Pediatric Trauma

Jessica Mills, MD, FRCSCAssistant Professor Surgery, Pediatric

Surgeon

Objectives

Epidemiology of Pediatric Trauma

Pediatric Injury Patterns

Imaging in Pediatric Trauma

Pediatric ABCDE’s and Pitfalls Clinical Decision Rules to guide Imaging choices

Pediatric Pain Assessment tools

Triage of Pediatric Trauma in NY State STAC 2014 Guidelines

The Scope of the Problem

Trauma most common cause of death > 1 yr

Causes almost half of deaths < 15 yrs 38% MVC 13% Homicide 13% Drowning 9% Fire/Burn 5% Suicide

In-hospital mortality low

20 children die every day

Burden of disability incalculable1/2 have social, affective and learning

disabilities2/3 siblings have emotional disturbancesFinancial/Employment troubles for parentsMarital strain

The Scope of the Problem

Why so Vulnerable?

Children put themselves at riskHigh curiosity + Low Judgement = Injury

Falls most common mechanism in younger children

Violence most common in older teens

Higher risk of significant injury

Why so Vulnerable?

Goal = Prevention

Reality = Minimizing morbidity and mortality

What can we do?

Pediatric Injury Patterns

Multitrauma is the Rule

Multitrauma is the Rule

Multitrauma is the Rule

Very difficult in conscious younger children

Invest time in starting slowlyChildren can smell fear!Develop rapportSoothe and cajole

Use parent as your allyControl personal emotions

Examine the Patient?

Scan the Patient?

CT Scan considered gold standard

Worry about missed injuries ? Increase in morbidity/mortality ? Legal concern

Increasing awareness of radiation risks Younger patient = More vulnerable

Bottleneck Resource Triage CT Scans in disaster scenario

Risk of Malignancy

Lifetime cancer mortality risks attributable to the radiation exposure from a CT in a 1-year-old are 0.18% (abdominal) and 0.07% (head)-

600,000 pediatric CT head/abdomen per year Estimate 500 deaths from cancer due to CT

radiation

Brenner D et al. Estimated risks of radiation-induced fatal cancer from pediatric CT. Am J Roentgeno. 2001;176(2):289-96.

Risk of Malignancy

Estimated effect of Pediatric CT radiation 50 mGy ?= 3 x risk of leukaemia 60 mGy ?= 3 x risk of brain cancer

Cumulative absolute risks are small In 10 yrs following radiation exposure under

10 yrs of age 1 leukemia/10,000 1 brain tumor/10,000 head CT

Pearce MS et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012 4;380(9840):499-505

So What?

If you are going to scan, make it the best scan possible Make sure IV contrast, PO contrast if

necessary Don’t turn down the radiation too much

Don’t decrease the radiation of the scan

Decrease the number of scans Use Clinical Decision Rules

Mild head injury Low/moderate suspicion abdominal injury

ABCDE’s of Pediatric Trauma

AAirway

Big tongue, Big occiputMost common cause of airway obstructionPositioning, oral airway

Much larger adenoidsDifficult viewBleeding with nasopharyngeal airway

attemptsAirway narrows with depth, sits anterior

Difficult view and intubationSensitive gag

Oral airway only if unconscious

Airway Pitfalls

Only if unconsciousCan help hold tongue forwardDO NOT place backward and flip in

oropharynxPlace directly under vision

tongue blade helpful

Oral Airway

PreOxygenateProtect the c-spineCorrect tube size + one up & one down

Cuffed tubes improve ventilationAvoid high cuff pressure

Confirm tracheal placementIf not sure: remove the tube and try

againRecheck with every move

Orotracheal Intubation

BBreathing

#2 cause of pediatric trauma deathNo obvious fracture = Coast is clear

Ribs flexiblePulmonary contusion without fracture

Fracture = Large amount of forceLook for the other injuries

Need high index of suspicionMechanism of injuryExternal signs of injury

Is there a chest injury?

Pitfalls

Overventilation> 1 year : 20 breaths per minute< 1 year: 30 breaths per minute

Breathe, Rest, Rest

Power of the CXR

CXR will find common injuriesRib fracturesPulmonary contusionsPneumothoraces

CXR will miss rare but deadly injuriesHeart and great vesselsTracheobronchial tree and esophagusDiaphragm

CT Chest

Efficient

Sensitive

BUT Radiation Risk ? Need for Anesthesia

Clinical Decision Rules

Type of Injury No.Frequency Among Patients With Thoracic Injuries (n=80), % (95% CI)

Frequency Among Total Population (n=986), % (95% CI)

Pulmonary contusion 57 71 (60-81) 5.8 (4.4-7.4)

Rib fracture 28 35 (25-46) 2.8 (1.9-4.1)

Isolated rib fracture 9 11 (5-20) 0.9 (0.4-1.7)

Pneumothorax 20 25 (16-36) 2.0 (1.2-3.1)

Hemothorax 9 11 (5-20) 0.9 (0.4-1.7)

Hemopneumothorax 5 6 (2-14) 0.5 (0.2-1.2)

Pneumomediastinum* 6 8 (3-16) 0.6 (0.2-1.3)

Cardiac 5 6 (2-14) 0.5 (0.2-1.3)

Aortic 2 3 (0-9) 0.2 (0.0-0.7)

Diaphragmatic injury 1 1 (0-7) 0.1 (0.0-0.6)

Sternal fracture 1 1 (0-7) 0.1 (0.0-0.6)

*Includes 2 patients with tracheal lacerations.

Holmes JF et al. A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma. Ann Emerg Med 2002; 39:492–499

Chest Trauma Decision Rule

Prospective study, n= 968

Predictors of thoracic injury Low systolic BP Elevated age-adjusted respiratory rate Abnormal thoracic exam Abnormal auscultation of lung fields Femur # GCS < 15

Decision Rule Performance

Identified 78 /80 patients with injury Sensitivity 98% Specificity 37% PPV 12% NPV 99%

2 missed injuries found on Abdominal CT Both observed No morbidity from missed diagnosis

CCirculation

Is there bleeding?

Vital signs can mislead

Tachycardia

Hypotension

30% Blood Loss

Blood Pressure

So How Will I know?

Subtle physical findings Skin mottling Cool extremities compared to the trunk Thready/weakening peripheral pulses Prolonged capillary refill > 2 seconds Decreased sensorium * dulled pain response

How Much Do I Give?

Weight based dosing Crystalloid Blood Drugs

Ask parent 2.2 pounds per kilogram

Broselow tape

Formula Weight (kg) = (2 x age) + 10

What and How Much?

Crystalloid 20 cc/kg WARMED saline/ LR Repeat x 1 Repeat x 2 think about blood

PRBC 10 cc/kg O negative WARMED PRBC

Have I Given Enough?

Improving tachycardia

Better peripheral pulses

Improved skin color and warmth

More active and responsive

Venous Access

Peripheral IV : 2 attempt max Antecubital fossa Saphenous veins at ankle

Intraosseous Anteromedial Tibia Distal Femur

? Intra-abdominal Injury

Physical Exam findings

Laboratory Evaluation

FAST

Clinical Decision Rules

CT Scan

Physical Exam

Sensitivity of Abdominal Pain and Tenderness

Strongly dependent on GCS GCS 15: Sensitivity 79% GCS 14: Sensitivity 50’s GCS 13: Sensitivity 30’s

Isolated abdominal pain/tenderness Rate of injury = 8% Rate of intervention = 1%

Adelgais KM et al. Accuracy of the abdominal examination for identifying children with blunt intra-abdominal injuries. J Pediatr. 2014 Dec;165(6).

Seat Belt Sign

Seat Belt Sign Worry about compression of organs against

vertebrae Injured organs related to location

How predictive of IAI?Sensitivity 25% Specificity 85%

Can we ignore it? Higher rate of IAI : hollow viscus, mesentery Only sign in 5% conscious asymptomatic

patients

Laboratory Evaluation

Transaminases Varying cutoffs Most useful in a clinical decision rule

Possible screening tool in suspected NAI Child with no abdominal bruising, tenderness,

or distention AST or ALT >80 IU/l Sensitivity = 77% Specificity = 82%

FAST

Focused sonography right upper quadrant left upper quadrant pelvis pericardial windows

Look for free peritoneal fluid Blood (bile, urine)

FAST

Prospective study, clinically important free fluid Sensitivity poor : 50% Specificity good: 96%

Positive scan suggests hemoperitoneum CT Scan or OR

Negative scan cannot rule out hemoperitoneum Need further imaging……..Fox JC et al. Test characteristics of focused assessment of sonography for

trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med 2011; 18:477–482.

FAST plus Labs

FAST plus elevated Transaminases AST/ALT > 100 IU/L

Sensitivity : 88%

Consider observation in patients with normal FAST and “normal” Transaminases

Sola JE et al. Pediatric FAST and elevated liver transaminases: an effective screening tool in blunt abdominal trauma. J Surg Res 2009; 157:103–107

Abdominal CT Scan

Good for solid organ injury Guide non-operative care

Not as good for hollow viscus peritoneal fluid without solid organ injury bowel wall enhancement and thickening extraluminal gas bowel wall discontinuity mesenteric stranding

Isolated free fluid serial exams

Identifying IAI

12,000 patients 46% had CT Scans 6.3% IAI 75% of patients with

IAI had Intraperitoneal fluid

Spleen (39%) Liver (37%) Kidney (19%) Gastrointestinal tract (15%) Adrenal gland (12%) Pancreas (7%) Intra-abdominal vascular

structure (2%) Urinary bladder (2%) Ureter (0.5%) Gallbladder (0.5%) Traumatic fascial defect

(0.5%).

Holmes JF et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med. 2013 Aug;62(2):107-116

Prediction Rule

Evidence of abdominal wall trauma or seat belt sign

GCS score less than 14

Abdominal tenderness

Evidence of thoracic wall trauma

Complaints of abdominal pain

Decreased breath sounds

Vomiting

Prediction Rule Performance

Sensitivity = 97%

Specificity = 42.5%

Use to reassure in low risk patients

NOT meant to indicate need for scan

DDisability

#1 organ system injury death

Large head to body ratioBrain less myelinatedSkull bones thinnerBrain more susceptible to secondary

injury• Main risk = hypovolemia

Always Worry about the Head

CDR for Mild Head Injury

CHASE vs CHALICE vs PECARN

PECARN only one with 100% sensitivity 2 age groups Only GCS 14 or 15: lower risk of TBI GCS </= 13 : 20% injury risk : CT scan

PECARN < 2 years old

GCS=14 Other signs of altered mental status Palpable skull fracture

Scalp hematoma-Occip/parietal/tempHistory of LOC ≥5 secSevere mechanism of injury Not acting normally per parent

CT Recommended

Observation versus CT• Physician experience• Multiple versus isolated findings• Worsening symptoms or signs after ED observation • Age <3 months• Parental preference

YES

YES

NO

NO

No CT Recommended

PECARN >/= 2 years old

GCS=14 Other signs of altered mental status Signs of basilar skull fracture

History of LOCHistory of vomitingSevere mechanism of injurySevere headache

CT Recommended

Observation versus CT• Physician experience• Multiple versus isolated findings• Worsening symptoms or signs after ED observation• Parental preference

YES

YES

NO

NO

No CT Recommended

Think C-spine

Pediatric spine injuries: C-spine

Pseudosubluxation

Physiologic misalignment occurring in normal children Disappears with age

40% < 7 yrs 20% < 16 yrs

Usually at C2-C3

Check spinous process line

SCIWORA

Usually C-spine injury 5 to 35% of spinal cord injuries

No signs of bony/ligamentous injury on plain film/CT 2/3 have MRI abnormality

Suspect if: Blunt trauma Early/transient defecits Neurologic findings on initial assessment

EExposure

Undress but Cover

Need to fully expose

Cover ASAP High BSA to Body Mass Cool very quickly Warm everything

Blankets Fluids Consider Bair Hugger

Pediatric Pain

Morbidity of Pain

Trauma #1 cause of acute pain in children

Effects wildly variable Anxiety Crying Regression Aggression

Not related to injury severity

Inadequate treatment longterm effects

Barriers to Pediatric Analgesia

Difficulty in rating pediatric pain

Variable provider training

Limited choice of agent/route

Assessing Pediatric Pain

Vital signs unreliable

Patient self report Teenagers can use 1-10 Pain Scale Younger children need different approach

Parent report Correlates well with child self report Good surrogate measure

Brieri Faces Pain Scale

Wong and Baker Pain Scale

Pediatric Pain Treatment

Pharmacologic Fentanyl 1 to 3 μ/kg ? Intranasal fentanyl

Non pharmacologic Splinting # Diversion and distraction

Triage of Pediatric Trauma

CDC Triage Guidelines

#1Vital Signs

Level of Consciousne

ss

#2Anatomy of

Injury

#3 Mechanism

of Injury

#4Special

Circumstances

Vitals and LOC

Glasgow Coma Scale </= 13

Systolic Blood Pressure <90mmHg

Respiratory Rate <10 or >29

or <20 in infant aged <1 year

or need for ventilatory support

Anatomy of Injury

All penetrating injuries to head, neck, torso, and extremities proximal to elbow or knee

Chest wall instability or deformity (e.g. flail chest)

Two or more proximal long-bone fractures

Crushed, degloved, mangled, or pulseless extremity

Amputation proximal to wrist or ankle

Pelvic fractures

Open or depressed skull fracture

Paralysis

Mechanism of Injury

Fall >10 feet or 2 – 3 x height of the child

High-risk auto crash Intrusion >12 inches occupant site; >18 inches any site

Ejection (partial or complete)

Death in same passenger compartment

Vehicle telemetry data indicates high risk of injury

Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact

Motorcycle crash > 20 mph

Special Circumstances

Older Adults

Children Triage preferentially to pediatric capable

trauma centers

Anticoagulants and bleeding disorders

Burns

Pregnancy >20 weeks

EMS provider judgment

NY StateSTAC Guidelines for Pediatric Trauma Patients

November 2014

Prehospital

Pediatric TraumaMeets CDC guidelines

Transport time </= 60 minutes

Level I or II Pediatric Trauma Center

Adult Trauma / Non Trauma Hospital

If CDC triage criteria still met

Level I or II Pediatric Trauma Center

Adult Trauma / Non Trauma Hospital

Transfer Early Decision to Transfer

Once the primary survey and resuscitation phases are initiated usually within 30 minutes of arrival

Initiation of Transfer Should be made immediately upon recognition of meeting

criteria for transfer usually within 15 minutes following initiation of the primary

survey

Transfer Should occur as soon as possible thereafter

ideally within 1 hour of arrival definitely within 2 hours of arrival.

Summary

Pediatric Trauma significant problem

Beware of Multitrauma and Pitfalls

Triage your CT Scans Consider Clinical Decision Rules

Optimize pediatric analgesia

Severely injured kids should go to Level I/II Pediatric Trauma Center