PEDIATRIC TRAUMA

By dr. Mohamed kamara

(Registrar Connaught hospital (pediatric surgical department)
 23.05.2020
PEDIATRIC TRAUMA
A LEADING CAUSE
OF DEATH IN
CHILDREN.
Age Classificcation

• Neonate: Birth to 1
month
• Infant: 1-12 months
• Toddler: 1-3 years
• Preschooler: 3-6 years
• School age: 6-12 years
• Adolescent: 12-18 years
 Neonate: Infection, Neglect.

Infant: Infection, Neglect, Abuse

Common Toddler: Poisoning, Fall, Foreign body aspiration

Emmergencie
s By Age Preschooler: Poisoning, Fall, Pedestrian

Schooler Age: Pedestrian, Fall, Recreation

Adolescent: MV, OD/Poison, Homicide, Recreation

 MECHANISM OF INJURY

PENETRATING
BLUNT TRAUMA OTHER
TRAUMA

• Falls • Gunshot • Drownings

• Physical wound
Abuse • Stabbing
• Motor Vehicle • Crush
Accidents
ANATOMICAL
DIFFERENCES Head and Neck
Head and Neck Neck
Chest Occiput
Abdomen
Fontanels & Sutures
Musculoskeletal System
Scalp
Abdomen Chest
Liver
Spleen
Duodenum
Thorax
Bladder Mediastinum
Kidneys Lungs
Musculoskeletal System

Bone properties
Presence of growth plates
Pseudosubluxation of C2 on C3
PHYSICAL EXAMINATION
 Trauma Scores
Glasgow Coma Score
Trauma Score
Pediatric Trauma Score
Injury Severity Scores
GLASGOW COMA
SCORE

•Eye-opening, verbal
And motor responses.
•.3-15 points
• Beware the
“A.V.P.U” system.
CALCULATIN
G THE GCS
 Overall assigment based on
combined physiological findings:

REVISED GCS

TRAUMA
SCORE (RTS) Systolic B/P

Respiratory rate
CALCULATING THE RTS
 Developed to
reflect differences
between adult
and child
physiology

PEDIATRIC Superiority over Deminished

TRAUMA RTS is as yet
unproven.
emphysis on
blood pressure
SCORE
Socres reflect
size, airway
potency and
severity and
multiplicity of
obious wounds.
CALCULATING
THE PTS
 Head Trauma, Chest Trauma, Abdominal Injury, Musculoskeletal Injury, Spinal Cord Injury
Head Trauma
• Mild head injury is a common
cause for Emergency Department
visits
• 43% of all head injuries in
children are related to sports and
recreational activities
• 93% of all head-injured children
are admitted to the hospital
• or injury
Head Injury Scalp Lacerations
• Scalp lacerations • The scalp is highly vascular and
• Skull fractures may result in profuse bleeding
• Concussion when injured
• Contusion • A subgaleal hematoma may be the
• Hematomas only sign of intracranial injury in
an infant. 73% of infants with an
Epidural Hematoma also had a
significant subgaleal hematoma
HEAD TRAUMA

Skull Fractures Linear Skull Fractures Depressed Skull Fracture

• Linear • 75 - 90% of skull • Disruption of the

• Depressed fractures in children integrity of the skull
• Compound • Parietal bone is the • Considered clinically
• Basilar most common site of significant if the bone
skull fractures fragment is depressed
below the inner table
of the skull to a depth
greater than the full
thickness of the skull
Raised ICP - Brain
Herniation

•Uncontrolled increases in ICP push the brain

downward
•The brain can herniate laterally (1) or
downwards (2) through the tentorium cerebri or
through the foramen magnum (3) (numbers refer to
diagram below)
•Herniation of brainstem through the foramen
magnum produces Cushing's Triad -- hypertension,
bradycardia, and irregular respirations
HEAD TRAUMA

Basilar Skull Fracture Concussion Contusion

Brief alteration in This alteration in Result of the brain

May also be Damage to the
consciousness (with consciousness is parenchyma When brain injury
Frequent site Signs & or without Loss of accompanied by a
associated with a
period of vomiting,
becoming bruised or occurs on the side of
opposite side of the
brain from the site of
of fracture Symptoms Consciousness) after flaccid motor state,
pallor, confusion, or
crushed, resulting in impact a coup lesion
impact is a
sustaining a closed followed by hemorrhage and develops
amnesia contrecoup lesion
head injury complete recovery oedema

Ecchymosis behind
CSF Rhinorrhoea Hemotympanum the ear over the Raccoon eyes
mastoid
 Head Trauma
Diffuse Axonal Injury
• Damage to the axons of the
Central Nervous System can
be caused by the shearing
forces associated with Closed
Head Injuries
• DAI may accompany
concussion, contusion &
subdural hematomas
• May lead to temporary
alterations in consciousness,
neurological deficits and in the
most severe cases; coma
Hematomas
• Epidural
• 2% of all serious head injuries
• Arterial in nature, middle
meningeal artery tear
• Associated with Skull
Fractures in 40-85% of cases
• Transient loss of
consciousness followed by a
lucid interval
Hematomas
• Subdural
• 5% of all head trauma patients
• Damage to the subdural veins
“bridging veins”
• Manifest hours after injury
• Underlying brain injury
occurs in 50% of cases
 CHEST TRAUMA

Chest Trauma Chest Trauma Pneumothorax

• Responsible for 10 - 25% of acute • Pneumothorax • Open
deaths • Haemothorax • Closed
• Contributes to up to 50% of other • Flail Chest • Tension
deaths • Traumatic asphyxia
• May have associated abdominal • Cardiac tamponade
trauma • Myocardial contusion
• Blunt injury is the most common • Aortic rupture
cause

Open Pneumothorax
• Etiology: Penetrating trauma
• Pathophysiology
• Loss of chest wall integrity
• Involved lung collapses on
inspiration and expands slightly
on expiration
• Inability to generate negative
pressure
• Treatment: Dressing secured on
three sides only
CHEST TRAUMA
Tension Pneumothorax Tension Pneumothorax
• Etiology • Pathophysiology
• Blunt Trauma • Pleural pressure rises
• Penetrating Trauma • Lung collapses
• Mechanical ventilation • Mediastinum shifts
• Diagnosis • Opposite lung compressed
• Neck veins distended • Vena Cava kinks
• Trachea deviated • Decreased venous return
• Shock • Decreased cardiac output
Haemothorax

• Etiology • Pathophysiology

• Blunt trauma • Laceration to a vessel, bleeding from the lung

• Moderate blood loss • Accumulation of blood in the pleural space
• Bleeding sites usually located on the leads to hypoxia resulting from ventilatory
chest wall or lung parenchyma
compromise
• Penetrating trauma
• Radiograph
• Risk of massive blood loss
• Supine film may miss blood loss approaching
• Bleeding: aorta, systemic, or
30% estimated blood loss
pulmonic vessels, heart
 RIB FRACTURES

Rib Fractures Rib Fractures

• Signs & Symptoms
• Rare in healthy infants and • Tachypnoea with shallow
children breathing
• Etiology • Pain on inspiration,
• 82% caused by abuse in infants coughing, crying, moving.
• 8% accidental (major trauma) • Tenderness, bony, chest wall
• 7% fragile bones deformity, localized pain.
• 3% birth trauma • Crepitus, ecchymosis
• Swelling over fracture site
 CARDIAC TAMPONADE
Cardiac Tamponade Beck’s triad
• Hypotension
• Raised JVP(distended veins)
• Decreased heart sound
• Pulsus paradoxus (>10mmHg fall in
pressure during inspiration)
• Kussmaul sign (raised JVP during
inspiration or failure in the appropriate fall
of the JVP with inspiration
 MYOCARDIAL CONTUSION

• Etiology
• Blunt trauma - sharp direct blow to the sternum
• Presentation
• Chest pain, Sinus tachycardia, ST -wave
changes
• Treatment
• Oxygen, analgesics, cardiac monitoring
 AORTIC RUPTURE

 Penetrating trauma or motor vehicle accident to the aorta  can

cause aortic rupture.

Difficult to diagnose because the

 patient often has multiple traumatic injuries

 with symptoms that may mask the ruptured aorta.

Signs & Symptoms of Ruptured Aorta

• tearing pain in the abdomen, back, flank or groin.

• loses consciousness.
• hypotensive (low blood pressure), hypovolemic shock.
• tachycardia (rapid heart rate).
• Cyanosis bluish discoloration of the skin.
• Disorientation or changes in mental status.
• Flank ecchymosis- a sign of retroperitoneal bleeding.
 Splenic Injury
Liver Injury
Abdominal
injury Mesenteric Injury
Abdominal injury

Splenic Injury
Liver Injury
• Etiology
• Blunt trauma to the upper Etiology: Blunt trauma
abdomen or lower thorax. Classifications
• 50 % related to recreational Contusions
activities Parenchymal lacerations
• Treatment Injuries to the hepatic vein or
• Aimed toward splenic preservation vena cava
• ICU monitoring for 48hours Treatment
• Blood transfusions Non-operative management
• Splenectomy Liver resection
ABDOMINAL INJURY

LAP BELT COMPLEX

Anatomical differences
Mechanism of injury
 Deceleration
 Compression
 Injury pattern
Hip & Abdominal Contusions

Lumbar spine injuries

Intrabdominal injuries
ABDOMINAL INJURY

Bicycle Handlebar Injury

Blunt abdominal injury from hitting

the handle bars after a fall from a bicycle.
It is more typically observed in children
LQ usual point of injury
Spleen, pancreas, bowel and kidney of
injured.
Persistent LQ pain.
 SEAT-BELT SIGN

Tear/ avulsion of mesentery

Rupture of small bowel or colon
Rib fracture
 CULLEN SIGN
Bluish discoloration around
umbilicus Diffusion of blood
along periumbilical tissues or
falciform ligament
Hemoperitoneum
Severe pancreatitis
 KEHR’S SIGN
•Referred Pain, Left Shoulder
Irritation Of The Diaphragm
(Splenic Injury, Free Air, Intra-
abdominal Bleeding)
 BALANCE’S SIGN

Dullness on percussion of the left

upper quadrant ruptured spleen
GREY-TURNER’S
SIGN

Bluish discoloration of the flanks

Retroperitoneal Hematoma
haemorrhagic pancreatitis.
 LABIA AND SCROTUM

Pooling Of Blood From Abdominal And Pelvic Cavities.

 ABDOMINAL INJURY

Musculoskeletal Injury
Spinal Cord Injuries
SCIWORA
Extremity trauma Spinal
Cord
Fractures
Injury
Subluxations &
Without

Dislocations Radiographic

Amputations Abnormalities
Cervical Spine Injury Risks

• Children are prone to non-

bony cervical spine injuries
("SCIWORA" = spinal cord
injury w/o radiograph
abnormality)
 SCIWORA

SPINAL CORD INJURY WIT DUE TO STRETCHING OF ACCOUNTS FOR UP TO 70% MOST COMMON IN SYMPTOMS MAY BE
H OUT RADIOGRAPHIC AB ELASTIC LIGAMENTS & OF SPINAL CORD INJURIES CHILDREN < 8 YEARS OF IMMEDIATE OR DELAYED
NORMALITY STRETCHING OF CORD IN CHILDREN AGE FOR 4-5 DAYS

CHANGES CAN BE SEEN STEROID THERAPY IS COMPLETE RECOVERY IS

ON MRI BUT NOT ON COMMONLY USED LIKELY (UNLESS CORD IS
PLAIN FILMS TRANSECTED
Spinal Cord Injury
Pseudosubluxation
PRIMARY SURVEY

AIRWAY BREATHING CIRCULATION

 Primary Survey
Airway Management Circulation

Hypovolemic
 clues

100%
 oxygen Vital
 signs & blood pressure guidelines vary with age

Tachycardia
 can be caused by multiple factors
Suctioning

Fixed stroke volume so compensate for hypovolemia by


Jaw
 thrust or chin lift increasing heart rate

Efficient
 compensation makes recognition of shock difficult –
Oral
 airway
assess perfusion
Oro-tracheal
 intubation Hemorrhage
 control

Cricothyroidotomy
 vs. Intravenous
 access

Fluid
 resuscitation
Tracheostomy
Maintain
 CPP > 40 mm Hg
Primary Survey
Aetiologies of Shock
Circulation
Hemorrhage control Hypovolemic Fluid Loss
Intravenous access Distributive Neurogenic
Fluid Loss
Neurogenic
Fluid resuscitation Cardiogenic Pump Failure
Pump Failure
Tamponade

Maintain CPP > 40 mm Hg Obstructive Tamponade

 AVPU evaluation system
Responds to
Responds to
Alert verbal Unresponsive
pain
commands

Disability

Control of Intracranial Pressure

3 % Normal Saline
Secondary Survey

Secondary Survey Monitoring

• Vital signs, CPP > 40 mmHg

• Head to toe evaluation • ECG
• Fingers and tubes in every orifice • Pulse oximeter
• Review history • End Tidal CO2 monitor
• Assess and assign trauma scores • Urine Output
• Laboratory analysis • Arterial blood gas
• Radiographic studies • Frequent re-examination
 Focused History - AMPLE

• Brief Medical History using the mnemonic AMPLE

• Allergies
• Medication use (prescription, alcohol, street drugs)
• Past medical history
• Last meal (time and type of food)
• Events leading to the current medical condition
RECOGNIZING CHILD
ABUSE

•Injury severity/location inconsistent

with history
•Skin injuries
•Human bite marks
•Burns
•Hair loss
•Head, facial, oral injuries
•Sexual abuse
•Shaken Baby Syndrome
 Small body size
Anatomic • multiple injuries from a single impact
• small blood volume → hypovolemic
Risk shock can result from relatively small
blood loss
Factors in Large surface area
Children • hypothermia develops rapidly

Cartilaginous skeleton
• visceral / brain injuries common in the
absence of bony injuries
SUBMERSION
INJURIES
 Submersion injury is also
known as the “SILENT
EVENT”. It is the second
leading cause of accidental in
SUBMERSION children.
INJURIES
500 000 deaths due to
drowning per year.
 >50% drowning victims <5yrs

Fatality is highest in children<5yrs

SUBMERSION
INJURIES
M>F

Most common of cardiac arest in children.

 <1 yr: bathtups(55%)

Most common sites of 1-4 yrs: pools, wells

drowning (56%)

>4yrs:
freshwater(63%)
 Drowning = death within
24hrs of suffocation from
submersion in liquid.
Drowning vs
Near drowning Near
drowning/submersion
injury = survival> 24hrs
past event.
INSTRUMENTAL
DIAGNOSESE
 ABDOMINAL IMAGING IN PEDIATRIC TRAUMA

• FAST is very specific but poor sensitivity for abdominal injuries in

children
• FAST (+), pt stable ->  CT
• FAST (+), pt unstable ->
• Decompensated shock -> direct to surgery
• Active bleeding necessitating ongoing blood transfusion -> surgery
• Resuscitation leading to stable hemodynamic – > CT
• FAST (-), high clinical suspicion of injury or elevated liver enzymes -> CT
• FAST (-), low clinical suspicion – > serial physical exams and FASTs
Indications for CT abdomen
depend on whether the patient is
considered high risk or low risk for
significant injury
HIGH RISK – Indications for CT
• History that suggests severe intraabdominal injury
• Concerning physical – tenderness, peritoneal signs, seatbelt
sign or other bruising
• AST >200 or ALT >125
• Signs of basilar skull fracture
• Decreasing Hb or Hct
• Gross haematuria
• Positive FAST
LOW RISK – Clearing the abdomen without CT (PECARN RULE – 99.9% NPV)

• No evidence of abdominal wall or thoracic

wall trauma
• GCS>13
• No abdominal pain or tenderness
• Normal breath sounds
• No history of vomiting
Which pediatric trauma patients do not require a pelvic x-ray?

Pelvic x-ray can be forgone if the following criteria are

fulfilled:
• Hemodynamically stable
• Normal GCS
• No evidence of abdominal injury
• Normal pelvic exam
• No femur fractures
• No haematuria
TREATMENT
PEDIATRIC
TRAUMATIC
BRAIN INJURY
MANAGEMENT
Severe TBI is defined as GCS score of 3-8
after cardiopulmonary resuscitation
 Give Sedation
Lower intra- Incre. Cerebral
and
cranial Perfusion
neuromuscular
hypertension Pressure (CPP)
blockade
TREATMENT
ALGORITHM CSF drainage
Hyperosmolar
therapy Hyperventilation
OF BRAIN
Decompressive
Barbiturates Hypothermia
craniectomy

Anti-seizure
Corticosteroids
prophylaxis
Lower Intra-Cranial IV administration of Mannitol
Hypertension/Pressure hyperosmolar agents Enteral Urea Administration
Glycerol
shown to reduce ICP
 >Viscosity
autoregulation
of Cerebral
Blood Flow
(CBF)
>Osmotic effect

Mechanisms • Acute Tubular Necrosis (ATN)

with serum osm >320
of action for Limitations of
Mannitol • Injured Bundle Branch Block

Mannitol (BBB) – reverse osmotic shift

• Osmolar effect Level of 360

Hypertonic
mOsm/L tolerated Central
Saline
pontine myelinolysis
 Main objective of
decompressive craniectomy
is to control ICP, maintain
CPP and cerebral
oxygenation, as well as
prevent herniation. Is
decompressive craniectomy
successful in controlling
ICP?
Decompressive
craniectomy
a re dec Do
t s te e
a t
n
ie pria or cra ompr s
p pro es f e im nie ess
ap idat essiv pro ct ive
a n d pr y ? out ve c omy
c om t om com lini
dec aniec es? cal
cr
 Corticosteroids Reduce cerebral oedema
have been
commonly used Attenuation of free radical
in children for production
a wide range of
neurologic Complications:
disorders

Infections
Note!!! Use of steroids is not
recommended for improving
outcome or reducing ICP in
traumatic brain injury Gastrointestinal bleeding
Treatment Algorithm Summar
External ventricular drain (EVD)
PEDIATRIC
TRAUMATIC
THORACIC INJURY
MANAGEMENT

Chest trauma
 X-rays, CT-Scan reveils….

Rib fracture

Pilmonary contusion
AFTER
SECONDARY pneumothrax
SURVEY… Haemothrax

Blunt aortic injury

Blunt myocardial injury

RIB
FRACTURE
MANAGEME
NT
 Pain relief ( Analgesics e.g. PCT, Ibuprofen,
etc..

Bed-rest

Treatment
Restrictive bandaging is not useful

Cough and deep breathing with splint

pillow
 PEDIATRIC
TRAUMATIC
THORACIC
INJURY
MANAGEMENT
Pneumothorax, haemothorax,
Tension Pneumothorax.
 Immediate chest
decompression
Lateral thoracostomy
( Thoracocenthesis at 2nd
intercostal space)
Pneumothorax/Tension
Pneumothorax,
Haemothorax

Bilateral drains for

Insert chest drain
bilateral tension

Open procedure; blunt Complication:

disection at 5th Haematoma, thoracic and
intercostal space 1 cm abdominal visceral injury,
anterior to mid-axillary infection, intecostal
line. neurovascular injury
Thoracostomy
Needle Chest Decompression
Chest Injury
Needle Chest Decompression

Chest Injury
Cardiac Tamponade
• Pericardiocentesis
• Procedure: Position the patient
in reverse Trendelenburg.
Attach a needle to ECG lead
and insert needle at a 45 degree
angle one centimetre to the left
of the xiphiod process.
Management
• Augment venous return(Raise pt
leg if possible)
• Rapid IV infusion (RL, DNS)
• Surgical evacuation of clot/repair
of cardiac laceration (via medial
sternotomy)
• Pericardiocentesis should only be
considered if expertise not
available and patient is dying.
Pediatric Intubation Considerations
Equipment And BP Measurement ( 2 Years Old)

• ET tube size mm I.D. (Age in years x 4) / 4

• ET tube depth (Age in years x 2) /12
• BP Estimates ( 1 year)
• Median BP 90 mm Hg (2 x age years)
• Lower Limit BP 70 mm Hg (2 x age yrs)
Which one of the following statements regarding pediatric
patients is TRUE?

A. Brain injuries are always accompanied by skull

fractures
B. Hypothermia develops rapidly due to their large
surface area
C. Small body size shields them from injuries
D. Lung injuries are unlikely if there are no fractured
ribs
Which one of the following statements is TRUE about SCIWORA (Spinal
Cord Injury With Out Radiographic Abnormality)?

A. MRI is useful in diagnosis

B. Neurological deficits always occur immediately
following injury
C. It is more common in adults than in children
D. Prognosis is very bad for patients with SCIWORA
Child abuse should be suspected in all the following settings
EXCEPT:

A. Injuries that are inconsistent with the history

B. Injuries consistent with sexual abuse
C. Bicycle injuries in unhelmeted children
D. Human bite marks
Questions?????

Thank you for your

attention!!!