Pediatric Trauma

James Huffman, PGY-2August 2, 2007

Special thanks to Dr. Vincent Grant& Dr. Katharine Smart

Objectives

1. Identify the unique characteristics of

the child as a trauma patient:

Types and patterns of injury

Anatomic and physiologic differences from adults

2. Discuss primary management of critical injuries in children

Airway management

Shock / Fluids

Head injuries

Outline

1. Pediatric-specific trauma issues

2. Assessment/Management Pediatric Assessment Triangle

Primary

ABCDEF

Secondary

Adjuvant testing

3. Current status in Calgary

Short Snapper: Name the condition

Tachypnea Hypoxemia Hypotension +/- JVD +/- absent breath

sounds

Tension Pneumothorax

Case #1

5yo male MVC – rollover Ejected, found 6 meters from vehicle 120, 92/58, 362, 26, 94% on room air GCS=10 (E2, V3, M5)

What are some special considerations in pediatric trauma?

Special Considerations“Not just little adults”

pre-injury level of functioning mechanism of injury size and shape skeleton surface area psychologic status long-term effects equipment

Special Considerations: Mechanism

Blunt (80%) Head injuries very common (55%)

Apnea, hypoventilation and hypoxia occur 5 times more commonly than hypovolemia and hypotension in seriously injured children (ATLS Manual, 7th Edition)

Aggressive management of airway and breathing

Consider non-accidental trauma Up to ~35% of trauma deaths

Special Considerations: Size and Shape

Greater force per unit body area Less body fat less connective tissue Organs at close proximity to surface

High frequency of multiple organ injuries

Special Considerations: Size and Shape

Larger head prone to head injuries major source of heat loss prominent occiput cranial bones thinner

Shorter neck Supports a relatively larger mass More frequently disrupt upper cervical

vertebrae or their ligamentous attachments SCIWORA = 50% of kids with SCI

Special Considerations: Size and Shape

Larynx more cephalad / anterior

Epiglottis tilted at 45 “floppy”

Cricoid cartilage narrowest part of airway in children < 8 years old

Special Considerations: Size and Shape

Thorax More pliable Ribs cartilaginous and

flexible Less overlying muscle

and fat

Mobile mediastinum

Contusions (common) Fractures (rare)

Blunt force transmitted to underlying tissues

Special Considerations: Size and Shape

Abdomen Less protected by ribs and muscles Organs less insulated by fat

1) Small forces may cause significant injury 2) Significant injuries with minimal external

evidence

Special Considerations: Skeleton

Incomplete calcification Growth centers – weak point Salter-Harris classification More pliable

Organ damage without overlying bony fractures

Special Considerations: Surface Area

Surface area / volume ratio Highest at birth Decreases with age

Thermal energy loss significant Hypothermia may develop quickly

Good for head-injured patients Bad for hypotensive patients

Special Considerations: Psychological Status

Impaired ability to interact Unfamiliar individuals Strange environment Emotional instability Fear / pain / stress Parents often unavailable

History taking and cooperation can be difficult

Special Considerations: Long-term Effects

Injury may impact growth / development 60% of children with severe, multisystem

trauma have residual personality changes at 1 year*

50% show cognitive or physical handicaps* Impact on family structure

* ATLS Manual, 7th Edition

Special Considerations: Family Presence

Not just “one patient”

Advantages availability of historical data comfort to child

Disadvantages may be a distraction may influence care of patient

Special Considerations: Family Presence

Facilitate whenever possible

Important to have designated support person to stay with family at all times

Encourage family member to talk to and touch child

Primary survey should be completed prior to family’s arrival in trauma bay

Special Considerations: Equipment

What do you want to have ready for the arrival of our patient?

Special Considerations: Equipment

Multiple sizes of everything

Broselow™ Equipment systems

Broselow™ Measuring Tape

Resuscitation Guides

Back to the case:

Are there any tools you know of to rapidly assess how sick this child is?

PEDIATRIC

ASSESSMENT

TRIANGLE

Pediatric Assessment Triangle

Circulation to SkinCirculation to Skin

AppearanceAppearance Work ofWork of BreathingBreathing

The Triangle focuses on three aspects of physical assessment that reflect:

Severity of illness or injury Urgency of intervention

Pediatric Assessment Triangle

Pediatric Assessment Triangle

Appearance Mental status and muscle tone Suggests level of consciousness

Work of Breathing Increased, laboured, or decreased Indicates the adequacy of ventilation and

oxygenation

Circulation Skin and mucous membrane colour Reflects the adequacy of oxygenation and

perfusion

Our patient:

Appearance: Abnormal (↓ LOC, ↓ tone)

Work of Breathing: Normal

Circulation: Abnormal (Pallor, some mild mottling)

Primary Survey

A – Airway with C-spine protection

B – Breathing

C – Circulation and hemorrhage control

D – Disability / neurologic screening exam

E – Exposure and environmental control

F – Films / fluids / foley

Primary Survey: Airway

Anatomy: Disproportion between size of cranium and midface

passive c-spine flexion Needs padding under shoulders/torso Relatively large soft tissues Funnel-shaped larynx, more cephalad and anterior Epiglottis Short trachea

Primary Survey: Airway

Assessment: Does the child have a patent airway?

Blood, emesis, maxillofacial trauma, neck trauma Assess visually, auscultation (stridor)

Can the child protect their airway? Level of consciousness

Primary Survey: Level of consciousness

“AVPU”

A – alert V – voice P – pain U – unresponsive

in general GCS < 8

Primary Survey: Airway / C-spine

Always suspect a c-spine injury

Immobilize all patients Rigid collar

Rolls / sandbags

In-line stabilization

Primary Survey: Airway

Management: Jaw thrust – “sniffing position” Clear debris/secretions

Oxygen

Oral airway *insertion technique

ET intubation

Needle cricothyrotomy

Use the Broselow Tape!!

Case: Continued

132, 84/56, 362, 26, 90% on room air No obvious facial trauma, no debris in airway No stridor

?Responding to verbal commands and definitely to painful stimuli

How do you assess his breathing?

Primary Survey: Breathing

Is the child able to:

a) Ventilate? (exchange CO2)

b) Oxygenate? (exchange O2)

*Hypoxia is the most common cause of cardiac arrest in the child

Primary Survey: Breathing

Assessment: Spontaneous respirations Tachypnea / work of breathing Breath sounds Cyanosis SaO2

Chest symmetry Tracheal deviation Neck vein distention Changes in mental status

Primary Survey: Breathing

Interventions: 100% O2

BVM Ventilation

Definitive airway ETT

Surgical

Needle / Tube thoracostomy

Case: Continued

↓ breath sounds on the right Trachea deviated to the left More tachypnea since EMS arrival ↓ LOC since EMS arrival

What do you want to do now?

Case: Continued

14g angiocath placed in 2nd intercostal space mid-clavicular line.

“Whoosh” of air 122, 92/60, 362, 22, 94% on room air Assistant preps for chest tube placement

However, patient is now not responding to voice at all

What do you want to do now?

Primary Survey: Intubation

Airway Protection unconscious severe facial trauma risk for aspiration risk for obstruction

Oxygenation/Ventilation apnea

paralysis LOC

inadequate resps tachypnea hypoxia cyanosis

severe closed head injury

Primary Survey: Intubation

Remember pitfalls!! ETT size

Broselow internal diameter = 4 + age (y)/4 width of patient’s 5th finger or nare

ETT insertion distance short tracheas compared to adults infants = 5cm; toddler @ 18 mo = 7 cm distance = 12 + age (y)/2 (> 2 yo) distance = internal diameter of ETT x 3

Cuffed?

Straight Blade Technique

Curved Blade Technique

Primary Survey: Intubation

The “P”s of RSI preparation

Preoxygenation

Premedication

paralysis

“pass the tube”

position of ETT

Primary Survey: Intubation - Premedication

Atropine anticholinergic prevent HR (age < 2-6 yrs) airway secretions dose 0.02mg/kg (min 0.1 mg; max 2 mg)

Lidocaine

Analgesic (morphine, fentanyl)

Short Snapper: Name the condition

Tachypnea Hypoxemia Hypotension Muffled heart sounds +/- JVD

Pericardial Tamponade

Case: Continued

Patient intubated and placement confirmed

A, B, then C…

How do we assess circulation?

*In reality, ABC’s are managed in parallel/simultaneous fashion

Primary Survey: Circulation

Assessment: Early hemorrhagic shock

Difficult to diagnose because of compensation ↓ BP is an ominous sign (30% loss required for alteration)

Tachycardia Skin perfusion Pulses LOC Hemorrhage Urine output

Primary Survey: Circulation

Primary Survey: BP Rule of Thumb

Minimal acceptable systolic blood pressure:

70 mm Hg + (2 x age in years)

Represents 5th %ile of normal BP

Hypotension in children is a late and often sudden sign of cardiovascular decompensation

Case: Continued

126, 86/58, 362, 22, 94% Skin becoming more mottled, cool, dry Cap refill >3 seconds Intubated Minimal urine output Abdomen soft / no external hemorrhage Obvious deformity right femur

How do you want to proceed?

Primary Survey: Circulation

Management: Apply pressure to control hemorrhage 2 large-bore (14-18g) IVs Intraosseous infusion if needed Crystalloid – 20cc/kg bolus if indicated Relieve pericardial tamponade if indicated Thoracotomy when indicated (rare)

Transfuse with blood if child is hypotensive and poorly responsive to crystalloid boluses (~3)

10cc/kg of type-specific of o-negative PRBCs

Short Snapper: Name the condition

Hypotension Warm, flushed skin Decreased reflexes Flaccid sphinters Hypotonia

Neurogenic shock

Primary Survey: Shock

Hypovolemic shock (most common) Unusual sites

Cardiogenic shock Distributive shock

septic neurogenic anaphylactic

Obstructive shock

don’t forget about these causes

Primary Survey: Why Crystalloid?

intracellular

extracellular IS IV

hypotonicisotonic

colloid

66.7%

100%

25%

75%

8.3%

25%

Primary Survey: Fluid resuscitation

Isotonic crystalloid solution Normal saline / Ringer’s lactate

fluids of choice inexpensive readily available effectively expand interstitial space only transiently expand intravascular volume

Primary Survey: Fluid resuscitation

Colloid solutions blood, albumin, FFP, Pentaspan™

more efficient volume expanders remain in intravascular compartment sensitivity reactions risk of blood-borne infection

Case: Continued

Received 2 x 20cc/kg boluses NS Cross-matched, blood on way 116, 92/74, 362, 20, 96% Skin better perfused Cap refill ~ 2seconds

Primary Survey: Disability

Assessment: Pupils: size and reactivity Level of Consciousness:

AVPU Glasgow Coma Scale (GCS) is gold standard for

the neurologic assessment of trauma patients Movement of extremities Posturing More in-depth neurological assessment in the

secondary survey

Primary Survey: Disability

Primary Survey: Disability

Primary Survey: Disability

Short Snapper: Name the condition

Headache Vomiting Altered LOC Papillary dilation Respiratory irregularity Bradycardia

Increased ICP

Case: Continued

Pupils 3mm, ERL GCS – intubated and sedated but just prior was

9 (E2, V3, M4)

Who needs CT scanning?

All head-injured children <17 years old

Mild, moderate and severe

N = 22 772

Outcome: composite of death as a result of HI, requirement for NSx intervention, ‘marked abnormality’ on CT scan

Derived a 14-point rule (Hx, Physical, Mechanistic factors)

CHALICE study

History Witnessed LOC >5min Amnesia >5min abN drowsiness ≥3 vomits Suspicion of NAT Seizure w/o hx of epilepsy

Mechanism High speed (>40m/h) road

traffic accident Fall >3m in height Injury from projectile

object

Examination GCS <14, or <15 if <1 yo Suspicion of depressed

skull injury or tense fontanelle

Signs of basal skull # Positive focal neuro signs Bruise, swelling of

laceration >5cm if <1yo

CHALICE study

Results:

Sensitivity: 98.6% (95% CI, 96.4-99.6)Specificity: 86.9% (95% CI, 86.5-87.4)

CT Rate: 14.1%

CATCH study

Currently in validation phase Derivation:

N =3 781 Inclusion:

<17 years Blunt head trauma with GCS 14-15 and one of:

Known LOC, disorientation, confusion, amnesia, persistent vomiting, irritability

Outcomes: Need for NSx intervention or lesion on CT (phone f/u at 14 days if no CT scan)

CATCH study

High risk criteria (for NSx intervention) GCS <15 2hrs post injury Suspected depressed skull fracture Worsening headache Irritability on examination

Sensitivity: 100% (95% CI, 86-100) Specificity: 70.4% (95% CI, 69-72) CT rate: 29.6%

CATCH study

Medium risk criteria (for acute brain injury on CT scan) Any signs of basilar skull fracture Boggy scalp hematoma Dangerous mechanism (Fall from >3 feet / 5 stairs,

automobile-related)

Sensitivity: 98.3% (169/172 positive scans) Specificity: 50.1% CT scan rate: 49.9%

Head Trauma

Big Head Brain doubles in size by 6months of age Achieves 80% of adult size by 2 years

Brain Development Plasticity Myelination Subarachnoid space is initially small – less protection ++Cerebral blood flow – sensitive to hypoxia

Head Trauma: Emergent Management of Increased ICP

Therapy Dose Mechanism

Head elevation (30°)

- Lowers intracranial venous pressure

Head in midline - Prevents jugular vein compression

Hyperventilation pCO2 30-35 mmHg

Promptly decreases cerebral blood volume pressure

Mannitol 0.25-2g/kg IV Rapid osmotic diuresis

Hypothermia 27-31°C Decreases cerebral blood flow and metabolic rate

Head Trauma

Management pearls

1. Fluids Children (esp <3yo) are particularly susceptible to the

effects of the secondary brain injury - Hypotension from hypovolemia is the worst single risk factor

2. Infants Significant bleeding into subgaleal or epidural spaces

3. Open Fontanelles May disguise ↑ ICP – lower threshold for investigation

Primary Survey: BP in head injuries

CPP = MAP - ICP

CPP = MAP - ICP CPP = MAP - ICP

CPP = MAP - ICP

Case: Continued

CT: 5mm x 3mm subdural hemorrhage (non – surgical) ?Basal skull fracture

Admitted to ICU. Femur fracture - placed in 90 degree/90 degree

spica cast Extubated next morning Good result

Primary Survey: Exposure

Remove all clothes Keep patient warm

warm blankets, warm fluids, overhead warmer, warm the room

Log roll

Adjuncts to the primary survey

Continuous monitoring of vitals NG or OG tube Urinary catheter (after GU / rectal exam) Bloodwork

CBC, Type & Cross, PT/PTT electrolytes, KFTs, LFTs, amylase

Radiological investigations

Radiology

Portable C-spine Chest x-ray Pelvis (Others)

abdomen extremity

(CT)

Radiography: C-spine pseudosubluxation

Population variant ~ 40% of children

under 7 and 20% of children up to 16 years exhibit anterior displacement of C2 on C3

Exacerbated by flexion

Secondary survey

Goal: identification of all injuries History – AMPLE “Head to toe” exam Look, listen & feel Fingers & tubes in every orifice If any change in patient…re-assess primary

survey

ABCDEF “G”

G – Go around again!!

Thanks to Christine Hall

Additional Interventions

Administer on-going analgesia / sedation

Splint all fractures

Sterile dressings to wounds

Antibiotics as needed

Tetanus as needed

Summary: Airway

Assess: Airway patency Level of consciousness Maxillofacial injury Stridor or cyanosis

Interventions: Jaw thrust, suction, airway adjuncts C-spine immobilization 100% O2 Intubate for:

GCS ≤8, Absent gag, PCO2>50, PO2<50

Needle cricothyrotomy if intubation impossible

Summary: Breathing

Assess: Respiratory rate Chest wall movement Paradoxical breathing Tracheal deviation Flail segment

Interventions: 100% O2

Needle thoracostomy / Chest tube Intubation

Summary: Circulation

Assess: Cap refill Heart rate Peripheral pulses Sensorium Pulse pressure Skin condition / perfusion

Interventions: Oximeter and cardiac monitor, q5min vitals 2 large bore IV’s – central access, IO 20 cc/kg bolus of crystalloid – may repeat x 2 PRBCs 10cc/kg – consider at start of third NS bolus

Summary: Disability

Assess: LOC AVPU or GCS Pupil size and reactivity Extremity movement and tone Posturing Reflexes

Interventions: Maintain BP, oxygenation and ventilation If head injured with GCS ≤9, RSI and intubate (mannitol) If head injured, hyperventilate to PCO2 of 30-35 If blunt cord trauma – Solu-medrol 30cc/kg bolus

Summary: Exposure

Assess: Undress Look under collar and splints Log roll and examine back / rectal

Interventions: Warm patient unless head injured

BE SYSTEMATIC

Questions?