pediatric trauma case studies: assessment and intervention ankush gosain, md, phd, facs medical...
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Pediatric Trauma Case Studies:Assessment and Intervention
Ankush Gosain, MD, PhD, FACS
Medical Director, Pediatric Trauma Program
American Family Children’s Hospital
University of Wisconsin – Madison
06 December 2012
Disclosures
I do not have any relationships with commercial interests to disclose.
I do not intend to reference unlabeled or unapproved uses of drugs or products in my presentation.
Objectives
1. To understand the incidence and epidemiology of pediatric trauma.
2. To understand pediatric anatomic and physiologic factors relevant to pediatric trauma resuscitation.
3. To understand the current approach to management of pediatric solid organ injury
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Objectives
1. To understand the incidence and epidemiology of pediatric trauma.
2. To understand pediatric anatomic and physiologic factors relevant to pediatric trauma resuscitation.
3. To understand the current approach to management of pediatric solid organ injury
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Objectives
1. To understand the incidence and epidemiology of pediatric trauma.
2. To understand pediatric anatomic and physiologic factors relevant to pediatric trauma resuscitation.
3. To understand the current approach to management of pediatric solid organ injury
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Children are NOT just small adults
Anatomic considerations
Physiology responds differently to trauma
Injury patterns differ from adults
Anatomy - Airway
Larger head
Smaller jaw
Short, narrow airway
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Anatomy – Head/Spine
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Anatomy - Head
Soft cranium Open fontanelle –
easy estimate of fluid status/intracranial pressure
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Anatomy - Spine
Spine–SCIWORA
Flexible ligaments
Pseudo-subluxation
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Anatomy - Chest
Soft flexible chest wall
Weak muscles Significant force
required to fracture ribs
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Anatomy - Abdomen
Liver and spleen project farther below the costal margin
Thin abdominal wall
Multiple injuries common
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Physiology – Vital Signs
Different normal range
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Physiology
Blood volume
About 70-80 mL/Kg
Resuscitation/Blood Loss need to be Weight-based
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Physiology
Vigorous ability to compensate for blood loss – typically increased HR
May see very little change in vital signs until loss of 30% of intravascular volume
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Physiology
Sudden cardiovascular collapse
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Physiology – Blood Loss
System < 25% Loss 25-45% Loss >45% Loss
Cardiac Increased heart rate
Weak pulse, increased heart rate
Hypotension, tachycardia or bradycardia
CNS Lethargic, irritable
Change in level of consciousness, dulled response to pain
Comatose
Skin Cool, clammy Cyanotic, decreased capillary refill, cold extremities
Pale, cold
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Physiology - Thermoregulation
Higher body surface area to mass ratio
Thin skin Limited subcutaneous fat
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Physiology – Hypothermia
Keep them dry Keep them covered Keep the heat on Warmed fluids and blankets if
available
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Differences Between Adults and Children
Difference Impact
Large tongue Easy to obstruct airway
High anterior larynx Straight blade for intubation
Proportionately larger head Padding under torso
Proportionately larger head CNS/head injuries more common
Proportionately smaller torso Fewer chest and abdominal injuries
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Differences Between Adults and Children
Difference Impact
Body more compact Multiple injuries more common
Softer/thinner outer shell Underlying organ injury
Thin skin, less fat Hypothermia!
Vigorous compensatory response Sudden deterioration/arrest
Medications/fluids Broselow tape
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Injury Prevention
Helmets Window locks Seat belts/car seats Motorized vehicles
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Abuse/ Non-accidental trauma
About 7% of admissions to a pediatric trauma center
More severe injuries Younger Higher mortality (9%)
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NAT – History
Delay in care Repetitive injuries Discrepancies Inappropriate responses Medical neglect
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NAT – Physical Exam
Multicolored bruises Femur fractures Unusual scald/contact burns Bilateral subdural hematoma Retinal hemorrhage
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Response to abuse
Document the “story” Don’t ask too many questions Treat the trauma Report, report
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Objectives
1. To understand the incidence and epidemiology of pediatric trauma.
2. To understand pediatric anatomic and physiologic factors relevant to pediatric trauma resuscitation.
3. To understand the current approach to management of pediatric solid organ injury
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Non-operative management of splenic trauma
Prior to the 1960s – routine splenectomy for injury– “not a vital organ”
Risk of OPSS recognized– Non-operative management championed
in pediatric patients– Success led to adoption of practice by
adult trauma surgeons in the late 1990s
Spleen Injury: Non-operative Management
Hospital for Sick Children, Toronto– First proposed non-operative
management in 1948
Upadhyaya & Simpson. Surg Gynecol Obstet. 1968.
Douglas & Simpson. J Peds Surg. 1971.
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AAST Spleen Injury Scale
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Non-operative Management Rate
Splenic Salvage LOS
Mortality Transfusion Rate
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- Grade of injury per AAST criteria- Grade I/II – Bedrest overnight- Grade III-V – Bedrest 2 nights
- Night of bedrest = in hospital room by time of AM rounds, regardless of time of admission
- Ambulate, with Hgb drawn 4 hours later- Discharge if stable Hgb- Time of obs reset if transfusion given
- Resume normal activity in 6 weeks
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- 131 patients, 76 spleen, 59 liver- Mean grade of injury: 2.6 +/- 1.0- Mean bedrest 1.6 +/- 0.6 nights- Mean LOS 2.2 +/- 1.3 days- If APSA guidelines had been used, bedrest 3.6 +/- 1.1
- 24 pts transfused (18%)- 2 deaths – TBI, grade V liver injury
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AFCH Solid Organ Injury Protocol
Grade of injury determined by radiologic (attending pediatric radiologist) and/or surgical evaluation (attending pediatric trauma surgeon)
Bedrest definition – If the patient is in their room at the time of morning work rounds, regardless of time of admission, it isconsidered a night
Bedrest observation– Grade I & II = One night– Grades III - V = Two nights– If both organs are injured the highest grade is used
ICU admission only for hemodynamic change or other injuries requiring ICU monitoring (e.g. head injury)
Period of observation reset to time zero if a transfusion is needed Ambulation begins after bedrest period
– Patients that require ongoing hospitalization for other injuries are allowed to ambulate/move to chair using the protocol
Serum Hgb level checked 4 hours after ambulation Discharge allowed for patients with stable hgb levels and no indication for
ongoing hospital care Restriction from contact sports = 6 weeks
Objectives
1. To understand the incidence and epidemiology of pediatric trauma.
2. To understand pediatric anatomic and physiologic factors relevant to pediatric trauma resuscitation.
3. To understand the current approach to management of pediatric solid organ injury
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Ankush Gosain, MD, PhD, FACSMedical Director, Pediatric Trauma Program
[email protected](608) 263-9419 (office)
Questions?
Mary Anderson, RN, MSN, CEN, CPEN, SANE-AProgram Manager, Pediatric Trauma [email protected](608) 890-8328(office)