Pediatric Trauma - Hennepin County Medical Center

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Case Reports Multiple classification systems for pelvic fractures exist, however most crucial is differentiating a stable vs. unstable pelvic fracture. Stable pelvis fractures include isolated iliac wing fractures and isolated fractures of the anterior pelvic ring, such as pubic rami fractures. Unstable fractures are those that involve the anterior and/or posterior sacroiliac ligaments of either or both sacroiliac joints, or vertical sacral fractures, and may result in pubic symphysis or sacroiliac diastasis. Significant hemorrhage generally is seen with unstable fractures and arises from the venous plexus immediately anterior to the sacrum, from cancellous bone edges, and from branches of the internal iliac artery. Measures to tamponade this hemorrhage include minimizing pelvic movement, pelvic wrapping, external fixation, internal packing, angiography with embolization, and possibly aortic balloon occlusion. Pelvic wrapping is most effective when there is sacroiliac or pubic symphysis diastasis without significant vertical displacement or acetabular fractures. Commercial pelvic binders may be utilized or a sheet wrapped low across the pelvis compressing the greater trochanters of the femur inward (Figure Two). Wrapping is particularly useful for pre-hospital and emergency providers and should be applied when pelvic fracture is suspected. External fixation is best applied by a skilled orthopedist in cases of significant hemorrhage; vertical displacement or iliac wing fractures decrease its effectiveness. Internal packing of the pelvis and retroperitoneum with surgical sponges is most often utilized when the patient has concomitant hemoperitoneum or other indication for open abdominal surgery and can be done in conjunction with pelvic wrapping or external fixation. Angiography with embolization is indicated in patients with hemodynamically significant bleeding refractory to more conservative measures and is most effective when arterial bleeding can be identified. At times angiography may be prioritized despite hemoperitoneum or other active bleeding. Aortic balloon occlusion for pelvic fractures, recently described in adults, is a method of occluding the abdominal aorta with an intraluminal balloon as temporizing measure in the patient dying of hemorrhagic shock and may pose a future role in pediatric patients. Our patient had injuries of nearly every organ system, but his shock was due to ongoing bleeding from a pelvic fracture. Interventional radiology reviewed the pelvic CT in the event that the patient should become unstable and need angiography. In this setting, despite an acetabula fracture, orthopedics felt the patient would benefit from external wrapping with reduction of the vertical displacement of the posterior pelvis via femoral traction pin under emergency department procedural sedation. The pediatric team and trauma surgery managed the continuing hemodynamic stabilization of the patient while he was in the PICU pending the operative stabilization of the pelvis. After a repeat head CT and serial neurologic examination confirmed stability of his intracranial hemorrhages, and after receiving a blood transfusion, he was taken for ORIF of his pelvis on hospital day one, within 24 hours of presentation. ■ Figure Two. Application of a commercially available pelvic wrap . References Hauschild O, Strohm PC, Culemann U, Pohlemann T, Suedkamp NP, Koestler W, Schmal H. Mortality in patients with pelvic fractures: results from the German pelvic injury register. J Trauma. 2008 Feb;64(2):449-55. Junkins EP, Furnival RA, Bolte RG. The clinical presentation of pediatric pelvic fractures. Pediatr Emerg Care. 2001 Feb;17(1):15-8. Leonard M, Ibrahim M, McKenna P, Boran S, McCormack D. Paediatric pelvic ring fractures and associated injuries. Injury. 2010 Aug 23. Martinelli T, Thony F, Declety P, Sengel C, Broux C, Tonetti J, et al. Intra-Aortic Balloon Occlusion to Salvage Patients With Life- Threatening Hemorrhagic Shocks From Pelvic Fractures. J Trauma. Feb 18 2010. Silber JS, Flynn JM. Changing patterns of pediatric pelvic fractures with skeletal maturation: implications for classification and management. J Pediatr Orthop. 2002 Jan-Feb;22(1):22-6 Silber JS, Flynn JM, Koffler KM, Dormans JP, Drummond DS. Analysis of the cause, classification, and associated injuries of 166 consecutive pediatric pelvic fractures. J Pediatr Orthop. 2001 Jul-Aug;21(4):446-50 Spiguel L, Glynn L, Liu D, Statter M. Pediatric pelvic fractures: a marker for injury severity. Am Surg. 2006 Jun;72(6):481-4. 4 | Approaches in Critical Care | June 2011
Case Reports Pediatric abdominal trauma after an ATV rollover by Marc Osbourne, MD Chad Richardson, MD Department of Surgery Hennepin County Medical Center Case report A 10-year-old boy taken to a local hospital after an all-terrain vehicle (ATV) rollover crash was transferred to Hennepin County Medical Center (HCMC) by helicopter after it was determined that he was neurologically intact, but had sustained several other injuries, including an occlusion of the left renal artery. This case describes a patient with two rare injuries in an unusual injury pattern. It highlights the complex surgical and medical management of children with severe abdominal trauma. The 10-year-old patient was the passenger on an ATV driven by his father. Neither the patient nor his father were wearing a helmet. The ATV struck an object, resulting in the rollover. The boy was able to ambulate at the scene, but complained of abdominal and back pain. Bystanders called 911 and the patient was initially taken to a local hospital at about 2 p.m. His airway was intact and he was breathing and oxygenating well. He was tachycardic, but otherwise hemodynamically stable. Secondary exam showed a tender abdomen. Computed tomography (CT) scans of the head, C spine, chest, abdomen, and pelvis were obtained. The CT scans revealed several injuries, including an occlusion of the left renal artery without perfusion of the left kidney, a hematoma of the third and fourth portion of the duodenum with concern for possible perforation, free fluid within the peritoneum, a fracture of the body of L2, and fractures of the transverse processes of T12, L2, and L3. Given these findings, the patient was transferred via helicopter to HCMC. The patient arrived at HCMC at 8:30 p.m. He was mildly tachycardic and normotensive. On secondary exam, he had a tender and distended abdomen, as well as tenderness with palpation of the thoracic and lumbar spine. He had no neurologic deficit. A Focused Assessment with Sonography for Trauma (FAST) exam was positive for free fluid around the spleen. His radiographic studies arrived via electronic transfer to HCMC, where radiologists were also suspicious for transaction of the duodenum in the third or fourth portion. Representative images of his CT are shown in Figures One and Two. All providers, including trauma and pediatric surgery, did not feel there were any viable options for renal salvage. Given the clinical and radiographic findings, including a possible duodenal transaction, trauma surgery recommended exploratory laparotomy. This was discussed with the patientʼs mother. In the operating room (OR), the patient was found to have a moderate amount of intra-abdominal hemorrhage, a small bowel perforation approximately 15 cm from the Ligament of Treitz, a small serosal tear of the transverse colon, a perforation of the duodenum at the junction of the third and fourth portion of the duodenum, and a left Zone II retroperitoneal hematoma (Figure Three). The Zone II hematoma was slowly bleeding into the abdomen via a defect in the posterior peritoneum. These findings were consistent with severe blunt force trauma within which the energy was delivered to a very focal area of the upper abdomen just to the left of the midline. The Zone II retroperitoneal hematoma was explored, revealing a small amount of muscular bleeding, as well as an ischemic left kidney. A thrombus could be visualized transluminally in his left renal artery, consistent with an intimal dissection. Figure One Left. Abdominal CT showing the ischemic left kidney and renal artery thrombosis Figure Two Middle. Abdominal CT showing the site of the suspected duodenal transection Figure Three Right. Retroperitoneal Zones: Zone 1–Central–bounded by the diaphragm superiorly and pelvic inlet inferiorly and the medial border of the psoas muscles laterally; Zone 2–Lateral–includes the areas lateral to zone 1 and above the pelvic inlet; Zone 3–Pelvic–area below the pelvic inlet Approaches in Critical Care | June 2011 | 5
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