Pediatric Trauma

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January 24, 2016
Edward Smith

File:US Navy 040203-N-4182M-001 National Naval Medical Center physician, Capt. David Thompson performs an ear tube surgery on a young hospital patient.jpg

Pediatric Trauma

Ed Smith is one of the top rated personal injury lawyers in Sacramento. Pediatric trauma is the leading cause of death among children and the leading cause of disability.  The principles of trauma care are the same in children as with adults but there are very big differences in the physiology of children that mean they are treated somewhat differently than adults.  Children have different patterns and causes of injury depending on age.  For this reason, there is a need for pediatric trauma centers apart from trauma centers dealing with adults.

Children’s injuries usually come from rapid acceleration and deceleration injuries, such as is seen in motor vehicle accidents.  Accidents around the home, falls, and bicycle injuries are also major causes of pediatric trauma.

Initial Assessment and Resuscitation of the Injured Child

Simultaneous assessment and resuscitation happen in children who are injured in the same way as it is done in adults.  Multiple organ injuries are more common in kids so it is better to assume that every organ is injured until proven otherwise.

Airway management is the first step.  If oxygenation is poor, then an injury to the lungs must be assumed.  If the child needs intubation, this indicates a very severe injury.  Those with airway issues have a higher death rate when compared to those who don’t need to be intubated.  Care must be taken to protect the cervical spine if the child needs intubation.

Rapid sequence intubation to paralyze the child may have to be done if the child is combative and needs evaluation such as a CT scan or to protect the cervical spine.  There are special techniques for determining the child’s height and weight as well as to determine the size of the endotracheal tube to use.  A chest x-ray should be done to determine if the endotracheal tube is in place.

Getting an IV access is important.  If a peripheral IV line cannot be done, an interosseous line should be inserted (directly through the tibia bone).  If this can’t be done, more sophisticated techniques should be done to gain vascular access.

Other Pediatric Trauma Concerns

Children with significant blood loss can have a normal blood pressure because they compensate very well for loss of blood.  This means that a normal blood pressure doesn’t mean they don’t have blood loss.  The blood pressure of children is also much lower than that seen in adults so a low blood pressure may be normal.

Hypothermia is common in injured children, even in the summertime.  This can contribute to blood clotting problems and can cause acid to build up in the bloodstream.  Warmed fluids and warmed blankets are recommended to keep their body temperature up.

X-Rays and CT Scans

X-rays should be done as soon as possible, even if they have to be portable x-rays in the emergency room.  Chest x-ray, abdominal x-ray, cervical spine x-tray, pelvic x-ray and extremity x-rays should be done.  A focused abdominal sonography for trauma or FAST ultrasound can be done in children to check for chest, abdominal, or pelvic injuries.

CT scan is generally accepted as the diagnostic study of choice in kids, especially for head, chest, and abdomen injuries.  CT scans can be done with or without contrast, especially in abdominal CT scans.  Radiation damage later in life is possible in children, so the use of repeated CT scans should be weighed against the risk of later developing cancer.

Lab studies haven’t been found to be particularly helpful with the exception of a urinalysis and an arterial blood gas determination.

Brain Injuries in Pediatric Trauma

Acute brain trauma is the most common cause of death and disability in the pediatric population.  Intentional brain injuries are more common in kids under the age of 2.  Kids have more brain plasticity than adults so that focal injuries are less likely to lead to permanent disability.  Because the head of an infant is a greater proportion of their body, they are more likely to get brain injuries after an acceleration/deceleration injury.  The skull is thin and this makes it more likely to get fractured.

There are primary and secondary injuries to the brain.  The primary injuries are those that are incurred right at the time of injury.  Secondary injuries occur from brain swelling and a lack of oxygen to the brain.  Secondary injuries are usually because of increased pressure inside the brain.

A CT scan of the head can be obtained once the cervical spine has been found to be clear of injury or has been stabilized.  This is usually about 30-60 minutes after arrival to the emergency department.  One should also avoid elevated body temperatures as this can make the secondary injuries to the brain worse.  The pressure inside the brain can be brought down by hyperventilating the child or by giving them barbiturates.

Pediatric Trauma to Back and Chest

Injuries to the cervical spine represent less than 1 percent of all pediatric fractures, usually as a secondary fact of a motor vehicle injury.  If two views of the cervical spine don’t show injury but one is suspected, a CT scan or MRI scan can be done to evaluate the spine.

Injuries to the chest are common and account for up to 25 percent of all pediatric injuries.  Most come from blunt trauma to the chest.  The chest wall is more compliant than in adults so there are fewer fractures of the ribs.  Bruising of the lung tissue is more common.  This bruising can be seen on chest x-ray but better seen on evaluation of the chest with a CT scan.  Oxygen and pain management are the best treatments for lung bruising.

Internal Injuries in Pediatric Trauma

A pneumothorax of the lung is best treated with a chest tube to get the air out of the lung space.  Injuries to the esophagus, trachea, and aorta are extremely rare in children except in severe automobile accidents.  If they occur, they are often fatal.

Abdominal injuries are common because the abdominal wall in children is very thin.  Children with intra-abdominal injuries can be missed for hours or days since the emphasis is on not doing surgery on many abdominal injuries.  These kids need to be kept in the hospital and reevaluated frequently in order to make sure an injury isn’t missed.  Repeat ultrasounds can be done as well.

Rupture of the diaphragm is rare and injuries to the spleen and liver along with diaphragmatic rupture is high.  If a diaphragmatic rupture is not found right away, it must be repaired by going into the chest to fix the diaphragm because scar tissue often develops on the abdominal side.

Kids have a higher rate of stomach perforations than adults from blunt trauma.  Free air is seen where it doesn’t belong on x-ray and a nasogastric tube often comes back with bloody fluid.  Injuries to the duodenum are uncommon but may be able to be treated without surgery if there is only a blood clot in the wall of the duodenum.

The jejunum and ilium (small bowel) are the most commonly injured parts of the gastrointestinal tract to occur in children.  Usually the injury is from a crush injury between the abdomen and the spine behind the small bowel.  Injuries to the colon and rectum are not common in children but can occur after motor vehicle trauma.

Injuries to the spleen usually stop bleeding on their own so aren’t treated with surgery.  If a child receives half of his or her blood volume in 24 hours, then surgery may need to be necessary to repair or remove the spleen.  Immunizations need to be given to prevent infections common after a child has had a removed spleen.

Liver injuries are often treated without surgery as the bleeding stops on its own.  If both the liver and spleen are injured, there is a higher risk of death.  Surgery is done similar to spleen injuries, when half of the blood volume is necessary to be replaced in 24 hours.

Injuries to the pancreas can happen with damage from handle bars of a bicycle.  These are usually treated without surgery.  In juries to the kidneys are also secondary to blunt trauma and these are usually treated without surgery as well.  Rarely, a kidney will have to be removed if there is a lot of hemorrhaging.

Injuries to the skeletal system are the most common injuries requiring surgery in kids.  These injuries are often very painful and distract the child from complaining about other, more serious injuries.  Injuries usually involve the growth plate of the long bones and can result in inability of the bone to grow properly after the injury.

I’m Ed Smith, a Sacramento Car Accident Lawyer, and I’ve handled serious traumatic injuries to children since 1982. Whether it be Pediatric Wrist or Hand fractures, Pediatric Foot Fractures, Pediatric Hip Injuries of forearm or other injuries we can help. Call in Sacramento 916-921-6400 for free, friendly advice. Elsewhere call 800-404-5400.

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Photo Attribution: By U.S. Navy photo by Journalist Seaman Erica Mater. [Public domain], via Wikimedia Commons