Pediatric Trauma to the Head and Neck Christian Rocholl MD Pediatric Emergency Medicine
Injuries injuries account for majority of childhood deaths disease death rates have ↓ faster than injury death rates Car Crashes Leading Cause of Teen Deaths in U.S. CDC report
Traumatic death motor vehicle crashes account for ≈ half of traumatic deaths children more frequently pedestrians than adults falls cause injury & less likely fatal
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Trauma
Prevention is topic for another discussion For the topic of discussion today: The injury has already occurred
Head Trauma Minor scalp lacerations major bleeding Galea Aponerotica Skull consists of frontal, parietal, occipital, temporal bones Thinnest bones are more likely to fracture parietal, temporal, and skull base
Bones of the skull
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Skull Base
nebraskabraininjurylawyer.com
Pediatric Fractures Infants have thinner bones Short distance falls Older children Adolescents Motor Vehicles / Sports Related 70% of fractures in Parietal Bone Next temporal / occipital Frontal least likely
Basilar Skull Fractures Hemotympanum Battle sign Raccoon eyes CSF rhinorrhea / otorrhea May have normal scalp and no signs or symptoms of injury
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Hemotympanum
mdconsult.
Battle sign
itim.nsw.gov.au
www.nzma.org.nz/
Raccoon Eyes
pbnation.com
www.itim.nsw.gov.au/images/racoon_eyes
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Primary and Secondary Brain Injury Neuronal injury at initial trauma Shearing, contusion, laceration, penetration Subsequent injury to additional brain cells hypoxia, hypoperfusion, hyperthermia, hyperglycemia, inflammatory cytokines
Brain Injuries Coup injury Contusion or hemorrhage at point of contact Contrecoup injury opposite side of impact
Contre-Coup Injury
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Contusion: Primary Brain Injury less cushion by CSF / more skull contact undersurface of frontal lobe & temporal lobe poles (anterior portion of temporal lobe) local mass effect and inflammation risk of late intraparenchymal hemorrhage Seizures are common Sx’s vary dramatically as does outcome
Cerebral Contusion
crash.lshtm.ac.uk
Diffuse Injuries Diffuse Axonal injury >50 % normal initial CT DAI: Shear forces (acceleration / deceleration) disrupts axons of subcortical white matter Usually associated with punctate hemorrhages Diffuse Brain Swelling multifactorial
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Epidural Hematoma & The Lucid Interval Dura adheres to skull at sutures: Potential space Meningeal arteries and Dural sinuses Blunt injury to cranium: deformation of skull Majority caused by falls Shaking does not cause deformation Headache, vomiting, lethargy Head CT: biconvex high density lesion adjacent to skull Treatment is craniotomy & surgical drainage
Epidural
mtn.missouri.edu
Subdural hematomas cerebral veins aka bridging veins can be sheared blood collects between dura mater and arachnoid mater shearing injury (acceleration/deceleration) Falls / NAT and MVAs Head CT hyperdense crescentric extraaxial fluid
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Subdural
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Subarachnoid Hemorrhage tearing of small vessels of pia mater severe blunt trauma or shearing forces Associated with other injuries & importance may be as a marker for severe primary injury Head CT 90 % sensitive hyperdense fluid in CSF (↓sensitive > 24 hrs) No direct therapy
Subarachnoid Hemorrhage
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Hypoperfusion Cerebral Blood Flow Cerebral Perfusion Pressure = Mean arterial pressure - Intracranial Pressure Maintain adequate blood pressure Maintain intracranial pressure
ICP Compliance Curve After 5 mL of volume 1mL can increase ICP by 25 mm Hg Diffuse Brain Swelling and/or Intracranial Hemorrhage rcsed.ac.uk
Management ABC’s Intubation: Keep it REAL Atropine 0.02 mg/kg (0.1 to 0.5mg) Age < 8 yrs Lidocaine 1 to 2 mg/kg to blunt airway reflexes which ↑ ICP Etomidate 0.3 mg/kg Little effect on blood pressure and decreases cerebral metabolism Rocuronium 1 mg/kg action in 60 to 90 Sec. Isotonic crystalloid to restore intravascular volume
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Access Issues •
Intraosseous dosing is same as intravenous
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Other options •
Fentanyl: •
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Intramuscular (IM) 5 min; 1 to 2 mcg/kg
Versed: •
Intranasal (IN)
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IM 5 min > .1 mg/kg
10 min .4 mg/kg
More access issues •
Rocuronium preferred IV •
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Study by Kaplan 1999 with IM use only 60 % had good intubating conditions at 4 min •
Infants 1 mg/kg
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Children 1.8 mg/kg
Succinylcholine IM onset 2 to 3 min •
IM dose of 2.5 to 4 mg/kg Max 150 mg
Management of Brain Injury In Pediatrics Diffuse Brain Swelling more common than intracranial hematoma Elevate head of bed to 30° Head and neck in midline Promotes Venous Drainage Sedation / Paralysis
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Buying Time for Acute Deterioration not Prophylaxis Therapy Hyperventilation (Take a breath yourself and slow down!) PCO2 of 30 to 35 using ABG or Endtidal CO2 Blood Viscosity Mannitol 0.5 to 1 g/kg Hypertonic Saline
Tentorial Herniation Syndrome Tentorium cerebelli Edema pushes temporal lobe through tentorial notch compressing CN III, midbrain, brainstem Headache, depressed consciousness, blown pupil, ptosis / loss of medial gaze, hemiparesis, decerebrate posturing, cushing’s triad
Tentorium Cerebeeli
wberesford.hsc.wvu.edu
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Herniation
rad.usuhs.mil
Cervical Spine injuries Statistics 1-2% of patients with significant trauma 5% of spinal injuries occur in age < 16 years 72% of spinal injuries in children < 8 years are cervical 3 to 25% of cord injuries occur during transit or initial management Significant mechanism: MVC, Falls, High-impact sports, Child abuse Cervical injuries associated with head injuries
Pediatric Spine lax ligaments allow ↑ movement or subluxation of vertebrae paraspinal muscles less developed Less protective decreased ossification allows more pliable spine flattened or horizontal facet joints allow subluxation
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Pediatric Neck Excess strain on upper cervical spine Fulcrum of movement is C2-C3 for infant, C3-C4 at age 5, and C5-C7 by age 8 (adult) Young children: fractures of upper spine More fatal Older children and adults: lower spine Neck less accessible to direct trauma
Primary and Secondary Spinal cord Injury Primary: transection, contusions, shear injuries, vascular disruption Secondary: inflammation, mass effect, hypoxia or ischemia
High Cervical Cord
Spinal shock: bradycardia, hypotension, peripheral vasodilation abnormal or absent respirations C3,4,5 keeps the diaphragm alive
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Neurologic deficits Motor, Sensory, Bowel / Bladder Motor and Sensory levels can be determined clinically dorsiflexion of the wrist (C6), extension of the elbow (C7), extension of the knee (L2-L4), and dorsiflexion of the great toe (L5) Sensory innervation by dermatomes
Dermatomes
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Specific Cord Injury Patterns Brown - Sequard syndrome with cord hemisection Ventral cord with hyperflexion Central cord syndrome from hyperextension injuries
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Spinal Cord Anatomy
Management ABC’s: Head tilt / Chin Lift or Jaw Thrust Intubation requires at least 2 people Immobilization from above or below Anterior trachea requires opening of collar Release jaw immobilization of collar
Primary Injury and Secondary Prevention Prevent injury and prevent progression Scenario where it is safe to assume injury Prove otherwise Cervical collars should not be removed by normal imaging
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Immobilization Cervical collars & Sand Bags Tallest collar without hyperextention No place for soft collars Spine immobilization boards / Log rolling Reassessment
Infant / Child Positioning Head reaches 50% of adult size by age 2 Takes chest until age 8 to reach same % Correct neutral positioning avoids flexion Occiput lower then shoulders Recess in spine board Blankets under torso
Appropriate Pediatric Spine Position
ncbi.nlm.nih.gov
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Helmets •
Neutral position
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Shoulder pads raise chest and helmets are better left initially in place
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Remove face mask to access airway
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ABC’s prevail if helmet interferes
Helmet Removal
fmtitampa.com
examiner.com
Clinically Cleared No cervical Tenderness Alert & Orientation & NO intoxication Normal exam including neurologic NO distracting injuries Normal active neck mobility without pain
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Imaging Lateral neck x-ray properly read is > 80 sensitive AP and odontoid views improve sensitivity CT: bone injury Radiation exposure MRI: cord and ligamentous injury
Head CT + Spine x-rays: extend CT down to base of C2 in children
Challenging Radiographic Evaluation •
Cartilage radiolucent
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Spine reverts to normal position
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Soft tissue changes important •
adjacent soft tissue < 1/2 width of C3
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below C4 it is a full width
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Needs to be reproducible
Normal Pediatric Variants Lordosis absent until age 15 years 3 Years: Posterior arch of C1 fuses 10 years: Anterior arch of C1 fuses 6 years: odontoid fuses with base fusion line may persist until age 10 7 years: anterior wedging confused with compression fractures 6 years: posterior lamina fusion lines confused with fracture 8 years: C2 C3 pseudosubluxation in 40% of patients
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Normal Pediatric Spine
hawaii.edu
Pseudosubluxation & Swischuk’s Line •
Line from cortex of posterior arches of C1 to C3
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1mm from line to posterior arch of C2
hawaii.edu
Where is Swischuk’s Line?
hawaii.edu
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Swischuk’s Line
hawaii.edu
SCIWORA •
Spinal Cord Injury Without Radiographic Abnormality
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Greater severity in < 8 YO
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Delay in onset of neurologic signs minutes to days
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Transient neurologic symptoms may be only presenting sign
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Cervical Collars
Steroids Controversial whether beneficial Option not a standard of care Higher rate of complications 8 hour cutoff (ideally before 3 hours) Methylprednisolone at 30 mg/kg bolus then 5.4 mg/kg/hr x 23 hours Post injury 3 to 8 hours then RX x 48 hours
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9 YO Male in ATV Rollover •
NO LOC stood up and walked but c/o neck pain
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Wearing Helmet and Neck Protection
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Brief Tingling in his hands
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Left Upper Quadrant Abdominal pain
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Laceration Left Chin
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Neurologically intact
Spine Imaging with CT
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Unstable C2 vertebral fracture with 25° acute ventral angulation, 2 mm traumatic anterolisthesis, traumatic disruption of the posterior C2-C3 disc, bilateral C2 pedicle fractures, bilateral C2-C3 facet dislocations
Treatment •
No steroids were administered •
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No neurologic symptoms
Surgery •
Open reduction of dislocation / fracture with instrumentation / grafting for stabilization with placement of Halo vest
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Bibliography Greenes, David S MD Neurotrauma Chapter 105 Textbook of Pediatric Emergency Medicine, Fleisher, GR, Ludwig, S, Henretig, FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006 Pgs 1360-1388 Woodward, George A MD, MBA Chapter 106 Textbook of Pediatric Emergency Medicine, Fleisher, GR, Ludwig, S, Henretig, FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006 Pgs 1389-1432
Bibliography •
Kaplan RF MD, Uejima T MD, Lobel G MD, et al, Intramuscular Rocuronium in Infants and Children: A Multicenter Study to Evaluate Tracheal Intubating Conditions, Onset, and Duration of Action, Anesthesiology, 1999,91(3),633-8
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Hoffman JR MD; Mower WR MD; Wolfson AB MD; Todd KH MD; Zucker MI MD, Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency XRadiography Utilization Study Group, N Engl J Med. 2000 Jul 13;343(2):94-9
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