pediatric trauma james huffman, pgy-2 august 2, 2007 special thanks to dr. vincent grant & dr....
TRANSCRIPT
Pediatric Trauma
James Huffman, PGY-2August 2, 2007
Special thanks to Dr. Vincent Grant& Dr. Katharine Smart
Objectives
1. Identify the unique characteristics of
the child as a trauma patient:
Types and patterns of injury
Anatomic and physiologic differences from adults
2. Discuss primary management of critical injuries in children
Airway management
Shock / Fluids
Head injuries
Outline
1. Pediatric-specific trauma issues
2. Assessment/Management Pediatric Assessment Triangle
Primary
ABCDEF
Secondary
Adjuvant testing
3. Current status in Calgary
Short Snapper: Name the condition
Tachypnea Hypoxemia Hypotension +/- JVD +/- absent breath
sounds
Tension Pneumothorax
Case #1
5yo male MVC – rollover Ejected, found 6 meters from vehicle 120, 92/58, 362, 26, 94% on room air GCS=10 (E2, V3, M5)
What are some special considerations in pediatric trauma?
Special Considerations“Not just little adults”
pre-injury level of functioning mechanism of injury size and shape skeleton surface area psychologic status long-term effects equipment
Special Considerations: Mechanism
Blunt (80%) Head injuries very common (55%)
Apnea, hypoventilation and hypoxia occur 5 times more commonly than hypovolemia and hypotension in seriously injured children (ATLS Manual, 7th Edition)
Aggressive management of airway and breathing
Consider non-accidental trauma Up to ~35% of trauma deaths
Special Considerations: Size and Shape
Greater force per unit body area Less body fat less connective tissue Organs at close proximity to surface
High frequency of multiple organ injuries
Special Considerations: Size and Shape
Larger head prone to head injuries major source of heat loss prominent occiput cranial bones thinner
Shorter neck Supports a relatively larger mass More frequently disrupt upper cervical
vertebrae or their ligamentous attachments SCIWORA = 50% of kids with SCI
Special Considerations: Size and Shape
Larynx more cephalad / anterior
Epiglottis tilted at 45 “floppy”
Cricoid cartilage narrowest part of airway in children < 8 years old
Special Considerations: Size and Shape
Thorax More pliable Ribs cartilaginous and
flexible Less overlying muscle
and fat
Mobile mediastinum
Contusions (common) Fractures (rare)
Blunt force transmitted to underlying tissues
Special Considerations: Size and Shape
Abdomen Less protected by ribs and muscles Organs less insulated by fat
1) Small forces may cause significant injury 2) Significant injuries with minimal external
evidence
Special Considerations: Skeleton
Incomplete calcification Growth centers – weak point Salter-Harris classification More pliable
Organ damage without overlying bony fractures
Special Considerations: Surface Area
Surface area / volume ratio Highest at birth Decreases with age
Thermal energy loss significant Hypothermia may develop quickly
Good for head-injured patients Bad for hypotensive patients
Special Considerations: Psychological Status
Impaired ability to interact Unfamiliar individuals Strange environment Emotional instability Fear / pain / stress Parents often unavailable
History taking and cooperation can be difficult
Special Considerations: Long-term Effects
Injury may impact growth / development 60% of children with severe, multisystem
trauma have residual personality changes at 1 year*
50% show cognitive or physical handicaps* Impact on family structure
* ATLS Manual, 7th Edition
Special Considerations: Family Presence
Not just “one patient”
Advantages availability of historical data comfort to child
Disadvantages may be a distraction may influence care of patient
Special Considerations: Family Presence
Facilitate whenever possible
Important to have designated support person to stay with family at all times
Encourage family member to talk to and touch child
Primary survey should be completed prior to family’s arrival in trauma bay
Special Considerations: Equipment
What do you want to have ready for the arrival of our patient?
Special Considerations: Equipment
Multiple sizes of everything
Broselow™ Equipment systems
Broselow™ Measuring Tape
Resuscitation Guides
Back to the case:
Are there any tools you know of to rapidly assess how sick this child is?
PEDIATRIC
ASSESSMENT
TRIANGLE
Pediatric Assessment Triangle
Circulation to SkinCirculation to Skin
AppearanceAppearance Work ofWork of BreathingBreathing
The Triangle focuses on three aspects of physical assessment that reflect:
Severity of illness or injury Urgency of intervention
Pediatric Assessment Triangle
Pediatric Assessment Triangle
Appearance Mental status and muscle tone Suggests level of consciousness
Work of Breathing Increased, laboured, or decreased Indicates the adequacy of ventilation and
oxygenation
Circulation Skin and mucous membrane colour Reflects the adequacy of oxygenation and
perfusion
Our patient:
Appearance: Abnormal (↓ LOC, ↓ tone)
Work of Breathing: Normal
Circulation: Abnormal (Pallor, some mild mottling)
Primary Survey
A – Airway with C-spine protection
B – Breathing
C – Circulation and hemorrhage control
D – Disability / neurologic screening exam
E – Exposure and environmental control
F – Films / fluids / foley
Primary Survey: Airway
Anatomy: Disproportion between size of cranium and midface
passive c-spine flexion Needs padding under shoulders/torso Relatively large soft tissues Funnel-shaped larynx, more cephalad and anterior Epiglottis Short trachea
Primary Survey: Airway
Assessment: Does the child have a patent airway?
Blood, emesis, maxillofacial trauma, neck trauma Assess visually, auscultation (stridor)
Can the child protect their airway? Level of consciousness
Primary Survey: Level of consciousness
“AVPU”
A – alert V – voice P – pain U – unresponsive
in general GCS < 8
Primary Survey: Airway / C-spine
Always suspect a c-spine injury
Immobilize all patients Rigid collar
Rolls / sandbags
In-line stabilization
Primary Survey: Airway
Management: Jaw thrust – “sniffing position” Clear debris/secretions
Oxygen
Oral airway *insertion technique
ET intubation
Needle cricothyrotomy
Use the Broselow Tape!!
Case: Continued
132, 84/56, 362, 26, 90% on room air No obvious facial trauma, no debris in airway No stridor
?Responding to verbal commands and definitely to painful stimuli
How do you assess his breathing?
Primary Survey: Breathing
Is the child able to:
a) Ventilate? (exchange CO2)
b) Oxygenate? (exchange O2)
*Hypoxia is the most common cause of cardiac arrest in the child
Primary Survey: Breathing
Assessment: Spontaneous respirations Tachypnea / work of breathing Breath sounds Cyanosis SaO2
Chest symmetry Tracheal deviation Neck vein distention Changes in mental status
Primary Survey: Breathing
Interventions: 100% O2
BVM Ventilation
Definitive airway ETT
Surgical
Needle / Tube thoracostomy
Case: Continued
↓ breath sounds on the right Trachea deviated to the left More tachypnea since EMS arrival ↓ LOC since EMS arrival
What do you want to do now?
Case: Continued
14g angiocath placed in 2nd intercostal space mid-clavicular line.
“Whoosh” of air 122, 92/60, 362, 22, 94% on room air Assistant preps for chest tube placement
However, patient is now not responding to voice at all
What do you want to do now?
Primary Survey: Intubation
Airway Protection unconscious severe facial trauma risk for aspiration risk for obstruction
Oxygenation/Ventilation apnea
paralysis LOC
inadequate resps tachypnea hypoxia cyanosis
severe closed head injury
Primary Survey: Intubation
Remember pitfalls!! ETT size
Broselow internal diameter = 4 + age (y)/4 width of patient’s 5th finger or nare
ETT insertion distance short tracheas compared to adults infants = 5cm; toddler @ 18 mo = 7 cm distance = 12 + age (y)/2 (> 2 yo) distance = internal diameter of ETT x 3
Cuffed?
Straight Blade Technique
Curved Blade Technique
Primary Survey: Intubation
The “P”s of RSI preparation
Preoxygenation
Premedication
paralysis
“pass the tube”
position of ETT
Primary Survey: Intubation - Premedication
Atropine anticholinergic prevent HR (age < 2-6 yrs) airway secretions dose 0.02mg/kg (min 0.1 mg; max 2 mg)
Lidocaine
Analgesic (morphine, fentanyl)
Short Snapper: Name the condition
Tachypnea Hypoxemia Hypotension Muffled heart sounds +/- JVD
Pericardial Tamponade
Case: Continued
Patient intubated and placement confirmed
A, B, then C…
How do we assess circulation?
*In reality, ABC’s are managed in parallel/simultaneous fashion
Primary Survey: Circulation
Assessment: Early hemorrhagic shock
Difficult to diagnose because of compensation ↓ BP is an ominous sign (30% loss required for alteration)
Tachycardia Skin perfusion Pulses LOC Hemorrhage Urine output
Primary Survey: Circulation
Primary Survey: BP Rule of Thumb
Minimal acceptable systolic blood pressure:
70 mm Hg + (2 x age in years)
Represents 5th %ile of normal BP
Hypotension in children is a late and often sudden sign of cardiovascular decompensation
Case: Continued
126, 86/58, 362, 22, 94% Skin becoming more mottled, cool, dry Cap refill >3 seconds Intubated Minimal urine output Abdomen soft / no external hemorrhage Obvious deformity right femur
How do you want to proceed?
Primary Survey: Circulation
Management: Apply pressure to control hemorrhage 2 large-bore (14-18g) IVs Intraosseous infusion if needed Crystalloid – 20cc/kg bolus if indicated Relieve pericardial tamponade if indicated Thoracotomy when indicated (rare)
Transfuse with blood if child is hypotensive and poorly responsive to crystalloid boluses (~3)
10cc/kg of type-specific of o-negative PRBCs
Short Snapper: Name the condition
Hypotension Warm, flushed skin Decreased reflexes Flaccid sphinters Hypotonia
Neurogenic shock
Primary Survey: Shock
Hypovolemic shock (most common) Unusual sites
Cardiogenic shock Distributive shock
septic neurogenic anaphylactic
Obstructive shock
don’t forget about these causes
Primary Survey: Why Crystalloid?
intracellular
extracellular IS IV
hypotonicisotonic
colloid
66.7%
100%
25%
75%
8.3%
25%
Primary Survey: Fluid resuscitation
Isotonic crystalloid solution Normal saline / Ringer’s lactate
fluids of choice inexpensive readily available effectively expand interstitial space only transiently expand intravascular volume
Primary Survey: Fluid resuscitation
Colloid solutions blood, albumin, FFP, Pentaspan™
more efficient volume expanders remain in intravascular compartment sensitivity reactions risk of blood-borne infection
Case: Continued
Received 2 x 20cc/kg boluses NS Cross-matched, blood on way 116, 92/74, 362, 20, 96% Skin better perfused Cap refill ~ 2seconds
Primary Survey: Disability
Assessment: Pupils: size and reactivity Level of Consciousness:
AVPU Glasgow Coma Scale (GCS) is gold standard for
the neurologic assessment of trauma patients Movement of extremities Posturing More in-depth neurological assessment in the
secondary survey
Primary Survey: Disability
Primary Survey: Disability
Primary Survey: Disability
Short Snapper: Name the condition
Headache Vomiting Altered LOC Papillary dilation Respiratory irregularity Bradycardia
Increased ICP
Case: Continued
Pupils 3mm, ERL GCS – intubated and sedated but just prior was
9 (E2, V3, M4)
Who needs CT scanning?
All head-injured children <17 years old
Mild, moderate and severe
N = 22 772
Outcome: composite of death as a result of HI, requirement for NSx intervention, ‘marked abnormality’ on CT scan
Derived a 14-point rule (Hx, Physical, Mechanistic factors)
CHALICE study
History Witnessed LOC >5min Amnesia >5min abN drowsiness ≥3 vomits Suspicion of NAT Seizure w/o hx of epilepsy
Mechanism High speed (>40m/h) road
traffic accident Fall >3m in height Injury from projectile
object
Examination GCS <14, or <15 if <1 yo Suspicion of depressed
skull injury or tense fontanelle
Signs of basal skull # Positive focal neuro signs Bruise, swelling of
laceration >5cm if <1yo
CHALICE study
Results:
Sensitivity: 98.6% (95% CI, 96.4-99.6)Specificity: 86.9% (95% CI, 86.5-87.4)
CT Rate: 14.1%
CATCH study
Currently in validation phase Derivation:
N =3 781 Inclusion:
<17 years Blunt head trauma with GCS 14-15 and one of:
Known LOC, disorientation, confusion, amnesia, persistent vomiting, irritability
Outcomes: Need for NSx intervention or lesion on CT (phone f/u at 14 days if no CT scan)
CATCH study
High risk criteria (for NSx intervention) GCS <15 2hrs post injury Suspected depressed skull fracture Worsening headache Irritability on examination
Sensitivity: 100% (95% CI, 86-100) Specificity: 70.4% (95% CI, 69-72) CT rate: 29.6%
CATCH study
Medium risk criteria (for acute brain injury on CT scan) Any signs of basilar skull fracture Boggy scalp hematoma Dangerous mechanism (Fall from >3 feet / 5 stairs,
automobile-related)
Sensitivity: 98.3% (169/172 positive scans) Specificity: 50.1% CT scan rate: 49.9%
Head Trauma
Big Head Brain doubles in size by 6months of age Achieves 80% of adult size by 2 years
Brain Development Plasticity Myelination Subarachnoid space is initially small – less protection ++Cerebral blood flow – sensitive to hypoxia
Head Trauma: Emergent Management of Increased ICP
Therapy Dose Mechanism
Head elevation (30°)
- Lowers intracranial venous pressure
Head in midline - Prevents jugular vein compression
Hyperventilation pCO2 30-35 mmHg
Promptly decreases cerebral blood volume pressure
Mannitol 0.25-2g/kg IV Rapid osmotic diuresis
Hypothermia 27-31°C Decreases cerebral blood flow and metabolic rate
Head Trauma
Management pearls
1. Fluids Children (esp <3yo) are particularly susceptible to the
effects of the secondary brain injury - Hypotension from hypovolemia is the worst single risk factor
2. Infants Significant bleeding into subgaleal or epidural spaces
3. Open Fontanelles May disguise ↑ ICP – lower threshold for investigation
Primary Survey: BP in head injuries
CPP = MAP - ICP
CPP = MAP - ICP CPP = MAP - ICP
CPP = MAP - ICP
Case: Continued
CT: 5mm x 3mm subdural hemorrhage (non – surgical) ?Basal skull fracture
Admitted to ICU. Femur fracture - placed in 90 degree/90 degree
spica cast Extubated next morning Good result
Primary Survey: Exposure
Remove all clothes Keep patient warm
warm blankets, warm fluids, overhead warmer, warm the room
Log roll
Adjuncts to the primary survey
Continuous monitoring of vitals NG or OG tube Urinary catheter (after GU / rectal exam) Bloodwork
CBC, Type & Cross, PT/PTT electrolytes, KFTs, LFTs, amylase
Radiological investigations
Radiology
Portable C-spine Chest x-ray Pelvis (Others)
abdomen extremity
(CT)
Radiography: C-spine pseudosubluxation
Population variant ~ 40% of children
under 7 and 20% of children up to 16 years exhibit anterior displacement of C2 on C3
Exacerbated by flexion
Secondary survey
Goal: identification of all injuries History – AMPLE “Head to toe” exam Look, listen & feel Fingers & tubes in every orifice If any change in patient…re-assess primary
survey
ABCDEF “G”
G – Go around again!!
Thanks to Christine Hall
Additional Interventions
Administer on-going analgesia / sedation
Splint all fractures
Sterile dressings to wounds
Antibiotics as needed
Tetanus as needed
Summary: Airway
Assess: Airway patency Level of consciousness Maxillofacial injury Stridor or cyanosis
Interventions: Jaw thrust, suction, airway adjuncts C-spine immobilization 100% O2 Intubate for:
GCS ≤8, Absent gag, PCO2>50, PO2<50
Needle cricothyrotomy if intubation impossible
Summary: Breathing
Assess: Respiratory rate Chest wall movement Paradoxical breathing Tracheal deviation Flail segment
Interventions: 100% O2
Needle thoracostomy / Chest tube Intubation
Summary: Circulation
Assess: Cap refill Heart rate Peripheral pulses Sensorium Pulse pressure Skin condition / perfusion
Interventions: Oximeter and cardiac monitor, q5min vitals 2 large bore IV’s – central access, IO 20 cc/kg bolus of crystalloid – may repeat x 2 PRBCs 10cc/kg – consider at start of third NS bolus
Summary: Disability
Assess: LOC AVPU or GCS Pupil size and reactivity Extremity movement and tone Posturing Reflexes
Interventions: Maintain BP, oxygenation and ventilation If head injured with GCS ≤9, RSI and intubate (mannitol) If head injured, hyperventilate to PCO2 of 30-35 If blunt cord trauma – Solu-medrol 30cc/kg bolus
Summary: Exposure
Assess: Undress Look under collar and splints Log roll and examine back / rectal
Interventions: Warm patient unless head injured
BE SYSTEMATIC
Questions?