BTK Big T Peds 2
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[00:00:00] Welcome back to Behind the Ninth. This is Patrick Geoff, and I'm thrilled to be back with another episode in our Big T trauma series where we talk shop about trauma care. This series gets its name from the University of Texas at Houston Memorial Hermann Red Duke Trauma Institute, one of the busiest trauma centers in the entire country.

And today we are joined by Dr. Teddy Puzio, one of my former co-fellows and current faculty at UT Houston, pediatric trauma expert Dr. Charles Cox, also out of UT Houston. And Dr. Tyler Simpson, a trauma fellow at Duke University. Alright, Teddy, enlighten us.

What is on tap for today's episode? Alright, so today we're gonna run through a handful of case-based scenarios to highlight trauma, pearls, and pitfalls. Except this time we're sticking to pediatric pearls and pitfalls. These topics are high yield. So tune in, stay focused, because as I like to say, the eyes do not see what the mind does not know.

Yeah, Teddy. That's true. Thanks for inviting me back for another episode. Episode number 900 and [00:01:00] whatever it is now, pediatric trauma is common even in the adult trauma centers. But there are some key distinctions from the adult population in terms of physiology, injury, patterns, decision making, and hopefully today we'll be able to highlight some of these distinctions.

Yeah, couldn't agree more and beyond those distinctions. Pediatric trauma is particularly tough. It's emotional, it's a real gut punch when you see a child injured. I think that's especially true if you happen to be a parent, and that's why we're doing this episode, so you can stay levelheaded and understand the key differences in pediatric and adult trauma care.

So let's get the show on the road. Scenario one is a 9-year-old male who was involved in a fall from a bicycle. So he was racing his older brother down a hill when he hit a curb and the handlebar struck his abdomen. He was wearing a helmet and did not have loss of consciousness. But he's complaining of abdominal pain, so he is transported to the ER via EMS.

Tyler, how are you gonna approach this patient? Well, this scenario highlights one of the central principles of pediatric [00:02:00] trauma, and that is that mechanism predicts injury pattern. Despite this patient's age, we should approach this patient just like any other trauma, and that means beginning our initial assessment with our XABC Ds and using a standardized approach, we should still keep a few nuances in mind that are specific to kiddos.

One of these nuances is the recognition that pediatric specific mechanisms of injury like handlebars to the gut can result in pediatric specific trauma. Recognizing this will help you anticipate certain injuries, and that can be helpful in managing these kids in the trauma bay. All right.

So what anatomic considerations are there that contribute to these injury patterns, Tyler? Sure. I can think of a few anatomical considerations that explain these injury patterns. For example, kids have disproportionately larger head sizes, and that increases their likelihood of a head injury.

Another important anatomic difference is that children have [00:03:00] remarkably compliant chest walls. So intrathoracic injury can occur even in the absence of rib fracture. The abdominal viscera and retroperitoneal contents are also at higher risk of injury due to their relatively thin abdominal wall layers and the lack of adiposity in many kids.

In addition to the fact that the abdominal organs are relatively large for their size yeah. They also have different bone structures than adults. Right. That's right. Children are susceptible to subtle or incomplete skeletal fractures. And in children cortical bone is much more porous compared to adults, so that makes their bones less dense and less brittle.

Instead of breaking sharply, pediatric bones tend to bend or buckle under stress. And we should recall that the periosteum is a thin, tough outer layer surrounding a bone. Children have much thicker and more elastic periosteum. This acts like a sleeve to hold a fracture in place and [00:04:00] limit the degree of displacement.

This can result in incomplete fractures such as the commonly referred to green stick and buccal fractures. These are all good anatomical considerations. Let's go around the table and discuss these Can't miss pediatric mechanisms and there are classic associated injuries.

Dr. Cox, if we can start with you. Absolutely. So, let's start with one of the classic pediatric trauma injury complexes, which is a motor vehicle collision, which a child's an occupant and improperly restrained principally with a lap belt alone. And in this circumstance we wanna be aware of the seatbelt syndrome or lap belt complex of injuries, which is a result of deceleration and hyper flexion.

With the. Pivot point being the actual lap belt. And those injury patterns include lumbar fracture chance fracture intraabdominal injuries that are due to compression of the either duodenum jejunum or [00:05:00] pancreas between the lap belt and the anterior spine.

And so those sides are an abdominal wall contusion in the pattern of the seatbelt, abdominal tenderness, back pain, vomiting and and so that's a classic set up in terms of mechanism of injury. Another unfortunate mechanism we often see is an auto pedestrian. And because children are shorter, the constellation of injuries are often different.

Than than in adults. What else? Triad describes an ipsilateral femoral shaft fracture, ipsilateral chest or abdominal injury, and a contralateral head injury as a consequence of the the typically a bumper hitting the child at the level of the femoral shaft. And then the upper part of the car, of the IP lateral chest.

Yeah. Another mechanism is fall. We see that often, so especially in infants and toddlers who fall from the bed or a changing station, you have to have a high index of suspicion for skull fractures and intracranial [00:06:00] hemorrhage. In kids that are older and fall at the playground, for example, from the monkey bars, they often present with supracondylar humerus fractures from foosh, AKA fall on an outstretched hand.

And you don't wanna miss a neurovascular injury or compromise at the elbow from median or anterior nerve compression and or injury also to the brachial artery. One more quick one. The toddler whose leg hurts after going down a slide. In this case, their feet can catch on the slide, it gets stuck and the leg can twist, resulting in a tibial spiral fracture.

Teddy, others slide. The slides are, I know. Slides interest. Oh. Every time I stopped doing 'em myself. Okay. What about sports collisions? So, as Tyler said, the abdominal organs are relatively bigger in kids and less protective. So, liver, spleen, kidney injuries can all occur after, a simple tackle or a collision in the outfield.

Similar to seatbelt injuries, the pancreas, the du anum can be injured relatively easy with blunt force of the [00:07:00] abdomen that essentially squishes these organs against the spine. And like we've already discussed, pulmonary contusions can occur without rib fractures way more common in kids than adults.

Another type of injury we should touch base on is perhaps the worst acronym in surgery Skia Spinal cord injury Without radiographic abnormality. That one should probably be rethought, but this refers to serious spinal cord injury in a child that causes neurological deficits without any visible fracture or dislocation on plain radiographs or CT scans.

And it occurs due to the flexible nature of the spine the cervical spine in particular. And the diagnosis relies on MR. Imaging, which can show ligamentous damage and or cord edema and hematoma that, may not have been picked up on the original imaging. I like saying skia, but that's just me.

So I liked it too. [00:08:00] I feel like it's bad now. I've always liked it. Tyler let's bring this case back around. We have that 9-year-old going down the hill chasing his brother, boom, falls off helmeted, no loss of consciousness, but has that abdominal pain and you're worried about the handlebars being jammed into the abdomen.

So whatcha gonna do upfront. The child just arrives to the trombe. Well, first up, I'd begin with my rapid primary and secondary survey. Okay. Primary survey is normal. Secondary survey is notable for upper abdominal tenderness. No mosis and no peritoneal signs. What's next? Next, we should obtain a chest x-ray given the possibility of a direct blunt thoracic trauma.

And if that's normal, we can defer obtaining a CT chest. We'll discuss this more a little bit later in the podcast. But the presence of abdominal tenderness warrants consideration of CT abdomen and pelvis, or at minimum labs to include LFTs and an abdominal ultrasound. Yeah, deciding when to image is one of the hardest things possible.

That's [00:09:00] actually our next case. So, we'll move on from that. And this case the mechanism of injury did in fact predict the actual injury and a CT scan is obtained. It shows a duodenal hematoma, and this is managed with bowel, rest, NG tube decompression and nutritional support. So that wraps up scenario number one.

Remember, mechanism can often predict injury. Alright, as I mentioned, we're gonna dive into a tough one: scans for kiddos. This gets me confused every time. Dr. Cox, is there general overview that you wanna mention in terms of ionizing radiation and kids who present with trauma?

I believe in it. Okay. I believe in ionizing radiation. I think that I, i, and we personally over the years, have had these pendulum swings in terms of imaging. And I went through a period where I was an imaging nihilist, and I thought that we should maybe have no imaging since we don't seem to do anything with it.

Or we just keep scratching our heads and get another image. I think the consensus within the field is as a principle. [00:10:00] Ionizing radiation does have some risk, especially if you're in a center that doesn't have pediatric dosimetry dialed into your imaging protocols.

And surprisingly, even in big metropolitan areas, not so much a level one trauma center, but if you're. Child's image somewhere that's not accustomed seeing pediatric patients, then they may in fact get imaged with an adult dosimetry. And while that absolute risk is small there is an increase in the lifetime risk of of malignancies particularly liquid malignancies, thyroid, and brain.

And so, estimates being one additional malignancy per thousand scans. And so if you think about that in terms of your center, right, , so here we see 1500, 1800 pediatric trauma patients a [00:11:00] year. If everybody got scanned, that's almost two kids with cancer that wouldn't have had.

Potentially. If we could, or if you could cut it in half, you reduce one patient with cancer per year. In terms of prevention, things that we do that's probably pretty good. Bang for the buck. The risk is really manifest by them having a longer window if I get a CT scan.

Tomorrow, I'm only gonna live another 10 years anyway. Right. These kids are gonna stop, right. These kids are gonna live another, 70 years. And so I think that's really , the biggest part of it.

And really it's about just modify. It's not about not do not imaging patients who need it because dying of a missed injury is also a way to die. But I think that the point is modifying the exposure risk whenever we can, and not to get scans when we're not gonna really generate any actionable [00:12:00] information out of it.

And that's where the whole, minimization of in principally thoracic CT scans came about. Yeah. It's, there are a lot of abnormalities that you'll find, but very few actionable that, that will generate something actionable. Right.

There's a lot of gray in this area of making that decision to, Hey, yeah, I'm gonna go ahead and scan this child. And Tyler, that leads us to a very important resource, and that's the Pediatric Emergency Care Applied Research Network or PARN imaging guidelines. And if you take care of pediatric trauma patients, these are really the guidelines that you want quick and easy access to, especially if you don't take care of a ton of pediatric trauma patients.

And we'll put the link in the show notes for the best practices in pediatric trauma imaging. And this has got some nice, easy to understand and follow flowcharts, and we highly recommend you download this and save it. Or better yet, add it to your trauma programs guidelines that you have easy access to it.

Dr. Cox, before we move on to the next scenario, [00:13:00] when you mentioned CT imaging of the chest in kids, I know we are restrictive, what's your thoughts on screening for blunt thoracic aortic injury? Is it similar to adults mechanism wide mediastinum? It seems like that's something that comes up as a discussion point.

Right, and I think it depends on what you mean by child. Every day you take care of some 15 year olds who are doing adult things and are, appear as completely developed as you, and so have a mechanism of injury. How are you still developing and yeah, and a physical habitus that by all accounts is adult.

And so I think that those patients just common sense would be more apt to follow an adult type protocol. So on the limits of our [00:14:00] imaging the 4-year-old probably isn't going to crush their chest against the steering wheel, and it has a much more elastic chest. And the bo, the probability of them transecting their aorta is not zero, but it's close.

You can see zero from there. And so the there may be some, a reported case here or there, but in general terms, as you get down to the lower age range, transected a typical type of transected aorta or aortic c aneurysm from blood thoracic trauma is extraordinarily rare.

And so that's why we would rely on the typical pre, probably pre nineties approach in terms of screening for those. Yeah. Awesome. Good stuff. All right, let's let's put Tyler back in the hot seat and move on to our second scenario. See how these guidelines can help us.

In this scenario, we have an 11-year-old male who was struck by a motor vehicle traveling at about 20 [00:15:00] miles an hour. He lost consciousness at the scene. He arrives to your center with a sea collar. In place on a long backboard. He is hemodynamically normal for his age except for some tachycardia and tachypnea.

He has a GCs of 15 and is complaining of nausea and vomiting. He's complaining of nausea and he vomits once on the way in. And his primary and secondary surveys are notable for a posterior scalp laceration with a hematoma. He has some midline thoraco, lumbar tenderness, left chest wall tenderness, and has a tenderness to his left thigh.

After completing your initial assessment, which adjuncts would you order as part of your workup? So for this patient, I would begin with the chest x-ray, a pelvic x-ray, and EFAs. Okay. Chest x-ray shows left-sided pulmonary contusion. There's no rib fractures and your pelvic x-ray and EFAs are otherwise normal.

So the question then is do you get a CT scan? Well, [00:16:00] I would have to take a minute and open the Duke handy Dandy trauma app and find our PAN rules to reveal. Well, good move. And now, when you said the Duke Trauma app, I thought you meant the Red Duke trauma app. And then I recognized that they both, other, both excellent resources and I thought that then I realized that there was another Duke.

That's a good move. And for the head, there's some key decision making features that include the GCS or altered mental status, signs of a skull fracture, loss of consciousness, post-concussive symptoms of nausea and vomiting, the mechanism of injury. And so, and in this case, the mechanism of injury, loss of conscious vomiting would prompt a CT at the head.

Okay, so based on those rules we'll check the box on our order set for CT head. How about cervical spine? The kid has normal GCS, no focal neurologic deficits. And let's say you're able to ask this patient and interact with them they deny neck pain. So, Dr. Cox, what are we doing for the C spine?

So [00:17:00] the PRN rules would recommend a lateral c-spine x-ray based upon a low risk of injury around two to 3%. I think in some centers you bump up against the logistical practicality, right? Getting an actual good seven vertebrae la cine series versus they're gonna be having their head scan and you go ahead and either get the top three vertebrae, which is what some places will do or go ahead and get the cervical spine done while you're there.

Logistically, and this and sometimes that comes down to, yeah just the practical logistics of Saturday night. Yeah. Yeah. Understood. So we just talked about the chest to some degree. How about in this child? Would you be ordering a CT scan of the chest? No. Okay. How about abdomen pelvis?

Yeah. So the chest x-ray showed contusions. You don't have any other actionable items. So the CT of the chest [00:18:00] would, in all probability, bump up the injury severity score for your trauma registrars, but it wouldn't it would not realistically alter anything actionable. Right. So a harder question, or I guess a more potentially actionable one is the CT scan of the abdomen and pelvis and this kid.

Yeah. And so the the I think that, that's a, it's a good. Thing to, you look at these algorithms that you have on hand and and the kind of, the first kind of screening component of it involves abdominal tenderness, abdominal wall bruising or contusion, lap belt sign. Altered mental status is described by GCS less than 13 hemodynamic instability.

I'll put an asterisk there. 'cause if you're really unstable, then it's not going to the CT scanner. Yeah. And concern for non-accidental trauma. And so that would be first, so that's the first pass you said, right? That's the first box on our flow sheet. And so we don't have any of those in [00:19:00] this patient.

So there's a second box, right. You move to Right. And so that second pass is, has vomiting, which is present in this case. And then the CT of the. Pelvis should be considered if there's any laboratory abnormalities, of course, those take time to come back. Abnormal chest x-ray hematocrit less than 30% or gross hematuria.

Yeah. So we also have an abnormal chest x-ray in this case. And so you could probably make a game time decision here. Right. Scan upfront, again, we are gonna go get a CT scan of the head, maybe the cervical spine you could scan or potentially even admit for observation, right? Yes, correct. And, in our practice in all probability, this patient would get scanned Yeah.

And observed. Yeah. I'm confused already. I like the adult world where you just scan everyone, send them through the truth detector, no holds, maybe multiple times over while they're still in the ed. But all joking aside, I think it's nice to have these [00:20:00] guidelines, right?

If you're a. Adult trauma center who responds to pediatric traumas as the initial responders? 'cause we're in-house. It's good to have a reference to look at and remind you how we think about these things. Yeah, there's a few, there's only a few things left nowadays that I will actually pull, open up one of these guidelines to look at.

And this is certainly one of 'em because I don't, there, there's some very highly specific things we just talked with. Dr. Cox, we went through this first pass, the second pass. It is nice to be able to look at that. But in general though, the patient's overall presentation, as you mentioned if they need to scan, they should get that scan he and stable peritonitis.

Any other signs of badness, we shouldn't be shy about putting 'em through the scanner. A hundred percent. And I think that, I think the other thing that there needs to be an asterisk around what observation means. Sure. And who's doing the observing? How observant they are is often determined by, if there is a, [00:21:00] if there's an abnormality or something that's suspicious on the scan.

And so, maybe this isn't the right thing to say on a podcast, but if they're being, but if they're being observed by the ophthalmology rotating intern on pediatric surgery for two weeks, and that's my first line of defense in determining if a patient needs some time of escalation, then, maybe observation doesn't mean the same thing in every circumstance.

And so I think that's where I think judgment comes in terms of those things too. 'cause it's not always the same. I think it goes also, it goes back to the phrase that I like. The eyes do not see what the mind does not know, right? If you're assigning the least experienced person to do a task that they don't even know what it is they're looking for it can, well, an observation's an active thing, right?

This is not just. A branch point [00:22:00] where you fall off and just say, Hey, just go be observed. You need to have specific criteria in mind for what you're doing in terms of that abdominal exam. Maybe you're checking crits and certainly criteria for failure. So this patient ended up having a frontal lobe contusion, lung contusion, and a femur fracture. They recovered well. So let's move on to the next case. Tyler, nine month old male who presents after reportedly falling off the bed.

He's accompanied by his caregiver who states that the injury occurred a few days ago, and the evaluation is remarkable for ecchymosis in various stages of healing and a small for age baby. And the caregiver reports fussiness during diaper changes and right lower extremity swelling. And you get a subsequent radiograph that shows a healing spiral fracture of the F femur.

There's a lot of keywords, buzzwords there. Tyler, what's going through your head? Oh, man. Well, this case, it immediately raises some red flags for non-accidental trauma or NAT. Yeah, go on. What's, what else is included in that non-accidental [00:23:00] trauma? It accounts for about 5% of significant traumatic injuries and NAT it should be suspected in all cases of unexplained injury injuries with lengthy delays to obtaining treatment or evaluation injuries with vague or incompatible history, or if the caretaker blames siblings or other home resuscitation efforts as a contributing factor to the injury.

If the injuries have bruises or fractures in various stages of healing also skulls or contact burns in unusual locations or patterns, unconsciousness occurring with low level falls. All of these should raise suspicion for non-accidental trauma. Yeah, these Are the ones that stick with you.

I can think back and remember some of these cases that just like really pull at your heartstrings. So Tyler, we hear about shaken baby syndrome, right? What, can you tell us what that is? Of course, shaken baby syndrome. Now it may be more commonly referred to as abusive head trauma. It's a form of NAT that's [00:24:00] characterized by a classic triad of altered mental status, bilateral subdural hematomas and retinal hemorrhages.

Okay. Terrible but. Definitely things we should know about. Right? So how do you work these kids up? The initial assessment in management is no different than any other traumatic injury. We begin with our XABC ds, just like always. However, there's some specific findings on secondary survey that we should look for.

If we're concerned about NAT, these include things like bruises on the child, less than four years old, fractures in children less than 12 months, and specific injuries like burns and anal genital trauma. All injuries need to be documented thoroughly and if possible with images uploaded into the electronic medical record.

So how should we move on from there? So you Do your primary, do your secondary. What's the next step? We wanna obtain some basic pediatric trauma labs, things like a CBC [00:25:00] liver function test, coags, amylase, lipase, and a type in screen. And then additional imaging should be obtained according to the pcan rules, which we've already discussed.

However, all children less than 24 months should receive a skeletal survey in cases of suspected abuse. Which simply is a comprehensive set of x-rays that look at the entire body. And finally, a dilated retinal exam should be performed by an ophthalmologist in all cases of suspected non external trauma.

Tyler, the elephant in the room.

Right. What are the social implications here? This gets complicated pretty quickly. Can you walk us through some of the things we should start going through in our mind? Of course. So non-accidental trauma requires very specialized social, medical and legal management. All suspected cases of NAT must be reported to Child Protective Services in all North American states, territories and provinces.

Mandated [00:26:00] reporting is required in most developed nations worldwide. Also, for example, here in North Carolina, all cases of abuse or neglect should be recorded to the County Department of Social Services or DSS. Yeah. Getting DSS Involved is absolutely paramount to the child's wellbeing because there's literature that shows that at least 10% of abused children have been previously evaluated at a hospital setting, and that was missed which is heartbreaking.

And abused children that return to the same setting from which they came are actually a higher risk of death too. Dr. Cox, how do you approach the parents or potential perpetrators in cases where you maybe have a slam dunk, non-accidental trauma, or you just have a sneaking suspicion of it? Yeah, so I think if there's anywhere along the spectrum, you're obliged to report it for the reasons that you just mentioned.

Right? Abuse as a or non-accidental trauma as a mechanism is the most lethal mechanism of injury for children, [00:27:00] right? So more than. Any of the other mechanisms. So, I think that's really important. And I think the other piece of it is , in terms of the shaken baby abusive head trauma situation, , there is a peak age incidents in which this occurs as well.

And that's around four to five months. And that happens to correspond with the time period of when babies cry uncontrollably the most. If you look at, if you look at the time, when does a, when babies have this, they call it purple crying, or they just scream uncontrollably for no particular reason.

And it can be frustrating as a parent, especially a low resource parent or a single parent, or. Whatever and it's thought that's one of the big drivers. there's a disconnect of what your role is. Role is to hand that part of it off to another group of people, and then you take care of the child.

The weird part of it is that typically when we're taking care of a [00:28:00] child, the parents are the historians, right? And so if the history is purposely misleading, then, it becomes a lot more veterinary in terms of how you're trying to figure these things out.

But I think the other piece of it in terms of the interface is, clean documentation of who you're talking to and what they said happened. And that almost always you have a sense that something's not right. Adding up or just doesn't smell right. Your spidey senses. Exactly. And so , I think you just pay attention to that objectively document that

but it's really good within your system if you have a team of people. So we have something called a care team. You have a team of people who are not the caregivers, right? So we're taking care of the kid, but it's a group to have another team who investigates all that. In some ways it [00:29:00] makes me think of organ donation.

Exactly. You can triangulate that, that discussion. It's look I'm just here taking care of your kid and if you're upset about X, Y, or Z, that's those people that are there. When this type of injury pattern shows up, I'm required by law to put that into these expert's hands about determining what this may or may not be. And I'm here taking care of your child. You can direct all of that towards these people over here and it helps to deconflict

And having to standardize, strategy around this. Also de conflicts another thing, and that is social and racial bias against different groups by different providers to get more for the same pattern of injuries.

If you're black, you are more likely to have a CPS [00:30:00] activity initiated than if you're white. It's unfortunate, but that's not me confabulating. This is a, it's a described phenomenon and so having a standardized approach takes all that out of it, and it just is Hey, look, this is what we do, and.

Good. Yeah, that helps. So it, going back to this scenario the patients initially only found to have that femur fracture, and this is actually a real case. So they were getting ready to be discharged home. There was a particularly astute ed resident that developed suspicion based on some discussions with family. And they performed a more thorough exam and documented some bruising on the arms. There was pictures taken, a skeletal survey was performed that showed fractures multiple additional fractures.

And there was an ophthalmologic exam that also revealed retinal hemorrhage, which is, it's awful. Yeah. That the retinal hemorrhages is the. On the coffin, right? [00:31:00] But the child ended up getting the help and the protection that they needed, and that was all, again, due to a junior resident who was managing that patient.

And so, sad. But that wraps up the last pitfall. Always be suspicious of non-accidental trauma. So thanks to everyone for joining for another amazing Big T episode. As Teddy Ozio likes to say, the eyes do not see what the mind does not know, but now you know that much more. So until next time, dominate the day.