FAST is a helpful adjunct to the initial evaluation of adult trauma patients. Unfortunately, due to small numbers the usefulness is not as clear in children. In part, this is due to the fact that many children (particularly small children < 10 years old) have a small amount of fluid in the abdomen at baseline. This makes interpreting a FAST exam after trauma more difficult.
Despite this, use of FAST in children is widespread. A survey of 124 US trauma hospitals in 2007 showed an interesting pattern of ultrasound usage. In adult-only institutions 96% use FAST, and at hospitals that see both adults and kids, 85% use it. Most of these centers that use FAST have no lower age limit, and the physician most commonly performing the exam was a surgeon. However, only 15% of children’s hospitals do FAST exams, and they were usually done by nonsurgeons! The reasons for this are not clear. It appears that the pediatric surgeons have not embraced this technology as much as their adult counterparts.
What about that confusing bit of fluid found in kids? Several groups have looked at this (retrospectively). Fluid in the pelvis alone appears to be okay, but fluid anywhere else is a good predictor of solid organ injury. Fluid seen outside the pelvis had a 90% sensitivity and 97% specificity for injury, and positive and negative predictive values were 87% and 97% respectively.
Bottom line: FAST exam is useful in pediatric victims of blunt abdominal trauma. Fluid in the pelvis alone is normal in most children, but fluid seen anywhere else indicates a high probability of solid organ injury.
- Use of focused abdominal sonography for trauma at pediatric and adult trauma centers: a survey. J Pediatric Surgery 44:1746-1749, 2009.
- Minimal pelvic fluid in blunt abdominal trauma in children: the significance of this sonographic finding. J Pediatric Surgery 36(9):1387-1389, 2001.
- Clinical importance of ultrasonographic pelvic fluid in pediatric patients with blunt abdominal trauma. Ulus Travma Acil Cerrahi Derg 16(2):155-159, 2010.
We all have a pretty good idea of when an inpatient adult trauma patient is getting into trouble. Most rapid response teams have a set of criteria that are used by nursing personnel to initiate an RRT response. However, children who are beginning to decompensate can show it in more subtle ways. Fortunately, there is a tool that can be used to identify children who are showing early signs of developing problems.
The Pediatric Early Warning Signs tool (PEWS) is an objective system for assessing the potential for deterioration in a child. It can be customized based on institutional needs, and typically has behavioral, cardiovascular, and respiratory components. At our pediatric trauma center, we added a urinary output component as well. Scoring for each component ranges from 0 (best) to 3 (worst).
The total score is calculated, and is used to classify the child as green (benign) to red (immediate action needed). Again, these thresholds can be adjusted by each hospital. At our center, nursing calculates the PEWS score every 4 hours on non-ventilated patients.
Score category and actions are as follows:
- Green (0-3 points) – no action, reassess as ordered
- Yellow (4-6 points) – notify charge nurse, resident and attending physician
- Red (7 or more points) – call rapid response team, resident and attending physician
- A score of 3 in any category – call resident and attending physician
We implemented this system earlier this month and will be validating it during the coming year. Our hope is that it will reduce the number of RRT and code calls by identify deterioration at a much earlier stage.
You can download a copy of our PEWS instrument here. Thanks to Tracy Larsen RN, our pediatric Trauma Program Manager, for providing information on this system.
Here’s an interesting concept for a “speed bump.” Make it look like something you would want to slow down for!
The use of radiographic imaging in trauma patients has exploded over the past decade. A growing amount of research is looking at adult patients, but what about children?
Johns Hopkins did a one year retrospective review of radiographic imaging in kids age 14 and below. The studies performed and the estimated radiation dose was calculated for each child. A total of 719 children were studied and they underwent a total of 4603 studies:
- CT scans – 1457 (32%)
- Plain radiographs – 3097 (67%)
- Fluoroscopy – 49 (1%)
CT accounted for only 32% of studies but delivered 91% of the total radiation dose. Children involved in car crashes received the highest dose of radiation (18mSv) versus burned children, who had the lowest dose (1.2 mSv). Radiation exposure increased as the injury severity increased. The average age was 8 years, which means that these children have a long time until possible side-effects emerge.
What to do? First, seriously weigh the risks and benefits of every radiographic study before you order it. If CT is not essential, do something else. The ALARA concept is key (as low as reasonably achievable):
- Use weight-based CT protocols in order to deliver the minimum amount of radiation needed to get decent images
- Shield all sensitive areas that are not being imaged
- Use focused studies
- Avoid repeat exams
- Become knowledgeable about the effects of radiation exposure
- Ask yourself: “What if this were my child?”
Reference: Brown, et al. Diagnostic radiation exposure in pediatric trauma patients. J Trauma 2010, ahead of print.
Trauma professionals routinely worry about the thoracic aorta when evaluating adults after major blunt trauma. The question is, how much do we have to worry about blunt thoracic aortic injury in children?
Younger children are more elastic, and their organs tend to withstand more punishment than adults. After reviewing the literature, I’ve come to the conclusion that this injury is very rare in children in the single digit age range. It’s difficult to find a good paper that addresses this question. The majority include kids up to age 16 or 18, which really skews the results. These patients are most commonly involved in motor vehicle crashes, although a significant number are also pedestrians struck by cars.
The National Trauma Data Bank (NTDB) was queried for all children <18 years old sustaining blunt injury with at least 1 diagnosis code. There were nearly 27,000 records matching these criteria. Of these, only 34 had an injury to the thoracic aorta. And in the age range under 10, there were only 2! Both of these children were in very high energy car crashes.
The bottom line: Injury to the thoracic aorta practically never happens in children in the single digit age range. As they get closer to adolescence, they behave more like adults and become more susceptible. The diagnosis should be only be entertained in small children who are involved in very high-energy car crashes. Falls from the usual heights (2-3 stories) are probably not significant enough to cause it. A chest xray may show a full mediastinum, but this will most likely be due to a normal thymus. If investigation is warranted, the standard is to obtain a helical CT of the chest. This study would most likely be obtained anyway to evaluate the torso in a high-energy mechanism. Aortorgraphy is no longer used.
Reference: Trooskin, et al. Risk factors for blunt thoracic injury in children. J Pediatric Surg 40(1):98, 2005.