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Pediatric Trauma

Pediatric Trauma. Julie Williamson, DO Clinical Assistant Professor of Anesthesia and Pediatrics Lucile Packard Children’s Hospital. Objectives: to review. Epidemiology of trauma The Primary Survey (ABCs) Fluid resuscitation and massive transfusion Non-Neurologic Injury

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Pediatric Trauma

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  1. Pediatric Trauma Julie Williamson, DO Clinical Assistant Professor of Anesthesia and Pediatrics Lucile Packard Children’s Hospital

  2. Objectives:to review • Epidemiology of trauma • The Primary Survey (ABCs) • Fluid resuscitation and massive transfusion • Non-Neurologic Injury • Traumatic Brain Injury

  3. Introduction • Trauma is the leading cause of death in children and young adults in the US (ages 1-44 years old) • Most pediatric deaths from trauma involve motor vehicles • Brain injury is most common cause of death • In children, about half involve multiple organs or body regions

  4. 5 Leading Causes of Death, California2006, All Races, Both Sexes WISQARSTMProduced By: Office of Statistics and Programming, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention Data Source: National Center for Health Statistics (NCHS), National Vital Statistics System

  5. Ages 1 to 4 years

  6. Ages 5 to 9 years

  7. Ages 10 to 14 years

  8. Incidence and Mortality of Pediatric Trauma From Roger’s Textbook of Pediatric Intensive Care, fourth edition

  9. Changes in Mortality1987 - 2004 http://www.usa.safekids.org National Center for Health Statistics. Centers for Disease Control and Prevention. National Vital Statistics System. WISQARS Injury Mortality Reports, 1987 to 2004. Hyattsville (MD): National Center for Health Statistics, 2007

  10. Children are different • Smaller bodies mean more kinetic injury into a smaller space  impact on multiple organs • Larger BSA  heat loss • Anterior liver and spleen, mobile kidneys • Immature bone has increased elasticity  more soft tissue injury (misleading lack of fractures) • Head:body greater, cranial bones thinner • More robust response to catechol driven vasoconstriction  preserved blood pressure until catastrophic shock ensues • More likely to suffer a respiratory than cardiac arrest

  11. Initial AssessmentThe “Platinum Half Hour” • “Scoop and run” vs. “stay and play” • Out of hospital airway management • Improved outcomes associated with care in a pediatric trauma center/hospital with PICU • Loss of airway and IV access twice as common during transport, 10 times more common if not a specialized team

  12. Image from calhoun.cc.al.us

  13. The Pediatric AirwayAnatomic Differences and Trauma Management • Relatively larger tongue – most common cause of airway obstruction • Larger adenoids • Floppy omega shaped epiglottis • Larynx appears more cephalad and anterior • Cricoid ring is narrowest part of airway • Narrow tracheal diameter, smaller distance between rings • Shorter tracheal lengths ( 4 cm newborn, 7 in 18 month old) • Large airways more narrow

  14. Primary Survey:Airway and C Spine • Assume C spine injury in pediatric trauma • Jaw thrust, oral airway • Assume full stomach/RSI indicated • Induction agents – risks of propofol, ketamine, etomidate and succinylcholine • Pre-oxygenation • Avoid nasal intubation with severe facial/head trauma. Blind NI less successful in children • Consider cuffed ETT • Needle cricothyroidotomy (no slash trachs in kids) • Orogastric tube to decompress stomach

  15. A note about C spines • More likely to have high cervical trauma under 8 years old (OA fulcrum) • Radiographs are over and under-read • SCIWORA • Harder to immobilize • CT scan vs. MRI Tuggle David W, Garza Jennifer, "Chapter 46. Pediatric Trauma" (Chapter). Feliciano DV, Mattox KL, Moore EE: Trauma, 6th Edition: http://www.accesssurgery.com.laneproxy.stanford.edu/content.aspx?aID=169962.

  16. Primary Survey:Breathing • Apply 100% oxygen immediately while doing primary survey • Watch for age-appropriate respiratory rates • Hypercarbia/inadequate ventilation often under appreciated • Pneumothorax more difficult to diagnose by auscultation due to transmitted breath sounds. If hemodynamically unstable, needle chest early • Respiratory arrest from C spine injury

  17. Primary Survey:Circulation • Intravenous access • 3 attempts, 90 seconds, or obtunded  IO • Large bore PIV is optimal • CVL or cut down PIV • Control of hemorrhage • Direct pressure over bleeding • Tourniquets? • Hemorrhage into thorax, retroperitoneum, thigh or intracranial in infants • More then 3cc/kg/hour from chest tube is an indication for operation • Aortic injury is 2nd cause of death after TBI

  18. Primary Survey:Circulation • Hypotension is a late finding correlating to loss of 30% of circulating blood volume • Monitor for poor perfusion or confusion • 20cc/kg warmed isotonic solution X 2 then PRBC • Crystalloid vs. colloid? • 0.9 NS or LR • Colloid • 3% saline • Albumin • Hetastarch  coagulopathy • Blood products • Over-resuscitation • Edema, abd compartment syndrome, ARDS, hypothermia

  19. Blood Products and Massive Transfusion Protocols • Emergency release blood – O neg or O pos • ABO & Rh type specific uncrossmatched blood • Dilutional thrombocytopenia after replacement of ½ blood volume • After replacement of one blood volume with type O, stick with O • Early coagulopathy • MTP protocols: 1:1:1 PRB to FFP to Platelets • “Storage lesion” • Whole warmed blood • Activated factor VII in children?

  20. Primary Survey: Disability Pediatric GCS or AVPU Check pupil size and reactivity

  21. Primary Survey: Disability • Orthopedic injuries • Primary cause of operative intervention in pediatric trauma • Greenstick and buckle fractures • Growth plate injury • Supracondylar fractures • Immobilize and monitor vascular status • Vascular injury • 95% limb salvage

  22. Primary Survey: Disability • Fully undress patient – keep warm • Look under collar and splints • Log roll patient, exam back • Rectal exam

  23. Primary Survey: Exposure and Environment • Complete visual inspection • Maintain normothermia • Platelet inhibition below 34 C • 100% mortality below 32 C • Hyperthermia causes secondary injury in TBI

  24. The TRIAD OF DEATH isHYPOTHERMIAACIDOSISCOAGULOPATHY

  25. Monitor and Reassess • Perfusion and mentation • Lactate or base deficit • Do NOT wait for labs or radiographs to indicate need to evacuate pneumothorax or transfuse

  26. Secondary Survey • Continuously resuscitate and reassess – vital signs every 5 to 15 minutes • Easy to miss orthopedic injuries • Plain films • FAST • CT

  27. Thoracic Injury • 4 – 25% of pediatric trauma, up to 40% mortality • Low SBP, elevated RR, external thoracic injury or femur fracture associated with intrathoracic injury • Compliant chest wall • Mobile mediastinum • Pneumothorax • Hemothorax • Aortic injury accounts for 14% of mortality

  28. Abdominal Injury • Thin body wall and closely spaced organs • Any external markings or tenderness are ominous • Gastric decompression to benefit ventilation • Diaphragmatic rupture • Gastric rupture • Bowel injury injury • Splenic or hepatic injury • Renal injury

  29. Traumatic Brain Injury Among children ages 0 to 14 years, TBI results in an estimated: • 2,685 deaths; • 37,000 hospitalizations • 35,000 emergency department visits annually What causes TBI? • Falls (28%); • Motor vehicle-traffic crashes (20%); • Struck by/against events (19%); and • Assaults (11%) Langlois JA. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2004.

  30. Subdural and epidural hematomas Vascular injuries – SAH and IVH serve as markers of severity

  31. Control of secondary injury • Mass effect • Parenchyma • CSF • Blood • Hypoxia • Ischemia • Target thresholds in children?

  32. Management of TBI:Control secondary injury • Normothermia vs. hypothermia (why doesn’t this work in kids??) • Normoventilation: PCO2 < 25 ischemia • Osmolar therapy - rheology • Mannitol • Hypertonic Saline • ICP and CPP mangement – what numbers are adequate in children? • Decompressive craniotomy • CSF drainage • Glycemic control – not a simple answer • Coagulopathy -30% incidence of DIC in children with severe TBI

  33. References • Avarello JT and Cantor RM, Pediatric Major Trauma: An approach to evaluation and management. Emerg Med Clin N Am 25 (2007) 803-836. • Tuggle David W, Garza Jennifer, "Chapter 46. Pediatric Trauma" (Chapter). Feliciano DV, Mattox KL, Moore EE: Trauma, 6th Edition: http://www.accesssurgery.com.laneproxy.stanford.edu/content.aspx?aID=169962. • Letarte Peter, "Chapter 20. The Brain" (Chapter). Feliciano DV, Mattox KL, Moore EE: Trauma, 6th Edition: http://www.accesssurgery.com.laneproxy.stanford.edu/content.aspx?aID=157936.

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