Approaches to the Hemorrhaging Pediatric Trauma Patient
November 1, 2021
AUTHORS
Megan Panapa, MD, Chief Resident, Allegheny Health Network, Pittsburgh
Moira Davenport, MD, Associate Program Director, Emergency Medicine Residency, Allegheny Health Network, Pittsburgh
PEER REVIEWER
Steven M. Winograd, MD, FACEP, Attending Emergency Physician, Keller Army Hospital, West Point, NY
Clinicians might be surprised to learn that, after central nervous system (CNS) injury, hemorrhage/hemorrhagic shock is the second most common injury complex resulting in death for pediatric trauma patients. A thorough understanding of subtle presentations and management is essential to improve the outcome for these children.
— Ann M. Dietrich, MD, Editor
Epidemiology and Etiology
Trauma is the leading cause of death in children. A majority of deaths among those 1 to 21 years of age are the result of motor vehicle accidents, nonaccidental trauma, homicide, and suicide.1,2 The leading injury complex associated with these fatalities is traumatic brain injury (TBI), followed by hemorrhage and hemorrhagic shock. In hemorrhage, early intervention is thought to offer greater odds of meaningful survival when compared to early intervention with central nervous system injury.3 In pediatrics, hemorrhagic shock has been estimated to have twice the mortality rate as in adults.4 Pediatric protocols often are based on adult protocols, but these pediatric protocols are evolving as the nuances of the pediatric patient’s needs are better understood.5
Definition
Massive hemorrhage is defined as bleeding that requires transfusion of greater than 40 mL/kg of blood products or bleeding that requires transfusion of one or more total blood volumes within 24 hours. In adults and adult-size children,
10 units of blood products is considered massive hemorrhage. Total blood volume in the premature infant is approximately 90 mL/kg to 100 mL/kg, while in the term infant up to 3 months of age, total blood volume is approximately 80 mL/kg to 90 mL/kg. The total blood volume in children older than 3 months of age is approximately 70 mL/kg.6,7
Approximately 5% to 15% of pediatric trauma patients will qualify as having a massive hemorrhage.7 Sites of life-threatening hemorrhage in children include the abdomen, pelvis, retroperitoneum, proximal thighs, chest, and any site that persistently bleeds into an external space. In neonates, subgaleal hemorrhages during childbirth have been noted to cause hemorrhagic shock.8 In children, hemorrhage often occurs concurrently with TBI, but the cause of mortality typically is tissue injury, increased intracranial pressure, and herniation associated with the TBI, rather than the sequelae of hemorrhagic shock.
Pathophysiology
Hemorrhage proceeds into hemorrhagic shock when oxygen demands cannot be met, anaerobic metabolism dominates, and compensatory measures begin to prioritize perfusion to the brain and heart. Lactic acid accumulates incrementally, inciting inflammatory cascades as adenosine triphosphate (ATP) in the cells is depleted and cell death ensues. Multisystem organ failure develops in the setting of hypoperfusion and cell death. In the setting of catecholamine surges and worsening oxygen depletion in the tissues, the endothelium sheds its protective glycocalyx barrier, causing significant endothelial dysfunction.
At the site of hemorrhage, the clotting cascade is activated, and platelets aggregate to create a plug. Distal to the site of clotting, fibrinolytic activity is activated presumably as a compensatory measure to reduce thrombosis in other tissues. In severe hemorrhage, these mechanisms are excessively activated, and diffuse coagulopathy develops. Without intervention, progressive acidosis, coagulopathy, and hypothermia develop, contributing to deterioration and, eventually, death. Without careful management, interventions to address hemorrhagic shock can exacerbate these three deadly factors. Excess cold infusion of crystalloids dilutes oxygen-carrying capacity along with clotting factors while worsening hypothermia, which further decreases enzyme activity in the clotting cascade. Balanced transfusion of warmed blood and blood products is more beneficial than crystalloids, but even in the most ideal resuscitations, these measures are simply bridges to definitive hemostasis through surgery or embolization.9
Stabilization and Initial Management
The care of the hemorrhaging patient begins in the field when emergency services arrive at the scene. Rapid recognition of hemorrhage is essential for survival, and the initial approach can be lifesaving. Measures may include minimizing blood loss by using direct pressure or tourniquets, applying hemostatic dressings, or placing a pelvic binder in the setting of pelvic trauma. Large-bore intravenous (IV) access and resuscitation with fluids or blood often is initiated. This occurs simultaneously with rapid transport to a hospital that ideally can provide definitive care, but may be the nearest hospital that can stabilize the patient for transport to the site of definitive care.
Once in the emergency department (ED), the initial approach is guided by Advanced Trauma Life Support (ATLS) protocols with important distinctions for the pediatric patient and specific concerns for the hemorrhaging patient. Typically, a team of providers is at the bedside on arrival of the patient to simultaneously address each element of the primary survey, which is designed to identify life-threatening conditions systematically and rapidly and to address them immediately. This involves evaluation and management of the airway, respiratory dynamics, hemodynamic status, neurologic function, and final identification of hidden injury by exposing the patient head to toe while simultaneously protecting the patient from environmental heat loss. This is followed by the secondary survey, which consists of taking a history, performing a more complete but focused physical examination, and providing additional urgent interventions. This is not a complete discussion of ATLS but elements important to the hemorrhaging pediatric patient.10
Airway Management
The initial step to the primary survey is evaluating and establishing a patent airway while maintaining cervical spine immobilization. There are three possible scenarios:
1) Airway is patent without intervention.
2) Intervention occurred in the field and needs to be verified.
3) Airway is obstructed and requires intervention.
In the first scenario, airway status should be assessed by asking the patient’s name, assessing for stridor or voice changes, and inspecting for craniofacial injuries. Patients who arrive intubated need the appropriateness of the size and depth of the endotracheal tube (ETT) confirmed, end tidal carbon dioxide (CO2) measurements, and chest X-ray. In the pediatric patient, inadvertently deep ETT placement is common. The size of and depth of the ETT can be calculated easily. The uncuffed ETT = (age in years /4) + 4 with cuffed tube 0.5 size smaller. The depth is the uncuffed ETT × 3. A Broselow tape also can be used to obtain these numbers quickly. Chest X-ray is required as final confirmation.
In the third scenario where there is airway compromise, the patient may simply need to be repositioned but may need as much as intubation. Small children may require a rolled towel under the torso because of the relatively large head placing the neck into a kyphotic position, potentially causing obstruction when lying on a flat surface. If this maneuver is performed, care must be taken to maintain cervical spine immobilization. Oxygen application with jaw thrust may be sufficient initially. Indications for intubation include apnea, airway protection from aspiration of blood or vomit, impending or potential airway compromise because of injury (burn victims, expanding neck hematoma, etc.), inability to oxygenate with supplemental oxygen, or Glasgow Coma Scale (GCS) score less than or equal to 8. Cervical spine stabilization also is considered part of the airway evaluation. The Broselow tape (or similar system) may be used to determine medication doses required for intubation.
If the patient cannot be intubated, bag-valve mask is ineffective (despite airway adjuncts and two-person technique), and laryngeal mask airway (LMA) has failed, a surgical airway is indicated. In those patients 12 years of age and younger, needle cricothyrotomy should be performed, while patients older than 12 years typically have a large enough airway to accommodate a surgical cricothyrotomy.11
Breathing
The second part of the primary survey, assessment of breathing and respiratory dynamics, often occurs simultaneously with assessment of the airway. Auscultation for bilateral breath sounds, obtaining pulse oximetry and end tidal CO2 readings, assessing respiratory rate, and observing breathing are the steps in quick evaluation. Injuries that impair ventilation, such as open pneumothorax, flail chest, tension pneumothorax, and massive hemothorax, should be identified rapidly and management initiated. A patient with clinical signs of tension pneumothorax, including tracheal deviation, lack of breath sounds on one side, neck vein distension, respiratory distress, tachycardia, and/or hypotension, should have needle decompression completed and followed rapidly by tube thoracostomy. A patient with massive hemothorax may present with similar tension physiology and require immediate tube thoracostomy.
Traditional teaching and current ATLS guidelines instruct needle decompression with a large-bore angiocatheter to the midclavicular line at the second intercostal space in children. In adults, there has been a transition to use of the midaxillary fifth intercostal space — a transition that has occurred because of variability in the depth of the pleural space and failure of the angiocatheter to provide adequate or sustained decompression.11,12 Several studies using ultrasound and computed tomography (CT) imaging have shown that, in small children, vital organs such as the mediastinum and heart can be present at the second intercostal space at the midclavicular line with potential risk of significant injury with needle decompression in this area.13,14 Finger or instrument thoracostomy in the “triangle of safety” to avoid inadvertent injury to important vital structures, and to eventually facilitate definitive treatment with tube thoracostomy, has been adopted in some facilities.12
Given the relative compliance of the pediatric rib cage, rib fractures are less common in children than in adults, and intrathoracic injury can occur without rib fractures. When rib fractures are present, typically a significant trauma has occurred, and multiple injuries likely are present. When two or more contiguous ribs have two or more fractures, a segment of chest wall becomes disconnected from the remainder of the ribcage and may cause paradoxical chest wall movement, resulting in ventilatory compromise and decreased oxygenation. This may require immediate intubation.15 If there is injury to intrathoracic blood vessels, massive hemothorax can result. This diagnosis is best determined on chest X-ray, but it may be obvious on patient presentation because of decreased breath sounds or dullness to percussion. Compromised ventilation/oxygenation and hemodynamics are an indication for immediate drainage via tube thoracotomy.16
Appropriate chest tube size is calculated through the following equation: 4 × ((age/4) + 4) or 4 × ETT. As in adults, the thoracostomy incision is completed at the fourth or fifth intercostal (nipple line) space between the anterior and mid-axillary lines and sized to accommodate the tube (~2-4 cm) with the arm in 90 degrees abduction. Blunt dissection should be completed with mosquito forceps for children 0 to 4 years of age, artery forceps for children 5 to 12 years of age, and Roberts forceps in patients older than 13 years of age. In children older than 13 years, the procedural sweep should be done with a finger, as it is in the adult. In the younger age groups, this should be completed with the instrument used for blunt dissection. A common mistake is advancing the chest tube too far; it is recommended to insert the chest tube to the 4-cm mark, which indicates the last chest tube opening is inserted 4 cm into the chest wall. The output of the chest tube should be followed closely. In the setting of immediate output of 20 mL/kg (~25% of total blood volume) or 2-4 mL/kg/hour over the next two to four hours, emergent thoracotomy in the operating room should be considered.11,12,15,17,18
Circulation
The third element of the primary survey is evaluation of circulation and early identification of shock. The initial evaluation includes measurements of heart rate and blood pressure and assessment of pulses and capillary refill. These parameters should be assessed while IV access is obtained. Ideally, two peripheral IVs are obtained in the antecubical fossa, but if there is persistent difficulty gaining access, progression to intraosseous placement or central line placement should be considered.
Greater physiologic reserve in children makes the identification of hemorrhagic shock more challenging than in adult patients. Exam and vital sign findings associated with blood loss are reviewed in Table 1, including tachycardia, change in mental status, and signs of decreased peripheral perfusion (decreased pulses, capillary refill > 2 seconds, or skin color). Severe blood loss, class IV hemorrhage, is defined as > 45% of total blood volume. A severe hemorrhage for the 3.5-kg term neonate would be approximately 130 mL; for the 10-kg 12-month-old, it would be approximately 315 mL; for the 26-kg 8-year-old, it would be approximately 800 mL; and for the 50-kg 14-year-old, it would be 1,500 mL. Signs of decreased peripheral perfusion may be the first and only evident change in children because of their excellent compensatory responses. To further complicate matters, findings such as tachycardia often have multiple non-life-threatening etiologies, such as fever or pain.
Table 1. Hemorrhage Classification and Signs of Blood Loss in Pediatric Patients | ||||
|
Hemorrhage Class |
I |
II |
III |
IV |
|
Blood loss: % loss of circulating volume) |
< 15% |
15% to 30% |
30% to 45% |
> 45% |
|
Heart rate |
Normal |
Mild tachycardia |
Tachycardic |
Severe tachycardia |
|
Pulses |
Normal |
Weak peripheral |
Weak central |
Very weak or absent peripheral pulses, weak central |
|
Blood pressure |
Normal 80-90 + 2 × age in years |
Normal BP 80-90 + 2 × age in years |
Low normal BP 70-80 + 2 × age in years |
Hypotension < 70 + 2 × age in years |
|
Pulse pressure |
Normal |
Normal |
Narrowed |
Narrowed or undetectable diastolic pressure |
|
Central nervous system |
Anxious |
Irritable |
Lethargic and dulled response to pain |
Comatose |
|
Skin |
Warm and pink |
Cold, mottled, prolonged capillary refill |
Cyanotic markedly prolonged capillary refill |
Pale and cold |
|
Urine output |
Normal |
Low to very low |
Minimal |
None |
|
Adapted from: Gann DS, Drucker WR. Hemorrhagic shock. J Trauma Acute Care Surg 2013;75:888-895. Naiditch JA, Dingeldein M, Tuggle D. Evaluation, stabilization, and initial management after trauma. In: Zimmerman JJ, Rotta AT, Clark RSB, et al, eds. Fuhrman & Zimmerman’s Pediatric Critical Care, 6th ed. Elsevier; 2021:1363-1374. | ||||
It is important to note that children who have lost up to 40% of their blood volume may still be normotensive. Hypotension is a very late finding of shock in children, is a sign of impending circulatory failure, and is associated with very high mortality rates. Pediatric patients noted to be hypotensive in the ED on arrival have approximately a 13-fold increased odds of mortality compared to those who are normotensive.19,20
In adults, the concept of permissive hypotension allows for low blood pressures, given the idea that aggressive resuscitation or pressors that provide normotension may worsen hemorrhage from the site of injury and dislodge clot formation. This concept encourages balancing ongoing blood loss vs. perfusion to vital organs. In children, hypotension should not be tolerated, given the significant mortality associated with this parameter, and this concept should not be applied.21 Hypotension in pediatric trauma patients is presumed to be caused by hypovolemia from hemorrhage until proven otherwise, but it is important to remember that high spinal injuries and isolated head injury also can be other causes of hypotension, especially in younger children.22,23 Cardiac contusion with cardiogenic shock also is possible, although very unlikely in children.3,15 Given the life-threatening nature of hemorrhagic shock, hypotensive pediatric trauma patients should receive immediate aggressive resuscitation with balanced blood products.
If hemorrhagic shock is suspected, 20 mL/kg warmed crystalloid fluids should be given as a bolus (normal saline is preferred in the setting of traumatic brain injury). This should be transitioned quickly to blood products if there is a lack of response or significant hemorrhage is suspected.11 This determination often occurs prior to availability of crossmatched products, therefore, 10 mL/kg uncrossed O negative packed red blood cells (pRBCs) should be administered next. In the setting of suspected life-threatening hemorrhage, massive transfusion protocol should be initiated, since early initiation of these protocols shows improvements in mortality.24 Massive transfusion protocols trigger the blood bank to prepare pRBCs, platelets, and plasma, to be given in a 1:1:1 ratio of red cells, plasma, and platelets until the life-threatening bleeding stops.25-29 The additional products are important to avoid the multiple causes of coagulopathy that occur with massive hemorrhage. As described previously, this coagulopathy is thought to be caused by physiologic effects of hemorrhage, hemodilution, hypothermia, and acidosis, all of which have metabolic and iatrogenic etiologies. It has been estimated that coagulopathy affects one of four seriously injured trauma patients, exacerbating hemorrhage.3
In adult massive hemorrhage, initial resuscitation has been transitioning from 1:1:1 ratio massive transfusion protocol transfusion to group O whole-blood transfusion because of demonstrated survival benefits and logistical advantages. This transition has not occurred in pediatrics, most likely because of the lack of large-scale studies to demonstrate its benefit.4 Smaller-scale studies have demonstrated advantages to whole blood administration in pediatric hemorrhagic shock and the safety of this approach.4,19,24,30 Studies to evaluate the benefits further are likely to occur in the future and may guide changes to the accepted approach with whole blood taking precedence over administering separate blood products.
Disability
The next step to the primary survey is the assessment of disability or the gross neurologic function of the patient by determining GCS and pupillary function. The GCS score in trauma is used to quickly identify severe TBI. The GCS has three components: best eye opening, best verbal response, and best motor response. In preverbal children, the verbal response is very challenging to assess, and their ability to follow commands is limited. There have been age-appropriate modifications, which have been shown to be somewhat less accurate and operator-dependent than the standard GCS but remain helpful in identifying TBI and significant intracranial hemorrhage.31,32 (See Table 2.) The best eye opening category is unchanged in preverbal children and adults, with a score of 4 for spontaneous eye opening, 3 for opening eyes to voice, 2 for open eyes to pain, and 1 for no eye opening. The best verbal response score requires the most changes to assess the preverbal child. The following scores are given for preverbal child vs. adult, respectively: 5 for a cooing and babbling vs. demonstrating orientation, 4 for irritable crying vs. confusion, 3 for crying to painful stimuli vs. inappropriate words, and 2 for moaning to pain vs. incomprehensible words. A score of 1 is given for no audible response in both preverbal children and adults. The best motor response score requires only a few adaptations for the preverbal child. A score of 6 is given for spontaneous movement vs. following commands and a score of 5 for withdrawing to touch vs. localizing pain for the preverbal child and adult, respectively. Otherwise, scoring in the child is unchanged from the adult score, with score of 4 given for withdrawing to pain, 3 for abnormal flexion, 2 for abnormal extension, and 1 for no response.31,33 The motor component of the GCS has been shown to be the best of the three components in predicting for TBI, including in children.11,34,35
Table 2. Glasgow Coma Scale Modified for Pediatrics | |
|
Sign |
Score |
|
Eye Opening | |
|
Spontaneous |
4 |
|
To sound |
3 |
|
To pain |
2 |
|
None |
1 |
|
Verbal Response | |
|
Age-appropriate vocalization, smiles, or orientation to sound |
5 |
|
Cries, irritable |
4 |
|
Cries to pain |
3 |
|
Moans to pain |
2 |
|
None |
1 |
|
Motor Response | |
|
Spontaneous (obeys verbal command) |
6 |
|
Withdraws to touch |
5 |
|
Withdraws to pain |
4 |
|
Abnormal flexion to pain (decorticate posture) |
3 |
|
Abnormal extension to pain (decerebrate posture) |
2 |
|
None |
1 |
|
Total |
|
Children with signs of impending herniation, such as pupillary dilation, systemic hypertension, bradycardia, and extensor posturing, require an immediate response. If not already intubated, the patient’s airway should be secured. Awaiting definitive management in the operating room, hyperventilation can be used for a brief period of time and can be titrated to reverse pupillary dilation. Mannitol (0.5-1.0 g/kg) or hypertonic saline (3% 1-3 mL/kg to max of 30 mL) should be given. If an external ventricular drain (EVD) is in place, this should be set to drain continuously. The patient should be sedated appropriately, and a pediatric neurosurgeon should be consulted.33
Exposure
The final part of the primary survey is exposing the patient and completing a head-to-toe inspection. This requires stabilizing the spine and coordinating a log roll of the patient. In the hemorrhaging patient, special note should be taken of areas of ecchymosis and tenderness. Children should be covered immediately with warm blankets following exposure, and temperature should be taken. Children are especially prone to hypothermia because of the large surface area to the body volume and may require other measures, such as a Bair hugger or increasing the temperature of the room, to maintain normothermia. Blood and fluids should be warmed prior to administration. In the hemorrhaging child, hypothermia exacerbates coagulopathy that is already present. Temperature should be monitored, and hypothermia should be avoided to improve patient outcomes.11
Secondary Survey
After the primary survey is complete and immediate life threats have been addressed, the secondary survey can begin. This involves taking a more complete history and performing a more complete physical examination to refine the differential diagnosis, which then will guide diagnostics and immediate management. Unlike the primary survey, this is more free-form and will be completed with the clinical context in mind. A simple history reviewing allergies, medications, past medical history, last meal, and the events related to the injury are reviewed and can be remembered with the acronym AMPLE. This occurs while the patient is being monitored closely for decompensation. Any significant change in status is followed by completing the primary survey again.
Laboratory Testing
If there are signs of hemodynamic instability or severe injury, a complete blood count, type and screen, prothrombin time/international normalized ratio (INR), blood gas for pH and base excess, comprehensive metabolic panel, lactate, and thromboelastography (TEG) (if available) should be ordered. Initial hemoglobin may not yet reflect acute hemorrhage but is important for trending. Liver function testing (LFT) is important for screening for abdominal trauma. In the setting of massive transfusion, excess citrate can cause hypocalcemia and other electrolyte derangements. Electrolyte and coagulation studies may become abnormal in the setting of TBI. Lactate can be used as a guide to resuscitation occurring. Other testing that should be considered includes a point-of-care glucose in the altered child, pregnancy test in menarcheal female, and urinalysis to screen for hematuria and genitourinary/renal injury.
TEG and rotational thromboelastometry (ROTEM) are viscoelastic hemostatic assays that give real-time information about potential coagulopathies and have become more commonly used in pediatric trauma as they have become the standard of care in adult trauma. Both the TEG and ROTEM measure clot initiation, clot kinetics, clot strength, and fibrinolysis.
In a standard TEG, reaction time (R time) represents the time until measurable clot formation. In a rapid TEG, R is replaced with activated clot time (ACT). Both reflect clotting factor function, and an abnormality in this would be treated with plasma. K is the time until the clot has a certain level of strength. The slope between R or ACT is measured to give the slope between the two points, the alpha angle. This reflects fibrinogen function, and an abnormality would be treated with cryoprecipitate. Maximum amplitude (MA) is the point of greatest clot strength and platelet function. An abnormality is treated with platelets. Lastly, lysis at 30 minutes (LY30) measures the breakdown of the clot 30 minutes after MA is achieved. This is treated with an antifibrinolytic agent, such as tranexamic acid (TXA).36 A review of these values and treatment is in Table 3.
Table 3. TEG Values and Treatment | ||||
|
Value |
Normal |
Transfusion Trigger |
Product |
Dose |
|
ACT |
86-118 seconds |
> 128 seconds |
Plasma |
20 mL/kg |
|
Alpha angle |
64-80 degrees |
< 60 degrees |
Cryoprecipitate |
1 unit/10 kg |
|
MA |
52-71 mm |
< 55 mm |
Platelets |
15 mL/kg |
|
LY30 |
0% to 8% |
> 3% |
Tranexamic acid |
< 12 years old: 15 mg/kg (max 1 g) loading dose over 10 minutes followed by 2 mg/kg/hr infusion for 8 hours ≥ 12 years old (adult dose): 1 g loading dose over 10 minutes followed by
|
|
TEG: thromboelastography; ACT: activated clot time; MA: maximum amplitude; LY30: lysis at 30 minutes
| ||||
Recent studies in pediatric populations have shown that TEG-directed resuscitations were associated with better outcomes than those that were not. Additionally, certain abnormalities on TEG (LY30) were predictive of the need for massive transfusion and failure of nonoperative management.37,38
Imaging and Management
For the hemorrhaging child, it is important to identify the site of hemorrhage as quickly as possible so definitive management can occur; imaging and management will depend on the clinical presentation. In pediatrics, there is no standard set of diagnostic tests that are done, and imaging is considered carefully, given the increased lifetime cancer risk associated with radiation in pediatrics.39-41 In the deteriorating and unstable child, identification of the hemorrhage may occur in the operating room, and definitive hemostasis achieved immediately.
Head Trauma
In the child presenting with head trauma, initial neurologic examination is key. In blunt head trauma, a GCS less than 14 is an indication for CT head, given the risk of TBI is estimated to be greater than 20% in this population.42 In children with a GCS of 14 or greater, the Pediatric Emergency Care Applied Research Network (PECARN) created a validated decision rule that identifies children who are at very low risk of clinically important TBI after blunt head trauma and for whom CT can be avoided. This is demonstrated in Figure 1.
Figure 1. Computed Tomography Head Decision Rule for Children with No Signs of Severe Head Injury |
|
GCS: Glasgow Coma Scale; CT: computed tomography; ciTBI: clinically important traumatic brain injury; LOC: loss of consciousness † Other signs of altered mental status: agitation, somnolence, repetitive questioning, or slow response to verbal communication. ‡ Severe mechanism of injury: motor vehicle crash with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by motorized vehicle; falls of more than 0.9 m (3 feet) (or more than 1.5 m [5 feet] for panel B); or head struck by a high-impact object. § Patients with certain isolated findings (i.e., with no other findings suggestive of traumatic brain injury), such as isolated LOC, isolated headache, isolated vomiting, and certain types of isolated scalp haematomas in infants older than 3 months, have a risk of ciTBI substantially lower than 1%. ¶Risk of ciTBI exceedingly low, generally lower than risk of CT-induced malignancies. Therefore, CT scans are not indicated for most patients in this group. Reprinted with permission from: Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: A prospective cohort study. Lancet 2009;374:1160-1170. |
Suggested CT algorithm for children younger than 2 years (A) and for those aged 2 years and older (B) with GCS scores of 14-15 after head traumaImportant lesions identified on CT head include epidural hematomas, subdural hematomas, intraparenchymal hemorrhages, and diffuse axonal injuries. Depending on the extent of these injuries, some mass lesions will require surgical evacuation, and all will require close monitoring in an intensive care unit. Some may require intracranial pressure monitoring and, for best neurologic outcome, it is important to maintain normal oxygenation, normothermia, euvolemia, and hemoglobin > 7 g/dL, and to treat coagulopathies.33
Thoracic Trauma
In the child presenting with blunt trauma of the chest, the initial screening examination should be a chest X-ray. The most common positive findings include pulmonary contusions, pneumothorax, and rib fractures. A majority of the clinically important findings will be seen on chest X-ray, or abnormalities will be present to suggest the need for more imaging. In the pediatric population, the risk of aortic or great vessel injury is very low and a majority of the time is accompanied by abnormalities on chest X-ray, such as widened mediastinum, prominent aortic knob, and wide paratracheal stripe.43 Those patients with findings on chest X-ray and a concerning mechanism may need to undergo a chest CT in consultation with a pediatric trauma surgeon.
In children, evidence of rib fracture indicates severe injury given the elasticity of their chest wall secondary to increased cartilage in the rib cage. Rib fractures are associated with higher rates of TBI and intra-abdominal injury. Rib fractures causing injury to intercostal vessels or other injury to hilar or mediastinal vessels can cause hemothorax. Even outside of hemodynamic compromise, a hemothorax requires drainage because the blood from the pleural space can cause lung entrapment as the hematoma expands and solidifies or empyema as infection forms in nutrient-rich blood. When thoracostomy drains greater than 20% to 30% of total blood volume or 2-3 mL/kg/hour over six hours, the patient should have CT angiography completed and percutaneous intervention as appropriate, or the patient should be brought to the operating room for emergent thoracotomy for hemostasis.15
Cardiac injuries are rare but can occur in pediatric patients. These injuries most commonly are associated with penetrating trauma but can occur after blunt trauma. Survival from stab wounds is greater than from gunshot wounds. A cardiac laceration can lead to pericardial tamponade where blood fills the pericardial sac around the heart, causing compression. The traditional presentation of Beck’s triad, distended neck veins (if not hypovolemic from hemorrhaging), hypotension, and muffled heart sounds, would indicate pericardial tamponade. More practically, an ultrasound at the bedside can quickly evaluate for an effusion and cardiac tamponade if there is clinical suspicion.
Unstable patients with impending collapse should have resuscitative posterior-lateral thoracotomy in the ED.15 A child who arrives after a traumatic event and loses vital signs in the ED should have a prompt thoracotomy if there is a trained trauma surgeon present; however, evidence has demonstrated very low survival rates, even lower than in the adult population.11,44
Abdominal Trauma
Most pediatric patients with abdominal trauma present with blunt abdominal trauma. The most frequently associated injuries with blunt abdominal trauma in pediatrics involve solid abdominal organs, such as the spleen, liver, and kidney, rather than the hollow abdominal organs. In pediatric patients, the spleen and liver are less protected by the chest wall than in adults. Additionally, pediatric kidneys are more mobile than adult kidneys and, thus, are more susceptible to deceleration injuries. The majority of children requiring intervention for blunt abdominal trauma will have abnormal physical exam findings, such as tenderness, ecchymosis, or instability of the pelvis.45 Penetrating abdominal trauma is less common but typically is the result of stabbings or firearm injuries. Gunshot injuries to the abdomen and stab wounds that penetrate the transversalis fascia typically will require exploratory laparotomy.
In adults, the focused assessment with sonography in trauma (FAST) is a method to assess quickly for intraperitoneal bleeding and the need for urgent laparotomy. It is routine in the assessment of adult trauma patients and has high sensitivity and specificity for hemoperitoneum. However, the use of FAST in pediatrics is less useful. In a study of 14 Level I pediatric trauma centers, FAST in patients presenting with abdominal injury was found to have a sensitivity of 28% and specificity of 91%. Additionally, in this study every patient who required transfusion, interventional angiography, or surgery who had a FAST immediately underwent a CT of the abdomen and pelvis. In the same study, FAST was shown to miss clinically significant solid organ injuries, specifically liver and spleen injuries. There is a growing body of evidence to show that FAST cannot be used as a stand-alone screening tool in the pediatric population.46
CT of the abdomen and pelvis is the most accurate method for evaluating for intra-abdominal injury outside of surgery in the pediatric blunt abdominal trauma patient, but there remains concern for radiation exposure in children and the increased lifetime cancer risk associated with this radiation. Factors associated with clinically important abdominal injuries include pain or tenderness, microscopic or macroscopic hematuria, and elevated liver function testing. Additionally, other injuries, such as pelvic fracture, lower rib fracture, and femur fracture, are associated with intra-abdominal injuries of significance.
Several decision rules have been developed and validated to help identify children who are at low risk of intra-abdominal injury and in whom CT can be avoided. PECARN found that, in patients with no evidence of abdominal trauma on examination, no abdominal tenderness, no complaints of abdominal pain, no thoracic wall trauma, no vomiting, normal breath sounds, and GCS > 13, CT could be avoided safely with only 0.1% incidence of intra-abdominal injury requiring intervention. The negative predictive value was 99.9% and sensitivity was 97%.47 The Pediatric Surgical Collaborative created a similar decision rule in which patients with no abdominal pain; no abdominal wall trauma, tenderness, or distension; aspartate transaminase level not greater than 200 mg/dL; and no elevation in pancreatic enzymes could safety avoid a CT. The negative predictive value was 99.4% for intra-abdominal injury and 100% for intra-abdominal injury requiring intervention.48 This clinical tool also was validated with similar results.49 In pediatric abdominal trauma, clinical examination and laboratory testing can be used to selectively define when CT is indicated.50
The most common intra-abdominal injury in children is of the spleen, followed by the liver. Renal trauma is less common but, when present, is accompanied by other intra-abdominal injuries.
The standard of care for solid organ injury is nonoperative, with the majority of injuries requiring no intervention. If an intervention is necessary, primary hemorrhage control may be completed initially by interventional angiography and embolization. In hemodynamically unstable patients, exploratory laparotomy is warranted. More specifically, operative management may be needed in patients with splenic trauma who have persistent hypotension, have lost greater than 50% of their blood volume, or have other life-threatening abdominal injuries. In liver trauma, operative management may be needed when there is hepatic vein or retrohepatic caval injury.
Intestinal injuries are very rare in pediatric blunt trauma, but once diagnosed, typically are treated with laparotomy. An exception is a duodenal hematoma, which is more common in children than adults and is managed initially with observation. Pancreatic injury, also rare, may be managed operatively depending on the severity of injury and the integrity of the pancreatic duct. In patients who present with diminished lower extremity pulses following abdominal trauma, the very rare abdominal aorta injury may be present, and angiography may be required for assessment. Early surgical management of these patients improves mortality dramatically.
Pelvic Trauma
Children with evidence of pelvic trauma should have their pelvis stabilized with a binder or a tied sheet. Traditional ATLS teaching recommended pediatric patients with evidence of pelvic trauma on initial examination, altered mental status, and any distracting injury that would prevent reliability of pelvic examination should prompt a pelvic X-ray. This use of pelvic X-ray has been called into question because of redundancy of testing and lack of clinical usefulness from a lack of sensitivity for clinically important fractures. Pelvic fractures in children are rare and, when present, indicate a severe mechanism of injury that would necessitate further evaluation for soft tissue injury by CT of the abdomen and pelvis. In a retrospective analysis of imaging done at one trauma center from 2010-2017, no additional information was gained from standard pelvic X-rays over other imaging modalities. The authors did note one use of pelvic radiographs that helped guide a resuscitation in which the child was too clinically unstable for CT. Given the concern for radiation exposure in children, the use of pelvic X-rays seems best suited to these situations and in the unstable hemorrhaging child, since these films may reveal the source to be related to pelvic vessel disruption.51-54
Nonaccidental Trauma
Children and infants who have been victims of abuse may present as trauma patients. Once the patient is stabilized, a careful history should be obtained from the parents and a thorough examination should be completed to assess if there is suspicion of nonaccidental trauma (NAT). It is the responsibility of physicians to report concerns of NAT to the child protective agencies for further evaluation. Depending on the situation, a child abuse specialist should be consulted. Injuries caused by NAT commonly are more severe than those resulting from accidental trauma. Abusive head trauma is the leading cause of fatal head injuries in children and is responsible for 53% of severe or fatal TBI. Subdural hemorrhages are two to three times more common in NAT, while epidural hematomas are more common in accidental trauma.42 Abusive abdominal trauma is the second leading cause of death in abused children after abusive head trauma. Physicians have a critical role in the recognition, evaluation, and management of NAT, and these patients may present with hemorrhage.55
Disposition
An important aspect of managing the hemorrhaging child is determining when to initiate the transfer of the patient to a facility providing a higher level of care. After initial resuscitation and stabilization, it may be appropriate to defer further imaging and laboratory studies until the patient arrives at the tertiary care facility. Children who are found to be hemorrhaging may require admission to a pediatric trauma service, an intensive care unit, or a hospital ward. Alternatively, the patient may need to go to the operating room for definitive management.
Summary
Hemorrhage is a major contributor to death in children, but the timely treatment of hemorrhage has the opportunity to save many lives. Hemorrhagic shock causes changes in physiology that create coagulopathy and acidosis that perpetuate worsened hemorrhage. The recognition of hemorrhage in children requires the physician to be astute, recognizing the early signs of shock, including tachycardia and poor perfusion, and instituting treatment prior to the child’s development of hypotension, which is a late indicator of shock. Once hemorrhage is recognized, balanced blood and blood products should be initiated. Laboratory studies, such as TEG, can guide further resuscitation. Imaging studies should be considered carefully in the pediatric population, given the risk associated with radiation. When encountering the pediatric trauma patient, NAT should always be considered. The hemorrhaging child requires a concerted effort of healthcare providers to provide timely care that can save lives.
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Clinicians might be surprised to learn that after central nervous system injury, hemorrhage/hemorrhagic shock is the second most common injury complex resulting in death for pediatric trauma patients. A thorough understanding of subtle presentations and management is essential to improve the outcome for these children.
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