Beaumont Children’s Hospital Pediatric Trauma: What's the difference? Robert Morden, MD Pediatric...
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Transcript of Beaumont Children’s Hospital Pediatric Trauma: What's the difference? Robert Morden, MD Pediatric...
Beaumont Children’s Hospital
Pediatric Trauma: What's the difference?
Robert Morden, MDPediatric Trauma Medical Director
What’s the Difference? Pre-hospital
• Different Mechanisms: Things children do and their changing levels of maturity predispose them to different injury patterns.
• Different Injuries: When involved in the same kind of accident as adults, children suffer quite different injuries.
Epidemiology of Childhood Injury( the U.S. numbers)
9. 9.2 million medical visits
151,319 hospitalizations
16% with permanent disability
Pediatric Trauma Factors
• Sex- males 2x risk• Economic conditions• Ethnic group• Race• Geography
How are Children Different?
• Anatomically• Physiologically• Cognitively• Psychologically
Age and Injury Related Deaths
• < 1y/o: airway obstruction• 1 to 4: drowning and
transportation related• 5 to 9: MVA• 10 to 14: MVA
Injury Pyramid
Injury Fatality Rate
Haddon “Matrix” and Injury Prevention
• Injuries result from predictable events and thus offer an opportunity for systemic intervention
• Pre-event• Event• Post-event
Interventions
• Cross walk timers• Helmets • Seat belts• Child proofing• Smoke alarms
Trimodal Pattern of Trauma Mortality and Morbidity
I. Death at the scene ie CNS and central vasculature. (prevention)
II. Second peak minutes to hours after ie solid organ, CNS, Cardiothoracic. (focus of ATLS protocols) preventable deaths
III. Days or weeks ie complications, RDS, infection. Uncommon in children
The ABCDE of Pediatric Trauma
• Application of a systemic protocol designed to standardize diagnostic and treatment decisions so that individual variations in patterns of injury do not distract the caregivers from recognizing and treating injuries that can have a profound impact upon outcome.
The Difference: Pre-hospital
• Kids are more difficult to intubate-50% failure rate.
• IV access-50% failure.• Unfamiliar with pediatric
resuscitation; pediatric patients account for only 10% of paramedic transport volume.
• Emotional factors-terrified child, distraught parent.
Airway Priorities
• Ensure Oxygenation• Ensure Ventilation• Protect Spine• Protect Airway
Considerations
• When and When not to intubate. O2 Sat <95% =clinical hypoxia Assess airway (teeth, debris,blood)
• Neurologically intact and phonates normally, and ventilates without stridor then leave them alone and monitor only.
• Coma, combativeness, shock, or direct trauma then needs a tube.
Pediatric Intubation
• Children’s airways differ both anatomically and physiologically.
• The best trained should intubate.
• Have appropriate equipment and medication available for best results.
• Pediatric Airway Differences
• Subglottic –tube type and size affect
• Narrow oropharynx• Larynx—anterior and cephalad• Epiglottis—short, floppy, angled
acutely• Vocal Cords— difficult to
visualize and are fragile and easily torn
• Trachea Shorter—endobronchial intubation and dislodgement are more common in kids.
More Pediatric Airway Considerations
• Nose breather—first 4 to 6 months
• Large tongue—relative to adults (jaw lift)
• Large head—occiput flexes head forward (support neck for neutral position)
Video Laryngoscope
Breathing (the differences)
• Laryngeal Mask Airway– unsuccessful then
• Cricothyrotomy >10 and needle 16 or 18 gauge if <10
• Tracheostomy—ONLY IN OR• Impaired spontaneous ventilatory drive
– head injury• Impaired lung expansion
– thoracic injury• Mortality rate for thoracic trauma in children
is 25%
Breathing
• Pediatric mediastinum mobile– more susceptible to tension pneumo
• Compliant chest wall– more susceptible to injury to the cardiothoracic
structures. (severe lung contusions)
Circulation
Seriously injured children often have normal vital signs even with significantly decreased circulating volume as a result of a remarkable cardiovascular reserve.
Circulation
• In children, hypotension in the presence of blood loss = OMINOUS SIGN
• Child’s blood volume 80-90ml/kg vs adult 65-70ml/kg
• Fixed stroke volume infants. To increase cardiac output can only increase heart rate.
Circulation
System < 25% Blood Loss 25%-45% Blood
Loss
> 45% Blood Loss
Cardiac Weak, thready pulse; increased heart rate
Tachycardia Hypotension, tachycardia to bradycardia
CNS Lethargic, irritable, confused
Changing level of consciousness; dulled response to pain
Comatose
Skin Cool, clammy Cyanotic, decreased capillary refill, cold extremities
Pale, cold
Renal No decrease in output, increased specific gravity
Decreased urine output
No urine output
Clinical Signs of Shock
Circulation
• Vascular access-2 lines (above and below)• Central lines (if experienced)• Cut downs (saphenous easiest)• Interosseous (<6, 14 or 16 gauge, IO needle
preferred)• Fluids 20ml/kg RL• If after 40ml/kg –give pRBC 10ml/kg(AB0)
Intraosseous Line
• Less than 6 years of age• Fluids, blood products, and drugs can be given• Proximal tibia or distal femur best location• Fracture of the bone only contraindication• Obtain alternate access ASAP
Circulation
Signs of adequate perfusion -Slowing HR (<100) -Increase in Pulse Pressure(>20)
-Normal skin color -Increase warmth of extremities
-Improving GCS
-Increase systolic BP (>80)
-Urinary output-1-2 infant/ 1 child
Circulation
If hemodynamic remains unstable• hemorrhage intraabdominal or pelvic• cardiac dysfunction • tension pneumothorax• CNS (atlantooccipital dissociation)• profound hypothermia
Disability
• A rapid CNS evaluation A—alert V—voice responsive P—pain responsive
U—unresponsive• Pupillary responsiveness and symmetry
Disability
• GCS 13-15 mild TBI; 9-12 moderate TBI; 3-8 severe TBI (70% mortality)
• May have significant blood loss from associated scalp laceration
• Basilar skull fracture– Raccoon's eyes, hemotympanum, otorrhea,
rhinorrhea– Indicates significant force but not important
to immediate outcome– No prophylactic antibiotics
Disability
• Open sutures (the fontanelles) -Ant. Open age 12-18mo
-Post. Open 2mo• Thinner cranial bones• Head relatively larger -heat
loss -higher center of gravity-more head trauma
Exposure
• Relatively small size– greater likelihood of multiple organ injury
• Higher BMR and surface area– heat loss and increase oxygen consumption
• Increased glucose needs and low glycogen– small glycogen stores therefore monitor glucose levels.
Exposure
• Hypothermia effects– cognitive function– cardiac activity– coagulation
• Keep core temp 35 to 36 degrees Celsius
– warm room, bed, fluids, gases
Other thoughts
• Gastric dilatation-NG tube– respiratory compromise and vagal bradycardia.
Decreases risk of aspiration.– no if facial fx or rhinorhea
• Foley only after perineal assessment• ECG-rarely abnormal but if it is then multiple
possibilities.
CNS Injury
• Cause of 70% of the deaths.• <2 Non-Accidental Trauma (abuse) is the
most common cause.• >2 falls, MVA, bicycle, pedestrian.• Traumatic Brain Injury
-Primary or Secondary
Primary
• Structural derangement of cerebral architecture from direct mechanical impact-cellular and vascular disruption
-infarction
-tissue loss
-epidural hematoma(thin skull)
-subdural (less common)
Secondary
• Decreased cerebral perfusion after the event– brain swelling leads to impairment of O2 and substrate.
– treatment principle is to protect cerebral perfusion and is the difference between disaster and success.
CPP=MAP-ICP
Secondary
• Maintain ICP <20mmHg in all ages• CPP >45mmHg in <8 years• CPP>70 to 80 mmHg older than 8 years
– intubate and controlled hyperventilation
• Pco2 30 to 35, Po2>100,and PH 7.4 -ventriculostomy to optimize CPP-osmotherapy (Mannitol or 3%Saline)-mild to moderate hypertension
• Decompressive craniectomy when ICP refractory
Spinal Cord Injury
• C1 and C2 fx unlike adults C6/C7• Compression and flexion distraction
fx– (Chance)
• SCIWORA-Spinal cord injury without radiologic abnormality– 10-20% of SCI– a documented neurologic deficit that
may have changed or resolved• MRI
The Childs Chest
• Narrow airway-obstructs easier• Anterior/Superior glottis-difficult
intubation• Shorter trachea-endobronchial intubation• Diaphragmatic breathing-hypoxia with
abdominal distension• Compliant rib cage-retraction and injury• Mobile mediastinum-tension pnemo
Clinical Predictors of Chest Injury
• Hypotension• Increased respiratory rate• Abnormal physical exam of chest• Femur Fx• GCS<15
– 98% of proven chest injuries had 1 or more of these.
Thoracic Injuries
• Second leading cause of death• In absence of external signs of trauma
significant intrathoracic injury– pliable chest– mobile mediastinum
• >50% of rib fx in <3 year olds– abuse
Thoracic Injury
• Pneumothorax-blunt burst type injury usually• Not all need chest tubes. If <20% and O2 Sat OK.• 4th or 5th intercostal space• Newborn 12 –16F• Infant 16 –18 F• School age 18-24 F• Adolescent 28 –32 F
Pneumothorax
Tension Pneumothorax
(usually a major injury if seen)• Severe distress,trachea shift, neck vein
distension, collapsed lung with flattened diaphragm, reduced venous return to heart.
• Treatment immediate needle-catheter (without waiting for Xray) 2nd intercostal space anteriorly or lateral in 4th or 5th .
Hemothorax
• Most bleeding stops-low pressure pulmonary circulation
• Massive-laceration of vessel (intercostal commonest)
• Thoracotomy consider: -Initial blood 20-25% of EBV -4ml/kg/hr
-Increasing bleeding-If can’t get out clot
Pulmonary Contusion
• Commonest Injury• Rare to need ventilation• Rare to go on to ARDS• Differentiate from Aspiration• Most clear in 7 to 10 days.
Trachea and Bronchi
• Rare but often fatal• Presentation-Voice disturbance, cyanosis,
hemoptysis,• Massive sub Q air and mediastinal
emphysema• Large leak from chest tube.• ATLS and then OR unless stable
Heart and Pericardium
• Concussion –commotio cordis• Contusion-commonest and difficult to
diagnosis (rarely of clinical significance in children)
• Myocardial rupture-commonest cause of death in blunt trauma. (if survive may see tamponade.)
Pericardial Tamponade
• Suspect when-tachycardia, peripheral vasoconstriction, jugular venous distension, persistent hypotension despite fluids.
• Beck’s triad-elevated jugular venous pressure, systemic hypotension, muffled heart sounds (rarely seen in acute trauma)
• Diagnosis –FAST exam and transthoracic echo.
Traumatic Asphyxia
• Unique to Children• Compression of Chest and/or Abdomen against a
closed glottis• Increase in intrathoracic pressure leads to increase
in the SVC pressure and the veins from the upper body that drain into it.
• Extravasation of blood into skin, sclera, brain• Seizures, disorientation, petechiae of upper body
and conjunctivae• Most recover
Petechiae
Pediatric Abdomen Difference
• Thin musculature (particularly <2)• Ribs flexible-don’t protect or dissipate energy• Solid organs larger• Lower fat content• Elastic attachments• Higher bladder
The Abdomen Exam
• Abdominal wall bruising:– 74% of children with had major injury– 99% of children without had none
• Lower rib fracture:– associated with 31% splenic injury and 15%
hepatic injury
The FAST?
• Focused Assessment Sonography in Trauma• Useful – free fluid detection, pericardial +/-• Not useful-solid organ injury (does not determine
grade)• Limitations: user dependent, high false negative
results.• Conclusions: Get CT if suspicious.
Solid Organ Injury
Splenic Laceration Liver Laceration
Solid Organ Injury
• The non-operative management:– Universally successful and the standard of care
>90%– Yet: The operative rate is 4 to 6 times greater in
non-pediatric centers.• Operate when hemodynamic instability
unresponsive to crystalloid and blood transfusion
.
Lab studies and blunt abdominal trauma
• CBC,TandC• U/A• Transaminases : elevated AST and ALT
strong association alone with injury.• Pancreatic enzymes: controversial but
baseline importance.
Seat Belt Sign
Bowel Injuries
CT or not CT
• Glasgow coma scale 14 or >• No evidence of abdominal wall trauma• No abdominal tenderness• No complaints of abdominal pain• No vomiting• No thoracic wall trauma• No decreased breath sounds.
Case Study: KW
• 11 yo female presented 16 hours following fall on cement block
• CC epigastric pain, nausea and emesis
• PMH/PSH negligible
Case Study: KW
• Physical Exam
• Afebrile, HR 120, BP 90/50
• NAD, Pale, lethargic, dry mucous membranes
• Abdomen soft, ND, TTP epigastrium, abrasion across left subcostal extending across anterior chest
Pancreatic Injury
Pancreatic Injury
• Treated non-operatively• NPO/IVF/TPN• PTD 7, +Clears introduced• PTD 14 discharged home on TPN and clear diet• 10/2 ultrasound, no pseudocyst, diet advanced
Pediatric Renal Trauma
• Most commonly injured abdominal organ in blunt trauma.– Fetal lobulations predispose to renal seperation– Less protection by pliable thoracic cage and less
developed musculature– Higher incidence of pedicle injury
• 80 % with renal injury has associated non-renal injuries
Pediatric Renal Trauma
• Pre-existing renal abnormalities are 3-5 times more common in peds patients undergoing screening CT for trauma than in adults.
• Classically, congenital renal abnormality presents with hematuria disproportionate to severity of trauma
Organ Injury Scale
Case Study: BF
• 15 y/o male presents to OSH after he was hit with a line drive while playing indoor baseball
• C/O pain to R abdomen/rib/flank• Pain is getting progressively worse and
patient is now vomiting
Case Study BF: Exam
• No acute abdominal tenderness• Unilateral rib x-rays negative• Labs drawn-CBC, CMP, PT/PTT• Given Vicodin and Zofran for pain and
nausea• UA ordered and staff recognized gross
hematuria, A/P CT was ordered
Case Study BF: Diagnosis
• CT shows at least AAST grade III laceration involving the medial interpolar right kidney with moderate surrounding perinephric hematoma.
• Patient transferred to RO Beaumont for eval.
Case Study BF: Admit
• Admit to Peds Urology• q6hr Hgb • -strict bed rest • -IVF • -pain control • -PICU for monitoring • -Type and Cross
Case Study BF: Disposition
• Patient was treated non-operatively • He remained in Pediatric ICU for 2 days, and
was transferred to the peds floor for 4 more days.
• Was discharged on day 6; home care included bedrest for 1 month and no school
Case Study: GSW
• 3 year old boy found fathers 45 under mattress inserted in mouth and pulled the trigger. Presents with bleeding from mouth and exit wound below mandible on right.
• A: Unable to visualize cords (blood and swelling)
• B: Harsh breath sounds• C: BP normal, mild Tachycardia• D: Crying (Glasgow 15)
Case Study: GSW
• Discrepancies in story• Changing history• Inappropriate response
– parents and child• Multiple injuries in past• Classic abuse injuries• Child’s development• Sexual abuse
Child Abuse “Red Flags”
Injuries that would be suspicious for abuse
• Multiple SDH, retinal hemorrhage• Ruptured viscus without antecedent history• Perianal, genital trauma• Multiple scars, fractures of varying age• Long bone fractures less than 3 years old• Bizarre injuries: bites, cigarette burns, rope
marks• Sharply demarcated burns
Overview: What’s the difference
Characteristic• Large BSA• Poor neck musculature• Large blood volume in head• Decreased alveolar surface area• High metabolic rate• Small airway• Heart high in chest• Small pericardial sac• Compliant skeleton• Thin walled, small abdomen• Poorly developed renal function
Result• Hypothermia• Flex/extension injury• Cerebral edema• Rapid desats• Rapid desats• Inc airway resistance• Injury/tamponade• Injury/tamponade• Fracture less common• Organs not protected• Risk renal failure
Questions?