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

3. Introduction Epidemiology Primary Survey Specific Injuries
Orthopedic Injuries
Abused Child
Pitfalls

4. Pediatric Trauma
Size
Skeleton
Surface Area
Psychological
Equipment

5. Broselow Tape

6. 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

7. Pediatric Trauma Unstable Patient Physical Findings
Mechanism of Injury

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

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

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

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

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

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

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

15. Epidemiology
Gender
Boys twice girls
Economics
Poor
2.6 times

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

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

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

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

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

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

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

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

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

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

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

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

32. Asherman Chest Seal

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

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

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

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

37. Cardiac Arrest Penetrating Trauma Blunt Trauma Thoracotomy
Poor Outcomes

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

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

40. Disability
Level of Consciousness
Pupils
Motor Function
GCS

41. Pediatric Disability Glascow Coma Scale AVPU system Pupils
Motor strength

42. Exposure
Fully disrobe patient
Logroll to check back/spine

43. Pediatric Exposure
Identify wounds
Hypothermia
Surface area to volume

45. 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

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

47. Symptoms
Vomiting
Headache
Lethargy
Coma

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

49. Increased Intracranial Pressure
Mild hyperventilation
PaCO mmHg
Fluids
Elevate HOB degrees
No steroids

50. CT Scan
LOC
Distal injury
GCS 14
Amnesia to events

51. Pediatric Head Trauma
2043 children  1,271 CT scan  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 ; 42:

53. Pediatric Spinal Trauma
Uncommon
Younger children
Falls
Older children
MVA
Sports

54. 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

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

56. 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

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

58. 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

60. 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

61. 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

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

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

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

65. 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

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

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

68. 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

69. 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

70. 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

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

72. Mandated Reporting
Physicians
Teachers
Social Workers
EMS personnel

73. Physical Findings Subdural hematomas Retinal hemorrhage
Perioral injuries
Genital trauma

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

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

76. The End