Pediatric Trauma: A Review
PediatricTrauma:A ReviewJuly thru September2017This continuing education packet covers pediatric trauma, head injuries,and pediatric sports related injuries. The content covers theory andpractice that relates to the first responder thru critical care paramedics,including nursing, in pediatric trauma. The completion of this packet andassociated quiz will give the participant 2 hours of medical directorapproved education in pediatric trauma.EMSContinuingEducationSeries
Pediatric Trauma: A Review 2017Continuing Education SeriesJuly 2017Trauma is the most common cause of mortality and morbidity in the US pediatric population.Caring for the injured child requires special knowledge, precise management, and scrupulous attentionto details. All clinicians who are responsible for the care of a pediatric trauma patient, includingpediatricians, emergency room clinicians, pediatric emergency room clinicians, and trauma surgeons,must be familiar with every tenet of modern trauma care. The special considerations, characteristics,and unique needs of injured children must also be recognized. (Brian J Daley & Ramanathan Raju, 2015)EpidemiologyInjury is the leading cause of death among children older than 1 year. In fact, for children, injuryexceeds all other causes of death combined. Death from unintentional injury accounts for 65% of allinjury deaths in children younger than 19 years. From 1972-1992, motor vehicle accidents (MVAs) werethe leading cause of death in children aged 1-19 years, followed by homicide or suicide (predominantlywith firearms) and drowning. Each year, approximately 20,000 children and teenagers die as a result ofinjury. Moreover, for every child who dies from an injury, 40 others are hospitalized and 1120 aretreated in emergency departments. An estimated 50,000 children acquire permanent disabilities eachyear, most of which are the result of closed head injuries. Thus, pediatric trauma continues to be one ofthe major threats to the health and well-being of children.Several factors influence childhood injuries, including age, sex, behavior, and environment. Ofthese, age and sex are the most important factors affecting the patterns of injury. Male children youngerthan 18 years have higher injury and mortality rates, perhaps in part because of their more aggressivebehavior and exposure to contact sports. (Fabricant PD, 2013) In the infant and toddler age group, fallsare a common cause of severe injury, whereas bicycle-related mishaps, with or without the interactionof motor vehicles, are the main culprits for injury of older children and adolescents. Use of helmetsresults in fewer head injuries and decreases the severity of them as well. Tragically, the homeenvironment is the next most common scene of pediatric injury. Approximately 35% of significantinjuries occur as the result of accidents in the very environment that should be the most sheltering andnurturing to children.Most pediatric trauma occurs as a result of blunt trauma, with penetrating injury accounting for10-20% of all pediatric trauma admissions at most centers. (Sheehan B, 2013) Gunshot wounds areresponsible for most penetrating injuries and carry a significantly higher mortality compared with bluntmechanism injuries. A rising incidence of pediatric penetrating trauma, particularly penetrating thoracicAurora Lakeland Medical Center Aurora Memorial Hospital of Burlington1
Pediatric Trauma: A Review 2017trauma, has occurred in recent years. Unfortunately, the proliferation of handguns and increasedproclivity to urban violence in our society has increased the frequency of penetrating injury in childrenaged 13-18 years. Regardless of the classification, the 2 mechanisms of injuries are interrelated in thatblunt mechanical force can result in penetrating injury, such as that caused by fender edges, doorhandles, or shrapnel. Thus, treating clinicians must be thorough and must proceed with a rational planwith scrupulous attention to detail.A review by Guice and colleagues queried the Healthcare Cost and Utilization Project Kids’Inpatient Database to define contemporary trends in pediatric trauma epidemiology (Guice KS, 2007).Trauma continues to remain the leading cause of death for children aged 1-17 years. The average age inthis review was about 10 years, and, for every year, male gender was more prevalent than femalegender. This disparity increases toward adolescence, with boys having a significantly higher incidence oftraumatic injury. Burns were found to be most common in children aged 1-4 years, upper limb fractureswere found to be common in children aged 5-9 years, and lower limb fractures and traumatic braininjuries were found to be more common in adolescents.Specific InjuriesApproach ConsiderationsDevelopmental milestones correlate with mechanisms of childhood injuries. Head injuries,either alone or in association with multiple system injuries, are the most severe and cause the mostdeaths. Head injuries also account for most disability in children. All factors considered, clinicians mustbecome aware of the anatomic and physiologic characteristics that make children unique.CNS InjuriesAmong children, the CNS is the most commonly injured isolated system. Because CNS injury isthe leading cause of death among injured children, it is the principal determinant of outcome. However,numerous observations have shown that patients from the pediatric population recover morefrequently and more fully than similarly injured adults. Although this might be euphemistically ascribedto the "physiologic reserve" of the child, it suggests that injured children respond exceedingly well topreservation of cerebral oxygenation and perfusion. Therefore, management of the whole patient mustfocus on preservation of cerebral perfusion and elimination of potential detrimental effects ofextracranial lesions to it.In children aged 2 years or younger, physical abuse is the most commoncause of serious head injury. Shaken baby syndrome (SBS) is characterized by retinalhemorrhage 1, subdural or subarachnoid hemorrhage, and little evidence of external1Retinal hemorrhage is a disorder of the eye in which bleeding occurs into the light sensitive tissue on the back wall of the eye.Aurora Lakeland Medical Center Aurora Memorial Hospital of Burlington2
Pediatric Trauma: A Review 2017trauma. In children aged 3 years and older, falls and motor vehicle, bicycle, and pedestrian accidents areresponsible for most traumatic brain injuries.Children tend to sustain injuries that produce diffuse edema rather than those that cause focalspace-occupying lesions. At this point, precise management makes the difference between disaster andsuccess. Judicious fluid resuscitation, precise ventilatory care, and careful titration of cerebral perfusionpressure are the keys to success.The Glasgow Coma Scale (GCS) score is the universal tool for the rapid assessment of theconsciousness level of injured children. A modified verbal and motor version has been developed to aidin the evaluation of consciousness level in infants and young children. The GCS score and its modifiedversion (with scores of 3-15) are based on children's best response in 3 areas: (1) motor activity, (2)verbal response, and (3) eye opening. Traumatic brain injury in children is classified as mild (GCS 13-15),moderate (GCS 9-12), or severe (GCS 3-8). Regardless of the GCS score, a head CT scan should beperformed on any child with a history of trauma and loss of consciousness longer than 5 minutes or analtered level of consciousness.Several factors predict mortality with head injury. A presenting GCS score of less than 8,unilateral dilated pupil, and transcranial gunshot wound are associated with mortality of almost 70-98%.Hypotension and hypoxia should be aggressively avoided and are known to produce secondary injury.This secondary injury, when present, is a substantial cause of morbidity, and aggressive protocols toprevent it should be in place.Mild Head InjuryA concussion is defined by the American Academy of Neurology as "trauma-induced alteration in mentalstatus that may or may not involve loss of consciousness."Children with a mild head injury (GCS 14-15) 2 with a history of transient loss of consciousness oramnesia of the events and normal findings on a head CT scan can be discharged and observed at home2General Symptoms of Concussion Headaches or neck pain that do not go awayDifficulty remembering, concentrating, or making decisionsSlowness in thinking, speaking, acting, or readingGetting lost or easily confusedFeeling tired all of the time, having no energy or motivationMood changes (feeling sad or angry for no reason)Changes in sleep patterns (sleeping a lot more or having a hard time sleeping)Light-headedness, dizziness, or loss of balanceUrge to vomit (nausea)- Continued on the next page-Aurora Lakeland Medical Center Aurora Memorial Hospital of Burlington3
Pediatric Trauma: A Review 2017after at least 6 hours of uneventful observation in the pediatric emergency department. Caretakersshould be provided with specific discharge instructions. Warn caretakers of a possible post-concussionsyndrome, which includes the constellation of headaches, memory loss, behavior disturbances, andimpaired concentration. This should prompt reevaluation and possibly a repeat head CT scan.The post-concussive symptoms can last up to months after the injury but only rarely extendbeyond 3 months. No specific treatment exists for these symptoms other than symptomatic support;however, with severe mood alteration, psychiatric treatment may be indicated.Determining which pediatric patients with mild head injury need neuroimaging studies has beendifficult. It has been reported that less than 5% of children with mild head injury (variably defined) haveCT findings indicative of traumatic brain injury. Also, the concern for limiting radiation exposure has ledto scrutiny of this practice. A meta-analysis of 16 studies, including over 20,000 children with mild headinjury, defined associated risk factors for traumatic brain injury. Skull fracture, focal neurologic signs,GCS less than 15, and loss of consciousness were all associated with traumatic brain injury. Headacheand vomiting were not associated with traumatic brain injury with a presentation of mild head injury.The very young child ( 2 y) with mild head injury is perhaps the most difficult evaluation. Thelimitations of the neurologic examination often present a decision-making dilemma as to theappropriate imaging studies. The key point to remember in this evaluation is that a higher index ofsuspicion is required in a young child as compared with an older child because there is a higherincidence of skull fracture and traumatic brain injury in a child younger than 2 years after mild head Increased sensitivity to lights, sounds, or distractionsBlurred vision or eyes that tire easilyLoss of sense of smell or tasteRinging in the earsChildren Concussion SymptomsChildren with a concussion can have the same symptoms as adults, but it is often harder for them to share how they feel. Tiredness or listlessnessIrritability or crankiness (will not stop crying or cannot be consoled)Changes in eating (will not eat or nurse)Changes in sleep patternsChanges in the way the child playsChanges in performance at schoolLack of interest in favorite toys or activitiesLoss of new skills, such as toilet trainingLoss of balance or unsteady walkingVomitingAurora Lakeland Medical Center Aurora Memorial Hospital of Burlington4
Pediatric Trauma: A Review 2017injury. Up to 30% of children younger than 2 years with a skull fracture may have traumatic brain injurydemonstrable on CT scan.The current American Academy of Pediatrics consensus guideline for CT evaluation of childrenyounger than 2 years after mild head trauma include signs of depressed or basilar skull fracture, acuteskull fracture, altered mental status, focal neurologic findings, bulging fontanel, loss of consciousness for1 minute or longer, and multiple episodes of emesis; these findings are indications to proceed with CTscan. In the absence of these findings, plain skull radiographs are a reasonable evaluation method, withthe finding of skull fracture prompting further evaluation with CT scan given the high association ofunderlying brain injury with skull fracture in this population.A study by Königs et al investigated the impact of pediatric traumatic brain injury (TBI) onattention, a prerequisite for behavioral and neurocognitive functioning. The study concluded that lapsesof attention represent a core attention deficit in children with mild TBI or moderate/severe TBI, andrelate to daily life problems after pediatric TBI. (Königs M, 2015) (K., 2015)Severe Head InjuryThe goal of initial resuscitation must be to limit or prevent secondary brain injury by maximizingcerebral perfusion and oxygen delivery while minimizing increased intracranial pressure (ICP). Hypoxiaand hypotension should be aggressively treated. ICP monitoring is recommended in infants and childrenwith a GCS score of 8 or less. Epidural hematoma occurs in about 2% of pediatric head traumaadmissions. The characteristic lucid interval 3 occurs in about 20 to 50% of patients with epiduralhematoma.Prospective data is limited in pediatric traumatic brain injury. Posttraumatic seizures may occurin up to 30%, and a lower GCS score portends a higher risk. There is insufficient data on prophylactictreatment in the pediatric population. When present, seizures should be treated to decrease metabolicdemand and elevation of ICP that may extend an insult.Spinal Cord InjuryAlthough spinal cord injury is relatively uncommon in the pediatric population, cervical spineinjury must be presumed until proven otherwise. The most common cause of spinal cord injury (SCI) inthe pediatric population is motor vehicle collision, accounting for about 40%. The common cervicalfracture usually involves the first 2 vertebrae. If it remains undetected, cervical fracture can result indevastating injuries. Other common spinal fractures among pediatric patients with trauma are3In emergency medicine, a lucid interval is a temporary improvement in a patient's condition after a traumatic brain injury,after which the condition deteriorates. A lucid interval is especially indicative of an epidural hematoma.Aurora Lakeland Medical Center Aurora Memorial Hospital of Burlington5
Pediatric Trauma: A Review 2017compression fractures and flexion-distraction (Chance) fractures of the lumbar spine, usually frominappropriate use of a lap seat belt.Spinal cord injury without radiologic abnormality (SCIWORA) syndrome is a problem unique tothe pediatric population. SCIWORA has been reported in 10-20% of children with SCI. The incompletelycalcified vertebral column of the child may transiently deform and allow stretching of the cord or nerveroots with no residual anatomic evidence of injury. The hallmark of thissyndrome is documented4 neurologic deficit that may have changed orresolved by the time the child has arrived in the emergency department.Immediate re-injury of the same area may produce permanent disability, sothorough neurosurgical evaluation is essential whenever reliable evidence ofeven a transient neurologic deficit is present.Neck InjuriesThere are 3 horizontal zones of the neck for classification of injurylocation. Zone 1 extends from the sternal notch to the cricoid cartilage. Zone2 extends from the cricoid cartilage to the angle of the mandible. Zone 34EMS providers must document all neurological deficits in the Patient Care Record (PCR) after a thorough examination payingclose attention to the signs & symptoms of a spinal cord injury.Spinal cord injuries of any kind may result in one or more of the following signs and symptoms: Loss of movementLoss of sensation, including the ability to feel heat, cold and touchLoss of bowel or bladder controlExaggerated reflex activities or spasmsChanges in sexual function, sexual sensitivity and fertilityPain or an intense stinging sensation caused by damage to the nerve fibers in your spinal cordDifficulty breathing, coughing or clearing secretions from your lungsEmergency signs and symptoms of spinal cord injury after an accident may include: Extreme back pain or pressure in your neck, head or backWeakness, incoordination or paralysis in any part of your bodyNumbness, tingling or loss of sensation in your hands, fingers, feet or toesLoss of bladder or bowel controlDifficulty with balance and walkingImpaired breathing after injuryAn oddly positioned or twisted neck or backAurora Lakeland Medical Center Aurora Memorial Hospital of Burlington6
Pediatric Trauma: A Review 2017extends from the angle of the mandible to the skull base. Early airway control is paramount. Grosslaryngotracheal injury, stridor, pulsatile bleeding, or expanding hematoma requires urgent operativetreatment. Local exploration or probing of wounds is not recommended.A 5-year retrospective study of pediatric admissions with penetrating neck injury was conductedby Abjurama et al., in this study, 31 children (mean age, 9.5 y) were examined. Most of these injuries(84%) were in zone 2. The 3 deaths had major findings on presentation and were characterized to be inextremis. A major physical examination finding was defined as shock, neurologic deficit, pulsatilehematoma, bruit/thrill, absence of pulses, or crepitus. Surgical exploration was conducted in 31% (8patients), and all yielded negative findings. (Abujamra L, 2003)Oropharyngeal injury represents a complex array of injury, and most are due to falls in thepediatric population. The generous blood supply to this area usually leads to excellent healing but alsocan result in copious bleeding from wounds.Ocular TraumaHalf of pediatric eye injuries occur during sporting events. Significant morbidity may result frompediatric eye trauma because of the continued development of the visual system up to age 9 years.(Similarly, the full adult complement of pulmonary alveoli is not present until about age 7 years.) If arupture of the globe is suspected, the examination should cease; the eye should be covered with aprotective device, and urgent ophthalmologic consultation is indicated.In evaluation of a foreign body, topical anesthetic may be useful for a complete examination. The lidshould be everted with a cotton swab for a thorough evaluation. Examination should include anassessment of visual acuity and extraocular motion 5. Eyelid lacerations deserve careful evaluation forlacrimal duct involvement. Orbital floor fractures may result in entrapment of extraocular muscles withcomplaints of diplopia 6.Thoracic InjuriesThoracic injury is the second leading cause of death in pediatric trauma. Thoracic injury occurs inabout 5% of children hospitalized for trauma. Blunt trauma, particularly from MVAs, is responsible formost thoracic injuries. Not surprisingly, isolated thoracic injuries seen commonly in adults are relatively5Check extraocular movements (eye movements) by having the patient look in all directions without moving their head and askthem if they experience any double vision.6Diplopia is the subjective complaint of seeing two images instead of one and is often referred to as double-vision in layparlance. An accurate, clear description of the symptoms (eg, constant or intermittent; variable or unchanging; at near or at far;with one eye [monocular] or with both eyes [binocular]; horizontal, vertical, or oblique) is critical to appropriate diagnosis andmanagement.Aurora Lakeland Medical Center Aurora Memorial Hospital of Burlington7
Pediatric Trauma: A Review 2017uncommon in children. The pediatric thorax has a greater cartilage content and incomplete ossification 7of the ribs. Due to the pliability of the pediatric rib cage and mediastinal mobility, significantintrathoracic injury may exist in the absence of external sign
to details. All clinicians who are responsible for the care of a pediatric trauma patient, including pediatricians, emergency room clinicians, pediatric emergency room clinicians, and trauma surgeons, must be familiar with every tenet of modern trauma care. The special considerations, characteristics,File Size: 542KB
LEVEL I PEDIATRIC TRAUMA CENTER The Level I Regional Pediatric Trauma and Burn Center at Children’s Hospital Colorado is a large, multi-disciplinary program. We provide timely, comprehensive, cost- . Trauma/Burn Medical Director Trauma/Burn Program Manager Trauma Coordinators Trauma Registrars Staff Assi
Objectives Review current pediatric trauma statistics at UMC/EPCH Understand why children are not small adults Discuss tools to evaluate the pediatric trauma patient How to perform an initial evaluation of the pediatric trauma patient Discuss
Behind the Term: Trauma Prepared in 2016 by Development Services Group, Inc., under contract no. HHSS 2832 0120 0037i/HHSS 2834 2002T, ref. no. 283– 12–3702. 1 Behind the Term: Trauma Related terms: complex trauma, historical trauma, human-caused trauma, naturally caused trauma, trauma,
categories of trauma as a framework for trauma assessment. “Little t” trauma “Big T” trauma Complex trauma “Little t” Trauma “Little t” trauma involves events that we encounter day to day that can make life difficult but are not out of the ord
The assessed content included prima - ry survey, secondary survey, airway and ventilation, circulation, shock, thoracic trauma, head/spinal trauma, abdomen/pelvis trauma, musculoskeletal trauma, paediatric trauma, geriatric trauma, obstetric trauma, trans - fer of care, and other course specific inclusions.
Pediatric trauma centers and hospital-based care are only one aspect of a larger trauma system. An . Special planning considerations must be made for pediatric patients based on the availability of pediatric trauma resources within the geographic area that the trauma
Communication Skills Learning Tools for the Pediatric Clerkship 37 Pediatric History Taking Approach to the Pediatric Patient 38-39 Explanation of Pediatric H&Ps/Pediatric Database 40-43 Example H&Ps (older child and infant) 44-52 Pediatric Physical Examination Benchmarks for Pediatric Physical Examination 53 54-65
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