an overview of pediatric trauma Omar abdulwahed MD.DU.FEBPS Head of pediatric surgery division Damascus hospital

Introduction…. Pediatric trauma accounted for 59.5% of all mortality for children under 18 in 2004. In the US approximately 16,000,000 children go to a hospital due to some kind of injury every year. Male children are more frequently injured then female children by a ratio of two to one. The direct costs alone of childhood injury exceed eight billion dollars per year .

Pediatric multiple trauma victims present a unique set of problems to the emergency physician, pediatrician, or surgeon. Children rarely sustain lethal injury; however, delayed recognition and inappropriate management of the common problems encountered in the pediatric trauma patient can lead to a poor outcome.

management of the ‘‘Golden Hour’’ in pediatric trauma

I am not asmall adult….i have my own personality…y…y..

Infants and young children, in particular, have a relatively large body-surface-area-to- body-cell mass ratio and are thus prone to developing hypothermia. Young children have relatively large heads. The glottis lies in a more superior and anterior position relative to the pharynx. This makes orotracheal intubation much easier than nasotracheal intubation,

Rule of 9’s

In children, the thorax is much more compliant to external forces and the vital organs are closer to the surface, both of which tend to increase the risk of blunt injury to the tracheobronchial tree, the heart, and great vessels. the mediastinum is more mobile so that an increase in pressure from a pneumothorax or hemothorax on one side is more apt to compromise both lungs.

Pathology Potentially Noted on Chest X Rays Bony thorax fracture,,, Consolidation Ribs Clavicles Vertebrae Scapulae Sternum Soft tissues Emphysema Opacification Foreign object Lung fields Lung contusion Pneumothorax Hemothorax Foreign bodies Mediastinum Pneumomediastinum- airway rupture Widening of the mediastinum-aortic rupture Shift of the mediastinum- tension pneumo/hemothorax Foreign body Cardiac silhouette

In the abdomen : the liver, spleen, and kidneys are less well protected by the ribs in children because the ribs are more pliable and because these organs are less well covered by the ribs.

AIRWAY Movement of the neck, as is commonly employed to provide an airway,can convert a bony or ligamentous injury into a permanent disability. *C-spine protection should be initiated at the scene and maintained in the emergency department.

Heat Loss Children are much more susceptible to hypothermia than adults Be very aggressive in preventing and managing hypothermia

Incubator is essential… NICU…PICU

Hypothermia…

pediatric trauma center the Broselow System :is a reasonable method of organizing the trauma room. This system provides color-code dequipment : *airways, laryngoscopes, endotracheal tubes, suction catheters, vascular access devices, nasogastric (NG) tubes, urinary catheters, chest tubes. The color-coding is based on the child’s weigh

Glasgow Coma Scale

Broselow/Hinkle System

Endotracheal Tube Size in Relation to Age Age Internal diameter (mm) Term infant 3.0 6 months 3.5 1 year 4.0 2 years 4.5 4 years 5.0 6 y 5.5 8 years 6.0 10 years 6.5 12 years 7.0 14 years 7.5 Adult 8.0

Pediatric trauma Usual ABC’s , and C-spine Use your Broselow Weight can also be estimated: < 8: (AGE x 2) + 8 > 8: AGE x 3

ABCs assessment…. Before a child leaves the trauma room for a diagnostic procedure, they must have their ABCs assessed and stabilized

Normal Vital Signs by Age Age Weight Heart rate B. Pressure breaths/min Urine 0–6m 3-6 160-180/m 60-80 60 2 Infant 12 160 80-40 40 1.5 Preschool 16 120 90 30 1 Adolescent 35 100 100 20 0.5

Abdominal Trauma in Children 8% to 12% of blunt injured children will have abdominal injury. Good news>>>>>: 90% of those with blunt abdominal injuries survive 22% of the deaths are related to the abdominal injury

Abdominal Trauma: Anatomic issues larger solid organs, less musculature, compact torso, elastic rib cage, liver & spleen anterior  potential internal injury spleen>liver>kidney>pancreas>intestine bladder intra-abdominal 10% have GU injury low BP late sign of shock mechanism handlebars, lap belt

SOLID ORGAN INJURY… Spleen and Liver The spleen and liver are the organs most commonly injured in blunt abdominal trauma with each representing one-third of the injuries. Abdominal CT is the most useful diagnostic test because it produces images that define the presence and extent of splenic and hepatic injury and associated changes.

Abdominal Trauma: Management spleen and liver: 90% conservative: admit, observe, Hct more fatal hemorrhage with liver injuries laparotomy in unstable after resussitation. hematuria: gross or >20 RBC + unstable  IVP in OR >10 RBC + stable  CT- cystoscopy.

Abdominal Imaging: CT most widely used stable patients only Low sensitivity for hollow viscous (25% sens), pancreas (85% sens)

Abdominal Trauma: DPL Rarely needed in pediatric. +ve: >100,000 RBC (blunt in adult, in pediatric it is controversial ). FP 5-14%.?

When to operate..? The decision to operate for spleen or liver injury, which should always be made by a surgeon, is best based on clinical signs of continued blood loss such as low blood pressure, elevated heart rate, decreased urine output, and falling hematocrit.

Blood transfusion…. It has been suggested that non operative management of blunt splenic injuries requires more blood transfusion than operative hemostasis. In fact, many studies showed that in children: conservative treatment had a significantly lower rate of transfusion compared to a group of hemodynamically stable patients undergoing celiotomy for blunt splenic injury

Two recent studies of more than1100 patients with isolated spleen or liver trauma showed a tranfusion rate of less than 5% in children with grade I–III injuries. a low hematocrit alone is not an absolute indication for transfusion.

APSA Evidence-Based Consensus Guidelines

Missed Associated Abdominal Injuries There is no justification for an exploratory celiotomy solely to avoid missing potential associated injuries in children.

The indications for immediate surgery following abdominal trauma in children Children hemodynamic instable. evidence of persistent hemorrhage. Suspicion of hollow viscus perforation. major pancreatic ductal disruption.

A recent report of 328 children with liver injury revealed that hemodynamic instability, as defined by the need for blood transfusion in excess of 25 mL/kg within the first two hours of presentation, was a strong indicator of the need for surgical intervention and hepatic vascular injury

Most liver injuries requiring operation are amenable to simple methods of hemostasis using some combination of manual compression, suture, and topical hemostatic agents

Spleen injury,,,, *I Hematoma Subcapsular, <10% surface area Laceration <1 cm parenchymal depth * II Hematoma Subcapsular, 10–50% surface area; intraparenchymal, <5 cm Laceration 1–3 cm parenchymal depth *III Hematoma Subcapsular, >50% surface area; intraparenchymal, >5 cm Laceration >3 cm parenchymal depth *IV Laceration Segmental or hilar vessels; devascularization >25% spleen *V Laceration Completely shattered spleen Vascular Hilar injury which devascularizes spleen

INJURIES TO THE DUODENUM AND PANCREAS 1% - 4% of intraabdominal injuries in children sustaining blunt trauma. blunt injury to the duodenum occurred in about (0.2%), of whom only (14.56%) had full-thickness rupture.

Pancreatic trauma… Injuries to the pancreas are slightly more frequent than duodenal injuries with estimated ranges from 3% to 12% in children sustaining blunt abdominal trauma

INJURIES TO THE STOMACH, SMALL INTESTINE, AND COLON

Renal injuries… *Blunt trauma is more common, accounting for greater than 90% of injuries. *Penetrating trauma accounts for 10–20% of renal injuries

Renal injury’s grading … grade I renal contusion or nonexpanding subcapsular hematoma without a renal parenchymal laceration; grade II non-expanding perirenal hematoma a renal cortex laceration (<l cm) without urinary extravasation; grade III renal cortex laceration (>l cm) and no urinary extravasation; grade IV renal cortical laceration extending into the collecting system (as noted by contrast extravasation), or a segmental renal artery or vein injury (noted by segmental parenchymal infarct), or main renal artery or vein injury with a contained hematoma; grade V shattered kidney, avulsion of the renal pedicle, or thrombosis of the main renal artery

INJURIES TO THE PERINEUM, ANUS, AND GENITALIA Injury to the urinary tract occurs in 3–10% of patients suffering from blunt or penetrating trauma

Child abuse….

conclusion Trauma is still the most important cause of mortality in pediatrics. Assessment in the first golden hours is very important in preventing or decreasing this mortality. Observation..reassessment are the main keys in the management of the majority of cases of blunt trama in children

Thank you…