Trauma and extremes of age case file

Trauma and extremes of age case file

Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD, Adam J. Rosh, MD, MS

Case 49

It is approximately 2 AM, when a woman presents to the emergency department (ED) with her 3-year-old son. According to the mother, the patient had been playing and fell off the upper level of his bunk bed earlier in the evening. On examination, the child is somnolent. His pulse rate is 110 beats per minute, blood pressure is 100/85 mm Hg, respiratory rate is 28 breaths per minute, and Glasgow coma scale (GCS) score is 11 (eye opening 2, verbal 5, motor 4). There is presence of soft-tissue contusion over the left frontal scalp and ecchymosis over the left periorbital region. The chest is clear with bilateral breath sounds. The abdomen is mildly distended and tender throughout. The patient’s left thigh is markedly swollen and tender, and all his extremities are mottled and cool.

⯈ What is the most likely mechanism responsible for this patient’s clinical picture?

⯈ What are the next steps in the management of this patient?

ANSWER TO CASE 49:

Trauma and Extremes of Age

Summary: A 3-year-old boy presents several hours after an unwitnessed fall, with somnolence and external signs of head injury. In addition to the contusions on the scalp, his abdomen is distended and tender, left thigh is swollen and tender, and his skin is mottled and cool.

• Most likely responsible mechanism: This child has multiple injuries, possibly secondary to intentional trauma.
• Next steps in management: Pediatric trauma resuscitation and evaluation to include administration of intravenous fluids, a thorough examination, and a computed tomography (CT) scan of the head and abdomen. Protection of the child by reporting potential child abuse, and admission to the hospital.

ANALYSIS

Objectives

1. Become familiar with the evaluation and management of pediatric and geriatric patients with multiple severe injuries presenting in shock.
2. Recognize the signs in the presentation of children and elderly patients that are consistent with abuse and become familiar with the appropriate response.

Considerations

The presentation of this child should raise concerns for multiple reasons, and it is vitally important to appropriately prioritize your attention to these concerns. The first priority should be concern over his medical condition, not the mechanism of the injury. This patient’s vital signs presented in the case scenario are not out of the range of normal for his age (Table 49–1). Despite the normal vital signs, his

general presentation indicates the potential for multisystem injuries, and putting that together with the findings of mottled and cool skin indicate that this child is in hemorrhagic shock until proven otherwise. The vital signs of an injured child can be within normal ranges for an extended period of time secondary to an excellent ability to compensate physiologically for hypovolemia. However, when the limits of

that compensatory reserve are reached, the ability of a child to tolerate shock is poor and his condition will likely decline very rapidly.

The secondary concern regarding this child is the manner in which he presented suggesting potential abuse. Factors that raise these concerns include the delay in presentation, the extent of the injuries that appear much more severe than can be accounted for by the history, the age of the child, and the unwitnessed report of the injury. All 50 states have mandatory child abuse reporting laws for the treating physician. Regardless of the management plan, this child should be placed in a protected environment (admission to the hospital), and a report of suspected abuse should be submitted. However, the treating physician’s suspicions or emotions should not delay the child’s medical care (which is the first responsibility). Accurate and complete evaluations and documentation of your findings in an unbiased manner is the first important step. Confrontations with family members in the midst of a trauma room evaluation are rarely fruitful, and can hamper your efforts to care for the child.

Approach To:

The Pediatric Trauma Patient

CLINICAL APPROACH

A systematic and expeditious approach to children with unknown injury mechanisms or mechanisms capable of producing multisystem injury should include a rapid survey for all potential injuries, consideration of the need for intubation, administration of intravenous fluids, and the prevention of heat loss. CT scan of the head and abdomen may be obtained for further evaluation as needed, and the patient should be prepared for operative care as indicated. In those patients with multiple injuries identified, prioritizing the most life-threatening problem is of paramount importance. Even when intracranial hemorrhage may be suspected on the basis of physical presentation, the immediate threat to most children with multisystems injury is hypovolemic shock from abdominal injury and other hemorrhagic sources. Addressing blood loss source is critical not only for the correction of hemorrhagic shock but also for the prevention of secondary brain injury in these patients.

The guidelines found in the advanced trauma life support (ATLS) and advanced pediatric life support (APLS) manuals should be followed in the initial management of injured children. The initial priorities are the assessment and maintenance of airway, oxygenation, and ventilation. Determination for immediate intubation is dependent on the initial evaluation of the child and the resources available. Certainly, if there is any airway compromise, or if the neurological status raises concern of airway protection (a GCS score <9; Table 49–2), then intubation is mandatory. If the airway is not compromised and the GCS score is adequate, then the decision for elective intubation may be determined by the level of patient cooperation for the timely completion of potentially lifesaving diagnostic studies such as CT imaging.

The circulation and the neurological status should be the next priorities. Approximately 90% of pediatric patients presenting with blunt trauma are successfully 

managed without operative intervention. However, the initial signs of shock, including tachycardia, skin changes, and lethargy, represent a loss of approximately 25% of the child’s blood volume (Table 49–3). The likelihood of injury requiring operative control of hemorrhage is much greater in these children, and careful attention should be paid to the amount of fluid or blood that is required to maintain stable vital signs. A large-bore IV should be started, and two sequential boluses of 20 mL/kg of warmed crystalloid solution should be administered. If further fluids are required beyond this, then administration of packed red blood cells (10 mL/kg) should be considered. Evaluation of the abdomen by ultrasound (if unstable) or CT scan should be performed to determine the extent of injuries. If the vital signs worsen during the attempt to obtain a head and abdominal CT scan, this should be abandoned and a laparotomy performed to control any hemorrhage.

There is no doubt that the child presented in this case often presents a considerable challenge. Not only does the possibility of abuse evoke strong emotions that are difficult to ignore during the evaluation, there is potential of multiple life-threatening injuries that must be prioritized. A systematic and efficient approach, with focus on the most immediate of concerns, cannot be emphasized enough (Table 49–4).

THE BATTERED CHILD

There are very few other things encountered by physicians that will evoke such strong distasteful emotions as child abuse, making one think that reporting of these cases would not be a significant problem. However, to report a case of child abuse, the physician must first recognize that it is child abuse. The subtleties of recognizing

Data from ATLS Manual, American College of Surgeons. 1997:297.

Data from O’Neill JA. Principles of Pediatric Surgery. St Louis, MO: Mosby; 2003:783.

child abuse, and the fear of making incorrect accusations of caregivers that appear well meaning can make this a difficult issue. The reporting and protection of the battered child is further confounded by the legal requirements for appropriate and complete documentation by the physician, which often is lacking if suspicions of abuse were not entertained upon initial presentation.

Intentional injury accounts for approximately 10% of all trauma cases in children younger than 5 years old. While this figure may be alarming, it also suggests that the vast majority of trauma in children is actually accidental. There are several key aspects of the history, physical examination, and presentation of the child that should alert the practitioner to the possibility that the trauma was not accidental. Table 49–5 lists suggestive characteristics that should alert the practitioner to abuse. Skin and soft-tissue injuries are the most common injuries encountered in child abuse cases. This is followed by fractures, which often are multiple or repetitive. The third most common problem with child abuse is head injury. Unfortunately, this is also the injury with the highest mortality.

Currently, there is no federal standard regarding the legal requirements for reporting of child abuse. However, all states have mandatory reporting legislation for suspected child abuse that includes healthcare workers, school personnel, social workers, and law enforcement officers. Very few states recognize the physician patient communication privilege as exempt from these reporting requirements. Most states impose either a fine or imprisonment penalty to individuals that knowingly or willfully fail to report abuse. However, several states also impose penalties for false reports of child abuse.

When intentional injury is suspected in a pediatric trauma case, the appropriate child protective agency should be notified after the child’s medical condition is addressed. During the investigational process, it is often incumbent on the medical personnel to provide a high-visibility protected environment for the child. Although it is often emotionally tempting for the physician to become involved in the investigational process, it is important at this stage to maintain focus on the medical

condition. This becomes particularly important in terms of adequate documentation. A complete, unbiased, and well-recorded history and physical examination can be vital in the protection of the child at a later date.

Particularly important information includes detailed descriptions of the reported mechanism of the injury, the time of the injury and any delay in presentation, the presence of witnesses, conflicts, and inconsistencies. A complete physical examination should be documented and should include pictures or diagrams of all bruises, documentation of the color of each bruise, a complete neurological examination, and a genital examination. An eye examination for retinal hemorrhages should be performed because this is often encountered with cerebral trauma and the “shaken baby syndrome.” Radiographic evaluations should be performed on all extremities to search for patterns of previous injury (Table 49–6). Any reports from previous admissions (including from other hospitals) should be referenced.

Data from, O’Neill JA. Principles of Pediatric Surgery. St Louis, MO: Mosby; 2003.

GERIATRIC TRAUMA

Older patients often have coexisting medical problems that may impact the response to the acute injuries. Details surrounding the initial injuring events are frequently relevant (eg, medication reactions, chest pains, strokes). Nevertheless, the basic approach to trauma in the elderly patient is the same as the approach to the adult patient.

When assessing the geriatric trauma patient, the possibility of elder abuse must be taken into consideration. If elder abuse is suspected, practitioners should follow the same steps used when assessing suspected child abuse.

Physiological Changes

The older age group is one of the fastest growing population sectors in the United States. Thus, the number of geriatric trauma incidents, arbitrarily defined as affecting those older than age 65 to 70 years, is expected to likewise increase. Injuries in these individuals are associated with higher mortality and longer hospital stay. Many physiological changes occur with aging (Table 49–7), including the progressive loss of myocyte number and increase in myocyte volume resulting in the ventricular stiffness and cardiac diastolic dysfunction. Furthermore, atherosclerotic changes cause large vessel stiffness and increased afterload. Additionally, aging contributes to diminution of cardiac β-adrenergic response, leading to diminished heart rate response. Because of the age-related cardiovascular changes, the elderly patient is much less

capable of responding to increases in cardiac output demands. Myocardial infarction is the leading cause of death among 80-year-old patients in the postoperative and postinjury settings. The elderly patient’s limited ability to respond to stress and injuries has prompted some groups to apply age (>70 years) as the sole criteria for trauma-team activation, and by adapting to this approach, these investigators have demonstrated significant reduction in geriatric trauma mortality.

Outcome Predictors in Geriatric Patients

Various groups have attempted to identify outcome predictors in geriatric trauma patients (Table 49–8). “High-risk” patients can be identified based on mechanism, physiological parameter, and laboratory parameters. In the management of “highrisk” patients, early admission to the ICU, with earlier initiation of invasive hemodynamic monitoring, and aggressive resuscitation based on hemodynamic parameters are associated with a reduction in geriatric trauma patient mortality. Thus, expedited patient disposition to allow early invasive monitoring and resuscitation is helpful. Scalea and colleagues (1990) showed that early resuscitation of the “high-risk” elderly trauma patients, with goals directed at attaining cardiac output of more than 3.5 L/min and/or a mixed venous saturation of greater than 50%, led to an improvement in survival from 7% in historical control patients to 53% in the aggressively managed patients. More recent observations have not supported aggressive resuscitation measures based on predetermined parameters, because overly aggressive fluid resuscitation can contribute to pulmonary and cardiovascular complications. Close observations and monitoring directed toward the avoidance of tissue hypoperfusion and minimizing stresses related to hypothermia and pain are the important priorities during the initial management of older victims of traumatic injuries.

Given the overall poorer survival of geriatric trauma patients, some questions have been raised regarding the quality of life of the survivors. Long-term studies

of geriatric trauma patients indicate that majority of survivors return to a level of previous independence. Factors associated with long-term reduced independence include hemodynamic shock upon admission, GCS score <7, age >75 years, head injury, and sepsis.

COMPREHENSION QUESTIONS

49.1 A 3-year-old boy is brought into the ED with multiple bruises, abrasions, and several deep lacerations over the flank region. The parents state that he fell out of his bed. Which of the following is the most important next step in this patient?

A. Reporting these injuries to child protective services.

B. Firmly, but without judgment, confront the parents with the discrepancy of the story and the injuries.

C. Take accurate pictures of the injuries and seal them in an evidence envelope.

D. Evaluate the ABCs and any urgent injuries.

E. Station guards in front of the exits of the building to prevent the parents from leaving.

49.2 An 11-month-old infant is brought into the ED after rolling down a staircase while still buckled into the infant car seat. The baby is crying, but is consolable by his mother. His heart rate is 116 beats per minute and blood pressure 80/40 mm Hg at rest. The physical examination reveals only slight bruising over the knees. The abdomen is nontender. Which of the following is the best next step?

A. CT scan of the abdomen to assess for intraperitoneal hemorrhage

B. Chest radiograph to assess for pleural hemorrhage

C. Continued observation and reassurance

D. IV access and infusion of normal saline 10 mL/kg

E. Transfuse 10 mL/kg PRBC

49.3 An evaluation of an 80-year-old woman who was a pedestrian struck by an automobile traveling at a speed of 20 miles per hour identified right tibia and fibula fracture, right pubic ramus fracture, and facial lacerations. Her vital signs are a pulse of 80 beats per minute, blood pressure of 120/70 mm Hg, respiratory rate of 20 breaths per minute, and a GCS score of 15. Which of the following sequences of events is the most appropriate in management of this patient?

A. Computed tomography (CT) scan of the abdomen; plain x-rays of the pelvis, lower extremities, and spine; splinting of fractures; and invasive monitoring in the ICU.

B. CT scan of the abdomen; splinting of fractures; invasive monitoring in ICU; and x-rays of the pelvis and lower extremities.

C. Invasive monitoring in ICU; splinting of the fractures; and CT of abdomen.

D. Splinting of fractures; invasive monitoring in the ICU; and CT of abdomen; and x-rays of the extremities and pelvis.

E. Exploratory laparotomy, splinting of the femur fracture, and pelvic fixation.

ANSWERS

49.1 D. The first and foremost priority is the patient’s medical condition, and as normal, initially addressing the ABCs. Child protective services probably do need to be notified, and the injuries do need to be documented. In general, the parents should not be confronted, but rather asked about their story.

49.2 C. The normal heart rate and blood pressure levels of a child are substantially different from that of any adult. These values are normal for this infant; therefore, more aggressive measures are not indicated at this time.

49.3 B. This sequence of events outlined is most appropriate for immediate identification of possible intra-abdominal hemorrhagic source in a patient with injury mechanism capable of producing multiple injuries. When this life-threatening problem is ruled out, the next steps are early invasive monitoring in the ICU and stabilization of fractures to decrease pain and injuries to adjacent soft tissue, while simultaneous efforts are made to identify other non–life-threatening injuries. Exploratory laparotomy is not indicated in this patient at this time because she is hemodynamically stable and without clear signs of intraabdominal injuries.

CLINICAL PEARLS

⯈ The first priority in evaluating a pediatric or geriatric trauma patient is the ABCs.

⯈ The most life-threatening injury in intentional child injury is head injury.

⯈ Soft-tissue and skin injuries are the most common child injury.

⯈ Myocardial infarction is the leading cause of death among 80-year-old patients in the postinjury setting.

⯈ Early management of geriatric trauma patient should be directed toward early monitoring of patients to avoid hypovolemia, inadequate treatment of pain, and hypothermia.

References

Aalami OO, Fang TD, Song HM, et al. Physiologic features of aging persons. Arch Surg. 2003;138: 1068-1076. 

Cooper A. Early assessment and management of trauma. In: Whitefield Holcomb III G, Murphy JP, Ostlie DJ, eds. Ashcraft’s Pediatric Surgery. 5th ed. Philadelphia, PA: Saunders Elsevier; 2010:167-181. 

DiScala C, Sege R, Li G, Reece R. Child abuse and unintentional injuries: a 10-year retrospective. Arch Pediatr Adolesc Med. 2000;154(1):16-22. 

Victorino GP, Chong TJ, Pal JD. Trauma in the elderly patient. Arch Surg. 2003;138:1093-1098.

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