The paediatric trauma victim

Dr Michael Clifford

Dept of Anaesthesia and Pain Management and the Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, Victoria, Australia

In Australia trauma is the prime cause of death and serious injury in childhood1. Many of these children commence resuscitation at hospitals before transport to tertiary paediatric centres1,2,11. Anaesthetists and intensivists who often have little or no ongoing exposure to children are called upon for their specific skills in airway management, intravenous cannulation, fluid and blood product resuscitation, analgesia, sedation and increasingly transport to specialist centres11.

Despite commonly providing skilled lifesaving intervention they often feel out of their comfort zone and criticized by receiving teams more comfortable with the nuances of paediatric management11

Children ARE different - but the skills honed in the management of adult trauma are germane to paediatric resuscitation - ABCDE becomes abcde1 and not vwxyz. This serves to emphasize the same core but provides for some important specific differences. The child has anatomical, physiological and psychological peculiarities that determine much of the epidemiology and injury patterns we see1,2.

Children lead with their heads - an underdeveloped brain encased in a large underprotected cranium nestled on a cartilaginous scaphold1,2 swinging on a different cervical fulcrum1,2 .The importance of traumatic brain injury (TBI) as the leading cause of morbididty and mortality in this age group1,2,5 and its sensitivity to secondary injury are the focus of much ongoing research5. Clearing the cervical spine in children prior to theatre is even more problematic6,7,8 and adult spinal immobilization devices need modification to allow for the enlarged oociput1,2. SCIWORA previously thought to be confined to childhood is now known to be more common in adults1!

The airway is high and soft with a narrow cricoid ring (now known to be an ellipse9) intubation is a feared intervention by many but it is the delays of definitive protection that contribute to worse outcomes1. The use of cuffed endotracheal tubes is recommended in cardiopulmonary resuscitation10 is increasing in paediatric anaesthesia despite debate as to their merits9, and the same is true in paediatric trauma - particularly burns11 (watch this space!). The thoracic cage is compliant and less likely to fracture but affords lesser protection to the underlying lung - and whilst shearing mediastinal injuries are less common pulmonary contusion and hypoxaemia are not.

The abdomen has large visceral organs less protected by the soft thoracic cage - contusions and burst injuries are common1,2. The FAST scan beloved of adult traumatologists has little positive or negative predictive capacity in children12. Non-operative intervention is preferred particularly for the spleen in the immunologic immature13.

Communication with terrified and or preverbal children is often limited, affects coma scores and is made worse if analgesia is inadequate - with or without the parents (who may be injured or dead) it is often an experience the adult practitioner finds the most stressful. Techniques used with success are based on an awareness of developmental psychology and the provision of judicious analgesia often with identical pharmacologic choices and regional techniques used in adult trauma3,4.

The risk of non-accidental injury (NAI) must be born in mind and risk factors are well publicised1,2,15. It is these children and children who die who affect team members most and consideration of our pastoral role post resuscitation should be remembered1,15.

Definitive management often involves semi-urgent transport to the nearest tertiary (or even quarternary) paediatric centre14,15. Patient instability or delay of a retrieval team often necessitates local surgical intervention or a period of post-resuscitation care (in the Emergency Department, Theatre or Intensive Care Unit) respectively. Local expertise is often called upon to support these teams or even provide transport at times14. Knowledge of paediatric transportation and intensive care management is encouraged - the emerging role of internet based communication and protocol access facilitates this16.

Finally, involvement in the post acute phase with ongoing procedures, chronic pain issues, rehabilitation or the psychological effects of prolonged hospitalization will often occur in hospitals closer to home and experience gleaned in adults should be seen as an ideal platform to build skills in this rewarding population whose outcomes are much better than adults1,2,3,4,15.

1. Cameron P, Jelinek G, Everitt I, Browne G, Raftos J (eds) 2006 Textbook of Paediatric Emergency Medicine Churchill Livingstone (Elsevier)- multiple sections, locally made and highly recommended to all

2. Mikrogianakis A, Valani R, Cheng A (eds) 2008 The Hospital for Sick Children Manual of Pediatric Trauma Lippincott Williams & Wilkins - slick, evidence based and filled with pearls

3. Australian and New Zealand College Anaesthetists and Faculty of Pain Medicine The paediatric patient (Chapter in) Acute Pain Management: Scientific Evidence 2005; 2nd edn: 199-222

4. McKenzie IM, Gaukroger PB, Ragg PG, Brown TCK (eds) 1997 Manual of Acute Pain Management in Children - multiple chapters of practical information

5. Orliaguet GA, Meyer PG, Baugnon T. Review - Management of the critically ill children with traumatic brain injury. Pediatric Anesthesia 2008; 18: 1-7

6. Muchow MD, Resnick DK, Abdel MP, Munoz A, Anderson PA. Magnetic resonance imaging (MRI) in the clearance of the cervical spine in blunt trauma: a meta analysis. J Trauma 2008; 64(1): 179-89

7. Morris CGT and McCoy É. Review Article - Clearing the cervical spine in unconscious polytrauma victims, balancing risks and effective screening. Anaesthesia 2004; 59: 464-482

8. McLeod ADM and Calder I. Editorial - Spinal cord injury and direct laryngoscopy - the legend lives on. BJA 2000; 84: 705 709

9. Weiss M, Gerber AC. Editorial - Cuffed tracheal tubes in children - things have changed. Pediatric Anesthesia 2006; 16: 1005-1007

10. Tibballs J. Australian Resuscitation Council: paediatric advanced life support guidelines 2006. Crit Care Resusc 2006; 2: 132-134

11. Sheridan R. Uncuffed endotracheal tubes should not be used in seriously burned children. Ped Crit Care Medicine 2006; 7: 258-259

12. Holmes JF, Gladman A, Chang C. Performance of abdominal ultrasonographry in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg 2007; 42 (9): 1588-94

13. Spelman D, Buttery J, Daley A, Isaacs D, etal. Guidelines for the prevention of sepsis in asplenic and hyposplenic patients. 2008 Inter Med J (online publication) doi:10.1111/j.1445-59994.2007

14. Royal Children's Hospital, Melbourne 2008 Paediatric Intensive Care Unit PETS (Paediatric Emergency Transport Service) Database - with permission Dr Robert Henning

15. White JRM, and Dalton HJ. Pediatric trauma: Postinjury care in the pediatric intensive care unit. CCM 2002; 30: S478-88

16. Royal Children's Hospital, Melbourne, Australia. 2008 Clinical practice guidelines resuscitation: Emergency drug and fluid calculator. [http://www.rch.org.au/clinicalguide/cpg] for example Identification and bookmarking of state based guidelines is suggested and should be updated