Case Presentation: Pediatric Trauma - University of … Presentation: Pediatric Trauma Jerrod Keith,...

Case PresentationCase PresentationPediatric TraumaPediatric Trauma

Jerrod Keith MDJerrod Keith MDUniversity of ColoradoUniversity of Colorado

General Surgery Grand RoundsGeneral Surgery Grand RoundsOctober 1October 1stst 2007 2007

HPIHPI

4yo healthy male4yo healthy maleMVC headMVC head--on at 65mphon at 65mphBack seat passengerBack seat passengerRestrained by lap beltRestrained by lap beltCrying at the sceneCrying at the sceneUnable to move lower extremitiesUnable to move lower extremitiesTaken to outside hospitalTaken to outside hospital

Outside HospitalOutside Hospital

HypotensiveHypotensive2 units 2 units pRBCspRBCs 800ml NS 800ml NS

hcthct 185 185 INR 172INR 172 72430349137243034913--1313IntubatedIntubatedDislocated right ankleDislocated right ankle

Reduced and splintedReduced and splinted

Head CT Head CT ndashndash normalnormalChest CT Chest CT ndashndash normalnormalAbdominal CTAbdominal CThelliphellip

Abdominal CTAbdominal CT

Aortic thrombosis extending into bilateral Aortic thrombosis extending into bilateral iliacsiliacsL2 Chance fractureL2 Chance fractureFree abdominal fluidFree abdominal fluidMesenteric injuryMesenteric injuryRight sided abdominal wall ruptureRight sided abdominal wall rupture

Transfer to TCHTransfer to TCH

100cc 100cc pRBCspRBCs enrouteenrouteArrived approx 3 hours since MVCABG 703496313 BE -18 Hct 247 platelets 208PT 191 INR 158 PTT 35

Additional fluid resuscitationAdditional fluid resuscitationPlacement of left chest tube for effusionPlacement of left chest tube for effusionTo ORTo OR

Emergent Exploratory LaparotomyEmergent Exploratory Laparotomy

Evacuation of Evacuation of intraperitonealintraperitoneal bloodbloodLigationLigation of bleeding mesenteric vesselsof bleeding mesenteric vessels

Multiple mesenteric tearsMultiple mesenteric tears

Packing of right abdominal wall disruptionPacking of right abdominal wall disruption


Aortic repairAortic repairLongitudinal Longitudinal aortotomyaortotomyComplete circumferential transection of the intima Complete circumferential transection of the intima below IMA sliding inferiorly and occluding bilateral below IMA sliding inferiorly and occluding bilateral iliacsiliacsDistal intima pulled up and tacked downDistal intima pulled up and tacked downDistal thrombectomiesDistal thrombectomiesAorta closed longitudinally with running Aorta closed longitudinally with running proleneprolene


Traumatic transection of the terminal ileum Traumatic transection of the terminal ileum from the cecumfrom the cecumResection of Resection of devascularizeddevascularized bowelbowel

Included some ascending colonIncluded some ascending colon

Three segments of closedThree segments of closed--loop bowelloop bowelvented with drainsvented with drains

Open abdomenOpen abdomen


Prophylactic bilateral lower extremity Prophylactic bilateral lower extremity fasciotomiesfasciotomiesRight chest tube for effusionRight chest tube for effusion

To PICU on dopamine and epinephrineTo PICU on dopamine and epinephrineABG 736356720 BE ABG 736356720 BE --5555Hematocrit 39Hematocrit 39Platelets 109Platelets 109INR 117INR 117


EBL 3 Liters Fluid Replacement

14 units pRBCs1 liter FFP13 platelet random donor units24mg Factor VIIa65 L crystalloid500ml Albumin

UOP 1800ml

POD 1POD 1

Continued resuscitationContinued resuscitationProfound respiratory failureARDSProfound respiratory failureARDS

HypoxemiaHypoxemiaSwitched from conventional ventilation to High Switched from conventional ventilation to High Frequency Oscillatory Ventilation (HFOV)Frequency Oscillatory Ventilation (HFOV)Improved respiratory statusImproved respiratory status

Taken back to OR for Taken back to OR for decompensationdecompensationResection of necrotic ileum ascending colon and Resection of necrotic ileum ascending colon and left colonleft colon

Postoperative CoursePostoperative Course

Abdominal washout POD 1 and 3Abdominal washout POD 1 and 3Abdominal closure POD 5Abdominal closure POD 5

115cm of proximal small bowel ends as jejunostomy115cm of proximal small bowel ends as jejunostomyTransverse colon mucous fistulaTransverse colon mucous fistulaHartmannHartmannrsquorsquos pouchs pouch

Fevers POD10Fevers POD10Candida from tracheal aspirateCandida from tracheal aspirate

Extubated POD 14Extubated POD 14


Spinal fusion on POD 33Spinal fusion on POD 33

CurrentlyCurrentlyAwake and alertAwake and alertAbdominal wound closedAbdominal wound closedPO intake + tube feedsPO intake + tube feedsParaplegiaParaplegia

Approx T10 levelApprox T10 level

Seat Belt SyndromeSeat Belt SyndromeGarret and Garret and BraunsteinBraunstein in 1962in 1962Hip and abdominal contusionsHip and abdominal contusions

ldquoldquoseat belt signseat belt signrdquordquo

Pelvic fracturesPelvic fracturesIntraabdominal injuriesIntraabdominal injuries

Solid and hollow visceraSolid and hollow viscera

Lumbar spine injuriesLumbar spine injuriesSubluxationsSubluxations and compression fractures L2and compression fractures L2--44

Abdominal Wall EcchymosisAbdominal Wall Ecchymosis

2004 2004 J Pediatric SurgeryJ Pediatric Surgery Lutz et al Lutz et al147985 children in 102548 crashes147985 children in 102548 crashesOccurred in 133Occurred in 133

Intraabdominal injury occurred in 115Intraabdominal injury occurred in 115Significant intraSignificant intra--abdominal injury 232 times more abdominal injury 232 times more likelylikely

Sensitivity Sensitivity ndashndash 735735Negative predictive value Negative predictive value ndashndash 999999

Mechanism of InjuryMechanism of Injury

Improper position of lap belt serves as a fulcrum Improper position of lap belt serves as a fulcrum during rapid decelerationduring rapid deceleration

Spine Spine hyperflexeshyperflexesDirect pressure on abdominal visceraDirect pressure on abdominal viscera

Presubmarining and jackknifing

Classic submarining

Submariningjackknifing

IntraIntra--abdominal Injuriesabdominal Injuries

GI tract perforationsGI tract perforationsSmall bowel mesenteric tearsSmall bowel mesenteric tearsSolid organ injurySolid organ injury

Due to direct compressionDue to direct compression

Lumbar Spine InjuriesLumbar Spine Injuries

Compression fracturesCompression fracturesChance fracturesChance fractures

Horizontal fracturesHorizontal fracturesSpinous processSpinous processPediclesPediclesVertebral bodyVertebral body

Rupture of posterior ligaments in up to 50Rupture of posterior ligaments in up to 50

Seat Belt AortaSeat Belt Aorta

Dissection of the intima caused by direct Dissection of the intima caused by direct compression of the vessel between the compression of the vessel between the horizontal part of the seat belt and the horizontal part of the seat belt and the vertebraevertebraeDescribed in 1979 by Described in 1979 by DajeeDajee et alet alTwo forcesTwo forces

Direct compressionDirect compressionIndirect shear forcesIndirect shear forces


Blunt injury to Blunt injury to abdominalabdominal aorta is uncommonaorta is uncommonAortic injury after blunt trauma occurs in 10Aortic injury after blunt trauma occurs in 10--1515

lt5 involves abdominal aortalt5 involves abdominal aorta1997 1997 J TraumaJ Trauma ndashndash 62 reported cases62 reported cases

Commonly associated injuriesCommonly associated injuriesSeat belt sign Seat belt sign ndashndash 4747Bowel injury Bowel injury ndashndash 4747LumbosacralLumbosacral spine injury spine injury ndashndash 3535

Mortality rate 24Mortality rate 24


Recognized abnormalitiesRecognized abnormalities39 39 -- intimal injury with acute and complete vessel intimal injury with acute and complete vessel occlusionocclusion16 16 -- intimal tears without occlusionintimal tears without occlusion15 15 -- true aneurysmstrue aneurysms5 5 -- aortic ruptureaortic rupture

Aortic Occlusion Secondary to Aortic Occlusion Secondary to Blunt TraumaBlunt Trauma

2002 2002 J TraumaJ Trauma MeghooMeghoo et al et al 36 reported cases36 reported cases

78 cases from 78 cases from MVCsMVCs

Prolapse of distal intimal flap after Prolapse of distal intimal flap after circumferential tearcircumferential tearAccompanying Accompanying subintimalsubintimal thrombusthrombus

Higher incidence in atherosclerotic diseaseHigher incidence in atherosclerotic disease

Mortality 41Mortality 41

Our PatientOur Patient

Rare injury triadRare injury triadAbdominal aortic injuryAbdominal aortic injuryLumbar Chance fractureLumbar Chance fractureMesentericvisceral injuriesMesentericvisceral injuries

12 reported cases in pediatric patients12 reported cases in pediatric patients2006 2006 J TraumaJ Trauma ChoitChoit et alet alAll secondary to All secondary to MVCsMVCs7 lap belts7 lap belts5 unknown restraints5 unknown restraints

Proper RestraintsProper Restraints

2007 2007 Journal of TraumaJournal of Trauma ArbogastArbogast et alet alRestrained children with abdominal organ Restrained children with abdominal organ injuriesinjuriesLow injury rates in other vehicle occupantsLow injury rates in other vehicle occupants

40 drivers 40 drivers 10 other child occupants10 other child occupants

Suboptimal restrained kids 38 times more likely Suboptimal restrained kids 38 times more likely to suffer intraabdominal injuryto suffer intraabdominal injury

High Frequency Oscillatory High Frequency Oscillatory Ventilation (HFOV)Ventilation (HFOV)

Introduced in 1972Introduced in 1972Reciprocating pumps or diaphragmsReciprocating pumps or diaphragms

Active inspiration and expirationActive inspiration and expiration

Small tidal volumes (Small tidal volumes (VVTTss))Higher mean airway pressure (mPaw)Higher mean airway pressure (mPaw)

Limits alveolar Limits alveolar derecruitmentderecruitment and overdistentionand overdistention

Rapid respiratory ratesRapid respiratory ratesAdequate gas exchangeAdequate gas exchange

Chan K P W et al Chest 20071311907-1916

Schematic representation of the purported waveforms of HFOV and conventional pressure-controlled ventilation in the distal airways

HFOVHFOV

Oscillating piston pump (or diaphragm)Oscillating piston pump (or diaphragm)180 to 600 breathsmin (3 to 10 Hz)180 to 600 breathsmin (3 to 10 Hz)Active inspiration and expirationActive inspiration and expiration

Inspiratory bias gas flow (30 to 60 Lmin)Inspiratory bias gas flow (30 to 60 Lmin)mPawmPaw

Resistance valveResistance valvemPawmPaw

OxygenationOxygenationFiO2 and mPawFiO2 and mPaw

VentilationVentilationRespiratory frequency and pressure amplitudeRespiratory frequency and pressure amplitude

Mechanism of Gas TransportMechanism of Gas Transport

Conventional Mechanical Ventilation (CMV)Conventional Mechanical Ventilation (CMV)Convective or bulk flowConvective or bulk flow

HFOVHFOVConvective and diffusiveConvective and diffusive

Bulk flow proximallyBulk flow proximallyAsymmetric velocity profilesAsymmetric velocity profilesTaylor dispersionTaylor dispersionPendelluftPendelluftCollateral ventilationCollateral ventilationCardiogenic mixingCardiogenic mixing

Krishnan J A et al Chest 2000118795-807

Proposed mechanisms of gas transport during HFV

1) Direct Bulk Flow2) Longitudinal (Taylor)

dispersion3) Pendelluft4) Asymmetric velocity

profiles5) Cardiogenic mixing6) Molecular diffusion

VentilatorVentilator--Induced Lung InjuryInduced Lung Injury

Increased in ALIARDSIncreased in ALIARDSBarotraumaBarotrauma

Secondary to pressureSecondary to pressure

VolutraumaVolutraumaAlveolar overdistentionAlveolar overdistentionDistributed to compliant lungDistributed to compliant lung

AtelectraumaAtelectraumaParenchymalParenchymal injuryinjuryRepetitive openingcollapse of distal airwaysRepetitive openingcollapse of distal airways

HFOVHFOV

LungLung--protective strategies developedprotective strategies developedHFOV may be idealHFOV may be ideal

Comparatively higher mPawComparatively higher mPawAllows recruitmentprevents Allows recruitmentprevents derecruitmentderecruitmentHigher endHigher end--expiratory lung volumeexpiratory lung volume

Lower tidal volumeLower tidal volumeGas exchange at lower airway pressuresGas exchange at lower airway pressuresLimits alveolar overdistentionLimits alveolar overdistentionLess cardiovascular effectLess cardiovascular effect

ldquoldquoOpen LungOpen Lungrdquordquo conceptconceptMaintains open airwaysMaintains open airways

HFOVHFOV

Conversion to HFOVConversion to HFOVPeak pressures gt35cm H2OPeak pressures gt35cm H2OmPaw approaches 15 to 18cm H2OmPaw approaches 15 to 18cm H2OFiO2 gt 06FiO2 gt 06

Better to convert earlierBetter to convert earlier of days on CMV was an independent predictor of mortality of days on CMV was an independent predictor of mortality

Initial settingsInitial settingsFiO2 09 FiO2 09 ndashndash 1010mPaw 5cm above last measured mPaw on CMVmPaw 5cm above last measured mPaw on CMVBias flow 40LminBias flow 40LminConsider recruitment maneuversConsider recruitment maneuvers

PRCT CMV PRCT CMV vsvs HFOVHFOV

2002 2002 Am J Am J RespResp CritCrit Care Care DerdakDerdak et alet al148 adults 13 centers148 adults 13 centers

HFOV earlier improvement in PaO2FiO2 ratioHFOV earlier improvement in PaO2FiO2 ratiolt16 hourslt16 hoursDid not persist beyond 24 hoursDid not persist beyond 24 hours

HFOV HFOV nonsignificantnonsignificant trend toward lower 30trend toward lower 30--day mortalityday mortality37 37 vsvs 52 (p=0102)52 (p=0102)

Similar but low adverse eventsSimilar but low adverse eventsPrior to ARDS Network trialPrior to ARDS Network trial

VVTTss 10mlkg used10mlkg used

ARDS in Surgical PatientsARDS in Surgical Patients2006 2006 J TraumaJ Trauma Kao et alKao et al16 surgical patients with ARDS16 surgical patients with ARDS

Oxygenation failureOxygenation failure

HFOV significant findingsHFOV significant findingsIncreased PaO2FiO2 ratio after 30 minIncreased PaO2FiO2 ratio after 30 min

Maintained after 12 hours out to 40 hoursMaintained after 12 hours out to 40 hours

Oxygenation index decreased at 24 and 32 hrsOxygenation index decreased at 24 and 32 hrsOI [ FiO2 x mPaw x 100 PaO2 ]OI [ FiO2 x mPaw x 100 PaO2 ]

No change in systolic BPNo change in systolic BPNo complicationsNo complications

PediatricsPediatrics

No pediatric studies to support lung protective No pediatric studies to support lung protective strategy in ARDSstrategy in ARDSMost HFOV studies looking at neonatesMost HFOV studies looking at neonatesJaballahJaballah et al 20 patientset al 20 patients

Failed CMV switched to HFOVFailed CMV switched to HFOVAfter 1 hourAfter 1 hour

Improved ventilation in all 20Improved ventilation in all 20Improved oxygenation in 1920Improved oxygenation in 1920

Only 1 death from respiratory failureOnly 1 death from respiratory failure

HFOV SummaryHFOV Summary

2007 review of HFOV in ARDS2007 review of HFOV in ARDS2 2 PRCTsPRCTs and 12 case seriesand 12 case seriesSafe and consistently improves oxygenation Safe and consistently improves oxygenation when used as rescue mode for ventilationwhen used as rescue mode for ventilation

Delayed initiation of HFOV is an independent Delayed initiation of HFOV is an independent predictor of deathpredictor of deathTrend towards lower mortalityTrend towards lower mortality

AAP AAP -- Car Seat GuidelinesCar Seat GuidelinesRearRear--facing seatfacing seat

Infant Infant 1 year 1 year andand 20 lbs20 lbsForwardForward--facing seatfacing seat

Until 3Until 3--5 years old or 405 years old or 40--60 lbs60 lbsBooster seat with lapshoulder beltBooster seat with lapshoulder belt

Until approx 8Until approx 8--12 years old12 years oldUntil 4Until 4rsquorsquo 99rdquordquo

Seat beltSeat beltShoulder belt crosses mid chestShoulder belt crosses mid chestLap belt across upper thighs not stomachLap belt across upper thighs not stomachKnees bent over seatKnees bent over seat

ReferencesReferences

Durbin D et al Seat belt syndrome in children A case report Durbin D et al Seat belt syndrome in children A case report and review of the and review of the literature literature PedPed Emergency CareEmergency Care 2001 1716 4742001 1716 474--477477ArbogastArbogast K et al Mechanisms of abdominal organ injury in seat beltK et al Mechanisms of abdominal organ injury in seat belt--restrained restrained children children J TraumaJ Trauma 2007 6214732007 621473--14806831480683MeghooMeghoo C et al Complete occlusion after blunt injury to the abdominC et al Complete occlusion after blunt injury to the abdominal aorta al aorta J J TraumaTrauma 200355795200355795--799799ChoitChoit R et al Abdominal aortic injuries associated with chance fraR et al Abdominal aortic injuries associated with chance fractures in pediatric ctures in pediatric patients patients J J PedPed SurgSurg 20064111842006411184--11901190Lutz N et al Incidence and clinical significance of abdominalLutz N et al Incidence and clinical significance of abdominal wall bruising in wall bruising in restrained children involved in motor vehicle crashes restrained children involved in motor vehicle crashes J J PedsPeds SurgSurg 2004 399722004 39972--975975LalencetteLalencette M et al SeatM et al Seat--belt aorta A rare injury associated with blunt abdominal belt aorta A rare injury associated with blunt abdominal trauma trauma Ann Ann VascVasc SurgSurg 200620681200620681--Turner D and Arnold J Insights in pediatric ventilation timinTurner D and Arnold J Insights in pediatric ventilation timing of g of intubationintubation ventilatoryventilatory strategies and weaning strategies and weaning Current Opinion in Critical Care Current Opinion in Critical Care 2007 13572007 1357--6363Kao K et al High frequency oscillatory ventilation for surgicKao K et al High frequency oscillatory ventilation for surgical patients with acute al patients with acute respiratory distress syndrome respiratory distress syndrome J TraumaJ Trauma 2006 614837 2006 614837--843843Chan K et al HighChan K et al High--frequency oscillatory ventilation for adult patients with ARDS frequency oscillatory ventilation for adult patients with ARDS ChestChest 2007 131619072007 13161907--19161916Krishnan J and Brower R HighKrishnan J and Brower R High--frequency ventilation for acute lung injury and ARDS frequency ventilation for acute lung injury and ARDS ChestChest 2000 118 7952000 118 795--807807

Case PresentationPediatric Trauma

HPI

Outside Hospital

Abdominal CT

Transfer to TCH

Emergent Exploratory Laparotomy





POD 1

Postoperative Course


Seat Belt Syndrome

Abdominal Wall Ecchymosis

Mechanism of Injury

Intra-abdominal Injuries

Lumbar Spine Injuries

Seat Belt Aorta

Seat Belt Aorta

Seat Belt Aorta

Aortic Occlusion Secondary to Blunt Trauma

Our Patient

Proper Restraints

High Frequency Oscillatory Ventilation (HFOV)

HFOV

Mechanism of Gas Transport

Ventilator-Induced Lung Injury

HFOV

HFOV

PRCT CMV vs HFOV

ARDS in Surgical Patients

Pediatrics

HFOV Summary

AAP - Car Seat Guidelines

References

HPIHPI

4yo healthy male4yo healthy maleMVC headMVC head--on at 65mphon at 65mphBack seat passengerBack seat passengerRestrained by lap beltRestrained by lap beltCrying at the sceneCrying at the sceneUnable to move lower extremitiesUnable to move lower extremitiesTaken to outside hospitalTaken to outside hospital




























UOP 1800ml

POD 1POD 1


























Classic submarining








































HFOVHFOV




















HFOVHFOV





HFOVHFOV
































HPI

Outside Hospital

Abdominal CT

Transfer to TCH






POD 1



Seat Belt Syndrome


Mechanism of Injury



Seat Belt Aorta

Seat Belt Aorta

Seat Belt Aorta


Our Patient

Proper Restraints


HFOV



HFOV

HFOV

PRCT CMV vs HFOV


Pediatrics

HFOV Summary


References




























UOP 1800ml

POD 1POD 1


























Classic submarining








































HFOVHFOV




















HFOVHFOV





HFOVHFOV
































HPI

Outside Hospital

Abdominal CT

Transfer to TCH






POD 1



Seat Belt Syndrome


Mechanism of Injury



Seat Belt Aorta

Seat Belt Aorta

Seat Belt Aorta


Our Patient

Proper Restraints


HFOV



HFOV

HFOV

PRCT CMV vs HFOV


Pediatrics

HFOV Summary


References

POD 1POD 1


























Classic submarining








































HFOVHFOV




















HFOVHFOV





HFOVHFOV
































HPI

Outside Hospital

Abdominal CT

Transfer to TCH






POD 1



Seat Belt Syndrome


Mechanism of Injury



Seat Belt Aorta

Seat Belt Aorta

Seat Belt Aorta


Our Patient

Proper Restraints


HFOV



HFOV

HFOV

PRCT CMV vs HFOV


Pediatrics

HFOV Summary


References























Classic submarining








































HFOVHFOV




















HFOVHFOV





HFOVHFOV
































HPI

Outside Hospital

Abdominal CT

Transfer to TCH






POD 1



Seat Belt Syndrome


Mechanism of Injury



Seat Belt Aorta

Seat Belt Aorta

Seat Belt Aorta


Our Patient

Proper Restraints


HFOV



HFOV

HFOV

PRCT CMV vs HFOV


Pediatrics

HFOV Summary


References







































HFOVHFOV




















HFOVHFOV





HFOVHFOV
































HPI

Outside Hospital

Abdominal CT

Transfer to TCH






POD 1



Seat Belt Syndrome


Mechanism of Injury



Seat Belt Aorta

Seat Belt Aorta

Seat Belt Aorta


Our Patient

Proper Restraints


HFOV



HFOV

HFOV

PRCT CMV vs HFOV


Pediatrics

HFOV Summary


References















HFOVHFOV





HFOVHFOV
































HPI

Outside Hospital

Abdominal CT

Transfer to TCH






POD 1



Seat Belt Syndrome


Mechanism of Injury



Seat Belt Aorta

Seat Belt Aorta

Seat Belt Aorta


Our Patient

Proper Restraints


HFOV



HFOV

HFOV

PRCT CMV vs HFOV


Pediatrics

HFOV Summary


References

HFOVHFOV
































HPI

Outside Hospital

Abdominal CT

Transfer to TCH






POD 1



Seat Belt Syndrome


Mechanism of Injury



Seat Belt Aorta

Seat Belt Aorta

Seat Belt Aorta


Our Patient

Proper Restraints


HFOV



HFOV

HFOV

PRCT CMV vs HFOV


Pediatrics

HFOV Summary


References





























HPI

Outside Hospital

Abdominal CT

Transfer to TCH






POD 1



Seat Belt Syndrome


Mechanism of Injury



Seat Belt Aorta

Seat Belt Aorta

Seat Belt Aorta


Our Patient

Proper Restraints


HFOV



HFOV

HFOV

PRCT CMV vs HFOV


Pediatrics

HFOV Summary


References

Case Presentation: Pediatric Trauma - University of … Presentation: Pediatric Trauma Jerrod Keith,...

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