Transcript Training

Pediatric Trauma:
- An Overview
of the Problem Presented by:
Oklahoma EMSC Resource Center
Objectives:
Upon completion of this presentation the
participant will have:
 Increased awareness of issues specific to children
and trauma.

Improved skills in assessing pediatric trauma:
• Mechanisms of injury
Objectives: (Continued)
• Identify key components of the assessment process
• Recognize differences between adult and child
priorities
• Identify and avoid common errors in the care of the
traumatized pediatric patient
• Implement appropriate treatment plans
Nature of the “Beast”

Pediatrics account for 5-15% of total EMS calls.
• but up to 33% of these calls require ALS.

Trauma is 50% of pediatric EMS calls
• usually over 2 years old
• (more medical calls under 2.)

Injury is the leading cause of death in children
• MVC = 50%
Nature of the “Beast” cont’d

Up to 70% of major Pediatric trauma cases die
because of the severity of injury.
• NOT because of deficit in pre-hospital care

When a child is injured, the whole family is
injured too!
• >40% divorce rate within 1 year after a major
trauma.
General Principles:
Pediatric Trauma
 Priorities
are similar to adults
• All roads lead to the ABC (DE)’s
• Start with “A”, not the most obvious
General Principles (Continued)
 Children
have certain key differences
• size = different types of energy transfer
• metabolism
• ability to respond to words and give history
 History
of accident may be critical in
determining treatment plan
Physical Differences: Children

Larger Head
• More leverage on neck and to brain during impacts
• Forces neck into flexion while lying flat
– airway tends to buckle and close on adult spine board
without shoulder support

Shorter neck
• causes different injury patterns
• (C2-C4 more common injuries)
Physical Differences in Children
cont’d

Chest more pliable
• Pulmonary contusion more likely
• Diaphragm motion essential for ventilation
• Energy transmitted to chest organs

Abdominal organs less well protected.
• Liver is not covered by the rib cage.
• Less muscle mass to abdominal wall.
• Less Sub-Q tissue to absorb the injury.
Effects w/Size: Energy Transfer

Children are smaller
• more force per square inch of body.
• organs are closer together = multi-system injury is
the rule.

Children are softer (= more flexible, bouncy)
• Bones don’t break but instead pass on energy
• Internal organ damage without fractures is more
common.

Larger surface area to size ratio
• Lose heat more rapidly
Metabolic Differences in Kids

Children have a higher metabolic rate
•
•
•
•
Nearly twice as rapid O2 consumption
Need more blood flow
More frequent feedings
More fluid intake per size ratio
Metabolic Differences cont’d
 Children
“shock out” differently
• Children compensate better initially
– May show minimal signs and symptoms.
• Children have less reserves than adults
– Platinum half-hour in trauma resuscitation
– Rapid intervention critical
– Once reserves are exhausted,
Bad Things Happen
The Bad Things

Decompensation can be rapid
• A conscious, crying child can become pulseless and
apneic in less than 2 minutes.

Once decompensated, it may be too late
• Limited Reserves are gone; whole system collapses

Early recognition and intervention are critical
ASSESSMENT is the
for SURVIVAL!!!
Approaching the Scene

The first step in a cardiac arrest
or other critical situation is to:
Take your own pulse!!!
Prepare Yourselves
 Assign
•
•
•
•
roles ahead of time
History taker
Spine Management
Airway management
Equipment
On the Scene
SAFETY FIRST!!!!

BSI

Scene Hazards

Resources
On the Scene

Careful Attention to the
Initial assessment is
CRUCIAL
• Don’t be distracted by the
blood and screams
A quiet Kid should scare the `*^@*
out of you !!!!

If practical, keep the parents
with the child to help reduce
the child's fear.
Brilliance vs. Basics

For every “brilliant”
maneuver or diagnosis you
make which saves a life,
you’ll save 10 by just doing
a good, solid job; stay
focused on the basics in the
heat of the moment.
On the Scene cont’d
Initial Assessment
“Quickie ABC’s”
Pediatric
Assessment
Triangle
CIRCULATION
Appearance
STOP
Remember the
‘s
“...the biggest failure among the basic services is to call
for an ALS ground or air unit and ignore the basics while
they are waiting.”
“Proper basic airway management is often performed
inadequately if at all, apparently due to fear and panic.”
Theodore M. Barnett, M.D.
Children's Mercy Hospital, Kansas City, MO
Airway Assessment - LOOK
Is the patient breathing? How well?
 Respiratory Rate

• A slow or irregular respiratory rate in a child is an
OMINOUS SIGN
LOOK cont’d

Watch for the effort needed to breathe
• chest, neck, or abdominal muscle retractions
• flaring of the nostrils

Level of Awareness
• Agitated child could lack oxygen
• Obtunded/ gorked could be excessive CO2
• How does the child respond to its parents??
Assessment #2 - Listen

Observe the skin
– pale and clammy - ??shocky
– cyanosis - inadequate oxygen
 Listen
-
• anything loud is a good sign, airway-wise,but a
noisy airway may be partly obstructed
– Snoring, gurgling, crowing = upper airway
– Grunting
– Wheezing - lower airways
– Hoarseness - voicebox affected
RAPID ASSESSMENT and SUPPORT
[SIGNS OF DEEP DOO-DOO ]
Respiratory rate > 60
 Heart Rate

– Less than 5 years
– Over 5 years

<80 or >180 per minute
<60 or >160 per minute
Increased work of breathing
• retractions
nasal flaring
grunting
Cyanosis
 Altered level of consciousness

• Failure to recognize parents Lethargy Irritable
Airway w/C-Spine Protection
Failure to secure airway is major preventable
cause of death in Peds trauma
 Must protect spine

• Avoid flexing or extending neck
• Use jaw thrust to open airway

Suspect possible neck injury if:
• Any injury to head or above clavicles
• Ejected, thrown, rollover
• Unconscious trauma case
A=Airway w/C-spine Control

Unconscious patients often can’t protect their
airway
ClipArt
• Tongue most common obstruction
• Little airways are easily blocked by blood, teeth - have
rigid suction available
• Jaw thrust to open airway
• May need oral/nasal airway
– Do not rotate in children

Infants need to breathe through their noses• may need to suction out blood/mucus
Airway Adjuncts
Use of oral and nasal-pharyngeal airways. How to
insert (e.g do not invert OPA in younger child to
insert, and directing NPA directly posterior, not up
into nasal turbinates).
~ Also contraindications to OPA/NPA use.
If neck is OK, allow the child to be in position of
comfort - they open their own airway.
–Sniffing position is an option
Immobilization
I am a pediatric ICU fellow at Mass. General Hospital. I have been
teaching a one hour segment on pediatric trauma, and have found these to be some of the more
common questions or misconceptions:
1. Practical aspects of stabilizing a c-spine. Particularly in infants and
toddlers for whom there are no C-collars (because at this age they don't
have necks yet!). We have also emphasized the fact that two points are
necessary to stabilize a c-spine when doing in line stabilization. When
doing case scenarios with mannequins, I was surprised to see that in-line
stabilization was consistently provided by holding the patient at the ears,
allowing the body to continue to move relative to the position of the head.
I imagine this problem is greater with children who tend to kick and scream
and resist immobilization more. I have tried to emphasize that the
head/C-spine need to be immobilized relative to the body in order to be
effective. Most BLS providers have felt more comfortable doing this from
above the head and stabilizing against the shoulders, much as a c-collar
does. I have also demonstrated stabilizing with forearms against the chest,
hands around the head and occiput as a second option, particularly if they
are assisting a paramedic who can provide intubation or advanced airway
maneuvers.
Proper Immobilization
3. commercial cervical collars often do not fit, stabilization best
provided by smaller collar (if you have to choose one evil over another)
NO SOFT COLLARS !!!!!
4. when placed on an extrication board, most children under 5 years
will be in cervical flexion, unless you elevate their upper thoracic region
by 1 inch (say with a few towels)
[or use a peds board with head well.]
Infant immobilization
Immobilization
1) Keep infants in car seats unless treatment of injuries
requires removal (IV, ETT, BVM, control of
hemorrhage). If they survived the crash in an intact car
seat, they are usually better off to stay in it for the ride to
the hospital.
William E. Hauda, II, MD
Pediatric Emergency Medicine Fellow
Attending Emergency Medicine Physician
Fairfax Hospital, Falls Church, VA
B = Breathing


All children get Oxygen
May need to assist with bag-valve-mask
• Good mask seal is the KEY to bagging
– Proper fit of mask.
– Watch your fingers and your jaw thrust
• Two people should bag whenever possible


If the chest doesn’t rise, you ain’t doing it right
Avoid distending the stomach
• Cricoid pressure
• Easy does it
• Distended stomach = less room for air in lungs
Breathing advice
Having given this talk many times to EMS providers at George
WashingtonUniversity and through the Maryland PALS courses I can
offer a few hints.
Airway
1) Remember to mention all those anatomic differences, but stress the
large tongue. Good airway positioning is crucial.
2) All children can be ventilated with a bag valve mask. This most
common reasons that providers have difficulty is
a) partially obstructed airway because of poor positioning,
b) poor technique in getting the mask to seal,..
c) gastric distension from crying or vigorous bagging
4) All injured children get oxygen. Always. Everytime. No
exceptions.
Recognizing early signs of shock, and suspecting it sooner if
significant mechanism of injury
A few pediatric trauma messages for EMT's:
1. a little bleeding is a lot the smaller you are (I use e.g. of a 10 kg
child with a 30% hemorrhage = only 210 ml of blood, all too easily
obtained with a scalp lac & extremity fracture)
2. BP often maintained until very late in hemorrhage by young
patients because of their overactive vasoconstrictive responses
Good luck.
Tom Terndrup, MD
University Hospital
Director of Pediatric Emergency Medicine
Syracuse, N.Y.
What is shock??



Any abnormality of the circulation
which causes inadequate blood flow
or oxygen to the tissues of the body.
BLOOD LOSS most common type
of shock in trauma
Can occur from open bleeding,
internal bleeding, into fractures
Recognizing Possible Shock
Early signs can be subtle
• May be minimal signs with under 20% loss
 50% and over blood loss usually pulseless and
unconscious
 Any injured patient who is cool and tachycardic is
in shock until proven otherwise!!!

Shock recognition #2

Anxiety, fear, and cold weather can all mimic
early shock.
• Increased heart rate
• Decreased capillary refill
• Pale, cool extremities

Since the consequences of preventing
decompensated shock are so high, sometimes all
you have is the history.

Shock #3
First sign is loss of capillary refill
• Hold for 5; release for 3
• > 4 critical; > 2 but < 4 transition to critical

Next comes a decrease in pulse pressure
• (Systolic - diastolic)
• May feel this as a rapid, thready pulse

Drop in Blood Pressure is a late sign
• Systolic should be >[ 70 + 2(age in years)] but it rarely falls
below this until 25-30% blood loss

Altered mental status may be from shock
• Should recognize parents!!!!
• Shock may cause irritability or lethargy
C = Circulation and Shock Control


If cool, clammy, thready pulse, then
already over 25% of blood volume lost
External Bleeding - usually obvious
• Use a little gauze and a big finger

Internal Bleeding
• Mechanism of injury very important
• Physical findings not clear
• Need definitive treatment (IV’s Surgery…)
Stopping Bleeding







Failure to control external hemorrhage using direct
pressure. I have seen any number of cases, particularly
with scalp lacerations (but also extremity arterial
hemorrhages) where prehospital personnel apply
"mounds and mounds" of gauze. I have seen many
patients lose excessive amounts of blood into these
dressings, sometimes to the point of developing
hypotension. I like to emphasize the importance of
using a small amount of gauze, and firm continuous direct
pressure. I tell them to assign one
person to this job .
Michael A. Shapiro MD
Vice Chairman
Dept of Emergency Medicine
Women's Christian Association Hospital
Jamestown, NY 14701
Treating Shock
1) Hypotension means the child is in shock, but children are often in
shock without hypotension. An agitated child with cool skin is in
shock until proven otherwise at the hospital.
2) Any signs of shock require fluid administration. For Basic EMTs
this means rapid transport or meeting an ALS crew en route.
3) PASG or MAST are out, no good, dangerous in children, especially
if the abdominal compartment is inflated because of impingement
upon the diaphragm. The leg compartments can be used for
stabilizing femur fractures or air splints.
WORK QUICKLY
Let me say that I have been in EMS for three years, and have been a
paramedic since March. One of the strongest points people forget to about
trauma is time. (Platinum 10 Minutes, and the Golden Hour are the phrases
used to describe the `time criteria'.) In any trauma, pediatric or adult, the
ideal setting is for the patient to be in surgery within one hour (The Golden
Hour) of their injuries. It is stressed in our training that scene time be less
than 10 minutes to remain under the curtain of that hour.
I think that you need to stress that. In many medical settings, the
ambulance can do almost as much as an ED, but in trauma, the patient
needs more than what we can provide - namely surgery. Time is the most
critical factor in patient survival.
D = Disability


Down’s syndrome and large headed children may have
cervical spine injury from apparently minimal trauma.
Ideal immobilization is hard collar, full spine board with
soft spacers and head straps.
• Secure child across forehead, collar, shoulders and pelvis
• Make sure chest can rise!!
• May need blunt under torso under age 8 to prevent neck flexion
on the spine board.

Injured brains need adequate oxygen !
Quickie neuro eval - “D”
Assessment:
1) Reassess, reassess, reassess. The only way to know if your patient
is getting better or worse is to be diligent in evaluation.
2) Use the AVPU system (alert, responds to verbal, responds to pain,
unresponsive) in children. The GCS score is time consuming if
you're using your memory and doesn't "paint a picture" of the
patient. Avoid "lethargic" "semi-conscious" etc.. because everyone
has different meanings with these terms.
3) Remember what children of various stages are capable of doing (a
two year old may not talk yet, especially if frightened).
E = Exposure
Children lose heat quickly
 Keep them covered
 If you are comfortable, it’s probably
too cold for them

Exposure-
Staying Warm
5. Keeping the patient warm. (especially if this winter is at all like last
winter)
6. To emphasize the above point in burn victims. Cool wet dressings
may feel good on a small isolated burn, but with involvement of greater
body surface area, priorities become maintaining temperature and
preventing fluid loss which can be best accomplished with a dry sterile
dressing. Many of our local EMTs have asked about the new "gelpacks" that are available. To be honest, they sound great, but I have
little information about them specifically and am in the process of
reading up on them.
SAMPLE History for Trauma
S= Signs and Symptoms
 A= Allergies
 M = Medications currently taken

– Grab pill bottles
P = Pertinent Past/ Present Illnesses
 L = Last Meal
 E = Events/ environment related to the
injury

Always think about child abuse when you see an injured child.
. Many EMTs have asked about child abuse. They feel that those of us
in the hospital and ED are leaving them out in the cold, particularly at
smaller hospitals where they do not have a "Child protective services
team" who become involved. Many tell me they have heard comments
such as "Oh, good. You are filing the DSS report, so I don't have to".
This is something that needs to be addressed at individual hospitals and
ED's. Hopefully we can assure our EMS providers that they will not be
alone in filing and following up with these cases.
Common cause of injuries in children.
50% of second hospital visits for these children result in death
EMT awareness of signs and symptoms of abuse would help
identify cases.
Summary


The more critical the patient, the more important it is to focus on
the basics IN ORDER
• Airway
• Oxygen
• Good mask and bagging
• Proper immobilization
• Keep them warm
• Speed of transport is a key issue.
Assign roles ahead of time to keep responsibilities clear.
Rewards from the job
 Thank
you for your
time and attention
External rewards are scarce in this field.
Knowing you did right by your patients
Where to get more information

Other training sessions


* Andrew W. Stern
* NYS*DOH Emergency Medical Services
* 1 Commerce Plaza, Room #1126 # (518) 474-2219

Dr. Jane Ball 301-650-8066 peds EMS

• NERA 310-328-0720
• SafeKids 202-884-4993

Web sites
• Global Emergency Medicine Archives
• Website of Trauma
Resources






For anyone interested, the Pediatric Airway Management Project headed by Dr.
Marianne Gausche just completed a curriculum for a 2-day pediatric airway
management course for paramedics (ALS), and another course for EMT's
(BLS), complete with slides for lectures and videos. This is the curriculum used
to train all of LA and Orange county's paramedics airway management in
children by the project. The curriculum emphasizes many facets of ALS, not
just intubating.
The curriculum is available through the National EMSC Resource Alliance
(NERA) at 310-328-0720
Kelly D. Young, MD
Dept of Emergency Medicine
Harbor-UCLA Medical Center, Box 21
Fax: (310) 782-1763
1000 West Carson Street
Torrance, CA 90509 mail: [email protected]
Acknowledgements
This presentation has been adapted from a
powerpoint presentation developed by:
Bruce Nayowith MD
Ellenville Community Hospital ER
We gratefully acknowledge his willingness to share
this information with others.