Waddell Triad


Article Author:
Michael Paz


Article Editor:
Magda Mendez


Editors In Chief:
Russell McAllister
Jason Widrich
Daniel Sizemore


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/6/2019 1:32:10 AM

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]


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Waddell Triad - Questions

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A 6-year-old child struck by a car is found to have Waddell triad. Which of the following is not part of the triad?



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An 8-year old child is brought to the emergency department after being struck by a car while crossing the street. He is not alert. He required immediate intubation at the scene by emergency management services. His Glasgow coma scale is 8. He appears to have a significant laceration of his scalp on the left side, but there are no skeletal fractures. The initial chest x-ray reveals a right-side pneumothorax. A chest tube was inserted. His hematocrit is 23% and hemoglobin are 7.6 g/dL. What is the next step in management?



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A 10-year-old female arrives at the emergency department following a motor vehicle collision. Thirty minutes earlier, she was crossing the street when a car drove through the red light and hit the left side of her body. She was awake when paramedics arrived at the scene, but then had a 30-second generalized seizure, followed by several minutes of decreased responsiveness. Her level of consciousness has improved gradually since the seizure occurred. She is maintaining her airway, has clear and equal breath sounds, and her vital signs are normal. She has had no episodes of vomiting. On physical examination, the patient is lying flat with her entire spine immobilized. She is awake, follows commands, and answers questions, although she seems confused. Her Glasgow coma scale score is 14. She has a 2 cm by 5 cm boggy hematoma over her right temple, which is tender to palpation. Her pupils are equally reactive to light and accommodation. She has full strength and normal reflexes in all extremities. The rest of the physical examination is unremarkable. Which of the following is the best next step in the evaluation of this patient?



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A 12-year-old previously healthy boy is brought to the emergency department (ED) after he was struck on his right side by a motor vehicle while he was running across the street. His upper body was thrown forward, and he bumped his left forehead on the pavement. He was alert and oriented when the paramedics arrived at the scene. They immobilized his entire spine using a pediatric backboard and cervical spine collar before transport. In the ED, he is anxious but fully oriented. He reports pain in his head, abdomen, and legs. His vital signs include a temperature of 37.6 C, heart rate of 89 beats/min, respiratory rate of 19 breaths/min, blood pressure of 100/70 mmHg, and pulse oximetry of 99% (room air). On physical examination, the boy’s airway is clear, he is breathing spontaneously with normal respiratory effort, and his pulses and perfusion are normal. A superficial abrasion over his left forehead is noted. His abdomen is soft and non-distended, but it is tender to palpation in the right upper quadrant. He displays no peritoneal signs. There is tenderness to palpation over his right thigh with swelling and bruising. Imaging is performed which shows a hepatic contusion and a non-displaced skull fracture on the left side. What additional finding in this patient would confirm the diagnosis of Waddell triad?



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An 11-year-old male presents to the emergency department after a motor vehicle hit him. His vital signs show a temperature of 37.5 C, blood pressure 115/75 mmHg, pulse 62 beats/min, and respiratory rate 17 breaths/min. He is awake and alert and complains of a headache and blurry vision. He denies any other pain, nausea, vomiting, or difficulty breathing. There is a boggy, tender area over his left temporal area with no other signs of trauma. His pupils are 3 mm, equal, and reactive. When he looks straight ahead, his left eye deviates medially. Eye movements and cranial nerves are otherwise intact. The mental status examination and the rest of the neurologic examination are unremarkable. Computed tomography of the head confirms the diagnosis. Which of the following is the most appropriate initial step in management?



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A 7-year old girl is brought to the hospital after suffering multiple injuries after being run over by a car. She has since been intubated, and her vital signs include a temperature of 37 C, pulse of 130 beats/min, respiratory rate of 20 breaths/min, and blood pressure of 90/50 mmHg. The girl has bruising involving her posterior trunk, buttocks, and abdomen. On auscultation, her heart has a regular rate and rhythm with no murmurs, and her lungs are clear bilaterally. Her abdomen is rigid and slightly distended. Her extremities are cool and mottled, with a capillary refill time of 3 seconds. There are no other external signs of trauma. What is the most appropriate fluid management for this child’s first 24 hours of treatment?



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Waddell Triad - References

References

N��ez-Fern�dez AI,Nava-Cruz J,Sesma-Julian F,Herrera-Tenorio JG, [Clinical assessment of pediatric patients with Waddel's triad]. Acta ortopedica mexicana. 2010 Nov-Dec     [PubMed]
Fein DM,Fagan MJ, Overall Approach to Trauma in the Emergency Department. Pediatrics in review. 2018 Oct     [PubMed]
Orsborn R,Haley K,Hammond S,Falcone RE, Pediatric pedestrian versus motor vehicle patterns of injury: debunking the myth. Air medical journal. 1999 Jul-Sep     [PubMed]

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