Signs and Symptoms
History
- AMPLE history is used to obtain a focused history from prehospital providers, caregivers, or the patient: Allergies, Medications, Past medical history, Last meal and menses, and Events leading to the injury
- Obtaining a history should not delay the primary survey
- Mechanism of injury is a relatively poor predictor of injury severity, but may suggest type(s) of injury
- Variables that increase the likelihood of serious injuries include hand lebar injuries, significant passenger space intrusion, and lack of proper restraint in a motor vehicle collision or helmet in a bicycle or skateboard crash
- If the history is changing or inconsistent with injury, consider NAT
Physical Exam
- Primary survey - ABCDE
- Identify and address life- or limb-threatening injuries
- A - Airway and cervical spine immobilization
- Assess for obstruction, pooling of blood/secretions, facial instability, and phonation
- Temporize with suction, chin lift/jaw thrust, and airway adjuncts; proceed to endotracheal intubation if corrective steps unsuccessful
- Cervical spine immobilization is indicated for neurologic deficit, neck pain or guarding, a predisposition to cervical injury (Down syndrome), altered mental status or intoxication, substantial torso injury, or severe mechanism (auto vs. pedestrian, fall from height, diving accident)
- Special considerations: 1) The pediatric glottis is high and anterior; 2) large tongue and tonsillar hypertrophy may obstruct the airway; 3) needle (rather than surgical) cricothyrotomy is recommended for infants and children after failed endotracheal intubation and supraglottic airway placement; 4) the cricoid cartilage is the narrowest portion of the airway in children <8 yr; 5) maintaining a neutral cervical spine and aligning the oral, pharyngeal, and laryngeal axes requires elevating the shoulders/back in an infant due to their prominent occiput
- B - Breathing
- Assess for respiratory rate, breath sounds, chest rise, chest wall tenderness or instability, crepitus, flail segments, paradoxical breathing, oxygen saturation, and ETCO2 to identify pneumothorax (including open and tension), hemothorax, pulmonary contusion, rib fracture, flail chest, hypoxic/hypercapnic respiratory failure, and diaphragm rupture
- Temporize with high flow oxygen via a nonrebreather, bag-valve-mask ventilation, or needle thoracostomy prior to endotracheal intubation and tube thoracostomy; seal open chest wounds with a three-sided dressing
- Special considerations: 1) Compliant chest walls make pulmonary contusions more likely than rib fractures in young children; 2) gastric insufflation with BVM ventilation can compromise ventilation (avoid excessive volumes and place NG tube expeditiously
- C - Circulation
- Assess for evidence of hemorrhage and shock: Delayed capillary refill, cool extremities, diminished peripheral pulses, hypotension (<70 + Age × 2), tachycardia, peritonitis, pelvic fracture, external hemorrhage
- While controversial in children, the FAST exam can identify pericardial effusion and tamponade, large volumes of intraperitoneal free fluid to assist management
- Obtain IV/IO access × 2 (ideally at least one above the diaphragm); femoral central venous access can be considered but is not necessary
- Temporize with compression of external hemorrhage or tourniquet placement, crystalloid bolus (20 cc/kg, repeat), reduction of long bone fractures, and pelvic binding until blood transfusion (10 cc/kg, repeat) and surgical consultation/operative management
- Special considerations: 1) Compensatory mechanisms (tachycardia and vasoconstriction) may maintain blood pressure until loss of up to 45% of blood volume, at which time decompensation abruptly occurs; 2) smaller total blood volume (5 yr old weighing 20 kg, 80 cc/kg = 1.6 L total blood volume); 3) nonoperative management of high-grade splenic and liver lacerations is increasing; 4) anterior tibia then distal femur and medial malleolus are preferred sites for IO access
- D - Disability
- Assess for level of consciousness using pediatric GCS or AVPU, pupil size and reactivity, and extremity movement and tone
- Interventions: Restrict spinal movement, intubate for GCS <9 or rapid decline; if suspected increased ICP/impending herniation raise head of bed to 30°, give hypertonic saline or mannitol, temporarily hyperventilate, and avoid hypotension and hypoxia
- E - Exposure
- Undress to assess completely for injuries, log roll to evaluate back while maintaining spinal immobilization and perform rectal exam if indicated
- Special consideration: Due to their large surface area to volume ratio, children are at higher risk for hypothermia, leading to greater metabolic demand and coagulopathy
- Secondary survey
- Once life and limb threats ruled out or addressed, perform a head-to-toe injury assessment; key physical exam findings and pediatric considerations listed below by system
- If patient deteriorates during secondary survey, repeat the primary survey
- HEENT: Bulging fontanel, scalp hematomas, lacerations, midface instability, auricular and septal hematomas, hemotympanum, CSF leak. Fundoscopy for hemorrhage to R/O NAT
- Open sutures/fontanelle or multiple skull fractures may delay signs of increased ICP
- Chest: Reassess breath sounds, tenderness, crepitus, and breathing pattern
- Elasticity of chest wall allows for pulmonary injury without rib fractures
- Rib fracture (esp posterior) may suggest NAT
- Abdomen: Bruising, seat belt sign, and tenderness
- Distention often due to gastric air
- The spleen and liver are anterior, poorly protected, and prone to injury in children
- Genitourinary: Perineal lacerations/hematomas, blood at urethral meatus, pain on palpation of pelvic ring
- Children's kidneys are less protected and more mobile than adult's, making them susceptible to deceleration injury
- Bladder is intra-abdominal in children <2 yr
- Rectal exam for “high-riding prostate” unnecessary
- Extremities: Palpate all bones, range all joints, and assess compartments
- Fractures are relatively more common than ligamentous injury in children than adults
- Salter-Harris classification of physeal injury
- Neurologic exam: Mental status, movement and sensation of extremities
- Due to their large head and high fulcrum, children <8 yr are prone to upper cervical spine injuries
- Elasticity of the vertebral column predisposes children to ligamentous and spinal cord injury without fracture
- Skin: Bruising, capillary refill, and pallor
- Bruising of the ears, dorsa of the feet, or genitalia may suggest NAT
- Patterns of injury:
- Auto vs. pedestrian: Waddell triad - femur fracture, torso injury, and head injury
- Hand lebar injuries: Pancreatic, hollow viscous or mesenteric injury
- Lap belt syndrome: Abdominal seat belt sign with bowel injury and Chance fracture
- Minor trauma history with major injury - consider NAT
Essential Workup
- History and physical exam are the only mand atory components to the evaluation of children who present following trauma
- Routine labs and imaging are not recommended; workup should be determined according to each patient's clinical presentation
Diagnostic Tests & Interpretation
Lab
- Lab tests should generally be individualized, reflecting the patient's clinical presentation
- A normal initial hemoglobin does not rule out a significant hemorrhage but will provide a baseline value for later comparison
- Check blood glucose for any child with altered mental status following trauma
- Initial electrolyte measurement is unnecessary
- Routine amylase and lipase are not recommended because of low incidence of pancreatic injuries and high false-positive rate
- Liver function tests may be helpful in the evaluation of pediatric blunt abdominal trauma in combination with the physical exam; AST >200 U/L or ALT >125 U/L are highly associated with intra-abdominal injury but cannot be used in isolation to rule out injury
- If NAT is suspected, CT abdomen/pelvis should be obtained for AST/ALT >80 U/L
- Gross hematuria (>50 RBC/HPF) is concerning for renal or urinary tract injuries
- Type and cross-match should be sent for any patient who may require a blood transfusion
- Hemodynamically unstable and severely injured children should have PT/INR, pH, base excess, lactate, and fibrinogen sent
- A pregnancy test is indicated for adolescent females
- Diagnostic peritoneal lavage or aspiration is rarely used in the era of CT
Imaging
- C-spine, chest, and pelvis radiographs should not be obtained routinely; selective approach is appropriate
- CXR is indicated for an abnormal thoracic examination, hemodynamic instability, severe mechanism, or after endotracheal intubation or thoracostomy tube placement
- Pelvic x-ray is seldom useful in hemodynamically stable children; significant pelvic pain or instability warrants CT imaging
- Cervical spine imaging can be safely avoided in children who are alert without neurological deficit, midline cervical tenderness, painful distracting injury, unexplained hypotension, intoxication, or severe mechanism/concern for NAT (if <3 yr)
- Cervical x-rays are adequate unless there is concern for atlanto-occipital dislocation or atlantoaxial rotatory fixation based on mechanism or exam
- The term spinal cord injury without radiologic abnormality (SCIWORA) does not have the same implications in the era of CT and MRI; obtain an MRI after negative CT in children with neurologic symptoms (even transient)
- Pseudosubluxation (anterior displacement of C-2 on C-3) occurs in 20% of normal patients
- Children <2 yr:
- CT head for AMS or palpable skull fracture
- CT head vs. observation for nonfrontal scalp hematoma, LOC >5 s, not acting normal per parents, or severe mechanism
- Children ≥2 yr:
- CT head for AMS or signs of basilar skull fracture
- CT head vs. observation for LOC, severe headache, vomiting, or severe headache
- CT abdomen/pelvis can be avoided in children at very low risk of intra-abdominal injury who meet the following criteria: GCS ≥14 without evidence of abdominal wall trauma or seat belt sign, abdominal pain, tenderness, vomiting, thoracic wall trauma, or decreased breath sounds
- Negative predictive value of a normal abdominal CT is 99.6%
- CT chest is unnecessary unless there is concern for thoracic vascular injury, tracheobronchial injury, or an abnormal x-ray suggesting significant injury
- The utility of the focused abdominal sonography for trauma (FAST) exam in children needs further study but should not be used to rule out intraperitoneal hemorrhage
Differential Diagnosis
NAT should be considered when the history is inconsistent with the injury
Disposition
Admission Criteria
- Patients requiring operative intervention; ongoing hemodynamic, neurologic, respiratory, or laboratory monitoring; blood transfusion; endotracheal intubation; thoracostomy tube placement; ongoing IV or regional pain control should be admitted or transferred to a pediatric trauma facility
Discharge Criteria
- Children with stable vitals, normal mental status, the ability to ambulate (if age appropriate) and tolerate PO, normal labs and imaging (if obtained), and reassuring physical exam can be discharged home to reliable caregiver after observation
Follow-up Recommendations
- Specialists as indicated by injury
- Psychiatric evaluation may be indicated for evidence of posttraumatic stress for child and family
- Primary care provider prior to return to play after concussion
- American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual. 9th ed.Chicago, IL: American College of Surgeons; 2012.
- American College of Surgeons Committee on Trauma. Withholding or termination of resuscitation of pediatric out-of-hospital traumatic cardiopulmonary arrest . Ann Emerg Med. 2014;63:504-515.
- GoldenJ, IsaniM, BowlingJ, et al. Limiting chest computed tomography in the evaluation of pediatric thoracic trauma . J Trauma Acute Care Surg. 2016;81:271-277.
- HaaszM, SimoneLA, WalesPW, et al. Which pediatric blunt trauma patients do not require pelvic imaging?J Trauma Acute Care Surg. 2015;79:828-832.
- HannonM, MannixR, DorneyK, et al. Pediatric cervical spine injury after blunt trauma: A clinical decision analysis . Ann Emerg Med. 2015;65:239-247.
- HolmesJF, LillisK, MonroeD, et al. Identifying children at very low risk of clinically important abdominal injuries . Ann Emerg Med. 2013;62:107-116.
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