Continuing Education Activity
Waddell’s triad represents a pediatric emergency. The triad comprises of three distinct features seen in pediatric pedestrian patients subject to blunt force trauma, usually secondary to a direct impact by a motor vehicle. They include ipsilateral femoral shaft fracture, ipsilateral intra-thoracic or intra-abdominal injury, and contralateral head injury. The combination of these 3 injuries can lead to significant blood loss via internal hemorrhage. This activity outlines the evaluation and management of patients presenting with Waddell's triad and highlights the role of the interprofessional team in managing the patients with this condition.
Objectives:
Summarize the epidemiology of Waddell's triad .
Outline the necessary workup for evaluation of a patient presenting with Waddell's triad.
Explain the importance of pediatric trauma score for the assessment of severity of injury in patients presenting with the Waddell's triad.
Address the importance of coordination among interprofessional team members to improve outcomes for patients presenting with Waddell's triad.
Introduction
Waddell’s triad represents an emergency for pediatric patients due to the high incidence of injuries associated with a femur fracture.[1] The triad comprises 3 distinct features seen in pediatric pedestrian patients with blunt force trauma, usually secondary to a direct impact by a motor vehicle. They include (1) ipsilateral femoral shaft fracture, (2) ipsilateral intra-thoracic or intra-abdominal injury and (3) contralateral head injury.[2] The combination of these 3 injuries can lead to significant blood loss via internal hemorrhage. Emergency medical services should transport these patients to a pediatric trauma center capable of treating this special patient population. Children have lower mortality rates after severe blunt trauma when treated in designated pediatric trauma centers or in hospitals with pediatric intensive care units.[3]
In this injury, the pedestrian absorbs all the energy of the collision. The severity of the injuries depends on factors such as the speed of the vehicle, the weight of the pedestrian, and the frontal structure of the vehicle. There is also the potential of severe hemorrhaging in the abdomen, and these patients should consequently have blood crossed and typed in case an emergent transfusion is necessary. Also, when Waddell’s triad is present, monitoring patients closely for hypotension and other signs of shock is of utmost importance.[3]
Etiology
Wadell triad occurs due to the blunt force trauma sustained secondary to direct pedestrian impact by a motor vehicle. Classically, there are 3 phases in the injuries sustained by these patients: the impact of the bumper, followed by the impact of the windshield/hood, and finally, the impact on the ground. The injuries of the pelvic limbs are due to the impact of the bumper, the thoracic or abdominal trauma results from the impact of the hood/windshield and the head or cervical spine trauma results from hitting the ground.[1] Any individual who presents with Waddell triad should be treated as significantly injured with the potential for severe hemorrhage and subsequent hypovolemic shock.[3]
Epidemiology
According to the World Health Organization (WHO) report on child injury prevention, worldwide, unintentional injuries are the leading cause of death in children between 10 to 20 years. In the United States, more than 12,000 children die each year secondary to unintentional injury. Motor vehicle injuries are the leading cause. Each year, 9.2 million children are treated in US emergency departments (EDs) for injury due to falls, but motor vehicle injuries rank among the top 15 causes of disability in children worldwide.[3]
History and Physical
A complete history and physical examination is part of the secondary survey which is done once the patient is stabilized. The patient’s age or clinical condition may preclude them from relaying details of the trauma, so physicians should seek information from a family member, other witnesses of the trauma, and EMS workers. The mnemonic AMPLE can capture important information to obtain about the patient and the clinical scenario:
- Allergies the patient has
- Medications the patient is on
- Past medical history
- Last time the patient ate
- Events related to the sustained trauma (and any intervention by EMS)
Healthcare professionals should seek a detailed mechanism of injury because important information can be gleaned from even seemingly trivial statements.[3]
Waddell triad occurs as a result of a high energy impact; therefore, a clinician's primary goal during the initial physical exam should be to rule out associated injuries and subsequently treat all injuries requiring emergency care.[1] When a child presents with 1 or 2 signs of the triad after a motor vehicle injury, it is important to look for the third sign which may present later.
Evaluation
The full workup includes a whole body CT scan which can rapidly identify injuries to the brain (intracranial hemorrhage), chest, abdomen, and presence of any fractures. This is usually done as part of the tertiary trauma survey which follows the secondary survey (a focused history and physical exam). As part of the tertiary survey, laboratory and radiological evaluations in the emergency setting have prognostic importance but be limiting. Examples include a lateral cervical spine radiograph missing clinically significant injuries; hemoglobin and hematocrit levels which have not yet equilibrated after a hemorrhage; and abnormal liver function tests which may be seen in abdominal trauma but these patients usually go for CT scan and surgery immediately. These labs are also not standard procedure for every patient which may slow down the triage process. Clinical prediction rules that combine the history and physical exam have been developed to identify those at low risk of injury and subsequent deterioration. In these patients, specific radiographic and laboratory studies may not be necessary.[3]
Treatment / Management
The initial management of a patient with Waddell triad begins with the usual primary assessment or survey for trauma. The primary survey addresses airway, breathing, circulation, neurologic deficit, and exposure of the patient and control of the environment (ABCDE).[3]
Key Points
Airway/Cervical Spine
Remember to check for cervical spine injury while optimizing oxygenation and ventilation. The current standard is to immobilize the cervical, thoracic, and lumbar spine in a neutral position with a stiff collar, head blocks, tape, or cloth positioned across the forehead, torso, and thighs, and a rigid backboard. This restrains the child. Airway obstruction usually manifests as snoring, gurgling, hoarseness, stridor, and/or diminished breath sounds. Airway obstruction can also result from fractures of the facial bones, secretions such as blood or vomitus, crush injuries of the larynx, or foreign body aspiration. If the healthcare preofessionals need to open the airway, a jaw thrust without head tilt is recommended. This procedure minimizes cervical spine motion.
Breathing
Breathing can be assessed by counting the respiratory rate, visualizing chest wall motion for symmetry, expansion, accessory muscle use, and auscultating breath sounds. In addition to observing for cyanosis, pulse oximetry monitoring is the standard. If ventilation is inadequate, bag-mask ventilation with 100% oxygen must be initiated immediately, followed by endotracheal intubation.
Circulation
Circulation deals with the perfusion of the various body organs and identifying signs of poor perfusion or shock. The most common shock in trauma is hypovolemic shock caused by hemorrhage. Signs include tachycardia, weak pulse, delayed capillary refill, cool, mottled, pale skin, and altered mental status. Loss of more than 40% of blood volume causes severe hypotension that may become irreversible; therefore, direct pressure should be applied to control external hemorrhage. Two large bore IVs should be inserted to maintain adequate hydration. Aggressive, intravenous fluid resuscitation is crucial in early stages of shock to prevent further deterioration. An isotonic crystalloid solution, such as lactated Ringer injection or normal saline (20 mL/kg) should be infused rapidly. Serial hematocrits should be measured to ensure that there is no acute bleeding but if the patient remains in shock despite fluid boluses, then 10 to 15 mL/kg of cross-matched, packed red blood cells should be transfused. Intra-thoracic bleeding, if present, is usually managed by placing a chest tube for drainage. Blood loss from a femur fracture can be massive and may require multiple blood transfusions.
Neurologic Deficit
Neurologic deficit can be assessed by determining the level of consciousness which is classified using the AVPU scoring system:
- Alert
- Responsive to Verbal commands only,
- Responsive to Painful stimuli only
- Unresponsive
In addition, a Glasgow coma ccale (GCS) score should be assigned to every child with significant head trauma. This scale assesses eye opening and motor and verbal responses. The GCS helps categorize neurologic disability, and serial measurements can help identify improvement or deterioration over time. A child with severe neurologic impairment (a GCS score of 8 or less) should be intubated. Head injuries account for at least 75% of pediatric blunt trauma deaths and are usually managed with supportive care, but one should always monitor the child for the development of elevated intracranial pressure (ICP) due to an epidural or subdural hematoma. Signs of increased ICP, including progressive neurologic deterioration and transtentorial brain herniation, must be treated immediately with brief hyperventilation and Neurosurgical consultation in case emergency surgery is necessary.
Exposure and Environmental Control
Upon arrival at the emergency room, all clothing should be removed to reveal any injuries. Cutting is the quickest method and minimizes unnecessary patient movement. Health care professionals should also remember that children often can arrive hypothermic because of their higher body surface area to mass ratios. Warming techniques include the use of radiant heat, heated blankets, and intravenous fluids.
Overall, there is no systematic treatment for the femur fractures in children. However, other factors should be considered, for example, the age of the child, the soft tissue injuries, the type and location of the fracture, the concomitant head, thoracic and abdominal trauma, and the surgeon’s expertise and the family’s psychosocial situation. Trauma scores provide an objective description of a patient’s condition and help clinicians recognize the individuals who have sustained the most severe injuries and need the most immediate medical care. The pediatric trauma score (PTS), for example, can easily be applied for the triage (patient classification according to the severity) of these particular patients at the scene of injury and in the hospital. It also has multiple applications which include predicting the chance of survival and degree of central nervous system impairment.[1]
Pearls and Other Issues
Whenever children pedestrians are involved in a motor vehicle accident, it is important not to assume that they have only one organ injury. The full trauma team should be involved in the management of children with Waddell triad.
Enhancing Healthcare Team Outcomes
Serious, multisystem trauma may cause significant, long-term psychological and social difficulties for the patient and their family. Children are also at risk for depressive symptoms and posttraumatic stress disorder. Psychological and social support during the resuscitation period and afterward is important. A member of the resuscitation team should be made responsible for answering the family’s questions and supporting them in the trauma room.[3]
Waddell Triad