Management of Pediatric Trauma

dr. Riana P. Tamba, Sp.B, Sp.BA

Riana P. Tamba
Department of Surgery, Division of Pediatric Surgery, Faculty of Medicine, Universitas Indonesia, Cipto
Mangunkusumo Hospital, Jakarta, Indonesia

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More than 45% of all deaths in children from 1 to 14 years are
the result of trauma

Rates of 80% have been reported in patients with combined

thoracoabdominal injuries

Pediatric thoracic trauma is overwhelmingly caused by blunt

mechanisms

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 EPIDEMIOLOGY
• #The leading cause of morbidity and mortality of children older than
the age of 1 to 14 years

The Centers for Disease Control and Prevention

report that more than 50,000 children died in
motor vehicle accidents from 1999 to 2006,
the largest single cause of death in the
pediatric population.

Sharma Mukesh, Lahoti K B, Khandelwal Gaurav et al. Epidemiological trends of pediatric trauma : A single-center
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study of 791 patients. Journal of Indian Association of Pediatric Surgeons. 2011 Jul-Sep; 16(3): 88–92.
Sharma Mukesh, Lahoti K B, Khandelwal Gaurav et al. Epidemiological trends of pediatric trauma : A single-center
study of 791 patients. Journal of Indian Association of Pediatric Surgeons. 2011 Jul-Sep; 16(3): 88–92. 4
 Incidence and Mortality from the Major Categories of
Pediatric Trauma

By Injury Mechanism Incidence (%) Mortality (%)

Blunt 92 3
Fall 32 0.3
Motor Vehicle Accident 25 3
Struck by, against 11 0.5
Pedal cyclist, other 3.7 0.25
Penetrating 8
Gunshot wound 4.5 12
Stabbing 3.5 1.3

Data from the American College of Surgeons, National Trauma Data Bank 2012
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 Etiology
Pediatric thoracic trauma is overwhelmingly caused by blunt mechanisms.

The most common causes of pediatric blunt chest trauma are :

Falls
Motor Vehicle Collisions (MVCs)
Pedestrians struck by vehicles

The most common injuries after blunt thoracic trauma :

Pulmonary contusions
Rib fractures
Pneumothorax
Hemothorax
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 Incidence and Mortality of Injuries to Thoracic and Abdominal
Organs

Organ Incidence (%) Mortality (%)

Thoracic
Lung 52 18
Pneumothorax/hemothorax 42 17
Ribs/ Sternum 32 11
Heart 6 40
Diaphragm 4 16
Great Vessels 2 51
Bronchi <1 20
Esophagus <1 43

Holcomb W George, Murphy Patrick J, Ostlie J Daniel. Ashcraft’s Pediatric Surgery 6th Ed : Early Assessment
and Management of Trauma. 2014. p:180. 7
THORACIC TRAUMA

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Children have unique anatomic and physiologic that are salient to the
diagnosis and management of chest injuries :

• The head of infant is proportionally much larger than adult, thus predisposising to
neck flexion and occlusion of the airway in the supine position

• The larger tongue and soft palate, as well as the more anterior glottis, can make
the airway difficult to visualize

• The child’s trachea is shorter relative to body size, and narrower and more easily
compressed compared with an adult

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• The subglottic region is the narrowest part of the trachea in children. Because of its
small cross-sectional diameter, the pediatric airway is more suspectible to plug with
mucus or minimal airway edema

• The chest wall is more compliant in children, with less muscle mass for soft tissue
protection

• Increased risk for hypoxia owing to their higher oxygen consumption per unit body
mass and their lower functional residual capacity to total lung volume ratio

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• The mediastinum is more mobile in children than in older patients

• Infants and children also have a higher body surface area to weight ratio than adults,
which predisposes them to hypothermia

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 Early management in emergency care

Primary Survey :
Airway : clear and maintain, protect cervical spine
Breathing : ventilate and oxygenate, fix chest wall
Circulation : Control Bleeding, restore volume
Disability : GCS and pupils
Exposure : Disrobe, logroll, avoid hypothermia, foley catheter
unless contraindicated, Gastric tube unless
contraindicated

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 Early management in emergency care

Secondary Survey

History & Physical : SAMPLE (Symptoms, Allergies, Medications,

Past Illness, Last Meal, Events and
Environment) history, complete examination

Imaging studies : Plain radiographs, special studies

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SPECIFIC INJURIES AND MANAGEMENT

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 Rib Fractures

Rib fractures are often suspected on physical examination and are

identified on a chest radiograph (CXR) during the initial assessment

The management of rib fractures is typically supportive. Attention to adequate

pain relief will prevent atelectasis and pneumonia. Because rib fractures can be
associated with a hemothorax or pneumothorax, immediate drainage of fluid,
blood, or air via a chest tube or catheter is appropriate.

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 Hemothorax

Hemothorax can result from blunt or penetrating injury to any of intrathoracic

vessels, the chest wall vessels, the pleura, or the pulmonary parenchyma.

Prompt chest tube placement allows for the evacuation of the blood from the
pleural space and re-expansion of the lung. It also allows the surgeon to assess the
volume of blood loss and whether the hemorrhage is ongoing.

After tube thoracostomy, the immediate blood return of 15 ml/kg, or ongoing

losses of 2-3 ml/kg/h for 3 or more hours, are indicators for thoracic exploration.

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 Hemothorax

If undrained, the hemothorax can become organized with the development of a

fibrothorax that can cause a restrictive lung defect.

However, there are also data to suggest that thrombolytic therapy is equally
effective in treating a chronic hemothorax.

The use of intrapleural tissue plasminogen activator (tPA) has also been used for
the treatment of traumatic residual hemothoraces and other parapneumonic
processes with good results.

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 Open Pneumothorax

The negative pressure in the pleural cavity created by spontaneous breathing sucks
air into thorax.

Treatment requires placement of an occlusive dressing to prevent further air from

entering the chest cavity as well as chest tube or catheter insertion to drain a
hemo/pneumothorax thay may be developed.

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 Liver and Spleen

Close to 90-95% of injuries to the liver and spleen in children can be managed
nonoperatively.

Nonoperative management (NOM) is dependent upon the accurate diagnosis and

staging of the injured organ, usually by CT imaging at present.

In order to be a candidate for NOM, the child should have normal hemodynamics,
and be monitored closely for signs of ongoing hemorrhage.

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 Liver and Spleen

Based on the present data, the non-operative treatment of haemodynamically

stable paediatrics patients with liver injury seems safe : complications are rare
and in the present series, the success rate of NOT (Non Operative Treatment) is
96% which is in accordance with the literature.

CT Scan is seen by many as the gold standart for diagnosing traumatic intra-
abdominal injury in children.

In children, “Focused Assessment with Sonography in Trauma” (FAST) has a high

specifity for the presence of hemoperitoneum (83-98%) but a low sensitivity.

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 Liver and Spleen

Based on the present data, the non-operative treatment of haemodynamically

stable paediatrics patients with liver injury seems safe : complications are rare
and in the present series, the success rate of NOT (Non Operative Treatment) is
96% which is in accordance with the literature.

CT Scan is seen by many as the gold standart for diagnosing traumatic intra-
abdominal injury in children.

In children, “Focused Assessment with Sonography in Trauma” (FAST) has a high

specifity for the presence of hemoperitoneum (83-98%) but a low sensitivity.

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 Liver and Spleen

The goal of initial operative exploration is to stop bleeding and control damage
control.

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 Abdominal Compartement Sydrome

Abdominal compartment syndrome (ACS) is defined as sustained intra-abdominal

hypertension (IAH) that is associated with the new onset organ dysfunction or
failure. ACS is associated with a 40-60% mortality in children.

The current proposed working definition for ACS in children is an elevated intra-
abdominal pressure (IAP) of 10 mmHg or greater with the development of new or
worsening multiorgan failure.

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 Abdominal Compartement Sydrome

Initial management strategies in the trauma patient include improving abdominal

wall compliance via adequate sedation and paralysis, evacuation of intraluminal
intestinal contents, evacuation of large abdominal fluid collections, optimization
of fluid administration by goal directed therapies and correcting positive fluid
balance, and optimization of abdominal perfusion pressure.

In the unstable trauma patient who requires an emergent laparotomy and massive
fluid resuscitation, maintaining an open abdomen with planned staged closure may
prevent the development of ACS but often needs to be performed prophylactically.

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 Abdominal Compartement Sydrome

The goals of operation are to decrease the elevated IAP to stop organ dysfunction,
allow room for continued expansion of the viscera during ongoing resuscitation,
provide temporary abdominal closure, prevent excessive fascial retraction, and
allow a means for continued evacuation of fluid from the abdominal cavity.

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 Pancreatic Injury

CT scan with IV contrast is the preffered imaging study

In unusual cases, magnetic retrograde cholangiopancreatography (MRCP) can be

helpful.

ERCP, if available, may be helpful in determining whether there is a major ductal

injury, and may have a potential therapeutic role, but it is an invasive and a
technically challenging procedure

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 Renal Trauma

The susceptibility of children for major renal trauma compared to adults appears
in part secondary to the fact that the kidney occupies a relatively larger amount
of the retroperitoneal space, the thoracic cage is less well ossified, the
abdominal musculature is weaker, and there is less cushioning from perirenal fat.

Patients with renal trauma typically present with gross hematuria and flank pain.

The diagnosis is confirmed by abdominal CT scan which is highly sensitive.

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 Renal Trauma

The main indications for immediate exploration in a child with a renal injury are
hemodynamic instability, penetrating mechanism, and associated non-renal
injuries.

Stable patients with high grade injury are typically placed at bed rest with serial
exams, blood counts, and close hemodynamic monitoring until the gross
hematuria resolves

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Muñiz Antonio. Pediatric Emergency Medicine Practice : Evaluation and Management of Pediatric Trauma. EBMedicine. 2008;
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5: 1-32.
Muñiz Antonio. Pediatric Emergency Medicine Practice : Evaluation and Management of Pediatric Trauma. EBMedicine. 2008; 5:
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1- 32.
 Algorithm for the Evaluation of Blunt Thoracic Trauma

Nesbit E, Chadd. Considerations in Pediatric Thoracic and Abdominal Trauma. Trauma in Children 2011: 18-27. 31
 Early Assessment and Management of Chest Injuries in Childhood

Holcomb W George, Murphy Patrick J, Ostlie J Daniel. Ashcraft’s Pediatric Surgery 6th Ed : Thoracic
Trauma. 2014. p:190-197. 32
 Indications for Early Operation in Abdominal Trauma in Childhood

Holcomb W George, Murphy Patrick J, Ostlie J Daniel. Ashcraft’s Pediatric Surgery 6th Ed : Abdominal and Renal
Trauma. 2014. p:200-211. 33
 Pediatric Trauma Cases in
dr Cipto Mangunkusumo Hospital

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Trauma ginjal kiri grade IV ec
trauma tusuk tembus flank kiri
Trauma tumpul abdomen dengan
hemodinamik stabil.
Susp Ruptur total a. Femoralis sinistra
Skin loss dan open degloving regio
thorak, abdomen, dan femoral
bilateral dengan exposed
peritoneum, vena femoralis sinistra
dan testis
Ruptur vesika urinaria intraperitoneal dengan peritonitis umum ec trauma
tumpul abdomen
Prolaps ileum
Fraktur pelvis MTA 1