TABLE 2445 Spinal Column Differences in Children

Children with incomplete spinal cord deficits have a better prognosis for improvement in neurologic condition than those children with complete spinal cord injuries. Spinal cord trauma is associated with a higher mortality rate in children than in adults.

CLINICAL FINDINGS Presentation is related to the presence or absence of a spinal cord injury. Children with fractures only will have pain, tenderness, or overlaying soft tissue injury. Children with spinal cord injuries with or without fracture will present based on the type of spinal cord injury.

Over 50 percent of children with SCIWORA have a delayed onset of paralysis, sometimes up to 4 days. 20 Many of these children have transient paresthesias, numbness, or weakness at the time of or shortly after the injury. Because most spinal injuries fail to improve substantially, even in children, the most important factor in prognosis is the initial neurologic status. 20 Children with fractures and neurologic symptoms do worse than children with SCIWORA alone. 20

RADIOGRAPHY Cervical spine radiographs should be obtained on any patient with neurologic symptoms including coma, or if any symptoms are referable to the neck. Up to 66 percent of spinal cord injuries in children have no radiographic abnormality and thus fall into the category of SCIWORA. 20 Widening of the prevertebral soft tissues to 8 mm or more in front of C2 or more than 75 percent of the adjacent vertebral body width is considered abnormal. In infants, however, this becomes less reliable.

In alert unintoxicated adult blunt trauma patients without neck symptoms, cervical spine radiographs can be forgone and cervical spine immobilization can be released. Because children have a much lower frequency of cervical spine fractures, following this algorithm in children is appropriate. Any child with neurologic complaints, neck pain, limited neck movement, neck tenderness, or evidence of neck trauma, must have plain films consisting of at least three views: lateral, anteroposterior, and odontoid. The single lateral cervical spine radiograph has been shown to miss fractures and result in a delay in diagnosis. 21 If the child has neck pain but no neurologic symptoms, plain radiography is generally all that is required to clear the cervical spine. Occult fractures and misinterpretation of plain films do occur, so if there is any doubt, a CT scan should be obtained. If the child had paresthesias, numbness, or weakness or currently has neurologic symptoms, a CT scan is also recommended.20 If all plain film radiographs are negative, but the diagnosis of SCIWORA is being entertained, then a flexion and extension lateral cervical spine x-ray must be obtained to identify any ligamentous instability. This is not detectable on CT scan. These films should be done under close supervision and only in an awake and cooperative patient. Fluoroscopy may be helpful, as well. Anytime the diagnosis of SCIWORA is considered, the child requires a neurosurgical consultation from the ED and admission for observation.20

MANAGEMENT Treatment of spinal cord injuries in the prehospital and ED settings consists of immobilization, diagnosis of the specific injury, and steroid administration. Prehospital personnel must be instructed that an infant's relatively large head may cause the neck to flex in the standard supine position, so they require padding behind the shoulders to prevent this. Steroids should be started if there is evidence of a neurologic deficit with a loading dose of 30 mg/kg of methylprednisolone.10 Steroids should be started within 8 h of the injury. Those who receive steroids within 3 h should be maintained on steroids for 24 h. Those who receive steroids 3 to 8 h after the injury require maintenance for 48 h. The maintenance dose is 5.4 mg/kg/h. The maintainance dose is initiated 45 min after the initial bolus. Children with a spinal cord injury require immediate neurosurgical consultation. If a spinal fracture is also present, a pediatric orthopedist should also be consulted.

Children, with their relatively compliant chest walls, may not show external evidence of serious intrathoracic trauma. Blunt trauma occurs more frequently than penetrating trauma and may be equally as serious. Isolated chest trauma in children carries a 4 to 12 percent mortality rate. Most children with chest trauma will have other significant injuries. In a multiply-injured child, death is 10 times more likely if chest trauma is present. 22 Penetrating chest injuries are becoming more frequent as the number of firearm injuries steadily increases in the United States. Children under the age of 12 are more likely to be injured in unintentional crossfire and require a longer hospitalization than do adolescents and adults.

Evaluation of a patient who has evidence of, or who has a good mechanism for, chest injury should include a thorough physical examination looking for bony defects, crepitus, paradoxical chest movement, and unequal breath sounds. A chest x-ray should be taken. To minimize interruption of the resuscitation, a supine chest x-ray can be initially obtained. A rib fracture is a sensitive indicator of serious underlying injury. 22 The most common injury is pulmonary contusion, but this may not be visible on the early ED chest x-ray.22

Most injuries requiring emergent treatment can be identified on the standard supine anteroposterior chest x-ray. Mediastinal widening is common on supine chest x-rays, but aortic injury is quite rare in children who survive to the ED. An upright chest x-ray, preferably using posteroanterior technique, will often obviate the need for additional studies. Aortography is still considered essential to exclude aortic injury, when suspected, although contrast-enhanced spiral CT scanning may also identify aortic injury. If an abdominal CT scan is obtained, additional occult chest injuries are often detected, but these rarely require emergent therapy.

Tube thoracostomy alone is usually sufficient management for pneumothorax or hemothorax, both of which are uncommonly associated with blunt trauma in children. Other specific injuries should be managed as outlined in the primary survey section. Emergent thoracotomy should be performed selectively as with adults. Survival from pulseless arrest at the scene or en route to the ED is rare in both blunt and penetrating trauma.9 Only children who have sustained penetrating trauma and experience a loss of vital signs in the ED should have a resuscitative thoracotomy performed. In all other cases, the attempt is futile and the financial costs are high. 9

DIAGNOSIS The physical examination of a child's abdomen is frequently misleading in the detection of intraabdominal injury. Children with severe injuries can have minimal physical findings, while other children may have occult serious injuries. Physical exams have been shown to be unreliable in up to 45 percent. In most children with abdominal symptoms or a mechanism of injury to the abdomen, an investigative study should be obtained.

Diagnostic peritoneal lavage (DPL) has been shown to be quite accurate in the identification of serious intraabdominal injury in children. 23

False-negative DPLs are unusual. False-positive rates are in the range of 4.5 to 14 percent. 23 DPL criteria considered indicative of the need for laparotomy in children are listed in Table.. ..244-6. Elevated amylase levels are associated with both pancreatic injury and bowel injury.24 Because DPL is invasive and most children will not need an operation to manage their injuries (see below), abdominal CT scan is gaining popularity. A DPL is indicated, however, in children who have hemodynamic instability or other nonabdominal injuries that require immediate operative management. Some authors have also advocated use of DPL before CT scan in stable patients with an equivocal exam, because of its higher sensitivity; if the DPL is positive by red blood cell (RBC) criteria only, then a CT scan is performed to determine the need for laparotomy based on the extent of solid organ injury.23

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