Transcript 10 month old boy falls down the stairs, landing on his head. No loss

Hot Topics in
Pediatric Trauma Care
Todd Nickoles
Manager, Pediatric Trauma and Injury Prevention
2
3
Disclosures
No disclosures or financial
conflicts of interest
4
Objectives
Cervical spine clearance
Traumatic brain injury
Concussion
Lap belt complex
Massive transfusion
Non-accidental trauma
Regional trauma system care
5
Case Study #1
10 month old boy falls down the stairs, landing on his head…
6
Pediatric TBI
Special considerations:

Large heads

Thinner pliable skull

Fontanels

Less myelination

Changes in cerebral blood flow
7
Brain injury
Primary injury
■ Diffuse vs focal
■ DAI, mTBI, EDH, SDH, SAH, IPH, etc.
Secondary injury
■ Edema and cell death following primary injury
Second insult
■ Hypotension, hypoxia, ICH, seizures, hyperthermia
*Goal of most of our interventions is to decrease secondary insult/injury
Optimize balance of energy in brain tissue
8
Case Study #1
10 month old boy falls down the stairs, landing on his head. No
loss of consciousness, cries immediately.
Mild (GCS 13-15)
• Do well; may have radiographic abnormalities
• May have headaches, seizures, vomiting
Moderate (GCS 9-12)
Severe (GCS 3-8)
• LOC, posturing, combative, abnormal neuro exam
9
Brain injury
Diffuse injuries:
mTBI
No damage
10
DAI
PCS
Severe
damage
PVS/Death
Brain injury
Linear
Stellate
Diastatic
Cranial
Depressed
Open vs Closed
Basilar
Focal Injuries
EDH
SDH
Intracranial
SAH/IVH
Parenchymal
11
Case Study #1
10 month old boy falls down the stairs, landing on his head. No
loss of consciousness, cries immediately. Remains fussy
through dinner and overnight. Brought to the ED. GCS 13…
12
From Contemporary Pediatrics
Case Study #1
10 month old boy falls down the stairs, landing on his head. No
loss of consciousness, cries immediately. Remains fussy
through dinner and overnight. Brought to the ED. GCS 13. CT
head shows bilateral subdural hematomas…
13
Cervical spine
Special considerations:

Large heads

Flexible joint capsules/ligaments

Weak muscles

Vertebral body wedging

Flat facets
14
Mechanisms of
injury
McQuillan, K., Von Rueden, K.,
Hartsock, R., Flynn, M., & Whalen,
E. (eds.). (2002). Trauma Nursing:
From Resuscitation Through
Rehabilitation. Philadelphia: W. B.
Saunders Company. Reprinted
with permission.
15
16
17
18
19
20
Case Study #1
10 month old boy falls down the stairs, landing on his head. No
loss of consciousness, cries immediately. Remains fussy
through dinner and overnight. Brought to the ED. GCS 13. CT
head shows bilateral subdural hematomas. CXR shows healed
rib fracture…
21
Non-accidental trauma
3 categories of “red flag” findings:

Medical History

Physical Exam

Radiological Exam
22
 Medical History:
•
Self report
•
No history of trauma
•
•
•
23
Inconsistent
story/injury/event
Not developmentally
capable
Lacking details
•
Delay in treatment/multiple
sites
•
Inappropriate parent/child
interaction
•
Signs of medical neglect
•
Caregiver under the
influence
 Physical exam:
•
Unusual bruise patterns
•
Inconsistent burns
•
Intra-oral injuries, frenulum
tears
•
Macrocephaly
•
Genital/anal injuries not
adequately explained
24
 Radiographic:
•
Metaphyseal fractures
(bucket-handle, corner,
chip)
•
Unexpected finding of
healing fracture
•
Complex skull
fractures/intracerebral
injuries not well explained
•
Rib fractures (esp. post)
•
Fractures in nonambulating children
•
Stages of brain injury
Multiple fractures
•
Any other significant injury
not well explained
•
25
Prevention?
27
28
Case Study #2
12 year old boy riding in back seat of midsize car…
29
Case Study #2
12 year old boy riding in back seat of midsize car, head on
collision with tree. Presents to ED via EMS with abrasions to
abdomen matching seat belt distribution.
30
Case Study #2
12 year old boy riding in back seat of midsize car, head on
collision with tree. Presents to ED via EMS with abrasions to
abdomen matching seat belt distribution.
31
Lap belt complex
32
Lap belt complex
Injury pattern:
Linear
ecchymosis
Chance
Hollow
33
fracture of lumbar spine
viscus (bowel > bladder), free air
Lap belt complex
Injury pattern:
Linear
ecchymosis
Chance
Hollow
34
fracture of lumbar spine
viscus (bowel > bladder), free air
Lap belt complex
Injury pattern:
Linear
ecchymosis
Chance
Hollow
35
fracture of lumbar spine
viscus disruption (bowel > bladder), free air
36
Case Study #2
12 year old boy riding in back seat of midsize car, head on
collision with tree. Presents to ED with abrasions to abdomen
matching seat belt distribution. To OR for repair of injuries.
37
Case Study #2
12 year old boy riding in back seat of midsize car, head on
collision with tree. Presents to ED with abrasions to abdomen
matching seat belt distribution. To OR for repair of injuries.
Hospital course- 5 separate operations to closure. Withdrawn,
poor eye contact, wakes up with nightmares…
38
Acute Stress Reaction
Findings:
•
Persistent frightening thoughts/memories
•
Nightmares, flashbacks, intrusive thoughts
•
Hyperarousal symptoms, sleep disturbances
•
Avoidance symptoms, detachment or dissociation
39
Case Study #2
12 year old boy riding in back seat of midsize car, head on
collision with tree. Presents to ED with abrasions to abdomen
matching seat belt distribution. To OR for repair of injuries.
Hospital course- 5 separate operations to closure. Withdrawn,
poor eye contact, wakes up with nightmares.
Discharged on PTD 24 to home.
40
Injury Prevention Opportunity?
41
42
43
Case Study #3
15 year old boy doing boy things
for 5 seconds…
44
Some physics…
Kinematics
Mechanical
First law of thermodynamics
Gravitational
Force = Weight X Speed2
2
Thermal
Blunt
Chemical
Crush
Penetrating
Transfers
of energy
Burn
45
Electrical
Blast
Radiant
Case Study #3
15 year old boy in a rodeo is stepped on by a bull. Initially
unconscious, transferred emergently to the local ED.
46
47
Solid organ injuries – liver & spleen
48
APSA guidelines for children with
isolated spleen or liver injury
CT grade
I
II
III
IV
ICU stay (d)
0
0
0
1
Hospital stay (d)
2
3
4
5
Predischarge imaging
none
none
none none
Postdischarge imaging
none none
none none
Activity restriction (wk)
49
3
4
5
6
Management goals
Serial H&H
Pain meds
Bowel rest
Bed rest
Prevent constipation
Incentive spirometry
50
Damage control surgery
51
Case Study #3
15 year old boy in a rodeo is stepped on by a bull. Initially
unconscious, transferred emergently to the local ED. Damage
control laparotomy, transfusion, air medical transport to Level 1
Trauma Center.
1 FFP
2 Platelets
TXA
52
53
Case Study #3
15 year old boy in a rodeo is stepped on by a bull. Initially
unconscious, transferred emergently to the local ED. Damage
control laparotomy, transfusion, air medical transport to Level 1
Trauma Center. On arrival, immediately back to OR. Massive
transfusion protocol initiated.
Arrival: BP 51/28, HR 94, Hgb 8.5, LA 9.8
54
Shock in pediatrics
Class I
Class II
Class III
Class IV
Blood loss
Up to 15%
15%–30%
30%–40%
≥40%
Pulse
Normal
Mild tachy.
Mod. tachy.
Severe tachy.
BP
Normal/
increased
Normal/
decreased
Decreased
Decreased
Mental
Status
Slightly
anxious
Mildly anxious Anxious/
confused
Confused/
lethargic
Fluid
Crystalloid
Crystalloid
Crystalloid &
blood
55
Crystalloid &
blood
Goals of massive transfusion
■
■
■
■
■
■
■
56
Accurate assessment of blood loss
Size-appropriate goals for resuscitation
Clear start and stop points
Patient safety – blood compatibility and availability
Early FFP to treat/prevent coagulopathy
Balanced ratio of products (1:1:1)
Provision of transfusion-related medications – Calcium,
Factor VIIa, TXA
Estimates of blood loss
Based on volume of blood product given to maintain
hemodynamic stability
■ Actual OR anticipated
Other relevant clinical parameters:
■ HR, BP, CVP
■ BD, lactate, pH
■ Hgb/Hct not a reliable indicator
57
Estimates of blood loss
At physician’s discretion, MTP can be initiated for either:
1.
Actual or anticipated transfusion of blood products AND
other IV fluids greater than the patient’s estimated blood
volume within 24 hour period
2.
Need for transfusion equal to half of the patient’s estimated
blood volume at one time
58
Estimates of blood loss
Age
Est blood volume
Premature infant
90-100 ml/kg
Term infant to 3 months
80-90 ml/kg
Children older than 3
months
70 ml/kg
Obese children
65 ml/kg
So…a 6 year old non-obese child, weighing 22 kg
1540 kg
22kg X 70ml/kg =__________
2 units of PRBC given so far, with fluid resuscitation…
MTP?
59
Children <10kg (order-specific)
Product
MTP Pack 1
MTP Pack 2
MTP Pack 3
MTP Pack 4
PRBC
25 ml/kg
25 ml/kg
25 ml/kg
25 ml/kg
FFP
20 ml/kg
20 ml/kg
20 ml/kg
20 ml/kg
PLT
10 ml/kg
10 ml/kg
10 ml/kg
10 ml/kg
Cryo.
4 ml/kg
4 ml/kg
4 ml/kg
4 ml/kg
Ca++?
rFVIIa?
Ca++?
Ca++?
62
Children 11-25 kg
Product
MTP Pack 1
MTP Pack 2
MTP Pack 3
MTP Pack 4
PRBC
2 Units
2 Units
2 Units
2 Units
FFP
2 Units
2 Units
2 Units
2 Units
PLT
1 Pack
1 Pack
1 Pack
1 Pack
Cryo.
5 Units
(1/2 bag)
5 Units
(1/2 bag)
5 Units
(1/2 bag)
5 Units
(1/2 bag)
Ca++?
rFVIIa?
Ca++?
Ca++?
63
Children 26 kg and up
Product
MTP Pack 1
MTP Pack 2
MTP Pack 3
MTP Pack 4
PRBC
4 Units
4 Units
4 Units
4 Units
FFP
4 Units
4 Units
4 Units
4 Units
PLT
1 Pack
1 Pack
1 Pack
1 Pack
Cryo.
10 Units
(1 bag)
10 Units
(1 bag)
10 Units
(1 bag)
10 Units
(1 bag)
Ca++?
rFVIIa?
Ca++?
Ca++?
64
Case Study #3
15 year old boy in a rodeo is stepped on by a bull. Initially
unconscious, transferred emergently to the local ED. Damage
control laparotomy, transfusion, air medical transport to Level 1
Trauma Center. On arrival, immediately back to OR. Massive
transfusion protocol initiated. Closure, to IR for embolization. To
ICU for supportive care. Elevated ventilator pressures and low
blood pressure.
65
Abdominal Compartment Syndrome
Def: the acute onset of tense abdominal distention with
associated renal, pulmonary and/or cardiovascular dysfunction
66
Abdominal Compartment Syndrome
Causes:

increased ICP

decreased preload & afterload

increased pulmonary pressures & resistance

renal dysfunction

gut dysfunction→ MODS
67
Intra-abdominal pressure
Pressure (mm Hg)
0-5
Normal
6-11
Minimal elevation, common finding in critically ill
12-15
Grade I – Mild to moderate IAH
16-20
Grade II – Moderate to severe IAH, watch for
ACS
21-25
Grade III – High risk of ACS
>25
68
Grade and Interpretation
Grade IV - ACS
Abdominal Compartment Syndrome
Treatments:
•
A high index of suspicion for ACS
•
Prophylactic decompression
•
Immediate decompression
•
Bladder pressure monitoring
69
Case Study #3
15 year old boy in a rodeo is stepped on by a bull. Initially
unconscious, transferred emergently to the local ED. Damage
control laparotomy, transfusion, air medical transport to Level 1
Trauma Center. On arrival, immediately back to OR. Massive
transfusion protocol initiated. Closure, to IR for embolization. To
ICU for supportive care. Elevated ventilator pressures and low
blood pressure. Decompression surgery. Discharged PTD #25.
70
Prevention?
71
72
Regionalized trauma care
73
Objectives

Cervical spine clearance

Traumatic brain injury

Concussion

Lap belt complex

Massive transfusion

Non-accidental trauma

Regional trauma system care
74
Thank You!
75
76