Odontoid CT Major trauma mechanism Head CT

SCIWORA In children due to variable elasticity of spinal column Spinal cord stretches ¼ inch Cartilage, ligaments and soft tissue can stretch 2 in Symptoms  from transient parathesias or weakness to complete motor/sensory level Symptoms can be delayed up to 4 days MRI important for diagnosis/prognosis

Pediatric Abdominal Trauma Common injury in blunt trauma Of blunt trauma 10% have abdominal injury Greater than 90% with abdominal injury survive MVA leading cause abdominal trauma Solid organ most common site of injury

Pediatric Abdominal Trauma Physical exam may be misleading May have external signs (contusions) as evidence of injury Most important is serial exams by experienced provider

Diagnosis US sensitive for free fluid Ct scan is imaging of choice  determines location and severity of injury

CT Scan Tenderness, distention, bruising Hematuria Dropping hematocrit Vomiting Obtundation

Stomach Injuries Blunt injuries to stomach more common Blowout or perforation of greater curvature Peritoneal signs Bloody GI aspirate

Splenic and Liver Injuries 95% non-operative management ICU admission, serial HCT, serial exams and transfusions as needed If hemodynamically unstable and not controlled by transfusion may need operative management

Pancreatic Injuries Uncommon Most common cause of acute pancreatitis High index of suspicion

Bowel Trauma <5% of Abdominal Trauma Jejunum, ileum, cecum Duodenal hematoma

Orthopedic Injuries #1 emergency in children Upper extremity 7x more likely than lower extremity Fracture clavicle most common Most significant difference in children and adults is presence of growth plates

Salter Classification Type 1  physis plate Type 2  physis to metaphysis Type 3  physis to epiphysis Type 4  epiphysis to metaphysis Type 5  Crush injury

Salter Classification Type 1 and 2 fx reduced heal well Type 3 and 4 more complex alignment often require open alignment can heal with minimal complications if aligned Type 5 Crush injury high incidence of growth disturbance

Abused Child History vs. physical exam Long time seeking help Repeated trauma Parents respond inappropriately History changes Discrepancy

Mandated Reporting Physicians Teachers Social Workers EMS personnel

Physical Findings Subdural hematomas Retinal hemorrhage Perioral injuries Genital trauma

Physical Findings Healed fractures Long bone fractures < 3 years Bites, cigarette burns Sharply demarcated burns

Pitfalls ETT obstruction ETT dislodgement Illusion of hemodynamic normalcy Orthopedic injuries subtle

The End