Outline  the  differences  in  management of  multi-trauma  occurring in  a  6-year-old child, compared with management of multi-trauma occurring in an adult.

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College Answer

Many candidates missed multiple aspects of management, usually because they did not follow a systematic approach (eg. according to EMST guidelines). Basic principles of management

according to EMST guidelines are the same – ie primary survey (ABCDE), resuscitation, secondary survey, re-evaluation, definitive care. However, candidates need to recognise and accommodate the different characteristics of the 6 year old trauma patient:

Mechanism of injury: falls and assaults more likely

Patterns of injury: more likely blunt trauma with multiorgan injury and head injury common

Physiologic and anatomic differences:

•    Different airway anatomy

•    Large body surface area/volume ratio – implications for exposure and heat loss

•    Different normal physiologic values

•    Increased cardiovascular reserve – 30% blood volume may be lost before vital signs change; hypotension indicates >45% loss

•    Immature skeleton – Incomplete skeletal calcification, with more flexible bones– eg pulmonary contusions without rib fractures common; ligament flexibility and increased head mass makes cervical spine injuries above C4 more likely and Spinal Cord Injury Without Obvious Radiological Abnormality (SCIWORA) may occur.

Assessment:

•    History – may be difficult to obtain

•    Examination – may need to modify for age - eg modified GCS, but a 6 year old can be scored as per an adult

•    Investigations – may require modification – eg uncooperative child may require GA for CT

•    Treatment:

•    Airway: uncuffed tube, size estimated from age, cervical precautions

•    Breathing

•    Circulation: IV access may be difficult, consider intraosseous needle. Fluid boluses calculated according to weight (20ml/kg) as are maintenance requirements

•    Disability: modified GCS

•    Exposure: care to maintain body temperature

•    Drug doses calculated according to weight (average 6 year old 20kg)

•    Equipment sizes (eg chest drains, urinary catheters, nasogastric) appropriate for size – Broselow tape useful

Other specific issues:

•    Psychological issues – patient and parents

•    Consent issues

•    Potential child abuse

•    Consider transfer to a specialist paediatric centre

Discussion

The examiners complained that a systematic approach needed to be followed, but the college answer also fails to use such an approach. Typicaly, trauma management follows an "ABCDE" system. The summary below offers a brief systematic discussion of the differences between adult and paediatric trauma, following the ATLS system of 

  • Airway: 
    • More difficult anatomy; cricothyroidotomy is challenging
    • Breathing:
    • Tension pneumothorax is harder to identify. 
    • Ribs rarely fracture (cartilaginous): force is transmitted to the lungs, causing more pulmonary contusions. Hypoxia is of more rapid onset.
  • Circulation:
    • Increased reserve of compensation: more blood may be lost before manifestations of shock are seen.
  • Disability:
    • Modified GCS must be used. Greater risk of raised ICP because of anatomical differences (bigger brain, smaller skull). C-spine injury is usually much higher (C1-C3) and is possible without radiological evidence (SCIWORA).
  • Exposure:
    • Hypothermia is more likely (mass:BSA ratio)
  • Family and social issues:
    • very important: family is the "F" in "ABCDEF" of paediatric trauma
    • counselling of carer
    • Guilt, blame, etc
  • Abdominal issues:
    • Organs are unprotected by rib cage
    • Spleen and liver are often lacerated
    • Shallow pelvis fails to protect the bladder
    • Kidneys are more mobile and less defended
    • Laparotomy is rarely indicated
  • Metabolic problems:
    • Hyperglycaemia and glycogen reserve depletion is more rapid; hypercatabolism develops early
  • Injury patterns as compared with adults:
    • more multiple injuries (force is transmitted to more of the body)
    • improved survival from trauma
    • shorter ICU stay, fewer complications
    • need to consider non-accidental causes
    • Burns are of a different pattern : more head/face from falling pots, more hands from grabbing hot objects

More detail is available in the chapter on Trauma in Children. When preparing for such a low-yield topic, one has got to keep in mind the relative value of storing this information versus the revision of more frequently examined topics.

References

Wetzel, Randall C., and R. Cartland Burns. "Multiple trauma in children: critical care overview." Critical care medicine 30.11 (2002): S468-S477.

Schalamon, Johannes, et al. "Multiple trauma in pediatric patients." Pediatric surgery international 19.6 (2003): 417-423.

Magin, M. N., et al. "Multiple Trauma in Children-Patterns of Injury-Treatment Strategy-Outcome." European journal of pediatric surgery 9.05 (1999): 316-324.

Reichmann, I., et al. "Comparison of multiple trauma in children and adults." Der Unfallchirurg 101.12 (1998): 919-927.

Reichmann, I., et al. "Comparison of multiple trauma in children and adults." Journal of Orthopaedic Trauma 13.3 (1999): 232.

Avarello, Jahn T., and Richard M. Cantor. "Pediatric major trauma: an approach to evaluation and management." Emergency medicine clinics of North America 25.3 (2007): 803-836.

Adelson, P. David, et al. "Phase II clinical trial of moderate hypothermia after severe traumatic brain injury in children." Neurosurgery 56.4 (2005): 740-754.

Coley, Brian D., et al. "Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma." Journal of Trauma and Acute Care Surgery 48.5 (2000): 902-906.