Journal of Pediatric Critical Care

P - ISSN : 2349-6592    |    E - ISSN : 2455-7099

Review Article
Year : 2019 | Volume : 6 | Issue : 3 | Page : 31 - 39

Management of Pediatric Trauma

Aparna Pande1, Kapil Dev Soni2

1Critical Care Trainee, 2Associate Professor, Critical & Intensive Care JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi

Correspondence Address:

Dr. Kapil Dev Soni. Associate Prof. Critical & Intensive Care.
JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi.
E-mail – kdsoni111@gmail.com
Received: 30-Apr-19/Accepted: 22-May-19/Published online:05-Jun-19

Source of Funding:None Conflict of Interest:None

DOI:10.21304/2019.0603.00501


ABSTRACT
Injuries are one of the commonest causes of disability and death worldwide. They affect all populations in all geographic regions. Injuries are amongst the commonest causes of mortality in the pediatric population, after infections, congenital and neonatal complications. Children have considerable variations in their anatomy and physiology when compared to adults, which change with advancing age. A similar mechanism of trauma leads to different injuries with unique management and treatment strategies in pediatric patients. This review focuses on these aspects and management of pediatric trauma.

Key words:
Pediatric Trauma; Glasgow Coma Scale; PICU

Introduction
Injuries are one of the commonest causes of disability and death worldwide. They affect all populations in all geographic regions. But more commonly, injuries affect the younger population and cause long term disabilities. Better understanding of the characteristics of injuries and magnitude of the problem would help in formulating better injury prevention programs, improve public awareness and would subsequently result in better pre-hospital and hospital care systems for the injured patients.
Injuries are amongst the commonest causes of mortality in the pediatric population, after infections, congenital and neonatal complications.1 A child is not a ‘small adult’. Children have considerable variations in their anatomy and physiology when compared to adults, which change with advancing age. These differences must be accounted for while managing any pediatric patient as they impact the medical care of an acutely ill child. A similar mechanism of trauma leads to different injuries with unique management and treatment strategies in pediatric patients. Motor vehicle accidents account for most of the mortality in the adolescent age group globally. This trend is expected to worsen with time as motorization increases world over.

Variations in Pediatric Anatomy
Most of trauma organization systems are similar as in adults, however variations in the pediatric anatomy and physiology makes the assessment and management of the injured child considerably different, and diffi cult.

Pediatric airway
Children have smaller oral cavities and relatively larger tongue. Enlarged tonsils further reduce the size of the oropharynx. All these contribute to increased propensity of airway obstruction in children especially when comatose. The occiput of a child is relatively large which leads to fl exion of the cervical spine when supine further worsening the airway obstruction as well as potentially exacerbating an unstable cervical spine injury. The pediatric larynx is more cranial and anterior when compared to the adult larynx. Moreover, the pediatric epiglottis is large and fl oppy. This hampers visualization of the pediatric glottis thereby making endotracheal intubation more diffi cult than in adults. A narrow trachea with reduced distance between tracheal rings and a diffi cult to palpate cricothyroid membrane further result in a technically challenging needle cricothyroidotomy. Shorter trachea leads to increased risk of mainstem bronchus intubation as well as accidental tube dislodgement with movement of the neck. Therefore, securing airway in a child is more challenging especially in patients with age less than three years.2,3

Head
The head constitutes the most to the total body surface area of a young child since they have disproportionately large head. Therefore, head injury is exceedingly common in pediatric trauma. This also results in a greater surface area involvement in case of thermal injuries to the head and neck.
Infants have open sutures with larger subarachnoid space and increased tolerance to expanding hematoma than the skull of the older child or adults with closed sutures. However, the cranial vault is thinner and more prone to fracture. The pediatric brain is incompletely myelinated at birth and therefore is overall more prone to parenchymal injury owing to the lesser protection.

Brain and spine
Infants have skulls with open sutures, and their brains have a larger subarachnoid space and increased extracellular space. As a result, they tend to tolerate an expanding intracranial hematoma better than older children or adults. However, the pediatric cranial vault being thinner and less protective in children, together with less degree of myelination make the pediatric patient more vulnerable to parenchymal brain injury.4 A relatively fl exible spine protects children against injuries and there are usually no detectable injuries on the plain radiograph or the computerized tomograph of the spine. An entity called SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) may sometimes be picked up on the MRI of small children because of fl exibility of the spine which allows it to stretch greater than what can be tolerated by the spinal cord.5

Chest and Abdomen
A compliant thoracic cage results in lesser incidence of rib fractures, and lung contusions may be present in the absence of any bony injury. Relatively mobile mediastinal contents predispose children to development of tension pneumothorax.6The liver and spleen in infants and young children are inadequately protected by the pliable rib cage and direct injury leading to liver and splenic lacerations may be observed more frequently.7This may also be attributed to more caudal extension of the solid organs in this age group. Owing to the rich vascularity of the liver and spleen, lacerations to these organs may lead to signifi cant blood loss.

Musculoskeletal system
More pliable bones and immature growth plates may result in physeal disruption and greenstick and buckle fractures in children.8Isolated fractures may not lead to signifi cant blood loss in the pediatric population as they do in adults.

Vascular System
Securing a vascular access in a pediatric patient may be particularly challenging and for a patient in shock, and intraosseous route may be the only saviour.9

Variations in Pediatric Physiology
The vital signs in pediatric population, are in different ranges for different age groups. It is necessary to be aware of these differences to pick up subtle changes to detect disturbance in homeostasis.10In general, the heart rates and respiratory rates are higher in young children and reach adult values by adolescence. Pain – now considered as the ‘fi fth vital sign’ is also more diffi cult to assess in non-verbal children.11 Children may be irritable, in part because of pain, or because of trauma related metabolic disturbances.

Metabolism
Children have a relatively large body surface area which predisposes them to hypothermia. A defi cient subcutaneous fat further leads to rapid convective heat losses. A larger body surface area to weight ratio also makes them prone to greater insensible fl uid losses. Not only does hypothermia constitute ‘the lethal triad of trauma’ by worsening metabolic acidosis and coagulopathy12; it also leads to negative cardiac inotropy.13

Respiration
A reduced functional capacity along with increased metabolic demand makes infants and young children extremely prone to hypoxia when ventilation is impaired.14Hypoxia is most commonly implicated cause of pediatric cardiac arrest.15 At the other end of the spectrum, pediatric population is more susceptible to iatrogenic barotrauma resulting from aggressive mechanical ventilation.16

Hemodynamics
Insuffi cient myocardial muscle mass and a stiffer myocardium result in poor contractile response to increased catecholamines. Therefore, pediatric cardiac output is primarily dependent on heart rate than on stroke volume. This makes children exquisitely sensitive to volume losses. Blood pressure may be preserved even with 30-45 percent intravascular volume depletion. Hypotension manifests late in children with hypovolemia and may be a marker of impending cardiac arrest.17Vasoconstriction maintains blood pressure at the expense of reduced tissue perfusion. Tachycardia and poor capillary refi ll along with reduced urine output may be the only initial signs of depleted intravascular volume in an exsanguinated child. Bradycardia in bleeding infant is an ominous sign and should prompt aggressive resuscitation with fl uids and blood products to prevent imminent cardiovascular collapse.

Classifi cation of pediatric trauma
Injuries may be classifi ed according to extent, severity and mechanism. Extent – trauma confi ned to one anatomic region is considered as localized whereas that involving two or more body regions is termed as polytrauma. Injury types include blunt and penetrating. Injury severity is determined by the mechanism of trauma and the physical fi ndings.

Injury Prevention
Principles of primary and secondary injury prevention remain the same as in adults. Tertiary prevention involves interventions which prevent clinical deterioration and reduce complications in an injured child. This involves rapid identifi cation of injured children in the pre-hospital setting to appropriately triage them and effectively utilize the resources of the emergency medical response teams. In the United States, children are preferably triaged to a centre with clinicians skilled in the management of pediatric trauma.18 With the widespread adoption of trauma systems, and development of trauma registries and databases, pediatric trauma is being categorized more accurately which allows better resource allocation. There are two major reasons for having a classifi cation system for trauma.19 The fi rst is to effectively triage patients and guide transport disposition to attain optimal outcomes. The outcome of trauma being time sensitive, mandates prompt referral and transport of injured children to appropriate levels of care. The second reason is for severity of injury classifi cation – which is an essential part of research and is necessary to standardize and predict the outcomes.
The scoring systems may be physiological, anatomical or a combination of both.20They may be based on the body region with mechanism and severity of injury. Physiological systems are based upon the physiological parameters, physical examination with or without mechanism of injury. These help in standardization of the assessment protocols when an injured child is received in the trauma bay and help to standardize the assessment of the injured child. Some of the most commonly used physiological systems include the Pediatric Glasgow Coma Scale, the Trauma Score, Revised Trauma score, the Pediatric Trauma score and Age-Specifi c pediatric Trauma Score.
The modifi cation of Glasgow coma scale for pre-verbal children has reasonable accuracy thus supporting its use in clinical practice (Table 1).21 Furthermore, it may be used to prognosticate a child with head injury. The use of the motor component alone (mGCS) has been suggested for fi eld triage of patients, however there is insuffi cient data on how this would impact clinical outcomes.22

Table 1:
Modifi ed Glasgow Coma Scale



The trauma score has fi ve physiological variables which are scored and added together to determine the total score and probability of survival. The limitation of this score includes subjective parameters like the respiratory effort and capillary refi ll time.23 Furthermore, it may give false sense of security in a hemodynamically stable child with isolated head injury. These subjective parameters were removed from the revised trauma score.

Table 2:
Revised Trauma Score



Pediatric traumatologists argued the applicability of the RTS to children as it was derived from adult data and this led to the evolution of the Pediatric trauma Score.24It is the sum of six measures incorporating size as a surrogate for age and vital signs plus organspecifi c injury data.20However most of the studies show good concordance between RTS and PTS in pediatric trauma.24
The age-specifi c pediatric trauma score (ASPTS) incorporates vital signs with GCS to predict severity of injury and outcomes.25

Table 3:
Pediatric Trauma Score




Anatomic scoring systems are usually considered inferior as they can be applicable only after all injuries have been identifi ed which may be possible after extensive radiological evaluation only. However, these systems may be used for comparison of injury severity amongst trauma patients. Examples include the Abbreviated injury Scale (AIS), Injury Severity Score (ISS) and the Anatomical profi le (AP).26-28
Combination systems incorporating both physiological and anatomical data may be used for outcome analysis of the injured pediatric population. These include Trauma Injury Severity Score (TRISS)29, Pediatric- Age Adjusted Trauma Injury Severity Score (PAAT)30, A Severity Characterization Of trauma (ASCOT)31, Pediatric Risk of Mortality (PRISM III)32, Pediatric Index Of Mortality (PIM 3)33, International Classifi cation Injury Severity Score (ICISS)34, Pediatric Trauma BIG score.35 Champion et al compared the various scoring systems and concluded that physiological scoring systems had better mortality predictive value in comparison to the anatomical ones however combination scoring systems did not fare better in this regard.36 They also found that TRISS score was better able to predict morbidity viz a viz other score. They also demonstrated that pediatric specifi c scores were no better than trauma scores used in adult population. In an Indian study, Soni et al showed physiologically based RTS Score as better predictor for inhospital mortality compared to anatomical based scores –ISS and NISS for unintentional pediatric falls. This was attributed to higher propensity of respiratory and neurological derangements seen frequently in absence of anatomic injuries.37

Management of the Injured Child
Primary Survey
The ATLS protocol of primary survey is similar as in adults. The ABCDE (airway, breathing, circulation, disability, exposure) cognitive model is used to identify life threatening injuries immediately to begin prompt management. It is imperative for the traumatologist to assess age specifi c vital signs in the pediatric population. A Broselow tape and colour-coded pediatric resuscitation equipment must be available at the trauma-bay that caters to pediatric population.38 This allows rapid utilization of appropriately sized equipment to minimize unnecessary delays. Continuous monitoring of the vital signs should be done with frequent re-assessments to ascertain the response to intervention. Early pediatric consultations should be sought to achieve better clinical outcomes. In case of clinical deterioration, it may be benefi cial to repeat the primary survey to identify any injuries that may have been overlooked at initial presentation.

Airway
Airway obstruction leading to hypoxia is the most commonly implicated cause of cardiac arrest in pediatric trauma.39 The airway patency must be confi rmed rapidly and presence of foreign body while actively searching for faciomaxillary fractures or laryngotracheal disruption. It is unlikely for an actively crying child to have airway related complications; however frequent reassessments are mandatory. The cervical spine must be stabilized, particularly in children with altered sensorium and suspected head injuries. To gain airway control, a ‘sniffi ng position’ may be utilized which involves placing padding under shoulder- which is characteristically different from adults where padding is kept under the head to obtain a neutral spine position. In case any airway manipulation is required, manual in-line stabilization of the spine is recommended. A chin-lift or jaw-thrust manoeuvre may be used to improve airway patency. If airway needs to be secured, then supraglottic airway devices of endotracheal intubation may be utilized in accordance to the type of injury and clinical situation.

Breathing
Breathing assessment begins with the visual inspection of chest and thorax. The presence of visible injuries on the thorax, and the use of accessory muscles of respiration should be noted. High fl ow oxygen may be administered. In case of inadequate respiratory effort, positive pressure ventilation must be administered. A chest tube placement may be done for tension pneumothorax or hemothorax which is impeding respiratory efforts. End-tidal carbon dioxide monitoring and blood gas measurement may be done to provide additional information.

Circulation
Early recognition and treatment of hypovolemia is crucial during trauma management as it is the most common cause of shock in the pediatric patient.40 Inspite of signifi cant blood loss, the blood pressure is maintained owing to tachycardia and hypotension. Tachycardia, cold-clammy extremities and stupor may be the only indicators of hypovolemic shock in an injured child. Sources of bleeding must be sought actively with necessary interventions undertaken to correct them. Visible bleeder may be compressed or a tourniquet or alternatively, a clip may be used – depending upon the site of bleeding. Splinting of long bone fractures may further reduce bleeding in case of isolated long bone injuries. When pelvic fracture is the suspected source of internal bleeding; a pelvic binder may offer some respite. Tranexamic acid and other antifi brinolytics may be used as an adjunct in ongoing major haemorrhage as they have shown to offer mortality benefi t along with improved neurological outcomes and are associated with reduction of transfusion requirements.41
Securing an appropriate vascular access may be challenging in the exsanguinated child. In case of lack of peripheral venous access, resuscitation should not be delayed, and immediate decision must be taken to secure a central venous access, peripheral venous cut down or an intraosseous access. A fl uid bolus of 20ml/ kg body weight of prewarmed balanced salt solution must be administered rapidly. In case of poor response to fl uid bolus, packed red blood cell transfusion must be considered.42A patient presenting to trauma centre already in a state of hemodynamic compromise might benefi t from immediate transfusion of type specifi c or unmatched O negative packed red blood cell of 10- 20 ml/kg body weight by a rapid infuser system. In case of profound haemorrhage, a massive transfusion protocol is initiated. It is then imperative to administer packed red cells, platelets and plasma in a 1:1:1 ratio before laboratory investigations are available.43 The optimal trigger for initiation of a massive transfusion protocols varies with age and weight in the pediatric population. A common consensus is to follow a weight-based approach.

Table 4:
Recommendations for massive transfusion protocol trigger44


There is insuffi cient evidence to promote the use of controlled hypotension in pediatric trauma resuscitation and it should particularly be avoided in patients with head injury.45-46 Vasopressors may be used as bridge while awaiting blood products and to maintain perfusion pressures in patients with neurogenic shock.Emergency thoracotomy may be indicated in case of recalcitrant hypotension when the source is not obvious – however there is paucity of literature pertaining to pediatric population.47

Disability
Rapid neurological assessment is mandatory, and the Glasgow Coma Scale modifi ed for the pediatric population may be used.21 GCS<8 warrants rapid resuscitative efforts and further neurological evaluation. Pupil responsiveness to light and brainstem refl exes must be assessed. This would further help in assessing the need for measures to reduce intracranial pressure. In cases where intracranial hypertension is suspected, management strategies should focus on prevention of secondary brain injuries.48This might require supplemental oxygen administration or airway control to target oxygen and carbon dioxide levels within the specifi ed ranges. Cerebral perfusion pressures must be maintained by targeting normovolemia and normotension. In case of evidence of cerebral herniation, immediate administration of intravenous mannitol 0.5-1 gram per kg body weight or hypertonic saline (3%) 1-3 mEq per kg body weight is recommended. There is insuffi cient evidence to promote the use of one over the other although hypertonic saline may offer theoretical advantage as it does not exacerbate hypovolemia.49Simultaneously a neurosurgical consultation must be sought.

Exposure
Completely undressing the patient will facilitate assessment of any obvious deformities, at the same time wet clothes will be removed. Log roll may be done at this time to assess the back, and a per rectal examination may also be performed. Subsequently the child should be covered well to prevent hypothermia. In neonates and infants, the head should be wrapped to prevent heat losses from the relatively large surface area. Increasing ambient temperatures may confer some protection against development of hypothermia. Alternatively, radiant heat warmers or forced air warmers may be used.

Adjuncts to Primary Survey
Laboratory studies and imaging constitute important adjuncts to the primary survey. Laboratory studies include but are not restricted to – a complete hemogram, serum chemistry, blood glucose concentration, coagulation profi le, blood type and cross match and blood gases. Although these investigations do not help in identifi cation of any specifi c injury, they are used as a baseline to follow the course of trauma resuscitation. Viscoelastic hemostatic assays like TEG/ROTEM may be used whenever available to formulate the need for blood product transfusion in a patient with signifi cant bleed.50, 51
Screening radiographs may be taken after stabilization of the child. These include lateral views of the cervical spine, anteroposterior view of chest and pelvis. They may aid in identifi cation of life-threatening injuries which were missed by the clinical examination.
A FAST (Focused Assessment with Sonography for Trauma) scan is usually available at most trauma centres as the primary tool for evaluation of an unstable injured patient. It helps in detection of hemopericardium or intra-abdominal fl uid collections as a cause of hemodynamic instability. Although FAST has been used uniformly for the management of adult trauma, its utility in pediatric population remains controversial.52Due to widespread availability, noninvasive and radiation-free nature, there seems to be no rationale to discourage its use in an unstable child. The utility of FAST examination in a stable child with blunt trauma abdomen is less clear.53

Secondary Survey
This is the second more comprehensive head-totoe examination that is undertaken after the primary survey with continuous post-resuscitation monitoring. This includes a detailed history, physical examination and imaging for identifi cation of injuries which may be non-life threatening in nature. Each system is examined thoroughly, though briefl y and a note is made of all the injuries detected at this stage. Fractures causing neurovascular compromise should be reduced and stabilized at this stage to prevent pain and further injury and dislocation. An orthopaedic evaluation should be sought for further management of these fractures. All open wounds should be lavaged and appropriate antibiotics may be administered. Tetanus immunization and analgesia are also addressed at this point.
After a patient has been stabilized, imaging is undertaken to ascertain specifi c injuries which were not detected on screening radiographs. CT scan is the modality of choice to identify intracranial and intraabdominal injuries. It is also the investigation of choice in patients with potential cervical spine injuries. Furthermore, it can help in concluding the need for early operative intervention. To avoid unnecessary radiation-hazard, the mechanism of injury and the clinical status of the patient must be taken into consideration before proceeding for a CT scan.54In a stable child with suspected intraabdominal inury, CT with intravenous contrast is preferred to detect liver, spleen, retroperitoneal injuries, all of which may be managed conservatively, thus obviating the need for surgical exploration. However, ordering a CT scan for every injured child is not justifi ed. Various prediction tools have been suggested to identify patients where the scan may be forsaken.55 The fi nal decision should be individualized as none of the prediction models are accurate. The ‘ALARA principle – as low as reasonably achievable’ may be utilized, should imaging be considered.56

Disposition
The decision for admission must be based on consultation with the surgical team as well as the pediatrician. Severely injured children have improved outcomes when admitted to a pediatric intensive care unit. The patient must be stabilized, and all major injuries diagnosed before shifting to the PICU. The main concept is to admit children requiring continuous monitoring for deterioration or complications of trauma or owing to the nature of injury. Regional or institutional protocols must be established for operative interventions. Patients who remain unstable despite of maximal resuscitative efforts are beyond doubt – candidates for surgical exploration. Additionally, in cases of suspected child abuse, it may be prudent to admit the child for treatment as well as for their protection.

Psychosocial Support and Rehabilitation
Polytrauma can have a lasting impact on the child. Patients and their families may benefi t from psychosocial support – a fact that is often overlooked in the overburdened health care system. A holistic approach is important and a multidisciplinary team comprising of psychotherapists, psychiatrists and social workers along with physiotherapists may help the patient and their families in the long term.

Conclusion
Trauma remains to a leading cause of pediatric mortality world over. It is essential to conform to the ATLS protocols and regional protocols for appropriate management of pediatric trauma. It is important to develop a structured yet focused approach when dealing with children by paying strict attention to the differences in their anatomy and physiology. A thorough physical examination with necessary laboratory and radiographic adjuncts will help in managing these patients in an effi cacious and safe manner in order to attain best clinical outcomes.

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