Pediatric Trauma Management: What You Need To Know

1. The Division of Paediatric Emergency Medicine Presents: Pediatric Trauma Management What You Need To Know Thanks to: Angelo Mikrogianakis MD, FRCPC Pediatric Emergency Physician and Trauma Team Leader Emergency Medicine & Critical Care The Hospital for Sick Children Pediatric Patch Physician Ornge

2. Objectives • General overview of pediatric trauma • Anatomy and patterns of injury • Case Study

3. Why does pediatric trauma cause so much anxiety? • Emotional impact • Different equipment sizes • Different drug and fluid calculations • Differences in anatomy,physiology and pathophysiology specific to children • Communication difficulties • Lack of staff experience

4. We can all be better prepared for pediatric trauma! “We Forgot The Patient!”

5. PEDIATRIC TRAUMA Isolated head Multiple injury trauma Airway compromise Respiratory failure Shock Cardiopulmonary arrest

6. PEDIATRIC TRAUMA Blunt injury is much more common than penetrating injury • Head (CNS) injury present in 55% of blunt trauma victims • Internal injuries present in 15% of blunt trauma victims

7. ANATOMY & PHYSIOLOGY BODY • small body mass with large surface area • heat loss • greater force per body unit area • less protective muscle and fat • high metabolic rate • higher oxygen and glucose demands

8. ANATOMY & PHYSIOLOGY HEAD • large compared to body size • heat loss • more prone to injury • weak neck muscles • prominent occiput • sutures open until 18 months • relatively larger tongue

9. PEDIATRIC HEAD TRAUMA • Most common single organ system injury associated with 80% of all deaths • Concussion common injuries • Subdural bleeds common in infants • Epidural bleeds less common than adults • Acute neurosurgical intervention required less often than adults

10. Systemic Causes (Extracranial) hypotension hypoxemia anemia hypo/hypercarbia hyperthermia hypo/hyperglycemia hyponatremia Neurologic Causes (Intracranial) raised ICP herniation vasospasm hematoma seizures infection hyperemia CAUSES OF SECONDARY BRAIN INJURY

11. BREATHING FOR HEAD INJURED PATIENTS • Controlled ventilation • cerebral vasculature responds to PaCO2 • maintain cerebral oxygenation • PaO2< 60 mm Hg associated with  morbidity & mortality • Hyperventilation with caution • hyperventilation decreases CBF & worsens outcome • hyperventilation NOT recommended unless herniation • goal is PaCO2 = 35 mmHg

12. MANAGEMENT OF RAISED ICP • Elevate HOB (unless  BP) • Medication • Mannitol: osmotic diuresis • 3% Hypertonic saline: Early transfer to neurosurgical facility • Hyperventilation • only if impending herniation

13. ANATOMY & PHYSIOLOGY NECK • shorter; supports more mass • veins & trachea hard to see • larynx - cephalad & anterior • cricoid narrowest part • epiglottis at 45o & floppy • short trachea (5cm at birth) • spine– elasticity of ligaments • Less calcified

14. PEDIATRIC C-SPINE • C-Spine injury is uncommon (1-4%) • < 8 y.o.  10-15% • 8-12 y.o.  20-25% • > 12 y.o.  60-70% • Anatomic fulcrum of spine at C2-C3 • Fractures below C3 < 30% of spine lesions in children < 8 years of age *** • Adult pattern of injury at 12 years old

15. CSI - pediatric differences •  mobility at C2-C3 (pseudosubluxation) • normal mobility 3 mm (children 4-5 mm) • tip of odontoid < 1 cm from base of skull • pre-dental space 3 mm (children 4-5 mm) • retropharyngeal space 5-7 mm (children < 7-8 mm) • vertebral bodies may be wedged anteriorly • especially on their superior surfaces • until  age 10

16. ANATOMY & PHYSIOLOGY CHEST • ribs are cartilaginous and pliable • greater transmitted injury • rib fracture = massive force • little protective muscle and fat • mediastinum very mobile

17. PEDIATRIC THORACIC INJURIES • Less serious thoracic injuries than adults • Rarely will chest injuries occur in isolation • Rarely are the sole cause of death • Blunt cardiac & great vessel injuries are rare • Management is mainly conservative: • Assisting oxygenation and ventilation • Chest tube insertion • Replacing lost blood volume • < 15% require a chest tube

18. PEDIATRIC THORACIC INJURIES • U.S. data in pediatric blunt chest trauma • 50% pulmonary contusions • 20% pneumothorax • 10% hemothorax • Canadian incidence is most likely less • Chest tube sized to occupy most of the intercostal space.

19. ANATOMY & PHYSIOLOGY ABDOMEN • less protection from ribs and muscle • liver and spleen vulnerable • small forces can cause severe injury • propensity for gastric distension • abdominal pain • respiratory distress • GU organs well protected by pelvis

20. Gastric distension • common after trauma • from crying and swallowing air • can interfere with respiration / ventilation • limits diagphragmatic motion • reduces lung volume • increases the risk of vomiting • difficult to discern abdominal findings

21. Gastric distension

22. PEDIATRIC ABDOMINAL INJURIES • Gastric distention = OG/NG tubes • Solid organs are most vulnerable. • 8% of admissions to peds trauma centres • 85-90% of all pts with hepatic & splenic injuries can be managed nonoperatively. • Missed hollow viscus injury is uncommon.

23. SickKids Patient PopulationApril 1998 – March 2001 Male 62.2% Age 8.6 years (std dev 4.5) Weight 33.8 kg (std dev 18.1) ISS 14 (std dev 11) Direct 47.8% Referred 52.2%

27. The more important requisite is the ability to evaluate hemodynamic stability.

28. AMBULANCE PATCH • 7 y.o. male, pedestrian struck by truck while crossing street • Witnesses describe LOC • Now confused & agitated • O2 applied • IV access x 1 • VITALS: HR=120, BP=105/69, RR=30, SATS=91%

29. RAPID CARDIOPULMONARY ASSESSMENT • A. Airway and C-spine control • B. Breathing • C. Circulation and hemorrhage control • D. Disability (rapid neurologic assessment) • E. Exposure and Environmental control

30. PREPARATION • Assemble team - define roles • physicians • nurses • RT • radiology • Prepare equipment for: • airway management • IV access & fluid resuscitation • Broselow tape

31. PRIMARY SURVEY AIRWAY • position - jaw thrust • suction • 100% oxygen • oral airway • ensure C-spine is immobilized

32. AIRWAY • Bag & mask ventilaton • C-spine precautions • Intubating Criteria • RSI meds

33. PRIMARY SURVEY BREATHING • colour • chest movement • retractions • breath sounds • assess work of breathing • oxygen saturations

34. PRIMARY SURVEY CIRCULATION • heart rate • capillary refill • skin colour and temperature • blood pressure • peripheral pulses • organ perfusion: brain, kidney

35. CIRCULATION IN THE TRAUMA VICTIM • Assess for signs of hypovolemic shock: • quiet tachypnea • tachycardia • prolonged capillary refill • cool extremities • thready pulses • narrow pulse pressure • altered mental status

36. RESPONSE TO FLUID BOLUS • Slowing of heart rate • increased systolic BP • increased pulse pressure (>20mmHg) • decrease in skin mottling • increased warmth of extremities • clearing of sensorium • urinary output of 1 - 2 ml/Kg/hour

37. PRIMARY SURVEY DISABILITY • pupils: size and reactivity • level of consciousness • A - Alert • V - Verbal stimulus • P - Painful stimulus • U - Unresponsive

38. PRIMARY SURVEY EXPOSURE • remove all clothes • keep patient warm • warm blankets • warm fluids • overhead warmer • warm the room

39. SECONDARY SURVEY HEAD TO TOE EXAM • systematic exam of all body organs • look, listen & feel • fingers & tubes in every orifice

40. SECONDARY SURVEY HISTORY • A - Allergies • M - Medications • P - Past medical history • L - Last meal • E - Events/Environment

41. RE-ASSESS And ASSESS AGAIN If patient deteriorates, go back to ABC’s

42. KEY MESSAGES • Prevention is the best defense • Pediatric patients have special differences • Recognize head-injured patients early • Prevent secondary brain injury • Be excellent airway managers • Provide adequate fluid resuscitation • Anticipate need for transfer ASAP • Ensure appropriate transport personnel

43. Psychologic status • impaired ability to interact • unfamiliar individuals • strange environment • emotional instability • fear / pain / stress • parents often unavailable • history taking and cooperation can be difficult

44. Strange environment?

45. Strangers in environment?

46. CASE STUDY: 7 year old, male • Pedestrian struck by truck while crossing street • On Arrival to Primary Hospital • Moaning with bruising & swelling to face, large scalp laceration • 100% O2 • Cardio, Resp, BP & Sat monitors • 2 large bore IV’s placed

47. CASE: 7 year old male • Vitals: HR=160, BP=110/70, RR=24, SAT= 99 • A - Patent, teeth loose, facial contusions • B - Breath sounds decreased on RIGHT • C - Heart sounds N, cap refill brisk • D - Eyes open to speech, Verbally confused, Obeys commands (GCS=13), PERL • ABDO - soft, tender RUQ, bruising R flank/hip

48. CASE: 7 year old • Interventions: • Broselow Tape • Bolus 20 cc/kg NS rapidly • Reassess • Vitals: HR=140, BP=105/75, RR=14, SAT= 99 • Resp effort decreased, BS decreased to R • Eyes open to pain, no longer verbal, abnormal flexion to pain

49. Summary of Pitfalls • Beware of hypothermia in systemic trauma • especially if hemodynamic compromise • Beware of unusual bleeding sites • subgaleal hematomas • long bone fractures • Beware of the distended stomach

50. CASE • 14 y.o. male, previously healthy • Un-helmeted cyclist struck by truck ~ 19:00 • Thrown & rolled • Initially unconscious then agitated, Vx X 1 • Arrival at primary hospital ~ 19:50 • Tachycardic • Comatose – decorticate posturing – GCS=5 • Extension of extremities