Approach to trauma the paeds emerg perspective

1. Approach to traumathe paeds emerg perspective Stephen C. Porter MD MPH MSc Division Chief, Pediatric Emergency Medicine The Hospital for Sick Children Associate Professor of Paediatrics University of Toronto School of Medicine

2. Outline for today • “Children are not little adults” • General concepts in pediatric trauma • Multiple trauma – major trauma/ ATLS • Quick hits: body parts and bones

3. How do injuries happen…

4. Children versus adults in trauma • More energy from trauma distributes across more surface area • The bony skeleton is less calcified, has active growth centers, and is more pliable • Ratio of surface area to volume means thermal losses are a concern

5. You are called to the trauma bay… • A 2 year old who was run over by a heavy delivery truck when she dashed out in front of the truck. She fell forward as she was struck by the bumper. The front tire rolled over her body prone on the pavement from the buttocks toward her left shoulder. She was crying and her parents who noticed what happened immediately drove to the hospital in their own car. • VS T37, P140, R40, BP 100/65, oxygen saturation 94% in room air.

6. The exam • She is crying, alert and cooperative. Her head and face show no tenderness, bruising or abrasions. Pupils are reactive. TM's are normal. Teeth are intact without evidence of oral injury. Her neck is non-tender. Her neck range of motion is not restricted. Heart regular. Lungs clear, with an occasional grunting sound. Anterior chest shows no bruises. Her abdomen is soft, not tender with active bowel sounds. There is extensive bruising over her anterior pelvis. There is no bleeding. Her labia are bruised but no bleeding or tears are noted. Her lower extremities are non-tender distal to the pelvis. Her back shows mild bruising in the upper chest and the buttocks. She can move all her fingers and toes well. She does not move her lower extremities spontaneously. No extremity deformities noted. Color and perfusion are good.

7. Describe and treat this patient • Nature and seriousness of injuries • Multiple or local • Blunt/penetrating • Severity • ATLS principles Primary assessment Resuscitation Comprehensive secondary assessment Transition to definitive care

8. Describe and treat this patient • Nature and seriousness of injuries • Multiple or local • Blunt/penetrating • Severity • ATLS principles Primary assessment Resuscitation Comprehensive secondary assessment Transition to definitive care

9. Describe and treat this patient • Nature and seriousness of injuries • Multiple or local • Blunt/penetrating • Severity • ATLS principles Primary assessment AND resuscitation Comprehensive secondary assessment Repeat exams and monitoring for changes Transition to definitive care

10. Major trauma: important questions • Is the airway stable? • Is respiratory effort sufficient? • Is the patient in shock? • Is there a neurologic deficit? • What are the extent of the injuries?

11. Crew resource management

12. Trauma team activation • Physiologic criteria • Cardiac arrest • Hypotension per age • Respiratory distress • Neurologic failure • Trauma score < 12 • Anatomic criteria • Penetrating wound to head, chest, abdomen • Facial/tracheal injury with potential for airway compromise • Burn > 30% BSA • Major electrical injury

13. Pediatric Trauma Score

14. Predicting mortality from trauma • The trauma BIG score • Admission Base deficit • INR • Glasgow Coma Scale • Score = (base deficit + [2.5*INR] + [15-GCS]) • Predicted mortality = 1 / (1 + e-x) where x = 0.2 * BIG – 5.208 • Mortality of 50% is predicted for a child with • Base deficit 10, INR 3.6, GCS of 6 Borgman et al Pediatrics 2011

15. Observed and predicted mortality by the BIG score quintile in the derivation set

16. Pediatric trauma: Airway and C spine

17. Pediatric trauma: Shock • Up to 30% loss of circulating volume may be required to influence systolic BP in a child • If more than 2 fluid boluses of 20 cc/kg have been given to support perfusion, PRBC are needed and surgeon’s involvement is key

18. Pediatric trauma: neurologic disability • Neurologic assessment occurs in both primary and secondary survey phases • Primary survey - a “quick scan” for disability • Pupils, GCS, lateralizing signs, level of spinal cord injury • Secondary survey - comprehensive assessment • Repeat of pupils and GCS • Full assessment of cranial nerves and distal motor and sensory function as able to given age of patient

19. Loss of vital signs in the trauma bay • Children who suffer blunt trauma and then develop cardiac arrest are known to have poor outcomes • 10/10 patients with blunt trauma died despite thoracotomies in the trauma bay • 1 patient with penetrating injury and stable vital signs on arrival who underwent emergent thoracotomy survived Hofbauer et al Resuscitation 2011

20. Back to our 2 year old patient • Pertinent history • She fell forward as she was struck by the bumper. The front tire rolled over her body prone on the pavement from the buttocks toward her left shoulder. • Vitals • T37, P140, R40, BP 100/65, O2 saturation 94% in room air • Exam • Bruising over her anterior pelvis, labia are bruised • Back shows bruising, upper chest and buttocks • No spontaneous movement of lower extremities

24. A pain in the neck

25. Swischuk and his line

26. Neurotrauma • Key facts, current thinking • Cerebral perfusion pressure depends on a normal MAP • Goal for ventilation in neurotrauma is normocarbia • When increased ICP is suspected, • Elevation of head of bed • Sedation • Mannitol • Hypertonic saline

27. Thoracic trauma • Lung contusion is the most common pediatric thoracic injury • Pediatric patients are more sensitive to mediastinal shifts from air/fluid in pleural space • Risk of intraabdominal injury higher in setting of thoracic trauma

28. Abdominal Trauma • CT is the preferred diagnostic imaging modality to identify abdominal injury • Chief indication for operative exploration in a child is a transfusion requirement that exceeds 40cc/kg in first 24 hours of care

29. Orthopedic trauma

33. Anterior humeral line Anterior humeral line • Line drawn from anterior cortex of humerus intersects middle third of capitellum

34. More lines and figures Radio-capitellar line • Line drawn along axis of the radius passes through centre of capitellum in all projections Figure- of- eight • Seen on true lateral elbow X-ray • If disrupted, may indicate fracture

38. Summing up Main themes • Blunt trauma is the hallmark of pediatric injury • Special considerations for pediatric trauma • anatomy and physiology • equipment • Teamwork is needed for optimal trauma care Main tasks • Is the airway stable? • Is respiratory effort sufficient? • Is the patient in shock? • Is there a neurologic deficit? • What are the extent of the injuries?

39. Haddon Matrix

40. A free and good PEM resource http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html