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Management of Multiply June 2018

Volume 15, Number 6


Injured Pediatric Trauma Authors

Andria Tatem, MD

Patients in the Emergency


Chief Resident, Department of Pediatrics, Instructor, Eastern
Virginia Medical School Children’s Hospital of The King’s Daughters,
Norfolk, VA

Department
Rupa Kapoor, MD, FAAP
Assistant Professor, Eastern Virginia Medical School, Norfolk, VA
Peer Reviewers

Abstract Michelle Hughes, DO, FAAP


Pediatric Emergency Medicine Attending, Associate Medical Director
for Trauma, Children’s Hospital of the King’s Daughters, Assistant
Management of the child with multiple traumatic injuries can be Professor of Pediatrics, Eastern Virginia Medical School, Norfolk, VA
Lara Zibners, MD, MMEd
challenging, and important injuries may not be readily recog- Honorary Consultant, Paediatric Emergency Medicine, St. Mary’s
nized. Early recognition of serious injuries, initiation of appropri- Hospital Imperial College Trust, London, UK; Nonclinical Instructor of
ate diagnostic studies, and rapid stabilization of injuries are key Emergency Medicine, Icahn School of Medicine at Mount Sinai, New
York, NY
to decreasing morbidity and mortality in the multiply injured
pediatric trauma patient. The differential diagnosis for these pa- Prior to beginning this activity, see “Physician CME Information”
on the back page.
tients is wide, and treatment is targeted to the specific injuries. In
this issue, a systematic approach to the multiply injured pediatric This issue is eligible for 4 trauma CME credits.

patient will be reviewed, with specific attention to commonly


missed injuries and those injuries that may cause significant mor-
bidity or mortality.
Editors-in-Chief Ari Cohen, MD, FAAP Joseph Habboushe, MD, MBA Robert Luten, MD Adam E. Vella, MD, FAAP
Chief of Pediatric Emergency Assistant Professor of Emergency Professor, Pediatrics and Associate Professor of Emergency
Ilene Claudius, MD Medicine, Massachusetts General Medicine, NYU/Langone and Emergency Medicine, University of Medicine, Pediatrics, and Medical
Associate Professor, Department Hospital; Instructor in Pediatrics, Bellevue Medical Centers, New Florida, Jacksonville, FL Education, Director Of Pediatric
of Emergency Medicine and Harvard Medical School, Boston, MA York, NY; CEO, MD Aware LLC Emergency Medicine, Icahn School
Pediatrics, USC Keck School of Garth Meckler, MD, MSHS
of Medicine at Mount Sinai, New
Medicine, Los Angeles, CA Jay D. Fisher, MD, FAAP Alson S. Inaba, MD, FAAP Associate Professor of Pediatrics,
York, NY
Clinical Professor of Pediatric and Pediatric Emergency Medicine University of British Columbia;
Tim Horeczko, MD, MSCR, FACEP, Emergency Medicine, University Specialist, Kapiolani Medical Center Division Head, Pediatric Emergency David M. Walker, MD, FACEP, FAAP
FAAP of Nevada, Las Vegas School of for Women & Children; Associate Medicine, BC Children's Hospital, Director, Pediatric Emergency
Associate Professor of Clinical Medicine, Las Vegas, NV Professor of Pediatrics, University Vancouver, BC, Canada Medicine; Associate Director,
Emergency Medicine, David Geffen of Hawaii John A. Burns School of Department of Emergency Medicine,
School of Medicine, UCLA ; Core Marianne Gausche-Hill, MD, FACEP, Joshua Nagler, MD, MHPEd
Medicine, Honolulu, HI New York-Presbyterian/Queens,
Faculty and Senior Physician, Los FAAP, FAEMS Assistant Professor of Pediatrics and
Flushing, NY
Angeles County-Harbor-UCLA Medical Director, Los Angeles Madeline Matar Joseph, MD, FACEP, Emergency Medicine, Harvard Medical
Medical Center, Torrance, CA County EMS Agency; Professor of FAAP School; Fellowship Director, Division Vincent J. Wang, MD, MHA
Clinical Emergency Medicine and Professor of Emergency Medicine of Emergency Medicine, Boston Professor of Pediatrics, Keck
Editorial Board Pediatrics, David Geffen School of and Pediatrics, Chief and Medical Children’s Hospital, Boston, MA School of Medicine of the
Jeffrey R. Avner, MD, FAAP Medicine at UCLA; EMS Fellowship Director, Pediatric Emergency University of Southern California;
James Naprawa, MD
Chairman, Department of Director, Harbor-UCLA Medical Medicine Division, University Associate Division Head, Division
Attending Physician, Emergency
Pediatrics, Professor of Clinical Center, Department of Emergency of Florida College of Medicine- of Emergency Medicine, Children's
Department USCF Benioff
Pediatrics, Maimonides Children's Medicine, Los Angeles, CA Jacksonville, Jacksonville, FL Hospital Los Angeles, Los
Children's Hospital, Oakland, CA
Hospital of Brooklyn, Brooklyn, NY Angeles, CA
Michael J. Gerardi, MD, FAAP, Stephanie Kennebeck, MD Joshua Rocker, MD
Steven Bin, MD FACEP, President Associate Professor, University of International Editor
Associate Chief and Medical
Associate Clinical Professor, UCSF Associate Professor of Emergency Cincinnati Department of Pediatrics, Director, Assistant Professor Lara Zibners, MD, FAAP, FACEP,
School of Medicine; Medical Director, Medicine, Icahn School of Medicine Cincinnati, OH of Pediatrics and Emergency MMed
Pediatric Emergency Medicine, UCSF at Mount Sinai; Director, Pediatric Anupam Kharbanda, MD, MS Medicine, Cohen Children's Medical Honorary Consultant, Paediatric
Benioff Children's Hospital, San Emergency Medicine, Goryeb Chief, Critical Care Services Center of New York, Donald and Emergency Medicine, St. Mary's
Francisco, CA Children's Hospital, Morristown Children's Hospitals and Clinics of Barbara Zucker School of Medicine Hospital Imperial College Trust,
Medical Center, Morristown, NJ
Richard M. Cantor, MD, FAAP, Minnesota, Minneapolis, MN at Hofstra/Northwell, New Hyde London, UK; Nonclinical Instructor
FACEP Sandip Godambe, MD, PhD Park, NY of Emergency Medicine, Icahn
Tommy Y. Kim, MD, FAAP, FACEP
Professor of Emergency Medicine Chief Quality and Patient Safety School of Medicine at Mount Sinai,
Associate Professor of Pediatric Steven Rogers, MD
and Pediatrics; Director, Pediatric Officer, Professor of Pediatrics and New York, NY
Emergency Medicine, University of Associate Professor, University of
Emergency Department; Medical Emergency Medicine, Attending California Riverside School of Medicine, Connecticut School of Medicine,
Director, Central New York Poison Physician, Children's Hospital of the Riverside Community Hospital, Attending Emergency Medicine Pharmacology Editor
Control Center, Golisano Children's King's Daughters Health System, Department of Emergency Medicine, Physician, Connecticut Children's Aimee Mishler, PharmD, BCPS
Hospital, Syracuse, NY Norfolk, VA Riverside, CA Medical Center, Hartford, CT Emergency Medicine Pharmacist,
Steven Choi, MD, FAAP Ran D. Goldman, MD Maricopa Medical Center,
Melissa Langhan, MD, MHS Christopher Strother, MD
Assistant Vice President, Professor, Department of Pediatrics, Phoenix, AZ
Associate Professor of Pediatrics and Assistant Professor, Emergency
Montefiore Health System; Director, University of British Columbia;
Research Director, Pediatric
Emergency Medicine; Fellowship Medicine, Pediatrics, and Medical CME Editor
Montefiore Network Performance Director, Director of Education, Education; Director, Undergraduate
Improvement; Executive Director, Emergency Medicine, BC Children's Deborah R. Liu, MD
Pediatric Emergency Medicine, Yale and Emergency Department
Hospital, Vancouver, BC, Canada
Montefiore Institute for Performance University School of Medicine, New Simulation; Icahn School of Medicine Associate Professor of Pediatrics,
Improvement; Associate Professor Haven, CT at Mount Sinai, New York, NY Keck School of Medicine of USC;
of Pediatrics, Albert Einstein College Division of Emergency Medicine,
of Medicine, Bronx, NY Children's Hospital Los Angeles,
Los Angeles, CA
Case Presentations being missed fractures. Earlier identification of these
injuries can greatly decrease the rates of morbidity
A 12-year-old previously healthy boy presents to the ED and mortality. Other organ systems in which certain
via EMS for a visible deformity of his right arm. His missed injuries can lead to serious morbidity in
18-year-old brother was pulling him around in an inner multiple-trauma patients include the gastrointestinal
tube that was attached by a long rope to a truck traveling and respiratory systems.6 Less common pathologies,
about 40 miles per hour through a lightly wooded area. His such as abdominal compartment syndrome,3 if not
brother made a sharp turn, and the patient went flying off recognized early, can lead to a decline in respira-
the inner tube and hit a tree. The brother said that the pa- tory status and decreased cardiac output. Blunt
tient did not lose consciousness, but that he was “stunned” chest trauma can cause morbidity primarily from
for a few seconds, then started complaining about his right lung contusions or hemothorax/pneumothorax or
arm. The patient said he was not wearing any personal secondarily as a result of a systemic inflammatory
protective equipment. He has multiple abrasions to his face, response syndrome leading to acute lung injury.
trunk, and extremities. He denies pain anywhere except This issue of Pediatric Emergency Medicine Practice
in his arm. He requests to have his neck brace removed will discuss evidence-based recommendations for
because it is “annoying.” He denies vomiting but reports early recognition of TBI during the primary survey,
feeling nauseous after receiving morphine from the para- initiation of the proper imaging to diagnose injuries,
medics en route to the hospital. Because this was a severe expedient stabilization of injuries, and utilization of
mechanism, though the patient appears to have an isolated a systematic approach to manage pediatric patients
injury, you begin to consider how much you should do. with multiple trauma.
Should you “pan-scan” the patient and draw labs because
of the mechanism? What other imaging studies do you need Critical Appraisal of the Literature
to obtain besides an x-ray of the arm? Is the patient at risk
for internal bleeding due to this blunt impact? Should you A literature search was performed in PubMed using
consult the surgeons or just call the orthopedist to reduce the search terms: multiple trauma, pediatrics, emergen-
the obvious fracture? cy room, trauma, children, polytrauma, imaging, FAST,
A 16-month-old previously healthy girl presents to permissive hypotension, transfusion, airway, tranexamic
the ED via EMS after a seemingly accidental fall out of a acid, and ATLS. A total of 193 articles from 1997 to
third-story apartment window. Onlookers said the girl fell the present were reviewed. The Cochrane Database
into a bush and appeared stunned but did not lose con- of Systematic Reviews and the National Guideline
sciousness. The mother says when she got downstairs, the Clearinghouse were searched for systematic reviews
child was crying but easily consoled. The girl has multiple using the key term multiple trauma pediatrics. Ap-
abrasions all over her body and a bloody nose, but oth- proximately 70 articles were found, most of them
erwise seems fine. She cries throughout the primary and being from the view of surgical management. The
secondary surveys. Is the crying merely developmentally ninth edition of the Advanced Trauma Life Sup-
appropriate stranger anxiety? Does this patient need labs port (ATLS) guidelines,7 released by the American
drawn? What type of imaging is warranted? If no other College of Surgeons Committee on Trauma, were
injuries are identified, what is the appropriate disposition also reviewed. While ATLS is not pediatric-specific,
for this patient? it is a system based on both best available evidence
and expert consensus. These guidelines are widely
Introduction considered the standard approach to all injured
patients. Very few guidelines or policy statements
Trauma is the leading cause of morbidity and mortal- were found specifically on pediatric trauma. The
ity in children aged > 1 year.1,2 When pediatric patients American Academy of Pediatrics (AAP) issued a
present with multiple traumatic injuries, life- or limb- policy statement in August 2016 that demonstrated
threatening injuries in 2 or more organ systems are not the importance of a diverse trauma team when car-
uncommon;1,3,4 traumatic brain injuries (TBIs) and or- ing for pediatric trauma patients.8
thopedic/musculoskeletal injuries are frequent.5 Death The search of the literature revealed few case
occurs in up to 27% of pediatric patients with multiple reports on multiple trauma in pediatric patients;
traumatic injuries and is mainly dependent upon the there were also few studies on the emergency medi-
severity of the TBI.4 cal management of these cases. There were more
Typically, major issues with airway, breathing, studies that focused on the surgical management of
and circulation are recognized and stabilized in a multiple trauma patients, including emergency sur-
timely fashion. Problems occur when TBIs and or- gical procedures and early involvement of surgical
thopedic injuries are not identified early, as they can specialties in resuscitation. The studies were retro-
lead to long-term disabilities in pediatric patients.2,6 spective, with very few prospective or randomized
In one study, 9% of injuries were initially missed in double-blinded studies.
pediatric trauma patients, with 46% of those injuries

Copyright © 2018 EB Medicine. All rights reserved. 2 Reprints: www.ebmedicine.net/pempissues


Etiology and Pathophysiology result in significant morbidity and are most likely
permanent. Early identification of secondary TBI is
Common Mechanisms of Injury possible with frequent neurologic checks, including
A search of the National Trauma Database by determination of the patient's Glasgow Coma Scale
Tracy et al revealed the most common causes of (GCS) score and monitoring vital signs for Cush-
pediatric trauma in patients aged 0 to 18 years.9 ing triad (bradycardia, hypertension, and irregular
The leading cause of trauma in children aged 0 to breathing).
9 years is falls;2,9-11 in children aged 10 to 18 years
it is motor vehicle crashes (which is second in chil- Differential Diagnosis
dren aged 0-9 years).12 The second most common
cause of trauma in children aged 16 to 18 years The differential diagnosis in the pediatric trauma pa-
is penetrating trauma. The third leading cause of tient and is broad, and it relies on thorough primary
trauma for children aged 3 to 6 years is pedestrian and secondary surveys. The mechanism of injury
accidents; for children aged 7 to 10 years, it is should be taken into consideration as well. Table 1,
bicycle accidents.9 page 4 summarizes some common injuries, by body
system.
Difficulties in Assessing Pediatric Patients
Depending on the stage of development, a child may Prehospital Care
not be able to effectively localize or communicate
discomfort, injury, or pain. Irritability and fear may Initial Stabilization and Communication With
also greatly affect how pediatric patients interact Field Emergency Medical Technicians
with emergency clinicians. Emergency clinicians may Initial evaluation and management of pediatric
also have stronger emotional reactions in caring for trauma patients are critical to minimizing morbid-
severely traumatized children, compared with injured ity and mortality.1,2 Initial stabilization is focused
adults.13 on ensuring that the airway is patent, supporting
respirations if inadequate, and rapidly establishing
Commonly Missed Injuries intravenous (IV) access. Prehospital providers may
A retrospective review of 1175 pediatric trauma have less experience with pediatric emergency care
cases revealed that the most commonly missed than with adult care, as most prehospital provid-
injuries in pediatric trauma patients were fractures.14 ers do not commonly see critically ill or injured
A broader list includes: intracranial injuries, intra- children.8 The AAP and the National Association of
abdominal injuries, retained foreign bodies, and Emergency Medical Technicians have established
peripheral nerve injuries.15 Patients most likely to courses to provide training in the stabilization of air-
have missed injuries were those requiring emergent way, breathing, and circulation in the field. Commu-
intubation, emergent surgeries, or pediatric intensive nication with pediatric trauma facilities can stream-
care unit admission. Unfortunately, missed injuries line provision of optimal field care.8 If transport to
are common in pediatric trauma patients. The results a pediatric trauma facility is not reasonable due to
of a study by Furnival et al indicated that barriers to distance or patient instability, the patient should be
communication between emergency clinicians and taken to the nearest hospital capable of providing
the severely injured child were the cause of these comprehensive trauma care.8
missed injuries.14 Because of this, there should be
ongoing evaluation of patients with multiple trau- Cervical Spine Immobilization
matic injuries during their hospitalization to assess The American Association for Neurological Sur-
for missed or worsening injuries. geons and the Congress of Neurological Surgeons
Joint Guidelines Committee recommend spinal
Traumatic Brain Injuries immobilization for all trauma patients with a
TBI can be classified as primary or secondary. Primary known or suspected spinal cord injury. The pre-
TBIs are a result of the initial force generated by ferred method of cervical spine immobilization is
the trauma.16 These injuries include contusions and the combination of a rigid collar and supportive
hematomas from direct contact and shearing of the blocks on a spine board with straps.17,18 These
neural axons from acceleration-deceleration injuries. guidelines are in agreement with the ATLS guide-
Secondary brain injury has 2 major causes. The first lines; collars should be used until the cervical
includes sequelae of potentially avoidable/treat- spine is cleared by a healthcare professional. In
able conditions including: hypoxemia, hypotension, children aged < 12 years, a high index of suspi-
intracranial hypertension, hypercapnia, glucose and cion should be maintained for spinal cord injury
electrolyte abnormalities, seizures, and hyperther- related to SCIWORA (spinal cord injuries with-
mia. The second cause is a result of the ongoing axo- out radiographic abnormalities), and a detailed
nal injuries and neuronal cell death. These injuries neurologic examination should be documented in

June 2018 • www.ebmedicine.net 3 Copyright © 2018 EB Medicine. All rights reserved.


high-risk patients.19,20 Clearance should be de- Emergent Management
layed when there are distracting injuries.
For more information on the management of cervi- Multisystem trauma often requires simultaneous
cal spinal injuries in pediatric patients, see the March history-taking, physical examination, evaluations,
2016 issue of Pediatric Emergency Medicine Practice, and stabilization/management.
“Cervical Spinal Injury in Pediatric Blunt Trauma
Patients: Management in the Emergency Department,” History
available at: www.ebmedicine.net/CSpine The mnemonic, SAMPLE (S, signs/symptoms; A, al-
lergies; M, medications; P, past medical history; L, last
Splinting Orthopedic Injuries oral intake or last menstrual period; E, events lead-
Application of splints in the prehospital setting ing to injury), is designed to obtain key points in a
is an area of controversy, because they can cause patient’s medical history and the events leading up to
significant morbidity if applied improperly. The the trauma. It is important to speak with the patient, a
American College of Surgeons Committee on caregiver, or first responder as soon as possible to ob-
Trauma believes that treatment of musculoskel- tain the history. However, in cases of pediatric trauma
etal injuries cannot be delayed.7 They recommend when the patient is unable to answer these questions
early management of musculoskeletal injuries and no caregiver is available for history or consent to
in the field to include proper pain management, treatment, stabilizing care should not be delayed.
repositioning, and splint application. Proper use of Additional immediate history-taking should fo-
early field interventions can reduce complications cus on details that may affect the workup or manage-
such as internal bleeding, increased pain, and fat ment but that cannot easily be ascertained from the
embolisms.2 Emergency medical technicians need physical examination. Examples include:
to be educated regarding the proper application of • Time of the injury
splints without reduction. • Mechanism of the injury
l
Speed of the vehicle
l
Restrained or unrestrained passenger

Table 1. Differential Diagnosis for Pediatric Trauma Patients


Body System Differential Diagnosis Body System Differential Diagnosis
Head • Concussion* Cardiac • Aortic injury
• Extracranial hematomas, • Myocardial contusion
lacerations, abrasions* • Cardiac tamponade
• Penetrating head trauma • Pericardial effusion
• Subarachnoid hemorrhage Abdomen • Liver laceration or hematoma
• Subdural hematoma • Splenic laceration or hematoma
• Epidural hematoma • Pancreatic injury
• Cerebral edema • Duodenal hematoma
• Skull fractures • Intestinal injury
Eye, Ear, Nose, Throat • Corneal abrasions* • Renal lacerations or hematoma
• Dental injuries* • Genitourinary injuries
• Traumatic iritis Skin • Burns*
• Optic burns • Lacerations*
• Open globe injuries • Abrasions*
• Facial fractures (may include nerve • Hematomas*
entrapment, CSF leak, etc)
Musculoskeletal • Fractures*
• Septal hematoma
• Muscle injury
• Glottic or subglottic edema
• Compartment syndrome
• Cervical-spine fractures
• Crush injuries
• Rotary subluxation
• Amputations
• SCIWORA
Other • Vascular injuries
Pulmonary • Costochondritis*
• Pneumothorax/hemothorax
• Pulmonary hemorrhage
• Pulmonary contusion
• Rib fractures
• Pneumomediastinum

The most common injuries are marked with an asterisk.


Abbreviations: CSF, cerebrospinal fluid; SCIWORA, spinal cord injury without radiographic abnormality.

Copyright © 2018 EB Medicine. All rights reserved. 4 Reprints: www.ebmedicine.net/pempissues


l
Height of fall Circulation
l
Death(s) at the scene The patient’s pulse, blood pressure, and perfusion
• Loss of consciousness should be assessed; sources of external or internal
• Recurrent vomiting bleeding should be identified; and intravascular
• Mental status at the time of and since the injury access should be obtained.13 The distal pulses (eg,
• Status of other individuals involved in the inci- the radial and dorsalis pedis) should be palpated.
dent (ejected, extracted, dead at the scene) If distal pulses cannot be palpated, proximal pulses
(eg, brachial and femoral) should be palpated. Gross
Physical Examination bleeding should be controlled with direct pres-
Primary Survey sure. Loss of pulses could be a sign of hypovolemic
The first step in evaluating any trauma patient is shock or significant blood loss and should be treated
the primary survey.21 In this initial evaluation, life- initially with administration of IV crystalloid fluid
threatening injuries are identified and simultane- (20 mL/kg) or blood (10 mL/kg packed red blood
ously addressed. The mnemonic, ABCDE, is used to cells) if hemorrhage is evident or suspected. Pericar­
remember the order of assessment. (See Figure 1.) dial tamponade can also lead to shock and should be
Once the primary survey is complete, a full head- considered in the differential. If pericar­dial tampon-
to-toe assessment (secondary survey) can be per- ade is suspected, an attempt to drain the collection
formed. (via needle or surgi­cally) should be made.

Airway Management Disability


If the patient is able to talk or cry, the airway is likely This basic neurological assessment includes evaluat-
clear. An unconscious patient may not be able to ing the patient’s level of consciousness, pupil size,
maintain his own airway or may have an obstructed and reaction.5 GCS scoring is a quick method to
airway. Interventions during this step of the assess- determine the patient’s level of consciousness, and
ment include suctioning fluid that could be blocking involves assessing the patient’s ability to open his
the airway, removing foreign bodies, using a chin lift eyes, along with his verbal and motor responses. The
or jaw thrust, using an airway adjunct (eg, an oral or GCS has been modified for use in pediatric patients.
nasal trumpet), or inserting an endotracheal tube.22 (See Table 2.) It is better to report the score broken
This should all be performed while maintaining into components of eye opening, verbal response,
cervical spine protection until the cervical spine can and motor response (E, V, and M). Typically, a GCS
be assessed during the secondary survey. score ≤ 8 indicates sufficient disability to require
intubation for airway protection. An altered level of
Breathing consciousness may indicate the need to reassess the
Problems that can be identified during the breath- airway, breathing, and circulation. Fixed and dilated
ing assessment include pneumothorax, hemothorax, pupils can be an early sign of TBI.
pulmonary injury, or flail chest.13 Assess the pa-
tient’s ability to move air and ventilate by inspec-
tion, palpation, and auscultation. Inspection can Table 2. Pediatric Glasgow Coma Scale
reveal tracheal deviation, unequal chest rise, pen- Scoring23
etrating injuries, or bruising. Palpation can reveal
Eye Opening Pts. Verbal Pts. Motor Pts.
subcutaneous emphysema. Auscultation can reveal
(E) Response Response
unequal breath sounds of pneumothorax. Significant (V) (M)
pneumothoraces should be treated immediately by
Spontaneous 4 Coos or 5 Spontaneous, 6
decompression with a needle or chest tube.
babbles purposeful
To voice 3 Irritable/ 4 Withdraws 5
continually from touch
cries
Figure 1. Primary Survey Evaluation for To pain 2 Cries to pain 3 Withdraws 4
Trauma Patients22 from pain
None 1 Moans to 2 Abnormal 3
A Airway with cervical spine protection
pain flexion

B Breathing and ventilation None 1 Extensor 2


response
C Circulation with hemorrhage control None 1
Points for E ___ Points for V ___ Points for M ___
D Disability: neurologic status
Maximum: 15 Score: E+V+M = GCS score

E Exposure and environmental control


Abbreviation: Pts, points.

June 2018 • www.ebmedicine.net 5 Copyright © 2018 EB Medicine. All rights reserved.


An MDCalc online tool for calculat- Primary Stabilization/Management
ing the pediatric Glasgow Coma Scale Pediatric Airway Management
score is available at: Early management of the airway in the pediatric
www.mdcalc.com/pediatric-glasgow- trauma patient warrants further discussion, as the
coma-scale-pgcs literature suggests that preventable deaths from pe-
diatric trauma are largely dependent on the airway.
The most common causes of cardiac arrest in pedi-
Exposure and Environmental Control
atric trauma patients are hypoxia and inadequate
During this assessment, the patient’s clothing is
ventilation.28 In a study of potentially preventable
removed and the patient’s entire body is thoroughly
pediatric trauma deaths, 9% of deaths were con-
inspected for gross bleeding and deformities.22 Envi-
sidered preventable, 36% of patients were deemed
ronmental control ensures that the patient is covered
to have received inappropriate care (regardless of
with warm blankets to prevent hypothermia and to
preventability), and 29% of inappropriate manage-
maintain privacy and modesty.5 Pediatric patients
ment was due to inadequate respiratory manage-
are prone to hypothermia; therefore, this has even
ment, including airway concerns.29 The identified
greater importance in the younger child than an
reasons for this included: (1) failure to establish a
adult. If gross bleeding, deformity, or hypothermia is
definitive airway, (2) failure to recognize the need
identified at any step during this process, it should
for an airway, (3) failure to recognize an improperly
be addressed immediately before moving on to the
placed airway, and (4) displacement of a previously
next step.
established airway.
ATLS clearly defines indications for establish-
Evaluation
ing a definitive airway.7 In addition to patients with
Focused Assessment With Sonography in Trauma
obvious airway or breathing issues, intubation may
(FAST) Examination
be necessary for patients with significant unstable
The focused assessment with sonography in trauma
facial fractures, risk of obstruction secondary to
(FAST) examination is a bedside ultrasound assess-
airway edema (laryngeal/tracheal injury, stridor),
ment of the perihepatic space, perisplenic space,
risk of aspiration from vomiting or bleeding, or
pericardium, and the pelvis to identify blood around
altered mental status with a GCS score ≤ 8. Maintain
the heart or in the abdominal cavity.5,24 The extended
a high level of suspicion for progression of airway
FAST (eFAST) also includes screening of the lungs
edema in patients with neck injuries and burns. If
for pneumothorax or hemothorax.
there are signs of compromise, establish an airway
These assessments involve no exposure to
sooner rather than later, even if the patient is stable
radiation and are quicker and less expensive than
on primary survey.
computed tomography (CT). However, FAST is
Classic teaching on the pediatric airway usu-
less accurate in children than in adults and rarely
ally focuses on challenges in comparison to adult
affects management in children.22,24-26 A recent
airways. (See Figure 2.) The relatively large head of
multi-institutional prospective study suggests that
infants and younger children means that flexion of
the use of FAST in children has low sensitivity for
the neck and airway can cause airway obstruction
intra-abdominal injury, with 28% sensitivity and
in the unconscious patient. This can be exacerbated
91% specificity in children with abdominal injury
who did not require interventions, and 44% sensitiv-
ity and 88.5% specificity in children with abdominal Figure 2. Differences in the Pediatric Airway
injury who did require intervention.26 There is large Compared to the Adult Airway
variability in the reported sensitivities (20%-80%)
for FAST detection of intra-abdominal free fluid in
children.24-26 Another study found that FAST did not
improve length of stay, resource utilization, cost, or
missed injuries.27 Of note, this study excluded high-
risk patients (eg, patients who were hypotensive),
and sensitivity for detection of hemoperitoneum is
higher in hypotensive children or those requiring
an operation. Therefore, while FAST is unlikely to
change management in the stable pediatric trauma
patient, it may still have a role in evaluation of the
critically ill patient.

Markenson, David S, Pediatric Prehospital Care, 1st, © 2001. Reprinted


by permission of Pearson Education, Inc., New York, New York.

Copyright © 2018 EB Medicine. All rights reserved. 6 Reprints: www.ebmedicine.net/pempissues


if a pediatric trauma patient is immobilized on an guidelines do not dictate which patients require a CT
adult backboard with head support or placed in an scan, but rather identify children who are at low risk
ill-fitting collar. Therefore, while attention to cervical for a clinically important TBI.32 The study included
spine immobilization cannot be ignored, attempts 42,412 patients (from 25 United States hospitals) who
at immobilization that force the neck into flexion presented within 24 hours of head trauma. Children
should be corrected before attempting intubation. with trivial injuries (including ground-level falls or
The shorter trachea may increase the risk of dis- walking/running into stationary objects, with no oth-
lodgement with patient movement or a shallow er signs or symptoms of head trauma besides scalp
intubation or, conversely, right main stem intubation abrasions or lacerations) were excluded. For patients
with deep intubations. Endotracheal tube placement aged < 2 years, the following factors increased their
should be reconfirmed after a field or interfacility risk of clinically important TBI:
transfer. • Altered mental status
In rapid sequence intubation, preoxygenation • Nonfrontal scalp hematoma
increases the time to place a definitive airway by • Loss of consciousness > 5 sec
providing a buffer during hypoventilation and • Severe injury mechanism
apnea. This “safe apnea” (until the saturation level • Palpable skull fracture
reaches 88%-90%) allows for longer periods of apnea • Not acting normally, according to the parent
prior to desaturation.30 This is important in pediatric
patients, as the safe apnea time for children is ap- Patients with none of these factors were classified
proximately half that of adults, and can be as brief as as being at low risk. The negative predictive value
90 seconds in an infant. Apneic oxygenation with 15 and sensitivity were both 100% for this group. For
L of high-flow nasal cannula can also be helpful to children aged ≥ 2 years, the factors that increased risk
prolong this safe period during intubation attempts. included:
If age-related anatomic variations in the airway • Altered mental status
and immobilization make intubation difficult, alter- • Any loss of consciousness
nate ventilation strategies may be required. This is • History of vomiting
especially true for patients with brain injury or facial • Severe injury mechanism
injury, specifically those with excessive blood in the • Clinical signs of basilar skull fracture
airway, loose dentition, or facial bone instability. • Severe headache
Having a back-up plan prior to initiating rapid se-
quence intubation may be prudent with anticipated The negative predictive value was 99.95% and
difficult airways. Typically, anesthesia or intensive the sensitivity was 96.8%. Children in the low-risk
care unit personnel or ear, nose, and throat special- category can generally be discharged home. Children
ists can be called for difficult airways. Although with highly concerning signs or symptoms (altered
video laryngoscopy in adults has been shown to mental status or an obvious skull fracture) usually
improve overall first-attempt intubation success and require a CT scan to rule out underlying intracranial
decrease complications, a systematic review of video injury. Children without these 2 findings but who are
laryngoscopy did not show the same benefit in chil- not considered to be at low risk by the PECARN crite-
dren, and it resulted in longer time to intubation.31 ria usually undergo a period of observation in the ED.
Surgical airways are occasionally required in The duration of observation typically ranges from 3 to
trauma. Needle cricothyrotomy and transtracheal jet 6 hours; however, a CT scan may be obtained if there
ventilation is preferred over standard cricothyrot- is a high level of concern or the observation period is
omy for patients aged < 10 years, and can be per- not reassuring.
formed quickly and easily. To perform this, puncture
the cricothyroid membrane with a 16- or 14-gauge An MDCalc online tool for the PECARN
catheter over a needle, withdraw the needle, and Pediatric Head Injury/Trauma
verify the position by aspirating air. Then place a Algorithm is available at:
3.0 endotracheal tube adaptor into the catheter and www.mdcalc.com/pecarn-
perform bagged ventilations through the endotra- pediatric-head-injury-trauma-algorithm
cheal tube adaptor. Laryngeal-mask airways can be
helpful airway adjuncts in children; however, their
utility is limited in trauma patients requiring airway Stabilization of Musculoskeletal Injuries
protection from swelling, blood, or vomit. Open Fractures
An open fracture is a disruption of the skin and soft
Management of Closed Head Injuries tissue by a penetrating wound or a displaced bone
The majority of children will have, at least, a minor fragment, allowing for communication between
head injury from a major trauma. The Pediatric Emer- the fracture and the outside environment. These
gency Care Applied Research Network (PECARN) fractures are considered orthopedic emergencies

June 2018 • www.ebmedicine.net 7 Copyright © 2018 EB Medicine. All rights reserved.


due to the risk for contamination leading to infec- to recognize compartment syndrome can lead to
tion.19 Initial ED assessment should include inspec- morbidity, including loss of limb.33 Patients with
tion, palpation, and neurovascular assessment of all displaced supracondylar and tibial fractures have an
extremities. The open wound should be inspected increased risk of developing compartment syn-
for bleeding, overt injury to underlying structures, drome. In a retrospective review of pediatric patients
crush injuries, bone exposure, and contamination. with forearm compartment syndrome, 66% of cases
After inspection, a moistened saline or povidone- were secondary to ulnar fractures, and earlier surgi-
iodine dressing should be applied to protect the cal intervention was associated with significantly
exposed soft tissue.2 Prior to advanced imaging or decreased functional deficits.34
repair, gross deformities should be realigned with The 6 Ps in identifying compartment syndrome
gentle traction and splinting to decrease soft-tissue include: pain out of proportion to the injury, sensa-
injury and pain. Prompt prophylactic IV antibiotics tion of paresthesias, pallor, paralysis, pulselessness,
are essential in the treatment of children with open and poikilothermia. Many of these are late findings,
fractures.2 Most first-line antibiotic choices include a and can present subtly in children. Restlessness, agi-
first-generation cephalosporin (generally cefazolin) tation, and anxiety, along with increased analgesia
to protect against gram-positive organisms. requirements, may be other indicators of compart-
The Gustilo-Anderson classification of open ment syndrome in children. However, these signs
fractures defines type I as an open fracture with a are difficult to quantify and have been inadequately
wound that is < 1 cm long and clean; type II as an studied. If compartment syndrome is suspected,
open fracture with a laceration that is > 1 cm long remove any external sources of compression and
without extensive soft-tissue damage, flaps, or avul- obtain tissue-pressure measurements while simul-
sions; and type III as an open segmental fracture or taneously consulting surgery for possible surgical
an open fracture with extensive soft-tissue damage decompression.33
or a traumatic amputation. Patients with type II or
For more information on the management of
III open fractures should receive additional cover- compartment syndrome in pediatric patients, see the
age with an IV aminoglycoside such as gentamicin. September 2017 issue of Pediatric Emergency Medicine
According to Kay and Skaggs, any patient with a Practice, “Pediatric Orthopedic Injuries: Evidence-
wound that is contaminated with soil or fecal mat- Based Management in the Emergency Department,”
ter should receive IV penicillin in addition to an IV available at: www.ebmedicine.net/Ortho
cephalosporin.2 A patient with penicillin or cephalo-
sporin allergies can receive clindamycin. Methicillin- Fluid Resuscitation
resistant Staphylococcus aureus (MRSA) infections are Second only to airway complications, shock is a
not common in open fractures; however, if there is a leading cause of death in pediatric trauma patients.
concern (such as a history of frequent MRSA skin/ Shock in pediatric trauma patients is usually second-
soft-tissue infections) IV vancomycin should also ary to hypovolemia from hemorrhage. Neurogenic
be given for MRSA coverage. Orthopedic surgical shock is rare; shock in trauma patients is hemorrhage
intervention is the critical definitive management in until proven otherwise. Recognition of shock can
the care of open fractures.2 be challenging, with subtle initial symptoms; often,
only tachycardia. Hypotension and/or irritability are
Tetanus Vaccination considered late findings, and are substantially more
The history in the secondary survey should include delayed and more concerning in pediatric patients
the patient’s tetanus status. Patients who have not compared with adults.35 Assessment for and control
received a tetanus vaccine or booster within the past of ongoing blood loss are essential to prevent end-
5 years should receive a dose of tetanus toxoid (0.5 organ damage secondary to hypoxia from hypovo-
mL intramuscular injection). If a patient has never lemia.
received a tetanus vaccine, did not receive the com- Obtaining vascular access can be challenging in
plete series of tetanus vaccinations, or is uncertain pediatric trauma patients, and ATLS guidelines for
whether the full tetanus vaccination series (3 doses) access and resuscitation should be utilized, mov-
was received, the patient should receive tetanus im- ing quickly to intraosseous (IO) access if IV access
mune globulin (250 units intramuscular injection) in cannot be obtained.7 In children, the proximal tibia
addition to the tetanus toxoid injection.2 is preferred for IO access, and consideration should
be given to anesthesia by slowly administering
Compartment Syndrome preservative-free lidocaine (0.5 mg/kg, max 40 mg)
Compartment syndrome should be considered in pe- through the IO line. Crystalloid fluids and blood
diatric patients with acute traumatic musculoskeletal products can be administered via an IO line; how-
injuries. Preoperative and postoperative assessments ever, push-pull technique or pressure bags may be
should include frequent neurovascular assessments required. It is imperative to verify that blood prod-
to ensure proper perfusion and sensation.2 Failure ucts are infusing at the desired rate.

Copyright © 2018 EB Medicine. All rights reserved. 8 Reprints: www.ebmedicine.net/pempissues


Traditionally, warmed crystalloid fluids are uni- decreased ventilator dependence.45 No increase in
versally recommended for initial pediatric trauma thrombotic events has been noted in pediatric pa-
resuscitation, with 2 rapidly infused boluses of 20 tients receiving TXA.
mL/kg, after which resuscitation with blood prod-
ucts should be considered. In the adult trauma lit- Diagnostic Studies
erature, evidence supports damage control resuscita-
tion in severe uncontrolled hemorrhage. The tenets Radiographic Studies
of this approach include permissive hypotension
Plain film radiographs are the quickest means of
and early transfusion, resulting in decreased mortal-
evaluating bony structures in trauma patients.2 Ad-
ity rates. However, there is no evidence to support
vantages include portability, low cost, and speed.46
permissive hypotension in children.36 Additionally,
In patients who are unstable and cannot be trans-
there is some evidence that timely treatment of hy-
ported to the radiology suite, portable radiographs
potension in children with TBI significantly reduces
are appropriate for assessment of fractures, endotra-
both morbidity and mortality.37,38 Because hypo-
cheal tube placement, and thoracic injuries. Disad-
tension is often a perimortum finding in children,
vantages include limited identification of soft-tissue
permissive hypotension is not recommended in
injuries and radiation exposure.6
pediatric trauma patients.
Further studies are needed to determine wheth-
Computed Tomography
er early transfusion or massive transfusion protocols
CT is the imaging modality of choice for rapid
affect outcomes in children with trauma. Most cur-
evaluation of injuries involving the head, face, neck,
rent literature suggests that massive transfusion pro-
abdomen, and pelvis.2 Advantages include avail-
tocols do not improve mortality rates, total amount
ability and high sensitivity and specificity compared
transfused, or intensive care unit/ventilator/
with plain film radiographs.10,46,47 However, CT is
pressor-free days for pediatric trauma patients.39,40
not the best modality for assessment of non–bony
Conversely, early coagulopathy is an independent
spinal cord injuries, because it exposes the patient to
predictor of higher mortality in severely injured
radiation, and it involves patients being transported
children, especially when combined with TBI,41 and
out of the department.6
early coagulopathy and metabolic acidosis appear to
predict the need for transfusion.42
Thromboelastography may yield valuable infor-
Magnetic Resonance Imaging
mation in pediatric trauma patients, but literature Magnetic resonance imaging is the imaging modal-
on this and specific guidelines are minimal-to- ity of choice for assessment of the spinal cord or
nonexistant at this time. Most expert opinion and nerve root.48 Advantages include lack of radiation
pediatric trauma center protocols reflect an opinion exposure and excellent evaluation of soft-tissue inju-
that a 1:1:1 balance may not be ideal in pediatric ries. Disadvantages include time to acquire imaging,
trauma, but that some massive transfusion protocol potential need for sedation, limited availability, in-
is indicated in pediatric patients who have lost or creased cost, and limited evaluation of certain bony
are expected to lose ≥ 40 mL/kg of blood within injuries.6,46
the first 24 hours (or requiring 4 or more 10 mL/kg
transfusions of packed red blood cells). Until further Laboratory Studies
data exist to guide this practice, extrapolating your Many EDs have a “trauma panel” for laboratory
center’s adult massive transfusion protocols to such evaluation of trauma patients.49 Basic laboratory
pediatric trauma patients is a reasonable strategy. studies can include a complete blood cell count,
In adults, administration of tranexamic acid electrolytes (basic metabolic panel or comprehen-
(TXA) reduces mortality and the need for blood sive metabolic panel), coagulation studies (pro-
products. In major pediatric surgeries, including thrombin time and partial thromboplastin time),
heart, spine, and craniofacial surgeries, TXA has blood bank assessment (type and crossmatch or
been shown to be safe and effective in decreasing screen), amylase, urinalysis, arterial blood gas,
transfusion requirements. TXA is typically initi- and lactate level. Overall, little utility has been
ated within 3 hours, with one author suggesting a found for routine use of trauma panels for children,
loading dose of 20 to 25 mg/kg (max, 1 g) IV over 10 and emergency clinicians should feel comfortable
minutes then 1 to 2 mg/kg/hr IV for 8 hours (max, ordering laboratory tests selectively in pediatric
1 g/8 hr) in children aged < 12 years.43,44 Children trauma.50,51 Depending on the circumstances, some
aged ≥ 12 years can receive adult dosing (1 g IV evaluation should be expanded to the following
over 10 minutes, followed by 1 g IV over 8 hours). tests: blood alcohol level, urine pregnancy test, and
A recent study suggests that TXA is associated with urine toxicology screen.
reduced mortality in severely injured children and
may improve neurologic status at discharge and

June 2018 • www.ebmedicine.net 9 Copyright © 2018 EB Medicine. All rights reserved.


Clinical PathwayClinical Pathway Department
For Emergency for the Management of a Of Multiple
Management
Shocks Pediatric Patient With Multiple Traumatic Injuries

Patient with multiple traumatic


injuries presents to the
emergency department

Activate trauma alert/team

Initiate primary survey

ABCDE

A: AIRWAY
ASSESSMENT

B: BREATHING
ASSESSMENT
Is the airway
patent?
NO YES
Is there
YES asymmetric chest NO
Consider: Is the cervical spine rise or breath
• Jaw thrust properly sounds?
• Adjunct airway immobilized?
Evaluate for Resolve any other
• Endotracheal
NO YES pneumothorax: breathing issues
tube intubation
Chest x-ray +/-
With cervical spine
needle
stabilization
decompression
(Class III) Continue to
(Class III)
Apply Continue to C: CIRCULATION
appropriate-sized B: BREATHING ASSESSMENT
cervical collar ASSESSMENT (page 11)
(Class III)

Class of Evidence Definitions


Each action in the clinical pathways section of Pediatric Emergency Medicine Practice receives a score based on the following definitions.
Class I Class II Class III Indeterminate
• Always acceptable, safe • Safe, acceptable • May be acceptable • Continuing area of research
• Definitely useful • Probably useful • Possibly useful • No recommendations until further
• Proven in both efficacy and effectiveness • Considered optional or alternative treat- research
Level of Evidence: ments
Level of Evidence: • Generally higher levels of evidence Level of Evidence:
• One or more large prospective studies • Nonrandomized or retrospective studies: Level of Evidence: • Evidence not available
are present (with rare exceptions) historic, cohort, or case control studies • Generally lower or intermediate levels of • Higher studies in progress
• High-quality meta-analyses • Less robust randomized controlled trials evidence • Results inconsistent, contradictory
• Study results consistently positive and • Results consistently positive • Case series, animal studies, • Results not compelling
compelling consensus panels
• Occasionally positive results

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2018 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.

Copyright © 2018 EB Medicine. All rights reserved. 10 Reprints: www.ebmedicine.net/pempissues


Clinical PathwayClinical Pathway Department
For Emergency for the Management of a Of Multiple
Management
Shocks Pediatric Patient With Multiple Traumatic Injuries

Patient with multiple traumatic


injuries presents to the
emergency department

Activate trauma alert/team

Initiate primary survey


C: CIRCULATION D: DISABILITY
ASSESSMENT ASSESSMENT

ABCDE
Are distal Is the patient's
pulses palpable? GCS score
NO YES YES NO
≤ 8?

Signs of NO Is gross bleeding Endotracheal Is the pupillary


tamponade? present? intubation examination normal?
(Class III)
YES NO
YES YES NO

+/- ultrasound; Apply direct Has IV/IO access Continue to Consider TBI:
pericardiocentesis, pressure been established? E: EXPOSURE • Obtain head
if indicated (Class III) ASSESSMENT CT scan
YES NO
(Class III)

Continue to Obtain IV/IO


D: DISABILITY Access
ASSESSMENT (Class III)

E: EXPOSURE
ASSESSMENT

Neurovascularly Are gross deformities Is there an open


YES NO
intact? present? fracture?

NO YES YES NO

• Obtain x-rays Is the patient


Obtain x-rays
Reduce • Place a splint covered/warm?
(Class III)
• Administer IV antibiotics
• Consult orthopedics
(Class III) YES NO

Abbreviations: CT, computed tomography; IO, intraosseous; IV,


Continue to Cover with
intravenous; TBI, traumatic brain injury.
secondary warm blankets
For Class of Evidence definitions, see page 10.
survey (Class III)

June 2018 • www.ebmedicine.net 11 Copyright © 2018 EB Medicine. All rights reserved.


Treatment nonaccidental trauma in pediatric patients, see
the July 2017 issue of Pediatric Emergency Medicine
Treatment is dependent on the type and severity of Practice, “Nonaccidental Injury in Pediatric Patients:
injuries that are found. In children, many injuries Detection, Evaluation, and Treatment,” available at:
that might otherwise be managed operatively in www.ebmedicine.net/NAT
adults (eg, high-grade splenic or liver lacerations)
are managed conservatively. Most closed orthope- Pregnant Teenagers
dic injuries are amenable to closed reduction and A urine pregnancy test should be obtained as part
do not require operative management in younger of the evaluation of any menstruating (or perime-
children. Children with multiple injuries are often narchal) female trauma patient, as pregnancy can
observed for a period of time to identify decompen- change some aspects of the evaluation and manage-
sation and ensure identification of injuries with a ment. Trauma is the leading nonobstetric cause of
delayed presentation (eg, duodenal hematoma). The death in pregnant women.54 While the primary as-
length of observation is usually determined by the sessment of a pregnant trauma patient should occur
mechanism, which injuries are present at the time of in the same order as any other trauma patient, the
presentation, and the preferences of the trauma or physiological changes occurring during pregnancy
intensive care unit team. The decision for surgical should be considered during resuscitation. The
intervention is determined by the trauma team in secondary assessment should include both obstetric
conjunction with the concerns of other emergency injuries and fetal well-being.54
clinicians.8 ATLS gives an overview of the changes in
anatomy and physiology of the pregnant patient
Special Populations that affect the primary survey assessment and
resuscitation.7 Significant changes occur in blood
Infants volume. Plasma volume increases without com-
pensatory change in red blood cell volume, lead-
Neurological assessment of infants can be challeng-
ing to physiologic anemia of pregnancy. A healthy
ing, given their developmental stage. Instead of the
pregnant woman can lose 1200 to 1500 mL of blood
regular Glasgow Coma Scale, the AVPU system or
before showing signs and symptoms of hypovole-
the modified Glasgow Coma Scale can be used.52
mia. Cardiac output increases due to the increase
(See Figure 3.) The AVPU system is an easy ap-
in plasma volume and decrease in vascular resis-
proach that can be used at any developmental stage
tance of the uterus and placenta. These changes in
and includes a motor component of neurological
cardiac output are also dependent on the position
evaluation.
of the pregnant patient. In the supine position, vena
If the mechanism of injury does not match
cava compression can decrease cardiac output due
the injuries present, nonaccidental trauma should
to the decreased venous return from the lower ex-
always be considered.53 Early identification of
tremities. The heart rate can increase 10 to 15 beats
nonaccidental trauma can be life-saving and
per minute, which should also be considered in the
should be considered in a patient with a constel-
assessment of hypovolemia. The diaphragm rises
lation of injuries consistent with abusive head
during pregnancy, which leads to increased minute
trauma, which includes TBI, retinal hemorrhages,
ventilation secondary to increased tidal volume
and cutaneous bruising. Any injury that is not
and leads to hypocapnia. It is important to note
consistent with the reported mechanism or that is
that a partial pressure of carbon dioxide of 35 to 40
suspicious (ie, patterned burn) is concerning for
mm Hg may indicate impending respiratory failure
nonaccidental trauma.
in the pregnant patient.
For more information on the management of
During radiographic evaluation of a pregnant
patient, fetal irradiation should be minimized by
Figure 3. AVPU System for Infant Neurologic shielding the abdomen with a lead apron whenever
Assessment feasible, although appropriate maternal assessment,
radiographic or otherwise, takes priority. Once
A Alert stabilized, the pregnant patient and fetus that is > 20
V Responds to Verbal stimuli weeks’ gestation should be evaluated by an obstetri-
cian and monitored for at least 4 hours on tocodyna-
P Responds to Painful stimuli
mometry. If there are ≥ 6 contractions per hour or a
U Unresponsive high-risk mechanism of injury, the patient should be
monitored for 24 hours.54
Reprinted from Emergency Medicine Clinics of North America, Volume
25, Issue 811. Jahn T. Avarello, Richard M. Cantor. Pediatric major
trauma: an approach to evaluation and management. Pages 803-836.
Copyright 2007, with permission from Elsevier.

Copyright © 2018 EB Medicine. All rights reserved. 12 Reprints: www.ebmedicine.net/pempissues


Controversies and Cutting Edge Transportation of Pediatric Trauma Patients
Although there are no guidelines for pediatric
Closed Head Injury trauma transport, studies on the topic support the
Early identification and medical management of a following practices:
fatal closed head injury is an area of intense interest • Obtaining a prehospital GCS score, as it is valu-
in pediatric trauma. There is still much to learn about able in predicting outcome.58
which interventions will improve outcomes. The ma- • Expeditious transport, as it improves outcomes
jority of deaths in the pediatric trauma population are for children with head injuries. Pediatric pa-
secondary to TBI. According to one study, the rate of tients with TBI transported to level I and II trau-
survival is 2.5% for pediatric patients with blunt head ma centers via helicopter had improved survival
trauma causing cardiac arrest.55 Aggressive resuscita- when compared to similar patients transported
tion is rarely successful after 10 minutes and is futile via ground emergency medical services.59
after 20 minutes. • Transport by personnel who have pediatric
training. In one study, the incidence of adverse
Severe Traumatic Brain Injury events during transport of children with head
The Acute Medical Management of Severe Traumatic injuries was lower when personnel with pedi-
Brain Injury in Infants, Children, and Adolescents atric training were used.60 There were 13 pre-
guidelines were initially written in 2003 and updat- ventable insults in 6 patients (55%) in the group
ed in 2012; however, the level of evidence to support of patients transported by personnel without
these guidelines suggests that further research is pediatric training and 5 preventable insults in 4
necessary.56 In addition to maintenance of normoten- patients (12%) in the group of patients in which
sion and prevention of hypoxemia (partial pressure trained pediatric personnel were used (P < .05).
of oxygen > 60), the direct guidelines relevant to car-
ing for children with severe TBI in the ED include: For more information on emergency transporta-
• Consider a minimum cerebral perfusion pres- tion of pediatric patients, see the April 2018 issue
sure of 40 mm Hg and a cerebral perfusion pres- of Pediatric Emergency Medicine Practice, “Pediatric
sure threshold of 40 to 50 mm Hg; there may be Emergency Transport: Communication and Coordi-
age-specific thresholds (Level 3 evidence). nation Are Key to Improving Outcomes,” available
• Consider 3% hypertonic saline for TBI associ- at: www.ebmedicine.net/EmergencyTransport
ated with intracranial hypertension; doses in the
acute setting range between 6.5 and 10 mL/kg Disposition
IV given over 20 minutes (Level 2 evidence). If
a continuous infusion is used, serum osmolarity For pediatric patients with isolated, minor, or stabi-
should stay < 360 mOsm/L (Level 2 evidence). lized traumatic injuries, discharge with close follow-
• Consider prophylactic treatment with phenytoin up with a general pediatrician in concert with strict
to reduce the incidence of early posttraumatic return precautions is generally acceptable. For ex-
seizures (Level 3 evidence); many centers use ample, a patient with a simple laceration can follow
levetiracetam as well. up with a primary care provider for wound checks
• Moderate hypothermia (32°C–33°C) was recom- and suture removal when given the caveat to return
mended in the guidelines as a consideration immediately to the ED for signs of infection, includ-
(Level 2 evidence). Since the release of these ing increased redness, pain, pus, or fever. Follow-up
guidelines, a more recent study does NOT sup- with specialists may be indicated for certain injuries,
port the use of moderate hypothermia to reduce such as burns, fractures, neck pain without radio-
intracranial hypertension.57 graphic evidence of fracture and normal neurologic
• Prophylactic hyperventilation is not recom- examination, or complicated concussions. Some of
mended (Level 3 evidence). these issues (eg, concussion) bridge multiple spe-
• Corticosteroids are not recommended (Level 2 cialties, and appropriate referral is often region- or
evidence). hospital-dependent.
For a patient with multiple injuries, a surgery
For more information on the management of consult in the ED is prudent. This can help prevent
severe TBI in pediatric patients, see the October 2016 missed injuries, ensure follow-up with surgical
issue of Pediatric Emergency Medicine Practice, “Severe specialists for patients who are discharged home, or
Traumatic Brain Injury in Children: an Evidence- facilitate admission when a short ED observation may
Based Review of Emergency Department Manage- not be sufficient.61 This is particularly true for patients
ment,” available at: www.ebmedicine.net/STBI who have ongoing symptoms despite symptomatic
treatment. Examples of this could include persistent
vomiting in a concussion patient with negative head
imaging despite administration of ondansetron,

June 2018 • www.ebmedicine.net 13 Copyright © 2018 EB Medicine. All rights reserved.


persistent pain in a patient with orthopedic injuries Summary
despite provision of pain medication, or ongoing ab-
dominal pain in a setting of a “seat belt” sign despite Pediatric trauma patients with multiple injuries require
negative laboratory results and imaging. systematic evaluation and a high index of suspicion for
Most patients with internal organ injuries, serious injuries. The leading causes of morbidity and
complicated or high-risk orthopedic injuries (crush mortality in this population are due to inadequate air-
injuries, large-bone fractures [femur or pelvis], way management, late identification of pediatric head
concern for vascular status), or severe head trauma injury, and lack of recognition and rapid treatment
will be admitted and observed for a period of time. of shock. Early recognition of musculoskeletal and
This allows for serial monitoring to ensure that there head injuries can decrease the likelihood of long-term
is no ongoing blood loss, development of compart- disabilities. Prehospital care and transport choice can
ment syndrome, or neurological decompensation.2 If affect outcomes. Consult the trauma team when appro-
admission is necessary, it is preferable to transfer the priate and involve specialists early in the management
patient to a pediatric trauma center once it is deter- of the patient to expedite definitive care and disposi-
mined that the patient requires intervention beyond tion for pediatric trauma patients with multiple inju-
the scope of what is available at the current facility. ries. It is critical to use appropriate imaging modalities
This would allow for rapid action should interven- to evaluate these patients to ensure that injuries are not
tion be necessary. The location of observation (ED, missed. Following emergent stabilization, treatment is
floor, or intensive care unit) is often dictated by targeted to the specific injuries found. Although man-
hospital protocol and clinician comfort level. aging children with multiple traumatic injuries can be

Risk Management Pitfalls in the Management of


Pediatric Patients With Multiple Injuries (Continued on page 15)

1. “The pulse oximeter showed a normal oxygen 4. “The patient vomited a couple of times after
level, so the patient had adequate airway and her head injury, but she was able to tolerate an
breathing. I’m surprised he had to be emer- oral challenge and seemed fine. I can't believe
gently intubated.” she became so altered.”
Inadequate airway management is a major Brain injury is the leading cause of morbidity
cause of morbidity and mortality in pediatric and mortality in injured children. TBI can be
trauma patients. Hypoxia is a late sign of airway missed early and can develop over hours,
or breathing problems in the pediatric patient. which is why anticipatory guidance and return
Early signs may be as subtle as tachypnea or precautions are essential for discharged patients.
hypoventilation. In hospitalized patients, recurrent neurologic
examinations are critical in patients with high-
2. “His blood pressure was normal. I was sur- risk mechanisms and in children with multiple
prised that he decompensated so rapidly.” injuries.
Hypotension is a late sign of hemodynamic
instability in the pediatric patient; tachycardia 5. “The nurse didn’t tell me that the patient's vi-
is the earliest sign. Complete assessment for tal signs were abnormal. If we had known the
trauma, which may involve hemorrhage in patient was bradycardic and hypertensive, we
large quantities (abdomen or femur), is critical. could have intervened sooner.”
Appropriate pain management and calming the Parameters for vital signs should be recognized
child are important to observe early tachycardia in the appropriate context and monitor alarms
as a sign of impending shock. Do not assume set accordingly. Often, emergency clinicians are
that tachycardia is due to pain or anxiety. looking for signs of shock, but in children with
head injuries, Cushing triad with hypertension
3. “The ultrasound of the abdomen was negative and bradycardia are opposite to the hypotension
for free fluid. I don’t know how the splenic and tachycardia of hypovolemic shock.
laceration was missed.” Abnormal vital signs are often dismissed in
The FAST examination is not sensitive in the face of anxiety or pain. Vital signs should
children. If intra-abdominal injury is suspected be continually reassessed as the child becomes
on examination or from laboratory results, CT more comfortable. It is also important to set
is a more sensitive test. parameters based on the child’s age—a normal
blood pressure for a teenager is hypertension in
a toddler.

Copyright © 2018 EB Medicine. All rights reserved. 14 Reprints: www.ebmedicine.net/pempissues


a complex task, early assessment, stabilization, and told you that they were normal—he was not tachycardic
treatment of injuries are crucial steps that are necessary or hypotensive. You requested repeat vital signs and found
to reduce morbidity and mortality. that his heart rate was 50 beats/min and his blood pres-
sure was 160/90 mm Hg. On your reassessment, he was
Case Conclusions combative and agitated with intermittent somnolence.
You relocated the patient to the trauma room and intu-
An x-ray of the forearm of the 12-year-old boy displayed bated him, due to concern for increased intracranial pres-
right midshaft radial and ulnar fractures with 100% sure. A CT scan of the patient’s head revealed an epidural
displacement and shortening. You also obtained a chest hemorrhage, and the neurosurgeon took the boy to the
x-ray, because of the abrasions over his thorax, and it operating room for immediate decompression, after which
was negative for fracture or pneumothorax. You decided the patient was admitted to the ICU.
to leave the cervical collar on, pending stabilization of Given the significant mechanism of injury for
distracting injuries. The boy's vital signs were stable, the 16-month-old girl who fell out of the window, the
and you decided to call the orthopedic surgeon to reduce trauma team was consulted. They elected to obtain a
his fracture. After administering IV morphine for pain CT scan of her head and neck, which were normal. Her
control and drawing a trauma panel to screen for organ trauma labs also returned normal. You decided that
injuries, you moved him out of the trauma bay to wait no other imaging was warranted; however, due to her
for the specialist. An hour later, the nurse informed you irritability, you decided to admit and observe her. On
that despite “sleeping comfortably,” the patient started repeat examination in the morning, the girl appeared
vomiting. When you asked about his vital signs, the nurse to be progressively fussy, with decreased movement of

Risk Management Pitfalls in the Management of


Pediatric Patients With Multiple Injuries (Continued from page 14)

6. “The swelling of her lower leg was minimal 8. “The neck CT was negative. How could I pos-
when the girl first came in. I didn’t see any sibly have known that there was spinal cord
signs of compartment syndrome related to the injury?”
fracture when the child was in the ED, but the Although it is an uncommon injury, SCIWORA
orthopedic surgeon was called in for a fasci- is a high-risk injury of concern in young
otomy overnight while the patient was being children. Negative plain film or CT imaging
monitored in the PICU.” is not sufficient to clear a cervical spine in a
Definitive care for serious injuries is often pediatric patient with neurologic findings or
operative in nature, so subspecialists should be significant pain.
involved early on for pediatric trauma patients
with multiple injuries. Delayed management 9. “The transferring facility said the child was
of serious fractures can result in compartment stable, but now the transport team is saying
syndrome, especially in intubated or nonverbal that the child is not acting right. They are not
patients. Compartment syndrome can progress sure what is wrong.”
over time, making serial examinations for Transport personnel with pediatric training have
high-risk fractures mandatory. Early diagnosis a decreased incidence of adverse events during
and definitive treatment require frequent transport for children with head injuries. In long
reassessment when extremity injuries are transports or for multiply injured, complicated
present, particularly those known to predispose pediatric trauma cases, consider using transport
a patient to compartment syndrome. personnel with pediatric training.

7. “Splinting all the fractures was time consum- 10. “We discharged the patient who was in a motor
ing. Now I am waiting on laboratory results vehicle crash after observation in the ED. He
while trying to arrange appropriate follow-up. just returned with leg pain.”
Trauma patients take so long to disposition.” The most commonly missed injuries in pediatric
Activating a trauma team, when available, patients are fractures. Make sure to complete
improves time to disposition, especially in a thorough secondary survey, including
complicated, multiply injured patients. It also ambulation, to avoid missing small fractures
ensures the availability of adequate resources that may not present with obvious deformity
and proper follow-up. and swelling.

June 2018 • www.ebmedicine.net 15 Copyright © 2018 EB Medicine. All rights reserved.


her left arm and swelling of her right leg. On x-ray, a Pediatr Orthop. 2006;26(2):268-277. (Review article)
distal nondisplaced tibia/fibular fracture was found, 3. Letts M, Davidson D, Lapner P. Multiple trauma in chil-
but no fracture of her left arm was found, which raised dren: predicting outcome and long-term results. Can J Surg.
2002;45(2):126-131. (Retrospective case series; 149 patients)
concerns for SCIWORA. The girl was scheduled for
4. Dereeper E, Ciardelli R, Vincent JL. Fatal outcome after poly-
an MRI and cervical spine immobilization was main- trauma: multiple organ failure or cerebral damage? Resuscita-
tained. tion. 1998;36(1):15-18. (Retrospective review; 98 patients)
5. van der Sluis CK, Kingma J, Eisma WH, et al. Pediatric
Time and Cost-Effective Strategies polytrauma: short-term and long-term outcomes. J Trauma.
1997;43(3):501-506. (Retrospective study; 74 patients)
• Involving the trauma team early for patients 6.* Miele V, Di Giampietro I, Ianniello S, et al. Diagnostic
imaging in pediatric polytrauma management. Radiol Med.
with multiple trauma may help to decrease time 2015;120(1):33-49. (Review article)
to diagnosis, treatment, and disposition. 7.* ATLS Subcommittee, American College of Surgeons' Com-
• Transfer to a pediatric trauma facility is prudent, mittee on Trauma. Chapter 10: Pediatric Trauma. Advanced
especially for severely injured children, since Trauma Life Support Student Course Manual. 9th ed: American
there may be improved survival compared to College of Surgeons; 2013. (Textbook)
treatment at adult trauma centers, regardless 8. Committee on Pediatric Emergency Medicine, Council on
of level. This also may help the family establish Injury Violence, and Poison Prevention, Section on Critical
Care, Section on Orthopaedics, Section on Surgery, Sec-
follow-up care with specialists in pediatrics (or- tion on Transport Medicine, et al. Management of pediatric
thopedics, plastic surgery, neurosurgery).62 trauma. Pediatrics. 2016;138(2). (AAP policy statement)
• Interfacility transfer by trained pediatric per- 9. Tracy ET, Englum BR, Barbas AS, et al. Pediatric injury
sonnel, though more difficult to arrange, may patterns by year of age. J Pediatr Surg. 2013;48(6):1384-1388.
benefit outcome and be cost-saving.60,62 (Review article)
10. Lallier M, Bouchard S, St-Vil D, et al. Falls from heights
among children: a retrospective review. J Pediatr Surg.
Key Points 1999;34(7):1060-1063. (Retrospective review; 64 patients)
11. Wang MY, Kim KA, Griffith PM, et al. Injuries from falls in
• Trauma is the leading cause of death in children the pediatric population: an analysis of 729 cases. J Pediatr
aged > 1 year. Surg. 2001;36(10):1528-1534. (Retrospective review; 729
• Morbidity and mortality are usually dependent patients)
on the degree of TBI. 12. Thompson EC, Perkowski P, Villarreal D, et al. Morbidity
• Initial field management and evaluation are and mortality of children following motor vehicle crashes.
Arch Surg. 2003;138(2):142-145. (Retrospective review; 191
critical to early recognition and stabilization of patients)
injuries. 13. Wetzel RC, Burns RC. Multiple trauma in children: critical
• A high index of suspicion is needed to ensure care overview. Crit Care Med. 2002;30(11 Suppl):S468-S477.
that major injuries are not missed. (Review article)
• A team approach is needed to ensure that all of 14. Furnival RA, Woodward GA, Schunk JE. Delayed diagnosis
the patients’ needs are being addressed. of injury in pediatric trauma. Pediatrics. 1996;98(1):56-62.
• Involve surgical consults as early as possible to (Retrospective review; 1175 patients)
prevent morbidity and mortality. 15. Gaines BA, Ford HR. Abdominal and pelvic trauma in chil-
dren. Crit Care Med. 2002;30(11 Suppl):S416-S423. (Review
article)
References 16. Werner C, Engelhard K. Pathophysiology of traumatic brain
injury. Br J Anaesth. 2007;99(1):4-9. (Review article)
Evidence-based medicine requires a critical ap- 17. Sundstrom T, Asbjornsen H, Habiba S, et al. Prehospital
praisal of the literature based upon study methodol- use of cervical collars in trauma patients: a critical review. J
Neurotrauma. 2014;31(6):531-540. (Review article)
ogy and number of patients. Not all references are
equally robust. The findings of a large, prospective, 18. Hadley MN, Walters BC, Grabb PA, et al. Management of pe-
diatric cervical spine and spinal cord injuries. Neurosurgery.
randomized, and blinded trial should carry more 2002;50(3 Suppl):S85-S99. (Literature review)
weight than a case report. 19. Pandya NK, Upasani VV, Kulkarni VA. The pediatric poly-
To help the reader judge the strength of each refer- trauma patient: current concepts. J Am Acad Orthop Surg.
ence, pertinent information about the study is included 2013;21(3):170-179. (Review article)
in bold type following the reference, where available. 20. Nau C, Jakob H, Lehnert M, et al. Epidemiology and
In addition, the most informative references cited in management of injuries to the spinal cord and column in
this paper, as determined by the authors, are noted by pediatric multiple-trauma patients. Eur J Trauma Emerg Surg.
2010;36(4):339-345. (Retrospective analysis; 35 patients)
an asterisk (*) next to the number of the reference.
21.* Meier R, Krettek C, Grimme K, et al. The multiply injured
child. Clin Orthop Relat Res. 2005(432):127-131. (Retrospec-
1.* Schalamon J, Bismarck SV, Schober PH, et al. Multiple
tive case study; 925 patients)
trauma in pediatric patients. Pediatr Surg Int. 2003;19(6):417-
423. (Retrospective review; 70 patients) 22. Avarello JT, Cantor RM. Pediatric major trauma: an approach
to evaluation and management. Emerg Med Clin North Am.
2.* Kay RM, Skaggs DL. Pediatric polytrauma management. J
2007;25(3):803-836. (Review article)

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23. Reilly PL, Simpson DA, Sprod R, et al. Assessing the tive cohort; 102 patients)
conscious level in infants and young children: a paediat- 40. Hwu RS, Spinella PC, Keller MS, et al. The effect of massive
ric version of the Glasgow Coma Scale. Childs Nerv Syst. transfusion protocol implementation on pediatric trauma
1988;4(1):30-33. (Retrospective review) care. Transfusion. 2016;56(11):2712-2719. (Retrospective
24. Holmes JF, Gladman A, Chang CH. Performance of abdomi- review; 11,995 patients)
nal ultrasonography in pediatric blunt trauma patients: a 41. Whittaker B, Christiaans SC, Altice JL, et al. Early coagu-
meta-analysis. J Pediatr Surg. 2007;42(9):1588-1594. (Meta- lopathy is an independent predictor of mortality in children
analysis; 25 studies, 3838 patients) after severe trauma. Shock. 2013;39(5):421-426. (Retrospective
25. Fox JC, Boysen M, Gharahbaghian L, et al. Test character- review; 803 patients)
istics of focused assessment of sonography for trauma for 42. Smith SA, Livingston MH, Merritt NH. Early coagulopa-
clinically significant abdominal free fluid in pediatric blunt thy and metabolic acidosis predict transfusion of packed
abdominal trauma. Acad Emerg Med. 2011;18(5):477-482. red blood cells in pediatric trauma patients. J Pediatr Surg.
(Prospective study; 357 patients) 2016;51(5):848-852. (Retrospective review; 96 patients)
26. Calder BW, Vogel AM, Zhang J, et al. Focused assessment 43. Rossaint R, Bouillon B, Cerny V, et al. The European guide-
with sonography for trauma in children after blunt abdomi- line on management of major bleeding and coagulopathy
nal trauma: a multi-institutional analysis. J Trauma Acute Care following trauma: fourth edition. Crit Care. 2016;20:100.
Surg. 2017;83(2):218-224. (Prospective study; 2188 patients) (Guidelines)
27. Holmes JF, Kelley KM, Wootton-Gorges SL, et al. Effect of ab- 44. Kozek-Langenecker SA, Afshari A, Albaladejo P, et al. Man-
dominal ultrasound on clinical care, outcomes, and resource agement of severe perioperative bleeding: guidelines from
use among children with blunt torso trauma: a randomized the European Society of Anaesthesiology. Eur J Anaesthesiol.
clinical trial. JAMA. 2017;317(22):2290-2296. (Randomized 2013;30(6):270-382. (Guidelines)
controlled trial; 925 patients)
45. Eckert MJ, Wertin TM, Tyner SD, et al. Tranexamic acid
28. Stafford PW, Blinman TA, Nance ML. Practical points in administration to pediatric trauma patients in a combat
evaluation and resuscitation of the injured child. Surg Clin setting: the pediatric trauma and tranexamic acid study
North Am. 2002;82(2):273-301. (Review article) (PED-TRAX). J Trauma Acute Care Surg. 2014;77(6):852-858.
29. Esposito TJ, Sanddal ND, Dean JM, et al. Analysis of pre- (Retrospective review; 766 patients)
ventable pediatric trauma deaths and inappropriate trauma 46. Baker N, Woolridge D. Emerging concepts in pediatric emer-
care in Montana. J Trauma. 1999;47(2):243-251. (Retrospective gency radiology. Pediatr Clin North Am. 2013;60(5):1139-1151.
chart review; 138 patients) (Review article)
30. Weingart SD, Levitan RM. Preoxygenation and prevention 47. Jakob H, Lustenberger T, Schneidmuller D, et al. Pediat-
of desaturation during emergency airway management. Ann ric polytrauma management. Eur J Trauma Emerg Surg.
Emerg Med. 2012;59(3):165-175. (Review) 2010;36(4):325-338. (Review article)
31. Abdelgadir IS, Phillips RS, Singh D, et al. Videolaryngos- 48. Frank JB, Lim CK, Flynn JM, et al. The efficacy of magnetic
copy versus direct laryngoscopy for tracheal intubation in resonance imaging in pediatric cervical spine clearance.
children (excluding neonates). Cochrane Database Syst Rev. Spine (Phila Pa 1976). 2002;27(11):1176-1179. (Retrospective
2017;5:CD011413. (Systematic review; 12 studies, 803 pa- chart review)
tients)
49. Asimos A. The trauma panel: laboratory test utilization in
32. Kuppermann N, Holmes JF, Dayan PS, et al. Identification the initial evaluation of trauma patients. Emergency Medicine
of children at very low risk of clinically-important brain Reports. February 1997. (Review)
injuries after head trauma: a prospective cohort study.
50. Capraro AJ, Mooney D, Waltzman ML. The use of routine
Lancet. 2009;374(9696):1160-1170. (Prospective cohort; 42,412
laboratory studies as screening tools in pediatric abdominal
patients)
trauma. Pediatr Emerg Care. 2006;22(7):480-484. (Retrospec-
33. Bae DS, Kadiyala RK, Waters PM. Acute compartment syn- tive medical record review; 382 patients)
drome in children: contemporary diagnosis, treatment, and
51. Keller MS, Coln CE, Trimble JA, et al. The utility of routine
outcome. J Pediatr Orthop. 2001;21(5):680-688. (Retrospective
trauma laboratories in pediatric trauma resuscitations. Am
chart review; 33 patients)
J Surg. 2004;188(6):671-678. (Retrospective study; 240 chil-
34. Ziolkowski NI, Zive L, Ho ES, et al. Timing of presentation dren)
of pediatric compartment syndrome and its microsurgi-
52.* Mathieson S, Whalen D, Dubrowski A. Infant trauma man-
cal implication: a retrospective review. Plast Reconstr Surg.
agement in the emergency department: an emergency medi-
2017;139(3):663-670. (Retrospective review; 35 patients)
cine simulation exercise. Cureus. 2015;7(9):e316. (Simulation
35. Greene N, Bhananker S, Ramaiah R. Vascular access, fluid exercise report)
resuscitation, and blood transfusion in pediatric trauma. Int J
53. Morrissey K, Fairbrother, HE. Pediatric trauma: pearls and
Crit Illn Inj Sci. 2012;2(3):135-142. (Review article)
pitfalls. emDocs.net. Available at: http://www.emdocs.net/
36. Hughes NT, Burd RS, Teach SJ. Damage control resuscita- pediatric-trauma-pearls-pitfalls/. Accessed May 15, 2018.
tion: permissive hypotension and massive transfusion (Online resource)
protocols. Pediatr Emerg Care. 2014;30(9):651-656. (Review)
54. Murphy NJ, Quinlan JD. Trauma in pregnancy: assess-
37. Kannan N, Wang J, Mink RB, et al. Timely hemodynamic ment, management, and prevention. Am Fam Physician.
resuscitation and outcomes in severe pediatric traumatic 2014;90(10):717-722. (Review article)
brain injury: preliminary findings. Pediatr Emerg Care.
55. Nesiama JA, Pirallo RG, Lerner EB, et al. Does a prehospital
2018;34(5):325-329. (Retrospective review; 234 patients)
Glasgow Coma Scale score predict pediatric outcomes? Pe-
38. Zebrack M, Dandoy C, Hansen K, et al. Early resuscitation diatr Emerg Care. 2012;28(10):1027-1032. (Retrospective chart
of children with moderate-to-severe traumatic brain injury. review; 185 patients)
Pediatrics. 2009;124(1):56-64. (Retrospective review; 299
56. Kochanek PM, Carney N, Adelson PD, et al. Guidelines for
patients)
the acute medical management of severe traumatic brain
39. Hendrickson JE, Shaz BH, Pereira G, et al. Implementation of injury in infants, children, and adolescents--second edition.
a pediatric trauma massive transfusion protocol: one institu- Pediatr Crit Care Med. 2012;13 Suppl 1:S1-S82. (Guidelines)
tion’s experience. Transfusion. 2012;52(6):1228-1236. (Prospec-

June 2018 • www.ebmedicine.net 17 Copyright © 2018 EB Medicine. All rights reserved.


57. Andrews PJ, Sinclair HL, Rodriguez A, et al. Hypothermia 2. During the primary survey of an 8-year-old
for intracranial hypertension after traumatic brain injury. N boy who was brought in with altered mental
Engl J Med. 2015;373(25):2403-2412. (Randomized controlled
trial; 387 patients)
status following ejection from a motor vehicle,
58. Widdel L, Winston KR. Prognosis for children in car-
you identify that he has severely inadequate
diac arrest shortly after blunt cranial trauma. J Trauma. respirations. Your next step should be to:
2010;69(4):783-788. (Retrospective chart review; 40 patients) a. Obtain a chest x-ray.
59. Missios S, Bekelis K. Transport mode to level I and II trauma b. Complete your primary survey before
centers and survival of pediatric patients with traumatic returning to address the issue.
brain injury. J Neurotrauma. 2014;31(14):1321-1328. (Retro- c. Correct the breathing issue before moving
spective cohort; 15,704 patients)
on with the primary survey.
60. Macnab AJ, Wensley DF, Sun C. Cost-benefit of trained
d. Give the patient some oxygen and return to
transport teams: estimates for head-injured children. Prehosp
Emerg Care. 2001;5(1):1-5. (Retrospective chart review; 43 reassess him after the secondary survey.
patients)
61. Acierno SP, Jurkovich GJ, Nathens AB. Is pediatric trauma 3. A 5-year-old boy presents with a heart rate of
still a surgical disease? Patterns of emergent operative in- 180 beats/min and a blood pressure of 60/40
tervention in the injured child. J Trauma. 2004;56(5):960-964. mm Hg after penetrating trauma. You should
(Retrospective study)
first administer:
62. Amini R, Lavoie A, Moore L, et al. Pediatric trauma mortal-
a. 20 mL/kg warm crystalloid solution and/or
ity by type of designated hospital in a mature inclusive
trauma system. J Emerg Trauma Shock. 2011;4(1):12-19. (Retro- 1 unit of O-negative packed red blood cells
spective chart review; 11,503 patients) administered rapidly
b. A 1-L bolus of 0.9% sodium chloride (normal
saline)
CME Questions c. 10 mL/kg matched red blood cells over 4
hours
Take This Test Online! d. Vasopressors

Current subscribers receive CME credit absolutely 4. A 2-year-old girl presents after a ceiling fan
free by completing the following test. Each issue fell on her head. During your examination, she
includes 4 AMA PRA Category 1 CreditsTM, 4 ACEP opened her eyes only to pain, she was moaning
Category I credits, 4 AAP Prescribed credits, or 4 but not saying any words, and she was with-
Take This Test Online!
AOA Category 2-A or 2-B credits. Online testing is drawing her extremities to pain. What is her
available for current and archived issues. To receive pediatric GCS score?
your CME credits for this issue, scan the QR code a. 5
below with your smartphone or visit b. 6
www.ebmedicine.net/P0618. c. 7
d. 8

5. A 10-year-old boy presents following a mo-


tor vehicle crash, in which he was a restrained
backseat passenger. On examination, the boy
presents with a seat belt sign, abdominal ten-
derness, very noisy inspiration, and retractions.
Which of the following is an ATLS indication
1. After a motor vehicle crash, a 2-year-old girl for intubation?
presents with altered mental status, a forearm a. Seat belt sign
fracture, abdominal tenderness, and a deep b. Abdominal tenderness
laceration to her right thigh. Which of her c. Stridor
injuries is most likely to cause morbidity and d. Retractions
mortality?
a. Head injury 6. Which of the following factors would increase
b. Forearm fracture the risk for a clinically important TBI in a
c. Abdominal injury young infant?
d. Deep laceration a. Loss of consciousness for 2 seconds
b. Frontal scalp hematoma
c. History of vomiting
d. Not acting normally, according to parents

Copyright © 2018 EB Medicine. All rights reserved. 18 Reprints: www.ebmedicine.net/pempissues


7. An 8-year-old girl presents with an open frac- 9. A critically injured 5-year-old girl with hy-
ture of her right forearm from a skateboarding potension, altered mental status, and hemor-
injury. All of the following should be ad- rhagic shock presents to your ED. Which of the
dressed at presentation EXCEPT: following interventions that have been shown
a. Consultation with orthopedics to improve outcomes in adults is most likely to
b. Temporary closure of the wound to prevent improve outcomes for this patient?
infection a. Permissive hypotension
c. Determining her tetanus immunization b. Tranexamic acid
status c. Massive transfusion protocol at a 1:1:1 ratio
d. Administering IV antibiotics d. Use of video laryngoscopy for intubation

8. A 10-year-old boy sustained a crush injury to 10. A 3-year-old girl comes in after falling out of
his right arm. The following signs would all be a 3-story window. Her head and neck CT are
concerning for development of compartment negative, but she appears to be in pain when
syndrome EXCEPT: you try to take off the cervical collar. The next
a. Redness of the extremity most appropriate step in the management of
b. Excessive pain this patient is:
c. Decreased pulses a. Remove the collar, since the imaging was
d. Numbness and tingling negative.
b. Repeat the CT scan in 6 hours.
c. Perform serial neurologic examinations and
possible MRI for concern for SCIWORA.
d. Obtain a spine (neurosurgery or
orthopedics) consultation.

The Definitive Guide to Pediatric


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June 2018 • www.ebmedicine.net 19 Copyright © 2018 EB Medicine. All rights reserved.


Physician CME Information
Date of Original Release: June 1, 2018. Date of most recent review: May 15, 2018. Termination date:
June 1, 2021.
ACEP
VISIT US AT
ASSEMBLY
SCIENTIFIC 29-31,
October
BOOTH 2342

Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education
(ACCME) to provide continuing medical education for physicians. This activity has been planned and
2017 implemented in accordance with the accreditation requirements and policies of the ACCME.
September
Number 9
Volume 14,

thopedic Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA
Pediatric Or ence-Based
Author San Diego,
of California

Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their
MD, FAAP University

id
Jamie Lien, e; Associate Physician,

Injuries: Ev t in the
CA
Private Practic Hospital, San Diego,
n’s
Rady Childre

en
ers

Managem Department participation in the activity.


Peer Review n’s
Boston ChildreHarvard
MD, MPH Medicine, ine,
Lois Lee, Emergency ency Medic
Division of rics and Emerg

Emergency
Physician, sor of Pediat
Attending ant Profes
Hospital; Assistl, Boston, MA ine,
Medical Schoo ency Medic

ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College
Sanders,
MD rics and Emerg
Jennifer E. tment of Pediat New York, NY
sor, Depar Sinai,
Assistant Profes Medicine at Mount
Abstract
l of
Icahn Schoo
in children,
are common
of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
tives
mity injuries r 1 in 5 CME Objec
should be
able to: s and how
lower extre at just unde article, you edic injurie
Upper and ure estimated iology produce age- compl etion of this critical pediatric orthop
all risk of fract te emergent
Upon on and
phys Describe comm s to evalua
with an over atric bone anatomy and that are unique to chil- y 1.
they typical
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diagnostic
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children. Pedi patterns and condition ric orthopedic
ult for emer gy
AAP Accreditation: This continuing medical education activity has been reviewed by the American
Determine edic condit
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tions for pediat
y nosis diffic 2.
pediatric orthopt treatment recommenda
specific injur e accurate
diag pathophysiolo
dren, whic
h can mak ws the etiology and ies of the 3. Explain curren
emergencies
. Information”
This issue
revie common injur mendations cian CME

Academy of Pediatrics and is acceptable for a maximum of 48 AAP credits per year. These credits
, see “Physi
clinicians. , as well as ing this activity back page.
ific fractures s. Evidence-based recom opriate Prior to beginn on the
of child-spec mitie , including
appr a CME credit
s.
r and lower extre fract ures . for 4 traum
atric is eligible

can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the
uppe ssed
ent of pedi are also discu This issue
for managem ies and treatment,
MHA
Wang, MD,
Vincent J. of Pediatr ics, Keck
stud
diagnostic Joshua Nagler,
MD, MHPEd cs and
r of Pediatri
Professor
School of
Medicine
of the
rn Californ
ia;

American Academy of Pediatrics.


University Assistant Professo e, Harvard Medical of Southe
of Pediatrics, School of University Division
Professor Emergency
Medicin Division Head, Children's
e and A. Burns hip Director
, Division Associate e,
ncy Medicin of Hawaii John lu, HI School; FellowsMedicine, Boston ncy Medicin
Clinical Emerge Geffen School of Honolu of Emerge Angeles, Los
Medicine, , of Emergency
Pediatrics,
David Fellowship , MD, FACEP l, Boston, MA Hospital Los
hief UCLA; EMS Matar Joseph Children’s Hospita Angeles, CA
Editor-in-C Medicine at Medical Madeline
al Editor
UCLA e a, MD
s, MD Director, Harbor- ent of Emergency FAAP
Emergency
Medicin James Napraw Emergency
Internation

AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 48 American Osteopathic
Ilene Claudiu Department Professor of Medical Physician,
Professor, Center, Departm Chief and Attending FACEP
Associate Medicin e and e, Los Angeles, CA and Pediatrics, ncy ent USCF Benioff d, CA Zibners , MD, FAAP, ric
ncy Medicin c Emerge Departm Lara ant, Paediat
of Emerge School of FAAP, Director, Pediatri , University Hospital, Oaklan Honorary Consult e, St. Mary's
USC Keck Gerardi, MD, Children's
Pediatrics, s, CA Michael J. Medicine Division of Medicine- Medicin
Los Angele nt , MD Emergency l College Trust, or
Medicine, FACEP, Preside or of Emergency of Florida College Joshua Rocker of
FL Hospital Imperia

Association Category 2-A or 2-B credit hours per year.


Profess e Jacksonville, Chief, Division Nonclinical
Instruct
Associate of Medicin Jacksonville, Associate e,
Editorial Board FAAP Icahn School Pediatric ncy Medicin London, UK; Medicine, Icahn
Medicine, Director, Kennebeck,
MD Pediatric Emerge n's Medica
l Center; ncy
Avner, MD, Stephanie University
of of Emerge Mount Sinai,
Jeffrey R. of at Mount Sinai; Goryeb Professor, Cohen Childre or of Emergency Medicine at
Department Medicine, Associate of Pediatrics, School of
Chairman, ides Infants
& Emergency l, Morristown ati Department Assistant Profess Pediatr ics, Hofstra York, NY
Maimon Hospita Cincinn e and New New
Children's Medicine,
gy Editor
Pediatrics, Brooklyn; NJ

Pediatric Heat-Related
Morristown, Medicin
Hospital of Cincinnati,
OH School of
Children’s Pediatrics, e, Medical Center,
nda, MD, MS
Northwell Pharmacolo

Needs Assessment: The need for this educational activity was determined by a survey of medical staff,
of Clinical be, MD, PhD NY BCPS
Professor College of
Medicin Anupam KharbaCare Services Hyde Park, r, PharmD,
Sandip Godam and Patient Safety Aimee Mishle Medicine Pharma
cist,
Clinics of , MD
Albert Einstein Montefiore, Chief, Critical
August 2017
Chief Quality or of Pediatrics and of
Hospital at Hospitals and MN Steven Rogers University Emergency

Illness: Recommendations for


Children's Children's Professor, Medical Center,
Officer, Profess Attending Minneapolis, Associate Medicine, Maricopa
Bronx, NY Medicine, Minnesota, School of
Emergency
Children's
Hospital of
the
FAAP, FACEP Volume 14, Number 8
Connecticut Medicine
Emergency Children's Phoenix, AZ

including the editorial board of this publication; review of morbidity and mortality data from the CDC,
MD Physician, System, Kim, MD, Attending
Steven Bin, Professor, Tommy Y. Connecticut , CT r
Quality Edito
ers Health r of Pediatric
Associate Clinical King's Daught Authors
Associate Professo e, University of Physician,

Prevention and Management


Medical
of Medicine; Medicin e, Medical Center,
Hartford
MD, FAAP
UCSF School Pediatric Norfolk, VA Emergency School of Medicin Steven Choi,
and Interim Chief, Benioff MD a Riversid e Roberta r, MD Preside nt,
Director an,
of Pediatrics, Californi nity Hospita J. Dunn,
l, MD pher Strothe
Emergency Assistant Vice ; Director,
Medicine, UCSF o, CA Ran
D. Goldm
Department
Christo
Professor, Health System ance
Emergency Riverside Commu e,

AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
l, San Francisc Professor, ia; Assistant
ncy Medicin Assistantof
Clinical Professor l Montefiore
of British Columb ent of Emerge cs, and Medica
Emergency Network Perform
Children's Hospita Univers ity ic Departm Riverside School of Medicine,
Medicin e, Pediatri Medicine,
raduate University
Montefi ore
of California ve Directo r,
Cantor, MD,
FAAP, Director, Pediatr Children's Riverside, CA Director, Underg
on; Riverside Community ment; Executi Performance
Abstract Richard M.
FACEP ncy Medicin
e
Research
Emergency
Medicine,
BC
ver, BC, Canada Melissa Langha Tommy
Emergency Medicine,Educati
n, MD, MHS
or of Pediatri
cs and
ent
Riverside,ncy Departm of Medicine
and Emerge CA
Hospital,
Improve Department
Montefiore
Institute for
of
Associate
Professor
Professor
of Emerge
r, Pediatric Hospital, Vancou Associate Profess e; FellowsKim,
Y. hip MD Simulation; Icahn School NY Improvement; Albert Einstein College
ics; Directo Medical MBA New York,
and Pediatr ushe, MD, Emergency Associateon,
Medicin Mount Sinai,
Professor ofatPediatric of Pediatrics,
Department; Poison Joseph Habbo or of Emerge
ncy of Educati Emergency
MD, FAAP Medicine, e, Bronx, NY

Target Audience: This enduring material is designed for emergency medicine physicians, physician
Infants, children, and adolescents
Emergency New York Assistant Profess ngone and Director, DirectorRiverside
ncy Medicin
e, Yale of Medicine,
School Adam E. Vella, Riverside of Emerge
ncy University
of Medicinof California
are at increased risk for heat-related
Director, CentralGolisano Children's Medicine,
NYU/La Pediatric Emerge Emergency New
Medicine,Medicine, Professor Community
Associate CA ics, and Medical Hospital, Editor
CME Department of
illness due to their inability to
Control Center, e, NY Medica l Centers,
New
ity School of Riverside, e, Pediatr
remove themselves from dangerous
Hospital, Syracus
Bellevu e
MD Aware
LLC Univers
Haven, CT Peer Reviewers
Medicin
Director Of
Pediatr ic
h R. Liu, MD ics,
environments. Evidence shows York, NY; CEO, FACEP, Education, Icahn School Debora te Professor of Pediatr
Medicine, e of USC;
that morbidity and mortality
, MD, FAAP ko, MD, MSCR,
MD Emergency Associa

assistants, nurse practitioners, and residents.


Ari Cohen Robert Luten,Pediatr Sinai, New of Medicin
heat illness is related to the length c Emergency from
Tim Horecz ics and
Ari Cohen, MD, ity of e at Mount Keck School Medicine,
Chief of Pediatri husetts General Professor, e, Univers FAAP of Medicin Emergency
of time core temperature is elevat-
Medicine, Massacr in Pediatrics,
FAAP
Professor
of Clinical Medicinof
Emergency Chief Pediatric Emergency York, NY Division of
Hospital Los
Angeles,
ed, so rapid reduction and accurate
Hospital; InstructoSchool, Boston, MA
Associate
Medicine,
David Geffen
Florida, Jackson
ville, FL
Instructor in Pediatrics,David
Medicine, , MD, FACEP, FAAP General
Massachusetts Children's
Hospital;
serial measurements are crucial Emergency
Medicine,
UCLA ; Core HarvardM. Walker
,Medical
Emergency
Pediatric School, Los Angele
s, CA
prevention of organ system
Harvard Medical to
School of an, Los r, MD, MSHS
Garth MeckleSean or M.ofFox, ics,
FACEP,Director
Boston,
, MA
damage and death. The primary
Jay D. Fisher,
MD, FAAP ic and Faculty and
Senior Physici Profess
Associate Associate
PediatrMD, FAAPe; Associate Director ncy Medicin
e,
of patient cooling are conduction or of Pediatr ity methods -Harbor-UCLA of British Columb
ia;
Professor,
Medicin
ent of Emerge

Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making
Clinical Profess Angeles County Torrance, CA University Department ncyAssociate Emergency ens,
(ice-water immersion, cold packs)
Medicine,
Univers
l Center, Pediatric Emerge
of Emergency
l,
Departm
York-Pr
Medicine
esbyterian/Que Program Director,
and convection (moisture and
Emerge ncy
, Las Vegas
School of Medica Division Head,
BC Childre
n's Hospita Medicine,
New
Flushing, NY
Carolinas Medical Center,
figures.
of Nevada moving air). The choice of method
NV Alson S. Inaba,
MD, FAAP e Medicine,
BC, Canada
Charlotte, NC
at tables and
used may depend on availability
Medicine,
Las Vegas,
MD, FACEP
, ncy Medicin
Pediatric Emerge ni Medical Center Vancouver, Prior to beginning this activity,
see “Physician closer look
for a Information”
of equipment, but there is evidence
Gausche-Hill, Kapiola icon CME

based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical ED
that can guide optimal use of
Marianne Specialist, Associate on the on
back the
& Children; Click page.
resources. This issue presents
FAAP, FAEMS r, Los Angeles for Women
based recommendations and Medical Directo Agency; Profess
or ofevidence-
best practices in heat-illness
County EMS
tion, including managing children resuscita-

presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
who are obese, have special
or take medications, and advocacy needs
for prevention strategies.

Editor-in-Chief Clinical Emergency Medicine

CME Objectives: Upon completion of this article, you should be able to: (1) Utilize a systematic approach
Ilene Claudius, MD and Professor of Pediatrics, University
Pediatrics, David Geffen School Joshua Nagler, MD, MHPEd
of of Hawaii John A. Burns School
Associate Professor, Department Medicine at UCLA; EMS Fellowship of Assistant Professor of Pediatrics Vincent J. Wang, MD, MHA
of Emergency Medicine and Director, Harbor-UCLA Medical Medicine, Honolulu, HI and Professor of Pediatrics, Keck
Emergency Medicine, Harvard
Pediatrics, USC Keck School Center, Department of Emergency Madeline Matar Joseph, Medical School of Medicine of the
of MD, FACEP, School; Fellowship Director,

for evaluation of trauma patients to reduce missed injuries in multiply injured children; (2) determine
Medicine, Los Angeles, CA Medicine, Los Angeles, CA FAAP Division University of Southern California;
of Emergency Medicine, Boston
Professor of Emergency Medicine Associate Division Head,
Editorial Board Michael J. Gerardi, MD, FAAP,
and Pediatrics, Chief and Medical
Children’s Hospital, Boston,
MA Division
of Emergency Medicine, Children's
FACEP, President James Naprawa, MD
Jeffrey R. Avner, MD, FAAP Associate Professor of Emergency Director, Pediatric Emergency Hospital Los Angeles, Los
Attending Physician, Emergency Angeles, CA

appropriate imaging modalities for identifying orthopedic and traumatic brain injuries in patients
Chairman, Department of Medicine, Icahn School of Medicine Division, University
Pediatrics, Maimonides Infants Medicine of Florida College of Medicine- Department USCF Benioff
Children’s Hospital of Brooklyn;
& at Mount Sinai; Director, Pediatric
Jacksonville, Jacksonville, Children's Hospital, Oakland, International Editor
Emergency Medicine, Goryeb FL CA
Professor of Clinical Pediatrics, Children's Hospital, Morristown Stephanie Kennebeck, MD Joshua Rocker, MD Lara Zibners, MD, FAAP, FACEP
Albert Einstein College of Medical Center, Morristown, Associate Chief, Division of Honorary Consultant, Paediatric
Medicine,

with multiple trauma; and (3) identify and manage traumatic brain injuries, orthopedic injuries, and
NJ Associate Professor, University
Children's Hospital at Montefiore, of Pediatric Emergency Medicine, Emergency Medicine, St. Mary's
Sandip Godambe, MD, PhD Cincinnati Department of Pediatrics,
Bronx, NY Cohen Children's Hospital Imperial College
Chief Quality and Patient Safety Cincinnati, OH Medical Center; Trust,
Steven Bin, MD Assistant Professor of Emergency London, UK; Nonclinical Instructor
Officer, Professor of Pediatrics Anupam Kharbanda, MD, Medicine and Pediatrics, Hofstra of Emergency Medicine, Icahn
Associate Clinical Professor, and MS
Emergency Medicine, Attending Chief, Critical Care Services

musculoskeletal injuries in pediatric patients with multiple trauma.


UCSF School of Medicine; Medical Northwell School of Medicine, School of Medicine at Mount
Physician, Children's Hospital Children's Hospitals and Clinics New Sinai,
Director and Interim Chief, Pediatric of the of Hyde Park, NY New York, NY
King's Daughters Health System, Minnesota, Minneapolis, MN
Emergency Medicine, UCSF Norfolk, VA Steven Rogers, MD Pharmacology Editor
Benioff Tommy Y. Kim, MD, FAAP,
Children's Hospital, San Francisco, FACEP Associate Professor, University
CA Ran D. Goldman, Associate Professor of Pediatric of Aimee Mishler, PharmD,
Richard M. Cantor, MD, FAAP, MD Connecticut School of Medicine, BCPS
Professor, Department of Pediatrics, Emergency Medicine, University Attending Emergency Medicine Emergency Medicine Pharmacist,
FACEP of

Discussion of Investigational Information: As part of the journal, faculty may be presenting


University of British Columbia; California Riverside School of Physician, Connecticut Children's Maricopa Medical Center,
Professor of Emergency Medicine Medicine,
Research Director, Pediatric Riverside Community Hospital, Medical Center, Hartford, CT Phoenix, AZ
and Pediatrics; Director, Pediatric Emergency Medicine, BC Department of Emergency Medicine,
Emergency Department; Medical Children's
Hospital, Vancouver, BC, Canada Riverside, CA Christopher Strother, MD Quality Editor
Director, Central New York Assistant Professor, Emergency
Poison Steven Choi, MD
Control Center, Golisano Children's Joseph Habboushe, MD, MBA

investigational information about pharmaceutical products that is outside Food and Drug Administration
Melissa Langhan, MD, MHS Medicine, Pediatrics, and Medical
Assistant Professor of Emergency Associate Professor of Pediatrics Assistant Vice President, Montefiore
Hospital, Syracuse, NY and Education; Director, Undergraduate
Medicine, NYU/Langone and Emergency Medicine; Fellowship Network Performance Improvement;
Ari Cohen, MD, FAAP and Emergency Department Director, Montefiore Institute
Bellevue Medical Centers, Director, Director of Education, Simulation; Icahn School of
Chief of Pediatric Emergency New Medicine for Performance Improvement;
York, NY; CEO, MD Aware Pediatric Emergency Medicine, at Mount Sinai, New York, NY

approved labeling. Information presented as part of this activity is intended solely as continuing medical
Medicine, Massachusetts General LLC Yale Assistant Professor of Pediatrics,
Tim Horeczko, MD, MSCR, University School of Medicine,
Hospital; Instructor in Pediatrics, FACEP, New Adam E. Vella, MD, FAAP Albert Einstein College of
FAAP Haven, CT Medicine,
Harvard Medical School, Boston, Associate Professor of Emergency Bronx, NY
MA Associate Professor of Clinical Robert Luten, MD
Jay D. Fisher, MD, FAAP Medicine, Pediatrics, and Medical
Emergency Medicine, David Professor, Pediatrics and Education, Director Of Pediatric CME Editor

education and is not intended to promote off-label use of any pharmaceutical product.
Clinical Professor of Pediatric Geffen
and School of Medicine, UCLA Emergency Medicine, University Emergency Medicine, Icahn Deborah R. Liu, MD
Emergency Medicine, University ; Core of School
Faculty and Senior Physician, Florida, Jacksonville, FL of Medicine at Mount Sinai,
of Nevada, Las Vegas School Los New Associate Professor of Pediatrics,
of Angeles County-Harbor-UC York, NY
Medicine, Las Vegas, NV LA Garth Meckler, MD, MSHS Keck School of Medicine of
Medical Center, Torrance, USC;
CA Associate Professor of Pediatrics, David M. Walker, MD, FACEP, Division of Emergency Medicine,
Marianne Gausche-Hill, MD, FAAP
FACEP, Alson S. Inaba, MD, FAAP University of British Columbia; Director, Pediatric Emergency Children's Hospital Los Angeles,
FAAP, FAEMS Pediatric Emergency Medicine Los Angeles, CA

Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency,
Division Head, Pediatric Emergency Medicine; Associate Director,
Medical Director, Los Angeles Specialist, Kapiolani Medical
Center Medicine, BC Children's Hospital, Department of Emergency
County EMS Agency; Professor for Women & Children; Associate Medicine,
of Vancouver, BC, Canada New York-Presbyterian/Queens,
Flushing, NY

and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or
implementation of a sponsored activity are expected to disclose to the audience any relevant financial
relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters
In upcoming issues of must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved
drugs or devices. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this
CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr.
Pediatric Emergency Tatem, Dr. Kapoor, Dr. Hughes, Dr. Zibners, Dr. Claudius, Dr. Horeczko, Dr. Mishler, and their related
parties report no significant financial interest or other relationship with the manufacturer(s) of any
commercial product(s) discussed in this educational presentation. Dr. Jagoda made the following
Medicine Practice.... disclosures: Consultant, Daiichi Sankyo Inc; Consultant, Pfizer Inc; Consultant, Banyan Biomarkers
Inc; Consulting fees, EB Medicine.
Commercial Support: This issue of Pediatric Emergency Medicine Practice did not receive any
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