Transcript 33. Pediatric Care

Pediatric Trauma
Pediatric Trauma
Lecture Objectives
ƒ Highlight the differences between
adult and pediatric trauma
management
ƒ Recognize some of subtleties of
pediatric trauma presentations
ƒ Use of the Pediatric Trauma Score
ƒ Recognize possible signs of child
abuse
Pediatric Trauma
Epidemiology
ƒ " After the first year of life, trauma is
the most serious pediatric health
problem in the U.S. "
ƒ 1/2 of pediatric deaths after the first
year of life are due to trauma
ƒ 22 million children (one in every 3) in
U.S. are injured each year
Pediatric Trauma
Most Common Etiologies
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Motor vehicle crashes*
Falls*
Child abuse
Fires
Penetrating trauma (higher incidence
in teenagers)
* Together account for 80
% of injuries
Pediatric Trauma : Unique Pediatric
Anatomic Features Compared to Adults
ƒ Head is disproportionately larger
ƒ Smaller body mass ; results in greater
force applied per unit area & higher
frequency of multiple organ injuries
ƒ Surface area to body weight ratio is higher
; results in faster heat loss & tendency
toward hypothermia
Pediatric Trauma : Pediatric
Anatomic Features Affecting
Trauma (cont.)
ƒ Child's skeleton is softer & less calcified
–Results in internal damage without overlying
bone fracture
–Presence of fractures implies higher energy
transfer
ƒ Mentally less developed
–Less able to understand questions &
procedures
ƒ Liver, spleen, bladder, & kidneys less
protected & more prone to injury
Pediatric Trauma : Airway Anatomic
Differences Compared to Adults
ƒ When supine, relatively larger head tends to flex neck &
obstruct the airway
ƒ Larynx is more anterior
ƒ Trachea is relatively short in length
–5 cm. in infants
–7 cm. by age 18 months
ƒ Narrowest portion of airway is subglottic region (this is why
uncuffed endotracheal tubes are preferred in children < 6 to
8 years old)
ƒ Infants are obligate nose breathers, and manifest
respiratory distress even if there is only partial nasal
obstruction
Optimal pediatric airway positioning
Pediatric Trauma
Airway Management Steps
ƒ Overall trauma care priorities are same as in adults
ƒ "Sniffing position" is best for airway maintenance
ƒ Start high flow oxygen early
ƒ Nasotracheal intubation usually should not be done in
children (because of the acute naso-pharyngeal angle, &
likelihood of hitting enlarged adenoids)
ƒ Pass endotracheal tube only 2 cm. past vocal cords
(under direct vision)
ƒ Ventilate gently to avoid lung overdistention and
pneumothorax
ƒ Needle cricothyroidostomy preferred to emergent
tracheostomy if possible
Pediatric Trauma
Size Selection for Endotracheal Tubes
ƒ Simplest rule is to use tube of same
diameter as patient's little (5th) finger
ƒ Or can use formula :
–Tube inner diameter = ( 16 + age in years)
divided by 4
(result is in mm.)
ƒ Use uncuffed tubes up to age 6 to 8 years
Pediatric Trauma
Rough Guidelines for Normal Vital Signs in Children
Age
(years)
Resp. Rate
(breaths per
min.)
Heart Rate
(beats per
min.)
Blood
Pressure
( mm Hg)
Urine
Output
( ml. per hr.)
120 to 160
80 / 40
10
0 to 1
40
1 to 5
30
120
100 / 60
20
6 to 10
20
100
110 / 70
30
14 to 18
80
120 / 80
> 30
> 10
Pediatric Trauma
Signs of Shock
ƒ Children tend to initially compensate for
shock with tachycardia and often maintain
their blood pressure until just preterminal
ƒ So hypotension in children can be a grave,
late sign of shock (usually represents > 40
% blood volume loss)
ƒ Change from tachycardia to bradycardia
may also be a grave, late sign
Pediatric Trauma
Signs of Shock
ƒ Early signs can be :
–Tachycardia ( can be > 180 to 200 beats / min.)
–Lethargy
–Irritability
–Confusion
–Combativeness
–Dulled response to pain
–Not paying attention to parents
–Delayed capillary refill
–Mottling of skin color
Pediatric Trauma
Blood Volume Considerations
ƒ Normal child blood volume = 80 ml/kg
–(8 % of body weight)
ƒ Shock ensues if 25 % of blood volume lost
ƒ So initial correction should be 25 % of 80
ml/kg = 20 ml/kg
ƒ Generally, systolic BP should be 80 + twice
age in years
ƒ Diastolic BP generally = 2/3 of systolic BP
Pediatric Trauma
Treatment of Shock
ƒ Start intraosseous line(s) if IV insertion difficult
ƒ Initial boluses X 1 or 2 of 20 cc/kg Lactated Ringers
ƒ Emergent transfusion initially with 10 cc/kg packed
red cell boluses if shock does not respond to the
Ringers, or if blood loss is ongoing
ƒ Important to warm IV fluids and blood to 37 to 39
degrees C before infusion (rapid infusion of room
temperature fluids can induce hypothermia)
ƒ Frequent reassessment is imperative
Pediatric Trauma
Signs of Correction of Shock
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Heart rate slows to < 130 bpm
Pulse pressure increases to > 20 mm Hg
Limbs become warmer and / or less mottled
Mental status / behavior improve
Urinary output increases to > 1 cc/kg/hr
Blood pressure increases to > 80 mm Hg systolic
Failure to correct shock with rapid fluid or blood
boluses implies need for emergency surgery to
control bleeding
Pediatric Trauma
Importance of Temperature Control
ƒ Children are at much greater risk of
developing hypothermia (body temp. < 35
degrees C)
ƒ Complications of hypothermia :
–Decreased mental status / coma
–Hypotension
–Arrhythmias
–Coagulopathy (often the worst complication)
–Ineffectiveness of medications
Pediatric Trauma
Prevention of Hypothermia
ƒ Warm the room ; keep room doors closed ; limit
traffic in & out of room
ƒ Heating lamps
ƒ Heating blanket
ƒ Warm IV fluids
ƒ Cover patient's scalp & as much of the rest of
the body as possible with warm blankets
ƒ Consider warm saline NG lavage if other
measures not adequate
Pediatric Trauma
Head Injury Considerations
ƒ Head injury :
–Comprises 80 % of blunt trauma in children
–Causes 80 to 90 % of trauma deaths
–Requires surgical intervention in only 6 % of
pediatric cases (30 % of adult cases)
–Diffuse cerebral edema more common & focal
intracranial hemorrhages less common
–Key treatments are restoration of blood
volume & prevention of hypoxia
Pediatric Trauma
Head Injury Considerations (cont.)
ƒ Rarely infants can become hypotensive from the
amount of blood loss into epidural or subgaleal
space
ƒ Bulging fontanelle may signify severe head injury :
almost always is indication for CT
ƒ Vomiting after head injury in children is common &
does not always indicate increased ICP
ƒ Once cerebral edema is identified, fluids should be
restricted (if the patient is not in shock from other
injuries)
Pediatric Trauma
Modified Glasgow Coma Scale (GCS)
ƒ Motor (M) and Eye Opening (E) scores are
same as for adults
ƒ Modified pediatric verbal (V) score :
–Smiles, follows objects, coos
–Cries but consolable
–Irritable, uncooperative, screams
–Lethargic, grunts
–No verbal noises
5
4
3
2
1
Pediatric Trauma
Neck Injury Considerations
ƒ Lax neck ligaments and larger proportional
head size contribute to severity of neck
injuries in children
ƒ Can have spinal cord injury without bony
C-spine injury
ƒ Preverbal children cannot communicate
presence of neck pain, so should have low
threshold to get C-spine films
Pediatric Trauma
Unique Cervical Spine X-ray Findings
ƒ Pseudosubluxation of C2 on C3 or C3 on C4
–Anterior longitudinal line is offset, but line at
base of spinous processes is not
ƒ Predental space may be up to 5 mm width (3
mm is upper limit of normal in adults)
ƒ Prevertebral space may falsely appear wide if
film is taken in expiration
ƒ Spinous process epiphyses may rememble
spinous process fractures
Pediatric Trauma
Chest and Abdominal Injuries
ƒ Diagnostic & treatment priorities are
basically same as in adults
ƒ Rib fractures represent greater
proportional degree of force to chest
ƒ Blunt aortic injuries are less common
than in adults but still can happen
Pediatric Trauma
Psychologic Considerations
ƒ Should routinely explain procedures to
children and be honest about potential
pain or discomfort
ƒ Should treat pain early once exam is
completed
ƒ Should address child's fears
ƒ If parents are mentally stable, allow
them to interact with child after
resuscitation
Pediatric Trauma
Child Abuse
ƒ Also termed non-accidental trauma (NAT) or
"child battering"
ƒ Refers to any deliberate injury inflicted by
child's caretaker
ƒ Recognition is important to prevent further
abuse ; may save child from fatal future injury
ƒ Any suspected case must be reported to child
protection authorities, & usually child must be
admitted to hospital for protection
Pediatric Trauma : Historical Features
That May Indicate Child Abuse
ƒ History not consistent with severity or type of
injury
ƒ Delay between time of injury & presentation
ƒ History of multiple prior injuries
ƒ Different history of injury from caretaker(s) and
/ or child
ƒ Caretaker reacts inappropriately to situation
ƒ Child is afraid of caretaker
Pediatric Trauma : Physical Exam Findings
Indicating Probable Child Abuse
ƒ Retinal hemorrhages ("shaken baby
syndrome")
ƒ Perioral, perineal, anal, or genital injuries
ƒ Bruises in different stages of development
and in areas not over bony prominences
ƒ Bizarre injuries such as cigarette burns, bite
or belt or rope marks
ƒ Sharply demarcated burns
Sharply demarcated inflicted scald burns
Pediatric Trauma : X-ray Findings
Indicating Possible Child Abuse
ƒ Multiple fractures in different stages of
healing
ƒ Multiple rib fractures
ƒ "Bucket handle" metaphyseal
fractures
ƒ Spiral fractures of long bones
Fractures caused by grabbing and twisting the child’s limb
Metaphyseal chip fracture of the radius caused by abuse
Multiple fractures due to abuse
Pediatric Trauma Score (PTS)
SCORE :
+2
+1
Minus 1
Weight
> 20 kg
10 to 20 kg
< 10 kg
Airway
Normal
Oral or Nasal
Airway
Intubated
> 90
50 to 90
Systolic Blood
Pressure (mm Hg)
Level of
Consciousness
Completely awake Obtunded or Loss
of consciousness
Open Wound
None
Minor
Fractures
None
Minor
< 50
Comatose
Major or
penetrating
Open or
multiple
Total score < 8 implies need to refer patient to pediatric
trauma center
Pediatric Trauma
Summary
ƒ Follow same priorities as in adults
ƒ Interpret vital signs carefully
ƒ Adjust fluid boluses and medication dosages to
the patient's weight
ƒ Act early to prevent hypothermia
ƒ Pay attention early to psychologic considerations
ƒ Be alert for child abuse as a cause for injuries
ƒ Assist in trauma prevention efforts for children