Polytrauma in Young Children

Age group

Weight range (kg)

Heart rate (beats/min)

Blood pressure (mmHg)

Respiratory rate (breaths/min)

Urinary output (ml/kg/h)

0–12 months

3.5–10

<160

>60

<60

2.0

1–2 years

10–14

<150

>70

<40

1.5

3–5 years

14–18

<140

>75

<35

1.0

6–12 years

18–36

<120

>80

<30

1.0

13–18 years

36–70

<100

>90

<30

0.5–1.0

Modified from ATLS [8]

Table 17.2

Age (years)	Blood loss (ml)	% total blood volume
4	500	40
8	500	25
Adult	500	10

17.4 Patterns of Injury

In young children, fall from a high place with resulting head and neck injuries leads statistics. The physiological conditions, especially the disproportionately large head and weak neck musculature in children less than 3 years of age (Fig. 17.1), puts them at a high risk for brain and neck injuries, even at low velocities [10].

Fig. 17.1

Relationship between head, trunk, and extremities in children vs. adults (Bernbeck and Dahmen [31])

With growing age, traffic accidents account for the majority of trauma and incidence of abdominal, thoracic, and extremity injuries gain numbers. Thereby, trauma by bicycle, pedestrian, and motor vehicle accidents each account a third of trauma cause, showing a higher proportion of pedestrians and bicyclists among children compared to adults.

Common trauma-injury conditions like the dash board injury in adults are the combination of lumbar spine fractures with abdominal lesions of liver or small bowels due to an insufficient safety belt [6] or the combination of thoracic injury and femur fracture on one side and head injuries on the opposite side due to hit facing the car (so-called Waddell’s triad).

17.5 Scoring

Although the Injury Severity Score (ISS) is usable for children, other scores like the PTS, the Pediatric Trauma Score, have been developed to provide a more specific tool. The PTS consists of a combination of anatomical and physiological values and can reach scores between −6 and +12. It has been shown that the PTS correlates with overall survival rates in polytraumatized children (Table 17.3) [11].

Table 17.3

I Scoring

A. Weight

1. Weight > 20 kg: score +2

2. Weight 10–20 kg: score +1

3. Weight < 10 kg: score −1

B. Airway

1. Normal airway: score +2

2. Maintained airway: score +1

3. Invasive airway (e.g., intubated): −1

C. Systolic blood pressure

1. SBP > 90 mmHg: score +2

2. SBP 50–90 mmHg: score +1

3. SBP < 50 mmHg: score −1

D. Central nervous system

1. Awake: score +2

2. Obtunded: score +1

3. Coma: score −1

E. Open wound

1. No open wound: score +2

2. Minor open wound: score +1

3. Major open wound: score −1

F. Skeletal trauma

1. No skeletal trauma: score +2

2. Closed fracture: score +1

3. Open fracture or multiple fractures: score −1

II. Interpretation

A. Score range: +12 to −6

B. Trauma score ≤8 indicates significant mortality risk

III. References

A. Tapas (1987) J Pediatr Surg 22:14

17.6 First-Line Treatment in Polytraumatized Patients

Training as well as strategic and attentive treatment algorithms are the answer to optimal first-line care in polytraumatized children [1].

Under optimal circumstances, an experienced trauma team, consisting of the basic disciplines of anesthesia, radiology, and trauma surgery, should be supported by a pediatric competence, ideally a pediatric surgeon, pediatric intensive care provider, or abdominal surgeon with pediatric experience. Similar to adult trauma therapy, additional disciplines like thoracic surgery, neuro surgery, etc., may be useful if available. Besides this ideal setting, in prehospital settings or small trauma centers, there might be initially only one medical professional. In any way, the major goal of the first-line treatment consists of three parts:

Protection of vital functions
Rapid diagnostic
Initiation of differentiated therapy

To reach these goals, working according to common and daily used algorithms is useful. The ATLS (advanced trauma life support), well established in adult polytrauma treatment, applies to most situations and is often recommended. The primary survey follows the maxim “treat first what kills first” and consists of an easy A-B-C-D-E pattern.

A. Airway: To maintain or reestablish supplementation of oxygen, neck protection with a rigid cervical collar is necessary until definitive exclusion of instability. As young children often have a prominent occiput, a pad placed under the thoracic spine should be used to provide neutral alignment of the spine.

Oxygen is delivered in all cases initially with high flow rates via mask. Foreign bodies, occluding the upper airways, have to be removed. If internal airways have collapsed, naso-pharyngeal or oro-pharyngeal tubes are available and easy to insert (Guedel or Wendel tube). If the neurological status puts the patient at risk for aspiration, endotracheal intubation should be performed. The anatomical preconditions, like a bigger tongue or cephaled larynx, have to be anticipated, as well as vagal reflexes due to pharyngeal stimulation like bradycardia or hypersecretion.
B. Breathing: Hypoxia is the major cause of cardiac arrest in children. Thereby, due to the increased elasticity of the pediatric thorax, also without clinical signs of thorax trauma, severe lung contusion can exist. Sufficient ventilation, also with high PEEP (15 mmHg), can be necessary, for example, in drowning accidents. In case of asymmetric thorax movement, thoracic emphysema, missing breathing murmurs, or other signs of a hemato-/pneumothorax, a chest tube must be inserted to evacuate hematoma and/or air.
C. Circulation: It is essential to know age-related heart frequencies and blood pressure to validly assess pediatric status. In hemodynamic shock and centralization, even for experienced pediatrics or emergency doctors it can be difficult and time consuming to establish sufficient peripheral vein access (that means 2 big and working intravenous accesses). In these cases, it is essential not to waste time (especially not in a prehospital setting with a central line), but to establish temporary intraosseous access through the proximal tibia. This can be easily done by modern drilling machine systems. If the proximal tibia is fractured on both sides, other body parts like the malleolus or proximal humerus may be chosen. The administered volume must be carefully reevaluated especially in young children, as hypervolemia can easily be reached. A bolus of 20 ml/kg saline is recommended.
D. The assessment of neurological status must be related to the age. In all case, the (p)GCS (Pediatric Glasgow Coma Scale) should be assessed. Neurological impairments due to injuries of the extremities or spine have to be assessed according to the overall situation and age-related compliance of the child.
E. Exposure: Hypothermia must be avoided and addressed as soon as possible; the younger the child, the more it is important. Due to the proportional larger surface compared to their body volume, loss of warmth can be enormous, especially when loss of warm body liquids accompany.

First-line treatment in the emergency room is completed by a body-to-toe examination and ultrasound examination of the abdomen. Native x-rays of the thorax and pelvis are taken synchronous to the clinical evaluation. In some cases, the diagnostic via MSCT (Multi Slice Computer Tomography) can be avoided, as sensitivity of repeated ultrasound examinations in combination with clinical assessment can reach sensitivity for abdominal injuries of up to 100 %. In most cases, a CT scan must be performed, to avoid missing life-threatening injuries in difficult accessible regions and incompliant patients. In this respect, it is of utmost importance that a dedicated CT protocol is performed with lower dosis and protection of the eyes.

The combination of volume refractory hypovolemia and abdominal or thoracic stab injury can lead to direct operative treatment without further diagnostic, especially if sonography detects intra-abdominal or thoracic fluids with a severe hemorrhagic shock.

In all other cases, a secondary survey with initiation of initial injury-specific therapy completes the emergency room treatment [8].

17.7 Specific Injuries

17.7.1 Head Trauma

Approximately 80 % of all pediatric polytrauma patients suffer from head injuries, with fall from a height being the main cause of trauma up to the age of 5. Thereby, brain injuries are the leading cause of trauma-related death in children [12]. Due to the disproportionately large head and weak neck musculature, even fall from low height may lead to severe brain injuries. Additional physiological preconditions of the immature brain like higher metabolic rate and vasoreactivity lead to significantly higher rates of posthypoxic edema [13].

Therefore, the fast assessing and addressing of brain injuries is crucial in pediatric polytrauma management. In all cases of higher trauma or significant deficits of the GCS, a CT scan should be performed. Kupperman et al. showed that the age-related combination of different clinical signs can help to decide whether in some cases a CT scan can be avoided in mild traumatic head injuries [14].

Hypoxia and hypotension exacerbate the direct brain injury and must be avoided at any price. The indication for intubation should be made generously, especially if the neurological state preconditions aspiration (GCS < 8). A GCS < 8 is also often seen as indication for the operative insertion of a ventricular or intraparenchymal pressure monitoring device.

Diffuse traumatic brain injury (TBI) is the most common type of injury and results in a range of injury severity from concussion to diffuse axonal injury (DAI). If CT scan detects a shift of the midline, a hemicraniectomy is recommended, and, as outcome even in severe brain injuries is better in children than in adults, should be considered even in worst injuries.

Large hematoma should be urgently evacuated via trepanation or hemicraniectomy, as both subdural hematoma as well as epidural hematoma have shown to worsen outcome after 3 h (Fig. 17.2). In some cases, also the evacuation of intraparenchymal bleedings can be useful.