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Trauma: Stabilization and Transport

Trauma: Stabilization and Transport. Division of Critical Care Medicine Children’s Healthcare of Atlanta Atlanta, Georgia. Trauma : Stabilization and Transport Objectives. Discuss the epidemiology of pediatric trauma Review the primary survey Identify priorities in care

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Trauma: Stabilization and Transport

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  1. Trauma:Stabilization and Transport Division of Critical Care Medicine Children’s Healthcare of Atlanta Atlanta, Georgia

  2. Trauma:Stabilization and TransportObjectives • Discuss the epidemiology of pediatric trauma • Review the primary survey • Identify priorities in care • Discuss differences between adult & pediatric trauma • Discuss pediatric trauma management • Review the development of andguidelines for transport

  3. Neurosurgeon Trauma Surgeon Resuscitation Team OrthopedicSurgeon ALWAYS OPEN TRAUMA CENTER Anesthesia SurgicalSpecialties MedicalSpecialties OR Nursing ICU

  4. Trauma:Initial StabilizationStats • 22 million children/yr • 1 in 4 suffer serious injury/year • More children die from trauma than all other causes combined!

  5. Trauma:Initial StabilizationThe Golden Hour • R. Adams Cowley, MD • Care within 60 min. • mortality if care given > 60 min.

  6. Trauma:Initial Stabilization "You live or die depending on where you have your accident because they take you to the nearest hospital!" R. Adams Cowley, MD “In the Blink of an Eye”

  7. Trauma A-M-P-L-E History A - Allergies M - Medications P - Previous history L - Last ate E - Events of accident

  8. Trauma:Initial Stabilization Management of Multiple Trauma • Primary survey • Initial stabilizationand resuscitation • Secondary survey • Definitive care

  9. Trauma:Initial Stabilization The Primary Survey • A rapid initial assessment • An "ABC" approach • Resuscitation done simultaneously

  10. Trauma:Initial Stabilization The Secondary Survey • After the "ABCs" • Head to toe examination

  11. Trauma Initial StabilizationDefinitive Care Phase • Overall management • Fracture stabilization • Stabilization/transport • Emergent surgery

  12. Trauma:Initial Stabilization Pediatric Considerations • ABCs • Differences: 1) Size 2) Injury pattern 3) Fluids 4) Surface area 5) Psychological 6) Long term effects

  13. Trauma:Initial Stabilization In pediatric trauma, you don’t just have and injured child, you have an injured family M. Eichelberger, MD “In the Blink of an Eye”

  14. Trauma:Initial Stabilization The Primary Survey A - Airway and C-Spine B - Breathing C - Circulation (with hemorrhage control) D - Disability E - Exposure

  15. Trauma:Initial Stabilization The Primary Survey • Airway: • Establish patency • Beware C- Spine • Do not: • Flex • Hyperextend

  16. Trauma: Initial StabilizationThe Primary Survey • Oxygen • treat potential hypoxemia • all trauma patients get O2

  17. Trauma:Initial Stabilization Pediatric Considerations • Craniofacial disproportion • "Sniffing" position • Obligate nose breathers • Anatomy • tongue • larynx • trachea

  18. Trauma:Initial Stabilization Suspected Airway Obstruction • Stridor • Cyanosis • Absence of breath sounds • Dysphagia, snoring, gurgling • Altered mental status • Trauma to head, face, neck

  19. Trauma:Initial Stabilization Cervical Spine Differences • Flexible interspinous ligaments • Underdeveloped neck muscles • Poorly developed articulations • Anterior vertebral bodies • Flat facet joints • Large head to BSA

  20. Trauma:Initial Stabilization Cervical Spine • Predisposed to serious high cervical injuries • Assume its presence in: • Blunt injury above clavicle • Multisystem trauma • Significant injury - MVA, fall • Altered sensorium

  21. Trauma:Initial Stabilization Cervical Spine: Radiographs • Pseudosubluxation • distance dens and C-1 • Growth plate fracture • SCIWORA

  22. Trauma:Initial Stabilization Airway Management • Clear airway • Jaw thrust/stabilization maneuver • Oral/nasal airway • Oxygenate/ventilate • Intubation • Cricothyroidotomy

  23. Trauma:Initial Stabilization C-Spine Immobilization • Backboard • Appropriate C-collar • Snadbags or towel • Tape • Torso immobilization

  24. Trauma:Initial Stabilization Primary Survey: Breathing • Assess via • Exposure • Rate/depth of respiration • Inspection/palpation • Quality/symmetry of breath sounds NB: An intact airway Does Not assure adequate ventilation!!

  25. Trauma:Initial Stabilization Primary Survey: Breathing • Oxygen • Assisted ventilation • Alleviate life threatening injuries

  26. Thoracic InjuryHeart, Lung, Mediastinum • Penetrating • Sucking, Bubbling • Hemopneumothorax • Tamponade • Blunt • Flail Chest • Contusion (lung, heart) • Aortic Dissection • Tracheal Rupture • Diaphram Rupture

  27. Trauma:Initial Stabilization Chest Trauma • Tension pneumothorax • Hemothorax • Flail chest • Cardiac tamponade

  28. Trauma:Initial Stabilization Chest Trauma • Blunt injury common • More compliant chest wall • Sensitive to flail segment • Mobile mediastinum • Major vascular injury uncommon

  29. Trauma:Initial Stabilization Tension Pneumothorax • Air in the pleural space without exit • Collapse of ipsilateral lung • Compressed contralateral lung • Mediastinal shift

  30. Trauma:Initial Stabilization Tension Pneumothorax: Signs and Symptoms • Respiratory distress • Unilaterally diminished breath sounds • Hyperresonance on affected side • Tracheal deviation • Distended neck veins • Cyanosis

  31. Trauma:Initial Stabilization Tension Pneumothorax: Treatment • Needle decompression • 2nd intercostal space mid-clavicular line • Chest tube • 4-5th intercostal space mid-axillary line

  32. Trauma:Initial Stabilization Hemothorax: Signs and Symptoms • breath sounds on affected side • Dullness to percussion • Hypovolemia • Flat vs distended neck veins

  33. Trauma:Initial Stabilization Hemothorax: Treatment • Fluids/blood • Decompression • Chest tube • Autotransfusion

  34. Trauma:Initial Stabilization Flail Chest • Boney discontinuity of the chest wall • Major problem = underlying injury • Signs and symptoms • respiratory distress • paradoxical chest wall movement • severe chest pain

  35. Trauma:Initial Stabilization Flail Chest:Treatment • Oxygen • Stabilize segment • Re-expand lung • + intubation • Give fluids cautiously

  36. Trauma: Initial Stabilization abdominal trauma • Following the head and extremities, the abdomen is the third most commonly injured anatomic region in children • significant morbidity and may have a mortality rate as high as 8.5% • abdomen is the most common site of initially unrecognized fatal injury in traumatized children

  37. Trauma: Initial Stabilization abdominal trauma • Why more prone to abdominal injury • child has thinner musculature • ribs are more flexible in the child • solid organs are comparatively larger in the child • fat content and more elastic attachments leading to increased mobility • bladder is more exposed to a direct impact to the lower abdomen

  38. Intraperitoneal Hemorrhage Management • Immediate surgical exploration • Non-operative protocols • successful in more than 95% of blunt abdominal trauma in appropriately selected cases

  39. Intraperitoneal Hemorrhage Immediate Surgical Exploration • Abdominal distention + “shock” • Transfusion requirement > 40 cc/kg • Peritonitis • Pneumoperitoneum • Bladder rupture

  40. Intraperitoneal Hemorrhage CT Scan • Hemodynamically stable • Unreliable exam • Immediate non-abdominal surgery • Specific Indicators Hematuria (any) SGOT 200, SGPT > 100 Hyperamylasemia

  41. Intraperitoneal Hemorrhage • FAST • standard part of the initial evaluation of bluntly injured abdomens in adults • rapid assessment of the peritoneal cavity and can detect free fluid

  42. Intraperitoneal Hemorrhage • Pediatrics role of FAST is still up for debate • Detailed information regarding the grade of organ injury is not provided by the FAST • operator-dependent and lacks specificity • FAST examination produces a significant number of false-negative results

  43. Intraperitoneal Hemorrhage • American Association for the Surgery of Trauma (AAST) has established grading classifications for all solid organs based on anatomic descriptive criteria • Grading used to determine treatment pathway

  44. Intraperitoneal Hemorrhage Diagnostic Peritoneal Lavage • Rarely used in children • Indicators • Hollow viscous injury suspected • CT scanner not available • “Screen” for CT scan • Technique • Mini-laparotomy (midline) • 15 cc/kg Lactated Ringer’s

  45. Heart rate Pulses Perfusion capillary refill temperature Color Sensorium Urine output Blood pressure Trauma:Initial Stabilization Circulation

  46. Trauma:Initial Stabilization Frequent Reassessment of Vital Signs What Are Normal Pediatric Vital Signs?

  47. Blood Pulse Respirations Pressure Infant 160 80 40 Preschool 140 90 30 Adolescent 80 100 20 Trauma:Initial Stabilization Pediatric Vital Signs

  48. Trauma:Initial Stabilization Circulation:Vital Signs • Normal blood pressure: • Lower limit of systolic BP mmHg = 70 + 2 x age in years

  49. Trauma:Initial StabilizationCirculation: Shock • Altered vital signs: • tachycardia (early) • tachypnea • narrow pulse pressure • hypotension (late)

  50. Trauma:Initial Stabilization Circulation: Shock • Physical findings: • cool, pale extremities • capillary refill • altered mental status

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