Pediatric Trauma Karim Rafaat, MD

Goals Time is short I’m going to presume you know your basic ATLS (that’s that whole ABCD thing, by the way) Discuss each general trauma susceptible region Focus on: Epidemiology Anatomic and physiologic differences between children and adults How this results in differing patterns of injury, and thus, different foci for concern

Yay Parenting!!

Epidemiology - General Trauma is the leading cause of death between the ages of Injury accounts for 5% of infant deaths 47% of these deaths are related to MVCs With rates higher in those >13yo 13% of deaths in those 1-14yo were a result of homicide In the school age group Pedestrian injuries and bike injuries predominate

Pediatric Head Injury #1 cause of death due to trauma ~2700 deaths/year 450,000 children present to EDs each year with head injury 90% suffer from minor injuries Perinatal period Birth injuries 1-4 years old Falls School age Pedestrian or bike injuries Adolescence MVA

Anatomic Considerations The skull is more plastic and deformable Better able to absorb initial impact without fracture Open sutures function as “joints” Allow shifting of bone to absorb impact Prevent early and rapid rise of ICP secondary to brain swelling/space occupying lesions This also means that infants can lose a significant portion of their blood volume into their cranium secondary to a head injury

Children have larger heads than adults in relation to their body The chance that it is hit in a traumatic event is larger Head is heavy Different acceleration dynamics

At birth, the brain contains very little myelin Progressive decrease in water content from birth until the brain is fully myelinated Neonatal brain water content is ~89%, adult content is 77% Brain is softer and more prone to acceleration/deceleration injury Myelination proceeds in a caudo- cranial and posterior-anterior direction Differential myelination results in different absorption of force Increases susceptibility of unmyelinated portions to shear injury

At birth, face to cranium ratio is 1:8, adult ratio is 1:2.5 Makes it more likely skull is hit in younger children Lack of pneumatization of sinuses is associated with more rigidity and less plasticity of facial skeleton Increases transfer of forces directly to brain

Pediatric Spine Injury 18.1 spinal cord injuries per milllion children 1300 new cases a year 60-80% of injuries occur at the cervical level Adults have a 30-40% incidence Children <8 yo More likely to sustain high cervical (C1-C3) injuries

Anatomic Considerations Immature C-spine has more horizontal orientation of facet joints Relative laxity of cervical ligaments Weaker neck muscles Relatively increased mass and volume of infant head

Anatomic Considerations Cervical flexion fulcrum C2-C3 in infants C3-C4 by 5yo C4-C5 at 10 C5-C6 (adult) at age 15 Pediatric C-spine is much more flexible than adult c- spine Spinal cord injury can occur without injury to bony spine (SCIWORA) Trauma related myelopathy, however transient, demands an MRI

Pediatric Thoracic Trauma #2 cause of trauma related mortality In isolation, thoracic trauma carries a 5% mortality 25% when combined with abdominal injury 40% with head and abdominal injury

Anatomic Considerations Incomplete ossification of ribs allows anterior ribs to be compressed to meet posterior Pulmonary contusions are common, rib fractures uncommon Presence of rib fractures in 0-3yo suggests NAT Pulmonary contusions are most common thoracic injury in traumatized children Trachea is narrow, short, more compressible Small changes in airway caliber due to external compression or internal FB lead to large changes in resistance Great vessel and cardiac injury are rare in children However, hemodynamic instability in the face of euvolemia should raise concern for myocardial contusion and/or mediastinal injury

Anatomic Considerations Commotio Cordis is a unique consequence of pediatric thoracic trauma Abrupt strike to the chest leads to V-Fib and arrest

Pediatric Abdominal Trauma Third leading cause of pediatric traumatic death Blunt causes in 85%, penetrating trauma in 15% Blunt trauma related to MVC’s causes more than 50% of abdominal injuries in children Boogie board related injury..!

Anatomic Considerations Proportionally larger solid organs Less subcutaneous fat Less protective abdominal musculature Relatively larger kidneys that predispose them to renal injury

Anatomic Considerations Splenic injuries are the largest proportion of pediatric abdominal trauma Liver is second most injured solid organ Lap Belt Injury Sudden increase in bowel intraluminal pressure can result in intestinal perforation Chance fracture of the lumbar spine

Anatomic Considerations The compliant chest wall, poor thoracic musculature and weak diaphragm can lead to considerable respiratory difficulty with gastric distention