The Pediatric Patient

David W. Tuggle and Nathaniel S. Kreykes

Pediatric trauma is the leading cause of death of children, as well as the leading cause of permanent disability in this population. It has often been said that children are not merely small adults, and this is never more accurate than in pediatric trauma.¹ Although the principles of trauma care are the same for children as with adults, the differences in care required to optimally treat the injured child require special knowledge, careful management, and attention to the unique physiology and psychology of the growing child or adolescent. With this in mind, it is important to view pediatric trauma as a similar but separate entity from adult trauma. It was Haller of Johns Hopkins University who stressed the importance of regional trauma systems for pediatric patients. His system for safe care included two-way communication, dependable transportation, emergency medical technicians trained in the care of newborns, infants, and children, a designated pediatric intensive care unit (ICU), and rehabilitation.² His work has helped shape and improve our pediatric trauma care significantly.

EPIDEMIOLOGY OF THE INJURED CHILD

Although medical science has made vast strides in the surgical care of the neonate and child, injury remains the leading cause of childhood death in patients under 14 years of age.³ As developing countries become more sophisticated, injury becomes the leading cause of death in children.⁴ Of interest, there was a 45.3% reduction in the mortality rates from unintentional injury in children in the United States from 1979 to 1996.⁵ This reduction is crucial if one accepts that the treatment of injuries sustained in the year 2000 will ultimately cost $406 billion—$80.2 billion in medical costs and $326 billion in productivity losses.⁶ Of that total, injuries among children aged 0–14 account for $51 billion.⁶ Using the Centers for Disease Control and Prevention Web-Based Injury Statistics Query and Reporting System (WISQARS), a death and injury report for any age group and any type of injury can be obtained.

Children have different patterns and causes of injury depending on age, further emphasizing the need for regional pediatric trauma centers. The defined age range constituting a pediatric age group, however, varies between institutions. The mechanisms of injury and mortality in children have remained remarkably consistent. In children over 1 year and under 14 years of age, motor vehicle crashes cause 44.2% of all pediatric trauma deaths (2000–2005). A detailed review of mortality statistics reveals the home as an area of continuing concern.⁷ Other areas of concern include falls, bicycle-related injuries, and injuries associated with crashes of all-terrain vehicles.⁸

Childhood injuries most commonly occur as energy is transferred abruptly by rapid acceleration, deceleration, or a combination of both. The body of a child is very elastic and energy can be transferred creating internal injuries without significant external signs. Due to the relative close proximity of vital organs when compared with adults, children can have multiple injuries from a single exchange of energy. Penetrating trauma is a much less common form of injury in small children, accounting for 1–10% of admissions to pediatric trauma centers. No matter the type of injury, the health care professional evaluating the injured child should keep in mind these significant differences during evaluation and management.

INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED CHILD

Primary survey with simultaneous resuscitation and secondary survey with definitive care, as promoted by the Advanced Trauma Life Support (ATLS) course of the American College of Surgeons Committee on Trauma (ACSCOT), apply to a child as well as the adult. Multiple organ injuries are much more common in the child than in the adult and, as a result, it is best to manage children as if every organ is injured until proven otherwise.

The care of the injured child often starts with a brief evaluation in the prehospital setting. The ASCOT has published a minimum set of criteria for the definition of a “major resuscitation” once the patient arrives at the hospital.⁹ A patient who needs major resuscitation is typically a child who would benefit from the trauma surgeon being present at the bedside at this point. This condition is ideally determined in the field as noted above or from a referring hospital. Although these criteria are the same for injured patients of all ages, hypotension is age specific.

Airway Management

Assessment of the child’s airway is the first step. Most children do not have preexisting pulmonary disease, so a room air saturation of greater than 90% indicates effective gas exchange. Children also tolerate lower oxygen saturations than adults, up to a point. If oxygenation is difficult, then an injury to the lung, a pneumothorax, or aspiration should be considered. In children, hypoventilation is common in the presence of a traumatic brain injury or shock. If any of these conditions exist, intubation is appropriate. Respiratory compromise requiring intubation commonly indicates a very severe injury. Although none of the previously mentioned criteria to determine a major resuscitation has been validated in children, compromise of the airway and intubation suggest a population that has a higher mortality when compared with those injured children who do not have airway issues.¹⁰ A child who is comatose or unresponsive is fairly easy to intubate with an appropriately sized orotracheal tube. Typically, this tube is not cuffed in children less than 8 years of age since the narrowest part of the airway, the cricoid ring, will stabilize the tube without the need for a cuff. Care must be taken to stabilize the cervical spine with appropriately sized pediatric cervical collars during critical maneuvers such as intubation and transportation.

Children who are combative from hypoxia or from emotional distress may need to be intubated to facilitate evaluation, including computed tomography (CT) scanning. For intubation, the injured child is best managed with a protocol for rapid sequence intubation (RSI). Table 43-1 describes an RSI protocol that is both safe and effective. If there is time, preoxygenating the child is useful. The tube size can be roughly approximated by either the width of the nail or the size of the child’s fifth finger. These rough calculations may not be accurate in children of Chinese descent.¹¹ The use of the Broselow Pediatric Resuscitation Measuring Tape has become the standard for determining height, weight, and the appropriate size for resuscitative equipment in a child. The Broselow cart has been found to be more useful than older “standard” carts for children.¹² In addition, this tape has been useful in determining drug doses and drip concentrations throughout the hospitalization.¹³

TABLE 43-1 Pediatric Rapid Sequence Intubation (RSI)

Intubating the injured child can be a very stressful event for those who are less familiar with the technique. The head should be held in line with cervical traction. After selecting the appropriately sized noncuffed tube and employing pharmacological adjuncts as needed for RSI, the airway is approached with a properly sized laryngoscope. The smaller the child, the more likely successful intubation can be achieved with a straight blade. Gentle cricoid pressure is useful to guide the larynx into view and to help close the esophagus during manipulation of the oropharynx. The endotracheal tube should be advanced about 3 cm beyond the vocal cords. Bilateral breath sounds along with symmetric chest excursion are assessed, followed by confirmation with a device that measures exhaled carbon dioxide. Due to the thin tissues of the chest wall, gastric insufflation may be confused with normal breath sounds. A chest x-ray should be obtained to confirm the correct position of the tube since a right mainstem intubation is the most common complication of pediatric intubation after missed intubation. Nasotracheal intubation is generally not used in small children in the emergency setting.

The need for invasive emergency airway access for acute obstruction of the pediatric airway is a very uncommon event. If needed, a 14 or 16 gauge angiocatheter may be placed through the cricothyroid membrane or even the tracheal wall. Care should be taken to not penetrate the posterior tracheal membrane. Oxygen can then be administered through the catheter, allowing time for attempts at orotracheal intubation. The needle cricothyroidotomy is preferred in patients under 10 years of age as the cricoid cartilage is very delicate and could be injured easily with a surgical incision. The needle cricothyroidotomy may then be followed by tracheostomy in a more organized fashion.

Postintubation issues include gastric decompression and surveillance for a pneumothorax. Gastric decompression with a nasogastric or orogastric tube should be employed in every patient since gastric distention will impair diaphragmatic excursion and cause respiratory compromise in the small child. A pneumothorax is especially treacherous in the child due to mediastinal mobility. A tension pneumothorax in a patient with a mobile mediastinum causes compression of the ipsilateral and contralateral lungs, as well as vascular compromise. If a pneumothorax is present, needle decompression can be employed, but this should be followed by immediate insertion of a thoracostomy tube.

Vascular Access

As in injured adult patients it is important to obtain reliable, quick, and safe intravenous access. Simpler measures should be attempted first and, if not successful, proceeding to more invasive measures may be necessary (Table 43-2). The ideal initial sites for vascular access for children are the peripheral veins in the upper extremities, especially the antecubital fossa. Ultrasonography may be used to aid in finding peripheral veins, as well.¹⁴ A percutaneous femoral venous catheter below the inguinal ligament is the next best choice and the most commonly used route for emergency venous access in the child.¹³ This should be done with the Seldinger technique to avoid a cutdown procedure. If the trauma team is unable to establish intravenous access using these techniques, a cutdown on the saphenofemoral junction or saphenous vein at the ankle will work in the emergency setting, as well.¹⁵ Surgeons who are familiar with subclavian or internal jugular vein catheterization in the child may utilize this route as the next choice as there are very few complications. This is especially true if a chest tube is already in place on the selected side of the subclavian venipuncture.

TABLE 43-2 Pediatric Vascular Access

Intraosseous access is a very useful technique for pediatric trauma victims without intravenous access. Contraindications include proximal fractures and sites of infection. The anteromedial surface of the proximal tibia is used, 2–4 cm distal to the tibial tuberosity. For insertion in the proximal tibia, the needle is directed inferiorly at a 45° angle from the perpendicular. If the insertion site is the distal tibia, the needle should be angled 45° superiorly. In both instances the goal is to angle away from the region of the growth plate and/or joint. There are specialized needles readily available to use with this technique. If these are not available, a spinal needle with a trocar may be employed. Multiple entries into the medullary cavity should be avoided as the leakage that occurs with multiple attempts may cause an iatrogenic compartment syndrome.

Restoration of Circulation

Age-specific hypotension is an indication for major resuscitation of an injured child. In an analysis of the National Pediatric Trauma Registry, 38% of recorded deaths occurred in children whose systolic blood pressure was less than 90 mm Hg.¹⁶ This group represented 2.4% of the study population. To determine which child has “age-specific hypotension” requires knowledge of normal blood pressures in children. National guidelines for the ranges of normal childhood blood pressures based on age were published in 2004.¹⁷ Health care professionals caring for injured children should be familiar with normal age-dependent blood pressures (Table 43-3).

TABLE 43-3 Vital Functions for Children

A child with an injury that produces significant blood loss may present with a normal blood pressure. The otherwise healthy child can readily compensate for blood loss by mounting a significant tachycardia coupled with peripheral vasoconstriction. Therefore, a normal blood pressure in a child does not mean that circulating blood volume is at normal levels. An accurate assessment is made by monitoring blood pressure and heart rate combined with a clinical assessment of peripheral perfusion. Clinical signs of poor perfusion in conjunction with altered mentation are the classic findings in pediatric hypovolemic shock. If these are present, an immediate bolus of 20 mL/kg of an isotonic crystalloid solution is indicated. If a second bolus is needed and there is little improvement, type-specific packed red blood cells or O-negative blood should be administered immediately followed by the standard infusions of fresh frozen plasma and platelets. As noted above, this scenario occurs in less than 3% of injured children. Caution must be employed, as overresuscitation may be as problematic as underresuscitation, especially in the presence of a traumatic brain injury. Overtreatment with crystalloid solutions may exacerbate cerebral edema in certain circumstances. In adults, excess infusions of crystalloid solutions may result in poor formation of clot and worsening of a compromised hemorrhagic state, and may have no impact on survival.¹⁸ One study in injured adults showed that supranormal trauma resuscitation increased the likelihood of an abdominal compartment syndrome, as well. Anecdotal reports of abdominal compartment syndrome following massive crystalloid resuscitation in children have been reported.¹⁹

Hypothermia is an extremely common occurrence in injured children and may occur at any time of the year, even in the heat of summer. The response to hypothermia includes catecholamine release and shivering, with an increase in oxygen consumption and metabolic acidosis. Hypothermia as well as acidosis then contributes to a posttraumatic coagulopathy.²⁰ A warm room, warmed fluids, heated air-warming blankets, or externally warmed blankets should be utilized during the initial resuscitation of an injured child. This aggressive approach to rewarming should be extended to the radiology suite during evaluation. If at all possible, the room should be warmed to 37°C or warmer, even if the trauma team feels some discomfort. Fluids and blood should be warmed to 39°C if the child is cool (<36°C). Conversely, care should be taken to avoid hyperthermia in the child with a traumatic brain injury²¹; therefore, maintenance of a normal core temperature is the goal for management. There is some evidence, however, to suggest that early, carefully controlled hypothermia in the child with a severe injury to the brain and no other injuries may be beneficial, but this treatment option is still experimental.²²

DIAGNOSTIC ASSESSMENT

The physical examination is a crucial first step in diagnosis as it will direct all other forms of assessment. It is the baseline for serial physical examinations by the trauma team performed later in the hospitalization. After the physical examination, other diagnostic adjuncts may be employed.

During the initial assessment diagnostic testing with standard x-rays is performed with a portable machine or one dedicated to the trauma room, thus avoiding transport of the patient. Frequently ordered imaging studies in the emergency department include the following: plain x-rays of the chest, abdomen, pelvis, cervical spine, and extremities. Thoracic and lumbar spinal x-rays are commonly ordered when neurological injuries are suspected or when the physical examination reveals point tenderness over the spine. The role of cervical, thoracic, or abdominal computed tomography (CT) with reconstruction to evaluate the vertebral column can be helpful. Detecting a pneumothorax, pneumoperitoneum, pelvic fracture, or fracture of a long bone is an important component of the initial care of an injured child. Plain x-rays of the skull may document fractures, but they have little value in directing management of the child with an injury to the brain, except for a penetrating injury or suspected child abuse.^23,24 The inability of x-rays to predict intracranial bleeding in the injured child has been documented, also.²⁵

In the past decade, surgeon-performed ultrasonography has been popularized in the United States. Several recent studies by adult and pediatric trauma surgeons have attempted to determine the role of the focused assessment for the sonographic examination of the trauma patient (FAST) in the evaluation of the injured child. The FAST evaluation examines the pericardium, right and left upper quadrants, and the pelvis for fluid. Some surgeons include a thoracic evaluation to detect a hemothorax or pneumothorax.

The technique of B-mode ultrasound in the hands of experienced ultrasonographers should be as accurate in detecting blood in the abdomen as CT scanning or diagnostic peritoneal lavage (DPL).^26–28 In a collected series of over 4,900 patients, surgeons who performed ultrasound to detect hemoperitoneum and visceral injury demonstrated a sensitivity of 93.4%, a specificity of 98.7%, and an accuracy of 97.5%.^26–29 A second study reviewed 1,043 patients in whom the ultrasonographic study was performed by radiologists. This collected series showed a sensitivity of 90.8%, a specificity of 99.2%, and an accuracy of 97.8%.^30–33 Both of these series included adults as well as children.

Surgeon-performed ultrasound evaluation in children should be coupled with the physical examination.³⁴ The typical FAST examination takes less than 2 minutes when performed by a physician experienced in its use. A 3.5 MHz probe is used for children over 10 kg, while either a 3.5 or a 5 MHz probe can be used for children under 10 kg. Obvious benefits of the FAST evaluation include its portability, repeatability, elimination of the need to transport the child to the radiology suite, and the decreased radiation exposure to the child.

CT scans of the head, chest, and abdomen are the accepted diagnostic radiologic studies of choice in the vast majority of hemodynamically stable injured children suspected of having a potentially life-threatening injury. Despite liberal use of CT scans of the head, a normal initial scan of a child may not detect late manifestations of a neurological injury or cerebral edema.³⁵ Unless an absolute indication for surgery is present, the majority of stable children with suspected intra-abdominal injuries should have a CT scan performed prior to instituting operative or nonoperative management. Although CT scanning is the imaging modality of choice in the evaluation of a stable injured child, it is generally accepted that a high percentage of those scans will reveal no injuries. CT scans of 1,500 consecutive children were performed after blunt abdominal trauma, and abnormal CT scans were seen in only 26% of patients.³⁵ A normal study was found to strongly predict a lack of deterioration as only one delayed laparotomy was required in the 1,112 children in this group. In addition, a CT scan affected the decision to operate on children with a solid organ injury in a very small subset of patients (5 of 1,500). The technique for performing an emergency CT scan on an injured child, with regard to the use of contrast material, remains unclear. Most institutions will perform an initial CT of the head without using intravenous contrast. The use of intravenous contrast during a CT scan to evaluate intrathoracic or intra-abdominal trauma improves its diagnostic accuracy, but is not required and can be omitted during the initial scan depending on the experience and protocols of the particular trauma center. The benefit of using oral contrast for an abdominal CT in injured children is also a matter of debate. In a randomized prospective clinical trial in adults, the addition of oral contrast to an acute abdominal CT scan for trauma was found to be unnecessary and caused a delay in the time to CT scanning.³⁶ In a review of 2,162 patients with blunt trauma and an abdominal CT, Tsang et al.³⁷ found that all 7 patients with an intestinal perforation had studies that showed neither extraluminal air nor extraluminal oral contrast. In some centers, due to the length of time needed to fill the bowel with contrast and the resultant full stomach that increases the risk of vomiting and aspiration, gastrointestinal (GI) contrast is avoided in the initial CT scan of the abdomen in the injured child. Other centers suggest that it improves the accuracy of abdominal CT scans when intestinal or retroperitoneal injury is suspected and that oral contrast in adults and children is safe and has a minimal incidence of aspiration.^38,39 In summary, at the present time the use of GI contrast in emergency CT scans of the abdomen for trauma is a matter of institutional preference.

Evidence of intra-abdominal injuries requiring operative correction on the CT scan may be subtle. Findings of free intraperitoneal or retroperitoneal air, extravasation of GI contrast, defects in the bowel wall, and active hemorrhage are often obvious and have a high correlation with an injury to the intestine that will require operative intervention.⁴⁰ There are, however, potentially life-threatening intestinal injuries that may present with only focal thickening of the bowel wall or the presence of peritoneal fluid without injury to a solid organ.⁴¹ Other less specific findings associated with intestinal injuries include mesenteric stranding, fluid at the mesenteric root, focal hematomas, mesenteric pseudoaneurysm, and the hypoperfusion complex.

Repeated CT scanning during an acute hospitalization may expose children to very high doses of radiation and an increased risk of cancer. Epidemiologic studies have demonstrated a much greater sensitivity to radiation in the pediatric population when compared with adults. The lifetime risk of cancer is significantly increased when children are exposed to diagnostic radiation. The current scientific evidence suggests that the risk of cancer from low-level radiation such as from CT may be as high as one fatal cancer death for every 1,000 CT performed in children.⁴² The amount of radiation a CT scan imparts depends on many factors, and protocols can be adjusted to provide adequate image quality while reducing exposure. Minimizing the risk of radiation exposure in diagnostic imaging is a complex task and a multidisciplinary approach is needed. Trauma clinicians should be aware of the potential risks and benefits of CT and consider these issues when selecting imaging studies.

Laboratory Studies

The routine use of laboratory studies in the ED, in general, has not been shown to be of significant value in the pediatric trauma population.^43–45 Some specific clinical laboratory tests such as urinalysis and arterial blood gases with base deficit may be of limited benefit in selected circumstances.⁴⁶ More often, laboratory testing delays the clinical decision-making process occurring in the ED during evaluation and resuscitation, and point-of-care testing has not altered this concept.⁴⁷ In the presence of a possible injury to the brain, testing for a coagulopathy, thrombocytopenia, or hyperglycemia may be of benefit to establish a baseline for later determinations or to assist in assessing the risk of morbidity or mortality.^48–50 During hospitalization, routine laboratory testing is appropriate as long as specific indications exist for monitoring, such as nonoperative management of an injury to the spleen or pancreas.

MANAGEMENT OF SPECIFIC INJURIES

Injury to the Head and Central Nervous System

Acute traumatic brain injury is the most common cause of death and disability in the pediatric population.⁵¹ In those who survive, minor injuries can be associated with reversible defects while major injuries can result in severe disabilities. The mechanisms of injury to the brain in children are related to age. Infants typically suffer more from falls such as from a table or the arms of a caregiver. Intentional injury is a common cause of death in children under 2 years of age. Injury with intention, independent of severity, raises the mortality in children with traumatic brain injuries.⁵² In older children the usual cause of injuries to the brain is from vehicle-related accidents or recreational activities. Although children have a better survival rate with injury to the brain when compared with adults, this does not mean they have a lesser morbidity with similar injuries. Children have a plasticity of the neuron related to myelination and the establishment of neuronal interconnections. This allows a given focal injury to produce a less severe deficit when compared with a mature brain. This same lack of maturity may also make the child more susceptible to a diffuse injury with greater cognitive impairment.⁵³

The head of an infant constitutes 15% of the total body mass, while the head of an adult makes up only 3%. Acceleration and deceleration injury in pediatric trauma, therefore, yields a greater amount of force applied to the brain. The neck muscles do not support this relatively larger head as well as they do in teenagers and adults. Also, the skull of the infant is thin and soft, and the closure of fontanelles and sutures is not completed until age 3. In addition, the volume of cerebrospinal fluid is smaller than that of the adult and the child’s brain has greater water content. Finally, myelination occurs between 6 and 24 months, making the brain very soft and prone to disruption prior to completion of this process.

Injuries to the brain are classified as primary and secondary. Primary injuries are those inflicted immediately by the trauma, while secondary injuries are those resulting from ischemia, hypoxia, hypotension, infection, hydrocephalus, seizures, or increased intracranial pressure (ICP). Children are more likely to have low-pressure venous bleeding from an overlying skull fracture than from arterial injuries resulting in a lower incidence of epidural hematoma. The very young infant can actually have a critical reduction in blood volume from intracranial bleeding due to the relatively large size of the brain compared with the body mass. Much as in adults, diffuse axonal injury is a shear stress to the brain caused by acceleration/deceleration mechanisms, often with angular or rotational motion. Even minor shearing can cause severe neurological deficits.

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