Approach to Pediatric Trauma: The Unstable Child Presented by: Jonna Bobeck BSN, RN, CEN

Introduction

• Trauma is leading cause of death in children • Blunt injury cause for majority of cases • Children’s anatomy different from adult • Initial approach and management of major trauma

Overview

• Standardized approach • ATLS/ENPC • Prevention • Golden hour

Injury Classification

• Injury extent • Injury type • Injury severity

Trauma Systems

• GCS • Trauma score • Pediatric trauma score • Age specific pediatric trauma score

Initial approach

• Rapid assessment • Key principles -Assessment and management

American Heart Association

• 2010 CPR updates: A-B-C to C-A-B

Primary Survey

• A- airway • B - breathing • C- circulation • D - disability • E - exposure

Airway

• Airway Assessment • Proper padding • Cervical spine immobilization • Tracheal intubation - pretreatment with lidocaine - sedative agents - paralytics

• Assessment - key findings • Management

Breathing

• Assessment • Management

Circulation

Circulation

• Hemorrhage control • IV access - two large bore within 90 seconds - intraosseous - percutaneous central access - venous cutdown

Circulation

• Fluid resuscitation - 20ml/kg warmed normal saline • PRBC - 10 – 20ml/kg • FFP • Platelets • Recombinant activated factor V11

Advanced Procedures

• Cardiac tamponade • Open thorocotomy

Disability :Neurological Assessment

• Pediatric GCS - severity of TBI • Prevent secondary injury

Exposure

• Rapid exposure of patient to identify and treat injuries • Avoid hypothermia

Labs

• Hematocrit/Hemoglobin • Type and cross • Rapid blood glucose • ABG • PT/PTT • Serum electrolytes

Radiographs

• C-spine • AP chest • AP pelvis • Ultrasound - FAST

Urinary Catheter and Gastric Tube

• Monitor urine output • Decompress

Secondary Survey

• History (SAMPLE) S - subjective A - allergies M - medications P - past medical history/pregnancy L - last meal E - events leading to injury • Head to toe physical exam

Adjuncts to Secondary Survey

• Radiographs • Head CT • Neck CT • Abdominal CT • Orthopedic management • Wound care

Specialized Care

• Definitive care • Pediatric trauma center

Summary

• Primary Survey • Resuscitation of vital functions • Secondary survey • Key principles

References

• • • • • • • • • • • • • American Heart Association, . "Highlights of the 2010 American Heart Association Guidelines for CPR and ECC."

American Heart Association Guidelines 2010

(2010): 2. Web. 21 Dec 2010. Bolick, Beth. "Emergency Nurse Pediatric Course Third ed.." Ed. Harriet Hawkins . United States of America: Emergency Nurses Association, 2004. Print. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors. American College of Surgeons, Chicago 2004. Slack, SE, Clancy, MJ. Clearing the cervical spine of paediatric trauma patients. Emerg Med J 2004; 21:189.

Sokolove, PE, Kuppermann, N, Holmes, JF. Association between the "seat belt sign" and intra-abdominal injury in children with blunt torso trauma. Acad Emerg Med 2005; 12:808.

Shlamovitz, GZ, Mower, WR, Bergman, J, et al. Poor test characteristics for the digital rectal examination in trauma patients. Ann Emerg Med 2007; 50:25.

Shlamovitz, GZ, Mower, WR, Bergman, J, et al. Lack of evidence to support routine digital rectal examination in pediatric trauma patients. Pediatr Emerg Care 2007; 23:537.

Cervical spine immobilization before admission to the hospital. Neurosurgery 2002; 50:S7.

Blackwell, CD, Gorelick, M, Holmes, JF, et al. Pediatric head trauma: changes in use of computed tomography in emergency departments in the United States over time. Ann Emerg Med 2007; 49:320.

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Frush, DP, Donnelly, LF, Rosen, NS. Computed tomography and radiation risks: what pediatric health care providers should know. Pediatrics 2003; 112:951.

Brenner, DJ, Hall, EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med 2007; 357:2277.

Palchak, MJ, Holmes, JF, Vance, CW, et al. A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med 2003; 42:492