Pediatric Trauma ReviewFocus on chest trauma and a JumpSTART ReviewSilver Cross Hospital EMSMay 2014 CE

Epidemiology - General Trauma is the leading cause of death between the ages of 1-18

Injury accounts for 5% of infant deaths

47% of these deaths are related to MVCs With rates higher in those >13yo

13% of deaths in those 1-14yo were a result of homicide

In the school age group Pedestrian injuries and bike injuries predominate

Pediatric Head Injury #1 cause of death due to trauma

~2700 deaths/year

450,000 children present to EDs each year with head injury

90% suffer from minor injuries

Perinatal period Birth injuries

1-4 years old Falls

School age Pedestrian or bike

injuries

Adolescence MVA

Children have larger heads than adults in relation to their body

The chance that it is hit in a traumatic event is larger

Head is heavy Different acceleration dynamics

At birth, face to cranium ratio is 1:8, adult ratio is 1:2.5

Makes it more likely skull is hit in younger children

Lack of pneumatization of sinuses is associated with more rigidity and less plasticity of facial skeleton

Increases transfer of forces directly to brain

Pediatric Spine Injury 18.1 spinal cord injuries per million children

1300 new cases a year

60-80% of injuries occur at the cervical level

Adults have a 30-40% incidence

Children <8 yo More likely to sustain high

cervical (C1-C3) injuries

Pediatric Thoracic Trauma #2 cause of trauma related mortality

In isolation, thoracic trauma carries a 5% mortality

25% when combined with abdominal injury

40% with head and abdominal injury

Anatomic Considerations

Incomplete ossification of ribs allows anterior ribs to be compressed to meet posterior

Pulmonary contusions are common, rib fractures uncommon

Pulmonary contusions are most common thoracic injury in traumatized children

Trachea is narrow, short, more compressible

Great vessel and cardiac injury are rare in children

Anatomic Considerations

Commotio Cordis is a unique consequence of pediatric thoracic trauma

Abrupt strike to the chest leads to V-Fib and arrest

Pericardial tamponade:

Pericardial tamponade is caused by blunt or penetrating trauma to the heart. Blood leaks into the pericardial sac, causing compression of the heart. As the volume of blood in sac increases, the compression of the heart becomes more pronounced. This causes cardiac output to fall dramatically and leads to a backup of volume in the venous system.

Pericardial Tamponade Signs of pericardial tamponade are:

Broken ribs or penetrations to chest wall.Dyspnea/CyanosisNeck vein distentionWeak, thready pulseDecreasing blood pressureShockNarrowing pulse pressure

Pericardial Tamponade Treatment:

OxygenationAssisted ventilation as necessaryIV therapyEKG monitoringRapid transport to nearest I Trauma facility

Cardiac Contusion:

Cardiac contusion is a common injury following severe blunt trauma to the chest. It usually occurs when the heart is compressed between the sternum and the spinal column. Severe contusions may include rupture of the heart wall. Most commonly, the right ventricle is injured, as it lays directly beneath the sternum.

Cardiac contusion Signs of cardiac contusion are:

Bruising, swelling, crepitus or deformity to chest wallTachycardiaIrregular heart rhythm

Cardiac Contusion Treatment:

OxygenationAssisted ventilation as necessaryIV therapyEKG monitoringTreatment of arrhythmias as necessaryTransport to nearest appropriate trauma facility

Commotio Cordis:

Commotio cordis, or “concussion” of the heart, is generally described as “instantaneous cardiac arrest produced by non-penetrating chest blows in the absence of heart disease or identifiable morphologic injury to the chest wall or heart.”Commotio Cordis represents one of the most common mechanisms of sudden death in sports seen in young athletes.

Commotio Cordis—Review of Condition

Classic presentation is a blow to the chest during a sporting activity that precipitates sudden collapse, followed by death if prompt resuscitation is not available.Most commonly occurs during baseball, but can occur during hockey, lacrosse, karate, and recreational activities such as sledding or biking.

Case Study You are called to a baseball game for a child hit with a baseball that is now unresponsive. Bystanders initiated CPR.

CPR is initiated and the Cardiac monitor is applied.

•Initial rhythm is:

1.What rhythm do you see?2.What is your treatment priority?

Case Study

Case Study After delivering 3 shocks, the patient remains unresponsive, pulseless, and apneic with the rhythm shown below.

What is your next intervention?

Case Study

The patient has been intubated with a 6.0 ETT, and is being ventilated with high FiO2 via BVM.

An IV of NS is initiated.

— What is your next intervention?

Case Study Epinephrine 1:10,000 is determined to be the next

intervention.

Continuation of CPR and PALS/SMO protocol

Case StudyJournal of the American Medical Association, 2002;287:1142-1146

In a study of 128 confirmed cases of commotio cordis, a 15% survival rate was reported when resuscitative measures were initiated within 3 minutes of the event.

In cases where resuscitation was delayed, >3 minutes, the survival rate was noted to be <1%.

Pediatric Abdominal Trauma Third leading cause of pediatric traumatic death

Blunt causes in 85%, penetrating trauma in 15%

Blunt trauma related to MVC’s causes more than 50% of abdominal injuries in children

Boogie board related injury..!

Anatomic Considerations Proportionally larger solid organs

Less subcutaneous fat

Less protective abdominal musculature

Relatively larger kidneys that predispose them to renal injury

Anatomic Considerations Splenic injuries are the largest proportion of pediatric abdominal trauma

Liver is second most injured solid organ

Lap Belt Injury Sudden increase in bowel

intraluminal pressure can result in intestinal perforation

Chance fracture of the lumbar spine

Anatomic Considerations The compliant chest wall, poor thoracic musculature and weak diaphragm can lead to considerable respiratory difficulty with gastric distention

Epinephrine

Generic Name: EpinephrineTrade Name: Adrenalin®Therapeutic Class: SympathomimeticMechanism of Action:—Alpha: Bronchial, cutaneous, renal & visceral arterial constriction.—Beta 1: Positive inotropic & chronotropic actions, increase in cardiac automaticity.—Beta 2: Bronchial smooth muscle relaxation and dilation of skeletal vasculature, blockage of histamine release.

Epinephrine Pharmacokinetics: Onset with IV injection is immediate and intensified. SC or IM injection gives a rapid onset with longer duration. Half-life is 1-4 minutes. Prehospital Indications: Cardiac arrest Bradycardia with profound hypotension Severe bronchospasm Anaphylaxis Contraindications: Hypertension Narrow angle glaucoma Pulmonary edema

JumpSTART review

The following is a PowerPoint from Dr. Lou Romig.

She developed jumpstart as a tool for evaluation and triaging pediatric MCI.

JumpSTART Review

Please note that JumpSTART was designed for use in disaster/multicasualty settings, not for daily EMS or hospital triage.

JumpSTARTSTART

Pediatric Multicasualty Pediatric Multicasualty Triage SystemTriage System

Lou Romig MD, FAAP, FACEPLou Romig MD, FAAP, FACEPMiami Children’s HospitalMiami Children’s HospitalMiami Dade Fire RescueMiami Dade Fire Rescue

South Florida Regional DMAT/IMSuRT South Florida Regional DMAT/IMSuRT SouthSouth

Medical Director, South Florida Area Medical Director, South Florida Area National ParksNational Parks

Earthquake, Algeria Earthquake, Iran

Earthquake, Italy

Tsunami, Indonesia

Bus crash, Michigan

Tornado, Kansas

Building collapse, Jerusalem

Moscow theater siege

Beslan school siege

OKC Bombing

We must assume We must assume each MCI will each MCI will

include children. include children.

We must be able to We must be able to assess and treat assess and treat

victims of victims of allall ages ages with equal with equal

confidence and confidence and competence.competence.

What’s your call?

Photos by Bryan Patrick, The Sacramento Bee, 2000

What’s your call?

A bus carrying school children of various ages and their

chaperones on a field trip loses control, slams into a median,

then rolls.

You are the triage officer.

What’s your call? A young school aged boy is found lying on the roadway 10 ft from the bus.

Breathing 10/min

Good distal pulse

Groans to painful stimuli

What’s your call? An adult kneels at the side of the road, shaking his head. He says he’s too dizzy to walk.

RR 20

CR 2 sec

Obeys commands

What’s your call? A school aged girl crawls out of the wreckage. She’s able to stand and walk toward you crying.

Jacket and shirt torn

No obvious bleeding

What’s your call? A toddler lies with his lower body trapped under a seat inside the bus.

Apneic

Remains apneic with modified jaw thrust

No pulse

What’s your call? Adult female driver still in the bus, trapped by her lower legs under caved-in dash.

RR 24

Cap refill 4 sec

Moans with verbal stimulus

What’s your call? A toddler lies among the wreckage.

RR 50

Palpable distal pulse

Withdraws from painful stimulus

What’s your call? A woman is carrying a crying infant. She is able to walk.

RR 20

CR 2 sec

Obeys commands

What’s your call? An infant is carried by the previous victim.

He’s screaming but the woman quiets him to RR of 34

Good distal pulse

Focuses on rescuer, reaches for mom.

No obvious significant external injuries.

What’s your call? A young school aged boy props himself up on the road.

RR 28

Good distal pulse

Answers question and commands.

Has obvious deformity of both lower legs.

What’s your call? A toddler is found outside the bus, lying on the ground in a heap.

Apneic

Remains apneic with jaw thrust

Faint distal pulse palpable

What’s your call? A school aged girl lies among the wreckage.

RR 40

Absent distal pulse

Withdraws from painful stimulus

What’s your call? A screaming infant is found among the bushes at the side of the road.

RR 38

Good distal pulse

Focuses and reaches for you.

Has a partial amputation of the foot without active bleeding.

What’s your call? An adult male lies inside the bus.

Apneic

Remains apneic with jaw thrust

What’s your call? A youngster is up and walking around but is limping

Alert, crying hysterically for his mother

What’s your call? A school aged boy lies close to the bus.

RR 36

Absent distal pulse

Sluggishly looks at you when you talk to him

What’s your call? A young teen girl lies among the wreckage, crying for someone to help her up. A man with her says she needs her wheelchair.

RR 22

Palpable distal pulse

Alert

Has minor cuts and bruises

What’s your call? An adult male lies on the ground

RR 20

Good distal pulse

Obeys commands but cries that he can’t move his legs

What’s your call? An older school aged child is found sitting outside the bus.

RR 28

Good distal pulse

Groggy, confused and slowly follows commands but won’t get up and walk.

Goal of Multicasualty Triage

“To do the best for the most

using the least.”

Primary Disaster Triage Goal: to sort patients based on probable needs for immediate care. Also to recognize futility.

Assumptions:

Medical needs outstrip immediately available resources

Additional resources will become available with time

Primary Disaster Triage Triage based on physiology

How well the patient is able to utilize their own resources to deal with their injuries

Which conditions will benefit the most from the expenditure of limited resources

The physiology of adults and children are not the same.

Why do we need a pediatric tool?

To optimize triage effectiveness to the benefit

of all victims, not just children.

Why do we need an objective pediatric tool?

The pediatric knowledge base and confidence levels of many EMS providers are not as good as

they can and should be.

Photo

by B

ryan P

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ick, The S

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ento

Bee, 2

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Pediatric multicasualty triage may be

affected by the emotional state of

triage officers.

START TriageRESPIRATIONS

NO

YES

Dead orExpectan

t

Immediate

Position Airway

NO YES

Over 30/min

Immediate

Under 30/min

PERFUSION

Cap refill> 2 sec

ControlBleeding

Immediate

Cap refill< 2 sec.

MENTALSTATUS

Failure to followsimple commands

Can followsimple commands

Immediate Delayed

Ambulatory = Green

START: Potential Problems with Children

An apneic child is more likely to have a primary respiratory problem than an adult. Perfusion may be maintained for a short time and the child may be salvageable.

RR +/- 30 may either over-triage or under-triage a child, depending on age .

START: Potential Problems with Children

Capillary refill may not adequately reflect peripheral hemodynamic status in a cool environment.

Obeying commands may not be an appropriate gauge of mental status for younger children.

JumpSTART Goals Modify an existing tool for use with children

Utilize decision points that are flexible enough to serve children of all ages and reflective of the unique points of pediatric physiology

Minimize over- and under-triage

Accomplish triage within 30 second/pt goal

JumpSTART: Age Initially ages 1-8 years chosen

Less than one year of age is less likely to be ambulatory.

The pertinent pediatric physiology (specifically, the airway) approaches that of adults by approximately eight years of age.

I’m 10!

JumpSTART: AgeCurrent recommendation:

If a victim appears to be a child, use JumpSTART.

If a victim appears to be a young adult, use START.

JumpSTART: Ambulatory

Identify and direct all ambulatory patients Identify and direct all ambulatory patients to designated to designated GreenGreen area for secondary area for secondarytriage and treatment. Begin assessmenttriage and treatment. Begin assessment

of nonambulatory patients as youof nonambulatory patients as youcome to them.come to them.

Modification for nonambulatory childrenAll children carried to the GREEN area by other

ambulatory victims must be the first assessed by

medical personnel in that area.

JumpSTART: Breathing? If breathing spontaneously, go on to the next step, assessing respiratory rate.

If apneic or with very irregular breathing, open the airway using standard positioning techniques.

If positioning results in resumption of spontaneous respirations, tag the patient immediate and move on.

The “Jumpstart” PartIf no breathing after airway opening, check for peripheral pulse. If no pulse, tag patient deceased/nonsalvageable and move on.

If there is a peripheral pulse, give 5 mouth to barrier ventilations. If apnea persists, tag patient deceased/nonsalvageable and move on.

If breathing resumes after the “jumpstart”, tag patient immediate and move on.

JumpSTART: Respiratory Rate

If respiratory rate is 15-45/min, proceed to assess perfusion.

If respiratory rate is <15 or >45/min or irregular, tag patient as immediate and move on.

JumpSTART:Perfusion

If peripheral pulse is palpable, proceed to assess mental status.

If no peripheral pulse is present (in the least injured limb), tag patient immediate and move on.

JumpSTART: Mental Status Use AVPU scale to assess mental status.

If Alert, responsive to Verbal, or appropriately responsive to Pain, tag as delayed and move on.

If inappropriately responsive to Pain or Unresponsive, tag as immediate and move on.

Modification for nonambulatory children

Infants who normally can’t walk yet

Children with developmental delay

Children with acute injuries preventing them from walking before the incident

Children with chronic disabilities

Modification for nonambulatory children

Evaluate using the JS algorithm

If any RED criteria, tag as RED.

If pt satisfies YELLOW criteria:

YELLOW if significant external signs of injury are found (ie. deep penetrating wounds, severe bleeding, severe burns, amputations, distended tender abdomen)

GREEN if no significant external injury

Individuals with special health care needs may

also be MCI victims!

Note for Black Category Victims

Unless clearly suffering from injuries incompatible with life, victims

tagged in the BLACK category should be reassessed once critical

interventions have been completed for RED and YELLOW patients.

Putting it into practice

What’s your call? A young school aged boy is found lying on the roadway 10 ft from the bus.

Breathing 10/min

Good distal pulse

Groans to painful stimuli

What’s your call? An adult kneels at the side of the road, shaking his head. He says he’s too dizzy to walk.

RR 20

CR 2 sec

Obeys commands

What’s your call? A school aged girl crawls out of the wreckage. She’s able to stand and walk toward you crying.

Jacket and shirt torn

No obvious bleeding

What’s your call? A toddler lies with his lower body trapped under a seat inside the bus.

Apneic

Remains apneic with modified jaw thrust

No pulse

What’s your call? Adult female driver still in the bus, trapped by her lower legs under caved-in dash.

RR 24

Cap refill 4 sec

Moans with verbal stimulus

What’s your call? A toddler lies among the wreckage.

RR 50

Palpable distal pulse

Withdraws from painful stimulus

What’s your call? A woman is carrying a crying infant. She is able to walk.

RR 20

CR 2 sec

Obeys commands

What’s your call? An infant is carried by the previous victim.

He’s screaming but the woman quiets him to RR of 34

Good distal pulse

Focuses on rescuer, reaches for mom.

No obvious significant external injuries.

What’s your call? A young school aged boy props himself up on the road.

RR 28

Good distal pulse

Answers question and commands.

Has obvious deformity of both lower legs.

What’s your call? Toddler found outside the bus, lying on the ground in a heap.

Apneic

Remains apneic with jaw thrust

Faint distal pulse palpable.

OR

What’s your call? A school aged girl lies among the wreckage.

RR 40

Absent distal pulse

Withdraws from painful stimulus

What’s your call? A screaming infant is found among the bushes at the side of the road.

RR 38

Good distal pulse

Focuses and reaches for you.

Has a partial amputation of the foot without active bleeding.

What’s your call? An adult male lies inside the bus.

Apneic

Remains apneic with jaw thrust

What’s your call? A youngster is up and walking around but is limping

Alert, crying hysterically for his mother

What’s your call? A school aged boy lies close to the bus.

RR 36

Absent distal pulse

Sluggishly looks at you when you talk to him

What’s your call? A young teen girl lies among the wreckage, crying for someone to help her up. A man with her says she needs her wheelchair.

RR 22

Palpable distal pulse

Alert

Has minor cuts and bruises

What’s your call? An adult male lies on the ground

RR 20

Good distal pulse

Obeys commands but cries that he can’t move his legs

OR

What’s your call? An older school aged child is found sitting outside the bus.

RR 28

Good distal pulse

Groggy, confused and slowly follows commands but won’t get up and walk.

JumpSTART’s reception

In use throughout the US and Canada

Being taught in Germany, Switzerland, Japan, Polynesia and other countries

Included in the NDMS Core Curriculum

Incorporated into the PDLS and APLS courses

Feature article, July 2002 JEMS magazine

Included in Brady’s Prehospital Emergency Care, 7th ed

Publication in other texts pending

Advantages JumpSTART provides a rapid triage system specifically designed for children, taking into consideration their unique physiology.

The algorithm is modified from an existing system widely accepted for adult triage.

For most patients, triage can be accomplished within the 30 second goal.

Advantages Objective triage criteria for children will help to eliminate the role of emotions in the triage process.

Objective triage criteria will provide emotional support for triage personnel forced to make life or death decisions for children in the MCI setting.

For more information on JumpSTART:

www.jumpstarttriage.com

Lou Romig MD

LouRomig@bellsouth.net

Thank you for your time and attention!

If you have any questions, please contact Silver Cross EMS Education at 815-300-2909