Pediatric Trauma

Karim Rafaat, MD

Goals
Time is short
Im going to presume you know your basic ATLS (thats 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

Yay Parenting!!

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

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

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

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

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 posterioranterior direction

Differential myelination results in different absorption of force
Increases susceptibility of

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

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 3040% incidence

Children <8 yo
More likely to sustain high cervical (C1-C3) injuries

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

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 cspine

Spinal cord injury can occur without injury to bony spine (SCIWORA) Trauma related myelopathy, however transient, demands an MRI

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

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 mediastinal injury

Anatomic Considerations
Commotio Cordis is a unique consequence of pediatric thoracic trauma
Abrupt strike to the chest leads to V-Fib and arrest

Pediatric Abdominal Trauma

Third leading cause of pediatric traumatic death Blunt causes in 85%, penetrating trauma in 15% Blunt trauma related to MVCs causes more than 50% of abdominal injuries in children

Boogie board related injury..!

Anatomic Considerations
Proportionally larger solid organs

Less subcutaneous fat

Less protective abdominal musculature

Relatively larger kidneys that predispose them to renal injury

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

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