Tia Dickson, RN, BSN

PCH trauma nurse and Utah EMSC nurse clinical consultant

Excerpts from June 10, 2024 PETOS

One child dies from injury every hour. Trauma is still the main reason EMS is called for a pediatric patient. We know that their large heads and weaker necks make a child more susceptible to serious head injury, but a child's anatomy also contributes to greater risk of abdominal injury. The square shape and crowding of organs means that thoracic (chest) and abdomen injury come hand in hand. Thinner muscle, less fat, and compliant bones make for terrible shock absorption. The intestines are not fully attached to the peritoneal cavity so they are vulnerable to sudden deceleration or compression.

• Abdominal trauma is present in approximately 25% of pediatric patients who have major trauma
  
• It is the most common site of initially unrecognized fatal injury in children, with a fatality rate as high as 8.5%
  
• The injury Is typically blunt in nature and 95% of these injuries are managed nonoperatively
  
• Penetrating injuries are less common
• U.S. firearm injuries are by far the most common mechanism
  

The frequency of organ injury is different for blunt vs. penetrating injuries, but typically there are multiple organs damaged in abdominal trauma.

The liver is the largest solid organ in the abdomen; the spleen is poorly anchored. These two organs are frequently injured. They do not typically result in death, especially in recent years. Death is more often due to associated head injury.

• Pediatric blunt spleen injury fatality rate has fallen from 4.1% to 2.9%
• Pediatric blunt liver injury fatality has fallen from 6.3% to 4.4%

Nearly all the time (98%) these injuries are managed non-surgically. Care decisions are based on hemodynamic stability and not by AAST grading.

Start with:

• Bed rest, diet advancement, hemoglobin checks
• Transfusion for instability or hemoglobin <7g/dl

Reasons requiring OR intervention:

• Hemorrhage or shock (49%)
  
• Peritonitis or bowel injury (42%)
• Pancreatic injury (8%)
• Ruptured diaphragm (1%)

Kidney injuries are also most often managed non-operatively (97%).

Those that require OR are related to:

• Collecting system hematomas
• Urinomas greater than 4cm
• Presence of dissociated renal fragments
• Interpolar extravasation

Although less common than the other abdominal organs, the hollow viscous organs are still at risk. Abdominal trauma related to child abuse carries a particularly high risk of hollow-viscous injury. While primary injury is typically not life-threatening, secondary injury often causes many life-threatening complications.

Air present in the bowel membrane lining from trauma, healing, or infection.

A temporary condition where your intestine can't push food and waste out of your body. The diagnosis is often associated with surgery, medications, trauma, peritonitis, or severe illness.

A condition in which fluid collects in spaces within the abdomen. We usually let it resolve on its own. But if the fluid causes pressure on organs, pain, or interferes with the movement of the diaphragm, doctors will perform a paracenteses. They insert a drain to drain off the fluid.

Management of these injuries involves mitigating the effects of these life-threatening complications, complete bowel rest (providing IV nutrition), and careful monitoring.

A patient arrived to our trauma bay from a serious MVA. He had multiple injuries including a traumatic brain injury, poor respiratory effort, a rigid abdomen, and a deformed leg. Bleeding had been stopped and incredible efforts in the field contributed to his delivery alive to the PCH trauma bay. Despite a mass transfusion protocol (MTP) we could not stabilize his hypotension. It wasn't until the trauma surgeon thought to check the pelvis that we discovered a missed unstable pelvic fracture. It takes considerable force to fracture the pelvis and that force can damage many vessels. Always assess the pelvis and bind if you suspect injury.

• When pelvic fractures occur in children, they are a marker for severe injury due to the force required
• Most commonly seen with MVC, auto-ped, motorcycle collisions and bicycle trauma
• In approximately 70% of pediatric pelvic fractures, two or more body regions sustain concurrent injuries, usually the head and abdomen

• The speed of the projectile is a more important factor than its mass in determining how much damage is done
• Most require surgical intervention; heads up is especially helpful in getting the OR ready
• Make a thorough search for all entrance and exit wounds, children may have remote entrance sites (thigh, buttock, or chest)

Abuse injury to the abdomen is most often associated with a direct blow to the belly. It usually occurs in those younger than age 3 but can range up into the teens. The average age of fatal injury is around 2 years old.

• In ages 0-4 years, 15% of blunt abdominal injuries are associated with abuse
• In <1 year, 1/4 of hospitalizations for abdominal trauma are secondary to abuse
• Out of all forms of pediatric abdominal trauma, abdominal trauma secondary to assault or abuse is associated with the highest mortality.
  
• Solid organ (liver) injuries are most common but abdominal trauma related to child abuse also carries a particularly high risk of hollow-viscus injury which are hard to detect on radiograph..

Certain injuries point to abuse. Abdominal trauma in babies often presents as vomiting, irritability, and abdominal distension followed by altered mental status. Bruising is often absent in these cases. ALWAYS suspect and assess pediatric patients for signs of NAT and all children with inflicted injury need their abdomen thoroughly evaluated.

Trauma is trauma is trauma for both adults and kids. The approach to both is essentially the same but there is an important difference that first responders should watch for. Children compensate in a way that adults do not. They are able to use their heart rate and healthy blood vessels to adjust for blood volume loss and shock.

In pediatric patients

• Hypotension is a LATE sign of shock and means the child is decompensating
• BP may be maintained despite a loss of up to 45% of circulating blood volume
• Tachycardia is often the earliest sign of distress

A patient who is cool and tachycardic should be considered in shock until proven otherwise.

Subtle signs of hemorrhagic shock include:

• Tachycardia
• Narrowed pulse pressure
• Prolonged capillary refill time
• Pallor
• Decreased urine output
• Altered mental status

Although not completely conclusive, these findings may indicate ongoing intraabdominal hemorrhage in the absence of other injuries.

•Recognize it!

•Stop the bleed where possible

•2 large bore upper extremity IVs

•Fluid boluses of NS or LR (20cc/kg)—reassess

•Transfusion if the patient remains hypotensive after the 2nd fluid bolus

•Tranexamic Acid (TXA) 1g IV bolus

•Pressors

The overall goal in ALL trauma is to treat and prevent hypoxia and hypotension. While this guideline is titled traumatic brain injury, the process also applies to abdominal trauma. Following it will mitigate secondary injury.

For additional guideline direction check out the UPTN website or the new app, "Utah PTN" on android and apple devices.

Test your skills, review the pediatric trauma simbox here. (https://www.emergencysimbox.com/emstelesimbox)

Training officers may review the topic above as a team training AND perform a simulation/skills check as directed. Once complete, send a roster of participants to Utah.PETOS@gmail.com and those listed will be issued 1-hour of CME credit from the DHHS Office of EMS and Preparedness.

Individuals who don't have a training officer can get CME credit on their own by viewing a PETOS presentation in our archives and completing the instructions on the webpage.

1. Perform a hands-on pediatric trauma sim (using the above Simbox).
2. Practice pediatric skills with your agency specific equipment

National EMSC has a newsletter filled with fantastic pediatric information, resources, and links. Check it out!

Preventing injuries in children with autism

Tuesday, July 23, 2024

12:00p-1:00p MST

Register now

The summer months bring new considerations for child safety, such as taking precautions for heat exposure, drowning, and playground safety. For children with autism, the risk of injury is often exponentially larger than the neurotypical population. The risk of drowning for children with autism is 160 times higher (Guan & Li, 2017), which, coupled with an increase in wandering, and communication challenges for non-verbal children, creates the need for additional considerations in preventing injuries.

In this webinar, Sarah Tinker, Ph.D. (Centers for Disease Control and Prevention or CDC) will present an overview of autism spectrum disorder in U.S. children, including why they may be at increased risk for injuries. Shericka Harris, MSPH (CDC) will describe unintentional drowning deaths in the U.S. among children and adolescents where autism was identified as a contributing cause of death.

Jiabin Shen, Ph.D., and Yan Wang, Ph.D. (University of Massachusetts Lowell or UML) will present their population-based research that investigates disparities in injury and injury-related medical service utilization in children with autism using 22 years of data from the Medical Expenditure Panel Survey (MEPS). The findings offer scientists, clinicians, and policymakers evidence-based data to inform development of tailored injury prevention programs for children with autism. They may also contribute to improvement of healthcare services and delivery of care for children with autism in the U.S. CSN-A member Judy Qualters, Ph.D. (CDC) will moderate the webinar.

For many years Erik Anderson, PM has served as the EMSC Lead Clinical Coordinator and has brought PEPP classes to our providers far and wide around the state. Erik is a fantastic teacher and advocate for the pediatric patient. With the transition of the Bureau of EMS over to the Department of Public Safety, EMSC will be changing our educational offerings and the ways they will be dispersed. We would like to thank Erik for his many years of service and wish him the very best in his new endeavors!

We are excited to welcome Tricia Boulton who will be leading the Utah Pediatric Trauma Network, one of EMSC's most active partners.

Here is a little about me. I have been in healthcare for 12 years. Before that, I was a hairdresser. I tell people my only talent is giving a great haircut. I love being in the mountains, watching K dramas, and spending time with my 2 kiddos. I am so excited to partner with you all in helping kids continue to get the best care across the state.

-Tricia Boulton

If your agency is interested in Jeff's autism training or in receiving the free John Wilson autism kits, contact Jeff @jeffwilson122615@gmail.com.

The Medical Home Portal is a unique source of reliable information about children and youth who have special health care needs (CYSHCN) and offers a “one-stop shop” for their:

· families

· physicians and medical home teams

· other professionals and caregivers

We are into our final month for this prehospital survey. This is the big one that will help us identify pediatric gaps so we can zero in on the state's needs. It will also determine whether your agency is peds ready and will tell you where to direct your efforts in the PECC role.

EMS and fire-rescue agencies across the nation are encouraged to participate in the Prehospital Pediatric Readiness Project Assessment to help them understand their pediatric capabilities and gaps. The online assessment is open now for EMS and fire-rescue agencies that respond to public 911 calls. It takes an average of 30 minutes to complete. Learn more about or complete the assessment at https://emspedsready.org/. You may also reach out to our state program manager with any questions, Jared.wright@utah.gov.

At this site you will find tools to help you explain the survey to your agency leadership. Make sure they understand the importance of this data collection.

https://emscimprovement.center/domains/prehospital-care/prehospital-pediatric-readiness/spread-word/

PECCs, the Western Pediatric Trauma Conference returns to Utah this year and is an excellent opportunity to associate with the state's trauma and ED MDs while learning all the latest in pediatric trauma. While live attendance is pricey, there is a special virtual option for EMS that is just $50 (early bird special of $25 has ended, RN's virtual option is $100). Spread the word and consider participating yourselves.

July 10-12, 2024 in Sundance, UT.

https://www.pedtrauma.org/

See below the information on a new webinar series designed for emergency managers and hospital PECCs on topics like decontamination operations, reunification, behavioral health, isolation/quarantine, and more! The goal is to help you plan better for pediatric patients at your facilities! All are welcome.

For hospital PECCs

• EMSC has launched its first pediatric emergency care coordinator (PECC) learning module for ED-based PECCs. You are invited to view the module and provide feedback.

For EMS PECCs

• EMS PECC resources can be found on the EIIC website here.

The Emergency Medical Services for Children (EMSC) Program aims to ensure emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, regardless of where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: (801) 707-3763