Pediatric Major Trauma:

Priorities and Perspectives

Sean M. Fox, MD, FACEP, FAAPCarolinas Medical Center Department of Emergency MedicineDivision of Pediatric Emergency Medicine

I receive a paycheck only from CMC

sometimes …academic salary seems to inflict Trauma...

At the completion of this presentation, you will be able to describe the:

1) Recognize the challenges inherent in the management of the pediatric trauma patient.

2) Describe how the anatomic and physiologic differences that exist in pediatric patients affect the management of the trauma.

3) Balance benefits of injury detection with risk of radiation in the pediatric patient with thoracic trauma.

•Injury leads to more Pediatric Deathsthan all other causes combined.

•~ 1/4 children sustain an unintentional injury that needs medical care each year

•EVERY 4 Seconds (in the USA), a child is treated in the ED for an injury!

Why Should You Stay Awake

• ~35,000 kids suffering from severe TBI / yr

• Head Injury is the Leading cause of death.

• 2nd leading cause of Death is Thoracic Tx

• 4 - 6% of Ped Trauma is Thoracic Trauma

• 14% of Ped Trauma related Deaths

• More common in adults, but still source of significant M&M, and Confusion.

Why Should You Stay Awake

• Trauma is more than additive…

• For instance… Thoracic Trauma:

• In isolation - 5% Mortality

• With Abd or Head - 25% Mortality

• All three together - 40% Mortality

Why Should You Stay Awake

The Challenge - Kids• Appropriately Assess and Evaluate

• Reluctant to be evaluated

• Not as commonly evaluated as adults

• Anatomic and physiologic differences

• Do No Harm

• Psychiatric harm

• Physical harm

Child Life Resources

Systematic Approach

Special Considerations

• Size Matters• Kids are Flexible• Kids are Oxygen Pacman

Size Matters• Small Size (Single impact can affect more organs) • Disproportionally Large Head w/ Large Occiput • Small airway• Auscultation often can deceive (transmit sounds so

easily from opposite side)• SA:Mass - Heat Loss is always a problem!

Greater Flexibility• Trachea: Narrow, Short, More Compressible • Thoracic Cage More Compliant

• No external signs of force exerted• Increases actual work of breathing• Doesn’t protect abdominal organs

Greater Flexibility• Abdominal organs are Resilient.

• Spleen injuries don’t necessitate surgery.• Mediastinum is Mobile

• Good = Allows Aorta to get out of way• Bad = Can compromise Preload

“Chew up O2 like a Pacman”• High Metabolic Rate

• Low FRC

Cardiac Function• Usually not the problem (unlike our older pts)• Compensates well for hypovolemia• CO is dependent upon HR and Preload

ATV vs Kid

6 yo thrown from ATV when it rolled over.Was wearing helmet! Cried immediately. No LOC.

Complains of left flank pain.

Primary survey - normal. Symmetric chest rise and breath sounds. O2 sat normal.Abdomen diffusely tender with abrasions over flank.

Pelvis stable.CXR - normal.

Chest CT

PanScan

ATV vs Kid

Pneumothorax

Specific Injuries

Pulmonary ContusionTamponadeAortic Injury

Difficult to Dx• May be asymptomatic• Size (of the patient) Matters!

• Small Airway easily occluded• Auscultation can fool you

• Many Mimics• AP CXR may be misleading

Pneumothorax

• Time is on your side• Emergent thoracostomy is rarely require in kids

• Inspection >> Auscultation• Flexible rib cage

• Augment your Physical Exam!

Pneumothorax

Augment Your Exam

Courtesy of Anthony Weekes, MD

Air vs Lung

• Chest Tubes in Kids aren’t easy.

• Risk of complications is greater in small children

Pneumothorax

Air vs Lung

•Stable patient•Small pneumothoraces•Not in need of PPV

(relative)•Consider transport

Pneumothorax

What do I do with this information?????

Normal CXR, but Ptx on Abd CT?(Holmes. J Trauma 2001)

• “Minuscule” and “anterior”

• Rarely require intervention

• No complications

• Even the ones intubated

• PE not as reliable, so AUGMENT it.• No need to be more sensitive. CXR is fine.• Chest tubes are trickier, so be humane.

Pneumothorax

Pneumothorax

Specific Injuries

Pulmonary ContusionTamponadeAortic Injury

• Thoracic Cage More Flexible• No external signs of force exerted

• Pulm Contusion without Rib Fx

• Increases actual work of breathing

• Leads to V/Q mismatch and Hypoxemia

• Chew up O2 like PacMan!

Pulmonary Contusion

• Volume of Lung Injured Matters• CXR doesn’t show Volume well

Pulmonary Contusion

Radiation - Big Deal?

=?

Committee to assess health risks from exposure to low levels of ionizing radiation; nuclear and radiation studies board, division on Earth and life studies, national research council of the national academies. Health Risks From Exposure to Low Levels of ionizing Radiation: BEIR VII Phase 2.

Washington, DC: The National Academies Press; 2006.

Kids are More Sensitive

Brenner, DJ. Hall, DP. Computer Tomography - An Increasing Source of Radiation Exposure. NEJM; 2007: 2277-2284

• More radiosensitive tissues

• More time to develop Cancer

• More radiation exposure time

The Risk

Risk is Cumulative• Background radiation = 3.5 mSv/year• CXR = 0.1 mSv (~10 days worth)• Head CT = 2 mSv (~8 months worth)• Chest CT = 7 mSv (~2 years worth)• Abd/Pelvis CT = 10 mSv (~3 years worth) • Lumbar CT = 15 mSv (~5 years worth)

Kwon, et al. CT diagnosis of Pulm Contusion does not correlate with increase mortality. J Ped Surg; 2006: 78-82.

Imaging IssuesIn Favor of CT:

• CT detects contusion earlier, estimates volume

• Symptoms depend on amount of lung involved

Against CT:• Pulm Contusion on CT Only does not increase morbidity and has limited

clinical significance

• Pulm Contusion on CXR had statistically significant longer LOS, more ICU days, and more Vent Support

Pulmonary Contusion

Kwon, et al. CT diagnosis of Pulm Contusion does not correlate with increase mortality. J Ped Surg; 2006: 78-82.

Management Strategies• Fluid Restrict, O2, Pain Control, I/S

• BiPap may be useful

• Large Contusions - may need Mech. Vent

Pulmonary Contusion

• Utilize CXR over CT.

• Manage the patient’s clinical symptoms!

Pulmonary Contusion

Pneumothorax

Specific Injuries

Pulmonary ContusionTamponadeAortic Injury

• Size Matters (once again)• Classic Triad is hard to appreciate• CO = HR x SV • Rare - so hard to consider

Tamponade

Courtesy of Anthony Weekes, MD

Tamponade

• Augment my Physical Exam!

• Consider when hypotensive!

• Think of if deterioration after procedure

Tamponade

Pneumothorax

Specific Injuries

Pulmonary ContusionTamponadeAortic Injury

• Uncommon - 0.1%, but Bad News. • Mediastinum is Mobile

• Good = Allows Aorta to get out of way

• Bad = Can compromise Preload

Aortic Injury

4 studies illustrate common themes:• Older Age (Adolescents)• Multi-trauma with Concomitant Injuries

(Hip Dislocation, Rib, Femur, or Pelvis Fxs, Liver or Splenic lacerations and/or CHI)

• High Force Karmy-Jones et al. Thoracic Surg. 2003; 75:1513-1517Heckman et al. J Ped Sx. 2005; 40: 98-102

Takach et al. Tex Heart Inst J. 2005; 23: 16-20

Anderson et al. J Ped Sx. 2008; 43: 1077-1081

Aortic Injury

Management• Debated still...

• Tx with Beta-blockers

• Operation after recovery of good pulses and cardiac function and all other major injuries resolved (CNS)

ATLSReferences the increasing

literature that supports endovascular repair for blunt

traumatic aortic injury.

Aortic Injury

• Know who is at High Risk.

• Younger - Flexible; Older - Fragile

• Carefully evaluate all trauma CXRs.

Aortic Injury

Something Tangible...Predictors of Thoracic Injury (Sensitivity: 98%)

• Low SBP (OR-4.6)

• Tachypnea (OR-2.9)

• Abnormal Thoracic Physical Exam (OR-3.6)

• Abnormal Auscultation (OR-8.6)

• Femur Fx (OR-2.2)

• GCS < 15 (OR-3.3)

63% of thoracic injuries were seen on CXR

• Pulm Contusion (71%)

Holmes, Sokolove. Clinical decision rule for identification of pediatric thoracic injury. Annal EM; 2002.

• CT added to the diagnosis list in 42%:• Contusion/atelectasis (61.8%); Pneumothorax (14.7%); Hemothorax (5.9%)

• First-rib Fracture (8.8%) (not actually associated with increased vascular injury)

• Pneumomediastinum (8.8%)

• CT changed management in 3%• 1 chest tube for pneumothorax in pt going to OR (?)

• 2 had extra imaging (that didn’t change management)

• Aortic Injury • 1 pt, struck by car, polytrauma

• Had abnormal mediastinum on CXR

A normal physical exam and VS are very reassuring

U/S is more sensitive for ptx than CXR

Traumatic aortic injury in kids is RARE

Chest CT rarely alters management

ATV vs Kid

Head?

Neck?

Abdomen?

Head?Low Risk if:

• Normal mental status• No LOC• Non-severe mechanismand…

Children

Neck?NEXUS

• No high risk mechanism or trauma above clavicles and:• No midline tenderness• No focal neuro finding• Normal level of alertness• No intoxication• No distracting injury

PECARN• No altered mental status• No focal deficit• No neck pain• No torticollis• No substantial torso injury• No predisposing conditions• No diving• No high risk MVC

Abdomen?

Low Risk for IAI• No evidence of abd wall trauma• GCS >13• No abdominal tenderness• No evidence of thoracic wall trauma• No complaint of abdominal pain• No decreased breath sounds• No vomiting

GCS Matters

Sensitivity of abd tenderness decreases with decreasing GCS

GCS 15 - sensitivity = 79%GCS 14 - sensitivity = 57%GCS 13 - sensitivity = 37%

Seat Belt Sign Matters

Seat belt sign - increased risk for hollow viscus or mesenteric injury

Seat belt sign WITHOUT tenderness still warrants evaluation

MAJOR HEAD TRAUMA?

PREVENT SECONDARY INJURY

• The Primary injury has already occurred.• Hypotension and / or Hypoxia stress the injury!• Avoid Hypotension.• Avoid Hypoxia.

• Keep Head of Bed at 30 degrees.• Keep head Midline. • Consider Hypertonic Saline• Keep Sedated and Paralyzed.

In infants

Look for high risk findingsAltered GCS

Abdominal wall trauma

Don’t forget about serial exams!

Labs may help risk stratify, but controversial

FAST - good, but does not assess retroperitoneum

Abdominal tenderness

Use Your Tools Wisely

CT does demonstrate injury better than CXR, but…

physical exam and CXR adequately stratify patients.

Do No Harm

Use Your Tools Wisely

Pearls

Always work through the complex equations• Size Matters!

- (More organs involved, Risk of heat loss)• Greater Flexibility (for good and bad)• Greater Oxygen Consumption - rapid Desats

Because Trauma Happens

Thank you!“Silent gratitude isn’t much use to anyone.”

G.B. Stern

smfoxmd@gmail.com

www.pedemmorsels.com

@PEDEMMORSELS

mailto:smfoxmd@gmail.comhttp://www.pedemmorsels.com

Pediatric Major Trauma: Slide Number 2Slide Number 3Slide Number 4Slide Number 5Slide Number 6The Challenge - KidsSlide Number 8Slide Number 9Slide Number 10Slide Number 11Slide Number 12Slide Number 13ATV vs KidATV vs KidSpecific InjuriesSlide Number 17Slide Number 18Augment Your ExamAir vs LungAir vs LungWhat do I do with this information?????Slide Number 23Specific InjuriesSlide Number 25Slide Number 26Radiation - Big Deal?Kids are More SensitiveThe RiskSlide Number 30Slide Number 31Slide Number 32Imaging IssuesSlide Number 34Slide Number 35Specific InjuriesSlide Number 37Slide Number 38Slide Number 39Specific InjuriesSlide Number 41Slide Number 42Slide Number 43Slide Number 44Something Tangible...Slide Number 46Slide Number 47ATV vs KidSlide Number 49Slide Number 50Slide Number 51Slide Number 52Slide Number 53Slide Number 54Slide Number 55Use Your Tools WiselyDo No HarmPearlsBecause Trauma HappensThank you!