Diagnosis And Management Of Motor Vehicle Trauma In Children: An Evidence-Based Review (Trauma CME)

Table of Contents

 

1. Abstract
2. Case Presentation
3. Introduction
4. Critical Appraisal Of The Literature
5. Epidemiology And Risk Factors For Injury
6. Differential Diagnosis
   1. Head Injury
      1. Skull Fracture
      2. Intracranial Injury
   2. Spine And Spinal Cord Injury
      1. Cervical Spine Injury
      2. Thoracolumbar Spine Injury
      3. Spinal Cord Injury Without Radiographic Abnormality
   3. Abdominal Injury
      1. Hepatic Injury
      2. Spleen Injury
      3. Renal Injury
      4. Clinical Implications Of Abdominal Wall Ecchymoses
   4. Thoracic Injury
      1. Pulmonary Injury
      2. Rib Fractures
      3. Pneumothoraces, Hemothoraces, And Other Thoracic Injury
7. Prehospital Care
8. Emergency Department Evaluation
   1. Primary Survey
   2. Secondary Survey
      1. Head And Neck
      2. Cardiac And Respiratory Systems
      3. Abdominal And Genitourinary Systems
      4. Musculoskeletal
      5. Neurologic
   3. Clinical History
9. Diagnostic Studies
   1. Laboratory Studies
      1. Detection Of Occult Hemorrhage
      2. Detection Of Intra-Abdominal Injury
      3. Trauma-Induced Coagulopathy
   2. Radiographic Evaluation
      1. Imaging Of The Head
      2. Imaging Of The Cervical Spine
      3. Imaging Of The Abdomen
   3. Utility Of Plain Radiographs In The Evaluation Of Motor Vehicle Trauma
10. Treatment
11. Disposition
12. Special Circumstances
    1. Airbag-Related Injuries In Children
    2. Motor Vehicle Accidents Complicated By Drowning Or Hypothermia
    3. Injury Prevention Strategies
13. Summary
14. Case Conclusion
15. Clinical Pathway For Evaluation Of Head Injury After Motor Vehicle Trauma In Children Aged < 2 Years
16. Clinical Pathway For Evaluation Of Head Injury After Motor Vehicle Trauma In Children Aged > 2 Years
17. Clinical Pathway For Evaluation Of The Cervical Spine In Children With A Reliable Clinical Examination
18. Clinical Pathway For Evaluation Of The Cervical Spine In Children With An Unreliable Clinical Examination
19. Clinical Pathway For Evaluation Of Pediatric Blunt Abdominal Trauma
20. Risk Management Pitfalls For Motor Vehicle Trauma In Children
21. Time- And Cost-Effective Strategies
22. Case Conclusion
23. Tables and Figures
    1. Table 1. PECARN Predictors Of Cervical Spine Injury in Children
    2. Table 2. NEXUS Low-Risk Criteria
    3. Table 3. PECARN Clinical Prediction Rule To Identify Children At Very Low Risk Of Intra-Abdominal injury
    4. Table 4. American Academy of Pediatrics Child Passenger Safety Recommendations
    5. Figure 1. The American Association For The Surgery of Trauma Injury Scoring Scale
24. References

Abstract

Injuries from motor vehicle crashes are the leading cause of mortality in children aged 5 years and older in the United States. This review discusses common injuries in children after motor vehicle trauma and examines the evidence regarding the evaluation and treatment of pediatric patients involved in motor vehicle crashes. Both prehospital and emergency department care are discussed along with a differential diagnosis of the injuries most commonly seen in motor vehicle crashes. The various options for imaging modalities are also discussed in this review. A critical appraisal of the existing guidelines for the management of motor vehicle trauma and for the use of appropriate child-safety restraints is presented. Emergency clinicians will be able to use the patient’s history and physical examination findings along with knowledge of common injuries to determine the most appropriate workup and treatment of pediatric patients who present with motor vehicle trauma.

Keywords: motor vehicle crash, motor vehicle injury, motor vehicle accident, motor vehicle trauma, motor vehicle collision, automobile accident, pedestrian injury, pedestrian-versus-automobile, pedestrian accident, car accident, blunt abdominal trauma, head injury, cervical spinal injury

Case Presentation

You receive a call that an 8-year-old child who was in a motor vehicle crash will be arriving by air transport in 8 minutes. The child was the unrestrained passenger in the back seat of a sport utility vehicle that was involved in a high- speed collision on a busy freeway. The child was ejected from the vehicle. When EMS arrived on scene, the child was lying on the side of the road and was moaning in pain. He was noted to have abrasions on his abdomen and swelling of his left thigh. En route to the hospital, the child’s heart rate was 115 beats/min, respiratory rate was 24 breaths/min, and blood pressure was 90/42 mm Hg. While you are waiting in the trauma bay for the patient, you consider the injuries for which he is at risk and the interventions, laboratory studies, and radiographic studies he may require.

A 14-year-old girl is brought in by ambulance after a motor vehicle crash. She was a restrained passenger in the front seat of a car driven by her mother. When the car in front of them stopped suddenly, the patient’s car slammed into it and was then rear-ended by the car behind theirs. She was wearing both her lap and shoulder restraints, and there was no airbag deployment, passenger space intrusion, or damage to the windshield or windows. The girl denied any head injury or loss of consciousness. The girl was ambulatory at the scene, but when EMS arrived, she was placed in a cervical collar, positioned on a backboard, and brought to the ED. On arrival, she is alert and oriented but is complaining of neck and back pain. She has no other associated injuries. You wonder whether the patient’s cervical collar and backboard can be safely removed and what, if any, radiographic studies you should order.

An ambulance arrives with a 3-year-old girl who was involved in a pedestrian-versus-automobile accident. The child was playing in the front yard of her family’s home when the ball she was playing with rolled onto the driveway. She ran out to grab the ball just as her father was backing his car out of the driveway; he felt a “thump” as he backed over her. He immediately got out of the car and found his daughter lying on the driveway underneath the car between the front and rear wheels, crying. An ambulance was called, and the child was placed in a cervical collar and positioned on a backboard and brought to the ED. On arrival, the child is alert and awake with a Glasgow Coma Scale score of 15. Her head and neck examination is within normal limits, but she appears to have some abdominal tenderness and bruising on the lower portion of her abdomen. As you complete the remainder of your examination, you consider the injuries for which this patient is at risk, based on her mechanism of injury, and decide which imaging studies to order.

Introduction

Motor vehicle crashes (MVCs) are the leading cause of morbidity and mortality among children in the United States, and they often present a diagnostic challenge for emergency clinicians, given the variety of injuries that may be sustained. In these situations, the emergency clinician must determine the most likely injuries and decide upon the appropriate workup for each patient. Given that a variety of laboratory and radiographic studies can be used to evaluate these injuries, determining the most appropriate workup for each patient is often a challenge. This issue of Pediatric Emergency Medicine Practice focuses on the evaluation and management of children injured in MVCs, using the best available evidence from the literature.

Critical Appraisal Of The Literature

A PubMed search for articles pertaining to children aged < 18 years published since 1980 was performed using the search terms motor vehicle crash, motor vehicle injury, motor vehicle accident, motor vehicle trauma, motor vehicle collision, traffic accident, road traffic accident, traffic injury, automobile accident, automobile injury, pedestrian, pedestrian injury, pedestrianversus- automobile, pedestrian accidents, car accident, blunt abdominal trauma, head injury, and cervical spinal injury. More than 2200 articles were identified, and a total of 166 resources relevant to the topic of motor vehicle trauma are included in this review. Although several large prospective studies were included, the majority of studies are retrospective. No randomized controlled trials were identified. A search of the Cochrane Database of Systematic Reviews did not produce any reviews addressing the specific patterns of injury seen in MVCs or the workup and management of these patients.

Risk Management Pitfalls For Motor Vehicle Trauma In Children

1. “There were no rib fractures on chest film, so his chest must be fine.” Pediatric rib cages are pliable and, as a result, significant pulmonary injury in the form of pulmonary contusions or hemothoraces can occur without overlying rib fractures. Emergency clinicians should consider pulmonary injuries in children with tachypnea, hypoxemia, or bruising of the thorax even in the absence of rib fractures.
2. “She had a femur fracture on examination, but I didn’t see any other injuries, so I didn’t get any further imaging.” The presence of a femur fracture is often indicative of a serious mechanism of injury. Even when an obvious femur fracture is seen, a full evaluation for other injuries should still be performed.
3. “The child wasn’t hypotensive, so he couldn’t have lost that much blood.” Hypotension is a late finding in children with significant hemorrhage. Unlike adults, children can often effectively compensate for hemorrhage until 30% to 45% of the blood volume has been lost.
4. “He was wearing a lap and shoulder belt, so his injuries probably aren’t severe.” Because of their stature, young children are at increased risk for injuries from seat belts. Without a booster seat, the lap belt often rides up onto the abdomen and the shoulder belt often rides up onto the neck, increasing the risk for intra-abdominal injuries, thoracolumbar spinal injuries, and injuries to the neck.
5. “She’s younger than 2 years of age, so she must have been in a car seat.” Although the American Academy of Pediatrics recommends that children aged < 2 years be restrained in a rear-facing car safety seat, rates of unrestrained and improperly restrained children in the United States remain high, putting these children at increased risk for injury.
6. “She was backed over in her driveway at a very low speed, so her injuries probably aren’t severe.” Although back-over or driveway injuries occur at a low vehicular speed, they are associated with a significantly greater injury severity than other types of MVCs or pedestrian-versus-automobile accidents. Emergency clinicians must maintain a high index of suspicion for occult injuries with this mechanism of injury.
7. “His FAST examination was negative, so he can’t have a serious intra-abdominal injury.” Although the utility of the FAST examination has been demonstrated in adults, its utility in the pediatric population remains unclear, given its low sensitivity. While a positive FAST examination can be helpful in decision-making, a negative FAST examination is of minimal utility and cannot be used to rule out intra-abdominal injury.
8. “We removed her cervical collar while we were intubating her, since there was no risk of her moving on her own.” In patients who are unconscious or chemically paralyzed, it is crucial to either leave the cervical collar in place during intubation or to maintain inline stabilization of the cervical spine during intubation. Although the patient is unable to move, passive movements that occur during intubation could cause further damage to the spinal cord.
9. “His abdominal CT showed a splenic laceration; he will definitely need a splenectomy.” Although, historically, both splenic and hepatic lacerations were managed operatively, the current standard of care for most pediatric solid organ injuries is nonoperative management. Only patients who are hemodynamically unstable require urgent operative intervention.
10. “He’s just a child. We can’t clinically clear his cervical spine.” Although it may be challenging to obtain a reliable physical examination in some children, it is possible to clinically clear the cervical spine in many pediatric patients. Particular caution should be exercised, however, in children aged < 2 years.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.

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