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PEDIATRIC TRAUMA STANDARDIZING CARE !/?

PEDIATRIC TRAUMA STANDARDIZING CARE !/?. DAVID A. LISTMAN, MD DIRECTOR PEDIATRIC EMERGENCY MEDICINE ST. BARNABAS HOSPITAL. LEARNING OBJECTIVES. EPIDEMIOLOGY/ HISTORY ATLS PRIMARY SURVEY/RESUSCITATION SECONDARY SURVEY PEDIATRIC SPECIFIC ISSUES REFERENCES. EPIDEMIOLOGY/ HISTORY.

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PEDIATRIC TRAUMA STANDARDIZING CARE !/?

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  1. PEDIATRIC TRAUMASTANDARDIZING CARE !/? DAVID A. LISTMAN, MD DIRECTOR PEDIATRIC EMERGENCY MEDICINE ST. BARNABAS HOSPITAL

  2. LEARNING OBJECTIVES • EPIDEMIOLOGY/ HISTORY • ATLS • PRIMARY SURVEY/RESUSCITATION • SECONDARY SURVEY • PEDIATRIC SPECIFIC ISSUES • REFERENCES

  3. EPIDEMIOLOGY/ HISTORY • 5 million trauma related deaths worldwide in 2000 • Age <20 in US visits for injuries • 10 million ED visits and • > 10 million primary care office visits • 300,000 pediatric hospitalizations annually • 11,090 injury related pediatric deaths per year

  4. INTRODUCTION • Trauma - # 1 cause of death in children older than 1 year • Effective initial resuscitation can reduce mortality by 25-30% (Stafford et al 2004) • National Pediatric Trauma Databank 2008 (≤ 19 yrs): • 474 Trauma Centers (127 Level 1) • 108,863 cases from 2007 record

  5. NATIONAL PEDIATRIC TRAUMA DATA BANK 2008

  6. NATIONAL PEDIATRIC TRAUMA DATA BANK 2008

  7. MECHANISM OF INJURY • Motor vehicle/traffic: 31.5% of injuries • Increases at 14 years of age with a peak at 19 years of age • Associated with largest number of hospital/ICU days • 47% of all mortalities • Falls: 26.6% of injuries • Peak at 19 years • 2nd highest hospital/ICU days • 4.2% of all mortalities • Firearms 5.7% of injuries • Peak at 19 years • 26% of all mortalities

  8. TRI- MODAL DISTRIBUTION OF DEATHS • First peak- within seconds to minutes of injury • Second Peak- within minutes to several hours of injury • Third Peak- days to weeks after the injury

  9. TRI- MODAL DISTRIBUTION OF DEATHS • First peak- within seconds to minutes of injury • Apnea- brain or spinal cord injury • Rupture of the heart or great vessels • Treatment- prevention • Second Peak- within minutes to several hours of injury • Third Peak- days to weeks after the injury

  10. TRI- MODAL DISTRIBUTION OF DEATHS • First peak- within seconds to minutes of injury • Second Peak- within minutes to several hours of injury • Subdural and epidural hematomas • Hemopneumothorax • Ruptured spleen/ liver • Pelvis fx’s and other sources of major blood loss • Treatment- golden hour and ATLS • Third Peak- days to weeks after the injury

  11. TRI- MODAL DISTRIBUTION OF DEATHS • First peak- within seconds to minutes of injury • Second Peak- within minutes to several hours of injury • Third Peak- days to weeks after the injury • Sepsis • Multi organ system failure • Treatment- maximize care during preceding stages, Hospital/ ICU care

  12. Friday Sept 30, 2005

  13. HOW DO WE IMPROVE SURVIVAL DURING SECOND PEAK? • Standardize evidence based best practices • A 1976 crash of a private plane piloted by an Orthopedic surgeon. His wife and children were on board. • Hospital care in rural Nebraska was substandard • 1978- 1st ATLS course to standardize initial care of trauma patients by doctors who do not manage major trauma regularly.

  14. CASE • 4 year old female in stroller • Mother and stroller hit by car • Child ejected from stroller • No LOC • C-spine immobilized at scene • Minor contusions and abrasions of scalp

  15. CASE • 4 year old female in stroller • Does patient require trauma evaluation? • What if any radiologic workup should be done?

  16. Who requires trauma evaluation?

  17. ACTIVATION OF TRAUMA TEAM • Level of activation determined by • Physiologic parameters • Anatomic location/type of injury • Mechanism of injury • Options: code, alert, consultation

  18. ACTIVATION OF TRAUMA TEAM • Trauma Alert • Anatomic • Significant injuries above and below the diaphragm • 2 or more proximal long bone fractures • Burn of 15-30% BSA (second/third degree burn) • Traumatic amputation of limb proximal to wrist or ankle • Crush injury of torso • Spinal injury with paralysis

  19. ACTIVATION OF TRAUMA TEAM • Trauma Alert • Mechanism • Ejection from automobile • Extrication > 20 minutes • Fatality of another passenger • Intrusion of vehicle by collision • Unrestrained passenger or vehicle traveling > 20 mph • Fall  20 feet • Pedestrian struck at significant rate of speed • Lightning

  20. ACTIVATION OF TRAUMA TEAM • Trauma Code • Physiologic • Cardiopulmonary arrest • Hypotention (by age) • Respiratory distress • Neurologic failure (GCS8)

  21. ACTIVATION OF TRAUMA TEAM • TraumaCode • Anatomic • Penetrating wound to head, chest or abdomen (prox to knees/ elbows) • Burn > 30% BSA, inhalation airway burn • Major electrical injury

  22. Who requires trauma evaluation? • All patients with significant or potentially significant injury should have a systematic evaluation

  23. Standard Precautions • Cap • Gown • Gloves • Mask • Shoe covers • Goggles / face shield

  24. INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES • Primary Survey • Airway • Breathing • Circulation • A,B,C’s with special trauma concerns

  25. INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES • Primary Survey • Airway maintenance, with cervical spine control • Breathing, with special concern for pneumothorax • Circulation- control bleeding • Disability- neurologic deficits • Exposure- expose (examine) all of patient & prevent hypothermia • Resuscitation • Oxygenation, airway management, ventilation • Shock management • Intubations – urinary tract, gastrointestinal tract

  26. INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES • As you perform the Primary Survey, stop and intervene as needed • Airway maintenance, with cervical spine control • Airway positioning • Oxygen • Airway adjuncts- nasopharyngeal airway, oral airway • Endotracheal intubation • Surgical Airway

  27. CHIN LIFT MANEUVER • Airway obstruction by tongue and epiglottis • Relief by head-tilt/chin-lift

  28. Airway Management Basic Techniques Chin-lift Maneuver

  29. Airway Management Basic Techniques Jaw-thrust Maneuver

  30. INDICATIONS FOR INTUBATION • Shock • Cardiac arrest • Respiratory distress or failure • Severe head injury • GCS < 8

  31. RAPID SEQUENCE INTUBATION I • Preoxygenate with 100% O2, insert IV lines, attach cardiac/respiratory monitor • Prepare equipment for possible emergency surgical airway • Inline manual immobilization of cervical spine • Lidocaine 1.5 mg/kg (for elevated ICP) • Atropine 0.02 mg/kg (minimum of 0.1 mg, maximum 0.5 mg) to prevent bradycardia • Begin Sellick maneuver (cricothyroid pressure to prevent vomiting and aspiration)

  32. RAPID SEQUENCE INTUBATION II • Paralyzing agent • Rocuronium (0.6 – 1.0 mg/kg) or • Vecuronium (0.1 mg/kg) • Succinyl Choline (1mg/kg) • Sedative agent: problem specific • Hypotension: Etomidate (0.3 mg/kg) • Head injury without hypotension: Thiopental (3-5 mg/kg) • Severe asthma: Ketamine (1-2 mg/kg) • Oral intubation • Confirm location of ET tube with end-tidal CO2 measurement

  33. SURGICAL AIRWAY • RARELY needed in children • AVOID in children < 12 years due to small target size and risk of damage to surrounding structures (Reamy 2004) • Indications: failure to intubate, apneic with c-spine injury, facial trauma with c-spine injury, severe facial and neck trauma • Needle cricothyroidotomy with needle jet insufflation is a short term solution

  34. SURGICAL AIRWAY

  35. SURGICAL AIRWAY

  36. COMPLICATIONS OF SURGICAL AIRWAY • Hemorrhage • Laceration of surrounding structures • Subcutaneous emphysema • Hypoxia after failed/prolonged attempts • Aspiration • Infection • Tracheal stenosis or cricoid cartilage damage

  37. INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES • Primary Survey • Breathing, with special concern for pneumothorax • If pneumothorax suspected and patient unstable- needle decompression • If pneumothorax suspected and patient stable- x-ray and chest tube • Pt may require intubation and mechanical ventilation • Prevent hypoxemia

  38. INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES • Primary Survey • Circulation- control bleeding • Control Bleeding • External- direct pressure • Bony- align and splint fractures • Internal- surgery/ interventional radiology • Establish 2 large bore IV’s • Crystalloid fluid • O neg blood

  39. SHOCK I • Early recognition of shock critical • Tachycardia, pain, anxiety • Decreased pulse pressure (<20mm Hg) • Mottled skin, warm/cool extremities • Most common cause is hypovolemic shock due to hemorrhage • BUT beware of: • Spinal cord injury can cause distributive shock • Cardiac tamponade or tension pneumothorax can cause obstructive shock

  40. SHOCK II • Minimum systolic BP: [70 + 2 (age in years)] • Compensated shock • Normal BP (may see orthostatic changes) • Tachycardia • Tachypnea • Bounding pulses, widened pulse pressure • Altered mental status • Warm and dry extremities • Delayed capillary refill (> 2 seconds) • Uncompensated shock • Hypotension • Severe tachypnea • Cold extremities • Capillary refill > 4 seconds

  41. SHOCKMANAGEMENT I • 20cc/kg infused rapidly • 0.9% NaCl or Lactated Ringer’s solution • 2 large bore IV’s • If severe shock  10cc/kg type specific or O- packed red blood cells • Identify and treat source of bleeding

  42. SHOCKMANAGEMENT II • Maintain urine output 1-2cc/kg/hour • Monitor urine output with catheter/feeding tube placed in urethra • Contraindications to catheter placement • Pelvic fracture • Blood at urethral meatus • Blood in the scrotum

  43. VENOUS ACCESS • 2 attempts peripheral vein • Intraosseous needle • Central line • Complications: arrhythmias, thrombosis, and embolism • Locations • Subclavian vein • Femoral vein • Jugular vein • Cutdown

  44. VENOUS ACCESS: INTRAOSSEOUS NEEDLE PLACEMENT

  45. VENOUS ACCESS: INTRAOSSEOUS NEEDLE PLACEMENT

  46. INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES • Primary Survey • Disability- neurologic deficits • Level of consciousness- GCS

  47. Glasgow Coma Scale • Eye Opening • Spontaneous – 4 • To speech – 3 • To pain – 2 • No Response – 1 • Best Motor Response • Obeys -6 • Localizes – 5 • Withdraws – 4 • Abnormal flexion – 3 • Extension response – 2 • No Response – 1 • Verbal response • Oriented – 5 • Confused conversation – 4 • Inappropriate words – 3 • Incomprehensible sounds – 2 • No response - 1

  48. GLASCOW COMA SCORE

  49. Glasgow Coma Scale A strong predictor of outcome • 13: mild brain injury • 9-12: Moderate brain injury • < 8: Severe brain injury (coma)

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