Transcript STFM Trauma Curriculum Pediatrics

Trauma - Pediatrics
Amanda S. Cuda, MD,MPH
Learning Objectives
• Recognize common mechanism of
pediatric trauma
• Demonstrate knowledge of ageappropriate physiology, assessment,
equipment, and dosing
• Demonstrate appropriate approach to
resuscitation in a pediatric trauma patient
Introduction: Pediatric Trauma
•
•
•
•
•
•
•
Leading cause of US mortality, ages 1-14
16 million ED visits per year
15,000 deaths
45,000 permanent disability, brain injury
2:1 male to female ratio
Blunt trauma 90%, penetrating trauma 10%
Falls, MVA, pedestrian, bicycle, assault
(National Pediatric Trauma Registry, 1999)
Peitzman, 2008)
Age Appropriate Assessment
•
•
•
•
•
Age and weight
Vital Signs
Mental Status
Skin
Urine output
• Table summarizing
age specific vital
signs from ATLS or
CHOP Benedum
Pediatric Trauma
Program, Field
Reference (need
permission)
Assessment in Peds Patients
• Hypoventilation, hypoxia cause cardiorespiratory
arrest
• Poor end organ perfusion evidenced by
hypotension, but also decreased cap refill,
mental status change, and low urinary output
• GMC and GCS equivalent predictive for injury
(Cicero, 2013)
Age Appropriate Equipment
•
•
•
•
Age and weight
ET tube
Foley
Broselow tape
• Table summarizing
age specific
equipment from
CHOP Benedum
Pediatric Trauma
Program, Field
Reference or ATLS
Age-appropriate Dosing
•
•
•
•
Age and Weight
Rapid Sequence Intubation algorithm
PediStat
Broselow Tape
Pediatric Resuscitation Approach
• Approach airway—
• Be prepared to secure airway with RSI
• Enable patient to breath in sniffing position
while awaiting transport
• Bottom line– Get the airway if it can’t wait
Pediatric Resuscitation Approach
• Assess breathing–
• Assess circulation–
•
•
•
•
Apply direct pressure to bleeding wounds
Fluid resuscitation:
Type and crossmatch for multiple units
Place large bore IVs, tibial intraosseous (IO)
Diagnostic evaluation: imaging
• Proceed to imaging if any suspicion of
occult injury
• Pediatric small frame more frequent
multisystem injury
Diagnostic evaluation: lab
• Proceed to imaging if any suspicion
whatsoever of occult injury
• Airway compromise or other injuries may
have delayed presentation
Additional Management
• Early consultation with surgeon
• Transport to pediatric trauma center when
possible
Summary
• Similar approach to rescusitation in adults
• Age appropriate assessment, equipment,
and dosing
• Remember differences in cardiovascular
response
References
1. Cicero MX, Cross KP. Predictive value of
initial Glasgow Coma scale score in
pediatric trauma patients. Pediatric
Emergency Care, 29(1):43-38, 2013.
2. American College of Surgeons, Advanced
Trauma Life Support for Doctors (Student
Manual), 8th Edition, Oct 2008.
3. Peitzman A. The Trauma Manual: Trauma
and Acute Care Surgery, 3rd Edition, 2008.
Lippincott Williams & Wilkins.
Simulation Training Assessment
Tool (STAT)– Pediatric Trauma
Amanda Cuda, MPH, MD
Simulation Training Assessment Tool (STAT)– Pediatric Trauma
SCENARIO ALGORITHM
SET UP
•Trauma room w/ IV, O2, trauma equip
•PediaSim or equivalent w/ bruising
moulage to abdomen & bleeding from
scalp, lying flat , in c collar and on back
board
•Broselow tape and bags/cart, Airway
equip, RSI drugs
•Bandages
Date:
CRITICAL
ACTIONS
Lead resuscitation at
bedside w/ clear
coms
PRIMARY SURVEY
•A- Slow breathing, no obvious
obstruction, making moaning noises and
occasionally speaking coherently
•B—BS CTA, no chest injuries
•C– BP100/80 HR120 RR12 POX92
•D– PERRL, not moving extremities
when arrives, speaking but not coherent
•E– Scalp laceration with some
surrounding swelling of scalp; also has
abdominal bruising in seat belt
distribution
Assess breathing –
clear BS, CXR
SECONDARY SURVEY
Patient with no other injuries
Finish safety net–
incl IV x 2 contra to
inj, T&C multi units,
post-intub CXR with
RT, possible abx
DISPOSITION
Surgeon arrives after intubation and IVF
resusitation and secondary survey.
Learner(s):
Learning Objectives:
1. Recognize common mechanism of pediatric trauma
2. Demonstrate knowledge of age-appropriate physiology, assessment, equipment, and dosing
3. Demonstrate appropriate approach to resuscitation in a pediatric trauma patient
4. Demonstrate proper placement of tibial IO in pediatric patient.
PRE ARRIVAL
•As a family physician, you are working
in a community hospital ER
•6 yo male; EMS s/p MVA, restrained in
backseat, booster/seat belt, has
bleeding scalp, decreased mental status,
and abdominal bruising, IV established
•VSS BP100/50 HR120 RR12 POX92%
LABS & IMAGES
POC labs WNL. Post intubation CXR
shows tube in adequate position
Instructor(s):
MS
2
3
4
SUSTAIN
IMPROVE
Assess airway–
GCS<8, head injury
Proceed to RSI
Assess circulation –
confirm
hypovolemia, begin
IVF resuscitation
Vital signs now 80/40, HR 150; discover after RSI that IV is no longer functioning. If order fluids prior to RSI,
then IV does not function. Process to tibial IO placement.
Assess D, E and
Secondary Survey
Disposition to
medevac
TOTAL
Debriefing Notes





Approach to pediatric resuscitation is the same as
for adults. Review each step and unique aspects
of pediatric care
 Airway
 Breathing
 Circulation
 Disoability
Age appropriate decision making must be done.
Use Broselow tape. .
In approaching imaging, remember multisystem
trauma. Head CT – non contrast, abdominal CT –
with and without contrast if possilble
Early consultation with surgical trauma team
Remember to start broad spectrum antibiotics
promptly if aerodigestive injury is suspected.



Review age appropriate vital signs, equipment
choice, and dosing of medications–
Beware—injuries in one area will often have other
injuries.
This case is a multisystem injury with decreased
mental status and compromised airway. Head or
abdominal trauma, if present and with the
following signs indicate direct disposition to OR
and include—
 Unstable vital signs
 Active bleeding
 Hematemesis or hemoptysis
 Large, expanding, or pulsatile hematoma
 Neurologic deficit
Additional Instructor Notes
Case Synopsis



6 yo male suffered a mild traumatic brain injury and abdominal contusion as a result of being a restrained passenger in a high
velocity (55mph) MVA. He has decreased mental status and it has worsened since EMS arrival on scene and through
transport to hospital. He is able to maintain airway prior to arrival but on arrival, the pt is somnolent and should be intubated
quickly with RSI drugs using IV that was placed by EMS. Could consider requirement of intraosseous placement with IV that
now can’t flush or IO may be attempted immediately. Once IO and intubation are performed, VS will immediately stabilize.
Learner must continue through the ABCs and the rest of the critical actions.
Consider telling the learner that the patient is moving around if post-RSI sedation not given by the end of the case.
If intubation and fluid resuscitation are not performed, the patient will die in about 5 minutes with falling Pox and other vital
signs ending in asystolic arrest. The patient cannot be saved if this occurs.
Personnel and Roles




Instructor—Introduces case, switches to “EMS” as case begins, provides ancillary data as requested and plays
“Neurosurgeon” at the end of the case
Assistant (may be resident) —Acts voice of patient, manages respiratory distress in PediSIM and manages monitor (tell
Primary Learner that the assistant will be the patient’s voice prior to entry)
Primary learner (resident)—Is the responding doctor. May lead the Trauma Team response or act as sole provider, depending
on how your institution manages trauma
Secondary learners (residents)– Prompt primary learner to assign roles, e.g. Airway, Procedures, Nursing etc prior to
beginning case.
Props/Supply Checklist




PediSIM w/ ability to intubate and perform tibial IO
Moulage for MVA with blood on scalp with laceration and bruising of the abdomen.
Airway equipment–Broselow bag/tape, aryngoscope, suction, BMV, RSI drugs
IO set – use IO that is available in your organization.
Supporting Stimuli



EMS Run Sheet– give to learner at start of case
Point of care labs– give to learner only if ordered, after credible time lapse
Post intubation CXR– give to learner only if ordered, after credible time lapse
EMS Run Sheet
• 6 yo male s/p MVA with bleeding scalp,
decreased mental status, abdominal
bruising
•
•
•
•
BP 100/50
HR 120
RR 12
POX 92%
Point of Care Labs
•
•
•
•
•
•
•
•
•
Sodium: 140
Potassium: 3.8
Chloride: 106
TCo2: 25
BUN: 15
Creatinine: 0.9
Glucose: 100
Hemoglobin 11.4
Hematocrit 32.5
• Need peds non con head CT that is
normal
• Need peds abdominal CT that is also
normal