Basics
Description
- Pathophysiology and anatomy of adolescents and young adults are similar.
- 80% of pediatric trauma is blunt; 80% of multisystem trauma includes head injury.
- Trauma is the leading cause of death and disability in children >1 yr in US and Europe.
- Most victims of child abuse are <3 yr. 1/3 of these patients are <6 mo.
Etiology
- Most cases of pediatric trauma are single-system, minor, blunt injuries.
- Common mechanisms of injury include motor vehicle collisions and bicycle accidents, struck by a vehicle as a pedestrian, and fall from height.
- Penetrating injuries are rare in younger children.
- Risk factors include inadequate supervision, developmental inadequacy of child to perform task, inadequate attention to task, risk taking, drugs, and alcohol.
Diagnosis
Signs and Symptoms
History
- History is often straightforward and provided by the child, parents, witnesses, or paramedics. If inconsistent with injury, consider child abuse.
- Mechanism(s) of injury relatively poor predictor of injury severity, but may suggest type of injury.
- Variables that increase the likelihood of serious injuries include handlebar injuries, significant passenger space intrusion, and failure to use proper restraint during a motor vehicle collision or helmet when riding a bike or skateboard.
- AMPLE history includes allergies, medications, past medical history, time of last meal, and events leading up to injury.
Physical Exam
- Primary survey:
- For all children who have sustained a major trauma, a traditional stepwise ABCDE evaluation based on assessing the airway, breathing, circulation, disability, and exposure is appropriate.
- Secondary survey:
- General:
- Mass-to-surface ratio may impact insensible water loss and increase the risk of hypothermia.
- Compensatory mechanisms may delay signs of hypovolemia. Few findings may be present until loss of 25 " “30% of blood volume, at which time decompensation abruptly occurs.
- Smaller total blood volume (80 mL/kg)
- Head:
- Note bulging fontanel, scalp hematomas, midface instability, auricular and septal hematomas, lacerations, functional or cosmetic deformities to the face, and pupillary abnormalities.
- Open sutures/fontanelles or multiple skull fractures may delay the onset of other signs and symptoms of increased intracranial pressure.
- Large head/occiput causes cervical spine flexion when patient is supine on adult backboard.
- Eye/ears, nose, and throat exam:
- Look for evidence of blood, trauma, hemotympanum, hyphema, and CSF fluid.
- Large tongue and tonsillar hypertrophy may obstruct the airway.
- Neck:
- Tracheal deviation and posterior neck step-offs are exceedingly unusual in children.
- Shorter trachea increases risk of right mainstem intubation.
- Cricoid cartilage is narrowest portion of airway in children <8 yr.
- Children with altered mental status cannot have their cervical spine precautions cleared in the ED. These children should remain in a cervical collar (and be taken off the spinal board) while in the ED.
- Pseudosubluxation (anterior displacement of C-2 on C-3) occurs in 20% of patients.
- The term spinal cord injury without radiologic abnormality (SCIWORA) is controversial in the MRI era.
- Chest:
- Note the overall work of breathing, grunting, asymmetric breath sounds, posterior abrasions, chest wall deformities, and crepitus.
- Flexible and compliant chest walls make pulmonary contusions more likely than rib fractures in young children. Rib fractures may be a sign of abuse.
- Diaphragmatic breathing
- Abdomen:
- Bruising, abrasions, and tenderness
- Distention is usually caused by gastric air.
- Liver and spleen relatively large
- Rib cage covers less of abdomen.
- Bladder is intra-abdominal in children <2 yr.
- Extremities:
- Palpation and evaluation of joint stability and tenderness
- Assess pulses and compartments.
- Salter " “Harris classification of fractures
- Unique injuries: Greenstick and buckle fractures
- Neurologic exam:
- Age-appropriate mental status assessment
- Assess movement of the extremities.
- Skin:
- Assess for prolonged capillary refill and pallor.
- Bruising of the ears, dorsa of the feet, or genitalia may suggest nonaccidental trauma.
- Patterns of injury:
- Car vs. pedestrian: Waddell triad (femur, torso, and head injuries) " ”uncommon
- Bicycle handlebar injuries may impale child: Pancreatic or small bowel injury.
- Lap belt syndrome: Abdominal ecchymoses and intestinal injury with or without lumbar spine fracture (chance fracture)
- Minor trauma history with major injury: Consider child abuse
Essential Workup
- History and age-appropriate physical exam are the only essential components to a workup for all children who present for an evaluation following trauma.
- Obtaining standard radiographic and lab "trauma panels " ť is not evidence based in children.
Diagnosis Tests & Interpretation
Lab
- Lab tests should generally be individualized, reflecting the patients clinical presentation.
- A normal initial hemoglobin and hematocrit do not rule out a significant hemorrhage but will provide a baseline value for later comparison; tachycardia may be only sign of fluid/blood loss early in presentation, although it is nonspecific for blood loss.
- Initial electrolyte measurement is unnecessary.
- Routine amylase and lipase are not recommended because of the low incidence of pancreatic injuries; false-positive tests are common.
- Elevated LFTs should not be used as the sole determinant in deciding which children should undergo CT of the abdomen. Patients with AST >200 IU/L or ALT >125 IU/L who have sustained abdominal trauma should be considered for CT if hemodynamically stable. Physical exam should guide imaging decision.
- Gross hematuria (>50 RBC/HPF) is concerning for urinary tract injuries, but microscopic hematuria is not.
- Blood bank specimen for typing in appropriate patients
- A pregnancy test is indicated for teenage girls.
- Diagnostic peritoneal lavage is rarely indicated with availability of imaging modalities.
Imaging
- The traditional "c-spine, chest, pelvis " ť set of radiographs is no longer universally obtained; selective approach is more appropriate.
- Forgo cervical spine radiographs in children who are awake, alert, cooperative, neurologically intact without neck pain or midline tenderness on palpation of the neck, are without pain on range of motion testing, and are without distracting injury:
- An unconscious child will not be able to have the cervical spine cleared in the ED and may later need MRI (less often CT) as an inpatient.
- Chest radiographs indicated for grunting respirations, hypoxia, asymmetric breath sounds, dyspnea, crepitus, endotracheal intubation, and thoracostomy tube or central venous catheter placement in the internal jugular or subclavian veins
- Pelvic radiographs are seldom indicated. Children with clinically significant pelvic pain or instability typically undergo CT of the abdomen and pelvis.
- CT of the head is indicated for abnormal mental status, focal neurologic deficit, prolonged loss of consciousness, bulging fontanel, temporal or parietal scalp hematoma, depressed skull fracture, and uncontrollable persistent vomiting.
- CT of the abdomen and pelvis is typically indicated for children with altered mental status, gross hematuria, abdominal bruising above the ileac crests, handlebar injuries, and abdominal tenderness with hemodynamic effect.
- US has limited utility since the presence of free fluid (i.e., blood) does not always indicate the need for laparotomy. The usefulness of focused abdominal sonography for trauma exam in young children needs further study.
Differential Diagnosis
Nonaccidental trauma should be considered when the history is inconsistent with the injury. ‚
Treatment
Pre-Hospital
- Rapid transport to a facility capable of managing the childs suspected injuries
- Priorities include stabilization of airway (intubation by paramedics in the pre-hospital setting is controversial), breathing, circulation.
- Immobilization of cervical spine and extremity fractures
Initial Stabilization/Therapy
- Most traumatized children are stable throughout their ED course.
- Stabilization may require:
- Cardiorespiratory and pulse oximetry monitoring
- Early oxygen administration
- Placement of 2 large-bore IVs and aggressive fluid resuscitation with normal saline
- Pain control with morphine
- Labs and radiographs as indicated
- Administration of packed red blood cells if not responding to 2 crystalloid boluses
- Endotracheal intubation:
- Rapid sequence intubation should be performed with etomidate or ketamine and succinylcholine
- Sedate patient with a benzodiazepine or propofol
- Cervical spine immobilization
- Thoracostomy tube as indicated
- Urinary catheter (look for blood at the meatus)
- Gastric decompression with a nasogastric or orogastric tube
Ed Treatment/Procedures
- Risk stratify based on history and physical exam.
- Acknowledge the limitations of using the mechanism of injury to predict its severity.
- Assess priorities; reassess frequently.
- Provide analgesia; sedate as appropriate.
- Clean wounds and splint fractures.
- Tetanus immunization if indicated
- Allow parents at the bedside during resuscitation and treatment.
Medication
- Normal saline/lactated Ringer: 20 mL/kg boluses IV
- Packed red blood cells: 10 mL/kg U IV
- Etomidate: 0.3 mg/kg IV
- Morphine sulfate: 0.1 mg/kg IV
- Succinylcholine: 1.5 mg/kg IV
- Lorazepam: 0.1 mg/kg IV
- Propofol: 2 mg/kg IV
- Ketamine: 2 mg/kg IV (generally thought to raise intraocular and intracranial pressure " ”usually avoided when head injury is suspected)
Follow-Up
Disposition
Admission Criteria
- Persistent altered mental status, endotracheal intubation, thoracostomy tube placement, intra-abdominal or intracranial injury identified on CT, pulmonary contusion, fractures requiring operative management, nonaccidental trauma
- Hemodynamic instability
- Airway concerns
- CT negative for intra-abdominal injury, but persistent abdominal pain as pancreatic or bowel injury is possible
- Failure to identify an appropriate adult to be responsible for the child (e.g., both parents are admitted to the hospital for their own injuries)
Discharge Criteria
- Most traumatized children with normal mental status and normal radiographic tests (if obtained) can be discharged home to a reliable caregiver.
- Post-traumatic stress syndrome may develop, and parents should be advised to seek appropriate counseling should concerns develop.
Follow-Up Recommendations
- Specialists as indicated by injury
- Psychiatric evaluation may be indicated for evidence of post-traumatic stress.
- Neurologic assessment for evidence of residual from postconcussion syndrome.
Additional Reading
- Capraro ‚ AJ, Mooney ‚ D, Waltzman ‚ ML. The use of routine laboratory studies as screening in pediatric abdominal trauma. Pediatr Emerg Care. 2006;22:480 " “484.
- Davies ‚ DA, Pearl ‚ RH, Ein ‚ SH, et al. Management of blunt splenic injury in children: Evolution of the nonoperative approach. J Pediatric Surg. 2009;44:1005 " “1008.
- Dudley ‚ NC, Hansen ‚ KW, Furnival ‚ RA, et al. The effect of family presence on the efficiency of pediatric trauma resuscitations. Ann Emerg Med. 2009;53:777 " “784.
- Herman ‚ R, Guire ‚ KE, Burd ‚ RS, et al. Utility of amylase and lipase as predictors of grade of injury or outcome in pediatric patients with pancreatic trauma. J Pediatr Surg. 2011;46:923 " “926.
- Holmes ‚ JF, Lillis ‚ K, Monroe ‚ D, et al. Identifying children at very low risk of clinically important abdominal injuries. Ann Emerg Med. 2013;62:107 " “116.
- Hutchings ‚ L, Willett ‚ K. Cervical spine clearance in pediatric trauma: A review of current literature. J Trauma. 2009;67:687 " “691.
- Hutchison ‚ JS, Ward ‚ RE, Lacroix ‚ J, et al. Hypothermia after traumatic brain injury in children. N Engl J Med. 2008;358:2447 " “2456.
- 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.
See Also (Topic, Algorithm, Electronic Media Element)
- Abuse, Pediatric
- Fractures, Pediatric
- Trauma, Multiple
Codes
ICD9
- 920 Contusion of face, scalp, and neck except eye(s)
- 959.01 Head injury, unspecified
- 995.50 Child abuse, unspecified
- 873.40 Open wound of face, unspecified site, without mention of complication
- 879.8 Open wound(s) (multiple) of unspecified site(s), without mention of complication
- 879.9 Open wound(s) (multiple) of unspecified site(s), complicated
- 919.0 Abrasion or friction burn of other, multiple, and unspecified sites, without mention of infection
- 924.8 Contusion of multiple sites, not elsewhere classified
ICD10
- S00.83XA Contusion of other part of head, initial encounter
- S09.90XA Unspecified injury of head, initial encounter
- T76.92XA Unspecified child maltreatment, suspected, initial encounter
- S01.81XA Laceration w/o foreign body of oth part of head, init encntr
- T14.8 Other injury of unspecified body region
- T14.90 Injury, unspecified
SNOMED
- 82271004 Injury of head (disorder)
- 397940009 victim of child abuse (finding)
- 125668004 contusion of face (disorder)
- 370247008 Facial laceration (disorder)
- 285345008 Multiple lacerations (disorder)
- 390835003 Post-traumatic bruising (disorder)
- 399963005 Abrasion (disorder)