The Division of Paediatric Emergency Medicine Presents: Pediatric
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
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 Multiple injury 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
vasospasm hematoma seizures infection hyperemia BREATHING FOR HEAD INJURED PATIENTS Controlled ventilation cerebral vasculature responds to PaCO2
maintain cerebral oxygenation PaO < 60 mm Hg associated with morbidity & mortality 2 Hyperventilation with caution hyperventilation decreases CBF & worsens outcome hyperventilation NOT recommended unless herniation goal is PaCO = 35 mmHg 2 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 45o & 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.
SickKids Patient Population April 1998 March 2001 Male Age Weight ISS Direct Referred 62.2% 8.6 years (std dev 4.5) 33.8 kg (std dev 18.1) 14 (std dev 11) 47.8%
# of Patients 25 30 35 Organ Requiring Surgical Intervention 3 Normal 2 Bladder
1 Spleen 2 Liver 10 Bowel 0 2
4 6 # of Patients 8 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 O2 applied IV access x 1 VITALS: HR=120, BP=105/69, RR=30, SATS=91% RAPID CARDIOPULMONARY ASSESSMENT A. B. C. D. E.
Airway and C-spine control Breathing Circulation and hemorrhage control Disability (rapid neurologic assessment) Exposure and Environmental control PREPARATION Assemble team - define roles physicians nurses RT radiology
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 ABCs 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% O2 Cardio, Resp, BP & Sat monitors 2 large bore IVs 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 Initial Treatment ABCs, Needle decompression Insert chest tube
ABCs Positive-pressure ventilation May require chest tube Open pneumothorax ABCs 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
Its 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 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 bodys 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 lifethreatening complications of major trauma in pediatric age group. QUESTIONS
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