10 things you must know about
Pediatric Trauma
Ahmad Althekair, MD
Fellow, Pediatrics Emergency Medicine
Hospital for sick children
Objectives
1. RSI
2. When to EFAST
3. X-ray vs. CT in C-spine injury
4. To pan-CT or not
5. Thermal injures
6. Envenomation
7. NAT
Epidemiology
 Leading cause of death above the age of
infancy
 25% of traumatic injuries occur in children
Epidemiology
 Most common causes of injury-related
deaths:
 Traumatic brain injury
 Motor vehicle crashes
 Submersion injury
 Homicide
 Suicide
 Fires
Epidemiology
 > 700 000 injury-related deaths world-wide
occur in the <15 year old age group (in
2002)
 Bimodal distribution in injury death rates:
 Children and Teens
 Teens are at increased risk due to:
 Increased exposure to hazards
 Infants:
 Are at higher risk of inflicted trauma
Trauma Triage Scores
• RTS
Trauma Triage Scores
• PTS
Trauma Triage Scores
• ISS
Primary & Secondary Survey
 Primary survey:
 Quick, initial patient assessment to identify lifethreatening injuries
 Occurs with active resuscitation
 Secondary survey:
 More detailed assessment of injuries
Primary Survey
 A,B,C,D,E
 Every trauma patient should arrive boarded
and C-spine immobilized
 Collar for school-age/adolescents
 Rolls and tape for infants/toddlers
 Immediate vitals signs
A,B,C,D,Es
 A = Airway & C-Spine Precautions
 B = Breathing
 C = Circulation
 D = Disability
 E = Exposure
A: Airway & C-Spine Protection
 Check for airway patency and clear
secretions
 If already intubated, confirm ETT position
with:
 Chest x-ray, End tidal CO2, Oxygen saturation,
Auscultate the lungs for equal air entry, Take a look with
a laryngoscope
 Ensure adequate C-spine protection
B: Breathing
 Check for
adequacy of
breathing
 Effort, breath
sounds, oxygenation
 Apply oxygen by
facemask or blow
by.
 Assess need for
intubation
C: Circulation
 Most common cause of shock in
pediatrics = hypovolemia
 2 large bore IV’s started
 Xmatch or Type and screen ordered
 20 ml/kg IV crystalloid bolus (x 3 then
PRBC’s)
 Look for obvious and non-obvious
sources of bleeding
D: Disability
E: Exposure
 Assess all surface areas
 Log-roll with using spinal precautions
 Examine the spine: note step deformities or pain
 Assess rectal tone and sensation
 Check for vaginal/urethral bleeding
 Prevent hypothermia
 Keep trauma room warm, use blankets and overhead
warmer for infants
Primary Survey Goals
IDENTIFY
INTERVENE
Airway
Inadequate airway
Secure and protect
Breathing
Apnea
Positive pressure ventilation
Hypoxia
Supplemental oxygen
Tension
pneumothorax
Needle decompression, chest tube
Massive
hemothorax
Chest tube
Open
pneumothorax
Occlusive dressing, chest tube
Primary
Survey Goals
IDENTIFY
INTERVENE
Circulation
Hypovolemic shock
Fluid bolus, blood products
Pericardial tamponade
Fluid bolus,
pericardiocentesis,
thoracotomy
Cardiac Arrest
Chest compressions,
thoracotomy if penetrating
trauma
Disability
Spinal cord injury
Immobilization
Cerebral herniation
Hyperventilation, mannitol
Exposure
Hypothermia
Warmed fluid, external
warming
Exsanguinating hemorrhage Direct pressure
Adjuncts to Primary Survey
 Access: IV vs. IO
 Monitor: Cardiorespiratory/Pulse oximetry.
 Trauma bloodwork
 CBC, electrolytes, blood gas, creatinine, BUN, PT/PTT,
Xmatch, liver function studies, lipase or amylase
 BHCG if female of child-bearing age
Imaging Prior to Secondary
Survey
 Xrays:
 CXR (AP only)
 Pelvis (AP only)
 C-spine: lateral, AP and odontoid if cooperative
 FAST
Head Trauma
Head Trauma
 Leading cause of death & disability in childhood
 Mortality rate 20-30%
 0-14y age range TBI = 400 000 visits/year to ED
 1-2% of all comers to ED
 Only 3-5% of those with intracranial injury
 <1% of above require neurosurgery
Head Trauma
 Causes:
 Infancy: NAT, falls
 Childhood: MVA, pedestrian, bicycle
 Adolescence: MVA, pedestrian, bikes/boards, violence
 Sex:
 M = F ~ 5 yo
 M > F > 5 yo (2-5:1)
Head Trauma
Common Signs & Symptoms of
Increased ICP in Children
Acute Medical Management of
Raised ICP
 Position head of bed at 300
 Mannitol IV 20% = 1g/kg per dose
 Must chase with bolus of NS
 Prevent hypoxia and hypotension
 Control external hemorrhage
 Maintain C-spine precautions
 Early intubation using RSI to prevent
complications
Head Injury
 Definitive management dependant on lesion
and examination
 Early involvement of neurosurgery
recommended
 Admission for observation and closely
monitoring for deterioration a must
 Consider need for IV Mannitol early for
raised intracranial pressure
Chest Trauma
Chest/Thoracic Trauma
 Accounts for 4.5 – 8% pediatric trauma
 2nd most common cause of mortality in
pediatric trauma
 Most common causes:
 Motor vehicle accidents (MVA’s)
 Pedestrians
 Unrestrained passengers
 Bicycle riders
 Falls
Chest/Thoracic Trauma
 Pediatric thoracic trauma higher risk:
 More compliant chest wall
 Increased mediastinal mobility
 Tension pneumothorax develops quicker
 Children more prone to hypoxia
 Less ability to compensate for hypovolemia
Chest/Thoracic Trauma
 Blunt versus penetrating
 Blunt:
 High energy trauma affects internal organs
 Deceleration mechanisms affect mediastinal structures
 Penetrating:
 Disrupts underlying structures
 Do not remove penetrating objects! Must remove in a
controlled setting (Operating Room)
Chest/Thoracic Trauma
Tension Pneumothorax
 Hypotension, distended jugular veins, shifted
heart sounds, hyper-resonance, trachea not
midline
 Treatment:
 Emergent needle decompression = Large bore IV
inserted over rib in 2nd ICS after sterile drape/prep if
possible
 Chest tube needed for definitive management
Chest Tube Insertion
Abdominal Trauma
Abdominal Trauma
 3rd leading cause of traumatic death
 Often unrecognized in children
 Consider abdominal injury in the following:
Sign
Possible Injuries
Seatbelt Injury
Small bowel injury
Chance fracture
Handlebar injury
Duodenal hematoma
Pancreatic injury
Sport related injury
Spleen, kidney, bowel
Abdominal Trauma
Abdominal Trauma
 If unstable vitals, indication for OR
 FAST to look for free fluid in the abdomen.
 IV contrast enhanced CT gold standard for
diagnosis of stable patient
 Definitive management dependant upon
specific organ injured
Burns/Thermal Injury
Burns/Thermal Injury
 70% pediatric burns secondary to hot liquid
 Up to 20% burns in younger children secondary
to abuse or neglect
 Consider inhalational injury and need for EARLY
intubation if not secondary to liquid
 Hoarseness
 Black sputum
 Facial burn
 Accident in closed area
Burns
 Burn Assessment
 Depth
 1st degree: superficial (epidermis)
 2nd degree: superficial or deep partial thickness (dermis)
 3rd degree: full thickness (beyond dermis)
Burn/Thermal Injury
 Burn Assessment
Time to healing
Appearance
Surface
Sensation
1st degree
Pink or red
Dry
Painful
Days
Superficial
2nd degree
Pink, clear
blisters
Moist
Painful
14–21 days
Deep 2nd degree
Pink,
hemorrhagic
blisters, red
Moist
Painful
Weeks, or may progress
to 3rd degree and
require graft
3rd degree
White, brown
Dry, leathery
Insensate
Requires excision
4th degree
Brown, charred
Dry
Insensate
Requires excision
Burn/Thermal Injury
 Estimating Burn Size
Palm of patient’s hand =
~ 1% BSA
Burn/Thermal Injury:
Management
 ABCDE’s
 Consider early intubation if airway involvement
 Tetanus prophylaxis and ANALGESIA
 Fluid resuscitation mainstay of treatment
 Parkland Resuscitation Formula: using Ringer’s Lactate
 Give 4ml/kg/%TBSA
 First half of resuscitation fluids (AS WELL AS
MAINTENANCE FLUIDS) over first 8 hours
 Second half over following 16 hours
 u/o goal: 1-2 ml/kg/hour
Burn/Thermal Injury
 Consider referral to a burn centre if:
 Inhalational injury
 Burn size >10% TBSA in child <10yo
 Burn size >20% in any patient
 Full-thickness burns >5% TBSA
 Burn involving hands/feet/face/perineum
 Mutiple comorbidities
 NAT
 Chemical/Electrical injury
Submersion Injuries
Submersion Injuries
 500 000 deaths due to drowning per year
worldwide
 >50% drowning victims <5yo
 Fatality is highest in children <5yo
 M>F
 Most common cause of cardiac arrest in
children
Submersion Injury
 Most common sites of drowning:
 <1yo : Bathtubs (55%)
 1 – 4yo : Pools (56%)
 >4yo : Freshwater (63%)
 Definition of drowning versus Near
Drowning:
 Drowning = death within 24h of suffocation from
submersion in liquid
 Near Drowning/Submersion injury = survival >24h past
event
Submersion Injury
 Pathophysiology of drowning:
 Accidental submersion
 Loss of normal breathing pattern
 Possible laryngospasm
 Pulmonary aspiration/breath-holding/apnea
 Hypoxemia:
 Low O2, hypercarbia, acidosis
 End-organ damage – circulatory arrest
Submersion Injury
 ABCDE’s
 Consider early intubation
 Always consider C-spine immobilization
 0.5% submersion victims have c-spine injury
 Remove wet clothing
 Treat hypothermia
Poor Prognostic signs
 Prolonged submersion >25 minutes
 Delay in CPR initiation
 Resuscitation >25 minutes
 pH <7.1
 Pulseless, cardiac arrest on arrival to emergency department
 Elevated blood glucose on arrival
 Dilated and fixed pupils on arrival
 Abnormal initial CT of brain
 Initial GCS of <5
Conclusion
 Pediatric trauma and injury are preventable
conditions
 Principles of management should always
include a well orchestrated primary and
secondary survey
 Never hesitate to admit for observation, ask
for help or consult specialty services -the
earlier the better.