Trauma

Definition of trauma
1. Application of force [mechanical – chemical – electrical] to the body and the body’s response
to that Force.
2. Forceful disruption of the body’s homeostasis

Extensive trauma: is the one with

1. Injury severity score [ISS] 10 or more
2. Pediatric trauma score [PTS] 8 or less.
3. Injury to one or more body cavities or 2 or more extremities which may endanger life.

What is first and second trauma

1. 1st trauma: is the anatomic and physiologic disruptions that result from injury.
2. 2nd trauma: are the social and familial dislocations associated with first trauma .these are
considerable in children.

Epidemiology of trauma
1. Trauma is the leading cause of mortality in children 1-14 yrs
Leading causes of death in this age group are:
1. Trauma 62 %.
2. malignancies 8 %
3. Congenital anomalies 5 %.
4. Heart diseases 3 %.
5. Others [e.g. infections – metabolic] 22 %.
2. Trauma is the leading cause of morbidity in children 1-14 yrs. in the US :
1. Annually 1 in 4 children receives medical treatment for trauma.
2. For every trauma death there are 4 permanent disabilities.
3. Incidence of severe trauma
Hospitalization is the indication of severity is 420 per 100,000 = 0,4 %
4. Incidence of mortality
1. hospital based mortality = 2.4 per 100.000
2. population based mortality = 11.8 per 100.000
Thus 78 % of fatally injured children die before reaching hospital.
5. Boys are injured more than girls: 2 : 1 because they :
1. play rough
2. take more risk
3. are more exposed to activities that result in trauma
6. In the US trauma accounts for:
1. 10 % of all pediatric hospitalizations.
2. 15 % of all pediatric ICU admissions.
3. 20 % of all hospitalization for trauma among all age groups.
4. 25 % of all pediatric A/E visits.
5. > 10.000 pediatric deaths annually.
6. Nearly 30 000 permanent disability annually.
Prevalence of serious injury has increased. Causes are the:
1. Mechanization of society.
2. Endemic crime violence.
3. Indiscriminate assaults against civil population by weapons.
4. Terrorism.

Causes of multiple injuries

1. Motor vehicle accidents.
2. Occupational injuries [adults].
3. Falls.
4. Interpersonal violence.
5. Gunshot trauma.

Trauma related death

1. Leading causes of traumatic death in children
1. MVC 38 %
2. Homicide 13 %
3. Drowning 13 %
4. fire – burn 9 %
5. Suicide 5%
6. Suffocation 4 %
7. Other 16 %

2. Commonest causes of traumatic death in children

1. Intracranial injury
2. Intrathoracic – abdominal injury
3. Hypotensive shock
1. Intracranial injury
 Responsible for 1/3 of trauma related deaths.
 80 % of trauma death have some sort of head trauma .
 This is because of the effect of traumatic come on the :
1. Airway patency
2. Breathing control
3. Cerebral perfusion
2. Intrathoracic – abdominal injury
 Cause less death because they are seldom associated with hypotensive shock.
3. Hypotensive shock
 Occurs in 6 -8 % of children with demonstrable mortality risk

3. Pattern of death from trauma in relation to time :

 Death from trauma has trimodal pattern over time.
 In adults
 1st peak = 50 % of total
 2nd peak = 30 % of total
 3rd peak = 20 % of total
  This is modified in children
1. 1st peak
 Death occurs seconds to minutes after injury
 It is due to severe damage to the :
1. Central and peripheral nervous system
2. Major vessels.
 Here only prevention can improve survival.
2. 2nd peak.
 Death within hours after injury [mean = 4 hours].
 Death is duo to :
1. Mass lesion in the CNS: epidural – subdural hematoma.
2. Major solid organ injury.
3. Fluid collection in the pleural or pericardial cavities.
 Potentially treatable injuries [hence the golden hour concept].
 Focus of ATLS- APLS.
3. 3rd peak
 Death occurs days to weeks after injury.
 Duo to :
1. Sepsis.
2. Systemic inflammatory reaction that lead s to multi organ failure.
 Less frequent in children.

Classification of injury in children

1. Unintentional injury : 93 %
 Most blunt trauma.
 Sustained during family – sport – or play activity.
2. Intentional injury: 7 %
 ½ of these are due to child abuse.
 Blunt trauma penetrating trauma 12: 1.
 Penetrating injuries are more lethal.

Types of injuries in children are different from adults

 Factors which explain these differences are the general body differences between children and
adults i.e.
1. Size and shape of children
2. Skeleton of the child
3. Surface area of the child.
4. Degree of psychological development of the child.
5. Long term effects of the injury.

1. The size and shape of the child:

Compared to adults Children have:
1. Less fat and connective tissue available for protection.
2. Small size thus :
 1. Energy is transferred and dispersed over small body surface area.
2. The internal organs are in close proximity to each other and to the body surface.
Thus multisystem injury is more frequent in children.
3. Solid organs are larger compared with the rest of the abdomen.
4. The rib cage is higher providing less protection to the abdominal organs.
5. The infants head is disproportionately larger compared with the adult and subjected to the hight
incidence of shear injuries.
6. The size of th child determines the various types of injuries :
 Children have small torso – small hepatic recesses and shallow pelvis.
 This predisposes certain organs to injury namely the liver – spleen and urinary bladder.

2. The skeleton of the child

1. Bones in children have less calcium [ i.e. they are less ossified] thus are more pliable hence
1. They are less likely to break but undergo partial # [Greenstick # - torus # - Buckle #]
2. Forces are transmitted below the skeleton causing injury to the inner organs without bone #
e.g. lung contusion without rib #
2. Injury to the growth plate results in growth abnormalities e,g,
1. Discrepancy in length of limbs –
2. Scoliosis – kyphosis.

3. The surface area of the child

 Children have large ratio of body surface area to weight.
 This results in greater predisposition to heat loss [ 3 times greater ] and hypothermia
 Hypothermia can occur rapidly in children from :
1. Resuscitation in a cold room
2. Administration of cold IV fluids
3. Inhaled gases
 The hypothermia is predisposed by the :
1. Large surface area relative to body mass and weight → rapid heat exchange with the
environment.
2. Lack of sufficient subcutaneous tissue → poor insulation.

4. Psychological development of the child

 Children often regress to a previous developmental stage during stressful and anxiety provoking
situations
 Factors that may add to this include :
1. The presence of strangers which causes further disorientation to the child
2. Pain is not understood by children
3. The method by which children are examined can have positive or advert effects.

5. Long term effects of injury on children

1. Splenectomy predisposes children to sepsis [ overwhelming postsplenectomy sepsis OPSS
2. Fracture of the growth plate of bone results in discrepancy in limb length.
3. Psychological regression may become permanent.
4. Injury may result in permanent physical or mental disability.
 Mechanisms of injury

1. Blunt trauma 7. Less common causes

2. Penetrating trauma 1. Electricity
3. Blast injury 2. radiation
4. Deceleration injury 3. Extremes of temprature
5. Crush injury 4. Barotrauma
6. Burn 5. Chemicals

1. The blunt trauma

 Accounts for nearly 90 % of pediatric injuries
 Results from deceleration forces [RTA - direct blow – fall].
 The magnitude of injury reflects the direct transfer of kinetic injury to the patient
E = ½ mass X velocity ²
I.e. the kinetic energy transferred equals ½ of the mass of the impacting object times its velocity
squared. Thus the higher the impact speed the higher is the energy transfer.
 Deceleration injury give rise to 3 types of forces [ damages ] : shearing –tension- compression
1. Shearing
 Occurs when 2 forces act in opposite direction.
 Result in :
1. Skin abrasions and lacerations that tend to be irregular and have high risk of infection
2. Damage to surrounding tissue with extensive scarring
3. Visceral damage at points where the viscera are tethered down I.e. at the
1. Peritoneal attachment of the duodeno-jejunal flexure – spleen and iliocolic
Junction
2. Vascular attachment of the liver
2. Tension
 Occurs when a force hits the tissue surface at an angle < 90 °
 Results in
1. Avulsion and flap formation
2. More tissue damage and necrosis than the shearing forces
3. Compression
 Occurs when the force hits the tissue surface at 90 °
 Results in :
1. Contusion – hematoma or breach at the site of impact
2. Extensive damage and necrosis of the under lying tissue
3. Increased internal pressure → rupture of the outer layer of the closed gas or fluid
filled organs [ viscera - spleen]
 In blunt trauma the combination of the 3 forces contribute to the pattern of injury.
 MVC are the most common cause of blunt trauma
 In MVC the damage is caused by :
1. Direct injury from the impact
2. Indirect damage from the
1. Shearing forces generated by angulation or bone #
2. Avulsion forces causing joint dislocation
Patterns of injury
 Poly trauma patients exhibit characteristic pattern of injury.
 Recognition of the patterns helps predicting as assessing the extent of the injury.
1. In frontal impact the patient may present with :
1. Facial fracture 7. Liver – splenic injury
2. Cervical injury 8. Posterior hip dislocation
3. Obstructed airway 9. # femur -# acetabulum
4. # rib- flail chest 10. # patella- tibia –fibula
5. Pneumothorax 11. Carpometacarpal injury
6. Cardiac contusion 12. Tarso-metatarsal injury
2. Patients falling from height and landing on their feet
1. #s : calcaneus –ankle – tibia – fibula- hip – pelvis
2. Compression # of the thoracic and lumbar vertebrae
3. Cervical injury
4. Rupture of the major vessels [ aorta – IVC]
5. Avulsion of the liver
6. Tracheo-bronchial disruption
3. Motorist – pedestrian – person ejected from a car
 May sustain multiple injuries
 Classic pattern of injury of a child pedestrian hit by a car is the Waddell’s triad :
1. Initial impact injury to the thorax –abdomen – femur.
2. The child is thrown.
3. Sustains closed head injury from striking the head.
4. The commonest injury patterns in children :
1. pedestrian – MVC trauma : Waddell’s triad
2. occupant injury :
1. Unrestrained passenger: head-face and neck injury
2. restrained passenger:
1. cervical spine injury
2. bowel disruption or hematoma
3. Chance #

2. The penetrating injury

 Result from
1. Sharp instruments : knives – blades – glasses
2. Hand guns
3. Hight velocity instruments – military
 The extent of the damage depends on the :
1. Transfer of energy to the tissues.
2. The anatomical factors.
1. The transfer of energy to the tissues
 Several factors affect the degree of energy transfer to the tissues surrounding the tract of
weapon or missile
 These include the
1. Kinetic energy of the weapon
2. Mean presenting area of the weapon
3. Tendency of the weapon to deform and fragment
 4. Density of the tissues
5. Mechanical characteristics of the tissue
 It follows that
1. Stab wounds – low velocity firing arm injuries
 Velocity = 300 m/ sec. [ 100 feet/second]
 Produces
1. Entrance wound similar to the side of the weapon or bullet
2. Damage confined to the track of the bullet
3. Exit wound if present similar to the size of the bullet.
2. High velocity injury :
 Velocity > 750 m/sec [ > 1000 feet /sec]
 Produces :
1. Entrance wound similar to the size of the bullet
2. Cavitation and massive damage along the tract
3. Large exit wound
 Tissue damage reflects the degree of dissipation of the kinetic energy of the weapon :
1. Bullets which fail to exit the tissue transfer all their kinetic energy to the tissues.
2. Bullets which tumble or fragment slow down and transfer a greater amount of energy
3. High velocity bullets push the tissues away forming a temporary cavitatation which then
retracts to a permanent cavity at the path of the missile.
 Cavitation has 3 consequences :
1. Mechanical and functional disruption of the neighboring tissues.
2. Gross contamination of the wound from :
1. Clothes carried into the wound in front of the bullet and.
2. Material sucked into the wound from negative pressure at the exit wound.
3. Exit wound larger than the entry wound.

2. The anatomic factors

The significance of the penetrating wound depends on the:
1. Type of organ involved
2. Extent of injury :
1. low velocity – stab wounds : little edema and infection
2. stab wound in the abdomen : visceral and vascular injury
3. stab wounds in the heart : fatal

3. The blast injury

 result from :
1. domestic or industrial explosion
2. bombing
3. fire work
 Detonation results in sudden release of energy. 2 things occur
1. The shock front [blast wave]
2. The blast wind
1. The blast wave [ shock front]
 Is instantaneous rise in the pressure in the surrounding air
 It travels faster than the speed of sound
  It travels in all directions
 It is reflected and multiplied by solid objects such as those found in closed or confined spaces.
2. The blast wind
 It is the movement of air itself.
 It comes behind the shock front
 It carries fragments of debris which can produce high velocity injury
 Bomb blasts cause injury in many ways. There are primary -2ndary and tertiary effects

1. The primary effects

 Result from the shock front [blast wave]
 Affect the air- containing organs : lungs –bowels –ears
 When the shock front[blast wave] hits the body surface it causes distortion which produces :
1. blast damage to the lungs – gut- tympanic membranes
2. air embolism
1. The blast damage: includes
1. hemorrhage into the alveolar space
2. damage to the alveolar septa
3. stripping of the bronchial epithelium
4. production of emphysematous blebs in the pleural space
5. contusion of the gut wall
6. leakage of the blood into the gut
7. gut perforation
8. rupture or contusion of the tympani membrane
9. If pulmonary changes are extensive they may lead to ventilation /perfusion
mismatching → hypoxia.
2. The air embolism
Sudden death may occur if the air emboli obstruct the cerebral or coronary arteries

2. the secondary effects

 Results from impacts of fragments carried in the blast wind.
 Lethal area for these fragments is > that of the shock front
 The patient presents with multiple contaminated wounds
3. The tertiary effects
 Result from the dynamic force of the blast wind itself .
 This force causes :
1. deceleration injury by carrying the whole person
2. amputation of part of the person
 in addition the patient may sustain injury from :
1. falling masonry
2. toxic fumes
3. fire
4. flash burns
5. chronic psychological disturbance

4. the deceleration injury

 occurs in :
 1. MVCs
2. Air crashes
3. Falls from great hight
 On impact the deceleration forces cause injury to
1. sites where mobile structures are anchored
2. less robust tissues
 vulnerable tissues include the ;
1. brain
2. junction of the cranium and the cervical spine
3. main bronchi
4. isthmus of the thoracic aorta
5. vascular pedicle of the kidney
6. transverse mesocolon
 many of these injuries are not immediately apparent and can be missed and surface later when the
patient is in critical condition

5. The crush injury

 occurs in :
1. MVCs
2. Building collapse
3. Train accidents
4. Industrial injury
5. mining accidents
6. Earth quakes
7. Landslides
 The injuries are caused by :
1. Falling masonry
2. Compression of body parts under the weight of rubble → Ischaemia of the affected part.
3. The combination of trauma and Ischaemia causes muscle necrosis resulting in :
1. growth of bacteria mainly clostridia → gas gangrene
2. Crush syndrome i.e.
1. ischemic changes in the muscles
2. reperfusion injury after restoration of circulation i.e. massive release into circulation
of :
1. myoglobin
2. muscle degradation products which cause :
1. Aggravation of the shock
2. Acute tubular necrosis
6. Burn
7. Electrical injury
8. Barotrauma
9. Extremes of temprature
10 Chemicals
For each of the above mechanisms see respective chapters
Most common causes of pediatric trauma
1. fall
 2. MVA
3. Pedestrian
4. Bicycle
5. Assault

Age-specific mechanisms of injury

1. 0 – 1 yr
1. Child abuse 4. Inhalation/ ingestion of FB - poisons
2. Fall 5. MVA
3. Burn 6. Drowning
2. 1 -4 yrs
1. Fall 4. Poison
2. Drowning 5. Burn
3. MVA
3. 5 – 9 yrs
1. MVA 5. firearm
2. Bicycle 6. Sport
3. Drowning 7. Pedestrian v. car
4. burn
4. 10 – 15 yr
1. MVA 5. fall
2. Drowning 6. Bicycle accident
3. Burn 7. Sport
4. firearm

Leading cause of trauma –related death according to age group :

1. 0 – 1 yr : airway obstruction
2. 1-4 yrs : drowning
3. 5- 9 yrs : MVA occupant injury
4. 10 -14 yr : MVA occupant injury

Anatomical and physiological variations in children

 Children are not small adults

 They differ from adults anatomically and physiologically

1. General body differences:

1. Shape and size
1. Less fat and connective tissue available for protection
2. Energy is transferred and dispersed over a smaller body surface area
3. Internal organs are in close proximity .this predisposed to multiorgan injury
4. Solid organs are larger compared with the rest of the abdomen
5. The rib cage is higher offering less protection to the abdominal organs
6. The infant’s head is disproportionately higher compared with the adult and subjected to
high incidence of shear injuries
 2. The skeleton
1. Incomplete ossification of bone causes them to be more pliable thus less likely to fracture :
1. Children sustain linear # e.g. green stick – torus and buckle
2. Pulmonary contusions and splenic lacerations often occur without fracture
2. Injuries to growth plates result in specific pattern of injuries and later discrepancy in limb
length
3. Surface area : children have large ratio of body surface area to weight .this predisposes to
heat loss [3 times greater] and hypothermia
4. Psychological development
Children often regress to previous developmental stage during stressful and anxiety provoking
situations
5. Long term effect of injury
1. Splenectomy predisposes children to lifelong risk of overwhelming post splenctomy sepsis
2. Injury to growth plates results in discrepancy in limb length

2. The airway
1. Head and neck : children have
 Large occiput : causes neck flexion in supine position
 Short neck
 Large head – short neck + weak shoulder girdle result in easily obstructed airway .
2. The oral cavity
 Small oral cavity
 Large tongue which can occlude the airway when displaced posteriorly
 Large tonsils and adenoids with plenty of blood supply
3. The larynx
 Situated higher in the neck [ at level of C3 – 4] adults at C4-5 and
 More anterior
 It is small and immature
 It collapses on inspiration
 It is funnel shaped
 Hyperextension of the head causes upper airway obstruction
4. The epiglottis
 Large , long , floppy and narrow
 Angled away from the long axis of the trachea thus difficult to control by the laryngoscope.
 Susceptible to trauma and swelling
5. The air passages
 Narrower ,shorter
 Tissues are softer and more pliable
 Thus pressure under the chin when lifting it can occlude the airway
 Young infants [2 – 6 mo] are obligate nose breathers
6. The vocal cords
 Shorter ,concave , with lower attachment anteriorly
 More cartilaginous thus easily injured during intubation
7. The trachea
 Shorter. in the newborn = 4-5 cm. – 1 ½ yrs old = 7-8 cm
 The supporting cartilage is less well developed thus
 1. Advancing the ET tube into the right bronchus is common
2. Trachea is susceptible to obstruction by blood, edema and mucous
8. The narrowest part of the airway
 In children < 10 yrs it is the cricoid ring[ subglottis]
 In adults the epiglottis
 Thus a tube may pass the vocal chord but becomes stucked in the subglottis hence
1. Uncuffed tubes are used
2. Air leak is common
Consequences of the anatomical variations of the airway
1. Speed of deterioration of the airway is mathematical
 The airways are circular. diameter of the circle is ΠR²
Π=
R = radius
 The child’s airway is small. A mm or 2 of circumferential edema narrows it considerably
 The smaller the diameter of the airway the more is the resistance to airflow thus more
pressure need be exerted for ventilation.
2. Intubation is more difficult because:
1. The larynx is high thus the angle between the tongue base and the glottic opening is more
acute hence:
 Controlling the epiglottis is more difficult
 Straight blade laryngoscope is more useful for visualization
2. The ET tube can easily enter the esophagus or become caught in the anterior commisure e of
the vocal cords
3. ET size must be based on the cricoid ring rather than the glottis opening.
3. Lack of the cartilaginous support of the larynx and the trachea + esophageal flaccidity allow
swallowed F.B. in the cervical esophagus to balloon into the wall between the trachea and
esophagus and occlude the airway

3. The respiratory system

1. The chest wall :
 Cylindrical in shape
 The ribs lie horizontally
 The intercostal muscles are poorly developed
 The chest wall is pliant
2. The alveoli
 70 million at birth . Small , primitive
 Increase in adults to 200 – 300 millions [average 375 million].
 Infants have increased risk of atelectasis.
3. The tidal volume
 In children = 8 – 10 ml /kg
 During stress children cannot increase their tidal volume because :
1. The ribs are horizontal
2. The sternum is soft
3. The intercostal muscles re not well developed
Thus they have poor ability to create negative intrathoracic pressure .
Instead they increase the respiratory rate [tachypnea].
 4. The pulmonary reserves
 These are poor due to the
1. Soft sternum and soft pliable ribs
2. Big heart and abdomen
3. Decreased functional reserve capacity
 Because of the poorly developed intercostal muscles children up to 3 years of age depend on
diaphragmatic breathing thus any thing that impedes the diaphragmatic function will
compromise the respiration
 The intercostal muscles contribute little to the chest wall movement during inspiration. When
in distress the chest wall will retract

Management of trauma

1. Prehospital care
Objectives
1. Recognition and treatment of immediate life - threatening conditions.
2. Assessment of mechanisms of trauma and extent of injury.
3. Triage to appropriate level of pediatric trauma facility.

Results till now:

1. Death rate of prehospital resuscitation is twice that of adults
2. Survival rate from cardiac arrest is half that of adults
3. Rate of resuscitation failure is twice that of adults
4. Failure of endotracheal intubation is close to 50 %
Reasons for this failure
1. Different causes of cardiac arrest in children
2. Inadequate training of staff
3. Unfamiliarity of staff with children
4. Difficulty comforting a terrified injured child

What to do?
Paramedics function best by adopting strict protocols of resuscitation

2. Hospital resuscitation
 Basic goals of management :
1. Saving lives
2. Repair of damage
3. Relief of symptoms
4. Rehabilitation
 Accepted protocols :
1. Advanced trauma life support ATLS
2. Advanced pediatric life support APLS
 ATLS [APLS] protocol has 3 components :
 1. Primary survey and resuscitation
2. 2ndary survey
3. Definitive e treatment
 Essential preparations :
1. Trauma team [trained to work together ]
2. Essential equipment [resuscitation trolley – O2]
3. Team wears universal precautions [gown- gloves – mask – eye wear ]

The trauma team: 5 persons

1. Team leader : overseas the resuscitation process
2. a person responsible for the head and neck : airway management . manipulation above the chest
3. a person for mid portion of the body and vascular access
4. a person for lower part of the body : vascular access- urinary catheterization - # immobilization
5. 5th person takes history of the patient