Tag Archives: pediatric

Where Are All The Pediatric Trauma Centers?

I have constructed this map from available resources from the American College of Surgeons and numerous state agencies. ACS verified pediatric centers have a diamond in their icon; Level I is red and Level II is yellow. Non-ACS centers are pink (Level I) or blue (Level II). The Level I pediatric center at Regions Hospital is the green star.

I have made every attempt at accuracy, but things do change. If I have omitted any centers or misclassified them, please leave a comment or email me!

Thoracic Aortic Injury in Very Young Children

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. 

Pediatric ATV Injuries: A Look At The Data

ATVs (all-terrain vehicles) are motor vehicles that are designed for use on uneven surfaces. Full-size ATVs can weigh up to 600 pounds and reach speeds of 75mph. There are up to 7 million ATVs currently being used in this country.

Unfortunately, young riders make up a disproportionate number of injuries and fatalities. About a third of all ATV-related deaths and ED visits involve riders under the age of 16. The risk factors for ATV injuries are well known:

  • No helmet
  • Risk-taking behaviors
  • Male (seems to go along with the previous one)
  • Large engine
  • Small child
  • 3-wheeled ATVs
  • Driving on public roads
  • Riding with a passenger

The University of Connecticut published a recent study in which they surveyed youths at four major agricultural fairs covering the 4 major geographic areas of the state. The average age that the kids began riding was 9 years. The majority rode for fun, but more than a third admitted to racing informally with friends. 70% engaged in double-riding, 59% rode alone without family present, and 46% rode after dark. Most kids were trained on ATVs by family or friends, although 25% were self-taught. The majority wore appropriate clothing and 80% wore a helmet.

Nearly half of these kids admitted to being involved in at least one ATV crash. The most frequent type of crash was a rollover, followed by collision with a stationary object. 10% were pinned under the ATV. Commonly reported causes of the crash were poor driving conditions, lack of experience, and lack of strength to control the ATV. Those who reported crashing were also more likely to engage in risky ATV behavior like racing, riding after dark, riding without supervision, or riding a large ATV.

This study points to the need for additional education and training for both children who want to ride an ATV and their parents. The only way to reduce the number of children injured or killed by these vehicles is to make sure both groups understand the need for safe riding practices.

Reference: Campbell et al, J Pediatric Surg 45:925-929, 2010.

Contrast Blush in Children

A contrast blush is occasionally seen on abdominal CT in patients with solid organ injury. This represents active arterial extravasation from the injured organ. In most institutions, this is grounds for call interventional radiology to evaluate and possibly embolize the problem. The image below shows a typical blush.

Splenic contrast blush

This thinking is fairly routine and supported by the literature in adults. However, it cannot be generalized to children!

Children have more elastic tissue in their spleen and tend to do better with nonoperative management than adults. The same holds true for contrast blushes. The vast majority of children will stop bleeding on their own, despite the appearance of a large blush. In fact, if children are taken to angiography, it is commonplace for no extravasation to be seen!

Angiography introduces the risk of local complications in the femoral artery as well as more proximal ones. That, coupled with the fact that embolization is rarely needed, should keep any prudent trauma surgeon from ordering the test. A recently released paper confirms these findings.

The only difficult questions is “when is a child no longer a child?” Is there an age cutoff at which the spleen starts acting like an adult and keeps on bleeding? Unfortunately, we don’t know. I recommend that you use the “eyeball test”, and reserve angiography for kids with contrast extravasation who look like adults (size and body habitus).

Reference: What is the significance of contrast “blush” in pediatric blunt splenic trauma? Davies et al. J Pediatric Surg 2010 May; 45(5):916-20.

Nursing Tips for Managing Pediatric Orthopedic Trauma

Nurses have a complementary role with physicians in caring for children with orthopedic injuries. Typically, the child will have been evaluated and had some sort of fracture management implemented. In children, nursing management is easer than in adults since a child is less likely to need an invasive surgical procedure. Many fractures can be dealt with using casts and splints alone.

Here are a few tips for providing the best care for you pediatric patients:

  • Ensure adequate splinting / casting. You will have an opportunity to see the child at their usual level of activity. If it appears likely that their activity may defeat the purpose of the cast or splint, inform the surgeon or extender so they can apply a better one.
  • Focus on pain control. Nothing aggravates parents more than seeing their child in pain! Make sure acetominophen or ibuprofen is available prn if pain is very mild, or scheduled if more significant. Ensure that mild narcotics are available if pain levels are higher. Remember, stool softeners are mandatory if narcotics are given.
  • Monitor compartments frequently. If a cast is used, check the distal part of the extremity for pain, unwillingness to move, numbness or swelling. If any are present, call the physician or extender and expect prompt attention to the problem.
  • Always think about the possibility of abuse. Fractures are rarely seen in children under 3, and almost never if less than 1 year old. If you have concerns about the physical findings or parent interactions, let the physician and social workers know immediately.