Transcript PEDIATRIC AMBULATORY NUMBERS

PEDIATRIC TRAUMA
STANDARDIZING CARE !/?
DAVID A. LISTMAN, MD
DIRECTOR
PEDIATRIC EMERGENCY MEDICINE
ST. BARNABAS HOSPITAL
LEARNING OBJECTIVES
• EPIDEMIOLOGY/ HISTORY
• ATLS
• PRIMARY SURVEY/RESUSCITATION
• SECONDARY SURVEY
• PEDIATRIC SPECIFIC ISSUES
• REFERENCES
EPIDEMIOLOGY/ HISTORY
• 5 million trauma related deaths worldwide in
2000
• Age <20 in US visits for injuries
• 10 million ED visits and
• > 10 million primary care office visits
• 300,000 pediatric hospitalizations annually
• 11,090 injury related pediatric deaths per
year
INTRODUCTION
• Trauma - # 1 cause of death in
children older than 1 year
• Effective initial resuscitation can
reduce mortality by 25-30% (Stafford et al
2004)
• National Pediatric Trauma Databank
2008 (≤ 19 yrs):
• 474 Trauma Centers (127 Level 1)
• 108,863 cases from 2007 record
NATIONAL PEDIATRIC TRAUMA
DATA BANK 2008
Incidents by Mechanism of Injury
35.00
30.00
Percent
25.00
20.00
15.00
10.00
5.00
0.00
Motor Vehicle
Traffic
Fall
Struck by,
Transport,
against
other
Mechanism of Injury
Firearm
Cut/pierce
NATIONAL PEDIATRIC TRAUMA
DATA BANK 2008
Case Fatality Rate by Mechanism of Injury
Case Fatality Rate (%)
14.00
12.00
10.00
8.00
6.00
4.00
2.00
0.00
M otor Vehicle
Traffic
Fall
Struck by,
Transport,
against
other
Mechanism of Injury
Firearm
Cut/pierce
MECHANISM OF INJURY
• Motor vehicle/traffic: 31.5% of injuries
• Increases at 14 years of age with a peak at
19
years of age
• Associated with largest number of hospital/ICU days
• 47% of all mortalities
• Falls: 26.6% of injuries
• Peak at 19 years
• 2nd highest hospital/ICU days
• 4.2% of all mortalities
• Firearms 5.7% of injuries
• Peak at 19 years
• 26% of all mortalities
TRI- MODAL DISTRIBUTION OF DEATHS
• First peak- within seconds to minutes of
injury
• Second Peak- within minutes to several hours
of injury
• Third Peak- days to weeks after the injury
TRI- MODAL DISTRIBUTION OF DEATHS
• First peak- within seconds to minutes of
injury
• Apnea- brain or spinal cord injury
• Rupture of the heart or great vessels
• Treatment- prevention
• Second Peak- within minutes to several hours
of injury
• Third Peak- days to weeks after the injury
TRI- MODAL DISTRIBUTION OF DEATHS
• First peak- within seconds to minutes of
injury
• Second Peak- within minutes to several hours
of injury
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Subdural and epidural hematomas
Hemopneumothorax
Ruptured spleen/ liver
Pelvis fx’s and other sources of major blood loss
Treatment- golden hour and ATLS
• Third Peak- days to weeks after the injury
TRI- MODAL DISTRIBUTION OF DEATHS
• First peak- within seconds to minutes of
injury
• Second Peak- within minutes to several hours
of injury
• Third Peak- days to weeks after the injury
• Sepsis
• Multi organ system failure
• Treatment- maximize care during preceding
stages, Hospital/ ICU care
Friday Sept 30, 2005
HOW DO WE IMPROVE SURVIVAL
DURING SECOND PEAK?
• Standardize evidence based best practices
• A 1976 crash of a private plane piloted by an
Orthopedic surgeon. His wife and children
were on board.
• Hospital care in rural Nebraska was
substandard
• 1978- 1st ATLS course to standardize initial
care of trauma patients by doctors who do
not manage major trauma regularly.
CASE
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4 year old female in stroller
Mother and stroller hit by car
Child ejected from stroller
No LOC
C-spine immobilized at scene
Minor contusions and abrasions of scalp
CASE
• 4 year old female in stroller
• Does patient require trauma evaluation?
• What if any radiologic workup should be
done?
Who requires trauma evaluation?
ACTIVATION OF TRAUMA TEAM
• Level of activation determined by
• Physiologic parameters
• Anatomic location/type of injury
• Mechanism of injury
• Options: code, alert, consultation
ACTIVATION OF TRAUMA TEAM
• Trauma Alert
• Anatomic
Significant injuries above and below the
diaphragm
• 2 or more proximal long bone fractures
• Burn of 15-30% BSA (second/third
degree burn)
• Traumatic amputation of limb proximal
to wrist or ankle
• Crush injury of torso
• Spinal injury with paralysis
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ACTIVATION OF TRAUMA TEAM
• Trauma Alert
• Mechanism
Ejection from automobile
Extrication > 20 minutes
Fatality of another passenger
Intrusion of vehicle by collision
Unrestrained passenger or vehicle
traveling > 20 mph
• Fall  20 feet
• Pedestrian struck at significant rate of
speed
• Lightning
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ACTIVATION OF TRAUMA TEAM
• Trauma Code
• Physiologic
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Cardiopulmonary arrest
Hypotention (by age)
Respiratory distress
Neurologic failure (GCS8)
ACTIVATION OF TRAUMA TEAM
• Trauma Code
• Anatomic
Penetrating wound to head, chest or
abdomen (prox to knees/ elbows)
• Burn > 30% BSA, inhalation airway
burn
• Major electrical injury
•
Who requires trauma evaluation?
• All patients with significant or potentially
significant injury should have a systematic
evaluation
Standard Precautions
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Cap
Gown
Gloves
Mask
Shoe covers
Goggles / face shield
INITIAL ASSESSMENT AND
MANAGEMENT GUIDELINES
• Primary Survey
• Airway
• Breathing
• Circulation
• A,B,C’s with special trauma concerns
INITIAL ASSESSMENT AND
MANAGEMENT GUIDELINES
• Primary Survey
• Airway maintenance, with cervical spine control
• Breathing, with special concern for
pneumothorax
• Circulation- control bleeding
• Disability- neurologic deficits
• Exposure- expose (examine) all of patient &
prevent hypothermia
• Resuscitation
• Oxygenation, airway management, ventilation
• Shock management
• Intubations – urinary tract, gastrointestinal tract
INITIAL ASSESSMENT AND
MANAGEMENT GUIDELINES
• As you perform the Primary Survey, stop
and intervene as needed
• Airway maintenance, with cervical spine control
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Airway positioning
Oxygen
Airway adjuncts- nasopharyngeal airway, oral
airway
Endotracheal intubation
Surgical Airway
CHIN LIFT MANEUVER
• Airway
obstruction by
tongue and
epiglottis
• Relief by
headtilt/chin-lift
Airway Management
Basic Techniques
Chin-lift Maneuver
Airway Management
Basic Techniques
Jaw-thrust Maneuver
INDICATIONS FOR
INTUBATION
• Shock
• Cardiac arrest
• Respiratory distress or failure
• Severe head injury
• GCS < 8
RAPID SEQUENCE
INTUBATION I
• Preoxygenate with 100% O2, insert IV lines,
attach cardiac/respiratory monitor
• Prepare equipment for possible emergency
surgical airway
• Inline manual immobilization of cervical spine
• Lidocaine 1.5 mg/kg (for elevated ICP)
• Atropine 0.02 mg/kg (minimum of 0.1 mg,
maximum 0.5 mg) to prevent bradycardia
• Begin Sellick maneuver (cricothyroid pressure to
prevent vomiting and aspiration)
RAPID SEQUENCE
INTUBATION II
• Paralyzing agent
• Rocuronium (0.6 – 1.0 mg/kg) or
• Vecuronium (0.1 mg/kg)
• Succinyl Choline (1mg/kg)
• Sedative agent: problem specific
• Hypotension: Etomidate (0.3 mg/kg)
• Head injury without hypotension: Thiopental
mg/kg)
• Severe asthma: Ketamine (1-2 mg/kg)
(3-5
• Oral intubation
• Confirm location of ET tube with end-tidal CO2
measurement
SURGICAL AIRWAY
• RARELY needed in children
• AVOID in children < 12 years due to
small target size and risk of damage to
surrounding structures (Reamy 2004)
• Indications: failure to intubate, apneic
with c-spine injury, facial trauma with
c-spine injury, severe facial and neck
trauma
• Needle cricothyroidotomy with needle
jet insufflation is a short term solution
SURGICAL AIRWAY
SURGICAL AIRWAY
COMPLICATIONS OF
SURGICAL AIRWAY
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Hemorrhage
Laceration of surrounding structures
Subcutaneous emphysema
Hypoxia after failed/prolonged attempts
Aspiration
Infection
Tracheal stenosis or cricoid cartilage
damage
INITIAL ASSESSMENT AND
MANAGEMENT GUIDELINES
• Primary Survey
• Breathing, with special concern for
pneumothorax
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If pneumothorax suspected and patient
unstable- needle decompression
If pneumothorax suspected and patient
stable- x-ray and chest tube
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Pt may require intubation and mechanical
ventilation
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Prevent hypoxemia
INITIAL ASSESSMENT AND
MANAGEMENT GUIDELINES
• Primary Survey
• Circulation- control bleeding
• Control Bleeding
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External- direct pressure
Bony- align and splint fractures
Internal- surgery/ interventional radiology
• Establish 2 large bore IV’s
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Crystalloid fluid
O neg blood
SHOCK I
• Early recognition of shock critical
• Tachycardia, pain, anxiety
• Decreased pulse pressure (<20mm Hg)
• Mottled skin, warm/cool extremities
• Most common cause is hypovolemic
shock due to hemorrhage
• BUT beware of:
• Spinal cord injury can cause distributive
shock
• Cardiac tamponade or tension pneumothorax
can cause obstructive shock
SHOCK II
• Minimum systolic BP: [70 + 2 (age in years)]
• Compensated shock
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Normal BP (may see orthostatic changes)
Tachycardia
Tachypnea
Bounding pulses, widened pulse pressure
Altered mental status
Warm and dry extremities
Delayed capillary refill (> 2 seconds)
• Uncompensated shock
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Hypotension
Severe tachypnea
Cold extremities
Capillary refill > 4 seconds
SHOCK
MANAGEMENT I
• 20cc/kg infused rapidly
• 0.9% NaCl or Lactated Ringer’s
solution
• 2 large bore IV’s
• If severe shock  10cc/kg type
specific or O- packed red blood cells
• Identify and treat source of bleeding
SHOCK
MANAGEMENT II
• Maintain urine output
2cc/kg/hour
• Monitor urine output with
catheter/feeding tube placed in
urethra
1-
• Contraindications to catheter placement
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Pelvic fracture
Blood at urethral meatus
Blood in the scrotum
VENOUS ACCESS
• 2 attempts peripheral vein
• Intraosseous needle
• Central line
• Complications: arrhythmias, thrombosis,
and embolism
• Locations
• Subclavian vein
• Femoral vein
• Jugular vein
• Cutdown
VENOUS ACCESS:
INTRAOSSEOUS NEEDLE
PLACEMENT
VENOUS ACCESS:
INTRAOSSEOUS NEEDLE
PLACEMENT
INITIAL ASSESSMENT AND
MANAGEMENT GUIDELINES
• Primary Survey
• Disability- neurologic deficits
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Level of consciousness- GCS
Glasgow Coma Scale
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Eye Opening
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Best Motor Response
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Spontaneous – 4
To speech – 3
To pain – 2
No Response – 1
Obeys -6
Localizes – 5
Withdraws – 4
Abnormal flexion – 3
Extension response – 2
No Response – 1
Verbal response
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Oriented – 5
Confused conversation – 4
Inappropriate words – 3
Incomprehensible sounds – 2
No response - 1
GLASCOW COMA SCORE
Glasgow Coma Scale
A strong predictor of outcome
13: mild brain injury
9-12: Moderate brain injury
< 8: Severe brain injury (coma)
INITIAL ASSESSMENT AND
MANAGEMENT GUIDELINES
• Primary Survey
• Exposure- expose (examine) all of patient &
prevent hypothermia
• Remove all clothing
• Roll Patient
• Examine axillae, groin, rectum
• Cover patient with warm blankets etc…
INITIAL ASSESSMENT AND MANAGEMENT
• Primary Survey
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Airway
Breathing
Circulation
Disability
Exposure
• Adjuncts to primary survey
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Labs
Cardiopulmonary Monitoring
Urinary and Gastric Catheters
X-rays- chest and pelvis
FAST/ DPL
SECONDARY SURVEY
• Begins after primary survey is
completed
• Resuscitation in place
• Vital signs improving
• Head/toe complete evaluation of
trauma patient
• Complete history/physical exam
• Reassessment of ALL vital signs
SECONDARY SURVEY HISTORY
• Obtain AMPLE history: allergies,
medications, past illnesses, last
meal, events related to injury
• Mechanism of injury – blunt vs
penetrating
• Motor vehicle/pedestrian: head
injury, traumatic aortic disruption,
abdominal visceral injuries,
fractured lower extremities/pelvis
• Injury due to burns/cold
INITIAL ASSESSMENT AND MANAGEMENT
• Secondary Survey- head to toe exam
• Head/ Face
• Neck/ C-spine
• Chest
• Abdomen
• Perineum
• Extremities/ Musculoskeletal
• Neurologic
• Adjuncts to secondary survey
INITIAL ASSESSMENT AND MANAGEMENT
• Secondary Survey- head to toe exam
• Adjuncts to secondary survey
• Additional studies that may include
X-rays of c-spine
CT scans of head, c-spine, chest,
abdomen/ pelvis
• Angiography
• Extremity x-rays
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UNIQUE PEDIATRIC
CHARACTERISTICS
• Compared to adults, children have…
• Smaller body mass to surface area ratio 
increased susceptibility to insensible fluid and
heat loss
• More elastic connective tissue; less rigid
skeleton protecting tightly packed thoracic and
abdominal structures
• Transmitted energy delivers greater
force/volume;  multisystem injuries
• Thoracic and spinal injuries rare
RESUSCITATION EQUIPMENT
FACILITIES/EQUIPMENT
REQUIREMENTS
• Designated “Trauma Area” with essential
pediatric equipment always ready
• Full range of pediatric endotracheal tubes, chest
tubes, blood drawing equipment –
angiocatheters, butterfly needles
• Heated air, warming blankets, heat lamps,
room temperature 85°F
• Ultrasound available for “Focused
Abdominal Thoracic Sonography for
Trauma” (FAST Scan)
• Broselow Tape
UNIQUE PEDIATRIC CHARACTERISTICS;
THERMOREGULATION
• Critical in children
• High evaporative heat loss/caloric
expenditure in children
• High body surface area/mass
• Little subcutaneous tissue
• Hypothermia can affect coagulation time,
CNS recovery
• Management focus
• Overhead heat lamps
• Warm room
• Warm fluids, blood products
PEDIATRIC AIRWAY
AIRWAY I
• Larger occiput results in neck flexion
with obstruction of the posterior
pharynx
• Larynx more anterior orienting
midface slightly superior and anterior
for protection of airway
• Need to protect cervical spine
• Large tongue may obstruct airway
AIRWAY II
• Cricoid cartilage at level of C6 in
adults, but C4 in children
• Cricoid ring – most narrow anatomic
site until 8 years of age
• Trachea is short – increases risk of
mainstem bronchial intubation
SCIWORA
• Spinal Cord Injury WithOut Radiologic
Abnormality
• Accounts for up to 2/3 of severe
cervical spine injuries in children
• Elasticity in cervical spine allows severe
spinal cord injury to occur
• Diagnosis of exclusion; MRI useful
• Watch for pseudosubluxation; anterior
displacement may be up to 4mm
Radiation Exposure
• Increasing concern in literature for
malignancies secondary radiation
exposure
• CNS lymphoma
• Thyroid cancers
• Unshielded radiation to genitals
Radiation Exposure
• Use of Abdomino-pelvic CT scans is
more common
• C-spine scanning done as a routine in
adults if scanning the head to replace
plain film
Radiation Exposure
• Pediatricians have championed injury
prevention
• “Kids are not small adults”
Radiation Exposure
• Attempt to decrease plain pelvis films
as routine part of trauma series
• Review of all blunt trauma 2002-2006
at SBH age </= 25
• 579 patients, 580 trauma evaluations
• 22 pelvis fractures (4%)
• Can we identify low risk for pelvis fx?
Radiation Exposure
• Can we identify low risk for pelvis fx?
• No lower extrem injury (NPV 98.3%)
• Normal Exam of pelvis (NPV 99%)
• No clinical need for abdomino-pelvic CT
(NPV 99.5%)
• If all three are absent (NPV 100%).
• Retrospectively applying criteria to study
group would eliminate 45% of pelvis xrays.
Wong et al. Pediatric Emerg Care in Publication
Radiation Exposure
• Trend in trauma care towards routine CT scan of cspine if head CT is to be done (replacing plain films).
• CT c-spine exposes the thyroid to 90-200 times the radiation
dose of plain films.
(Jimenez et al Pediatr. Radiol)
• Rate of c-spine injuries is very low in children 1-2%, 0.8 %
in SBH
• Ligamentous injuries are more common
• NEXUS criteria are valid in children
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Absence of midline tenderness
Not intoxicated
Normal level of alertness
Normal neurologic exam
Absence of painful distracting injury
• Develop new protocols for Peds specific concerns
SUMMARY
• Practice routines in ”Mock Code”
• Primary survey (ABCs, emergency
conditions), resuscitation
• Secondary survey
• Consider unique characteristics of children
(temperature requirements, anatomy)
• Prepare protocols, dedicated area, equipment
REFERENCES
• Yamamoto LG. Multiple trauma in a 2 year old.
Radiology Cases in Pediatric Emergency Medicine
Volume 7, Case 8.
http://www.pediatriconcall.com/fordoctor/
DiseasesandCondition/Multiple_Traumadia.asp
• DeRoss AL and Vane DW. Early evaluation and
resuscitation of the pediatric trauma patient. Sem
Pediatric Surgery. 13(2); May, 2004, 74-79.
• National Trauma Data Bank. Pediatric Section.
http://www.facs.org/trauma/ntdbpediatric2004.
pdf
• Stafford PW et al. Practical points in evaluation
and resuscitation of the injured child. Surg Clin
North Amer 82:273-301, 2002.
• Prince JS et al. Unusual seat belt injuries in
children. J Trauma 56(2);420-427, Feb 2004.
REFERENCES
• Arensman RM and Madonna MB. Initial
management and stabilization of pediatric trauma
patients
http//www.childsdoc.org/fall97/trauma/trauma.as
p
• Reamy RR and Losek JD. Pediatric trauma and initial
resuscitation. Jour South Carolina Med Assn
100(12); Dec 2004: 317-321.
• Advanced Trauma Life Support 6th edition. American
College of Surgeons, Chicago, Illinois, 1997.
• Nguyen D et al. Considerations in pediatric
trauma.http://www.emedicine.com/med/topic
3223.htm
• Ruddy RM and Fleisher G. An approach to the
injured child. In Textbook of Pediatric Emergency
Medicine, Fleisher G et al., Ed. Lippincott,
Philadelphia, 5th edition, 2006.
• Walzman M and Mooney DP. Major trauma. In
Textbook of Pediatric Emergency Medicine, Fleisher
G et al., Ed. Lippincott, Philadelphia, 5th edition,
2006.