pediatics

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PEDIATRIC TRAUMAPEDIATRIC TRAUMA

LTC Brenda Sowards, Chief Nurse

141st MDG

Washington Air National Guard

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EpidemiologyEpidemiology

Injuries are the number Injuries are the number one cause of death and one cause of death and disability in children disability in children over one year of ageover one year of age

Deaths from natural Deaths from natural causes have declined; causes have declined; not from traumatic not from traumatic injuryinjury

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Mechanisms of InjuryMechanisms of Injuryand Biomechanicsand Biomechanics

Toddler/preschooler: Fires, burns, drowning, struck Toddler/preschooler: Fires, burns, drowning, struck by vehicle, motor vehicle crashes, and child by vehicle, motor vehicle crashes, and child maltreatmentmaltreatment

School age: Struck by vehicle, motor vehicle School age: Struck by vehicle, motor vehicle crashes, drowning, fires, and burnscrashes, drowning, fires, and burns

Middle school age: Motor vehicle crashes, Middle school age: Motor vehicle crashes, pedestrian versus motor vehicle, homicidepedestrian versus motor vehicle, homicide

High school age: Motor vehicle crashes, homicide, High school age: Motor vehicle crashes, homicide, suicide, drowning, and poisoningsuicide, drowning, and poisoning

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Mechanisms of InjuryMechanisms of Injuryand Biomechanicsand Biomechanics

Motor vehicle crashesMotor vehicle crashes FallsFalls Lap belt complexLap belt complex Air bag injuriesAir bag injuries

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Child MaltreatmentChild Maltreatment

Associated with:Associated with: Head injuriesHead injuries BurnsBurns Abdominal injuriesAbdominal injuries Soft tissue injuriesSoft tissue injuries FracturesFractures

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Types of InjuriesTypes of Injuries

Blunt trauma: 80% Blunt trauma: 80% Order of frequencyOrder of frequency

HeadHead MusculoskeletalMusculoskeletal Abdomen, lAbdomen, liver and iver and

spleen most common spleen most common abdominal injuryabdominal injury

ThoraxThorax

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Anatomic and Physiologic DifferencesAnatomic and Physiologic Differences

Tongue is larger when compared to oral cavityTongue is larger when compared to oral cavity Airway cartilage is soft; smaller diameterAirway cartilage is soft; smaller diameter Infants are obligatory nose breathersInfants are obligatory nose breathers Larynx is higher and more anterior; trachea is shorterLarynx is higher and more anterior; trachea is shorter Cricoid cartilage is narrowest portion of trachea Cricoid cartilage is narrowest portion of trachea

(under 8 years)(under 8 years) Diaphragm is positioned more horizontally (until 12 Diaphragm is positioned more horizontally (until 12

years of age)years of age) Chest wall is more pliableChest wall is more pliable Lower glycogen storesLower glycogen stores 7

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CardiovascularCardiovascular

Blood pressure is an unreliable indicator of Blood pressure is an unreliable indicator of shockshock

Tachycardia is one of the first signs of shockTachycardia is one of the first signs of shock Blood volume depends on sizeBlood volume depends on size

90 ml/kg in the infant90 ml/kg in the infant 80 ml/kg in the child80 ml/kg in the child

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Temperature RegulationTemperature Regulation

Children have less effective thermoregulatory Children have less effective thermoregulatory mechanismmechanism

Greater body surface area to body massGreater body surface area to body mass Less subcutaneous tissueLess subcutaneous tissue Hypothermia is not well toleratedHypothermia is not well tolerated Infants and small children lose heat through Infants and small children lose heat through

their headstheir heads9

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Other Anatomic and Other Anatomic and Physiologic CharacteristicsPhysiologic Characteristics

Metabolic demands are twice that of adultsMetabolic demands are twice that of adults

Neck is short, fat, with weaker musclesNeck is short, fat, with weaker muscles

Fontanelles are open in infantsFontanelles are open in infants

Head is heavier and larger, cranium is thinner, Head is heavier and larger, cranium is thinner, occiput more prominentocciput more prominent

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Other Anatomic and Other Anatomic and Physiologic CharacteristicsPhysiologic Characteristics

White matter not well myelinated; sheaths White matter not well myelinated; sheaths around nerves less developedaround nerves less developed

Abdominal muscles are thinner, weakerAbdominal muscles are thinner, weaker

Liver is more anterior; kidneys more mobileLiver is more anterior; kidneys more mobile

Spine more flexible; extremities more pliableSpine more flexible; extremities more pliable11

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Nursing Care - AssessmentNursing Care - Assessment

HistoryHistory Who is the caregiver?Who is the caregiver? Is immunization status current?Is immunization status current? The child’s weight?The child’s weight? Mechanism of injury and associated factors?Mechanism of injury and associated factors?

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Nursing Care - Nursing Care - Physical AssessmentPhysical Assessment

InspectionInspection Assess breathing for nasal flaring and Assess breathing for nasal flaring and

intercostal retractionsintercostal retractions Assess circulation for pallor, mottled skin, or Assess circulation for pallor, mottled skin, or

differences in central versus peripheral colordifferences in central versus peripheral color Inspect abdomen for abrasions or ecchymosisInspect abdomen for abrasions or ecchymosis

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Nursing Care -Nursing Care -Physical AssessmentPhysical Assessment

AuscultationAuscultation Breath sounds: Auscultate at anterior Breath sounds: Auscultate at anterior

axillary linesaxillary lines Apical heart rate: Bradycardia is ominous Apical heart rate: Bradycardia is ominous

signsign Blood pressure: Hypotension is a late sign Blood pressure: Hypotension is a late sign

of shockof shock14

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Nursing Care -Nursing Care -Physical AssessmentPhysical Assessment

PalpationPalpation Fontanelles for fullness and bulgingFontanelles for fullness and bulging Central and peripheral pulsesCentral and peripheral pulses Capillary refillCapillary refill Abdomen for distentionAbdomen for distention Neurological assessment is tailored to the Neurological assessment is tailored to the

age and developmental stage of the childage and developmental stage of the child

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Pediatric Coma Scale ScorePediatric Coma Scale Score

Eye openingEye opening Best motor responseBest motor response Best verbal responseBest verbal response

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Diagnostic ProceduresDiagnostic Procedures

Radiographic StudiesRadiographic Studies Spinal Cord Injury Without Radiographic Spinal Cord Injury Without Radiographic

Abnormality (SCIWORA)Abnormality (SCIWORA) Extremity films may need comparison viewsExtremity films may need comparison views

Laboratory StudiesLaboratory Studies Other: Diagnostic peritoneal lavage (not Other: Diagnostic peritoneal lavage (not

commonly done)commonly done)

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Nursing DiagnosesNursing Diagnoses

Aspiration riskAspiration risk Impaired gas exchangeImpaired gas exchange Fluid volume deficitFluid volume deficit Altered tissue Altered tissue

perfusionperfusion HypothermiaHypothermia

Infection riskInfection risk PainPain Altered health Altered health

maintenancemaintenance Anxiety and fearAnxiety and fear PowerlessnessPowerlessness

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Planning and ImplementationPlanning and Implementation

Administer oxygen via a pediatric nonrebreather Administer oxygen via a pediatric nonrebreather maskmask

Assist with endotracheal intubationAssist with endotracheal intubation Verify endotracheal tube placementVerify endotracheal tube placement Stabilize and/or immobilize cervical spineStabilize and/or immobilize cervical spine Initiate CPR as indicatedInitiate CPR as indicated Insert a gastric tubeInsert a gastric tube

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Cannulate 2 veins with 22-gauge cathetersCannulate 2 veins with 22-gauge catheters Infuse warmed lactated Ringer’s solutionInfuse warmed lactated Ringer’s solution Infuse a bolus of 20 ml/kgInfuse a bolus of 20 ml/kg Reassess circulation Reassess circulation Give 2nd bolus, if indicatedGive 2nd bolus, if indicated

Anticipate blood replacementAnticipate blood replacement Red blood cells at 10 ml/kgRed blood cells at 10 ml/kg

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Site for Intraosseous InfusionSite for Intraosseous Infusion

If peripheral venous access If peripheral venous access cannot be established cannot be established within 3 attempts or 90 within 3 attempts or 90 seconds, initiate seconds, initiate intraosseous (IO) access intraosseous (IO) access with a 16- or 18-gauge bone with a 16- or 18-gauge bone marrow needlemarrow needle

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Intraosseous InfusionIntraosseous Infusion

In children under 6 In children under 6 years of age, use the years of age, use the proximal tibiaproximal tibia

Verify placement by Verify placement by aspiration of bone aspiration of bone marrowmarrow

Fluid, blood, and Fluid, blood, and medications can be medications can be infused infused

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Insert an indwelling catheterInsert an indwelling catheter Infants: 2 ml/kg/hrInfants: 2 ml/kg/hr Children: 1 ml/kg/hrChildren: 1 ml/kg/hr

Keep the child warmKeep the child warm Get a complete set of vital signs, including Get a complete set of vital signs, including

temperaturetemperature Obtain a pediatric consultObtain a pediatric consult

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Psychosocial supportPsychosocial support Utilize anxiety-reducing techniquesUtilize anxiety-reducing techniques Provide family members with information; include Provide family members with information; include

them in care; refer them to support programsthem in care; refer them to support programs Report suspected child maltreatmentReport suspected child maltreatment Prepare for operative intervention, admission, or Prepare for operative intervention, admission, or

transfer transfer Provide injury prevention teachingProvide injury prevention teaching

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Evaluation and Ongoing AssessmentEvaluation and Ongoing Assessment

MonitorMonitor Vital signsVital signs Urinary output Urinary output Level of anxiety of patient Level of anxiety of patient

and family and their ability and family and their ability to copeto cope

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pediatics

Health & Medicine