PEDIATRIC TRAUMA
Highlights from Pediatric Trauma: Protecting Our Future, sponsored by Nemours
| CERVICAL SPINE: CLEAR OR NOT TOO CLEAR —John Loiselle, MD, Associate Professor of Pediatrics, Jefferson
Medical College, and Assistant Director of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington,
DE
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| Goals of evaluation: recognize unstable injury; determine which patients at risk for cervical spine (C-spine) injury and
which of these need imaging; decide which imaging and adjunctive studies would be most helpful; assess patient for referral,
recognizing that every at-risk patient cannot be cleared in emergency department (ED) and that some need further
evaluation by experts outside ED; patient categories—1) can be cleared clinically; 2) can be cleared radiographically;
3) cannot be cleared in ED
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| Algorithm: reduces time to clearing; good algorithm must be—1) simple and easy to remember; 2) practical, ie, use resources
available in ED but not exclude their use for other patients for extended periods; 3) evidence-based (little evidence
available); 4) highly sensitive
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| Patients at risk: in children, mechanisms of injury age-related; forces act on immature C-spine; developmental stage affects
ability to communicate, ie, child may be nonverbal and/or crying; mechanisms of injury—<8 yr of age, motor vehicle
accident (MVA), most common; >8 yr of age, sports predominate; significant falls (eg, from second story window
or higher); tumbling down stairs or banging head against table seldom serious; pediatric anatomy—due to relatively
larger head, fulcrum for flexion-extension of neck at C2-C3, rather than at C5-C6 as in adults (data suggest fractures
higher in cervical spine more common in children); underdeveloped neck muscles provide less protection and more mobility
of neck; facet joints more horizontal and slip off more easily; odontoid synchondrosis potential weak area; wedge-
shaped vertebrae and ligamentous laxity contribute to high mobility of C-spine; frequency of C-spine injuries lower in
children than in adults (<10% of C-spine injuries occur in children <15 yr of age)
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| Management of child at risk: ABCs (airway, breathing, circulation) take priority; protect neck and delay further evaluation;
National Emergency X-radiography Utilization Study (NEXUS)—found 5 criteria for low risk 99% sensitive for
ruling out C-spine injury (CSI); criteria not explicitly defined, but based on clinical judgement of physician doing evaluation;
good agreement among physicians; looked at >3000 children, of whom 30 had CSI, and none of patients with CSI in
low-risk group; need for imaging reduced by >20%; only 88 patients <2 yr of age, and only 4 of patients with CSI <9 yr of
age
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| Imaging studies: plain x-rays—first choice; begin with 3-view series, ie, anteroposterior (AP), lateral, and odontoid
(open mouth); if open-mouth view cannot be obtained, use 2-view series; if level of suspicion for CSI especially high and
odontoid view not possible, add computed tomography (CT) of C1 and C2; pitfalls of interpretation of x-rays—
inadequate view; widths acceptable in young children different from those in adults, ie, predental space 4 to 5 mm, prevertebral
space different, and C2-C3 override can be higher and still be normal in young child; pseudosubluxation normal
finding in ≈20% of children; when posterior cervical line drawn through anterior cortex of spinous process of C1 and C3,
anterior cortex of C2 should fall on or within 2 mm of that line; with fracture, line often displaced >2 mm posteriorly
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| Spinal cord injury without radiographic abnormalities (SCIWORA): transient neurologic symptoms, ie, remitting,
then recurring after evaluation; thought due to injury to spinal cord without fracture or ligamentous injury; children
<8 yr of age at greater risk because of high spinal mobility; SCIWORA reported in ≤50% of children with spinal
cord injuries (none in NEXUS); magnetic resonance imaging (MRI) gives more definitive diagnosis
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| Adjunctive studies: indications for CT—inadequate radiographs; speaker obtains CT of C1-C2 routinely in infants
and toddlers who need CT of head; abnormality on x-ray; normal x-ray but significant focal pain or other neurologic
change; flexion-extension views—dynamic studies; used to help rule out unstable ligamentous injury; speaker does not
use because 1) rarely abnormal in setting of normal lateral and AP views, 2) limited in young child by spasm, pain, or inability
to cooperate; MRI—gives better views of soft tissue, eg, spinal cord edema; not as good as CT for bony abnormalities;
not acute study; done after patient admitted
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| Patients to refer: unconscious patient; patient with abnormal x-ray, (eg, fracture) referred to neurosurgeon or orthopedic
surgeon to determine whether injury stable or unstable; patient with neurologic symptoms possibly due to CSI; patients
with concerning clinical symptoms
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| Cases: 1) child 7 yr of age struck by car; Glasgow Coma Score (GCS) of 7; facial and abdominal injuries; ABCs; AP and
lateral x-rays and CT for odontoid view; immobilize and intubate; send to operating room (OR) or intensive care unit
(ICU); 2) 10-month-old fell down stairs; on back board with collar; crying; low-risk mechanism; calm child; perform
neurologic and physical examination; no imaging; 3) 4-yr-old awakens with neck pain; may have struck head during fall
on previous day; low-risk mechanism; use NEXUS criteria to clear; treat musculoskeletal pain; 4) 16-yr-old football
player ran headfirst into another player; unable to move arms or legs for several minutes; presents in collar on back board,
but neurologic examination normal; 3-view series negative; high-risk mechanism; consider SCIWORA; send patient for
evaluation by consultant and possibly MRI; 5) boy 8 yr of age fell off bike; obvious fracture of right forearm; given morphine;
splint arm; attempt to apply NEXUS criteria; make clinical judgement about distracting injury and how much morphine
affecting symptoms; comments—presence of cervical collar does not mandate C-spine series (prehospital staff
must have low threshold for applying; discuss mechanism of injury with them); use NEXUS criteria; when evaluating x-
rays, bear in mind differences between adults and children; negative C-spine x-ray series (87% to 98% sensitive) does not
rule out significant injury; cannot always clear C-spine in ED; protection of C-spine priority
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| WHACKS TO THE TRUNK: PEDIATRIC SOLID ORGAN INJURY —Sarah A. Jones, MD, Clinical Instructor, Department
of Surgery, Division of Pediatric General Surgery, and Associate Director of Trauma, Nemours/Alfred I. duPont Hospital for
Children, Wilmington
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| Mechanisms of injury: compressive forces squeeze abdomen; deceleration forces can tear organs; children’s bodies
have—smaller surface area to dissipate forces; less overlying fat; weaker abdominal muscles to protect organs; larger organs
relative to compartments
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| Approach to injured child: assume patient in hemorrhagic shock from bleeding inside head, chest, abdomen and pelvis,
or into femur; hidden bleeding makes hemorrhagic shock more difficult to diagnose; work-up—ABCs; inspection,
auscultation, and palpation; standard laboratory evaluation for blunt trauma; liver function tests (LFTs) and pancreatic
enzymes provide additional information, but should not be main tools in ruling out injury, since no other values available
for comparison; blood typing and crossmatching; imaging; if patient with hemodynamic compromise not responding to
fluid resuscitation, transfer to OR of interventional radiology (CT contraindicated); imaging indicated in patients who become
hemodynamically stable
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| Liver: mobile except at points of fixation; types of injury—lacerations (caused by deceleration forces); hematomas
(caused by compressive forces); vascular disruption (liver torn from blood supply); grading based on CT findings; 6
grades in American Association for Surgery of Trauma guidelines (higher the number, more serious the injury); ≈90% of
children with liver injuries managed nonoperatively (admit, observe, and restrict activity after discharge)
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| Spleen: most pediatric splenic injuries managed nonoperatively; grading as in liver injury (1-6; based on CT findings of
depth of injury and how much of organ involved)
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| Kidneys and adrenals: injuries diagnosed by CT; ≈63% of patients with multisystem injuries have hematuria, indicating
significant force and mandating careful examination of abdomen; 50% of patients with adrenal injury have another
intra-abdominal injury; right adrenal gland more prone to injury than left; kidney grading system on scale of 1 to 5, 5 being
worst, with injury to vascular pedicle and disruption of collecting system; no grading for adrenals
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| Pancreas: not as easily injured as other organs; treatment strategies controversial, but conservative management often
best; high index of suspicion required for diagnosis; CT helpful; no set grading system
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| Nonoperative management: for grade 2 splenic or liver injury, patient hospitalized for at least 3 days (grade plus 1)
for observation; grade of injury plus 2 gives number of weeks patient has activity restriction at home; ICU stay for 24 hr
required for grade 3 or higher injuries
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| CAN THEY THINK? AFTERMATH OF BRAIN INJURY —Jane A. Crowley, PsyD, Psychologist, Division of Rehabilitation
Medicine, Alfred I. duPont Hospital for Children, Wilmington
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| Incidence: 80,000 to 90,000 people annually acquire long-term disability due to traumatic brain injury (TBI); currently,
5.3 million Americans living with disability due to TBI; TBI leading cause of death and disability in childhood; 20,000
children acquire school-related disability each year; by tenth grade, 1 in 30 children have had brain injury; most TBI diagnosed
in ED; preschool children 46% of pediatric TBI diagnosed in ED
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| Developmental issues: the younger the brain, the more vulnerable to effect of injury; while adults simply have to get
back to where they were before injury, children have to get back to where they were and continue to develop beyond that;
this creates delayed onset of impairment that attenuates connection between TBI and later behavioral or cognitive deficiency;
50% of children in coma >6 hr have deficits for at least 2 yr in postacute phase (not counting delayed-onset impairment)
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Preschool Children
| Confluence of incidence and development: 0- to 4-yr age group—at highest risk for incidence and for severe developmental
impact; 1 to 4 yr after trauma—preschoolers have worst outcomes of all childhood ages; data show 68%
of group abnormal (primarily cognitive delays), with 52% rate of behavioral problems; delayed onset—in child injured
at 10 mo of age, behavioral problems do not emerge until 2 to 3 yr of age, and academic problems not seen until school
age; connection to TBI often not made
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| Developmental effects: correlate with severity of TBI; severe TBI—intelligence (global IQ) affected if TBI occurs in
preschool age group, but not in middle childhood or adolescence; adaptive skills also affected, ie, ability to do day-to-day
tasks; difficulty with impulse control and inhibition; IQ scores deteriorate over time (not seen in survivors of TBI in middle
childhood and adolescence); mild and moderate TBI (as shown by GCS)—verbal IQ reduced (adjusting for financial
status and social class); language impaired; specific effect on expressive language, ie, children able to understand
what is said to them but have impaired capacity to communicate their thoughts; history of preschool TBI—found in
high percentage of children placed in special education classes
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Adolescents (15-19 yr of age)
| Development: adolescents working, driving, and participating in high-stakes testing activities; brain development ongoing;
here-and-now thinking predominates, and prevention messages often ignored; natural narcissism predominant
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| Concussion in high school athletes: high incidence; heightened vulnerability (reason unknown); more stringent return-to-play
guidelines needed because accumulation of concussions particularly detrimental (disability accrues); unlike in
adults, cognitive deficits persist after somatic symptoms gone; narcissism leads to underreporting of concussions and of
symptoms afterwards; some underreporting due to lack of awareness, eg, not knowing that loss of consciousness not required
for concussion
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 | Follow-up: cognitive testing; postural stability (difficult to fake); obtain cognitive baseline at start of school year; after
concussion, player must return to baseline functioning; mild concussion defined by alteration in cognitive function;
player may “lowball” baseline, but sophisticated programs can detect this and indicate retesting
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Survivors of Pediatric TBI
| Rehabilitation services: school transition services play major role (80% of population require special education); family
education and support (parents become primary case managers; family determines ultimate outcome); at 5-yr follow-
up, 24% of children still have obvious cognitive deficits; long-hospitalization group requires monitoring for at least 3 to 5
yr; 76% of children outside trauma-referral process
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| Follow-up services: 1-yr study—looked at 4 trauma centers across United States; children hospitalized between ages
of 5 and 15 yr; done through telephone interviews with caregivers; found 30% had unmet or unrecognized needs; most
problems cognitive; 50% had changing needs, ie, additional problems arising from injury; reasons for unmet needs—
not recommended by physician or school; 33% of children had no physician contact during first year after injury; survey
found widespread ignorance about brain injury
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| Evidence-based medicine: meta-analysis shows practice guidelines and attempts to draw attention to problem of
childhood TBI effective; at time of ED visit, giving parents printed material about short- and long-term symptoms effective
way to help them manage after effects of injury
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| Outreach: at speaker’s institution, family members of TBI survivors being trained to be ambassadors to educational and
medical system; targets include pediatricians’ offices, and public schools (eg, regular classroom teachers trained to elicit
information about TBI from children who return to school with broken bones); many TBI survivors mislabeled as having
mental retardation (preschoolers) or learning disabilities (older children) and placed in special education; guidance counselors
must also be trained to consider TBI in children who “act up”
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Suggested Reading
Anderson RC et al: Cervical spine clearance after trauma in children. J Neurosurg 105:361, 2006; Bonnier C et al:
Neurodevelopmental outcome after severe traumatic brain injury in very young children: role for subcortical lesions. J
Child Neurol 22:519, 2007; Cantu RC: Athletic concussion: current understanding as of 2007. Neurosurgery 60:963,
2007; Cuff S et al: Validation of a relative head injury severity scale for pediatric trauma. J Trauma 63:172, 2007;
Haider AH et al: Black children experience worse clinical and functional outcomes after traumatic brain injury: an analysis
of the National Pediatric Trauma Registry. J Trauma 62:1259, 2007; Heffernan DS et al: What defines a distracting
injury in cervical spine assessment? J Trauma 59:1396, 2005; Henderson CG et al: Management of high grade
renal trauma: 20-year experience at a pediatric level I trauma center. J Urol 178:246, 2007; Epub 2007 May 17. Hendey
GW et al: Spinal cord injury without radiographic abnormality: results of the National Emergency X-Radiography Utilization
Study in blunt cervical trauma. J Trauma 53:1, 2002; Hoffman JM et al: Understanding pain after traumatic
brain injury: impact on community participation. Am J Phys Med Rehabil 86:962, 2007; Isaacman DJ et al: Closed
head injury in children. Pediatr Emerg Care 18:48, 2002; Johnston KM et al: Current concepts in concussion rehabilitation.
Curr Sports Med Rep 3:316, 2004; Knudson MM et al: Improving outcomes in pediatric trauma care: essential
characteristics of the trauma center. J Trauma 63:S140, 2007; Laatsch L et al: An evidence-based review of cognitive
and behavioral rehabilitation treatment studies in children with acquired brain injury. J Head Trauma Rehabil 22:248,
2007; Marmery H et al: Optimization of selection for nonoperative management of blunt splenic injury: comparison of
MDCT grading systems. AJR Am J Roentgenol 189:1421, 2007; Putukian M: Repeat mild traumatic brain injury: how
to adjust return to play guidelines. Curr Sports Med Rep 5:15, 2006; Ropper AH et al: Clinical practice. Concussion. N
Engl J Med 356:166, 2007; Sarko J: Clinical prediction rule for pediatric blunt head injury. Ann Emerg Med 50:483,
2007; Stiell IG et al: The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J
Med 349:2510, 2003; Tataria M et al: Pediatric blunt abdominal injury: age is irrelevant and delayed operation is not
detrimental. J Trauma 63:608, 2007; Taylor HG et al: Bidirectional child-family influences on outcomes of traumatic
brain injury in children. J Int Neuropsychol Soc 7:755, 2001; Yanar H et al: Pedestrians injured by automobiles: risk
factors for cervical spine injuries. J Am Coll Surg 205:794, 2007; Epub 2007 Sep 17.
Educational Objectives
| The goal of this program is to improve the management of pediatric trauma, including clearing the cervical spine (C-spine),
solid organ injuries, and the aftermath of traumatic brain injury. After hearing and assimilating this program, the clinician
will be better able to:
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| 1. Determine which pediatric trauma patients are at risk for C-spine injury, which ones need imaging, and which imaging
and adjunctive studies would be most helpful.
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| 2. Decide which children with C-spine injuries cannot be cleared in the emergency department and refer them for further
evaluation.
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| 3. Describe the mechanisms of injury from blunt trauma to the trunk, and manage children with injuries to the liver,
spleen, kidneys, adrenals, and pancreas.
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| 4. Explain the developmental effects of traumatic brain injury (TBI) in preschool children and adolescents in general,
as well as the special case of concussions in high school athletes.
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| 5. List the special needs of survivors of pediatric TBI, including rehabilitation services, follow-up, and community outreach.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts
of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health
care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported
nothing to disclose.
Acknowledgements
Drs. Loiselle, Jones, and Crowley spoke at Pediatric Trauma: Protecting Our Future, recorded September 21, 2007, in
Wilmington, DE, and sponsored by Nemours. The Audio-Digest Foundation thanks the speakers and the sponsor for their
cooperation in the production of this program.
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