The Division of Paediatric Emergency Medicine Presents: Pediatric

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

CAUSES OF SECONDARY BRAIN INJURY Neurologic Causes Systemic Causes (Extracranial) hypotension hypoxemia anemia hypo/hypercarbia hyperthermia hypo/hyperglycemia hyponatremia (Intracranial) raised ICP herniation

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%

52.2% 20 0 5 3 Assault 10 Other 18

Winter Sport 25 ATV 40 Bike Alone Bike vs. Car

60 Fall 95 MVC 100 Ped Struck No. Of Patients

Mechanism Of Injury 94 80 52 10 Intra-Abdominal Injuries Bladder, 3 Pancreas, 5 Renal/Adrenal 16

Bowel & Mesentery, 14 Liver, 31 Spleen, 32 0 5 10 15 20

# 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

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 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

Massive hemothorax ABCs Pleural decompression Insert chest tube Replace fluids Uncommon Life-Threatening Chest Injuries Type Flail chest Initial Treatment

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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