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: https://www.rch.org.au/clinicalguide/guideline_index/Cervical_spine_assessment/

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 https://www.rch.org.au/kidsinfo/fact_sheets/Hard_collar_Aspen_collar/
  - 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