Pediatric Trauma

1. Pediatric Trauma James Huffman, PGY-2 August 2, 2007 Special thanks to Dr. Vincent Grant & Dr. Katharine Smart

2. Objectives • Identify the unique characteristics of the child as a trauma patient: • Types and patterns of injury • Anatomic and physiologic differences from adults • Discuss primary management of critical injuries in children • Airway management • Shock / Fluids • Head injuries

3. Outline • Pediatric-specific trauma issues • Assessment/Management • Pediatric Assessment Triangle • Primary • ABCDEF • Secondary • Adjuvant testing • Current status in Calgary

4. Short Snapper:Name the condition • Tachypnea • Hypoxemia • Hypotension • +/- JVD • +/- absent breath sounds Tension Pneumothorax

5. Case #1 • 5yo male • MVC – rollover • Ejected, found 6 meters from vehicle • 120, 92/58, 362, 26, 94% on room air • GCS=10 (E2, V3, M5) What are some special considerations in pediatric trauma?

6. Special Considerations“Not just little adults” • pre-injury level of functioning • mechanism of injury • size and shape • skeleton • surface area • psychologic status • long-term effects • equipment

7. Special Considerations:Mechanism • Blunt (80%) • Head injuries very common (55%) • Apnea, hypoventilation and hypoxia occur 5 times more commonly than hypovolemia and hypotension in seriously injured children (ATLS Manual, 7th Edition) •  Aggressive management of airway and breathing • Consider non-accidental trauma • Up to ~35% of trauma deaths

8. Special Considerations:Size and Shape • Greater force per unit body area • Less body fat • less connective tissue • Organs at close proximity to surface  High frequency of multiple organ injuries

9. Special Considerations:Size and Shape • Larger head • prone to head injuries • major source of heat loss • prominent occiput • cranial bones thinner • Shorter neck • Supports a relatively larger mass • More frequently disrupt upper cervical vertebrae or their ligamentous attachments • SCIWORA = 50% of kids with SCI

10. Special Considerations:Size and Shape • Larynx • more cephalad / anterior • Epiglottis • tilted at 45 • “floppy” • Cricoid cartilage • narrowest part of airway in children < 8 years old

11. Special Considerations:Size and Shape • Thorax • More pliable • Ribs cartilaginous and flexible • Less overlying muscle and fat • Mobile mediastinum  Contusions (common) Fractures(rare)  Blunt force transmitted to underlying tissues

12. Special Considerations:Size and Shape • Abdomen • Less protected by ribs and muscles • Organs less insulated by fat  1) Small forces may cause significant injury  2) Significant injuries with minimal external evidence

13. Special Considerations:Skeleton • Incomplete calcification • Growth centers – weak point • Salter-Harris classification • More pliable  Organ damage without overlying bony fractures

14. Special Considerations:Surface Area • Surface area / volume ratio • Highest at birth • Decreases with age  Thermal energy loss significant • Hypothermia may develop quickly • Good for head-injured patients • Badfor hypotensive patients

15. Special Considerations:Psychological Status • Impaired ability to interact • Unfamiliar individuals • Strange environment • Emotional instability • Fear / pain / stress • Parents often unavailable  History taking and cooperation can be difficult

16. Special Considerations:Long-term Effects • Injury may impact growth / development • 60% of children with severe, multisystem trauma have residual personality changes at 1 year* • 50% show cognitive or physical handicaps* • Impact on family structure * ATLS Manual, 7th Edition

17. Special Considerations:Family Presence • Not just “one patient” • Advantages • availability of historical data • comfort to child • Disadvantages • may be a distraction • may influence care of patient

18. Special Considerations:Family Presence • Facilitate 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 trauma bay

19. Special Considerations: Equipment What do you want to have ready for the arrival of our patient?

20. Special Considerations:Equipment • Multiple sizes of everything • Broselow™ Equipment systems • Broselow™ Measuring Tape • Resuscitation Guides

21. Back to the case: Are there any tools you know of to rapidly assess how sick this child is?

22. PEDIATRIC ASSESSMENT TRIANGLE

23. Pediatric Assessment Triangle Appearance Work of Breathing Circulation to Skin

24. Pediatric Assessment Triangle The Triangle focuses on three aspects of physical assessment that reflect: • Severity of illness or injury • Urgency of intervention

25. Pediatric Assessment Triangle • Appearance • Mental status and muscle tone • Suggests level of consciousness • Work of Breathing • Increased, laboured, or decreased • Indicates the adequacy of ventilation and oxygenation • Circulation • Skin and mucous membrane colour • Reflects the adequacy of oxygenation and perfusion

26. Our patient: • Appearance: • Abnormal (↓ LOC, ↓ tone) • Work of Breathing: • Normal • Circulation: • Abnormal (Pallor, some mild mottling)

27. Primary Survey A – Airway with C-spine protection B – Breathing C – Circulation and hemorrhage control D – Disability / neurologic screening exam E – Exposure and environmental control F – Films / fluids / foley

28. Primary Survey:Airway Anatomy: • Disproportion between size of cranium and midface  passive c-spine flexion • Needs padding under shoulders/torso • Relatively large soft tissues • Funnel-shaped larynx, more cephalad and anterior • Epiglottis • Short trachea

30. Primary Survey:Airway Assessment: • Does the child have a patent airway? • Blood, emesis, maxillofacial trauma, neck trauma • Assess visually, auscultation (stridor) • Can the child protect their airway? • Level of consciousness

31. Primary Survey:Level of consciousness • “AVPU” • A – alert • V – voice • P – pain • U – unresponsive in general GCS < 8

32. Primary Survey:Airway / C-spine • Always suspect a c-spine injury • Immobilize all patients • Rigid collar • Rolls / sandbags • In-line stabilization

33. Primary Survey:Airway Management: • Jaw thrust – “sniffing position” • Clear debris/secretions • Oxygen • Oral airway *insertion technique • ET intubation • Needle cricothyrotomy Use the Broselow Tape!!

34. Case: Continued • 132, 84/56, 362, 26, 90% on room air • No obvious facial trauma, no debris in airway • No stridor • ?Responding to verbal commands and definitely to painful stimuli How do you assess his breathing?

35. Primary Survey:Breathing Is the child able to: a) Ventilate? (exchange CO2) b) Oxygenate? (exchange O2) *Hypoxia is the most common cause of cardiac arrest in the child

36. Primary Survey:Breathing Assessment: • Spontaneous respirations • Tachypnea / work of breathing • Breath sounds • Cyanosis • SaO2 • Chest symmetry • Tracheal deviation • Neck vein distention • Changes in mental status

37. Primary Survey:Breathing Interventions: • 100% O2 • BVM Ventilation • Definitive airway • ETT • Surgical • Needle / Tube thoracostomy

38. Case: Continued • ↓ breath sounds on the right • Trachea deviated to the left • More tachypnea since EMS arrival • ↓ LOC since EMS arrival What do you want to do now?

39. Case: Continued • 14g angiocath placed in 2nd intercostal space mid-clavicular line. • “Whoosh” of air • 122, 92/60, 362, 22, 94% on room air • Assistant preps for chest tube placement • However, patient is now not responding to voice at all What do you want to do now?

40. Airway Protection unconscious severe facial trauma risk for aspiration risk for obstruction Oxygenation/Ventilation apnea paralysis  LOC inadequate resps tachypnea hypoxia cyanosis severe closed head injury Primary Survey:Intubation

41. Primary Survey:Intubation • Remember pitfalls!! • ETT size • Broselow • internal diameter = 4 + age (y)/4 • width of patient’s 5th finger or nare • ETT insertion distance • short tracheas compared to adults • infants = 5cm; toddler @ 18 mo = 7 cm • distance = 12 + age (y)/2 (> 2 yo) • distance = internal diameter of ETT x 3 • Cuffed?

42. Straight Blade Technique Curved Blade Technique

43. Primary Survey:Intubation • The “P”s of RSI • preparation • Preoxygenation • Premedication • paralysis • “pass the tube” • position of ETT

44. Primary Survey:Intubation - Premedication • Atropine • anticholinergic • prevent  HR (age < 2-6 yrs) •  airway secretions • dose 0.02mg/kg (min 0.1 mg; max 2 mg) • Lidocaine • Analgesic (morphine, fentanyl)

45. Short Snapper:Name the condition • Tachypnea • Hypoxemia • Hypotension • Muffled heart sounds • +/- JVD Pericardial Tamponade

46. Case: Continued • Patient intubated and placement confirmed A, B, then C… How do we assess circulation? *In reality, ABC’s are managed in parallel/simultaneous fashion

47. Primary Survey:Circulation Assessment: • Early hemorrhagic shock • Difficult to diagnose because of compensation • ↓ BP is an ominous sign (30% loss required for alteration) • Tachycardia • Skin perfusion • Pulses • LOC • Hemorrhage • Urine output

48. Primary Survey:Circulation

49. Primary Survey: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

50. Case: Continued • 126, 86/58, 362, 22, 94% • Skin becoming more mottled, cool, dry • Cap refill >3 seconds • Intubated • Minimal urine output • Abdomen soft / no external hemorrhage • Obvious deformity right femur How do you want to proceed?