Indian J Crit Care Med April-June 2004 Vol 8 Issue 2 IJCCM October-December 2003 Vol 7 Issue 4

Pediatric Section

Management of a with multiple trauma

Praveen Khilnani

Introduction Emergency room management protocol Trauma is a preventable pediatric disease. It is the lead- Proper care of the young child with multiple trauma ing cause of death in children over one year of age. Two- demands a systematic approach that has been re- thirds of pediatric victims have an isolated hearsed - mentally and physically - so often by all mem- head . is the most common cause of bers of the pediatric that it has to become death due to multiple trauma in pediatrics.1 Pre-hospital a automatic reaction. This plan includes, but is not lim- trauma care ideally involves a fast response transport ited to, an understanding of the pediatric airway, control system where an emergency medical technician of hemorrhage and principles of . Only fol- (paramedic), trained in resuscitation and stabilization of lowing the stabilization of the child can an assessment the injured child goes to the scene of the accident, and of, the extent of be undertaken and priorities in carries out the task of on going trauma care until arrival definitive treatment be established. to the . In Delhi CATS (Central- ized accident and trauma service) has been in place to Centers that lack this disciplined protocol can provide, transport trauma victims to the nearest tertiary care on occasion, adequate care to the severely injured child, center. Unfortunately due to insufficient ambulances, lack but the quality of that care will be variable and often be- of trained personal, traffic congestion and a lack of or- low that which is considered state of the art. ganized air transport system to transport a trauma vic- tim, this system has a lot of scope for improvement. Pri- Priorities vate ambulance companies as well as private hospitals Primary survey are able to provide somewhat more efficient dispatch Involves a quick survey from head to toe to prioritize system as well as trained personnel, however the prob- management of life threatening issues.2 lem of traffic congestion and lack of uniform standards of many such private transport systems remain. The ABC’s of life-saving care are now well known: A. Airway assessment and management, with cervi- Most of the time a trauma victim is brought to the emer- cal spine immobilization gency room (ER)/Casualty by private vehicle by the rela- B. Breathing and provision of essential alveolar venti- tives, the police, or by standers in the event of an ambu- lation lance delay, which is a frequent occurrence. This review C. Circulation with prompt control/arrest of hemorrhage is intended to familiarize the pediatrician, the pediatric D. Disability, with a rapid neurological examination emergency physician and the pediatric intensivist with a E. Exposure of entire child for detection, evaluation and gross overview of protocolized care of a child with multi- stabilization/treatment of injuries. ple trauma in the ER and in the PICU. This easily recalled mnemonic is aimed at the immedi- From: ate identification and treatment of those specific injuries Apollo Center for Advanced Pediatrics (ACAP), Indraprastha Apollo Hospital, Sarita Vihar, New Delhi - 110044, India. capable of producing death, i.e. airway obstruction, ten- Correspondence: sion , pericardial tamponade and shock B-42, Panchsheel Enclave, New Delhi - 110017, India. E-mail: [email protected] from blood loss.

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Following the ABC’s, in sequence, comes treatment of ways be confirmed by clinical exam (bilateral chest ex- the greatest threats to life in the order in which these cursions and breath sounds) and a chest radiograph. threats kill. As an example, airway obstruction is more rapidly fatal than is tension pneumothorax, which is more B. Breathing quickly lethal than shock. While space does not allow a Mechanical ventilation will be a mainstay of therapy detailed description of specific injuries to organ systems, for, most children who suffer severe multiple trauma. A the principles of initial management will be briefly dis- decreased lung compliance can be a major problem, cussed. particularly in those patients with extensive thoracic and/ or . A. Airway The relatively large tongue of children tends to fall pos- Appropriate ventilation can generally be initiated with terior and obstruct the airway, particularly in unconscious an initial tidal volume of 10-15 ml/kg, 3-5 cm H20 of posi- patients.3 This obstruction is accentuated by either ex- tive end-expiratory pressure (PEEP). Ventilator rates in cessive flexion or extension of the neck and minimized the infant, toddler and older child can be started at 30, by adopting the sniffing (midflexion) position. This is 25 and 20 inspirations per minute, respectively. Initial achieved by placing a folded towel beneath the occipit, inspired 02 concentration should always be 100%. A causing slight flexion of the lower, and minimal exten- variety of factors will determine changes in ventilator sion of the upper, cervical spine. Jaw thrust can be used settings, but in the final analysis, repeated arterial blood as airway opening maneuver instead of head tilt and chin gas determinations and oxygen saturation are the ma- lift in patients with possible cervical injury, which should jor parameters dictating ventilator therapy. pH modifiers be presumed on all trauma victims. Foreign matter in (NaHC03) play a role in correcting acidosis, but are gen- the oral cavity loose teeth, blood, mucus, roadside de- erally withheld until the PaCO2 has been controlled and bris, etc. - can fatally obstruct and is removed best by a adequate fluid resuscitation has been performed. finger sweep and large bore suction device. Blind finger sweep, however, is not recommended as it can push the Circulation foreign body deeper into the pharynx. Remaining for- After the child’s airway is secured and ventilation es- eign matter out of reach may be removed using a Magill's tablished, Hemodynamic stability becomes the major forceps under vision. consideration. In blunt, as well as , the more common urgent problems are control of ongo- Oxygen is supplied by the most readily available means. ing hemorrhage and treatment of shock. Much less com- Mouth to mouth resuscitation, or air from a self-inflating mon, though equally critical, are and bag are acceptable techniques until oxygen by mask is cardiac arrest. available. A plastic oral airway, placed to hold the tongue forward, is appropriate only if the child accepts it. Direct pressure applied to bleeding wounds remains the safest method to control external hemorrhage. Tor- Should endotracheal intubation be required in emer- rential hemorrhage from a child’s scalp, however, fre- gency situations, this should be performed with an quently overlies compound or depressed skull fractures uncuffed tube by the oral route as a rapid sequence in- with disruption of intracranial veins. Direct pressure on tubation (RSI) with presumed full stomach and high risk these sites may be impractical. Elevation of the head of aspiration of gastric contents. several inches above the level of the heart will minimize blood loss. The clamping of spurting vessels, with Preoxygenation, cricoid pressure,intravenous induction hemostats (artery forceps) should generally be avoided, followed by short acting muscle relaxant and oral intu- particularly in deep, poorly visualized wounds. Impor- bation are essential steps of RSI. The internal diameter tant nerves closely accompany most major arteries, and of the tube is age-dependent and, in millimeters, is (4.0 injudicious clamping may irreparably damage these. Tour- + age in years divided by 4). The distance to which the niquets or pressure dressings may be utilized for the tube is inserted past the lips, in centimeters, is 11-12 + temporary control of rapidly bleeding extremity wounds. age in years, though ultimate tube position should al- Blood pressure cuffs are preferable to narrow; make shift

79 Indian J Crit Care Med April-June 2004 Vol 8 Issue 2 IJCCM October-December 2003 Vol 7 Issue 4 tourniquets as they deliver a quantifiable pressure over involved in the care of traumatized children. The place- a broad area. The pressure applied with a tourniquet ment of a central venous catheter for the acute fluid re- must exceed systolic blood pressure or it is worse than suscitation of a traumatized child can lead to wastage of no tourniquet at all; if too loose, arterial blood is shed time. Such catheters are appropriate only subsequently and venous blood cannot return to the body. in the pediatric intensive care unit for venous pressure monitoring, and/or provision of parenteral nutrition cen- In any case, any tourniquet should be replaced as trally. quickly as possible with a sterile pressure dressing. Introsseous access In many areas, tourniquets have been replaced by the Increasing utilization of Intraosseous infusions6 by pre- pre-hospital application of the military anti-shock trou- hospital personnel has made time consuming vascular ser (MAST). While there is controversy regarding their access procedures in the emergency department less use in pediatrics, the MAST garment is of particular value necessary. Other advantages of this technique include: in patients with unstable pelvic fractures and/or exten- (i) many easily accessible routes (tibia, femur, ileum or sive intra-abdominal injuries. Hemorrhage is reduced and sternum); (ii) very little skill is required to perform the circulation to the heart, lungs and brain is assisted.4,5 procedure, and (iii) the complication rate is exceedingly low. While this modality should be considered for infu- Shock in the pediatric patient following major injury is sion of fluid, blood and most drugs in the initial minutes practically always due to blood loss. of resuscitation, conversion to a secure intravenous cath- eter should be performed when this can be accom- Neurogenic, cardiogenic and septic shock do occur in plished. this setting, but they are rare and precise differentiation is unnecessary initially since initial management differs Choice of resuscitation fluid little, if at all, with that of hypovolemic shock. Debate continues to rage over the ideal initial resusci- tation fluid, though most centres utilize Ringer’s lactate, Clinically, shock is characterized by tachycardia, cool, normal saline (crystalloids).7 All patients are given two pale or mottled extremities, irritability or an obtunded to three rapid intravenous fluid boluses of 20 ml/kg each. sensorium. Oliguria is a fairly constant finding unless Further management is dictated by the hemodynamic head injury has produced diabetes insipidus. Hypoten- response, or lack of response to this initial infusion. If sion is a late manifestation of hypovolemia and may only blood pressure returns to normal, fluid infusion is con- appear after loss of 25% of circulating blood volume due tinued at a maintenance rate. If shock persists after half to compensatory mechanisms (primarily release of en- of the blood volume has been replaced by crystalloid dogenous catecholamines) present during the early (two to three boluses), blood transfusion is necessary. phase of blood loss. A normal blood pressure may fool Usually 10-20 ml/kg of packed red blood cell transfusion the clinician into a false sense of security, so meticulous is adequate. Ongoing transfusion requirements gener- attention to the more subtle manifestations of shock in ally indicate the need for operative intervention. pediatric patients is essential, such as tachycardia, poor capillary refill, cool extremities, mental status and urine Secondary survey output. This survey is performed after life threatening injuries have been addressed. Vascular access is initially attempted by percutaneous insertion technique at the antecubital vein at the ankle, Secondary survey involves detection of all injuries. traditionally the favored sites. An upper extremity cath- eter is preferred if the potential for serious abdominal Following is a discussion of protocol of management injury exists. If patient movement or vasoconstriction of common injuries in a multiple trauma victim. Head makes 2 or 3 attempts unsuccessful, intraosseous ac- injury has been omited from this discussion as it is a cess should be promptly undertaken. Expertise in this separate topic. Specific bony injuries are beyond the fairly simple maneuver is an essential skill for anyone scope of this discussion. This description of protocols

80 IJCCM October-December 2003 Vol 7 Issue 4 Indian J Crit Care Med April-June 2004 Vol 8 Issue 2 will concentrate on major thoracic and abdominal inju- vere hypoxemia with or without air leak syndromes (pneu- ries. mothorax) and will require chest tubes, low tidal volume ventilation and inotropic support until improvement in lung Thoracic injuries condition occurs. Airway obstruction with blood clot is a Significant pumonary parenchymal, cardiac or great frequent risk alleviated by keeping the endotracheal tube vessel injury may result from both penetrating and blunt open by humidification and suctioning. trauma.8 In all cases, examination includes inspection of position of trachea, symmetric movement of chest, arises most commonly from penetrating palpation of fractures and injuries and requires a chest tube in most circumstances. and auscultation for quality and location of breath sounds. Retained hemothorax is a significant risk factor for post Outcome of this process is reflected in the arterial blood traumatic emphysema and fibrothorax. For many inju- gas analysis or by monitoring of both oxygen saturation ries, thoracostomy is a sufficient surgical intervention. and end tidal carbon dioxide. Many guidelines for operative intervention based on the amount of initial drainage and ongoing hemorrage from Lacerations that do not communicate with the pleural the chest tube have been proposed. These guidelines cavity are handled in the usual fashion. Externally vis- should be individualized. ible lung constitutes open pneumothorax and is treated with application of partially occlusive dressing and im- Chest wall soft tissue loss may be encountered oc- mediate tube thoracotomy. casionally in the trauma setting. The chest wall can be closed initially with PTFE mesh; however complex flap Tracheobronchial or esophageal injury may result or prospective closure is often required for long term in extra anatomic air, as may cervical, facial and retro- coverage. peritoneal injuries. A massive air leak, failure of lungs to re expand after placement of chest tube should raise Cardiac and Great vessel injury is common in both suspicion of tracheobronchial injury. Prompt broncoscopy penetrating and blunt thoracic trauma. Widening of the is performed before definitive repair. Esophagoscopy or heart shadow on an chest X-ray and a focused Ultra- Gastrograffin swallow may exclude Esophageal injury. sound examination for trauma (FAST) of the chest pro- Upper tracheal injuries are approached via median ster- vides early evidence of cardiac tamponade and medias- notomy. Distal tracheal, bronchial and esophageal inju- tinal injury. Auscultation of diminished heart sounds in ries are associated with significant morbidity and mor- association with shock (Beck’s trail) provides a late di- tality. agnostic clue that a cardiac injury with pericardial tam- ponade has occurred. Breath sounds must be auscul- Rib fractures trigger a progression of pain, splinting, tated because tension pneumothorax has a similar pic- atelectasis and hypoxemia. It is important to prevent this ture. Echocardiography must be performed in stable progression through appropriate use of adequate anal- patients to rule out underlying cardiac injury. Pericardio gesia and pulmonary toilet. Parenteral narcotics, local centesis has little role in diagnosis or management of anesthesia and epidural delivery of narcotics must be cardiac injury or tamponade. Tamponade once diagnosed considered in appropriate cases. arises when needs to be relieved immediately by pericardiocentesis. >3 ribs are fractured in two or more places gives rise to paradoxical chest wall motion with respiration. Thoracic Great vessel injury most commonly results from penetrating injury and presents with profound shock frequently coexists with rib frac- and associated hemothorax. Occasionally, cardiac tam- tures, flail chest and penetrating pulmonary parenchymal ponade may result from proximal aortic or venacaval in- injury. Contused regions are perfused but hypoventilated jury. These patients often require thoracic surgeon to causing severe hypoxemia. Placing injured side up pro- operate without the benefit of preoperative vascular di- motes perfusion to the better ventilated down side lung. agnostic studies. The most severe contusions require admission to the PICU and expert critical care. These patients have se- Blunt Thoracic Trauma frequently results in serious

81 Indian J Crit Care Med April-June 2004 Vol 8 Issue 2 IJCCM October-December 2003 Vol 7 Issue 4 cardiac or great vessel injury. Injuries associated with stricture. Stomach may be used to buttress a repair. rapid deceleration can cause aortic rupture, typically when ligamentum arteriosum inserts just below the ori- Simple lacerations of stomach are generally repaired gin of the left subclavian artery. When there is suspicion in one or two layers. Massively devitalizing injuries may of Aortic transaction based on previous radiographic pro- require formal resection with restoration of continuity via cedures, immediate aortography is indicated. If it dem- a gastroenterostomy. Vagotomy is helpful in reducing the onstrate an aortic tear, urgent surgical repair is manda- risk of marginal ulcer. tory. Minor blunt hepatic injuries require no therapy. Even Abdominal Trauma major blunt hepatic injuries that are contained within The abdomen extends from the diaphragm to the pel- Glissons capsule may be treated expectantly and fol- vic floor. The anterior surface marking of the abdomen lowed serially. Those with increasing pain or ongoing therefore extends from the nipples to the inguinal blood loss may be treated with embolotherapy with creases. The purpose of secondary survey is to deter- laparotomy reserved for patients who fail this modality. mine whether an abdominal injury has occurred rather than what the abdominal injury is. Local wound explora- Violation of liver capsule with associated bleeding tion, in patients with penetrating abdominal injury, will in blunt hepatic trauma requires surgical intervention. tell whether peritoneum is violated in an otherwise sta- Penetrating injuries should likewise be explored. Man- ble patient. agement of major hepatic venous or juxta or retrohepatic venacaval injuries, is one of the most challenging issue Abdominal ultrasonography, CT scan and faced by the trauma surgeon. These patients have laparoscopy have been proposed as useful adjuncts to exsangiunating hemorrhage requiring placement of evaluate and manage patients with penetrating and blunt atriocaval shunt. abdominal injuries. With the nearly universal utilization of abdominal CT scanning in pediatric trauma9 patients Gall bladder injuries frequently coexist with hepatic, with potential intra-abdominal injuries, the indications for portal triad and pancreatoduodenal injuries and are abdominal paracentesis have been greatly reduced. CT managed by cholecystectomy. scan of the abdomen certainly plays no role in the neurologically intact child without significant abdominal Injuries of enterohepatic biliary system are appar- findings, nor is it of value when abdominal operation is ent at the time of laparotomy but may be confirmed with required on clinical findings. Moreover, the presence of intraoperative cholangiography. Repair is done over a T- blood within the peritoneal cavity is not considered an tube. Roux-en-Y choledochojejunostomy is best for seg- absolute indication for laparotomy in children whose solid mental loss. organ injuries may be well-treated by non-operative regi- mens. It is, therefore, reserved for those patients with Duodenal injuries with devastating GI and abdomi- head injuries who are difficult to examine, uncoopera- nal vascular injuires represent a diagnostic and thera- tive or when an abdominal CT scan cannot (or should peutic challenge. In exploration, complete mobilization not) be performed. of duodenum is performed and repair done in two layers with closed suction drains placed around the leak. Diaphragmatic injuries are being increasingly recog- Panecreatoduodenectomy is reserved for the most com- nized in cases of in which evident elevation plex injuries involving the duodenum including duodenal of intra abdominal pressure results in diaphragmatic rup- devascularization and combined injuries including pan- ture. All such injuries must be recognized to prevent long creatic head and distal common bile duct. term complications of diaphragmatic hernia. Blunt Splenic injuries can often be managed without Simple lacerations of abdominal esophagus can be surgery especially in children who are hemodynamically repaired, after mobilization of left lobe of liver, using fine stable and injury that can be demonstrated on CT scan. absorbable suture taking care not to create a surgical Splenectomy is indicated for progressive clinical dete-

82 IJCCM October-December 2003 Vol 7 Issue 4 Indian J Crit Care Med April-June 2004 Vol 8 Issue 2 rioration, failling hemotasis or radiologic progression of quently primary care responsibilities, by a surgeon is injury. essential.

Small intestinal injury may be repaired primarily or Nonetheless, optimum management is provided by a may require segmental resection and anastomosis. Me- team approach, necessitated by the multidisciplinarian senteric defects should be closed. problems that overlap consistently in pediatric trauma patients. Pediatric intensivists, surgeons and Small stab wounds in colon may can be closed in pediatricians must communicate at least daily, and two layers using absorbable sutures. A large injury may ready access to consultation from other pediatric medi- require resection the injured segment with end colos- cal and surgical subspecialists is essential to support tomy, Hartmann’s pouch or mucus fistula. any PICU that regularly cares for traumatized infants and children. The PICU nurses should be included in Rectal injuries most often result from penetrating all major discussions. They spend more time with the wounds and are often associated with genitourinary / patient and family than any physician possibly could, pelvic injury. They are managed by construction of di- and their input on the patient’s status and treatment verting sigmoid colostomy, rectal washout and presac- must be actively sought. ral drains. Visitors to a modern PICU are invariably impressed by Pediatric intensive care unit (PICU) man- the amount of monitoring equipment available. As a re- agement protocol sult of this technology, it is easy and tempting to spend Trauma is a systemic disease. In fact, seriously injured the majority of time on trauma rounds reviewing the “num- children in the PICU are multisystem disease patients. bers” generated by this expensive gadgetry, at the ex- A child whose mechanism of injury (particularly when pense of hands-on time with the child. This is an unfor- as a result of blunt forces) is of sufficient severity to war- tunate tendency. Monitors should complement and even rant ICU care is quite likely to develop alterations in physi- enhance the physical examination of the small child, not ology of other organ systems not initially traumatized. replace it. As an example, a child with an isolated severe closed head injury may subsequently develop alterations in car- PICU Monitoring of a trauma patient diovascular, respiratory, gastrointestinal and/or renal Frequent clinical examination is the most important function. These can occur early or late following trauma, human monitoring. so a systems approach to the daily care of the patient is Some of the specific monitoring utilized in the acute a clear necessity. This can only be effectively provided care of the traumatized child include, by system: in the environment of the PICU, where concentrated Cardiovascular monitoring equipment and capabilities can generate a Vital signs sophisticated physiologic profile on virtually any patient. Electrocardiogram (cardiorespiratory monitor) Noninvasive blood pressure(NIBP) The overwhelming majority of pediatric trauma patients Continuous arterial blood pressure in the PICU do not require a major surgical procedure. Central venous pressure In spite of this, unreported children will require at least the same degree of support and monitoring, and fre- Respiratory Ventilator alarms quently more, since they furnish a larger unknown ele- Ventilator graphics ment regarding anatomic alterations, than in those pa- Pulse oximetry tients whose precise injuries were documented (and re- End tidal C02 monitoring paired) by operative intervention. It is a caveat among pediatric surgeons that trauma may not, in any given Central Nervous systein patient, require operative care, it does, in all patients, Intracranial pressure monitoring require surgical care. Serious injuries can and do es- Psychological/mental status evalu- cape initial detection and ongoing surveillance, and fre- ation

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Coagulation geon, pediatric intensivist, pediatric neurosugeon and Clotting parameters many other subspecialists. Pediatric emergency physi- Transfusion requirement cian should take charge of performing primary survey and initial resuscitation. Pediatric intensivist should take Other systems that demand constant monitoring in- charge of ongoing medical management in the picu in clude: renal status, metabolic and nutritional status, in- the preoperatve or postoperative period. Pediatric sur- fection status and dermatologic manifestations of trauma geon should take overall charge of investigations to de- complications. tect various injuries and coordinating surgical repair inorder of priority by himself or involving various surgi- The pediatric surgeon will also pay particular attention cal specialists such as neurosurgeon, cardiothoracic to the changes in abdominal girth, volume of drainage surgeon, plastic surgeon, orthopedic surgeon as deemed from chest tubes and other drains, and steep drops in necessary. hemoglobin and hematocrit levels. A high index of sus- picion should be kept for the development of thoraco References abdominal abscess, particularly in the context of pen- 1. Tepas JJ, et al. Pediatric trauma score as a predictor of injury etrating trauma and/or postoperative patients. Though severity in the injured child. J Pediatr Surg 1987;22:14-8. children are most impressive in their recuperative pow- 2. Eichelberger M, Randolph J. Pediatric trauma: An algorithm for ers, the recovery of a child with massive trauma tends diagnosis and therapy. J Trauma 1983;23:91-7. to be slow and gradual, while deterioration may be abrupt 3. Johnson DG, Jones R. Surgical aspects of airway management and rapid. Anticipation of the potential complications with in infants and children. Surg Clin North Am 1976;56:263-79. any given injury, readiness for any unsuspected seque- 4. Bivins MG. Blood volume displacement with inflation of anti-shock lae or previously unrecognized diagnosis, and a willing- trousers. Ann Emerg Med 1982;11:409-12. ness to continually reassess the patient and his or her 5. Abraham E. Pneumatic anti-shock trousers. West J Med progress must accompany our increasing reliance upon 1983;138:84. (and fascination with) machines and tests that interfaces 6. Heinild S, et al. Bone marrow infusions in childhood: Experience intimately with the small child. from a thou-sand infusions. J Pediatr 1947;30:400-12. 7. Poole CV. Comparison of colloids and crystalloids in resuscitation Summary from hemorrhagic shock. Surg Gynecol Obstet 1982;154:577-86. Successful management of a child with multiple trauma 8. Eichelberger MR, Randolph JG. Thoracic trauma in children. Surg involves a well planned organized coordinated team ef- Clin North Am 1981;61:1181-97. fort on the part of critical care transport system personel, 9. Karp MP. Role of computed tomography in the evaluation of blunt pediatric emergency physician in casualty, pediatric sur- abdominal trauma in children. J Pediatr Surg 1981;16:316-23.

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