Transcript Pediatric Trauma - Stanford University

Julie Williamson, DO
Clinical Assistant Professor of
Anesthesia and Pediatrics
Lucile Packard Children’s Hospital
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Epidemiology of trauma
The Primary Survey (ABCs)
Fluid resuscitation and massive transfusion
Non-Neurologic Injury
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Traumatic Brain Injury
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Trauma is the leading cause of death in
children and young adults in the US (ages 1-44
years old)
Most pediatric deaths from trauma involve
motor vehicles
Brain injury is most common cause of death
In children, about half involve multiple organs
or body regions
Rank <1
1-4
5-9
10-14 15-24 25-34 35-44 45-54 55-64 65+
All
Ages
1
Congenital
Anomalies
724
Unintention
al
Injury
171
Unintention
al
Injury
109
Unintention
al
Injury
117
Unintention
al
Injury
1,540
Unintention
al
Injury
1,355
Unintention
al
Injury
1,741
Malignant
Neoplasms
4,914
Malignant
Neoplasms
9,438
Heart
Disease
53,330
Heart
Disease
64,871
2
Short
Gestation
428
Congenital
Anomalies
76
Malignant
Neoplasms
63
Malignant
Neoplasms
71
Homicide
986
Homicide
645
Malignant
Neoplasms
1,549
Heart
Disease
3,610
Heart
Disease
6,322
Malignant
Neoplasms
37,317
Malignant
Neoplasms
54,140
3
Maternal
Pregnancy
Comp.
157
Malignant
Neoplasms
53
Congenital
Anomalies
29
Homicide
50
Suicide
408
Malignant
Neoplasms
475
Heart
Disease
1,155
Unintention
al
Injury
2,259
Unintention
al
Injury
1,282
Cerebrovascular
12,766
Cerebrovascular
15,039
Malignant
Neoplasms
253
Suicide
468
Suicide
589
Liver
Disease
1,160
Cerebrovascular
1,140
Chronic
Low.
Respiratory
Disease
11,167
Chronic
Low.
Respiratory
Disease
12,829
Heart
Disease
82
Heart
Disease
291
Liver
Disease
387
Suicide
752
Chronic
Low.
Respiratory
Disease
1,136
Alzheimer's
Disease
8,054
Unintention
al
Injury
11,375
4
5
SIDS
137
Homicide
36
Homicide
13
Congenital
Anomalies
26
Placenta
Cord
Membranes
109
Influenza
&
Pneumonia
17
Heart
Disease
10
Heart
Disease
21
WISQARSTM Produced By: Office of Statistics and Programming, National Center for Injury Prevention and Control, Centers for Disease
Control and Prevention
Data Source: National Center for Health Statistics (NCHS), National Vital Statistics System
Mechanism
Incidence (%)
Mortality (%)
Blunt
92
3
Fall
27
<1
MVA - occupant
21
4
MVA – peds struck
12
5
Bicycle
9
2
Penetrating
8
5
Gunshot Wound
2
10
Stabbing
3
3
Crush
<1
1
From Roger’s Textbook of Pediatric
Intensive Care, fourth edition
Percent
Decrease/Increase
Type of Incident
Number of Deaths
in
Year 1987
Number of Deaths
in
Year 2004
Motor vehicle crash
3,587
2,431
32%
Drowning
1,363
761
44%
Pedestrian injury
1,283
583
55%
Fire and/or burn
injury
Suffocation
1,233
512
58%
690
963
28%
Falls
149
107
28%
Poisoning
100
86
14%
Firearm
247
63
74%
http://www.usa.safekids.org
National Center for Health Statistics. Centers for Disease Control and Prevention. National Vital Statistics System.
WISQARS Injury Mortality Reports, 1987 to 2004. Hyattsville (MD): National Center for Health Statistics, 2007
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Smaller bodies mean more kinetic injury into a
smaller space  impact on multiple organs
Larger BSA  heat loss
Anterior liver and spleen, mobile kidneys
Immature bone has increased elasticity  more
soft tissue injury (misleading lack of fractures)
Head:body greater, cranial bones thinner
More robust response to catechol driven
vasoconstriction  preserved blood pressure
until catastrophic shock ensues
More likely to suffer a respiratory than cardiac
arrest
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“Scoop and run” vs. “stay and play”
Out of hospital airway management
Improved outcomes associated with care in a
pediatric trauma center/hospital with PICU
Loss of airway and IV access twice as common
during transport, 10 times more common if not
a specialized team
Image from calhoun.cc.al.us
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Relatively larger tongue – most common cause
of airway obstruction
Larger adenoids
Floppy omega shaped epiglottis
Larynx appears more cephalad and anterior
Cricoid ring is narrowest part of airway
Narrow tracheal diameter, smaller distance
between rings
Shorter tracheal lengths ( 4 cm newborn, 7 in 18
month old)
Large airways more narrow
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Assume C spine injury in pediatric trauma
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Assume full stomach/RSI indicated
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Jaw thrust, oral airway
Induction agents – risks of propofol, ketamine,
etomidate and succinylcholine
Pre-oxygenation
Avoid nasal intubation with severe facial/head
trauma. Blind NI less successful in children
Consider cuffed ETT
Needle cricothyroidotomy (no slash trachs in
kids)
Orogastric tube to decompress stomach
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More likely to have high cervical trauma under
8 years old (OA fulcrum)
Radiographs are over and under-read
SCIWORA
Harder to
immobilize
CT scan vs. MRI
Tuggle David W, Garza Jennifer, "Chapter 46. Pediatric Trauma" (Chapter). Feliciano DV, Mattox KL, Moore EE: Trauma, 6th
Edition: http://www.accesssurgery.com.laneproxy.stanford.edu/content.aspx?aID=169962.
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Apply 100% oxygen immediately while doing
primary survey
Watch for age-appropriate respiratory rates
Hypercarbia/inadequate ventilation often
under appreciated
Pneumothorax more difficult to diagnose by
auscultation due to transmitted breath sounds.
If hemodynamically unstable, needle chest
early
Respiratory arrest from C spine injury
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Intravenous access
3 attempts, 90 seconds, or obtunded  IO
 Large bore PIV is optimal
 CVL or cut down PIV
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Control of hemorrhage
Direct pressure over bleeding
 Tourniquets?
 Hemorrhage into thorax, retroperitoneum, thigh or
intracranial in infants
 More then 3cc/kg/hour from chest tube is an indication
for operation
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Aortic injury is 2nd cause of death after TBI
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Hypotension is a late finding correlating to loss of 30% of
circulating blood volume
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Monitor for poor perfusion or confusion
20cc/kg warmed isotonic solution X 2 then PRBC
 Crystalloid vs. colloid?
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 0.9 NS or LR
 Colloid
 3% saline
 Albumin
 Hetastarch  coagulopathy
 Blood products
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Over-resuscitation
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Edema, abd compartment syndrome, ARDS, hypothermia
Emergency release blood – O neg or O pos
 ABO & Rh type specific uncrossmatched blood
 Dilutional thrombocytopenia after replacement of ½
blood volume
 After replacement of one blood volume with type O,
stick with O
 Early coagulopathy
 MTP protocols: 1:1:1 PRB to FFP to Platelets
 “Storage lesion”
 Whole warmed blood
 Activated factor VII in children?
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Pediatric GCS or AVPU
Eyes
Verbal
Motor
1
No opening
None
None
2
Opens to pain
Inconsolable, agitated
Extension
3
Opens to speech
Inconsistently inconsolable,
moans
Flexion
4
Opens spontaneously
Cries but consolable
Withdraws to pain
Appropriate, interactive
Withdraws to touch
5
6
Purposeful or
spontaneous
movement
Check pupil size and reactivity
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Orthopedic injuries
Primary cause of operative intervention in pediatric
trauma
 Greenstick and buckle fractures
 Growth plate injury
 Supracondylar fractures
 Immobilize and monitor vascular status
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Vascular injury
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95% limb salvage
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Fully undress patient – keep warm
Look under collar and splints
Log roll patient, exam back
Rectal exam
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Complete visual inspection
Maintain normothermia
Platelet inhibition below 34 C
 100% mortality below 32 C
 Hyperthermia causes secondary injury in TBI
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Perfusion and mentation
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Lactate or base deficit
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Do NOT wait for labs or radiographs to
indicate need to evacuate pneumothorax or
transfuse
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Continuously resuscitate and reassess – vital
signs every 5 to 15 minutes
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Easy to miss orthopedic injuries
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Plain films
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FAST
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CT
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4 – 25% of pediatric trauma, up to 40%
mortality
Low SBP, elevated RR, external thoracic injury
or femur fracture associated with intrathoracic
injury
Compliant chest wall
Mobile mediastinum
Pneumothorax
Hemothorax
Aortic injury accounts for 14% of mortality
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Thin body wall and closely spaced organs
Any external markings or tenderness are ominous
Gastric decompression to benefit ventilation
Diaphragmatic rupture
Gastric rupture
Bowel injury injury
Splenic or hepatic injury
Renal injury
Among children ages 0 to 14 years, TBI results in
an estimated:
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2,685 deaths;
37,000 hospitalizations
35,000 emergency department visits annually
What causes TBI?
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Falls (28%);
Motor vehicle-traffic crashes (20%);
Struck by/against events (19%); and
Assaults (11%)
Langlois JA. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2004.
Vascular injuries – SAH and IVH serve as markers of
severity
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Mass effect
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Parenchyma
CSF
Blood
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Hypoxia
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Ischemia
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Target thresholds in children?
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Normothermia vs. hypothermia (why doesn’t this
work in kids??)
Normoventilation: PCO2 < 25 ischemia
Osmolar therapy - rheology
Mannitol
 Hypertonic Saline
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ICP and CPP mangement – what numbers are
adequate in children?
Decompressive craniotomy
 CSF drainage
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Glycemic control – not a simple answer
Coagulopathy -30% incidence of DIC in children
with severe TBI
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Avarello JT and Cantor RM, Pediatric Major
Trauma: An approach to evaluation and
management. Emerg Med Clin N Am 25 (2007)
803-836.
Tuggle David W, Garza Jennifer, "Chapter 46.
Pediatric Trauma" (Chapter). Feliciano DV, Mattox
KL, Moore EE: Trauma, 6th Edition:
http://www.accesssurgery.com.laneproxy.stanfor
d.edu/content.aspx?aID=169962.
Letarte Peter, "Chapter 20. The Brain" (Chapter).
Feliciano DV, Mattox KL, Moore EE: Trauma, 6th
Edition:
http://www.accesssurgery.com.laneproxy.stanfor
d.edu/content.aspx?aID=157936.