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Pediatric trauma

Pediatric trauma. Wirut phchiansatian , MD Emergency medicine. Epidemiology. Half of all deaths in children Trauma Motor vehicle crashes (MVCs) Most fatalities occur in the field Most common organ  Head trauma Multiple injuries are common Child abuse

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Pediatric trauma

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  1. Pediatric trauma Wirutphchiansatian , MD Emergency medicine

  2. Epidemiology • Half of all deaths in children • Trauma • Motor vehicle crashes (MVCs) • Most fatalities occur in the field • Most common organ  Head trauma • Multiple injuries are common • Child abuse • 25-35% in Some children's hospitals

  3. Pediatric VS AdultAnatomic and Physiologic differences

  4. Anatomic Differences • Body size • Greater distribution • Multiple trauma is common • Relative body surface • Greater heat loss area • Liver and spleen • More anterior placement • Less protective musculature and subcutaneous tissue mass

  5. Anatomic Differences • Kidney • Less well protected and more mobile • Deceleration injury • Congenital abnormalities • Growth plates • Not yet closed • Salter-type fracturespossible limb-length abnormalities with healing

  6. Anatomic Differences • Head injury • Head-to-body ratio is greater • Brain less myelinated • Cranial bones thinner

  7. Body proportions

  8. Anatomic Differences : Airway • Relatively larger tongue • Most common cause of airway obstruction • Head positioning or use of airway adjunct (oropharyngeal or nasopharyngeal airway) • Larger mass of adenoidal tissues • Nasotracheal intubation • Nasopharyngeal airways • Infants <1 year old

  9. Anatomic Differences : Airway • Epiglottis is floppy and more u-shaped • Use of a straight blade

  10. Anatomic Differences : Airway • Larynx more superior and anterior • Difficult to visualize the cords • Cricoid ring is the narrowest portion • Uncuffed tubes • Up to size 6mm or about 8 years old

  11. Anatomic Differences : Airway • Narrow tracheal diameter and distance between the rings • Tracheostomy more difficult • Surgical cricothyrotomy more difficult • Needle cricothyroidotomy • Emergent surgical airway of choice • Younger than 8 to 10 years old

  12. Needle cricothyroidotomy

  13. Anatomic Differences : Airway • Shorter tracheal length • Intubation of right main stem • Dislodgment • Airways more narrow • Airway resistance (R α 1/radius)

  14. Physiologic Differences • Maintenance requirements • Water, trace metals, minerals • Energy and caloric

  15. Physiologic Differences • Child's physiologic response to injury • Great capacity • Blood losses 25-30% of total blood volume  normal BP • Subtle changes • Heart rate, blood pressure, and extremity perfusion • Impending cardiorespiratory failure

  16. ADVANCED TRAUMA LIFE SUPPORT ( ATLS )

  17. THE CONCEPT • Outline of ATLS consists of • Primary survey & Resuscitation • Adjuncts to primary survey • Secondary survey • Adjuncts to secondary survey • Continued monitoring and reevaluation • Definitive care

  18. Primary survey and resuscitation • The primary survey in ATLS consist of. • A : Airway maintenance with cervical spine protection. • B : Breathing and ventilation. • C : Circulation with hemorrhage control. • D : Disability or Neurologicstatus. • E : Exposure and environmental control

  19. A-Airway and Cervical Spine Stabilization • Possible airway obstruction • clearing the oropharynx of debris • jaw-thrust maneuver • Stabilize neck

  20. B-Breathing and Ventilation • Adequacy of chest rise • Bag valve mask device • Gastric distention and impair ventilation • diaphragm  ventilatory status • cricoid pressure • early placement of a nasogastric tube

  21. B-Breathing and Ventilation Indications for endotracheal intubation • Inability to ventilate by bag valve mask or need for prolonged control of the airway • GCS score < 9 • Respiratory failure • hypoxemia (flail chest, pulmonary contusions) • hypoventilation (injury to airway structures) • Decompensated shock

  22. C-Circulation and Hemorrhage Control • Pediatric vasculature • constrict and increase systemic vascular resistance • Signs of poor perfusion • cool distal extremities, decreases in peripheral versus central pulse quality, delayed capillary refill time

  23. C-Circulation and Hemorrhage Control

  24. D-Disability Assessment • Glasgow Coma Scale (GCS) • AVPU System • A - Alert • V - Responds to Verbal stimuli • P - Responds to Painful stimuli • U - Unresponsive

  25. E-Exposure and Thorough Examination • Fully undressing • Assess for hidden injury • Hypothermia

  26. F-Family • Rapidly informing the family • Caregiver is present • Explain the process

  27. Secondary Survey • Complete head-to-toe examination • Appropriate tetanus immunization • Antibiotics as indicated • Continued monitoring of vital signs • Ensure urine output of 1 mL/kg/hr • AMPLE History

  28. Specific Pediatric Injuries

  29. Specific disorders/injuries • Leading cause of traumatic death • Head injuries • Thoracic injuries • Abdominal injuries • Cervical Spine Injury

  30. Head Injury • Cranial vault • Larger and heavier in proportion to total body mass • More pliable • Parenchymal injury in the absence of skull fractures • Less myelinated • Shearing forces and further injury

  31. Head Injury Common Symptoms and Signs of Increased Intracranial Pressure in Infants • Full fontanel • Split sutures • Altered state of consciousness • Paradoxical irritability • Persistent emesis • “Setting sun” sign (inability to open eyes fully)

  32. Head Injury Common Symptoms and Signs of Increased Intracranial Pressure in Children • Headache • Stiff neck • Photophobia • Altered state of consciousness • Persistent emesis • Cranial nerve involvement • Papilledema • Hypertension, bradycardia, and hypoventilation • Decorticate or decerebrate posturing

  33. Head Injury • Lucid interval • Epidural hematomas • May be the result of venous bleeding • Subtle and more subacute presentation over days • Associated with overlying skull fractures

  34. Head Injury • Subdural hematomas • Most commonly in < 2 years old • 93% of cases < 1 year old • Shaken baby syndrome • Chronic subdural hematomas • Retinal hemorrhages

  35. Head Injury Recommendations for CT scanning • Neurologic deficits • GCS scores of less than 14 • Major forcible insults Children < 1 year • Special challenge neuro sign • Any loss of consciousness, protracted vomiting, irritability, poor feeding, or suspicion of abuse

  36. Anatomic Differences in the Pediatric Cervical Spine • Relatively larger head size, resulting in greater flexion and extension injuries • Smaller neck muscle mass with ligamentous injuries more common than fractures • Increased flexibility of interspinous ligaments • Flatter facet joints with a more horizontal orientation • Incomplete ossification making interpretation of bony alignment difficult • Basilar odontoidsynchondrosis fuses at 3-7 years of age • Apical odontoid epiphyses fuses at 5-7 years of age • Posterior arch of C1 fuses at 4 years of age • Anterior arch fuses at 7-10 years of age • Epiphyses of spinous process tips may mimic fractures

  37. C1-C2 • Apical odontoid epiphyses fuses at 5-7 years of age • Posterior arch of C1 fuses at 4 years of age

  38. C2 • Basilar odontoid synchondrosis fuses at 3-7 years of age

  39. Anatomic Differences in the Pediatric Cervical Spine • Increased preodontoid space 4-5 mm (3 mm in an adult) • Pseudosubluxationof C2 on C3 seen in 40% of children • Prevertebralspace size may change because of variations with respiration

  40. Preodontoidspace • Increased preodontoid space 4-5 mm (3 mm in an adult)

  41. Pseudosubluxation of C2 on C3

  42. Cervical Spine Injury • SCIWORA • Elasticity of ligamentous structures • 25-50% spinal cord injury (SCI) without radiographic abnormality

  43. Cervical Spine Injury • Anatomic fulcrum of the spine • Underdeveloped neck musculature • Head is disproportionately large and heavy • C2 and C3 vertebrae

  44. Cervical Spine Injury • Pseudosubluxation of C2 on C3 • Common in children up to adolescence Line of Swischuk • Anterior cortical margin of the spinous process of C1 down through the anterior cortical margin of C3 crosses the anterior cortical margin of the spinous process at C2 within 2 mm • No fractures

  45. Line Of Swischuk

  46. Line of Swischuk

  47. Management • Neutral positioning • Large cranium in proportion to the rest of their body • Absence of modified backboards with cutouts for the occiput of the child

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