Pediatric Trauma

1. Pediatric Trauma EMS Professions Temple College

2. Pediatric Trauma #1 Killer of children after neonatal period Priorities same as adult  ABC’s Children not small adults

3. Pediatrics • Prehospital providers often have: • Limited pediatric patient contacts • Limited knowledge, training, and experience specifically directed towards pediatrics • Many other healthcare providers are similarly affected • Children are not little adults!!!

4. Age Classification • Neonate: Birth to 1 month • Infant: 1 - 12 months • Toddler: 1 - 3 years • Preschooler: 3-6 years • School age: 6 - 12 years • Adolescent: 12 - 18 years

5. How Does Serious Injury Occur in Children? • Function of Age & Development • Does not yet understand harm or risk • Does not yet understand cause and effect • Feeling of invincibility • Injury is the leading cause of death in children and young adults • 1/2 of the injuries result from motor vehicles

6. Common Emergencies By Age • Neonate: Infection, Neglect • Infant: Infection, Neglect, Abuse • Toddler: Poisoning, Fall • Preschool: Poisoning, Fall, Pedestrian • School Age: Pedestrian; Fall, Recreation • Adolescent: MV, OD/Poison, Recreation

7. Pediatric Trauma • Traumatic injuries often involve blunt trauma to the head • Drowning leading cause of death < 4 years • Pedestrian leading cause of death 5 - 9 years • Injuries from Falls, Motorized vehicles, Bicycles, Sports • Mechanism & Kinematics are critical • serious injuries in a child may not be evident initially

8. Mechanisms of Pediatric Injury Waddell’s Triad

9. Mechanisms of Pediatric Injury

10. Pediatric Assessment:First Impression • Pediatric Assessment Triangle • Appearance - mental status, body position, tone • Breathing - visible movement, effort • Circulation - color Appearance Breathing Circulation

11. First Impression • Consider the possibility of serious injury if: • the injured child has altered mental status or appears behaving inappropriately initially • there is significant mechanism regardless of whether there are obvious injuries • the injured child has evidence of poor systemic perfusion

12. Pediatric Assessment:Initial Assessment • Pediatric Assessment Triangle • Appearance - AVPU • Breathing - airway open, effort, sounds, rate, central color • Circulation - pulse rate/strength, skin color/temp, cap refill, BP ( use at early ages) Appearance Breathing Circulation

13. General Assessment • Observations of the child, family and environment are critical! • Form a first impression of the child’s status • Maintain distance • Talk to parents. Keep child with parent • Is the behavior appropriate for the child’s age? • Mental status and ABCs are critical!

14. Focused Exam • Vitals signs are age dependent • Use pediatric vital signs charts • Systemic perfusion • Best evaluated by presence and volume of peripheral pulses and mental status • Low output shock: weak, thready, narrow PP • High output shock: bounding, wide PP • Loss of central pulses is a premorbid sign

15. Focused Exam • Skin •  skin perfusion may be early sign of shock • Skin/cap refill dependent on ambient temp • Mottling, pallor, delayed cap refill and peripheral cyanosis often indicate poor skin perfusion • Severe vasoconstriction = gray/aschen in newborns and pallor in older children

16. Focused Exam • Mental Status • Lost muscle tone, Seizure,  Pupil size • Confusion, Irritability/Agitation, Lethargy • Tachycardia may be an unreliable sign • BP Estimates (> 1 year) • Median BP = 90 mm Hg + (2 x age years) • Lower Limit BP = 70 mm Hg + (2 x age yrs)

17. Focused History & Exam • History of the Present Injury • Family/Witness/Caretaker • Older child • Pertinent Past Medical History • Often none or not obtainable • Immediately Treat Life-Threats • Some exceptions (epiglottitis, febrile seizure)

18. Larger occipit increases neck flexion Large, floppy epiglottis Larger tongue relative to size of oropharynx Children younger than 10 have narrowest portion of airway below vocal cords (subglottic) Larynx is anterior As a result Due to airway angles, straight blade is more useful difficult to lift and control epiglottis with blade Subglottic edema, constriction or compression results in significant airway compromise Need to position yourself very low during intubation Anatomical Differences

19. Pediatric Intubation Considerations • Equipment (> 2 years old) • ET tube size mm I.D. = (Age in years  4) + 4 • Term Newborn = 3.0 or 3.5 • Premie = 2.0, 2.5 or 3.0 • 1 year = 3.5 or 4.0 • 2 years = 4.0 or 4.5 • Uncuffed tubes at approx. 8 years and younger • straight blade • ET tube depth = (Age in years  2) + 12 • OR, 3 x tube size

20. Pediatric Intubation Considerations • Place in the sniffing position • Manually immobilize head in suspected C-spine injury • A small folded towel may need to be placed: • Under the head of the child > 2 years • Under the shoulders of the child < 2 years • Move the tongue out of the way! • Lift the epiglottis directly with the blade

21. Pediatric Intubation Considerations • If bradycardia ensues, ventilate adequately before re-attempting intubation • Pretreat with Atropine 0.02 mg/kg if using neuromuscular blockers or sedation • Consider NG or OG tube if excessive gastric distention was created by BVM ventilations

22. Pediatric Intubation Considerations • Intubation complications - DOPE • D = Dislodgment • O = Obstruction • P = Tension Pneumothorax • E = Equipment failure • FREQUENTLY Reassess! • Little movement is required to inadvertently extubate the pediatric patient

23. Pediatric Intubation Considerations • Tubes migrate with head movement • Secure tube well • Immobilize head in neutral position • Never let go of tube • ET tubes wind up in mainstem bronchi, due to short trachea

24. Surgical Airways • Surgical cricothyrotomy is not recommended in children < 8 - 10 years of age • Needle cricothyrotomy is preferred for children, if required at all

25. C-Spine Immobilization • Many experts now oppose the transport of an injured child in his/her car seat • The car seat may have been damaged in the accident • It is difficult to adequately examine the child • It is difficult to adequately immobilize the C-spine • KED is frequently used for this purpose • A rolled towel may be used when a properly sized C-collar is not available • Remember the large occiput of the small child

26. Breathing High metabolic rates + Low reserve capacity result in high sensitivity to airway/breathing problems Oxygenate and ventilate aggressively

27. Breathing • Adequate ventilation and oxygenation are crucial to the seriously injured child • Higher demand for oxygen normally as compared to adults • Head injuries require adequate oxygenation to minimize secondary injury • At a minimum, supplemental oxygen is indicated

28. Airway Management • Simple supplemental oxygen is usually adequate in the spontaneously breathing child • If the child does not tolerate a mask or nasal cannula, blow-by oxygen is better than no oxygen • Proceed slowly in the anxious or distrusting child

29. Airway Management • BVM ventilation often is sufficient and preferable over ETT • Complication of BVM ventilation gastric distention • May interfere with diaphragm movement • Increase risk of emesis & aspiration

30. Circulation • Assessment of the BP is seldom useful • Assess BP last. Use other assessment findings. • Hypotension will be a very late sign in the pediatric shock patient • Hypertension may be subtle in the head injured patient • Serious injuries may not be obvious externally

31. Circulation • Rapid control of external bleeding • Essential due to small blood volume • Efficient compensation for shock may lead to sudden decompensation and onset of irreversible shock

32. Circulation • BP monitoring - poor way to detect shock • Assess rate, quality of peripheral pulses • Skin color and temperature • LOC (Silence is not Golden) • Capillary refill

33. Shock • Children will not tolerate respiratory failure or shock • Shock may be seen as tachycardia and poor skin perfusion or mental status • Children have excellent compensatory mechanisms - UP TO A POINT! • Then they crash • Hypotension is an ominous sign

34. Shock • Bradycardia, hypotension or irregular respirations are late and ominous signs!!! • Treatment • Oxygenation/Ventilation • Fluids: 20 cc/kg as a bolus (not wide open infusion) • Additional vascular access options: intraosseous and umbilical vein (newborn)

35. Head Trauma • Major cause of pediatric trauma • Large heads • Thin skulls • Poor muscle control • Diffuse edema more common than intracranial hematomas

36. Head Trauma • Monitor for Signs of ICP • AVPU • Pupils • Vomiting • Cushing Response • Controlled hyperventilation if  ICP • Resuscitate hypovolemic shock aggressively

37. Spinal Trauma • Rare. Usually at C1, C2, C3. Dislocations more common. • Suspect if trauma involves • Sudden deceleration • Head injuries • Decreased LOC • If Spinal immobilization is thought, then do it. • Resist temptation to pick up child and run.

38. Chest Trauma • Second only to head trauma as cause of trauma death • 90% of pedi chest trauma - blunt trauma • Chest wall is pliant. Rib fracture is uncommon • Extensive intrathoracic injury without rib Fx

39. Chest Trauma • Mobile mediastinum - do not tolerate tension pneumothorax well • Limited respiratory reserve • Poor tolerance of chest injury

40. Abdominal Trauma • Most common from of pediatric trauma. • Usually blunt • Liver, spleen injury more common than in adults • High, broad costal arch • Relatively larger organs

41. Abdominal Trauma • Tenderness • Significant trauma UPO • Distention • Significant trauma UPO • May also be due to air swallowing • Early NG tube placement may avoid unnecessary surgery

42. Extremity Trauma • Priorities ABC’s • Orthopedic trauma never severe enough to warrant attention before head, chest, abdominal injury • Pliant pedi bones absorb/ dissipate significant force. • Greenstick Fx common • Treat painful, tender or favored extremities as Fx

43. Extremity Trauma • Epiphyseal plate frequently involved • 50% have growth abnormalities • Neurovascular injury - most common injury • Humerus • Femur • Assess distal pulse, skin color, temp, cap refill, motor/sensory function

44. Burns • 50% burn admissions • 33% burn deaths • Large BSA increases fluid loss • Large BSA increases heat loss - hypothermia • Smaller airway - increased airway burn difficult

45. Burn Resuscitation • LR with 4cc/kg/%BSA • 50% in first 8 hours • 25% in second 8 hours • 25% in third 8 hours

46. NG Tube • Need to be placed early • Shock may be secondary to decreased venous return from distended stomach pressing under diaphragm

47. Management • Airway • 100 % O2. Consider early ventilation. • Prevent Hypothermia • Large surface/volume ratio - increase heat loss • Cover with blanket • Consider effects of cold IV fluids

48. Fluid Replacement • IV’s should be enroute to hospital • Warm fluids • After 60cc/kg without reversal, need blood replacement

49. Management • MAST/PASG • Legs only initially • If child needs abdominal compartment also intubate and ventilate • Elastic ace bandages or air splints can be used on legs if child too small for MAST