Current Controversies in Managing Pediatric Trauma Patients

1. Current Controversies in Managing Pediatric Trauma Patients Robert W. Letton, Jr., MD Pediatric Trauma Medical Director The Level 1 Pediatric Trauma Center Oklahoma University Medical Center Oklahoma City, Oklahoma

3. Objectives • Discuss differences in adult and pediatric trauma patients • Relate how these differences lend to controversy in management • Provide options for “Best Practice” for Pediatric Trauma based on evidence based medicine

6. Airway • Airway complications as high as 25% with pediatric field intubation • Oral and nasopharyngeal airways not as effective • LMA may provide effective airway control in field until definitive airway can be obtained

7. Prehospital RSI

9. Prehospital RSI

10. Should Monitor ETCO2 Just confirming the presence of ETCO2 is not enough

11. 20 cases of missed injuries Awards averaged $2.9 million Fear of lawsuits encourages defensive medicine Low threshold for CT is reasonable in adults

12. C-Spine Injury by Age • Infants • Injuries to the upper cervical spine • Mostly ligamentous • Adolescents (13 years and over) • Pattern of injury similar to adults • In between (6-12 years) • Variable position of injury • Variable likelihood of boney vs. ligamentous injury

13. Infants and Children • Likely to injure atlanto-occipital region. • Significant injuries lead to death at the scene • Very likely to have ligamentous injury without a fracture or dislocation • Clearance is either clinical or with radiographs / MRI • Odontoid view is not necessary or helpful • Limited data comparing MRI to CT • Spinal motion restriction is difficult

14. The problem with spine mobilization

15. Better . . . But not perfect ASPEN MIAMI J

16. Spinal Cord Injury With Out Radiographic Abnormality SCIWORA 0.07% - 0.8% No fractures, just ligaments

17. What about MRI? • Too sensitive?? • Optimal timing? • Magnet problem • Time • Risks of transporting unstable patient • Limited availability • Cost • Is it really better than CT??

18. Infants and Children • CT is unlikely to define injury • Does not assess ligaments • Useful only to better define a known boney injury identified by other modalities • Increasing evidence that radiation is harmful and should be used with caution

19. CT Cervical Spine • Under the age of five CT did not have an advantage over standard radiographs of the C-spine EmergRadiol. 2004 Feb;10(4):176-8

20. Teenagers Are Just Little Adults • Physeal plates are closed • Ligaments have lost water content and elasticity • Body of vertebra are square • Patterns of injury are similar to adult patients • Risk of secondary cancer is much less • Clearance is similar to adult patients

21. In-between children 6-12 years of age • Vertebra are less cartilaginous • Ligaments less lax • Variable fracture patterns and variable degrees of ligamentous injury

22. Clearance of the Cervical Spine for “Tweeners” • Clinically • Radiographically • 3 view • Davis Series • Wait, anti-inflammatory • Repeat • MRI

23. Principles of Clinical Clearance • Likelihood of injury • High energy • Injury above the clavicles • Ability to examine • Unaltered • Normalneuro exam • Communicative and cooperative • No Distracting injury

24. NEXUS Criteria No midline tenderness No intoxication Normal alertness No focal deficit No distracting injury Canadian C-Spine Rule 3 high risk criteria 5 low risk criteria Ability to rotate neck A Rational Approach for Awake Cooperative Patients

25. Conduct of a Clinical Clearance of the Cervical Spine • Anteriorly – no injury or swelling • Posteriorly • No bruising, swelling or midline pain • Full, unaided ROM without pain or rigidity

26. Clinical Clearance Not Feasible • Ensure proper fit of collar and pad pressure points and restrict motion as appropriate • Plain films / CT & document neuro exam • Estimate of time-frame to clearance. (there’s little hurry) • Radiographs • CT • Flexion – extension with fluoroscopy • MRI

27. Clinical Clearance Not Successful • Ensure proper collar fit and pad pressure points • Motion restriction as appropriate • Treat pain appropriately, wait and document • Radiographs based on anatomy • Plain films • Davis series • CT • MRI

28. Clinical Clearance Not Appropriate • Neurological deficit • Plain films • Urgent MRI with CT (thin cut) • Steroids: • Not proven in children • 8TH Edition of ATLS has changed this to an option

30. Stylianos, et.al., JPS 35:164-9, 2000

31. Stylianos, et.al., JPS 35:164-9, 2000

32. 101 patients managed by hemodynamic status, not grade • Average LOS was 1.9 days vs 3.2 days projected • Grades III to V 2.5 actual vs 4.3 projected • Excluded if unstable on arrival and taken to OR immediately • No failures in NOM group

35. Embolization??

36. Over 1800 patients with a failure rate of only 5% • More than 1 organ injured and pancreas injuries most likely to fail • Bicycle mechanism most likely to fail • Median time to failure 3 hours • 38% by 2 hrs, 59% by 4 hrs, 76% by 12

37. Seat Belt Stripe • Bowel injuries associated with seat belt stripe • 20% will have seat belt stripe • 15-20% of these have significant intestinal injury • Physical exam can be difficult • abdominal wall bruising painful

38. Seat Belt Stripe • CT sensitive and specific for solid organ injury • Not as sensitive or specific for bowel injury • looking for secondary signs of injury

39. Seat Belt Stripe

41. PEDIATRIC TRAUMA ULTRASOUND: WHY NOT?

42. Focused Abdominal Sonography for Trauma FAST • FAST has become an accepted tool to assess the adult trauma patient • It has become the study of choice to rule out hemoperitoneum or cardiac tamponade in the unstable adult trauma patient • It’s acceptance in pediatric trauma has not been as widespread

43. Why Not FAST? • Less fluid may mean less sensitivity • Less volume leads to less experience and comfort with the procedure • Estimated as high as 40% of pediatric abdominal trauma is solid organ injury without intra-abdominal fluid • Children rarely unstable from hemorrhagic shock • SO WHY FAST?

44. A trip to the CT might not be

45. Ionizing Radiation • 700% increase in the number of CT scans the past decade • 11% of all CT scans performed on children • Appendicitis and trauma the 2 most cited areas of abuse • Children’s cells more rapidly dividing and more sensitive than adults • Current Opinion in Pediatrics 2008, 20:243–247

46. Ionizing radiation • Chest CT = 150 CXR • Head CT = 200 CXR • Abdomen CT = 250 CXR • At least 1:1000 children who get a CT will develop radiation induced cancer • Thyroid very sensitive • At current pace that is 7000 children a year • Current Opinion in Pediatrics 2008, 20:243–247

47. 37/193 patients < 15, with a positive FAST • 1/22 with USS < 3 required ex lap • 8/15 with USS > 3 required ex lap • USS > 3: sensitivity of 89% and specificity of 75% for predicting the need for therapeutic laparotomy in patients < 15 • J Trauma. 2003;54:503–508

48. 547 patients (age 1-90) with initial US and a secondary US 4 hours later J Trauma. 2004;57:934 –938.

49. 118 patients < 17 with FAST, PE and CT scan • FAST vs CT • Sensitivity 70%, specificity 100%, PPV 100%, NPV 92% • (FAST + PE) vs CT • Sensitivity 100%, Specificity 74%, PPV 53%, NPV 100% • Surgeon directed FAST + PE can rule out injury The American Surgeon 2004, 70: 164-168

50. Disability