Pediatric Trauma

Ray Taylor

Valencia Community College

Department of Emergency Medical Services

Objectives

Overview Anatomic Features Injury patterns Initial assessment Review trauma resuscitation (ABCDE’s) Specific Protocol

NAEMSP

Pediatric Trauma

Background

Background

0

200000

400000

600000

800000

1000000

1200000

1400000

1600000

Injuries Admissions Deaths

Fortune JB. Adv Trauma Crit Care 1994; 9: 169

20,000

500,000

Background

0%

10%

20%

30%

40%

50%

60%

70%

Head Thorax Abdomen

Cause of Death in Children with Truncal Trauma

Cooper J Pediatr Surg 1994; 29: 33.

**

** most common unrecognized cause of death

Adults vs. Children

Children vs. Adults more

multi-system injury pedestrian injury falls All terrain vehicles MVA occupant

less penetrating trauma assault

Injury Patterns & Mechanisms

Knowledge of the exact mechanism & surrounding events can help in

the evaluation & management

Injury Patterns

MVA29%

PED23%

Other Penet3%

Stab3%GSW

7%Bike10%

Fall11%

Other blunt14%

National Pediatric Trauma Registry

Mechanism vs. Relative Mortality

1 1.2

0.8 0.75 0.8

Mechanism Mortality rate prediction

site of impact vs. seat location

Injury Prediction for site of impact vs. seat location vs. age Vehicle side intrusion vs. no intrusion Head/Face = Frontal impact Spine injury = Rear impact Seat belt injury = Frontal impact Rear seat = lateral impact/no intrusion

Agran PF J Trauma 1987; 27: 58-64.Evans L Am J Publ Health 1988; 78: 1456-8

Lap Belts

Belt123

No Belt290

Head/neck 46% 59%*Face 8% 15%*Thorax 8% 12%Extremity 25% 35%Abdomen 18% 12%*ABD ISS 8.2% 12.8%*Death 2.4% 4.5%*

National Pediatric Trauma RegistryAm J Public Health 1992; 82: 42.

* p < 0.05

Lap Belt Complex

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

0-3 4 to 9 10 to 14

HeadChest/AbdExtremitySpine (strains)

Injuries in Seat Belted Children Treatedin a Hospital Emergency Room

Agran PF J Trauma 1987; 27: 58-64

Pedestrians

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Extremity Head Abdominal

System Injuries in Pediatric Pedestrian TraumaKong LB J Am Coll Surg 1996; 182: 17.

What is a British Waddel’s Triad?

Waddell’s triadIpsilateral femurSpleenIntracranial injury

•Bicycle Handlebars

Bottom Line - Injury Patterns Knowledge of incident is important

Exact mechanism of accident Location in car Helmets

bicycle vs. motorcycle

Seat belt? Airbags Prehospital Vitals, GCS, Interventions

Missing information may cause delayed diagnosis, misdiagnosis worse outcome potential

Dispatch Information

You and your partner, both EMTs, are dispatched to a reported child struck by a car

While en route, the dispatcher tells you that ALS is unavailable at the moment and asks you to advise if they are needed.

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Dispatch Information

Your partner comments that the nearest hospital, which happens to be a trauma center, is a 20-minute drive response from the accident scene.

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Initial Impression

7 y/o male Supine on the

street in front of a car

Crying and moaning

No obvious injury Minimal damage

to car

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Discussion

What is your initial impression of the patient’s status?Concerns?

What are your immediate priorities?

Would you call for an ALS unit?

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Treatment/Assessment

You check with a police officer who is on scene and confirm that there are no other patients

Your partner radios dispatch and cancels the fire department’s response

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Treatment/Assessment

You immediately go to the patient’s head, introduce yourself, and hold c-spine

The patient is crying, tells you his name is Ben, and you note that he is breathing about 26-30 times a minute

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Discussion

What do you know about the patient’s airway and breathing?

Are you comfortable with the patient’s airway and breathing?Why or why not?

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Treatment/Assessment

You and your partner take off the patient’s helmet, which you note has not suffered any damage

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Treatment/Assessment

Your partner applies a nonrebreather mask with a flow rate of 12 lpm, then starts taking vital signs as you start your assessment

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Assessment

The patient states:He was riding his bike, was hit by car on

right side, then fell to groundHit his head but was wearing his helmetNo loss of consciousnessHas abdominal pain

You note:Skin pale, warm, dryCapillary refill 2 sec

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Assessment

Your partner reports:HR = 132 regularRR = 28 regular BP = 118/70SpO2 =

97% room air 100% on 12 lpm

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Discussion

What is your impression of the patient’s status?Concerns?

What is your next course of action?

If you have not yet, would you call for an ALS unit?

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Detailed Assessment

You continue to talk to the patient, explaining that your partner is going to perform a physical exam

Physical exam reveals:Head

No trauma noted PEARL No blood in ears, nose, or mouth

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Detailed Assessment Physical exam reveals:

Neck Atraumatic No JVD or tracheal

deviation

Chest No obvious trauma to

anterior, posterior, lateral chest

Lung sounds clear/= bilaterally

No pain with palpation Equal chest rise and fall

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Detailed Assessment

Physical exam reveals:Abdomen

Small bruise noted to upper right quadrant

Pain with palpation to upper right quadrant

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Detailed Assessment

Physical exam reveals:Pelvis

Atraumatic, stable No pain with palpation

Extremities Atraumatic Full range of motion all

extremities

Patient weighs approximately 55 lbs

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Discussion

What is your impression of the patient’s status?Concerns?

What is your next course of action?

If you have not yet, would you call for an ALS unit?

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Treatment/Assessment

You and your partner perform full spinal immobilization and recheck vital signs

Vital signs:HR = 136 regularRR = 26 regular BP = 116/72SpO2 = 100% on 12

lpm

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Treatment/Assessment

You and your partner load the patient into the ambulance and note that the patient is no longer crying

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Discussion

Does this concern you?

What would be your immediate course of action?

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Ongoing Assessment

You go to the patient’s head and note that he is responsive to verbal stimuli but slightly confused

You also note:Skin cool, ashen, slightly diaphoreticCapillary refill delayed

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Ongoing Assessment

Your partner reports the following vital signs:HR = 108 regularRR = 22 regular, shallow BP = 82/42SpO2 = 97% on 12 lpm

Palpation of the patient’s abdomen reveals it to be slightly distended and rigid

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Discussion

How would you describe the patient’s current condition?

What would be your immediate actions?

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Ongoing Assessment

You ask the officer to begin transport to the ED and attempt to have ALS meet you while en route.

You assess the patient’s airway and note:It’s openNo need for suctionHe is able to verbally respond to

stimuli

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Ongoing Assessment/Treatment

Radial pulses are absent You raise the patient’s feet and place a blanket

over him

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Ongoing Assessment

The ALS unit meets you while en route The paramedic joins you in the patient

compartment and instructs the officer to continue the response to the ED

The paramedic listens to your report while performing a rapid exam

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Treatment

In the remaining 10 minutes, the paramedic has time to:Initiate 2 large-bore IV

lines and administer 500 mLs of normal saline

Place the patient on the cardiac monitor

Sinus tachycardia noted

Give a report to the receiving physician at the trauma center

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Discussion

How should fluid bolus volumes be determined in pediatric patients?

How much fluid would you administer to this patient?

What should your next actions be?

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Ongoing Assessment

Vital signs upon arrival at ED:HR = 108 regularRR = 22 regular, shallow BP = 80/40SpO2 = 99% on 12 lpm

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

ED Treatment and Beyond

The patient’s airway is assessed and determined to be adequate at the time

Whole blood is administered An ultrasound is performed and a large

amount of intraperitoneal blood identifiedCBC and crossmatch ordered

Lab studies orderedArterial blood gas, trauma panels

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

ED Treatment and Beyond

The patient is rushed to the OR for surgical repair of a lacerated hepatic artery

Post-surgical CT scan reveals the presence of a small pulmonary contusion on the lower right lung

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Discussion

What about the mechanism of injury, pediatric anatomical characteristics, and physical exam findings should have led to suspicions of intrathoracic and intraabdominal injuries?

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Discussion

What signs of compensated shock were present early in patient care?

How should this call have been managed differently?

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Epidemiology

Traumatic injury the leading cause of death in children < 1 year old

In children, trauma greater than all other causes of death combined

50% of deaths occur within the first hour after injury

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Epidemiology

Blunt trauma most frequent mechanism of injury (80-90% of all injuries)

Motor vehicle collisions account for 40% of deaths, followed by:DrowningsPedestrian injuriesFires/burnsBicycle crashesFirearmsFalls

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

A & P Review

Differences in the pediatric thoraxChest cage mostly

cartilage Blunt trauma forces

transmitted to thoracic organs without breaking ribs

Lower rib cage does not adequately protect liver, spleen

Intercostal muscles not fully developed

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

A & P Review Differences in the

pediatric abdomenAbdominal contents

normally located high up in thorax

Consider abdomen to begin at level of nipple

Liver, spleen relatively unprotected by lower rib cage

Infants/small children are abdominal/diaphragmatic breathers

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

A & P Review

Physiologic differences: HemodynamicsCan compensate for developing hypoxia

with tachypneaBlood volume much lower

Small-volume blood loss may be significant

Can compensate for developing shock with tachycardia and vasoconstriction

Unable to effectively increase cardiac contractility Patient “crashes” when cardiac output can no longer meet

demand

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Pathophysiology

Early and effective support of airway, ventilation, oxygenation, and

circulation is vital in the pediatric blunt-trauma patient.

Survival of an out-of-hospital cardiac arrest secondary to

blunt trauma is poor.

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Pathophysiology

Significant intrathoracic injury can occur without external signs of traumaPulmonary contusions, pneumothorax

commonly present without rib fractures

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Pathophysiology

Spleen, then the liver most commonly injured abdominal organsSpleen and liver injuries tend to stop

bleeding spontaneously, unless major blood vessels involved

Major blood vessel injury creates significant hemodynamic instability

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Pathophysiology

Children are able to compensate for shock very effectivelyIncreased cardiac output through

tachycardia

When blood loss overwhelms compensatory mechanisms, cardiovascular collapse develops rapidly

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Pathophysiology

Fig 7-1 Pediatric prehospital Care. Graph of peds versus adult CO, BP, HR during compensation.

Figure 4.2-3

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Pathophysiology

Avoid hypothermia in trauma patientsChildren can lose body heat rapidlyCan result in:

Vasoconstriction Low-flow states Acidosis Consumptive coagulopathy

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Clinical Assessment Airway

Open it, clear it, and keep it openC-spine precautionsModified jaw thrust if necessary

Figure 4.2-4

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Clinical Assessment

BreathingEnsure adequate breathing and oxygenation

Rate, depth, effort of breathing Inspect, palpate, auscultate chest

Anterior, lateral, and posterior

Fig 9-31k: Prehospital EC, 7th ed. Pic of palp of chest

Figure 4.2-5

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Clinical Assessment Circulation

Identify and control external hemorrhageAssess and support systemic perfusion

Pulse Level of consciousness Capillary refill

Figure 2-4g: Prehospital Pediatric Care. Pic of radial pulse

Figure 2-4h: Prehospital Pediatric Care. Pic of capillary refill

Figure 4.2-8Figure 4.2-7© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Clinical Assessment

Compensated shockEvidenced by:

Tachycardia Tachypnea Adequate blood pressure Irritability, anxiety Delayed capillary refill Cool, pale extremities

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Clinical Assessment

Decompensated shockEvidenced by:

Decreased level of consciousness Marked tachycardia or bradycardia Absent peripheral, weak central pulses Markedly delayed capillary refill Hypotension

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Clinical Assessment

Estimating normal vital sign rangesUpper limit of child’s pulse rate

HR = 150 - (5 X age in years)

Normal systolic blood pressure SBP = 80 + (2 X age in years)

Normal lower limit of systolic blood pressure LLSBP = 70 + (2 X age in years)

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Clinical Assessment

DisabilityRapid assessment of neurologic functionGCS, AVPU Pediatric Response Scale

ExposeRemove clothing as appropriatePerform head-to-toe physical exam

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Clinical Assessment Chest

Inspect for obvious trauma

DCAP-BTLS, may not be present in peds!

Equal chest rise and fall

Auscultate lung soundsPalpate chest for pain,

crepitusPercussion

Not practical in a lot of prehospital settings

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Clinical Assessment

AbdomenInspect for

obvious trauma DCAP-BTLS

Palpate4 quadrants Pain, rigidity,

guarding, masses

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Clinical Assessment

Cardiac monitorDysrhythmiaMyocardial

contusion

SpO2

Developing hypoxia

Figure 4.2-12

Fig 4-5A , Prehospital Ped Care. Insert pic vertically.

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Treatment

Ensure patent airway, ventilation, and oxygenationBLS airway maneuversC-spine stabilizationBLS airway adjuncts if required

Figure 7-5D, Prehospital Ped Care. Pic collar, stabilization.

Figure 3-8D, Prehospital Ped Care. Pic OPAs.

Figure 4.2-14Figure 4.2-13

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Treatment

Ensure patent airway, ventilation, and oxygenationBVM ventilations,

endotracheal intubation if necessary

Cricoid pressure if providing BVM ventilations

Consider NG tube for gastric decompression

High-flow, 100% O2

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Treatment

BLS maneuvers: raise lower extremities

IV accessLarge-bore as

appropriateFluid volume

administration if shock present

DO NOT wait for hypotension to develop; administer fluids early in pediatric trauma

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Treatment

Protect against hypothermia Cardiac monitoring SpO2 monitoring Pain control

Morphine for skeletal injury as appropriate

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Treatment

Emotional supportFor family and child

Fig 2-25: PCP&P Vol 5, 2nd Ed. Pic of immobilized child in ambulance with mom & medic providing emotional support.

Figure 4.2-17

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

ED Treatment and Beyond

Continuation of airway, breathing, and oxygenation supportRSI, surgical airways if needed

Peripheral IV access if not accomplished in fieldCentral line placement if patient

hemodynamically unstable

Administration of blood or blood products for volume expansionCBC, type and crossmatching

© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

ED Treatment and Beyond

Diagnostic imagingInitial screening X-rays

C-spine series, anteroposterior chest and pelvis

CT scanUltrasoundDiagnostic peritoneal lavage has limited role

Laboratory studiesArterial blood gas analysisTrauma panels

Consideration of antimicrobial prophylaxis© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ

Anatomy & Physiology

Head Injury

Head Trauma

Injuries are the leading cause of death in children, and brain injury is the most common cause of pediatric traumatic death.

The automobile is the most lethal component of a child's environment.

Head Trauma: Statistics

200-300 cases/per 100,000 population annually

$7.5 Billion $ per annual in the USA

multiple etiologies automobiles abuse falls (bikes,

skateboards, ATVs, walkers,windows)

missiles (bullets)

maturational differences have implications for assessment and prognostication

the young child's brain presents a different developmental substrate for injury

Pediatric Head Trauma

has greater water content than the adult's

is relatively resistant to damage from hypoxia / ischemia

typically responds to injury with hyperaemia with out edema. .

The child's brain

diffuse axonal injury

brainstem injury

bilateral hemispheric damage

Coma can result from:

Head Injury

# 1 killer Thinner skull - < 1-2 years Vascular scalp

scalp hematoma/cephalohematoma

hypotension

Open fontanelle - protection?

Unreliable examination

Head Injury CNS injuries

Skull fracture Depressed Growing - weeks/months

Subdural - Venous bleeding Shaking/abuse

Epidural hematoma Arterial bleed > venous Delayed bleeding and delayed deterioration 30% no fracture

50% from falls < 4-6 feet Diffuse Edema

Abnormal (increased flow)

eye opening (1-4)

1 none

2 response to pain

3 response to voice

4 spontaneous

Glascow coma scale

best motor response (1-6)

1 none

2 abnormal extension

3 abnormal flexion

4 withdrawal from pain

5 localization of pain6 obeys commands

Glascow coma scale

best verbal response (1-5)

1 none

2incomprehensible

3 inappropriate

4 confused

5 oriented

Glascow coma scale

best verbal response (1-5)

1 none

2 restless, agitated

3 persistently irritable

4 consolable crying

5 appropriate words, smiles, fixes +

follows

Glascow coma scale (modified for young children)

Subdural vs. Epidural

is venous in origin (bridging veins)

is associated with a reasonable outcome if removed early

Subdural hematoma I

usually arise from the bridging veins

bridging veins are more susceptible to tearing when there is cortical atrophy

Subdural hematoma II

Subdural hematoma III

is arterial in origin

middle meningeal artery is torn

often is a true neurosurgical emergency

Epidural hematoma I

Epidural hematoma II

Hematoma: distortion

hematoma displaces brain toward the right

strain or distortion of brain tissue visualized colorimetrically: deep blue low distortion, and yellow and red high distortion or stretching

in this case there is about 17% distortion

Hematoma: edema formation

contour map illustrates the relative amount of edema formation induced by the hematoma

again the greatest amount of change occurs in ipsilateral tissue abutting the tentorium

is usually frontal or temporal lobe

can be bilateral (contracoup injury)

Intracerebral hemorrhage

is usually frontal or temporal lobe

Focal injury

Coup - contracoup injury

a fall backwards resulted in bilateral injury

inferior frontal and temporal lobes

Coup - contracoup injury

Cervical Spine

Spinal/Neck Injuries

Spine/Neck Injuries

Locations < 8 years C1-2 (more room) > 8 years C5-6 Diaphragm C3 (respiratory arrest)

Abdominal breathing Hypoventilation/Apnea

Unique reflexes - infants mass flexion withdrawal from stimulation

when paralyzed indistinguishable from normal movement

Spine/Neck Injuries

SCIWORA Spinal Cord Injury Without Radiologic Abnormality DELAYED ONSET of Neurologic Deficit (54%)

Swelling Vascular Insult to Cord (hypermobility) Many with initial Symptoms - disappear - reappear

Cervical Spine

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

0-2 3-4 5-6 7-8 9-10 11-12 13-14 15-16

C1-4C5-7

J Pediatr Surg 2001; 36: 100-105.

Level of Injury Based On Age

Cervical Spine

0%

10%

20%

30%

40%

50%

60%

70%

80%

0 to 4 5 to 8 9 to 12 13 to 16 17 to 20

Fracture

Dislocation

Cord-No Fx(SCIWORA)

Specific Injuries Occurring at Different Ages

J Pediatr Surg 2001; 36: 100-105.

Thoracic Injuries

“Rubber ribs” do not break upper abd trauma lung trauma

Mobile mediastinum no aortic injuries tension pneumothorax

Less lung reserve more hypoxia

Diaphragm less intercostals quicker fatigue

Abdominal InjuriesPhysiology Clinical correlate

Poor muscle tone Less protection

More protuberant More injuries

Less fat No insulation

More elasticconnections

Tear mesentery,bowel, vessels(normal CT)

Spleen capsule(relatively thicker)

Contained ruptureLess surgery

Abdominal bladder No pelvic protection

Air swallowing Air (limits exam &limits respirations)

Renal/Ureteral Injuries

ALS vs. BLS Interventions

0 1 2 3 4

AverageMortality

ALS

Liberman J Trauma 2000; 49: 584.

ALS vs. BLS Mortality in 15 studies

ALS vs BLS Interventions

0

5

10

15

20

ALS BLS

Mean On Scene Times ALS vs BLS

BVM vs. ETT prehospital

830 patients BVM vs. ETT every other day < 13 years old or < 40 kg

Gausche. JAMA 2000; 283: 783.

BVM vs. ETT

Time Period BVM ETT P value

Dispatch to scene 5 5 0.45

Scene time 9 11 < 0.001

Transport 6 6 0.21

Total time 20 23 < 0.001

Gausche JAMA 2000; 283: 783.

Prehospital BVM vs. ETT Survival

0%

20%

40%

60%

80%

100%

Headinj

FB asp Seizure Resparrest

Abuse All

BVMETT

Gausche JAMA 2000; 283: 783.

**

**

* statistically significant

Pediatric Trauma Arrests

0%

20%

40%

60%

80%

100%

Mortality

ETT no ETT

Prehospital Pediatric Trauma Arrest Outcome Based on Intubation (N = 729)

Perron Prehosp Emerg Care 2001; 5: 6-9.

Pediatric Trauma Protocol Basic Life Support (ABCDE)

Establish responsiveness Airway/breathing

Assessment Jaw thrust - NOT chin lift 100% oxygen bag valve mask/laryngeal mask airway

Circulation Control hemorrhage Assess circulation

Pulses (proximal vs. distal) Capillary refill

Pediatric Trauma Protocols

Disability Brief neurologic exam

AVPU Pupils

Pediatric Trauma Protocols

Exposure Splint obvious fractures of long bones Maintain normal temperature

Pediatric Trauma Protocols Advanced Life Support Repeat ABCDEs Airway (Cspine immobilization)

Advanced - BVM/ETT/LMA

Breathing Assess work, rate Listen Pulse oximetry/ETC02

Pediatric Trauma

Breathing - Injury Blunt Penetrating

Contusion/Lac 53% 29%

HemothoraxPneumothorax

38% 64%

Rib fractures 36% 8%

Cardiac 5% 13%

Diaphragm 2% 15%

Major vessel 1% 10%

Tension PTX < 0.1% < 1%

Pediatric Trauma

Simple pneumothorax/contusion Abdominal bleeding

Massive Hemothorax Tension pneumothorax Flail chest - contusion/hypoxia Cardiac tamponade Diaphragm rupture

Pediatric Trauma

BP JVD Hypoxia BS TracheaHyper

resonantSimple pneumothorax

Pulmonary contusion

Hemothorax

Tension pneumothorax

Flail Chest

Cardiac Tamponade

Needle Thoracostomy

Indications Hypotension AND Diminished Breath Sounds AND Hyperresonance AND Hypoxia AND Severe Respiratory Distress (PRE-CODE) ALSO

Consider in all blunt/penetrating arrests Who are difficult to bag/Injuries compatible with

Tension Pneumothorax

Needle Thoracostomy

Adverse effects of needle (if no tension) Lacerated Subclavian Tension Pneumothorax Simple Pneumothorax Hemothorax Lacerated Lung Lacerated Internal Mammary Artery Lacerated Intercostal vessels Cardiac Tamponade/laceration Death

Management Priorities

Advanced Life Support Airway Breathing Circulation

Cardiac Monitor/Vitals Compress bleeding sites Initiate IV 0.9% NS DO NOT let IV access delay transport IO is indicated if in shock Fluid bolus

20 ml/kg IV/IO -may repeat up to total 60 ml/kg

Transport Priorities

Reassess ABCDEs Pulse oximetry/Capnometry Vitals

Prevent hypothermia Focused history and physical exam

if patient status permits

ED Arrival

History of event/Mechanism Initial Exam (pertinents)

BP/HR RR/Effort/Lung exam/O2 saturation GCS Obvious injuries

Prehospital Interventions/Course

Emergency Department Trauma Alert

11 Member trauma team 3 surgeons/2 EM/2 RNs/2Xray/1Resp tech

+/- additional pediatric surgeon if < 16

Goal Rapid OR - life threatening thoraco-abdominal trauma Rapid Evaluation/Resuscitation (xray/CT) Rapid Airway Management

Trauma Red - seen within minutes by EM attending/resident

Trauma Green/Yellow seen ASAP - if not sitting on wall

Prehospital triage

Pediatric Trauma Score

Feature +2 +1 -1Size/ kg > 20 10-20 < 10

Airway Patent Maintaine Non-Maint

SBP > 90 50-90 < 50

Mental Awake Obtunded Coma

OpenWound

None Minor Major

Ext fx None Closed open/multi

Prehospital Triage Pediatric Trauma Score

Used only 3% of time in Florida Not “user friendly” Poor inter-observer variability

FSU/State Office of EMS/2 studies studied new CURRENT triage criteria

compared to Injury Severity/Mackenzie Dade 9 Co.

Undertriage 13% 33%

Overtriage 58% 15%

Phillips. Pediatr Emerg Care 1996; 12: 394.Johnson Prehospital Dis Med 1996; 11: 20.

Trauma Alert Criteria (1 red/2 blue)Criteria Blue (1) Red (2)

Size 11 kg (24 lbs) orBroeslow (< 33 in)

Airway Assist beyond 02

Conscious Amnesia/LOC Lethargy,No commandsNo voice resp.? spinal cord

Circ Carotid/FemSBP (50-90)

No/weak Car/FemSBP < 50

Fracture Closed long bone(not wrist/ankle)

Open long, or multiplefracture/dislocations

(not wrist/ankle)Skin Major disruption

2nd/3rd burn > 10%Amputation (not W/A)Penetrating H/N/Torso

• Judgement

Prehospital care PTS > 8 0% mortality PTS < 0 100% mortality PTS 0-8 variable Protocols

Send to pediatric trauma center if: 1 RED or 2 BLUE trauma criteria PTS < 8

If these criteria not MET 0% Mortality risk Go to closest ED Any identified injuries can be transferred

Phillips Pediatr Emerg Care 1996; 12: 394.

Tepas J Pediatr Surg 1987; 22:14

Thank you!