Critical Care Medicine
Differential trauma approaches in the child vs. adult
- 1. Description of the problem
- 2. Emergency Management
- 3. Diagnosis
What's the evidence?
PEDIATRIC TRAUMA: Children are not little adults
1. Description of the problem
Pediatric trauma overview
Trauma is the most common cause of death in the pediatric population. The epidemiology of pediatric trauma differs from adults in that there is a higher proportion of head injury. The infant's and child's head is disproportionately larger than their body compared to an adult. The most common cause of traumatic death in children is motor vehicle crashes.
There are several factors that make management of pediatric trauma challenging. The pediatric trauma patient can range from a premature newborn up to a 21-year-old. For the purpose of this discussion, we will divide the patients into three populations: infants (less than 1 year old), toddlers and school age, adolescents and young adults. Each of these populations presents unique challenges.
The care of pediatric trauma patients requires the availability of equipment in various sizes. Everything from IV catheters to endotracheal tubes to Foley catheters and NG tubes need to be stocked in multiple sizes to accommodate the pediatric population. This poses a particular challenge for pre-hospital providers, who must carry expanded stock on their vehicles. There are several ways to determine the correct size equipment to use. Some of the easiest to use are the Broselow tapes (Armstrong Medical, Lincolnshire, IL). The tape is used to measure the child and various ranges are color-coded. Each color code corresponds to appropriate-sized endotracheal tubes and proper resuscitation drug dosing. This is a quick and easy way to guide the appropriate resuscitation of pediatric patients.
Teamwork is essential for the care of the pediatric trauma patient. The team ideally consists of a General Pediatric Surgeon, or Trauma Surgeon with experience with pediatric patients, Pediatric Emergency physicians, Pediatric nurses, Pediatric Respiratory therapists, Radiology techs, phlebotomist/lab personnel, blood bank personnel, chaplaincy and child life.
2. Emergency Management
Initial resuscitation (ABCs)
Initial trauma resuscitation of the pediatric patient follows Advanced Trauma Life Support (ATLS) guidelines established by the American College of Surgeons. The initial priorties are the Airway, Breathing and Circulation (ABC). The ABCs are undertaken as they would be for any resuscitation. The indications for establishing an airway (intubation) are a Glasgow Coma Scale (GCS) score < 8, inability to maintain a clear airway due to injury to the oropharynx, shock.
Skill in effective bag-mask ventilation is very useful and can temporize the patient's condition until someone capable of intubating a child is available. The need for a surgical airway is very rare in children. In adolescents, an emergency cricothyrotomy is the procedure of choice, as it is in adults. In younger children, a surgical airway is usually established through a tracheotomy. Ventilation is ideally performed with an inline pressure monitor and at an appropriate rate for age. For practitioners not used to pediatric patients, it is easy to forget that infants need frequent small breaths.
Once the airway is secure and adequate gas exchange is established, attention should be directed to establishing adequate circulation. Two intravenous lines should be established. In an emergency situation, an interosseous line can be placed. Large-bore peripheral intravenous lines are sufficient for trauma resuscitation. Central access should be reserved for situations where peripheral access cannot be obtained.
Secondary survey (D and E)
Once the ABC's are secure, the next priorities are Disability and Exposure. That is, a detailed neurological exam is performed, including GCS. The extremities should be checked for fractures and neurological deficits. A rectal exam is performed to determine tone and to look for gross blood. The patient's clothes are removed and the patient is log-rolled to look for abrasions, seat belt signs, and penetrating injuries and to palpate the spine for step-offs or crepitance. All four extremities should be examined to look for fractures and document peripheral pulses.
The patient's core temperature should be taken. Pediatric patients, especially infants, have a larger surface area to weight ratio and will rapidly get hypothermic. The room should be kept warm and fluid warmers should be used for large resuscitations. Warming devices, such as the Bear Hugger (Arizant, Inc., Eden Prarie, MN), can be used.
Complete physical exam is essential to determine the extent of injuries. This includes a rectal exam to look for gross blood and to document tone. Hemocult testing is not necessary in the trauma environment.
Trauma resuscitation medications/blood products
Fluid Bolus: NS or LR 10 ml/kg aliquots
PRBC: 10 ml/kg
Platelets: 10 ml/kg
Fresh Frozen Plasma: 10 ml/kg
Ideally blood products should be given as part of a massive transfusion protocol. Such protocols have been shown to improve survival.
Resuscitation medications are discussed in the Pediatric CPR chapter.
Pediatric patients have more pliable skeletons and may have severe, or even life-threatening, injuries without much external trauma. For example, the most common thoracic injury in children is pulmonary contusion, compared to rib fractures in adults.
Imaging and diagnostic studies are carried out much as they would be in an adult. This includes routine chest radiograph, pelvic film and lateral cervical films. The films should be read by someone experienced with pediatric films. A normal thymus in an infant may be mistaken for a widened mediastinum. The open epiphysis on a pelvic film may be mistaken for a fracture.
A focused abdominal ultrasound for trauma (FAST) exam can be undertaken as in an adult. The FAST can identify pericardial tamponade and free fluid in the abdomen.
Hematocrit/Hemoglobin - all patients
AST/ALT - used to determine need for CT scan of the abdomen (either >200), in conjunction with clinical exam
PT/PTT - not usually necessary but can be helpful in patients with a head injury (with release of endogenous TPA), or those who have had massive hemorrhage
Urinalysis - used to look for RBCs as an indication of abdominal/GU injury
Management: Peds vs adult
See the chapter on pediatric thoracic and abdominal trauma.
It is often stated that the pediatric trauma patient can appear stable one minute and then "crash" the next. This is because healthcare providers who are primarily treating adults don't always know the subtle signs of shock in a child. Pediatric patients, with their normal blood vessels and good vascular tone, can maintain a stable blood pressure in the face of profound hypovolemia. Pediatric patients increase their cardiac output by increasing heart rate. Tachycardia is one of the earliest signs of shock in children. Evaluation of peripheral perfusion is also helpful in determining if a child is in shock.
Pediatric trauma is the leading cause of death for children and adults 1 to 41, with motor vehicle crashes causing the majority of injuries and deaths. Most deaths are from closed head injuries.
What's the evidence?
(The ATLS manual is published by the American College of Surgeons Committee on Trauma and guides treatment of trauma. It includes chapters on the pediatric patient.)
Cook, CC, Gleason, TG. "Great vessel and cardiac trauma". Surg Clin North Am. vol. 89. 2009; Aug. pp. 797-820.(Summary of injuries to the thorax.)
Stylianos, S. " Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. The APSA Trauma Committee". J Pediatr Surg. vol. 35. 2000; Feb. pp. 164-7.(Provides evidence-based clinical research for current management of blunt injury to the liver or spleen in children.)
Haller, JA. "Nonoperative management of solid organ injuries in children. Is it safe". Ann Surg. vol. 219. 1994; Jun. pp. 625-8.(An evaluation of the safety of nonoperative management of blunt abdominal injury.)
Taylor, GA. "Indications for computed tomography in children with blunt abdominal trauma". Ann Surg. vol. 213. 1991; Mar. pp. 212-8.(Offers insight into criteria warranting additional imaging/radiation exposure.)
Newman, KD. "The lap belt complex: intestinal and lumbar spine injury in children". J Trauma. vol. 30. 1990; Sep. pp. 1138-40.(Description of seatbelt injuries and their attendant complications.)
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