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:
- Higher Metabolic Rate + Smaller Functional Residual Capacity = Desaturations occur RAPIDLY!
- Compliance Chest Walls = Poor protection to underlying structures (ie, more likely to have pulmonary contusion and solid organ injury than rib fractures)
- Thin Abdominal Wall Musculature = Poor protection to underlying organs which can be injured even without objective signs of abdominal trauma.
- Very Flexible Tissues = which can be advantageous (very low risk for aortic traumatic injury), but airways can be easily compressed.
- Relatively Large Head / Occiput = Hyperflexion of the young child’s neck when supine which can lead to suboptimal airway alignment.
- Additionally, children are dependent upon adults… who don’t always do the right thing to protect the child.
- Inappropriate use of Safety Devices
- Non-Accidental Trauma (NAT)
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.
- Over-utilization of CT scans
- We have to weigh the risk of missed injury with the ramifications of our evaluation tools.
- Ionizing radiation risk is real.
- Scanning should not be done indiscriminately! DO NOT ORDER A “PAN SCAN” in a child!
- For low mechanism head injury – use PECARN Head Injury Rules.
- Chest CT is often not of great utility in children who have a normal Chest X-ray.
- Don’t forget about serial abdominal exams and serial FAST exams as a way to reduce over-dependence on Abdominal CTs.
- 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!
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]