Pediatric Trauma Management

What You Need To Know

Thanks to:Angelo Mikrogianakis MD, FRCPCPediatric Emergency Physician and Trauma Team LeaderEmergency Medicine & Critical CareThe Hospital for Sick ChildrenPediatric Patch PhysicianOrnge

The Division of Paediatric Emergency Medicine

Presents:

Objectives

General overview of pediatric trauma Anatomy and patterns of injury Case Study

Why does pediatric trauma cause so much anxiety?

Emotional impact Different equipment sizes Different drug and fluid calculations Differences in anatomy,physiology and

pathophysiology specific to children Communication difficulties Lack of staff experience

We can all be better prepared for pediatric trauma!

“We Forgot The Patient!”

PEDIATRIC TRAUMAIsolated head Multiple

injury trauma

Airway compromise

Respiratory failure

Shock

Cardiopulmonary arrest

PEDIATRIC TRAUMA

Blunt injury is much more common than penetrating injuryHead (CNS) injury

present in 55% of blunt trauma victims

Internal injuries present in 15% of blunt trauma victims

ANATOMY & PHYSIOLOGY

BODY small body mass with large surface area

heat lossgreater force per body unit area

less protective muscle and fat high metabolic rate

higher oxygen and glucose demands

ANATOMY & PHYSIOLOGY HEAD

large compared to body size heat loss more prone to injury

weak neck muscles prominent occiput sutures open until 18

months relatively larger tongue

PEDIATRIC HEAD TRAUMA Most common single organ system injury

associated with 80% of all deaths Concussion common injuries Subdural bleeds common in infants Epidural bleeds less common than adults Acute neurosurgical intervention required

less often than adults

CAUSES OF SECONDARY BRAIN INJURY

Systemic Causes (Extracranial)

hypotensionhypoxemiaanemiahypo/hypercarbiahyperthermiahypo/hyperglycemiahyponatremia

Neurologic Causes (Intracranial)

raised ICPherniationvasospasmhematomaseizures infectionhyperemia

BREATHING FOR HEAD INJURED PATIENTS

Controlled ventilation cerebral vasculature responds to PaCO2

maintain cerebral oxygenation PaO2< 60 mm Hg associated with morbidity & mortality

Hyperventilation with caution hyperventilation decreases CBF & worsens outcome hyperventilation NOT recommended unless herniation goal is PaCO2 = 35 mmHg

MANAGEMENT OF RAISED ICP

Elevate HOB (unless BP) Medication

Mannitol: osmotic diuresis3% Hypertonic saline: Early transfer to

neurosurgical facility Hyperventilation

only if impending herniation

ANATOMY & PHYSIOLOGY NECK

shorter; supports more mass veins & trachea hard to see larynx - cephalad & anterior cricoid narrowest part epiglottis at 45o & floppy short trachea (5cm at birth) spine– elasticity of ligaments

Less calcified

PEDIATRIC C-SPINE C-Spine injury is uncommon (1-4%)

< 8 y.o. 10-15%8-12 y.o. 20-25%> 12 y.o. 60-70%

Anatomic fulcrum of spine at C2-C3 Fractures below C3 < 30% of spine lesions

in children < 8 years of age *** Adult pattern of injury at 12 years old

CSI - pediatric differences

mobility at C2-C3 (pseudosubluxation) normal mobility 3 mm (children 4-5 mm)

tip of odontoid < 1 cm from base of skull pre-dental space 3 mm (children 4-5 mm) retropharyngeal space 5-7 mm (children < 7-8 mm) vertebral bodies may be wedged anteriorly

especially on their superior surfaces until age 10

ANATOMY & PHYSIOLOGY

CHEST ribs are cartilaginous and pliable

greater transmitted injuryrib fracture = massive force

little protective muscle and fat mediastinum very mobile

PEDIATRIC THORACIC INJURIES

Less serious thoracic injuries than adults Rarely will chest injuries occur in isolation Rarely are the sole cause of death Blunt cardiac & great vessel injuries are rare Management is mainly conservative:

Assisting oxygenation and ventilation Chest tube insertion Replacing lost blood volume < 15% require a chest tube

PEDIATRIC THORACIC INJURIES

U.S. data in pediatric blunt chest trauma50% pulmonary contusions20% pneumothorax10% hemothorax

Canadian incidence is most likely less Chest tube sized to occupy most of the

intercostal space.

ANATOMY & PHYSIOLOGYABDOMEN

less protection from ribs and muscle liver and spleen vulnerable small forces can cause severe injury

propensity for gastric distension abdominal pain respiratory distress

GU organs well protected by pelvis

Gastric distension common after trauma from crying and swallowing air can interfere with respiration / ventilation

limits diagphragmatic motionreduces lung volume

increases the risk of vomiting difficult to discern abdominal findings

Gastric distension

PEDIATRIC ABDOMINAL INJURIES

Gastric distention = OG/NG tubes Solid organs are most vulnerable. 8% of admissions to peds trauma centres 85-90% of all pts with hepatic & splenic

injuries can be managed nonoperatively. Missed hollow viscus injury is uncommon.

SickKids Patient PopulationApril 1998 – March 2001

Male 62.2%Age 8.6 years (std dev 4.5)Weight 33.8 kg (std dev 18.1)ISS 14 (std dev 11)Direct 47.8%Referred 52.2%

95 94

52

2518

10 5 3 10

0

20

40

60

80

100No

. Of P

atie

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Ped

Stru

ck MVC Fa

llBi

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one

Bike

vs. C

ar ATV

Win

ter

Spor

tAs

saul

t

Othe

r

Mechanism Of Injury

Spleen, 32

Liver, 31

Bowel & Mesentery, 14

Renal/Adrenal 16

Pancreas, 5

Bladder, 3

0 5 10 15 20 25 30 35

# of Patients

Intra-Abdominal Injuries

102

1

2

3

0 2 4 6 8 10

# of Patients

Bowel

Liver

Spleen

Bladder

Normal

Organ Requiring Surgical Intervention

The more important requisite is the ability to evaluate hemodynamic stability.

AMBULANCE PATCH 7 y.o. male, pedestrian struck

by truck while crossing street Witnesses describe LOC Now confused & agitated O2 applied IV access x 1 VITALS: HR=120, BP=105/69,

RR=30, SATS=91%

RAPID CARDIOPULMONARY ASSESSMENT

A. Airway and C-spine control B. Breathing C. Circulation and hemorrhage control D. Disability (rapid neurologic

assessment) E. Exposure and Environmental control

PREPARATION Assemble team - define roles

physicians nurses RT radiology

Prepare equipment for: airway management IV access & fluid resuscitation Broselow tape

PRIMARY SURVEY

AIRWAYposition - jaw thrustsuction100% oxygenoral airwayensure C-spine is

immobilized

AIRWAY

Bag & mask ventilaton

C-spine precautions

Intubating Criteria

RSI meds

PRIMARY SURVEY

BREATHINGcolourchest movementretractionsbreath soundsassess work of

breathingoxygen saturations

PRIMARY SURVEYCIRCULATION

heart ratecapillary refillskin colour and

temperatureblood pressureperipheral pulsesorgan perfusion:

brain, kidney

CIRCULATION IN THE TRAUMA VICTIM Assess for signs of hypovolemic shock: quiet tachypnea tachycardia prolonged capillary

refill cool extremities thready pulses narrow pulse pressure altered mental status

RESPONSE TO FLUID BOLUS

Slowing of heart rate increased systolic BP increased pulse pressure (>20mmHg) decrease in skin mottling increased warmth of extremities clearing of sensorium urinary output of 1 - 2 ml/Kg/hour

PRIMARY SURVEY

DISABILITY pupils: size and reactivity level of consciousness

A - AlertV - Verbal stimulusP - Painful stimulusU - Unresponsive

PRIMARY SURVEY

EXPOSURE remove all clothes keep patient warm

warm blanketswarm fluidsoverhead warmerwarm the room

SECONDARY SURVEY

HEAD TO TOE EXAM

systematic exam of all body organs look, listen & feel fingers & tubes in every orifice

SECONDARY SURVEY

HISTORY A - Allergies M - Medications P - Past medical history L - Last meal E - Events/Environment

RE-ASSESS

And ASSESS AGAIN

If patient deteriorates, go back to ABC’s

KEY MESSAGES

Prevention is the best defense Pediatric patients have special differences Recognize head-injured patients early Prevent secondary brain injury

Be excellent airway managers Provide adequate fluid resuscitation

Anticipate need for transfer ASAP Ensure appropriate transport personnel

Psychologic status

impaired ability to interactunfamiliar individualsstrange environmentemotional instabilityfear / pain / stressparents often unavailable

history taking and cooperation can be difficult

Strange environment?

Strangers in environment?

CASE STUDY: 7 year old, male

Pedestrian struck by truck while crossing street

On Arrival to Primary Hospital Moaning with bruising & swelling to

face, large scalp laceration 100% O2

Cardio, Resp, BP & Sat monitors 2 large bore IV’s placed

CASE: 7 year old male

Vitals: HR=160, BP=110/70, RR=24, SAT= 99 A - Patent, teeth loose, facial contusions B - Breath sounds decreased on RIGHT C - Heart sounds N, cap refill brisk D - Eyes open to speech, Verbally confused,

Obeys commands (GCS=13), PERL ABDO - soft, tender RUQ, bruising R flank/hip

CASE: 7 year old

Interventions:Broselow TapeBolus 20 cc/kg NS rapidlyReassess

Vitals: HR=140, BP=105/75, RR=14, SAT= 99 Resp effort decreased, BS decreased to R Eyes open to pain, no longer verbal,

abnormal flexion to pain

Summary of Pitfalls Beware of hypothermia in systemic

traumaespecially if hemodynamic compromise

Beware of unusual bleeding sitessubgaleal hematomas long bone fractures

Beware of the distended stomach

CASE 14 y.o. male, previously healthy Un-helmeted cyclist struck by truck ~ 19:00 Thrown & rolled Initially unconscious then agitated, Vx X 1 Arrival at primary hospital ~ 19:50 Tachycardic Comatose – decorticate posturing – GCS=5 Extension of extremities

CASE

A - IntubatedNo maxillofacial trauma

B - Trachea midlineGood A/E bilaterallyNo subcutaneous air

C – HR = 126, BP = 120/35 D - PERL – myosis, extension to painful stimuli Abrasion L chest & abdomen Abdomen distended

Common Life-Threatening Chest Injuries

TypeTensionpneumothorax

Massivehemothorax

Initial TreatmentABC’s,Needle decompressionInsert chest tube

ABC’sPleural decompressionInsert chest tubeReplace fluids

Uncommon Life-Threatening Chest Injuries

Type

Flail chest

Open pneumothorax

Initial Treatment

ABC’s

Positive-pressure ventilation

May require chest tube

ABC’s

Occlusive dressing

Insert chest tube

Surface area

surface / volume ratiohighest in infantsdiminishes as child matures

thermal energy loss significanthypothermia may develop quicklymay be good for isolated head injuriesbad for hypotensive patients

Tachycardia

Why is evaluation of HR so important?

CO = HR x SV

CO = HR x SV

CO = HR x SV

Hypotension

Why is evaluation of BP so important?

BP = CO x SVR CO = HR x SV

BP = CO x SVR

It’s “Shock” ing

BP @ 25% loss

normal blood volume = 80 mL/kg

6 month old 7 kg 7 kg = 560 mL

25% 140 mL

140 mL ½ cup

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

BP in head injuries

Secondary brain injury = neuronal injury as a result of the pathological

processes that are initiated as the body’s response to primary injury hypercarbia cerebral edema ICP hypotension hypoxemia

BP in head injuries

CPP = MAP - ICP

CPP = MAP - ICP CPP = MAP - ICP

CPP = MAP - ICP

Long-term effects

effect on growth and developmentgrowth deformityabnormal development

children with severe multisystem trauma60% residual personality changes at 1 year50% show cognitive and physical handicaps

Long-term effects

other disabilitiessocialaffective learning

significant impact on family structurepersonality and emotional disturbances in 2/3

of uninjured siblingsstrain on marital relationship

CORE KNOWLEDGE & SKILLS

1.Understand the principles of airway management in the injured pediatric patient.

2.Recognize and manage shock in the injured pediatric patient.

3.Recognize and treat common life-threatening complications of major trauma in pediatric age group.

QUESTIONS