Trauma (peds)

Background

• 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
  • No complaints of abdominal pain
  • No vomiting
  • No thoracic wall trauma
  • No decreased breath sounds

• Peds triad is appearance, work of breathing & circulation (skin color)

• 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

• Wadell Triad in auto/ped= CHI, abd inj, femur Fx

AIRWAY/BREATHING

• Cricoid ring is narrowest part of airway allowing for uncuffed tubes up to 6.0 ETT or up to about 8 yrs

CIRCULATION

• Key is to recognize & Rx shock early (before decr BP), s/s of shock= child may have lost 25% of BV

• 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.

See Also

• Pediatric head trauma

Source

• Holmes JF et al. Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries. Ann Emerg Med. 2013
• Gausche 2004