pediatric trauma management what you need to know thanks to: angelo mikrogianakis md, frcpc...
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Pediatric Trauma Management
What You Need To Know
Thanks to:Angelo Mikrogianakis MD, FRCPCPediatric Emergency Physician and Trauma Team LeaderEmergency Medicine & Critical CareThe Hospital for Sick ChildrenPediatric Patch PhysicianOrnge
The Division of Paediatric Emergency Medicine
Presents:
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 TRAUMAIsolated head Multiple
injury trauma
Airway compromise
Respiratory failure
Shock
Cardiopulmonary arrest
PEDIATRIC TRAUMA
Blunt injury is much more common than penetrating injuryHead (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 lossgreater 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 (Extracranial)
hypotensionhypoxemiaanemiahypo/hypercarbiahyperthermiahypo/hyperglycemiahyponatremia
Neurologic Causes (Intracranial)
raised ICPherniationvasospasmhematomaseizures infectionhyperemia
BREATHING FOR HEAD INJURED PATIENTS
Controlled ventilation cerebral vasculature responds to PaCO2
maintain cerebral oxygenation PaO2< 60 mm Hg associated with morbidity & mortality
Hyperventilation with caution hyperventilation decreases CBF & worsens outcome hyperventilation NOT recommended unless herniation goal is PaCO2 = 35 mmHg
MANAGEMENT OF RAISED ICP
Elevate HOB (unless BP) Medication
Mannitol: osmotic diuresis3% 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 injuryrib 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 trauma50% pulmonary contusions20% pneumothorax10% hemothorax
Canadian incidence is most likely less Chest tube sized to occupy most of the
intercostal space.
ANATOMY & PHYSIOLOGYABDOMEN
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 motionreduces 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 PopulationApril 1998 – March 2001
Male 62.2%Age 8.6 years (std dev 4.5)Weight 33.8 kg (std dev 18.1)ISS 14 (std dev 11)Direct 47.8%Referred 52.2%
95 94
52
2518
10 5 3 10
0
20
40
60
80
100No
. Of P
atie
nts
Ped
Stru
ck MVC Fa
llBi
keAl
one
Bike
vs. C
ar ATV
Win
ter
Spor
tAs
saul
t
Othe
r
Mechanism Of Injury
Spleen, 32
Liver, 31
Bowel & Mesentery, 14
Renal/Adrenal 16
Pancreas, 5
Bladder, 3
0 5 10 15 20 25 30 35
# of Patients
Intra-Abdominal Injuries
102
1
2
3
0 2 4 6 8 10
# of Patients
Bowel
Liver
Spleen
Bladder
Normal
Organ Requiring Surgical Intervention
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. 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
AIRWAYposition - jaw thrustsuction100% oxygenoral airwayensure C-spine is
immobilized
AIRWAY
Bag & mask ventilaton
C-spine precautions
Intubating Criteria
RSI meds
PRIMARY SURVEY
BREATHINGcolourchest movementretractionsbreath soundsassess work of
breathingoxygen saturations
PRIMARY SURVEYCIRCULATION
heart ratecapillary refillskin colour and
temperatureblood pressureperipheral pulsesorgan 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 - AlertV - Verbal stimulusP - Painful stimulusU - Unresponsive
PRIMARY SURVEY
EXPOSURE remove all clothes keep patient warm
warm blanketswarm fluidsoverhead warmerwarm 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 interactunfamiliar individualsstrange environmentemotional instabilityfear / pain / stressparents 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 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 TapeBolus 20 cc/kg NS rapidlyReassess
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
traumaespecially if hemodynamic compromise
Beware of unusual bleeding sitessubgaleal 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 - IntubatedNo maxillofacial trauma
B - Trachea midlineGood A/E bilaterallyNo 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
TypeTensionpneumothorax
Massivehemothorax
Initial TreatmentABC’s,Needle decompressionInsert chest tube
ABC’sPleural decompressionInsert chest tubeReplace fluids
Uncommon Life-Threatening Chest Injuries
Type
Flail chest
Open pneumothorax
Initial Treatment
ABC’s
Positive-pressure ventilation
May require chest tube
ABC’s
Occlusive dressing
Insert chest tube
Surface area
surface / volume ratiohighest in infantsdiminishes as child matures
thermal energy loss significanthypothermia may develop quicklymay be good for isolated head injuriesbad 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 developmentgrowth deformityabnormal development
children with severe multisystem trauma60% residual personality changes at 1 year50% show cognitive and physical handicaps
Long-term effects
other disabilitiessocialaffective learning
significant impact on family structurepersonality and emotional disturbances in 2/3
of uninjured siblingsstrain 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.
QUESTIONS