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The Division of Paediatric Emergency Medicine Presents: Pediatric Trauma Management What You Need To Know Thanks to: Angelo Mikrogianakis MD, FRCPC Pediatric Emergency Physician and Trauma Team Leader Emergency Medicine & Critical Care The Hospital for Sick Children Pediatric Patch Physician Ornge
Objectives
General overview of pediatric trauma
Anatomy and patterns of injury
Case Study
Why does pediatric trauma cause so much anxiety?
Emotional impact
Different equipment sizes
Different drug and fluid calculations
Differences in anatomy,physiology and pathophysiology specific to children
Communication difficulties
Lack of staff experience
We can all be better prepared for pediatric trauma!
“We Forgot The Patient!”
PEDIATRIC TRAUMA
Isolated head injury Multiple trauma Airway compromise Respiratory failure Shock Cardiopulmonary arrest
PEDIATRIC TRAUMA
Blunt injury is much more common than penetrating injury
Head (CNS) injury present in 55% of blunt trauma victims
Internal injuries present in 15% of blunt trauma victims
ANATOMY & PHYSIOLOGY
BODY
small body mass with large surface area
heat loss
greater force per body unit area
less protective muscle and fat
high metabolic rate
higher oxygen and glucose demands
ANATOMY & PHYSIOLOGY
HEAD
large compared to body size
heat loss
more prone to injury
weak neck muscles
prominent occiput
sutures open until 18 months
relatively larger tongue
PEDIATRIC HEAD TRAUMA
Most common single organ system injury associated with 80% of all deaths
Concussion common injuries
Subdural bleeds common in infants
Epidural bleeds less common than adults
Acute neurosurgical intervention required less often than adults
CAUSES OF SECONDARY BRAIN INJURY
Systemic Causes Neurologic Causes (Extracranial) (Intracranial)
hypotension
hypoxemia
anemia
hypo/hypercarbia
hyperthermia
hypo/hyperglycemia
hyponatremia
raised ICP
herniation
vasospasm
hematoma
seizures
infection
hyperemia
BREATHING FOR HEAD INJURED PATIENTS
Controlled ventilation
cerebral vasculature responds to
PaCO 2
maintain cerebral oxygenation PaO 2 < 60 mm Hg associated with
mortality morbidity &
Hyperventilation with caution
hyperventilation decreases CBF & worsens outcome
hyperventilation NOT recommended unless herniation
goal is PaCO 2 = 35 mmHg
MANAGEMENT OF RAISED
ICP
Elevate HOB (unless
BP)
Medication
Mannitol: osmotic diuresis
3% Hypertonic saline: Early transfer to neurosurgical facility
Hyperventilation
only if impending herniation
ANATOMY & PHYSIOLOGY
NECK
shorter; supports more mass
veins & trachea hard to see
larynx - cephalad & anterior
cricoid narrowest part
epiglottis at 45 o & floppy
short trachea (5cm at birth) spine – elasticity of ligaments
Less calcified
PEDIATRIC C-SPINE
C-Spine injury is uncommon (1-4%)
< 8 y.o.
10-15%
8-12 y.o.
20-25%
> 12 y.o.
60-70%
Anatomic fulcrum of spine at C2-C3
Fractures below C3 < 30% of spine lesions in children < 8 years of age ***
Adult pattern of injury at 12 years old
CSI - pediatric differences
mobility at C2-C3 (pseudosubluxation)
normal mobility 3 mm (children 4-5 mm)
tip of odontoid < 1 cm from base of skull
pre-dental space 3 mm (children 4-5 mm)
retropharyngeal space 5-7 mm (children < 7-8 mm)
vertebral bodies may be wedged anteriorly
especially on their superior surfaces until
age 10
ANATOMY & PHYSIOLOGY
CHEST
ribs are cartilaginous and pliable
greater transmitted injury
rib fracture = massive force
little protective muscle and fat
mediastinum very mobile
PEDIATRIC THORACIC INJURIES
Less serious thoracic injuries than adults
Rarely will chest injuries occur in isolation
Rarely are the sole cause of death
Blunt cardiac & great vessel injuries are rare
Management is mainly conservative:
Assisting oxygenation and ventilation
Chest tube insertion
Replacing lost blood volume
< 15% require a chest tube
PEDIATRIC THORACIC INJURIES
U.S. data in pediatric blunt chest trauma
50% pulmonary contusions
20% pneumothorax
10% hemothorax
Canadian incidence is most likely less
Chest tube sized to occupy most of the intercostal space.
ANATOMY & PHYSIOLOGY
ABDOMEN
less protection from ribs and muscle
liver and spleen vulnerable
small forces can cause severe injury
propensity for gastric distension
abdominal pain
respiratory distress
GU organs well protected by pelvis
Gastric distension
common after trauma
from crying and swallowing air
can interfere with respiration / ventilation
limits diagphragmatic motion
reduces lung volume
increases the risk of vomiting
difficult to discern abdominal findings
Gastric distension
PEDIATRIC ABDOMINAL
INJURIES Gastric distention = OG/NG tubes
Solid organs are most vulnerable.
8% of admissions to peds trauma centres
85-90% of all pts with hepatic & splenic injuries can be managed nonoperatively.
Missed hollow viscus injury is uncommon.
Male
Age
Weight
ISS
Direct
Referred SickKids Patient Population April 1998 – March 2001 62.2% 8.6 years (std dev 4.5) 33.8 kg (std dev 18.1) 14 (std dev 11) 47.8% 52.2%
100 80 60 40 20 0
Mechanism Of Injury
95 94 52 25 18 10 5 3 10
0 5 Intra-Abdominal Injuries Bladder, 3 Pancreas, 5 Renal/Adrenal 16 Bowel & Mesentery, 14 10 15 20 # of Patients 25 30 Liver, 31 Spleen, 32 35
Organ Requiring Surgical Intervention 3 Normal Bladder Spleen Liver Bowel 0 1 2 2 2 4 6 # of Patients 8 10 10
The more important requisite is the ability to evaluate hemodynamic stability.
AMBULANCE PATCH
7 y.o. male, pedestrian struck by truck while crossing street
Witnesses describe LOC
Now confused & agitated
O 2 applied IV access x 1
VITALS: HR=120, BP=105/69, RR=30, SATS=91%
RAPID CARDIOPULMONARY ASSESSMENT
A.
Airway and C-spine control
B.
Breathing
C.
Circulation and hemorrhage control
D.
Disability (rapid neurologic assessment)
E.
Exposure and Environmental control
PREPARATION
Assemble team - define roles
physicians
nurses
RT
radiology
Prepare equipment for:
airway management
IV access & fluid resuscitation
Broselow tape
PRIMARY SURVEY
AIRWAY
position - jaw thrust
suction
100% oxygen
oral airway
ensure C-spine is immobilized
AIRWAY
Bag & mask ventilaton
C-spine precautions
Intubating Criteria
RSI meds
PRIMARY SURVEY
BREATHING
colour
chest movement
retractions
breath sounds
assess work of breathing
oxygen saturations
PRIMARY SURVEY
CIRCULATION
heart rate
capillary refill
skin colour and temperature
blood pressure
peripheral pulses
organ perfusion: brain, kidney
CIRCULATION IN THE
TRAUMA VICTIM
Assess for signs of hypovolemic shock:
quiet tachypnea
tachycardia
prolonged capillary refill
cool extremities
thready pulses
narrow pulse pressure
altered mental status
RESPONSE TO FLUID BOLUS
Slowing of heart rate
increased systolic BP
increased pulse pressure (>20mmHg)
decrease in skin mottling
increased warmth of extremities
clearing of sensorium
urinary output of 1 - 2 ml/Kg/hour
PRIMARY SURVEY
DISABILITY
pupils: size and reactivity
level of consciousness
A - Alert
V - Verbal stimulus
P - Painful stimulus
U - Unresponsive
PRIMARY SURVEY
EXPOSURE
remove all clothes
keep patient warm
warm blankets
warm fluids
overhead warmer
warm the room
SECONDARY SURVEY
HEAD TO TOE EXAM
systematic exam of all body organs
look, listen & feel
fingers & tubes in every orifice
SECONDARY SURVEY
HISTORY
A - Allergies
M - Medications
P - Past medical history
L - Last meal
E - Events/Environment
RE-ASSESS And ASSESS AGAIN If patient deteriorates, go back to ABC’s
KEY MESSAGES
Prevention is the best defense
Pediatric patients have special differences
Recognize head-injured patients early
Prevent secondary brain injury
Be excellent airway managers
Provide adequate fluid resuscitation
Anticipate need for transfer ASAP
Ensure appropriate transport personnel
Psychologic status
impaired ability to interact
unfamiliar individuals
strange environment
emotional instability
fear / pain / stress
parents often unavailable
history taking and cooperation can be difficult
Strange environment?
Strangers in environment?
CASE STUDY: 7 year old,
male
Pedestrian struck by truck while crossing street
On Arrival to Primary Hospital
Moaning with bruising & swelling to face, large scalp laceration
100% O 2
Cardio, Resp, BP & Sat monitors
2 large bore IV’s placed
CASE: 7 year old male
Vitals: HR=160, BP=110/70, RR=24, SAT= 99
A Patent, teeth loose, facial contusions
B Breath sounds decreased on RIGHT
C Heart sounds N, cap refill brisk
D Eyes open to speech, Verbally confused, Obeys commands (GCS=13), PERL
ABDO soft, tender RUQ, bruising R flank/hip
CASE: 7 year old
Interventions:
Broselow Tape
Bolus 20 cc/kg NS rapidly
Reassess
Vitals: HR=140, BP=105/75, RR=14, SAT= 99
Resp effort decreased, BS decreased to R
Eyes open to pain, no longer verbal, abnormal flexion to pain
Summary of Pitfalls
Beware of hypothermia in systemic trauma
especially if hemodynamic compromise
Beware of unusual bleeding sites
subgaleal hematomas
long bone fractures
Beware of the distended stomach
CASE
14 y.o. male, previously healthy
Un-helmeted cyclist struck by truck ~ 19:00
Thrown & rolled
Initially unconscious then agitated, Vx X 1
Arrival at primary hospital ~ 19:50
Tachycardic
Comatose – decorticate posturing – GCS=5 Extension of extremities
CASE
A Intubated
No maxillofacial trauma
B Trachea midline
Good A/E bilaterally
No subcutaneous air C – HR = 126, BP = 120/35 D PERL – myosis, extension to painful stimuli
Abrasion L chest & abdomen
Abdomen distended
Common Life-Threatening Chest Injuries
Type Tension pneumothorax Massive hemothorax Initial Treatment ABC’s, Needle decompression Insert chest tube ABC’s Pleural decompression Insert chest tube Replace fluids
Uncommon Life-Threatening Chest Injuries
Type Flail chest Initial Treatment ABC’s Positive-pressure ventilation May require chest tube Open pneumothorax ABC’s Occlusive dressing Insert chest tube
Surface area
surface / volume ratio highest in infants diminishes as child matures thermal energy loss significant hypothermia may develop quickly may be good for isolated head injuries bad for hypotensive patients
Tachycardia
Why is evaluation of HR so important?
CO = HR x SV
CO
= HR x
SV
CO =
HR
x
SV
Hypotension
Why is evaluation of BP so important?
BP = CO x SVR
CO
=
HR
x
SV
BP =
CO
x
SVR
It’s “Shock” ing
BP @ 25% loss normal blood volume = 80 mL/kg 6 month old 7 kg 7 kg = 560 mL 25% 140 mL 140 mL ½ cup
BP Rule of Thumb
Minimal acceptable systolic blood pressure: 70 mm Hg + (2 x age in years) Represents 5th %ile of normal BP Hypotension in children is a late and often sudden sign of cardiovascular decompensation
BP in head injuries
Secondary brain injury =
neuronal injury as a result of the pathological processes that are initiated as the body’s response to primary injury hypercarbia cerebral edema ICP
hypotension
hypoxemia
BP in head injuries
CPP = MAP - ICP
CPP =
MAP - ICP
CPP = MAP -
ICP
CPP =
MAP -
ICP
Long-term effects
effect on growth and development growth deformity abnormal development children with severe multisystem trauma 60% residual personality changes at 1 year 50% show cognitive and physical handicaps
Long-term effects
other disabilities social affective learning significant impact on family structure personality and emotional disturbances in 2/3 of uninjured siblings strain on marital relationship
CORE KNOWLEDGE & SKILLS
1.
Understand the principles of airway management in the injured pediatric patient.
2.
Recognize and manage shock in the injured pediatric patient.
3.
Recognize and treat common life threatening complications of major trauma in pediatric age group.