Trauma in the Extremes of Age

Padiatrics
Elderly


Paediatric Trauma
Paediatric principles
Airway
Breathing
Circulation
Chest trauma

Abdo trauma
Head trauma
Spinal cord
Musculoskeletal
Battered child
Childhood norms

Paediatric principles

Injury is the most common cause of death & disability in children.
Children with multi-system injury deteriorate rapidly and develop serious complications.
Children have unique anatomy / physiology:
- most serious paediatric trauma is blunt trauma involving the brain
- apnoea, hypoventilation and hypoxia are 5x as common than hypovolaemia with hypotension.
--> aggressive A&B control is paramount in management.

Size & Shape
More force is applied per unit body area.
Less fat, less CT, more proximity to vital organs.
--> higher multiple organ injuries
Greater brain injury.

Skeleton
More pliable and has growth centres.

Surface area
Ratio of surface area to body V is highest at birth then diminishes.
hermal energy loss is significant.
--> preempt hypothermia.

Psychological factors
A significant challenge
Cooperative manipulation is extremely difficult.
May easily be upset / aggressive.
Also injury can upset future growth/development.
- don't underestimate these physiological and psychological results.
- 60% show personality change at 1 yr
- 50% show cognitive / physiological handicap
- QOL can be impaired by growth plate damage, splenectomy etc.

Equipment
Need different sizes.

Airway

Anatomy
Midface size small relative to cranium.
- c-spine is liable to flex
--> keep head in sniffing position (plane of face parallel to spinal board)
Place padding between torsoand spinal board
Larynx visualisation is more difficult due to soft tissues in the oropharynx.
- secretions accumulate in the retropharyngeal area.
Trachea is ~5cm in an infant, 7cm by 18mo.
--> don't intubate the R mainstem bronchus.

Management
Optimise by sniffing position with neutral c-spine position.
Chin lift, jaw thrust, inline immobilisation.
Clear secretions, O2 very well before mechanical airway control.

Oral airway

Only when unconscious else will vomit.
Do not insert backwards then rotate (risk trauma to oropharynx)

Intubation
For severe brain injury, airway / ventilatory failure or requires operative intervention for hypovolaemia.
Used uncuffed tube of appropriate size (fragile airway) if <9
Gauge size by matching diametre to external nares or child's little finger.
- 3-3.5 tube in newborns
- 4 by 6-9mo
- then 4+(age/4) for uncuffed
- and 3+(age/4) for cuffed
- insert to tube size x 3 or if >2yrs to (Age/2)+12
Notes:
-
If intubation not possible, bag-mask until definitive airway secured.
- avoid nasotracheal intubation in children >9yrs (anatomy makes it difficult and easy to cause damage)
- position tube 2-3cm below vocal cords and carefully secure
- ausculaate both hemithoraces and axillae to preclude R mainstem bronchus intubation
- get a CXR

Rapid sequence intubation
for a child
i) preoxygenate
ii) atropine sulphate 01.-0.5mg
iii) sedation (midazolam HCL 0.1mg/kg if hypovolaemic; midazolam 0.3mg/kg if normovolaemic)
iv) cricoid pressure
v) paralysis (succinylcholine chloride <10kg: 2mg/kg; >10kg: 1mg/kg
vi) intubate, check tube position
vii) release cricoid pressure.

Needle cricothyroidotomy
Preferred method before surgical airway
Needle jet insufflation is an appropriate temporising technique.

Breathing

Do not damage airway / alveoli with vigorous bag masking.
Hypoxia is the most common cause of cardiac arrees in a child.
- a relatively normal pH should be maintained (acidosis preceeds arrest) with adequate ventilation / perfusion
- caution: do not simply correct hypercarbia with bicarbonate(!)
Manage thoracic injuries / tube thoracostomy as required
- use an appropriate sized-tube, insert at same site: 5th ICS.
- 10-14 for newborns
- 12-18 to 6mo
- 14-20 to 1yr
- 14-24 to 3yrs
- 20-32 to 7 yrs
- 28-38 to 10 yrs

Circulation

Recognition
Children have greater reserve and subtle manifestations
- tachycardia and poor skin perfusion are the only keys to early recognition
- more subtle signs are loss of peripheral pulses, narrowing pulse pressure (<20mmHg), skin mottling, cool extremities, decreased LOC, dulled pain response
- 30% blood V reduction is required to manifest a change in vital signs.
- drop in urinary output will follow
- hypotension marks uncompensated shock and blood loss >45%, may occur suddenly.
- early surgical assessment is crucial.
Note tachycardia will also accompany fear, pain and stress.

Resuscitation
Rapidly replace circulating volume
- estimated at 80ml/kg
System
Mild <30% Loss
Mod 30-45% Loss
Severe >45%
Cardio
Tachy, weak pulses
Low normal BP
Narrowed PP
Markedly tachy
Absent peripheral pulses
Weak thready central p.
Hypotension
Tachycardia
Then bradycardic
CNS
Anxious, irritible
Lethargic, dull to pain.
Comatose
Skin
Cool, long cap refill
Cyanotic, long cap refill
Pale, cold
Renal
Minimal reduction
Minimal
None
Used warmed 20ml/kg bolus when shock suspected.
- would represent 25% of blood volume if stayed in circulation
- may need 3 boluses if 25% loss (3:1 rule)
Consider Packed RBCs if 3rd bolus started
- bolus 10ml/kg of type-specific / O-neg
Ensure thermoregulation

Return to Normal Indicated by:
Slowing HR (age dependent)
Clearing sensorium
Peripheral pulses returning
Skin colour returning
Extremities warming
Increasing BP (90mmHg + 2xAge)
Increased PP (>20mmHg)
Urine 1-2ml/kg/hr (age dependent)

Classification
Responders
- stabilise on crystalloid
Transient responders
- deteriorate after fluid/blood
Nonresponders
- do not stabilise
--> operate on latter two.

Venous access preferences:
Percutaenous peripheral (2 attempts)
Intraosseous
Percutaneous (femoral)
Venous cutdown (saphenous, ankle)
Percutaneous placement (ext jugular)
Note: IV access in the child <6 is perplexing and challenging.
- intraosseous is safe efficaceous and quick.

Urine output
Excellent measure of adeuquacy of volume
- 2ml/kg/hr in the infant
- 1.5ml/kg/hr in the toddler
- 1ml/kg/hr in the child/adolescent.
Straight catheter for children <15kg.

Chest trauma

8% child injuries
2/3 associated with other organ injuries.
Principally blunt eg MVAs
Internal organs may be damaged without bony #.
Rib #s suggest massive energy transfer and major multiple serious injury.
Specific injuries are same as for adult
- however mediastinal mobility makes tension pneumo and flails more likely
- pulmonary contusionsa are more common
- diaphragm, aortic, major tracheobronchial, flail injuries rare in childhood.
Manage as per adult chest trauma.

Abdo trauma

Assessment
Mainly blunt, MVAs
- penetrating injury dictates prompt surgical involvement especially if hypotensive.
Be gentle and calm to aid palpation
Decompress stomach as children swallow air (12Fr)
- and urinary bladder

Adjuncts
CT for stable kids if immediate, early and does not delay Rx (may need sedation)
DPL is used in hypotensive children when FAST not available.
- same as adult DPL; to be performed by managing surgeon.
- blood does not mean mandatory laparotomy if child stable / responding, but leukocytes, foreign matter does.
FAST is yet to be studied in children, but is used.

Management
Bleeding from an injured liver, spleen, kidney is often self-limiting
- if child cannot be normalised and if blood in abdo suggested, prompt operation required.
- else manage nonoperatively in a capable facility
- frequent reevaluation is required
Surgeon must manage the child.
All hollow viscus ruptures need early repair.

Specific Injuries
Duodenal haematoma from strikes to RUQ (low abdo tone)
- NG tube and parenteral nutrition
Small bowel perforations at lig of Treit
Mesenteric small bowel perfs
- often diagnosed late due to vague symptoms
Bladder rupture (shallow pelvis)
Perineum injuries (near surface) from straddles.
Lap belts relate to enteric disruption
Spleen, liver kidney disruption from blunt force
- often present hypovolaemic and respond
- CT and ICU monitoring
- delayed splenic haemorrhage is less common.

Head trauma

Common in children: MVAs, falls, bikes.
Hypotension and hpoxia worsen outcome of intracranial injury.
- ABCDEs and hypotension warrant aggressive attention.
- hypotension is the worst single factor
Need early ET use and O2.
Continuously reassess.

Brains of children are different:

1. Increased H20, plasticity, incomplete myelinisation, vast neurochemical change, smaller subarachnoid space (less protective)
- thus head damage produces more parenchymal damage.
- outcome is better than adults, but worse if <3.

2. Cerebral blood flow is twice adult level by 5 then decreases linearly.
- severe susceptibility to hypoxia

3. Rarely infants may be hypotensive from blood loss into epidural space / subgaleal space
- treat hypovolaemia rapidly.

4. More tolerant of expanding mass lesions if young (open fontanelles, stretchy sutures)
- treat a child without coma and bulging fontanelles cautiously and get an early neurosurg consult.

5. Vomiting and amnesia are common and don't necessariliy relate to high ICP
- persistent vomiting demands CT
- gastric decompression is warranted.

6. Seizures are more common and usually self limited
- investigate recurrent siezures with CT

7. Mass lesions less common, but elevated ICP / brain swelling more common
- replace blood volume rapidly or worse secondary brain injury worsens ICP problems.
- emergency CT those with possible surgical need.

8. Modify verbal score of GCS

9. Early surgical consult for ICP monitoring if:
- GCS <8 or motor scores 1-2.
- multiple inuries and brain injury with major volume resuscitation or prolonged stabilisation
- abnormal CT

10 Adjust meds
- phenobarbital: 10-20mg/kg/dose
- diazepam 0.1-0.2 mg/kg/dose slow IV
- phenytoin 15-20mg/kg at 0.5-1.5 ml/kg/min loading then 4-7mg/kg/day maintenance
- mannitol (rarely needed; may worsen hypovolaemia): 0.5-1g/kg

Spinal cord injury

Uncommon, 5% of spinal injuries are in children.
- mostly MVAs, sports.

Radiologic considerations
See spine XR notes

SCIWORA
Spinal cord injury without radiogaphic abnormality is more common in kids
- 2/3 of children with spinal cord injury have a normal spine series
Spinal XRs do not exclude significant spinal cord injury
Assume instability
Maintain immobilisation
Obtain consult

Musculoskeletal trauma

Similar to adult except:

1. Concerns for growth plates
- history is more important
- epiphysial injury retards growth, especially difficult-to-recognise crush injuries
2. Proportionally less blood loss with isolated #s eg femur
3. Buckle #s common
4. More vascular injury eg supracondylar elbow/knee #s.
5. Simple splinting is adequate until definitive orthopaedic evaluation performed
- a single attempt at # reduction is OK.

Battered child

Suspect abuse if:
- injury does not fit mechanism
- if prolonged interval before advice sought
- if repeat trauma, different EDs
- parents inappropriate, negligent
- history murky / changes.
- multiple subdurals, esp without fresh skull #
- retinal haemorrhages
- perioral injuries
- rupture viscera, without major blunt trauma
- genital / perineal trauma
- frequent injuries with old scar / healed #s
- long bone #s in children <3
- bizarre injuries
- sharply demarcated burns, unusual places.

Drs are bound by law to report incidences of abuse.
- 50% of children presenting dead from abuse have presented before, so be active.


Childhood Norms

Age ranges
Newborn - minutes to hours
Neonate - <28 days
Infant - <1 yr
Child - 1-8 yrs

Respiratory Norms
<1yr: 30-40
2-5yrs: 25-30
5-12yrs: 20-25
>12 yrs 15-20

Cardiac Norms
<1yr: 110-160
2-5yrs: 95-140
5-12yrs: 80-120
>12 yrs 60-100

BP Norms
- changes are late.
0-28d <60
<1yr: 70-90
2-5yrs: 80-100
5-12yrs: 90-110
>12 yrs 100-120

Elderly Trauma
Epidemiology
Airway
Breathing/Ventilation
Circulation
Disability
Exposure/Environment
Other Organ Systems
Special Circumstances

Epidemiology

Growing fast.
Trauma is 7th leading cause of death in the elderly.
Falls (40% of deaths), MVAs and burns most common.
- physical impairments, physiological changes and comorbidities contribute.

Airway

Management Tips
Supplemental O2 is important early.
Intubation should be considered early due to low cardiopulmonary reserve.
Dentition, nasopharynx fragility, macroglossia and microstomia and cervical arthitis can make airway difficult.
- keep intact well-fitting dentures in place to facilitate bag-masking
- place nasal tubes with great care.

Breathing/Ventilation

Management tips
Comorbidities speed physiological decline in respiratory reserve.
Careful respiratory monitoring is essential
Caution with O2 if COPD suspected.
- but do not allow hypoxia; if CO2 necessarily rising, intubate in discussion with senior ICU staff.
Simple pneumo/haemothorax are poorly tolerated.
- adequate pain control is importat
Complications eg pneumonia occur frequently
Overzealous fluid infusion should be avoided.

Circulation

Reserve loss
Heart loses reserve rapidly with age and CAD becomes common.
- total blood volume decreases, circulation time increases, myocardium stiffens, conduction slows, and cell mass reduces.
- the endogenous catecholamine release with stress is less responsive
- diastolic dysfunction makes heart more dependent on atrial filling to increase cardiac output.
- kidney loses mass rapidly after 50 yrs, with decreased GFR & renal blood flow; max concentration ability drops to 70% of a thirty-year-old's.

Management tips
220-age = max typical HR
A common pitfall is a mistaken pressure of normal BP and HR indicate normovolaemia.
- blood pressure often increases with age and 120 may be low.
- onset may be delayed, and chronic high afterload state may limit cardiac output and ultimately end-organ perfusion.
- the elderly hypertensives on diuretics may have a low vascular volume and K+ anyway.
Severely injured hypotensive pts with metabolic acidosis almost always die due to low reserve.
Ringer's lactate is the initial fluid of choice: give 1-2L and closely monitor response.
Some say maintain >100 Hb level
Assess for blood loss quickly, including rapid FAST (and DPL)
Little role for nonoperative management of blunt abdo solid-viscus injury
Retroperitoneal exsanguinating haemorrhage is not uncommon in the elderly
- negative FAST/DPL and ongoing hypotension with pelvic/lumbar # should prompt angiography and transcatheter embolisation.
33% of pts who die do so late from sequential organ failure reflecting early unsuspected states of hypoperfusion.
Impaired cardiac performance may supervene.
- hypovolaemic and cardiogenic shock may coexist.

Disability

Age changes
Atrophy and CSF reduction occur with aging.
Dura becomes tightly adherant
--> bridging veins stretched and subdural more common, with surprising volumes possible.
Blood flow reduces by 20% over 70,  atheroma may make this worse.
Intervertebral disc dehydration changes loads and spinal stenosis places cord at greater risk, esp if osteoporotic.

Management tips
Higher incidence of subdurals, brain haemorrhage, less severe cerebral contusions.
- gradual onset neuro decline is possible with subdurals.
- liberal use of CT is encouraged
C-spine injury is more common
- more occult and harder to diagnose due to age changes.
- MRI is useful.

Exposure/Environment

Dermis loses thickness, loss of vascularity occurs, and less thermal regulatory ability follows.
Less barrier to infection.
Protect from hypothermia
- think of occult disease also, ep sepsis, pancreatitis.

Other Organ Systems

Musculoskeletal
Aging stiffens body tissues
Deterioration of tendons, ligaments and capsules means injury easier.
Less muscle mass due to less response to anabolic hormones.
Osteoporosis decreases normal bone with consequent strenth loss and less resistance to #s.
Immobility predisposes to pulmonary morbidity and mortality.
Undertake the least invasive, most definitive procedure that allows early mobilisation.

Nutrition

Caloric needs decline, but protein needs may increase
Poor nutrition is common anyway, and increases complications.
--> early support

Immune/Infections
Immune response declines with age.
- less ability to respond to bacteria / viruses.
Infections and mortality higher.

Special Circumstances

Medications
Drugs may impair physiological responses.
- beta blockers limit chronotropic activity
- Ca channel blockers prevent peripheral vasoconstriction
- NSAIDs promote bleeding
- steroids reduce stress response
- anticoagulants
- diuretics dehydrate and give electrolyte abN
- diabetics take hypoglycaemics
- psychotropics can be problematic if stopped suddenly
- tetanus is infrequently not up-to-date.

Consider elder abuse

End of life decisions
Doctor, family and patient may choose supportive care in certain situations.
- eg extensive burns with unprecedented survival rates
Seek existence of a living vill, advance directives etc.
Remember:
- self-determination is paramount
- medical intervention is only appropriate when in the pt's best interests
- medical therapy must outweight consequences

References
ATLS