CHALLENGES OF SEVERE TRAUMA IN CHILDREN

AS Shaik

MBChB (Natal), FCS(SA), Cert Paed Surg(SA), AMP (MBS)

PAEDIATRIC TRAUMAPrevention

• Education

• Safety measures – Seatbelts– Helmets– Airbags– Car seats– Smoke detectors

Post injury care

• Progressive access to graduated care centres

• Improve likelihood of survival

• Prevention of permanent disability

CHALLENGES IN PAEDIATRIC TRAUMA• Burden of trauma – challenge of

socio-political will

• Challenges of trauma registries

• Challenges in paediatric trauma care

• Challenges in funding of paediatric trauma programs

• Challenge of personnel training

• Challenge of prevention

• Challenge of rehabilitation

• Challenge of post trauma psychological care

Ademuyiwa, O Journal of Emergencies, Trauma, and Shock I 5:1 I Jan - Mar 201

CHALLENGES IN PAEDIATRIC TRAUMA• Unique Challenges

– Practical• Anatomic• Physiologic• Metabolic• Results in different patterns of injury

for same insult as in an adult• Different management strategies

– Cognitive • Level of maturity dictates

expression of events and symptoms

• Resuscitation of the child with trauma follows ATLS principles

• General surgeons have skills and competencies to deal with paediatric trauma

• Lacking is the experience required to understand the common injury patterns, physiologic differences, and treatment approaches

APPROACH TO PAEDIATRIC TRAUMA6 year old boy, crossing the street at school is knocked down by a rapidly

moving taxi. He is crying. Pale. Left scalp haematoma, left sided upper

abdominal bruising and abrasions. An obvious, closed, deformity of his

left lower limb is present.

Heart rate is 140 bpm, respiratory rate is 30 breaths per minute and his

BP is 92/62 mmHg at the scene. The paramedics record his Sats as 90%

on room air and 98% on Oxygen.

Adapted from Mikrogianakis A, Emergency Medicine Clinics of North America, Volume 36 (1)

OVERVIEW OF PAEDIATRIC TRAUMA• Mode of injury – blunt trauma

• Factors involved – Anatomy – big head, short weak

neck – “bobbing head”

– So some form of head injury– Supportive therapy for TBI and

monitor for raised ICP

• C-spine injuries rare but protect and note neck movement

• Pulmonary contusion common. Flexible ribs.

• Abdomen – bleeding

• Fractures - common

ABCDE FOR CHILDREN• Talking or crying

– Patent airway– Can maintain cerebral perfusion– Stable

• Quiet, non vocalizing– Low level of consciousness– Severe multisystem injuries

• Airway with C spine immobilization– Usually BMV adequate– Intubate if

• Decreased LOC• Maxillofacial trauma• Apnoea, cardiac arrest• Inhalation injury• Airway obstruction

– Short trachea – right main bronchus intubation

AIRWAY CHALLENGES• Skull shape causes flexion• Need towel between shoulders• Small mouth, larger tongue, large

adenoid• Epiglottis floppy • Needs straight , thinner blade• Larynx more cephalad and

anterior • Vagal response to laryngoscopy • Gentle manipulation

• Failed airway management is leading cause of preventable deaths

• Place pad under child• Align ear with sternal notch

horizontally

• Apply bag with tight seal correctly – obviates need for intubation

AIRWAY CHALLENGES

https://www.paediatricemergencies.com/intubationcourse/course-manual/intubation-preparation-and-equipment/

ABCDE FOR CHILDREN• Breathing

• Supplemental oxygen to all• Prongs for <2 years – 2 lpm• Mask for older – 6-10 lpm

• Reassess position of ETT

• Nasogastric tube– Low level of consciousness– Severe, multisystem injuries

• Arguably the most important tube

• Gastric distension can be life threatening

ABCDE FOR CHILDREN• Circulation

– IV access – 3 attempts– Intraosseous line

• Blood volume 80 mls/kg

• Hypovolaemia is usually from bleeding– Usually intra-abdominal solid

viscus bleed

• Resuscitation– 20 mls /kg MRL– Repeat boluses - >2 boluses,

review– Warmed fluids

• Monitor• Heart rate important. Early

warning. BP late sign

• Remember orthopaedic injuries

CHALLENGES IN IV ACCESS• Peripheral

– Know anatomy– Three attempts– Cutdown

• Intraosseous– Proprietary– Bone marrow aspiration needle– Cannula

• Central venous line– Ultrasound guided– Large bore

ABCDE FOR CHILDREN• Disability

• Assess GCS

• AVPU (alert, voice, pain, unresponsive)

• Moves limbs spontaneously

• Expose

• Regional exposure

• Prevent hypothermia

• Complete examination including diaper area

APPROACH TO PAEDIATRIC TRAUMA6 year old boy, crossing the street at school is knocked down by a rapidly

moving taxi. He is crying (V in AVPU). Pale. Left scalp haematoma, left

sided upper abdominal bruising and abrasions. An obvious, closed,

deformity of his left lower limb is present.

Heart rate is 140 bpm, respiratory rate is 30 breaths per minute and his

BP is 92/62 mmHg at the scene. The paramedics record his Sats as 90%

on room air and 98% on Oxygen. GCS = 13.

CHALLENGE - RECOGNITION OF SHOCK• Clinical parameters can be difficult.• Heart rate most important

• Newer technologies – scoring systems (Shock index paediatric age adjusted = HR/Systolic BP)

• Change in haematocrit predicts surgery for blunt trauma

• Ward haemoglobin not reliable

IMAGING IN PAEDIATRIC TRAUMA• Chest X-ray in any polytrauma• Pelvis if signs or haematuria

• C spine in poly trauma or if c-spine was immobilized for any reason (SCIWORA)

• Lodox is an alternative• Limit radiation

• CT or FAST

• FAST used less frequently

• CT Brain when clinically indicated

• Awareness of radiation risk

CHALLENGES IN TRAUMA IMAGING• Single contrast CT avoids negative

laparotomies and grades injuries• Consider ultrasound

– >24h after injury– Experienced paediatric radiologist– Serial sonar exams if no CT

• Serial clinical examinations still important• Identifies

– Concomitant injuries – Incidental anomalies– Rule out major solid organ injuries– Detects most hollow viscera injuries

• Increased negative scan rate– Expense and radiation

• Clinical signs overlooked– Bowel injuries undetected radiologically– Is scan indicated?

• Unnecessary if laparotomy indicated anyway

• Is US adequate (especially in delayed presentation)

• May lead to an aggressive transfusion protocol attributable to imaging rather than patient profile

Arnold M, S Afr J Surg 2013;51(1):26-31.

CHALLENGES IN TBI• Traumatic brain injury major

cause of mortality and morbidity

• Most children with severe trauma will exhibit some TBI

• Usually closed injury with no elevated ICP

• Management is supportive

• Prevent hypoxia and hypotension

• Protect airway

• Raised ICP – position, mannitol, saline, image brain, neurosurgical care

CHALLENGES IN THORACIC TRAUMA• Common cause of increased

mortality in polytrauma

• Pliable chest wall in children

• Intrathoracic injury without bony involvement

• Usually present with ABC problems

• Pulmonary contusion –transmission of forces through compliant chest wall

• May not have external signs• Chest wall elasticity may

protect from great vessel injury (rare)

• Beware of cardiac contusions (enzymes)

CHALLENGES IN ABDOMINAL TRAUMA• Anatomy

– Smaller, greater energy transfer– Pliable ribs. Greater force.– Thin muscles. Less protection– Close proximity of organs in infants

so multiple organs injured

• Repeated clinical examination

• Free air or peritonitis = laparotomy

• Suspicion– Seat belts – hollow viscus– Handle bar – pancreas– MVA – spleen and liver

• Clinical, lab, FAST and CT

• Usually non operative management

OUR PATIENT• After first bolus of 20 mL/kg of NS

patient remains HR 130 beats/min, capillary refill of 3.5 seconds

• Tenderness and bruising to LUQ with LLL pulmonary contusion

• Clinical suspicion for an acute splenic injury

• Second bolus of 20 mL/kg • FAST - free fluid in abdomen • Blood available

• Remains tachycardic, pale, and poorly perfused

• Transfuse 10 mL/kg

OUR PATIENT• CT Scan confirms splenic

injury• No evidence of hollow visceral

injury

• Continued resuscitation in ICU and settled after second blood transfusion

CHALLENGES IN BLUNT ABDOMINAL TRAUMA

• Non operative if – Remains stable– No evidence of ongoing

bleeding– No evidence of concomitant

injury requiring laparotomy eg bowel injury

– Reliable imaging of injury

• Responders – improved vitals, skin colour, better perfusion, neurologically improved

• Transient responders –preliminary improvement

• Non-responders

• Bed rest – Grade of injury + 1 day

CHALLENGES IN BLUNT ABDOMINAL TRAUMA

• Splenic injury– Bleeding– Preserve spleen if possible– Splenorraphy– Immunizations early– Complications of cyst, false

aneurysm

• Liver injury– Angiography– Biliary injury

• Diaphragmatic injury– Acute (respiratory) or delayed

presentation (usually intestinal obstruction)

– Surgery

• Pancreatic injury– Surgery versus conservative– Omental patch, resection, diversion– Complications

CHALLENGES IN BLUNT ABDOMINAL TRAUMA

• Renal injury– Urinary extravasation on CT/IVP– Pedicle injury– At laparotomy –Renal

exploration for pulsatile or expanding haematoma

• Angiography

COMPARTMENT SYNDROME• Usually of limbs

– Snake bites– Crush injuries– Tourniquet application– Iatrogenic – IV and arterial lines– Fasciotomy – ensure extent of

incision

• Chest– Burns

• Abdomen– Uncommon– Measure bladder or gastric

pressures– Open abdomen but not frequent

CHALLENGES IN NEAR DROWNING• Tragic, poor prognosis under 3 years of age• Fresh water worse

• Persist with CPR as hypothermia protective.• Prognosis poor if CPR >10 minutes

• ECMO is a useful intervention with positive effect on outcome

CHALLENGES IN PENETRATING TRAUMA• Still a problem

• Clinical assessment usually adequate to guide surgical management

• Laparoscopy now part of armamentarium

• Social determinants– Gunshot injuries

• Overall decrease over time

• Management is fairly well defined

CHALLENGES IN VASCULAR TRAUMA• Blunt (crush)• Penetrating (stabs and

gunshots or broken glass)• Compartment syndrome• Iatrogenic (arterial lines,

coronary catheterizations)• Orthopaedic / hyperextension

injuries• False aneurysms

• Small vessels• Good collaterals

• Intervention for clinical indication

• Angiography

• Microsurgical reconstruction

CHALLENGES IN NAI• Multiple head trauma• Retinal haemorrhages• Perioral injuries• Incidental Ruptured viscera• Genital or perianal injury• Old healing injuries• Long bone fractures <3yrs• Bizarre injuries• Sharply demarcated burns in

unusual areas

• Discrepancy between history and degree of injury or changing history

• Long delay in seeking treatment• Repeated trauma (different

doctors)• Inappropriate parental reaction

• Child Care Act

FAMILY COMMUNICATION• Parent Management

• Tell them your name and qualifications

• Acknowledge their fears and concerns

• Reassure them it is all right to feel as they do

• Redirect their energies - help you care for child

• Remain calm and in control

• Keep them informed and don't talk down to parents

• Assure parents that everything is being done

CONCLUSIONTWO SIDES

• Tube• Warmth• Oxygen• Stabilize

• IV access• Documentation• Escort• Specimens

Resuscitate, evaluate and image aggressively, but manage conservatively