1. Beaumont Children’s Hospital Pediatric Trauma: What's the difference? Robert Morden, MD Pediatric Trauma Medical Director

2. What’s the Difference? Pre-hospital Different Mechanisms: Things children do and their changing levels of maturity predispose them to different injury patterns. Different Injuries: When involved in the same kind of accident as adults, children suffer quite different injuries.

3. Epidemiology of Childhood Injury ( the U.S. numbers) 9.9.  9.2 million medical visits  151,319 hospitalizations  16% with permanent disability

4. Pediatric Trauma Factors Sex- males 2x risk Economic conditions Ethnic group Race Geography

5. How are Children Different? Anatomically Physiologically Cognitively Psychologically

6. Age and Injury Related Deaths < 1y/o: airway obstruction 1 to 4: drowning and transportation related 5 to 9: MVA 10 to 14: MVA

7. Injury Pyramid

8. Injury Fatality Rate

9. Haddon “Matrix” and Injury Prevention Injuries result from predictable events and thus offer an opportunity for systemic intervention Pre-event Event Post-event

10. Interventions Cross walk timers Helmets Seat belts Child proofing Smoke alarms

11. Trimodal Pattern of Trauma Mortality and Morbidity I.Death at the scene ie CNS and central vasculature. (prevention) II.Second peak minutes to hours after ie solid organ, CNS, Cardiothoracic. (focus of ATLS protocols) preventable deaths III.Days or weeks ie complications, RDS, infection. Uncommon in children

12. The ABCDE of Pediatric Trauma Application of a systemic protocol designed to standardize diagnostic and treatment decisions so that individual variations in patterns of injury do not distract the caregivers from recognizing and treating injuries that can have a profound impact upon outcome.

13. The Difference: Pre-hospital Kids are more difficult to intubate- 50% failure rate. IV access-50% failure. Unfamiliar with pediatric resuscitation; pediatric patients account for only 10% of paramedic transport volume. Emotional factors-terrified child, distraught parent.

14. Airway Priorities Ensure Oxygenation Ensure Ventilation Protect Spine Protect Airway

15. Considerations When and When not to intubate. O2 Sat <95% =clinical hypoxia Assess airway (teeth, debris,blood) Neurologically intact and phonates normally, and ventilates without stridor then leave them alone and monitor only. Coma, combativeness, shock, or direct trauma then needs a tube.

16. Pediatric Intubation Children’s airways differ both anatomically and physiologically. The best trained should intubate. Have appropriate equipment and medication available for best results.

17. Pediatric Airway Differences Subglottic –tube type and size affect Narrow oropharynx Larynx—anterior and cephalad Epiglottis—short, floppy, angled acutely Vocal Cords— difficult to visualize and are fragile and easily torn Trachea Shorter—endobronchial intubation and dislodgement are more common in kids.

18. More Pediatric Airway Considerations Nose breather—first 4 to 6 months Large tongue—relative to adults (jaw lift) Large head—occiput flexes head forward (support neck for neutral position)

19. Video Laryngoscope

20. Breathing (the differences) Laryngeal Mask Airway –unsuccessful then Cricothyrotomy >10 and needle 16 or 18 gauge if <10 Tracheostomy—ONLY IN OR Impaired spontaneous ventilatory drive – head injury Impaired lung expansion –thoracic injury Mortality rate for thoracic trauma in children is 25%

21. Breathing Pediatric mediastinum mobile –more susceptible to tension pneumo Compliant chest wall –more susceptible to injury to the cardiothoracic structures. (severe lung contusions)

22. Circulation Seriously injured children often have normal vital signs even with significantly decreased circulating volume as a result of a remarkable cardiovascular reserve.

23. Circulation In children, hypotension in the presence of blood loss = OMINOUS SIGN Child’s blood volume 80-90ml/kg vs adult 65-70ml/kg Fixed stroke volume infants. To increase cardiac output can only increase heart rate.

24. Circulation

25. Clinical Signs of Shock

26. Circulation Vascular access-2 lines (above and below) Central lines (if experienced) Cut downs (saphenous easiest) Interosseous (<6, 14 or 16 gauge, IO needle preferred) Fluids 20ml/kg RL If after 40ml/kg –give pRBC 10ml/kg(AB0)

27. Intraosseous Line Less than 6 years of age Fluids, blood products, and drugs can be given Proximal tibia or distal femur best location Fracture of the bone only contraindication Obtain alternate access ASAP

28. Circulation Signs of adequate perfusion - Slowing HR ( 20) -Normal skin color -Increase warmth of extremities -Improving GCS -Increase systolic BP (>80) -Urinary output-1-2 infant/ 1 child

29. Circulation If hemodynamic remains unstable hemorrhage intraabdominal or pelvic cardiac dysfunction tension pneumothorax CNS (atlantooccipital dissociation) profound hypothermia

30. Disability A rapid CNS evaluation A—alert V—voice responsive P—pain responsive U—unresponsive Pupillary responsiveness and symmetry

31. Disability GCS 13-15 mild TBI; 9-12 moderate TBI; 3-8 severe TBI (70% mortality) May have significant blood loss from associated scalp laceration Basilar skull fracture –Raccoon's eyes, hemotympanum, otorrhea, rhinorrhea –Indicates significant force but not important to immediate outcome –No prophylactic antibiotics

32. Disability Open sutures (the fontanelles) - Ant. Open age 12-18mo -Post. Open 2mo Thinner cranial bones Head relatively larger - heat loss -higher center of gravity-more head trauma

33. Exposure Relatively small size –greater likelihood of multiple organ injury Higher BMR and surface area –heat loss and increase oxygen consumption Increased glucose needs and low glycogen –small glycogen stores therefore monitor glucose levels.

34. Exposure Hypothermia effects –cognitive function –cardiac activity –coagulation Keep core temp 35 to 36 degrees Celsius –warm room, bed, fluids, gases

35. Other thoughts Gastric dilatation-NG tube –respiratory compromise and vagal bradycardia. Decreases risk of aspiration. –no if facial fx or rhinorhea Foley only after perineal assessment ECG-rarely abnormal but if it is then multiple possibilities.

36. CNS Injury Cause of 70% of the deaths. <2 Non-Accidental Trauma (abuse) is the most common cause. >2 falls, MVA, bicycle, pedestrian. Traumatic Brain Injury -Primary or Secondary

37. Primary Structural derangement of cerebral architecture from direct mechanical impact -cellular and vascular disruption -infarction -tissue loss -epidural hematoma(thin skull) -subdural (less common)

38. Secondary Decreased cerebral perfusion after the event –brain swelling leads to impairment of O2 and substrate. –treatment principle is to protect cerebral perfusion and is the difference between disaster and success. CPP=MAP-ICP

39. Secondary Maintain ICP <20mmHg in all ages CPP >45mmHg in <8 years CPP>70 to 80 mmHg older than 8 years –intubate and controlled hyperventilation Pco2 30 to 35, Po2>100,and PH 7.4 - ventriculostomy to optimize CPP -osmotherapy (Mannitol or 3%Saline) -mild to moderate hypertension Decompressive craniectomy when ICP refractory

40. Spinal Cord Injury C1 and C2 fx unlike adults C6/C7 Compression and flexion distraction fx –(Chance) SCIWORA-Spinal cord injury without radiologic abnormality –10-20% of SCI –a documented neurologic deficit that may have changed or resolved MRI

41. The Childs Chest Narrow airway-obstructs easier Anterior/Superior glottis-difficult intubation Shorter trachea-endobronchial intubation Diaphragmatic breathing-hypoxia with abdominal distension Compliant rib cage-retraction and injury Mobile mediastinum-tension pnemo

42. Clinical Predictors of Chest Injury Hypotension Increased respiratory rate Abnormal physical exam of chest Femur Fx GCS<15 –98% of proven chest injuries had 1 or more of these.

43. Thoracic Injuries Second leading cause of death In absence of external signs of trauma significant intrathoracic injury –pliable chest –mobile mediastinum >50% of rib fx in <3 year olds –abuse

44. Thoracic Injury Pneumothorax-blunt burst type injury usually Not all need chest tubes. If <20% and O2 Sat OK. 4 th or 5 th intercostal space Newborn 12 –16F Infant 16 –18 F School age 18-24 F Adolescent 28 –32 F

45. Pneumothorax

46. Tension Pneumothorax (usually a major injury if seen) Severe distress,trachea shift, neck vein distension, collapsed lung with flattened diaphragm, reduced venous return to heart. Treatment immediate needle- catheter (without waiting for Xray) 2 nd intercostal space anteriorly or lateral in 4 th or 5 th.

47. Hemothorax Most bleeding stops-low pressure pulmonary circulation Massive-laceration of vessel (intercostal commonest) Thoracotomy consider: -Initial blood 20-25% of EBV -4ml/kg/hr -Increasing bleeding -If can’t get out clot

48. Pulmonary Contusion Commonest Injury Rare to need ventilation Rare to go on to ARDS Differentiate from Aspiration Most clear in 7 to 10 days.

49. Trachea and Bronchi Rare but often fatal Presentation-Voice disturbance, cyanosis, hemoptysis, Massive sub Q air and mediastinal emphysema Large leak from chest tube. ATLS and then OR unless stable

50. Heart and Pericardium Concussion –commotio cordis Contusion-commonest and difficult to diagnosis (rarely of clinical significance in children) Myocardial rupture-commonest cause of death in blunt trauma. (if survive may see tamponade.)

51. Pericardial Tamponade Suspect when-tachycardia, peripheral vasoconstriction, jugular venous distension, persistent hypotension despite fluids. Beck’s triad-elevated jugular venous pressure, systemic hypotension, muffled heart sounds (rarely seen in acute trauma) Diagnosis –FAST exam and transthoracic echo.

52. Traumatic Asphyxia Unique to Children Compression of Chest and/or Abdomen against a closed glottis Increase in intrathoracic pressure leads to increase in the SVC pressure and the veins from the upper body that drain into it. Extravasation of blood into skin, sclera, brain Seizures, disorientation, petechiae of upper body and conjunctivae Most recover

53. Petechiae

54. Pediatric Abdomen Difference Thin musculature (particularly <2) Ribs flexible-don’t protect or dissipate energy Solid organs larger Lower fat content Elastic attachments Higher bladder

55. The Abdomen Exam Abdominal wall bruising: –74% of children with had major injury –99% of children without had none Lower rib fracture: –associated with 31% splenic injury and 15% hepatic injury

56. The FAST? Focused Assessment Sonography in Trauma Useful – free fluid detection, pericardial +/- Not useful-solid organ injury (does not determine grade) Limitations: user dependent, high false negative results. Conclusions: Get CT if suspicious.

57. Solid Organ Injury Splenic LacerationLiver Laceration

58. Solid Organ Injury The non-operative management: –Universally successful and the standard of care >90% –Yet: The operative rate is 4 to 6 times greater in non-pediatric centers. Operate when hemodynamic instability unresponsive to crystalloid and blood transfusion.

59. Lab studies and blunt abdominal trauma CBC,TandC U/A Transaminases : elevated AST and ALT strong association alone with injury. Pancreatic enzymes: controversial but baseline importance.

60. Seat Belt Sign

61. Bowel Injuries

62. CT or not CT Glasgow coma scale 14 or > No evidence of abdominal wall trauma No abdominal tenderness No complaints of abdominal pain No vomiting No thoracic wall trauma No decreased breath sounds.

63. Case Study: KW 11 yo female presented 16 hours following fall on cement block CC epigastric pain, nausea and emesis PMH/PSH negligible

64. Case Study: KW Physical Exam Afebrile, HR 120, BP 90/50 NAD, Pale, lethargic, dry mucous membranes Abdomen  soft, ND, TTP epigastrium, abrasion across left subcostal extending across anterior chest

65. Pancreatic Injury

66. Treated non-operatively NPO/IVF/TPN PTD 7, +Clears introduced PTD 14 discharged home on TPN and clear diet 10/2  ultrasound, no pseudocyst, diet advanced

67. Pediatric Renal Trauma Most commonly injured abdominal organ in blunt trauma. –Fetal lobulations predispose to renal seperation –Less protection by pliable thoracic cage and less developed musculature –Higher incidence of pedicle injury 80 % with renal injury has associated non- renal injuries

68. Pediatric Renal Trauma Pre-existing renal abnormalities are 3-5 times more common in peds patients undergoing screening CT for trauma than in adults. Classically, congenital renal abnormality presents with hematuria disproportionate to severity of trauma

69. Organ Injury Scale

70. Case Study: BF 15 y/o male presents to OSH after he was hit with a line drive while playing indoor baseball C/O pain to R abdomen/rib/flank Pain is getting progressively worse and patient is now vomiting

71. Case Study BF: Exam No acute abdominal tenderness Unilateral rib x-rays negative Labs drawn-CBC, CMP, PT/PTT Given Vicodin and Zofran for pain and nausea UA ordered and staff recognized gross hematuria, A/P CT was ordered

72. Case Study BF: Diagnosis CT shows at least AAST grade III laceration involving the medial interpolar right kidney with moderate surrounding perinephric hematoma. Patient transferred to RO Beaumont for eval.

73. Case Study BF: Admit Admit to Peds Urology q6hr Hgb -strict bed rest -IVF -pain control -PICU for monitoring -Type and Cross

74. Case Study BF: Disposition Patient was treated non-operatively He remained in Pediatric ICU for 2 days, and was transferred to the peds floor for 4 more days. Was discharged on day 6; home care included bedrest for 1 month and no school

75. Case Study: GSW 3 year old boy found fathers 45 under mattress inserted in mouth and pulled the trigger. Presents with bleeding from mouth and exit wound below mandible on right. A: Unable to visualize cords (blood and swelling) B: Harsh breath sounds C: BP normal, mild Tachycardia D: Crying (Glasgow 15)

77. Case Study: GSW

78. Discrepancies in story Changing history Inappropriate response –parents and child Multiple injuries in past Classic abuse injuries Child’s development Sexual abuse Child Abuse “Red Flags”

79. Injuries that would be suspicious for abuse Multiple SDH, retinal hemorrhage Ruptured viscus without antecedent history Perianal, genital trauma Multiple scars, fractures of varying age Long bone fractures less than 3 years old Bizarre injuries: bites, cigarette burns, rope marks Sharply demarcated burns

80. Overview: What’s the difference Characteristic Large BSA Poor neck musculature Large blood volume in head Decreased alveolar surface area High metabolic rate Small airway Heart high in chest Small pericardial sac Compliant skeleton Thin walled, small abdomen Poorly developed renal function Result Hypothermia Flex/extension injury Cerebral edema Rapid desats Inc airway resistance Injury/tamponade Fracture less common Organs not protected Risk renal failure

81. Questions?