Management of Pediatric Trauma - Unsyiah

Nasional Symposium & Workshop “Aceh Surgery Update 2”, Banda Aceh 16 – 17 September 2017 1

Management of Pediatric Trauma

dr. Riana P. Tamba, SpBA

Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, Universitas

Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia ABSTRAK

Lebih dari 45% semua kematian pada anak umur 1-14 tahun disebabkan oleh trauma. 80%

terjadi pada pasien dengan trauma torako-abdominal. Sebagian besar trauma thoraks pada

anak disebabkan oleh benda tumpul. Kontusio paru, fraktur iga, pneumothoraks dan

hemothoraks merupakan cedera yang paling sering terjadi setelah trauma tumpul pada

thoraks dan organ padat, hati dan limpa merupakan organ yang paling sering cedera setelah

trauma abdomen. Pilihan tes diagnostik untuk menilai trauma thoraks adalah X-ray dada dan

CT scan dada dan untuk evaluasi awal dan diagnosis trauma abdomen adalah tes

laboratorium, CT scan abdomen dan Focused Abdominal Sonography for Trauma (FAST).

Semua anak dengan trauma sebaiknya dievaluasi dan ditatalaksana menggunakan prinsip

Advanced Trauma Life Support (ATLS), Primary Survey dan Secondary Survey. Hal ini

membutuhkan pemahaman mengenai perbedaan anatomi dan fisiologi antara anak dan

dewasa. Evaluasi ABCs merupakan suatu proses dinamis yang membutuhkan penilaian

simultan dan resusitasi, maupun penilaian persisten sampai anak stabil secara hemodinamik.

Selanjutnya, secondary survey dilakukan untuk menilai pasien dan penanganan cedera

tambahan yang tidak ditemukan pada primary survey dan juga untuk mendapatkan riwayat

yang lebih lengkap dan detail. Penanganan trauma pada anak tidak selalu operasi. Abstract

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. Pulmonary contusions, rib

fractures, pneumothorax, and hemothorax are the most common injuries after blunt thoracic

trauma and the solid organs, liver and spleen, are most frequently injured in abdominal

trauma. The diagnostic test of choice to assess chest injury is chest X-ray and CT scans of the

chest and to intial evaluation and diagnosis abdominal injuries is laboratory testing, CT

Scan abdomen and Focused Abdominal Sonography for Trauma (FAST). All injured children

should be evaluated and managed according to the principles of the Advanced Trauma Life

Support (ATLS), Primary Survey and Secondary Survey. It requires sufficient knowledge of

the anatomic and physiologic differences between children and adults. Evaluation of the

ABCs is a dynamic process that requires simultaneous assessment and resuscitation, as well

as persistent reassessment until the child is hemodynamically stable. Next, the secondary

survey is designed to assess the patient and treat additional injury not found on the primary

survey and also to obtain a more complete and detailed history. Management of pediatric

trauma is not always need an operation. Keywords : Pediatric trauma, thorax, abdominal


Epidemiology

Injury is the leading cause of death of children older than the age of 1 year, and, in this

population exceeds all other causes of death combined. Injury results in more years of life

lost than sudden infant death syndrome, cancer, and infection combined. Most deaths in the

youngest children are from unintentional injury, but homicide and suicide become more

prevalent as the population nears young adulthood. 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 and adolescent population. Non-fatal

injuries take an even greater toll on the pediatric population. Male children have a higher rate

of visits than females, while younger children have higher visit rates than older children.

About 40% of the yearly ED visits are for traumatic injury. The International Classification

of Diseases (ICD) codes for “unintentional fall” and “unintentional struck by/against”

account for most of these visits.1

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

5000 traumatic deaths per year occur within this age group; 80% of these mortalities were

unintentional and 47% directly related to motor vehicle collisions (MVCs). Injury accounts

for approximately 5% of infant deaths as well. Nationwide estimates of mortality for children

hospitalized after injury are uniformly low; however, most fatalities occur in the field before

arrival at a health care facility. This contributes to an underestimation of the magnitude of

overall mortality figures. The most common single organ system injury associated with death

in injured children is head trauma. Rates of 80% have been reported in patients with

combined thoracoabdominal injuries. Within the subset of MVC, death rates begin to climb

steeply in children 13 years of age and beyond. MVC mortality statistics demonstrate that the

youngest occupant in the vehicle is the most vulnerable to injury. Within the school-age

group of 5 to 9 years old, pedestrian injuries and bicycle crashes predominate. Submersion

injury accounts for 10% to 15% of injury, burns 5% to 10%, and falls from heights

approximately 2%. Nationwide, the number of children who are victims of violent acts has

decreased by 39% from 1994 to 2004. Even with this significant decline, 13% of all traumatic

deaths in the age group of children 1 to 14 years old were a result of homicide in 2004.2

Etiology

Pediatric thoracic trauma is overwhelmingly caused by blunt mechanisms. The most common

causes of pediatric blunt chest trauma are motor vehicle collisions (MVCs), pedestrians struck by

vehicles, and falls. The vast majority of these are deemed accidental. There are patterns that are

somewhat predictable based on age. MVCs and abuse are the leading causes of chest trauma for

infants and toddlers. Once children start to attend school, pedestrian accidents come into play;

impulsivity can lead them to run into the paths of cars, or their inquisitive nature causes them to

play or hide around cars. As they age, skateboarding and cycling start to emerge as causes of

significant trauma. Pulmonary contusions, rib fractures, pneumothorax, and hemothorax are the

most common injuries after blunt thoracic trauma. Aortic, esophageal, diaphragmatic, cardiac,

and tracheobronchial injuries are uncommon in children.3 Unfortunately thoracic trauma is rarely

a child‟s only injury, as more than 50% will


have more than one intrathoracic injury while about 70% will have additional extrathoracic

injuries. 1

Peclet and colleagues report that in children with multiple injuries, death is 10 times more

likely if a thoracic injury is present. Likewise, the vast majority of pediatric abdominal

trauma is from blunt mechanisms. The most common causes are associated with MVCs,

handlebar injuries, and intentional injury. The pattern of injury changes with age. Children

younger than 2 years of age are the most likely to suffer intentional injury, while older

children are typically involved in physical activities that may lead to injury. They may suffer

collisions during bicycling, sledding, snowboarding, sporting activities, or aggressive play.

The solid organs, namely liver and spleen, are most frequently injured. Bowel, bladder, and

kidney injuries also occur, but are much less frequent. Penetrating thoracic and abdominal

trauma, when it does occur, is usually the result of violence. Stabbing and gunshot wounds

are the most common mechanisms seen as the pediatric population approaches adulthood.

The majority of these types of injuries will likely require operative intervention. 1

Pathophysiology

Children differ considerably from adults anatomically and physiologically. Proportionally

different, children have larger heads than adults, raising their centers of gravity and

contributing to different patterns of injury than seen in adults. Thoracic trauma accounts for

about 5% of injuries in hospitalized children, but is the second leading cause of death in

pediatric trauma. Differing injury patterns are partially due to the flexibility of pediatric

thoracic structures. The chest wall of a child is elastic and pliable due to increased

ligamentous laxity, less rib mineralization, and incomplete ossification of the ribs. Instead of

breaking, children‟s ribs bend when compressed, transmitting more energy to the lungs and

thoracic contents. In addition, the mediastinum of children is more mobile. Consequently,

large pneumothoraces or hemothoraces can cause dramatic mediastinal shift, resulting in

more respiratory or vascular compromise than adults. Lastly, the higher metabolic demands

and decreased pulmonary function residual capacity of children results in faster development

of hypoxemia.4

Abdominal trauma accounts for about 10% of all pediatric trauma admissions, and the

abdomen ranks second in the list of most commonly injured sites. The abdominal walls of

children are thinner, with less developed musculature and fat, than those of adults. This

provides less protection to the abdominal organs, allowing the transmission of greater force

to the abdominal and retroperitoneal organs. Proportionally, the abdominal organs of a child

are also larger, providing a greater surface area over which to absorb force. Additionally, the

mesentery is less adherent in children, allowing for greater mobility of some organs, possibly

contributing to greater bowel injury in deceleration type trauma such as MVCs or falls from a

height. Seemingly minor injuries involving handlebar-to-abdomen impacts are associated

with injuries to the small bowel and pancreas and are actually a greater risk for injury than

flipping over the handlebars. The bladder of very young children is partly located in the

abdomen, descending into the pelvis as they age. Thus, bladder injury should also be

considered in the younger child presenting with abdominal trauma. 5


Abdominal trauma in children should also raise concern for spine injury. The spinal columns

of children have significantly greater ligamentous laxity, less supporting musculature, and a

higher fulcrum of flexion than those of adults. Children restrained only by a lap belt may

suffer the so-called “lap belt syndrome” of abdominal wall injury, intra-abdominal organ

injury, and vertebral fracture.1

The physiological differences between children and adults can lull us into a false sense of

security based on “normal” vital signs taken out of context with the overall picture of the

patient. Children‟s vital signs vary significantly with their age, and it is important to realize

that normal vitals signs in one age group may be an ominous sign in another group. A

minimum systolic blood pressure can quickly be calculated by multiplying the age in years of

the child by 2 and adding 70 to the result. The finding of hypotension in an injured child is

ominous, as children have a greater capacity to compensate for volume loss, and may occur

later in children than it does in adults. Normal or nearly normal vital signs do not exclude

significant hypovolemia secondary to blood loss. Children may lose 30% of their blood

volume before showing the obvious signs of shock. Frequent vital sign checks are imperative.

Simply having a child on continuous monitoring may be insufficient, as the numbers may be

deceivingly reassuring. Altered mental status, tachycardia, tachypnea, and diaphoresis may

also be indicators of hypoperfusion with impending decompensation. Speaking with the

child, if he or she is verbal and old enough, may better allow the additional assessment of

perfusion of the brain based on mental status. Helping calm an otherwise frightened and

anxious child is an additional benefit.1

Clinical Features

Physical exam findings on children with thoracic injuries may include chest crepitance,

subcutaneous emphysema, nasal flaring, diminished or absent breath sounds, tachypnea,

dyspnea, or low oxygen saturation. Children with significant thoracic injury may have very

little in the way of external signs of trauma due to compliance of the chest wall. Remember

that a normal external superficial exam does not exclude significant internal injury. 1

Signs of abdominal injuries include abrasions, abdominal tenderness, or distention, Cullen‟s

sign (ecchymosis in the periumbilical region), Turner‟s sign (lateral abdominal wall

ecchymosis), and vomiting. There is debate about the importance of the “seat belt sign,”

which is abdominal erythema, ecchymosis, or abrasions across the abdomen. At the very

least, signs of external abdominal injury should alert the team to the potential presence of

internal injury that will necessitate further examination and possible imaging or lab studies to

assess for injury.1

Diagnostic Studies

In children, however, there is less literature on the subject. It is undisputed that the use of CT

scan uncovers many injuries, but does the detection of these injuries affect management and,

ultimately, outcomes of patients? Commonly used to evaluate trauma patients. Despite this

finding, Fenton and colleagues showed that CT scans of the chest are most likely to show

injury in excess of a screening chest X-ray. The diagnostic test of choice to assess intra-


abdominal injury in stable trauma patients is rapid abdominal CT scanning. The role of

diagnostic peritoneal lavage (DPL) and Focused Abdominal Sonography for Trauma (FAST)

is somewhat more limited although the FAST exam is gaining more acceptance. As with all

of these tests, the finding of intraperitoneal hemorrhage alone is not an indication for surgery

in the pediatric patient Similarly, a retrospective review of 333 pediatric trauma patients by

Markel and colleagues found that conventional chest X-ray remained an acceptable screening

tool to evaluate for thoracic trauma. Of the six patients that required emergent surgery for

cardiac or arterial compromise, all the injuries were seen on chest X-ray or the scout view of

the chest CT. Unfortunately, 5% of chest X-rays in their series falsely reported normal

findings that may have ultimately altered management.6

There are similar findings when abdominal trauma is considered. In the past, abdominal

injuries were diagnosed and managed mainly through an exploratory laparotomy. Today,

however, about 95% of children with liver or spleen injuries are managed non-operatively.

Holmes and his group reported that 95% of 1,818 patients with solid organ injury were

managed non-operatively. The median time to failure (requiring operative intervention) for

the remaining 5% was only three hours. The non-operative approach decreased lifetime risk

of asplenic sepsis and was associated with shorter hospital stays, fewer blood transfusions,

and decreased overall mortality. As most abdominal injuries are managed expectantly via

cautious observation, the question becomes “Is any imaging necessary initially?” The

decision to operate should ultimately be based on the patient‟s physiologic response to the

injury, not the imaging findings.6

Although CT scans provide invaluable information, are there alternatives for the detection of

serious thoracic and abdominal injuries? As outlined above, the routine chest X-ray,

combined with physical examination, provides excellent information about the likelihood of

serious thoracic injury. The use of ultrasound and diagnostic peritoneal lavage (DPL) for the

evaluation of abdominal injury requires further evaluation. The use of ultrasound assessment

of the abdomen is routine in many adult trauma centers and the focused abdominal

sonography for trauma (FAST) exam is an adjunct to the ATLS protocols for management of

trauma patients. Intuitively, pediatric patients seem ideal for a FAST exam as they have small

abdominal cavities without large abdominal fat deposits. However, there is considerably less

evidence of the utility of FAST in assessment of pediatric trauma. A paper by Eppich and

Zonfrillo reviews the literature regarding management of blunt abdominal trauma. In this

review, based on four papers, they note that FAST in children for the detection of blunt

abdominal trauma demonstrates variable sensitivity (55%–92.5%) and negative predictive

value (50%–97%) but consistently good specificity (83%–100%) when compared to

abdominal CT scanning. While the FAST exam does miss some patients with free fluid, the

clinical significance of this is not clear given that most abdominal injuries in children are

managed expectantly. One of the four papers, that by Soudack and colleagues, concludes that

a positive FAST exam necessitates further “definitive imaging.” The use of DPL has fallen

out of favor given the discomfort to the patient and lack of specificity of the exam. It is not

recommended for the assessment of an isolated abdominal injury, but is useful to diagnose

children with abdominal trauma who sustained multiple injuries and require immediate


surgery for another injury, often a subdural or epidural hematoma. Can laboratory testing

help in identifying children who should undergo CT scans for injuries? Capraro, Mooney,

and Waltzman examined the utility of the “trauma panel” in the assessment of blunt

abdominal trauma. In a retrospective review of 382 pediatric patients, they found that none of

their regularly tested chemical or hematological parameters had sufficient sensitivity or

negative predictive value to be helpful as a screening tool. Cotton and Beckert considered

both clinical and laboratory data. They determined that 23 variables were potentially

associated with intra-abdominal injury. Logistic regression identified four positive predictors

for injury: tenderness, abrasions, ecchymosis, and elevated ALT. Holmes and colleagues

published two papers in May 2002 addressing this subject in both abdominal and thoracic

trauma. They derived clinical decision rules to identify children with thoracic or intra-

abdominal injuries after blunt trauma. The prospective series for abdominal trauma enrolled

1,095 children younger than 16 years with blunt trauma. They identified 107 patients with

intra-abdominal injuries. Statistical analysis identified six findings associated with abdominal

injury: low systolic blood pressure, abdominal tenderness on exam, femur fracture, serum

AST >200 U/L or serum ALT >125 U/L, urinalysis with >5 RBCs per high-powered field,

and an initial hematocrit of less then 30%. Of the 107 children with an intra-abdominal

injury, 105 had at least one of these findings, while absence of any of the six was seen in all

but two children with injury.5

Initial Evaluation and Diagnosis of Abdominal Injuries

Laboratory Testing

Studies using sophisticated regression analyses have demonstrated that elevations of aspartate

aminotransferase (AST) and/or alamine aminotransferase (ALT), in combination with an

abnormal physical examination, correlate with the presence of intra-abdominal injury,

although the tests are not diagnostic for a particular injured organ. Elevations in AST or ALT,

or abnormal physical examination findings (such as bruising, distention, or tenderness) may

indicate the need for further abdominal imaging looking for occult injury. 7

Computed Tomography

Computed tomography (CT) with intravenous contrast (IV) is the preferred modality for the

diagnosis of intra-abdominal injuries in hemodynamically stable children. Upwards of 95%

of liver, spleen, and renal injuries can be diagnosed and staged by CT. Injuries to the intestine

and pancreas are more difficult to definitively diagnose by CT.7

It has been suggested that in young children who lack visceral fat, the addition of oral

contrast to the standard IV contrast may be helpful, especially in evaluating the duodenum

and pancreatic head. Intravenous contrast, however is essential for the evaluation of traumatic

injuries. If IV contrast is contraindicated, alternative methods of abdominal evaluation should

be considered. 7


Ultrasound

The original descriptions about ultrasound in trauma centered on the rapid evaluation of the

unstable adult trauma patient to determine the presence and source of life-threatening

hemorrhage. The FAST (Focused Assessment with Sonography in Trauma) examination was

developed to assess the presence of intra-abdominal free fluid (with examination of

Morrison‟s pouch, the pouch of Douglas, and the left flank) on fluid within the pericardial sac

and thus indicate the need for operative exploration. A recently published large series directly

comparing FAST examination in children to CT or laparotomy for the presence of free fluid

concluded that a positive FAST suggested hemoperitoneum and associated abdominal injury,

but a negative FAST adds little in decision making.7

Management

Anatomic difference in adults and children implications for pediatric trauma management:

- The child‟s body size allows for a greater distribution of traumatic injuries, therefore

multiple trauma is common. - The child‟s greater relative body surface area also causes greater heat loss. - The child‟s internal organs are more susceptible to injury based on more anterior placement

of liver and spleen and less protective musculature and subcutaneous tissue mass. - The child‟s kidney is less well protected and more mobile, making it very susceptible to

deceleration injury. - The child‟s growth plates are not yet closed, leading to Salter-type fractures with possible

limb length abnormalities with healing. - The child‟s head-to-body ratio is greater, the brain less myelinated, and cranial bones

thinner, resulting in more serious head injury.2

Initial assessment priorities/primary survey

A primary survey of the airway, breathing, circulation and neurologic disabilities should be

completed to identify and correct deficits that pose an immediate threat to life. The primary

survey continues with complete exposure of the patient to ensure that no injuries are missed,

taking care to avoid hypothermia. The placement of therapeutic adjuncts, such as a urinary

and gastric catheter (unless contraindicated), is also completed during the intial survey.

Diagnostic adjuncts, such as pulse oximetry, radiographs, and Focused Assessment by

Sonography in Trauma (FAST), facilitate the early recognition and treatment of immediate

threats to vital functions. The complete “trauma series” of radiographs obtained as an adjunct

to the primary survey in adults may not always be necessary in children, since the lateral

cervical spine radiograph will not detect SCIWORA, and the screening pelvic radiograph

seldom identifies a pelvic fracture. If a pelvic fracture is suspected on physical examination, a

computed tomography (CT) scan should be obtained. 7


Resuscitation

For the child with respiratory distress (increased work of breathing), a nonbreather mask

normally will suffice, provided the airway is open and breathing is spontaneous. For the child

with significant respiratory distress (labored or inadequate work of breathing). Assisted

ventilation via face-mask or an endotracheal tube (ETT) attached to a bag-valve device

should be immediately available. Endotracheal intubation with rapid-sequence induction

techniques is necessary in respiratory failure.7

The first step in management of the circulation is control of bleeding. Direct pressure using

sterile dressings is applied to all actively bleeding external wounds. Blind clamping is

avoided, owing to the potensial risk of injury to neovascular bundles. Recent data suggests

equivalent effectiveness for tourniquets in children.7

The child with significant trauma will require volume resuscitation if signs of hypovolemic

shock are present. Intraosseous access should be used if conventional intravenous access with

peripheral large bore catheters is not rapidly obtainable. Central venous catheher insertion,

except in cases when venous access cannot otherwise readily be obtained, is not warranted.

Simple hypovolemia usually responds to 20-40 ml/kg of warned lactated Ringer‟s solution.

Urinary output should be measured in all seriously injured children as an indication of tissue

perfusion. The minimum urinary output that indicates adequate renal perfusion is 2 ml/kg/h

in infants, 1 ml/kg/h in children, and 0.5 ml/kg/h in adolescents.7

Due to the ability of a child‟s blood vessels to compensate vigorously for hypovolemia by

intense vasoconstriction, systolic hypotension is a late sign of shock and may not develop

until 30-35% of circulating blooad volume is lost. Thus, any child who cannot be stabilized

after infusion of 40-60 ml/kg of lactated Ringer‟s solution and 10-20 ml/kg of packed red

blood cells likely has internal bleeding and needs a operation. 7

Table 1 : Trauma Scores Commonly Used in Children1


Table 2 : Anatomic differences in the pediatric airway-implications in pediatric trauma

management2

Secondary survey

Once the primary survey has been performed, and the resuscitation phase is ongoing, a

secondary survey is undertaken. This consists of a „SAMPLE‟ history (symptoms, allergies,

medications, past illness, last meal, events, and environment) and a complete head-to-toe

physical examination (including all body regions and organ systems). 7

Selective laboratory evaluation is an integral part of the secondary survey although routine

trauma laboratory panels are of limited utility owing to their relatively low sensitivity and

specificity. Arterial blood gases are important in determining the adequacy of ventilation

(PCO2), oxygenation (PO2), and the perfusion (base deficit).7

Selective radiologic evaluation is another important part of the secondary survey: CT of the

head (without contrast) and abdomen (intravenous and oral) should be obtained as indicated.

CT of the chest adds little to what is already known from the chest radiograph obtained

during the primary survey, since the incidental pulmonary contusions identified by CT of the

chest do not correlate with increased fatality. CT of the abdomen should be obtained : (1) in

intubated patients; (2) with signs of internal bleeding (abdominal tenderness, distention,

bruising, or gross hematuria), a history of hypotensive shock (which has responded to volume

resuscitation), or a hematocrit <30%; (3) if a femur fracture is evident; (4) if serum

transaminase levels are elevated; (5) if significant microscopic hematuria is present, or (6) if

the mechanism of injury is deemed significant.7

FAST itself is most useful in detecting intra-abdominal blood, but is not sufficiently reliable

to exclude blunt abdominal injury, although it does have the advantage that such injuries can

be detected by repeated examination. FAST adds relatively little to the management of

pediatric abdominal trauma, since unstable patients with presumed intra abdominal injuries

need immediate operation, while stable pastients are managed nonoperatively without regard


to the presence of intra-abdominal blood. However, diagnostic sonography has been

successfully used in screening for intra-abdominal CT is unavailable or contraindicated.7

SPESIFIC INJURIES AND MANAGEMENT

Chest Wall

Rib Fractures

Young children have a compliant thorax and do not begin to resemble adults until around 8 to

10 years of age. Rib fractures are often suspected on physical examination and are identified

on a chest radiograph (CXR) during the initial assessment. If a rib fracture is found in a child

younger than 3 years, nonaccidental trauma (NAT) should be considered. In addition to

pneumothorax and hemothorax, chidren with first rib fractures may have fractures of the

clavicle, central nervous system injury, fasial fractures, pelvic fractures, extremity fractures,

and major vascular trauma.7

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. 7

Hemothorax

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

chest wall vessels, the pleura, or the pulmonary parenchyma. Occasionally, a rib fracture can

lacerate an intercostal vessels or the lung. Smaller volumes may be more easily detected on

CT scan. Each hemithorax can hold approximately 40% of a child‟s blood volume and it is

difficult to estimate the amount of blood loss on a CXR. 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. 7

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. If undrained, the

hemothorax can become organized with the development of a fibrothorax that can cause a

restrictive lung defect. This predisposes to atelectasis, ventilation-perfusion mismatching, and

subsequent pneumonia. In this situation, thoracoscopy may be useful to evacuate the residual

clot. Patients who undergo early thoracoscopy may experience less morbidity. 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.7


Open Pneumothorax

Open pneumothorax (sucking chest wound) occurs when there is a gasping defect in the chest

wall, and typically is caused by a blast injury, a severe avulsion injury, or an impalement.

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

thorax. Air trapping results in collapse of the ipsilateral lung and mediastinal shift, similar to

a tension pneumothorax. 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.7

Abdominal Injuries

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. Most children who fail NOM do so within four hours of injury as result

of shock, peritonitis, or persistent bleeding. Routine follow up imaging is not indicated and

children can return to regular activity after grade of injury plus two weeks from the time of

injury. Most splenic and hepatic injuries in children will resolve without the need for

operative intervention with excellent long-term outcomes. Evidence of ongoing bleeding with

an abnormal examination or a positive abdominal FAST examination necessitates urgent

operative exploration. Rapid transfusion protocols while not formally validated in children,

are utilized with the goal of 1:1:1 transfusion of packed red blood cells (PRBC), Fresh Frozen

Plasma (FFP), and platelets. In infants and children, this translates to 20 ml/kg of PRBC, FFP

and platelets. The goal of initial operative exploration is to stop bleeding and control the fecal

stream (damage control).7

Splenectomy easily controls bleeding in the hemodynamically unstable patient with the active

exsanguination from a massively damaged spleen, although at the theoretical cost of a long

term risk of postsplenectomy sepsis. Children with splenic injuries who have ongoing

bleeding, but are not in shock, are potential candidates for splenic sparing operations. Partial

splenectomy and mesh splenorrhapy are techniques that can successfully save splenic

parenchyma, although they may be time consuming, and are therefore not appropriate in the

unstable patient.7

Key components of operative controls of hepatic parenchymal injury include adequate

exposure, an experienced co-surgeon, good anesthesia support, and supradiaphragmatic

intravenous access. They recommend initial management of deep parenchymal fractures with

compression, followed by suture ligation of bleeding vessels, and the avoidance of deep liver

sutures. Ideally, intermittent clamping of the porta hepatic should be performed to decrease

the degree of hepatic ischemia.7


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. 7

As IAH in children is different from adults, 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. There are three different types of ACS : (1) primary ACS refers to ACS that occurs due to a primary intra-abdominal cause such as

abdominal trauma; (2) secondary ACS or extra-abdominal compartment syndrome occurs as

a result of massive bowel edema secondary to sepsis, capillary leak, and other conditions

requiring massive fluid resuscitation; and (3) tertiary ACS or recurrent ACS in which ACS

recurs after resolution of an earlier episode of either primary or secondary ACS. IAP can be

measured by using the bladder pressure.7

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.

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. 7

Pancreatic Injury

Injury to the pancreas occurs in fewer than 5% of pediatric abdominal injuries, and can be

difficult to diagnose. CT scan with IV contrast is the preffered imaging study, although

definitive identification of these injuries can be difficult. 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.7

Renal Trauma

With abdominal trauma in children, the kidney is injured in approximately 10% of patients,

and is the most commonly injured GU organ. 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.7


Blunt trauma accounts for 80-90% of renal injuries in children. The most common

mechanisms are related to MVC, falls, bicycle, and all-terrain vehicle (ATV)-related injuries.

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

diagnosis is confirmed by abdominal CT scan which is highly sensitive.7

Treatment for children with high grade renal injury (grade IV and grade V) remains

controversial. Urinary extravasation and urinoma continue to be relative indications for

exploration in some centers. Endourologic interventions are reserved primarily for persistent

extravasation or symptomatic urinomas rather than all injuries with disrupted collecting

systems. The main indications for immediate exploration in a child with a renal injury are

hemodynamic instability, penetrating mechanism, and associated non-renal injuries.7

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. 7

Fig. 2 : Algorithm for the Evaluation of Blunt Abdominal Trauma8


Figure 3 : Algorithm for the Evaluation of Blunt Thoracic Trauma1

Table 3 : Early Assessment and Management of Chest Injuries in Childhood1


Table 4 : Indications for Early Operation in Abdominal Trauma in Childhood


REFERENCES

1. Nesbit E, Chadd. Considerations in Pediatric Thoracic and Abdominal Trauma.

Trauma in Children 2011: 18-27. 2. Avarella J, Than. Cantor M, Richard. Pediatric Major Trauma : An approach to

Evaluation and Management. Emerg Med Clin N Am 2007; 25: 803-836. 3. Moore M, Wallace EC, Westra S. The imaging of paediatric thoracic trauma. Pediatr

Radiol 2009;39:485-496. 4. Sartorelli KH, Vane DW. The diagnosis and management of children with blunt

injury of the chest. Semin Pediatr Surg 2004;13:98-105. 5. Holmes J, Sokolove PE, Brant WE, et al. Identification of children with intra-

abdominal injuries after blunt trauma. Ann Emerg Med 2012;39:500-509. 6. Markel TA, Kumar R, Koontz NA, et al. The utility of computed tomography as a

screening tool for the evaluation of pediatric blunt chest trauma. J Trauma

2009;67:23-28. 7. Holcomb, W George. Murphy, Patrick J. Ostlie, J Daniel. Ashcraft‟s Pediatric

Surgery. Thoracic and Abdominal Trauma 2014: 190-214. 8. Muniz, Antonio. Evaluation and Management of Pediatric Abdominal Trauma.

Pediatric Emergency Medicine Practice March 2008; 5(3): 1-24.

Management of Pediatric Trauma - Unsyiah

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