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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
Ornge
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
Systemic Causes
(Extracranial)
hypotension
hypoxemia
anemia
hypo/hypercarbia
hyperthermia
hypo/hyperglycemia
hyponatremia
Neurologic Causes
(Intracranial)
raised ICP
herniation
vasospasm
hematoma
seizures
infection
hyperemia
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 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%
0
5
3
Other
10
Assault
20
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
18
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 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 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 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
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
X1
Arrival at primary hospital ~ 19:50
Tachycardic
Comatose – decorticate posturing –
GCS=5
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
ABC’s,
Needle decompression
Insert chest tube
Massive
hemothorax
ABC’s
Pleural decompression
Insert chest tube
Replace fluids
Uncommon Life-Threatening
Chest Injuries
Type
Flail chest
Initial Treatment
ABC’s
Positive-pressure ventilation
May require chest tube
Open pneumothorax
ABC’s
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
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 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