Pediatric Trauma Amy Henry, RN, CFRN “If a disease were killing our children in the proportions that injuries 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 injury (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 • Blunt trauma 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 • Tachycardia early • Capillary refill • External blood loss • Hypotension 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. Head Injury • Traumatic brain injury (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 Spinal Cord Injury 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 Resuscitation 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 • Penetrating trauma 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 – Pulmonary Contusion – Pneumothorax – Open Pneumothorax – Hemothorax – Flail Chest – 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