Pediatric Trauma Pitfalls

School is out and Summer is in full swing (at least up here in the Northern Hemisphere) and that means … more pediatric trauma (sadly)! Pediatric Trauma can be very challenging to manage for numerous reasons (many that we have already touched upon within the Morsels). The child’s different anatomy and physiology and their changes that occur relative the patient’s age make the can obscure the potential hazards. Recently, a nice review was published [Acker, 2019] that reminds us to remain vigilant for some of these Pediatric Trauma Pitfalls:

Pediatric Trauma: Some Differences

  • Trauma is the leading cause of Morbidity and Mortality (M&M) in children (as well as young adults)!
  • While not aliens, children do have different anatomy and physiology that needs to be accounted for, like:
    1. Higher Metabolic Rate + Smaller Functional Residual Capacity = Desaturations occur RAPIDLY!
    2. Compliance Chest Walls = Poor protection to underlying structures (ie, more likely to have pulmonary contusion and solid organ injury than rib fractures)
    3. Thin Abdominal Wall Musculature = Poor protection to underlying organs which can be injured even without objective signs of abdominal trauma.
    4. Very Flexible Tissues = which can be advantageous (very low risk for aortic traumatic injury), but airways can be easily compressed.
    5. Relatively Large Head / Occiput = Hyperflexion of the young child’s neck when supine which can lead to suboptimal airway alignment.

Pediatric Trauma Pitfalls: Remain Vigilant

  • Aside from the above considerations, other potential Errors / Pitfalls to be considered while evaluating the pediatric trauma patient include: [Acker, 2019]
  • Under-appreciating Hemodynamic Instability
    • Shock can be challenging to recognize in a child.
    • Children compensate very well! May not see hypotension until loss of >30% blood volume!
    • Blood pressure may not be your best indicator! Look at Cap Refill!
    • Use the Shock Index Age Adjusted also.
    • Don’t delay getting access… if it is denied… use an Intraosseous line!
    • If blood loss is significant consider Damage Control Resuscitation!
  • Overlooking Blunt Cerebrovascular Injury
    • Blunt injury to the carotid or vertebral arteries is rare, but if present can lead to significant M&M.
    • Often present in delayed fashion (10-72 hours) after initial injury.
    • The risk factors for cerebrovascular injury in children have yet to be defined clearly… but one study found the following to be associated with it:
      • GCS </= 8
      • ISS = 16
      • Presence of cerebral hemorrhage
      • Infarct on head imaging
      • Cervical spine fracture
      • Basilar skull fracture
    • Clavicular fractures have also been associated with it.
  • Overlooking Small Bowel / Mesentery Injury
    • Less protective rib cage and abdominal musculature place the intra-abdominal organs at risk.
    • Hollow viscus can be injured via direct blows (ie, handlebar) or by compression from seat belt against spinal column.
    • Hollow viscus injuries may present in a delayed fashion.
    • Respect the presence of a Seat Belt Sign!
    • Serial exams are important, as CT may not show the injury.
  • Under-appreciating the Potential for NAT
    • NAT can lead to very dramatic presentations, but can also be subtle – look for sentinel bruising.
    • Head Injury is the most common and most lethal injury due to NAT.
    • ANY SUSPICION (not actual diagnosis) needs to be reported to the authorities!

Moral of the Morsel

  • Pediatric Patients are NOT Aliens! They do, however, have different anatomy and physiology that must be considered!
  • Pediatric Trauma patients can be even more challenging than adults to evaluate. Remain vigilant and be aware of the presence of the pitfalls!

References

Acker SN1, Kulungowski AM2. Error traps and culture of safety in pediatric trauma. Semin Pediatr Surg. 2019 Jun;28(3):183-188. PMID: 31171155. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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