Pediatric Trauma BEST Literature review of all kinds of trauma in pediatric for emergency physicians working in settings were they see pediatric cases

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scanner. I recommend the one below

4. STATISTICS

6. • ABCDEF
• Continuous monitoring of vital signs
• analgesia + reassessment of pain
• intubated  adequate sedation & analgesia
• Antibiotics and tetanus as appropriate
• UOP = 1 mL/kg/hr
• Head injury  frequent neuro assessment
•C-spine clearance is not your role in major
trauma .
+

8. All what you need is

9. Skull shape cause flexion Need towel between shoulders
Small mouth, larger tongue, large adenoid
Epiglottis floppy
Needs straight , thinner blade
Larynx more cephalad and anterior + narrow
subglottic +↑ vagal response to laryngoscopy
Gentle manipulation and pre medication
Small diameter & Shorter tracheal
4-5 cm in newborns
7-8 cm in 18 month
Needs calculations

11. ETT size
• 4.0  1 year
• 5.0  5 years
• 6.0  8-10 years
• Depth =3x tube size
Benefis of cuffd
• prevention
of hospital-acquired pneumonia
• prevention extubation
• more accurate titration of
ventilation.
• prevention of tracheal mucosal
injury if < 20 cm H2O
• Reduced need for reintubation
due to air leak
Blade Size
0  preemies
1  infant
2  2yrs+
3  3rd Grade (8-9 yr) +

14. Tip on bagging
Holding the bag from below
prevents accidental
• extubation
• hypervent
• Barotrauma

15. NOT FOR < 8 Years

16. • Injury not common
• fulcrum : C2-C3 in toddlers & C5-C6
by 8 yr.
• Difficult xrays
• Flatter facet joints + horizontal
orientation = atlanto occipital
dislocation is common
• Paravertebral soft tissue may appear
widened in crying child
• Preodontoid space 4-5 mm in <8 yrs
and <3 mm in ≥ 8 yrs
• Pseudosubluxation of C2 on C3 seen
in 40% of 8 to 12 yr.

17. • BDI should be ≤12
• A space should be also ≤12
• Wachenheim line over the dens
post edge
• Power ratio (BC/OA) should be < 1

19. pulmonary injury without skeletal
injury.
• CXR is it enough?
• Is ECG & troponin needed?
• drainage > 15 mL/kg or output > 2
mL/kg/hr  OR

23. • HR Vs. BP in assessment
• capillary refill alone gives false reassurance
• Q5 min Vitals HR> 150 = danger in > 1yr
•90 sec for cannulation or else IO
• Proximal humerus Vs. lower extremity
• No Intraosseous in a fractured extremity
• Umbilical vein  up to 2 wks
• vasopressors/highly osmotic NOT on umbilical
v.

25. Massive blood transfusion
• Pediatric Massive transfusion:
actual/anticipated rapid transfusion of blood
products and other intravenous fluids to
individuals less than 18 years of age to
replace greater than the patient’s estimated
blood volume within twenty-four (24) hour
period and/or need for transfusion equal to
half of the patient’s estimated blood volume
at one time, such as within one hour.
• eTBV :
• Newborn – 1 month 90 mL/kg
• 1-12 months 85 mL/kg
• 1-14 years 80 mL/kg
• > 14 years 75 mL/kg
• Obese children 65 mL/kg

26. The PMTP
Labs before initiating :
• Type & Cross,
• CBC (Hgb, plt),
• PT/PTT,
• Fibrinogen,
• ionized Ca,
• K+ (basic metab panel),
• pH
During
• After first 80 mL/kg PRBC: repeat above + FDPs
• After every 40 mL/kg PRBC from then on: repeat above + FDPs, lactate

27. MTP eWt < 30 kg

29. What else ..
• Tranexamic Acid:
• 20 mg/kg bolus over 10 minutes (max of 1000
mg) followed by the same dose (20mg/kg, max of
1000 mg) over 8 hours.
• should be given within three hours of injury.
• no IV line for 2nd dose  give after 3.
• Discontinue once bleeding is controlled.
• Recombinant Factor VIIa: 90-120mcq/kg IV
(Effective only if pH >= 7.20 )
• Prothrombin complex concentrate
(PCC)/Factor IX Complex: NOT APPROVED FOR
USE IN PEDIATRIC TRAUMA

31. Abdominal Trauma

32. Spleen injury
PAT small bowel >large bowel >liver.
• 3.6% of hospital admission
• Ttt: exploratory laparotomy Vs. conservative
( stable with no FF on CT)
BAT Spleen > liver> Kidney
• Spleen n injury signs in x-ray
• left diaphragmatic elevation, left lower lobe
atelectasis, and left pleural effusion.
• medially displaced gastric bubble or inferior
displacement of the splenic flexure.
TTT: No Sx for vitally , Angio is an option
• 3-6 weeks of activity restriction

33. Liver injury
• half of all patients with no liver
injury on CT had elevated AST
or ALT levels
Management.
• hemodynamically stable 
managed conservatively.
• Surgery unstable, needing blood
transfusions over 30 mL per kg in
the fist 24 hours, or are having
peritoneal irritation or evidence of
concomitant hollow organ
perforation.

34. Kidney injury
• imaging  if gross hematuria and/or
hemodynamic instability.
Management
• Stable  Non operative
• OR  if single kidney with a signifiant
renovascular injury
• Unstable  angioembolisation even for
grade 4

35. • higher incidence of duodenal injury 
“classic handlebar injuries.
• Often accompanying pancreatic injury bowel
injuries  nonoperative
• pancreatic injuries often require operative
management.
• Minor injuries without suspected injury to
the main pancreatic duct are initially
managed nonoperatively with serial re-
evaluation for development of complications
such as pseudocyst or pancreatic fitula.
• pancreatic duct injury  surgery 2steps
• Large

37. To CT or Not ?
BATiC score
• > 6 (out of a possible score of 18)
resulted in a sensitivity of 100% and
specificity of 87% for IAI.
• 7 resulted in a sensitivity of 89%
and a specificity of 94%.
• Using cut off of 6 and 7 could have
avoided 47% and 56%, respectively,
of the 34 computed tomography
scans performed
•

39. • 600,000 TBI/annum
• <5% with important intracranial injuries
• 62,000 patients are admitted annually for management of TBI.
• Neurosurgical intervention in <1%
• 5-10% sustain substantial lifelong disability
• Economic impact estimates $56.3 billion / yr (adult + pediatric)

40. Symptoms topography
• LOC : in 39% the risk of TBI is 0-2.5%. If brief + isolated
• Seizure: 50% of children have an abnormality on CT scan Injuries.
• Vomiting: ciTBI was only found in 0.2% of patients with isolated
vomiting, and 2.5% for those accompanied by other findings
• Headache: in older children common in all .
• Scalp Hematoma:
• Isolated in older children without other signs  no ciTBI.
• infants, a non-frontal region, and larger than 3 cm = underlying intracranial
• <2 years  increased risk of skull fracture and intracranial hemorrhage.
• Ophthalmologic findings: Retinal in 65-90%
• Fontanel fullness may indicate increased intracranial pressure in
infants.

41. Disability Assessment
Glucocheck if deteriorated at any moment

43. Specific injuries
• concussion is a brain insult with transient
alteration of consciousness.
• Simple =<10 d
• complex >10 days
• Scalp injury
• Caput succedaneum hematoma in the
connective tissue layer. This is freely mobile
and crosses suture lines.
• subgaleal hematoma is subgaleal within the
loose areolar tissue above the periosteum.
• cephalohematoma is a collection of blood
under the periosteum.
• Skull Fractures
• Linear  benign, no intervention
unless of a fracture overlying a vascular
channel, a depressed fracture, a
diastatic fracture (leptomeningeal cyst)
, or a fracture that extends over the
area of the middle meningeal artery.

44. To CT or not ?
• 22,772 patients
• 98% sensitivity and 87% specificity
• CT scan rate of only 14% in
• missed 3/21 ciTBI
• 3866 patients
• 100%  91% sen
• CT rate ≈ 50%
• 33,875 patients
• Sens.99% & Spec. 54% <2 yrs,
Sens.97% & Spec. 59% >2yrs
• for CT was not to be indicated

45. Why PECARN
• for whom a CT was not indicated (low-risk group)
• The only CDR to undergo validation on a diverse population in a
multicentre study similar in demographics to the derivation
population
• Picked up all cases of ciTBI and was found to have the second best
specificity and second lowest CT scan rate

48. • sensitivity of
100% and
specifiity of
72.1%
• But not validated
yet
• What you can do
is
• U/S for skull #
CT vs. ED Observation

52. Management of head trauma

53. Don’t forget
Disability also means
• Compartment Syndromes
• Deformed limbs splinting

54. Damage control resuscitation
1. Early Hemorrhage control Surgery
2. Permissive Hypotension
3. Limit fluid infusion
4. Target Coagulopathy

55. • Thorough Examination is always
needed even for simple injury
• Keep always low threshold for
unexplained injuries
• Cover after exposure hypothermia
quickly

56. • History from care givers,
witnesses, or EMS.
• focus on mechanism and
timing.
• Important features
• LOC and duration
• headache
• Nausea
• vomiting,
visual disturbances
• amnesia, or confusion.
• Progression of symptoms or
resolution
• possibility of abusive trauma
if suspicious

57. Reassess ABCDE
A
B
C
D

58. Anti tetanus in Peds Trauma
• Vial = Td/ Tdap 0.5ml IM.
• Dose is 4 units/Kg minimum 250U once

59. Take home message
• ABCDEF +
• Correct at time then start all over
• Repetitive Vital, pain, neuro assessment, sedation
• Intubation can exacerbate an undiagnosed spinal
injury.
• Go less radiation unless indicated
• Don’t forget the Anti-tetanus +/- TIG

60. Thank you …

63. Pain Control
• Fentanyl is a good choice
• advantage hemodynamic profile.
• Advantage of short action
• Localized Injections and Nerve Blocks
• Ice