Pediatric Injuries Gassem Gohal FAAP FRCPC

Learning Objectives o  Understand Major pediatric anatomical issues

o  understand and describe the utility and benefit of the primary and secondary surveys

o  Gain exposure to general categories of pediatric

trauma

Epidemiology

o 25% of traumatic injuries occur in children

o Trauma is the leading cause of death after infancy (age 1-14y)

Epidemiology o Most common causes of injury-related

deaths: n  Traumatic brain injury n  Motor vehicle crashes n  Submersion injury n  Homicide n  Suicide n  Fires

Epidemiology o  Data from 2002 shows > 700 000 injury-related deaths

world-wide occur in the <15 year old age group o  Teens are at increased risk due to:

n  Increased exposure to hazards n  Risk-taking behaviors

o  Infants: n  Are at higher risk of inflicted trauma

PRIMARY AND SECONDARY SURVEYS

Primary & Secondary Survey o  Primary survey:

n  Quick, initial patient assessment to identify life-threatening injuries

n  Occurs with active resuscitation

o  Secondary survey: n  More detailed assessment of injuries

Primary Survey

o A,B,C,D,E o  C-spine immobilized

n Collar for school-age/adolescents n Rolls and tape for infants/toddlers

o  Immediate vitals signs

A,B,C,D,Es

o  A = Airway & C-Spine Precausions o  B = Breathing o C = Circulation o D = Disability o  E = Exposure

A: Airway & C-Spine Protection

o Check for airway patency and clear secretions such as: n  Blood, foreign bodies, loose teeth

o Assess need for intubation n  If there are facial burns or signs of inhalation

injury – INTUBATE EARLY!

o Ensure adequate C-spine protection

C-Spine Injuries o  Overall rare

n  Associated with 1.2% of pediatric trauma

o  After 8y, spine anatomically similar to adult o  Children <14y = injury C1-C4 more common

B: Breathing o  Check for adequacy of breathing

n  Effort, breath sounds, oxygenation o  Apply oxygen by facemask o  Consider need for intubation o  If already intubated confirm ETT position with:

n  Chest x-ray if available n  End tidal CO2 n  Oxygen saturation if available n  Auscultate the lungs for equal air entry

C: Circulation o  Most common cause of shock in pediatrics =

hypovolemia o  TBV of child = 80ml/kg o  2 large bore IV’s started

o  20 ml/kg IV crystalloid bolus (x 3 then PRBC’s)

o  Look for obvious and non-obvious sources of bleeding

D: Disability

o Pupils reactive? Equal? o GCS (modified) or Verbal Score o Spontaneously moving? o Obvious deformities?

Pediatric Verbal Score

Verbal Response V-Score

Appropriate words/coos Smiles, fixes/follows

5

Cries but consoles 4

Persistently irritable 3

Restless, agitated 2

None 1

From American College of Surgeons’ Committee on Trauma. Advanced Trauma Life Support for Doctors (ATLS) Student Manual . 7th ed. Chicago: American College of Surgeons; 2004.

Glasgow Coma Scale (GCS) Eye Opening Spontaneous 4 To voice 3 To pain 2 None 1 Verbal Response (Peds) Appropriate 5 Cries, consoles 4 Persistently irritable 3 Restless, agitated 2 None 1

Motor Response Obeys Commands 6 Localizes pain 5 Withdraws to pain 4 Flexion with pain 3 Extension to pain 2 None 1

Question o What is GCS for an Injured child who has

no verbal response, open his eye only to pain, flex his arm to pain ?

o Why we use GCS?

E: Exposure o  Assess all surface areas o  Log-roll with using spinal precautions

n Examine the spine: note step deformities or pain

n Assess rectal tone and sensation n Check for vaginal/urethral bleeding

o  Prevent hypothermia n Keep trauma room warm, use blankets and

overhead warmer for infants

log-roll , using spinal precuation

History

o Ask about the Mechanism of injury: n Speed, distance thrown, fall from

height, landing surface, accident? o What protective devices used?

n Seatbelts, carseats, helmets o What were the initial findings ,vitals

Primary Survey Goals

IDENTIFY INTERVENE Airway

Inadequate airway Secure and protect

Breathing Apnea Positive pressure ventilation Hypoxia Supplemental oxygen Tension pneumothorax Needle decompression, chest tube Massive hemothorax Chest tube Open pneumothorax Occlusive dressing, chest tube

Primary Survey Goals IDENTIFY INTERVENE

Circulation Hypovolemic shock Fluid bolus, blood products Pericardial tamponade Fluid bolus, pericardiocentesis,

thoracotomy Cardiac Arrest Chest compressions, thoracotomy

if penetrating trauma

Disability Spinal cord injury Immobilization Cerebral herniation Hyperventilation, mannitol

Exposure Hypothermia Warmed fluid, external warming Exsanguinating hemorrhage Direct pressure

Adjuncts to Primary Survey o  Access: Intravenous or Intraosseous needles o  Monitor: Cardiorespiratory/Pulse oximetry; size

appropriate blood pressure cuff o  Imaging (x-rays) o  Trauma bloodwork

n  CBC, electrolytes, blood gas, creatinine, BUN, PT/PTT, Xmatch, liver function studies, lipase or amylase

Imaging Prior to Secondary Survey o  Xrays:

n  CXR (AP only) n  Pelvis (AP only) n  C-spine: lateral, AP and odontoid if cooperative

Secondary Survey o  Head to toe examination o  Tetanus status o  IV antibiotics if necessary o  AMPLE history: allergies, medications, past

medical history, last meal, events surrounding injury

Vascular Access - The IO Needle o  If No access within 90 seconds = IO o  fluids, drugs, blood products o  up to 72h

Head Trauma

Head Trauma

o  Head  trauma  is  the  leading  cause  of  death  &  disability  in  childhood  n  Mortality  rate  20-­‐30%  

 n  1-­‐2%  of  all  comers  to  ED  n  Only  3-­‐5%  of  those  with  intracranial  injury  n  <1%    of  above  require  neurosurgery  

Head Trauma o  Epidemiological/Environmental  factors:  

n  Infancy:    falls  n  Childhood:  MVA,  pedestrian,  bicycle  n  Adolescence:  MVA,  pedestrian,  bikes/boards,  

violence  

 

q  Cerebral blood flow depends on both autoregulation and the Central Perfusion Pressure

CPP = MAP – ICP

q  cerebral perfusion will slow down

Head Trauma: Pathophysiology

Signs & Symptoms of Increased ICP in Children o  Full fontanel o  Splitting sutures o  Altered state of cosciousness o  Paradoxical irritability o  Persistent vomiting o  Cranial nerve paralysis o  Papilledema o  Cushing’s Triad:

n  Hypertension, bradycardia and hyperventilation

o  Decorticate or decerebrate posturing

Signs & Symptoms of Increased ICP in Children

Etiology of brain injury o  Diffuse axonal injury more common in children than

adults n  Require less neurosurgical intervention

Etiology of brain injury o  Epidural hematomas are a neurosurgical emergency –

most often follow trauma to temporal region n  Consider if period of LUCIDITY followed by

deterioration

Etiology of brain injury

o Subdural hematomas – be suspicious for non-accidental Trauma (NAT) if no history of trauma

Acute Medical Management of Raised ICP o  Position head of bed at 300

o  Mannitol IV 20% = 1g/kg per dose o  Prevent hypoxia and hypotension

n  Focus on maintaining MAP’s with IV fluids o  Control external hemorrhage o  Maintain C-spine precautions o  Early intubation using RSI to prevent complications

o  Rapid Sequence Intubation of the Head Injured Child

Head Injury o  Early involvement of neurosurgery recommended o  Admission and close monitoring for deterioration

Chest Trauma

Chest/Thoracic Trauma

o  2nd most common cause of mortality in pediatric trauma

o More compliant chest wall o Tension pneumothorax develops quicker

Chest/Thoracic Trauma o Consider:

n  Hemothorax n  Pneumothorax (+/- Tension Pneumothorax) n  Flail chest n  Diaphragmatic ruptures n  Bronchial/Tracheal tears n  Esophageal ruptures n  Pulmonary contusions n  Cardiac tamponade

Tension Pneumothorax o  Hypotension, distended jugular veins, shifted

heart sounds, hyper-resonance, trachea not midline

o  Treatment: n  Emergent needle n  Chest tube

Abdominal Trauma

Abdominal Trauma3,22 o  3rd leading cause of traumatic death o  Often unrecognized in children o  Consider abdominal injury in the following:

Sign Possible Injuries Seatbelt Injury Small bowel injury

Chance fracture Handlebar injury Duodenal hematoma

Pancreatic injury Sport related injury Spleen, kidney, bowel

Abdominal Trauma o What are the odds of having intra-

abdominal injury? n  Based on the Abdominal Exam:

o Tenderness on exam = o Ecchymosis = o Abrasions = o Low blood pressure = Repeat abdominal exams cornerstone of diagnosis

Burns/Thermal Injury

Burns/Thermal Injury o  70% to hot liquid o  Up to 20% in younger children secondary to abuse or

neglect o  inhalational injury = EARLY Intubation

n  Hoarseness n  Black sputum n  Facial burn n  Accident in closed area

Burns 13,30 o  Burn Assessment

n  Depth o  1st degree: superficial (epidermis) o  2nd degree: superficial or deep partial thickness

(dermis) o  3rd degree: full thickness (beyond dermis)

http://www.unboundedmedicine.com/pics/burn.jpg

Burns o  4th degree: involves underlying

subcutaneous tissue, tendon, bone

Burn/Thermal Injury 13,22 o  Burn Assessment

Appearance Surface Sensation Time to healing

1st degree Pink or red Dry Painful Days

Superficial 2nd degree

Pink, clear blisters Moist Painful 14–21 days

Deep 2nd degree Pink, hemorrhagic blisters, red

Moist Painful Weeks, or may progress to 3rd degree and require graft

3rd degree White, brown Dry, leathery Insensate Requires excision

4th degree Brown, charred Dry Insensate Requires excision

Burn/Thermal Injury 3,13 o  Estimating Burn Size

Palm of patient’s hand = ~ 1% BSA

Burn/Thermal Injury: Management3 o  ABCDE’s

n  Consider early intubation if airway involvement o  Tetanus prophylaxis and ANALGESIA o  Fluid resuscitation mainstay of treatment

n  Parkland Resuscitation Formula: looks for it ?

Burn/Thermal Injury o Consider referral to a burn centre if:

n  Inhalational injury n  Burn size >10% TBSA in child <10yo n  Burn size >20% in any patient n  Full-thickness burns >5% TBSA n  Burn involving hands/feet/face/perineum n  Mutiple comorbidities n  NAT n  Chemical/Electrical injury

Submersion Injuries

Submersion Injuries o Most common cause of cardiac arrest in

children

Submersion Injury o Most common sites of drowning:

n  <1yo : Bathtubs (55%) n  1 – 4yo : Pools (56%) n  >4yo : Freshwater (63%)

: n  Drowning = death within 24h of suffocation

from submersion in liquid n  Near Drowning/Submersion injury = survival

>24h past event

Submersion Injury o  ABCDE’s o Consider early intubation o  Always consider C-spine immobilization

n  0.5% submersion victims have c-spine injury o Remove wet clothing o  Treat hypothermia

Poor Prognosis in Submersion Injury o  Prolonged submersion >25 minutes o  Delay in CPR initiation o  Resuscitation >25 minutes o  pH <7.1 o  Pulseless, cardiac arrest on arrival to emergency

department o  Elevated blood glucose on arrival o  Dilated and fixed pupils on arrival o  Abnormal initial CT of brain o  Initial GCS of <5

Injury Prevention

Injury Prevention

o  90% injuries can be prevented

o  Supervision and understanding child development critical in keeping them safe

Injury Prevention o  Bike Helmets:

o  Window Stops/Guards:

o  Smoke alarms:

o  Medication: n  Must be LOCKED and inaccessible

Injury Prevention o  Street Safety

n  Children <9yo do not judge traffic safely n  Should NOT cross the road WITHOUT an ADULT

o  Choking/Strangulation n  <4yo should not eat raw carrots, candies,

popcorn, hotdogs, or have access to small toys n  Children should sleep in own crib, on their

back, with well-fitted bedding to decrease risk of SIDS

Conclusion o  Pediatric trauma and injury are preventable

conditions o  Principles of management should always

include a well orchestrated primary and secondary survey

o Never hesitate to admit for observation, ask for help or consult specialty services -the earlier the better.

Quiz Question 5 o What percentage of injuries in children are

preventable? 1.  None of them, children are unpredictable. 2.  Around 10% 3.  Between 15-130% 4.  >90%

Thank you