PEDIATRICS PART 2: TRAUMA
| PEDIATRIC TRAUMA —Lance Brown, MD, MPH, Associate Professor of Emergency Medicine and Pediatrics and
Chief, Division of Pediatric Emergency Medicine, Loma Linda University Medical Center and Children’s Hospital,
Loma Linda, California
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| Introduction: every emergency department (ED) sees pediatric trauma because children portable; pediatric patients defined
politically and financially as ages 0 to 21 yr, but clinically must separate ages; teenagers have penetrating
trauma and have “hey, baby” phenomenon (ie, lover’s triangle; boxer’s fracture and ruptured testicle); pediatric
trauma is blunt trauma
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| Vascular access: do not put intraosseous (IO) needle into fractured extremity; when inserting, IO needle usually sinks
into back wall of bone; pull out slightly to gain access; do not wiggle too much or fluid will leak around sides; nurses
prefer connecting intravenous (IV) tubing to pump (seldom works); instead, push in with syringe (sometimes requires
little more force than pump); in babies, femoral lines more difficult than subclavian lines; give intramuscular
(IM) ketamine in children too awake for IO line placement, then place IO (safe in children in shock because it gives
them adrenergic boost); have several sizes of lines available (3 F catheter for little babies, 4 or 5 F for bigger infants)
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| Computed tomography (CT): tool to look in “black box,” ie, head, abdomen, and pelvis; 2001 Food and Drug Administration
(FDA) warning about radiation exposure from CT; recommendation based on theoretic model and lifetime
risk for cancer (“don’t worry about it; if you have to scan a kid, scan them”); article does not say do not get CT; article
estimates 0.35% increase in lifetime cancer risk attributable to CT; talk to radiologist and hospital physicist and
have them adjust CT scanner for little bodies; ultrasonography not indicated because presence of free fluid not decision
node for trauma
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| Weights and sizes: at birth, most children weigh 7 lb (3 kg); double weight at 4 mo (6 kg); triple weight at 1 yr (10 kg);
at 3 yr average child weighs 15 kg, at 5 yr 20 kg, at 7 yr 25 kg, at 9 yr 30 kg; at 11 yr ask child how much he or she
weighs; use size 3 endotracheal (ET) tube for newborns, size 5 for 5-yr-olds; between those 2 ages, try size 4; memorize
some drug dosages; if child between memorized weights, drug dosages still fine
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| Why pediatric trauma intimidating: healthy normal child suddenly becomes abnormal; emotional; do not see many
seriously traumatized children; physicians often unfamiliar with drug dosages and unfamiliar with what is considered
normal in children; internal injuries must always be considered, even in absence of external signs of trauma; physician
worried about making serious mistake; IV access challenging; x-rays look abnormal when they are normal (normal
spine x-rays do not exclude internal spinal cord injuries); literature filled with “occult” pediatric injuries
implying that pediatric injuries mysterious; pediatricians use word “occult” to mean “somewhat subtle”; pediatric injuries
rather straightforward
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| “Children are different”: all textbooks have same list, ie, big head, short neck, higher closer airway, omega-shaped
epiglottis, big tongue, airway narrows below cords, more exposed abdominal organs, proportionately more body surface
area
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| If children are normal, adults are: more likely to be pregnant, have fibromyalgia, carpal tunnel, sciatica, be drunk,
abuse drugs, have access to hallucinogens, use weapons, have more rage (except for 3-yr-old boys), have foot
odor, and be morbidly obese
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 | Elderly have: tissue paper skin, “driftwood bones”, poor physiologic reserve, heart disease, calcified major blood
vessels, traumatic thoracic aortic dissection, and long list of medications
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| Summary: children designed to live to reproductive age and to bounce back after injuries
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| Mental status examination: do not undermine mental status examination by doing things to children that hurt and scare
them immediately upon their arrival (like cutting off their clothing, putting sticky things on them, poking them with
needles); child’s mental status best determined by level of detail they provide, not factual accuracy of responses;
children should be asked different questions; asking “who is the president of the United States?” does not assess
child’s mental status; children have no concept of time and make many factual errors; traditional trauma approach
fails in children; first question should be, “Hi, what’s your name?”
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| Pearls: be first clinician at child’s bedside; do not ask if things hurt because child will say “yes,” whether it does or not
because child wants to please clinician; play with child while performing examination, eg, speaker guesses what
foods child likes to eat while examining and palpating abdomen, and asking if child has pony tail while examining
head and neck; when child cries or seems uncomfortable, injury found; never tell child, “don’t help us, we will roll
you” (children want to help); continually assess mental status by talking to them; get child off back board as quickly
as possible; if child unresponsive, intubate and send to CT; sedate child if needed
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| Clearing cervical spine: National Emergency X-Radiography Utilization Study (NEXUS) criteria say, “x-rays are indicated
for trauma patients unless they exhibit all of the following: no posterior midline cervical spine tenderness, no
evidence of intoxication, normal levels of alertness, no focal neurological deficits, and no distracting injuries” (distracting
injuries not defined but left to judgment of clinician); NEXUS criteria have sensitivity of 99%, good negative
predictive value, and reasonable specificity, but this applies to adults, not children
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| How to clear cervical spine in children: talk to child during examination, eg, ask child’s name and age, if they have
brothers and sisters; have child take deep breaths, move hands and feet, squeeze clinician’s finger, feel clinician
touching their leg, look from side to side; if all looks good, unstrap child and ask if he or she wants to sit up; since
speaker has been using this technique, he has had 2 children who had broken backs and could not sit up
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| Spinal cord injury without radiographic abnormality (SCIWORA): child seems fine, then can be paralyzed; can take
days to develop; exclusive disorder of children; original concept came from 1982 paper which performed retrospective
study from 1960 to 1980 (magnetic resonance imaging [MRI] had not been invented); all clinically meaningful,
sustained injuries show on MRI; NEXUS study had 27 cases of SCIWORA, none in children; SCIWORA probably
problem of semantics; difficult to interpret literature because of heterogeneity
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| Future management: more and more cases of pediatric trauma will be thrust upon emergency physicians because it is
more commonly being managed nonoperatively
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| CHILD ABUSE/CHILD WITNESS —Charles Scott, MD, University of California, Davis, School of Medicine, Associate
Clinical Professor of Psychiatry and Chief, Division of Psychiatry and the Law, Sacramento
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| Modern history of child abuse: Mary Ellen Wilson was 8-yr-old girl in New York who was being horrifically abused;
neighbors petitioned local missionary for help; missionary went to local authorities who said there was nothing they
could do because there were no laws against child abuse; some states had laws against cruelty to animals; legally had
to declare Mary Ellen animal before state authorities could intervene
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| Advances: x-ray made diagnosis of child abuse possible (enabled demonstration of unusual fractures related to abuse);
landmark paper written in 1962 defining battered child syndrome resulted in all 50 states passing mandated reporting
laws in next 4 yr; Child Abuse Prevention Act required states to intervene and made clinicians mandated reporters;
Adoption Assistance and Child Welfare Act established that reasonable efforts should be made to keep child in home
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| Physical abuse: not accidental
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| Sexual abuse: inappropriate use of minor for sexual exploitation
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| Emotional abuse: making someone feel unloved, unwanted, or unworthy
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| Neglect: not taking care of child’s basic needs
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| Referrals: 2.9 million reported cases of child abuse in 2003; 34% screened out (call taken but nothing further done);
only 30% of investigated cases substantiated; neglect most commonly reported (60% of cases)
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| Statistics of abuse: ages 0 to 3 yr most commonly abused because they cannot run away; rates of abuse equal in boys
and girls; rates of reported sexual abuse more common in girls; 1500 documented cases of mortality due to child
abuse in 2003; perpetrators are women in 60% of cases (probably because they more typically stay at home with children);
men more commonly abuse children sexually; look for maternal depression in severe assault on children ages
0 to 3 yr (strong correlation); of 8000 surveyed adults, >50% of men and 40% of women said they were physically
abused during childhood
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| Types of child neglect: not giving care or getting them care in time; abandonment; inadequate supervision; not taking
them to school; not meeting their needs emotionally; child endangerment (eg, no car seat)
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| Emotional abuse: not commonly reported but associated with every other type of abuse
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| Sexual abuse: incidence in girls 1.6 per 1000, rate for boys lower but may be underreported; majority of perpetrators
are men known to victim; look for medical indications suggesting abuse, eg, presence of sexually transmitted disease
in very young child
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| Forensic interviewing: should be recorded on videotape; interview should not be repeated >3 times (“the fewer the better”);
establish rapport with child before asking about abuse; use of anatomically correct dolls controversial (do not
use in children ≤3 yr of age); absence of sexual play with doll does not prove child not abused, nor does presence of
sexual play prove child was abused (does not give definitive answer)
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| Mandated reporting: only need reasonable suspicion to report; immunity generally granted to those who refer in good
faith; failure to report can result in legal consequences (civil or criminal); standard of proof required to remove child
from home is “clear and convincing evidence” (ie, 75% certainty, not as high as “beyond a reasonable doubt” but not
as low as “preponderance of evidence”)
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| Child witness testimony: based on reliability, ie, how good is their memory and how suggestible are they?
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| Memory: has 3 key components, namely, do they have ability to observe correctly? can they encode it? can they produce
it?
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| Errors of memory: errors of omission (ie, leave something out unintentionally; done by younger children more
than by older children); errors of commission (telling incorrect information; may be lie, but child may be confused
between 2 events)
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| Recognition memory: earliest and easiest form of memory; 3-yr-old can recognize rubber ducky; 4.5-yr-olds can distinguish
their bike from anyone else’s bike; by age 6 yr, child should be able to recognize familiar people
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| Recall: some people, when they recall facts, become convinced of them even when wrong; preschoolers make
more omission errors; young children (≤7 yr of age) unreliable for relativity or comparison; for preschoolers,
must make sure they understand language
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| Suggestibility: ie, getting people into mindset where they agree to what they are being told; various techniques used,
sometimes unintentionally
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| Repetition of questions: repeating same question over and over, implying child needs to give different answer
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| Stereotype inducement: examiner tells child that he or she already knows what happened, so child needs to tell
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| Guided imagery: “close your eyes and imagine your father touching your leg; now open your eyes; did your father
touch you?”
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| Peer pressure: all other kids in the class know what happened, and your brothers and sisters have told us what happened
as well
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| Selective reinforcement: praising child when desired answer given
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| Study of 3-yr-olds: children videotaped during examination by pediatrician and later asked suggestive questions during
follow-up; half of children had no examination of genitalia; 50% of girls not touched made false claims, some
of which were outrageous
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| Mt. Sinai study (1998): examined 108 children ages 3 to 15 yr with suspected abuse; given anogenital examination
on day 2 as part of routine follow-up for abuse; asked on day 5 very suggestive questions like, “did the doctor
kiss you?” which clearly did not happen; 40% of preschoolers gave incorrect answers
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| Conclusion: many incorrect answers given because interviewers contaminate accuracy of children’s answers by
using suggestive techniques
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| Summary: degree of suggestibility remains somewhat controversial; children’s abuse allegations should be taken seriously;
forensic examiners must be diligent about not contaminating child’s statements; preschool children may be
more sensitive; adults can influence examinations
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Educational Objectives
| The goal of this program is to educate the listener about pediatric trauma and child abuse. After hearing and assimilating
this program, the clinician will be better able to:
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| 1. Discuss vascular access in children.
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| 2. Review the physical examination of the pediatric trauma victim.
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| 3. Describe how to perform a mental status examination on a young child and how to clear the cervical spine of a
child.
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| 4. List the types of child abuse and review the statistics on child abuse.
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| 5. Define and illustrate the elements of memory and suggestibility as they relate to the testimony of child witnesses.
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Discussed on This Program
Atropine sulfate (many trade names)
Ketamine HCl [Ketalar]
Programs of Related Interest
Bovis GK et al: Spinal trauma. Audio-Digest Orthopaedics 29:01(Jan 1), 2006; Mattox KL, Henry GL: Spotlight on
trauma. Audio-Digest General Surgery 51:06(Mar 21), 2004; Plumley DA, Scalea TM: Trauma from beginning to
end. Audio-Digest Emergency Medicine 21:20(Oct 21), 2004.
To Order, Contact Subscriber Service (1-800-423-2308)
Suggested Reading
Brenner D et al: Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 176:289,
2001; Buldini B et al: Spinal cord injury without radiographic abnormalities. Eur J Pediatr 165:108, 2006; Cederborg
AC: Factors influencing child witnesses. Scand J Psychol 45:197, 2004; Chiang VW, Baskin MN. Uses and
complications of central venous catheters inserted in a pediatric emergency department. Pediatr Emerg Care 16:230,
2000; Faller KC: Anatomical dolls: their use in assessment of children who may have been sexually abused. J Child
Sex Abus 14:1, 2005; Feigal DW Jr: FDA public health notification: reducing radiation risk from computed tomography
for pediatric and small adult patients. Int J Trauma Nurs 8:1, 2002; Green SM, Rothrock SG. Is pediatric trauma
really a surgical disease? Ann Emerg Med 39:537, 2002; Herman S: Improving decision making in forensic child
sexual abuse evaluations. Law Hum Behav 29:87, 2005; Jones JG, Worthington T: Management of sexually abused
children by non-forensic sexual abuse examiners. J Ark Med Soc 101:224, 2005; Kempe CH et al: The battered-child
syndrome. JAMA 181:17, 1962; Koestner AJ, Hoak SJ: Spinal cord injury without radiographic abnormality (SCIWORA)
in children. J Trauma Nurs 8:101, 2001; Lamb ME et al: Differences between accounts provided by witnesses
and alleged victims of child sexual abuse. Child Abuse Negl 27:1019, 2003; Mattera CJ: Little lifelines. Smart
strategies for establishing peripheral vascular access in pediatrics. Part one. JEMS 25:66, 2000; Pang D, Wilberger
JE Jr: Spinal cord injury without radiographic abnormalities in children. J Neurosurg 57:114, 1982; Slack SE,
Clancy MJ: Clearing the cervical spine of paediatric trauma patients. Emerg Med J 21:189, 2004; Stiell IG et al: The
Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 286:1841, 2001; Tepas JJ 3rd et al:
Pediatric trauma is very much a surgical disease. Ann Surg 237:775, 2003; Viccellio P et al: NEXUS Group. A prospective
multicenter study of cervical spine injury in children. Pediatrics 108:E20, 2001.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
Dr. Scott discloses being on the Speakers’ Bureau for Janssen Pharmaceutical and Abbott Laboratories.
Dr. Brown was recorded May 13, 2005, in San Francisco at High Risk Emergency Medicine, sponsored by the University
of California, San Francisco, School of Medicine, and Division of Emergency Services, San Francisco General
Hospital; Dr. Scott, on October 25, 2005, in Montreal at Forensic Psychiatry Review Course, sponsored by the
American Academy of Psychiatry and the Law. The Audio-Digest Foundation thanks the speakers and the sponsors
for their cooperation in the production of this program.
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