Pediatric Trauma Overview Christine Kennedy Pediatric Emergency Fellow July 29th, 2010
Objectives • Review the key differences between pediatric and adult trauma patients • Discuss the approach to Pediatric blunt trauma • Thoracic • Abdominal • Head 3) Review Pediatric penetrating trauma cases
Special Considerations Mechanism of injury
Mechanism of Injury Blunt injury most common (85%) head injury 55% internal injuries 15% Be attentive for the possibility of non-accidental trauma (child abuse)
Special Considerations Size and shape
Size and shape Smaller mass greater force applied per unit body area • Larger head • prone to head injuries • major source of heat loss • prominent occiput • cranial bones thinner
Size and shape Neck weak muscles supports greater mass short / fat Difficult to see trachea and neck veins cervical spine injuries not as common • Larynx • more cephalad & ant • Epiglottis • tilted at 45 & floppy • Cricoid cartilage • narrowest part of airway
Size and shape Thorax more pliable ribs cartilaginous and flexible less overlying muscle and fat Mobile mediastinal structures contusions (common), fractures(rare) blunt force transmitted to underlying tissues
Size and shape Abdomen less protected by ribs and muscles organs less insulated by fat spleen / liver more caudad and anterior small forces may cause significant injury significant injuries with minimal external evidence
Size and shape Abdomen Prone to gastric distension may be difficult to ventilate
Skeleton Incompletely calcified active growth centers pliable internal injuries without overlying bony injuries
Skeleton Growth plates weakest area of bone weaker than ligaments common site of fractures potential impact on growth
Special Considerations Surface area
Surface area Body surface area / body volume ratio highest in infants diminishes as child matures Thermal energy loss significant hypothermia may develop quickly good for head injured patients?? Recent study shows increase in harm with cooling James Hutchison et al. N Engl J Med 2008; 358:2447-2456 bad for hypotensive patients
Special Considerations Psychologic status
Psychologic status impaired ability to interact unfamiliar individuals strange environment emotional instability fear / pain / stress parents often unavailable history taking and cooperation can be difficult (if not impossible!)
Family involvement Not just “one patient” Advantages availability of historical data comfort to child Disadvantages may be a distraction may influence care of patient
Family presence Facilitate family presence 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 resus room
Special Considerations Long-term effects
Long-term effects Children with severe multisystem trauma 60% residual personality changes at 1 year 50% show cognitive and physical handicaps Significant impact on family structure personality and emotional disturbances in 2/3 of uninjured siblings strain on marital relationship
Special Considerations Equipment
Equipment Multiple sizes of everything!! Broselow Measuring Tape
Circulation • What % decrease in circulating blood volume is required to change the vital signs? • What are the key clinical signs? • What is the lower limit of systolic BP?
Circulation • What % decrease in circulating blood volume is required to change the vital signs? • What are the key clinical signs? • What is the lower limit of systolic BP? 30% Tachycardia & CRT 70 + (2 X age)
Tachycardia Why is evaluation of HR so important?
Tachycardia Why is evaluation of HR so important? CO = HR x SV
Circulation • What % decrease in circulating blood volume is required to change the BP?
Circulation • What % decrease in circulating blood volume is required to change the BP? 45%
Circulation • What is a child’s blood volume? • How much blood does this equate to in a 5 year old child?
Circulation • What is a child’s blood volume? • How much blood does this equate to in a 5 year old child? • 5 year old 20 kg • 20 kg = 1600 mL • So a 30% loss in blood volume=480ml (<2 cups!) 80ml/kg
Circulation - Interventions Control hemorrhage Restore volume warmed crystalloid solution 20 mL/kg; repeat X 1 then consider blood blood (10mL/kg packed RBCs)
Intravenous access arm leg
Intravenous access scalp external jugular
Intraosseous any IV drug / fluid same dosing best spot - tibia anteromedial surface 2 cm below tibial tuberosity Be sure to secure!!! How do you know when you’re in?
Circulation issues unusual hemorrhage sites subgaleal
Level of consciousness “AVPU” A – alert V – voice P – pain U – unresponsive in general GCS < 8
Level of consciousness if the patient looks like “PU” . . . . . . they probably can’t protect their airway!
Exposure remove all clothes Look under collar! keep child warm!!! warm blankets warm fluids overhead warmer warm the room
Case 1 • 14 yr old male, 53kg • Checked into boards playing hockey • Skated off ice, complained of mid-back pain • Went back onto ice, hit again, then complained of increasing back pain • Emesis X1 on route to hospital
Case 1 • GCS 15, HR 63, RR 40, BP 141/72 • Sats 100% on O2 10L NRB • Pale, diaphoretic • Pluritic chest pain (L) and dyspnea • No syncope • What now?
3 hours later pt arrives at ACH RR 29, HR 60, BP 107/47 Sat 99% 2L • Decreased A/E to left lung base • Pale & diaphoretic, pain on inspiration • What would you like to do?
Hb 122, plt 238, WBC 11.7 INR 1.2, PTT 27.8 Na 140, K 4.0, Cl 107, CO2 22 Cr 67, BUN 4.8, glc 5.9 Plan now?
Case 1 • Chest tube inserted • Drains 800cc blood • Patient admitted to surgery, but remains in ED • 5 hours later drainage at 1365cc • What would you like to do now?