Pediatric Trauma Pearls and Pitfalls: Cases and Imaging Guidelines

Understanding Pediatric Trauma Mechanisms

• 💡 Mechanism predicts injury pattern in pediatric trauma, requiring a standardized approach like XABCD E's with specific considerations for children.
• 🧠 Children have unique anatomical features, including larger heads, compliant chest walls, thinner abdominal walls, and more elastic bone periosteum, leading to distinct injury patterns like greenstick and buckle fractures.
• 🚗 Classic pediatric trauma mechanisms include motor vehicle collisions (seat belt syndrome, auto-pedestrian impacts), falls (from heights, playground equipment), and sports collisions, each with associated high-risk injuries.
• ⚠️ Spinal cord injury without radiographic abnormality (SCIWORA) is a critical consideration in pediatric trauma due to the spine's flexibility, often requiring MRI for diagnosis.

Imaging Decisions in Pediatric Trauma

• ☢️ While ionizing radiation carries risks, imaging is crucial when it provides actionable information; the goal is to modify exposure risk and avoid unnecessary scans.
• 📈 The PECARN pediatric imaging guidelines are essential resources, offering flowcharts to guide decisions on imaging for head, cervical spine, chest, and abdomen/pelvis injuries.
• 🧐 Decisions on imaging, particularly CT scans, should be based on specific criteria such as GCS, altered mental status, signs of skull fracture, mechanism of injury, and physical exam findings.
• 🫁 Thoracic CT scans are often restricted in children unless there are actionable findings, and blunt thoracic aortic injury screening relies on adult-like mechanisms in older adolescents.

Navigating Non-Accidental Trauma (NAT)

• 🚩 Non-accidental trauma (NAT) should be suspected in unexplained injuries, delayed evaluations, vague histories, or injuries with various stages of healing.
• 🚨 Key indicators for NAT include bruises in young children, fractures in infants, burns, anogenital trauma, and altered mental status after low-level falls.
• 🤕 Abusive head trauma, formerly shaken baby syndrome, is characterized by altered mental status, bilateral subdural hematomas, and retinal hemorrhages.
• 📝 Workup for suspected NAT involves standard trauma assessment, specific secondary survey findings, basic labs, a skeletal survey for children under 24 months, and a dilated retinal exam by an ophthalmologist.
• ⚖️ Suspected NAT requires mandatory reporting to child protective services, involving a multidisciplinary team to manage social, medical, and legal implications and mitigate bias.
• 🔍 A thorough, objective documentation of history, physical exam findings, and any discrepancies is vital, and a standardized approach helps ensure consistent care and reduce bias.