Special Considerations Trauma

Pediatric Trauma
Introduction

• Traumatic injuries are the number one cause of mortality and morbidity in the pediatric patient population.
• The most common etiology of traumatic injuries in the pediatric patient is secondary to motor vehicle accidents either as a vehicle passenger, pedestrian or bicycle rider. The incidence of motor vehicle accidents as the cause of traumatic injuries in pediatrics is approximately 35% followed by trauma secondary to falls at 26%.
  Other causes of pediatric trauma that are commonly seen include drowning/near drowning, residential fires and assault with either no penetrating or penetrating trauma.
• The most frequent age group for pediatric trauma based on data collected by the National Pediatric Trauma Registry is between the ages of 5-9 years.
• The highest incidence of traumatic injuries is during the summer and spring seasons usually during daylight hours.
• It cannot be over-emphasized that the best way to treat pediatric trauma is through an active community education and prevention program focused on reducing the risks of trauma.
• In the evaluation and management of the pediatric trauma patient, it is important to remember that theses patients do not just represent small versions of the adult trauma patient. There are sufficient differences between the adult and pediatric trauma patient that the one algorithm concept of trauma management is in many cases ineffective and can even be hazardous. The purpose of this pediatric trauma section is to elucidate the major differences in the primary and secondary survey and management criteria.

  Table: Pediatric resuscitation formulas

• Patient < 1 yr of age Weight in Kg = (age in months/2) + 4
• Patient >1 yr of age Weight in Kg = (2 times age in years) + 10
• Minimal Systolic Blood Pressure = (2 times the age in years) + 70
• Endotracheal tube size = Age in Years divided by 4 + 4
• Endotracheal tube placement depth in cm = 3 times ETT size
• NG tube size = 2 times ETT size
• Foley catheter size = 2 times ETT size
• Chest tube size = 4 times ETT size
• Initial crystalloid intravenous fluid bolus = 20 ml/kg
• Initial blood replacement 10 ml/kg
• Alternative to above is the use of Breslow Tape which will also supply commonly used resuscitation drug dosages
• The primary and secondary survey for the adult patient is discussed in detail elsewhere in this chapter. In the following section the significant differences with the pediatric trauma patient will be highlighted.

Primary Survey
Airway

• The pediatric airway has some important anatomical differences when compared to the adult which can at times make their airway management more challenging.
• The pediatric patient has a tongue and tonsillar tissue that are disproportionately larger compared to the size of their oropharynx making visualization of the vocal cords during endotracheal intubation much more difficult.
• The smaller mouth and orophayngeal size reduces the work area available thus limiting visualization and airway access.
• The larynx is in a much more anterior position and smaller making visualization of the vocal cords and subsequent ETT placement more challenging.
• The cricoid cartilage is the narrowest part of the pediatric airway, unlike the vocal cords in the adult. This cricoid narrowing serves as a functional endotracheal tube cuff in patients under the age of eight; therefore in this age group endotracheal tubes are uncuffed.
• Because of the small internal diameter of the pediatric airway, airway adjuncts and endotracheal tubes are more easily occluded with secretions.
• The pediatric epiglottis is larger and can be floppier interfering with visualization of the glottic opening (vocal cords).
• Until approximately 6 mo of age children generally are obligate nose breathers meaning that any nasal obstruction whether from secretions or otherwise must be treated to prevent subsequent development of hypoxia.
• The head size in the pediatric patient population is proportionally larger placing the supine patient naturally into a sniffing position.
• In the pediatric patient population, it is generally easier to perform endotracheal intubation using a straight laryngoscope blade because of their anterior larynx.
• It should be kept in mind that should a surgical airway be necessary in the pediatric patient, because of the small size of the cricothyroid membrane, a needle cricothyrotomy only should be performed in the patient < 10 yr of age.
• The short length of the pediatric trachea makes it much easier to accidently intubate the patient’s main stem bronchus.
• The use of uncuffed ETT in patients under age eight also predisposes the ETT to be more easily displaced.
• It is important to emphasize that during all airway manipulations and procedures when clinically indicated cervical spine immobilization must be maintained.

Breathing

• It is important to be able to recognize early on the pediatric patient who is in respiratory distress or failure or has the potential based on history and physical of developing these entities. The best way to treat a pediatric respiratory or cardiopulmonary arrest is prevention.
• Clinical evidence of the development of respiratory distress includes any or all of the following: tachypnea, the use of accessory musculature, retractions, nasal flaring, splinting and cyanosis.
• The child with an abnormally slow respiratory rate in the setting of trauma may be manifesting respiratory muscle fatigue and should be considered to be in respiratory failure. This must be considered a prearrest state and BVM ventilation commenced immediately with subsequent endotracheal intubation.
• Head bobbing is also frequently associated with respiratory muscle fatigue.
• Lethargy and/or alteration of mental status may be an indication of cerebral hypoxia either secondary to respiratory failure or to the development of a shock state.
• Supplemental oxygen should routinely be administered to pediatric trauma patients and pulse oximetry continuously monitored.
• Early intervention with assisted ventilation (BVM) and endotracheal intubation when clinically indicated is extremely important.
• Infants require an assisted ventilatory rate of approximately 40 breaths per min and children 20/min.
• The appropriate tidal volumes range from 7-10 ml/kg for both infants and children. Care must be taken to limit the amount of pressure generated in the pediatric airway during assisted ventilation. Excessively high ventilatory pressures can injury the fragile tracheobronchial tree leading to barotrauma such as pneumothorax.
• Hesitation and delay in the recognition and management of any compromise with the pediatric patient’s airway or breathing can lead to a disastrous outcome. Early recognition and effective management are the keys to a successful outcome.

Circulation

• The pediatric patient has significant cardiovascular reserves and is able to sustain considerable blood loss before there is a significant change in the patient’s vital signs.
• The patient may actually be in a shock state and have a normal blood pressure which is referred to as compensated shock.
• Uncompensated shock is when hypotension also occurs.
• The blood pressure is usually the last vital sign to become abnormal in the pediatric patient in shock. Hypotension in the pediatric trauma patient is a late finding and usually indicates significant blood loss and/or inadequate volume resuscitation.
• Tachycardia is one of the earliest signs of shock. The patient’s pulse should also be evaluated for its strength and regularity.
• The patient’s capillary refill should also be assessed and normally is < 2 seconds. In order to accurately measure a patient’s capillary refill, the extremity to be tested should be elevated slightly above the level of the heart to avoid refilling of the capillary bed by venous backflow. Also capillary refill is only accurate in a warm environment. In a cold environment peripheral vasoconstriction occurs to maintain body core temperature which will abnormally prolong capillary refill.
• Another indicator of perfusion is the comparison of distal to proximal pulses in the same extremity. The absence or decrease of more distal pulses in the presence of proximal pulses indicates severe peripheral vasoconstriction as the body attempts to maintain perfusion of vital organs is a sign of shock.
• In shock the skin may become cool, pale and clammy as a result of vasoconstriction. The skin may also appear cyanotic in some cases that can be directly related to the shock state itself and/or respiratory failure with its resulting hypoxia.
• The pediatric patient in shock may become lethargic, irritable or confused secondary to a decrease in CNS perfusion although we must keep in mind the many other traumatic and nontraumatic causes.
• A decrease in urinary output may also be seen secondary to a decrease in renal perfusion.
• All of the above clinical manifestations of shock share one thing in common and that is that they are all indicators of a decrease in the patient’s end organ perfusion. It is extremely important that shock is detected in the earliest stage possible and appropriate intervention is initiated immediately.
• One of the goals of initial therapy is to aggressively treat the patient’s volume deficit and shock state and prevent the compensated shock from progressing to uncompensated shock.
• When shock is identified intravenous access should be obtained as rapidly as possible.
• At least two large bore IVs should be obtained (IV catheter size varies with patient).
• Intraosseus access is an excellent alternative should peripheral access become difficult.
• Intraosseus access used to be restricted to the patient < 6 yr of age, but this is no longer true; there is currently no upper age limit for intraosseus access.
• It is important that intraosseus access not be placed into an injured extremity.
• Intraosseus access should be considered a temporary form of intravenous access, and once the patient has been stabilized and peripheral access obtained the intraosseus line should be discontinued.
• The location of choice for intraosseus access is on the medial aspect of the proximal tibia just inferior to the level of the tibial tuberosity.
• The complication rate of this procedure is low. Complications include cellulites and osteomyelitis.
• Central line intravenous access and venous cutdowns are other alternatives.
• The initial resuscitation fluid of choice is a crystalloid solution consisting of either normal saline or Ringers lactate.
• The initial volume of resuscitation of crystalloids is 20 ml/kg as a bolus, which is approximately equivalent to 20-25% of the normal circulating pediatric blood volume.
• This fluid bolus can be repeated as necessary based on the continuing reassessment of the patient.
• If possible, warmed resuscitation fluids should be used to decrease the chance of developing hypothermia.
• If blood infusion becomes necessary, infused O negative or type-specific blood should be at 10 ml/kg.
• Any external hemorrhage should be controlled by applying direct pressure to the wound.

Disability

• Use the AVPU method
  A—Alert
  V—Response to verbal stimuli
  P—Response to painful stimuli
  U—Unresponsive

Exposure

• The patient should be completely undressed to receive a complete examination and evaluation.
• The pediatric patient is at higher risk for developing hypothermia than the adult during this process because they have an increased total body surface area and less subcutaneous fat stores.
• Warm blankets and intravenous solution warmers should be available.
• The development of iatrogenic hypothermia can worsen preexisting acidosis and also can induce a coagulopathic state through inactivation of various coagulation factors.

Resuscitation

• When performing the primary survey in the pediatric trauma patient, as in the adult, it is important to remember that the primary survey and the resuscitation phase are to be performed simultaneously. When compromise of airway, breathing or circulation is encountered, immediate resuscitative intervention should occur even if the entire survey is not complete.

Secondary Survey

• The secondary survey commences when the primary survey is completed and initial resuscitation is initiated. The secondary survey consists of a detailed history with a head-to-toe physical examination of the pediatric trauma patient.
• The patient’s complete vital signs are obtained at this time.
• Appropriate radiological and laboratory studies are obtained.
• A bedside ultrasound (FAST scan) can be performed to evaluate for evidence of intra-abdominal free fluid/hemoperitoneum or pericardial effusion.
• A nasogastric tube and Foley catheter should be placed as clinically indicated.
• The nasogastric tube is important for gastric decompression.
• In the pediatric patient population, aerophagia may occur with any degree of respiratory distress leading to gastric distention which limits diaphragmatic excursion further aggravating the patient’s respiratory distress.
• A more detailed neurological exam including Glasgow Coma Scale should be performed at this time.
• Always consider transfer to a trauma center for further management of the pediatric trauma patient. It is helpful to have prearranged transfer agreements in place with trauma centers and tertiary care centers to help expedite the transfer process.

Elderly Trauma

• The Emergency Medicine healthcare provider must have a clear understanding of the physiologic differences that occur in the elderly trauma patient and how these changes affect resuscitation and stabilization in the Emergency Department.
• Elderly trauma patients account for only a small percentage (10%) of the total population of trauma patients yet they account for approximately 25% of all trauma-related healthcare expenditures in this country.
• The increased cost of care is related to many of the physiologic changes that occur with aging along with the increased incidence of various disease processes and co morbidities that exist in this population.
• The most common cause of trauma in the elderly patient is falls; approximately 40% of traumatic events in the elderly (Table 16.8).
• Burns are the third leading cause of trauma in the older patient population.
• Fractures and head injuries account for the largest percentage of injuries in this age group.

  Table Etiology of falls in the elderly

• Cardiac dysrhythmias
• Valvular heart disease
• Vasovagal syncope
• Myocardial ischemia
• Orthostatic hypotension
• Anemia
• Hypovolemia
• CVA/TIA
• Hypoglycemia
• Hypoxemia
• Medication side effects

• Penetrating trauma in the elderly occurs but to a lesser extent than blunt trauma but still has a disproportionately high morbidity and mortality rates compared to the general population.
• Elder abuse should always be considered as a potential source of geriatric trauma. Often under-recognized by healthcare providers when compared to spousal or child abuse, estimates of potential elder abuse range between 500,000 to 2,500,000 incidents per year in the United States.

Special Considerations

• Medications for more chronic medical problems may complicate the management of trauma in the elderly patient.
• Beta-blockers and calcium channel blockers may blunt the hemodynamic response to hypovolemia.
• Coumadin and antiplatelet drugs can increase the risk of hemorrhage and can make it more difficult to control.

Head Trauma

• Geriatric brain atrophy can lead to several important problems:
• Cognitive/memory impairment, which may make it difficult to obtain an accurate history.
• The risk of intracranial hemorrhage secondary to stretching of the bridging veins from the brain to the dural sinuses. This leads to subdural hemorrhage.
• Therefore CT should be used liberally in this population.

Spinal Injuries

• The presence of degenerative joint disease (DJD) and osteoporosis in the elderly increases their risk of sustaining spinal injuries.
• The more frequent incidence of spinal stenosis means a higher incidence of spinal cord injury with or without fracture or subluxation.
• Compression fractures can occur more often in the thoracic and lumbar spine than in the general population.
• The elderly population is more predisposed to the development of spinal cord contusions which can lead to cord syndromes especially central cord syndrome.
• In a symptomatic patient, much lower threshold must be maintained to obtain flexion-extension cervical spine radiographs and CT scans of the cervical spine in the elderly even in the presence of normal cervical spine radiographs.

Chest Trauma

• The chest wall in the elderly patient is much less flexible than in the younger patient, and these patients are more likely to sustain fractures of the bony structures of the thorax.
• Pneumothorax and hemothorax occur more frequently because of the increased incidence of rib fractures in this population.
• Delayed complications such as atelectasis, pneumonia and ARDS are also increased in frequency.
• In some cases early endotracheal intubation should be considered at the first signs of respiratory insufficiency.

Abdominal Trauma

• The physical examination of the abdomen and pelvis is less reliable in the elderly population which should lead the clinician to more liberal use of radiographic imaging studies.
• Repeat serial examinations of the abdomen are important in all trauma patients but especially in this population.
• If intravenous contrast agents are to be used in imaging studies, the patient should be kept well hydrated to reduce the chances of the renal insufficiency.
• Over hydration should be avoided as it may exacerbate any cerebral edema or pulmonary contusions that are present.
• In the case of cardiac co morbidity, excess fluid may lead to respiratory compromise.

Treatment

• The primary and secondary surveys should be performed as discussed previously.
• Due to their general inability to tolerate physiologic stress as effectively as younger individuals, the elderly patient may decompensate from their traumatic injury much more readily.
• Transfusion should be performed in the face of anemia or dropping hemoglobin early on to maximize the oxygen carrying capacity of the blood.
• This is necessary to avoid exacerbation of any ongoing ischemic processes in the elderly such as myocardial ischemia and strokes.
• Early and liberal consultation with a trauma surgeon and any other necessary consultants should be obtained.
• Hospital admission is necessary in most cases.

Trauma in Pregnancy

• In the evaluation and treatment of the pregnant trauma patient it is important to remember that fetal well being is dependent on effective resuscitation of the mother.
• The normal physiologic response to maternal trauma in pregnancy is self-preservation of the mother at the expense of the fetus.
• Blood flow is shunted away from the uterus to maintain flow to the mother’s vital organs in the presence of hypotension. The presence of this shunting can mask signs of clinical shock until maternal blood loss is approximately 30-35%.
• Initial treatment priorities for the pregnant trauma patient remain essentially the same as for the no pregnant trauma patient with a few modifications which take into account the physiologic changes seen in pregnancy:
• An approximately 50% increase in circulating blood volume occurs during pregnancy, but there is a lesser increase in red blood cell mass leading to the physiologic anemia of pregnancy.
• Heart rate will also increase 10-15 beats/min during the course of pregnancy.
• Blood pressure decreases by 5-15 mm Hg in both systolic and diastolic readings usually starting in the second trimester.
• Supine hypotension may be seen in pregnancy secondary to the gravid uterus compressing the inferior vena cava thereby decreasing venous return.
• Placing the patient in the left lateral recumbent position or manually displacing the uterus usually will correct supine hypotension in pregnancy.
• Elevated progesterone levels in pregnancy lead to a decrease in both gastric and intestinal motility leading to an increase in the risk of gastric aspiration.
• Early use of nasogatric tube decompression can help to reduce this risk of aspiration.
• The diaphragm becomes elevated during the course of pregnancy secondary to displacement by the enlarging uterus. This results in a decrease in functional residual capacity and residual volume, which leads to a lower oxygen reserve. The pregnant patient compensates for the decrease in functional residual capacity by increasing tidal volume by up to 40%, resulting in hypocapnea and a mild respiratory alkalosis. A normal pCO2 therefore, may represent an early sign of respiratory compromise in these patients.
• The pregnant patient’s symphysis pubis widens by approximately 28 wk gestation, as do the sacroiliac joint spaces.

Clinical Presentation
Blunt Trauma

• Motor vehicle accidents represent the most common source of blunt trauma in pregnancy with falls and assaults, including domestic violence, as other potential causes.
• The most common serious injury seen with blunt trauma is placental abruption which occurs in approximately 50% of major abdominal traumatic injuries and in 5% of minor trauma events.
• Fetal death may occur in the presence of only minor maternal injuries.
• Uterine rupture may also occur but is a relatively uncommon occurrence (0.6%); however, if it does occur, fetal mortality is close to 100%.
• The clinical presentation of uterine rupture is highly variable.
• Common findings are the loss of the normal uterine contour and the palpation and/or visualization of fetal parts outside of the uterus by ultrasound.
• Maternal hypotension and shock usually rapidly ensue with an associated no reassuring fetal heart rate pattern.
• Premature labor and/or premature rupture of membranes may also occur secondary to blunt trauma.

Penetrating Trauma

• During the course of a developing pregnancy as uterine size begins to increase, the other abdominal and pelvic organs become increasingly protected from penetrating trauma.
• The enlarging uterus, however, becomes progressively more susceptible to penetrating trauma.
• Penetrating abdominal or pelvic trauma in pregnancy have a relatively high fetal mortality rate, in some studies approaching 66%.
• The maternal mortality rate (5%) for penetrating abdominal/pelvic trauma is surprisingly low due to the shielding effect of the enlarging uterus.

Emergency Department Treatment of Pregnant Trauma Patients

• The initial evaluation of the pregnant trauma patient does not differ significantly from the initial management of the no pregnant trauma patient.
• The patient’s airway patency should be maintained while simultaneously protecting the cervical spine.
• The chin lift or jaw thrust techniques can be used to open the patient’s airway and allow maintenance of cervical spine immobilization.
• Supplemental oxygen should be administered to maintain adequate oxygenation of both the mother and fetus. Other airway adjuncts such as nasal pharyngeal and oral pharyngeal airways may be useful in selected patients in maintaining airway patency.
• Endotracheal intubation may be necessary to maintain airway protection along with adequate oxygenation and ventilation in some cases.
• Adequate circulating blood volume must be maintained at all times. The presence of the increased blood volume seen in pregnancy means that in the setting of trauma the pregnant patient can lose a large percentage of her circulating blood volume prior to the development of tachycardia, hypotension and other signs of hypovolemic shock occur.
• This is important because decreased placental perfusion with associated fetal hypoxia may be occurring when the maternal vital signs appear stable.
• The pregnant patient with significant trauma should have two large bore intravenous catheters (14-16 gauge) placed as soon as possible for intravascular volume replacement and resuscitation.
• Crystalloid either as lactated Ringers or normal saline are the resuscitation solutions of choice for initial resuscitation of the pregnant patient.
• In the supine patient the uterus can compress the vena cava which leads to decreased venous return and subsequently a decrease in cardiac output. This decrease in cardiac output can cause or exacerbate a preexisting shock state. The uterus can be manually deflected to the left and the patient can be placed on her left side by placing a wedge under her right hip or backboard, which will alleviate the vena caval compression.
• The patient should be placed on a monitor and pulse oximetry. If the fetal gestational age is at least 20-24 wk continuous fetal monitoring should be performed.
• A thorough secondary survey should be performed consisting of a complete head-to-toe physical examination to include a pelvic examination unless there is a contraindication such as a suspected placenta previa.
• A nasogastric tube and Foley catheter may be indicated.
• Laboratory evaluation should consist of CBC, urinalysis, type and screen, PT/PTT, and HCG Quantitative. In the case of abdominal trauma, LFTs and lipase should be added.
• If the mother is Rh negative, a Kleihauer-Betke test should be obtained to detect the presence of fetal RBCs in the maternal blood smear. Regardless of the results or availability of the Kleihauer-Betke test, every Rh negative patient with a history of abdominal trauma should be given Rh immunoglobulin (Rhogam) to avoid sensitization. This should occur, regardless of the gestational age of the fetus.
• In the setting of a pregnancy of < 13 wk, mini-Rhogam may be used Radiographic evaluation should be obtained as clinically indicated by physical findings during the secondary survey.
• Bedside ultrasound is an extremely useful tool in evaluating the pregnant trauma patient. It can be used for initial evaluation of fetal age and viability pending monitoring. A Focused Abdominal Sonogram for Trauma (FAST) can also be performed looking for signs of free fluid (hemoperitoneum) in the abdomen and pelvis.
• Obstetrical and/or surgical consultation is indicated depending on the nature and severity of the mother’s injuries. Patients with abdominal/pelvic pain, vaginal bleeding, ruptured membranes or uterine contractions should be admitted with obstetrical consultation for further evaluation and continuous fetal monitoring.
• Perimortem c-section in the emergency department in the setting of maternal hypovolemic cardiac arrest can occasionally be successful, but in many cases the fetus has already been exposed to a period of prolonged hypoxia prior to the maternal cardiac arrest. This contributes to a generally poor outcome in many of these cases. If perimortem c-section is to have any chance of being successful, it must be initiated within 4-5 min of the onset of the maternal cardiac arrest.