Trauma
Trauma Overview: Auto Versus Pedestrian
Background
- Trauma causes 50% of all pediatric mortality (leading cause of death in children)
- For every pediatric death, 40 others are hospitalized and 1140 need emergency treatment
- Motor vehicle collisions (50%) > falls (25%) > burns (5%)
- Most common cause of fatalities are due to Head injuries
- In pediatrics, blunt trauma accounts for 90%, whereas penetrating trauma is 10%
- Male >> female (2:1)
- Most deaths occur w/in 24 hours of injury
- High incidence
- In 2007, there was 70,000 pedestrians injured and 4,654 killed in the United States
- “Fatal Triad”
- Skull, pelvis and knee fractures
- Associated mortality of 25%
Know normal vital signs for Pediatric Patients
- Table 1. Vitals by Age
| Age |
Heart Rate (HR) |
Respiratory Rate |
SBP (mmHg) |
DBP (mmHg) |
| Newborn |
90-180 |
30-50 |
60 +/- 10 |
37 +/- 10 |
| 1-5 Months |
100-180 |
30-40 |
80 +/- 10 |
45 +/- 15 |
| 6-11 Months |
100-150 |
25-35 |
90 +/- 30 |
60 +/- 10 |
| 1 Year |
100-150 |
20-30 |
95 +/- 30 |
65 +/- 25 |
| 2-3 Years |
65-150 |
15-25 |
100+/- 25 |
65 +/- 25 |
| 4-5 Years |
65-140 |
15-25 |
100 +/- 20 |
65 +/- 15 |
| 6-9 Years |
65-120 |
12-20 |
100 +/- 20 |
65 +/- 15 |
| 10-12 Years |
65-120 |
12-20 |
110 +/- 20 |
70 +/- 15 |
| 13+ Years |
55-110 |
12-18 |
120 +/- 20 |
75 +/- 15 |
Low-Speed - Auto Vs Adult
- Tibial Plateau Fracture
- Background
- Critical load bearing areas
- Valgus force with axial loading
- Diagnostics
- History/Physical Exam
- Soft tissue injury
- Neurovascular status
- Gentle stress testing
- 50% of the knees have injuries of the menisci and cruciate ligament
- Evaluate for compression syndrome
- Imaging
- Anteroposterior and lateral imaging of the lower extremity
- MRI to assess meniscal, collateral and cruciate ligamentous injury
- Classification
- Type I: wedge or split fracture of the lateral aspect of the plateau
- Type II: lateral wedge or split fracture with associated compression
- Type III: pure compression fracture of the lateral plateau
- Type IV: fracture of the medial plateau
- Type V: split elements of both the medial and lateral condyles, and may include articular compression
- Type VI: complex bicondylar fracture, where the condyles are separate from the diaphysis
- Treatment
- Anti-edema measures
- Joint aspiration
- Rest
- Immobilization, compression, elevation
- Traction
- Debridement of open injuries
- Fasciotomy for impending compartment syndrome
- Nonoperative treatment indications for splinting/casting
- Nondisplaced stable split fractures
- Minimally displaced or depressed fractures
- Submeniscal rim fractures
- Fractures in elderly, low-demand, or osteoporotic patients
- Surgery
- Open plateau fractures
- Fractures with associated compartment syndrome
- Fractures associated with vascular injury
- Knee Ligament Injuries
- Diagnostics
- History/Physical Exam
- Medial collateral ligament
- Excessive valgus force
- Able to ambulate
- Pain and stiffness to the medial knee
- Instability or mechanical symptoms are uncommon
- Palpate with knee in 25-300 of flexion
- Tenderness along MCL
- Isolated tenderness at proximal or distal insertion may indicate avulsion injury
- Swelling is visible
- Valgus stress testing
- Pain with stretching of MCL
- Lateral collateral ligament
- Varus force to the knee
- Able to ambulate
- Pain and stiffness to lateral knee
- Erythema after several days
- Swelling
- Palpate with knee in 200 of flexion
- Tenderness along LCL
- Isolated tenderness at proximal or distal insertion may indicate avulsion injury
- Swelling is visible
- Varus stress testing
- Pain with stretching of LCL
- Injury Severity Grading
- Grade I: < 5 cm laxity
- Grade II: 5-10 cm laxity
- Grade III: > 10 cm laxity
- Imaging
- Mostly clinical
- If concern for fracture: plain radiography
- MRI: to rule out other soft tissue injuries
- Treatment
- MCL
- Grade I: compression, elevation and cryotherapy, short-term use of crutches
- Grade II: short-hinged brace that blocks 200 of terminal extension, but allows full flexion
- Grade III: non-weight bearing, hinged brace
- LCL
- Grade I: compression, elevation and cryotherapy, short-term use of crutches
- Grade II: short-hinged brace that blocks 200 of terminal extension, but allows full flexion
- Grade III: surgical due to rotational instability
Low-Speed - Auto Vs Child
- Head Trauma
- Background
- Head Injuries
- Most common injury in MVCs
- Skull Fractures
- Intracranial hemorrhage
- Cerebral contusions
- Cerebral edema
- Concussions
- Skull Fractures
- Linear skull fractures v depressed skull fractures
- Most MVC patients have large scalp hematomas, palpable step-offs or bony deformities
- Basilar skull fractures
- Battle sign (posterior auricular or mastoid hematomas)
- Hemotympanum
- Cerebrospinal fluid otorrhea or rhinorrhea
- Periorbital ecchymoses (“raccoon eyes”)
- Cranial nerve palsies
- Often associated with intracranial injury even if GCS of 15 and normal neurological exam
- Intracranial Injury
- Diagnostics
- History/Physical Exam
- Altered mental status
- Focal neurological findings on physical exam
- Focal lesions
- Epidural
- Subdural
- Intraparenchymal
- Diffuse injuries
- Cerebral edema
- Diffuse axonal injury
- Injury resulting from acceleration and deceleration forces
- Estimated up to 40% of children with severe traumatic brain injury
- Imaging
- CT of head
- GCS < 14
- Altered level of consciousness
- Palpable skull fracture
- Indications for observation for several hours vs head CT
- Nonfrontal scalp hematoma
- Loss of consciousness > 5 sec
- Severe mechanism of injury
- Rollover
- Ejection from motor vehicle
- Death of another passenger
- Not acting normally (per parent)
- Chest Trauma
- Rib Fractures
- Background
- In children rib fractures indicate a much higher force causing the injury
- Pediatric chest walls are more compliant than adults
- Diagnostics
- History/Physical Exam
- Complain of pain on inspiration and dyspnea
- Tenderness on palpation
- Crepitus
- Chest wall deformity
- Imaging
- Rib radiographs
- Bedside ultrasound
- Treatment
- Possible Rib Fracture-Associated Injuries
- Aortic Injury
- Background
- Rapid deceleration injury as in an MVC
- Approximately 95% of patients die before reaching the hospital
- If suspected: obtain a radiograph
- Diagnostics
- Common History/Physical Exam
- Upper extremity hypertension
- Interscapular murmurs
- Diminished or absent pulses in upper or lower extremities
- Imaging
- Radiographic signs of mediastinal pathology
- Straightening of the mediastinal borders with loss of the anteroposterior window
- Mediastinal diameter greater than that of the hemothorax
- Right shift of on orogastric tube off the vertebral column
- Radiographic signs of aortic disruption
- Widened mediastinum
- Left pleural effusion
- Apical capping
- Depression of the left main bronchus
- Rightward shift of an orogastric tube off the vertebral column
- Fractures of the first or second rib or scapula
- Diagnostic procedure of choice
- Aortography: if stable
- Computed tomography: alternative
- Treatment
- Open repair: surgical intervention
- Pulmonary Contusions
- Background
- Most common pulmonary injury
- From high energy trauma on lung parenchyma
- In pediatric patients often without rib fracture
- Diagnostics
- History/Physical Exam
- Hypoxemia
- Hypoventilation
- Imaging
- Consolidation on chest radiography
- No need for computed tomography
- Treatment
- Aggressive pulmonary toilet
- Pain management
- Oxygen for hypoxia
- Pneumothorax
- Background
- Common in children with blunt trauma
- Decreased/absent breath sounds
- Hypotension: usually with tension pneumothorax
- Immediate treatment
- Needle decompression through the second intercostal space at midclavicular line
- Tube decompression
- Hemothorax
- Background
- Common in children with blunt trauma
- Decreased/absent breath sounds
- Hypotension: with massive hemothorax
- Immediate treatment
- Needs evacuation with tube decompression
- Flail Chest
- Background
- Most serious of blunt chest wall injuries
- Upon inspiration, flail segment is pulled inward by negative intrathoracic pressure
- With exhalation, positive pressure forces segment to protrude outward
- Results in ventilation-perfusion mismatch, atelectasis, and progressive shunting
- Chest radiograph or chest CT is necessary
- Treatment
- Sternal Fractures
- Diagnostics
- History/Physical Exam
- Localized sternal pain
- Dyspnea is present in 15-20%
- Assess for other complications
- Rib fractures
- Flail chest
- Pneumothorax
- Hemothorax
- Pulmonary contusion
- Blunt cardiac injury
- Pericardial tamponade
- Vascular injury
- Pain over fracture site and readily reproducible
- Crepitation or displacement is rare, unless sternum is disrupted with unstable fragments
- Soft-tissue edema or ecchymosis in 40-55% of patients
- Labs/Tests
- Electrocardiogram to assess for cardiac contusion
- Imaging
- Radiographs
- With sternal views to enhance visualization of sternum
- Bedside ultrasound
- As sensitive as plain radiographs
- CT scan
- Most common imaging to make the diagnosis
- Treatment
- Supportive oxygen, cardiac monitoring, IV access
- Initial analgesia is treatment of choice
- Encourage deep breathing to decrease pulmonary complications
- Cardiac Contusion
- Background
- Myocardial contusion is the most common of cardiac injuries
- Bruising due to rupture or hemorrhage of small vessels in the myocardium
- Right ventricle is at greatest risk due to its location
- Cardiac output may decrease:
- Valvular dysfunction
- Decreased preload
- Increased afterload
- Direct injury of the tricuspid or mitral valve
- Diagnostics
- History/Physical Exam
- Pain in the ribs or breastbone
- Palpitations
- Syncope
- Nausea or vomiting
- Short of breath
- Shock
- Needs to be differentiated from tension pneumothorax, neurogenic, and hypovolemic
- Labs/Tests
- Electrocardiogram
- Dysrhythmias
- Diffuse changes in the ST-segment or T-waves
- ST-segments may be elevated or depressed
- T-wave may be flattened or inverted
- Ectopy
- CK-MB isoenzyme may be elevated
- Imaging
- Echocardiography shows
- Ischemic changes
- Atrial premature contractions
- Ventricular premature contractions
- Wall motion abnormalities
- AAST Injury Scale
- Grade I
- Blunt cardiac injury with minor EKG abnormality
- Non-specific ST of T wave changes
- Premature atrial or ventricular contractions
- Persistent sinus tachycardia
- Blunt or penetrating pericardial wound without cardiac injury, tamponade, or cardiac herniation
- Grade II
- Blunt cardiac injury with heart block or ischemic changes without cardiac failure
- Penetrating tangential cardiac wound, up to but not extending through endocardium, without tamponade
- Grade III
- Blunt cardiac injury with sustained or multifocal ventricular contractions
- Blunt or penetrating cardiac injury with
- Septal rupture
- Pulmonary or tricuspid incompetence
- Papillary muscle dysfunction
- Distal coronary artery occlusion without cardiac failure
- Blunt pericardial laceration with cardiac herniation
- Blunt cardiac injury with cardiac failure
- Penetrating tangential myocardial wound, up to but not through endocardium, with tamponade
- Grade IV
- Blunt or penetrating cardiac injury with
- Septal rupture
- Pulmonary or tricuspid incompetence
- Papillary muscle dysfunction
- Distal coronary artery occlusion producing cardiac failure
- Blunt or penetrating cardiac injury with aortic or mitral incompetence
- Blunt or penetrating cardiac injury of the right ventricle, right or left atrium
- Grade V
- Blunt or penetrating cardiac injury with proximal coronary artery occlusion
- Blunt or penetrating left ventricular perforation
- Stellate injuries, less than 50% tissue loss of the right ventricle, right or left atrium
- Grade IV
- Blunt avulsion of the heart
- Penetrating wound producing more than 50% tissue loss of a chamber
- Treatment
- Hypotension
- If stable admit for cardiac monitoring
- Upper Abdominal Trauma
- Background
- Difficult to assess initially because the abdominal exam is often unreliable and inaccurate, with high rate of missed abdominal injuries
- Serial abdominal exams are essential to exclude evolving abdominal problem
- Physical exam signs of the abdominal wall may be an indicator of abdominal injury
- Abrasions and contusions (seat belt sign)
- Abdominal distention
- Tenderness
- Aerophagia leading to massive gastric distention
- Hemoperitoneum
- Splenic Injury
- Background
- Most frequently injured intra-abdominal organ in children
- Results from direct blow to the left upper quadrant
- Diagnostics
- History/Physical Exam
- Left shoulder pain (Kehr’s sign), from diaphragmatic irritation by blood from the spleen
- Left upper quadrant abrasions
- Tenderness
- Abdominal distension
- Labs/Tests
- CBC, CMP, Type and Cross
- Evaluate amount of blood loss
- Imaging
- Abdominal/pelvic computed tomography scan if patient is stable
- Treatment
- If hemodynamically stable
- If hemodynamically unstable despite aggressive resuscitation
- Liver Injury
- Background
- Second most common injured organ
- More severe than splenic injuries because they tend to re-bleed
- Diagnostics
- History/Physical Exam
- Right shoulder pain (Kehr’s sign)
- Upper abdominal or right lower chest pain
- Labs/Tests
- CBC +Diff, BUN/Cr, CMP
- Elevated transaminases are highly suggestive of liver injury
- Imaging
- Abdominal/Pelvic CT mainstay of evaluation
- Treatment
- Typically nonoperative with careful serial reexaminations
- Indications for nonoperative management
- Hemodynamic stability
- Absence of peritoneal signs
- Indications for exploratory laparotomy
- Hemodynamic instability
- Transfusion required within 2 hours of presentation
- Associated retrohepatic vena cava or major hepatic vein trauma
- Pancreatic Injury
- Background
- Rare; most are missed or underestimated initially
- Compression of the pancreas against the rigid spinal column
- If isolated injury, there may be a delay of hours or days before the onset of abdominal symptoms
- Diagnostics
- History/Physical Exam
- Abdominal pain
- Nausea
- Vomiting
- Fever
- Labs/Tests
- CBC +Diff, BUN/Cr, BMP
- Lipase > 1800 IU/L correlates with major pancreatic injury
- Imaging
- Abdominal CT identify traumatic injury to the pancreas
- Visualized transection
- Thickening of the gland with edema
- Peri-pancreatic fluid collections
- Ductal dilatation
- Treatment
- Determined by injury
- Severity
- Location
- Presence or absence of associated abdominal injuries
- Currently no clear recommendation in pediatric patients
- Pseudocyst formation is the main complication of nonoperative management
- Duodenal Injuries
- Background
- Rare type of injury
- Two forms
- Force of trauma disrupts the vessels between the submucosa and muscularis
- Causes development of an intramural hematoma, which may obstruct the duodenal lumen
- Diagnostics
- History/Physical Exam
- Abdominal pain
- Nausea
- Vomiting
- Hematemesis/bilious emesis
- Abdominal distention
- High output in the nasogastric tube
- Labs/Tests
- CBC +Diff, BUN/Cr, BMP
- Elevated serum transaminases, amylase and lipase
- Imaging
- CT is only diagnostic in 60% of cases of duodenal perforation
- Treatment
- Nasogastric decompression
- Surgical
- Small Intestine Injury
- Background
- Much less frequently injured than either the spleen or liver
- Only 2-5% of children with blunt abdominal trauma will have intestinal injury
- Jejunum is the most commonly injured segment of the bowel > duodenum > ileum
- Difficult to diagnose
- Diagnostics
- History/Physical Exam
- Progressive symptoms:
- Peritonitis
- Fever
- Tachycardia
- Diminished urine output over 12-24 hours
- Labs/Tests
- CBC +Diff
- CMP, BUN/Cr, LFTs
- Serial Liver transaminases
- Imaging
- Abdominal radiography
- CT abdomen
- Nonspecific bowel injury
- Moderate-to-large amounts of unexplained fluid
- Unexplained extraluminal air
- Bowel wall enhancement
- Bowel wall thickening
- Bowel dilatation
- Extravasation of contrast
- Multiple fluid-filled loops of bowel
- Treatment
- Broad spectrum antibiotics
- Intravenous fluid resuscitations
- Admit
- Pain Management
High Speed
- Life-threatening multisystem injury
- For every 5 km/h increase in impact speed
- The severity of pedestrian injury increases by average of 3.4 units on the Injury Severity Score (ISS)
- The risk of mortality increases by 4%
- ISS increased for all body regions
- Head and face
- Torso
- Upper extremities
- Lower extremities
- Compared to children, adult pedestrians were more likely to sustain severe injury or mortality
Related Topics
References
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- Gaines BA, Scheidler MG, Lynch JM, Ford HR. Pediatric Trauma. In: Peitzman AB, Rhodes M, Schwab CW, et al; (eds). The Trauma Manual: Trauma and Acute Care Surgery, 3rd ed. Philadelphia, PA:Lippincott Williams & Wilkins, 2008;Chapter 46
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Contributor(s)
- Hughes, Michelle, DO
Updated/Reviewed: November 2023