Kirsten Morrissey

Featured on #FOAMED REVIEW 34TH EDITION – Thank you to Michael Macias from emCurious for the shout out! Featured on the LITFL Review #169 – Thanks to Simon Laing (@HEFTEMCAST) and the LITFL Review group for the shout out! Authors: Kirsten Morrissey, MD & Hilary E. Fairbrother, MD, MPH, FACEP // Edited by: Jennifer Robertson, MD and Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)  Background  In the United States, injury remains the leading cause of death and disability in children (1). Based on data from the National Trauma Database, the leading mechanisms of injury were falls in children 0-9 years of age, and motor vehicle collisions (MVCs) in children ages 10-18 (1).  Overall, MVCs accounted for more than 60% of trauma-related deaths in children under age 18. Although blunt trauma accounts for the majority of pediatric injury, in children without insurance or with public insurance penetrating trauma accounted for 21% of injuries among adolescents (1). While the general ATLS approach to trauma is similar in both adults and pediatrics, there are anatomic and physiologic differences to consider in the pediatric trauma patient.  The goal for this article is to discuss these differences as we review pearls and pitfalls of pediatric trauma. ABCDE and beyond… Airway and Breathing Airway remains the priority in the initial assessment. However, there are a few important considerations in the pediatric population. Children become hypoxemic more quickly than adults and may require more rapid intervention. A young child will also have a larger tongue, a more floppy epiglottis, and a larger head. Infants are obligate nasal breathers, which is an important consideration with facial trauma. Unlike adults, the cricoid cartilage in children is the narrowest part of the airway. Use of a shoulder roll, an oral airway, a smaller size ET tube, and a straight blade in younger patient may assist you with intubation (3). A needle cricothyrotomy should be performed in children under 8 years of age rather than a surgical cricothyrotomy. As long as appropriate cuff pressures are used, a cuffed ET tube may be used in ages outside of the newborn period (3).  Circulation The circulating blood volume in a pediatric patient is approximately 70-80 ml/kg. It is important to remember that children remain normotensive for a longer period of time and may sustain significant blood loss before developing hypotension.  Early compensatory measures include elevated heart rate and systemic vascular resistance. Pay close attention to tachycardia that does not improve after initial assessment and pain medications. Early aggressive fluid resuscitation may help prevent decompensated shock (3). Disability A rapid assessment of the neurologic status can be obtained through use of the AVPU scale, used to describe decreasing levels of consciousness. AVPU stands for: Alert responsive to Voice responsive to Pain Unresponsive Rapidly obtaining a blood glucose level is also an important part of initial assessment. Exposure As always it is important to completely undress and logroll your trauma patient, but remember that children have a larger ratio of surface area to body mass. Smaller patients are more susceptible to hypothermia, so keep them warm after exposure and examination.  Pediatric trauma scores Trauma classification is important to help with triage decision making and rapid assessment of severity.  Tools available include the Glasgow Coma Scale (GCS), Trauma Score (TS), and the Pediatric Trauma Score (PTS). The pediatric trauma score includes six components and is designed to assist with rapid triage of the injured child.  It has good correlation with injury severity and mortality risk, but should be used with caution in patients with isolated blunt abdominal trauma (4) as the PTS does not correlate well with trauma severity in this group. Image adapted from: https://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=132&seg_id=2659 Head Head injury is the most common cause of death in pediatric trauma, and falls are the most common mechanism of head injury in children (2). In an infant, a scalp laceration can cause bleeding significant enough to cause hemodynamic compromise (2). The majority of simple skull fractures in pediatric patients do not require intervention, but it is important to remember that they are associated with up to 20-fold increase in risk of intracranial injury. Children under the age of 18 months may still have an open fontanelle, so check to see if it is bulging or flat. Infants and young children are at higher risk of intracranial injuries, and parietal and occipital fractures are most commonly associated with injury (5). Clinical signs of intracranial injury may be more subtle in infants, and a modified GCS scale for infants should be used (2). Skull fractures and intracranial injuries, especially in infants, should raise concern for possible non-accidental trauma as discussed below. In the pediatric patient it is particularly important to limit unnecessary radiation exposure. Recently, significant efforts have been made to decrease utilization of unnecessary head CT scans. For minor head trauma the PECARN head trauma study can assist with risk stratification and decision making for imaging. Secondary analyses from the initial study data published in 2014 have reported on the low risk of clinically important traumatic brain injury (ci-TBI) in patients presenting with only vomiting or loss of consciousness alone (6,7). With no other significant findings, observation rather than immediate head CT should be considered for these patients.    Image adapted from: Kuppermann et al, 2009  Neck It is important to consider the anatomic differences between the pediatric and adult cervical spine when addressing potential injury. Upper cervical segments in children under 8 years old are hypermobile during flexion and more prone to flexion injuries (8). Although injury is uncommon, children under age 8 are more susceptible to higher cervical injury (above C3). Children have a high fulcrum at level C2-3, more prevertebral soft tissue, less developed musculature, larger heads, and anterior wedging and horizontal facets (9). As a result the increased mobility and positioning of the vertebra allow for the segments to twist, glide, and separate more easily without obvious damage (8). The above anatomic differences lead us to a discussion of SCIWORA (spinal cord injury