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seventh edition International Trauma Life Support for Emergency Care Providers Trauma in Children CHAPTER 17 Trauma in Children © Pearson International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Overview • • • • Effective techniques to gain confidence Injuries based on mechanisms of injury ITLS Primary and Secondary Surveys Consent and the need for immediate transport International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Overview • Pediatric equipment needs • Various methods of SMR on children • EMS involvement in prevention programs International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Trauma in Children • Different from adults – Anatomical differences Different patterns of injuries Different responses to those injuries Special equipment required – Assessment equipment and treatment equipment – Difficult to assess and communicate – Come with parents and other family members International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Communicating • Family-centered care is critical – Caregiver not always parent – Involve parent as much as possible in care – Give explanations and careful instructions – Inclusion and respect will improve stabilization – Keep parents in physical and verbal contact • Demonstrate competence and compassion International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Assessing Mental Status • Consoled or distracted – Most sensitive indicator of adequate perfusion – Parents best at detecting subtle changes • Initial level of consciousness – Preschool child: sleeping vs. unconscious Most will not sleep through arrival of ambulance Ask parents to wake child Suspect hypoxia, shock, head trauma, seizure International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Communicating • Interaction strategies – Appropriate language for developmental level – Speak simply, slowly, clearly Be gentle and firm – Avoid “no” questions – Get a favorite belonging – Get on child's level – Explain SMR necessity – Allow parent to accompany child International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians © Pearson Parental Consent • Critical care should not be delayed. • Emergency care needed – Consent not available Transport before permission, document why, notify medical direction – Consent denied Try to persuade, document actions, obtain signature Notify law enforcement and appropriate authorities Report suspected abuse International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Pediatric Equipment • Length-based tape – Weight estimate – Fluid and medication doses precalculated – Common equipment size estimates Courtesy of James Broselow, MD Photos courtesy of Kyee Han, MD Courtesy of Louis B. Mallory, MBA, REMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Mechanisms of Injury • Falls – Usually land on head – Serious head injury unusual from <3 feet (1 meter) – Protective gear • MVCs – Seat-belt syndrome Liver, spleen, intestines, lumbar spine • Auto-pedestrian crashes International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians General Assessment (Copyright American Academy of Pediatrics. Used with permission.) International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Airway Assessment • Opening airway – Tongue is large; tissue soft Jaw-thrust Oropharyngeal airway Nasopharyngeal airways – Too small to work predictably Courtesy of Louis B. Mallory, MBA, REMT-P – Neonate obligate nose breather Clear nose with bulb syringe International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Airway Assessment • Signs of obstruction – Apnea – Stridor – “Gurgling” respiration Courtesy of Bob Page, NREMT-P • Contribute to obstruction – Hyperextension – Hyperflexion © Pearson International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Breathing Assessment • Work of breathing – Retractions, flaring, grunting Persistent grunting requires ventilation • Respiratory rate – Fast, then periods of apnea or very slow • Minor blunt neck trauma can be critical International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Ventilation • Give ventilations slowly • Lowest pressure necessary • 20, 15, 10 – 20 bpm < 1 year old – 15 bpm > 1 year old – 10 bpm adolescent International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Breathing Management Effective BVM ventilation— Courtesy of Louis B. Mallory, MBA, REMT-P intubation is elective. International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Endotracheal Intubation • Oral endotracheal intubation – No blind nasotracheal intubation for <8 years • Uncuffed tube – Length-based tape system – Same diameter as tip of child's little finger age in years = size of tube (mm) –4+ 4 – Frequently reassess placement – Alternative airways International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Circulation Assessment • Early shock more difficult to determine – Persistent tachycardia Rate >130 usually shock in all ages except neonates – Prolonged capillary refill and cool extremities – Level of consciousness Circulation can be poor even if child is awake – Low blood pressure is sign of late shock BP <80 mmHg in child; <70 mmHg in young infant International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Bleeding • Control immediately – Avoid large bulky dressings – Constant direct pressure – Hemostatic agents – Tourniquets with caution • Blood volume 80-90 mL/kg – Example: 200-mL loss is approximately 20% in a 10 kg child International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Critical Trauma Situation • Perform only necessary procedures – Control bleeding – SMR – Oxygenation – Ventilation • Rapid, safe transport – Appropriate destination International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Hemorrhagic Shock • Strong compensatory mechanisms – Appear surprisingly good in early shock – “Crash” when deteriorate – Be prepared – Fluid administration 20 mL/kg in each bolus Consider intraosseous infusion – Frequent Ongoing Exams International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Life-Threatening Injuries • Head injury – Most common cause of death Level of consciousness change best indicator Pupil assessment important International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Life-Threatening Injuries • Head injury – Treatment High-flow oxygen Hyperventilate only with cerebral herniation syndrome Monitor ventilation with capnography Fluid administration titrated to systolic BP – Preschool child: 80 mmHg; older child: 90 mmHg Be prepared to prevent aspiration International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Life-Threatening Injuries • Chest injury – Respiratory distress common – Pneumothorax or tension pneumothorax Difficult to assess Needle thoracostomy can be lifesaving – Pulmonary contusion – Rare injuries Rib fractures, flail chest, aortic rupture, pericardial tamponade International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Life-Threatening Injuries • Abdominal injury – Liver and/or spleen rupture Second leading cause of traumatic death Bleeding often contained within organ – Difficult to diagnose Severe injury with minimal signs Suspect with any abnormal abdominal assessment – Be prepared to prevent aspiration International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Life-Threatening Injuries • Spinal injury – Uncommon before adolescence <9 years usually upper cervical-spine injuries >9 years usually lower cervical-spine injuries – SMR Pad under torso for neutral position May have to secure without cervical collar Do not restrict chest movement International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Child Restraint Seats • Child in car seat – Serious injury Remove from car seat Apply SMR – No apparent injury Secure and transport in car seat Courtesy of Louis B. Mallory, MBA, REMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Child Neglect and Abuse • A leading cause of death in U.S. – Be alert to signs – Transport if suspected – Know local laws © Pearson International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Summary • Good trauma care for children – Proper equipment – Interact with frightened parents – Know normal vital signs for various ages Reference chart – Be familiar with common injuries in children – Be active in prevention programs International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians