David W. Tuggle and Nathaniel S. Kreykes
Pediatric trauma is the leading cause of death of children, as well as the leading cause of permanent disability in this population. It has often been said that children are not merely small adults, and this is never more accurate than in pediatric trauma.1 Although the principles of trauma care are the same for children as with adults, the differences in care required to optimally treat the injured child require special knowledge, careful management, and attention to the unique physiology and psychology of the growing child or adolescent. With this in mind, it is important to view pediatric trauma as a similar but separate entity from adult trauma. It was Haller of Johns Hopkins University who stressed the importance of regional trauma systems for pediatric patients. His system for safe care included two-way communication, dependable transportation, emergency medical technicians trained in the care of newborns, infants, and children, a designated pediatric intensive care unit (ICU), and rehabilitation.2 His work has helped shape and improve our pediatric trauma care significantly.
EPIDEMIOLOGY OF THE INJURED CHILD
Although medical science has made vast strides in the surgical care of the neonate and child, injury remains the leading cause of childhood death in patients under 14 years of age.3 As developing countries become more sophisticated, injury becomes the leading cause of death in children.4 Of interest, there was a 45.3% reduction in the mortality rates from unintentional injury in children in the United States from 1979 to 1996.5 This reduction is crucial if one accepts that the treatment of injuries sustained in the year 2000 will ultimately cost $406 billion—$80.2 billion in medical costs and $326 billion in productivity losses.6 Of that total, injuries among children aged 0–14 account for $51 billion.6 Using the Centers for Disease Control and Prevention Web-Based Injury Statistics Query and Reporting System (WISQARS), a death and injury report for any age group and any type of injury can be obtained.
Children have different patterns and causes of injury depending on age, further emphasizing the need for regional pediatric trauma centers. The defined age range constituting a pediatric age group, however, varies between institutions. The mechanisms of injury and mortality in children have remained remarkably consistent. In children over 1 year and under 14 years of age, motor vehicle crashes cause 44.2% of all pediatric trauma deaths (2000–2005). A detailed review of mortality statistics reveals the home as an area of continuing concern.7 Other areas of concern include falls, bicycle-related injuries, and injuries associated with crashes of all-terrain vehicles.8
Childhood injuries most commonly occur as energy is transferred abruptly by rapid acceleration, deceleration, or a combination of both. The body of a child is very elastic and energy can be transferred creating internal injuries without significant external signs. Due to the relative close proximity of vital organs when compared with adults, children can have multiple injuries from a single exchange of energy. Penetrating trauma is a much less common form of injury in small children, accounting for 1–10% of admissions to pediatric trauma centers. No matter the type of injury, the health care professional evaluating the injured child should keep in mind these significant differences during evaluation and management.
INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED CHILD
Primary survey with simultaneous resuscitation and secondary survey with definitive care, as promoted by the Advanced Trauma Life Support (ATLS) course of the American College of Surgeons Committee on Trauma (ACSCOT), apply to a child as well as the adult. Multiple organ injuries are much more common in the child than in the adult and, as a result, it is best to manage children as if every organ is injured until proven otherwise.
The care of the injured child often starts with a brief evaluation in the prehospital setting. The ASCOT has published a minimum set of criteria for the definition of a “major resuscitation” once the patient arrives at the hospital.9 A patient who needs major resuscitation is typically a child who would benefit from the trauma surgeon being present at the bedside at this point. This condition is ideally determined in the field as noted above or from a referring hospital. Although these criteria are the same for injured patients of all ages, hypotension is age specific.
Assessment of the child’s airway is the first step. Most children do not have preexisting pulmonary disease, so a room air saturation of greater than 90% indicates effective gas exchange. Children also tolerate lower oxygen saturations than adults, up to a point. If oxygenation is difficult, then an injury to the lung, a pneumothorax, or aspiration should be considered. In children, hypoventilation is common in the presence of a traumatic brain injury or shock. If any of these conditions exist, intubation is appropriate. Respiratory compromise requiring intubation commonly indicates a very severe injury. Although none of the previously mentioned criteria to determine a major resuscitation has been validated in children, compromise of the airway and intubation suggest a population that has a higher mortality when compared with those injured children who do not have airway issues.10 A child who is comatose or unresponsive is fairly easy to intubate with an appropriately sized orotracheal tube. Typically, this tube is not cuffed in children less than 8 years of age since the narrowest part of the airway, the cricoid ring, will stabilize the tube without the need for a cuff. Care must be taken to stabilize the cervical spine with appropriately sized pediatric cervical collars during critical maneuvers such as intubation and transportation.
Children who are combative from hypoxia or from emotional distress may need to be intubated to facilitate evaluation, including computed tomography (CT) scanning. For intubation, the injured child is best managed with a protocol for rapid sequence intubation (RSI). Table 43-1 describes an RSI protocol that is both safe and effective. If there is time, preoxygenating the child is useful. The tube size can be roughly approximated by either the width of the nail or the size of the child’s fifth finger. These rough calculations may not be accurate in children of Chinese descent.11 The use of the Broselow Pediatric Resuscitation Measuring Tape has become the standard for determining height, weight, and the appropriate size for resuscitative equipment in a child. The Broselow cart has been found to be more useful than older “standard” carts for children.12 In addition, this tape has been useful in determining drug doses and drip concentrations throughout the hospitalization.13
TABLE 43-1 Pediatric Rapid Sequence Intubation (RSI)
Intubating the injured child can be a very stressful event for those who are less familiar with the technique. The head should be held in line with cervical traction. After selecting the appropriately sized noncuffed tube and employing pharmacological adjuncts as needed for RSI, the airway is approached with a properly sized laryngoscope. The smaller the child, the more likely successful intubation can be achieved with a straight blade. Gentle cricoid pressure is useful to guide the larynx into view and to help close the esophagus during manipulation of the oropharynx. The endotracheal tube should be advanced about 3 cm beyond the vocal cords. Bilateral breath sounds along with symmetric chest excursion are assessed, followed by confirmation with a device that measures exhaled carbon dioxide. Due to the thin tissues of the chest wall, gastric insufflation may be confused with normal breath sounds. A chest x-ray should be obtained to confirm the correct position of the tube since a right mainstem intubation is the most common complication of pediatric intubation after missed intubation. Nasotracheal intubation is generally not used in small children in the emergency setting.
The need for invasive emergency airway access for acute obstruction of the pediatric airway is a very uncommon event. If needed, a 14 or 16 gauge angiocatheter may be placed through the cricothyroid membrane or even the tracheal wall. Care should be taken to not penetrate the posterior tracheal membrane. Oxygen can then be administered through the catheter, allowing time for attempts at orotracheal intubation. The needle cricothyroidotomy is preferred in patients under 10 years of age as the cricoid cartilage is very delicate and could be injured easily with a surgical incision. The needle cricothyroidotomy may then be followed by tracheostomy in a more organized fashion.
Postintubation issues include gastric decompression and surveillance for a pneumothorax. Gastric decompression with a nasogastric or orogastric tube should be employed in every patient since gastric distention will impair diaphragmatic excursion and cause respiratory compromise in the small child. A pneumothorax is especially treacherous in the child due to mediastinal mobility. A tension pneumothorax in a patient with a mobile mediastinum causes compression of the ipsilateral and contralateral lungs, as well as vascular compromise. If a pneumothorax is present, needle decompression can be employed, but this should be followed by immediate insertion of a thoracostomy tube.
As in injured adult patients it is important to obtain reliable, quick, and safe intravenous access. Simpler measures should be attempted first and, if not successful, proceeding to more invasive measures may be necessary (Table 43-2). The ideal initial sites for vascular access for children are the peripheral veins in the upper extremities, especially the antecubital fossa. Ultrasonography may be used to aid in finding peripheral veins, as well.14 A percutaneous femoral venous catheter below the inguinal ligament is the next best choice and the most commonly used route for emergency venous access in the child.13 This should be done with the Seldinger technique to avoid a cutdown procedure. If the trauma team is unable to establish intravenous access using these techniques, a cutdown on the saphenofemoral junction or saphenous vein at the ankle will work in the emergency setting, as well.15 Surgeons who are familiar with subclavian or internal jugular vein catheterization in the child may utilize this route as the next choice as there are very few complications. This is especially true if a chest tube is already in place on the selected side of the subclavian venipuncture.
TABLE 43-2 Pediatric Vascular Access
Intraosseous access is a very useful technique for pediatric trauma victims without intravenous access. Contraindications include proximal fractures and sites of infection. The anteromedial surface of the proximal tibia is used, 2–4 cm distal to the tibial tuberosity. For insertion in the proximal tibia, the needle is directed inferiorly at a 45° angle from the perpendicular. If the insertion site is the distal tibia, the needle should be angled 45° superiorly. In both instances the goal is to angle away from the region of the growth plate and/or joint. There are specialized needles readily available to use with this technique. If these are not available, a spinal needle with a trocar may be employed. Multiple entries into the medullary cavity should be avoided as the leakage that occurs with multiple attempts may cause an iatrogenic compartment syndrome.
Restoration of Circulation
Age-specific hypotension is an indication for major resuscitation of an injured child. In an analysis of the National Pediatric Trauma Registry, 38% of recorded deaths occurred in children whose systolic blood pressure was less than 90 mm Hg.16 This group represented 2.4% of the study population. To determine which child has “age-specific hypotension” requires knowledge of normal blood pressures in children. National guidelines for the ranges of normal childhood blood pressures based on age were published in 2004.17 Health care professionals caring for injured children should be familiar with normal age-dependent blood pressures (Table 43-3).
TABLE 43-3 Vital Functions for Children
A child with an injury that produces significant blood loss may present with a normal blood pressure. The otherwise healthy child can readily compensate for blood loss by mounting a significant tachycardia coupled with peripheral vasoconstriction. Therefore, a normal blood pressure in a child does not mean that circulating blood volume is at normal levels. An accurate assessment is made by monitoring blood pressure and heart rate combined with a clinical assessment of peripheral perfusion. Clinical signs of poor perfusion in conjunction with altered mentation are the classic findings in pediatric hypovolemic shock. If these are present, an immediate bolus of 20 mL/kg of an isotonic crystalloid solution is indicated. If a second bolus is needed and there is little improvement, type-specific packed red blood cells or O-negative blood should be administered immediately followed by the standard infusions of fresh frozen plasma and platelets. As noted above, this scenario occurs in less than 3% of injured children. Caution must be employed, as overresuscitation may be as problematic as underresuscitation, especially in the presence of a traumatic brain injury. Overtreatment with crystalloid solutions may exacerbate cerebral edema in certain circumstances. In adults, excess infusions of crystalloid solutions may result in poor formation of clot and worsening of a compromised hemorrhagic state, and may have no impact on survival.18 One study in injured adults showed that supranormal trauma resuscitation increased the likelihood of an abdominal compartment syndrome, as well. Anecdotal reports of abdominal compartment syndrome following massive crystalloid resuscitation in children have been reported.19
Hypothermia is an extremely common occurrence in injured children and may occur at any time of the year, even in the heat of summer. The response to hypothermia includes catecholamine release and shivering, with an increase in oxygen consumption and metabolic acidosis. Hypothermia as well as acidosis then contributes to a posttraumatic coagulopathy.20 A warm room, warmed fluids, heated air-warming blankets, or externally warmed blankets should be utilized during the initial resuscitation of an injured child. This aggressive approach to rewarming should be extended to the radiology suite during evaluation. If at all possible, the room should be warmed to 37°C or warmer, even if the trauma team feels some discomfort. Fluids and blood should be warmed to 39°C if the child is cool (<36°C). Conversely, care should be taken to avoid hyperthermia in the child with a traumatic brain injury21; therefore, maintenance of a normal core temperature is the goal for management. There is some evidence, however, to suggest that early, carefully controlled hypothermia in the child with a severe injury to the brain and no other injuries may be beneficial, but this treatment option is still experimental.22
The physical examination is a crucial first step in diagnosis as it will direct all other forms of assessment. It is the baseline for serial physical examinations by the trauma team performed later in the hospitalization. After the physical examination, other diagnostic adjuncts may be employed.
During the initial assessment diagnostic testing with standard x-rays is performed with a portable machine or one dedicated to the trauma room, thus avoiding transport of the patient. Frequently ordered imaging studies in the emergency department include the following: plain x-rays of the chest, abdomen, pelvis, cervical spine, and extremities. Thoracic and lumbar spinal x-rays are commonly ordered when neurological injuries are suspected or when the physical examination reveals point tenderness over the spine. The role of cervical, thoracic, or abdominal computed tomography (CT) with reconstruction to evaluate the vertebral column can be helpful. Detecting a pneumothorax, pneumoperitoneum, pelvic fracture, or fracture of a long bone is an important component of the initial care of an injured child. Plain x-rays of the skull may document fractures, but they have little value in directing management of the child with an injury to the brain, except for a penetrating injury or suspected child abuse.23,24 The inability of x-rays to predict intracranial bleeding in the injured child has been documented, also.25
In the past decade, surgeon-performed ultrasonography has been popularized in the United States. Several recent studies by adult and pediatric trauma surgeons have attempted to determine the role of the focused assessment for the sonographic examination of the trauma patient (FAST) in the evaluation of the injured child. The FAST evaluation examines the pericardium, right and left upper quadrants, and the pelvis for fluid. Some surgeons include a thoracic evaluation to detect a hemothorax or pneumothorax.
The technique of B-mode ultrasound in the hands of experienced ultrasonographers should be as accurate in detecting blood in the abdomen as CT scanning or diagnostic peritoneal lavage (DPL).26–28 In a collected series of over 4,900 patients, surgeons who performed ultrasound to detect hemoperitoneum and visceral injury demonstrated a sensitivity of 93.4%, a specificity of 98.7%, and an accuracy of 97.5%.26–29 A second study reviewed 1,043 patients in whom the ultrasonographic study was performed by radiologists. This collected series showed a sensitivity of 90.8%, a specificity of 99.2%, and an accuracy of 97.8%.30–33 Both of these series included adults as well as children.
Surgeon-performed ultrasound evaluation in children should be coupled with the physical examination.34 The typical FAST examination takes less than 2 minutes when performed by a physician experienced in its use. A 3.5 MHz probe is used for children over 10 kg, while either a 3.5 or a 5 MHz probe can be used for children under 10 kg. Obvious benefits of the FAST evaluation include its portability, repeatability, elimination of the need to transport the child to the radiology suite, and the decreased radiation exposure to the child.
CT scans of the head, chest, and abdomen are the accepted diagnostic radiologic studies of choice in the vast majority of hemodynamically stable injured children suspected of having a potentially life-threatening injury. Despite liberal use of CT scans of the head, a normal initial scan of a child may not detect late manifestations of a neurological injury or cerebral edema.35 Unless an absolute indication for surgery is present, the majority of stable children with suspected intra-abdominal injuries should have a CT scan performed prior to instituting operative or nonoperative management. Although CT scanning is the imaging modality of choice in the evaluation of a stable injured child, it is generally accepted that a high percentage of those scans will reveal no injuries. CT scans of 1,500 consecutive children were performed after blunt abdominal trauma, and abnormal CT scans were seen in only 26% of patients.35A normal study was found to strongly predict a lack of deterioration as only one delayed laparotomy was required in the 1,112 children in this group. In addition, a CT scan affected the decision to operate on children with a solid organ injury in a very small subset of patients (5 of 1,500). The technique for performing an emergency CT scan on an injured child, with regard to the use of contrast material, remains unclear. Most institutions will perform an initial CT of the head without using intravenous contrast. The use of intravenous contrast during a CT scan to evaluate intrathoracic or intra-abdominal trauma improves its diagnostic accuracy, but is not required and can be omitted during the initial scan depending on the experience and protocols of the particular trauma center. The benefit of using oral contrast for an abdominal CT in injured children is also a matter of debate. In a randomized prospective clinical trial in adults, the addition of oral contrast to an acute abdominal CT scan for trauma was found to be unnecessary and caused a delay in the time to CT scanning.36 In a review of 2,162 patients with blunt trauma and an abdominal CT, Tsang et al.37 found that all 7 patients with an intestinal perforation had studies that showed neither extraluminal air nor extraluminal oral contrast. In some centers, due to the length of time needed to fill the bowel with contrast and the resultant full stomach that increases the risk of vomiting and aspiration, gastrointestinal (GI) contrast is avoided in the initial CT scan of the abdomen in the injured child. Other centers suggest that it improves the accuracy of abdominal CT scans when intestinal or retroperitoneal injury is suspected and that oral contrast in adults and children is safe and has a minimal incidence of aspiration.38,39 In summary, at the present time the use of GI contrast in emergency CT scans of the abdomen for trauma is a matter of institutional preference.
Evidence of intra-abdominal injuries requiring operative correction on the CT scan may be subtle. Findings of free intraperitoneal or retroperitoneal air, extravasation of GI contrast, defects in the bowel wall, and active hemorrhage are often obvious and have a high correlation with an injury to the intestine that will require operative intervention.40 There are, however, potentially life-threatening intestinal injuries that may present with only focal thickening of the bowel wall or the presence of peritoneal fluid without injury to a solid organ.41 Other less specific findings associated with intestinal injuries include mesenteric stranding, fluid at the mesenteric root, focal hematomas, mesenteric pseudoaneurysm, and the hypoperfusion complex.
Repeated CT scanning during an acute hospitalization may expose children to very high doses of radiation and an increased risk of cancer. Epidemiologic studies have demonstrated a much greater sensitivity to radiation in the pediatric population when compared with adults. The lifetime risk of cancer is significantly increased when children are exposed to diagnostic radiation. The current scientific evidence suggests that the risk of cancer from low-level radiation such as from CT may be as high as one fatal cancer death for every 1,000 CT performed in children.42 The amount of radiation a CT scan imparts depends on many factors, and protocols can be adjusted to provide adequate image quality while reducing exposure. Minimizing the risk of radiation exposure in diagnostic imaging is a complex task and a multidisciplinary approach is needed. Trauma clinicians should be aware of the potential risks and benefits of CT and consider these issues when selecting imaging studies.
The routine use of laboratory studies in the ED, in general, has not been shown to be of significant value in the pediatric trauma population.43–45 Some specific clinical laboratory tests such as urinalysis and arterial blood gases with base deficit may be of limited benefit in selected circumstances.46 More often, laboratory testing delays the clinical decision-making process occurring in the ED during evaluation and resuscitation, and point-of-care testing has not altered this concept.47 In the presence of a possible injury to the brain, testing for a coagulopathy, thrombocytopenia, or hyperglycemia may be of benefit to establish a baseline for later determinations or to assist in assessing the risk of morbidity or mortality.48–50 During hospitalization, routine laboratory testing is appropriate as long as specific indications exist for monitoring, such as nonoperative management of an injury to the spleen or pancreas.
MANAGEMENT OF SPECIFIC INJURIES
Injury to the Head and Central Nervous System
Acute traumatic brain injury is the most common cause of death and disability in the pediatric population.51 In those who survive, minor injuries can be associated with reversible defects while major injuries can result in severe disabilities. The mechanisms of injury to the brain in children are related to age. Infants typically suffer more from falls such as from a table or the arms of a caregiver. Intentional injury is a common cause of death in children under 2 years of age. Injury with intention, independent of severity, raises the mortality in children with traumatic brain injuries.52 In older children the usual cause of injuries to the brain is from vehicle-related accidents or recreational activities. Although children have a better survival rate with injury to the brain when compared with adults, this does not mean they have a lesser morbidity with similar injuries. Children have a plasticity of the neuron related to myelination and the establishment of neuronal interconnections. This allows a given focal injury to produce a less severe deficit when compared with a mature brain. This same lack of maturity may also make the child more susceptible to a diffuse injury with greater cognitive impairment.53
The head of an infant constitutes 15% of the total body mass, while the head of an adult makes up only 3%. Acceleration and deceleration injury in pediatric trauma, therefore, yields a greater amount of force applied to the brain. The neck muscles do not support this relatively larger head as well as they do in teenagers and adults. Also, the skull of the infant is thin and soft, and the closure of fontanelles and sutures is not completed until age 3. In addition, the volume of cerebrospinal fluid is smaller than that of the adult and the child’s brain has greater water content. Finally, myelination occurs between 6 and 24 months, making the brain very soft and prone to disruption prior to completion of this process.
Injuries to the brain are classified as primary and secondary. Primary injuries are those inflicted immediately by the trauma, while secondary injuries are those resulting from ischemia, hypoxia, hypotension, infection, hydrocephalus, seizures, or increased intracranial pressure (ICP). Children are more likely to have low-pressure venous bleeding from an overlying skull fracture than from arterial injuries resulting in a lower incidence of epidural hematoma. The very young infant can actually have a critical reduction in blood volume from intracranial bleeding due to the relatively large size of the brain compared with the body mass. Much as in adults, diffuse axonal injury is a shear stress to the brain caused by acceleration/deceleration mechanisms, often with angular or rotational motion. Even minor shearing can cause severe neurological deficits.
Secondary injury is most often the result of an elevated ICP. An elevated ICP may be caused by increased cerebral blood volume, increased brain volume, or hematomas. An elevated ICP can cause direct injury due to compression resulting in herniation under the falx cerebri or through the tentorium cerebelli. Increased ICP causes a reduction in cerebral perfusion pressure (CPP). The CPP should be 60–80 mm Hg in older children and at least 50 mm Hg in children under the age of 8. Injury to the brain can impair autoregulation, and inappropriate vasodilation may occur resulting in significant increases in tissue volume and ICP. With this deranged physiology, even minor injuries to the brain in children can lead to global hyperemia and death.54
The Brain Trauma Foundation has published guidelines for the management of trauma to the brain in children.55 These recommendations are based on the available literature, at times drawing from adult data. Few definitive guidelines exist, and the majority of recommendations are based on treatment options commonly used in the clinical setting. The Glasgow Coma Scale (GCS) can be used for children over the age of 5, while some modification is often used for children under 5 (Table 43-4). If a score of less than 9 is determined, that patient typically requires airway management and measurement of the ICP.
TABLE 43-4 Pediatric Glasgow Coma Scale
During the initial evaluation and resuscitation of the child with an injury to the brain, care should be taken to avoid a secondary injury due to the causes noted above. Also, clinical and radiologic evaluation of the cervical spine is important to rule out injury. The presence of cervical tenderness mandates the application of a rigid collar and imaging aimed at identifying the possible injury. Three-view x-rays of the cervical spine are a necessary start followed by a CT scan or MRI as needed depending on the age of the child.
Once the patient has undergone an initial evaluation, causes of secondary brain injury have been managed, and the cervical spine has been stabilized, a CT of the head and brain should be obtained, ideally 30–60 minutes after arrival depending on the hemodynamic stability of the patient. If there is evidence of swelling of the brain, monitoring of ICP is indicated. This is best done with a ventriculostomy that allows for drainage of cerebrospinal fluid. The ICP should be maintained under 20 mm Hg, while cerebral perfusion pressure should ideally be in the range of 40–65 mm Hg as noted previously.
Avoiding hyperthermia is important as this may cause a secondary injury to the brain. Another management technique is hyperosmolar therapy with hypertonic saline or mannitol. Hypertonic saline is delivered in a continuous 3% solution at 0.1–1.0 mL/(kg h) on a sliding scale to keep , while mannitol is used as a bolus at 0.25–1 g/kg of body weight. Euvolemia should be maintained with appropriate administration of intravenous fluids. The serum osmolarity should be maintained at 320 mOsm for mannitol, and below 360 mOsm with hypertonic saline. Other methods to decrease ICP and protect the injured brain include sedation, the rare use of hyperventilation, the administration of barbiturates, and decompressive craniectomy. The latter approach should only be considered in children with cerebral edema and medically uncontrolled intracranial hypertension. It is not likely to be useful in children who have suffered an extensive secondary injury to the brain or in those who have an admission GCS of 3 and no improvement with therapy. Nutritional support, avoiding the use of steroids, and treating postinjury seizures are also important aspects of the care of the child with an injury to the brain.
Injury to the Cervical Spine
Injuries to the cervical spine represent less than 1% of all pediatric fractures.56 Trauma to the upper cervical spine tends to occur in younger children (less than 8 years), while midcervical injuries occur in older children. Motor vehicle crashes are the primary cause of associated injuries to the spinal cord in younger children while sporting activities are more common in older children.57 Children have more flexible interspinous ligaments and joint capsules, flatter facet joints, and vertebral bodies that are wedged anteriorly and tend to slide forward with flexion. Their head to neck ratio is also different, placing them at risk for different injuries than in adults.
The diagnosis of injuries may be challenging, as radiologic differences exist in the maturing cervical spine. There may be anterior displacement of C2 on C3 appearing as a subluxation. This is a normal pediatric variant described as a pseudosubluxation (Fig. 43-1A–C). In addition, skeletal growth centers may be easily confused for fractures. A careful physical exam is always warranted, as spinal cord injury without radiographic abnormalities (SCIWORA) has been shown to occur in as many as 66% of children.58
FIGURE 43-1 (A) Normal pediatric C spine x-ray. (B) Mild pediatric pseudosubluxation at C2–C3. (C) Moderate pediatric pseudosubluxation at C2–C3.
The pediatric trauma population can be divided into two populations with respect to injuries to the cervical spine, including those 8 years of age and less and those 9 years and older. Each group has different patterns of injury to the cervical spine as a result of differing anatomic and biomechanical properties, and a tailored evaluation and management of these injuries is required. The anatomy/biomechanical profile of children 9 years and older mirrors that of adults, and evaluation of cervical spine can be accomplished with adult protocols. A modified approach to the child 8 years of age or less should be employed. If history or examination suggests a child at risk for injury, then a two-view cervical spine series would be indicated to identify any obvious injury. If plain films are negative in this age group and there is still concern for injury, the available data would suggest that flexion extension films or an MRI should be obtained since most injuries are ligamentous in nature. Given the high frequency of SCIWORA in this age group, one should proceed to MRI if there is a neurological deficit (Fig. 43-2). In the interim the child’s head and neck should remain immobilized at all times.
FIGURE 43-2 MRI of C spine showing cord compression.
Injury to the Thorax
Thoracic trauma is an important cause of morbidity and mortality in children. It accounts for 4–25% of pediatric injuries and is associated with a greater mortality rate when compared with injuries in other systems.59,60 Isolated thoracic trauma in a child is associated with a mortality rate of approximately 5%59 and is largely due to penetrating trauma. About 80% of thoracic injuries in children are from a blunt mechanism. Children with associated neurosurgical trauma, thoracic trauma, and abdominal trauma may have a mortality rate that approaches 40%. Thoracic trauma is likely to be present in children who present with a low systolic blood pressure, an elevated respiratory rate, abnormalities on physical examination of the thorax, and the presence of a fracture of the femur.61
The child’s thorax has unique anatomic and physiologic properties that are important to the diagnosis and treatment of thoracic trauma. The trachea is shorter relative to body size, more anterior, narrower, and more easily compressed as compared with the adult. Also, the subglottic region is the narrowest part of the airway. Therefore, the pediatric airway is more susceptible to mucus plugging and edema. The chest wall is more compliant in children with less muscle mass, and this allows a greater transmission of energy to underlying organs when injury occurs. Finally, the mediastinum is more mobile than in older patients, especially in young children. Unilateral changes in thoracic pressure such as with a tension pneumothorax can lead to a shift of the mediastinum to the extent that venous return is markedly reduced. This response is more pronounced than typically seen in an adult.
Young children have a compliant thorax that becomes more adult-like at 8–10 years of age. As a consequence, rib fractures are relatively uncommon in young children and occur more frequently in adolescents. Although rib fractures are uncommon, injuries to the lung, liver, and spleen lying underneath the ribs are quite common. One of the most common thoracic injuries in children is a pulmonary contusion, which can occur with blunt or penetrating trauma. The presence of a pulmonary contusion contributes to decreased pulmonary compliance, hypoxia, hypoventilation, and a ventilation perfusion mismatch. A chest x-ray taken during the initial assessment may demonstrate a pulmonary contusion, while a thoracic CT scan may show areas of pulmonary contusion not appreciated on the x-ray. Treatment of a pulmonary contusion includes appropriate fluid resuscitation, supplemental oxygen, pain management, and strategies to prevent atelectasis and pneumonia. Unfortunately, some patients may develop pneumonia or respiratory distress syndrome (RDS) after sustaining a pulmonary contusion.62 In an occasional patient, a large pulmonary contusion may cause life-threatening hypoxia that cannot be supported with conventional or advanced techniques of ventilation including high-frequency oscillation. Extracorporeal life support has been used in extreme circumstances to support patients with severe pulmonary contusions and secondary RDS.
A pneumothorax is typically treated with a thoracostomy tube appropriately sized for the patient, while a hemothorax is treated with the largest tube that can be inserted. Intrathoracic blood loss of 15 mL/kg immediately or ongoing losses of 2–3 mL/(kg h) for ≥3 hours mandate thoracic exploration to control bleeding in children.63,64 Cardiac injuries are extremely rare, as are tracheobronchial or esophageal injuries. They do occur, however, and should be ruled out in any child with cervicothoracic injuries. Similarly, injuries to the great vessels occur in children with rapid deceleration injuries, and these types of injuries should be considered in any child with the appropriate mechanism.65
Injuries to the thoracic aorta are rare in the pediatric population and are often lethal. Aortic injury is the second leading cause of death in the pediatric population and accounts for 14% of trauma deaths.66 The age of victims of aortic injury has been shown to range from 6 to 17 years, and most are victims of motor vehicle crashes. Several identifiable risk factors have been associated with blunt injury to the thoracic aorta. Clinical predictors that have been noted include a low systolic blood pressure on admission, increased respiratory rate, abnormal thoracic exam, especially chest auscultation, an associated fracture of the femur, and a GCS of less than 15.60 If there is a high index of suspicion based on history, physical examination, or an x-ray of the chest, further testing is required. Helical chest CT and transesophageal ECHO (TEE) have been found to be equally sensitive when compared with aortography in the detection of an aortic injury. Once the injury is found, the treatment of thoracic aortic injuries is similar to that in adults. Beta-blockers should be started early, while treatment options include nonoperative management, operative management, and the use of an endovascular stent graft if a correctly sized graft is available. The long-term outcome of endovascular stenting in children is unknown.67
Injury to the Abdomen
Due to the relatively thin pediatric abdominal wall, a modest amount of force may cause a significant injury to one or more organs in the abdomen. Multiple organs may be injured from a single blow due to proximity. The assessment for abdominal injury begins with the physical examination, and inspection may reveal bruising, a mark from a lap seat belt, or abdominal distention. Tenderness on physical examination should prompt a higher level of evaluation with CT scanning. A nasogastric or orogastric tube should be placed to decompress the stomach.
With the emphasis on nonoperative management of abdominal injuries in children, injuries requiring operative management have been missed for hours to days. It has been noted that a delay in diagnosis is not usually associated with an increased mortality; however, an increase in septic complications has been seen when operative intervention is delayed more than 24 hours postinjury. This phenomenon is peculiar to children and, as a result, inhospital observation with serial examinations should be employed in all children with abnormal abdominal examinations. Repeat ultrasound is particularly useful in this subset of patients. When abdominal injuries occur under suspicious circumstances, the diagnosis of child abuse should be entertained.
Blunt diaphragmatic rupture is an uncommon injury in children. The left hemidiaphragm is more likely to be injured, but bilateral ruptures have occurred. The frequency of associated injuries, especially the liver and spleen, is very high.68 An abnormal contour of the diaphragm, a high-riding diaphragm, or a questionable overlap of abdominal visceral shadows may indicate injury on a chest x-ray. Visceral herniation, the abnormal position of a nasogastric tube overlaying the hemithorax, or early intestinal obstruction after trauma makes the diagnosis likely. CT has been used to establish this diagnosis, but may appear normal in some patients. Therefore, ultrasound or a high-resolution CT scan through the diaphragm may be needed to establish a diagnosis. Many diaphragmatic ruptures are not identified in the first few days after injury and may not be detected for a considerable period of time.69 Repair of an acute diaphragmatic rupture is best accomplished with an abdominal approach. If a late diagnosis of a diaphragmatic injury is made, a thoracic approach to repair is often considered secondary to the scarring and adhesions that may have formed.
Blunt injuries to the stomach are the third most common perforation of the GI tract in the injured child and occur relatively more frequently in children than in adults.70 The site of perforation is most often the greater curve of the stomach. The diagnosis is usually made quickly, due to the common occurrence of peritonitis and free air seen on an initial x-ray in the emergency department or a bloody nasogastric aspirate. At operation, the stomach is closed in two layers when possible, with the use of a decompressive gastrostomy considered when a massive injury is present. Every effort should be made to salvage the spleen during repair of the gastric injury.
Duodenal injuries are uncommon in children. The child with a duodenal injury that requires surgery most often presents with abdominal distention, bilious vomiting, peritonitis, and pneumoperitoneum on an abdominal x-ray. In a recent review from 2 busy pediatric trauma centers, 42 patients with a duodenal injury were identified in 10 years.71 There were 33 blunt and 9 penetrating injuries. Operative management was necessary in 24 patients and included primary repair, duodenal resection, and gastrojejunostomy with pyloric exclusion. In contrast, a duodenal hematoma is usually treated nonoperatively with nasogastric decompression and total parenteral nutrition. This management has a high rate of success, but may take as long as 3 weeks for the obstruction to resolve. A late diagnosis of duodenal perforation can occur with this injury and is usually associated with an increase in complications, but not mortality.
The jejunum and ileum are the most common parts of the GI tract to sustain injury in the child. The mechanism of injury to the small bowel is a crush injury between the delivered force and the vertebral column. Adult-sized seat belts are often employed by conscientious parents and, as a result, the risk of injury to the small bowel increases. This increase in risk is remarkable in children under 100 lb in weight. If a hematoma from a seat belt is present on the abdominal wall, the risk of an intra-abdominal injury is 232 times more likely. Therefore, a higher index of suspicion should be employed.72 Children with rupture of the small bowel due to blunt trauma invariably have an abnormal physical examination. A recent multi-institutional review suggested that delay in operative intervention does not have a significant effect on prognosis after pediatric blunt intestinal injury.73 Free fluid seen on ultrasound (FAST) or CT scan, coupled with a tender abdomen and no injury to a solid organ on the CT, mandates an abdominal exploration for a suspected injury to the small bowel. Even if no perforation is identified at surgery, care should be taken to repair mesenteric rents, evacuate large hematomas, and rule out retroperitoneal injuries. In this same setting, an associated compression injury of the lumbar vertebrae (Chance fracture) is often present.
Injuries to the colon and rectum are not common in children. Accidental causes of colon and rectal injuries include motor vehicle crashes with pelvic fractures and penetration of the rectum by bone shards, occasional serosal injuries from seat belts, and straddle injuries. Nonaccidental injuries are invariably related to abuse, typically from instrumentation. If the mucosa is injured or the injury is superficial, observation is appropriate. Full-thickness injuries of the distal rectum can be managed with primary repair in many cases. Similar to adults, devastating colon injuries above the peritoneal reflection occasionally need temporary fecal diversion.74
As the injured spleen in a child will usually stop bleeding without intervention, nonoperative management is widely accepted.75 Occasionally, a child with a severely injured spleen may develop a left pleural effusion (Fig. 43-3A and B). After an occult diaphragmatic injury has been ruled out, the effusion can typically be treated with a thoracostomy tube. Children who have received or are likely to receive half their blood volume in transfusions within 24 hours of injury (40 mL/kg) have progression of the rupture during nonoperative management or have hemodynamic instability and should be treated operatively. The physiologic response to splenic injury correlates with the grade of splenic injury.76 If splenectomy must be performed, postsplenectomy immunization and antibiotic therapy is appropriate and necessary based on available guidelines.77 It is recommended that all persons aged 2–64 years receive pneumococcal vaccine and meningococcal vaccine, with Haemophilus influenzae type B vaccine administered to high-risk patients, as well. Vaccination should be given 2 weeks after emergency splenectomy. A booster dose of pneumococcal vaccine is recommended after 5 years, while no revaccination recommendation is made for meningococcal or H. influenzae type B vaccine. In addition, many children are given penicillin on a daily basis if the splenectomy is performed before the age of 5 years.
FIGURE 43-3 (A) Note the grade IV spleen injury. (B) The admission chest x-ray of the child injured in Fig. 43-1A, and the chest x-ray 4 days later showing a pleural effusion.
Nonoperative management of hepatic injuries is now widely accepted. Injuries to the liver parenchyma, without involvement of a major intrahepatic vessel or bile duct, can nearly always be successfully treated with observation. This is especially true in patients with isolated hepatic injuries, although these are associated with a slightly higher mortality rate when compared with splenic injuries. The combination of hepatic and splenic injuries is clearly associated with a higher mortality rate, which increases as the severity of injury rises.78 As with splenic injuries, operative intervention is indicated when half of the blood volume has been transfused. If a blush is seen on CT, angioembolization may replace operation in the stable patient. Others have advocated early operative packing in more unstable patients coupled with embolization and early reoperation as a means to improve survival.79 The physiologic and hematologic effects of massive transfusion in the child often make the operative management of a major hepatic injury very difficult unless the new paradigm of a 1:1:1 red blood cell unit:fresh frozen plasma unit:platelet transfusion is followed. When perihepatic packing has been necessary or the midgut is edematous after a major hepatic repair, a commercially available vacuum system or off-the-shelf supplies such as soft bowel bags, laparotomy packs, adhesive dressings, and silastic drains placed on suction can provide a very effective damage control dressing. Eventual fascial closure should be able to be accomplished with most survivors (see Chapter 38).80
Pediatric pancreatic injuries are uncommon and are most often due to blunt trauma81 (Fig. 43-4). A common mechanism is contact with the handlebar of a bicycle. The majority of pancreatic injuries in children may be treated successfully with nonoperative management including gut rest, intravenous nutrition, and, occasionally, pancreatic antisecretory medication. Conservative management of children with a pancreatic transection is much more controversial. A small group of patients with a prolonged median hospitalization and incomplete follow-up has been reported, and nonoperative management was advocated.82 Late pancreatic pseudocysts were common and required intervention. Others have reported the beneficial effects of a spleen-sparing distal pancreatectomy even in the face of a delayed diagnosis.83 Operative intervention allowed an earlier return to normal activities and avoided the stress of prolonged hospitalization. When capabilities for pediatric ERCP are available, ductal stenting may be of significant benefit.84 Some surgeons have been able to employ laparoscopic distal pancreatectomy with splenic salvage for pancreatic transection when stenting could not be accomplished.85
FIGURE 43-4 Transection of the pancreas; arrow denotes the transection point.
Blunt trauma is the most common mechanism of renal injury in children (Fig. 43-5). Contusion is the most common injury seen, and renal injury can occur in the absence of hematuria. Nonoperative management of most pediatric renal injuries (grades I–IV) can be accomplished safely, and operative renal salvage for grade V injuries appears to be uncommon.86,87 Some investigators have noted a good salvage rate with nonoperative management of grade V injuries, but scarring and loss of parenchymal volume did occur.88 Ureteral stenting for urine leaks may be needed in patients with injuries of the collecting system. Rarely, nephrectomy for exsanguinating injury may be needed. The majority of patients will not require an emergency intervention, but angioembolism may be considered in selected cases of intraparenchymal bleeding. Since most injured children now undergo abdominal CT scanning, CT cystography may be considered on every child to evaluate for the presence of an injury to the bladder.89The majority of retroperitoneal bladder ruptures can be treated successfully with urethral catheters, without the need for additional suprapubic drainage.90
FIGURE 43-5 Left renal injury.
Injury to Blood Vessels
Injuries to vessels in the extremities are equally divided between blunt and penetrating mechanisms.91 Such injuries in children are uncommon, and children can tolerate complete vascular occlusion to the extremities to a greater extent than adults. Due to the elastic nature of the child’s body, injuries to large vessels do not occur as often as adults. Limb salvage is typically greater than 95% using a team approach to care for associated orthopedic and soft tissue injuries. Pediatric peripheral vascular injuries requiring resection are repaired with autologous tissue whenever possible.92
Injuries to the abdominal aorta have been caused by seat belts, bicycle crashes, and ATV crashes.93 These are repaired immediately, and missed abdominal aortic injuries have resulted in late deaths.94 The rare injuries to the thoracic aorta in children have been treated like those in adults with good results.67 The use of endovascular stents in children, while successful in the short term, has not been evaluated for long-term use.
Injury to the Skeletal System
Orthopedic injuries are the most common injuries requiring operative intervention in the injured child. These injuries are often painful and may distract the child from complaining of other more serious injuries. As orthopedic injuries can be missed in the injured child, a tertiary examination should be considered for all children admitted to the hospital to evaluate for possible missed injuries.95 As previously discussed, injuries to the cervical spine are often misdiagnosed, and most of the missed injuries are due to normal variants.96
Orthopedic injuries in children may involve the growth plate. The physis, also known as the growth plate, exists in the immature skeleton and can cause potential confusion on diagnostic studies and with treatment. New bone is laid down by the physis near the articular surfaces and causes lengthening of the bone. When an injury occurs before the physis has closed, retardation of normal growth and development of the bone may occur.
As children grow and bones mature, changes in porosity, composition of collagen fibers, and mineral content occur. Due to the immature, elastic nature of immature bones, specific fractures can be seen in children. Greenstick fractures are incomplete fractures with angulation supported by cortical splinters on the concave surface. Buckle fractures can be seen in growing bones and are angulations due to cortical impaction. Other fractures that may cause injury to the growth plate include supracondylar fractures of the humerus or femur. These fractures may be associated with vascular injuries.
Blood loss is associated with fractures of long bones and the pelvis. The blood loss is proportionately less than in adults and usually not enough to cause shock. If hemodynamic instability exists with an isolated fracture of the femur or pelvis, an evaluation for other sources of blood loss should be undertaken starting with the abdomen.
The key principle of the treatment of fractures is immobilization and splinting of fractured extremities until more definitive treatment is undertaken. Also, it is important to obtain a good vascular exam in every patient with fracture of a long bone. Compromise of arterial inflow requires an early diagnosis, realignment of the fracture, and an occasional revascularization procedure to prevent permanent dysfunction or loss of tissue. Finally, it is important to be aware that a compartment syndrome secondary to hemorrhage from the fracture may occur and should be addressed within 6 hours of injury to prevent permanent damage.
PEDIATRIC CRITICAL CARE
In general, hemodynamic instability, traumatic brain injury, altered mental status, significant injuries of the spleen, liver, or pancreas, multiple orthopedic injuries, severe pulmonary contusion, and polytrauma require more care than can be provided in a general hospital setting. Patient management in the ICU allows for continuous monitoring of vital signs, oxygen saturation levels, urine output, and neurological exams. There are data that suggest that the care of injured children in a pediatric ICU improves survival.97
Monitoring in the ICU may be noninvasive or invasive. Arterial lines, which allow for closer observation of blood pressure and for drawing of blood gases, should be placed in the ICU. A line to measure central venous pressure should be inserted, as well.
Acute respiratory distress syndrome (ARDS) may occur within 3–4 days after major trauma, and ventilation modes are somewhat similar to adults in concept. The two common modes of ventilation are based on pressure and volume. Pressure control is rapid variable flow that provides a peak inspiratory pressure throughout inspiration. Volume control provides a constant tidal volume and minute ventilation regardless of pulmonary compliance. Pressure-regulated volume control is a combination that has a set tidal volume and inspiratory time, but allows the ventilator to adjust the flow rate. If the patient’s respiratory status is refractory to conventional modes of ventilation, the oscillator or high-frequency ventilation may be necessary. This allows for continuous high airway pressures, low tidal volumes, and a very fast rate. If all modes of ventilation have failed and the patient is a candidate, extracorporeal membrane oxygenation (ECMO) may be necessary as previously mentioned. It is important to note that ECMO does not reverse any disease process, but allows the heart and lungs to rest in order to heal the primary process.
Rehabilitation is an important part of the recovery from injury for both children and adults. A rehabilitation facility assists patients with new-onset disabilities and impairments due to trauma to regain function and autonomy. The rehabilitation team focuses on medical issues as well as teaching compensatory techniques, lifestyle modifications, use of adaptive equipment depending on injury, how to deal with posttraumatic psychological impairment, and prevention of deterioration. The major difference between adult and pediatric rehabilitation is that growth and development must be taken into account with children. The age of the child must be considered at every stage of the process to ensure that appropriate developmental goals are set and being met if possible.
Rehabilitation begins by carefully outlining all the injuries, disabilities, and impairments. Based on age, a multidisciplinary team formulates a plan with the family and patient (if possible). It is important to acknowledge and treat any grief, sadness, anger, or depression that is present and may impede the process of rehabilitation. Prior to discharge a plan with the family and patient should be in place. Follow-up with the surgical team should continue throughout rehabilitation and after as needed.
Child abuse is a serious problem and represents 3–4% of all traumatic injuries seen in pediatric trauma centers.98 It is important for clinicians to know the signs of child abuse in order to protect and care for those who cannot protect themselves. A thorough history and physical examination are paramount. Suspicion should be raised if there is a discrepancy between the history and the extent of injury, there are explanations that do not fit, and a long period of time has passed from the incident to when medical advice was sought. Unexplained events such as loss of consciousness should be questioned. A history of repeated trauma treated at different emergency rooms with “doctor shopping” is also ominous. Fractures from different time periods as well as long bone fractures in children under 3 years of age should alert the clinician to the possibility of child abuse. In addition, if the history changes between caregivers and there is inappropriate behavior displayed from parents or caregivers in regard to the medical advice given, a suspicion should be raised. It is important to observe the relationship between the child and the parents and decipher whether the relationship appears strained or abnormal.
On examination, it is very important to observe multicolored bruises signifying different stages of healing and evidence of frequent injuries demonstrated by old scars or healed fractures on x-ray. Long bone fractures in children younger than 3 years old, multiple subdural hematomas, especially without a new skull fracture, and retinal hemorrhage are suspect injuries. Other concerning injuries are those in odd places such as the perioral, genital, or perianal areas. Ruptured internal viscera without a history of major blunt trauma have also been associated with abuse. Finally, it is important to recognize and thoroughly investigate abnormal injuries such as bites, cigarette burns, or rope marks as well as sharply demarcated second- and third-degree burns in odd locations.
The workup should include a skeletal survey to look for other or old fractures. CT scans and MRIs should be obtained accordingly. It is important to emphasize that it is a requirement for the examining physician in all 50 states to report any questionable circumstance to Child Protective Services (CPS). Once reported, it is up to CPS to investigate and proceed with the appropriate measures.
EMERGENCY DEPARTMENT MANAGEMENT AND FAMILY RELATIONS
The majority of injured children are not cared for at pediatric trauma centers.99 Every emergency department should have the equipment, supplies, and the mindset to care for an injured child. Many nontrauma centers see children with injuries that are beyond their capabilities. With this in mind, establishing good communication and plans for transfer to referral centers that care for large volumes of children is mandatory. Also, many pediatric trauma centers are allowing families at the bedside of children with severe injuries, after or during the initial resuscitation. Some centers even have the family at the bedside while cardiopulmonary resuscitation is in progress. This takes a serious commitment to professionalism and sensitivity during a time when stress in the emergency room is at its highest.
This work is supported in part by the Paula Milburn Miller/CMRI Chair in Pediatric Surgery.
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