Chapter 17 Trauma in Children

1. Chapter 17 Trauma in Children

2. Trauma in Children Trauma in Children

3. Overview Effective techniques to gain confidence Injuries based on mechanisms of injury ITLS Primary and Secondary Surveys Consent and the need for immediate transport Pediatric equipment needs Various methods of SMR on child EMS involvement in prevention programs Trauma in Children -

4. Trauma in Children Different from adults • Different patterns of injuries • Different responses to those injuries • Special equipment required • Assessment equipment and treatment equipment • Difficult to assess and communicate • Come with caregivers and other family members Trauma in Children -

5. Communicating Family-centered care is critical. • Caregiver not always parent. • Involve caregivers as much as possible in care. • Give explanations and careful instructions. • Inclusion and respect will improve stabilization. • Keep caregivers in physical and verbal contact. Demonstrate competence and compassion. Trauma in Children -

6. Assessing Mental Status Consoled or distracted • Most sensitive indicator of adequate perfusion • Caregivers best at detecting subtle changes Initial level of consciousness • Preschool child: sleeping vs. unconscious • Most will not sleep through arrival of ambulance • Ask caregivers to wake child • Suspect hypoxia, shock, head trauma, seizure Trauma in Children -

7. Communicating Interaction strategies • Appropriate language for developmental level • Speak simply, slowly, clearly • Be gentle and firm • Avoid “no” questions • Get a favorite belonging • Get on child’s level • Explain SMR necessity • Allow caregiver to accompany child Trauma in Children -

8. Caregiver Consent Critical care should not be delayed. Emergency care needed • Consent not available • Transport before permission, document why, notify medical direction • Consent denied • Try to persuade, document actions, obtain signature • Notify law enforcement and appropriate authorities • Report suspected abuse Trauma in Children -

9. Pediatric Equipment Length-based tape • Weight estimate • Fluid and medication doses precalculated • Common equipment size estimates Photo courtesy of Kyee Han, MD Trauma in Children -

10. Mechanisms of Injury Falls • Usually land on head • Serious head injury unusual from <27 inches • Protective gear MVCs • Seat-belt syndrome • Liver, spleen, intestines, lumbar spine Auto-pedestrian crashes Trauma in Children -

11. Mechanisms of Injury Burns Airway obstruction • Foreign body Child abuse • Suspect if history does not match injury • Story keeps changing Trauma in Children -

12. Airway in Children Signs of obstruction • Apnea • Stridor • “Gurgling” respiration Contribute to obstruction • Hyperextension • Hyperflexion Courtesy of Bob Page, NREMT-P Trauma in Children -

13. Airway in Children Opening airway • Tongue is large; tissue soft • Jaw-thrust • Oropharyngeal airway • Nasopharyngeal airways • Too small to work predictably • Neonate obligate nose breather • Clear nose with bulb syringe Trauma in Children -

14. Breathing in Children Work of breathing • Retractions, flaring, grunting • Persistent grunting requires ventilation Respiratory rate • Fast, then periods of apnea or very slow Minor blunt neck trauma can be critical. Trauma in Children -

15. Ventilation Rate 20, 15, 10 20 per minute for <1 year 15 per minute for >1 year 10 per minute for adolescent Trauma in Children -

16. Breathing Management Effective BVM ventilation— intubation is elective. Trauma in Children -

17. Endotracheal Intubation Oral endotracheal intubation • No blind nasotracheal intubation for <8 years Uncuffed tube • Length-based tape system • Same diameter as tip of child’s little finger • Frequently reassess placement Trauma in Children -

18. Circulation in Children Persistent tachycardia is most reliable indicator of shock. Trauma in Children -

19. Circulation in Children Early shock more difficult to determine. • Persistent tachycardia • Rate >130 usually shock in all ages except neonates • Prolonged capillary refill and cool extremities • Level of consciousness • Circulation can be poor even if child is awake • Low blood pressure is sign of late shock. • BP <80 mmHg in child; <70 mmHg in young infant Trauma in Children -

20. Shock in Children Strong compensatory mechanisms • Appear surprisingly good in early shock • “Crash” when deteriorate • Be prepared • Fluid administration 20 mL/kg in each bolus • Consider intraosseous infusion • Frequent Ongoing Exams Trauma in Children -

21. Pediatric Trauma Center Criteria • Obstructed airway • Need for airway intervention • Respiratory distress • Shock • Altered mental status • Dilated pupil • Glasgow Coma Scale score <13 • Pediatric Trauma Score <8 Trauma in Children -

22. Pediatric Trauma Center Mechanism that predicts severe injury • Fall from height >10 feet • Motor-vehicle collision • MVC with fatalities • Ejection from an automobile in a MVC • In MVC, significant intrusion into compartment • Hit by a car as a pedestrian or bicyclist • Fractures in more than one extremity • Significant injury to more than one organ system Trauma in Children -

23. Pediatric Trauma Center Recommended • Burns • Near-drowning • Head injuries with loss of consciousness Notify hospital as early as possible. Trauma in Children -

24. Life-Threatening Injuries Head injury • Most common cause of death • Level of consciousness change best indicator • Pupil assessment important • Treatment • High-flow oxygen • Hyperventilate only with cerebral herniation syndrome • Fluid administration titrated to systolic BP • Preschool child: 80 mmHg; older child: 90 mmHg • Be prepared to prevent aspiration Trauma in Children -

25. Life-Threatening Injuries Chest injury • Respiratory distress common • Pneumothorax or tension pneumothorax • Difficult to assess • Needle thoracostomy can be life-saving • Pulmonary contusion • Rare injuries • Rib fractures, flail chest, aortic rupture, pericardial tamponade Trauma in Children -

26. Life-Threatening Injuries Abdominal injury • Liver and/or spleen rupture • Second leading cause of traumatic death • Bleeding often contained within organ • Difficult to diagnose • Severe injury with minimal signs • Suspect with any abnormal abdominal assessment • Be prepared to prevent aspiration. Trauma in Children -

27. Life-Threatening Injuries Spinal injury • Uncommon before adolescence • <9 years usually upper cervical-spine injuries • >9 years usually lower cervical-spine injuries • Higher incidence of SCIWORAspinal-cord injury without radiographic abnormality • SMR • Pad under torso for neutral position • May have to secure without cervical collar • Do not restrict chest movement Trauma in Children -

28. Child Restraint Seats Child in car seat • Serious injury • Remove from car seat • Apply SMR • No apparent injury • Secure and transport in car seat Trauma in Children -

29. Child Neglect and Abuse A leading cause of death in U.S. • Be alert to signs • Transport if suspected • Know local laws Trauma in Children -

30. Summary Good trauma care for children • Proper equipment • Interact with frightened caregivers • Know normal vital signs for various ages • Reference chart • Be familiar with common injuries in children • Be active in prevention programs Trauma in Children -

31. Discussion Trauma in Children -