Intracranial bleeding as well as brain swelling and edema can increase intracranial pressure and reduce cerebral perfusion. Cerebral blood flow (CBF) is related to the intracranial pressure (ICP) and the
Area Infants Children Score assesseda
Eye opening Open spontaneously Open spontaneously 4
Open in response to verbal stimuli Open in response to verbal stimuli 3 Open in response to pain only Open in response to pain only 2
No response No response 1
Verbal response Coos and babbles Oriented, appropriate 5
Irritable cries Confused 4
Cries in response to pain Inappropriate words 3
Moans in response to pain Incomprehensible words or nonspecific sounds
2
No response No response 1
Motor responseb Moves spontaneously and purposefully
Obeys commands 6
Withdraws to touch Localizes painful stimulus 5
Withdraws in response to pain Withdraws in response to pain 4 Responds to pain with decorticate
posturing (abnormal flexion)
Responds to pain with flexion 3
Responds to pain with decerebrate posturing (abnormal extension)
Responds to pain with extension 2
No response No response 1
Table 16.3 Modified Glasgow Coma Scale for infants and children
a Score: 12 suggests a severe head injury, 8 suggests need for intubation and ventilation, 6 suggests need for intracranial pressure monitoring
b If the patient is intubated, unconscious, or preverbal, the most important part of this scale is motor response. This section should be carefully evaluated
cerebral perfusion pressure (CPP). The ICP value in children should be between 3 and 17 mmHg. It is man- datory to keep the ICP less than 20 mmHg. The CPP should be >50 mmHg up to 4 years of age, >60 mmHg between 5 and 8 years of age, and >70 mmHg for chil- dren over the age of 8. The current standard of care prompts a head computed tomography if the GCS value is less than 12 points. The indications for surgery are similar to adults, which include midline shifts (Fig. 16.2). For patients with a GCS of less than 8 points, monitoring with an intracranial ventricular or intraparenchymal device is recommended. In general, prognosis for recovery of the pediatric brain following head trauma is better than that of adults. If an intracra- nial hematoma is detected, emergent surgical evacua- tion is required. Initially, the head should be elevated up to 30. Respirator settings should aim at achieving O2 saturations of 100%.
16.7.2 Thoracic Trauma
Approximately 50% of pediatric polytrauma patients sustain thoracic injuries, and 25% of these are associ- ated with skeletal injuries. Mortality rises up to 39% if thoracic trauma is compounded with brain and abdom- inal injuries. The diagnosis of subcutaneous emphy- sema and/or paradoxical breathing requires rapid intubation and ventilation.
In children, increased chest wall compliance can cause severe pulmonary contusions in the absence of fractures, and life-threatening hemorrhage can occur.
Therefore, a chest CT should be performed, followed by blood gas analysis to monitor the oxygenation index (PaO2/FIO2 ratio, normal value 300–400) [11–13]
(Fig. 16.3). Surgical intervention is rarely necessary, but a thoracotomy is performed when control of bleed- ing is necessary. If lung fistulas develop, they may be treated electively. Although diaphragmatic lesions are rare, care must be taken to rule them out as bowel her- niations may occur with these injuries. The risk of Acute Respiratory Distress Syndrome (ARDS) is simi- lar to that of adults and Extracorporeal Membrane Oxygenation (ECMO) may be required.
16.7.3 Abdominal
Approximately 45% of polytraumatized children have abdominal trauma. Abdominal wall ecchymosis is a sign of serious visceral injury. Because the spleen and liver of children are proportionately larger and the dia- phragm is lower than in adults, intra-abdominal organs are more vulnerable to blunt trauma (Fig. 16.4).
Diagnostic tests to evaluate these organs include ultra- sound, commonly followed by a CT scan. Diagnostic
Fig. 16.2 Epidural hematoma, patient 8 month, fall from chair
Fig. 16.3 Lung contusion in X-ray plain (a) and in CT scan (b), patient 5 years, car accident
184 H.G. Dietz et al.
peritoneal lavage and diagnostic laparoscopy are rarely performed if a CT scan is available. Once diagnosed, blunt liver trauma can be graded according to the clas- sification of the American Association for the Surgery of Trauma (AAST) [6, 11, 14, 15] (Table 16.4).
Recent studies show that with most cases of solid organ injury, conservative treatment can be employed.
In cases with vascular injuries and minor bleeding, interventional radiology may be useful. When laparo- tomy for hemorrhagic control of the liver is required, direct suture and ligation of the bleeding vessels is employed to control blood loss. In grade V liver inju- ries, abdominal packing can allow time for resuscita- tion with a planned second look at a later time.
Although bowel lacerations and ruptures require sur- gery, intramural hematomas are usually well treated by conservative means. Pancreatic injuries such as contu- sions and ruptures usually heal, but may lead to the development of pseudocysts. Complete ruptures of the kidney or avulsed renal vessels require surgery and reconstruction. Hematomas and urinomas can easily be diagnosed by ultrasound, and ureteral or renal lesions can be managed by percutaneous drainage or endoscopically applied stents.
16.7.4 Spine Trauma
The relation between the head and the weak neck mus- cles in children is responsible for injuries to the cervi- cal spine. Injuries from C1 to C3 are more frequent in young children compared to adults. The majority of pediatric thoracic and lumbar spine injuries are type A injuries according to the OTA/AO classification and are treated with a removable molded body jacket, or fiberglass body cast. Distraction and rotation lesions are rare and require internal fixation [16].
16.7.5 Orthopaedic Injuries
Extremity injuries in the growing skeleton have to be treated cautiously. Some fractures do not require ana- tomic reduction, depending on age and classification.
Grade Injury description liver
I Hematoma Subcapsular, nonexpanding,
<10 cm surface area Laceration Capsular tear, nonbleeding,
<1 cm parenchymal bleeding II Hematoma Subcapsular, nonexpanding,
10–50% surface area
Intraparenchymal nonexpanding
<10 cm in diameter
Laceration Capsular tear, active bleeding;
1–3 cm parenchymal dept <10 cm in length
III Hematoma Subcapsular, >50% surface area or expanding;
Ruptured subcapsular hematoma with active bleeding;
Intraparenchymal hematoma
>10 cm or expanding Laceration >3 cm parenchymal depth IV Hematoma Ruptured intraparenchymal
hematoma with active bleeding Laceration Parenchymal disruption involving
25–75% of hepatic lobe
V Laceration Parenchymal disruption involving
>75% of hepatic lobe
Vascular Just a hepatic venous injury (i.e., retrohepatic vena cava)
VI Vascular Vascular avulsion
Table 16.4 Injury description liver
Fig. 16.4 Thoracic and abdominal marks in a patient ran over by a tractor
The ability to correct varus deformities may be as high as 60°. However, rotational deformities do not have the potential to remodel, and this may pose challenges in the lower extremity. Moreover, transi- tional fractures during skeletal maturation should not be overlooked and may require surgical inter- vention to avoid inadequate growth plate recovery (Fig. 16.5).
16.7.5.1 Diaphyseal Fractures
In closed diaphyseal fractures, the indications for elastic stable intramedullary nailing (ESIN) are more frequent than in adults. Given the short healing time of the growing skeleton, this technique is ideal to avoid injuries to the physis. Most surgeons prefer the ESIN technique because of higher patient comfort when compared with external fixation and plate oste- osynthesis. The elastic properties of the nails sup- port the biology of pediatric fracture healing by stimulating both periosteal and endosteal callus for- mation [18].
16.7.5.2 Articular Fractures
Articular fractures require meticulous reduction in order to avoid secondary deformities or early growth plate closure. These injuries should be treated by an expert in pediatric orthopaedic trauma.
16.7.5.3 Pelvic Fractures
Injuries to the pelvis are rare, but are frequently associ- ated with injuries to the bladder, urethra, and the rec- tum. The greater plasticity and elasticity of the pediatric pelvic ring explains why these injuries are often over- looked initially. Hemorrhage in the retroperitoneal or intraperitoneal space originates from the fractured bone or from disrupted vessels (veins) and can lead to life-threatening bleeding. Techniques for surgical sta- bilization are different than in the adult, and external fixation is frequently the technique of choice [19].
16.7.5.4 Physeal Injuries
Traumatic injuries to the growth plate (physis) may lead to growth arrest with length discrepancies or angu- lar deformities. Numerous descriptive and prognostic classification schemes have been devised. The anatom- ical classification of Salter and Harris described in 1963 [20] is widely accepted and utilized routinely (Table 16.5 and Fig. 16.6).
80 30
70 55
45 80
20
Fig. 16.5 Corrective potential (in %) of extremity injuries [17]
Type I
A complete physeal fracture with or without displacement Type II
A physeal fracture that extends through the metaphysis, producing a chip fracture of the metaphysis, which may be very small
Type III
A physeal fracture that extends through the epiphysis Type IV
A physeal fracture plus epiphyseal and metaphyseal fractures Type V
A compression fracture of the growth plate Table 16.5 Salter Harris classification [20]
186 H.G. Dietz et al.
16.7.5.5 Corrective Potential
In the growing child, there is the potential of correct- ing angular deformities in all three planes. The correc- tive potential is dependent on the fracture type, location, age, degree of angulation, and the level of activity of the physis. Younger patients have greater metabolically active physes, with greater potential for correcting malunited fractures spontaneously. Sagittal plane angular deformities correct better than coronal plane deformities, and varus deformities correct better than valgus deformities. Bones remodel in response to body weight, muscle action, and by intrinsic control mechanisms of the periosteum. In meta-diaphyseal angular deformities, bone degradation will occur on the convex side and appositional bone formation occurs on the concave side. These biological mechanisms are described in the law of Roux and the thesis of Wolff.
Although spontaneous correction is possible, accurate anatomic alignment should be attempted whenever reasonably achieved by conservative or operative means, especially in the lower limbs.
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I II III IV V
Fig. 16.6 Anatomical classification of Salter and Harris [20]