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)