Transcript TRAUMA Pediatric Critical Care Medicine Emory University Children’s Healthcare of Atlanta Epidemiology • 22 million children/yr • 1 on 4 suffer serious injury/year • More children.

TRAUMA
Pediatric Critical Care Medicine
Emory University
Children’s Healthcare of Atlanta
Epidemiology
• 22 million children/yr
• 1 on 4 suffer serious injury/year
• More children die from trauma than other causes combined
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Management
• Like any other critical patient: it’s all about the ABC
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Trauma
• ABCs
• Differences:
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Size
Injury pattern
Fluids
Surface area
Psychological
Long term effects
Trauma
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A= airway
B= breathing
C= circulation
D = D’Brain
E= electrolytes
F= fluids
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G= GI
H= heme
I= ID
J= Joints
K= kidney
Airway
• Usually secured in ER but occasional mental status or
respiratory effort changes & adjuncts necessary
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Airway Intervention
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Control of ventilation
Circulatory failure (shock)
Upper airway obstruction
Acute respiratory failure
Airway Intervention
• Size of tongue, oral cavity & upper
airway
• Position of the larynx
• Anatomy of the epiglottis
• Position of the vocal cords
• Narrowest portion of the airway
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B- breathing
• Trauma can lead to difficulty with both oxygenation &
ventilation
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B- breathing
• Pulmonary contusion
– Injury to lung parenchyma,
leading to edema & blood
collecting in alveolar spaces
– Poor gas exchange, increased
resistance & decreased compliance
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B- breathing
• Pulmonary contusions
– 50-60% w/ significant contusions will develop ARDS
– approximately 20% of blunt trauma patients with an Injury
Severity Score over 15
– is the most common chest injury in children
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B- breathing
• Pulmonary contusion
– Worsens over 24-48 hours
– Resolves 3-5 days
– Pneumonia is also a common complication of pulmonary contusion
– Care is supportive
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B- breathing
• Pneumothorax
– Pneumothorax is the
collection of air in the
pleural space. Air may
come from an injury to
the lung tissue, a
bronchial tear, or a
chest wall injury
allowing air to be
sucked in from the
outside
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B- breathing
• Pneumothorax
– Treatment depends on size
» Small pneumothorax can be watched
» Large require chest tube
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B- breathing
• Also other injuries may effect the way one controls the
breathing
– TBI keep PCO2 normal to low normal
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C- circulation
• Most often difficulty with BP is related to hypovolemia
– Volume , volume, volume
– Normal SBP 70 + (2x age)
– Normal MAP 50 + (2x age)
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C- circulation
• Unless blood loss no acute benefit of crystalloid over colloid
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C- circulation
• Cardiac contusion
– hypotension and arrhythmia
– diagnosis of a cardiac contusion and identification of patients at risk
remain a challenge
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C- circulation
• Cardiac tamponade
– caused by the accumulation of fluid in the pericardial space,
resulting in reduced ventricular filling and subsequent hemodynamic
compromise
• Cardiac tamponade
– Narrow pulse pressure
– increased jugular venous pressure, hypotension, and diminished
heart sounds
– Give volume
– Pericardiocentesis
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C- circulation
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C- circulation
• TBI
– Need to maintain CPP (age dependent)
» CPP= MAP-ICP
» May need pressors to maintain
• Most often Dopa or NE
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D= D’Brain
• Wide array of injuries from contusion and DAI to bleeds
• Intervention depends on injury
• Most common difficulties in PICU are AMS, ICP issues and
SZ
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D= D’Brain
• Traumatic seizures
– incidence of PTS for all types of head injuries is 2-2.5%
– increases to 5% in hospitalized neurosurgical patients
– Glasgow Coma Scale score <9 the incidence is 10-15% for adults and
30-35% for children
• Duration of treatment of traumatic seizures is a bit
controversial
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D= D’Brain
• ICP
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HOB 30 degrees and midline
Normal temp
Normal CO2
Good pain and sedation control
3% or mannitol
EVD
D= D’Brain – spinal cord
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Flexible inter spinous ligaments
Underdeveloped neck muscles
Poorly developed articulations
Anterior vertebral bodies
Flat facet joints
Large head to BSA
D= D’Brain – spinal cord
• Neurological injury represent 18% of pediatric injuries and
accounted for 23% of pediatric traumatic deaths (Durkin, et
al., 1998).
• However, spinal cord injury in young children is rare
accounting for only 5% of spinal cord injuries (Proctor et al.,
2002)
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D= D’Brain – spinal cord
• Predisposed to serious high cervical injuries
• Assume its presence in:
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Blunt injury above clavicle
Multisystem trauma
Significant injury - MVA, fall
Altered sensorium
D= D’Brain – spinal cord
• Kids less than 2 yrs more likely C1-C2
– As increase with age approach more adult pattern C5-C6
• Kids much more likely to have ligamentous injury
• Fractures involving the thoracolumbar spine in tend to
involve the junction between the thoracic and lumbar spine
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D= D’Brain – spinal cord
• spinal cord injury without radiographic abnormalities
• flexion/extension films of the cervical spine and CT scans are
also normal
• Cervical and thoracic spinal levels are injured with almost
equal frequency and lumbar levels are rarely involved
• Consider MRI
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D= D’Brain – spinal cord
• mismatching of elasticity response between the spinal
column and spinal cord is the major factor contributing to
the high incidence of SCIWORA injuries in young children
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D= D’Brain – spinal cord
• Steroids
– No good pediatric studies
– Evidence in adults now controversial and leading toward non use
(Spine. 26(24S) Supplement:S39-S46)
» Dosing if used: 30 mg/kg i.v. bolus within 8 hours followed by 5.4
mg/kg/hour for 24 hours
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D= D’Brain – spinal cord
• Children with spinal cord injury may have autonomic
instability and hypotension
– Fluid resuscitation
– pressors
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E= Electrolytes/Fluids
• Glucose
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w/TBI usually no dextrose
Maintain 80-140
Stress may cause hyperglycemia
Adult lit increase mortality w/ hyperglycemia
E= Electrolytes/Fluids
• Sodium
– If head injury use NS
– Keep high end of normal up to 160’s if having cerebral edema
• Calcium
– If cardiac contusion make sure with in normal range
– Low Calcium can promote arrhythmias
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GI
• Liver/Splenic Laceration
– most common injuries in blunt abdominal trauma
– Often supportive care
» Follow HCT q4-6 hours
» Transfuse HCT < 20-24 or hemodynamic instability
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GI
• Following the head and extremities, the abdomen is the third
most commonly injured anatomic region in children
• significant morbidity and may have a mortality rate as high
as 8.5%
• abdomen is the most common site of initially unrecognized
fatal injury in traumatized children
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GI
• Why more prone to abdominal injury
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child has thinner musculature
ribs are more flexible in the child
solid organs are comparatively larger in the child
fat content and more elastic attachments leading to
increased mobility
– bladder is more exposed to a direct impact to the lower
abdomen
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GI
Immediate Surgical Exploration
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Abdominal distention + “shock”
Transfusion requirement > 40 cc/kg
Peritonitis
Pneumoperitoneum
Bladder rupture
Heme
• Often trauma can lead to blood loss
• Use conservative management in giving blood
• If necessary consider losing whole blood and replacing
PRBC
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Heme
• If significant amount of PRBC (generally > 3 transfusions)
think about replacing factor and platelets
• If using the massive transfusion protocol this will happen
automatically
• Additionally Blood will cause chelation and may need to
give calcium
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Heme
• DIC
– Inappropriately accelerated systemic activation of coagulation
– Both the coagulation and the fibrinolytic systems are activated in
trauma
• DIC
– Widespread areas of tissue damage (particularly the brain).
» Head Injury common cause of DIC in infants and children
• Because of the high thromboplastin content of the brain
• Proportionately increased ratio of surface area of the head to total BSA.
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Heme
• DIC
– Replacement therapy is helpful until the primary
problem is controlled
» Fresh frozen plasma (FFP)
» Cryoprecipitate
» Platelet concentrates
– The use of heparin in DIC controversial and not
indicated in patients w/ trauma
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ID
• Routine use of antibiotics is not standard
• Occasionally with facial fractures will prophylactically treat
• Sepsis
– Sepsis occurred in 2% of all adult patients
– Respiratory tract infections are the most common cause
of sepsis
– Severity Score, Revised Trauma Score, lower admission
Glasgow Coma Scale score, and preexisting diseases as
significant independent predictors of sepsis
Critical Care Medicine. 32(11):2234-2240, November 2004
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ID
• Sepsis
– Injury Severity Score was associated with increased incidence of
sepsis
» Moderate (Injury Severity Score 15-29) and severe injury (Injury
Severity Score >=30) had a six-fold and 16-fold
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Joints
• Occult fractures are sometimes missed on initial survey
• Watch for signs of decreased movement and increased
swelling
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Kidney
• Renal contusions/lacerations
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Increased Creatinine
Bloody UOP
HTN
Usually supportive care
MODS/SIRS
• MODS is a clinical syndrome of progressive physiologic
dysfunction of organ systems
• Trauma high risk because of circulatory shock with tissue
hypoxemia, tissue injury, and infection
• Management requires control/elimination of the source of
inflammation, maintenance of tissue oxygenation,
nutritional/metabolic support, support for individual
organs, and effective pain control.
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MODS
• Preditors in adults
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Preexisting chronic illness
Acidosis
> 1L blood loss
ISS >24
Labs
» Lactate, transferrin, CRP
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