Approach to trauma
the paeds emerg perspective
Stephen C. Porter MD MPH MSc
Division Chief, Pediatric Emergency Medicine
The Hospital for Sick Children
Associate Professor of Paediatrics
University of Toronto School of Medicine
Outline for today
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“Children are not little adults”
General concepts in pediatric trauma
Multiple trauma – major trauma/ ATLS
Quick hits: body parts and bones
How do injuries happen…
Children versus adults in trauma
• More energy from
trauma distributes across
more surface area
• The bony skeleton is less
calcified, has active
growth centers, and is
more pliable
• Ratio of surface area to
volume means thermal
losses are a concern
You are called to the trauma bay…
• A 2 year old who was run over by a heavy
delivery truck when she dashed out in front of
the truck. She fell forward as she was struck by
the bumper. The front tire rolled over her body
prone on the pavement from the buttocks toward
her left shoulder. She was crying and her parents
who noticed what happened immediately drove
to the hospital in their own car.
• VS T37, P140, R40, BP 100/65, oxygen saturation
94% in room air.
The exam
• She is crying, alert and cooperative. Her head and face show no
tenderness, bruising or abrasions. Pupils are reactive. TM's are
normal. Teeth are intact without evidence of oral injury. Her neck is
non-tender. Her neck range of motion is not restricted. Heart
regular. Lungs clear, with an occasional grunting sound. Anterior
chest shows no bruises. Her abdomen is soft, not tender with active
bowel sounds. There is extensive bruising over her anterior pelvis.
There is no bleeding. Her labia are bruised but no bleeding or tears
are noted. Her lower extremities are non-tender distal to the pelvis.
Her back shows mild bruising in the upper chest and the buttocks.
She can move all her fingers and toes well. She does not move her
lower extremities spontaneously. No extremity deformities noted.
Color and perfusion are good.
Describe and treat this patient
• Nature and seriousness of injuries
– Multiple or local
– Blunt/penetrating
– Severity
• ATLS principles
Primary assessment
Resuscitation
Comprehensive secondary assessment
Transition to definitive care
Describe and treat this patient
• Nature and seriousness of injuries
– Multiple or local
– Blunt/penetrating
– Severity
• ATLS principles
Primary assessment
Resuscitation
Comprehensive secondary assessment
Transition to definitive care
Describe and treat this patient
• Nature and seriousness of injuries
– Multiple or local
– Blunt/penetrating
– Severity
• ATLS principles
Primary assessment AND resuscitation
Comprehensive secondary assessment
Repeat exams and monitoring for changes
Transition to definitive care
Major trauma: important questions
• Is the airway stable?
• Is respiratory effort
sufficient?
• Is the patient in shock?
• Is there a neurologic
deficit?
• What are the extent of
the injuries?
Crew resource management
Trauma team activation
• Physiologic criteria
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Cardiac arrest
Hypotension per age
Respiratory distress
Neurologic failure
Trauma score < 12
• Anatomic criteria
– Penetrating wound to
head, chest, abdomen
– Facial/tracheal injury
with potential for airway
compromise
– Burn > 30% BSA
– Major electrical injury
Pediatric Trauma Score
Predicting mortality from trauma
• The trauma BIG score
– Admission Base deficit
– INR
– Glasgow Coma Scale
• Score = (base deficit + [2.5*INR] + [15-GCS])
• Predicted mortality =
1 / (1 + e-x) where x = 0.2 * BIG – 5.208
• Mortality of 50% is predicted for a child with
– Base deficit 10, INR 3.6, GCS of 6
Borgman et al Pediatrics 2011
Observed and predicted mortality by the BIG score quintile in the derivation set
Pediatric trauma: Airway and C spine
Pediatric trauma: Shock
• Up to 30% loss of
circulating volume may
be required to influence
systolic BP in a child
• If more than 2 fluid
boluses of 20 cc/kg have
been given to support
perfusion, PRBC are
needed and surgeon’s
involvement is key
Systemic response to blood loss: children
System
<30%
blood loss
30-45%
blood loss
>45%
blood loss
CV
Nl BP
Low BP
Absent
peripherals
CNS
Anxious
irritable
Lethargic
Comatose
Skin
Cool,
mottled
Cyanotic,
delayed refill
Pale, cold
UO
Low
Minimal
None
Pediatric trauma: neurologic disability
• Neurologic assessment occurs in both primary
and secondary survey phases
– Primary survey - a “quick scan” for disability
• Pupils, GCS, lateralizing signs, level of spinal cord injury
– Secondary survey - comprehensive assessment
• Repeat of pupils and GCS
• Full assessment of cranial nerves and distal motor and
sensory function as able to given age of patient
Loss of vital signs in the trauma bay
• Children who suffer blunt trauma and then
develop cardiac arrest are known to have poor
outcomes
• 10/10 patients with blunt trauma died despite
thoracotomies in the trauma bay
• 1 patient with penetrating injury and stable
vital signs on arrival who underwent emergent
thoracotomy survived
Hofbauer et al Resuscitation 2011
Back to our 2 year old patient
• Pertinent history
– She fell forward as she was struck by the bumper.
The front tire rolled over her body prone on the pavement
from the buttocks toward her left shoulder.
• Vitals
– T37, P140, R40, BP 100/65, O2 saturation 94% in room air
• Exam
– Bruising over her anterior pelvis, labia are bruised
– Back shows bruising, upper chest and buttocks
– No spontaneous movement of lower extremities
A pain in the neck
Swischuk and his line
Neurotrauma
• Key facts, current thinking
– Cerebral perfusion pressure
depends on a normal MAP
– Goal for ventilation in
neurotrauma is normocarbia
– When increased ICP is
suspected,
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Elevation of head of bed
Sedation
Mannitol
Hypertonic saline
Thoracic trauma
• Lung contusion is the
most common pediatric
thoracic injury
• Pediatric patients are
more sensitive to
mediastinal shifts from
air/fluid in pleural space
• Risk of intraabdominal
injury higher in setting
of thoracic trauma
Abdominal Trauma
• CT is the preferred
diagnostic imaging
modality to identify
abdominal injury
• Chief indication for
operative exploration in
a child is a transfusion
requirement that
exceeds 40cc/kg in first
24 hours of care
Orthopedic trauma
Anterior humeral line
Anterior humeral line
• Line drawn from
anterior cortex of
humerus intersects
middle third of
capitellum
More lines and figures
Radio-capitellar line
• Line drawn along axis of
the radius passes
through centre of
capitellum in all
projections
Figure- of- eight
• Seen on true lateral
elbow X-ray
• If disrupted, may indicate
fracture
Summing up
Main themes
• Blunt trauma is the
hallmark of pediatric
injury
• Special considerations
for pediatric trauma
– anatomy and physiology
– equipment
• Teamwork is needed for
optimal trauma care
Main tasks
• Is the airway stable?
• Is respiratory effort
sufficient?
• Is the patient in shock?
• Is there a neurologic
deficit?
• What are the extent of
the injuries?
Haddon Matrix
Example of a phase-factor matrix for motor vehicle injury
Pre-event
Event
Post-event
Host
Amount of sleep
Use of safety belt
Bystander care
Vehicle
Antilock brakes
Air bag deployment
Crash scene audit
Environment
Speed limits
Impact-absorbing
barriers
Access to trauma
system
A free and good PEM resource
http://www.hawaii.edu/medicine/pediatrics/pe
mxray/pemxray.html