The Role of the Intensivist in Trauma Care Bunmi Okanlami M.D, MBA, FAAP

Objectives:  Overview of ICUs, intensivists, specialists and the multidisciplinary team  Trauma in children: Unique considerations  Multidisciplinary approach to trauma care: Benefits and Challenges  Essential tools for successful team work in ICUs

 Trauma is still the leading cause of death and disability in children: ≈20,000 deaths per year  Falls account for most injuries, but not deaths  Motor-vehicle related injuries are most common cause of death in children of all ages  Drowning, house fires, homicides and falls are next  Blunt force results in multisystem injuries in children

   Multiple trauma: 90% caused by blunt force and involving injury to abdominal organs and/or head injury Principles of trauma resuscitation are similar to those in adults:    Primary Survey: Secondary survey: ABCDE H&P, X-rays, CT, Labs Definitive management: Operative/Non-operative  Disposition: Discharge, Admit or Transfer to Trauma center Airway compromise, hypovolemic shock or CNS damage are the usual causes of early death in trauma care

 Traumatic Brain Injury (TBI): most important cause of death and disability in children  3000-4000 reported deaths annually from TBI  10 -15% of TBI in infants and children is severe  Inflicted (abusive) head trauma is a leading cause of severe TBI and contributes to poor outcome in age group 0-4 yrs  In inflicted head trauma, patients present late, with secondary insults such as apnea and seizures complicating management and outcome

 Rapid and complete physiologic resuscitation is essential to treatment of TBI in children  PICU management directed towards:    Optimizing substrate delivery and cerebral metabolism Preventing herniation, reducing ICP Prevention of secondary injury  Outcomes are better in ages 5-15yrs compared to adults with TBI

 Anatomy  Small oral cavities and large tongues and tonsils ▶ airway obstruction  Short, narrow trachea and anterior larynx, floppy epiglottis ▶ difficult intubation  Large occiput, causing flexed neck in supine position ▶ airway obstruction and unstable C-spine  Relatively large head ▶increased incidence and mortality of head trauma

 Anatomy  Increased flexibility ▶ SCIWORA more likely in children  Compliant Chest wall ▶ rib fractures less likely, but pulmonary contusions may still occur  Abdominal organs are less well protected by rib cage and in close proximity ▶ high risk of solid organ injury Summary: Smaller body mass, less fat, less connective tissue and incomplete bone mineralization ▶ greater force per unit body weight, even in trivial impacts

 Physiology  Thermoregulation: higher surface area relative to weight ▶ risk of hypothermia and hyperthermia  High metabolic rate ▶ increase in insensible losses and metabolic impact of hypoxia, transfusions (acidosis)  Vital Signs: Normal ranges vary with age Lower limit of Systolic BP: 2 x age (yrs) + 70mmHg  Shock compensation: Tachycardia and Increased SVR ▶ normal BP in spite of 30 - 40% blood volume loss

 Technical challenges  Vascular access may challenge: Intraosseous infusions are lifesaving in the unstable patient  Appropriate size equipment: urinary and vascular catheters, neck collars, airway adjuncts  Availability of personnel and resources required for the safe and skilled management of children must be assessed and disposition planned early to ensure good coutcomes

 Psychosocial factors  History-taking and examination may be complicated by child’s maturity level and inability to cooperate  Emotional responses to unfamiliar individuals and strange environment, pain, anxiety and perceived threat ▶ regressive behavior even in adolescents Non-accidental trauma must always be considered, reported and investigated

     Long Term Effect: Trauma threatens a child’s immediate survival and his/her long term quality of life Injuries may impact subsequent growth and development Up to 60% of children have residual personality changes 1 yr after multisystem injuries 50% have cognitive and physical delays Even minor injuries may cause prolonged cerebral or other organ disabilities

NTDB ® Annual Pediatric Report 2010 © American College of Surgeons 2010. All Rights Reserved Worldwide

NTDB ® Annual Pediatric Report 2010 © American College of Surgeons 2010. All Rights Reserved Worldwide

 First ICU in USA was at Johns Hopkins Hospital: a 3-bed unit for postoperative neurosurgical patients  Complexity of ICU care has increased over the past 30 years  Increasing evidence published of better outcomes for critically ill and injured patients managed by trained critical care personnel

 ICU patients, including trauma patients, are complex and often require the expertise of various medical and surgical specialists  The potentially conflicting recommendations must be integrated into a coordinated care plan for optimal patient care  Multidisciplinary intensivist-led model of care has been shown to have best patient outcomes

 There are various ICU models (>6,000 ICUs) in the US;  Closed – units: all patients are in the care of the intensivist  Open-units: patient can be admitted to ICU by any physicians of record with optional intensivist consultation  Semi-closed: Many surgical ICUs operate this model  Orders should be written only by the ICU team to avoid confusion of nursing staff  This model requires good communication between services

 The Organized ICU approach provides:  Continuous monitoring and care of patient 24-hrs/day     Lower patient: nurse ratios Care by specialized personnel with critical care training Specialized monitoring and therapeutic equipment Designated space  Benefits include:  Improved survival with fewer complications   Shorter ICU and hospital length of stay Improved resource utilization and reduced cost of care

The scientific evidence:  Pediatric Intensivist-directed model reduced mortality from 13.7% to 9.9% in level 1 PICU Santana et al, Crit Care Med Vol. 34, No 12 (Suppl.)  Care in intensivist-model ICUs is associated with large reduction in-hospital mortality, following trauma especially in the elderly Nathens et al, Ann Surg 2006;244

 In the Pediatric ICU, team members include  Critical care nurses  Respiratory therapists  Pharmacists  Social workers  Child Life specialists  Physical, Occupational and Speech therapist’ s  Chaplains  Physicians: surgeons, intensivists, hospitalists etc  Parents/Guardians  Every one has an important role, but there must be a “captain of the ship”

 Critical Care Nurses play a pivotal role in ICUs    Coordination of the care plan Interaction with parents, subspecialists and other care team members Coordinate the patient’s and family’s experience, providing a human touch in a high tech environment and especially when death is imminent  Clinical Pharmacists can significantly reduce medication errors and improve outcomes when included in ICU rounds

 Resistance to Change  Patient Control issues  Personal Egos  Reimbursement Concerns

    Each institution must define the roles of team members working in their ICU Team work model requires mutual respect, accountability and trust for each member of the team Effective communication among all members of team and the patient/family is crucial Use of clinical pathways jointly developed by members of the team enhances working relationship

   Definitions have been published by SCCM in 1992 and the Leapfrog Consortium An intensivist is a physician who is board certified in internal medicine, anesthesiology, surgery or pediatrics AND completed a critical care fellowship training in Critical care medicine The intensivist serves as primary care physician of the ICU and usually serves as administrator as well

The intensivist must establish rapport with multiple surgical and medical specialists and learn to coordinate and integrate their recommendations into the plan of care for the patient.

Considering the resources available at your institution, how could you improve the management and outcomes for Pediatric Trauma patients in your community?