This document discusses isolated head injuries in pediatric trauma patients and the association with shock and hypotension. The key points are: 1) A study found that among pediatric patients with isolated head injuries, rates of hypotension were highest in those aged 0-4 years, with 1/3 of hypotension cases associated with isolated head injuries in that age group. 2) Several potential causes for this association between isolated head injuries and hypotension in young pediatric patients were hypothesized, including neurogenic or autonomic responses. 3) Due to the risks of cerebral edema from large fluid volumes, providers may need to adjust treatment to include early vasopressors or anticholinergic drugs to support blood pressure in these

1. Level I Compliance 2015
Isolated head injuries linked to shock and hypotension
According to current ATLS guide-
lines, “For all practical purposes,
shock does not result from isolat-
ed brain injuries.”(1) Following
these guidelines, when shock is
identified, immediate resuscita-
tion with fluid boluses followed
by blood products as needed.
Shock associated with trauma is
often thought to be hemorrhagic
but emerging evidence is suggest-
ing that it could also be associated
with isolated head injuries (IHI).
One study set out to identify if
presenting hypotension could
indeed be associated with ISI.
The study was able to utilize 2009
data from the National Trauma
Data Bank (NTDB) and extract
78,673 patients with relevant data
recorded. (2)
Their results concluded that
among patients with IHI, the
rates of hypotension were greatest
in the 0-4 years of age grouping.
In fact, researchers found that
within this age group, one third
of hypotension was associated
with IHI as opposed to one fifth
with hemorrhagic injury and only
one hundredth with spinal cord
injury.
Several causes of this finding were
hypothesized including a possible
neurogenic response similar to
spinal shock or an autonomic
process with increased vagal tone
or poor sympathetic tone.
Because of the association of
increased cerebral edema with
large volumes of isotonic fluids,
providers may have to adjust their
treatment plans to include less
volume resuscitation and early
administration of vasopressors to
increase sympathetic tone or atro-
pine to block increased vagal
tone.
M O N R O E C A R E L L J R . C H I L D R E N ’ S H O S P I T A L A T V A N D E R B I L T
January 20, 2016
Volume 4, Issue 1
Pediatric Trauma Service IEP
Special points of
interest:
 Remember after re-
viewing the IEP con-
tent, you must suc-
cessfully pass the
post-test in order to
receive assigned CME
credit of 1.5 hr.
Inside this issue:
WBCT scanning in
adult and pediatric
centers
2
Benefits of protocol
utilization in association
with abdominal trauma
2
MCJCHV Abdominal
Trauma Work-Up
Algorithm
3
MCJCHV Chest
Trauma Work-Up
Algorithm
3
MCJCHV CHI ≥2 yo
Work-Up Algorithm
4
MCJCHV CHI <2 yo
Work-Up Algorithm
5
Vascular injuries in
pediatric
6
References 6
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Total
Total 9 8 8 10 16 13 17 10 15 4 7 16 133
Present 8 6 7 10 12 12 15 8 15 3 5 12 113
No show 1 2 2 1 1 2 1 1 4 15
Time not 1 1
Past time 1 2 1 4
Percentage 86% 75% 88% 100% 82% 92% 88% 80% 100% 75% 71% 75% 85%
For Level I activations, attendings &/or fellows have 15 minutes to respond to the bedside from time of
arrival.
Per ACS, Level I facilities must maintain 80% or greater

2. Over the last 20 years, there has been a
fivefold increase in the utilization of CT
scans in pediatric patients who present
to the emergency department, with head
injury being the most frequent
indication that prompts CT scan use.
(3) With the rising awareness of
radiation-induced malignancy, a
nationwide push towards limiting the
use of CT scans has been observed since
2008. In the pediatric population,
physicians often rely on these radiology
studies since physical exam may be an
unreliable means of identifying injuries.
One study examined the frequency of
CT utilization, specifically whole body
computed tomography (WBCT), in
adult versus pediatric trauma centers.
Utilizing the National Trauma Data
Bank (NTDB), they were able to identify
30,667 patients to include in the study,
of which 38.3% were managed at a
designated pediatric trauma center. (3)
The following factors were linked to
the use of WBCT scanning: age ≥ 6
years, male gender, intoxication, GCS
score ≤ 8, hypotension and tachycardia
on presentation, blunt injury, motor
cycle collision, head, thoracic or
abdominal AIS ≥ 3, injury severity
score ≥ 25 and management in an
ATC. After adjusting for age, GCS
score, admission vital parameters,
mechanism, type and severity of injury,
patients who presented in an ATC
were 1.8 times more likely to undergo
a WBCT scan ultimately increasing
their risk of radiation without a
difference in outcomes. There was no
noted difference in hospital and ICU
length of stay as well as hospital
disposition between adult and
pediatric center patients that received
WBCTs.
Of note, head CT rates did not differ
between adult and pediatric trauma
centers, however the use of thoracic and
abdominal CTs were significantly higher
in the adult programs. (3) This may be
attributed to the utilization of
guidelines and prediction models put in
place at pediatric trauma centers. These
guidelines recommend selective imaging
based on mechanism of injury, physical
examination, and laboratory studies.
At MCJCHV, liaisons from PEM,
PICU, Trauma, NSGY, Ortho, ANES,
and Radiology have collaborated to
establish recommended radiology work-
ups for trauma patients presenting with
blunt chest, blunt abdominal, and
closed head injuries. These are
included in this issue for your review.
should take into account the patient’s
GCS, reliability of an abdominal
exam, and the presence of abdominal
wall bruising.
One designated pediatric trauma
center instituted their own protocol
in hopes of decreasing the negative
CT rate and the cost of laboratory
studies utilized in the evaluation of
abdominal trauma. (5) After institut-
ing their evidenced based protocol,
the rate of positive CT scan findings
increased from 23% to 49%. For
them, protocol deviation occurred
most frequently in the conscious,
reliable exam group (40%) with the
scans being obtained in the absence
of abdominal tenderness/pain or lack
of surgery consult prior to the scan.
When evaluating pediatric patients,
assessing for abdominal trauma can be
challenging due to few external signs,
unreliable communication, difficulty
obtaining an accurate abdominal exam,
a physiological reserve that maintains
normotension despite ongoing volume
loss, and injury patterns specific to cer-
tain age groups. (5) CTs of the abdo-
men and pelvis are routinely obtained
for adult patients if the physical exam is
unreliable. However with children,
current data suggests judicious use of
CT radiation due to the increased can-
cer risk. Many institutions have report-
ed overuse of CT scanning in pediatrics,
especially when evaluating for ab-
dominal trauma. Guidelines determin-
ing the diagnostic work up in children
Only 8% of patients had clinically sig-
nificant scans when the protocol was
not followed as opposed to 31% when
the protocol was followed.
This protocol also led to the reduction
of total laboratory costs of 39%. The
protocol specified ordering a HGB/
HCT and AST/ALT instead of a CBC
and CMP or liver panel.
The majority of studies covering the
topic recommend a combination of
specific laboratory studies and physical
exam in determining the need for CT.
Specifically hematuria and elevated ALT
with an abnormal abdominal exam are
the best predictors of intra-abdominal
injury.
Utilization of whole body CT scans in adult and pediatric trauma centers
The benefits of protocol utilization in abdominal trauma
Page 2
Pediatric Trauma Service IEP

3. Key points :
 When performed,
CT should always
be performed with
IV contrast to avoid
the need for repeat
imaging.
 A hemodynamically
stable patient with
normal cognition
can generally be
safely screened with
careful physical
exam (tenderness or
abdominal bruising)
and laboratory
values (AST, ALT,
Amylase, HCT).
 For evaluation of
the pelvis, a CT is
only recommended
if a fracture is
identified on x-ray
or if there is
uncertainty
regarding the
presence of a
fracture. (4)
Page 3
Volume 4, Issue 1
Key points :
 Chest CT should be
reserved for cases
where the chest
radiograph is
abnormal or there is
an abnormally high
level of clinical
concern despite a
normal chest
radiograph.
 CT is highly
recommended in
penetrating chest
trauma no matter
the CXRY however.

4. Pediatric Trauma Service IEP

5. Volume 4, Issue 1

6. Epidemiology
 Account for only 0.6%-1.4% of all pediatric injuries.
 Upper extremity injuries most common in 2-6 years of age.
 Lower extremity injuries most common in >12 years of age.
 Brachial artery injuries occur in 53% of cases followed by
popliteal at 9.5%, and the common femoral arties at 5.9%.
Fallon, S., Delemos, D., Akikuotu, A., Christopher, D., & Naik-Mathuria, B. (2016). The use of an institutional pediatric abdominal trauma
protocol improves resource use. Journal of Trauma and Acute Care Surgery, 80(1), 57-63.
Gardner, A., Diz, D., Tooze, J., Miller, C., & Petty, J. (2015). Injury patterns associated with hypotension in pediatric trauma patients: A
national trauma database review. Journal of Trauma and Acute Care Surgery, 78(6), 1143-1148.
Pandit, V., Michailidou, M., Rhee, P., Zangbar, B., Kulvatunyou, N., Khalil, M., . . . Joseph, B. (2015). The use of whole body computed
tomography scans in pediatric trauma patients: Are there differences among adults and pediatric centers? Journal of Pediatric Surgery.
Pierce, D., Mangona, K., Bisset, G., & Naik-Mathuria, B. (2015). Computed tomography in the evaluation of pediatric trauma. Clinical Pediatric
Emergency Medicine, 16(4), 220-229.
Wahlgren, C., & Kragsterman, B. (2015). Management and outcome of pediatric vascular injuries. Journal of Trauma and Acute Care Surgery, 79
(4), 563-567.
References
Pediatric Trauma Service IEP
Vascular injuries
Operative techniques
 Repair techniques include interposition graft (24%),
patch (19%), primary repair- lateral suture/direct
anastomosis (12%), bypass (9.5%), endovascular
techniques (3.7%), and miscellaneous- i.e.,
thrombectomy, thrombendarterectomy, ligation(8.1%)
 Exploration or release of artery was performed 23% of
the time.
 Vein is the leading graft material followed by synthetics.
 In younger patients (≤10 years), patch repair techniques
were more common (28% vs. 9.6%).
 In the older pediatric population (11-15 years),
reconstruction with interposition and bypass grafts was
more common (49% vs. 23%).

Complications and follow-up
 Arterial occlusion/thrombosis most common
postoperative complication.
 Amputations are associated with occluded vein grafts in
reconstructions at the level of the femoral artery.
CME instructions