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Pediatric Trauma

Pediatric Trauma. Karim Rafaat, MD. Goals. Time is short I’m going to presume you know your basic ATLS (that ’ s that whole ABCD thing, by the way) Discuss each general trauma susceptible region Focus on: E pidemiology Anatomic and physiologic differences between children and adults

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Pediatric Trauma

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  1. Pediatric Trauma Karim Rafaat, MD

  2. Goals • Time is short • I’m going to presume you know your basic ATLS • (that’s that whole ABCD thing, by the way) • Discuss each general trauma susceptible region • Focus on: • Epidemiology • Anatomic and physiologic differences between children and adults • How this results in differing patterns of injury, and thus, different foci for concern

  3. Yay Parenting!!

  4. Epidemiology - General • Trauma is the leading cause of death between the ages of 1-18 • Injury accounts for 5% of infant deaths • 47% of these deaths are related to MVCs • With rates higher in those >13yo • 13% of deaths in those 1-14yo were a result of homicide • In the school age group • Pedestrian injuries and bike injuries predominate

  5. Pediatric Head Injury • #1 cause of death due to trauma • ~2700 deaths/year • 450,000 children present to EDs each year with head injury • 90% suffer from minor injuries • Perinatal period • Birth injuries • 1-4 years old • Falls • School age • Pedestrian or bike injuries • Adolescence • MVA

  6. Anatomic Considerations • The skull is more plastic and deformable • Better able to absorb initial impact without fracture • Open sutures function as “joints” • Allow shifting of bone to absorb impact • Prevent early and rapid rise of ICP secondary to brain swelling/space occupying lesions • This also means that infants can lose a significant portion of their blood volume into their cranium secondary to a head injury

  7. Children have larger heads than adults in relation to their body • The chance that it is hit in a traumatic event is larger • Head is heavy • Different acceleration dynamics

  8. At birth, the brain contains very little myelin • Progressive decrease in water content from birth until the brain is fully myelinated • Neonatal brain water content is ~89%, adult content is 77% • Brain is softer and more prone to acceleration/deceleration injury • Myelination proceeds in a caudo-cranial and posterior-anterior direction • Differential myelination results in different absorption of force • Increases susceptibility of unmyelinated portions to shear injury

  9. At birth, face to cranium ratio is 1:8, adult ratio is 1:2.5 • Makes it more likely skull is hit in younger children • Lack of pneumatization of sinuses is associated with more rigidity and less plasticity of facial skeleton • Increases transfer of forces directly to brain

  10. Pediatric Spine Injury • 18.1 spinal cord injuries per milllion children • 1300 new cases a year • 60-80% of injuries occur at the cervical level • Adults have a 30-40% incidence • Children <8 yo • More likely to sustain high cervical (C1-C3) injuries

  11. Anatomic Considerations • Immature C-spine has more horizontal orientation of facet joints • Relative laxity of cervical ligaments • Weaker neck muscles • Relatively increased mass and volume of infant head

  12. Anatomic Considerations • Cervical flexion fulcrum • C2-C3 in infants • C3-C4 by 5yo • C4-C5 at 10 • C5-C6 (adult) at age 15 • Pediatric C-spine is much more flexible than adult c-spine • Spinal cord injury can occur without injury to bony spine (SCIWORA) • Trauma related myelopathy, however transient, demands an MRI

  13. Pediatric Thoracic Trauma • #2 cause of trauma related mortality • In isolation, thoracic trauma carries a 5% mortality • 25% when combined with abdominal injury • 40% with head and abdominal injury

  14. Anatomic Considerations • Incomplete ossification of ribs allows anterior ribs to be compressed to meet posterior • Pulmonary contusions are common, rib fractures uncommon • Presence of rib fractures in 0-3yo suggests NAT • Pulmonary contusions are most common thoracic injury in traumatized children • Trachea is narrow, short, more compressible • Small changes in airway caliber due to external compression or internal FB lead to large changes in resistance • Great vessel and cardiac injury are rare in children • However, hemodynamic instability in the face of euvolemia should raise concern for myocardial contusion and/or mediastinalinjury

  15. Anatomic Considerations • CommotioCordis is a unique consequence of pediatric thoracic trauma • Abrupt strike to the chest leads to V-Fib and arrest

  16. Pediatric Abdominal Trauma • Third leading cause of pediatric traumatic death • Blunt causes in 85%, penetrating trauma in 15% • Blunt trauma related to MVC’s causes more than 50% of abdominal injuries in children Boogie board related injury..!

  17. Anatomic Considerations • Proportionally larger solid organs • Less subcutaneous fat • Less protective abdominal musculature • Relatively larger kidneys that predispose them to renal injury

  18. Anatomic Considerations • Splenic injuries are the largest proportion of pediatric abdominal trauma • Liver is second most injured solid organ • Lap Belt Injury • Sudden increase in bowel intraluminal pressure can result in intestinal perforation • Chance fracture of the lumbar spine

  19. Anatomic Considerations • The compliant chest wall, poor thoracic musculature and weak diaphragm can lead to considerable respiratory difficulty with gastric distention

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