Trauma: Trauma in Pediatrics

Pediatrics

Normal Vital Signs

Modified GCS in Peds < Age 5

Score Motor (6) Verbal (5) Eyes (4)
1 None None None
2 Decerebrate Moans to Pain* Open to Pain
3 Decorticate Cries to Pain* Open to Speech
4 Withdraws to Pain Irritable Cries* Spontaneous
5 Withdraws to Touch* Coos & Babbles*
6 Spontaneous/Purposeful*
    • * = Different

General Considerations

  • Unintentional Injury is the #1 Cause of Death in Peds
  • Relative Neuron Plasticity
    • Focal Injury Produces Less Severe Deficit
    • Higher Risk for Diffuse Injury
  • Rib Fractures Uncommon in Peds

Resuscitation

  • Broselow Tape
    • Tape Laid at the Side of the Bed to Estimate Height & Weight
    • Used to Estimate Equipment Sizes & Drug Dosing
    • For Children ≤ 12 Years
    • Obesity will Confound
  • Shock
    • Best Indicator of Shock in Peds: Tachycardia
    • Hypotension is a Late Finding, Will Compensate Well and Decompensate Rapidly
    • BP Poor Indicator of Hemodynamic Stability
    • High Risk of Hypothermia (High Body Surface Area)
  • Fluids
  • Intubation

Broselow Tape 1

Imaging in Pediatrics

Malignancy Risk

  • Risk is Inversely Proportional to Age
  • Risk of Developing a Fatal Malignancy:
    • After Abdominal CT: 0.18%
    • After Head CT: 0.07%
  • 3x Increased Risk of Leukemia & Brain Tumors

Head CT – Indications (PECARN Guidelines)

  • Younger than 2 Years Old:
    • High Risk of TBI (4.4%): CT Head Recommended
      • Altered Mental Status
      • GCS < 15
      • Palpable Skull Fracture
    • Intermediate Risk of TBI (0.9%): CT Head vs Observation
      • Loss of Consciousness > 5 Seconds
      • Non-Frontal Scalp Hematoma
      • Not Acting Normally
      • Severe Mechanism
    • Low Risk of TBI (< 0.02%)
  • At Least 2 Years Old:
    • High Risk of TBI (4.3%): CT Head Recommended
      • Altered Mental Status
      • GCS < 15
      • Signs of Basilar Skull Fracture
    • Intermediate Risk of TBI (0.9%): CT Head vs Observation
      • Any Loss of Consciousness
      • History of Vomiting
      • Severe Headache
      • Severe Mechanism
    • Low Risk of TBI (< 0.05%)
  • Severe Mechanism:
    • Fall > 3 Feet (< 2 Years) or > 5 Feet (≥ 2 Years)
    • MVC with Ejection, Rollover or Fatality
    • Bike/Ped vs Vehicle without Helmet
    • Struck by a High-Impact Object

Neck CT Indications

Chest CT Indications

  • If Otherwise Indicated for Penetrating Thoracic Trauma
  • Abnormal CXR (Widened Mediastinum, etc.)

Abdominal CT Indications

  • If Otherwise Indicated for Penetrating Abdominal Trauma
  • Symptoms:
    • Abdominal Pain
    • Vomiting
  • Physical Exam:
    • GCS < 14
    • Abdominal Tenderness
    • Evidence of Abdominal Wall Trauma – Seat Belt Sign, Handlebar Sign or Ecchymosis
    • Decreased Breath Sounds
  • Positive FAST Exam
  • Labs:
    • AST > 200 U/L
    • ALT > 100-125 U/L
    • Elevated Lipase/Amylase
    • Hematuria with 0.5 RBC/hpf on Urinalysis

References

  1. Greene N, Bhananker S, Ramaiah R. Vascular access, fluid resuscitation, and blood transfusion in pediatric trauma. Int J Crit Illn Inj Sci. 2012 Sep;2(3):135-42. (License: CC BY-NC-SA-3.0)