Pediatric Trauma
Karim Rafaat, MD
Goals
Time is short
I’m going to presume you know your basic ATLS
(that’s that whole ABCD thing, by the way)
Discuss each general trauma susceptible region
Focus on:
Epidemiology
Anatomic and physiologic differences between children
and adults
How this results in differing patterns of injury, and thus,
different foci for concern
Yay Parenting!!
Epidemiology - General
Trauma is the leading cause of death between the ages of 118
Injury accounts for 5% of infant deaths
47% of these deaths are related to MVCs
With rates higher in those >13yo
13% of deaths in those 1-14yo were a result of homicide
In the school age group
Pedestrian injuries and bike injuries predominate
Pediatric Head Injury
#1 cause of death due to trauma
~2700 deaths/year
450,000 children present to EDs
each year with head injury
90% suffer from minor
injuries
Perinatal period
Birth injuries
1-4 years old
Falls
School age
Pedestrian or bike injuries
Adolescence
MVA
Anatomic Considerations
The skull is more plastic and
deformable
Better able to absorb initial
impact without fracture
Open sutures function as “joints”
Allow shifting of bone to
absorb impact
Prevent early and rapid rise of
ICP secondary to brain
swelling/space occupying
lesions
This also means that infants can
lose a significant portion of their
blood volume into their cranium
secondary to a head injury
Children have larger
heads than adults in
relation to their body
The chance that it is hit
in a traumatic event is
larger
Head is heavy
Different acceleration
dynamics
At birth, the brain contains very
little myelin
Progressive decrease in water
content from birth until the brain
is fully myelinated
Neonatal brain water content is
~89%, adult content is 77%
Brain is softer and more prone
to acceleration/deceleration
injury
Myelination proceeds in a caudocranial and posterior-anterior
direction
Differential myelination results
in different absorption of force
Increases susceptibility of
unmyelinated portions to shear
injury
At birth, face to cranium
ratio is 1:8, adult ratio is
1:2.5
Makes it more likely
skull is hit in younger
children
Lack of pneumatization of
sinuses is associated with
more rigidity and less
plasticity of facial skeleton
Increases transfer of
forces directly to brain
Pediatric Spine Injury
18.1 spinal cord injuries
per milllion children
1300 new cases a year
60-80% of injuries occur
at the cervical level
Adults have a 30-40%
incidence
Children <8 yo
More likely to sustain
high cervical (C1-C3)
injuries
Anatomic Considerations
Immature C-spine has more horizontal orientation of
facet joints
Relative laxity of cervical ligaments
Weaker neck muscles
Relatively increased mass and volume of infant head
Anatomic Considerations
Cervical flexion fulcrum
C2-C3 in infants
C3-C4 by 5yo
C4-C5 at 10
C5-C6 (adult) at age 15
Pediatric C-spine is much
more flexible than adult cspine
Spinal cord injury can occur
without injury to bony spine
(SCIWORA)
Trauma related myelopathy,
however transient, demands
an MRI
Pediatric Thoracic Trauma
#2 cause of trauma related
mortality
In isolation, thoracic
trauma carries a 5%
mortality
25% when combined
with abdominal injury
40% with head and
abdominal injury
Anatomic Considerations
Incomplete ossification of ribs allows anterior
ribs to be compressed to meet posterior
Pulmonary contusions are common, rib
fractures uncommon
Presence of rib fractures in 0-3yo suggests
NAT
Pulmonary contusions are most common
thoracic injury in traumatized children
Trachea is narrow, short, more compressible
Small changes in airway caliber due to
external compression or internal FB lead
to large changes in resistance
Great vessel and cardiac injury are rare in
children
However, hemodynamic instability in the
face of euvolemia should raise concern for
myocardial contusion and/or mediastinal
injury
Anatomic Considerations
Commotio Cordis is a
unique consequence of
pediatric thoracic trauma
Abrupt strike to the
chest leads to V-Fib and
arrest
Pediatric Abdominal Trauma
Third leading cause of
pediatric traumatic death
Blunt causes in 85%,
penetrating trauma in
15%
Blunt trauma related to
MVC’s causes more than
50% of abdominal
injuries in children
Boogie board related injury..!
Anatomic Considerations
Proportionally larger solid
organs
Less subcutaneous fat
Less protective abdominal
musculature
Relatively larger kidneys
that predispose them to
renal injury
Anatomic Considerations
Splenic injuries are the
largest proportion of
pediatric abdominal trauma
Liver is second most
injured solid organ
Lap Belt Injury
Sudden increase in bowel
intraluminal pressure can
result in intestinal
perforation
Chance fracture of the
lumbar spine
Anatomic Considerations
The compliant chest wall,
poor thoracic musculature
and weak diaphragm can
lead to considerable
respiratory difficulty with
gastric distention