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Pediatric Emergency Medicine Voll 11, No 1 Vo Editor Steven E. Krug, MD, FAAP
Feinberg School of Medicine, Northwestern University, Children’s Memorial Hospital, Chicago, IL
Advances In Pediatric Trauma Harold K. Simon, MD, MBA Guest Editor
GUEST EDITOR’S PREFACE . . . . . . . . . . . Ped Pediatric iatric Trauma: Trauma: A Roadmap for Evidence-Based, Evidence-Based, Patie Patient-Cente nt-Centered red Coordination Coordination and Care Harold K. Simon
4 . . . . . . . . . . Golden Hour or Golden Opportunity: Opportunity: Early Management of Pediatric Pediatric Trauma Trauma Wendalyn K. Little
Prehospital Management of Pediatric Trauma Trauma 10 . . . . . . . . . Manish I. Shah
18 . . . . . . . . . Do Routine Laboratory Test Testss Add to the Care of the Pediatric Trauma Patient? Jeffrey F. F. Linzer Sr
22 . . . . . . . . . Radiographic Evaluation of the Pediatric Trauma Patient and the Risk for Ionization Radiation Exposure
Ricardo R. Jiménez
28 . . . . . . . . . Analgesia for the Pediatric Pediatric Trauma Trauma Patient: Primum Non Nocere? Michael Greenwald
41 . . . . . . . . . When There Are no Inpatient Inpatient Beds: Pediatric Intensive Intensive Care Level Management Management of Trauma Traum Patients in the Emergency Department K. Little ToniaPetrillo-Albarano and Wendalyn
48 . . . . . . . . . Pediatric Patients in the Adult Trauma Bay—Comfort Bay—Comfort Level and Challenges Kimberly P. P. Stone and George A. Woodward
Consequences of Trauma Trauma:: The Unseen Scars Scars 57 . . . . . . . . . Mental Health Consequences Michael Finn Ziegler
W.B. W. B. Saunders
GUEST EDITOR'S PREFACE
Pediatric Trauma: A Roadmap for EvidenceBased, Patient-Centered Coordination and Care By Harold Harold K. Simon, MD, MBA
or children younger than 14cline years, there has been be en a dr dram amat atic ic an and d st stea eady dy de decli ne ov over er the pa past st 2 dec decade adess in inju injuryry-rel related ated mor mortali tality ty fro from m 942 9427 7 deaths in 1986 (age-adjusted rate of 18.04/100 000) to 65 6530 30 in 20 2006 06 (a (age ge-a -adj djus uste ted d ra rate te of 10 10.5 .59/ 9/ 1 100 000). Many factors contribute to this improvement including injury prevention strategies as well
gies on the subject, it will also take into perspective a more patient-centered approach to what can be done with new and emerging technologies, taking into account long-term implications when considering what interventions are most beneficial to the patient in the immediate care situation. It will look at qu ques esti tion onss su such ch as th the e ri risk sk vs be bene nefi fits ts of
as tr treat eatmen mentt and aft afterc ercar are e of tra trauma uma pat patien ients. ts.
computed tomographic scanning in light of radia-
Altho ugh tremend Although tremendous ous strides have been made, injury inj ury rem remain ainss a lead leading ing cau cause se of mor morbid bidity ity and morta mor tali lity ty in th the e Un Unit ited ed St Stat ates es an and d is es espe peci cial ally ly concerning within the pediatric population where trauma can rob years of happiness and productivity. This issue of Clinical Clinical Pediatric Emergency Medicine focu fo cuses ses on th the e co comp mplet lete e sp spect ectru rum m of pe pedi diat atri ric c trau tr auma ma ca care re,, be begi ginni nning ng wi with th th the e in init itia iall golden hour, emerg emergenc ency y med medic ical al se serv rvic ices es ca care re at th the e scene, through critical care management. It incorporate por atess per perspe specti ctives ves fro from m ped pediat iatric ric eme emerge rgency ncy medicine medicin e physici physicians, ans, emerge emergency ncy medica medicall service servicess prov pr ovid ider ers, s, an and d cr crit itic ical al ca care re ph phys ysic icia ians. ns. It wi will ll address present state of care, improvement strategies, and potential areas that can help us not only decr de crea ease se mo mort rtal alit ity y bu butt do so in a co cost st-e -effe ffect ctiv ive e manne man nerr co cogn gniza izant nt of fa faci cilit lity y an and d ma manp npowe owerr re re-source limitations. Unlike many previous antholo-
tion exposure. exposure. This issue will address topics such as coordination of care between subspecialties, transitions of care, and care of pediatric trauma patients in adult-based centers. It will, however, go beyond the traditional bounds and will touch on the more holistic approach to care that can and should be part of our broader perspective on pediatric trauma managem mana gement. ent. This will inc include lude sections sections on pai pain n contro con troll as well as pos posttra ttrauma umatic tic str stress ess dis disord order er recognition recogn ition and preve prevention. ntion. Trauma care has emerged from its infancy in the latter part of the 21st century as a focus of modern medicine. medici ne. Militar Military y experi experiences ences have helped push the envelope of trauma care and continues to help us mold our our perspectives, p erspectives, knowledge, and treatment 2,3 of trauma. Trauma centers have been proven to have ha ve a po posit sitiv ive e im impa pact ct on pa pati tien entt ma man nagement, ultimately ultimat ely leading to decre decreased ased mortality.4 Pediatric trauma care has, however, as is the case in most areas are as of ped pediat iatric ric med medici icine, ne, tak taken en a bac backse kseat at to much of the initia initiall focus that has been adult patient base ba sed. d. It wa wass not unt until il th the e de deve velo lopme pment nt of th the e
Depart Dep artmen ments ts of Pedi Pediatr atrics ics and Eme Emergen rgency cy Medi Medicin cine, e, Emo Emory ry University School of Medici University Medicine, ne, Child Children's ren's Healthcare Healthcare of Atlant Atlanta, a, Atlanta, GA.
PEDIATRIC TRAUMA: A ROADMAP FOR COORDINATION AND CARE / SIMON • VOL. 11, NO. 1 1
2 VOL. 11, 11, NO. NO. 1 • PEDIAT PEDIATRIC RIC TRAUMA: A ROADM ROADMAP AP FOR COOR COORDINATI DINATION ON AND CARE / SIMON
Emergency Medical Services for Children program
Even when we are fortunate enough to have an
in 19 1984 84 an and d th the e In Inst stit itute ute of Me Medi dici cine ne re repo port rt on Emergen Emer gency cy Med Medica icall Ser Service vicess for Chil Children dren tha that t pediatric trauma care began to separ separate ate itself out 5,6 as a functio functionally nally distinct discipline. Evidence has mounted over the years that regionalized liz ed cen cente ters rs wit with h ped pediat iatri ric c equ equip ipmen ment, t, pe perso rsonne nnel, l, and exper exp ertis tise e hav have e con contri tribut buted ed to the ove overall rall improvement in pedi pediatri atric c traum trauma a manag management ement..7-9 In addit addition, ion, coordina coor dinated ted afte aftercar rcare e in cent centers ers with pedi pediatri atric c surgeons geo ns and ped pediat iatri ric c cri critic tical al car care e phy physic sician ianss has improve imp roved d out outcome comes. s. Dif Differ ferenc ences es in ope operat rative ive vs support supp ortive ive tre treatm atment ent of the ped pediat iatric ric pat patien ientt as compared with the adult trauma patient, especially for blunt abdominal trauma, and comfort levels and expertise wit h t he he pediatric patient may contribute to 10 these effects. Consensus opinion and present standards dar ds for fie field ld tr triag iage e of ped pediat iatric ric tra trauma uma pat patien ients ts
abundance of resources or tertiary care pediatric faci fa cili liti ties es in a re regi gion on,, we mus mustt al also so de dete term rmineif ineif we ar are e using our resources appropriately and, in doing so, delivering deliveri ng evidence evidence-based, -based, highest-q highest-quality uality care. Technology simply for technology's sake may not alway al wayss le lead ad to th the e be best st out outco comes mes.. We mus mustt th ther eref efore ore critically evaluate the sensitivities and specificities of such advancements as well as balance the longterm effects and costs (financial and even adverse medical) medica l) that can come from their usage. Examples such as focused assessment sonography in trauma examinations and their use in the pediatric population, screening laboratories, and radi radiologic ologic studies 16-20 must all be cri critic tically ally eva evaluat luated. ed. The prese present nt state of knowledge and risks vs benefits of each will be addressed. Lastly, patient- and family-centered care needs to
11 sup suppor portt to thedir the ectio tion n of those tho se chi childr ldren en center. meetin mee ting g t rauma rauma criteria adirec pediatric capable trauma Many commu communiti nities es do not have the volu volume me of patients or resources required to support designated pediatric trauma centers. Facilities within communitiess tha tie thatt do ha have ve thi thiss vol volume ume ar are e oft often en str stret etche ched d beyond their functional capacity given the prevalence of eme emerge rgency ncy de depar partme tment nt ove overc rcrow rowdi ding ng an and d the use of
be at the th e fo fore onttiatric ofricwh what atuma. dist di st in guishes inguis hes manage man agemen ment t refr offron pediat ped trauma tra .21 Having Hav ing the the prop pr oper er eq equip uipme ment nt an and d pe pers rsonn onnel el fo forr th the e ba basic sic trau tr auma ma ne need edss of ch chil ildr dren en of al alll ag ages es re rema main inss essential. However, recognition of the need to treat both patients and their families can help bring a more holistic approach to meeting the needs of our most vulnerable patients and their families. Consid-
emergency departments as the safety net for medical for medical care for many unde underser rserved ved popu populati lations. ons.12,13 These factors, along with the shear cost of keeping trauma centers available 24/7 in communities that may not have ha ve th the e re requ quir ired ed re resou sourc rces es,, ma make ke it ev even en mo more re impor imp ortan tantt to dev develo elop p tr traum auma a cen center terss wit within hin wel welllcoordinated regional systems to best transport, stabilize, and and definitiv definitively ely care for crit critica ically lly inju injured red chil chil--
eration of the entire child and his or her family, and eration not just the injury (eg, the fracture in room one ), remains a crucial part of the challenge set forth in pediatric trauma care. Health care providers tend to underrecognize, undertreat, and fail to prevent pain and an d an anxie xiety ty in ch chil ildr dren en,, an and d li limit mit theimpa theimpact ct of th these ese 21 stressors related to trauma. This issue will therefore also address pain management of the pediatric
dren.11,14 Howev However, er, toda today, y, fewe fewerr than 200 ped pediatr iatric ic trauma centers exist in the United States; and more
trauma patient, posttraumatic stress disorder recogniti ogn ition, on, and pre prevent vention ion str strate ategie gies. s. Alth Although ough we stil stilll
than 28% of children younger than 15 years are more than 1 hour from such centers by ground or by air transport. This disparity is even greater in rural areas, wher wh ere e 77% of ch chil ildr dren en ar are e mo more re th than an 1 ho hour ur fr from om su such ch centers.15 Giv Given en the crit critical icalimpo importan rtance ce of stab stabiliz ilizatio ation n within the golden opportunity for care, we have a long lo ng wa way y to go in co coor ordi dina nati ting ng su such ch ca care re an and d es esta tabl blis ishhing centers capable of providing optimal management to this vulnerable population. This points to a need to expand expa nd acc access ess to ped pediatr iatric ic trau trauma ma care for gre greater ater number num berss of chi childr ldren en and to con contin tinue ue to gr grow ow and enhanc enh ance e the net networ works ks ava availa ilable ble.. Th Those ose cen center terss th that at do exist exi st nee need d to ful fully ly co coord ordina inate te ca care re ove overr lar large ge ca catch tchmen ment t “
have a long way to go to optimi optimize ze the care of injured children, childr en, this series should act as a roadma roadmap p for the broad bro ad ran range ge of car care e pro provid viders ers tre treati ating ng ped pediat iatric ric trauma patients.
areas withto the necessary support systems and transfer protocols best serve the children throughout their regions. These items will be among those addressed in this th is se seri ries es of ar arti ticl cles es an and d ar are e so some me of th the e mo most st challe cha lleng nging ing iss issues ues fac faced ed as we see seek k to con contin tinue ue to expand and enhance pediatric trauma networks.
REFERENCES 1. Natio National nal Cent Center er for Inju Injury ry Prev Preventi ention on and Cont Control. rol. WISQA WISQARS RS
Injury Mortality Reports, 1999 - 2006. Available at: http:// webapp.cdc.gov/sasweb/ncip webapp.cd c.gov/sasweb/ncipc/mortrate10_ c/mortrate10_sy.html sy.html.. Accessed 1/15/10. 2. Mullins RJ. A historical perspective of trauma system development in the United States. J Trauma 1999;47(Suppl 3): S8-S14. 3. Berge Bergerr E. Le Lesson ssonss fro from m Afg Afgha hanis nistan tan an and d Ira Iraq: q: the cos costly tly benefits bene fits from the battle battlefield field for emer emergenc gency y medi medicine cine.. Ann Emerg Med 2007;49:486-8. 4. MacKen MacKenzie zie EJ, Riva Rivara ra FP, Jurk Jurkovic ovich h GJ, et al. A nati national onal evaluation of the effect of trauma center care on mortality. N Engl J Med 2006;354:366-78.
PEDIATRIC TRAUMA: A ROADMAP FOR COORDINATION AND CARE / SIMON • VOL. 11, NO. 1 3
Preventive Health Amendments of 1984, Pub. L. 98-555 § 7, 98 Stat. 2854, 2856 (1984) (codified as amended at 42 U. S.C. § 300w-9). 6. Institut Institute e of Medic Medicine ine Comm Committe ittee e on Pedi Pediatri atric c Emer Emergenc gency y Medical Services. In: Durch JS, Lohr KN, editors. Emergency
PA, Butz DA, Lotte Lottenber nbergg L, et al. The cost of trau trauma ma center readiness. Am J Surg 2004;187:7-13. 15. Nance ML, Carr BG, Branas CC. Access to pediatric trauma care in the United States. Arch Pediatr Adolesc Med 2009; 163:512-8.
medical medi cal servi services ces for child children. ren. Wash Washingt ington, on, DC: Natio National nal Academy Press; 1993. 7. Ha Hall ll JR JR,, Re Reye yess HM HM,, Me Melle llerr JT JT,, etal. Ou Outc tcom ome e fo forr bl blun untt tr trau aumais mais best at a pediatric trauma center. J Pediatr Surg 1996;31:72-7. 8. Pot Potoka oka DA, Sc Schal halll LC, For Ford d HR. Imp Improv roved ed fun functi ctiona onall outcome for severely injured children treated at pediatric trauma centers. J Trauma 2001;51:824-34. 9. Bensard DD, McIntyre RC, Moore EE, et al. A critical analysis of acu acutel tely y inj injure ured d ch child ildrenmana renmanagedin gedin an ad adult ult lev level el I tra trauma uma center. J Pediatr Surg 1994;29:11-8. 10. Farrell Farrell LS, Hann Hannan an EL, Coop Cooper er A. Seve Severity rity of inju injury ry and mortality associated with pediatric blunt injuries: hospitals with pedi pediatric atric inte intensiv nsive e care unit unitss vs. other other hospi hospitals. tals. Pedi Pediatr atr Crit Care Med 2004;5:5-9. 11. Centers for Disease Control and Prevention. Guidelines for field triage of inju injured red patients: patients: reco recommen mmendati dations ons of the national expert panel on field triage. MMWR 2009;58:RR-1. 12. O Conn Connor or RE. Spec Specialty ialty coverage coverage at nonnon-tert tertiary iary care ’
centers. Prehosp Emerg Care 2006;10:343-6. MG, He Hedge dgess JR JR,, Bas Basss RR. The eff effect ect of am ambul bulan ance ce diversions on the development of trauma systems. Prehosp Emerg Care 2006;10:351-4.
13. Millin Millin
JF, Gladman A, Chang CH. Performance of abdominal ultrasonograp ultrasonography hy in pedi pediatri atric c blunt trauma patients: patients: a meta-analysis. J Pediatr Surg 2007;42:1588-94. 17. Holmes JF, Mao A, Awasthi S, et al. Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Ann Emerg Med 2009;54: 528-33. 18. Blackwell CD, Gorelick M, Holmes JF, et al. Pediatric head trauma: changed tomography in emergency departments in the Uni United ted Sta States tes ove overr tim time. e. Ann Emerg Med 200 2007;4 7;49: 9: 320-4. 19. Brenner DJ, Hall EJ. Computed tomography - an increasing source sourc e of radi radiatio ation n expos exposure. ure. New Engl J Med 2007;357: 2007;357: 2277-84. 20. Jimenez RR, DeGuzman MA, Shiran S, et al. CT versus plain radiog rad iograp raphs hs for eva evalua luatio tion n of c-s c-spin pine e inj injury ury in you young ng children: do benefits outweigh risks? Pediatr Radiol 2008; 38:635-44. 21. Ziegler
M, Grenwald MH, DeGuzman DeGuzman MA, et al. Posttraumatic Posttraumatic stress respo stress responses nses in children: children: awar awarenes enesss and practice practice amon amongg a sample samp le of pedi pediatri atric c emer emergenc gency y care prov provider iders. s. Pedi Pediatri atrics cs 2005;115:1261-7.
Abstract: The concept of a golden hour is a fixture in trauma care. There is a dearth of scientific proof for this concept but an abundance of controversy around how this concept “
Golden Hour or
should be inter interpreted, preted, especially especially for pediatric trauma patients. Health care providers should instead focus on the golden opportunity, different for each patient, to provide the best care in the most appropriate environment environ ment for all injured childr children. en. “
Keywords: pediatric trauma; golden hour; pediatric pediatric emergency; trauma systems; interfacility transport
Management of Pediatric Trauma Wendalyn K. Little, MD, MPH
There is a golden hour between life and There
death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be Pediatrics and Emergency Medicine, Division of Pediatri Pediatric c Emer Emergency gency Medicine, Medicine,
three days or two weeks later — —but b ut some-
Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA.
thing has happened in your body that is irreparable.” R Adams Cowley MD 1
Reprint requests and correspondence: Wendalyn Little, MD, MPH, Pediatric Emergency gen cy Medi Medicine cine,, 164 1645 5 Tul Tullie lie Circl Circle, e, Atlan Atlanta, ta, GA 30329. [email protected]
1522-8401/$ - see front matter © 2010 Elsevier Elsevier Inc. All rights reserved.
4 VOL VOL.. 11, NO. 1 • GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE
GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE
THE GOLDEN HOUR The term golden term golden hour is is a fixture in the lexicon of trauma care. The phrase refers to a critical period in th the e ca care re of tr trau auma ma pa pati tien ents ts du duri ring ng wh whic ich h appropriate care may limit morbidity and increase survival. The origin of this term is difficult to trace. It may have evolved from an early description of the relationship between survival and time from injury to tr trea eatme tment nt on th the e ba batt ttlef lefie ields lds of Wo Worl rld d Wa Warr I. This Th is an anal alysi ysiss of Fr Fren ench ch mil milit itary ary da data ta sh showe owed d a decrease in mortality from battle wounds from 10%
VOL. 11, NO. 1
improved improv ed outc outcomes omes for sev severe erely ly inj injure ured d patients 7,8 cared car ed for in ded dedica icated ted tra trauma uma cen center ters. s. A core principal in many of these systems is the belief that crit cr itic ical ally ly in injur jured ed pa pati tien ents ts ar are e be best st ca care red d fo forr in designated trauma centers, even if transport from the field toThe these centers bypasses closer medical facilities. combination of the concepts of the golden hour and the importance of trauma centers has been the impetus for the development of EMS policies such as rapid scene triage, minimization of on-scene treatment interventions in favor of rapid transport to emergency departments, and air eva-
within 1 within 1 hour of treatment to 75% at 8 hours post 2
injury. More recent rece nt “med medical ical literat lit erature uretrauma often oft en attr attribut ibutes es Mor thee phra phrase se golden gold en hour ” to tra uma surge sur geon on R. Ad Adams ams Cowley Cowley,, MD MD,, one of th the e ea earl rly y champio cha mpions ns of org organiz anized ed tra trauma uma car care. e. Dr Cow Cowley ley conduct cond ucted ed tra trauma uma res resear earch ch and wrot wrote e and spo spoke ke extensively on the subject of trauma care, and the coining of the term golden term golden hour is is often attributed to his speeches, yet none of his publications mentions or test test s th the e th theo eory ry of a go gold lden en ho hour ur in tr trau auma ma care.2,3 Modern support for the golden hour concept began in the 1960s when trauma care in the United Stat St ates es wa wass in it itss in infa fanc ncy y an and d ci civi vili lian an tr trau auma ma systems were nonexistent. Military data from each of the world wars, the Korean Conflict and the war in Vietnam, show decreased combat mortality with the development of faster, more organized systems for th for the e tr tran ansp spor ortt of in injur jured ed tr troo oop p s from from th the e battle bat tlefie field ld to med medica icall car care e fac facili ilitie ties. s.3,4 Th This is in in-crease cre ased d surv surviva ivall was att attrib ribute uted d in par partt to fas faster ter evacuation of wounded soldiers from the battle battl efield to the hospital by way of helicopter transport.4 The 1960 19 60ss an and d 19 1970 70ss sa saw w an in incr crea eased sed in inte tere rest st in civilia civ ilian n tra trauma uma car care. e. Fed Federa erall leg legisla islation tion led the way for funding emergency medical services (EMS) standar sta ndards ds and tra traini ining. ng. The Ame Americ rican an Col Colleg lege e of Surgeons published t he first of many guidelines for trauma care in 1976.4 Pioneers such as Dr Cowley championed champio ned trauma care as a sp spec ecia ialty lty with its roots roo ts in gen genera erall sur surger gery. y.5 Helico Helicopter pter trans transport port bega be gan n to be se seen en as a me mean anss of qu quic ickly kly moving moving injured patients to hospitals; some hospitals began to devote specialized resources and teams to care for trauma victims, and the concept of regionalized trauma tra uma syst systems ems gai gained ned supp suppor ortt f rom r om hea health lth car care e 4,6
cuation cuatio n of severely injured patients directly from the sit site e of in injur jury y to de desig signa nate ted d tr trau auma ma ce cent nter ers. s. These practices are not without cost, in money for equipment and staffing of helicopter transport and EMS resources. They are also not without risk to EMS teams, patients, and bystanders when priority is pl plac aced ed on ra rap pid tra transpo nsport, rt, some sometime timess acr across oss 9 greatt dista grea distances. nces. A commo common n debate in trauma system syst em dev develo elopmen pmentt cen center terss on whet whether her pat patien ients ts should shou ld be tra transfe nsferre rred d long longer er dist distanc ances es to tra trauma uma center cen terss or to the closest available available fac facilit ility, y, wher where e initial init ial sta stabili bilizat zation ion may be per perform formed, ed, and the then n those patients determined determined to need furthe furtherr specia specialty lty care are then transferred to a trauma center. Much of the current literature supports a varied approach based on geographic location. In urban areas, where level I trauma centers are often readily available, it may ma make ke se sense nse to by bypa pass ss cl close oserr fa faci cilit litie iess to reach the trauma facility, as differences in transport timess are likel time likely y to be minor. minor. In rur rural al areas, areas, how howeve ever, r, tran tr ansp spor ortt ti time mess to tr trau auma ma ce cent nters ers ma may y be pr proolonged, long ed, and pat patien ients ts may ben benefit efit from sta stabili bilizazation ti on in a cl clos oser er fa facil cilit ity y fol follow lowed ed by tr tran ansfe sferr to a trauma center after initia initiall stabil stabilization ization.. Effecti Effective ve trauma systems must therefore into account the location and capabilities of thetake facilities within a geographic catchment area, as well as any traffic or geogra geo graphi phical cal feat feature uress tha thatt may imp impact act tra transpo nsport rt times. tim es. Thi Thiss app approa roach ch to est establ ablish ishing ing eff effect ective ive trauma tra uma syst systems ems is per perhap hapss bes bestt cha charac racter terize ized d by the “3R ” rule att attrib ribute uted d to pio pionee neerin ringg tra trauma uma surgeon surg eon Dr Don Donald ald Tru Trunkey nkey of get gettin tingg th the e “right 10
patient to the right place at the right time. Some patients may have only minutes to survive without appropriate approp riate intervention, intervention, whereas some may sur-
providers provid ers and gover governing ning bodies.
TRAUMA SYSTEMS AND TRANSPORT TO TRAUMA CENTERS
vive the vive their ir in initi itial al inj injur uries ies but ne need ed sp spec ecia ializ lized ed care and rehabilitation to achieve maximum postinjur inj ury y fun funct ctio ion. n. Th This is co conc ncep eptt mig might ht we well ll be th the e best guiding principle of trauma management, and the im immed media iate te po posti stinju njury ry pe perio riod d mig might ht be best st be
Early Ear ly st studi udies es of tr trau auma ma pa patie tient ntss ap appe pear ared ed to show inc increa reased sed sur surviv vival al with the dev develo elopme pment nt of these early trauma systems and continue to show
though thou ghtt of as a “golden opport opportunity unity” to ensu ensure re prompt, appropriate treatment for each and every injured patient.
6 VOL VOL.. 11, NO. 1 • GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE
If th the e co conc ncep eptt of a go gold lden en ho hour ur an and d it itss re rela lati tion onsh ship ip to trauma systems is controversial and unproven in adult ad ults, s, it is ev even en mor more e so fo forr pe pedi diat atri ric c tr trau auma ma
performing procedures such as intra performing intravenous venous access, endotr end otrach acheal eal int intuba ubation tion,, and app approp ropria riate te ca cardiordiopulmonary resuscitation on pediatric patients.14,15 There is literature to suggest similar outcomes for pediat ped iatric ric pat patien ients ts ven ventil tilate ated d by mean meanss of bag baggin ging g inste in stead ad of en endo dotr trac achea heall in intu tuba bati tion on in ca case sess of
patients. The development of pediatric emergency medic med icine ine as a sp spec ecia ialty lty ha hass pr promo omote ted d th the e cr crea eati tion on of pedi pe diat atri ric c tr trau auma ma ce cent nter ers, s, so some me as pa part rt of fr free ee-standi sta nding ng chi childr ldren' en'ss hos hospit pitals als and oth others ers wit within hin general/adult facilities. Pediatric trauma care continues to evolve as a distinct facet of trauma care that recognizes the differ different ent anatomi anatomical, cal, physiol physiologogic, and developmental developmental reali realities ties of pedia pediatric tric patients
respiratory respirat ory fail failure, ure, sugg suggesti esting ng that intu intubati bation on should not be attempted in the field for pediatric patients in urban locations where transport times to hospita hosp itall emer emergen gency cy dep depart artment mentss is fai fairly rly sho short. rt.15 Anothe Ano therr stu study dy exa examin mining ing the eff effecti ectiven veness ess of pediat ped iatric ric hel helico icopte pterr tra transp nsport ort show showed ed no ben benefit efit for patients transported directly from the scene of injury inju ry to a ped pediat iatric ric trauma center center as com compar pared ed
as well as the different injury patterns seen in these patien pat ients. ts. The dev develop elopment ment and con concen centra tratio tion n of
with thos those e initially stabilized at the closest medical facility.17 All of this information could be inter-
PEDIATRIC TRAUMA AND TRAUMA CENTERS
pediatric expertise has improved the management of in inju jure red d ch chil ildr dren en,, wi with th pa pati tien ents ts ca care red d fo forr in pediatric trauma centers appearing to have equal or be bett tter er out outco come mess ov over eral alll wh when en co comp mpar ared ed to pediatric pediat ric patie patien nts car ared ed fo forr in ge gene nera rall or ad adul ult t 11-17 trauma cente centers. rs. Many factors likely contribute to this positive effect including the availability of appropri appr opriatel ately y sized equi equipmen pmentt and monit monitorin oring g capabi cap abilit lities ies for pe pedia diatr tric ic pat patien ients, ts, hea health lth car care e provid pro viders ers cap capable able of rec recogni ognizin zingg and tre treati ating ng the early, ear ly, oft often en sub subtle tle,, sig signs ns of sho shock ck in pe pedia diatri tric c patien pat ients, ts, and man manage agemen mentt str strate ategie giess uni unique que to pediatric injuries.
preted that time spent in EMS transport of critically ill and injured children should be minimized, and these patients should be transported to the closest facility able to provide stabilizing, if not definitive, care.
Despite evidence toms suggest outcomes for ped pediat iatric ric tra trauma uma victims victi treated tre atedbetter in ped pediat iatric ric tra trauma uma center cen ters, s, most ped pediat iatric ric tra trauma uma vic victim timss are car cared ed for, at least initially, in nonpediatric centers, as the number numb er and geo geogra graphi phic c loca location tion of ded dedica icated ted pediat ped iatric ric cen center terss lea leaves ves man many y ch chil ildr dren en ou outt of 12,13 reach rea ch for imme immedia diate te car care. e. The que questi stion on tha that t therefore arises is not only does a golden hour exist
pediatric patients and providing care (also trauma see article “ Pediatric Patients instabilizing the Adult Trauma Tra uma Bay—Comf Comfort ort Lev Level el and Cha Challen llenges ges,,” in this issue). Although most emergency department visits in the United States involving children occur in nonpediatric nonpediatric facilities, facilities, many of these facilities facilities are underprepared to deal with critically ill or injured chil ch ildr dren en.. In 20 2001 01,, th the e Ame Ameri rica can n Ac Acad adem emy y of
for the treatment of pediatric trauma patients, but also, al so, wha whatt sho should uld oc occu curr du duri ring ng th that at in init itia iall ti time me frame. One aspect of this debate centers on whether pediat ped iatric ric tra trauma uma pat patient ientss shou should ld be tra transpo nsporte rted d direct dir ectly ly to ped pediat iatric ric cen center ters, s, pos possibl sibly y byp bypassi assing ng other oth er eme emerge rgency ncy fac facilit ilities ies or tra trauma uma cen center terss on the way to specialized pediatric care, or should they be stabilized at the closest capable capable facility and then
Pediatrics and the American College of Emergency Physi Phy sici cian anss es esta tabl blish ished ed a set of gu guid idel elin ines es f or or pediatric pediat ric emerge emergency ncy depar department tment prepa preparedness. redness.18 These guidelines, which were recently updated in 2009, 20 09, ad addre dress ss equ equipm ipment ent,, tra traini ining, ng, and qua qualit lity y review for pediat review pediatric ric car care e in emer emergen gency cy dep depart art-ments.19,21 Surveys evaluating preparedness preparedness continue to show inadequate preparat preparat ion ion in equipment in equipment
transferred to specialized pediatric centers if their condition warrants. It is worrisome that pediatric patients may be subjected to longer transport times, possibly bypassing “adult ” trauma facilities to reach pediat ped iatric ric centers, centers, as EMS pro provid viders ers often do not have hav e gre great at fam familia iliarit rity y or exp experie erience nce wit with h cri critic tically ally ill
and training for pediatric patients.13,20,22 Nonpediatric tri c cen center terss oft often en tra transfe nsferr ser serious iously ly ill or inju injured red patients to pediatric centers for definitive care. The prese pr esenc nce e of a se seri rious ously ly in inju jure red d ch chil ild d ma may y en enge gend nder er a sense of anxiety in the emergency department and hass th ha the e po pote tent ntial ial to cr crea eate te a str stress ess-la -lade den n at atmomo-
EMERGENCY DEPARTMENT READINESS FOR CHILDREN If pediatric patients patients are to be transp transported orted to non – pediatric-specific hospitals, the emergency departments men ts at th these ese fa faci cilit litie iess mus mustt be ca capa pabl ble e of as asse sessi ssing ng
or injured children. The EMS pedia pediatric tric volumes are often quoted as around 10% of EMS calls, with less than 1% of these patients meeting the definition of critically critic ally ill. The EMS personn personnel el may have difficulty difficulty
sphere in which recognition and treatment of lifethreatening shock and respiratory failure go unaddressed and untreated in attempts to get the patient outt of th ou the e fa faci cili lity ty an and d en enro rout ute e to a pe pedi diat atri ric c
GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE • VOL. 11, NO. 1 7
specia specialty lty cen center ter as qui quickl ckly y as pos possib sible. le. Mis Missed sed injuries on an initial trauma survey are a common proble pro blem, m, and there is some evidence evidence from adu adult lt studies that seriousl seriously y injure injured d patie patients nts transfe transferred rred from rural hospitals to trauma centers frequently have unrecognized injuries.23,24 This suggests that patients may have injuries overlooked in favor of
threatening hemorrhage would seem to be candidates dat es for imme immedia diate te trans transfer fer to to a tra trauma uma center center wit with h pediat ped iatric ric sur surgeo geons ns and a ped pediat iatric ric int intensi ensive ve car care e unit un it bu butt at ti times mes may re requ quir ire e th the e se serv rvic ices es of a generall surgeon genera surgeon,, if availa available, ble, to control hemorrhage hemorrhage before transport. Most pediatric trauma is caused by blunt bl unt me mech chan anism ism of in inju jury ry su such ch as fa falls lls,, mot motor or
rapid transport to a trauma center. This problem may be even more widespread for pediatric patients in simi similar lar situ situatio ations. ns. Rece Recent nt lit litera erature ture supp supports orts early ear ly re recog cogni nitio tion n an and d tr treat eatmen mentt of sho shock ck an and d respiratory failure as important in improving ultimate survival and outcome of critically critica lly ill ill or injured 25,26 patien pat ients, ts, bot both h adu adult lt and ped pediat iatric. ric. Similarly, neurolo neu rologic gic outcome outcome has bee been n show shown n to imp improv rove e with early appropriate resuscitation and m and monitoring onitoring of children with traumatic brain injury.27 Unfortunately, studies of pediatric patients transferred to pediatric centers describe deficiencies in the detection ti on an and d tr trea eatm tmen entt of sh shoc ock, k, hypote ypotensi nsion, on, an and d
vehicle vehicl e collisio collisions, ns, assault, and sporti sporting ng activ activities. ities. Most patients will not require emergent surgical intervention. Pediatric trauma specialists have led the development of protoc protocols ols for expectant, nonoperativ era tive e mana managem gement ent of some con condit ditions ions,, nam namely ely liver and splenic injuries. In adult-oriented systems, these thes e injur injuries ies are gene generall rally y tre treated ated surg surgical ically, ly, whereas children cared for in pediatric centers are usually managed nonoperatively. Therefore, pediatric patients undergo fewer laparotomi laparotomies es and sple29,30 nectomies than do adult patients. The golden hour for these patients might best be spent ensuring adequate oxygenation and ventilation, securing an
respiratory failure before transfer.18,25,26
So what should be the scope of the evaluation and stabilization of pedia stabilization pediatric tric trauma patien patients ts in genera generall trauma facilities or community hospitals? A primary sur surve vey y fo focu cusin singg on ai airw rway ay,, br brea eath thin ing, g, an and d
airway if nee airway needed ded,, obt obtain aining ing vas vascula cularr acc access, ess, and provid pro viding ing ini initia tiall flu fluid id res resusci uscitat tation ion if nee needed ded.. Patien Pat ients ts wit with h tra trauma umatic tic bra brain in inj injury ury mus mustt be carefully monitored, and hypotension and hypoxia avoi av oide ded d as bo both th of th thes ese e st stat ates es ha have ve be been en fo foun und d to be indepe ind epende ndent nt pre predic dictor torss of inc increa reased sed mor mortal tality ity in patien pat ients ts with tra traumat umatic ic bra brain in inj injury ury.. Pedi Pediatr atric ic patien pat ients ts wit with h isol isolate ated d bra brain in inj injurie uriess may best be stabili sta bilized zed at the clos closest est med medica icall fac facili ility ty in whi which ch these conditions may be recognized and corrected
cir circul culat ation ion sho should ulditions be under erta take ken n and lifelif e-s threate thre atening ning conditi cond onsund correct corr ected. ed. All any patient pat ients should sho uld be pla place ced d on sup suppl pleme ementa ntall oxy oxyge gen. n. Ad Ad-vanced airway management in the form of endotracheal che al int intuba ubation tion may be nee needed ded in pat patien ients ts with severe traumatic brain injury, thoracic injuries, or shock. shoc k. Ade Adequat quate e oxyg oxygena enatio tion n and ven ventila tilatio tion n shou should ld be ensured. A portab portable le chest radiograph radiograph to evalua evaluate te
as needed. fashion Transport then be undertaken in a controlled andcould preferably with a specialized pediatric critical care transport team. Time should not be spent obtaining computerized tomography and other extensive imaging studies if the facility lacks the surgical capabilities to provide definitive care for injuries detected on imaging or if obtaining scans will delay transport. transport. Scans may inadvertently inadvertently
for pneumothorax may be helpful. Placement of a thora tho raco cost stomy omy tu tube be sh shoul ould d be pu pursu rsued ed fo forr mo most st ca cases ses of pneumothorax. Close attention should be paid to the child's hemodynamic status. Health care providers must keep in mind that the strong compensatory mechanisms in children and teenagers allow them to increase their systemic vascular resistance and an d ma main intai tain n blo blood od pr pre essur ssure e un unti till a sub subst stan anti tial al amount of blood is lost.19,28 Ear Early ly sig signs ns of shoc shock k such as tac tachyca hycardi rdia, a, ment mental al sta status, tus, and cap capilla illary ry refi re fill ll ti time me ar are e mor more e sen sensit sitiv ive e an and d sho should uld be monitored closely. An initial fluid bolus of isotonic saline sal ine sho should uld be ad admin minist ister ered ed and re repea peate ted d as needed nee ded.. Bloo Blood d com compone ponent nt tra transfu nsfusion sion shou should ld be considered for patients not responding to crystalloid resuscitation or for those with evidence of ongoing hemorrhage.27 Pat Patien ients ts with imme immedia diatel tely y life life--
fail to be transp transported orted with the patient or, in the case of di digit gital al ima images ges,, tra transf nsferr erred ed by com compac pactt dis disk, k, inaccessible at the receiving facility, thus, necessitatin ta tingg re repe peat at ima imagi ging ng wit with h in incr creas eased ed cos costs ts and unnecessary radiation exposure to the patient. In fact, fac t, one stu study dy foun found d tha thatt alm almost ost all rad radiogr iograph aphss performed at referring facilities were later rep repeated eated when patients arrived to the trauma center.31 Once critically ill or injured children are stabilize li zed d an and d th the e de deci cisi sion on is ma made de to tr tran ansf sfer er to a pediat ped iatric ric tra trauma uma cen center ter,, att attenti ention on must the then n be turned tur ned to the best mode of tra transfe nsfer. r. One recent recent study showed signif significantly icantly more complic complications ations and deaths dea ths (23 (23% % mor mortal tality ity vs 9% mor mortal tality ity)) amo among ng pediatric patients transferred from referring facilities ti es to a pe pedi diat atri ric c tr trau auma ma ce cent nter er by “general ” helicop heli copter ter tea teams ms vs spe specia cialize lized d ped pediat iatric ric tea teams. ms.
INITIAL STABILIZATION OF INJURED CHILDREN
8 VOL VOL.. 11, NO. 1 • GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE
This remained true even when corrected for patient mix and the greater average time from referral to arriva arr ivall in the ped pediat iatric ric cen center ter amo among ng pat patien ients ts transpo tra nsporte rted d by the spe specia cialty lty tea teams. ms. The aut author horss speculat spec ulate e that desp despite ite ove overall rall long longer er tran transpor sport t times, the patients transported by the specialized team tea m ac actua tually lly ben benefi efited ted fr from om an ove overa rall ll longer period per iod in the car care e of ped pediat iatric ric spe specia cialist lists. s.18 This concept conc ept of “br bring inging ing the ho hospi spita tall to th the e pa pati tien ent t ” may in fact be a critical piece of care that is currently lacking lac king in man many y tra trauma uma syst systems. ems. Sev Severa erall stud studies ies have hav e sho shown wn tha thatt tra transp nsport ort by spe specia cialty lty-tr -train ained ed “mob mobile ile int intensi ensive ve car care e unit ” teams teams is asso associa ciated ted with improved improved out outcome comes, s, eve even n if such tra transp nsport ort delays ultim ultimate ate patient arrival at the tertiary care center.18,19, 28-44
THE GOLDEN OPPORTUNITY So wha whatt is th the e be best st ca care re fo forr pe pedi diat atric ric tr trau auma ma pati pa tien ents ts? ? Ho How w ca can n a sy syst stem em ca capi pita tali lize ze on th the e “golden opportunity” to provide the right care in the th e ri righ ghtt pl plac ace e at th the e ri righ ghtt ti time me? ? Cr Crea eati tion on of
ongoing tre ongoing treatm atment ent vs “awaitin awaitingg transf transfer er” and and be capable of recognizing and responding to evolving clinicall change clinica changess in pediat pediatric ric patients.
SUMMARY Certainly, no one would argue that timely care is best for critically ill and injured persons. However, the exact meaning and significance significance of a golden hour in tr trau auma ma ca care re is th the e su subj bjec ectt of de deba bate te an and d controversy. So is there a golden hour? If there is, then what should occur during this time? Should this time be spent transferring a patient from the scene to a major trauma center, even if it is not the closest facility? Or should patients be stabilized at the closest clos esthow medica med l fac facilit ility y bef before transf tra nsfer? er? Fur Furthermore, doical the concepts ofore a golden hour andtrauma tra uma syst system em car care e app apply ly to ped pediat iatric ric pat patien ients? ts? Perhap Per haps, s, the ans answer werss lie some somewhe where re in bet betwee ween, n, and an d ra rath ther er th than an a go gold lden en ho hour ur,, he heal alth th ca care re providers should focus on the “golden opportunity” to provide stabilization of immediately life-threatening conditions at the closest appropriate facility
reg region ionali alized zed trauma tra umaand systems syst ems to ens ensure urefor timely tim access acc ess to basic e basic evaluation valuation stabilization allely patients 45 is vit vital al.. This Th is may re requi quire re ini initi tial al tr tran anspo sport rt of pediat ped iatric ric tra trauma uma pat patien ients ts to gen genera erall eme emerge rgency ncy facilities, especially in rural areas without immediately ate ly ava availa ilable ble ped pediat iatri ric c tra trauma uma cen center ters. s. The These se facilities facilit ies must be capable of evaluat evaluating ing and stabili stabilizzing pediatric trauma patients. Appropriately sized
followed by safe transfe transferr when neede needed d for definitive care. car e. Tr True ue rea realiz lizati ation on of thi thiss op oppor portun tunity ity for pediatric pediat ric trauma patients requir requires es indivi individualize dualized d conside con siderat ration ion for eac each h pat patien ientt wit within hin well well-es -estab tab-lished and well-coo well-coordinat rdinated ed systems of region regionalized alized trauma care.
equipmentt and moni equipmen monitori toring ng cap capabi abiliti lities es must be present pre sent.. Sta Staff ff must have ski skills lls in the assessment assessment and stabilization of pediatric patients, especially in the management management of shoc shock k and real or imp impend ending ing respiratory respir atory failure. Pediat Pediatric ric patien patients ts with severe or life life-thr -threat eatenin eningg inju injurie ries, s, espe especia cially lly thos those e in need of intensive care unit-level care, should then be transfe transferred rred to appro appropriate priate pediatric pediatric trauma faci-
lities as rapidly as possible after initial stabilization of any immedia immediately tely life-threatening life-threatening conditions. The criter cri teria ia for tra transfe nsferr and mec mechan hanisms isms for ref referr erral al and transfer must be put in place and maintained. Transfer agreements between general and pediatric trauma centers must be well designed with prompt, easily easi ly acc accesse essed d comm communic unicati ation on rea readily dily ava availa ilable ble between betw een fac faciliti ilities es to expe expedite dite tran transfer sfers. s. Car Careful eful cons co nsid ider erat atio ion n sho shoul uld d be gi give ven n to th the e mo mode de of transfe tra nsferr and com composi position tion of the tra transp nsport ort tea team. m. For many pediatric patients, this may mean awaiting the arrival of specialized transport teams from the rec receiv eiving ing inst institut itution ion.. In the these se situ situati ations ons,, per per-sonnel at the referring facility must be capable and remain rem ain comm committe itted d to car caring ing for the patient patient unt until il the team arrives. They must adopt a mentality of
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A limited body of literature about pediatric prehospital trauma care exists to date. Topics that have been studied include delaying transport to initiate treatment on-scene, the use of advanced life support or basic life support resources, identifying high-risk pediatric trauma patients, optimal airway management, obtaining intravenous or intraosseous access, immobilization of the cervical spine, optimal management of traumatic brain injury, and the assessment and management of pain. Translating the best available evidence into clinical practice is important to providing quality prehospital pediatric trauma care. This article will review the literature regarding the risks and benefits of various aspects of pediatric trauma care in the prehospital setting.
Keywords: pediatric trauma; intravenous
Prehospital Management of Pediatric Trauma Manish I. Shah, MD ecent estimates from the National Hospital Ambulatory Medical Care Survey database note that 27% of all emergency emerg ency department (ED) visits in the Unite United d State Statess are by children younger than 19 years, and 13% of all
patients transported via Emergency Medical Services (EMS) are children. Although the percentage of children who require EMS is small relative to adults, the acuity of pediatric EMS patients is often oft en hig higher her than tha thatt of adu adults lts.. Thi Thiss is esp especi eciall ally y tru true e wit with h trauma, in wh which ich 54 54% % of pe pedi diat atri ric c tr trau auma ma pa pati tien ents ts ar arri rive ve to th the e ED via EMS. 1 As the EMS system in the United States was originally
access; intraosseous access; cervical spine immobilization; traumatic brain injury; prehospital care; airway; emergency medical services
Depart Dep artmen mentt of Pedia Pediatri trics, cs, Sectio Section n of Emergency Medicine, Emergency Medicine, Baylor College College of Medicine, Houston, TX. Reprint requests and correspondence: Manish I. Shah, MD, Texas Children’s Hospital, 6621 Fannin Street, MC 1-1481, Houston, TX 77030. [email protected]
designed to meet the needs of adults, the integration of the unique needs of children into the existing EMS infrastructure has been one of the main goals of the federally funded Emerg ency Medical Services Servi ces for Child Children ren program for th for the e past 25 years.2 3 Twenty Twent y years ago, Ramen Ramenofsky ofsky descr described ibed esse essential ntial compo compo-nents of an integrated pediatric trauma system that addressed system design, prevention, education, standards of care, research and devel development opment,, quali quality ty assu assurance, rance, and fundi funding. ng. Succ Successfu essfully lly integrating the needs of children into the existing EMS infrastructure involves initiating high-quality high-quality preho prehospital spital care that uses preest pre establ ablish ished ed protocol protocols. s. Thes These e pro protoc tocols ols mus mustt the then n be app applie lied d by skilled skill ed emer emergency gency medical technicians (EMTs) with the assi assisstance of online medical control until ultimate transport to an appropriate facility capable of providing definitive care. Although much has been accomplished in each of these areas for pediatric trauma, there are still many areas that have not been adeq ad equat uatel ely y ad addr dres esse sed. d. On One e of the these se is th the e in inco corpo rporat ration ion of evi eviden ce-bas based ed in practi pra ctices ces into int o pre prehos hospita pital l car care. e. (IOM) Thiss con Thi concep cept t wasdencehighlighted the recent Institute of Medicine report, The Fu Futur ture e of Eme Emerge rgency ncy Car Care, e, whi which ch des descri cribes bes the imp importa ortance nce of ext extend ending ing evi eviden dencece-bas based ed pra practi ctices ces int into o pre prehos hospit pital al car care. e.4 Although the prehospital pediatric literature is limited to date, evalua eva luatin tingg the lit litera eratur ture e for ris risks ks and ben benefi efits ts of var variou iouss aspe aspects cts of pediatric trauma care in the prehospital setting is an important “
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VOL. 11, NO. 1 • PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH
PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH • VOL. 11, NO. 1 11
way to determine the value of certain decisions in the fie field. ld. The These se inc includ lude e del delayi aying ng tra transp nsport ort to ini initia tiate te treatm tre atment ent on-s on-scen cene, e, the use of adv advanc anced ed life sup suppor port t (ALS) or basic life support (BLS) resources, identifying high-risk pediatric trauma patients, optimally managing the airway, obtaining intravenous (IV) or intraos intr aosseo seous us (IO) acce access, ss, imm immobil obiliza ization tion of the cervical cervic al spine spine,, optim optimal al manag management ement of traum traumatic atic brain injury, and the assessment and management of pain. Each of these areas has been controversial in manage man agemen ment of ped pediat iatric ric tra traum a pat patien ients, ts, andthe examination oft the literature isuma important in determining local protocols.
PREHOSPITAL CARE TIME Some lit Some litera eratur ture e sug sugges gests ts tha thatt pre prehos hospit pital al car care e time has a significant impact on survival in severely injured patients and is a major majo r component of the golden hour of trauma care.5 Yet the impact of response respon se time interv intervals als on morb morbiidity and mortality of all trauma patients is unclear. 6 In a meta-analysis design des igned ed to des descri cribe be ave averag rage e tim time e int interv ervals als of prehospital care, 4 time intervals were defined and anal an alyz yzed ed:: (1 (1)) an ac acti tiva vatio tion n ti time me in inte terv rval al (A (ATI TI)) in th the e prealarm period defined as the time from receiving the call to the time of alarm, (2) a response time interval (RTI) defined as the time from alarm to arriv ar rival al onon-sc scene ene,, (3) an onon-sce scene ne tim time e int inter erva vall (OSTI) defined as the time from on-scene arrival to departure, and (4) a transport time interval (TTI) defined as the time from scene departure to arrival at a hospital. Average urban and suburban ground ambulance time intervals were similar to each other (ATI (A TI = 1 mi minu nute te;; RT RTII = 5 mi minu nute tes; s; OSTI OSTI = 14 “
PREHOSPITAL TRIAGE AND TRANSPORT Regionaliz Regiona lizing ing tra trauma uma care has dem demonst onstrat rated ed improved improv ed outcom outcomes es in pediat pediatric ric tra traum uma a an and d ha hass 4,9 been be en re reco comm mmen ende ded d by the IO IOM. M. Determining which patients are at high risk for mortality or need specialized treatment that can only be provided at a trauma center with pediatric capabilities is important. Using prehospital triage criteria that balances sensitivity and specificity to transport patients with the most severe injuries to trauma centers, to while transporting those with less severe injuries the closest hospital, is essential in regionalizing trauma care for children children.. Engum et al10 performed a retrospective analysis of the predictive value of certain physiologic and anatomical criteria in determining pediatric trauma patien pat ients ts who sub subseq sequen uently tly die died d in the ED, wer were e admitted admitt ed to the ped pediat iatric ric int intens ensive ive car care e uni unit, t, or required a major surgical procedure. Their findings showed sho wed tha thatt 5 cri criter teria ia had a pos positi itive ve pre predic dictive tive value val ue of 50% or hig higher her,, a sys systol tolic ic blo blood od pre pressu ssure re (SBP) of less than 90 mm Hg (86%), Glasgow Coma Score (GCS) of 12 or less (78%), respiratory rate (RR) (R R) of le less ss th than an 10 10/m /min in or mo more re th than an 29 29/m /min in (73%), (73 %), a sec second ond-- or thi thirdrd-deg degree ree bur burn n inv involv olving ing more than 15% total body surface area (79%), or paralysis (50%). Yet this analysis did not take into account varying normal vital sign values by age group, thus drawing some criticism on the utilization of SBP less than 90 mm Hg and RR of more than 29/min as predictors of predictors of poor outcomes in young children. Newgard et al 11 analyzed analyz ed a retro retrospecti spective ve cohort of injur injured ed childr children en in the Oregon state trauma registry over a 6-year
minutes; and TTI = 11 minutes) and significantly shorte sho rterr than tho those se for rur rural al gro ground und amb ambula ulance ncess (ATI = 3 minutes; RTI = 8 minutes; OSTI = 15 minu mi nute tes; s; an and d TT TTII = 17 mi minu nute tes) s).. Th The e av aver erag age e ov over eral alll prehospital prehos pital care time for urban/ urban/subur suburban ban setti settings ngs was 31 minutes compared to 43 minutes in the rural
period and inc period includ luded ed age age-ba -based sed phy physio siolog logic ic par paraameters to identify children at high risk for major nonorthoped nonort hopedic ic opera operative tive interv intervention ention,, intens intensive ive care unit stay of 2 days or longer, or in-hospital mortality. They found that the GCS was the most importa imp ortant nt pre prehosp hospital ital pred predict ictor or foll followed owed by (in
setting. Helicopter transport timesambula were significantly longer than those for ground ambul ances as a whole but were not compared by setting. 7 Using Usi ng the these se nat nation ional al ave averag rages es as a ben benchm chmark ark may be us usefu efull in ev evalu aluat ating ing the qu qual ality ity of pe pedia diatri tric c prehospital trauma care. Although standards exist for tim time e to def defini initiv tive e ca care re for ac acut ute e cor corona onary ry syndrome and stroke patients the impact of similar
ord order) er)and airway air way interv int erventi ention, on,mining RR,inghea heart rt fin rate rat e (HR (HR), ), SBP, shock shock index. inde x. Exa Examin the findin dings gs of 11 New gard gard et al in re refe fere renc nce e to th thos ose e of En Engu gum m et al,10 a RR of more than 29/min had no predictive valu va lue e in ch chil ildr dren en yo youn unge gerr th than an 5 ye year arss of ag age e an and d HR was significantly significantly more predi predictive ctive of poor outcomes in comparison to SBP or SBP or shock index. Yet, Ye t, Ne Newg wgar ard d et al12 perfor performed med a subs subsequent equent
prehospital care time standards for trauma patients is still unclear. The American College of Surgeons does strongly encourage rapid transport to a trauma center cen ter and min minimi imizat zation ion of onon-sce scene ne tim time e for tra trauma uma patients, and there is evidence to support support improved improved outcomes with shorter on-scene times. 5,8
analysis on pediatric patients using the American Colleg Col lege e of Su Surge rgeons ons Com Commit mittee tee on Tra Traum uma a fie field ld decisi dec ision on cri criter teria ia to dev develo elop p a cli clinic nical al dec decisi ision on rul rule e to identif ide ntify y hig high-ri h-risk sk inj injure ured d chi childr ldren. en. The dec decisi ision on rul rule e placed pla ced the these se cri criter teria ia in the fol follow lowing ing ord order er to ide identi ntify fy high-risk high-r isk injur injured ed child children: ren: need for assistance with
VOL. 11, NO. 1 • PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH
ventil ation on via end endotr otrach acheal eal int intuba ubatio tion n (ET (ETI) I) or bag bag-ventilati valve-mask ventilation (BVM), GCS of less than 11, pulse oximetry of less than 95%, and SBP of more
was still 5.2 minutes long long er er than that for patients 19 who were not intubated. Thus, intubation clearly increases on-scene time, which may result in poorer
tha than n 96 mm Hg Hg. . Of Of no note te,, HR H and an dmodel. RR di did d In notaddition, not prov pr ove e to be important predictors inR the the finding finding of a hi high gh SB SBP P as asso soci ciat ated ed wi with th po poor or outcom out comes es may be pla plausi usible ble wit with h tra traum umatic atic bra brain in injury but otherwise did not seem to be expected. Therefore, Theref ore, pedia pediatric tric patien patients ts with prehos prehospital pital findings of a low GCS, the need for airway interventions, hypox hyp oxia ia,, an and d hyp hyper erte tens nsion ion se seem em to be at hig high h ri risk sk fo forr
outcomes for patients. In a se sepa para rate te an anal alys ysis is of th the e sa same me co coho hort rt,, adju ad just stin ingg for the pr prop opens ensity ity to be in intu tuba bate ted, d, prehospital ETI was associated with an increased oddss of mor odd mortal tality ity (OR (OR,, 2.7 2.70; 0; 95% CI, 1.6 1.63-4 3-4.46 .46)) when ground transport distances were short ( b10 miles) mil es) com compar pared ed to non nonintu intubat bated ed pat patien ients. ts. Thi Thiss risk ris k gra gradua dually lly dec declin lined ed as gro ground und tra transp nsport ort dis dis--
poor outcomes. These predictors should potentially be incorporated into decision-making protocols f or or transport of pediatric patients to a trauma center. 12 The use of ALS vs BLS for the transport of trauma patien pat ients ts in the pre prehosp hospita itall set settin tingg has sti stirre rred d deb debate ate,, given giv en the res resour ource ce imp implic licati ations ons of usi using ng ALS for each patient, the lack of adequate ALS staffing in rural rur al are areas, as, and the ass assump umptio tion n tha that t pre prehospital hospital
tance increased, such that the 95% CI included an OR of 1 fo forr tr tran ansp spor ortt di dist stan ance cess gr grea eater ter th than an 20 miles.. Intub miles Intubated ated patie patients nts transp transported orted by helic helicopopter, however, had decreased mortality (OR, 0.36; 95% CI, 0.24-0.56). This finding may be due to the more mor e adv advanc anced ed air airway way man manage agemen mentt ski skills lls of air transport providers, but the evidence suggests that ETII in ad ET adul ults ts by gro groun und d cr crew ewss ne near ar a hos hospi pita tall
ALS decreases morbidity and mortality.13,14 Staffing an ALS unit compared to a BLS unit is esti ma mated ted to 15 cost co st an ex extr tra a $9 $94 4 92 928 8 pe perr ye year ar pe perr un unit it.. Also, procedures performed by ALS units take additional time, tim e, whi which ch ma may y de dela lay y ul ulti tima mate te tr trans anspo port rt to 16 definitive definit ive care. A meta-analysis evaluating 15 studie stu dies, s, inc includ luding ing pat patient ientss of all age ages, s, conc conclud luded ed that ALS ALS-tr -treate eated d tra trauma uma pat patien ients ts ove overal ralll had an increas incr eased ed odd oddss of mor mortal tality ity ove overr BLS BLS-tr -treat eated ed patients (odds ratio [OR], 2.92). Interpretation of the confid confidence ence interv intervals als (CIs), however, revealed only one study that favored ALS. The other studies had CIs that included 1, therefore did not show a significant signif icant diffe difference. rence.17 One stu study dy fro from m Fin Finlan land d reported slightly improved outcomes in ALS units staffed by a phys physician, ician, but this model is rare in the 18 United State States. s. Th Thus us,, it se seem emss tha thatt th ther ere e is no diffe di ffere renc nce e in mo mort rtal ality ity be betw twee een n AL ALS S an and d BL BLS S trauma tra uma care whe when n pro provid vided ed by EMT EMTs, s, but there
increases mortality.20 In a controlled trial of pediatric patients in the urban setting who either received BVM or ETI for prehospital prehos pital airwa airway y manag management, ement, intent intention-toion-to-treat treat analys ana lysis is rev reveal ealed ed tha thatt the there re was no dif differ ferenc ence e between the 2 interventions for both survival and neurol neu rologi ogic c out outcom come, e, eve even n in the sub subgro group up ana analys lysis is of various vario us categ categories ories of trau trauma ma pati patients ents inclu including ding submersion injury, head injury, and multiple trauma. The subgroup of child maltreatment patients demons dem onstra trated ted imp improv roved ed sur surviv vival al wit with h BVM com com-pare pa red d to ET ETII (O (OR, R, 0. 0.07 07;; 95 95% % CI CI,, 0. 0.01 01-0. -0.58 58), ), bu butt th ther ere e was no significant difference in neurologic outcome. Thiss stu Thi study, dy, how howeve ever, r, did not exa examin mine e pot potent ent ial ial effect eff ect mea measur sure e mod modifi ificat cation ion by tra transp nsport ort dis distanc tance. e.21 Maintenance of the rarely encountered task of prehosp pre hospita itall ped pediat iatric ric ETI ETI,, the ana anatom tomica icall dif differ fer-ences of the pediatric airway relative to an adult, and the limited pediatric continuing education for
are sig signifi nificant cant dif differe ferences nces in cos costt wit with h pos possib sible le benefi ben efitt onl only y in sit situat uation ionss of pro prolon longed ged tra transp nsport ort times or physician-staffed ALS units.
prehospita prehosp itall pro provid viders ers mak make e ped pediat iatric ric ETI a cha chall lenging task for the prehospital provider, especially in th the e ru rura rall se sett ttin ing. g. In ru rura rall pe pedi diat atri ric c tr trau auma ma patient pat ients, s, fiel field d int intuba ubation tion suc succes cesss rat rates es by bot both h
AIRWAY MANAGEMENT One of the most controversial topics in prehospital care is the method of airway management that reduces morbidity and mortality while optimizing safe sa fety. ty. Th This is is al also so an is issu sue e in ad adul ultt traum trauma a care, care, an and d a retrospective cohort analysis of trauma patients older than 14 years demonstrated that prehospital
EMT-p EMT-paramed aramedics ics and flightt regis fligh registered teredcompared nurses are significantly poorer (45%-70%) when to rates ra tes by ED ph physi ysici cian anss an and d anesthesiologi anesthesiologists sts at trauma centers (89%-100%).22 Theref The refore ore,, the ris risk k of inc increa reased sed onon-sce scene ne tim time e and pot potent ential ial com compli plicat cation ionss wit with h ETI mus mustt be weighed against the benefit of rapid transport to an appropriate trauma center when deciding whether
care time for patients undergoing rapid sequence intubation (RSI) was 10.7 minutes longer (95% CI, 7.7-13. 7.7 -13.8) 8) tha than n pat patient ientss who wer were e not int intuba ubated ted.. Also, prehospital care time for patients undergoing conventional convent ional ETI withou withoutt induc induction tion medic medications ations
to intubate or use less invasive means to manage the airway of a pediatric trauma patient. This may be especially true for ground transport distances less than 10 miles, in which higher mortality has been demonstrated in the adult population.
PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH • VOL. 11, NO. 1 13
Because many time intervals in prehospital care
patient outcomes. Computer modeling to evaluate the potent potential ial benef benefit it of admin administeri istering ng preho prehospital spital flui fl uids ds for ma major jor he hemor morrha rhage ge su sugg gges ests ts tha thatt onl only y trauma patients who had a bleeding rate of more
are sys system tem dep depend endent ent,, the mos mostt eff effect ective ive way to decrease prehospital times is to decrease the onscene sce ne dur duratio ation. n. Pro Proced cedure uress in the fie field ld may inc increa rease se
than 25 mL/min and prehospital time greater than 30 minutes would benefit. 26 Yet these findings have not been validated in children in the prehospital
INTRAVENOUS AND IO ACCESS AND INFUSIONS
the likelihood of survi survival val or may increase mortality mortality by delaying delaying definitive definitive care. In a retros retrospecti pective ve review of IV placement in trauma patients of all ages, this procedure ad adde ded d an ad addi diti tion onal al 5 mi minu nute tess of on on-16 scene time.
setting.. The onl setting only y stu study dy eva evalu luati ating ng the eff effica icacy cy of prehos pre hospit pital al IV flu fluid id adm admini inist strat ration ion to ped pediat iatric ric trauma tra uma pat patien ients ts was a ret retros rospec pectiv tive e rev review iew in which whi ch it was inconsequ inconsequent ential ial in 94% of pat patient ients, s, potentially beneficial in 4 in 4% % of cases, and potentially
Becaus Bec ause e thi thiss stu study dy did not inc inclu lude de a sub subgro group up analysis of pediatric patients, however, the time to place an IV in a child may actually be longer. A retrospective chart review of prehospital IV placement in pediatric patients, with subgroup analysis for trauma patients, showed a 57% success rate for IV placement in patients less than 6 years of age and 74% success rate in age 6 years or higher. Average time tim e to IV pla placem cement ent in tra trauma uma patients patients was 14 minutes (range, 7-24 minutes) in age less than 6 years and 12 minute minutess (range, 1-43 minutes) in age more than 6 years. 23 For some patients, decreasing on-scene time may be essential to survival, but for other oth ers, s, the ben benef efit it of ini initia tiatin tingg IV ac acces cesss ma may y outweigh outwe igh the risks risks.. Theref Therefore, ore, the deter determinati mination on of whether to place an IV needs to be based on the individual patient with respect to expected transport po rt ti time me an and d an antic ticip ipat ated ed ti time me to co comp mple lete te th the e procedure. Alt ho hough ugh ob obta tain inin ingg IV ac acce cess ss in pe pedi diat atri ric c patients may prolong on-scene time by up to 14 minutes, placement of an IO needle may provide more mo re ti time mely ly ac acce cess ss fo forr tr trau auma ma pa pati tien ents ts wi with th
harmful in 2% of cases. 27 It seems evident that adult trauma protocols may not be ap appl plic icab able le to ch chil ildr dren en,, pr preho ehosp spita itall IV placement prolongs on-scene time, and the benefit of pre prehos hospit pital al flu fluid id th ther erapy apy in ped pediat iatric ric tra traum uma a 28 patients patien ts is still unclear. unclear. Yet given the physiologic differences between children and adults, IV/IO fluid administration for hemorrhage secondary to trauma may be warranted. For some patients, decreasing on-scene time may be essential to survival, but for other oth ers, s, the ben benefi efitt of ini initia tiati ting ng IV acc access ess ma may y outweigh the risks. Therefore, the determination of whether to place an IV or IO needs to be based on the ind indivi ividua duall pat patien ientt wit with h res respec pectt to exp expect ected ed transp tra nsport ort tim time e and ant antici icipat pated ed tim time e to com comple plete te the procedure.
hemorrhagic shock. after In a prospective observational study of paramedics a brief training session on the placement of IO needles, 28 (84%) of 33 of the attempted IO infusions were successfully started in less than 1 minute in a simulated ambulance ambulanc e setting s etting 24 at a sp spee eed d of 25 to 35 mi milles per ho hour ur.. In a retrospective cohort of pediatric trauma patients in
bi bili liza zati tion oncr devi de vice ce or migh mi ght t be remo re move ved d tba base sed d rgo on clini cl inical cal crit iter eria, ia, the patie pa tient nt migh mi ght unde un derg o further imaging. The National Emergency X-Radiograph ogr aphy y Uti Utiliz lizatio ation n Stu Study dy (NE (NEXUS XUS)) der derive ived d and vali va lida date ted d a de deci cisi sion on ru rule le to de dete term rmin ine e wh who o ca can n safely have a cervical spine immobilization device remov rem oved ed in the ED wit withou houtt rad radiog iograp raphic hic eva evalua lua--
CERVICAL SPINE IMMOBILIZATION Common pra Common practi ctice ce amo among ng pre prehos hospit pital al pro profes fes-siona si onals ls is to im immo mobi bili lize ze th the e ce cerv rvic ical al sp spin ine e of a patientt who has had a traum patien traumatic atic injury. Once these patients arrive at the hospital, the cervical immo-
whom who m an IO was att attemp empted ted for car cardio diopul pulmon monary ary
arrest,, hypo arrest hypovol volemi emic c sho shock, ck, or neu neurol rologi ogic c ins insult ult,, successful succe ssful place placement ment by prehos prehospital pital profes professional sionalss was noted in 13 (93%) of 14 cases. These IO needles were used both in the prehospital and emergency department settings to successfully administer both colloi col loid d and cry cryst stall alloid oid inf infus usion ionss and mu multi ltipl ple e pharm pha rmaco acolo logic gic ag agent entss in pa patie tients nts 3 mon months ths to 10 ye year arss of ag age, e, wi with th on onlly one rep reporte orted d cas case e of
have already been immobilized, it is plausible that some som e EMS agencies agencies may attempt attempt to app apply ly the these se findings to the prehospital setting. To date, there are no publi published shed studies that provide evidence that prehospital professionals can forego cervical spine immobilization using the NEXUS criteria. Because only 10% of the patients in NEXUS were children, applying these findings to the prehospital care of children would be even more difficult.29,30 Analysis of the NEXUS pediatric patient data demonstrates thatt no ce tha cerv rvic ical al sp spin ine e in inju jury ry wo woul uld d ha have ve be been en missed if the NEXUS criteria had been applied to
minor tissue extravasation.25 Rega Re gard rdle less ss of wh whet ethe herr an IV or IO is pl plac aced ed,, controversy exists about whether administration of fluids in the prehospital setting actually improves
Although these data apply to patients who
VOL. 11, NO. 1 • PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH
this population. 30 Yet due to the low cervical spine injury rate of 0.98% in pediatric trauma patients in this study, it would be difficult to safely apply this rule rul e to chi childr ldren en in t he h e ED se sett tting ing,, le lett al alon one e th the e 30 prehospital prehos pital settin setting. g. Unti Un till th this is is issu sue e is st stud udie ied d
collision collis ion wit with h pat patien ientt eje ejecti ction, on, dea death th of anot another her pass pa sseng enger er or ro roll llove over, r, ped pedes estri trian an or bi bicyc cycli list st witho wi thout ut he helm lmet et st stru ruck ck by a mo moto tori rize zed d ve vehi hicl cle, e, fall fa llss of N5 fe feet et,, he head ad st stru ruck ck by a hi high gh-i -imp mpac act t object obj ect), ), cl clini inical cal si sign gnss of ba basi sila larr sk skul ulll fr fract actur ure e
further, children with a significant mechanism of injury should have their cervical spine immobilized using age-ap age-appropr propriate iate equip equipment ment before trans transport port to the hospital.
(posterior (poster ior aur auricul icular ar or per periorb iorbital ital ecch ecchymos ymoses, es, hemotympanu hemoty mpanum, m, or cerebr cerebrospinal ospinal fluid otorrhe otorrhea/ a/ rhinorrhea), or a severe headache were at risk for a cl clin inic ical ally ly si sign gnif ific icant ant TB TBI, I, wh whic ich h ma may y re requ quir ire e neurosurgic neuros urgical al interv intervention ention or hospit hospital al admis admission. sion. Patients younger than 2 years with altered mental
TRAUMATIC BRAIN INJURY Traumatic brain injury (TBI) in children results from a variety of causes, including nonacc nonaccidental idental injury, falls, and motor vehicle collisions. 31 In the young you ng ath athlet lete, e, TBI occ occurs urs wit with h act activi ivities ties such as football, soccer, cheerleading, basketball, and field football, hockey. 32 Bec Becaus ause e athl athleti etic c inju injuries ries and mot motor or vehicle collisions are common causes of pediatric TBI, the prehos prehospital pital professional professional must be equipped equipped to manage these common mechanisms of injury. 33 In addition, because 50% of the mortality due to TBI occurs in the first 2 hours after injury, prehosp prehospital ital 34 assessment and management of TBI is crucial. Yet variation varia tion exists in asses assessing sing and managi managing ng child children ren with TBI in the prehospital environme environment, and an evidence-based approach is necessary.31 Early correction of hypoxemia and hypotension,
status, occipital/parietal/temporal scalp hematoma, loss lo ss of co cons nsci ciou ousn snes esss fo forr 5 se seco cond ndss or mo more re,, severe mechanism of injury, palpable or equivocal skull fracture, or abnormal behavior according to the car caregi egiver ver w ere e re al also so at ri risk sk fo forr cl clin inic ical ally ly 36 important TBI. Being aware of what makes a pediatric patient high risk for complications from TBI is especially esse es senti ntial al for EM EMS S sys system temss in wh whic ich h EM EMTs Ts ca can n determ det ermine ine pat patien ientt dis dispos positi ition on in the pre prehos hospit pital al setting set ting.. Thi Thiss is als also o tru true e in the case of pot potent ential ial nontran nont ranspo sport rt of pat patien ients ts aft after er spo sports rts inj injuri uries es because providers must be aware of the sequelae of TBI and recommendatio recommendations ns to return to play after 31 sports-related injuries. For example, sports-related TBI can result in a clinic cli nical al ent entity ity cal called led second impact syndrome, in wh whic ich h
accur accurate ate assessme assessment of the GCS transport and pupils,decis airway management, manag ement, andntappro appropriate priate decision ion maki ma king ng is vi vita tal, l, ac accor cordi ding ng to the Br Brai ain n Tr Trau auma ma Foundation's evidence-based guidelines on prehospital management of TBI. Most of these guidelines are ar e ba base sed d on ad adul ultt st stud udies ies,, how howev ever er,, du due e to relati rel ativel vely y lim limite ited d stu studie diess on ped pediat iatric ric TBI in the prehospital setting. Regardless, modifying the GCS
a seco se cond nd co conc ncus ussi sion inconcussion a pa pati tien entt can who wh oresult is st stil illl symptomatic from aon first in cerebra cereb rall ed edem ema, a, br brain ain he herni rniati ation, on, co coma ma,, an and d 37 death. To prevent second impact syndrome, the Concussion in Sport Group has published recommendations on short-term management and when to return to play. These recommendations state that any pla player yer tha thatt sho shows ws sy symp mptom tomss of hea headac dache, he,
for a pediatric patient is essential essenti al due due to differences in preverbal children (Table (Table 1). 1).35 In add additi ition, on, the ass assess essmen mentt of pot potent ential ial TBI shou sh ould ld in incl clud ude e as aski king ng th the e ve verb rbal al ch chil ild d ab abou outt a rece re cent nt pr prior ior he head ad in inju jury ry an and d sy symp mpto toms ms of a concussion, concus sion, such as headac headache, he, dizzine dizziness, ss, naus nausea, ea, and blurred vision. In addition, it is also important to ask bystanders about loss of consciousness and
dizziness, nausea, or double vision should refrain from fro m the cur current rent spo sports rts act activi ivity, ty, und under er med medica icall evalua eva luation tion,, and should should onl only y ret return urn to pla play y whe when n asymptomatic w it it h a normal neurologic and cognitive evalu evaluation. ation.38 Also, patients who experience a loss of consci consciousnes ousnesss shoul should d be transpo transporte rted d to a 39 hospital for further evaluation. The prehospital management of TBI focuses on
the mec mechani hanism sm of inju injury. ry. Phy Physic sical al ass assess essmen ment t should include evaluation of the face and scalp for
minimizing secondary injury, essentially through handling the compromised airway and intervening
hematomas, ecchymoses, or palpable skull fracture; drai dr aina nage ge of bl blood ood from th the e ea ears rs or no nose se;; an and d a thorough neurologic examination, examination, including including an age31 adjusted assessment of the GCS. In a recent analysis of a prospective cohort of childr chi ldren en wit with h hea head d inj injuri uries, es, patients patients 2 yea years rs or older with altered mental status, any suspected or confirmed loss of consciousness, history of vomiting,, sev ing severe ere mec mechan hanism ism of inj injury ury (mo (motor tor veh vehicl icle e
to prevent hypotension. Hypoxemia (oxygen saturation, b90%) should be avoided by managing the airway by the most appropriate means, which may be supplem supplemental oxyge oxygen, n, BVM, ETI, or other airw airway ay 35 adjuncts. There is no evidence to support ETI over BVM in pediatric patients with TBI, however, and pediatric trauma patients as a whole may have fewer co comp mplic licati ations ons fro from m BV BVM M whe when n com compar pared ed 21 to ETI.
PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH • VOL. 11, NO. 1 15
blood bloo d pr pres essu sure re sh shou ould ld be mo moni nito tore red d wi with th an approp app ropria riatel tely y siz sized ed ped pediat iatric ric cuf cufff and pre preven vented ted by gi givi ving ng bo bolu luse sess of 20 mL mL// kg kg of is isot oton onic ic crystalloid crysta lloid (Table 2). 2).31,35 Prehospital providers should determine the GCS and pupil size after airway, breathing, and circula-
TABLE 1. Comparison of pediatric GCS with standard GCS GCS Eye opening Spontaneous Speech Pain None Verbal response Oriented Confused Inappropriate
4 3 2 1 5 4 3
Pediat Pediatric ric GCS Eye opening Spontaneous Speech Pain None Verbal response Coos, babbles Irritable cries Cries to pain
4 3 2 1 5 4 3
tion have been assessed and stabilized. The most appropriate airway should be established in patients patien ts with severe TBI, defined as a GCS less than 9. 35 Also, because hypoglycemia can result after TBI, blood glucose should be checked and t reated reated when 31 serum glucose is less than 80 mg/dL. Prehospita Preho spitall provid providers ers shoul should d direc directly tly trans transport port chil ch ildr dren en wi with th se seve vere re TB TBII to a pe pedi diat atri ric c tr trau auma ma cente ce nterr or an ad adul ultt tr trau auma ma ce cente nterr wi with th ad adde ded d
Incomprehensible None Motor response Obeys command Localizes pain Flexor withdrawal Flexor posturing
6 5 4 3
Moans to pain None Motor response Normal, spontaneous Withdraws to touch Withdraws to pain Abnormal flexion
6 5 4 3
qualifications to treat children. 35 Because nonaccidental head injury is also a common cause of death in infants, prehospital providers should thoroughly document findings at the scene and report unclear or imp implau lausib sible le mec mechan hanism ismss to law enf enforc orceme ement, nt, child protective services, and ED personn personnel, el, while
Extensor posturing None
Abnormal extension None
being cautious cautious to mainta maintain in scene safety.
PAIN ASSESSMENT AND MANAGEMENT
Data from Badjatia.
Children Child ren with susp suspected ected TBI shoul should d have their cervical spine (C-spine) immobili cervical immobilize zed d in th the e fi fiel eld d 31
Pain assessment and management in trauma is important importa nt for pat patien ientt com comfor fortt and pot potent ential ially ly for patient healing. In a retrospective chart review of 696 pediatric trauma patients, prehospital person-
due to risk for concurrent injury. If ETI is going to be att attemp empted ted,, ma manua nuall C-s C-spin pine e sta stabil biliza izatio tion n is necess nec essary ary to pre preven ventt sec second ondary ary inj injury ury.. For EMS agencies that use RSI medications for intubation, premedicat preme dication ion with 1.5 mg/kg of lidoca lidocaine ine follo followed wed by 0.3 mg/kg of etomidate for sedation and either 1.5 mg/kg of succinylcholine or 1 mg/kg of vecuronium are preferred to protect against increases in
nel documented a pain assessment in 81% of cases, but only 0.1% actually used a pain assessment tool. Of the 64% of patients with documented pain, only 15% received some sort of intervention to address their pain. For all patients, both pharmacologic and nonpharmacologic nonpharmacologi c interv nterventions entions were used equally in 13.4% of cases. 40 Because Beca use pain does not neces necessaril sarily y correl correlate ate with
intracraniall press intracrania pressure. ure. Otherwise, Otherwise, the decis decision ion to intubate should be made in consultation with online medica med icall con contro troll if the these se RSI med medica icatio tions ns are not available for use in the prehospital setting. Signs of increased intracranial pressure are represented by Cushing's Cushi ng's triad of hypert hypertensio ension, n, brady bradycardi cardia, a, and 31 irregular breathing. The EMS systems that use RSI protocols should monitor blood pressure, oxygenation, and end-tidal CO2 (ETCO2). Patients should be maintained with normal breathing rates (ETCO2 = 35-40 mm Hg), and hyperventilation (ETCO2 b 35 mm Hg) should be av avoid oided ed un unle less ss the there re are si sign gnss of ce cere rebr bral al
injury severity, pain assessment should occur in all children childr en in the prehos prehospital pital setting setting with a traum traumatic atic injury. In addition, parental report of pain is often
TABLE 2. Definition of pediatric hypotension by age Age 0-28 days
SBP 60 mm Hg
herniation. The evidence for the latter, however, is lacking in pediatrics, and this recom recommendation has been extrapolated from adult data.35 Beca Be caus use e hy hypo pote tens nsio ion n wi with th TB TBII in pe pedi diat atri ric c patients has been associated with poor outcomes,
1-12 months 1-10 years N10 years
70 mm Hg 70 + (2 × age in years) b90 mm Hg b b
Data from Badjatia.35
VOL. 11, NO. 1 • PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH
compar able e to a chi child ld's 's rep report ort and shou hould ld be comparabl 41 incorp inc orpora orated ted int into o a pai pain n ass assess essmen ment. t. Although pediatric pain scales that have been validated in the hospi hos pital tal se sett tting ing hav have e not be been en va vali lidat dated ed in th the e prehos pre hospit pital al set settin ting, g, the use of sta standa ndardi rdized zed and age-appropriate pain assessment tools by prehospital professional professionalss is more likely to lead to management of pain. 42
SUMMARY Prehospit Prehos pital al pro provid viders ers pla play y an ess essenti ential al rol role e in the th e ini initi tial al ma mana nage geme ment nt of pe pedi diat atri ric c tr trau auma ma patien pat ients ts by mi minim nimizi izing ng se secon condar dary y inj injur ury y and transporting injured children to definitive care in a ti time mell y ma mann nner er.. As th the e IO IOM M ha hass re rece cent ntlly recommended, it is essential for the United States to ha have ve an EM EMS S sy syst stem em th that at is re regi giona onali lized zed an and d
SA, Mitchell MK, Scherer LR, et al. Prehospital triage in the inj injure ured d pedi pediatr atric ic pati patient ent.. J Ped Pediat iatrr Sur Surgg 2000 2000;35: ;35: 82-7. 11. Newgard CD, Cudnik M, Warden CR, et al. The predictive value and appropr appropriate iate ranges of prehosp prehospital ital physiological physiological parameters paramet ers for high-r high-risk isk injur injured ed childr children. en. Pediat Pediatrr Emerg Care 2007;23:450-6. Newgard d CD, Rudser K, Atkins DL, et al. The availab availability ility and 12. Newgar use of out-of out-of-hospi -hospital tal physiol physiologic ogic information information to identi identify fy high-risk highrisk injured childr children en in a multis multisite, ite, population-based population-based cohort. Prehosp Emerg Care 2009;13:420-31. 13. Trunkey DD. Is ALS necessar necessary y for pre-ho pre-hospita spitall traum trauma a care. J Trauma 1984;24:86-7. 14. Lewis FR. Ineffective therapy and delayed transport. Prehosp Disaster Med 1989;4:129-30. 15. Or Orna natoJP, toJP, Ra Rach chtt EM EM,, Fi Fitc tch h JJ JJ,, et al al.. Th The e ne need ed fo forr AL ALS S inurb inurban an and subu suburbanEMS rbanEMS syst systems. ems. Ann Emer Emergg Med 1990 1990;19: ;19:1469 1469-70. -70. 16. Carr BG, Bra Brachet chet T, Guy D,
et al. et al. The tim time e cost cost of preh prehospi ospital tal intubations intubat ions and intr intraveno avenous us acce access ss in trau trauma ma pati patients ents.. Prehosp Emerg Care 2008;12:327-32. 17. Liberman M, Mulder D, Sampalis J. Advanced or basic life support for trauma: meta-analysis and critical review of the
coordinated to provide optimal care in a seamless fashion along the continuum from the prehospital to ED set setting tings. s.4 Although the evidence base for pediat ped iatric ric pre prehosp hospita itall tra trauma uma car care e is lim limite ited, d, transl tra nslati ating ng the bes bestt ava availa ilable ble inf inform ormati ation on int into o clinical practice is important to providing quality care. car e. In add additi ition, on, con conduc ducting ting fur furthe therr res resear earch ch in prehos pre hospit pital al ped pediat iatric ric tra trauma uma car care e wil willl be vit vital al to providing the best care possible in the future.
literature. J Trauma 2000;49:584-99. P, Baillie C, Kivioja A, et al. Prehospital care and survival of pediatric patients with blunt trauma. J Pediatr Surg 1998;33:1388-92.
intubation Cudni Cud nik k MT MT, , New Newga gard rd CD,, Wa CD Wang ng time H, etinal. Endot En dotra rach cheal eal increases out-of-hospital trauma patients.
MN, Cushman JT, Davis CO, et al. The epidemiology epidemiology of emergency medical services use by children: an analysis of the Nat Nation ional al Hos Hospit pital al Ambu Ambulat latory ory Med Medica icall Car Care e Sur Survey vey.. Prehosp Prehos p Emerg Care 2008;12: 2008;12:269-76. 269-76. 2. Krug S, Kupper Kuppermann mann N. Twent Twenty y years of emergen emergency cy medical services for children: a cause for celebration and a call for action. Pediatrics 2005;115:1089-91. 3. Ramenofsky ML. Emergency medical services for children
Prehosp Emerg Care 2007;11:224-9. MT, Newgard CD, Wang H, et al. Distance impacts mortality mortal ity in traum trauma a patien patients ts with an intuba intubation tion attempt. Prehosp Emerg Care 2008;12:459-66. 21. Gausche Gausche M, Lew Lewis is RJ, Stratton Stratton SJ, et al. Eff Effect ect of out out-of -of-hospital pediatric endotracheal intubation on survival and neurologic outcome. JAMA 2000;283:783-90. 22. Ehr Ehrlic lich h PF, Seidman Seidman PS, Atallah Atallah O, et al. Endo Endotra trache cheal al intuba int ubatio tions ns in rur rural al pedi pediatr atriactraumapatien iactraumapatients. ts. J Ped Pediat iatrr Sur Surg g 2004;39:1376-80. 23. Li Lilli lliss KA, Jaf Jaffe fe DM. Pre Prehos hospit pital al int intrav raveno enous us acc access ess in children. childr en. Ann Emerg Med 1992;21:1430-4. 24. Fu Fuchs chs S, La LaCov Covey ey D, Pa Pari riss P. A pr preho ehospi spital tal mod model el of intraosseous infusion. Ann Emerg Med 1991;20:371-4. 25. Gu Guy y J, Ha HaleyK, leyK, Zu Zusp span an SJ SJ.. Useof in intr trao aosse sseou ouss in infu fusi sion on in th the e pediatric trauma patient. J Pediatr Surg 1993;28:158-61. 26. Wears RL, Winton CN. Load and go versus stay and play:
and pediatric trauma system components. J Pediat Pediatrr Surg 1989;24:153-5. Medicine ne of the National Academies. Emergency Emergency 4. Institute of Medici medical medi cal ser service vices: s: at the cro crossr ssroads oads.. Was Washing hington ton,, DC: Nat Nation ional al Academies Press; 2006. 5. Sampalis JS, Lavoie A, Williams JI, et al. Impact of on-site care, car e, pre prehosp hospita itall tim time, e, and leve levell of inin-hos hospit pital al car care e on sur surviv vival al in severely injured patients. J Trauma 1993;34:252-61. 6. Lerner EB, Moscati RM. The golden hour: scientific fact or
analysis analys is of pre prehos hospit pital al IV flu fluid id the thera rapy py by com comput puter er simulation. Ann Emerg Med 1990;19:163-8. 27. Teac Teach h SJ, Antosia Antosia RE, Lund DP, et al. Pre Prehosp hospita itall flu fluid id therapy in pediatric trauma patients. Pediatr Emerg Care 1995;11:5-8. Prehospital spital intra intravenous venous fluid therapy in 28. Sadow KB, Teach SJ. Preho the pedi pediatr atric ic tra trauma uma pat patien ient. t. Cli Clin n Pedi Pediatr atr Eme Emerg rg Med 2001 2001;2: ;2: 23-7. 29. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of
medical legend . AcadJP, Emerg MedA 2001;8:758 2001;8:758-60. -60. BG,urban Caplan Capl an JM, Pryor et al. meta-a met a-analy nalysis sis of prehospi preh ospital tal car care e tim times es for trauma. trauma. Pre Prehosp hosp Emer Emergg Car Care e 2006 2006;; 10:198-206. 8. American College of Surgeons. Advanced trauma life support forr doc fo docto tors rs.. 8t 8th h ed. Chi Chicag cago o (I (Ill) ll):: Ame Ameri rican can Co Colle llege ge of Surgeons; 2008. Haller er JA JA,, Sho Short rter er N, Mil Miller ler D, et al. Or Organ ganiz izati ation on and 9. Hall functi fun ction on of a reg region ional al ped pedia iatri tric c tra trauma uma cen center ter:: doe doess a system management improve outcome. J Trauma 1983;23: 7. Carr Carr
clinical to trauma. rule out Ninjury the2000;343:94-9. cervical spine patientss criteria patient with blunt Engl JtoMed 2000;343:949. in 30. Vicc Viccelli ellio o P, Sim Simon on H, Pre Pressma ssman n BD, et al. A pros prospect pective ive multicen mult icenter ter stu study dy of cerv cervical ical spine inju injury ry in chi children ldren.. Pediatrics 2001;180:e20. 31. Atab Atabaki aki SM. Pre Prehos hospit pital al eva evaluat luation ion and mana manageme gement nt of traumatic brain injury in children. Clin Pediatr Emerg Med 2006;7:94-104. Covassin in T, Swa Swanik nik CB, Sac Sachs hs ML. Epi Epidemi demiolog ologica icall con32. Covass siderations sidera tions of concuss concussions ions among interc intercollegi ollegiate ate athlet athletes. es.
Appl Neuropsychol 2003;10:12-22.
PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH • VOL. 11, NO. 1 17
Eighteenth Annual Report, Fall 1982-S 1982-Spring pring 2000. Chapel Hill (NC): Univer University sity of North Caroli Carolina; na; 2000. 34. Baxt WB, Moody P. The impact of advanced prehospital care on the mortality of severely brain-injured patients. J Trauma 1987;27:365-9. Badjat atia ia N, Car Carney ney N, Cr Croc occo co TJ TJ,, et al. Gu Guid idel elin ines es fo forr 35. Badj prehospital management of traumatic brain injury, 2nd ed. Prehosp Emer Care 2007;12:S1-S52. 36. Kuppe Kupperma rmann nn N, Hol Holmes mes JF, Dayan PS, for the Ped Pediat iatric ric Emergenc Emer gency y Care Appl Applied ied Rese Research arch Netw Network ork (PEC (PECARN) ARN).. Identif Iden tifica icatio tion n of chi childr ldren en at ver very y low ris risk k of clin clinica icallyllyimportant import ant brain injur injuries ies after head trauma: a prospec prospective tive cohort study. Lancet 2009;374:1160-70. 37. Cant Cantu u R, VoyR. Se Secon cond d im impac pactt sy syndr ndrom ome: e: a ri risk sk in an any y spo sport rt.. Phys Sport Med 1995;23:27 1995;23:27-36. -36.
M, Cantu R, Dvorak J, et al. Summary and agreement statement of the First Intern statement International ational Symposium Symposium on Concussion in Sport Sport.. Vienna 2001. Phys Sport Med 2002;30:57 2002;30:57-63. -63. 39. Collins M, Stump J, Lovell MR. New developments in the management managem ent of sports concussion. concussion. Curr Opin Orthop 2004; 15:100-7. 40. Izs Izsak ak E, Moo Moore re JL, Str String ingfel fellow low K, et al. Pre Prehos hospit pital al pai pain n assessment in pediatric trauma. Prehosp Emerg Care 2008;12: 182-6. 41. Baxt C, Kassam-Adams N, Nance M, et al. Assessment of pain after aft er inj injur ury y in the ped pediat iatri ric c pat patien ient: t: chi child ld and par parent ent perceptions. J Pediatr Surg 2004;39:979-83. 42. Zemp Zempsky sky WT, Cra Craver vero o JP. Relief of pai pain n and anx anxiet iety y in pediatric patients in emergency medical systems. Pediatrics 2004;114:1348-56.
Abstract: Laboratory studies are often routiLaboratory nely obtained in the injured child. How broad a range of studies are needed and do they impact on the child's management? This article reviews the literature and makes recommendations for a simplified, cost-effective laboratory testing strategy.
Do Routine Laboratory Tests Add to the Care
pediatric trauma; laboratory studies; intraabdominal injury
of the Pediatric Trauma Patient? Jeffrey F. Linzer Sr, MD
aboratory tests are often obtained on children who have aboratory had ha d tr trau auma mati tic c in inju juri ries es.. Th Thes ese e te test stss ra rang nge e fr from om a compl com plet ete e bl blood ood co coun untt (C (CBC BC)) to ser serum um che chemi mist stri ries es,, liver and pancreatic enzymes, coagulation studies, and urinalysis urinal ysis (UA). The prima primary ry purpose for obtain obtaining ing these tests in the emergency department is either to (1) manage and monitor the unstable patient patient or (2) screen the stabl stable e patient to determ determine ine the need for imaging studies. In som some e cir circu cums mstan tances ces,, the ind indica icatio tion n for sp speci ecific fic te testi sting ng is straig str aightf htforw orward ard.. Fo Forr exa examp mple le,, a typ type e and cro cross ss ma match tch for bl blood ood would be indicated for the hemodynamically unstable patient. The decisi dec ision on to pro provid vide e ad addit dition ional al tre treatm atment ent or to obt obtain ain a com compu puter terize ized d tomographic (CT) study is often based on clinical evaluatio evalua tion n and is made before these laboratory results are made available.1,2 It is the patient who has had blunt trauma without obvious injury inj ury,, how howeve ever, r, whe where re the use of rou routin tine e lab labora orator tory y tes testing ting comes into question. Screening laboratory tests are most often
L Reprint requests and correspondence: Jeffrey F. Linzer Sr MD, Departments of Pediatrics and Emergency Medicine, Emory University University Schoo Schooll of Medici Medicine, ne, Children’s Child ren’s Healthcare Healthcare of Atlant Atlanta, a, GA 30322.
1522-8401/$ - see front matter © 2010 Elsevier Elsevier Inc. All rights reserved.
used determine theth need for CT As ther th ere einisthese now no w patients grea gr eate terr to reco re cogn gnit ition ion of the e po pote tenti ntial alimaging. risk ri skss fr from om ionizing radiation, especially in younger children, the question of the use of laboratory testing to determine who needs imaging has become a larger issue. A review of the literature shows that there is no simple answer as to what test(s) may be of benefit. The routine use of trauma panels in pediatric trauma vic v ictims tims does 1-5 not appea appearr to provid provide e any significant clinical clinical benefi benefit. t. “
VOL. 11, 11, NO. NO. 1 • LABORATORY TESTS IN PEDIATRIC TRAUMA CARE / LINZER
LABORATORY TESTS IN PEDIATRIC TRAUMA CARE / LINZER • VOL. 11, NO. 1
seen in the UA. In that same study, children with
Although no test has been shown to be 100% sensitive and specific, the UA appears to have some use in determining the presence of intraabdominal injury (IAI) in blunt trauma. There is controversy, however, as to the quantity of blood that needs to be present to determine the need for a CT scan. In adults who are not hypotensive and who have not
blunt abdominal trauma who were not be in nefi shock and had ha d le less ss th than an 50 RBC/ RB C/hp hpff di did d not bene fitt fr from om radiographic imaging.
had a decel deceleratio eration n entry, entry, imaging imaging is only indicat indicated ed if there is frank hematuria. In a ret retros rospec pectiv tive e stu study dy by Qu Quinla inlan n and Gearhart,6 frank hematuria along with a low hematocrit correlated correl ated w ith severe renal injury. In a review by Stei St ein n et al al,,7 an any y de degr gree ee of he hema matu turi ria a wa wass an indication f or or radiographic imaging. Isaacman and 8 colleagues found that there was a low prevalence of
blood cell elevation is often 3encountered, usually due to the stress of the injury. However, there is no correl cor relati ation on bet betwee ween n ele elevat vation ion and the deg degree ree of injury. inju ry. In one study, study, 1% of pat patient ientss had platelet platelet counts cou nts less tha than n 10 100 0 000 000/hp /hpf, f, but non none e req requir uired ed 1 platelet transfusions. Monitoring platelet counts in hemodynamic hemod ynamically ally unsta unstable ble patie patients, nts, espec especially ially those who are receiving massive transfusions, may
laboratory abnormalities laboratory abnormalities in child children ren with mild to moderate trauma. Using a cutoff of greater than 5 red blood cells per high-power field (RBC/hpf), they found the physical examination, in a patient with a Glasgow Coma Score (GCS) of 12 or higher, along with the UA, had a sensitivity of 100%, specificity of 64%,, and a negative predictive value of 100% for 64% IAI.8 In a prospective prospective study of children with blunt trauma, Holmes et al9 also found an association of IAI with a UA with more than 5 RBC/hpf (odds ratio, 4.8; 95% confidence interval [CI], 2.7-8.4). Tayl Ta ylor or et al10 fou found nd an ass associ ociati ation on bet betwe ween en abdominal symptoms and a UA with greater than
be of value. A low initial hematocrit may warn of ongoin ongoing g hemorr hem orrhag hage e fro from m an occ occult ult bleed. bleed. Hol Holmes mes et al9 foun fo und d an ini initi tial al va valu lue e of le less ss th than an 30% to be a predictor of IAI, whereas Cotton et al5 found each unit decrease resulted in an 11% increase risk for IAI. Although a low hematocrit may imply the need for transfusion, patients will usually have signs of hemodynamic hemodynam ic instabi instabilit lity y suc such h as tac tachyc hycard ardia ia or hypotension.1 One must however keep in mind that hypote hyp otensi nsion on is a lat late e sign sign of sho shock ck in chi childr ldren. en. Ser Serial ial hematoc hem atocrit ritss may hel help p in the mon monito itorin ringg of sol solid id organ injuries.
HEMATOLOGY A CBC, on the whole, provides little predictive information informa tion reg regard arding ing the tra traum uma a pat patient ient.. Whi White te
10 RBC/hpf, but noted that asymptomatic hematuria would have a low yield as an indicator f or CT or CT of the abdomen. Whereas Lieu and colleagues11 found that more than 20 RBC RBC/hp /hpff was associate associated d wit with h higher high er yield yield intravenous pyelography, Abou-Jaoude 12 et al found that using that same value missed 28% of genit genitourina ourinary ry tract injuries or anomal anomalies. ies. Both groups of investigators believed that clinical judgment me nt wa wass va valu luab able le in de dete term rmin inin ingg th the e ne need ed fo forr radiographic imaging.
Liver transaminases (aspartate aminotransferase [AST] [AS T] and ala alanin nine e ami aminot notran ransfer sferase ase [AL [ALT]) T]) are ofte of ten n us used ed as a sc scre reen en fo forr li live verr in inju jury ry.. Us Using ing recurs recu rsive ive partitioning partitioning retrospective analysis, Cotton 5 et al fo foun und d th that at 88 88% % of pa pati tient entss wi with th IA IAII we were re correctly identified when they had an AST more than 131 U/L with a hematocrit of less than 39%
Seve Se vera rallofst stud udies ies,, how howev ever er,,behav have e sh show n th that at a baseline 50 RBC/hpf can used toown determine the need for acute radiog radiog raphic raphic imaging to evaluate 13 for renal injury. Morey found that a CT scan was not indi indicat cated ed in pat patien ients ts wit with h min minor or abd abdomin ominal al trauma tra uma if the there re wer were e les lesss tha than n 50 RBC RBC/hp /hpf. f. The likelihood of significant genitourinary injuries w as as 2% in that group of patients. Perez-Brayfield et al 14
(se (sensi nsitiv tivity ity 100 100% [95% [95 % CI, 90% 90%-100 -100%] %] and specif spe cifici icity ty of 87% [95% CI,% 83%-91%]). An ALT of more than 105 U/L had similar findings. As other solid organ injury inj ury,, su such ch as kid kidney ney and pa pancr ncrea eas, s, can al also so 16 produce elevated transaminases, Chu et al found that a higher value, AST of more than 200 U/L or ALT of more than than 125 125 U/L, were predictors of liver injury. Holmes et al9,17 also identi identified fied these elevated elevated
also found that a CT was indicated in children with more than 50 RBC/hpf, who were hypotensive or had had a significant mechanism of injury (eg, highspeed deceleration injury). Stalker and colleagues15 found a direct relationship between the severity of renal injury injury and the degree of hematuria hematuria in that the higher the grade of injury the more RBCs that were
values valu es as am amon ongg the high-risk va vari riab able less us used ed in th the e decision decis ion to image childre children for IAI. Keller and colleagues1 found that children with elevat ele vated ed tra transa nsamina minases ses wer were e mor more e lik likely ely to hav have e liver injury compared to children with normal levels (elevated vs normal: AST 12% vs 0%, ALT 17% vs 0%; P b .05). However, he determined that only levels of
VOL. 11, 11, NO. NO. 1 • LABORATORY TESTS IN PEDIATRIC TRAUMA CARE / LINZER
more than 400 U/L were predictive of liver injury. Because these levels were associated with patients
When compared to other coagulation studies (activa (act ivated ted par partial tial thro thrombo mbopla plastin stin tim time e [PT [PTT], T],
who had other (eg, physical exami exa minat natio ion), n), indications the th e va valu lue e for didimaging nott in no infl flue uenc nce e th the e decision for imaging studies or other interventions. In a review of various trau trauma ma panel studies, 3 Capraro Caprar o et al did not find either the AST or ALT to be of any value in predicting IAI or in determining the need for CT imaging. They found that AST had a sensit sen sitivi ivity ty of 63% (95% CI, 51%-74%), 51%-74%), a neg negati ative ve
thr thromb ombin in tim time, e, deg bleedi ng tim time, e, pla platel telet et hematcount, cou nt, fibrinogen, fibrin dble eg radation reding adation products, and ocrit), Hymel et al20 found that prolongation of the prothrombin time (PT) was associated with parenchy ch ymal brain injury. In the review by Vavilala et al,22 a fibrin degradation product of more than 1000 μg/ g/mL mL wa wass as asso soci ciat ated ed wi with th a po poor or ou outc tcom ome e in children with a GCS betw een een 7 and 12.
predictive value of 71% (95% CI, 67%-82%), and a positive positi ve predictive value of 38% (95% CI, 29%-47%). Alanine aminotransaminase fared no better with a sensit sen sitivi ivity ty of 52% (95% CI, 41%-64%), 41%-64%), a neg negati ative ve predictive value of 75% (95% CI, 67%-82%), and a positive predictive value of 48% 48% (95% CI 37-60%). In the study by Isaacman et al,8 elevated AST and ALT levels lev els did not mak make e a sig signifi nifican cantt con contri tribut bution ion in predicting the presence of IAI or in determining the need for imagi imaging. ng. The use use of ser serum um amyl amylase ase and lip lipase ase for scre screeni ening ng of pancreatic injury in chil hildre dren n app appear earss to car carry ry 18 little use. Adamson et al found that although these values were elevated in pancreatic injury, there was no cost-benefit in using them as screening tests to determine the need for CT scanning. Simon et al 19 found fou nd tha thatt pan pancre creati atic c enz enzyme yme scr screen eening ing was of limi li mite ted d va valu lue e in th the e ini initi tial al as asse sess ssme ment nt of bl blun unt t 2 abdomi abd ominal nal tra traum uma. a. In add additi ition, on, Nam Namias ias et al di did d not find any corre correlation lation between serum amylase elevation and pancre pancreatic atic injury. Serum electrolytes also contribute very little in the eva evalu luati ation on of the hem hemody odynam namica icall lly y st stabl able e
Holmes and colle Holmes colleagues agues ascer ascertained tained that children with a GCS of 13 or lower had an odds ratio of 8.7 8. 7 (9 (95% 5% CI CI,, 4. 4.33-17 17.7 .7)) of ha havi ving ng an el elev evat ated ed international intern ational normal normalized ized ratio ratio (INR) of 1.5 1.5 or h or higher igher 24 or a PTT of 40 seconds or more. Keller et al used PT, INR, and PTT in finding that 43% of the children in his review with intracranial injuries had coagulation abnormalities.
COST Based on the Centers for Medicare and Medicaid Servi Se rvices ces 200 2009 9 me media dian n for la labor borat atory ory tes testt cod code e fee schedule sche duless (Ta Tabl ble e 1), a traditional trauma trauma pane panell consisting of a CBC, CBC, comprehensi comprehensive ve metabolic metabolic profile, profile, “
amyl amylase, lipase, lipa se, PTwould (includin (incl uding INR), INR ), 26 PTT TT, , an and d UA (withase, microscopy) costg$84.45. Hematocrit, AST,, and UA wou AST would ld cost $21.12, $21.12, whereas hematocri hematocrit t and UA alone would cost $10.92.
SUMMARY AND RECOMMENDATIONS In the unstable trauma patient, hematocrit, type
pati patient. ent.they Although Alth ough transient tran sient abnormal abno rmalities ities may occur, are not usually clinically clin ically relevant and 2,4,8 do not impact manag management. ement.
and cross match, PT, INR, injured and PTTpatient. are useful tests in managing the critically Transaminase min ases, s, pan pancre creati atic c enz enzyme ymes, s, and UA are not
COAGULATION STUDIES Coagulopathy has been sho s hown wn to be associated 20 with significant head hea d injuries and is a predictor of
TABLE 1. Laboratory 1. Laboratory charges.
poor out outcom come e. In a met meta-an a-analy alysis sis,, Har Harhan hangi gi and colle colleagues agues23 fo foun und d th that at 1 in 3 pa pati tien ents ts wi with th traumatic brain injury was at risk for developing a coagul coa gulopa opathy thy and tha thatt the pre presen sence ce abn abnorm ormal al coagulation studies was an independent predictor of prognosis (odds ratio of mortality 9.0 [95% CI, 7.3-11.6] and unfavorabl unfavorable e outcome 36.3 [95% CI, 24 18.7-70.7]). Keller et al found that children with
C C awtoith HB em croitut differential Basic metabolic profile Comprehensive metabolic profile Hepatic function profile AST ALT Amylase Lipase
$ $1 42 .6.7 77 $16.70 $20.86 $16.12 $10.20 $10.44 $12.79 $13.59
a GCS of less than 14 after traumatic brain injury appeared to be at the greatest risk of developing a coagulopathy (7% for a G CS of CS of 15 vs 67% for GCS 14; P b .05). Keller et al24 also found an inverse relationship between decreasing GCS and the risk of coagulopathy.
PT PTT Urinalysis (dip) UA (automated with microbiology)
$7.75 $11.84 $6.25 $6.25
Based on mid Based midpoi point nt val value ues s pu publi blishe shed d by Ce Cente nters rs fo forr Medicare and Medicaid Services, revised January 2009.26
LABORATORY TESTS IN PEDIATRIC TRAUMA CARE / LINZER • VOL. 11, NO. 1
necessary in determining the need for a CT scan becaus bec ause e ima imagin gingg dec decisi isions ons are typ typica ically lly bas based ed on the
10. Taylo Taylorr GA, Eic Eichelb helberg erger er MR, Pot Potter ter BM. Hem Hematu aturia ria:: a mar marker ker
of abdominal injury in children after blunt trauma. Ann Surg
physical status of the patient. Holding blood for later use (eg (eg,, blo blood od sam sample pless obta obtaine ined d dur during ing vas vascul cular ar access acc ess)) if the CT sca scan n sho shows ws liv liver er or panc pancrea reatic tic injury is cost-effective cost-effective and does not adversely affect patient management.27 In th the e he hemo mody dyna nami mica call lly y st stab able le ch chil ild, d, no labo la bora rato tory ry te test stss ar are e ne need eded ed to de dete term rmin ine e th the e need ne ed fo forr ra radi diog ogra raph phic ic im imag agin ingg if the there re ar are e an any y phys physica icalless finding fin dingsscon oftusion, abdomi abd ominal nala inju injury, ry,e inc includ luding ing tendern tend erness and contus ion, or positiv pos itive Focus Foc used ed Assessment by Sonography in Trauma (FAST) examin exa minati ation. on. The phy physic sical al exa examin minati ation on alo alone ne is clearly the best best determinant determinant for the need for CT imaging ima ging for IAI IAI..5,8,28 In th the e ch chil ild d wi with th bl blun untt tr trau auma ma to th the e th thor orax ax with wi thou outt an any y ph physi ysica call fi find nding ingss an and d a ne nega gati tive ve FA FAST ST,, a hematocrit hematoc rit and UA should should be obt obtain ained. ed. It is not unre un reas ason onab able le to ob obta tain in an AS AST T or AL ALT T in th this is scenario. Imaging is indicated if the hematocrit is less than 30%, UA has 50 RBC/hpf or more, AST is more than 200 U/L, and/or ALT is more than 125 U/ L. A pre pregna gnancy ncy test (ur (urine ine or ser serum um)) sho should uld be obtaine obta ined d on eve every ry fem female ale pat patient ient of rep reprod roduct uctive ive potential age. Prothrombin time, INR, and PTT have
clinic Lieu al Lieu TA,findi Fleish Fleisher Mahbou Mahboubi bi intrav S, et enous al. Hem Hematu aturia ria and clinical findings ngser as GR, indicators indica tors for intravenous pyelography in ped pediat iatri ric c blu blunt nt re renal nal tra trauma uma.. Ped Pediat iatric ricss 1988 1988;82 ;82:: 216-22. Abou-Ja -Jaoud oude e WA, Sug Sugarm arman an JM, Fal Fallat lat ME, et al. Indi Indicato cators rs of 12. Abou genitourinary tract injury or anomaly in cases of pediatric blunt trauma. J Pediatr Surg 1996;31:88-90. 13. Morey AF, Bruce JE, McAninc McAninch h JW. Effic Efficacy acy of radiog radiographic raphic imaging in pediatric blunt renal trauma. J Urol 1996;156: 2014-8. 14. Perez-Br Perez-Brayfi ayfield eld MR, Gatti Gatti JM, Smith Smith EA, et al. Blunt Blunt dramat dramatic ic hematuria and children. Is a simplified algorithm justified. J Urol 2002;167:2543-7. Stalker lker HP, Kau Kaufma fman n RA, Ste Stedje dje K. The sig signif nifica icance nce of 15. Sta hematuria hematu ria and childr children en after blunt abdominal trauma. Am J Roentgenol 1990;154:569-71. 16. Chu FY, Lin HJ, Guo HR, et al. A reliable screening test to pre predict dict liver inj injury ury in pedi pediatr atric ic blu blunt nt tor torso so tra trauma uma.. Eur J Trauma Emerg Surg 2009; doi:10.1007/s00068-009doi:10.1007/s00068-0099034-z.. 9034-z
JF, Mao A, Awasthi S, et al. Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Ann Emerg Med 2009;54: 528-33. 18. Adamson WT, Hebra A, Thomas PB, et al. Serum amylase and lipase alone are not cost-effective cost-effective screening methods for pedi pediatr atric ic panc pancreat reatic ic tra trauma uma.. J Ped Pediat iatrr Sur Surgg 2003 2003;38: ;38: 354-7. 19.
demonstrated value in monitoring patients with a GCS of less than 14.
REFERENCES 1. Keller
MS, Coln CE, Trimble JA, et al. The utility of routine trauma laboratories in pediatric trauma resuscitations. Am J Surg 2004;188:671-8.
chem Namias N, and McKenney MG, of pati admission chemist istry ry coagulat coag ulation ionMartin profil pro files esLC. in Utility trauma tra uma patient ents: s: a reappraisal of traditional practice. J Trauma 1996;41:21-5. 3. Capraro AJ, Mooney D, Waltzman ML. The use of routine
determi Simon Sim on nations HK,, Mu HK Muehl ehlbe berg rg A, patients Linakis Linak is presenting JG.. Se JG Seru rum amylas e determination s in pediatric presentin gmtoamy the lase ED with wi th acu acute te abd abdomi ominalpain nalpain or tr trau auma ma.. Am J Eme Emerg rg Me Med d 199 1994; 4; 12:292-5. 20. Hymel Hymel KP, Absh Abshire ire TC, Luc Luckey key DW, et al. Coag Coagulo ulopat pathy hy in pedi pediatr atric ic abus abusive ive head tra trauma uma.. Ped Pediat iatric ricss 1997 1997;99: ;99: 371-5. 21. Miner ME, Kaufman HH, Graham SH, et al. Disseminated intravascular intra vascular coagul coagulation ation fibri fibrinolyti nolytic c syndrom syndrome e follow following ing head injury in children: frequency and prognostic implications. J Pediatr 1982;100:687-91. 22. Vavi Vavilala lala MS, Dun Dunbar bar PJ, Riv Rivara ara FP, et al. Coag Coagulo ulopat pathy hy predic pre dicts ts poo poorr out outcom come e fol follow lowing ing head inj injury ury in chi childre ldren n
laboratory studies as screening tools in pediatric abdominal trauma. Pediatr Emerg Care 2006;22:480-4. Screening ing laboratory laboratory 4. Tasse JL, Janzen ML, Ahmed NA, et al. Screen and radiology panels for trauma patients have low utility and are not cost effective. effective. J Trauma 2008;65:1114-6. 2008;65:1114-6. Cotton n BA, Liao JG, Burd RS. The utility utility of cli clinica nicall and 5. Cotto laboratory labora tory data for predic predicting ting intraabdominal intraabdominal injury among children. J Trauma 2005;58:1306-7. 6. Quinla Quinlan n D, Gea Gearha rhart rt J. Blu Blunt nt ren renal al tra trauma uma in chi childho ldhood. od. Feat Fe atur ures es in indi dica cati ting ng sev sever ere e in inju jury ry.. Br J Ur Urol ol 19 1990; 90;66 66:: 526-31. 7. Stein J, Kaji D, Eastham J, et al. Blunt trauma in the pediatric population: indications for radiographic evaluation. Urology 1994;44:406-10. 8. Isaacman DJ, Scarfone RJ, Kost SI, et al. Utility of routine
less than 16 year yearss of age. J Neu Neuros rosurg urg Anesth Anesth 2001 2001;13: ;13: 13-8. 23. Harhangi BS, Kompanje EJ, Leebeek FW, et al. Coagulation disorders after traumatic brain injury. Acta Neurochir 2008; 150:165-75. 24. Kelle Kellerr MS, Fen Fendya dya DG, Web Weber er TR. Gla Glasgo sgow w Coma Scale predicts coagulopathy in pediatric trauma patients. Semin Pediatr Surg 2001;10:12-6. 25. Holmes Holmes JF, Goo Goodwi dwin n HC, Land C, et al. Coa Coagul gulati ation on tes testin tingg in pediatr pedi atric ic blun bluntt tra trauma uma pat patien ients. ts. Ped Pediat iatrr Eme Emerg rg Car Care e 2001 2001;17: ;17:324324-8. 8. 26. Cente Centers rs for Medi Medicare care and Medic Medicaid aid Serv Services. ices. Medi Medicare care clinical clinic al labora laboratory tory fee schedul schedule e (09CLA (09CLAB.Zip). B.Zip). Available at: http://www.cms.hhs.gov/ClinicalLabFeeSched/02_clinlab. asp#TopOfPage.. Accessed October 12, 2009. asp#TopOfPage 27. Bryant MS, Tepas JJ, Talbert JL, et al. Impact of emergency
laboratory testing for detecting intra-abdominal injury in the pediatric trauma patient. Pediatrics 1993;92:691-4. 9. Holmes JF, Sokolove PE, Brant WE, et al. Identification of children childre n with intra-abdominal intra-abdominal injuries after blunt trauma trauma.. Ann Emerg Med 2002;39:500-9.
room laboratory studies on the ultimate triage and disposition of the injured child. Am Surg 1988;54:209-11. 1988;54:209-11. 28. Miller D, Garza J, Tuggle D, et al. Physical examination as a reliable reliab le tool to predic predictt intraintra-abdomi abdominal nal injur injuries ies in braininjured children. Am J Surg 2006;192:738-42.
Abstract: With the introduction of faster computerized tomography (CT), this radiographic modality has
become widely used for the evaluation of the pediatric trauma patient. There is a substantially increased increa sed dose of ionizi ionizing ng radiat radiation ion associated associ ated with CT compare compared d to plain radiography. Multiple studies have demonstrated that the younger the patient at the time of exposure, the higher the radiation dose to the organs org ans.. Hig Higher her org organ an rad radiat iation ion dos doses es have been linked with an increased cancer can cer ris risk. k. The ind indisc iscrim rimina inate te use of CT in the evaluation of the pediatric trauma patient is therefore associated with an increased risk for cancer in this population. population. This article's articl e's objective is to review the relative risks and benefits associated with this radiographic modality.
Radiographic Evaluation of the Pediatric Trauma Patient and Ionizing Radiation Exposure
Keywords: CT scan; pediatric trauma; radiation risk
Ricardo R. Jiménez, MD
can th can them em un unti till th they ey gl glow ow said said the sur surge gery ry atte at tend nding ing on my fi firs rstt tr trau auma ma ca case se dur durin ingg my medical school surgery rotation. What he meant was that when dealing with a trauma patient, the overuse of computerized tomography (CT) was acceptable. But ”
Reprint requests and correspondence: Ricardo R. Jiménez, MD, Pediatric Emergency Medicine Attending, University of South Florida Affiliated Faculty, All Children's Hospital, 801 6th St South, Saint Petersburg, FL 33701. [email protected]
1522-8401/$ - see front matter © 2010 Elsevier Elsevier Inc. All rights reserved.
what about the glow part? Trauma is a leading cause of death in the pediatric population. A systematic detailed evaluation is necessary in the management of th the e pe pedi diat atri ric c tr trau auma ma pa pati tien ent. t. Th The e go goal al of th the e tr trau auma ma eval ev alua uati tion on is th the e ac accu cura rate te an and d ea earl rly y id iden enti tifi fica cati tion on of li life fe-threatening injuries while ensuring the safety of the patient. A larg la rge e pa part rt of th the e tr trau auma ma ev eval alua uati tion on is im imag agin ing, g, an and d it ha hass revol re voluti utioni onized zed th the e wa way y we pr prac actic tice e me medi dicin cine. e. Th The e im imag aging ing eval ev aluat uatio ion n ca can n ra rang nge e fr from om pl plai ain n ra radi diog ogra raph phy y of an inj injur ured ed extremity to a head, neck, and/or abdominopelvic CT scan. In the last decade, with the invention of faster CT technology and with the widespread availability of CT in most hospitals, there has been a substantial increase in its use as part of the trauma evaluation. evaluat ion. In a recent study, the use of CT increased from 12.8%
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RADIOGRAPHIC EVALUATION AND IONIZING RADIATION EXPOSURE / JIMÉNEZ • VOL. 11, NO. 1
to 22.4% from from 1995 to 2003 in the evaluation of head trauma.1 Furthermore, 11.2% of the CTs done in the U the U nited nited States were on patients 0 to 15 years 2 of age. Howeve How ever, r, rad radiog iograp raphic hic eva evalua luatio tion n is not an innocuo inn ocuous us pro proced cedure ure and bea bears rs some ris risk. k. Dia Diaggnostic radiography carries an exposure to ionizing radiat rad iation ion,, ran rangin gingg fro from m fai fairly rly low dos doses es in pla plain in radi ra diog ogra raph phy y to mu much ch hi high gher er do dose sess wi with th CT CT.. Exposu Exp osure re to hi high gh le leve vels ls of ion ioniz izing ing ra radi diat atio ion n is
Rece Re centl ntly, y, the there re ha hass be been en inc incre reas ased ed con conce cern rn regarding regard ing the asso associat ciation ion of dia diagnos gnostic tic rad radiat iation ion expo ex posur sure e an and d th the e ri risk sk fo forr ca canc ncer er.. Wi With th th the e in incr creas eased ed use of CT in the care of children, we have to ask if this risk outweighs the benefits and consider shortterm benefits vs long-term effects. Lastly, is it really necessary to scan them until they glow?
proven to increase the risk for cancer development later in life, especially leukemia, leukemia, breas breastt cance cancer, r, and thyroid thyr oid can cancer cer.. Unf Unfort ortunat unately, ely, chi childre ldren n are more susce sus cepti ptible ble to ra radia diati tion on eff effec ects ts tha than n ad adult ults. s.2-5 Chernob Che rnobyl yl and Hir Hiroshi oshima ma surv survivo ivorr stud studies ies hav have e demon de monst stra rate ted d an in incr crea ease se ca canc ncer er ri risk sk in t he he pediat ped iatric ric pop populat ulation ion whe when n comp compare ared d to adu adults. lts.6,7 Furthermore, an association has been shown with age at the time of exposure and cancer risk; the youn you nge gerr th the e pa pati tient ent at ex expo posur sure, e, th the e hi highe gherr th the e
HEAD INJURY EVALUATION Trau Tr auma ma is a le lead adin ingg ca caus use e of de deat ath h in th the e pe pedi diat atri ric c population, and head trauma is is the most common reason rea son for dea death th or disa disabili bility. ty.10 According to the Center for Disease Control and Prevention, there are ar e ro roug ughly hly 65 650 0 00 000 0 ho hosp spit ital al vi visi sits, ts, 30 3000 00 de deat aths, hs, an and d 50 000 0 00 hospitalizations associated with head injuries.11 Most head injuries are classified as mild. In the absence of validated clinical criteria that can identif ide ntify y wit with h 100 100% % sens sensiti itivit vity y tho those se pat patien ients ts wit with h
risk. Consider Conside rgher this, actively replicating replic ating cellri lines willl ha wil have ve a hi high er ri risk sk of mu mutat tatio ion; n; th this is risk sk is increased by ionizing radiation. It is important to be aware that the radiation dose to an organ is energy deposit dep osited ed div divide ided d by mass mass;; the theref refore ore,, the gre greate aterr the mass, the lower the dose to the organ. Now, also consi co nside derr th that at th the e ac actu tual al do dose se of ra radi diat ation ion to an organ is affected by the distance to the radiation
intracranial injurystudies (ICI), the traumathe physician often relies on imaging to assess extent of the head injury. Initially, skull radiography was used to detect fractures after a head injury, followed with a CT if the x-ray detected a fracture. The presence of skull fractures in a skull rad radiograph iograph is one of the stronge str ongerr pre predict dictors ors of ICI ICI..12 Sku Skull ll x-r x-ray ayss ha have ve a sensitivity of 65% and 83% negative predictive value
source, for example, if an organ is proximal to the radi ra diat atio ion n sou sourc rce, e, th the e do dose se wi will ll be hi high gher er;; as th the e source rotates and the organ is now distal and is partially shielded by body tissue, the dose to that organ org an wil willl be low lower er.. Be Beca cause use ch chil ildre dren n ar are e sti still ll undergoing underg oing development, they carry more repli replicatcating cells lines than adults, and because children are often oft en thin thinner ner tha than n the their ir adu adult lt cou counte nterpa rparts rts,, it is
and are better better for detecting detecting horizontal horizontal fractur fractures es that the CT can miss. Unfort Unfortunately unately,, skull x-rays cannot detec de tectt und under erlin lining ing bra brain in inj injury ury.. Hea Head d CT ha hass beco be come me th the e te test st of ch choic oice e fo forr th the e ev eval aluat uation ion of head hea d inj injury, ury, esp especi ecially ally sin since ce the int introd roduct uction ion of helical CT, which is much faster and minimizes the need for sedatio sedation. n. Computed tomography is clearly a better tool for
easy to und easy under ersta stand nd wh why y th they ey ha have ve a hi highe gherr ri risk sk associated associa ted with ionizing radiation radiation exposur exposure. e. In th the e pa past st ye year ars, s, th the e ma main in so sour urce ce of th this is ra radi diat atio ion n was env enviro ironme nmenta ntal, l, ave avera ragin gingg 3 mSv an annua nually lly depending on where the person lives. The typical single singl e CT radiation exposure ranges from 1 to 14 mSv.9 With the increased use of imaging studies, medical diagnostic evaluation has become a major source with CT accou accounting for 67% of the diagnostic
the evaluation of head injury, as it detects not only skull fractures but also ICI. Of course, it carries a higher level of ionizing radiation exposure and an increase in cancer risk. In the absence of a set of validated criteria that could reliably identify those patients with very low risk for ICI, the use of head CT has increased dramatically for the past decade. The problem lies in the overuse of CT in those head injured patients who have a very low risk for ICI,
radiation exposur radiation exposure. e.2 Comp Compute uted d tomo tomogra graphy phy has become for many the imaging study of choice in the ev evalu aluat ation ion of the ped pedia iatri tric c tr traum auma a pat patien ient, t, takin ta kingg the pla place ce of pla plain in ra radi diogr ograp aphy hy in th the e evaluation evaluat ion of head and neck injuri injuries es and perito peritoneal neal lava la vage ge in th the e ev evalu aluat atio ion n on ab abdo domin minal al inj injur urie ies. s. Although other modalities such as ultrasound and magneti magn etic c res resonan onance ce ima imagin gingg car carry ry no ioni ionizing zing radiation exposure, their use in the evaluation of the pediatric trauma patie patient nt remains unclear.
which some studies suggest range range from from 40% to 60% 13-16 of patients with head trauma. When comparing ionizing radiation exposure associated with skull xrayss vs CT, there is a not ray notice iceable able differen difference ce wit with h doses from plain radiographs ranging from 0.02 to 10 mGy and doses from CT ranging from 5 to 20 mGy.5 To pu putt th this is in pe pers rspe pect ctiv ive, e, we sh shou ould ld remembe rem emberr tha thatt the annu annual al bac backgr kground ound rad radiat iation ion exposure in the Unit Unit ed ed States averages 3 mSv and 9 that 1 mSv = 1 mGy. Therefore, radiation exposure
VOL. 11, 11, NO. NO. 1 • RADIOGRAPHIC EVALUATION AND IONIZING RADIATION EXPOSURE / JIMÉNEZ
associated with head CT is not only higher but is also additive to backg backgroun round d radiation. 3,4 Brenner and colleagues have estimated organ doses associated associated with CT use; the dose is depend dependent ent on th the e ac actua tuall mi milli lliam ampe pere re se sett ttin ingg us used ed in th the e scanner. The relationship between dose and milliampere is linear. When the setting used was 200 mAs, the organ radiation dose to the brain from one head he ad CT ra rang nged ed fr from om 15 to 65 mG mGy; y; th the e hi high ghes estt do dose se wass as wa asso socia ciate ted d wi with th th the e you young nges estt pa pati tien ents. ts. Th The e organ dose remained the same after 15 years of age and incre increased ased directly propor proportional tional to decre decreasing asing pati pa tient ent age. Conversely, in a study by Jimenez et 17
frontal, no loss of consciousness or loss of consciousness less than 5 seconds, nonsevere injury mechanism, no palpable skull fracture, and acting normally as pe perr pa pare rent nts. s. In th the e 2 to 18 ye year arss gr grou oup, p, th this is decision rule included normal mental status, no loss of consciousness, no vomiting, no severe headache, nonsevere injury mechanism, and no signs of basilar skull fracture. The younger-than-2-year-old rule had a negative predictive value and sensitivity of 100% and an d th the e 2- to 18 18-y -yea earr-ol old d ru rule le ha had d a ne nega gati tive ve predicti predi ctive ve va valu lue e of 99 99.9 .95% 5% an and d se sens nsit itiv ivit ity y of 19 96.8%. This is the largest and most comprehensive study evaluating minor head injury. The study was
al where whe rethe anthro ant hropomo pomorph rphic ic pha phantom ntoms s wer were e use used d to quantify organ doses after head and neck CT, the pituitary organ radiation dose in the 1-year-old phantom was 21.25 mGy, whereas in the 5-year-old 5-year-old phan ph anto tom, m, it wa wass 33 33.8 .8 mG mGy. y. It is im impo port rtan antt to recognize that there are data supporting an increas incre ase e 18 in individ individu ual cancer risk with these dose ranges. Brenner3 wa wass ab able le to ex extr trap apol olat ate e a li life feti time me
able to validate a prediction rule low thatrisk would to identify those children at very of serve ICI and those for whom a head CT may be obviated for the trauma evaluation as the risk for ionizing radiation will outweigh the benefits.
attributa attrib utable ble can cancer cer ris risk k asso associa ciated ted to the org organ an doses from a single head CT. The attributable risk was estimated to be highest in those younge youngerr than 2 year ye ars, s, wi with th a on one e in 20 2000 00 ri risk sk fo forr th the e de deve velo lopm pmen entt of canc ca ncer er as assoc socia iate ted d wi with th a si sing ngle le he head ad CT CT.. It is importa imp ortant nt to und underst erstand and tha thatt rad radiat iation ion dose dosess are cumulative and will increase with the number of exposu exp osure res, s, and als also, o, the at attri tribut butab able le ri risk sk is a
The evaluation of the cervical spine for cervical spine injury (CSI) is an integral part of the pediatric trauma patient evaluation. Cervical spine injuries can have severe deleterious deleterious effects if left untreated, untreated, from fro m per permane manent nt neu neurolo rologic gic def defect ectss to dea death. th. Because ca use CS CSIs Is ar are e ve very ry ha hard rd to ev eval aluat uate e cl clini inica cally lly,, radiographic radiog raphic evaluation evaluation has been an integr integral al part of the tra traumat umatic ic cer cervic vical al spin spine e eva evaluat luation. ion. Con Conven ven--
function of the scanner setting used (in this case 200 mAs). When evaluating for the pediatric trauma vict vi ctim im fo forr he head ad in inju jury ry,, we ne need ed to as ask k if th the e diagn dia gnost ostic ic be bene nefit fitss of CT ima imagin gingg out outwe weigh igh th the e radiation risk. For those children with a mechanism of injury or clinical findings indicative of a higher risk for ICI, the answer is yes. As discussed earlier earlier,, 40% to 60% of the children who wh o re rece ceiv ive e a CT as pa part rt of th the e he head ad in inju jurry evaluation are considered minor trauma, and only about abo ut 10% of the these se ch child ildre ren n wil willl ha have ve a pos positi itive ve findin fin ding. g. Th This is lar large ge dis discr crepa epancy ncy in the lar large ge num number ber of CTs an and d the small num numbe berr of pos positi itive ve fin findin dings gs in children with minor head trauma is associated with the lac lack k of va valid lidate ated d cr crite iteri ria a tha thatt wil willl ide identi ntify fy pat patien ients ts with a very low risk for ICI. Recent data obtained by the Ped Pediat iatri ric c Eme Emerge rgency ncy Ca Care re App Applie lied d Res Resea earch rch Networ Net work k (PE (PECARN CARN)) pre presen sented ted a ver very y pro promisi mising ng prediction rule for identifying children at very low risk of ICI. This prospective cohort study analyzed
tional 3-v tional 3-view iew (an (anter teropo oposte sterior rior,, lat latera eral, l, odo odonto ntoid) id) cervical cervic al spine plain radiographs radiographs are a standa standard rd part of th the e ne neck ck in inju jury ry ev eval alua uati tion. on. Bot Both h ad adult ult an and d pediatric literature supports the use of neck CT for the evaluation of CSI as it yields a hig her her detection rate rat e and is mor more e cost cost-ef -effec fectiv tive. e.20-23 Cer Cervic vical al CT alon al one e ha hass be been en sh show own n to ha have ve a se sens nsit itiv ivit ity y of 98 98% % fo forr CSIs;; in con CSIs contra trast, st, con conven ventio tional nal rad radiiogra ograph phy y ha hass 24,25 been s been shown hown to miss up to 5 to 57% 7% of CSIs. Keenan et al22 and Blackmore et al23 both support the use of cervical CT for the evaluation of high-risk patients, which whi ch in inclu clude de alt alter ered ed men mental tal sta status tus or foc focal al neuro ne urolo logi gic c de defi fici cit. t. An in incr creas ease e in the use of CT and its use without the use of plain radiog ra diog raphy raphy has been noted in the evaluation of CSIs.19,26 The adult literature recommendations for clearing the cervical spine after a traumatic injury seem to agree that those patients classified as high risk should be evaluated with a cervical spine CT. The most common criteria used in the adult literature to
NECK INJURY EVALUATION
more than 42 000 children with minor head injury divi di vidi ding ng th them em in 2 gr grou oups ps,, yo youn unge gerr th than an 2 ye year arss an and d2 to 18 yea years rs of ag age. e. PEC PECARN ARN investig investigat ator orss use used d a
classify a patient as high risk are focal neurologic defici def icitt and alt altere ered d men mental tal sta status tus.. A ped pediat iatric ric 27 literature review by Slack and Clancy suggested
pr pred edic icti tion rule ru tounge iden id enti fyan thos th e ars, with wi thth very ve low lo risk ri sk for fo ICI. IC I. Fo For r on thos th ose eleyo youn ger rtify than th 2ose year ye s, the ery rule ru lewin incl clud uded edr normal norm al ment mental al stat status, us, no scal scalp p hema hematoma toma except
a similar as approach in clearing the spine cervical spineare in children that in adults. Cervical injuries rare rar e in the ped pediat iatric ric tra trauma uma pat patien ient. t. The lar largest gest
RADIOGRAPHIC EVALUATION AND IONIZING RADIATION EXPOSURE / JIMÉNEZ • VOL. 11, NO. 1
study study eva evaluat luating ing CSI in the ped pediat iatric ric pop popula ulation tion,, The Th e Na Nati tiona onall Emerg ergenc ency y X-r X-ray ay Util Utiliza izatio tion n Stud Study y 28 (NEXUS) group, fou found nd a CS CSII inc incide idenc nce e ra rate te of 0.98% 0.9 8% in th the e pe pedi diatr atric ic pop popula ulati tion on com compa pare red d to 2.54% 2.5 4% in adu adults. lts. The difference difference in pre prevale valence nce of CSI between the pediatric and adult population is probably associated with the anatomical and physiologic iolo gic dif differ ferenc ences es that exi exist st amo among ng the them. m. Thes These e differences are more prominent in those younger than 8 yea ears rs bu butt pe pers rsis iste tent nt in th thos ose e 8 to 12 29,30 years. The Th e NE NEXU XUS S de deci cisi sion on ru rule le ha hass be been en shown to be 100% sensitive in the detection of CSI in the pediatric population. The decision rule used by the NEXUS group includes changes in sensorium,
strongest associa strongest association. tion.33 With the increased use of CT for the evaluation of neck injury, it is important to evalu evaluate ate the the risk for thyr thyroid oid canc cancer er lat later er in lif life e for those patien patient t s who are exposed. In the study by Jimenez et al,17 the excess relative risk for thyroid cancer was calculated. Those younger than 5 years appear to have a higher risk of developing thyroid cancer can cer,, with those you younger nger than 1 year doublin doubling g 19 their cancer risk with only one CT.
intoxication, focal neurolo intoxication, neurologic gic defici deficits, ts, distra distraction ction injury, and midline cervical tenderness. With the low incidence of CSI in the pediatric population and
involve the abdomen, abdominal abdomina33 l injuries are one of those thos e most comm commonly only miss missed. ed. The gen genera erall approach for the evaluation of pediatric blunt abdom-
ABDOMINAL EVALUATION Bluntt tr Blun trau auma ma ac acco coun unts ts fo forr 90 90% % of ch chil ildh dhoo ood d injurie inju ries, s, and alt althoug hough h onl only y 10% of the these se inj injuri uries es
a decision rule that can potentially identify those pedi pe diat atri ric c pa pati tien ents ts at lo lowe werr ri risk sk,, is th ther ere e a ne need ed to us use e CT as a scr scree eenin ningg to tool ol to cle clear ar th the e ce cerv rvic ical al spi spine ne an and d if so what is the risk? Once again, the risk has to be measured against
inal trauma is based upon the clinical status of the patien pat ient. t. Abd Abdomi ominal nal CT is wel welll acc accep epted ted as the standa sta ndard rd dia diagno gnosti stic c too tooll for the eva evaluat luation ion of abdomi abd ominal nal inj injuri uries. es. Thi Thiss woul would d sig signif nify y tha thatt most children childr en evalua evaluated ted for intraintra-abdomin abdominal al injuri injuries es will
the ben benefi efits. ts. It has alr alread eady y bee been n est establi ablishe shed d tha that t there is a substantial increase in ionizing radiation radiati on exposure associated with CT use. Jimenez et al17 studied the amount of radiation exposure between plain neck radiography and neck CT using anthropomorphic phantoms representing a 1-year-old and a 5-year-old. This study directly collected the dose received by certain organs in the neck, specifically the thyroid which is recognized as one of the most radiosensitiv radiosensi tive e or orga gans ns in th the e bo body dy.. Ji Jime mene nezz an and d 17 colleagues found that in the 1-year phantom, the radiat rad iation ion received received to the thyroid thyroid fro from m a CT was 385 times (59.28 mGy) that from a 3-view neck xray, ra y, an and d in th the e 55-ye year ar ph phan anto tom, m, th the e ne neck ck CT provided a dose 164 times greater (52.3 (52. 3 mGy) than that fro from m con conven ventio tional nal rad radiog iograp raphy. hy.19 Again, it appear app earss tha thatt the you younge ngerr the pat patien ient, t, the hig higher her the ra radi diat ation ion or orga gan n dos dose. e. Int Inter erest esting ingly ly en enoug ough, h, 17 Jimenez et al also found that the organ dose to the thyroid from a head CT was higher than that of a 3-view conventional neck x-ray, which is concerning as some patients receive both a hea h ead d and neck neck 19 CT as part of the trauma evaluation. Brenner3,4
undergo a CT, which of course is associated with radiati rad iation on exp exposur osure e to the abd abdomi ominal nal org organs. ans. Rec Recent ent-ly, a prediction rule for the identification of children with intra-abdominal injury has been validated; it showed good sensitivity but was unable to identify 100% 100 % of the chi childr ldren en wit with h int intrara-abd abdomin ominal al inj injuury.34,35 In this same study, the authors estimated that when these 6 high-risk variable predi prediction ction rules were used appropriately, it would decre would decrease ase the number of abdomina ab dominall CTs by one third third..34,35 Brenner3,4 eva evalua luated ted the rad radiat iation ion exp exposu osure re associa asso ciated ted with an abd abdomin ominal al CT and found that the organs that were most affected were the liver and the stomach. The doses range ranged d between 12 and 25 mGy at 200 mAs. Once again, this relation is linear and can be scaled up or down depending on the mAs use used d in a spe specifi cific c sca scanne nner/e r/exami xaminati nation. on. The relationship between organ radiation dose and age were again inversely proportional, putting the youngest children at highest risk. When the estimated risk risk for developing developing cancer cancer was calculated, calculated, the digest dig estive ive org organs ans wer were e the most affected, affected, and the canc ca ncer er ri risk sk in incr crea ease sed d as th the e ag age e at ex expo posu sure re
ha has s al also sothe confi co nfirm rmed ed tha that t th the e or orga gans that th at CT rece re ceiv ive e most of radiation secondary tons a head are the brain and thyroid. Studies Stu dies abo about ut Che Chernob rnobyl yl and Hir Hirosh oshima ima surv survivo ivors rs have reported an increase in thyroid cancer in the pediatric population with a significant linear association between radi radiation ation dose and cancer risk.6,7,31
dec decrea reased sed.. The estimat est imated ed 1/2000 lifetim life time etoris risk k was in found fou nd to be small, rangi ranging ng from 1/1000 the youngest patients.3,4 In the last decade, the use of focused assessment with sonography for trauma (FAST) by emergency physicians for the evaluation for abdominal trauma of the adult patient has become more accepted. The
reported repor ted that the age at time of
use of FAST has been shown to shorten the time to
exposure was strongly linked to the risk for thyroid cancer, with those younger than 15 years having the
the o35,36 the peratin pera tingg ro room om in the uns unsta table ble tr trau auma ma pa pa-tient. The Ame Americ rican an Col Colleg lege e of Eme Emerge rgency ncy
VOL. 11, 11, NO. NO. 1 • RADIOGRAPHIC EVALUATION AND IONIZING RADIATION EXPOSURE / JIMÉNEZ
Physician Physici an has issu issued ed gui guideli delines nes tha thatt str strongl ongly y encourage cour age the ava availa ilabili bility ty and use of of FAST FAST in th the e 36,37 evaluation of the trauma patient. It is understand sta ndabl able e tha thatt FAS FAST T co could uld de decr crea ease se th the e use of abdominal CT, reducing the organ radiation exposure. However, the use of FAST for the evaluation of the pediatric trauma patient has not been widely accepted, and there are no clear guidelines for its use in children. The reported sensitivity of FAST in the pediatric population ranges from 31% to 100%, and it appears to perform well in the detect detect ion ion of 37-39 free fre e flu fluid id in the hyp hypote otensi nsive ve pa patie tient nt.. More studies are needed that support the use of FAST in the pediatric trauma patient before guidelines can be dev devised ised for its reg regular ular implementa implementatio tion n in the pedia pe diatr tric ic po popu pulat lation ion.. Th This is is a too tooll th that at wil willl hopeful hope fully ly help reduce reduce the use of abd abdomin ominal al CT, thus, reducing the risk for cancer.
risks from exposure to low levels of ionizing radiation: BEIR VII Phase 2. Washington, DC: The National Academic Press; 2001. 6. Americ American an Acad Academy emy of Pedi Pediatri atrics cs Comm Committe ittee e on Envi Environronmental men tal He Healt alth. h. Ris Risk k of ion ionizi izing ng rad radiat iation ion exp exposu osure re to children chil dren:: a subje subject ct revi review. ew. Pedi Pediatri atrics cs 1998 1998;101( ;101(4 4 Pt 1):717-9 1):717-9.. 7. Kazakov VS, Demidchik EP, Astakhova LN. Thyroid cancer after Chernobyl. Nature 1992;359:21. 8.
Her Herna nande ndez JA,ldren Chupi Ch k C, Swisch Swi schuk uk pro LE.ductiv Cervic Cer vical spine ne traum tra uma a inz chi childr enupik under und er 5 years: yea rs: produc tivity ityalofspi CT. Emerg Radiol 2004;10:176-8. 9. Ionization radiation exposure of the population of the United States Sta tes.. Rep Report ort no. 93: Nat Nation ional al Cou Counci ncill on Rad Radiat iation ion Protecti Prot ection on and Mea Measure suremen ments. ts. Bet Bethesd hesda a (Md (Md): ): Nati Nationa onall Council on Radiation Protection and Measurements; 1987. 10. Natio National nal Cen Center ter For Inju Injury ry Prev Preventi ention on and Control. Traumatic Brain Injury in the United States: a report to Congress. Atlanta (Ga): Center for Disease Control and Prevention Prevention;; 1999. 11. Centers for Disease Control and Prevention. 2000 National Ambulatory Medical Care Survey, Emergency Department File Fil e 200 2002. 2. Hya Hyatts ttsvil ville le (Md (Md): ): Nat Nation ional al Ce Cente nterr for Hea Health lth Statistics; 2002. 12. Sch Schutz utzma man n SA, Bar Barne ness P, Duh Duhaim aime e AC. Eva Evalua luatio tion n and manageme mana gement nt of chil children dren younger younger than two year yearss old with
Computed Compute d tomo tomogra graphy phy has bec become ome one of the most frequently used diagnostic tools in the evaluation tio n of the pediatric pediatric trauma trauma pat patien ient. t. The There re is an inhere inh erent nt ris risk k ass associ ociate ated d wit with h ion ionizi izing ng rad radiat iation ion exposur exp osure e seco seconda ndary ry to CT use, and chi childr ldren en are more susceptible than adults to the development of radiation-induced cancer. Although the risk may be low an and d th the e be bene nefit fitss ma may y gr grea eatl tly y out outwei weigh gh th the e ri risk sk in certai cer tain n cas cases, es, such as thos those e chi childre ldren n with more sev sever ere etin inju juri es, ityis pa impo im porta rtant to we weig igh the risk ri sk the e bene be nefi fit for fo rries, ever ev ery pati tien ent. t. nt Exposi Exp osing ngh th a ech child ildvstoth a radiat rad iation ion dos dose e tha thatt inc increa reases ses the ris risk k for can cancer cer without a proven diagnostic advantage is no longer acceptable. accept able. This practice is also contrary to ALARA (as low as rea reasona sonably bly achi achieva evable) ble) that ack acknowl nowledg edges es that no level of diagno diagnostic stic radiation is without risks. Scan Sca n the them m unti untill the they y glo glow w violates violates the ALAR ALARA A
apparently minor head trauma: proposed guidelines. Pediatrics 2001;107:983 2001;107:983-93. -93. 13. Dunn Dunning ingss
J, Dal Daly y JP, Lomas Lomas JP, et al. De Deriv rivati ation on of the children child ren's 's he head ad inj injury ury alg algori orith thm m for th the e pre predic dictio tion n of importan impo rtantt clin clinical ical events decision decision rule for head injury in children. Arch Dis Child 2006;91:885-91. 14. Greenes DS, Schuztman SA. Clinical indicators of intracranial inju injury ry in head head-inj -injured ured infa infants. nts. Pedi Pediatri atrics cs 1999 1999;104: ;104: 861-2. 15. Palchak MJ, Holmes JF, Vance GW, et al. A decision rule for identifying children at low risk for low brain injuries after blunt head trauma. Emerg MedN,2003;43:493-506. Jaffe DM,Ann Kuppermann et al. Diagnostic testing
16. Quayle KS,
CD, Gorelick M, Holmes JF, et al. Pediatric head trauma: changes in use of computed tomography in emergency gen cy de depar partme tments nts in the Uni United ted Sta States tes ove overr tim time. e. Ann
for acu acute te he head ad inj injury ury in chi childr ldren: en: wh when en are com comput puted ed tomograp tomo graphy hy and skul skulll rad radiogr iograph aphss indi indicate cated. d. Ped Pediat iatrics rics 1997;99:1-8. 17. Jimenez RR, DeGuzman MA, Shiran S, et al. CT versus plain radiog rad iograp raphs hs for eva evalua luatio tion n of c-s c-spin pine e inj injury ury in you young ng children chil dren:: do bene benefits fits outwe outweigh igh risks risks.. Pedi Pediatr atr Rad Radiol iol 2008 2008;; 38:635-44. 18. Pie Pierce rce DA, Shi Shimiz mizu u Y, Pre Presto ston n DL, et al. Stu Studie diess of the mortal mor tality ity of ato atomic mic bom bomb b sur surviv vivors ors.. Re Repor portt 12, par partt 1. Cancer: 1950-1990. Radiol Res 1996;146:1-27. 19. Kupperman N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injures after head trauma: a prospective cohort study. Lancet 2009; 374:1160-70. 20. Nuñez DB, Zuluaga A, Fuentes-Bernardo DA, et al. Cervical spine spi ne tra traum uma: a: how muc much h mor more e do we lea learn rn by rou routin tinely ely usi using ng helical CT. Radiographics 1996;16:1307-18.
Emerg Med 2007;49:320-4.
21. Nuñ Nuñez ez
concept and is not an appropriate approach to the evaluation of the pediatric trauma patient.
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2. Met Mettle tlerr FA, Wie Wiest st PW, Loc Locke ken n JA, et al. CT sca scanni nning: ng: pat patter terns ns
of use and dose. [see comment] J Radiation Radiation Protect 2000;20: 2000;20: 353-9. 3. Brenner DJ. Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative. Pediatr Radiol 2002; 32:223-8 [discussion 242-224]. 4. Br Bren enne nerr D, Ell Ellis isto ton n C, Ha Hall ll E, et al al.. Es Esti tima mate ted d ri risk skss of rad radia iatio tionn-ind induce uced d fa fatal tal can cance cerr fro from m pe pedia diatri tric c CT. [See comment] AJR Am J Roentgenol 2001;176:289-96.
DB,, Qu DB Quen ence cerr RM RM.. Th The e ro role le of he heli lica call CT in th the e assessment of cervical spine injuries. AJR Am J Roentgenol 1998;171:951-7. 22. Keenan Keenan HT, Hollin Hollingshe gshead ad MC, Chun Chungg CJ, et al. Using CT of the ce cervi rvica call spi spine ne for ea early rly eva evalua luatio tion n of ped pediat iatric ric patients pati ents with head trau trauma. ma. AJR Am J Roen Roentgen tgenol ol 2001 2001;; 177:1405-9. 23. Blackmore CC, Ramsey SD, Mann FA, et al. Cervical spine screening with CT in trauma patients: a cost-effectiveness analysis. Radiology 1999;212:117-25.
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EC, Sheryl GA, Lenworth MJ, et al. A prospective analysis of a two-year experience using computed tomography as an adjunct for cervical spine clearance. J Trauma 1991;31:1001-6. 25. Nuñez BA, Adel A. Clearing the cervical spine in multiple trauma tra uma vic victim tim:: a tim time-e e-effe ffecti ctive ve pro protoc tocol ol usin usingg hel helica icall computed tomography. Am Soc Emerg Radiol 1994;1:273-7. 26. Shiran S, Jime Jimenez nez R, Altma Altman n D, et al. Evalu Evaluatio ation n of C-sp C-spine ine HRCT. Pediatr Radiol 2005 [abstr].
RA, Lund DP. Abdominal trauma. In: Fleisher GR, Ludwig S, eds. Textbook of pediatric emergency medicine, 5th ed. Phila Philadelp delphia hia (Pa): Lipp Lippinco incott tt Willia Williams ms & Wilki Wilkins; ns; 2006. p. 1453-62. 34. Ho Holm lmes es JF JF,, Ma Mao o A, Aw Awas asth thii S, et al al.. Va Vali lida dati tion on of a prediction rule for the identification of children with intraabdomina abdo minall inju injuries ries after blunt torso trau trauma. ma. Ann Emerg Med 2009;54:528 2009;54:528-33. -33. 35. Rozycki GS, Feliciano DV, Schmidt JA. The role of surgeon-
Slack SE, Clancy Emerg Clancy MJ. Clearing Clear ing the cervicall spine of paediatri cervica paediatric c trauma patients. Radiol J 2004;21:273-7. 28. Vicce Viccelli llio o
P, Sim Simon on H, Pre Pressm ssman an BD, et al. A pro prospe specti ctive ve multicente multice nterr stud study y of cer cervic vical al spi spine ne inj injury ury in chi childre ldren. n. Pediatrics 2001;108:e20 2001;108:e20.. 29. d'Amato C. Pediatric spinal trauma: injuries in very young children. Clin Orthop Related Res 2005:34-40. 30. Fes Fesmir mire e FM, Lut Luten en RC RC.. The ped pediat iatric ric cer cervic vical al spi spine: ne: developmental anatomy and clinical aspects. J Emerg Med 1989;7:133-42. 31. Sadetzki S, Chetrit A, Lubina A, et al. Risk of thyroid cancer after aft er chi childh ldhood ood exp exposu osure re to ion ionizi izing ng rad radiat iation ion for tin tinea ea capitis. J Cli Endocrinol Metab 2006;91:4798-804. 32. Ron E. Let's not relive the past: a review of cancer risk after diagnostic or therapeutic irradiation. Pediatr Pediatr Radiol 2002;32: 739-44.
per perform formed ed ultrasou asound nd in pat patien ients ts wit with h poss possible ible car cardia diac c wounds. Annultr Surg 1996;223:737-46. 36. Americ American an Colle College ge of Emer Emergenc gency y Physi Physician cians. s. Use of ultra ultra-sound imaging by emergency physicians. Ann Emerg Med 2001;38:470-81. 37. Ma Ma OJ, Mat Mateer eer JR JR.. Ped Pediatr iatric ic app applic licati ations. ons. In: Pri Price ce DP, Peterson MA, eds. Emergency ultrasound, 2nd ed. Columbus (Ohio): McGraw-Hill Companies; 2003. p. 464-89. 38. Mut Mutab abag agan anii KH KH,, Co Cole ley y BD BD,, Zu Zumb mber erge ge N. Pr Prel elim imin inar ary y experience with focused abdominal sonography for trauma (FAST) (FA ST) in ch child ildren ren is it use useful ful.. J Ped Pediat iatrr Sur Surgg 199 1999;3 9;34: 4: 48-52. 39. Holme Holmess JF, Bra Brant nt WE, Bon Bond d WF. Eme Emerge rgency ncy dep depart artmen ment t ultrasonograph ultrason ography y in the evalua evaluation tion of hypote hypotensive nsive and normotensive children with blunt abdominal trauma. J Pediatr Surg 2001;36:968-73.
Abstract: The acutely injured child poses unique clinical challenges in many respects. Our understanding of these unique characteristic differences and ability to care for pediatric trauma patients patien ts has greatly improved over recent decad decades; es; however, however, one one area in pediatric pediat ric trauma care continues to suffer from relative neglect in research and shows few signs of improvement improve ment in clinical practice: practice: analgesia. Studies of analgesia practices continue to describ describe e pervas pervasive ive undertreatment of pain in the pediatric trauma patient. A growing body of evidence evidenc e suggests that poorly controlled tro lled acu acute te pai pain n (olig (oligoan oanalge algesia) sia)not not only causes suffering suffering but may lead l ead to both immediate complications that worsen outcomes as well as debilitating chronic pain syndro syndromes mes that are often refractory to available treatments. This article will provide a review of pain in injured children with
Analgesia for the Pediatric Trauma Patient: Primum Non Nocere? Michael Greenwald, MD valuati valua ting ng pai pain n in the tr traum auma a pat patie ient nt po poses ses uni unique que challe cha llenge ngess as it may sim simult ultane aneous ously ly inv involv olve e bot both h somatic and visceral pain from a variety of origins. The pain response is a complicated process that may evolve from fro m acu acute te (no (normal rmal)) to chr chronic onic (ma (malad ladapt aptive ive)) pai pain n with per persist sistent ent
respect to its pathophysiology, respect pathophysiology, clin ical ramifications, and patterns of analgesia analge sia practic practices. es. Impedim Impediments ents to analgesia are examined regarding multiple providers of care for the acutelyy injured child including preacutel hospitall person hospita personnel, nel, nurses, and physicians sici ans.. Fin Finally ally,, the arti article cle will pro provide vide analgesia recommendations with an approach to pain relief and sedation for the injure injured d pediat pediatric ric patient.
orr repetitive exposure to injury-provoked pain. This is true for o patients of any age; however, children appear especially vulnerable to the harmful effects of oligoanalgesia. Understanding how both acute and pain occurs maycause help us betterchanges control and prevent thechronic pain responses that can harmful after injury. A comprehensive description of pain physiology in the pediatric trauma patients is beyond the scope of this article. Instead, Instea d, we will focus focus on select select concep concepts ts of the pain response response,, how the pediatric patient's response to injury and pain are unique, and how chronic pain syndromes are thought to occur. These painrelat re lated ed iss issues ues inc includ lude e vi visce scera rall vs som somat atic ic pa pain, in, the str stress ess response, hypersensitivity vs habituation, central nervous system (CNS) plastic plasticity, ity, hyper hyperalgesia algesia,, and centra centrall sensiti sensitization. zation.
Keywords: oligoanalgesia; oligoana lgesia; pain; pediatric; pediatric; trauma Pediatrics and Emergency Medicine, Emory Univer University sity School School of Medicine Medicine,, Chi Chilldren’s Health care of Atlanta, Atlanta, Atlanta, GA. Reprint requests and correspondence: Michael Greenwald, MD, 1604 Clifton Rd NE, Atlanta, GA 30322 30322.. [email protected]
1522-8401/$ - see front matter © 2010 Published by Elsevier Inc.
KEY CONCEPTS OF PAIN PATHOPHYSIOLOGY IN THE INJURED CHILD Visceral vs Somatic Pain
Somatic and vis Somatic viscera cerall pai pain n syst systems ems hav have e dis distinc tinctt phy physiol siologic ogic and clinical features. Cutaneous somatic innervation is more dense and an d li limi mite ted d to a fe few w sp spina inall se segm gment ents; s; th ther eref efor ore, e, cu cutan taneo eous us som somati atic c pain is better localized and characterized by specific sensations. Deep somatic pain (muscles, joints) resembles resembles visceral pain in its dull nature and poor localization. Visceral organs are innervated
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by 2 sets of nerves: vagal and spinal nerves nerves or pelvic and spinal nerves. Most internal organs are inner-
investigators found that the control group demonstrat str ated ed hig highe herr lev levels els of str stress ess hor hormon mones es (e (eg, g,
vated vate d by th the e va vagu guss ne nerv rve; e; ho howe weve ver, r, it itss ro role le in tran tr ansmi smitt ttin ingg pa pain in si sign gnals als is not ye yett cl clea ear. r. Mo Most st viscera visc erall aff affere erent nt fib fibers ers are thi thinly nly myel myelina inated ted or unmye unm yelin linat ated ed pr prov ovid idin ingg a du dull ll and dif diffic ficult ult to describe sensation. Visceral pain has poor localization tio n as inp input ut is typi typical cally ly dis distri tribut buted ed ove overr seve several ral spinal segments. This leads to similar pain sensations from nociceptive activity in unrelated organs (eg,, uri (eg urinar nary y bla bladde dderr and colon, gal galll bla bladde dderr and heart). Visceral nerves receive convergent somatic input (skin, muscle) resulting in referred pain to unrelated sites (eg, retrosternal pain to the neck, cardiac ischemic pain to neck, shoulder, or jaw). The str stronge ongerr emot emotiona ionall and aut autonom onomic ic rea reacti ctions ons seen with visceral pain may reflec reflectt the involv involvement ement of the ant anteri erior or cing cingula ulated ted gyr gyrus, us, amyg amygdal dala, a, and insular cortex. Last, visceral nociceptor activation can occur even in the absence absence of of tissue damage (eg, 1,2 functional abdominal pain).
hyperglycemia, lactic acidemia), greater incidence of sepsis and dissemi disseminated nated intravascular intravascular coagulopathy, and had a 27% mortality rate. The intervention ti on (m (med edic icat ation ion)) gr group oup ha had d no in incr crea ease se in pulmonar pulm onary y or cir circula culatory tory comp complica lication tionss and no deaths. The results starkly contradicted prevailing wisdo wi sdom m at th the e ti time me an and d we were re so re rema marka rkable ble the study was ended prematurely as it was considered too ri risky sky to co cont ntinu inue e pr prac acti tici cing ng th the e st stan anda dard rd of ca care re.. Finally, behavioral changes seen in patients with poorly controlled pain include crying, agitation, and sleep disturbance. In one study, children in a burn unitt wer uni were e fou found nd to hav have e pos posttr ttraum aumati atic c str stress ess disorder symptoms inversely related to the amount of morphine adminis administered tered 6 months prior at their 6 initiall present initia presentation. ation. Thus, many physiologic, biochemical, and behavioral changes associated with poorly controlled pain are the very consequences of injury we hope to prevent and control to facilitate healing and preve prevent nt harmful outcomes.
The Stress Response Acute pain results in a stress response that manifests in physiologic, biochemical, and behavioral changes associated with hemodynamic instabilit bi lity y an and d po poor or wo wound und he heali aling ng.. In Infa fant ntss ar are e particularly partic ularly vulnerable to chang changes es in intracr intracranial anial pressures related to fluctuations in systemic vascular pressures because of an immature blood brain barrier. Autonomic responses to acute pain lead to fluctuations in heart rate and blood pressure. These
Hypersensitivity vs Habituation One of to thepain clinical a healthyThat adult's response is thehallmarks ability to of habituate. is, with repeated or prolonged exposure to a similar stimulus, the the autonomic autonomic responses responses tend to lessen. lessen. In contrast, contra st, younger patie patients nts tend to demonstrate just the opposite. This is classically found with the heel prick of a neonate. With repeated exposures, the infan inf antt ex exhib hibit itss a low lower er pa pain in th thre resho shold ld (i (ie, e, mo more re br brisk isk
fluctuations in heart rate and blood pressure. These
infan inf antt ex exhib hibit itss a low lower er pa pain in th thre resho shold ld (i (ie, e, mo more re br brisk isk
respons respo nses es ma may y di dimi minis nish h wi with th pe pers rsist isten entt pa pain in an and d ar are e often not a reliab reliable le marker for the presen presence ce of pain. Pain is also ass associa ociated ted wit with h hyp hypove oventi ntilati lation on tha that t may ma y le lead ad to hy hypo poxi xia. a. Th This is ma may y ex expl plai ain n th the e seemingly paradoxical effect of improving respiratory function in critically ill patients when wh en treating treating 3,4 their pain with effective doses of opioids. Persis Per siste tent nt or sev sever ere e pa pain in is ass assoc ociat iated ed wit with h
flexor response) and autono autonomic mic labilit lability. y. Similarly, older children report increased perception o perception off pain if preceded by repeated painful experiences. 8 On a co conc ncep eptua tuall le leve vel, l, the re reaso ason n why in infan fants ts may differ in a pain experience lies in the difference in underst und erstand anding ing and pro process cessing ing the mea meaning ning of a painful experience. This is one of the most challenging areas to explore; it is unlikely we will ever
elevated eleva ted lev levels els of “ str stress ess horm hormone oness ” such such as catech cat echolam olamines ines,, gluc glucago agon, n, gro growth wth hor hormone mone,, and lacta lac tate te and ke keton tones, es, whe where reas as ins insuli ulin n le level velss ar are e suppressed. suppres sed. Neonat Neonatal al catec catecholamine holamine and metabo metabolic lic responses are 3 to 5 times greater than those in adults undergoing similar types of surgery. One of the most significant clinical studies on the harmful effects of poorly control controlled acute pain was reported by Ana Anand nd and Hickey Hickey5 in 1992. At the time the standard of care in anesthesia held that neonates would woul d exp experi erienc ence e wor worse se outc outcomes omes if pro provid vided ed a compar com parabl able e lev level el of ane anesthe sthesia sia dur during ing sur surger gery. y. 5 Anand and Hickey conducted a trial with neonates requirin requ iringg cong congenit enital al hea heart rt dise disease ase rep repair. air. The
know how inf know infant antss per percei ceive ve a pain painful ful exp experie erience nce.. Pain experiences experiences have both physic physical al and emotional components that affect the reaction. Our cognitive maturity allows us to attenuate the emotional and neurophysiologic response of a non–life-threatening injur inj ury. y. On One e ex exam ample ple is the pa pain in fr from om a per percu cuta tane neous ous needle nee dle ins insert ertion. ion. The pai pain n exp experi erience enced d fro from m tra trauma uma assoc ass ocia iate ted d wi with th a ne need edle le in inser serti tion on is li like kely ly sim simila ilarr on an ana anatomi tomical cal lev level el in dif differ ferent ent age aged d ind indivi ividua duals. ls. The pain stimulates the same nociceptors, results in the release of similar neurotransmitters, and travels on the same neural pathways to similar areas of the brain. A healthy, mature individual should recognize the source of the pain as something that has a
VOL. 11, NO. 1 ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
positive purpose (to improve health) and a limited
the site of injury and the dorsal horn of the spinal
duration and intensity. Even the adult with needle phobia will recognize that the pain experienced will
column. These changes may be temporary or long lasting. They are seen at a variety of levels including
dissipate and dissipate and not recur recur without warning warning.. Infants Infants and to a le lesse sserr ex exte tent nt ch chil ildr dren en la lack ck th this is pe pers rspe pect ctiv ive. e. Th This is may also help explain why the stress response to the same pain stimulus is more brisk brisk and and intense in less 7 mature or adapti adaptive ve individ individuals. uals. There are severa severall possibl possible e physiolo physiologic gic explanations for this phenomenon. One of the important components of pain physiology is modulation. Pain respo re spons nses es ar are e ei eith ther er amp amplif lifie ied d or at atte tenua nuate ted d at the th e le leve vell of th the e do dors rsal al ho horn rn of th the e sp spin inal al co cord rd through thro ugh the rele release ase of exc excitat itatory ory and inh inhibit ibitory ory neurotr neur otransmi ansmitte tters. rs. Less mat mature ure pat patien ients ts hav have e a relative deficiency of inhibitory neurotransmitters and some inh inhibi ibitor tory y neu neurotr rotransm ansmitte itters, rs, such as γ-Aminobut -Aminobutyric yric acid (GABA), (GABA), have an exc excitat itatory ory
changess in pro change protei tein n phos phospho phoryla rylatio tion, n, alt altere ered d gen gene e expre ex pressi ssion, on, los losss of neu neuron rons, s, for format mation ion of ne new w synaps syn apses, es, and los losss of inh inhibi ibitor tory y int intern erneur eurons ons.. Local tissue damage in the early postnatal period results in profound and lasting sprouting of sensory nerv ne rve e te term rmina inals ls (A & C fi fibe bers) rs) an and d sp sprou routi ting ng of neighboring dorsal root ganglia cells in the spinal cord cor d lea leadin dingg to ina inappr ppropr opriat iate e fun functio ctional nal con connec nec-tions tio ns and hyp hyperi erinnn nnnerv ervati ation. on. Cli Clinic nicall ally, y, the these se change cha ngess res result ult in allod llodynia ynia and oth other er fea featur tures es of 10 neuropathic pain. Repeti Rep etitiv tive e pai pain n also app appear earss to acc accele elerat rate e apo apo-ptosis. This refers to the “ pruning ” of unused neural pathways. Although this is a normal phenomenon durin dur ingg in infa fanc ncy, y, it app appea ears rs to be ac acce cele lera rate ted d in
effect in theexplanation premature infant. Another lies at higher levels in a process pro cess kno known wn as int integr egrati ation. on. Whe When n pai pain n sig signals nals ascend to the brain, they are distributed distributed to multiple supraspinal centers including the reticular activating system, olivary, paraventricular, and thalamic nuclei; nuc lei; limb limbic ic syst system; em; cin cingula gulate te and post postcent central ral gyrus; frontal and parieto-occipital areas. At these
lab labora orator tory y ani animals mals subject ected ed ed to with repeat rep eated ed ation painful pai nful stimuli. Finally, painsubj is associat associated activation activ of N -methyl -methyl D -aspart -aspartate ate (NMDA) recept receptors ors located on neurons neu rons.. The rec recept eptor or is act activa ivated ted by glut glutama amate te ++ + resulting in an influx of Ca and Na activating a Ca++–calmodulin complex. This leads to production of hea heatt sho shock ck pr prote oteins ins tha thatt ca cause usess lys lysoso osome me degranulation and necrosis of the nerve cell. The
levels, the pain signal is integrated and processed. Pain is identified by its localization and characteristics. The information is matched with memories of past pa st ex expe peri rien ence cess th that at in tu turn rn me medi diat ate e le leve vels ls of arousal, attention, attention, and sympathetic responses. responses. In laborat lab oratory ory stu studie dies, s, less mat mature ure subj subject ectss dem demononstrate less inhibitory pathway activation compared to more mature mature subj subject ects. s. It is hyp hypoth othesiz esized ed tha that t
activation of NMDA receptors is thought to contribute to the development of chronic pain syndromes. Intere Int eresti sting ngly, ly, thi thiss pr proc ocess ess is in inhib hibite ited d wi with th the administration of opioids as well as “ NMDA receptor antagonists” such as ket ketami amine, ne, met methad hadone one,, and 11,12 nitrous oxide. Clinical evidence of these changes is found in the association of chronic conditions conditions with with exposure to
recognition of nonharmful painful stimuli can aid in recognition blunting the pain signal. This ability logically relates
painfu pain full st stim imul uli. i. An Anan and d et al13 descr described ibed how functional abdominal pain is seen in higher rates
to experiences and and age and is inherently deficient in younger patients.9
Central Nervous System Plasticity One of the gre greate atest st con concer cerns ns reg regard arding ing olig oligoaoanalg na lges esia ia in yo youn ungg pa pati tien ents ts is th the e po pote tent ntia iall fo forr altering the developing CNS. The plasticity of the nervous system is now recognized in all age groups butt is th bu thoug ought ht to ha have ve a pa part rticu icula larly rly pr prof ofou ound nd impac imp actt on you young ng ch child ildre ren n be beca cause use the they y hav have e rapidly rapidl y develo developing ping nervous systems. Pain resea researchrchers have demonstrated that poorly controlled and repetitive repeti tive exposure to pain has a unique and lasting negative impact on the CNS of young patients and that this eff effect ect is pot potent entiall ially y mor more e pro profoun found d with less maturity. In lab labora oratory tory studies studies of rat pups, the rep repeat eated ed exposure to pain results in morphologic changes at
in for former mer pr prema ematur ture e in infan fants ts who ex expe perie rienc nced ed freque fre quent nt gas gastri tric c suc suctio tionin ning. g. Stud Studies ies usi using ng PET scans sc ans ha have ve re reve veal aled ed th that at th the e an ante teri rior or ci cing ngula ulate te cortex is particularly affected by pain. This area is associa asso ciated ted wit with h con control trol of emo emotio tion n and att attent ention ion and may help explain why premature infants who experience experi ence more medica medicall complic complications ations exhibit a highe hig herr ra rate te of ps psych ychoso osocia ciall dis disord order erss suc such h as attention atten tion defic deficit it hyper hyperactiv activity ity disord disorder er (ADHD (ADHD)) and low lower er ac acad ade emic ac achie hieve vemen mentt com compar pared ed to 14 matched controls.
Pathways to Chronic Pain: Hyperalgesia, Central Sensitization, and Sympathetically Mediated Pain Multiple pathways are described to explain the develo dev elopme pment nt of chr chronic onic pai pain n aft after er inju injury. ry. The These se mechanisms include hyperalgesia from local inflammatory markers, sensitization of neurons proximal
ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
to and sur surroun roundin dingg dam damage aged d ner nerves ves,, and symp sympaathetically thetic ally mediate mediated d pain. Afterr an injur Afte injury, y, infla inflammat mmatory ory medi mediator atorss are released that may cause the pain response to increase even ev en in th the e ab abse senc nce e of ad addi diti tion onal al in inju jury ry.. Th This is
VOL. 11, NO. 1 31
and stab stabiliz ilizing ing neur neurons. ons. The cli clinic nical al res result ult may includ inc lude e a low lower er inc incid idenc ence e of sep sepsis sis,, met metab aboli olic c acidosis, disseminated intravascular coagulopathy, and death. Given this information, it appears that pain pa in co cont ntro roll is im impo port rtan antt fo forr al alll pa pati tien ents ts an and d
sensitization of nociceptors results in primary hyperalgesi alg esia a at the sit site e or inj injury ury.. Pri Primar mary y hyp hypera eralge lgesia sia manifests clinically as a more intense pain response than expected from stimuli. Secondary hyperalgesia may ma y de deve velo lop p in th the e ar area ea su surr rrou ound ndin ingg th the e ar area ea of in inju jury ry as a result of sensitization of neurons in the CNS. This centra cen trall sen sensiti sitizat zation ion occ occurs urs whe when n rec recept eptors ors tha that t normal nor mally ly con conduc ductt non nonpai pain n sig signal nalss (eg (eg,, tou touch) ch) now transm tra nsmit it pa pain in sig signal nals. s. Whe When n non nonpai painfu nfull sti stimul mulii suc such h as touch result in a pain response the condition is called allodynia. Clinical examples of this include the severe and diffuse pain associated with burns (light touch), pharyngi phar yngitis tis (swal (swallowin lowing), g), arth arthriti ritiss (move (movement) ment),, and in more unusual conditions conditions such as compl complex ex regi regional onal
particularly the youngest. Ironically, studies of our clinical practice reflect just the opposite.
pai pain n syn synd d15 r ome (for (formerl merly y refle reflex x sympa sympathet thetic ic dystrophy). Hypera Hyp eralge lgesia sia may also res result ult fro from m dam damage aged d or severed nerves. Instead of a diminished pain signal, Wallerian degeneration of the severed nerve may result res ult in sens sensiti itizati zation on of noc nocice icepto ptors rs in adj adjace acent nt nerves (primary hyperalgesia) and increase spontaneous activity of adjacent nociceptors resulting in
examine the following aspects of clinical practice. What are the patterns of analgesia for pediatric patien pat ients? ts? Wha Whatt are the pat patter terns ns of ana analge lgesia sia for trau tr auma ma pa pati tien ents ts? ? Wh What at ar are e som some e of th the e imp imped edim iment entss to pro provid viding ing ana analge lgesia sia for ped pediat iatric ric tra trauma uma pat patien ients? ts?
Analgesia for Children
central sensitization (secondary hyperalgesia). This paradoxical pain response manifests in the clinical syndrome of neuropathic pain. Symptoms include intense burning and electrical sensations sensations that are often refractory to opioids in usual doses. 15 As noted above, nociceptor stimulation is often associated with a resulting increase in sympathetic activi act ivity. ty. In some cir circums cumstan tances ces,, the rea reacti ction on revers rev erses: es: noci nocicep ceptor torss may dev develop elop sens sensiti itivit vity y to catecholamines. This is known as sympathetically maintained maintai ned pain. In these condit conditions, ions, trauma (even seemingly trivial trauma) provokes a pain response that features not only hyperalgesia but also allody-
This Th is ye year ar ma mark rkss a de deca cade de si sinc nce e th the e Jo Join int t Commission Commissi on on the Acc Accred redita itatio tion n of Hea Healthc lthcare are Organi Org anizat zations ions cit cited ed ina inadeq dequat uate e ana analge lgesia sia as the first fi rst no nond ndise iseas ase e he healt althc hcar are e cr cris isis is in th the e Uni Unite ted d States Sta tes.. Its re respo sponse nse to thi thiss pr probl oblem em inc includ luded ed numerous guidelines, resources, and requirements to assess and tre treat at pain. Despite Despite this effo effort, rt, it is unclear whether we have seen improvement in the clinical practice of pain management for children. Pain Pai n re resea searc rch h sin since ce th the e 19 1970 70ss de descr scrib ibes es how children are given analgesics less often than adults for similar conditions and prescr prescribed ibed approximateapproximately 50% of the wei weight ght-ba -based sed equ equiva ivalen lentt of ana analge lge--
ANALGESIC PRACTICE FOR PEDIATRIC TRAUMA PATIENTS Most of the information available regarding pain management for pediatric trauma patients focuses on iso isola late ted d in inju juri ries es an and d bur burns ns.. Th Ther ere e ar are e mor more e studie stu diess ad addr dress essing ing pai pain n man manag ageme ement nt for ad adult ult trau tr auma ma pa pati tien ents ts th than an fo forr ch child ildre ren. n. In ge gener neral al,, studies on analgesia practice in medicine over the pastt sev pas severa erall dec decade adess rev reveal eal per pervas vasive ive pat patter terns ns of appare app arent nt und undert ertrea reatmen tment. t. In thi thiss sec section tion,, we will
Pain resp responses onses appear heig heighten htened ed in young younger er patien pat ients ts whose whose CNS is more vuln vulnera erable ble to phy physiol siologog-
sics.16 18 Furthermore, the milligram per kilogram dosing of analgesics is generally directly related to age, that is, younger patients receive lower milligram gr am pe perr kilogra kilogram m dosi dosing ng reg regar ardle dless ss of cl clin inic ical al situation.19 In 1996, Broome et al20 reported that younger children received inconsistent pain assessmentt and mana men managem gement ent and tha thatt ins instit tituti utiona onall standa sta ndards rds reg regard arding ing pai pain n cont control rol wer were e often often ignored. That same year, Cummings et al21 reported on children admitted to a Canad Canadian ian hospital, noting
ic stress. Repetitive Repetit ivechanges and persistent persist entnervous pain is associated associat with morphologic of the system ed at multiple levels. Analgesics have a neuroprotective effect effe ct by dec decrea reasing sing exhi exhibit bitory ory neu neurotr rotransm ansmitte itterr activity, increasing inhibitor inhibitory y neurotran neurotransmitters, smitters,
that hadanalgesics uncontrolled pain prescribed and thatedchildren were21% offered analgesi cs less than prescrib (ie, prn medications available but not provided). Interestingly, some studies have shown that those with pediatric subspecialty training may provide less
nia. The classic example is complex regional pain syndrome synd rome tha that, t, in the ped pediat iatric ric pat patien ient, t, typ typica ically lly involves the lower extremity of school-age girls and is of ofte ten n as asso soci ciat ated ed wit with h ed edem ema a an and d dr dram amat atic ic changess in cutaneous perfu change perfusion. sion.15
Summary of Neurophysiologic Reponses to Pain
VOL. 11, NO. 1 ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
analgesia than th eir generalist counterparts. In 2004, than their Cimpello et al22 described this in a review of more than 700 children with fractures seen in 3 emergency departments (EDs) for 2 years. In this study, general emergenc emer gency y physi physician cianss presc prescribe ribed d more anal analgesi gesics cs and recomm rec ommend ended ed pa pain in tre treatm atment ent and adv advice ice on dis dis-charg cha rge e mor more e oft often en tha than n the their ir ped pedia iatr tric ic emer emergenc gency y 23 medicine-trai medici ne-trained ned colleagu colleagues. es. Quinn des descri cribed bed a comparison of the use of local anesthetic for lumbar
therapeut therap eutic ic dos dosing ing,, and wit with h ana analge lgesic sic adv advice ice given at 74% of visits. Children with burns received analgesics even less often (26% of visits), with 70% therap the rapeut eutic ic dos dosing, ing, and with only 27% rec receivi eiving ng 28 analgesia analge sia instru instructions ctions at dischar discharge. ge. O'Donnell29 found that 49% of 172 children with musculoskeletall inj eta injuri uries es pre presen sentin tingg to an ED wer were e pro provid vided ed analgesics. Another 2002 study noted only 50% of burn victims rec received eived adequate analgesia in EDs. 30
puncture in children and found an even more striking contrast contr ast betw between een those with and with without out pedi pediatri atric c subspe sub speci cialt alty y tra traini ining ng.. In thi thiss stu study dy of ch child ildren ren
Neighbor et al31 described opioid use for severely injured patients in a level I trauma center over the course of 1 year. Of more than 500 cases, only 48%
pr pres esen enti ting ng to di diff ffer eren entt ED EDs s in Ba Balt ltim imor ore, e, training 93% 93 % of children treated by those without pediatric receive rece ived d loca locall lido lidocai caine ne bef before ore lumb lumbar ar punc puncture ture,, wher wh erea eass on only ly 4. 4.5% 5% of ch chil ildr dren en pr pres esen enti ting ng to th the e childr chi ldren' en'ss hos hospit pital al ED rec receiv eived ed lid lidocai ocaine. ne. At the pediatric institution, those receiving lidocaine included 0 of 168 infants, 1 of 18 toddlers, and only 8 of 12 children older than 4 years. The treating physicians
re rece ceiv ived intra in trave venou s opi opioid oidss towit withi hin the first rst 95 3 hour ho urs s ed with wi th the th e nous mean me an time ti me firs fi rstnt do dose se fi of minute min utes. s. Ris Risk k fac factor torss for rec receiv eiving ing les lesss opi opioid oid included younger age (b10 years old), intubation, lower low er re revis vised ed tra traum uma a score score,, or no nott re requ quir irin ing g 31 fracture manipulation. Studies of prehospital care demonstrate 2 patterns. In general, prehospital personnel tend to undertreat
were as were aske ked d wh whet ethe herr pa pain in wa wass ex expe peri rien ence ced d to th the e sa same me degree degr ee reg ardl ardles esss of ag age e an and d 51 51% % ag agre reed ed wi with th th this is statement.23 In ad addi diti tion on to th the e pa patt tter erns ns fo found und in ped pedia iatr tric ic patients, studies of other specific demographic groups have also demo demonstra nstrated ted patt patterns erns of oligo oligoanalg analgesia esia.. Elder Eld erly ly pa patie tients nts (N70 year yearss old old)) als also o re recei ceive ve les lesss analgesia in the ED.24 Analg Analgesia esia research research by Todd et
pain in trauma patients; however, when analgesia is provid pro vided ed by pre prehos hospi pital tal per person sonnel nel,, it mak makes es a significa signi ficant nt diff differen erence ce in the time to anal analgesia gesia compare pa red d to pa pati tien ents ts wh who o re rece ceiv ive e th thei eirr fi firs rstt do dose se of analge ana lgesia sia by hos hospit pital al per person sonnel nel.. A 200 2000 0 rep report ort on preho pr ehospi spital tal ana analge lgesia sia in mor more e tha than n 100 1000 0 pat patien ients ts showed that only 1.5% of pa of patients tients received analgesia after an extremity injury.32 A 2002 study on tran transs-
al25 has des descri cribed bed sign signific ificant ant ethn ethnic ic and rac racial ial dispar dis pariti ities es in the ad admin minist istrat ration ion of ana analge lgesia sia.. His Hispa panic nic patie pat ients nts in Los An Angel geles es wi with th iso isolat lated ed lon longg bon bone e fractures were twice as likely to receive no analgesia compared to non-Hispanic white patients, and black pati pa tien ents ts in At Atla lant nta a we were re le less ss li like kely ly to re rece ceiv ive e adequate analgesia analg esia comp compared ared with white pati patients ents..26 Finally, patte pat terns rns of sex di disc scri rimin minat atio ion n ar are e rep repor orte ted d wi with th women wom en oft often en re recei ceivin vingg les lesss ana analge lgesia sia tha than n men men..27 The Th e re reas ason onss fo forr th thes ese e pa patt tter erns ns of di disp spar arit itie iess ar are e difficult to elucidate but important to examine; they are addressed later in this article.
ports of patients ports patients with isola isolated ted lower lower extr extremity emity inju injuri ries es showed sho wed ana analge lgesic sic use in jus justt 18. 18.3% 3% of tra transp nsport orts. s.33 Sever Sev eral al stu studie diess on the use of pre prehos hospit pital al ana analge lgesia sia protoco pro tocols ls for inj injure ured d pat patien ients ts have dem demons onstra trated ted safety, effectiveness, effectiveness, and and increased use of prehospital 34-38 opioid analgesia. In a 2005 review of emergency medica med icall ser servic vices es (EM (EMS) S) tra transp nsport ortss by 20 dif differ ferent ent EMS agencies in Michigan, analgesia was provided by EMS for 22% of chi childr ldren en hav having ing fra fractu cture ress or bu burns rns;; how howeve ever, r, these the se ch child ildren ren re recei ceive ved d the their ir med medica icatio tions ns 1 hou hourr sooner than than those who had to wait for a dose provided by the ED.39
Impediments to Analgesia Analgesia in Trauma
Effortss to understand the causes of oligoan Effort oligoanalgesia algesia
Resea Res earch on analge ana lgesia sia pr prac actic e forrea traum tr auma a patien patients ts rch reveals revea ls similar patterns oftice undertr undert eatment, tment, partic par ticula ularly rly for chi childr ldren. en. Fri Friedl edland and et al28 compared analgesia provided for 215 children presenting to Ci Cinc ncinn innat atii Chi Child ldre ren's n's Hos Hospi pita tall (Oh (Ohio io). ). Children with vaso-occlusive crisis from sickle cell disease received analgesics at 100% of visits, within 52 min minutes utes (mea (mean), n), with 78% the therap rapeut eutic ic dosi dosing ng
have revealed a wide possible explanations. Influences may comearray from of the patient, family, and society as well as the medical profession. profession. For health care professionals, professionals, these explanations explanations include (1) fear of masking signs of serious injury or illness, (2) fearr of cau fea causing sing or exa exacer cerbati bating ng hem hemodyn odynamic amic or respiratory respir atory insufficiency, insufficiency, (3) inadeq inadequate uate pain assessment skills or efforts, (4) lack of understanding
(average) (avera ge),, and wit with h ana analge lgesia sia gui guidan dance ce giv given en on discharge dischar ge at 100% of visits. In compar comparison, ison, children with fractures received analgesics at 31% of visits, at 1.5 ho hours urs (me (mean) an) af after ter pr prese esenta ntati tion, on, wit with h 69 69% %
about pain and analgesics, and (5) concerns about creating addictive behavior by providing analgesia. One of the pur purpor ported ted rea reasons sons for with withhold holding ing analgesics in the trauma patient is the belief that
ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
VOL. 11, NO. 1 33
pain relie ieff ac achie hieved ved by ana analge lgesic sicss cou could ld mas mask k pain rel symptom symp tomss of an und underl erlying ying pat patholo hologic gic cond conditi ition. on. The Th e imp implic licat atio ion n is th that at out outco comeswill meswill wor worsen sen du due e to a delay in diagnosis and progression of symptoms. A study stu dy of 21 215 5 ph physi ysici cians ans an and d nu nurs rses es in 9 Is Israe raeli li
tion to this issue in a 1995 study that described a strikingg contrast in perceptions strikin perceptions among patien patients ts with multisystem injury in a critical care setting. Ninetyfive fi ve pe perc rcen entt of ho house usest staf afff an and d 81 81% % of nu nurs rses es re repo port rted ed adequate analgesia provided for patients who simul-
40 e fre tra trauma uma uni units ts rep report orted edassist thatt ana tha analges lgesics ics wer were freque quentntly (78%) withheld to diagnosis. Most providers in this study believed believed that analg analgesics esics should be withhe wit hheld ld in cas cases es of abd abdomi ominal nal or mul multis tisyst ystem em injury; however, 75% reported that they had had inade inadequate knowledge about pain management.40 Although seemingly logical, the paradigm that analgesia worsens outcomes is not substantiated in
taneously pain moderate or severe 74%ssment of the time.. It israted time logica log ical l tha that t imp improv roved ed pain pai n asse assessme nt would wou ld lea lead d to imp improv roved ed ana analge lgesia sia.. In a 200 2004 4 prospective study of 150 adult trauma patients, 60% of those with pain scores received analgesics compared to 33% without pain scores. The m The mean ean time to 51 analgesia was 68 minutes in this study. Howe However ver,, a recent pediatric study on pain assessment failed to
the li the lite tera ratu ture re.. Th The e ba basi siss fo forr th this is be beli lief ef ma may y li lie e in pa part rt with a classic surgical text originally authored by Cope, Early Diagnosis of the Acute Abdomen. The text states that in the setting of acute abdominal pain of unclear etiology analgesia will (1) mask signs and symptoms of a surgical condition causing a (2) delay in diagnosis with resulting (3) increase morbidity and mor mortal talit ity. y. Alt Althou hough gh th these ese ass asser ertio tions ns we were re
show a change in analgesia administration rates and time to analge analgesia sia with improved documentation of 52 pain scores. Barriers to analgesia likely occur at multiple steps beginning with pain assessment and then the response to that information. A study of 355 ED nurses revealed deficits in understanding underst anding pharma pharmacologic cologic analge analgesic sic princi principles ples and conc concept ept s such such as add addict iction, ion, tole toleran rance, ce, and
replicated in subseq replicated subseque uent nt editions, they do not offer supporting evidence.41 In recen recentt years, researchers researchers have attempted attempted to test this assumption with respec respect t to the patient with possible acute appendicitis. More than a half dozen studies have examined the use of morphine morphin e (typica (typicallly 5-mg 5-mg dose doses) s) in pat patien ients ts with 42,43 signs of peritonitis. None of the studies revealed a de dela lay y in di diag agnos nosis is or a ne nega gati tive ve ou outc tcome ome at attr trib ibute uted d to the the mor morphi phine. ne. One stud study y demonstrat d emonstrat ed improved ed improved localization of tenderness.44 Kim et al45 published the first pediatric study on this issue and also found no false-negative evaluations and no complications attributed to opioid used for children with an acute abdomen. Opioid use in trauma patients has received close examin exa minati ation on in the lit liter eratu ature. re. The 3 pr prima imary ry con concer cerns ns in acute pain management are altered mental status (ie,, mas (ie maskin kingg dis disord orders ers inv involv olving ing the CNS or CNS perfusion), respiratory depression, and masking serious injuries by blocking the pain response. Although exce ex cessi ssive ve do dosi sing ng of op opio ioid idss ca can n ce cert rtai ainl nly y ca caus use e CN CNS S or respir res pirato atory ry dep depres ressio sion, n, re resea search rch in cli clinic nical al use of opioi op ioids ds in tr traum auma a pat patie ient ntss do does es no nott sup suppo port rt the
dependence.53 Scor Scores es cor correla related ted with educ educati ation on level lev el and improved improved aft after er a 1-d 1-day ay semi seminar nar.. Fif Fiftytythree thr ee pe perce rcent nt of nur nurses ses ci cited ted the po poten tentia tiall for analgesics to mask signs of injury or illness as a barrier to providing treatment. Forty-eight percent p ercent reported report ed inadeq inadequate uate pain assessme assessment nt skills.53 In a 2004 study of prehospital personnel, Hennes et al54 found significant differences in the comfort level of EMS providers in administering analgesics depending depend ing on a patie patient's nt's condition. Of the subjects, 93% to 95% reported feeling comfortable providing analge ana lgesic sicss to pat patient ientss with pai pain n fro from m fra fractur ctures, es, burns, or nonspecific chest pain if the patient was older than 17 years. Much fewer respondents felt comfortable if similar patients were 7 to 17 years old (chest pain, 36%; extremity injury, 70%; burn, 77%) and even less if younger than 7 years (chest pain, pai n, 24% 24%;; ext extremi remity ty inju injury, ry, 38% 38%;; bur burn, n, 44% 44%). ). In this th is stu study dy,, re resp spon onde dent ntss ci cite ted d th the e fol follow lowin ingg as barriers to providing analgesia to pediatric patients: inabili ina bility ty to ass assess ess pai pain n (87 (87%), %), dif diffic ficult ult vas vascula cularr acce ac cess ss (8 (80% 0%), ), de dela lay y of tr tran anspo sport rt (66 (66%) %),, fe fear ar of compl co mplic icat ation ion (68 (68%) %),, re reco cord rd ke keepi eping ng (3 (30% 0%), ), and 54
presump presumpti tion on that analgesia outcomes. Buduhan et al46 studied more thanworsens 500 trauma patients and found fou nd no cor corre relat lation ion w ith ith op opio ioid id us use e an and d mi miss ssed ed 47 injuries. Lazarus et al reported a study of adverse
possible drugattention seeking (65%). Although to pain in the adult medical literature liter ature has incre increased ased exponentially exponentially in recent years, a focus on analgesia for children and trauma
drug events in more than 4000 trauma patients and found fou nd no ser seriou iouss eve events nts due to opi opioid oids. s. Fin Finall ally, y, sev severa erall large studies have demonstrated safety and efficacy of fentanyl used by EMS EMS for trauma patients 48 including
patients remains sparse. Much of the research in pediat ped iatric ric pai pain n cen center terss on ani animal mal mod models els.. Maj Major or pediatrics and pediatric emergency medicine texts still provide relatively little attention to pain. The
one pediatric study. Improving pain assessment is a prim primary focus for reducing oligoanalgesia. Whipple et al50called atten-
advanced trau advanced trauma ma life suppo support rt cours course e prac practical tically ly ignore ign oress the subject. subject. In pre previo vious us edi editio tions ns of the advanced trauma life support provider manual, pain
VOL. 11, NO. 1 ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
was bri brieflyaddre eflyaddresse ssed d in a par paragr agra aph thatfollow thatfollowed ed the 55 section on the secondary survey. The most recent editionhasomittedeventhisbriefmention.Theindex cites just 2 pages where pain is addressed in the current manual: as part of C-spine evaluation and under musculoskeletal trauma. In the latter section, the authors' guidance states “ Whenever analgesics, muscle musc le rel relaxa axants, nts, or sed sedativ atives es are admi adminis nister tered ed to an injured patient, the potential exists for respiratory injured arrest. ”56 In comp comparis arison, on, the Emer Emergenc gency y Nurs Nurses es Associa Ass ociation tion cour course, se, Adva Advanced nced Trau Trauma ma Nurs Nursing: ing: A Conceptual Approach, ha hass an entire chapter on pain pa in in the tr trau auma ma pa pati tien ent. t.57 This contra contrast st highli highlights ghts the differing emphasis emphasis on pain manage management ment seen in the nur nursin singg and med medica icall pro profess fession ions. s.
TABLE 1. Pain 1. Pain assessment scales. Patient Description
NIPS: Neonatal Infant Pain Scale
Wong Wo ng-B -Bak aker er Fa Face cess Sc Scal ale e
School age School adolescent
Visual Analog Scale