Rosen & Barkin's 5-Minute Emergency Medicine Consult (515 page)

• The traditional “c-spine, chest, pelvis” set of radiographs is no longer universally obtained; selective approach is more appropriate.
  
• Forgo cervical spine radiographs in children who are awake, alert, cooperative, neurologically intact without neck pain or midline tenderness on palpation of the neck, are without pain on range of motion testing, and are without distracting injury:
  
  • An unconscious child will not be able to have the cervical spine cleared in the ED and may later need MRI (less often CT) as an inpatient.
    
• Chest radiographs indicated for grunting respirations, hypoxia, asymmetric breath sounds, dyspnea, crepitus, endotracheal intubation, and thoracostomy tube or central venous catheter placement in the internal jugular or subclavian veins
  
• Pelvic radiographs are seldom indicated. Children with clinically significant pelvic pain or instability typically undergo CT of the abdomen and pelvis.
  
• CT of the head is indicated for abnormal mental status, focal neurologic deficit, prolonged loss of consciousness, bulging fontanel, temporal or parietal scalp hematoma, depressed skull fracture, and uncontrollable persistent vomiting.
  
• CT of the abdomen and pelvis is typically indicated for children with altered mental status, gross hematuria, abdominal bruising above the ileac crests, handlebar injuries, and abdominal tenderness with hemodynamic effect.
  
• US has limited utility since the presence of free fluid (i.e., blood) does not always indicate the need for laparotomy. The usefulness of focused abdominal sonography for trauma exam in young children needs further study.
  

Nonaccidental trauma should be considered when the history is inconsistent with the injury.

TREATMENT

• Rapid transport to a facility capable of managing the child’s suspected injuries
  
• Priorities include stabilization of airway (intubation by paramedics in the pre-hospital setting is controversial), breathing, circulation.
  
• Immobilization of cervical spine and extremity fractures
  

• Most traumatized children are stable throughout their ED course.
  
• Stabilization may require:
  
  • Cardiorespiratory and pulse oximetry monitoring
    
  • Early oxygen administration
    
  • Placement of 2 large-bore IVs and aggressive fluid resuscitation with normal saline
    
  • Pain control with morphine
    
  • Labs and radiographs as indicated
    
  • Administration of packed red blood cells if not responding to 2 crystalloid boluses
    
  • Endotracheal intubation:
    
    • Rapid sequence intubation should be performed with etomidate or ketamine and succinylcholine
      
    • Sedate patient with a benzodiazepine or propofol
      
  • Cervical spine immobilization
    
  • Thoracostomy tube as indicated
    
  • Urinary catheter (look for blood at the meatus)
    
  • Gastric decompression with a nasogastric or orogastric tube
    

• Risk stratify based on history and physical exam.
  
• Acknowledge the limitations of using the mechanism of injury to predict its severity.
  
• Assess priorities; reassess frequently.
  
• Provide analgesia; sedate as appropriate.
  
• Clean wounds and splint fractures.
  
• Tetanus immunization if indicated
  
• Allow parents at the bedside during resuscitation and treatment.
  

• Normal saline/lactated Ringer: 20 mL/kg boluses IV
  
• Packed red blood cells: 10 mL/kg U IV
  
• Etomidate: 0.3 mg/kg IV
  
• Morphine sulfate: 0.1 mg/kg IV
  
• Succinylcholine: 1.5 mg/kg IV
  
• Lorazepam: 0.1 mg/kg IV
  
• Propofol: 2 mg/kg IV
  
• Ketamine: 2 mg/kg IV (generally thought to raise intraocular and intracranial pressure—usually avoided when head injury is suspected)
  

FOLLOW-UP

• Persistent altered mental status, endotracheal intubation, thoracostomy tube placement, intra-abdominal or intracranial injury identified on CT, pulmonary contusion, fractures requiring operative management, nonaccidental trauma
  
• Hemodynamic instability
  
• Airway concerns
  
• CT negative for intra-abdominal injury, but persistent abdominal pain as pancreatic or bowel injury is possible
  
• Failure to identify an appropriate adult to be responsible for the child (e.g., both parents are admitted to the hospital for their own injuries)
  

• Most traumatized children with normal mental status and normal radiographic tests (if obtained) can be discharged home to a reliable caregiver.
  
• Post-traumatic stress syndrome may develop, and parents should be advised to seek appropriate counseling should concerns develop.
  

• Specialists as indicated by injury
  
• Psychiatric evaluation may be indicated for evidence of post-traumatic stress.
  
• Neurologic assessment for evidence of residual from postconcussion syndrome.
  

• Capraro AJ, Mooney D, Waltzman ML. The use of routine laboratory studies as screening in pediatric abdominal trauma.
  Pediatr Emerg Care.
  2006;22:480–484.
  
• Davies DA, Pearl RH, Ein SH, et al. Management of blunt splenic injury in children: Evolution of the nonoperative approach.
  J Pediatric Surg.
  2009;44:1005–1008.
  
• Dudley NC, Hansen KW, Furnival RA, et al. The effect of family presence on the efficiency of pediatric trauma resuscitations.
  Ann Emerg Med
  . 2009;53:777–784.
  
• Herman R, Guire KE, Burd RS, et al. Utility of amylase and lipase as predictors of grade of injury or outcome in pediatric patients with pancreatic trauma.
  J Pediatr Surg.
  2011;46:923–926.
  
• Holmes JF, Lillis K, Monroe D, et al. Identifying children at very low risk of clinically important abdominal injuries.
  Ann Emerg Med.
  2013;62:107–116.
  
• Hutchings L, Willett K. Cervical spine clearance in pediatric trauma: A review of current literature.
  J Trauma
  . 2009;67:687–691.
  
• Hutchison JS, Ward RE, Lacroix J, et al. Hypothermia after traumatic brain injury in children.
  N Engl J Med
  . 2008;358:2447–2456.
  
• Leonard JC, Kuppermann N, Olsen C, et al. Factors associated with cervical spine injury in children after blunt trauma.
  Ann Emerg Med.
  2011;58(2):145–155.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Abuse, Pediatric
  
• Fractures, Pediatric
  
• Trauma, Multiple
  

CODES

• 920 Contusion of face, scalp, and neck except eye(s)
  
• 959.01 Head injury, unspecified
  
• 995.50 Child abuse, unspecified
  

BASICS

• Infestation by organisms that live in close association with host
  
• Bites are painless
  
• Signs and symptoms result from host response to saliva and anticoagulant injected during feeding
  
• Transmitted by direct contact and fomites (inanimate objects)
  
• Head lice are transmitted by head-to-head contact:
  
  • Combs
    
  • Pillows
    
  • Hats
    
• Head lice are more common in children and females
  
• Pubic lice are transmitted by sexual contact
  
• Obligate human parasites cannot survive away from hosts >7–10 days
  

Infestation by:

• Pediculus capitis (head louse):
  
  • Most common
    
  • All socioeconomic groups
    
• Pediculus corporis (body louse):
  
  • Associated with poverty, poor hygiene, and overcrowding
    
  • Live in clothing and transfer to human host for feeding
    
  • Can live up to 30 days off of human
    
  • Related to bed bugs
    
• Phthirus pubis
  (pubic or crab louse)