Trauma in special Populations

1. Trauma in
Special
population
Dr Rashid A. M. Abuelhassan, MBBS
R3 Emergency Medicine Resident
Secretary of SEMS

2. Objectives
• Variations in 1ry assessment :
• Pediatric
• Geriatric
• Pregnant
• Variations in the management
and intervention in the three
main

3. Trauma
in
Pediatrics

4. 1RY SURVY
• Airway
• Breathing
• Circulation
• Disability
• Expose
• Fast & Family
• Continuous monitoring of vital signs
• Provision of analgesia, and continuous
reassessment of pain
• Antibiotics and tetanus as appropriate
• Ensure urine output of 1 mL/kg/hr
• If patient is intubated, ensure adequate sedation
and analgesia
• If head injury is present, frequent neurologic
assessment
To be kept in mind always

5. Statistics
• Mostly blunt
• Penetrating
injury 10-20%
of all
admissions
• leading cause
of death 1-17
years.

6. Difference
• head-to-body ratio is greater
• brain is less myelinated
• cranial bones are thinner
• internal organs are more susceptible to injury
• ↓ cardiac output primarily through ↑ HR and
systemic vascular resistance.
• kidney is less well protected and more mobile,
• pulmonary injury without skeletal injury due to
elastic chest wall .
• Salter-type fractures with possible resultant limb-
length abnormalities.
• more tenuous spinal cord blood supply and a greater
elasticity of the vertebral column, predisposing them
to spinal cord injury without radiographic
abnormality (SCIWORA)

7. Airway
• Increased vagal response to laryngoscopy
• Relatively larger tongue
• Larger mass of adenoidal
• Epiglottis floppy and more U shaped
• Larynx more cephalad and anterior
• Cricoid ring the narrowest portion of the
airway
• Narrow tracheal diameter and distance
between the rings
• Shorter tracheal length (4-5 cm in
newborns and 7-8 cm in 18-month-olds)
• Large airways more narrow

8. C-Spine
• C- spine fulcrum : from C2-C3 in toddlers to C5-C6 by 8 to 12 yr.
• larger head size, in greater flexion and extension injuries.
• large occiput in <2 years flexion of cervical
• Smaller neck muscle mass with ligamentous injuries
• Anterior wedge of cervical vertebral bodies is common.
• Increased flexibility of interspinous ligaments.
• Flatter facet joints with a more horizontal orientation.
• Incomplete ossification,difficult interpretation (synchondrosis).
• Uncinate processes do not calcify until 7 years.
• Basilar odontoid synchondrosis fuses at 3 to 7
• Apical odontoid apparent at 7 yr may fuse on 12 yr .
• Posterior arch of C1 fuses at 4 years of age.
• Ant C1 arch visible on 1 year , fuses at 7 to 10 yr
• Neural arches fuse to body by approximately 7 years
• Posterior arches fuse by 3 to 5 years of age.
• Epiphyses of spinous process tips may mimic fractures.
• Preodontoid space 4 to 5 mm in those <8 years of age and <3 mm
in those 8 years or older.
• Pseudosubluxation of C2 on C3 seen in 40% of children 8 to 12 yr.
• Prevertebral space size varies with phase of respiration

9. Breathing
• Respiratory rate
• Chest wall movements
• Percussion and breath
sounds
• drainage > 15 mL/kg or
output > 2 mL/kg/hr  OR
• Tracheal deviation
The use of end-tidal CO2
capnography allows better
ventilatory management
during head injury

10. Circulation and Hemorrhage Control
• Vital signs should be monitored Q5 min during the
initial assessment.
• Continuous oximeter and cardiac monitor.
• 2x large-bore intravenous sites
• Bolus with 20 mL /Kg of warmed normal saline
• Transfuse 10-20 mL/kg for decompensated shock
secondary to blood loss.
• Intraosseous placement in a fractured extremity is
contraindicated.
• Umbilical vein cannulation can be achieved in infants
up to approximately 2 weeks of age;
• With vasopressors or highly osmotic agents are to be
used, a more formal umbilical venous line placed
above the liver should be considered to avoid hepatic
injury.
• massive transfusion ≈ 80 mL/kg
• FFP 15-25 ml/Kg : plat 10ml/Kg : cryo 0.1- 0.2bag/Kg

11. Disability Assessment
• Thorough Neurologic Examination & Glucocheck if
deteriorated at any moment

12. Exposure
• Thorough Examination is
always needed even for
simple injury
• Keep always low threshold
for unexplained injuries

13. FAST and Family
• Allowing family members to
be present during
resuscitations is acceptable
and often preferred by
families.
• assign a staff member to be
with him or her during the
trauma resuscitation to
explain the process.

14. Pain Control
• Fentanyl is a good choice
• advantage hemodynamic profile.
• Advantage of short action

15. Specific injuries
• concussion is a brain insult with
transient alteration of
consciousness.
• Simple =<10 d
• complex >10 days
• Scalp injury
• Caput succedaneum hematoma in
the connective tissue layer. This is
freely mobile and crosses suture
lines.
• subgaleal hematoma is subgaleal
within the loose areolar tissue
above the periosteum.
• cephalohematoma is a collection of
blood under the periosteum.

16. • Skull Fractures
• Linear  benign, no intervention unless of a fracture overlying a
vascular channel, a depressed fracture, a diastatic fracture
(leptomeningeal cyst) , or a fracture that extends over the area of
the middle meningeal artery.
• Cerebral contusions
• Epidural Hematoma
• Subdural Hematoma.

18. To CT or not ?

19. Sens 100% in <2yrs ( NPV 100%) 96.8% in >
2yrs ( NPV 99.95%) but 100% for TBI need NS

21. Abdominal Trauma

26. Professor Karim Brohi

27. Trauma
in
Geriatrics

28. Who are they ?
• Who: aged 65 to
80 or 85 years
• oldest old older
than 80 or 85
years.

29. • In 2008, there were 2.1 million ED visits for falls
among those 65 and older—10 times more
common than motor vehicle collisions (MVCs).1
• one third of elders sustain a significant fall each
year, and serious injuries occur in up to a quarter.2
• Most falls are from standing and occur at the
elder’s place of residence.19
Centers for Disease Control and Prevention (CDC): Injury Prevention and Control: Data and Statistics (WISQARS). Available at www.cdc.gov/ injury/wisqars/index.html. Accessed
December 21, 2011
Centers for Disease Control and Prevention (CDC): Fatalities and injuries from falls among older adults—United States, 1993-2003 and 2001-2005. MMWR Morb Mortal Wkly Rep
2006; 55:

30. Risk factors for falling include :
• weakness,
• balance or gait deficit,
• visual deficit,
• mobility limitation,
• cognitive impairment,
• impaired functional status,
• postural hypotension
Bergen G, Chen LH, Warner M, Fingerhut LA, eds: Injury in the United States: 2007
Chartbook. Hyattsville, Md: National Center for Health Statistics; 2008

31. Elders are more likely to be struck by a
motor vehicle than younger pedestrians,
because of poor eyesight, limited
mobility, and slower reaction
time. Pedestrians struck sustain
significant injury patterns
have the highest fatality rate among
injuries, 30 to 55%.19
Bergen G, Chen LH, Warner M, Fingerhut LA, eds: Injury in the United States: 2007
Chartbook. Hyattsville, Md: National Center for Health Statistics; 2008

32. ↓ Brain mass
Eye disease
↓ Depth of perception
↓ Discrimination of colors
↓ Pupillary response
↓ Respiratory vital capacity
↓ Renal function
2- to 3-inch loss in height
Impaired blood flow to lower
leg(s)
↓ Degeneration of the joints
Total body water
Nerve damage (peripheral
neuropathy)
Stroke
Diminished hearing
↓Sense of smell and taste
↓Saliva production
↓Esophageal activity
↓Cardiac stroke volume and rate
Heart disease and high blood
pressure
Kidney disease
↓Gastric secretions
↓Number of body cells
↓Elasticity of skin, thinning of
epidermis
15 – 30% body fat

33. Difference in management
• Early intubation(Cricothyrotomy is more likely to be complex)
• signs of shock
• altered mental status
• significant chest trauma
• videolaryngoscopy is recommended.32
• dosages of induction agents should be reduced
• High risk for succinylcholine hyperkalemia,
• High-flow supplemental oxygen should be applied to all
patients, including those with chronic pulmonary
disease.

34. Disability
• Traumatic Brain Injury
• Vertebral Fractures and Spinal Cord Injuries
• Central Cord Syndrome
• Cervical Extension-Distraction Injury
• Odontoid Fractures
• Thoracic Trauma
• Abdominal Trauma
• Extremities

37. Hyperextension with superimposed
spondylosis
• 90-year-old male who tripped and fell
on his back and the back of his head.
He had immediate quadriparesis after
the event with no loss of
consciousness
The findings are:
• Widening of the disc space C5C6 in
the front and narrowing in the back.
• called 'an open book'.
 hyperextension injury.

38. END-OF-LIFE DECISIONS

39. ● A 79-year-old male is
brought to the ED
after he was found at
the base of the stairs
by his wife.
● Initial vital signs: RR
32, Pulse 64, BP
110/60, GCS score 12

40. ( geriatric Trauma )
• are prone to significant injuries with low-force trauma such as falls from
standing.
• Vigilance for occult injuries, including TBI, cervical spine injuries, hip and pelvis
fractures, and solid organ injuries, should be maintained.
• Vital signs, are unreliable to detect hemodynamic instability in older adults.
Clinicians should expand their assessment for shock by including alterations in
mental status, urine output, and skin perfusion and should have a low threshold
for considering shock in elderly trauma patients.
• Resuscitation should be rapid but should include frequent reassessments of
vitals signs, respiratory status, and other potential indicators of shock. Invasive
hemodynamic monitoring may be beneficial.
• A low threshold is advised for imaging in older adults with trauma.
• Fluid resuscitation should be initiated with defined boluses
• PCC is recommended for reversing warfarin
• to consider tranaxemic acid

41. Trauma
in
Pregnancy

42. Pregnancy
Epidemiology:
• complicates 6% to 10% of all US pregnancies.
• It is the leading cause non obstetric maternal death
• According to a study published by Gazamarian et al
there is a prevalence of 0.9% to 20% when it comes to
violence in pregnancy.
• There is an increasing trend with each trimester
• 8% of violence occurs in first trimester, 40% in second
trimester and 52% in the third trimester
Ghana Emergency Medicine Collaborative
Advanced Emergency Trauma Course

43. Pregnancy
• Trauma, relatively minor or major, is associated with
increased risk of:
• Preterm Labor
• Placental abruption
• Fetal-Maternal Hemorrhage
• Pregnancy loss
• The majority of the times when gravid women seek care, it
is the result of:
• Motor vehicle collision (MVC)
• Assaults and falls
• There are several normal anatomic and physiologic
changes in pregnancy that need to be considered in the
trauma patient
Ghana Emergency Medicine Collaborative
Advanced Emergency Trauma Course

45. Pregnancy Physiology
CARDIOVASCULAR
• Plasma ↑45% @ 6-8wks
• SV↓30%
• Chest comp. ↓
• BP ↓ in 1st  ↑ in 2nd
• CO ↑ 30 to 50%
• “Supine Hypotensive
Syndrome”@ 20 wks
Ghana Emergency Medicine Collaborative
Advanced Emergency Trauma Course
Pulmonary
• ↓ oxygen reserve
• ↓ airway “swelling of tissues”
• chest tube should be placed
one or two interspaces highe
• ↓ gastric emptying
• ↓ GI injuries if lower
abdominal trauma
• Dilated pelvic Vasculature
↑ retroperitoneal
hemorrhage
• Respiratory Alkalosis and
compensatory metabolic
acidosis.
• e ligaments of the
symphysis pubis
andsacroiliac joints are
loosened during pregnancy.
As a result, a base-line
diastasis of the pubic
symphysis may exist that
can be mis-taken for pelvic
disruption on a radiograp
Ecg CHANGES , flat-tened T waves or Q waves in leads III
and augmented voltageunipolar left limb lead may be
seen.

46. Complications
• Preterm Labor
• Preterm delivery
• Uterine rupture
• Feto-maternal
hemorrhage
• placental abruption.
Ghana Emergency Medicine Collaborative
Advanced Emergency Trauma Course

47. Complications
Vaginal bleeding  abruption
watery discharge  rupture of
membranes
- Abruption is a clinical diagnose
- 25% separation carries a 5.5-fold
increased risk of preterm delivery
- Contractions that are not self-limited
are often induced by some pathologic
condition
DIC pathophysiology
. The injured placenta can release thromboplastin
into the maternal circulation, resulting in DIC,
whereas the damaged uterus can disperse
plasminogen activator and trigger fibrinolysis

48. Blunt
threefoldto fourfold increase in force
transmission through the uterus
Penetrating
Pelvic and acetabular fractures during
pregnancy  high maternal(9%) and a
higher fetal (38%) mortality rate
.
lap belt should be placed under the gravid
abdomen, snugly overthe thighs, with the
shoulder harness off to the side of the
uterus,between the breasts and over the
midline of the clavicl

49. Evaluation

50. To X-RAY or to other?
• risk of 1-rad = 0.003%,
thousands of times smaller
than the spontaneous risks of
malformations, abortions, or
genetic disease
• Ultrasonography: accuracy of
97% for detecting intra-
abdominal injuries in blunt
trauma
• CT can miss diaphragm and
bowel injurie
• DPL can be done in any
trimester by an open
technique above the uterus
• DPL is limited in detecting
bowel perforations and does
not assess retroperitoneal and
intrauterine pathology.

51. Management
• No tocolytics if cervical
dilated 4 cm
• No Vasopressors.
• ? Fluid  look for ferning
(amniotic fluid not urine)
• If amniotic fluid leak
• group B streptococci
• Neisseria gonorrhoeae
• Chlamydia
• FMH is usually of more
concern after 12 weeks’
gestation but can be in 4
weeks
•

52. Management
• 4 hour CTG
• Extend to 24 h if
• > 3 contraction/h
• Uterine tenderness
• Worisome strips
• Vaginal bleeding
• Membrane rupture
• Serious maternal injury
• On d/c to record Fmfor
1wk if < 4/h to come to
hospital
• +ve FHS GA >= 26 wk
infant survival is 75%
• penetrating uterine
wounds  laparotomy
Ghana Emergency Medicine Collaborative
Advanced Emergency Trauma Course

53. Rhesus immune globulin
• (RhIG) within 72 hours of the incident
• 1st trimester 50-µg ( Total baby blood volume 4.2 mL)
• 50 µg ( covers 5 mL of bleeding).
• 2nd & 3rd  300-µg (30 mL of FMH)
• Tetanus Prophylaxis
• Tetanus toxoid and immune globulin have no
detrimental effecton the fetu

54. • Perimortem Cesarean Section
• within 4 min of maternal cardiac
arrest
• most experienced physician available
as cardiopulmonaryresuscitation is
continuing.
• A midline vertical incision from the
epigastrium to the symphysis pubis.
midline vertical incision for the
uterus.
• is advisable to monitor the fetal
heart during
maternalcardioversion.

55. Perimortem Cesarean Section video

57. Take Home Points
• requires a multidisciplinary team approach.
• The need for diagnostic imaging outweighs radiation risk to fetus, due to
low risk.
• Time is life: No fetus with absent tones survived emergency delivery while
75% with FHTs and age >26wks survived.
• The fetus is viable at 24 weeks’ gestation. This usually corresponds to
when the fundus is at or above the umbilicus.
• Stable pregnancies with a viable fetus should be monitored
continuously for a minimum of 4 hours after trauma.
• Keeping the mother tilted 30 degrees to the left or in the left lateral
decubitus position may alleviate hypotension and improve perfusion for
the mother and fetus.
• Perimortem cesarean section should be considered only for a viable
fetus with signs of life.
• If available, nonionizing radiation, including ultrasound and MRI, is
preferred for the evaluation of pregnant trauma patients.
Ghana Emergency Medicine Collaborative
Advanced Emergency Trauma Course

58. Thank you..

59. Injury Severity Score
• ISS = A2 + B2 + C2 where A, B, C are the AIS scores of the
three most injured ISS body regions
• The ISS scores ranges from 1 to 75 (i.e. AIS scores of 5
for each category