PEDIATRIC TRAUMAPEDIATRIC TRAUMA
ABCD & E APPROACHABCD & E APPROACH
PREPAREPREPARE
Room and equipmentRoom and equipment Staff: nursing, radiology, lab, RTsStaff: nursing, radiology, lab, RTs Discuss case/interventionsDiscuss case/interventions Paramedic reportParamedic report
TriageTriage
According to the needs of the patients and the resources available and there are other better options to serve the patients’ needs, they should be transferred to there safely after full information given to the receiving doctor and with all the collaboration.
PRIMARY SURVEY (Assessment and Management)
Airway Breathing Circulation Disability Exposure Full vitals
ADJUNCTS TO PRIMARY SURVEY
Pulsox, cardiac monitors, BP monitor, CO2 monitor
NG tube Foley ECG Xrays: Cspine, CXR, pelvis Trauma blood work ABG DPL/ABUS if appropriate
SECONDARY SURVEY
AMPLE history H/N Chest Abd U/G Neuro Msk Roll pt
ADJUNCTS TO SECONDARY SURVEY Xrays CT head, chest, pelvis, abd, spine ABUS DPL Contrast studies Endoscopy Angiography Esophagoscopy Bronchoscopy
PRIMARY SURVEYAirway and C-spine
LOOK levelof consciousness, agitated, cyanosis, retractions,
AMU, evidence of facial or laryngeal injury, evidence of UAW
burn (carbenaceous sputum, singed hairs, soot around mouth) LISTEN speech clear, stridor, gurgling, hoarseness FEELfacial/neck trauma, trachea midline, crepitus,
subQ emphysema MANAGE
Breathing: VentilationBreathing: Ventilation
Put on C - collar maneuvers: jaw thrust, suction, foreign body
removal devices: oropharyngeal airway, nasopharyngeal airway
Definitive airways: endotracheal intubation, jet insufflation, cricothyroidotomy, tracheostomy (nasotracheal intubation discouraged in peds)
Breathing and Ventilation
LOOK RR, depth of respirations, chest mvmts, flail
segments LISTEN breath sounds, heart sounds, bowel sounds in chest FEEL subQ emphysema, trachea midline, percussion,
chest wall injury
MANAGE & RESUSCITATION
100% 02: face mask with NRB at 10 - 12 L/min pulsoximeter, end tidal C02 ventilationas
necessary Thoracentesis for pneumo, chest tube for
hemo/pneumo, sealopen chest wounds with three sided dressing
Problems with intubated pt: Disloged, Distended stomach, Obstructed tube, Pneumothorax, Equipment failure
Circulation and Hemorrhage
LOOK Identify external bleeding, skin color, diaphoresis,
JVD, femur #s LISTEN Muffled heart sounds, murmur FEEL Pulse rate, pulse quality, BP, cool/clammy skin
MANAGE
cardiac monitor, BP monitor two large bore IVs, send blood for trauma panel and ABG intraosseous catheter or venous cutdown if can’t get peripherals bolus 20 cc/kg NS or RL for hypotension packed rbcs 10 cc/kg if >2 boluses require direct pressure to bleeding sites; no clamping identify cause of hypotension: chest, belly, pelvis, external, SCI, MSK, head (rare): CXR and pelvic Xray should be done ASAP abdomenal ultrasound, DPL, thoracotomy, surgical consult prn
Disability & Neuro
PUPILS + GCS Manage: may include RSI intubation,
hyperventilation/mannitol for herniation
Exposure/Environment
Full exposure and prevent hypothermia with warmed solutions and
blankets
Full Vitals
Repeat vitals including core temp; are you stuck on primary survey b/c of poor vitals??
ADJUNCTS TO PRIMARY SURVEY
Most should already be done Monitors: Pulsox, BP and cardiac monitor, ET
CO2 monitor Xrays: C-spine, CXR, and pelvic Xrays (TRY
to get CXR and pelvis early; C-spine can wait until secondary survey) DPL, ABUS NG and urinary tubes if not contraindicated
(foley after rectal)
SECONDARY SURVEY
AMPLE history and details of accident including condition of vehicle, ejection, other
injured passengers, seat belts, blood loss at seen, vitals on route, interventions on route,
etc
Head and Neck
Head: lacerations, contusions, fractures, burns Face: maxillofacial fractures, racoon eyes, battle signs, look in mouth, burns, carbenaceous sputum, soot, singed hairs, nose for CSF leak Eyes: pupil size and reactivity, EOM, visual acuity, hemorrhage, racoon eyes Ears: battle signs, hemotympanum, CSF leak Cranial nerves: II - XII if not already tested; occulocephalics and occulovestibular reflexes, corneal reflex, gag reflex Neck: inspect for blunt injury, penetrating injury, tracheal deviation, accessory muscle use; palpate for deformity, tenderness, swelling, subQ emphysema, tracheal deviation, symmetry of pulses; listen to carotids, palpate C-spine.
Chest
Look: blunt or penetrating trauma, acc muscle use, chest expansion, JVD
Listen: breath sounds and heart sounds Feel: tenderness (AP and lateral
compression), rib tenderness, crepitation, subcutaneous emphysema,
percuss for hyperresonance or dullness
Abdomen
Look: blunt or penetrating trauma (look closely at sides re hepatic and
splenic injury may be suspected by lower rib cage lateral abrasion)
Listen: bowel sounds Feel: palpate for tenderness, guarding,
rebound; percuss for tenderness DPL, ABUS, ABCT, pelvic Xrays as
appropriate
Urogenital
Look: contusions, lacerations, urethral/vaginal/rectal bleeding
Rectal: prostate position, bone fragments, wall integrity, sphincter tone,
blood Vaginal: laceration, blood, bone
fragments
MSK
Look, feel, move all joints of upper and lower limb looking for lacerations,
contusions, deformities, crepitus, possible fractures
Compress pelvis AP and lateral Assess limb pulses and neuro status
distal to suspected fractures Obtain Xrays of injured parts
Neuro
Mental status and GCS Cranial nerves Strength, Reflexes, Sensation,
Coordination
Roll Pt
Look, feel for any injuries, lacerations, contusions, spine tenderness,
rectal
PATHOPHYSIOLOGY
Smaller body mass of children thus the energy force per unit body areas is much higher
in pediatrics than in adults resulting in more severe injuries Incomplete calcification of skeleton and growth plates make children more
susceptible Internal organ damage without obvious overlying external fractures b/c of
pliable skeleton: severe pulmonary contusions without rib fractures is an example Large surface area to body volume thus hypothermia more of a concern Increased physiological reserve allows near normal maintenance of vital
signs even in the presence of severe shock: hypotension is a LATE sign of shock; kids crash
quickly and LATE MUST keep in mind child abuse as a mechanism of injury
MANAGEMENT ISSUES
Fluid boluses: 20 cc/kg (compared to 2L in adults)
Blood transfusion: 10 cc/kg Braslow tape essential equipment Intraosseous or venous cutdown if can’t get iv
access (3Xs or 90sec) Increased emphasis on gastric decompression
re poor ventilation and vagal stimulation Hypothermia bigger issues in kids: make sure
iv fluids warmed, blankets, etc
AIRWAY MANAGEMENT
Oral Airways: do not put in backwards and rotate 180 degrees; put straight in with
depressor Orotracheal intubation: preferred route of definitive
airway management; RSI preferred Nasotracheal intubation: not recommended b/c of
increased risk of pharyngeal/adenoid bleeding and relatively acute angle of the posterior
nasopharynx Cricothryoidotomy: rarely indicated, should only be
done by surgeon, TTJV preferred TransTracheal Jet Ventilation (needle
cricothyroidotomy): preferred over surgical cric
AIRWAY EQUIPMENT
Cuffed tubes NO cuffs < 8yo b/c of narrow cricoid ring provides “functional cuff” Uncuffed tubes should have small air lead @ peak inflation pressure (30mmHg) ETT sizes Age/4 + 4 Size of pinky or nostril Have size above and size below available Blade sizes Premie Miller 0 0 - 2 Miller 1 2 - 10 Miller/Mac 2 > 10 Mac 3 Depth ETT size (i.d.) X 3 Age/2 +12 Vocal cord marker
AIRWAY AND VENTILATION: ANATOMY/PATHOPHYSIOLOGY
Head/Mouth/Pharynx Large head with prominent occiput: causes passive flexion of neck
and airway obstruction (AWO) to poor position Large tongue which easily obstructs airway; also makes
laryngoscopy more difficult b/c of large tongue in the way Loose teeth can easily be dislodged and cause AWO Relative poor tone of pharyngeal musculature thus passive AWO Relative prominence of adenoids: nasopharyngeal intubation not recommended Large, floppy epiglottis that doesn’t lift up as well with the curved
blade thus the use of the straight blade to raise the epiglottis
Larynx/Trachea/Bronchial tree/Lungs
Anterior larynx: harder to visualize; anterior larynx position makes the angle between the base of the tongue and glottic opening more acute thus the straight blades create a more direct visual plane from the mouth to the glottis Cricoid ring is the narrowest part of airway (compared to vocal cords in adults) and it forms a natural seal with the ETT hence uncuffed tubes < 8 yo; cuffed tubes risk pressure necrosis Short trachea: very easy to intubate the right mainstem bronchus Short airway: very easy to dislodge tube; minimal movement will dislodge ETT Narrow lumen: means using smaller ETTs which get blocked more easily with secretions, blood, etc
Narrow lumen: small amounts of edema, bleeding, etc will cause obstruction Resistence varies with 1/radius^4 (any decreased radius increases resistence to the fourth power) High compliance of pediatric airway makes it very susceptible to
dynamic collapse in presence of AWO: trachea will collapse in presence of
upper airway obstruction like croup or epiglotitis Small lung volumes, especially in neonates/infants thus aggressive ventilation can easily cause pneumothoraces (most common cause of pediatric pneumos)
Chest Wall
Cartilaginous ribs very compliant thus chest retraction during respiratory
distress decreases the ability to maintain FRC, prevents increase in tidal
volume and increases work of breathing Any compromise of diaphragmatic excursion can
increase respiratory distress due to reduced effectiveness of horizontal
diaphragm contractions (gastric distension, abdominal masses, etc)
DETERIORATION OF INTUBATED PATIENT
Displaced tube: listen, ETCO2, laryngoscopy to look, “if in doubt, pull it out”
Distension: gastric distension can reduces ventilation and cause vagal response; NG/OG
tube Obstruction: secretions, blood blocking the tube; pull
tube Pneumothorax: listen to chest, CXR Equipment: check ventilator, bag, BVM, seal, hoses
etc; d/c ventilator and bag, ?improvement
CHEST TRAUMA
Same injuries as adult but different frequencies
Injuries Rib fractures 50% Pneumothorax 20% Hemothorax 10%
Pathophysiology
Chest wall is less protective and transmits traumatic forces to the lung
parenchyma and mediastinal structures; mediastinal structures are more
mobile than in adults Children are diaphragmatic breathers
Injury Patterns as a result of compliant chess wall
Pulmonary contusion is more common Pulmonary contusion can occur without rib fractures Intrapulmonary hemorrhage more common in kids Tension pneumothorax more common in peds b/c
mobility of mediastinum means that less pressure is required to compress and shift
the mediastinal structures and contralateral lung Gastric distension easily compresses the lungs Diaphragmatic injury as profound affect on ventilation
Less common injuries in pediatrics
Bony chest injury: rib fractures less common b/c chest wall compliance
Other: aortic disruption, diaphragmatic hernia, major tracheobronchial
tears, flail chest, cardiac contusion
Pneumothorax
May not hear decreased BS b/c of easily transmitted sounds from other
side See braslow for tube sizes Occult pneumos require chest tubes Signs of tension pneumothorax are often subltle: can’t
see tracheal deviation b/c of short neck, may still have bilateral breath
sounds heard, hypotension late
Hemothorax
Indication for OR thoracotomy = initial drainage > 15 - 20 ml/kg or ongoing
drainage > 5 ml/kg/hr or continued air leak
Emergency Room Thoracotomy
Indications the same as adults Rarely needed but should be done if indicated Indicated in penetrating trauma only (NOT blunt) penetrating trauma + loss of vitals at scene penetrating trauma + loss of vital on transport penetrating trauma + loss of vitals in ED note: NOT indicated if NO vital signs at the scene
Commotio cordis = myocardial concussion
Sudden cardiac collapse after chest impact Results in brief dysrythmia, hypotension, or
LOC NO lasting pathological changes May result in asystole or VF Explains sudden cardiac death after blow to
chesst in which no hitolopathological changes are present on autopsy CASE: baseball to chest then Vfib arrest
ABDOMINAL TRAUMA
Injuries Spleen is MC Liver is 2nd MCPathophysiology Less abdominal wall musculature protection Less abdominal fat protection Larger spleen and liver Large mobile kidneys Compliant lower chest wall thus easy
compression of spleen and liver
Patterns of injury
Prone to liver and splenic injury Increased importance of gastric decompression (NG or OG tube)
because of reduced effectiveness of ventilation and potential vagal response Duodenal hematomas, traumatic pancreatitis, duodenal/jejunal perforations, mesenteric and small bowel avulsion injuries are all more common in pediatrics: less developed abdominal musculature and common mechanism of injury (bike handles, epigastric blow, etc) Bladder rupture more common due to shallowness of pelvis
Specific injuries
Diaphragmatic rupture: common with lap belts Splenic injury: most common, evaluate with
CT, delayed rupture also occurs, remember left shoulder tip pain Liver injury: 2nd most common injury, MOST
COMMON cause of lethal hemorrhage in pediatrics, Renal: deceleration and vascular injuries
Lap belt injuries in children
Chance fracture Small bowel perf Mesenteric artery Pancreatic injuries Diaphragmatic rupture
Similar approach to patient Generally emphasis is on non-surgical mx Clinical indication for laparotomy: to OR NO clinical indicator for laparotomy: abdominal
investigation-stable: CT scanning preferred -unstable: ultrasound or DPL (DPL in pediatrics
should only be done by surgeon according to ATLS)