Injury:
- Leading cause of death in children
after the 1st year of life
- Causes 40% of deaths ages 1-4
years
- Causes 70% of deaths ages 5-9
years
- Causes 22,000 childhood deaths
each year
- 6,000,000 hospitalizations per
year
- Causes >100,000 long-term
disabilities in children
Trauma 22,000
Congenital
anomalies 8,556
SIDS 5349
Cancer 527
14,432
Infants
-
Child abuse
-
Suffocation
-
MV Trauma
-
Fires
Preschool
-
Fires
-
Drowning
-
MV Trauma
School
age
-
Cycling
-
Pedestrian
Adolescents
-
MV Trauma
-
Homicide
-
Suicide
Primary Cause of
Childhood Death
-
Airway
compromised
-
Hypovolemic
shock
-
CNS injury
-
All lead to
progressive hypoxia and metabolic acidosis
Pre-Hospital Arrest
-
95% fatal
Causes:
- Tension PTX - Pericardial tamponade
- Severe intra-abdominal hemorrhage -
Severe head injury
ABCDE’s of ATLS
- Airway
- Breathing
- Circulation
- Disability
- Exposure
Airway Management
-
Supplemental oxygen
- Jaw thrust
- Remove any foreign body
- Endotracheal intubation with in-line
traction for semiconscious (GCS<S) or comatose patient
- Awake intubation contraindicated due to ICP
- Surgical airway if necessary
Airway,
child specific
- Large tongue
- Larynx/trachea smaller
- Larynx more anterior
- Floppy epiglottis
- Short trachea
Breathing
- Adequate ventilation
- Oxygen saturation
- End tidal CO2
- Chest wall motion
- Breath sounds
Breathing
- Beware of tension PTX
- Tracheal deviation to opposite side
- Respiratory distress
- Decreased breath sounds
- Hyperresonance
- Subcutaneous emphysema
Treatment,
Angiocath, Chest Tube
Circulation
- Venous access
- Peripheral IV
- Central Line
-
Intraosseous
Circulation
- Shock = Inadequate end organ O2@ delivery
- Pediatric compensatory mechanism for shock
tachycardia until…
- Pediatric blood volume 70-80cc/kg
- Hypotension occurs with 25%blood volume loss
-
Check peripheral perfusion (cap-refill)
Circulation
- Fluid resuscitation
-
Warm isotonic crystalloid (LR or NS) 20 ml/kg
-
Repeat 20ml/kg bolus LR or NS
-
Little or no response, tyransfuse 10-20ml/kg packed cells
-
OPERATE!
Disability
- Level of consciousness
-
-
A – Awake
-
V – Verbal
-
P – Pain
-
U – Unresponsive
- Pupillary check
- Deficitis
Exposure
and Environment
- Keep patient warm
- Warm trauma room
- Warming lights
- Bair-hugger
- Warm fluids
Hypotension:
What is the Cause?
- Eliminate body cavities
- Chest, right, left – HTX/PTX
- Abdomen – intraabdominal hemorrgahe
- Pelvis – sever FX with retroperitoneal hematoma
- Cardia – confusion, pericardial tamponade, aorta
- External blood loss
- Spinal cord injury
Initial X-Rays
- Chest x-ray
- PTX/HTX, rib fxs, mediastinal widening,
diaphragmatic ruptors
- C-Spine
- Fx, subluxation, AOD
- Pelvis
Abdominal Trauma in Children
- Accounts for 5 – 7% of trauma admissions
- Leading cause of death in children
-
85% as the result of blunt trauma
MVC/occupant 32%
MVC/pedestrian 27%
Falls 13%
Bicycle 12%
Other causes 16%
Abdominal Signs
- Tenderness
- Distension
- Pelvic FC
- Chest trauma
- Gross hematura
- Hct
< 25%
- Hypotension
- Lap belt mark, other contusion
Abdominal Injury
Assessment
- Physical exam
- Laboratory tests
- Radiologic examinations
- Peritoneal lavage
Physical Exam
- Very reliable
if
- Examiner is experienced
- Patient has normal sensorium
-
EtOH negative
- Serial exams increase accuracy
- Change in exam is significant
Laboratory Tests
- Hemoglobin
- Caveat….volume constructed state
- Amylase
- May be normal despite injury
- Intestine, pancreas,
salivary gland
- Urinalysis
- Hematuria
Surgical Indications
- Persisitant hemdynamic instability despite “adequate”
resuscitation
-
Transfusion of > ½ blood volume
-
Perionitis
-
Pneumoperitoneum
-
Indication for Imaging
- Hemodynamic stability
- Abdominal tenderness
- Abdominal distention
-
Abrasions/contusions
- Gross hematuria
-
High risk mechanism (eg Lap belt injury)
-
Neurologic impairment (uncertain physical exam)
Radiologic
Choices
- CT
scan
- Ultrasound
- MRI (no)
- Plain films
- Angio
CT Scan
- Panoramic View
- Peritoneal lavage
- Very reliable if
- Examiner is
experienced
- Patient has a
normal sensorium
- EtOH negative
- Serial exams increase accuracy
- Change in exam is significant
- Hemeglobin
- Caveat…volume
contracted state
- Amylase
- May be normal
despite injury
- Intestine,
pancreas, salivary gland
- Urinalysis
- Hematuria
- Persistant hemodynamic instability despite
“adequate” resuscitation
- Transfusion of ½ blood volume
- Peritonitis
- Pneumoperitoneum
- Indication for imaging
-
Hemodynamic stability
-
Abdominal tenderness
-
Abdominal distention
-
Abrasions/contusions
-
Gross hematuria
- High-risk
mechanism (eg. Lap belt injury)
-
Neurologic impairment (uncertain physical exam)
- CT Scan
- Ultrasound
- MRI (no)
- Plain films
- Angio
- Panoramic view
- Solid organ survey (liver, splean, pancreas,
kidney)
- Lung imaging (PTX not seen on plain film)
- Pelvic fx
- ? Oral contrast – NO!!!
-
Risk of vomiting and aspiration
-
Minimal time for contrast distribution
-
Extravasation rare
- Advantage
-
Quick bedside assessment for free intraperitoneal fluid even in the unstable
pt.
-
Serial exams at bedside
- Disadvantage
-
User dependant
-
Limited information
- Not as
accurate as CT
Diagnostic Peritoneal
Lavage
- Initially developed to select patients for
exploration
- Many DPL-positive injuries managed expectantly.
- False negatives
- Useful in patient with free fluid without solid
organ injury
- Spleen Conservative
- Liver Conservative
- Pancreas Conservative??
- Kidney Conservative
- Intestine Operative
- Common site of injury in accidental trauma
- Diagnostic techniques similar to liver
- Grading system
- 90+% managed nonoperatively
- Abdominal pain
- Nausea and vomiting
- Left shoulder pain (Kehr’s sign)
- Dyspnea
- Abdominal tenderness (localized or diffuse)
- Abdominal distention
- Peritoneal signs
-
Muscular rigidity and guarding
-
Rebound tenderness
- Gray-Turner sign
- Abrasion/contusion in LUQ
- Lower left rib fxs
- Elevated left hemidiaphragm
- Pleural effusion (sympathetic)
- Gastric distention or displacement
- Grade I
-
Hematoma <10%
-
Laceration <1cm
- Grade II
- Hematoma 10-20% of volume
- Laceration 1-3cm of pareochymal depth
- Hematoma 10-20% of volume
- Laceration>3cm pareochymal depth or >50% devascularized
- Grade V
-
Shattered spleen
-
Completely avulsed spleen
- Nonoperative
-
Bed rest (??? How many days)
-
Follow Hgb level (??? How often)
-
Discharge with limited activity
- Operative
-
Splenorrhaphy
-
Splenectomy
- Reccurant bleeding
- Respiratory (atelectasis, effusion, pnumonia)
- Subphenic abscess
- Splenic cyst
- Pancreatic injury
- Missed intestinal injury with nonoperative
management
- Splenic function
-
clearance and phagocytosis
-
Antibody formation
-
Hematopoesis
- Overwhelming post-splenectomy sepsis
- Prophylactic antibiotics
- Accounts for most death due to intra-abdominal
injury
- Difficult to control bleeding at laparotomy
- 45% of those explored require drainage only
- Right lobe most commonly injured
- 90+% managed nonoperatively
- RUQ pain
- Referred right shoulder pain
- Abdominal distention
- Peritoneal signs
- Unexplained hypotension
- CT grading of liver trauma similar to spleen
-
intraparenchymal hematoma
-
Laceration through capsule/hilum
-
Hemoperitoneum
- Refractory hemodynamic instability
- Transfusion >50% of blood volume
- Other injury requiring exploration
- Blush on CT with continued blood loss
-Arteriogram and coll
- Bile leak, biloma
- AV fistula
- Hemobilia
- Liver abscess
- Hepatic cyst
- Missed intestinal injury with nonoperative
management
- Most common cause of pediatric pancreatitis
- Common site after non-accidental trauma
- Usually a direct impact
-
Handle-bar, chair, etc.
- Amylase elevated
-
may be a later sign
-
Sign of intestinal injury
-
Also seen with salivary gland injury
- Progressively worsening abdominal pain,
distention, or vomiting
- Back pain
- Index of suspicion due to mechanism
- CT Scan
-
“boggy” pancreas
-
Peripancreatic fluid
-
Transection
- ERCP
- ObservationPercutaneuos external drainage
- ERCP
-
Ductal disruption - operate
- Exploration
- Pancreatic pseudocyst + infection
- Necrotizing pancreatitus
- Sympathetic pleural effusions
- Difficult to diagnose
- Often diagnosed within 12 to 24 hours post injury
- Injury mechanism may increase suspicion
- Lap-belt contusion
- Direct injury
- Initial mesenteric injury may lead to ischemia
- Perforation or stricture are late findings
- Abdominal pain
- Abdominal tenderness
- Peritoneal signs
- Hemodynamic instability with stable hemoglobin
- Results from improper use of seat belt
- “Lap-Belt” complex
-Seat belt echymosis
-Nearly 86% risk of
intestinal injury
-Intestinal perforation
-
CT scan
-
Free fluid without solid organ
injury
-
Associated with 25% bowel injury
rate
- Lumbar spine injury ( L2, L3, L4)
- Free intraperitoneum fluid in the absence of solid
organ injury
- Pncumoperitoneum
- Mesenteric injury
-
Defect may be site of internal hernia
- EXPLORITORY LAPAROTOMY
- Repair the injury if the patient is stable
- Damage control when unstable
- Manage pancreatic injury
- Retroperitoneal hematoma
-
Non-expanding – Leave it alone
-
Expanding – explore, repair, ligate
-
From pelvic fx – STAY OUT
- Abdominal wall closure???
-
Consider Vac-pack or Bogata bag
- More common in boys
- Occurs often with other injuries
- Rarely require surgical intervention
- Penetrating
-
Rare
-
Often iatrogenic (i. e. vents, ng tubes, thoracostomy tube and cvl)
- Blunt
-
Most injuries
- Usually MVA
or crush
- ABC’s
- Chest wall stability
- Subsequent emphysema
- Breath sounds
- Tracheal position
- Assess circulation
- CXR
- CT scan
- Bronchoscopy
- Esophagogram
- Angiogram
- Establish airway
- Needle decompression
- Chest tube
- Call for HELP (Intensivist, Surgeon, Anesthesia,
Referral)
- Thorax very pliable
- Mediastinum freely mobile
- Aerophagic
- Difficult IV access
- Unusual in children
- Marker of significant injury
- Present with chest pain and varying degree of
respiratory distress
- Treat with analgesia and adequate pulmonary toilet
- Acute ventilatory embarrassment
- Collapse ipsilateral lung
- Needle decompression
- Chest tube
- Collapse ipsilateral lung
- Displaced mediastinum
- Vascular collapse
- NO NEED FOR CXR – CHEST TUBE
- Breath sounds diminished
- CXR
- Chest tube
- Thoracotomy (20% blood volume or 10/cc/kg/hr)
- Common
- Often not apparent on initial CXR
- CT Scan
- Edema hemorrage and bronchospasm
- Treatment is vigorus puminary toilet
- Two or more ribs in two or more places
- Paradoxical motion in chest wall A
- Reduced ventilatory efficiency
- Increased work
- Uncommon
- Marker Severe Injury
- Monitor x24 hrs
- Echocardiogram
- Analgesia
- Widened mediastinum
- Pleural cap
- 1st or 2nd rib fractures
- Displaced trachea and esophagus
- Aortagram
- ?Spiral CT
Penetrating Chest Trauma
- Rare
- ?Chest Tube
- ?ECHO
- ?Angiogram
- ?Esophagogram
- ?Bronchoscopy
- Most just observe!
- Injury is the leading cause of death in children
- Pediatric trauma has unique characteristics, which
differ from adult trauma
- Critically injured children should be stabilized
and transferred to pediatric trauma centers
- Improved efforts for trauma prevention are a
necessity