Pediatric Trauma
Jessica Mills, MD, FRCSC
Assistant Professor Surgery, Pediatric Surgeon
Objectives
 Epidemiology of Pediatric Trauma
 Pediatric Injury Patterns
 Imaging in Pediatric Trauma
 Pediatric ABCDE’s and Pitfalls
 Clinical Decision Rules to guide Imaging choices
 Pediatric Pain
 Assessment tools
 Triage of Pediatric Trauma in NY State
 STAC 2014 Guidelines
The Scope of the Problem
 Trauma most common cause of death > 1 yr
 Causes almost half of deaths < 15 yrs
 38% MVC
 13% Homicide
 13% Drowning
 9% Fire/Burn
 5% Suicide
 In-hospital mortality low
The Scope of the Problem
 20 children die every day
 Burden of disability incalculable
 1/2 have social, affective and learning disabilities
 2/3 siblings have emotional disturbances
 Financial/Employment troubles for parents
 Marital strain
Why so Vulnerable?
Why so Vulnerable?
 Children put themselves at risk
 High curiosity + Low Judgement = Injury


Falls most common mechanism in younger children
Violence most common in older teens
 Higher risk of significant injury
What can we do?
 Goal = Prevention
 Reality = Minimizing morbidity and
mortality
Pediatric Injury Patterns
Multitrauma is the Rule
Multitrauma is the Rule
Multitrauma is the Rule
Examine the Patient?
 Very difficult in conscious younger children
 Invest time in starting slowly
 Children can smell fear!
 Develop rapport
 Soothe and cajole
 Use parent as your ally
 Control personal emotions
Scan the Patient?
 CT Scan considered gold standard
 Worry about missed injuries
 ? Increase in morbidity/mortality
 ? Legal concern
 Increasing awareness of radiation risks
 Younger patient = More vulnerable
 Bottleneck Resource
 Triage CT Scans in disaster scenario
Risk of Malignancy
 Lifetime cancer mortality risks attributable to the
radiation exposure from a CT in a 1-year-old are 0.18%
(abdominal) and 0.07% (head) 600,000 pediatric CT head/abdomen per year
 Estimate 500 deaths from cancer due to CT radiation
Brenner D et al. Estimated risks of radiation-induced fatal cancer from pediatric CT. Am J
Roentgeno. 2001;176(2):289-96.
Risk of Malignancy
 Estimated effect of Pediatric CT radiation
 50 mGy ?= 3 x risk of leukaemia
 60 mGy ?= 3 x risk of brain cancer
 Cumulative absolute risks are small
 In 10 yrs following radiation exposure under 10 yrs of age
 1 leukemia/10,000
 1 brain tumor/10,000 head CT
Pearce MS et al. Radiation exposure from CT scans in childhood and subsequent risk of
leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012 4;380(9840):499-505
So What?
 If you are going to scan, make it the best scan possible
 Make sure IV contrast, PO contrast if necessary
 Don’t turn down the radiation too much
 Don’t decrease the radiation of the scan
 Decrease the number of scans
 Use Clinical Decision Rules
 Mild head injury
 Low/moderate suspicion abdominal injury
ABCDE’s of Pediatric Trauma
Airway
Airway Pitfalls
 Big tongue, Big occiput
 Most common cause of airway obstruction
 Positioning, oral airway
 Much larger adenoids
 Difficult view
 Bleeding with nasopharyngeal airway attempts
 Airway narrows with depth, sits anterior
 Difficult view and intubation
 Sensitive gag
 Oral airway only if unconscious
Oral Airway
 Only if unconscious
 Can help hold tongue forward
 DO NOT place backward and flip in oropharynx
 Place directly under vision
 tongue blade helpful
Orotracheal Intubation
 PreOxygenate
 Protect the c-spine
 Correct tube size + one up & one down
 Cuffed tubes improve ventilation
 Avoid high cuff pressure
 Confirm tracheal placement
 If not sure: remove the tube and try again
 Recheck with every move
Breathing
Is there a chest injury?
 #2 cause of pediatric trauma death
 No obvious fracture = Coast is clear
 Ribs flexible
 Pulmonary contusion without fracture
 Fracture = Large amount of force
 Look for the other injuries
 Need high index of suspicion
 Mechanism of injury
 External signs of injury
Pitfalls
 Overventilation
 > 1 year : 20 breaths per minute
 < 1 year: 30 breaths per minute
Breathe, Rest, Rest
Power of the CXR
 CXR will find common injuries
 Rib fractures
 Pulmonary contusions
 Pneumothoraces
 CXR will miss rare but deadly injuries
 Heart and great vessels
 Tracheobronchial tree and esophagus
 Diaphragm
CT Chest
 Efficient
 Sensitive
 BUT
 Radiation Risk
 ? Need for Anesthesia
 Clinical Decision Rules
Type of Injury
No.
Frequency Among Patients With
Thoracic Injuries (n=80), % (95%
CI)
Pulmonary contusion
57
71 (60-81)
5.8 (4.4-7.4)
Rib fracture
28
35 (25-46)
2.8 (1.9-4.1)
Isolated rib fracture
9
11 (5-20)
0.9 (0.4-1.7)
Pneumothorax
20
25 (16-36)
2.0 (1.2-3.1)
Hemothorax
9
11 (5-20)
0.9 (0.4-1.7)
Hemopneumothorax
5
6 (2-14)
0.5 (0.2-1.2)
Pneumomediastinum* 6
8 (3-16)
0.6 (0.2-1.3)
Cardiac
5
6 (2-14)
0.5 (0.2-1.3)
Aortic
2
3 (0-9)
0.2 (0.0-0.7)
Diaphragmatic injury
1
1 (0-7)
0.1 (0.0-0.6)
Sternal fracture
1
1 (0-7)
0.1 (0.0-0.6)
*Includes 2 patients with tracheal lacerations.
Frequency Among
Total Population
(n=986), % (95% CI)
Chest Trauma Decision Rule
 Prospective study, n= 968
 Predictors of thoracic injury
 Low systolic BP
 Elevated age-adjusted respiratory rate
 Abnormal thoracic exam
 Abnormal auscultation of lung fields
 Femur #
 GCS < 15
Holmes JF et al. A clinical decision rule for identifying children with thoracic injuries after blunt
torso trauma. Ann Emerg Med 2002; 39:492–499
Decision Rule Performance
 Identified 78 /80 patients with injury
 Sensitivity 98%
 Specificity 37%
 PPV 12%
 NPV 99%
 2 missed injuries found on Abdominal CT
 Both observed
 No morbidity from missed diagnosis
C
Circulation
Is there bleeding?
Vital signs can mislead
Tachycardia
Hypotension
Blood Pressure
30% Blood Loss
So How Will I know?
 Subtle physical findings
 Skin mottling
 Cool extremities compared to the trunk
 Thready/weakening peripheral pulses
 Prolonged capillary refill > 2 seconds
 Decreased sensorium
 * dulled pain response
How Much Do I Give?
 Weight based dosing
 Crystalloid
 Blood
 Drugs
 Ask parent
 2.2 pounds per kilogram
 Broselow tape
 Formula
 Weight (kg) = (2 x age) + 10
What and How Much?
 Crystalloid
 20 cc/kg WARMED saline/ LR
 Repeat x 1
 Repeat x 2 think about blood
 PRBC
 10 cc/kg O negative WARMED PRBC
Have I Given Enough?
 Improving tachycardia
 Better peripheral pulses
 Improved skin color and warmth
 More active and responsive
Venous Access
 Peripheral IV : 2 attempt max
 Antecubital fossa
 Saphenous veins at ankle
 Intraosseous
 Anteromedial Tibia
 Distal Femur
? Intra-abdominal Injury
 Physical Exam findings
 Laboratory Evaluation
 FAST
 Clinical Decision Rules
 CT Scan
Physical Exam
 Sensitivity of Abdominal Pain and Tenderness
 Strongly dependent on GCS
 GCS 15: Sensitivity 79%
 GCS 14: Sensitivity 50’s
 GCS 13: Sensitivity 30’s
 Isolated abdominal pain/tenderness
 Rate of injury = 8%
 Rate of intervention = 1%
Adelgais KM et al. Accuracy of the abdominal examination for identifying children
with blunt intra-abdominal injuries. J Pediatr. 2014 Dec;165(6)
.
Seat Belt Sign
 Seat Belt Sign
 Worry about compression of organs against vertebrae
 Injured organs related to location
 How predictive of IAI?
Sensitivity 25%
Specificity 85%
 Can we ignore it?
 Higher rate of IAI : hollow viscus, mesentery
 Only sign in 5% conscious asymptomatic patients
Laboratory Evaluation
 Transaminases
 Varying cutoffs
 Most useful in a clinical decision rule
 Possible screening tool in suspected NAI
 Child with no abdominal bruising, tenderness, or distention
 AST or ALT >80 IU/l
 Sensitivity = 77%
 Specificity = 82%
FAST
 Focused sonography
 right upper quadrant
 left upper quadrant
 pelvis
 pericardial windows
 Look for free peritoneal fluid
 Blood (bile, urine)
FAST
 Prospective study, clinically important free fluid
 Sensitivity poor : 50%
 Specificity good: 96%
 Positive scan suggests hemoperitoneum
 CT Scan or OR
 Negative scan cannot rule out hemoperitoneum
 Need further imaging……..
Fox JC et al. Test characteristics of focused assessment of sonography for trauma for clinically
significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med
2011; 18:477–482.
FAST plus Labs
 FAST plus elevated Transaminases
 AST/ALT > 100 IU/L
 Sensitivity : 88%
 Consider observation in patients with normal FAST and
“normal” Transaminases
Sola JE et al. Pediatric FAST and elevated liver transaminases: an effective screening tool in
blunt abdominal trauma. J Surg Res 2009; 157:103–107
Abdominal CT Scan
 Good for solid organ injury
 Guide non-operative care
 Not as good for hollow viscus
 peritoneal fluid without solid organ injury
 bowel wall enhancement and thickening
 extraluminal gas
 bowel wall discontinuity
 mesenteric stranding
 Isolated free fluid 
serial exams
Identifying IAI
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


12,000 patients
46% had CT Scans
6.3% IAI
75% of patients with IAI had
Intraperitoneal fluid
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Spleen (39%)
Liver (37%)
Kidney (19%)
Gastrointestinal tract (15%)
Adrenal gland (12%)
Pancreas (7%)
Intra-abdominal vascular
structure (2%)
Urinary bladder (2%)
Ureter (0.5%)
Gallbladder (0.5%)
Traumatic fascial defect (0.5%).
Holmes JF et al. Identifying children at very low risk of clinically important blunt abdominal
injuries. Ann Emerg Med. 2013 Aug;62(2):107-116
Prediction Rule
 Evidence of abdominal wall trauma or seat belt sign
 GCS score less than 14
 Abdominal tenderness
 Evidence of thoracic wall trauma
 Complaints of abdominal pain
 Decreased breath sounds
 Vomiting
Prediction Rule Performance
 Sensitivity = 97%
 Specificity = 42.5%
 Use to reassure in low risk patients
 NOT meant to indicate need for scan
D
Disability
Always Worry about the Head
#1 organ system injury  death
 Large head to body ratio
 Brain less myelinated
 Skull bones thinner
 Brain more susceptible to secondary injury
• Main risk = hypovolemia
CDR for Mild Head Injury
 CHASE vs CHALICE vs PECARN
 PECARN only one with 100% sensitivity
 2 age groups
 Only GCS 14 or 15: lower risk of TBI
 GCS </= 13 : 20% injury risk : CT scan
PECARN < 2 years old
GCS=14
Other signs of altered mental status
Palpable skull fracture
YES
CT Recommended
NO
Scalp hematoma-Occip/parietal/temp
History of LOC ≥5 sec
Severe mechanism of injury
Not acting normally per parent
NO
No CT Recommended
YES
Observation versus CT
• Physician experience
• Multiple versus isolated findings
• Worsening symptoms or signs
after ED observation
• Age <3 months
• Parental preference
PECARN >/= 2 years old
GCS=14
Other signs of altered mental status
Signs of basilar skull fracture
YES
CT Recommended
NO
History of LOC
History of vomiting
Severe mechanism of injury
Severe headache
NO
No CT Recommended
YES
Observation versus CT
• Physician experience
• Multiple versus isolated findings
• Worsening symptoms or signs
after ED observation
• Parental preference
Think C-spine
 Pediatric spine injuries: C-spine
Pseudosubluxation
 Physiologic misalignment occurring in normal children
 Disappears with age
 40% < 7 yrs
 20% < 16 yrs
 Usually at C2-C3
 Check spinous process line
SCIWORA
 Usually C-spine injury
 5 to 35% of spinal cord injuries
 No signs of bony/ligamentous injury on plain film/CT
 2/3 have MRI abnormality
 Suspect if:
 Blunt trauma
 Early/transient defecits
 Neurologic findings on initial assessment
E
Exposure
Undress but Cover
 Need to fully expose
 Cover ASAP
 High BSA to Body Mass
 Cool very quickly
 Warm everything
 Blankets
 Fluids
 Consider Bair Hugger
Pediatric Pain
Morbidity of Pain
 Trauma #1 cause of acute pain in children
 Effects wildly variable
 Anxiety
 Crying
 Regression
 Aggression
 Not related to injury severity
 Inadequate treatment  longterm effects
Barriers to Pediatric Analgesia
 Difficulty in rating pediatric pain
 Variable provider training
 Limited choice of agent/route
Assessing Pediatric Pain
 Vital signs unreliable
 Patient self report
 Teenagers can use 1-10 Pain Scale
 Younger children need different approach
 Parent report
 Correlates well with child self report
 Good surrogate measure
Brieri Faces Pain Scale
Wong and Baker Pain Scale
Pediatric Pain Treatment
 Pharmacologic
 Fentanyl 1 to 3 μ/kg
 ? Intranasal fentanyl
 Non pharmacologic
 Splinting #
 Diversion and distraction
Triage of Pediatric Trauma
CDC Triage Guidelines
#1
Vital Signs
Level of
Consciousness
#2
#3
#4
Anatomy of
Injury
Mechanism of
Injury
Special
Circumstances
Vitals and LOC
 Glasgow Coma Scale </= 13
 Systolic Blood Pressure <90mmHg
 Respiratory Rate <10 or >29
 or <20 in infant aged <1 year
 or need for ventilatory support
Anatomy of Injury
 All penetrating injuries to head, neck, torso, and extremities proximal to
elbow or knee
 Chest wall instability or deformity (e.g. flail chest)
 Two or more proximal long-bone fractures
 Crushed, degloved, mangled, or pulseless extremity
 Amputation proximal to wrist or ankle
 Pelvic fractures
 Open or depressed skull fracture
 Paralysis
Mechanism of Injury

Fall


>10 feet or 2 – 3 x height of the child
High-risk auto crash

Intrusion >12 inches occupant site; >18 inches any site

Ejection (partial or complete)

Death in same passenger compartment

Vehicle telemetry data indicates high risk of injury

Auto vs. pedestrian/bicyclist


thrown, run over, or with significant (>20 mph) impact
Motorcycle crash > 20 mph
Special Circumstances
 Older Adults
 Children
 Triage preferentially to pediatric capable trauma centers
 Anticoagulants and bleeding disorders
 Burns
 Pregnancy >20 weeks
 EMS provider judgment
NY State
STAC Guidelines for Pediatric Trauma Patients
November 2014
Prehospital
Pediatric Trauma
Meets CDC guidelines
Transport time </= 60 minutes
Level I or II Pediatric Trauma Center
Adult Trauma / Non Trauma Hospital
If CDC triage criteria still met
Level I or II Pediatric Trauma Center
Adult Trauma / Non Trauma Hospital
 Transfer Early
 Decision to Transfer
 Once the primary survey and resuscitation phases are initiated
 usually within 30 minutes of arrival
 Initiation of Transfer
 Should be made immediately upon recognition of meeting criteria
for transfer
 usually within 15 minutes following initiation of the primary survey
 Transfer
 Should occur as soon as possible thereafter
 ideally within 1 hour of arrival
 definitely within 2 hours of arrival.
Summary
 Pediatric Trauma significant problem
 Beware of Multitrauma and Pitfalls
 Triage your CT Scans
 Consider Clinical Decision Rules
 Optimize pediatric analgesia
 Severely injured kids should go to Level I/II Pediatric
Trauma Center