Perioperative Care of Children with Trauma

Fig. 15. 1

Causes of high rate of blunt injury in children

Major and lethal pediatric traumas are relatively rare. This aspect makes difficult to accomplish guidelines for the management and treatment of pediatric trauma because most of the publications show small and poor statistically significant populations of patients.

Mortality for traumatic injury presents three peaks:

Immediate: within the first hour, often upon impact and due to injuries which are incompatible with life (laceration of major intra-thoracic or intra-abdominal vessels, high injury of the cervical spine, rupture of the cardiac chambers, severe brain injury)

Early: within the first two hours after the traumatic event and secondary to inadequate establishment, stabilization and control of airway, uncontrolled hemorrhage associated with hemodynamic collapse, respiratory failure for pulmonary contusion and hemorrhage or pneumothorax, and intracranial bleeding

Delayed: for complications occurring during hospitalization (sepsis, progressive respiratory failure, multiorgan failure)

Motor vehicle collisions, pedestrian and bicycle accidents, falls, and burns are the most common causes of injury in children [1].

The essential factors for obtaining successful management of trauma include the quick diagnosis and treatment of primary injuries and the avoidance of secondary injury. The term platinum 30 min (golden hour for adults), while not evidence based, refers to an early and critical period in the care of trauma victims, during which the appropriate management may significantly increase patients’ survival rate.

Early recognition of primary injuries with rapid control of the airway and replacement of the circulating blood volume remain the cornerstones for a successful resuscitation of the pediatric trauma victim. Secondary injuries, which result from hypoxia and hypotension, are important determinants of morbidity and mortality after trauma, particularly in the presence of head trauma [2].

Pediatric trauma presents significant challenges regarding the anesthetic management, because of the anatomical, physiological, and psychological peculiarities characterizing every step of the development of child that make him a separate individual for each aspect of clinical care. For this reason, successful treatment of the traumatized child requires an accurate knowledge of the anatomical and physiological features that distinguish children from adults. These differences differ as the age increases, with neonates presenting the greatest clinical challenge.

As previously mentioned (Fig. 15.1), children have less fat and more elastic connective tissue with a flexible skeleton placed in close proximity to abdominal and thoracic structures, which can be injured without external lesions.

The larger body surface area to body mass ratio predisposes children to high heat loss than adults, potentially resulting in severe hypothermia.

Children have different physiological response to major trauma compared to adults, since they are able to maintain a near-normal blood pressure until 30–40 % of blood volume is lost. In these situations, the most important monitoring parameters are represented by the increased heart rate and the decreased tissue perfusion, the latter detected by the assessment of capillary refill time. The latter is detected by compressing for 5 s the nail bed, in children, or the sternal region in neonate and infants. The resulting ischemic area (appearing pallid) should return normally perfused within 2 s. A longer capillary refill time indicates a condition of tissue hypoperfusion (Fig. 15.2).

Fig. 15.2

Detection of capillary refill time

Children may not cope well emotionally in the aftermath of an accident. They need to be managed in a calm, child-friendly environment. The presence of a parent or psychologist in the resuscitation room may help the trauma team by minimizing the injured child’s fear and anxieties. It is shown that 25 % of children suffer from post-traumatic stress disorder after a traumatic event [3].

The most challenging anatomical and functional aspects related to pediatric trauma concern the airway and pulmonary function. Children have high oxygen consumption rate, relatively low functional residual capacity, and rapid bradycardic response to hypoxia. They do not tolerate long apneic periods well. Therefore, accurate airway examination is crucial.

The anesthesiologist should be prepared to encounter the following anatomical features of pediatric airway:

A large protuberant occiput creates the natural flexion of the head in young children. It predisposes the airway to obstruction and requires careful positioning for intubation.
A small oral cavity, large tongue, the presence of adenoids and tonsils, and occasionally loose deciduous teeth may restrict intraoral manipulation, obstruct visibility with direct laryngoscopy, and create predisposition to easy bleeding.
The larynx is short and positioned relatively high and more anterior. The epiglottis is often U shaped, long, and floppy. This combination may pose potential difficulties with laryngoscopy, and a short larynx increases the possibility of endobronchial intubation.
The commonly accepted knowledge that the larynx in infants and children is funnel shaped with the narrowest point of the funnel at the cricoid ring must be revised. Litman et al. [4] demonstrated with magnetic resonance imaging scans that in neonates, infants, and children up to 14 years, the larynx is conical in the transverse dimension with the apex of the cone at the level of the vocal cord and cylindrical in the anteroposterior dimension and does not change throughout development. Subsequently, Dalal et al. [5] confirmed these findings by using video-bronchoscopy imaging.

The role of the anesthesiologist in the management of pediatric trauma extends long before the arrival to the operating room. It includes the emergency department, the radiology suite, the intensive care unit, and the acute pain service. Therefore, pediatric anesthesiologist is involved to provide any or all of these services at any time.

The anesthesiologist may have to take care of traumatized pediatric patients on following occasions:

Initial stabilization in the emergency department

Sedation and monitoring for imaging

Emergency surgical procedures, such as laparotomy or craniotomy

After initial stabilization, to perform anesthesia for the fixation of long bone fractures

Intensive care unit management

Pain control during hospitalization, especially using regional analgesia

For all these reasons, a rapid and well-organized trauma team of an injured child is essential.

15.1 Primary Survey

The main goal of the primary survey is to detect and treat immediate life-threatening conditions, such as bleeding or hypertensive pneumothorax.

In pediatric trauma, the primary survey is classically presented according to ABCDEF sequence with some peculiarities:

A: airway + cervical stabilization
B: breathing + ventilation and oxygenation
C: circulation + hemorrhage control
D: disability
E: exposure
F: family

The next step of the assessment is not started until the preceding abnormality has been managed and corrected.

Before starting any manipulation of the patient, the level of consciousness must be evaluated by the application of a verbal or slight painful stimulus.

15.1.1 Airway

A number of traumatized patients arrive to the emergency department (ED) already intubated, and therefore, the duty of the anesthesiologist is to evaluate the airway in terms of tube size, cuffed/uncuffed, the presence and magnitude of air leak if uncuffed tube, depth of the tube, breath sounds, ventilation, and oxygenation. Any chest X-ray done in the ED should be reviewed in order to ascertain the correct position of the tracheal tube in mid-trachea and the presence of pneumothorax. If the patient is not intubated, the assessment of the airway must simply determine the ability patency. The mouth is opened to visualize the cavity, and, if the patient is unconscious, the jaw thrust is performed to prevent that the tongue falls back obstructing the upper airways. At the same time, an appropriate-sized cervical collar is chosen and placed (Fig. 15.3). If an appropriate pediatric cervical collar is not available, rolled towels or blankets might be carefully placed on either side of patient’s head in young children and infants.

Fig. 15.3

Mouth opening, jaw thrust maneuver, and cervical collar placed

The airway can be obstructed by blood, foreign bodies, teeth, secretions, and vomit in the oropharyngeal space, and any effort should be done to remove or suction them. Throughout the maneuver, the axes of the head, neck, and thorax must be aligned to prevent any dangerous rotation or extension movements of the cervical spine.

15.1.2 Breathing

After step A has been completed, breathing must be assessed. If the patient is spontaneously breathing, then 100 % high-flow oxygen will be administered by a non-rebreathing face mask with a reservoir.

If the child is apneic or is making poor respiratory effort, assisted ventilation is required. When properly performed, bag-valve-mask (BVM) ventilation for a short period of time is as effective as ventilation via an endotracheal tube. Five ventilations must be performed, and of these, at least two must be effective, eventually with the aid of an oral airway, if the patient is unconsciousness (considering that inserting an oral airway into a semiconscious child’s mouth may cause gagging and vomiting). In traumatized patient, the insertion of the oral airway should be carried out directly (without 180° rotation) with the use of a tongue depressor.

If manual or assisted ventilations by facemask are not effective, endotracheal intubation or insertion of a supraglottic device (laryngeal mask airway (LMA)) has to be performed.

The use of appropriated-sized LMA has been validated even in the prehospital care [6]as an alternative in the case of difficult tracheal intubation.

The sizing of LMA is done on the basis of the weight of the patient (Table 15.1).

Table 15.1

Sizing of LMA

Size	Weight (kg)
1	≤5
1.5	5–10
2	10–20
2.5	20–30
3, 4, 5	>30

If intubation is necessary, a fast assessment of the airway should be made before inducing anesthesia and administration of neuromuscular blocking drug. A plan should be available in the case of a difficult or failed intubation. A video laryngoscope, bronchoscope, or LMA should also be kept handy.

In trauma patient, nasotracheal intubation is contraindicated, especially if an injury of the cranial base is suspected.

The pediatric trauma victims should always be considered as full stomach patients, and rapid sequence induction is preferred as the gold standard for airway management in these patients [7].

In children, the Sellick maneuver may be less effective than in adults, because of the pliability of laryngeal cartilages.

Severely injured children should be intubated with cuffed endotracheal tubes, even in the prehospital settings [8, 9]. The size of the cuffed tube is often determined by modified Cole formula (age [years]/4 + 4) for uncuffed tubes, decreased by half-size for cuffed tubes. The cuff should be inflated to get a seal at about 25 cm H₂O of airway pressure.

For neonates, the sizing of tracheal tube is reported in Table 15.2.

Table 15.2

Sizing of tracheal tube in neonates

Size	Weight (kg)
2.5	<1
3	1–2
3.5	>2

The insertion depth of the tracheal tube is calculated by multiplying by three the result of modified Cole formula for uncuffed tubes. The proper position of the tracheal tube must be confirmed by the auscultation of breath sounds and by capnography.

Any destabilization of respiratory parameters (e.g., oxygen desaturation) during ventilation through the tracheal tube should be carefully considered. For this purpose, the acronym DOPES is used:

D = dislodgment of the tracheal tube with possible accidental removal or deepening into a bronchus
O = obstruction of the tracheal tube by secretions, vomit, blood, or foreign body
P = pneumothorax
E = equipment (e.g., oxygen line)
S = stomach dilatation following entry of air during the manual ventilation

15.1.2.1 Tension Pneumothorax

Tension pneumothorax occurs when trauma to the chest resulted in wall injury with progressive entry of air that is unable to escape from the pleural space resulting in increased pressure and lung collapse. Since in children the mediastinum is very compliant, it shifts earlier in the course, resulting in decreased venous return and more rapid cardiovascular collapse. This condition leads to a severe condition with dyspnea, hypotension, increased respiratory rate, ipsilateral hyperresonance, and reduced breath sounds. The diagnosis of tension pneumothorax is clinical and not radiological, so the first rule for a correct treatment is to suspect it! Therefore, this life-threatening situation must be promptly treated by urgent needle thoracostomy followed by tube thoracostomy.

15.1.3 Circulation

In children, secondary cardiopulmonary arrest, caused by either respiratory or circulatory failure, is more frequent than primary arrests caused by arrhythmias. The outcome from cardiopulmonary arrest in pediatric patient is poor, and identification of the antecedent stages of cardiac or respiratory failure is a priority, and therefore, effective early intervention may be lifesaving.

The management of step C in children presents unique challenges, such as obtaining the cooperativeness of the child for intravenous placement and the potential for psychological trauma, smaller veins, and more subcutaneous fat in children, making both palpating and visualizing veins more difficult. Additional issues include higher likelihood of hypovolemia upon presentation, lower success rates of intravenous insertion by first responders with consequent hematomas, bruises, and nonavailability of these punctured veins for intravenous placement, fractures in the extremity bones, and hypothermia causing peripheral vasoconstriction.

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