Trauma (peds): Difference between revisions

(Created page with "==Background== *Peds triad is appearance, work of breathing & circulation (skin color) *Childs size allows for dist of injuries, thus mutliple trauma is common & internal orga...")
 
 
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{{Peds top}} [[Trauma (main)]].''
==Background==
==Background==
*Key is to recognize and treat [[pediatric shock|shock]] early (before blood pressure decreases),
**once child has signs and symptoms of shock, may have lost 25% of blood volume
*BP not usually helpful sign of blood loss in pediatric patients
**Can have high, low, or normal BP in shock
**pulse pressure is helpful
*80% of pediatric trauma deaths associated with neurological injury (see [[pediatric head trauma]])


{{Locations of Possible Life-Threatening Bleeding}}
{{Pediatric car seat rules}}


*Peds triad is appearance, work of breathing & circulation (skin color)
==Clinical Features==
*Peds assessment triad: appearance, work of breathing & circulation (skin color)
*Child's size allows for distribution of injuries
**multi-system trauma is common
**internal organs more susceptible to injury due to anterior placement of liver and spleen (as well as less protective muscle & fat)
**Kidneys also less well protected and more mobile, prone to decelleration injury
*Wadell Triad in auto vs. pedestrian child= femoral shaft fracture, intraabdominal/intrathoracic injury, and contralateral head injury


*Childs size allows for dist of injuries, thus mutliple trauma is common & internal organs more susceptible to injury d/t more ant placement of liver & spleen (& less protective muscle & fat), Kidenys also less well protected and more mobile=more prone to decel injury
==Differential Diagnosis==
*[[Trauma (main)|Standard trauma injuries]] plus:
*[[Child abuse]]
*[[SCIWORA]]
*[[Chance fracture]]


*Wadell Triad in auto/ped= CHI, abd inj, femur Fx
==Evaluation==
*[[FAST]] exam
*Consider as indicated:
**CBC, coags, T&S, [[LFTs]] for abdominal trauma<ref>The Utility of Laboratory Testing in Pediatric Trauma: A Primer from TAMING OF THE SRU Dec 13, 2019 available at  http://www.tamingthesru.com/blog/grand-rounds/diagnostics/labs-in-peds-trauma</ref>
**Plain films
**[[CT head]], [[cervical spine clearance]] clinically or with imaging
**CT abdomen/pelvis<ref>Holmes JF et al. Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries. Ann Emerg Med. 2013</ref>
***Significant intra-abdominal injury after blunt torso trauma highly unlikely (0.1%) if all of the following are true:
****Glasgow coma scale ≥14
****No evidence of abdominal wall trauma or seat belt sign
****No abdominal tenderness, abdominal pain, or vomiting
****No thoracic wall trauma or decreased breath sounds


==Management==
*[[ATLS]]
*In ED give [[IVF]] at 20cc/kg, if unresponsive after 40cc/kg give [[PRBCs]] at 10cc/kg (can start with PRBC if presents in decompensated shock & multiple injuries suspected)


AIRWAY/BREATHING
==Disposition==
*Depends on underlying injury


*Cricoid ring is narrowest part of airway allowing for uncuffed tubes up to 6.0 ETT or up to about 8 yrs
==See Also==
*[[Pediatric head trauma]]
**[[PECARN head trauma rule]]
*[[Trauma (main)]]


==External Links==
*[http://pemplaybook.org/podcast/multisystem-trauma-in-children-part-one-airway-chest-tubes-and-resuscitative-thoracotomy/ Pediatric Emergency Playbook Podcast -- Multisystem Trauma in Children Part One: Airway, Chest Tubes, and Resuscitative Thoracotomy]
*[http://pemplaybook.org/podcast/multisystem-trauma-in-children-part-two-massive-transfusion-trauma-imaging-and-resuscitative-pearls/ Pediatric Emergency Playbook Podcast -- Multisystem Trauma in Children Part Two: Massive Transfusion, Trauma Imaging, and Resuscitative Pearls]


CIRCULATION
==References==
<references/>


*Key is to recognize & Rx shock early (before decr BP), s/s of shock= child may have lost 25% of BV
[[Category:Pediatrics]]
 
[[Category:Trauma]]
*BP not usu helpful sign of blood loss in peds, can be in shock w/ incr, decr or nl BP b/c kids are more effective at incre HR & SVR (pp=key)
 
*In field stop bleeding w/ pressure & elevation, MAST never shown to help kids
 
*In ED give IVF @ 20cc/kg, if unresponsive after 40cc/kg give PRBC @ 10cc/kg (can start w/ PRBC if presents in decompensated shock & multip inj suspected)
 
*Chest Tube in Peds is 4 X ETT
 
*Dip urine if NO blood stop, if blood send UA (+blood on dip= NO correlation w/ RBCs), if on UA >20 RBC's do CT to chk kidneys (Renal inj common, followed by bladder, urethra/ureteral are xtremely rare
 
*In sick trauma can skip c/s and just immobilize!
 
*CT A/P is study of choice but may miss hollow visceral injury (may take 1-2 days to see periton. signs)
 
*Shock w/ no response to IVF, think T-PTX or card tamponade
 
*Unstable pts, no response to IVF/PRBC= OR!
 
 
DISABILITY
 
*SCIWORA (2-21% of pts<8yr w/ spinal inj)
 
*C/S increased preodontoid space (up to 4-5mm vs 3mm in adult)
 
*pseudosubluxation C2 on C3 in 40% (up to teens), chk for true sublux by drawing line from ant cortical margin of spinous process (spinolaminar) of C1 to spinolaminar line of C3 (line of Swischuk), if line is >1-2mm from ant cort margin of C2 spinous process suspect TRUE sublux OR Fx!
 
*Chance Fx (L spine Fx) from forward flexion over lap belt (usu of L1-L4), 50% assoc w/ intraabdominal inj!
 
*80% of peds trauma deaths assoc w/ neurologic inj (see HCT/Head trauma memo)
 
 
MISC.
 
*suspect physical abuse (cause of 60% femur fx if <1y & 100% non-supracond hum fx <3y), skeletal survey if <3y & suspect abuse.
 
*missed inj common, usu d/t aloc, etoh. kids usu decr b/c we are hypervigilent. most common is muscskel so MUST xray joint above & below injured ext!! If BHT or ortho & nd OR r/o abd inj 1st!!
 
*Re-exam is key, try & do gd secondary survey before OR.
 
*Lat c-s xr alone misses 15% of fx! nd all 3 views.
 
 
==Source==
 
 
Gausche 2004 -by Lampe
 
 
 
 
 
[[Category:Peds]]

Latest revision as of 19:16, 3 August 2022

This page is for pediatric patients. For adult patients, see: Trauma (main).

Background

  • Key is to recognize and treat shock early (before blood pressure decreases),
    • once child has signs and symptoms of shock, may have lost 25% of blood volume
  • BP not usually helpful sign of blood loss in pediatric patients
    • Can have high, low, or normal BP in shock
    • pulse pressure is helpful
  • 80% of pediatric trauma deaths associated with neurological injury (see pediatric head trauma)

Locations of Possible Life-Threatening Bleeding

Pediatric car seat rules[1]

Age Type of Car Seat Position Comments
<2 years old Infant-only or convertible car seat Back seat, rear-facing If child height or weight > seat limit (usually ~40-65lbs), go to next age up
2-8 years old Convertible or combination car seat Back seat, forward-facing If child height or weight > seat limit, go to next age up
8-12 years old Booster seat Back seat, forward-facing If child height or weight > seat limit (usually 4' 9"), go to next age up
12-13 years old Lap and shoulder seat belt Front or back seat, forward-facing

Clinical Features

  • Peds assessment triad: appearance, work of breathing & circulation (skin color)
  • Child's size allows for distribution of injuries
    • multi-system trauma is common
    • internal organs more susceptible to injury due to anterior placement of liver and spleen (as well as less protective muscle & fat)
    • Kidneys also less well protected and more mobile, prone to decelleration injury
  • Wadell Triad in auto vs. pedestrian child= femoral shaft fracture, intraabdominal/intrathoracic injury, and contralateral head injury

Differential Diagnosis

Evaluation

  • FAST exam
  • Consider as indicated:
    • CBC, coags, T&S, LFTs for abdominal trauma[2]
    • Plain films
    • CT head, cervical spine clearance clinically or with imaging
    • CT abdomen/pelvis[3]
      • Significant intra-abdominal injury after blunt torso trauma highly unlikely (0.1%) if all of the following are true:
        • Glasgow coma scale ≥14
        • No evidence of abdominal wall trauma or seat belt sign
        • No abdominal tenderness, abdominal pain, or vomiting
        • No thoracic wall trauma or decreased breath sounds

Management

  • ATLS
  • In ED give IVF at 20cc/kg, if unresponsive after 40cc/kg give PRBCs at 10cc/kg (can start with PRBC if presents in decompensated shock & multiple injuries suspected)

Disposition

  • Depends on underlying injury

See Also

External Links

References

  1. ↑ AAP 2011. http://pediatrics.aappublications.org/content/pediatrics/early/2011/03/21/peds.2011-0213.full.pdf
  2. ↑ The Utility of Laboratory Testing in Pediatric Trauma: A Primer from TAMING OF THE SRU Dec 13, 2019 available at http://www.tamingthesru.com/blog/grand-rounds/diagnostics/labs-in-peds-trauma
  3. ↑ Holmes JF et al. Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries. Ann Emerg Med. 2013
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