Pediatric Surgery

Pediatric Surgery

Brandt Sisson, MD1, Matthew J. Martin, MD,2 and Romeo Ignacio, MD,3

1 Naval Medical Center, San Diego, CA, USA

2 Trauma and Acute Care Surgery Service, Scripps Mercy Hospital, San Diego, CA, USA

3 Division of Pediatric Surgery, Rady Children’s Hospital, San Diego, CA, USA

  1. A 5‐year‐old child is struck by a car while crossing the street, and he sustains multiple abrasions and lacerations to his face. On arrival to the trauma bay his GCS is 6, and his oxygen saturation is 88% on room air. Multiple attempts at placing an endotracheal tube have been unsuccessful and he remains at 88% saturation with bag‐valve‐mask ventilation. What is the next best step for this patient?

    1. Reattempt endotracheal intubation
    2. Needle cricothyroidotomy with jet insufflation
    3. Surgical cricothyroidotomy
    4. Tracheostomy
    5. Place the patient on ECMO (extracorporeal membrane oxygen)

    Management of the pediatric airway in trauma patients represents unique challenges. Lack of oxygenation and ventilation due to the inability to establish an airway can lead to increased morbidity and potentially cardiac arrest in these patients. Anatomical differences between pediatric and adult patients include a larger head‐to‐total body surface area, as well as a shorter neck. The soft tissues of the oropharynx are also relatively larger than the oral cavity making the larynx and vocal cords difficult to visualize. The trachea is relatively more anterior, shorter, and narrower than those of adults and predisposes to possible airway challenges. Some of the airway problems that can occur in pediatric patients include right mainstem intubation, inadvertent extubation with small degrees of tube movement, and airway occlusion from mucous or blood. Many of the same principles in airway management are similar in children, including supplemental oxygenation, suctioning, and use of airway adjuncts.

    Bag‐mask ventilation is a helpful adjunct in ventilating patients; however, in a scenario where a patient is decompensating, a definitive airway needs to be obtained. Emergent surgical airways in children carry a higher risk of complications compared with adults. These include injury to the airway or esophagus, tube misplacement or dislodgment, and longer‐term risks of subglottic stenosis. In particular, a surgical cricothyroidotomy should be avoided in children <12 years old due to the higher risk of iatrogenic complications, as this is the narrowest part of the airway and is also immediately adjacent to the vocal cords. In this scenario, needle cricothyroidotomy with jet insufflation is the next best step to oxygenate the patient until a definitive airway can be established. If an endotracheal tube or needle cricothyroidotomy is unsuccessful, then a surgical tracheostomy should be performed to secure the airway in an emergent setting. ECMO is not indicated for this patient and would not be available as an immediate intervention.

    Answer: B

    Pediatric Trauma in American College of Surgeons Advanced Trauma Life Support Student Course Manual , 10th Ed . 2018, Chicago, IL, American College of Surgeons.

    Chameides L, Samson RA, Schexnayder SM, Hazinski MF (Eds) Pediatric Advanced Life Support Provider Manual. 2012, American Heart Association, Dallas.

    Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013; 118(2):251–70.

    TEACHING POINT: Definitive airway for children is an endotracheal tube. However, if placing and endotracheal tube is unsuccessful, other approaches such as needle cricothyroidotomy with jet insufflation, surgical cricothyroidotomy, and tracheostomy should be considered. Surgical cricothyroidotomy and tracheostomy are rarely indicated for children, especially <12 years of age.

  2. A 2‐year‐old girl requires emergent intubation for severe traumatic brain injury. Which of the following is the best method to confirm correct placement of a definitive airway?

    1. Auscultation of bilateral breath sounds
    2. Chest x‐ray appearance
    3. End‐tidal CO2
    4. Symmetrical chest rise
    5. Oxygen saturation >90%

    Orotracheal intubation is considered the most effective way of establishing a definitive airway in a child. A definitive airway is defined as a CUFFED endotracheal tube below the vocal cords. Cuffed endotracheal tubes provide the benefit of improving oxygenation and ventilation in these patients. Previous recommendations were for uncuffed tubes in pediatric patients due to cuffed endotracheal tubes causing tracheal necrosis or stenosis; however, this is no longer an issue due to improvements in cuff design with low‐pressure balloons. The gold standard for confirming correct tube placement is visualization of the tube passing through the vocal cords and confirmation with capnography demonstrating end‐tidal CO2. Although auscultation of breath sounds, symmetrical chest rise, and chest x‐ray are all important primary confirmation techniques, only end‐tidal CO2 using waveform capnography or colorimetric detector is considered the gold standard for confirmation of correct placement. Well‐oxygenated patients can maintain high oxygen saturations for several minutes even with esophageal intubation.

    Answer: C

    Pediatric Trauma in American College of Surgeons Advanced Trauma Life Support Student Course Manual , 10th Ed . 2018, Chicago, IL.

    Bano S, Akhtar S, Zia N, Khan UR, Haq AU. Pediatric endotracheal intubations for airway management in the emergency department. Pediatr Emerg Care. 2012; 28(11):1129–31.

    Sagarin MJ, Chiang V, Sakles JC, et al. Rapid sequence intubation for pediatric emergency airway management. Pediatr Emerg Care. 2002; 18(6):417–23.

    TEACHING POINT: Definitive airway must be confirmed in good placement by end‐tidal CO2 using waveform capnography or colorimetric detector.

  3. Which of the following statements is TRUE regarding spinal cord injury without radiographic abnormality (SCIWORA)?

    1. It is defined as a traumatic myelopathy with evidence of ligamentous instability but no fracture on plain radiography or CT scans.
    2. SCIWORA injuries are more common in the thoracic and lumbar spine than the cervical spine.
    3. SCIWORA injuries typically show no abnormalities on magnetic resonance imaging (MRI) and MRI provides no benefit in predicting the prognosis of the injury.
    4. A SCIWORA injury does not require further immobilization since there is no fracture or ligamentous damage.
    5. Younger children (<9 years) with SCIWORA are more likely to have severe or complete spinal cord injuries due to increased spinal elasticity.

    SCIWORA is a clinical diagnosis that is defined as a traumatic myelopathy or spinal cord injury with NO evidence of fracture or ligamentous instability on plain radiography or CT scans. It is an injury that occurs primarily in children, especially those <9 years old. This is due to several anatomical differences in the pediatric spine causing increased elasticity with significant, self‐reducing injuries of the spinal column. Younger children also have a disproportionately larger head with weaker cervical musculature that permits greater flexion and extension of the cervical spine, leading to more injuries in this region. MRI is useful in diagnosis of ligamentous and/or spinal cord injury in these patients and helps to predict outcomes. Patients with SCIWORA who have a normal MRI, minor hemorrhage, or edema only have an improved prognosis compared to that predicted by the initial neurological examination. The mechanism of injury occurs through hyperextension, flexion, distraction, and spinal‐cord ischemia. This allows the spinal cord to stretch beyond its ability to withstand injury and to create a significant injury without associated bony fracture of the vertebral column. Pooled data from multiple studies estimates that 63% of children with spinal cord injury (SCI) age 0–9 have SCIWORA, whereas 20% of children with SCI age 10–17 have SCIWORA. Younger children also have a higher incidence of upper level cervical spine injuries (C1–C4 level). Furthermore, cervical spine immobilization plays a key role in limiting repeated mobility of an already injured spinal cord and helps to limit further injuries.

    Answer: E

    Grabb PA, Pang D. Magnetic resonance imaging in the evaluation of spinal cord injury without radiographic abnormality in children. Neurosurgery. 1994; 35(3):406–14; discussion 414.

    Carroll T, Smith CD, Liu X, et al. Spinal cord injuries without radiologic abnormality in children: a systematic review. Spinal Cord. 2015; 53(12):842–8.

    Pang D, Pollack IF. Spinal cord injury without radiographic abnormality in children‐‐the SCIWORA syndrome. J Trauma. 1989; 29(5):654–64.

    Pang D. Spinal cord injury without radiographic abnormality in children, 2 decades later. Neurosurgery. 2004; 55:1325–43.

    Liao CC, Lui TN, Chen LR, et al. Spinal cord injury without radiological abnormality in preschool‐aged children: correlation of magnetic resonance imaging findings with neurological outcomes. J Neurosurg (Pediatr 1). 2005; 103:17–23.

    TEACHING POINT: Due to the increase elasticity of the spinal cord in children, SCIWORA is a unique finding in pediatric trauma patients, especially in those <9 years of age.

  4. An 11‐year‐old girl is the restrained backseat passenger in a high‐speed motor vehicle collision. On arrival to the trauma bay, she is noted to have a seatbelt sign over her neck with no hematoma. Her GCS is 15 with no neurologic deficits. What is the next best step for this patient in evaluating for a possible blunt cerebrovascular injury?

    1. Ultrasound of the neck
    2. Magnetic resonance angiography (MRA)
    3. Computed tomography angiography (CTA)
    4. Cerebral angiography
    5. Observation

    Pediatric patients with blunt cerebral vascular injury are generally asymptomatic at presentation. Early detection and management in these patients can prevent further neurological disabilities such as stroke or seizure. Several hard signs of vascular injury include an expanding hematoma, bruit, or focal neurological deficits, which all require further imaging and/or treatment. Furthermore, there are two well‐recognized screening guidelines for blunt cerebral vascular injury to include the Denver and Memphis guidelines. There are two modifications for evaluating BCVI in pediatric patients: the Utah and McGovern criteria (see below). These guidelines take into account certain injuries sustained, as well as injury mechanism for selection of patients for further imaging. Because of the lack of any of these variables, no imaging is warranted in this patient even with the presence of a seat belt sign. Even with the patient’s mechanism of injury, her score is <3.

    There are also several imaging modalities used to screen patients for BCVI. These include duplex ultrasonography, standard catheter‐based cerebral angiography, MRA, and CT angiography (CTA). In adult patients, CTA has become the current standard for evaluation and has largely replaced catheter‐based angiography. In pediatric patients, there is no clear data on the utility or benefit of aggressive screening with CTA, and there are heightened concerns with the risks associated with exposure to ionizing radiation from CT scans. Both duplex ultrasound and MRA have a lower sensitivity and specificity for detecting BCVI in adult and pediatric populations. Furthermore, operative intervention plays a limited role in these patients due to the nature and location of the injuries, except for patients with select high‐grade injuries or bleeding injuries in zone II of the neck. Endovascular treatment is the preferred approach for zone I and zone III injuries that are not readily accessible via an operative approach. Antithrombotic therapy with either an antiplatelet agent or anticoagulation plays a key role in management of these patients. The goal of therapy is to prevent propagation of thrombosis and avoid secondary injuries such as stroke or seizure.

    Denver criteria Modified Memphis criteria EAST criteria
    Focal neurological deficit Petrous temporal bone fracture Cervical hyperextension associated w/displaced midface or complex mandibular fracture or closed head injury consistent with diffuse axonal injury
    Arterial hemorrhage Carotid canal fracture Anoxic brain injury due to hypoxia as a result of squeezed arteries
    Cervical bruit in patients <50 years Le Fort fracture II or III Seatbelt abrasion or other soft‐tissue injury resulting in swelling or altered mental status
    Expanding neck hematoma Cervical spine fracture Cervical vertebral body fracture or carotid canal fracture in proximity to the internal carotid or vertebral arteries
    Neurological exam findings inconsistent w/ head CT scan Horner’s syndrome
    Cerebrovascular accident on follow‐up head CT scan not seen on initial head CT scan Neck soft‐tissue injury (seatbelt sign, hypoxia as a result of squeezed arteries, or hematoma)
    Presence of Le Fort II or III fractures Focal neurologic deficit not explained by imaging
    Cervical spine fracture w/ subluxation
    C1–C3 cervical spine fracture
    Cervical spine fracture extending into the transverse foramen
    Basilar skull fracture w/ carotid involvement
    Diffuse axonal injury w/ GCS score <6
    Hypoxic ischemia due to squeezed arteries

    For each of these 3 screening tools, if any of the screening criteria are met, the recommendation is to perform further workup with angiographic imaging.

    Variable No. of points
    Utah score
    GCS score ≤8 1
    Focal neurological deficit 2
    Carotid canal fracture 2
    Petrous temporal bone fracture 3
    Cerebral infarction on CT 3
    McGovern score
    GCS score ≤8 1
    Focal neurological deficit 2
    Carotid canal fracture 2
    MOI 2
    Petrous temporal bone fracture 3
    Cerebral infarction on CT 3

    A score ≥ 3 points on both scales signifies high risk for BCVI and indicates that the patient should undergo angiography.

    Source: Tables above cited from: Herbert JP, Venkataraman SS, Turkmani AH, et al. Pediatric blunt cerebrovascular injury: The McGovern screening score. J Neurosurg Pediatr. 2018;21(6):639–49.

    Answer: E

    Bromberg WJ, Collier BC, Diebel LN, et al. Blunt cerebrovascular injury practice management guidelines: The Eastern Association for the Surgery of Trauma. J Trauma. 2010; 68(2):471–7.

    Burlew CC, Biffl WL, Moore EE, et al. Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. J Trauma Acute Care Surg. 2012; 72(2):330–5.

    Grigorian A, Dolich M, Lekawa M, et al. Analysis of blunt cerebrovascular injury in pediatric trauma. J Trauma Acute Care Surg. 2019; 87(6):1354–9.

    Rossidis AC, Tharakan SJ, Bose SK, Shekdar KV, Nance ML, Blinman TA. Predictors of pediatric blunt cerebrovascular injury. J Pediatr Surg. 2017;S0022‐3468(17)30659‐0.

    Savoie KB, Shi J, Wheeler K, Xiang H, Kenney BD. Pediatric blunt cerebrovascular injuries: A national trauma database study. J Pediatr Surg. 2020; 55(5):917–20.

    TEACHING POINT: A cervical seatbelt sign is not an indication for imaging to evaluate for BCVI. The Utah and McGovern criteria can be utilized for suspected BCVI to consider if CTA is warranted.

  5. A 15‐year‐old girl sustains a gunshot wound (GSW) to her right chest.

    On arrival to the trauma bay, she is noted to be tachycardic and hypotensive. Intravenous access is obtained, and she receives two 20 mL/kg boluses of lactated ringer’s (LR), as well as 1 unit of packed red blood cells (PRBC). A right chest tube is placed with immediate output of 750 mL of bright red blood. She remains tachycardic and hypotensive despite this initial resuscitation. Which of the following is the optimal approach to continued fluid resuscitation in this patient?

    1. Give another 20 mL/kg bolus of crystalloid fluid.
    2. Initiate massive transfusion with 1:1:1 ratio resuscitation.
    3. Administer tranexamic acid (TXA).
    4. Administer 10 units of cryoprecipitate.
    5. Administer 2 additional units of PRBC.

    This patient has clear evidence of ongoing hemorrhage and physiologic shock as defined by persistent hypotension and tachycardia despite resuscitation. Trauma remains a major source of blood loss in pediatric, as well as adult patients. In comparison to adult patients, pediatric patients can better maintain a normal blood pressure by compensating with higher heart rates. Pediatric patients who are hypotensive may have lost already 30–45% of their blood volume. Initial management consists of fluid resuscitation with initial fluid boluses of crystalloid at 20 mL/kg. Most guidelines recommend two crystalloid boluses at 20 mL/kg, followed by a transfusion of one unit of packed red blood cells. After the initial blood transfusion, the next step is for balanced resuscitation with a 1:1:1 ratio of red blood cells, plasma, and platelets. The current blood replacement guidelines consist of 10 mL/kg of pRBCs, 1 unit of platelets per 10 kg, and 10 mL/kg of plasma. Furthermore, balanced resuscitation has led to improved survival of pediatric trauma patients that require large volume transfusions. The current definition of a massive transfusion in a pediatric trauma patient is debated but is often defined as administration of 40 mL/kg (approximately half of the pediatric circulating volume) of blood products in a 24‐hour period. The most important point in the initiation of a massive transfusion protocol (MTP) is for each hospital to have an established protocol and to expeditiously implement the MTP when required. Balanced resuscitation also has proven benefits in preventing coagulopathy. Cryoprecipitate has been added to some massive transfusion protocols to provide higher concentrations of fibrinogen. TXA showed a reduction in all‐cause mortality in the CRASH‐2 trial; however, no large studies have been conducted on pediatric trauma patients. Recent studies have now evaluated the benefits of whole blood as an initial resuscitation in trauma patients, and this would be an appropriate alternative to a 1:1:1 approach if available.

    Answer: B

    Pediatric Trauma in American College of Surgeons Advanced Trauma Life Support Student Course Manual , 10th Ed. 2018, Chicago, IL.

    Dehmer JJ, Adamson WT . Massive transfusion and blood product use in the pediatric trauma patient. Semin Pediatr Surg. 2010; 19(4):286–91.

    Parker RI. Transfusion in critically ill children: indications, risks, and challenges. Crit Care Med. 2014; 42(3):675–90.

    Neff LP, Cannon JW, Morrison JJ, et al. Clearly defining pediatric massive transfusion: cutting through the fog and friction with combat data. J Trauma Acute Care Surg. 2015; 78(1):22–8; discussion 28‐9.

    CRASH‐2 trial collaborators, Shakur H, Roberts I, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH‐2): a randomised, placebo‐controlled trial. Lancet. 2010; 376(9734):23–32.

    TEACHING POINT: Trauma patients that require a massive transfusion protocol should be considered for a balanced resuscitation of 1:1:1 blood, FFP, and platelets.

  6. Which of the following mechanisms of injury is responsible for the most pediatric deaths?

    1. Motor vehicle crash
    2. Drowning
    3. Non‐accidental trauma (NAT)/child abuse
    4. Falls
    5. Gunshot wounds

    Trauma‐related injury remains the most common cause of death and disability in childhood. Morbidity and mortality related to injury surpasses all major diseases in children and young adults, making trauma the most serious and preventable disease in this population. Motor vehicle crashes (MVC) continue to be the leading cause of pediatric deaths worldwide. This is related to blunt trauma causing multi‐organ system injury and the unique characteristics of pediatric trauma patients. More importantly, the majority of injured pediatric trauma patients have no hemodynamic abnormalities, and those with multisystem injuries can rapidly deteriorate, prompting immediate recognition and intervention. After MVC, pediatric mortality is due to drowning, house fires, homicides, and falls. In children <1 year of age, the majority of homicides are due to child abuse/NAT, whereas in children >1 year of age, the majority of homicides are related to firearm injuries. Firearm‐related deaths are the second leading cause of death overall among US children aged 1–17 years and the second leading cause of injury‐related death. Firearm‐related fatality is 49 TIMES higher for 15–24 year olds in the United States than any other high‐income country. Lastly, falls are the most common pediatric injury, but rarely result in mortality or severe injury.

    Answer: A

    Graph titled, Ten leading causes of child and adolescent death, 2016.

    Note: Based on data from the Centers for Disease Control and Prevention’s Wide‐ranging Online Data for Epidemiologic Research system.

    Source: Cunningham, RM, Walton, MA, Carter, PM. The major causes of death in children and adolescents in the United States. N Engl J Med. 2018;379(25): 2468–75.

    Pediatric Trauma in American College of Surgeons Advanced Trauma Life Support Student Course Manual , 10th Ed. 2018, Chicago, IL.

    Centers for Disease Control and Prevention (CDC). Vital signs: Unintentional injury deaths among persons aged 0‐19 years ‐ United States, 2000‐2009. MMWR Morb Mortal Wkly Rep. 2012; 61:270–6.

    Cotton, BA, Nance ML. Penetrating trauma in children. Semin Pediatr Surg. 2004; 13(2):87–97.

    TEACHING POINT: Motor vehicle collisions and firearm‐related injuries are the leading causes of death in children.

  7. Which child below would be considered both hypotensive and tachycardic based on the admission vital signs?

    1. 10‐year‐old girl with HR 110 beats/min and SBP 85 mm Hg
    2. 8‐month‐old boy with HR 155 beats/min and SBP 65 mm Hg
    3. 5‐year‐old boy with HR 142 beats/min and SBP 70 mm Hg
    4. 14‐year‐old girl with HR 98 beats/min and SBP 100 mm Hg
    5. 2‐year‐old girl with HR 148 beats/min and SBP 75 mm Hg

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Dec 15, 2022 | Posted by in CRITICAL CARE | Comments Off on Pediatric Surgery
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