Pediatric Trauma Amy Henry, RN, CFRN “If a disease were killing our children in the proportions that are, people would be outraged and demand that this killer be stopped.” -C. Everett Koop, MD Pediatric Trauma

Trauma is the leading cause of childhood death and disability in the US. On average 12,175 deaths annually! (CDC) • Traumatic brain (TBI) is the most common cause. • Chest Trauma ~ second. • Abdominal injuries rank third as a cause of traumatic death. Mechanisms of Injury

The transfer of kinetic energy arises from several sources: – Blunt (injury to internal organs)

– Penetrating (disruption of skin and organ integrity)

– Acceleration-Deceleration (abrupt, forceful back and forth movement)

– Crushing (direct compression of body structures) Epidemiology

• accounts for more than 80% of all pediatric injuries • External evidence of injury may be minimal as energy is often absorbed by underlying structures. • Must suspect underlying potential injuries! 90 80 70 60 50 40 30 20 10 0 Blunt Penetrating Crush Other Blunt Force Trauma

1. Falls 2. Motor Vehicle Crashes 3. Car vs. Pedestrian Crashes 4. Bicycle Crashes 5. Skateboarding Injuries 6. Infant Walker – Related Injuries 7. Sledding Injuries Mechanism of Injury

Knowledge of the Mechanism of Injury allows for a high index of suspicion for the resultant injuries in the child.

Initial Trauma Assessment and Intervention

Primary Assessment Identify life-threatening injuries. Focus should be on airway, breathing, circulatory and neurologic systems. Secondary Assessment Identify injuries to the remaining body systems. Not life threatening but may have long term consequences. Primary Assessment

1. Assess the Airway and Cervical Spine

2. Assess Breathing

3. Assess Circulation

4. Assess Disability (Neurologic System) Airway

• Oral airway • Nasopharyngeal airway • Endotracheal intubation • Needle cricothyroidotomy Breathing

• Rate and depth of respiration • Breath sounds, exhaled air • Crepitus, tracheal position • Oxygen saturation Circulation

• early • Capillary refill • External blood loss • late finding – Kids lose 25% of blood volume before hypotension • O2 sat probe not reading IV access

• Peripheral vein – Largest bore possible • Intraosseous line

Secondary Assessment

5. Expose the patient.

6. Fahrenheit – keep patient warm.

7. Get vital signs with pain scale.

8. Head-to-Toe Assessment/History.

9. Inspect the Back.

• (TBI) is the most common cause of traumatic childhood death and disability in the US. • Major cause of TBIs are motor vehicle related incidents in which the child is a passenger, a pedestrian or on a bicycle. • Other head injuries result from falls, sports and play injuries. Traumatic Brain Injury

• #1 cause of trauma death

• 30% of childhood trauma deaths

• 30,000 permanent disabilities TBI

• Airway – Normoventilation vs hyperventilation? • Maximize cerebral perfusion • Intracranial pressure monitor Head CTs Bony Structures

Superior articular process Transverse process

Spinous process

Inferior articular process

Spinous process Lamina Posterior Superior articulating Arch process Transverse process Pedicle Vertebral foramen

McQuillan, K., Von Rueden, K., Hartsock, R., Flynn, M., & Whalen, E. (eds.). (2002). Trauma Nursing: From Through Rehabilitation. Philadelphia: W. B. Saunders Company. Reprinted with permission. Spinal Nerves

Spinal Nerve Area Innervated

– C4 Diaphragm – C5 Deltoids and biceps – C6 Wrist extensors – C7 Triceps – C8 Hands – T2 – T7 Chest muscles Types of Spinal Injury

• Fracture

• Fracture with subluxation

• Subluxation alone

• SCIWORA ~ Spinal cord injury without radiographic abnormality SCI

• One study that looked at 122 injured children birth to 16 years old revealed – 41% had fracture alone – 33% fracture with subluxation – 10% with subluxation alone – 16% with SCIWORA • When subdivided further by age: Subluxation and SCIWORA are more likely to affect younger children and fractures being more common in older children (Proctor, 2002) Mechanism of Injury

• Hyperflexion • Hyperextension • Axial loading or vertical compression • Rotation •

Classification of SCI

• Complete • Incomplete*

– A total motor and – There is a partial sensory loss distal preservation of to the injury sensory and/or motor function below the level of the injury

*classified as spinal cord syndromes Classification of SCI

• Unstable Spine injury – Anatomic elements of the spine are disrupted, with deformity. – The spine can no longer maintain normal alignment – The vertebral and ligamentous structures are unable to support or protect the injured area Cervical Spine Injury

• Uncommon in young children and are associated with multiple injuries. • Child’s large head takes most of impact. • Highly elastic neck ligaments and incompletely calcified vertebral bodies allow for more pliancy of the neck. • Subluxation is more common in children. • Spinal Cord Injury Without Radiographic Abnormalities (SCIWORA) can occur.

Cervical Spine Fractures

• All patients involved in traumatic injury must be immobilized – Assume injured unless cleared – Hard collar – Miami-J – Log roll, Circulation, Motor, Sensory (CMS) exams – No high dose steroids – Spinal cord center for children

• The upper cervical spine C-1 and C-2 accounts for 20% of all c-spine fractures and the lower C-3 thru C- 7 accounts for 80%. Spinal Alignment Full Spine Immobilization Cervical Spine ~ Immobilization Cervical Spine Clearance

• Conscious patient – Alert, cooperative, no neck pain, no neck tenderness, distracting injury? • Unconscious patient – Plain film - Lateral c-spine with collar on • If unable to visualize to T1 on lateral film, obtain multi-detector complete cervical spine CT – Maintain in collar – Follow guideline: "Routine Management of the Patient in a cervical collar” – MRI if not expected to awaken Neurological Assessment

• Sensorimotor exam

• Reflex function Spinal Shock

• Spinal shock is manifested by

– Flaccid paralysis – Absence of cutaneous and/or proprioceptive sensation – Loss of autonomic function – Cessation of all reflex activity below the site of injury Neurogenic Shock

Injury to T6 and above Loss of sympathetic innervation Increase in venous capacitance

Bradycardia Decrease in venous return

Hypotension

Decreased cardiac output

Decreased tissue perfusion Cardiovascular Implications

• Hypotension – Maintain SBP > 90 mmHg for transport – establish adequate pressure for systemic perfusion • Bradycardia – Treat only if symptomatic • Temperature regulation – Will become hypothermic – Frequent to continuous monitoring – Warming strategies Surgical Intervention

• Physician preference • Decision driven by mechanism of injury, neurological deficit, and structural dysfunction • Timing is controversial – Within the first 72 hours – After 7 days • Emergent surgical intervention is required for neurologic deterioration with evidence of cord compression (bone or disc fragments, malalignment, or hematoma) Critical Care Phase

• Respiratory Complications • Cardiovasular – Bradycardia – Vasovagal response • Poikilothermia • Gastrointestinal • Pain and anxiety Abdominal and Thoracic Trauma Thoracic & Abdominal Injuries

• Musculature of the child’s chest and abdomen is less developed than in the adult. • Ribs are flexible and more anterior, thus are less protective of underlying organs. • Child’s protuberant abdomen along with its thin abdominal wall places organs close to impacting forces during a traumatic event. • Child’s small body size is predisposed to multiple injuries rather than isolated injury. Mechanism of Injury

• Should heighten suspicion regarding certain injuries • Blunt injury and types of forces • Use of restraint devices • Penetrating trauma Thoracic Trauma

• Penetrating verses Blunt – – – Open Pneumothorax – – – Pericardial Tamponade – Traumatic Asphyxia – Traumatic Diaphragmatic Hernia Thoracic Injury

• Most common ~ pulmonary contusion and pneumothorax • Rib fractures are not that common because of the child’s pliable rib cage. • If a rib fracture occurs, serious underlying organ damage should be presumed. • In penetrating injuries, the degree of injury depends on the type of gun and bullets used, the bullet trajectory and the distance of the victim from the weapon. Pulmonary Contusion

• Results from blunt trauma to the chest that transmits energy to the underlying lung tissue. • Pulmonary edema, alveolar hemorrhage, desquamative alveolitis and subsequent RDS may result. – RDS generally within first few hours of injury • Impaired gas exchange • VQ mismatch • ↓ lung compliance • Positive pressure ventilation with PEEP and oxygen support may be required. Pneumothorax

• Collection of air into the pleural space with partial or complete collapse of the lung. – Usually caused by blunt trauma to the chest causing alveoli rupture with a resultant escape of air, thus collapsing the lung. • This injury is closed and the lung seals, preventing further leakage. – May progress to tension pneumothorax. • Needle decompression to 2nd ICS midclavicular line or chest tube management may be necessary. Open Pneumothorax

• Results from penetrating thoracic injury. • May lead to tension pneumothorax or hemothorax. • There is progressive air entry into the pleural space without a means of escape. • Lung on affected side collapses and pushes toward the unaffected side producing a mediastinal shift and compression of heart and great vessels. • Treatment includes a 3-sided occlusive dressing over the wound and chest tube placement. Tension Pneumothorax Hemothorax

• Blood collection in pleural space as a result of blunt or penetrating injury • Clinical presentation – Respiratory distress • ↓ breath sounds on affected side • Dullness with percussion – CXR suggestive – Needle aspiration definitive • Management – Chest tube – Volume resuscitation – Thoracotomy for continued blood loss Pericardial Tamponade

• Occurs when a significant amount of blood, fluid or air accumulates in the pericardial sac. • In children, as little as 25 to 50 mL can compromise ventricular function. • Findings include hypotension, neck vein distention, elevated CVP, muffled heart sounds, pulsus paradoxis (fall in BP 8-10 mm Hg during inspiration). • Pericardiocentesis provides temporary relief until surgical repair is performed. Pericardial Tamponade Abdominal Trauma

Physical assessment: Abdominal distention or pain Dermal evidence of trauma

Abdominal Trauma

. Injury to the Solid Organs . Dense and less strongly held together . Prone to contusion .Bleeding .Fracture (rupture) . Unrestricted hemorrhage if organ capsule is ruptured . : pain referred to left shoulder . Liver: pain referred to the right shoulder Abdominal Injury

• Most common MOI is blunt trauma from an MVC-related event whether as an occupant, pedestrian or bicycle rider • Other causes include sports injuries, falls and child abuse • Organs usually involved are the liver, spleen, kidneys and GI tract • Injuries to the major vessels and the are less common Organ Injury Scaling

• Injury scale • Grades I-V • Injury description • Hematoma • Laceration • Vascular • Dependent on severity and location of injury

• Spleen is most commonly injured organ during blunt traumatic event. • Located on left side of abdomen below the ribs. • Injuries are classified by severity and the by the splenic structure involved (capsule, hilar vessels or parenchyma). • Signs include flank ecchymosis (Turner’s sign), umbilical ecchymosis (Cullin’s sign), left abdominal or flank pain with referred left shoulder pain (Kehr’s sign). • Treatment includes observation with serial HCTs and/or surgery. Splenic Injury Liver Trauma Indications for Non-operative Management

• Hemodynamically stable

• Appropriate monitoring

• Experienced personnel

• Liver is located in the right upper abdomen and is protected by the ribs. • Liver injuries are graded depending on the severity and location. • Clinical findings include abdominal abrasions, tenderness, distention, hypotension, and elevated SGOT and SGPT enzymes. • Treatment may include observation with serial HCTs, or surgical repair. Liver Injury

• Incidence – Second most commonly injured organs – MVC most common cause – Mortality 10% to 15% Liver

• Largest intra-abdominal organ in the body • Extremely vascular • Divided into the left and right lobes • Function – Stores products helpful to digestion of food – Filters toxins from the bloodstream • 75% of blood to the liver is delivered by the portal vein • Uncontrolled hemorrhage is the primary cause of death

• Blunt abdominal trauma accounted for 100% of pancreatic injuries in children • Relatively uncommon in Pediatrics Pancreas Anatomy

• Large, complex gland that lies outside of alimentary tract walls • Parallel to stomach at first and second lumbar vertebrae • Not encapsulated, so tears in tissue permits digestive enzymes to leak into the peritoneal cavity Pancreatic Injury

• Clinical Manifestations – Vague , exacerbated by eating – Nausea/vomiting – Classic sign in adults ~ abdominal pain radiating to back is rare in children • Diagnosis – Serum amylase (non- specific) – & trypsinogen (specific) – CT Kidney Injury

• Children have relatively large kidneys, underdeveloped abdominal wall and lesser rib cage protection. • Damage is directly related to the blunt force trauma. • Clinical findings include hematuria, abdominal pain and bruising, palpable flank mass and hypovolemia. • Treatment may include observation, surgical repair or nephrectomy. Kidney Injuries Bowel Injury

• Result from direct blunt trauma or penetrating forces. • Children are at greater risk because of their protuberant abdomens, thin wall, and propensity to swallow air. • A full stomach is more prone to injury. • Injuries include bowel transection, laceration and perforation. • Clinical findings include abdominal pain, vomiting and pneumoperitoneum (free air in abdomen). • Treatment may include observation and/or surgical repair. Bowel Injury Traumatic Diaphragmatic Hernia

• Results from severe abdominal compression. • Diaphragm ruptures, allowing abdominal contents to enter the chest cavity. • Common MOIs include a lap belt injury and pedestrian injury where the child is run over by the vehicle. • Treatment is surgical repair. Traumatic Diaphragmatic Hernia Drowning Drowning

• Drowning – Death from asphyxia by water submersion • Near-drowning – Survival after asphyxia from water submersion • Dry-drowning – Non-aspirating asphyxia during water submersion Drowning

• Most common in summer months • 50% in swimming pools • Bathtub drowning is most common in children with seizure disorders • Bucket drowning Drowning

• Pathophysiology – Pulmonary effects – Cardiovascular effects – CNS Effects • Management – EMS – Emergency Department – ICU Nonaccidental Trauma Child Maltreatment

• Shaken Baby Syndrome – Head injury – SDH, DAI – Retinal hemorrhages – Skeletal fractures – Mortality 13-30% • Munchausen Syndrome by Proxy (MSBP) – Parent simulates or causes disease in a child • Usually preverbal children – Pattern/response doesn’t correlate with disease • Symptoms associated with proximity of parent Abuse

• Defined as (1) any act or failure to act on the part of a parent or caretaker which results in the death, serious physical or emotional harm, sexual abuse or exploitation; or (2) an act or failure to act which present an imminent risk of serious harm. • 3 Types: – Physical (, hitting, choking, cigarette burns) – Emotional (constant criticism, rejection, threats) – Sexual (fondling, penetration, indecent exposure, exploitation) Neglect

• Defined as the failure to provide for a child’s basic needs • Examples: – Food, shelter, supervision, medical care, education Statistics

• Five or six children die per day in the U.S. of neglect and/or abuse. Most are under the age of six. • One in every seven victims of sexual assault is under the age of six. 90% of these victims know their offender. • 40% of the offenders of sexual abuse were under the age of 18. Disturbing Stats

• According to a 1992 study sponsored by the National Institute of Justice (NIJ), maltreatment in childhood increases the likelihood of arrest as: – A juvenile by 53 percent – An adult by 38 percent and for a violent crime by 38 percent – Being abused or neglected in childhood increases the likelihood of arrest for females by 77 percent. • A related 1995 NIJ report indicated that children who were sexually abuse were 28 times more likely than a control group of non-abused children to be arrested for prostitution as an adult Abuse and Neglect

• The actual number of abuse and neglect cases are estimated to be 3 times greater than the number reported

• Although we see more abuse cases, more than twice as many cases of neglect are reported Reporting

• Verbal Report immediately upon suspicion – Police or Sheriff’s Department (Does not include a school policy or security department) – County Probation Department (If County Designated) – County Welfare/County CPS Department • Follow up in writing – General Standard within 48 hours or as soon as possible – California Form 8572 Mandated Reporting

• Good Faith reporters are protected under the law from civil or criminal liability • Failure to report may result in fine up to $1,000

Additional Information and Training: http://mandatedreporterca.com Questions Credits

• Reid AB. Letts RM. Black GB. Journal of Trauma. [JC:kaf] 30(4):384-91, 1990 Apr • Diagnostic Imaging in Infant Abuse, Am J Roentgenol, Kleinman 155 (4):703 • The metaphyseal lesion in abused infants; a radiologic-histopathologic study, PK Kleinman, SC Marks, and B. Blackbourne, AM J Roentgenol., May 1986; 146; 895-905. • Parent, Stefan, Mac-Thiong, J., Roy-Beaudry, M., Sosa, J., and Labelle, H. Spinal Cord Injury in the Pediatric Population: A Systematic Review of the Literature. J Neurotrauma. 2011 Aug; 28(8); 1515- 1524.