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Pediatric Trauma- Skills Lab

Pediatric Trauma- Skills Lab. Natalie Wynn RN, BSN Valley Hospital Medical Center Emergency Room. Objectives. Review epidemiological data specific to pediatric trauma • Review the differences between pediatrics and adult patients • Review the mechanism of injury

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Pediatric Trauma- Skills Lab

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  1. Pediatric Trauma- Skills Lab Natalie Wynn RN, BSN Valley Hospital Medical Center Emergency Room

  2. Objectives • Review epidemiological data specific to pediatric trauma • Review the differences between pediatrics and adult patients • Review the mechanism of injury • Outline a general approach to the pediatric trauma patient • Discuss specific considerations for the following injuries: • Head trauma • Chest and abdominal trauma • Burns • Non-accidental trauma

  3. Pediatric Thorax, Abdomen and Pelvis

  4. Key Differences From Adults • Airway • Anatomic differences • Larger head and tongue • Special attention to positioning • Potential for airway obstruction • Place in sniffing position • Shorter trachea • Danger of main stem intubation • Conical shaped trachea • Uncuffed endotracheal tubes • Breathing • Respiratory complications

  5. Pediatric Airway Versus Adult Airway

  6. Signs of Respiratory Distress in Infants

  7. Respiratory Distress Begin immediate positive pressure ventilations • Altered mental status • Bradycardia • Hypotension • Irregular breathing pattern Begin immediate positive pressure ventilations

  8. Severe Respiratory Distress is a Medical Emergency Requires IMMEDIATE INTERVENTIONS!!! • The signs listed here occur late in a respiratory emergency and are an indication that you must immediately intervene and begin positive pressure ventilations:• Altered mental status• Bradycardia• Hypotension • Extremely fast, slow, or irregular breathing pattern• Cyanosis to the mucous membranes and body core (late sign)• Loss of muscle tone (limp appearance)• Diminished or absent breath sounds• Head bobbing• Grunting• See-saw or rocky breathing• Decreased response to pain• Inadequate tidal volume

  9. Key Differences Continued • Circulation • Pediatric patients compensate well but deteriorate quickly. • Less body fat, increased elasticity of connective tissue, and close proximity of organs to the body surface impair dissipation of energy applied. • Incomplete calcification of bones and active growth centers limit absorption of energy and can increase potential for injury.

  10. Key Differences Most pediatric injuries do not cause immediate exsanguination. Blood pressure is a poor indicator of blood loss and peripheral perfusion. Children remain in compensated shock longer than adults, but decline very rapidly.

  11. Mechanisms of Injury Lateral Impact Collisions (T bone) Rear Impact Collisions Rollover Mechanism Open Vehicle or Motorcycle/Moped Pedestrian Vs. Car Penetrating Injury (Guns vs. Knives)

  12. Head Trauma

  13. Head Trauma Key Differences from Adults • Communication barrier • Delay in care and identification of injury • Different injury types • Skull fractures are more clinically significant than adults • More distendable bony skull • Larger head proportionally • Children have fewer intracranial injuries BUT more edema than adults • In children < 20 years of age who deteriorate, 39% have brain swelling only • Children can experience hypovolemic hypotension due to head trauma • Consider non-accidental trauma in young children (<2 years of age) • Nearly 25% of head injured children <2 years • Up to 66% of head injured children < 1 year

  14. Head Trauma • Assessment (Disability) • Pupillary responsiveness • Corneal reflexes • Gag or cough reflex • Spontaneous motor movements • GCS modified scales • Mental status changes

  15. How to Hold Cervical Spine Immobolization To hold a pediatric in cervical spine immobolization, you will need at least three people. One to hold the patient’s neck in central position, the second to hold one hand on the patient’s should and the other on the hip and the thirds to check for posterior injuries. The person at the head counts prior to rolling and is in control of the cervical spine and the others follow directions.

  16. Cervical Spine Immobolization • Immobolize the cervical spine with what you have. Two towel rolls are a good modifier if nothing is available. Maintain in-line spine stabilization Suction as necessary Provide OXYGEN Provide complete spine immobilization

  17. Jaw Thrust Maneuver • Place two or three fingers of each hand at the angle of the jaw to lift it up and forward while the other fingers guide the movement. Insert an airway adjunct if the jaw thrust does not open the airway.

  18. Head Trauma • Increased intracranial pressure • Low GCS • Pupil decreased reactivity and/or inequality • Disconjugate gaze movements • Vomiting • Vital signs • Irregular breathing and heart rate • Widened pulse pressure • This is known as Cushing Triad. • Minor head injury • More pronounced signs and symptoms • Increased incidence of post-impact seizures and vision loss

  19. Head Trauma • High Risk: Cat Scan Recommended for All •   Decreased mental status  Focal neurologic findings  Signs of depressed or basilar skull fractures  Acute skull fracture by clinical examination or skull radiographs (if already obtained)  Irritability  Bulging fontanel  Seizure  Vomiting (5 or more times)  Age <3 months  LOC >1 min

  20. Head Trauma • Intermediate Risk •   Cat Scan scan or observation recommended  3 or 4 episodes of vomiting  Transient LOC (less than1 min)  History of lethargy or irritability, now resolved  Behavior not at baseline  Nonacute skull fracture (injury more than 24 hr old)  Either CT or Skull Radiograph or observation recommended  High-force mechanism  Fall onto a hard surface  Scalp hematoma  Unwitnessed trauma  Vague history with physical signs of traumaLow Risk: Observation Recommended •   Low-energy mechanism with no signs and symptoms 2 hr after trauma

  21. Head Trauma COMMON SYMPTOMS AND SIGNS OF INCREASED INTRACRANIAL PRESSURE IN INFANTS

  22. Signs and Symptoms of Head Trauma

  23. Pediatric Glascow Coma Scale Over 4 years of age, consider using adult Glascow Coma Scale

  24. Chest Trauma Epidemiology • Most serious injuries are from blunt trauma • Motor vehicle accidents • Rarely an isolated chest injury • Common blunt chest injuries • Pulmonary contusions (50%) • Pneumothorax (20%), hemothorax (10%) • Penetrating trauma 15% of pediatric chest trauma • Overall increasing incidence of firearm injuries • Majority are criminal acts • Some secondary to poor supervision

  25. Chest Trauma Key Differences from Adults • Respiratory compromise • Adults use thoracic wall muscles to pull ribs anteriorly • Expanding the chest wall • Children cannot change chest wall circumference • Decreased vital capacity • Increased respiratory rate • Hidden injuries • Compliant rib cage dissipates force of impact • Less bony injury • Less external signs of trauma • Multiple rib fractures are a sign of serious injury • Consider child abuse • Mobile mediastinum • Rapid development of cardiovascular compromise

  26. Chest Trauma Pneumothroax Types • Open pneumothorax Bi-directional airflow • Tension pneumothorax One-directional airflow Hemopneumothorax Blood into the pleural cavity

  27. Chest Trauma • Assessment for a pneumothorax • Children’s smaller thoracic cavity allows easy transmission of lung sounds to opposite side • Listen in the axilla • Appearance and work of breathing • Management • Tension pneumothorax • Large bore IV at the second intercostal space, midclavicular line • OVER the rib • Open pneumothroax • Three way occlusive dressing, or Vaseline dressing • One way valve • Hemothorax • Chest tube placement

  28. Pneumothorax Management Second Intercostal Space Midclavicular Line Find Location, After Insertion, Cover with Occlusive Dressing

  29. Abdominal Trauma • Third leading cause of traumatic death behind head and thoracic injuries • Most common unrecognized fatal injury in children • Blunt trauma related to MVC’s causes over 50% of abdominal trauma • The most lethal mechanism of injury • 5-10% of children suffer from seat belt injuries • Small bowel injury • Chance fracture • Bicycle (handlebar injuries) are also common • Duodenal hematoma or pancreatic injury • May have delay in presenting signs and symptoms • Sport related injuries • Spleen, kidney, intestinal injury • Approximately 5% of abdominal injuries occur from child abuse • Second most common cause of death in child abuse

  30. Abdominal Trauma • Pediatric Abdominal Anatomy • Larger solid organs • Less subcutaneous fat • Less protective musculature • Larger kidneys • Flexible cartilaginous rib cage • Compression of internal organs • More solid organ injury • Liver and spleen

  31. Pediatric Burns • Assessment • Airway, Breathing, Circulation, Disability, Exposure, Focus history • Assess for inhalation injury • Hoarseness • Black sputum or singed facial hair • Facial burns • Accident in closed area • Intubate early to avoid progression of edema • Consider other interventions • Cricothyrotomy

  32. General functions Mental status changes Back to Objectives

  33. Depth of Burns • Burn Assessment • Depth • 1st degree: Sunburn (epidermis) • 2nd degree: Partial or full thickness (dermis) • 3rd degree: Nerve damage (beyond dermis)

  34. Burn Assessment

  35. The Rule of Nines Cause use palm of patient’s hand size ~1% BSA

  36. Burns • Burn Care • Rinse with warm water • Wrap with Saran wrap • Provide warm blankets • Pain management • Frequent re-dosing • Fentanyl greater than Morphine • Resuscitation • Parkland Formula (greater than 30 kiligrams) • Volume = (percent total body surface area burned) x (Body Mass kiligrams) x (4 militers/LR) • ½ volume over 1st 8 hours • ½ volume over next 16 hours • Add maintenance fluids with glucose source • Monitoring • Urine output: 1cc/kiligram/hour

  37. Child Abuse • For all pediatric trauma patients • Do a thorough examination • Make sure they are undressed • Gather a careful history if possible • Ask who lives with the child • Gather every detail about the event • History of other injuries • Be alarmed if story is inconsistent

  38. Child Abuse and Neglect

  39. Key Points to Remember!! • Pediatric patients are not the same as adults • Use a systematic approach • Pediatric vital signs do not change like adults • Use proper technique in C-spine immobilization and airway management • Don’t forget about the IO when obtaining vascular access • Be on the lookout for child abuse

  40. References • Emergency Care (12th ed.). (2012). Brady. Dickensen, E., Grant, H., Limmer, D., Murray, B., O’Keefe, M. • http://handbook.muh.ie/trauma/Chest/TensionPneumothorax.html • http://newmexico.inetgiant.com/alamogordo/addetails/2-child-bike-helmet---free/3324985 • http://medicineworld.org/news/news-archives/Pediatric-news/March-16-2006.html • http://reference.medscape.com/features/slideshow/intraosseous-access • TNCC: Trauma Nursing Core Course (6th ed.). (2007). Park Ridge, Ill.: Emergency Nurses Association.

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