Pediatric Prehospital Trauma Overview: Hitting the Highlights

This series is a collaboration with the EMS for Children Innovation and Improvement Center (EIIC) and will be part of the pre-hospital resources for its Pediatric Education and Advocacy Kit (PEAK) for multisystem trauma. Click on the link to learn more! https://emscimprovement.center/education-and-resources/peak/. 

In this episode we kick off a multipart series on pediatric trauma just in time for summer and trauma season. Join your two hosts as they tackle the prehospital management of pediatric trauma. Everything from head to toe and the pathophysiology that makes pediatric trauma unique from the adult population. Below are the episode talking points you don’t want to miss. 

Objectives

• Assess the current landscape of pediatric trauma.
• Recognize the physiologic differences between adults and children in trauma.
• Evaluate how the mechanism of injury informs the management.
• Analyze how to approach a pediatric trauma patient.
• Summary and take-home points.

Brought to you by The National Association of EMS Physicians (NAEMSP) and Missouri Emergency Medical Services for Children (MO-EMSC).

Hosts: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney

Website: https://sites.libsyn.com/414020 

GET CEU CREDIT THROUGH PRODIGY EMS 

Content Experts: Joelle Donofrio-Odmann, DO and Joseph Finney, MD

Pediatric Assessment Triangle

 

The Changing Landscape of Traumatic Pediatric Death

 

Goldstick, 2022

Trimodal Distribution of Death

From McLaughlin et al, 2017:

74% of pediatric deaths age 1-14y were in first 24 hours. Of children who die from traumatic injuries, most die within 24 hours of arriving to the hospital. When compared to adult trauma patients, children are more likely to die in the emergency department (ED) rather than surviving long enough for hospital admission or transfer to the operating room.

Where you are treated matters

Theodorou et al in 2021 reviewed over 7000 pediatric trauma admissions and found, of the 134 patients who died, Traumatic brain injury was the most common cause of death (66%), followed by anoxia (9.7%) and hemorrhage (8%).  54% died in the ED. More likely to die if suffered penetrating trauma. 

Pediatric Trauma: ATC vs PTC

The United States Government Accountability Office found 57 percent of the nation’s 74 million children lived within 30 miles of a pediatric trauma center that can treat pediatric injuries, regardless of severity. 

The presence of pediatric trauma centers was associated with lower rates of MVC death in children. Adult level 1/2 trauma centers appear to offer comparable risk reduction. Where population differences in pediatric trauma mortality are observed, addressing disparities in county-level access to pediatric trauma care may serve as a viable target for system-level improvement.

Pediatric patients <14yo do better at Pediatric Trauma centers likely related to management in the ED, avoiding the second peak of mortality. 

Why Does All This Matter: Anatomic and Physiologic Differences in Pediatric Trauma

A Case

A 5-year-old boy injured while crossing the street when he was struck by a vehicle at city speeds (w50 km/h). He is crying and pale, with a hematoma to the right forehead; bruising to the left side of the upper abdomen; and an obvious, closed, deformity of his femur. His vital signs are heart rate (HR), 135 beats/min, respiration rate (RR), 30 breaths/min; blood pressure (BP), 95/65 mm Hg; and O2 saturations of 91% on room air, which improve to 97% with supplemental O2

Factors to Consider when approaching pediatric trauma:

Head and Neck

•       Large head on short weak neck with fulcrum out away from the center of gravity

•       Traumatic brain injury likely present and must be investigated.

•       80% of pediatric multisystem trauma involves the head.

•       Remember TBI is a major cause of trauma mortality. 

•       Heavy head compared to body, often first impact point so affected by rapid acceleration deceleration forces. Also, higher risk of axonal injury from shearing forces given limited myelin development. Prehospital management focused on H bombs.

Airway

•       Airway is crowded and easily obstructed.

•       Use a shoulder roll anytime you are managing a pediatric airway under 8 years.

•       Intubation is for your ego; SGA is for your patient 

•       Cuffed tubes are both safe and effective for pediatric patients.

Pediatric Airway Considerations:

Head: In the supine position, a young child’s head will cause a natural flexion of the neck due to its large size. This neck flexion can create a potential airway obstruction. Patients usually benefit from a towel to elevate the shoulders as well as someone to assist to help hold the head, as it can be floppy.

Nose: <4mo are obligate nose breathers and this means nasal congestion can cause significant respiratory distress. 

Tongue: A child’s tongue is proportionally larger in the oropharynx when compared to adults, and it may obstruct the airway due to this size.

Larynx: Located opposite C2—C3, a child’s larynx is higher up than in an adult, creating a more anterior location that often results in difficulty when a provider attempts to visualize a child’s airway. HARDER TO INTUBATE.

Epiglottis: The adult epiglottis is flat and flexible, while a child’s is U-shaped, shorter and stiffer. This makes it more difficult to manipulate and is a common reason providers can’t visualize an airway with a curved blade in a pediatric patient.

Vocal cords: The anterior attachment of a pediatric patient’s vocal cords is lower than the posterior attachment, which creates an upward slant, whereas in adults, the vocal cords are horizontal. This concave shape may affect ventilation, and it’s important for providers to use a jaw-lift maneuver to open the arytenoids.

Trachea: The trachea is shorter in pediatric patients, which increases the likelihood of right mainstem intubation and of the tube becoming dislodged. At birth, 1/3 the diameter of an adult (narrow the tube and increase resistance by a power of 4: Poiseuilles law)

Airway diameter: A child’s airway is narrowest at the cricoid ring. As a result, secretions can easily obstruct the airway, due to its small size, and even a small amount of cricoid pressure can cause complete airway obstruction.

Residual lung capacity: Smaller lung capacity in pediatric patients means that a child can become hypoxic more quickly than an adult. Providers should make sure to closely monitor oxygen saturation and avoid prolonged periods without ventilation. Children also have higher respiratory rates than adults making them more susceptible to agents in the air.

The ribs in infants and young children are oriented more horizontally than in adults and older children lessening the movement of the chest.

Rib cartilage is more springy in children making the chest wall less rigid. This can allow the chest wall to retract during episodes of respiratory distress and decrease tidal volume.

The intercostal muscles that run between the ribs are not fully developed until a child reaches school age. This can make it difficult to lift the rib cage especially when lying flat on the back or if the diaphragm is inhibited by blood in the abdominal cavity or air in the belly.

Spinal Injuries

•       Overall uncommon, but devastating if they do occur.

•       Primarily due to high-speed blunt trauma 

•       Associated with birth trauma (Forceps extraction)

•       Higher cervical spine (C1-C2)

•       Chance Fractures common in pediatrics

•       High suspicion for internal organ injury with thoracolumbar injury

•       To Collar or Not To Collar

•       Consider in the following situations.

•       AMS

•       Neck pain

•       Neck stiffness

•       Neurologic deficit

•       High speed MVC

•       Diving injury (not drowning)

•       Substantial torso injury present

Cardiovascular Considerations

•       Hypotension occurs after 30% blood loss.

•       Decompensated potentially irreversible shock.

•       Tachycardia is the pediatric body screaming at you.

•       Always investigate tachycardia.

•       Do not assume pain.

•       Compensation

Chest and Abdominal Anatomy

•       Compliant and cartilaginous skeletal structure

•       Force is transferred internally. 

•       May be no broken ribs or external signs of trauma.

•       Maintain high suspicion for internal injury.

•       Pulmonary contusion common

•       Horizontal ribs, exposed organs

•       Low set pelvis, higher risk of hollow organ injury

•       Shortened AP diameter meaning retroperitoneal structures closer to front of body and more exposed.

•       Minimal peri-organ fat and subcutaneous tissue

Back to our case: What are your priorities?

A 5-year-old boy injured while crossing the street when he was struck by a vehicle at city speeds (w50 km/h). He is crying and pale, with a hematoma to the right forehead; bruising to the left side of the upper abdomen; and an obvious, closed, deformity of his femur. His vital signs are heart rate (HR), 135 beats/min, respiration rate (RR), 30 breaths/min; blood pressure (BP), 95/65 mm Hg; and O2 saturations of 91% on room air, which improve to 97% with supplemental O2

•       Lethal Triad (hypothermia, acidosis, coagulopathy): Hypothermia is a modifiable prehospital factor

•       Large surface area to body mass ratioà rapid heat loss

•       Large head

•       Prioritize warming the patient both prehospital and in the ED

•       Turn on the heat in the ambulance.

•       Resuscitation: On-scene Priorities

•       C-ABC

Common Prehospital Pitfalls

•       Failure to recognize/investigate/act on tachycardia.

•       Fear and stress are diagnoses of exclusion in the tachycardic pediatric trauma.

•       Failure to identify abnormal behavior for age.

•       Sleeping or tired or quiet is NOT NORMAL

•       Should be assumed to be impaired cerebral perfusion.

•       Failure to suspect/assume internal injury in the absence of external signs of trauma.

•       Mechanism informs the injuries.

•       Treat Pain

•       Numerous studies underscore the failures of EMS to adequately address and treat pediatric pain

•       Worse for minority populations

•       Get pain medication on board early

•       Delayed pain treatment can have devastating psychologic effects long term

•       PTSD

•       Chronic pain syndrome

•       Behavioral abnormalities

Non-Accidental Trauma

•       Always consider NAT in your altered pediatric patient

•       Even without a history to support it.

•       Watch for red flags (TEN4FACES)

•       History doesn’t match developmental level.

•       Delayed presentation

•       Unwitnessed

•       Vague story

•       We are all mandated reporters if we suspect abuse.

Where to transport

•       Take a stroke to a stroke center.

•       Take a pediatric trauma to a pediatric trauma center whenever possible. This will decrease mortality and exposure to radiation and unnecessary procedures. 

Review of The Pediatric Traumatic Hemorrhagic Shock Consensus Conference Research Priorities

Whole Blood in Pediatric Hemorrhagic Shock

•       100% Agreement among experts

•       Practical application

•       Severe cases–>straight to blood

•       Less severe patients–>one bolus of crystalloid with close monitoring and immediate transition to blood if worsens/fails to improve.

•       Use Low Titer O Whole Blood if available.

•       If LTWOWB not available, use 1:1:1 plasma to RBCs to platelets.

•       MTP with balanced blood product administration

•       Consider calcium when giving blood: Siegler’s Lethal Diamond

•       Prehospital Blood in Pediatric Hemorrhagic Shock: “Reasonable based on availability and clinical judgement”

•       100% Expert Agreement

•       Death due to bleeding most common early after injury

•       Delays in transfusion associated with increased mortality and prolonged time to hemostasis.

•       Current evidence supports both the safety and feasibility of prehospital pediatric blood product.

Tranexamic Acid in Pediatric Hemorrhagic Shock

•       Use within 3 hours might be considered.

•       80% agreement among experts

•       Strong evidence in adults: CRASH-2

•       No high-quality evidence in pediatrics

Tourniquet Application in PHS

•       88% Agreement

•       Has shown benefit.

•       Biggest issues

•       Applied when unnecessary.

•       Applied incorrectly.

•       Inadequate training

There is no such thing as permissive hypotension in pediatrics

Resources and Sources:

•       Khalil M, Alawwa G, Pinto F, O’Neill PA. Pediatric Mortality at Pediatric versus Adult Trauma Centers. J Emerg Trauma Shock. 2021 Jul-Sep;14(3):128-135. doi: 10.4103/JETS.JETS_11_20. Epub 2021 Sep 30. PMID: 34759630; PMCID: PMC8527062.

•       McLaughlin C, Zagory JA, Fenlon M, Park C, Lane CJ, Meeker D, Burd RS, Ford HR, Upperman JS, Jensen AR. Timing of mortality in pediatric trauma patients: A National Trauma Data Bank analysis. J Pediatr Surg. 2018 Feb;53(2):344-351. doi: 10.1016/j.jpedsurg.2017.10.006. Epub 2017 Oct 8. PMID: 29111081; PMCID: PMC5828917.

•       Theodorou CM, Galganski LA, Jurkovich GJ, Farmer DL, Hirose S, Stephenson JT, Trappey AF. Causes of early mortality in pediatric trauma patients. J Trauma Acute Care Surg. 2021 Mar 1;90(3):574-581. doi: 10.1097/TA.0000000000003045. PMID: 33492107; PMCID: PMC8008945.

•       Mikrogianakis A, Grant V. The Kids Are Alright: Pediatric Trauma Pearls. Emerg Med Clin North Am. 2018 Feb;36(1):237-257. doi: 10.1016/j.emc.2017.08.015. PMID: 29132580.

•       Andrade EG, Onufer EJ, Thornton M, Keller MS, Schuerer DJE, Punch LJ. Racial disparities in triage of adolescent patients after bullet injury. J Trauma Acute Care Surg. 2022 Feb 1;92(2):366-370. doi: 10.1097/TA.0000000000003407. PMID: 34538831.

•       Calhoun A, Keller M, Shi J, Brancato C, Donovan K, Kraus D, Leonard JC. Do Pediatric Teams Affect Outcomes of Injured Children Requiring Inter-hospital Transport? Prehosp Emerg Care. 2017 Mar-Apr;21(2):192-200. doi: 10.1080/10903127.2016.1218983. Epub 2016 Sep 16. PMID: 27636186.

•       Byrne JP, Nance ML, Scantling DR, Holena DN, Kaufman EJ, Nathens AB, Reilly PM, Seamon MJ. Association between access to pediatric trauma care and motor vehicle crash death in children: An ecologic analysis of United States counties. J Trauma Acute Care Surg. 2021 Jul 1;91(1):84-92. doi: 10.1097/TA.0000000000003110. PMID: 33605706.

•       Träff H, Hagander L, Salö M. Association of transport time with adverse outcome in paediatric trauma. BJS Open. 2021 May 7;5(3):zrab036. doi: 10.1093/bjsopen/zrab036. PMID: 33963365; PMCID: PMC8105622.

•       Frank Lodeserto MD, “Approach to the Critically Ill Child: Shock”, REBEL EM blog, October 15, 2018. Available at: https://rebelem.com/approach-to-the-critically-ill-child-shock/.

•       Dai LN, Chen CD, Lin XK, Wang YB, Xia LG, Liu P, Chen XM, Li ZR. Abdominal injuries involving bicycle handlebars in 219 children: results of 8-year follow-up. Eur J Trauma Emerg Surg. 2015 Oct;41(5):551-5. doi: 10.1007/s00068-014-0477-5. Epub 2014 Nov 26. PMID: 26038003.

•       Ten-4 bruising rule. Face It website. Accessed January 20, 2023,

•       Newgard, Craig D. MD, MPH, FACEP; Fischer, Peter E. MD; Gestring, Mark MD; Michaels, Holly N. MPH; Jurkovich, Gregory J. MD, FACS; Lerner, E. Brooke PhD, FAEMS; Fallat, Mary E. MD; Delbridge, Theodore R. MD, MPH; Brown, Joshua B. MD, MSc, FACS; Bulger, Eileen M. MD;  the Writing Group for the 2021 National Expert Panel on Field Triage. National guideline for the field triage of injured patients: Recommendations of the National Expert Panel on Field Triage, 2021. Journal of Trauma and Acute Care Surgery 93(2):p e49-e60, August 2022. | DOI: 10.1097/TA.0000000000003627

•       Russell RT, Bembea MM, Borgman MA, Burd RS, Gaines BA, Jafri M, Josephson CD, Leeper CM, Leonard JC, Muszynski JA, Nicol KK, Nishijima DK, Stricker PA, Vogel AM, Wong TE, Spinella PC. Pediatric traumatic hemorrhagic shock consensus conference research priorities. J Trauma Acute Care Surg. 2023 Jan 1;94(1S Suppl 1):S11-S18. doi: 10.1097/TA.0000000000003802. Epub 2022 Oct 7. PMID: 36203242; PMCID: PMC9805504.