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Pediatric Trauma

(Not Just Small Adults)
Monday, Oct 29 2007

SURG GP.
425

Dr. Aayed Al-Qahtani
Ass. Professor & Consultant pediatric surgery

Outline :




Background .
Trauma scores .
Principles and Approach .
ABC’s .
Specific injuries 
Head, C-Spine, Chest, Abdominal, Burns
♣ Abuse .

Background:
♣ Leading cause of death in pediatric age.
♣ < 5 years 
highest risk.
♣ Boys > girls.
♣ Blunt > penetrating 
Falls>MVA (Motor Vehicle Accident) >MPA>rec>abuse>drown>burns.
♣ Regionalized peds trauma centers. 
Improved mortality of severely injured child .

Basic ATLS concepts include:
♣ Treat the greatest threat to life first.
♣ The lack of a definitive diagnosis should never impede the application of an indicated treatment.
♣ A detailed history is not an essential prerequisite to begin evaluating an acutely injured patient
(meaning detailed history is not initially required).

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Aayed Al-Qahtani Ass. Low trauma score . Complicated TBI . ♣ The third death peak occurs several days to weeks after the initial injury Sepsis. Acute cord injury . Common errors in resuscitation include failure to: ♣ Open and maintain the airway. Criteria for transfer to trauma centre : ♣ ♣ ♣ ♣ ♣ ♣ ♣ Multi-system . Neurovascular injury . ♣ Provide appropriate and adequate fluid resuscitation to head injured children. ♣ The second peak occurs within minutes to several hours of the injury  This is the period that ATLS (Advanced Trauma Life Support) focuses upon (*the most important). Oct 29 2007 SURG GP. brain stem. 425 Dr. Trimodal distribution of death from injuries: ♣ The first peak of death is within minutes of the injury usually due to:  Brain . Unstable . Axial skeleton bone . 2|Page . heart. high spinal cord.Pediatric Trauma (Not Just Small Adults) Monday. great vessels. Professor & Consultant pediatric surgery Principles: Improper resuscitation has been identified as a major cause of preventable pediatric death. ♣ Recognize and treat internal hemorrhage. MSOF .

♣ 0% mortality ≥ 8 (meaning: there will be no mortality if the trauma score is more than 8). ♣ Injury Severity Score (ISS)  Cumbersome. Pediatric trauma score: Size (kg) SBP* Airway CNS Open Wound Fractures +2 >20 >90 N awake none none +1 10-20 50-90 Secure obtund minor Closed -1 <10 <50 tenuous coma major Open *SBP=Systolic blood pressure ♣ Score +12 to -4 (the range of the score).  <12 increased mortality.  -4 to 12.Pediatric Trauma SURG GP. Aayed Al-Qahtani Ass. Oct 29 2007 Dr. ♣ 45% = 2 ♣ 100% = 0 up to -4 (there will be 100% mortality if the trauma score is zero). C-spine. ♣ Broselow tape (a tape for measuring height and weight used when we can't carry the patient and weigh him/her with a scale like in emergencies and gives the required drug doses according to that. Approach: ♣ ATLS (Advanced Trauma Life Support). ♣ Vital Signs: plus.) ♣ ABCs. ♣ Revised Trauma Score (RTS)  Same as adults . ♣ transfer to pediatric trauma center if PTS <8 .29 >29 6-9 1-5 0 Coded Value 10 3 2 1 0 *Glasgow coma scale is similar to that in adults but with BP and RR added to it in pediatrics. BP. weight. Revised trauma score: Glasgow Coma Scale Score 13-15 9-12 6-8 4-5 3 Systolic Blood Pressure (mm Hg) >89 76-89 50-75 1-49 0 Respiratory Rate (breaths/ min) 10 . 425 (Not Just Small Adults) Monday. <8 increased mortality. temp. underestimates survival. NG tube. Professor & Consultant pediatric surgery Trauma scores: ♣ Pediatric Trauma Score (PTS)  Accurate predictor of injury severity. 3|Page . ♣ Consent (incases of the patient's need for surgery).

-if radial pulse is not palpable and femoral pulse is then SBP is usually 80. ♣ B = Breathing and ventilation: (by checking the chest movements). Painful stimuli response. Unresponsive). -if cannot be felt in femoral but is palpable in carotid then SBP is usually 60 (60 is very low and the patient may go into an arrest). -when I'm able to palpate the radial pulse then the SBP is usually minimally 90. Aayed Al-Qahtani Ass. glucose & fluid requirements (hypothermia)  very imp. Primary survey: ♣ A = Airway maintenance with cervical spine control: (we know that airway is clear if the patient was able to cry or talk if not then we intubate. but prevent hypothermia . Verbal stimuli response. 425 Dr. and in this step it is very important to protect the C-spine if injured by in-line immobilization where we mobilize the spine without any significant flexion or extension). in pediatric trauma. Professor & Consultant pediatric surgery Principles : ♣ Kids are really not just small adults and there are differences between the two. 4|Page . ♣ Airway and shock management are very important. one of the commonest causes). ♣ C = Circulation with hemorrhage control: (by checking the pulse and BP and resuscitated by two IV access lines). ♣ E = Exposure/ Environmental control: completely undress the patient. Oct 29 2007 SURG GP. ♣ Forces over small area → multi-systemic injury. ♣ Little or no external injury does not rule anything out. ♣ D = Disability: neurologic status (AVPU= Alert. ♣ Kids die from hypoxia and respiratory arrest (*very important.Pediatric Trauma (Not Just Small Adults) Monday. ♣ Psyche sequel. ♣ Head injury: ↑ morbidity & mortality. ♣ ↑ Heat loss.

♣ Soft Vocal Cord  no stylet used (stylet: is the tool sed for guiding the tube into the larynx. ♣ big occiput (so there may be a spinal injury) ♣ big epiglottis that may obstruct the larynx while intubation  so we use a straight blade to elevate the epiglottis .e. ♣ respiratory failure #1 cause of arrest . . 425 Dr. 5|Page . ♣ Endotracheal tube (ET tube) size: for calculation of the tube size we do the following formula: (16 + age)/4 . ♣ narrowest part of trachea is at subglottis .Pediatric Trauma (Not Just Small Adults) Monday. cricothyrodotomy (because in pediatrics the cricothyroid membrane is very small if we do this cut we will injure the cricoids or the larynx). Professor & Consultant pediatric surgery Airway : ♣ 2 x O2 demands (usually we put them on 100% oxygen to start with). trachiastomy (sometimes it is exeptable is pediatrics). soft tissue → obstruction. ♣ short trachea . ♣ Anterior larynx. Anatomical airway issues in kids: ♣ Big tongue. Aayed Al-Qahtani Ass. ♣ Laryngeal Mask Airway (LMA) as rescue if >4 feet tall (used for ventilation and to access the airway). but if used here may injure the larynx). ♣ nose breathers < 6 months . ♣ Soft trachea  no cuff (usually not used below 8 years old because it may cause tracheal damage and ischemia due to compressing the vessels there). ♣ no surgical airway < 10years i. Oct 29 2007 SURG GP.

(where head injury is the first cause.02 mg/kg all < 6years . tachypnic.  aerophagia displaces diaphragm. tracheal tug. ♣ no defasciculating dose < 5 years .  Diaphragm 1° respiratory muscle  Easily fatigued. ♣ Thoracic structures and mediastinum is mobile → shift.3 mg/kg  propofol 2 mg/kg  thiopental 3-7 mg/kg  etomidate 0. Breathing : ♣ Signs of respiratory distress: indrawing. Chest trauma : ♣ 2nd leading cause of pediatric trauma death. 425 Dr. ♣ induction:  ketamine 1-2 mg/kg  midaz 0.) ♣ Compliant chest wall (‫∴)   . use of accessory respiratory muscles. Aayed Al-Qahtani Ass. Oct 29 2007 SURG GP.Pediatric Trauma (Not Just Small Adults) Monday. Professor & Consultant pediatric surgery Pediatric Airway RSI: (the doctor didn’t mention this subtitle) ♣ Pre-treat atropine 0. ♣ infants:  Immature response to hypoxia (they don’t tolerate it very well). tachycardiac. nasal flaring.3 mg/kg ♣ sux 2 mg/kg ♣ no evidence for lidocaine in kids .2-0.

♣ Pulmonary contusion is most common. If the bone fracture is present. this indicates severe injury. ♣ Mobility of mediasternal structures more sensitive to tension pneumothoraces and flail segments or flail chest (when part of the chest is moving in the opposite direction while breathing due to negative pressure causing sucking i. ♣ Treat conservatively: 15% require more than chest tube. For example when there are at least 3 ribs broken on each side of the cage. they will be flail segments. دون ا‬ ∴ rib bone uncommon Significant injuries without external signs. aortic injury is rare. 6|Page . the chest moves inwards with inhalation and outwards with exhalation.e.

Pediatric Trauma (Not Just Small Adults) Monday. 425 Dr. Oct 29 2007 SURG GP. Aayed Al-Qahtani Ass. hypotention. Professor & Consultant pediatric surgery Life threatening thoracic injuries: ♣ Tension pneumothorax: is a pneumothorax causing heamodinamical instability (tachycardia. shifting of mediastinum…). ♣ Flail chest. 7|Page . ♣ Massive hemothorax ♣ Cardiac tymponade: fluid in the pericardium.

425 Dr.Pediatric Trauma (Not Just Small Adults) Monday. Professor & Consultant pediatric surgery Circulation: ♣ Low BP is a LATE sign: kids compensate well but drop very quickly after that.  ≥ 25% loss of blood volume in order to have BP problems. ♣ Early Signs of shock: ↑HR. mottled   ‫)ا. Aayed Al-Qahtani Ass.  Minimum acceptable BP: 70 + (2 x age). Oct 29 2007 SURG GP. ↓RR.

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*NOTES: -normal saline: NaCl (Na 154 m. then intraosseous (a rigid needle that we pass to the bone marrow where we inject the fluid or blood there then it goes to the system immediately).Total blood volume: -adults 5 L. ة‬ (‫ ا‬#. . altered LOC. ♣ no role for MAST: ↑ mortality. femoral. ↓pulses. cap refill > 2 sec (prolonged). then 10cc/kg pRBC . -Children  80 -120 cc/kg. ♣ Management by IV lines: antecubital. external jugular. Cl  154 m. ♣ Scalp laceration can cause shock in pediatrics only and not in adults (due to high surface area in the head and high blood supply).  Age limit?  Landmarks? ♣ Fluids: crystalloid (normal saline because isotonic) 20cc/kg x 2.mol.mol). ♣ Attempt <90 sec. 8|Page . cool.

No evidence in peds for early surgery.  E = Events/ Environment related to the injury . 9|Page . Oct 29 2007 SURG GP.Pediatric Trauma (Not Just Small Adults) Monday.  L = Last meal time. just after primary.  M = Medications. X-rays are before 2nd survey.5%. Professor & Consultant pediatric surgery Figure: intraosseous Secondary survey : ♣ Begins once the primary survey (ABC’s) is completed. and complete history and physical examination. Falls > MVA > MPA > bicycle > assault. Few require surgery: 0. ♣ plasticity . AMPLE:  A = Allergies. 425 Dr.4 -1. 90 % “minor”. Head injury: Anatomic differences: Protective ♣ Fontanelles . ♣ A head-to-toe evaluation including: Vital signs. helps in expanding the skull. Aayed Al-Qahtani Ass. 4-6% with normal exam have ICH on CT  ?significance  ?long term sequel. Head injury: ♣ ♣ ♣ ♣ ♣ ♣ leading cause of death in peds trauma (80%) . resuscitation has commenced and the patient’s ABC’s have been reassessed.  P = Past illnesses. ♣ open sutures .

parenchymal. Head injury: Types of injury: (doctor didn’t mention this) ♣ Contusions. persistent emesis. <1 year. LOC. FTT. Skull fracture: (doctor didn’t mention this) ♣ 20 x ↑ risk ICH  50% of parietal bone. 425 Dr. less myelin → more shearing forces . poor outcome. alt.  SBS: vomit. soft cranium → injury without fracture . “setting sun” sign . retinal hemorrhages. ♣ Linear > depressed > basilar. irritable. DAI. Aayed Al-Qahtani Ass. ♣ depressed bone: may miss on CT . Professor & Consultant pediatric surgery Susceptible ♣ ♣ ♣ ♣ big head → torque . minor trauma.Pediatric Trauma (Not Just Small Adults) Monday. Interpretation? 10 | P a g e . ♣ Signs of ↑ ICP in infants:  Full fontanelle. Oct 29 2007 SURG GP. subtle presentation. <4 years. SAH. ♣ “Growing skull bone”:diastatic → dural tear → meninges herniate. 75% of occipital bone. ♣ Subdural: common. LOC. prone to reactive hyperemia . Head injury: Assessment: (doctor didn’t mention this) ♣ Pediatric GCS: not predictive in infants. ♣ 90% linear bones have overlying hematoma. seizure. ♣ X-rays neither sensitive nor specific. ♣ Epidural: uncommon. split sutures. prevents closure: NSx F/U .

J Neurosurg. basal skull #. focal deficit.Pediatric Trauma (Not Just Small Adults) Monday. seizure . 1990 ♣ alt LOC. Oct 29 2007 SURG GP. 425 Dr. ♣ all HI < 1 year . Aayed Al-Qahtani Ass. Professor & Consultant pediatric surgery Growing Skull Fracture Quayle et al. palpable depression. 11 | P a g e .

focal neuro (OR=8). 12 | P a g e .Pediatric Trauma (Not Just Small Adults) Monday. Aayed Al-Qahtani Ass.  hard to assess . not validated . 425 Dr. Pediatrics 1999  Scalp hematoma most sensitive clinical predictor ♣ Quayle. ♣ Beni-Adani. 2000 Predictors of ICH : ♣ Greene. Professor & Consultant pediatric surgery Who gets CT? ♣ Children < 2 years . ♣ various algorithms. Am J Emerg Med. J Trauma 1999  TINS score for EDH. Pediatrics 1997  depressed LOC (OR=4).  asymptomatic ICH (4-19%) . skull bone . no consensus. CT head algorithms : Savitsky.  low threshold .  prone to ICH. Oct 29 2007 SURG GP. LOC > 5 min. seizure (trend) . skull bone.

Pediatrics 2000  10 kids with TBI. prophylactic anticonvulsants: consider in moderate/severe HI. prophylactic Abx for basil skull bone : no role . Crit Care Med 1998 prospective RCT. falls>MVA>sports (trampolines). higher mortality . Normothermia: temp > 38.Pediatric Trauma SURG GP. Aayed Al-Qahtani Ass. HTS fewer interventions to keep ICP<15 HTS group. 425 (Not Just Small Adults) Monday. Euglycemia: ↑glucose worse neuro outcome . 35 TBI kids RL vs. same survival and total hospital stay . 13 | P a g e .5 worse neuro outcome . Hypertonic Saline : ♣ Simma et al. <8 years: 2/3 above C3 . C-Spine Injuries : ♣ ♣ ♣ ♣ Less common in kids. hyperventilation: not in 1st 24 hr . Professor & Consultant pediatric surgery AAP Guidelines: Management: (the main principle is to maintain brain blood supply and decrease intra cranial pressure) ♣ ♣ ♣ ♣ ♣ ♣ ♣ ♣ MAP > 70 teen. resistant to conventional Rx  statistically sign ↓ICP with HTS . HTS: small studies . 60 child. >1 seizure or prolonged . Oct 29 2007 Dr. ♣ Khanna et al. mannitol: no studies . Associated with Head Injury. shorter ICU stay with HTS (3 days) . 45 infant .

♣ cartilage > bone. ♣ prevertebral space: C2=7mm. ♣ facets joints horizontal. bottom line:  CT/MRI if abn neck/neuro exam. in destruction of ligaments and tendons with normal x-ray. less muscles → torque. 425 Dr. recur up to 4 days later . Professor & Consultant pediatric surgery C-Spine: Anatomic differences : ♣ big head. ♣ ♣ ♣ ♣ ♣ 16-50% SCI!! < 9 years . high risk mech DESPITE normal 3views. C-Spine Imaging : ♣ 3-views : AP. multiple centers . C3=5. Oct 29 2007 SURG GP.  94% sensitive . SCIWORA : (= Spinal Cord Injury WithOut Radiological Abnormalities) -Normal X-ray in major injury e. Open mouth .Pediatric Trauma (Not Just Small Adults) Monday. Lateral. ♣ predental space 4-5 mm . ♣ pseudosubluxation C2-3. C7=2cm . alt. C3-4: 3-4 mm or 50% vertebral body width . anterior wedging vertebral bodies . Aayed Al-Qahtani Ass. lax ligaments  injury without bone.but SCIWORA ♣ Flexion-extension? Ralston Acad Emerg Med 2001  no added info if 3 views normal . Case : ♣ 6. distracting injuries. LOC. fulcrum C2-3 . use Swischuk’s line .year-old girl fell off bike ♣ What’s the abnormality? 14 | P a g e .g. ♣ incomplete ossification. transient neuro symptoms (parasthesias) .

Age (years) + 4 4 . Pediatric trauma : ♣ Usual ABC’s (sugar) and C-spine ♣ Use your Broselow ♣ Weight can also be estimated: < 8: (AGE x 2) + 8 > 8: AGE x 3 15 | P a g e .Depth of insertion (cm): tube ID (mm) x 3 or age (years)/2 + 12 Failed intubation : ♣ ♣ ♣ ♣ BMV with Sellick LMA an option No cricothyroidotomy under 8 years In a pinch: Needle cric .Uncuffed < 8 years old (exceptions) . Professor & Consultant pediatric surgery Endotracheal intubaton :  ETT size?  cuffed?  depth of insertion? .Pediatric Trauma (Not Just Small Adults) Monday.Broselow . 425 Dr. Oct 29 2007 SURG GP. Aayed Al-Qahtani Ass.

Oct 29 2007 SURG GP. Aayed Al-Qahtani Ass. 425 Dr. Professor & Consultant pediatric surgery 16 | P a g e .Pediatric Trauma (Not Just Small Adults) Monday.

Aayed Al-Qahtani Ass. reassess. ♣ use: unstable. flank / lap ecchymosis . ♣ bladder intra-abdominal more than adults . ♣ mechanism handlebars. mechanism  handlebars. going to OR anyway .  >5. ↑ potential internal injury . Hct. 10% have GU injury . Abdominal trauma: Management: ♣ spleen and liver:  90% conservative: admit. Abdominal trauma: DPL : ♣ ♣ ♣ ♣ Rarely needed in pediatric. ♣ stable pt only ♣ strongly consider in Head Injury patient  25% with GCS <10 ♣ insensitive for hollow viscous (25% sens).  Lap in unstable after resus . lap belt Abdominal imaging: -C T : ♣ most widely used . reassess . 425 Dr. ♣ low BP late sign of shock . seat belt . retroperitoneum. in pediatric it is controversial). elastic ribcage. U/A.  often occult fatal injury . +ve:  >100. Oct 29 2007 SURG GP. sports. Abdominal trauma: Anatomic issues : ♣ In pediatrics there are larger solid organs and less musculature leading to compact torso.Pediatric Trauma (Not Just Small Adults) Monday. pancreas (85% sens). clinical findings unreliable . bikes. 17 | P a g e .000 RBC (blunt in adult. FP 5-14% ? solid organs.S looking fro fluids. reassess. ♣ blunt: MVA.000 (GSW). ♣ hematuria:  Gross or >20 RBC + unstable → IVP (intravenous pylogram) in OR. assault . -Focused Ultrasound: quick abdominal U. N/G . observe. intestine . spleen>liver>kidney>pancreas>intestine . liver & spleen anterior .  Why?  More fatal hemorrhage with liver injuries . shoulder tip pain. Professor & Consultant pediatric surgery Abdominal trauma : ♣ 3rd leading cause of trauma death . Abdominal Trauma: Assessment : ♣ ♣ ♣ ♣ ♣ ♣ low BP late sign of shock .

18 | P a g e . lipase.Pediatric Trauma (Not Just Small Adults) Monday. edema . Oct 29 2007 SURG GP. non-parietal . PT/PTT. ♣ CT if suspect . injury ≠ development . Professor & Consultant pediatric surgery  >10 RBC + stable → CT cysto. ♣ posterior rib bone. abdominal prn Child Protection. acceleration/deceleration . low birth weight . subdural. B/W: CBC. Burns : ♣ infants → spills > intentional immersions . spiral bone < 3 . ♣ Rules of Nines doesn’t work:  Lund & Brouder chart .  palm = 1% ♣ mgt same as adults . cutaneuos injuries most common . Child abuse: Clues : History ♣ ♣ ♣ ♣ ♣ story ≠ injuries . U/A . Child abuse : ♣ ♣ ♣ ♣ ♣ ♣ 1 million confirmed cases / year (US) . genital). skeletal survey . history changing . RF: poverty. disability. delay seeking help . CT head. single parent. death 2°to head & abdominal trauma . ♣ fractures:  bilateral. Aayed Al-Qahtani Ass. Child abuse: Management : ♣ ♣ ♣ ♣ ♣ ♣ ♣ Document . substance abuse. 28% re-injured . sternum bone. high index of suspicion . cigarette . cross sutures. ♣ IC injuires:  SAH. ♣ older kids → flames . diastatic. ♣ 31% missed. interview child & parent separately . ICH. ♣ immersion burns. inappropriate level of concern . full P/E (rectal. 425 Dr. Physical Exam ♣ multiple old and new bruises . Photograph . <2 years. LFTs. Child abuse: Head injury : ♣ blunt.

 FF ≠ lap.ksu. Annals Emerg Med 2001:  sens 55%.Pediatric Trauma (Not Just Small Adults) Monday.  may replace DPL in unstable pt. spec 83%. too specific . Oct 29 2007 SURG GP. To Get The Slides http://faculty. Aayed Al-Qahtani Ass. 425 Dr. 70-100% specifi ♣ Loiselle.edu. no FF ≠ no sign organ injury .sa/qahtani 19 | P a g e . Emerg Med J 2001: review  30-87% sensitive. Professor & Consultant pediatric surgery Abdominal trauma: FAST : ♣ Murphy. PPV 86% ♣ bottom line:  insensitive. NPV 50%.