Paediatric Trauma

Traumatology, Block 17

Extent of the Problem

• Injury is the leading cause of death for children older than 4 years

• Leading cause of injury death of children < 1 year are burns, older children die due to road traffic accidents

National Injury Mortality Surveillance System

Specific problems in Paediatric Trauma

• Small body size: Multitrauma

• Less protective musculature; soft rip cage: Internal organs are more susceptible to injury

• Kidney is less protected and more mobile

• Relatively large head, less myelinated brain and thinner cranial bones: more severe head injuries

Initial Assessment

• Identify and treat any life-threatening problems (ABCD)

• Identify any other problems, formulate a plan of action for these problems (secondary survey)

• Document the clinical features: Serves as a medico-legal record and as a baseline for further monitoring

Initial Assessment

• First check: Are there signs of life?

• Second check: Any life-threatening injuries? If yes: Provide immediate intervention – Standard approach based on assessment of the A(irway), B(reathing), C(irculation) and D(isability)

Airway - Anatomical issues

• Big tongue

• Narrow trachea

• Short trachea narrowest at cricoid ring

• Anterior larynx

• Big occiput

Airway (and cervical spine) management

• Always neck stabilization and protection in multi-trauma patient

• Indications for Intubation:– Depressed level of consciousness– Injury of the face, mouth, oropharynx, nasopharynx– Injury to larynx, trachea, major bronchi– Inhalation of foreign body into larynx or proximal

trachea– Inhalational burns

• Noisy breathing: Start on high flow oxygen and review breathing

Airway Management (ctd)

• Secretions present in the airway: Suction clear under direct vision and assess response

• Unconscious and not maintaining airway: Jaw thrust, consider Guedel oral airway, Intubation if airway must be maintained for transport

• Evidence of facial burns and noisy breathing: Urgent intubation

Airway Management (ctd)

• Facial trauma: Assess need for Guedel airway or endotracheal intubation

• Airway obstructed– If moving air provide high flow oxygen and

arrange laryngoscopy or bronchoscopy– If not moving air: Chest compression to

dislodge foreign body– Intubate

Jaw thrust

Chin lift

Guedel airway

Airway management: Indications for endotracheal intubation

• Inability to ventilate by bag-valve-mask methods or the need for prolonged control of the airway

• GCS of < 8

• Respiratory failure (flail chest, pulmonary contusions)

• Any patient in shock resistant to initial fluid resuscitation

Breathing - paediatric specifics

• Signs of distress: Indrawings

nasal flaring, use of accessory muscles

• Diaphragm is the primary respiratory muscle

• Easily fatigued

• Aerophagia: Big stomach displaces diaphragm → Nasogastric tube

• Thoracic structures mobile → shift

Breathing - Assessment

• Assess the effort of breathing: – Increased respiratory rate (normal RR: Infant 30 –

60, pre-school 20 – 30, older child 20), recession, nasal flaring, use of accessory muscles. Unconscious patient might show inappropriately low effort.

• Efficacy of breathing: – Chest movement, breathing sounds, saturation in

air and in oxygen. In a hypothermic or shocked patient the saturation reading might not be obtainable.

Breathing - Treatment• Normal breathing, normal voice

– Move to review of circulation

• Inadequate respiratory effort– Assist breathing: Bag mask ventilation, Guedel airway,

endotracheal tube ventilation

• Increased respiratory effort– High flow oxygen– Assess breath sounds, exclude chest pathology– Drain pneumothorax, drain haematothorax (have fluid

ready for resuscitation before doing that)

• Large bore gastric tube in any child with trauma and respiratory distress

Circulation - Specifics in Kids• Children compensate blood loss by increasing

the pulse-rate, children can not increase the stroke-volume like adults

• If blood loss is >25% of blood volume then BP starts dropping: First sign of decompensation.– Acceptable BP syst: 60: infant, 70: preschool, 80:

older child • Signs of shock:

– Tachycardia (HR: Infant > 175, pre-school  >140, older Child >120)

– Mottled and cool skin– Bradycardia is a preterminal sign – Altered consciousness, capillary refill > 2 sec– Decreased urinary output (normal 1 – 2 ml/kg/hour)

Assessment of the Circulation• May be difficult in the presence of pain

(tachycardia) and hypothermia (poor capillary refill)

• Cardiovascular signs: Heart rate and blood pressure

• Capillary refill time• Signs of cardiovascular insufficiency:

Depressed level of consciousness, pallor• Ongoing bleeding: Might be obvious or hidden

Circulation - Treatment

• Stop obvious bleeding • Short wide bore peripheral venous line or

central line. If unsuccessful: Intraosseous line (in children 6 yrs and younger) or cut- down

• Fluids: Ringer’s lactate in 10ml/kg boluses up to 4x, then 10 - 20cc/kg packed RBC

• If the child needs more than 20ml/kg: consult surgeon while continuing resuscitation as above

Disability• Treat (primary) damage to the brain and

spinal cord which occurred at the time of trauma: Neurosurgical advice

• Prevention and treatment of ongoing (secondary) damage to the CNS as a result of hypoxia, shock, increased intracranial pressure: – Priorities: Protect airway, high flow oxygen,

shock must be treated

Disability ctd.

• Check level of consciousness: A (awake and alert), V(responds to verbal stimuli), P (responds to painful stimuli), U (unresponsive)

• Check the pupills for size and response to light• Observe for posturing• Get neurological advice if child is unresponsive

or has focal signs• Bloodglucose if level of consciousness is less

than A on the AVPU score. Treat Blood glucose if less than 3mmol/L

Secondary survey

• This is the full examination which takes place after the initial ABCD

• Examination from head to foot, back and front

• If the child is taken to theatre before the secondary survey has been completed, this must be documented so that it can be completed later

Chest Trauma

• 2nd leading cause of paediatric trauma death

• Chest trauma is rarely isolated: Ruptured organs, broken bones in up to 70%. Reasons:– Severe blunt injury (MVA) very common– Immature and pliable ribcage with limited

protection of underlying organs

• Mortality in chest trauma is related to (1) age and (2) number of major systems involved

Chest trauma: Initial assessment

• Immediate supine AP CXR may be life- saving in the detection of tension PT and major haemothorax.

• Sonar useful in the detection of haemothorax and pericardial effusion

• Again: Rule out gastric distension

Chest trauma: Chest wall

• Compliant chest wall → rib fractures uncommon. Significant internal injuries possible without external signs. If fracture is present it means severe injury.

• pulmonary contusion common: Might need intubation and ventilation. O2 percuta-neous saturation monitoring: Hypoxaemia is indicative of severe lung injury.

Abdominal Trauma

• 3rd leading cause of trauma death

• Fatal injury often occult

• Blunt injury much more common than penetrating injury: Pedestrian accident, MVA, sports, assault

Abdominal Trauma: Anatomical issues

• Larger solid organs, less musculature,

compact torso, elastic ribcage

– risk ↑ internal injury

– mostly solid organ injury

– Frequency of injury: Liver > spleen >kidney > pancreas > intestine

• Bladder is intra-abdominal

Abdominal Trauma: Assessment

Most abdominal injuries in children can be managed without an operation: The examination must answer the question if the child requires an operation or not.

• Look for signs of shock

• If shocked: Resuscitate as above, transfer to OP if no response to resuscitation

Abdominal Trauma: Assessment

• Look for external injury marks: Abrasions, seat belt restraint marks, penetrating injuries

• If abdominal gaseous distention: nasogastric tube: Makes examination more meaningful and improves ventilation

• Pelvic ring: examine for stability

• Examine Urine for blood – U-tract injury

Abdomen: Special investigations

• Plain chest and abdominal Xrays: In all patients with suspected abdo injury: Ruptured diaphragm, presence of haemoperitoneum, intra- or retroperitoneal air

• Sonar: Screening for parenchymal injury or fluid

• CT with iv and intraluminal bowel contrast is the gold standard. Contraindicated in the unstable patient

Abdominal Trauma: Management

Spleen and liver: 90% can be treated conservatively if following criteria are met:

• Observation: High care unit must be available: Serial pulse, BP, Hct. Abdomen must be soft (no signs of peritonitis = bowel perf). Surgeon available anytime.

• After initial resus the patient must remain stable. Call the surgeon if after resus patient becomes unstable again

Bottom Lines

• Children are not small adults

• Multisystem injury is the RULE

• Occult injuries are common