Mark R. Zonfrillo
• Injury is the leading cause of death of children in the United States.
• Orotracheal intubation is the most reliable means of securing an airway.
• Hypovolemic shock is caused by blood loss, which makes up 8% to 9% of the body weight of a child. Determining the extent of volume depletion and shock requires evaluation of multiple parameters.
• Attempt vascular access en route.
• Intraosseous (IO) infusion should be used as a quick access for crystalloid infusion if attempts at intravenous (IV) cannulation are unsuccessful after 90 seconds.
• For shock, give an initial infusion of 20 mL/kg of crystalloid solution rapidly.
• Unique characteristics of the pediatric cervical spine (C-spine) predispose it to ligamentous disruption and dislocation injuries without radiographic evidence of bone injury.
Injury is the leading cause of deaths in children in the United States, representing almost 40% of all pediatric fatalities.1 Overall, mortality from pediatric trauma is one-third of the rate of adult trauma deaths; however, pediatric case–fatality rates are higher when compared with adults who have similar injuries. Eighty percent of their trauma deaths occur either at the scene or prior to admission.
Mortality data alone does not reveal the profound impact of trauma. For children <19 years of age, injuries are the leading cause of visits to emergency departments (EDs), numbering 9 million, accounting for more than 225,000 admissions, and resulting in nearly $87 billion in health care and societal costs.1 Even minor injuries can have lasting effects causing physical or cognitive functional impairment and affect quality of life years after the acute traumatic event. Therefore, physical, emotional, and psychological needs of the child and family must be considered.
NATURE OF INJURIES AND UNIQUE PEDIATRIC ASPECTS
The blunt trauma is the predominant mechanism in children, with only 10% to 20% suffering a penetrating injury. Boys are injured twice as frequently as girls. Motor vehicle crashes (MVCs) account for more than half of all childhood trauma deaths.1 Other major causes of death are falls, drowning, poisoning, and fire-related injuries, with the relative incidence for each injury type varying by age group (Table 22-1).2
Leading Causes of Fatal Injury in Children by Age Group in 2010
Children have anatomic, physiologic, and psychological responses to trauma that are different from those seen in adults, and an understanding of these differences is essential to provide appropriate expert care for children. Kinetic energy from injury is distributed over a smaller area and impacts a greater proportion of the total body volume. Musculoskeletal compliance is greater in children and they have less protective muscle and subcutaneous tissue. The increased flexibility and resilience of the pediatric skeleton and surrounding tissues permits external forces to be transmitted to the deeper internal structures. Always consider the possibility of internal injury, even in the absence of external signs of trauma.
A child’s head represents a larger percentage of total body mass than that of an adult, and head injuries are very common in children. The head is also a major source of heat loss in a child. The occiput is more prominent in young children and decreases in prominence from birth until approximately 10 years of age. Take this into account when positioning the head for intubation and airway management. The bony sutures are open at birth—they gradually fuse and completely close by 18 to 24 months of age. A bulging fontanel in younger infants in the setting of trauma suggests increased intracranial pressure (ICP) from hemorrhage.
A younger child’s neck is shorter and supports a relatively heavier weight than an adult’s, making it especially vulnerable to forces of trauma and sudden movements. A younger child’s short, thicker neck makes it difficult to evaluate neck veins and tracheal position.
The most dramatic and critical differences between children and adults are in the airway. A child’s larynx is located in a more cephalad and anterior position. In addition, the epiglottis is tilted almost 45 degrees in a child and is more floppy, making manipulation and visualization for intubation more difficult. Unlike the adult, where the glottis is the narrowest portion of the upper airway, the cricoid cartilage is the narrowest portion of the child’s airway.
The pediatric thorax is more pliable because of flexible ribs and cartilage, with less overlying fat and muscle. This allows a greater amount of blunt force to be transmitted to underlying tissues. The diaphragmatic muscle is much more distensible in a child. A child’s mediastinum is also very mobile. Therefore, the mediastinum and abdominal organs are subject to sudden, wide excursions that can be dramatically seen, such as in tension pneumothorax.
The diaphragm inserts at a nearly horizontal angle from birth until approximately 12 years of age, in contrast to the oblique insertion in the adult. This, in effect, causes abdominal organs to be more exposed and less protected by ribs and muscle. Therefore, seemingly insignificant forces can cause serious internal injury.
The spleen and the liver are in a more caudal and anterior position. Even though the increased elasticity and compliance of a child’s connective tissue and suspensory ligaments should protect these organs, they are actually more subject to injury because of the increased motion at impact.
Long bones in children differ from the adult because of the presence of growth plates and increased compliance (see Chapter 29). Ligaments are stronger than the growth plate, predisposing a child to physeal disturbances, as categorized by the Salter–Harris classification system.
PEDIATRIC TRAUMA SYSTEMS
The differences in mechanisms and patterns of injury observed in early childhood, late childhood, and adolescence, together with immature anatomic features and the developing physiologic functions of the pediatric patient, result in unique responses to major trauma, which in turn drive the need for specialized pediatric resources. Therefore, the injured pediatric patient has special needs that may be provided optimally at a children’s hospital with demonstrated expertise in and commitment to both pediatric and trauma care which can decrease injury-related mortality.3 Geographic areas with access to a pediatric trauma center should integrate them into the regional trauma system through invited participation, appropriate field triage, and interfacility transport of the most critically injured children.4 When a pediatric trauma center, whether freestanding or affiliated with an adult trauma center, is not available, this role should be fulfilled by the adult trauma center with the largest volume of pediatric patients.5–7
PREHOSPITAL CARE ISSUES
Considerations in the field care of the traumatized child include endotracheal intubation, intravenous (IV) access, immobilization, and rapid transport. Which procedures should be attempted in the prehospital setting is controversial, but rural systems may require more aggressive initial treatment because of longer transport times than those in urban areas. The prehospital success rate for endotracheal intubation varies based on injury severity, the age of the patient, education level of the health care provider, and use of neuromuscular blockade to facilitate intubation.8 Temporizing airway interventions such as bag-mask ventilation or laryngeal mask airway placement may be helpful until a definitive airway is placed, as to not delay transport times.
Vascular access is a difficult procedure under the best of circumstances and is often a reason for delay in transport of a critically ill child. It is reasonable for traumatized children to be transported immediately without vascular access if a short transport time is expected. Vascular access can be attempted en route to avoid prolonged scene time. Intraosseous (IO) infusion (Fig. 22-1) should be used as a quick access for crystalloid infusion if attempts at IV cannulation are unsuccessful after 90 seconds.9 IO lines can be placed rapidly and successfully in the prehospital setting.10
FIGURE 22-1. IO lines can provide adequate IV access.
INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES FOR THE INJURED CHILD
The highest priority is immediately identifying and treating life-threatening injuries (Fig. 22-2). The next priority is identifying injuries requiring operative intervention. Finally, the child is examined for non–life-threatening injuries and initiating specific therapy (Table 22-2). There are recognized criteria for transferring a patient to a trauma center or activating an in-house trauma team (Tables 22-3 and 22-4).
FIGURE 22-2. A team approach is required for management of multisystem trauma.
Initial Approach to the Pediatric Trauma Patient
Criteria for Trauma Activation
Reasons for Transfer of Pediatric Trauma Patients for Tertiary Care
Have available weight-based equipment tables or height-based reference tools (such as the Broselow tape) as an aid in determining equipment sizes and medication dosing.
The primary survey and initial resuscitation occur simultaneously usually during the first 5 to 10 minutes and focus on diagnosing and treating life-threatening disorders.10,11 The secondary survey continues with a more thorough physical examination and diagnostic testing. It is an anatomic survey that evaluates in a timely, directed fashion each body area from head to toe. In this fashion, life-threatening injuries are promptly recognized before proceeding to less urgent problems. Children with serious injuries require continual reassessment. Repeat vital signs should be performed every 5 minutes during the primary survey and every 15 minutes while in the ED awaiting transfer or operative intervention.
The primary survey includes evaluation of the airway, stabilization of the cervical spine (C-spine), adequacy of breathing, and ventilatory effort.12,13 Next, evaluate the circulatory status and control hemorrhage, then evaluate for disability (neurologic screening examination). This is followed by exposure and thorough examination. Remember to avoid hypothermia by keeping the child warm. The primary survey and resuscitation is carried on simultaneously. Airway management will be described in this section. Vital signs vary by age and one should have access to a table or chart with them (Table 22-5).
Pediatric Vital Signs9
The airway is secured while concomitantly stabilizing the neck. The jaw thrust maneuver is used to open the airway and the oropharynx is cleared of debris and secretions. Although bony C-spine injuries are less common in children, they are at high risk for cervical cord injuries. C-spine injury should be assumed until a normal examination and an adequate C-spine series is obtained, if indicated.
Indications for endotracheal intubation in the trauma patient include the inability to ventilate the child by bag-valve-mask methods, the need for prolonged control of the airway, prevention of aspiration in a comatose child, or the need for controlled mild hyperventilation in patients with serious head injuries. It should also be considered for flail chest with pulmonary contusion, in patients with shock that is unresponsive to fluid volume, and in those with Glasgow Coma Scale (GCS) 8 or less.
Orotracheal intubation is the most reliable means of securing an airway. Appropriate tube size is approximated by the diameter of the nostril or the diameter of the child’s fifth finger (Table 22-6). Emergency intubation should always be accomplished via the oral approach. Nasotracheal intubation should not be performed if there is any concern for facial trauma, and should otherwise only be considered as an alternative to orotracheal intubation. Besides being extremely difficult in an acutely injured child, it is relatively contraindicated because of the acute angle of the posterior pharynx, the necessity of additional tube manipulation, and the probability of causing or increasing pharyngeal bleeding. Preparation should always precede intubation and includes guaranteeing the presence of all equipment and drugs necessary to adequately manage an acute airway. This should be accomplished even before an injured child arrives.
Equipment Sizes for Pediatric Trauma
Intubation may be necessary to maintain an adequate airway. However, intubation may be difficult because of poor airway visualization, seizures, agitation, or combativeness. Prolonged intubation procedures can lead to ICP elevation, pain, bradycardia, regurgitation, and hypoxemia. Rapid sequence induction (RSI) can greatly facilitate intubation and reduce adverse effects significantly (see Chapter 17).
Emergency physicians must be able to secure an airway when unable to perform orotracheal or nasotracheal intubation. There are several options:
• Laryngeal mask airway, although not a definitive airway, can be a temporizing measure while stabilizing the patient.
• Cricothyrotomy has a role for patients in whom there is extensive central facial or upper airway injury or when there have been unsuccessful attempts at orotracheal intubation. However, it is difficult and hazardous in children. It is not recommended in children younger than the age of 10 and complication rates are as high as 10% to 40%.
• Tracheostomy is time-consuming, hazardous in the ED, and requires surgical skill.
• Needle cricothyrotomy with transtracheal jet ventilation (TTJV) currently is the preferred surgical method of choice to secure an emergency airway in children.
A percutaneous technique and TTJV has several advantages over a surgical cricothyrotomy in the ED because it is done through a straightforward technique, allows adequate ventilation for at least 45 to 60 minutes, which allows time for definitive airway placement. It plays a central role in those patients in whom intubation is not possible.
However, advantages over traditional surgical methodologies have not been scientifically demonstrated, despite being inherently obvious. Some expertise and/or practice are required and the airway is not protected from aspiration. Complications include subcutaneous emphysema, bleeding, and catheter dislodgment. However, the issue of CO2 retention, although controversial, is overstated and of relative unimportance when airway access and oxygenation are critical. TTJV undoubtedly provides a lifesaving and temporary airway, which should be adequate for 45 minutes to 2 hours, until endotracheal intubation can be achieved.
The procedure for TTJV is as follows. A 14-gauge angio-catheter or a TTJV needle is connected to a 5-mL syringe with 3 mL of saline. The trachea is stabilized with the nondominant hand and, after the region is prepped, the cricothyroid membrane is punctured at a 30- to 45-degree angle caudally. Special care is required to avoid puncturing the posterior wall of the trachea. Placement is verified with aspiration of air. Slide the catheter off the needle and reconfirm placement with the syringe. The catheter must be held constantly or secured in place and the jet ventilation tubing is attached to the O2 source. This O2 source must be a high-pressure source directly from the wall and not from a regulator valve. The psi (pounds per square inch) can then be adjusted on the pressure gauge. There are no well-studied guidelines for psi settings for TTJV in children. However, parameters are recommended by practitioners familiar with this technique. A low psi must be used initially in children and the provider should look for adequate chest excursion. The psi can be adjusted upward until adequate chest rise is observed and is the best indicator of adequate tidal volume. The inspiration:expiration ratio is 1:3 or 1:4 (Table 22-7).
Parameters for Transtracheal Jet Ventilation
Acceptable ventilation only occurs if there is adequate spontaneous air exchange with normal O2 saturation and CO2 levels. Pulse oximetry is mandatory and end-tidal CO2 monitoring should be used to confirm and monitor endotracheal tube placement. Hypoxemia may manifest as any combination of and degree of agitation, altered mental status, cyanosis, poor end-organ function, poor capillary refill, and desaturation on pulse oximetry. Children with respiratory failure must have positive-pressure ventilation (PPV) started immediately.
Signs that indicate that a child has inadequate ventilation include tachypnea, nasal flaring, grunting, retractions, stridor, and wheezing. Reasons for compromised ventilatory function include depressed sensorium, airway occlusion, restriction of lung expansion, and direct pulmonary injury. Restriction of lung expansion by gastric distention is more likely to occur in young children because of the limitation of diaphragmatic excursion. This problem is addressed by early placement of an oro- or nasogastric tube.
Ventilation with a bag-valve-mask device is initiated to treat inadequate ventilation.
At this phase of the resuscitation, immediate attention and treatment of tension or hemopneumothorax is required, if present or suspected. The classic presentation for tension pneumothorax of absent breath sounds, tympany, hypotension, and jugular venous distention is rare in children. Children are especially sensitive to mediastinal shift in tension pneumothorax and needle decompression should be performed immediately if any of the following are present: decreased breath sounds, refractory hypotension, hypoxia, or radiographically confirmed hemopneumothoraces. Massive hemothorax may present as absent breath sounds, dullness to percussion on the affected side of the chest, and hypotension. Jugular venous distention may not be seen because of hypovolemia. Operative thoracotomy should be considered when the initial drainage is greater than 15 mL/kg or the chest tube output exceeds 4 mL/kg/h.
For an open pneumothorax, place an occlusive dressing (petrolatum gauze or plastic sheet) that is secured by tape on three sides, leaving one side of the dressing open to act as a flutter valve to minimize the risk for development of a tension pneumothorax. A tube thoracostomy can wait until completion of the primary survey.
The initial circulatory assessment and treatment includes identifying and controlling both external and internal hemorrhage and assessing perfusion. Vascular access for infusion of fluids and phlebotomy are additional goals. The child’s volume status and perfusion are estimated by assessment of pulse, skin color, and capillary refill time and obtaining a blood pressure. A palpable peripheral pulse correlates with a blood pressure above 80 mm Hg, and a palpable central pulse indicates a pressure above 50 to 60 mm Hg. A euvolemic, euthermic patient’s capillary refilling time, assessed after blanching, will be 2 to 3 seconds. Control external hemorrhage by direct pressure. Application of extremity tourniquets or hemostats to bleeding vessels should be avoided. A properly applied external pelvic wrap is preferred for pelvic fractures. As in adults, Trendelenburg position may be of benefit in low perfusion states to maintain central circulation.
Absent pulses or cardiac arrest in a child with traumatic injuries portends a poor outcome. In children with penetrating chest or abdominal trauma, a resuscitative thoracotomy may be lifesaving if vital signs were recently lost. In children with blunt traumatic arrest, the outcome is invariably death. During resuscitation of traumatic arrest, follow standard advanced cardiac life-support algorithms and give blood products. If chest trauma is present or there has been a deceleration injury, as with a MVC or fall, consider the presence of cardiac tamponade, a rare condition in children. Echocardiography is diagnostic. Evaluate for Beck’s triad, which consists of hypotension, muffled heart sounds, and jugular venous distention. Fluid boluses should be administered early and may temporize until periocardiocentesis and resuscitative thoracotomy is undertaken.
Rapidly obtain vascular access with a capability to infuse the greatest possible volume of fluid. Attaining vascular access is difficult in children, so one functioning IV line is all that may be readily achieved and is usually adequate. Two lines are placed in the more severely injured child, so blood, fluids, and medications can be given simultaneously. Consider one or more IO lines in a severely injured child if vascular access is difficult. Any fluids, medications, or blood products can be given through this line. If central venous access is desired, the femoral vein is the easiest site because of identifiable landmarks and relative ease of the procedure compared with other sites in children. Ultrasound-guided placement of central lines has improved safety and ease of inserting them.
Administer fluid boluses in aliquots of 20 mL/kg and repeat as necessary until perfusion improves.14 These boluses should be given over 10 minutes. Since traumatic shock is caused by blood loss, packed red blood cells should be used when it becomes apparent that there is significant blood loss and crystalloids are inadequate for volume replacement. Low-volume fluid resuscitation is still being evaluated. It may be appropriate in penetrating trauma. Do not use low-volume approach in head- or spine-injured children.
Assess disability by performing a rapid neurologic examination to determine level of consciousness and pupil size and reaction to light. The GCS is a more quantitative measure of level of consciousness (Table 22-8). Although recently noted to be less predictive of overall outcomes in children with trauma, it is extremely useful to identify improvement or deterioration. The AVPU system (Table 22-9) is an alternative tool to quickly assess and follow mental status changes.
Pediatric Glasgow Coma Scale
AVPU Method for Assessing Level of Consciousness
Completely undress the patient in order to perform a thorough assessment. Children have a larger body surface area to weight ratio so preventing hypothermia is a constant concern.
This phase occurs simultaneously with the primary survey, but it is separated in presentation for clarity and organization.11,15,16
Ensure adequate oxygenation and ventilation of all trauma victims and obtain vascular access as discussed above. The highest success rate for vascular access is obtained at the antecubital fossae or the saphenous veins at the ankle (anterior to the medial maleolus). Veins are often visibly absent, difficult to cannulate with an appropriately sized catheter, or collapsed in the face of hypovolemia. In these situations, IO needle placements into the tibia marrow space or femoral vein central catheter are reasonable lifesaving alternatives. A third option is rapid venous cut down performed on an antecubital vein or the saphenous vein at either the ankle or in the groin.
Send blood for type and cross-match and complete blood count. Consider serum electrolytes, liver transaminases, prothrombin time (PT), partial thromboplastin time (PTT), amylase, lipase, and urinalysis. Send a blood gas for any patient who may have significant volume loss, respiratory compromise, or concomitant toxic exposure (e.g., carbon monoxide poisoning in a burn patient). Send a serum pregnancy test in postmenarchal females.
Perform an assessment for shock and determine whether or not adequate organ perfusion exists. Traumatic shock is usually due to hypovolemia. Recognize that children with early, compensated shock have tachycardia without hypotension, as blood pressure is maintained through vascular resistance and venous tone. Cardiogenic shock and neurogenic shock are less likely but need to be considered. Hypovolemic shock occurs most commonly after major trauma and is caused by blood loss (Table 22-10). The blood volume of the child makes up 8% to 9% of the total body weight. Determination of volume depletion and shock is difficult in children, and multiple parameters must be used. Hematocrit can be normal in the face of acute blood loss—and blood pressure alone is an insensitive indicator of shock, especially when determining treatment priorities. Pulse and respiratory rate and mental status are more sensitive in identifying early stages of shock.
Therapeutic Classification of Hemorrhagic Shock in the Pediatric Patient
Cardiogenic shock after a major childhood injury is rare but could occur because of cardiac tamponade or direct cardiac contusion. It should be suspected if there are dilated neck veins in a patient with decelerating injury, penetrating chest trauma, or sternal contusion. Neurogenic shock, typically secondary to spinal cord injury, presents with hypotension without tachycardia or vasoconstriction. Isolated head injury does not produce shock unless there is significant intracerebral hemorrhage in an infant. Distributive or septic shock is not a consideration immediately after trauma, even if there is contamination of the abdominal cavity.
Normal saline (NS) or Ringer’s lactate (LR) is the fluid of choice for initial resuscitation of the pediatric trauma victim. Fluid replacement can be divided into two phases: (1) initial therapy and (2) total replacement (Tables 22-11and 22-12). The initial resuscitative fluid should be isotonic crystalloid solution. Give an initial infusion of 20 mL/kg as rapidly as possible. This is best accomplished by pushing boluses using a three-way stopcock or via a rapid infuser, rather than trying to infuse via a pump or gravity. After a rapid 20-mL/kg bolus over 10 minutes, the child should be reassessed. Repeat fluid boluses up to four times if necessary. If the child continues to be unstable, 10- to 20-mL/kg packed red blood cells or whole blood need to be infused urgently. The 3:1 rule is commonly used in replacing lost blood with crystalloid as follows: 300 mL of crystalloid for each 100 mL of blood loss. If the initial hemoglobin value is <7, blood should be given immediately since this level of hemoglobin overwhelms compensatory mechanisms and increases cellular hypoxia.
Classification for Fluid Resuscitation in Shock
Guidelines for Fluid Resuscitation in Shock
Clinically assess volume and perfusion status during resuscitation. If a child is not responding to IV resuscitation, suspect continued bleeding and look for other causes of refractory shock, such as tension pneumothorax or hypoxemia. Insert a Foley catheter and use urinary output as a straightforward, readily available monitor as directed: 1 mL/kg/h for children >1 year of age and 2 mL/kg/h for children <1 year of age. Urinary output may help assess perfusion and intravascular status.
Blood at the urethral meatus or in the scrotum or abnormal placement of prostate on rectal examination prohibit urinary catheterization until a retrograde urethrogram (RUG) proves that the urethra is intact (see Urologic Studies below). This is done by instilling gastrografin into a partially inserted Foley catheter. Insert an orogastric tube if there is a possibility of a cribriform plate fracture when a patient has blood coming from the ears, nose, or mouth. Insert nasogastric tube carefully if there is no likelihood of such fracture.
Measure and monitor the patient’s body temperature. Hypothermia must be avoided and/or corrected. Use radiant warmers, warmed IV fluids, cover exposed body parts, and raise the room temperature.
Obtain radiographs at this time, but limit them to C-spine, chest, and pelvic films until the patient is initially resuscitated.
It is important to obtain surgical consultation in any significantly injured child as early in the evaluation as possible. If notified by EMS of a severely injured child coming to the facility, contact the surgeon on call for trauma or contact the referral center to prepare for early transfer of the critically injured child. Initiation of a transfer protocol, if warranted, should be activated at this time (Table 22-4).
SECONDARY SURVEY AND DEFINITIVE CARE
Once life-threatening conditions identified in the primary survey are stabilized, perform a timely, directed evaluation of each body area, proceeding from head to toe.11,13 Continuously reassess vital signs and abnormal conditions identified in the primary survey at a minimum of every 15 minutes. The components of the secondary survey include a history, a complete head to toe examination, laboratory studies, radiographic studies, and problem identification. Use an AMPLE history to determine the mechanism of injury, time, status at scene, changes in status, and complaints that the child may have. This includes Allergies, Medications, Past medical and surgical history, Last meal time, and Events preceding the injury. Complete laboratory and radiologic studies that were not done during the initial resuscitation. A decision regarding disposition can probably be made at this point during most resuscitations.
Reevaluate pupil size and reactivity. Perform a conjunctival and fundal examination for hemorrhage or penetrating injury. Assess visual acuity by determining if the patient can read, see faces, recognize movement, and distinguish light versus dark.
Palpate the skull and mandible looking for fractures or dislocations. Although relatively uncommon, infants may become hypotensive from blood loss into either the subgaleal or epidural space. An infant with an open fontanelle is more tolerant of an expanding intracranial mass lesion, and signs of this may be hidden until rapid decompensation occurs. Unlike adults, vomiting and altered mental status, such as amnesia, commonly occur in head-injured children and do not necessarily imply increased ICP. However, persistent vomiting, progressive headache, palpable skull defect, or an inability to observe a patient’s mental status (e.g., they are going to the operating room) are some of the indications for an immediate head CT scan. If airway is secure, maxillofacial trauma is a lower priority and the physician should move on quickly.
Injuries of the C-spine are not common in children. In lower-risk injuries, the C-spine can usually be cleared in the ED with a normal examination, and anteroposterior (AP), odontoid, and lateral view radiographs of the C-spine. Before ruling out a cervical injury, the patient should be awake, cooperative, and free of other distracting painful injuries, and the radiographs must show all seven C-spine vertebrae. The child, performing the movements voluntarily, should actively flex, extend, and rotate the neck with no symptoms or signs of spasm, guarding, pain, or tenderness. Patients at higher risk for C-spine injury include those with: altered mental status, focal neurologic deficits, complaint of neck pain, torticollis, substantial injury to the torso, predisposing condition, high-risk MVC, and diving.17Additional radiographic imaging should be considered, such as a CT for immediate evaluation of fractures and acute injury, and an MRI for a more detailed evaluation of ligamentous and spinal cord injuries.18
Unique characteristics of the pediatric C-spine predispose it to ligamentous disruption and dislocation injuries without radiographic evidence of bone injury. The incomplete development of the bony spine, the relatively large size of the head, and the weakness of the soft tissue of the neck predispose to spinal cord injury without radiographic abnormality (SCIWORA). Patients with altered sensorium cannot be cleared despite negative x-rays, and the cervical collar should remain in place while further testing and imaging studies are completed (see Chapter 24).
Special considerations are required in four situations:
• The child who requires immediate intubation because of airway compromise should not have airway management delayed waiting for C-spine film(s). The safety of oral intubation with in-line C-spine immobilization has been demonstrated in multiple studies.
• If such a child who is intubated is at high risk for C-spine injury, then a CT scan of the upper cervical vertebrae should be done when a head CT scan is performed.
• If an injured patient arrives with a helmet in place and does not require immediate airway intervention, then lateral C-spine can be done before removing the helmet. There should be careful attention to maintaining C-spine immobilization while removing the helmet.
• Penetrating injuries to the neck requiring operative intervention should have entry and exit sites noted with opaque markers on anterior–posterior and lateral films of the C-spine.
Expose and visually inspect the chest for wounds requiring immediate attention. Sucking chest wounds require a sterile occlusive dressing. A flail chest component could be splinted but the patient may need intubation to do so. Roll the patient, keeping in-line spine immobilization, and look for posterior wounds. Auscultate the chest and evaluate for pneumothorax, hemothorax, or cardiac tamponade. Tension pneumothorax may be manifested by contralateral tracheal shift, distended neck veins, and diminished breath sounds. However, a child’s small chest size facilitates the contralateral lung’s transmission of breath sounds that makes auscultation an insensitive marker for pneumothorax. Neck vein distention is difficult to appreciate and an insensitive marker when assessing for tension pneumothorax. Therefore, a hemodynamically unstable child should undergo immediate needle decompression thoracentesis if there is reason to suspect blunt or penetrating injury to the thorax. After thoracentesis, tube thoracostomy(ies) should be done. Impaled objects protruding from the chest should be left in place until the child undergoes surgery.
If the chest radiograph reveals a widened mediastinum or apical cap, or other signs suggesting aortic injury or there is a history of significant deceleration injury, CT angiography of the chest is indicated. Aortography may be needed in select circumstances. Although first or second rib fractures increase the likelihood of a vascular injury, their absence does not preclude an aortic injury.15
Air lucencies on chest radiography appearing to be of intestinal origin should be considered evidence of a diaphragmatic injury. Any penetrating injury to abdomen or lower chest carries a risk of diaphragmatic injury.
During the secondary survey, determining the exact etiology of an abdominal injury is secondary to determining whether or not an injury is present. Retroperitoneal injuries are difficult to identify, unless there is a high index of suspicion. Signs suggesting abdominal injury include abdominal wall contusion, distention, abdominal or shoulder pain, and signs of peritoneal irritation and shock. Penetrating wounds to the abdomen usually need immediate operative intervention.16,19
Controversies arise in diagnosing and managing blunt abdominal injuries. CT scan with IV contrast, and with or without oral contrast, may be the most sensitive and useful diagnostic modality (see Imaging section). Diagnostic peritoneal lavage (DPL) provides rapid, objective evaluation of possible intraperitoneal injury, especially involving the liver, spleen, and bowel. It can be considered more sensitive than a CT scan in diagnosing hollow viscous injuries, especially early in the evaluation of a child who is a victim of a deceleration injury while wearing a seatbelt (Fig. 22-3). It is much less sensitive than CT scan in diagnosing injuries to the pancreas, duodenum, genitourinary tract, aorta, vena cava, and diaphragm.
FIGURE 22-3. Children with bruises from seatbelts should be checked for deceleration injuries.
The role of the focused assessment sonography in trauma (FAST) in pediatric trauma is still equivocal. In children, FAST may identify intra-abdominal hemorrhage but this may not be adequate to dictate management. However, finding blood on a FAST examination in a patient who is hypotensive and is not responding adequately to crystalloid and packed red blood cell expansion would indicate a need for immediate laparotomy.20
DPL, although rarely performed in children, may have a role in the hypotensive, injured child because it is valuable in deciding whether or not a patient needs immediate laparotomy. Consider performing DPL in the patient requiring urgent anesthesia and nonabdominal surgery, such as evacuation of an epidural hematoma or treatment of a penetrating upper chest injury.
In children, after emptying the bladder with a Foley catheter, use a midline approach above or below the umbilicus. Instill 10 mL/kg of LR if the initial aspirate is not grossly bloody. An aspirate is considered positive if it has >100,000 red blood cells (RBCs)/μL, >500 white blood cells (WBCs)/μL, a spun effluent hematocrit >2%, bile, bacteria, or fecal material are found. False-positive tests most commonly occur in the face of a pelvic fracture. A positive DPL >100,000 RBCs may be due to a laceration of the liver or spleen but this would not be an indication for surgery, as many solid organ injuries are adequately treated nonoperatively (see Chapter 26).
Palpate the bony prominences of the pelvis for tenderness or instability. Examine the perineum for laceration, hematoma, or active bleeding, and examine the urethral meatus for blood. Blood loss from pelvic fractures can be critically significant and difficult to control, leading to fatal hemorrhage. If there is major pelvic disruption, stabilize the patient with IV fluids and blood products. In order to further reduce bleeding until definitive surgical care, bring the lower extremities together and apply an external pelvic sling made from a sheet to bind the pelvis or use the pneumatic antishock garment. Early use of angiography to embolize bleeding vessels may be lifesaving.
The perineum should be examined for contusions, hematomas, lacerations, and urethral bleeding. A routine rectal examination is not necessary in pediatric trauma patients, as it typically does not improve the identification of serious injury.21 However, it may be more useful as an adjunct to the examination in the patient if the patient has suspected abdominal, pelvic, or spinal cord injury. When performed, determine sphincter muscle tone, rectal integrity, prostatic position, presence of a pelvic fracture, and the presence of blood in the stool. For the female patient, a vaginal examination should also be considered in the secondary survey.
Examine all extremities looking for deformity, contusions, abrasions, intact sensation, penetrating injuries, pulses, and perfusion. The presence of a pulse does not exclude a proximal vascular injury or a compartment syndrome. Palpate long bones circumferentially assessing for tenderness, crepitation, or abnormal movement. Straighten severe angulations of the extremities if possible and apply splints and traction. Open fractures and wounds should be covered with sterile dressings. Inspect soft-tissue injuries for foreign bodies, irrigate to minimize contamination, and debride devitalized tissues. Remember to check for fractures involving the bones of the hands, wrists, and feet since they are commonly missed until the patient regains consciousness.
Examine the back, particularly in cases of penetrating trauma, looking for hematomas, exit or entry wounds, or spine tenderness. With the neck immobilized, log roll the patient for examination.
Examine for evidence of contusions, lacerations, burns, penetration sites, petechiae, and signs of abuse.
Obtain an additional GCS score and perform a more in-depth evaluation of motor, sensory, and cranial nerves. Presence of paresis or paralysis suggests a major neurologic injury. Conversely, lack of neurologic findings does not eliminate the possibility of a cervical cord injury, especially when the patient has a distracting injury and/or pain.
Any injured child is at risk for exposure to heat or cold. Because of their relatively larger body surface area, hypothermia can develop in the prehospital setting and/or in the ED. Hypothermia may impair circulatory dynamics and coagulation, worsen metabolic acidosis by increasing metabolic demand, and increase peripheral vascular resistance. The likelihood and risks of hypothermia can be minimized with the use of overhead warmers, warmed IV fluids, and warm blankets.
ADDITIONAL TREATMENT AND TESTS
Provide tetanus toxoid and tetanus immune globulin as necessary. Consider further radiographic or laboratory studies as dictated by the secondary examination and the patient’s clinical status. This is also the time to make arrangements for other diagnostic tests. Consider the psychosocial aspects of traumatic injuries. Permit parents at the child’s bedside as soon as the child’s clinical status is stabilized.
Burns are a common cause of unintentional deaths among younger children and may contribute to the morbidity of the multiply injured patient. For the principles and procedures of burn management, see Chapter 137.
A child with major blunt trauma needs three basic radiographs immediately: the anterior–posterior chest, anterior–posterior pelvis, and C-spine films. Chest radiographs are more sensitive than clinical examination in smaller children for detecting hemothorax and pneumothorax. Evaluate for widening of the mediastinum and fractured ribs. Pelvic fractures are important clinical indicators in that 80% of children with multiple fractures of the pelvis have concomitant abdominal or genitourinary injuries. C-spine films are obtained as appropriate. During the secondary survey, thoracolumbar and extremity films can be completed as indicated. Based on clinical findings in the primary and secondary surveys, further imaging studies may be needed.
CT SCAN OF HEAD
Prediction rules have been validated that identify children at very low risk for clinically significant intracranial injury and who do not need a CT scan of the head following injury (see Chapter 23).22 Patients who do not meet criteria for low risk of injury do not automatically require a CT scan; instead, the provider should consider many factors in the decision for neuroimaging. Some absolute indications for a head CT study include a GCS score of <14, altered mental status, signs of skull fracture, significant loss of consciousness, and confounding medical problems, such as a bleeding diathesis (see Chapter 23).
CT SCAN OF ABDOMEN
Indications for abdominal CT scanning include a hemodynamically stable victim of blunt trauma with clinical signs of intra-abdominal injury; hematuria >20 RBCs per high-powered field or even minimal hematuria with a history of deceleration injury; worrisome mechanism of trauma in the presence of neurologic compromise. Positive findings on abdominal CT scan are significantly increased if three of the following are present: gross hematuria, lap belt injury, assault, or abuse as a mechanism of trauma, positive abdominal findings such as tenderness, trauma score <12, and significant neurologic compromise (GCS <10).
Some trauma centers use double-contrast CT scan for trauma patients. Diluted gastrografin (20 mL/kg) is instilled via a nasogastric tube 20 minutes prior to CT scan and IV contrast after the initial survey is performed. During the CT scanning, the Foley catheter should be clamped to evaluate the bladder and the nasogastric tube should be pulled into the esophagus to avoid artifact (Table 22-13). Other centers use IV contrast only.
Dose of Contrast Media for Radiographic Studies
A limitation of CT scanning is the lack of sensitivity in diagnosing injuries to hollow viscous organs (bladder, intestinal perforations/rupture). If intraperitoneal fluid is found by CT scan with no apparent injury to the spleen or liver, consider injury to the bowel, bladder, or a vascular injury. Frequent reexaminations by the surgeon are needed or a DPL should be considered. CT scans may miss some cases of free intraperitoneal air or lumbar spine injuries. Therefore, if a patient is hemodynamically stable, consider obtaining thoracolumbar spine films (especially a lateral), an abdominal film looking for free air (e.g., left lateral decubitus film once C-spine injury is excluded), and a cystogram. If injury to bowel or bladder is confirmed, laparotomy is indicated.
Ultrasonography may be an alternative to CT scan in selected cases or when CT scan is not available. Ultrasound can diagnose injuries to the liver, spleen, and kidneys and can document intraperitoneal fluid. This modality is not a substitute for CT scan unless the examiner is very experienced in the use of ultrasound in traumatized children.19,20
If a patient has gross blood at the meatus, or the integrity of the urethra is in doubt because of the possible pelvic fracture, then a retrograde urethrogram should be performed. The study is performed by instilling contrast through a Foley catheter that has been inserted into the distal urethra and partially inflated (0.5–1.0 mL of saline in the balloon). If the urethra is not damaged, the catheter can be advanced to perform a cystogram.
A “1-shot” IV pyelogram can be performed in the ED to evaluate renovascular status if the patient is too unstable for CT scan. A 2 to 4 mL/kg bolus of 50% diatrizoate sodium (Hypaque) is injected and a radiograph of the abdomen is taken 5 minutes later. This will determine the absence or presence of blood supply to one or both kidneys and may also show the function of the upper ureters. Knowledge of the status of the blood supply is very important because a renovascular intimal tear with occlusion or vascular disruption must be identified immediately. The warm ischemic time in which to diagnose, repair, and avoid irreparable damage to a devascularized kidney is approximately 6 hours.
INJURY SEVERITY MEASURES
THE TRAUMA SCORES
The Revised Trauma Score (Table 22-14) was originally developed for rapid assessment, triage, measuring progression of injury, predicting outcome, and assisting in quality assessment. It is useful in the overall management of trauma patient but is less sensitive for severe injury to a single organ system. It is straightforward to calculate for all trauma patients. It allows for standardization of triage protocols and for scientific comparisons between groups of patients and institutions.23,24
Revised Trauma Scorea
The pediatric trauma score (Table 22-15) was developed to reflect the unique injury pattern in children. It incorporates age into the score.
Pediatric Trauma Scorea
• Score >8: Associated with 100% survival
• Score <8: Should transfer patient to pediatric trauma center
• Score <0: 100% mortality
In a study by Nayduch et al.,25 the Trauma Score had a better predictive value for overall outcome, whereas the pediatric trauma score was a better predictor for appropriate ED disposition. Unfortunately, no trauma score is totally reliable in predicting extent of either injuries or outcomes. For example, Jaimovich reviewed 305 pediatric trauma patients’ functional long-term outcomes and found that the current trauma scoring systems fall short in identifying “nonsalvageable” survivors who make meaningful neurologic recovery.26 In addition, study by Lieh-Lai et al.27 demonstrated that a low GCS does not always predict the outcome of severe traumatic brain injury and, in the absence of hypoxic insult, children with scores of 3 to 5 can recover independent function. Therefore, the trauma score or pediatric trauma score can be used to triage patients and predict outcome but exercise caution if used to predict functional outcome.
Facilities that receive trauma victims should have the appropriate personnel and patient care resources committed at all times. However, a majority of seriously injured children are not brought to comprehensive trauma centers. Children can and should receive appropriate care at all hospitals where EMS policies have established that the facility is capable of receiving patients with life-threatening conditions. In a hospital without pediatric surgical consultants, early transfers to a pediatric trauma center, adult trauma center, or pediatric intensive care unit should be considered. Establish contingency plans for transfers and prospectively arrange agreements between institutions (Table 22-4).
Children who appear to have clinical brain death should be considered for continued resuscitation since they may be candidates for organ donation and procurement. If heart, heart–lung, kidney, pancreas, and liver transplantation are considered, premortem management is essential to the viability of the organs. Considerations such as these are best handled in a facility that has the resources to do so. Sensitive parental consultation and support are paramount. Organ donation may provide traumatized families some consolation and strength in the face of such tremendous grief.
When dealing with a traumatized child, the physician must communicate openly and clearly with the family. Psychologic support is needed through the entire hospital course. Disposition and treatment decisions and progress reports need to be presented frequently, succinctly, and with sensitivity. Parents should be allowed to see the child and/or accompany him or her as soon as is practical.
Special thanks to Michael Gerardi, MD, who authored previous editions of this chapter.
1. Centers for Disease Control and Prevention, National Centers for Injury Prevention and Control. National action plan for child injury prevention. http://www.cdc.gov/safechild/pdf/National_Action_Plan_for_Child_Injury_Prevention.pdf. Accessed October 15, 2012.
2. Centers for Disease Control and Prevention. Ten leading causes of death and injury. http://www.cdc.gov/injury/wisqars/LeadingCauses.html. Accessed October 1, 2012.
3. Soundappan SVS, Holland AJA, Fahy F, Manglik P, Lam LT, Cass DT. Transfer of pediatric trauma patients to a tertiary pediatric trauma centre: appropriateness and timeliness. J Trauma. 2007;62(5):1229–1233.
4. Nance ML, Carr BG, Branas CC. Access to pediatric trauma care in the United States. Arch Pediatr Adolesc Med. 2009;163(6):512–518.
5. Gausche-Hill M, Fuchs S, Yamaoto L. Advanced Pediatric Life Support: The Pediatric Emergency Medicine Resource. Elk Grove Village, IL: American Academy of Pediatrics; American College of Emergency Physicians; 2007.
6. Legome E. Trauma: general considerations. In: Harwood-Nuss A, ed. Clinical Practice of Emergency Medicine. Philadelphia, PA: Lippincott; 2005:896.
7. Nathens AB, Jurkovich GJ, Maier RV, et al. Relationship between trauma center volume and outcomes. JAMA. 2001;285(9):1164–1171.
8. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA. 2000;283(6):783–790.
9. Hafeez W, Ronca LT, Maldonado TE. Pediatric advanced life support update for the emergency physician: review of 2010 guideline changes. Clin Pediatr Emerg Med. 2011;12(4):255–265.
10. Wright JL, Klein BL. Regionalized pediatric trauma systems. Clin Pediatr Emerg Med. 2001;2(1):3–12.
11. Waltzman M, Mooney DP. Major trauma. In: Fleisher G, Ludwig S, Henretig FM, eds. Textbook of Pediatric Emergency Medicine. 5th ed. Baltimore, MD: Lippincott, Williams & Wilkins; 2006:1349–1360.
12. Tepas J III, Fallat ME, Moriarty T. Trauma. In: Gausche-Hill M, Fuchs S, Yamamato L, eds. Advanced Pediatric Life Support: The Pediatric Emergency Medicine Resource. Revised ed. Elk Grove Village, IL: American Academy of Pediatrics; American College of Emergency Physicians; 2007:268–324.
13. Trauma ACo. Advanced Trauma Life Support Manual. Chicago, IL: American College of Surgeons; 2005.
14. Sadow KB, Teach SJ. Prehospital intravenous fluid therapy in the pediatric trauma patient. Clin Pediatr Emerg Med. 2001;2(1):23–27.
15. Sheikh AA, Culbertson CB. Emergency department thoracotomy in children: rationale for selective application. J Trauma. 1993;34(3):323–328.
16. Jaffe D, Wesson D. Current concepts: emergency management of blunt trauma in children. N Engl J Med. 1991;324(21):1477–1482.
17. Leonard JC, Kuppermann N, Olsen C, et al. Factors associated with cervical spine injury in children after blunt trauma. Ann Emerg Med. 2011;58(2):145–155.
18. Tilt L, Babineau J, Fenster D, Ahmad F, Roskind CG. Blunt cervical spine injury in children. Curr Opin Pediatr. 2012;24(3):301–306.
19. Potoka DA, Saladino RA. Blunt abdominal trauma in the pediatric patient. Clin Pediatr Emerg Med. 2005;6(1):23–31.
20. Hegenbarth MA. Bedside ultrasound in the pediatric emergency department: basic skill or passing fancy? Clin Pediatr Emerg Med. 2004;5(4):201–216.
21. Kristinsson G, Wall SP, Crain EF. The digital rectal examination in pediatric trauma: a pilot study. J Emerg Med. 2007;32(1):59–62.
22. Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160–1170.
23. Tepas Iii JJ, Ramenofsky ML, Mollitt DL, Gans BM, DiScala C. The Pediatric Trauma Score as a predictor of injury severity: an objective assessment. J Trauma. 1988;28(4):425–429.
24. Gaines BA. Pediatric trauma care: an ongoing evolution. Clin Pediatr Emerg Med. 2005;6(1):4–7.
25. Nayduch DA, Moylan J, Rutledge R, et al. Comparison of the ability of adult and pediatric trauma scores to predict pediatric outcome following major trauma. J Trauma. 1991;31(4):452–458.
26. Jaimovich DG, Blostein PA, Rose WW, Stewart DP, Shabino CL, Buechler CM. Functional outcome of pediatric trauma patients identified as ‘non-salvageable survivors’. J Trauma. 1991;31(2):196–199.
27. Lieh-Lai MW, Theodorou MA, Sarnaik AP, Meert KL, Moylan PM, Canady AI. Limitations of the Glasgow Coma Scale in predicting outcome in children with traumatic brain injury. J Pediatr. 1992;120(2 I):195–199.