Editing Paediatric trauma


== Altered physiology ==

* Increased physiologic reserve - maintenance of systolic BP in the normal range, even in the presence of shock - up to 30% decrease in circulating volume may be required
* Tachycardia and poor skin perfusion are often the only signs of early hypovolaemia
** Also progressive weakening of peripheral pulses, narrowing of pulse pressure to <20mmHg, skin mottling, cool extremities, and decreased LOC with dulled response to pain
* Shock is often manifested as a change to hypotension and bradycardia and indicates >45% blood loss
* Mean normal SBP is 90 + (2 x age), and diastolic BP should be 2/3 the SBP

== Haemostatic resuscitation ==

* Initial 20mL/kg bolus crystalloid
* With ongoing bleeding/symptoms, 10mL/kg pRBC +/- 10mL/kg FFP and platelets

== Thoracic trauma ==
Overall approach

* Keep in mind that significant internal injury is possible without rib fractures in children
* Children are predisposed to hypoxia due to lower FRC
* Children are at risk of obstructive shock from tension PTX due to a highly mobile mediastinum
* Vast majority of paeds thoracic trauma is blunt


Rib fractures

* Infrequent <8yo due to chest wall compliance
* Suspicion NAI esp <3yo
* Seems like they are essentially managed as in adults

Flail chest

* Extremely rare
* Manage as in adults

Open PTX

* Usually a/w blast injury/impalement
* High risk tension due to one way valve
* Needs chest tube and completely occlusive dressing
* If chest decompression is unavailable, a 3-sided dressing is used

Lung contusion

* Most common thoracic injury in children
* Usually self-resolves within a week without requiring resp support
* Seen on CXR
* Can be complicated by PTX or HTX or infection
* Supportive management, observing in case respiratory failure occurs and they require ventilation

Pneumothorax/haemothorax

* Note that each hemithorax can hold up to 40% of a child's blood volume! This can kill!
* Asymptomatic PTX (not seen on CXR) does not necessarily require drainage, but must be carefully observed
* Some guidelines say ALL paediatric HTX should be drained - discuss with paeds trauma team

Diaphragmatic rupture

Tracheobronchial injury

* Usually due to high acceleration/deceleration
* Usually membranous trachea, 2-3cm from carina
* Look for upper airway signs, which may also have features of PTX
* Can be diagnosed after chest tube insertion when there is persistent PTX/pneumomediastinum/constantly bubbling chest drain, and would need bronchoscopy
* Usually requires surgery

Oesophageal injury

* Diagnose contrast study/endoscopy/CT



Indications for thoracotomy

* Ongoing bleeding from ICC equivalent to 2-3ml/kg/hr over 3 hours
* Oesophageal disruption
* Tracheobronchial disruption
* Diaphragmatic injury
* Penetrating cardiac injury

Median sternotomy is the preferred approach if there is time

Resuscitative thoracotomy would be done through left anterolateral thoracotomy in 5th intercostal space.

== Abdominal trauma ==
Fluid resus: two boluses of 20ml/kg crystalloid if necessary, then blood (which is also given as 20ml/kg boluses)

Tachycardia is an important sign, but hypotension is only seen in severe shock


Blunt abdo trauma:

* Overall approach
** Solid organ injury is more common than for adults
** Most injuries to liver, spleen and kidneys can be managed non-operatively regardless of grade (treat haemodynamics rather than grade)
** Operations are rare in blunt trauma
* Indications for CT
** Haemodynamically stable patient with positive FAST
* Indications for laparotomy:
** Peritonitis
** Free intra-abdominal air
** Inability to normalise haemodynamic status despite resuscitation
** Rapidly expanding abdomen with persistent hypotension
** Need for transfusion of more than one-half the blood volume in 24 hours
* Other concerning findings:
** Seat belt sign is concerning in children - 1/9 have a significant intra-abdominal injury, and therefore observation is warranted, even with normal investigations
* Solid organ injury
** The following guidelines ASSUME HAEMODYNAMIC STABILITY
**

*

Penetrating abdo trauma:

* Manage along same lines as adults

== Spinal trauma ==
In children:
<nowiki>https://www.rch.org.au/clinicalguide/guideline_index/Cervical_spine_assessment/</nowiki>

* C-spine injuries are uncommon, but if known/suspected, they should be managed at RCH
* If age<8, they should be on a Thoracic Elevation Device to prevent flexion (as their head is too big to lie flat)
* If hard to maintain C-spine precautions because of anxiety or other issues, use in-line C-spine immobilisation
* C-spine immobilisation is required in the following:
** GCS<13
** Neck pain/midline tenderness/limitation of movement
** Using hands to support neck
** Any neurological deficit
** Significant head/facial/upper torso injuries
** Traumatic torticollis
** Substance affected with suspicious mechanism
** Any conditions known to predispose to C-spine injury
* Assessment
** Abnormal neurology - talk to NROS immediately
** Must be conscious, co-operative, unaffected by substances
** Ask about neck pain, weakness, paralysis or paraesthesiae
** Palpate midline, and lateral to midline
** If no midline tenderness or neurology, assess movement 45 degrees each way, then remove collar if they can do it without pain or developing neurological symptoms
** If they DO have any symptoms or signs, get cervical spine X-Rays
*** 5 or under - AP and lateral only
*** 6 or older - AP, lateral and odontoid
*** Lateral should include occiput to T1
** If x-rays are normal and symptoms resolved, C-spine can be cleared
** If abnormal X-rays, obviously needs discussion
** '''Normal x-rays:'''
*** '''Patients with ongoing neck symptoms'''
**** '''2 piece collar'''
**** '''Discuss with appropriate surgical team/ED consultant'''
*** Ambulant, otherwise well patients with midline tenderness +/- decreased ROM:
**** Two piece collar
**** Discharged home for r/v in ortho fracture clinic 1-2 weeks
**** Give handout off RCH website <nowiki>https://www.rch.org.au/kidsinfo/fact_sheets/Hard_collar_Aspen_collar/</nowiki>
*** Patients with significant other injuries and midline tenderness/decreased ROM
**** 2 piece collar
**** Cervical spine cannot be cleared
**** Probably going to need MRI
*** Obtunded/intubated multi-trauma patient
**** 2 piece collar
**** MRI when safe
**** If MRI normal, cease cervical spine precautions
** Normal CT does not exclude injury in the unconscious patient - can't be cleared, might need MRI

[[Category:Paed Surg]]