36 PEDIATRIC TRAUMA
David A. Partrick M.D., Denis D. Bensard M.D.

1. What is the leading cause of death in children in the United States?

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Injuries cause more death and disability in children from ages 1 to 18 years than all other causes combined. Unintentional injury deaths account for 65% of all injury deaths in children under 19 years of age. Each year, approximately 20,000 children and teenagers die as a result of injury and 50,000 children suffer permanent disabilities. Each year, nearly one child in four receives medical treatment for an injury. The estimated annual cost is $15 billion.

2. What age groups are at particular risk for traumatic death?

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Infants younger than age 2 years have a consistently higher mortality rate for the same level of injury. During adolescence, however, injury takes the greatest toll, accounting for nearly 80% of deaths.

3. What primary mechanisms account for pediatric traumatic injuries?

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Blunt (90%), penetrating (9%), and crush injuries (< 1%). Motor vehicle accidents are the most common cause of injury (50%) and death in childhood.

4. What is the incidence of injuries by body region?

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Multiple (50%), extremities (20%), head and neck (15%), abdomen (3%), face (2%), and thorax (1%).

5. What is the overall mortality from injury in children?

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2% of all injured children and 3% of hospitalized injured children.

6. What is the mortality rate of injuries by mechanism?

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See Table 36-1.
Table 36-1. MORTALITY RATE BY MECHANISM OF INJURY

7. Are boys and girls equally susceptible to injury?

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No. Boys are injured twice as often as girls. Boys and men are at a 4 times greater risk for “successful” suicide (although boys try it less often), 3 times greater risk for drowning, 2.5 times greater risk for homicide, and 2 times greater risk for motor vehicle-related trauma. The second X chromosome is clearly protective.

8. How is a child’s airway different from an adult’s?

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Children are at increased risk of airway obstruction because of their large tongue; floppy epiglottis; increased lymphoid tissue; and short, small-diameter trachea. Uncuffed endotracheal tubes are appropriate in children younger than age 8 years to minimize vocal cord trauma, subglottic edema, and ulceration. The narrowest part of a child’s airway is the cricoid ring, which functions as a seal for the uncuffed endotracheal tube.

9. What is the appropriate size of endotracheal tube to place in a child?

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The endotracheal tube should be the same size as the child’s small finger. For newborns, use a 3-mm tube; children in first year of life, 4-mm tube; children older than 1 year, internal diameter of the endotracheal tube = 18 + patients’s age in years ÷ 4 (but, in an urgent situation do not resort to extensive calculations; simply look at the child’s pinky).

10. What if oral endotracheal intubation cannot be accomplished?

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A needle cricothyrotomy is preferable to surgical cricothyrotomy and can be performed with a 14-gauge catheter. Conceptually, this is the same as jet insufflation in adults. Surgical cricothyrotomy is much more difficult in small children and has a high association with secondary subglottic stenosis.

11. What is a child’s total blood volume?

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80 mL/kg (8% of body weight).

12. What is the first sign of significant blood loss in children?

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Tachycardia. Young children are incredibly tough and have a remarkable tolerance to blood loss. Hemorrhage of 30% of blood volume may result in no blood pressure change, but such blood loss does cause a rapid increase in heart rate. A child’s cardiac output depends largely on heart rate; unlike adults, children have a limited capacity to increase stroke volume.

13. What are signs of hypovolemic shock in children?

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Tachycardia (progressing to bradycardia), altered mental status, respiratory compromise, delayed capillary refill (> 2 sec), and decreased or absent peripheral pulses.

14. Is hypotension a reliable indicator of blood loss in children?

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No. Fewer than half of injured children with documented hypotension have an identifiable insult resulting in significant volume loss. Hypotension is often associated with an isolated closedhead injury, especially in children younger than age 6 years.

15. Why are children at increased risk for hypothermia during resuscitation?

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The child’s surface area is large relative to internal body mass-an unclothed child can lose heat fast. Cold intravenous fluids and inhaled gases can exacerbate hypothermia, leading to hypoxemia, which causes pulmonary hypertension and progressive metabolic acidosis. Particularly vulnerable are infants < 6 months of age, who lack significant subcutaneous fat and an effective shivering mechanism.

16. What sites are preferred for venous access in children?

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Two large-bore intravenous (IV) catheters should be inserted percutaneously in the upper extremities. The second choice is percutaneous access to the distal saphenous vein (or a cutdown).

KEY POINTS: PEDIATRIC HEMODYNAMICS

1. Blood volume: 80 mL/kg.
2. The first sign of hypovolemia is tachycardia, which progresses to bradycardia.
3. Hypotension is not a reliable indicator of blood loss; children can lose 30% of blood volume without detectable change in blood pressure.
4. Preferred IV access routes in order: (1) two large-bore upper extremity IVs; (2) distal saphenous vein or cutdown; (3) intraosseous access.
5. Resuscitation fluid is lactate Ringer’s, 20 mL/kg × 2; then packed red blood cells (10 mL/kg) if instability continues.

17. What if you cannot establish an IV line?

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The intraosseous route is safe and actually requires less time than a venous cutdown. The anteromedial surface of the proximal tibia is used most commonly, with the needle placed 3 cm distal to the tibial tuberosity. The proximal femur, distal femur, and distal tibia are other potential sites. Saline, glucose, blood, bicarbonate, atropine, dopamine, epinephrine, diazepam, antibiotics, phenytoin, and succinylcholine have been administered successfully via the intraosseous route. Complications are rare and result primarily from infection or extravasation. Intraosseous volume resuscitation facilitates subsequent cannulation of the venous circulation.

18. What are the appropriate crystalloid and blood resuscitation volumes in children?

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Administer 20 mL/kg of Ringer’s lactate solution or normal saline by bolus. A response is a decrease in heart rate and an increase in urinary output. The 20-mL/kg bolus should be repeated if assessment reveals inadequate tissue perfusion. If evidence of shock persists after two bolus infusions of crystalloid solution, 10 mL/kg of packed red blood cells (type specific if available or O-negative) should be administered. Unfortunately, a favorable response to resuscitation does not exclude a big abdominal or thoracic injury.

19. Why are head injuries more common in children than adults?

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Similar to Olympic ski jumpers, children lead with their heads. Until age 10 years, children’s heads are larger in relation to the body than heads of adults. Central nervous system injury is the leading cause of death among injured children and, thus, is the principal determinant of outcome.

20. What types of head injuries are more common in children?

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Epidural hemorrhage is the most common; subdural hemorrhage is relatively rare. However, mortality from subdural hemorrhage is 40% versus 4% for an epidural bleed. Pediatric patients also tend to sustain injuries that produce diffuse edema rather than focal, space-occupying lesions.

21. Can children have significant chest trauma without rib fractures?

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Absolutely. The chest wall is much more compliant in children than in adults; thus, kinetic energy is transmitted more readily to structures within the thorax. A child with significant blunt chest trauma is at increased risk of life-threatening contusion to the lungs or heart even with no or relatively few rib fractures. Furthermore, pneumothorax may prove rapidly fatal in children because of a more mobile mediastinum. When present, rib fractures in children reflect non-accidental trauma. Thoracic injury is the second leading cause of death (after head trauma) in children.

22. What types of thoracic injuries are common or uncommon in children?

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Pulmonary contusion, traumatic asphyxia, and tracheobronchial injuries are common. Traumatic aortic rupture, flail chest, diaphragmatic rupture, and open pneumothorax are unusual.

23. What is the frequency of abdominal organ injury in blunt trauma?

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In decreasing order of frequency, they are spleen, liver, kidneys, intestine, pancreas, urinary bladder, and major blood vessels. Approximately one third of children with major trauma have significant intraperitoneal injuries that must be recognized and treated expeditiously.

24. How accurate is physical examination in the evaluation of pediatric blunt abdominal trauma?

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Poor. Physical examination is misleading in ≤ 50% of injured children.

25. What are the advantages and disadvantages of diagnostic peritoneal lavage (DPL) in children?

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DPL is 96% accurate in detecting intraabdominal injury. However, it may lead to nontherapeutic laparotomy rates of 15%.

26. What are the advantages and disadvantages of computed tomography (CT) in children?

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Abdominal CT scan is safe, noninvasive, and can assess retroperitoneal structures as well as identify specific organ injuries. CT is critical in the decision to manage children nonoperatively. Disadvantages include insensitivity for hollow visceral injury and the need for IV and enteral contrast agents. In addition, CT is time consuming (spiral CT may prove better) and requires patient transport and sedation. A trip to the scanner leaves patients vulnerable and unmonitored. Thus, CT is risky in unstable patients.

27. Is ultrasonography effective in the evaluation of children with abdominal traumaShow answer
Yes. It is simple, fast, readily available, and can be performed at the bedside. In addition, it is noninvasive and easily repeatable. The sensitivity and specificity of a focused abdominal ultrasonographic examination for traumatic injury exceeds 95%. Abdominal ultrasound is best used as a triage tool to detect significant intraperitoneal fluid, thus identifying hemodynamically unstable patients who might benefit from a laparotomy.
28. Is there a reliable method to diagnose hollow visceral injury in children?

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No. Serial physical examinations remain the gold standard. Repeat physical examination by the trauma surgical team is mandatory.

29. What are the “soft signs” of pediatric intraabdominal injury?

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* Lap-belt ecchymosis corresponds to a high incidence of solid organ injury, hollow viscus injury, and lumbar spine injury.
* Gross hematuria has a 30% risk for significant intraabdominal injury not even involving the genitourinary system.
* Elevation of the liver enzymes aspartate aminotransferase (> 250 U/L) or alanine aminotransferase (> 450 U/L) corresponds to a 50% risk for liver injury.
* Children with documented pelvic fracture have at least a 20% risk for associated intraabdominal injury.
* Children with severe neurologic impairment (Glasgow Coma Scale score < frequently suffer concurrent intraabdominal injury.

30. What should be suspected in children with seat-belt or handlebar injuries?

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The seat-belt complex consists of ecchymosis of the abdominal wall, a flexion-distraction injury to the lumbar spine (Chance fracture), and intestinal injury. Approximately 30% of children with the seat-belt sign have an associated intestinal injury.
A handlebar injury classically causes disruption of the pancreas at the junction of the body and tail, where the pancreas crosses the vertebral column and is vulnerable to anterior blunt compression.

31. Does the presence of hemoperitoneum in children require laparotomy?

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No. Unlike in adults, < 15% of children with hemoperitoneum require laparotomy for control of bleeding or repair of an injury.

32. Do all children with solid organ injuries require operative repair?

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No. Selective nonoperative management of solid organ injuries has revolutionized the management of pediatric trauma and is even gaining acceptance as safe and effective in the management of solid organ injuries in adults.

33. When is nonoperative management of solid organ injury in children appropriate?

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When the vital signs remain stable, 50% of the blood volume is replaced, and no other significant intraabdominal injuries are present. The decision for nonoperative management versus laparotomy should be based on the child’s physiologic condition and not on the extent of injury as documented radiographically.

34. What are the indications for operative intervention for solid organ injuries?

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Massive bleeding on presentation and transfusion of > 50% of blood volume (40 mL/kg) within 24 hours of injury.

35. What is SCIWORA?

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Spinal cord injury without radiologic abnormalities (SCIWORA) is a problem unique to children. A child’s spine has increased elasticity, shallow and horizontally oriented facet joints, anterior wedging of the vertebral bodies, and poorly developed uncinate processes. The spinal cord can be completely disrupted in young children without apparent disruption of the vertebral elements. However, most patients have evidence of spinal cord injury on magnetic resonance imaging. Two thirds of SCIWORA cases are seen in children ≤ 8 years of age.

36. What is the hallmark of SCIWORA?

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A documented neurologic deficit that may have changed or resolved by the time the child arrives in the emergency department. The danger is that immediate reinjury of the same area may produce permanent disability. Many children with SCIWORA tend to develop neurologic deficits hours to days after the reported injury. Therefore, spinal immobilization should continue, and thorough neurosurgical evaluation is essential in any child with reliable evidence of even a transient neurologic deficit.

37. What percentage of pediatric deaths attributed to injury are caused intentionally?

Twenty-five percent. More than 80% of deaths from head trauma in children younger than 2 years are caused by intentional abuse.

38. What signs are suspicious for nonaccidental trauma (NAT)?

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* History of failure to thrive
* Delay in obtaining medical care
* Multiple previous injuries
* Absent or uninterested caregiver
* Fluctuating or conflicting histories
* History inconsistent with the injury or developmental level of the victim

Suspicious physical findings include bite, pinch, slap, or cord marks or bruises in various stages of healing; multiple or bilateral skull fractures; a skull fracture in a fall < 4 feet; and retinal hemorrhages (from shaking).

39. List the characteristics of shaken-baby syndrome.

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* Retinal hemorrhage
* Subdural or subarachnoid hemorrhage
* Little evidence of external trauma
* Age < 2 years

40. What fracture patterns are suspicious for NAT?

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* Multiple rib fractures of different ages
* Extremity fractures such as metaphyseal “chip” or “bucket-handle” fractures
* Diaphyseal spiral fracture in children < 9 months of age
* Transverse midshaft long-bone fracture
* Femur fracture in infants < 2 years of age
* Fracture of the acromion process of the scapula
* Proximal humerus fracture

41. What percentage of NAT cases involve burn injuries? What are their characteristics?

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20% of abuse cases involve burns. Scalding by hot water is the most common. Specific patterns of injury may raise suspicion of abuse, including burns involving the buttocks and perineum (bathing trunk distribution), back, dorsum of the hand, and stocking-glove distribution. Cigarette burns look like circular punched-out ulcers of similar size.

42. What are the necessary steps in evaluation of children with suspected NAT?

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Any child with suspected NAT should have a detailed physical examination, head CT scan, skeletal survey (babygram), and retinal funduscopic examination. The appropriate child protective services should be contacted immediately.

43. How common is postinjury multiple organ failure in children?

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It is rare. With equivalent injury severity, multiple organ failure in children is much lower than in adults and carries a much lower mortality.

References
WEB SITE
http://www.emedicine.com/med/topic3223.htm

BIBLIOGRAPHY
1. American College of Surgeons Committee on Trauma: Recognition of Physical Child Abuse. Chicago, American College of Surgeons, 1997.
2. Calkins CM, Bensard DD, Moore EE, et al: The injured child is resistant to multiple organ failure: a different inflammatory response? J Trauma 53:1058-1063, 2002.

3. Dare AO, Dias MS, Li V: Magnetic resonance imaging correlation in pediatric spinal cord injury without radiographic abnormality. J Neurosurg 97(1 suppl):33-39, 2002.
4. Mazzola CA, Adelson PD: Critical care management of head trauma in children. Crit Care Med 30(11 suppl): S393-S401, 2002.
5. Mehall JR, Ennis JS, Saltzman DA, et al: Prospective results of a standardized algorithm based on hemodynamic status for managing pediatric solid organ injury. J Am Coll Surg 193:347-353, 2001. Medline Similar articles Full article
6. Partrick DA, Bensard, DD, Janik JS, et al: Is hypotension a reliable indicator of blood loss from traumatic injury in children? Am J Surg 184:555-560, 2002. Full article
7. Partrick DA, Bensard DD, Moore EE, et al: Ultrasound is an effective triage tool to evaluate blunt abdominal trauma in the pediatric population. J Trauma 45:57-63, 1998. Medline Similar articles Full article
8. Stafford PW, Blinman TA, Nance ML: Practical points in evaluation and resuscitation of the injured child. Surg Clin North Am 82:273-301, 2002.