Paediatric Trauma A/Prof Drew Richardson MB BS (Hons) FACEM Grad CertHE MD The Canberra Hospital May 2013
Objectives Identify unique anatomic and physiologic characteristics of injured children Describe common patterns and responses to both unintentional and intentional injury Explain the application of EMST management principles in paediatric trauma Recognise the importance of injury prevention in reducing the impact of childhood trauma
Injury in Children Injury mortality greater than all other childhood illnesses combined Anatomy, physiology, and mechanisms produce distinct patterns of injury Mechanisms related both to age and stage of development Neurologic and respiratory derangements much greater than haemodynamic derangements
Children are not Little Adults
Anatomic Considerations Airway Larger Head Smaller Jaw Large more mobile epiglottis Narrow subglottis Funnel shaped airway Shorter, narrower
Anatomic Considerations Head and Neck Larger head Prominent Occiput in very young 2.5cm pad under body for neutral position
Anatomic Considerations Cervical Spine Flexible spinal ligaments Anteriorly wedged vertebrae Flat facet joints Angular momentum forces Pseudosubluxation SCIWORA
Anatomic Considerations Head Brain relatively larger inside skull Tolerates bleeding/mass badly Brain more plastic, ongoing cognitive development
Anatomic Considerations Musculo-skeletal Soft not brittle bones Open Fontanelles Multiple growth plates Thin skin, poor veins High surface area/volume ratio
Anatomic Considerations Chest Soft, pliable, soft wall pulmonary contusion Horizontally aligned ribs, weak intercostal muscles Rib fractures indicate significant force Tension pneumothorax poorly tolerated
Anatomic Considerations Abdomen Softer, thinner, muscular wall Lower-riding liver, spleen Higher-riding bladder Multiple injuries are common
Anatomic Considerations Vascular Access Small child with fat reserves has tiny veins Shocked child has effective peripheral shutdown Low threshold for femoral or intraosseus access
PHYSIOLOGIC IMPACT Age-specific vital signs Smaller blood volume Decreased functional residual capacity Vigorous compensatory response Limited cardiorespiratory reserve Sudden deterioration
Management Issues Vital Signs Sign Heart Rate Blood Pressure Respiratory Rate Urine Output 0 2 years < 150-160 3 5 years 6 12 years < 140 < 100-120 > 60-70 > 75 > 80-90 < 40-60 < 35 < 30 1.5-2 ml/kg/hr 1 ml/kg/hr 0.5-1 ml/kg/hr
Physiologic Impact
Physiologic Impact Thermoregulation Higher body surface area to mass ratio Thinner skin Less insulation by subcutaneous tissue Prevent hypothermia!
Key Differences from Adults Physical Difference Larger tongue High anterior larynx Much larger occiput Head > torso injuries Much smaller torso Clinical Implication More airway obstruction Straight blade for ETI Padding under torso CNS, respiratory > shock Fewer truncal injuries
Key Differences From Adults Physical Difference Much larger head Body more compact Medications / fluids Softer outer shell Thin skin, less fat Clinical Implication More brain injuries Multiple injuries typical Broselow Tape Underlying organ injury Keep the child warm!
Types of Injuries Mechanis m Pedestrian Automobile Occupant Slow Pattern Soft tissue contusions, lower extremity fractures Fast Head, torso, lower extremity fracture Unrestrained Head, face, spine Restrained Lap belt complex
Types of Injuries Mechanis m Bicycle Fall Pattern No helmet Head, face, spine, upper extremity fractures Handle bar Liver, spleen, pancreas, duodenum Low Soft tissue contusions, upper extremity fracture High Head, face, spine, abdomen, longbone fracture
Management How do EMST principles apply to the treatment of children? A B ABCDE priorities are the same! C D E
Management Issues: ABCDEs A B C Obstructs easily; uncuffed ET tube Tension pneumothorax; avoid barotrauma Vascular access; fluid and blood D Pediatric GCS score; diffuse swelling E Gastric dilation; avoid heat loss
Analgesia Insufficient attention Follow the Butch Cassidy Rule Do you think you used enough dynamite? ANALGESIA?
Analgesia Pharmacological Non-Pharmacological
PITFALLS Pitfalls Short trachea: main stem bronchial intubation Narrow ETT easily obstructed Aerophagia make sure stomach emptied with NGT/OGT
PITFALLS Pitfalls Deceptive presentation of hypovolemic shock Difficult intravenous access in children < 6 years Missed hollow viscus injury Subtle musculoskeletal injury findings
Management Issues: Adjuncts CT US FAST Tubes
Abuse Injuries Warning signs of abuse injuries History Examination Discrepancies Multicoloured bruises Delay in care Bilateral subdurals Repetitive injuries Retinal hemorrhages Inappropriate Femur fracture(s) responses Unusual scald / contact Medical neglect burns
Injury Prevention Prevention ABCDEs Analyze injury data Build local coalitions Communicate the problem Develop prevention activities Evaluate program interventions The best outcome is from an injury that never occurred
Summary Basic principles are the same Unique anatomic, physiologic, and mechanistic differences modify the application of EMST principles Refer and transfer early Have a high index of suspicion for child abuse Injury prevention
QUESTIONS?