Management of Multiply Injured Pediatric Trauma Patients in the Emergency Department

Table of Contents

 

When children with multiple serious injuries present to the ED, how do you ensure that you identify and address all of their injuries? This issue provides a systematic approach to the management of pediatric patients with multiple traumatic injuries, with specific attention to commonly missed injuries and injuries that may cause significant morbidity or mortality. You will learn:

Recommendations for initial field management and evaluation that will aid in early recognition and stabilization of injuries

Critical elements of the primary survey that will help identify and address life-threatening injures

Which diagnostic imaging modalities are warranted, and which is the best choice, based on presentation

Evidence-based recommendations for a systematic approach to managing pediatric patients with multiple traumatic injuries

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology and Pathophysiology
   1. Common Mechanisms of Injury
   2. Difficulties in Assessing Pediatric Patients
   3. Commonly Missed Injuries
   4. Traumatic Brain Injuries
6. Differential Diagnosis
7. Prehospital Care
   1. Initial Stabilization and Communication With Field Emergency Medical Technicians
   2. Cervical Spine Immobilization
   3. Splinting Orthopedic Injuries
8. Emergent Management
   1. History
   2. Physical Examination
      1. Primary Survey
         • Airway Management
         • Breathing
         • Circulation
         • Disability
         • Exposure and Environmental Control
   3. Evaluation
      1. Focused Assessment With Sonography in Trauma (FAST) Examination
   4. Primary Stabilization/Management
      1. Pediatric Airway Management
      2. Management of Closed Head Injuries
      3. Stabilization of Musculoskeletal Injuries
         • Open Fractures
         • Tetanus Vaccination
         • Compartment Syndrome
      4. Fluid Resuscitation
9. Diagnostic Studies
   1. Radiographic Studies
   2. Computed Tomography
   3. Magnetic Resonance Imaging
   4. Laboratory Studies
10. Treatment
11. Special Populations
    1. Infants
    2. Pregnant Teenagers
12. Controversies and Cutting Edge
    1. Closed Head Injury
       1. Severe Traumatic Brain Injury
    2. Transportation of Pediatric Trauma Patients
13. Disposition
14. Summary
15. Risk Management Pitfalls in the Management of Pediatric Patients With Multiple Injuries
16. Case Conclusions
17. Time and Cost-Effective Strategies
18. Key Points
19. Clinical Pathway for the Management of a Pediatric Patient With Multiple Traumatic Injuries
20. Tables and Figures
    1. Table 1. Differential Diagnosis for Pediatric Trauma Patients
    2. Table 2. Pediatric Glasgow Coma Scale Scoring
    3. Figure 1. Primary Survey Evaluation for Trauma Patients
    4. Figure 2. Differences in the Pediatric Airway Compared to the Adult Airway
    5. Figure 3. AVPU System for Infant Neurologic Assessment
21. References

Abstract

Management of the child with multiple traumatic injuries can be challenging, and important injuries may not be readily recognized. Early recognition of serious injuries, initiation of appropriate diagnostic studies, and rapid stabilization of injuries are key to decreasing morbidity and mortality in the multiply injured pediatric trauma patient. The differential diagnosis for these patients is wide, and treatment is targeted to the specific injuries. In this issue, a systematic approach to the multiply injured pediatric patient will be reviewed, with specific attention to commonly missed injuries and those injuries that may cause significant morbidity or mortality.

Case Presentations

A 12-year-old previously healthy boy presents to the ED via EMS for a visible deformity of his right arm. His 18-year-old brother was pulling him around in an inner tube that was attached by a long rope to a truck traveling about 40 miles per hour through a lightly wooded area. His brother made a sharp turn, and the patient went flying off the inner tube and hit a tree. The brother said that the patient did not lose consciousness, but that he was “stunned” for a few seconds, then started complaining about his right arm. The patient said he was not wearing any personal protective equipment. He has multiple abrasions to his face, trunk, and extremities. He denies pain anywhere except in his arm. He requests to have his neck brace removed because it is “annoying.” He denies vomiting but reports feeling nauseous after receiving morphine from the paramedics en route to the hospital. Because this was a severe mechanism, though the patient appears to have an isolated injury, you begin to consider how much you should do. Should you “pan-scan” the patient and draw labs because of the mechanism? What other imaging studies do you need to obtain besides an x-ray of the arm? Is the patient at risk for internal bleeding due to this blunt impact? Should you consult the surgeons or just call the orthopedist to reduce the obvious fracture?

A 16-month-old previously healthy girl presents to the ED via EMS after a seemingly accidental fall out of a third-story apartment window. Onlookers said the girl fell into a bush and appeared stunned but did not lose consciousness. The mother says when she got downstairs, the child was crying but easily consoled. The girl has multiple abrasions all over her body and a bloody nose, but otherwise seems fine. She cries throughout the primary and secondary surveys. Is the crying merely developmentally appropriate stranger anxiety? Does this patient need labs drawn? What type of imaging is warranted? If no other injuries are identified, what is the appropriate disposition for this patient?

Introduction

Trauma is the leading cause of morbidity and mortality in children aged > 1 year.^1,2 When pediatric patients present with multiple traumatic injuries, life- or limb-threatening injuries in 2 or more organ systems are not uncommon;^1,3,4 traumatic brain injuries (TBIs) and orthopedic/musculoskeletal injuries are frequent.⁵ Death occurs in up to 27% of pediatric patients with multiple traumatic injuries and is mainly dependent upon the severity of the TBI.⁴

Typically, major issues with airway, breathing, and circulation are recognized and stabilized in a timely fashion. Problems occur when TBIs and orthopedic injuries are not identified early, as they can lead to long-term disabilities in pediatric patients.^2,6 In one study, 9% of injuries were initially missed in pediatric trauma patients, with 46% of those injuries being missed fractures. Earlier identification of these injuries can greatly decrease the rates of morbidity and mortality. Other organ systems in which certain missed injuries can lead to serious morbidity in multiple-trauma patients include the gastrointestinal and respiratory systems.⁶ Less common pathologies, such as abdominal compartment syndrome,³ if not recognized early, can lead to a decline in respiratory status and decreased cardiac output. Blunt chest trauma can cause morbidity primarily from lung contusions or hemothorax/pneumothorax or secondarily as a result of a systemic inflammatory response syndrome leading to acute lung injury.

This issue of Pediatric Emergency Medicine Practice will discuss evidence-based recommendations for early recognition of TBI during the primary survey, initiation of the proper imaging to diagnose injuries, expedient stabilization of injuries, and utilization of a systematic approach to manage pediatric patients with multiple trauma.

Critical Appraisal of the Literature

A literature search was performed in PubMed using the search terms: multiple trauma, pediatrics, emergency room, trauma, children, polytrauma, imaging, FAST, permissive hypotension, transfusion, airway, tranexamic acid, and ATLS. A total of 193 articles from 1997 to the present were reviewed. The Cochrane Database of Systematic Reviews and the National Guideline Clearinghouse were searched for systematic reviews using the key term multiple trauma pediatrics. Approximately 70 articles were found, most of them being from the view of surgical management. The ninth edition of the Advanced Trauma Life Support (ATLS) guidelines,⁷ released by the American College of Surgeons Committee on Trauma, were also reviewed. While ATLS is not pediatric-specific, it is a system based on both best available evidence and expert consensus. These guidelines are widely considered the standard approach to all injured patients. Very few guidelines or policy statements were found specifically on pediatric trauma. The American Academy of Pediatrics (AAP) issued a policy statement in August 2016 that demonstrated the importance of a diverse trauma team when caring for pediatric trauma patients.⁸

The search of the literature revealed few case reports on multiple trauma in pediatric patients; there were also few studies on the emergency medical management of these cases. There were more studies that focused on the surgical management of multiple trauma patients, including emergency surgical procedures and early involvement of surgical specialties in resuscitation. The studies were retrospective, with very few prospective or randomized double-blinded studies.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. 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 is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

1. Schalamon J, Bismarck SV, Schober PH, et al. Multiple trauma in pediatric patients. Pediatr Surg Int. 2003;19(6):417-423. (Retrospective review; 70 patients)
2. Kay RM, Skaggs DL. Pediatric polytrauma management. J Pediatr Orthop. 2006;26(2):268-277. (Review article)
3. Letts M, Davidson D, Lapner P. Multiple trauma in children: predicting outcome and long-term results. Can J Surg. 2002;45(2):126-131. (Retrospective case series; 149 patients)
4. Dereeper E, Ciardelli R, Vincent JL. Fatal outcome after polytrauma: multiple organ failure or cerebral damage? Resuscitation. 1998;36(1):15-18. (Retrospective review; 98 patients)
5. van der Sluis CK, Kingma J, Eisma WH, et al. Pediatric polytrauma: short-term and long-term outcomes. J Trauma. 1997;43(3):501-506. (Retrospective study; 74 patients)
6. Miele V, Di Giampietro I, Ianniello S, et al. Diagnostic imaging in pediatric polytrauma management. Radiol Med. 2015;120(1):33-49. (Review article)
7. ATLS Subcommittee, American College of Surgeons' Committee on Trauma. Chapter 10: Pediatric Trauma. Advanced Trauma Life Support Student Course Manual. 9th ed: American College of Surgeons; 2013. (Textbook)
8. Committee on Pediatric Emergency Medicine, Council on Injury Violence, and Poison Prevention, Section on Critical Care, Section on Orthopaedics, Section on Surgery, Section on Transport Medicine, et al. Management of pediatric trauma. Pediatrics. 2016;138(2). (AAP policy statement)
9. Tracy ET, Englum BR, Barbas AS, et al. Pediatric injury patterns by year of age. J Pediatr Surg. 2013;48(6):1384-1388. (Review article)
10. Lallier M, Bouchard S, St-Vil D, et al. Falls from heights among children: a retrospective review. J Pediatr Surg. 1999;34(7):1060-1063. (Retrospective review; 64 patients)
11. Wang MY, Kim KA, Griffith PM, et al. Injuries from falls in the pediatric population: an analysis of 729 cases. J Pediatr Surg. 2001;36(10):1528-1534. (Retrospective review; 729 patients)
12. Thompson EC, Perkowski P, Villarreal D, et al. Morbidity and mortality of children following motor vehicle crashes. Arch Surg. 2003;138(2):142-145. (Retrospective review; 191 patients)
13. Wetzel RC, Burns RC. Multiple trauma in children: critical care overview. Crit Care Med. 2002;30(11 Suppl):S468-S477. (Review article)
14. Furnival RA, Woodward GA, Schunk JE. Delayed diagnosis of injury in pediatric trauma. Pediatrics. 1996;98(1):56-62.(Retrospective review; 1175 patients)
15. Gaines BA, Ford HR. Abdominal and pelvic trauma in children. Crit Care Med. 2002;30(11 Suppl):S416-S423. (Review article)
16. Werner C, Engelhard K. Pathophysiology of traumatic brain injury. Br J Anaesth. 2007;99(1):4-9. (Review article)
17. Sundstrom T, Asbjornsen H, Habiba S, et al. Prehospital use of cervical collars in trauma patients: a critical review. J Neurotrauma.2014;31(6):531-540. (Review article)
18. Hadley MN, Walters BC, Grabb PA, et al. Management of pediatric cervical spine and spinal cord injuries. Neurosurgery. 2002;50(3 Suppl):S85-S99. (Literature review)
19. Pandya NK, Upasani VV, Kulkarni VA. The pediatric polytrauma patient: current concepts. J Am Acad Orthop Surg. 2013;21(3):170-179. (Review article)
20. Nau C, Jakob H, Lehnert M, et al. Epidemiology and management of injuries to the spinal cord and column in pediatric multiple-trauma patients. Eur J Trauma Emerg Surg. 2010;36(4):339-345. (Retrospective analysis; 35 patients)
21. Meier R, Krettek C, Grimme K, et al. The multiply injured child. Clin Orthop Relat Res. 2005(432):127-131. (Retrospective case study; 925 patients)
22. Avarello JT, Cantor RM. Pediatric major trauma: an approach to evaluation and management. Emerg Med Clin North Am. 2007;25(3):803-836. (Review article)
23. Reilly PL, Simpson DA, Sprod R, et al. Assessing the conscious level in infants and young children: a paediatric version of the Glasgow Coma Scale. Childs Nerv Syst. 1988;4(1):30-33. (Retrospective review)
24. Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg. 2007;42(9):1588-1594. (Meta-analysis; 25 studies, 3838 patients)
25. Fox JC, Boysen M, Gharahbaghian L, et al. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med. 2011;18(5):477-482. (Prospective study; 357 patients)
26. Calder BW, Vogel AM, Zhang J, et al. Focused assessment with sonography for trauma in children after blunt abdominal trauma: a multi-institutional analysis. J Trauma Acute Care Surg. 2017;83(2):218-224. (Prospective study; 2188 patients)
27. Holmes JF, Kelley KM, Wootton-Gorges SL, et al. Effect of abdominal ultrasound on clinical care, outcomes, and resource use among children with blunt torso trauma: a randomized clinical trial. JAMA. 2017;317(22):2290-2296. (Randomized controlled trial; 925 patients)
28. Stafford PW, Blinman TA, Nance ML. Practical points in evaluation and resuscitation of the injured child. Surg Clin North Am. 2002;82(2):273-301. (Review article)
29. Esposito TJ, Sanddal ND, Dean JM, et al. Analysis of preventable pediatric trauma deaths and inappropriate trauma care in Montana. J Trauma. 1999;47(2):243-251. (Retrospective chart review; 138 patients)
30. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012;59(3):165-175. (Review)
31. Abdelgadir IS, Phillips RS, Singh D, et al. Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in children (excluding neonates). Cochrane Database Syst Rev. 2017;5:CD011413. (Systematic review; 12 studies, 803 patients)
32. Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. (Prospective cohort; 42,412 patients)
33. Bae DS, Kadiyala RK, Waters PM. Acute compartment syndrome in children: contemporary diagnosis, treatment, and outcome. J Pediatr Orthop. 2001;21(5):680-688. (Retrospective chart review; 33 patients)
34. Ziolkowski NI, Zive L, Ho ES, et al. Timing of presentation of pediatric compartment syndrome and its microsurgical implication: a retrospective review. Plast Reconstr Surg. 2017;139(3):663-670. (Retrospective review; 35 patients)
35. Greene N, Bhananker S, Ramaiah R. Vascular access, fluid resuscitation, and blood transfusion in pediatric trauma. Int J Crit Illn Inj Sci. 2012;2(3):135-142. (Review article)
36. Hughes NT, Burd RS, Teach SJ. Damage control resuscitation: permissive hypotension and massive transfusion protocols. Pediatr Emerg Care. 2014;30(9):651-656. (Review)
37. Kannan N, Wang J, Mink RB, et al. Timely hemodynamic resuscitation and outcomes in severe pediatric traumatic brain injury: preliminary findings. Pediatr Emerg Care. 2018;34(5):325-329. (Retrospective review; 234 patients)
38. Zebrack M, Dandoy C, Hansen K, et al. Early resuscitation of children with moderate-to-severe traumatic brain injury. Pediatrics. 2009;124(1):56-64. (Retrospective review; 299 patients)
39. Hendrickson JE, Shaz BH, Pereira G, et al. Implementation of a pediatric trauma massive transfusion protocol: one institution’s experience. Transfusion. 2012;52(6):1228-1236. (Prospective cohort; 102 patients)
40. Hwu RS, Spinella PC, Keller MS, et al. The effect of massive transfusion protocol implementation on pediatric trauma care. Transfusion. 2016;56(11):2712-2719. (Retrospective review; 11,995 patients)
41. Whittaker B, Christiaans SC, Altice JL, et al. Early coagulopathy is an independent predictor of mortality in children after severe trauma. Shock. 2013;39(5):421-426. (Retrospective review; 803 patients)
42. Smith SA, Livingston MH, Merritt NH. Early coagulopathy and metabolic acidosis predict transfusion of packed red blood cells in pediatric trauma patients. J Pediatr Surg. 2016;51(5):848-852. (Retrospective review; 96 patients)
43. Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016;20:100. (Guidelines)
44. Kozek-Langenecker SA, Afshari A, Albaladejo P, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2013;30(6):270-382. (Guidelines)
45. Eckert MJ, Wertin TM, Tyner SD, et al. Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg. 2014;77(6):852-858. (Retrospective review; 766 patients)
46. Baker N, Woolridge D. Emerging concepts in pediatric emergency radiology. Pediatr Clin North Am. 2013;60(5):1139-1151. (Review article)
47. Jakob H, Lustenberger T, Schneidmuller D, et al. Pediatric polytrauma management. Eur J Trauma Emerg Surg. 2010;36(4):325-338. (Review article)
48. Frank JB, Lim CK, Flynn JM, et al. The efficacy of magnetic resonance imaging in pediatric cervical spine clearance. Spine (Phila Pa 1976). 2002;27(11):1176-1179. (Retrospective chart review)
49. Asimos A. The trauma panel: laboratory test utilization in the initial evaluation of trauma patients. Emergency Medicine Reports. February 1997. (Review)
50. Capraro AJ, Mooney D, Waltzman ML. The use of routine laboratory studies as screening tools in pediatric abdominal trauma. Pediatr Emerg Care. 2006;22(7):480-484. (Retrospective medical record review; 382 patients)
51. Keller MS, Coln CE, Trimble JA, et al. The utility of routine trauma laboratories in pediatric trauma resuscitations. Am J Surg. 2004;188(6):671-678. (Retrospective study; 240 children)
52. Mathieson S, Whalen D, Dubrowski A. Infant trauma management in the emergency department: an emergency medicine simulation exercise. Cureus. 2015;7(9):e316. (Simulation exercise report)
53. Morrissey K, Fairbrother, HE. Pediatric trauma: pearls and pitfalls. emDocs.net. Available at: http://www.emdocs.net/pediatric-trauma-pearls-pitfalls/. Accessed May 15, 2018. (Online resource)
54. Murphy NJ, Quinlan JD. Trauma in pregnancy: assessment, management, and prevention. Am Fam Physician. 2014;90(10):717-722. (Review article)
55. Nesiama JA, Pirallo RG, Lerner EB, et al. Does a prehospital Glasgow Coma Scale score predict pediatric outcomes? Pediatr Emerg Care. 2012;28(10):1027-1032. (Retrospective chart review; 185 patients)
56. Kochanek PM, Carney N, Adelson PD, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition. Pediatr Crit Care Med. 2012;13 Suppl 1:S1-S82. (Guidelines)
57. Andrews PJ, Sinclair HL, Rodriguez A, et al. Hypothermia for intracranial hypertension after traumatic brain injury. N Engl J Med. 2015;373(25):2403-2412. (Randomized controlled trial; 387 patients)
58. Widdel L, Winston KR. Prognosis for children in cardiac arrest shortly after blunt cranial trauma. J Trauma. 2010;69(4):783-788. (Retrospective chart review; 40 patients)
59. Missios S, Bekelis K. Transport mode to level I and II trauma centers and survival of pediatric patients with traumatic brain injury. J Neurotrauma. 2014;31(14):1321-1328. (Retrospective cohort; 15,704 patients)
60. Macnab AJ, Wensley DF, Sun C. Cost-benefit of trained transport teams: estimates for head-injured children. Prehosp Emerg Care. 2001;5(1):1-5. (Retrospective chart review; 43 patients)
61. Acierno SP, Jurkovich GJ, Nathens AB. Is pediatric trauma still a surgical disease? Patterns of emergent operative intervention in the injured child. J Trauma. 2004;56(5):960-964. (Retrospective study)
62. Amini R, Lavoie A, Moore L, et al. Pediatric trauma mortality by type of designated hospital in a mature inclusive trauma system. J Emerg Trauma Shock. 2011;4(1):12-19. (Retrospective chart review; 11,503 patients)