|SYMPOSIUM - POLYTRAUMA MANAGEMENT
|Year : 2013 | Volume
| Issue : 1 | Page : 58-62
Polytrauma management in children
Nitinkumar Bhajandas Borkar1, Sunita Singh2, Alok C Agrawal3
1 Department of Trauma and Emergency, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
2 Department of Surgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
3 Department of Orthopedics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
|Date of Web Publication||23-Sep-2013|
Nitinkumar Bhajandas Borkar
402, Type 4 A, All India Institute of Medical Sciences Residential Complex, Kabir Nagar, Raipur - 492 001
Source of Support: None, Conflict of Interest: None
Trauma is still the leading cause of death in children above one year of age even in countries with the most advanced medical services. Multiple trauma is always more than the sum of the single injuries; it should be considered as a systemic disease. Injury mechanisms vary with age. In infants non - accidental injuries (NAI) are common and are at higher risk for sustaining injury in the home environment. Fall is also major a cause of injury and home is the common place of injury. In caring for injured children the health care provider must be aware of the unique anatomic and physiological characteristics. This article is focused on these aspects only.
Keywords: Injury, pediatric, trauma
|How to cite this article:|
Borkar NB, Singh S, Agrawal AC. Polytrauma management in children. J Orthop Traumatol Rehabil 2013;6:58-62
| Introduction|| |
Trauma is still the most common cause of mortality in children above 1 year of age even in countries with the most advanced medical services. A fatal outcome is usually the consequence of combinations of injuries. Multiple traumas are always more than the sum of the single injuries; it should be considered as a systemic disease. Orthopedic injuries account for a high proportion of the damage incurred by the polytraumatized child but are rarely life-threatening in their own right. In India, prevalence of trauma in childhood patients is ranging from 5.5% to 19.23% in different series. ,, Home is found to be the most common place of injury, followed by road/street, with falls being the most common mechanism of pediatric trauma.  Most seriously injured children have multiple injuries.  Orthopedic injuries to be most common  account for a high proportion of the damage incurred by the polytraumatized child, but are rarely life-threatening in their own right and head injury itself accounts for 75% of deaths. Injury mechanisms vary with age.  In infants, non-accidental injuries are common and are at higher risk for sustaining injury in the home environment. Fall is also major a cause of injury and death in these children. Child abuse is also common in this age group. Toddlers and preschoolers can sustain motor vehicle trauma, as passengers, cyclist and as pedestrians. Many bicycle deaths occur in this age group. This is because their small stature and small size of their bicycles prevents them from being seen by rearview mirrors. The largest risk of injury occurs during the school-age years because of their developing a sense of independence and freedom, which predisposes them to new risks. Many school-age children and teenagers are injured while riding automobiles because these children begin to drive leading to the risk of both driver and an occupant injury becomes more common. Sports injuries are also common in this age group.
Unique pediatric characteristics
Unique anatomic and physiologic characteristics of pediatric patients with the different mechanisms of injury combine to produce a distinct pattern of injury. Resuscitation of the pediatric trauma patient requires that the practitioner must know the uniqueness of children's anatomy and their physiologic needs. Comparison of the child's anatomic and physiologic parameters to those of an adult patient demonstrates that children are not merely small adults and interventions must be varied to meet these subtle differences.
Surface area: In children, the ratio of body surface area to body volume is higher at birth and decreases as the child grows, leading to an increased risk of hypothermia at the time of injury as well as during the resuscitation. Children also have irregularly functioning sweat glands, increasing their susceptibility to temperature variations.
Skeleton: Mechanically speaking, children differ from adults in that their bone exhibits a much higher degree of elasticity. For this reason most of the time there can be internal organ damage without having bony fractures like there can be underlying lung contusion, mediastinal injury without rib fractures or sternum fracture.
Size and shape: Children have smaller body size so that energy generated from the impact like fall, result in a more force applied per unit of body area as compared to adults. Furthermore, children have less fat, less connective tissue resulting in multiple injuries in pediatric patients. Children have relatively larger heads that can be frequently injured in trauma.
| Systemic Pediatric Trauma Assessment and Management|| |
Advanced trauma life support (ATLS) principles apply to child also. The 'A' i.e., airway is the first assessment of "ABCDE" to be done as that of an adult. Providing and securing the patent airway should be the first priority to provide the proper oxygenation.
Airway evaluation and management
The larger head and relatively smaller mid-face make airway obstruction more as the posterior pharynx buckles anteriorly as a result of passive flexion of the cervical spine caused by large occiput. Tongue and tonsils are relatively larger in children making it difficult to visualize the larynx also children larynx are funnel-shaped that allows secretion to accumulate in the retropharyngeal area. This together with increased respiratory rate and increased oxygen consumption makes establishing and maintaining the airway in children more urgent. To avoid the passive flexion of the cervical spine the plane of the midface must be kept parallel to the spine board in a neutral position, rather than in the usual sniffing position.
If the child has partially obstructed airway, but has a spontaneous respiration then in such patients the airway should be secured by keeping their face parallel to the stretcher or spine board in a neutral position, placement of one inch thick layer padding beneath a child's entire torso will preserve the neutral alignment of the spinal column. Airway should be opened with jaw thrust and mouth and oropharynx should be cleared of secretions. Oxygen should be supplemented. If the patient is unconscious then mechanical methods of maintaining the airway may be necessary. The oral airway should be gently inserted directly into the oropharynx, the practice of inserting the airway backwards and rotating it 180° is not recommended for children. Use of tongue blade to depress may be helpful.
In trauma setting orotracheal intubation with is preferred to nasal route. It should be under direct vision with adequate immobilization and protection of the cervical spine. As the smallest area of the child's airway is at the cricoid ring the cuffed endotracheal tubes are uncommonly used under the age 9 years.
Indications of intubation are:
- Severe head injury that require controlled ventilation
- Respiratory inadequacy
- Need for prolonged ventilation
- Need for transport to a tertiary center
| Breathing|| |
Children have great oxygen consumption and small residual capacity pre-disposes them to the hypoxia. Hypoxia is the most common cause of cardiac arrest in the child. The respiratory rate decreases with age. An infant's respiratory rate is 30-40 breaths/min and older child 15-20/min. Tidal volume in children is 6-8 ml/kg. Hypoventilation causes respiratory acidosis, but bicarbonate should not be given without adequate ventilation and perfusion because it will paradoxically worsen hypercarbia and acidosis. Urgent intervention may be needed to treat tension pneumothorax, open pneumothorax, hemothorax, or flail chest.
| Circulation and Shock|| |
Assessment of circulation in children involves assessment of the pulse rate, pulse strength, skin color and capillary refill time. Assessment of blood pressure and pulse pressure also should be obtained; however, it is important to remember that children have an exceptional ability to maintain normal vital signs in the face of significant volume loss. Even, up to a 30% diminution in circulating blood volume may be required to manifest a decrease in the child's systolic blood pressure. Tachycardia and poor skin perfusion often are the only keys to early recognition of hypovolemia. Hypotension in a child represents a state of decompensated shock and indicates severe blood loss of greater than 45% of the circulating blood volume. Control of ongoing hemorrhage must be the first step in circulatory support; subsequently, vascular access should be initiated. Obtaining vascular access is often difficult in the small child; venous cannulation should be attempted as soon as possible for improved success. The longer the cannulation is delayed, the greater incidence of failure. If percutaneous access is unsuccessful after two attempts, intraosseous infusion via bone marrow needle or insertion of femoral line using Seldinger technique should be considered. If these procedures fail then expertise can perform venous cut down.
Initial fluid resuscitation should consist of warm isotonic crystalloid and should be administered in 20 ml/kg, boluses monitored carefully for response to fluid resuscitation by slowing heart rate, return of peripheral pulses, return of normal skin color, increase in blood pressure, increase pulse pressure (>20 mm of Hg), clearing of sensorium and urine output of 1-2 ml/kg/h. If failure to improve with 3 such boluses (60 ml/kg) of crystalloid, then packed red blood cells (PRBCs) should be considered. It is administered as a bolus of 10 ml/kg. In the face of ongoing hemorrhage, fresh frozen plasma and platelets will be required. Fluid resuscitation should be based on the child's weight, but it is difficult to estimate the weight in emergency. In such situations length based resuscitation tape  can be used to provide child's approximate weight, fluid resuscitation volume and a variety of drug dosages.
| Disability|| |
The rapid evaluation of neurological status is done at the end of primary survey, which should include level of consciousness, papillary reaction and size, lateralizing signs and level of spinal cord injury if it is there. Level of consciousness can be assessed rapidly using the A-Alert, V-Responding to voice, P-Responding to pain and U-Unresponsive. 
| Environmental Exposure|| |
As children are very susceptible for hypothermia and it may render child refractory to treatment and prolonged coagulation time. As the child is exposed during the initial survey and resuscitation, overhead warmers, heaters and warm blankets may be necessary to prevent hypothermia. It is better to warm the infusion fluid and blood products also.
| Secondary Survey|| |
The secondary survey is a systematic head-to-toe evaluation of the trauma patient that is the complete history and physical examination. The A-Allergy, M-Medication, P-Past medical history, L-Last meal and
E-Events history is a useful mnemonic for taking a history. Each region of the body completely examined. During the secondary survey, there is continued reassessment of ABCs. Specific radiographic evaluation and laboratory evaluation are also performed at this time.
Beginning at the head of the child, the scalp is palpated and assessed for bruising, lacerations, compound or depressed fracture and cerebrospinal fluid leak. The brain of the child is anatomically different from that of an adult. It doubles in size in first 6 months and achieves 80% of adult brain size by 2 years of age. The subarachnoid space is relatively smaller, so it offers less in protection to brain because there is less buoyancy. Cerebral blood flow increases progressively to nearly twice that of adult levels by the age of 5 years and then decreases that make them more susceptible to hypoxia, especially below 5 years. The mouth should be inspected for lost or loose teeth, bleeding and secretions. Neurologic assessment should include the patient's level of consciousness, Glasgow coma scale (GCS) score and papillary response. Intact brain stem reflexes indicate an intact neurological pathway. Evaluation of the corneal and gag reflexes should be obtained as part of the neurologic assessment. Inspect ears and nose for cerebrospinal fluid leakage. Children are more susceptible to secondary brain injury due to hypovolemia, hypoxia, hyperthermia and seizures. A computerized tomography (CT) of the brain is indicated if GCS <12, history of loss of consciousness at the time of injury, evidence of skull fracture, retrograde amnesia, neurological symptom/signs. The CT scan should also include cervical spine and may include chest and abdomen if indicated. The primary goals of management of child with a head injury are to prevent secondary brain injury, control of intracranial pressure and maintenance of adequate cerebral perfusion and to identify the mass lesion, which requires urgent surgical exploration.
Spinal cord injuries in children are fortunately rare, 2% of trauma victims.  In children, vertebral bodies are wedged anteriorly, facet joints are flat and have flexible interspinous ligament and joint capsule, which make their spine more mobile. Because of relatively large head compared with neck young children are more prone to suffer high spinal injuries. In all cases of major trauma, assume that spinal injury and un-stability exits, maintain immobilization of child's head and neck until spinal clearance is possible. It can be difficult to rule out spinal cord injury in children radiologically as up to 50% of spinal cord injuries may exist without radiological evidence.  CT scans are useful for upper spinal injuries. If clearance is not clinically possible at 72 h, then a magnetic resonance imaging scan is indicated. Spinal cord injury in children is treated in the same way as spinal cord injuries in adults.
Most pediatric abdominal injuries occur as a result of blunt trauma and accounts for around 10% of trauma in children, but it is one of the most frequent causes of preventable death. Splenic injury is the most common followed by hepatic, renal, intestine and pancreatic.  The abdomen must be assessed by palpation, but deep and painful palpation of the abdomen should be avoided at the onset of examination to avoid voluntary guarding. Distended bladder should be emptied and distended stomach should be decompressed before palpation. A physical examination detects 97% of abdominal injuries. The presence of bruising, abrasions, guarding, tenderness and abdominal distension is suggestive of injury. The presence of hematuria or bruising over the flank area is an early sign of renal trauma. A double contrast-enhanced CT scan of the abdomen is the diagnostic tool of choice to evaluate children who have sustained blunt trauma and have no hemodynamic abnormality. The greatest limitation of abdominal CT in trauma is inability to reliably identify intestinal rupture.  Focused assessment sonography in trauma is a good rapid screening study particularly in patients too unstable to undergo an abdominal CT scan. Diagnostic peritoneal lavage (DPL) has limited utility in pediatric patients as up to 90% of solid organ injuries do not require surgical intervention, the finding of free blood in the abdomen by DPL has limited clinical significance.  Nearly, 90% of abdominal injuries in children are managed non-operatively, but when non-operative management is selected then these children should be managed in pediatric intensive care under the supervision of a qualified pediatric surgeon. If the child's condition cannot be normalized hemodynamically and diagnostic tests performed are positive for blood then urgent laparotomy to control hemorrhage is indicated. Other indication for laparotomy should be proven peritonitis, pneumoperitoneum, penetrating injury abdomen and renal vascular injury.
Majority of chest injuries in childhood are due to the blunt mechanism. The pliability of the chest wall in children reduces the risk of the rib fracture but allows the transfer of energy to underlying organs. The presence of fracture rib indicates severe injury. Chest wall should inspect anteriorly, laterally and posteriorly for bilateral symmetrical chest movement and signs of blunt and penetrating injury. Furthermore, see for the use of accessory muscle of respiration using for respiration. Palpate the chest wall for surgical emphysema and crepitus. Percuss for dull and hyperresonance note. Ausculatate anterior chest wall and posterior bases for breathe sounds and heart sounds. If nature and extent of thoracic injuries are uncertain then a CT chest is indicated. Pneumothorax, hemothorax were need to urgent intervention in the form of needle decompression or tube thoracostomy.
Most pediatric thoracic injuries can be successfully managed with a combination of tube thoracotomy and supportive care. Thoracotomy is not generally needed in children. Penetrating trauma to chest managed the same way as in adults.
Skeletal injury occurs in 10-15% of the pediatric trauma victims. In younger children, X-ray diagnosis of fractures and dislocation is difficult because of lack of ossification of the ossification center. Blood loss associated with extremity trauma and pelvic fracture is less compared with adults. The initial priorities in the management of fractures in the child are similar to those for adults, with additional concern with injury to the growth plate.
| Recommendation and Summary|| |
- The child is not a miniature adult, so resuscitation of the pediatric trauma patient requires that the practitioner must know the uniqueness of children's anatomy and their physiologic needs.
- In children, the ratio of body surface area to body volume is higher at birth and decreases as the child grows, leading to an increased risk of hypothermia at the time of injury as well as during the resuscitation.
- ATLS principles apply to child also. The larger head and relatively smaller midface make airway obstruction more as the posterior pharynx buckles anteriorly as a result of passive flexion of the cervical spine caused by large occiput.
- As the smallest area of the child's airway is at the cricoid ring the cuffed endotracheal tubes are uncommonly used under the age 9 years. Indications of intubations should same as adults.
- Children have great oxygen consumption and small residual capacity pre-disposes them to the hypoxia and it is the most common cause of cardiac arrest in the child. So, it is important to prevent hypoxia or should be treated urgently.
- Rather than blood pressure in children tachycardia and poor skin perfusion often are the only keys to early recognition of hypovolemia. Initial fluid resuscitation should consist of warm isotonic crystalloid and should be administered in 20 ml/kg, failure to improve with 3 such boluses (60 ml/kg) of crystalloid and then PRBCs should be considered. It should be administered as a bolus of 10 ml/kg.
- As the children are susceptible to hypothermia, during the initial survey and resuscitation, overhead warmers, heaters and warm blankets may be necessary to prevent hypothermia.
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