Pediatric Head Trauma

PreHospitalSetting.comAntonio Sánchez González EMT-I

PreHospitalSetting.com

Pediatric trauma

• Forces hit a little surface and the delivery energy cause organic damage instead localized damage.

• Although trauma could appear insignificant it can produce prolonged incapacity, either cerebral, organic or psychological


• Compound fractures , depressed or penetrating injuries generally implies cerebral tissue damage and are consider critical.

• Lineal fractures may or not related with cerebral damage.

Pd Head trauma


Skull fracture signals:

Periorbital Echimosis (raccoon eyes)

Retroauricular Echimosis (battle’s sign)

Hemotímpano CSF Drainage


Pd Head trauma

• Laceration:Laceration:Implies damage to the cerebral Implies damage to the cerebral tissue, morbidity depends on tissue, morbidity depends on extension of injury and secondary extension of injury and secondary vascular complicationsvascular complications


Pd Head traumaEpidural hemorrhage• It is localized between skull and the

dura• Result of damage in middle

meningeal artery• It is Associated to lineal Fx,

depressed or temporal fracture


Pd Head trauma• Posterior Hemorrhage:

Shows nape rigidity, cerebelosus signs, vomiting and progressive lost of consciousness


Pd Head trauma

• Subdural hemorrhage:Affects mainly to young children

Symptoms is slow, without specific clinical data but we can find vomit, irritability and hypertermia. Symptoms may be present in subacute or chronic phases as generalized or focal seizures


Pd Head trauma• Cerebral functions and reflexes are

present, but cortical functions as memory and fine motor coordination are not completely developed and sometimes can not be assessed.

• Cortical injury can be not detected before 6 months


• Infant’s brain have a great amount of water and is not completely evolved by myelin, thus is more susceptible for diffuse injury.

• Symptoms are lose of conscious and midriasis

Pd Head trauma


Pd Head trauma• Increase on ICP by edema must be

assessed early:– Children with GCS 5 or motor

parameter 2– Politrauma– Hypovolemia– Prolonged assessment and

stabilization


Increase on Intracraneal Pressure

• Primary symptoms.– Headache, nausea, vomit y altered

mental status.

• Late symptoms– Increase on systolic blood pressure– Altered breathing– Decrease of pulse


Increase on Intracraneal Pressure

• Very late symptoms– Ataxic breathing– Midriatic pupils and without

response to light– Disritmia


Craneal nerve injury• I Cranial nerve:

– decrease of sense of smell or taste• II cranial nerve:

– Blindness or altered vision• III cranial nerve:

– Fixed and dilated pupils• VII cranial nerve:

– Facial Paralysis• VIII cranial nerve:

– Deafness


Spinal trauma Pd

• Spinal ligaments and articular capsules are more flexible

• Children have a prominent occiput, thereby cause neck flexion when the child lay supine and it can occlude the unprotected airway

• Children below 7 years old present anterior Children below 7 years old present anterior

displacement ofdisplacement of C2 y C3C2 y C3


Spinal Trauma Pd

• In some toddlers we can find a great

distance between the odontoid of C2 and

the anterior arc of C1

• Growing centers may appear such

fractures

• Cord injury may present without

radiological abnormality (SCIWORA)


Inappropriate care in the Inappropriate care in the immediate posttraumatic immediate posttraumatic period may affect survive period may affect survive and posterior life qualityand posterior life quality

Pediatric Trauma


AssessmentA. Airway

– Obstruction: secretions, strange objects, bleeding, edema, hematoma...

– Control cervical spine while perform any airway maneuver and inmovilization


Assessment• Breathing

– Apnea o Bradypnea– Diminished on breathing sounds– if pneumotorax are present may

not be heard the leak on ventilation.


Assessment• Circulation

– Weak cardiac sounds– Diminished capillary refill– Tachycardia, hypertension,

Bradycardia– Hemorrhage– Discrepancy between central and

distal pulses– Jugular vein distension


Sistemic response to blood lose

Organ Early< 25%

Prehypotensive25%

Hypotensive40%

Cardiac response

Weak Pulse, tachycardia

Tachycardia Hypotensión tachy or bradycardia

CNS Letargic, irritable, confuse, combative

Altered LOCslow response to pain

Comatose

Skin Cold, wet Cianotic, cold, retarded capilary refill

Pale and cold

Kidney Oliguria Increase on ureic nitrógen

Anuria


TreatmentA.Airway

– Chin lift, jaw trust– Oropharingeal airway, ETI,

PTV– CONTROL OF CERVICAL

SPINE


Treatment• CERVICAL SPINE CONTROL


R S I• Children with head trauma are in risk

to develop increase on intracraneal pressure and sometimes they have significant pain

• Rapid sequence intubation can diminished the increase on BP and ICP specially with use of tiophental y Lidocaine.


Drugs • Manitol and furosemide can

decrease the intracraneal pressure, but their use can be restricted to hospital

• The best actions in prehospital setting are to keep a good perfusion and oxygenation


Treatment• Breathing

– 100% Oxygen – Treatment of apnea– Positive pressure ventilation– Aspiration of pneumotorax– Tidal volume calculated at (10 -

15 cc)(kg)


Treatment• Circulation

– Two large bore peripheral catheters – Crystalloid 20 cc/kg– In massive bleeding may be request

fluids at 3:1– Control hemorrhages and avoid fall

of BP– children do not show early

decompeNsation


Pediatrics• Weight

weight (kg) = 8 + ( 2 x age in years )

• Systolic blood pressureSBP (mm Hg) = 80 + ( 2 x age in years )

• diastolic blood pressureDBP = 2/3 SBP

• total blood volumeVolume (cc) = 80 cc x weight in kg


Treatment• Disability

– AVPU SCALE– GLASGOW COMA SCALE– PEDIATRIC TRAUMA SCORE

(score < 8 transport to trauma center)

– PUPILS


Treatment• ESCALA DE AVDI

A Child is ALERT, responds to all kind of stimuli

V Child responds to VERBAL stimuli or talkhim/her loud

P Child responds to PAIN, when painful stimuli isapplyed the child respond and then become

depressed. Sometimes only reefer too much painbut is not capable to interact appropriately

U Child is UNCONSCIOUS, they do not respondto any kind of stimuli and is unnecessary to keep

applying painful stimuli


PEDIATRIC GLASGOW COMA SCALE

VERBAL RESPONSEVERBAL RESPONSE5 Coos and babbles5 Coos and babbles4 Irritable cries4 Irritable cries3 Cries to pain3 Cries to pain2 moans, grunts2 moans, grunts1 No response1 No response

MOTORA RESPONSEMOTORA RESPONSE6 Spontaneous and 6 Spontaneous and

purposefullypurposefully55 Withdraws to touchWithdraws to touch44 Withdraws to painWithdraws to pain33 Decorticating Decorticating 22 Decerebration)Decerebration)11 No responseNo response

EYE RESPONSEEYE RESPONSE4 Spontaneous4 Spontaneous3 Verbal3 Verbal2 Pain2 Pain1 No response1 No response


Pediatric Trauma Score+2 +1 -1

AgeChild / adolescent > 20

KgToddler 11 – 20 Kg Infant < 10 Kg

Airway Self-MaintainedNon maintained, oro ornasopharyngeal airway

needed

Controlled byendotracheal tube,

LMA, Cricotirotomy

Level ofconsciousness

AlertConfuse

Lost of consciousnessComa

Unconsciousness

Systolicblood

pressure

>90 mm HgPULSE PRESENT AT

WRIST

51-90 mm HgCOROTID /FEMORAL

PULSE PRESENT

<50 mm HgWITHOUT

PERCEPTIBLEPULSE

FracturesFractures Non

apparent and withoutsuspect.

Close Fracture anywhereMultiples fractures

or single openfracture

Coetaneous No visible injuriesContusion, abrasion,

laceration < 7cm and notaffect to fascia

Lost of tissue.Gun or stab wound


Treatment• Expose

– Remove clothes for search and asses injuries and bleeding

– Avoid hypothermia


Battered /abuse CHIld

• Is the damage by inappropriate or Is the damage by inappropriate or abnormal care, include physical, sexual abnormal care, include physical, sexual or emotional abuse, negligence, or emotional abuse, negligence, inappropriate accidental injuries and inappropriate accidental injuries and neglect.neglect.

• Is import for treat trauma and avoid Is import for treat trauma and avoid future injuries or even deathfuture injuries or even death


Battered /abuse CHIld

• Children below 6 years old rarely present

injuries by them self

• 90% of them present superficial injuries

and others shows injuries at different

stages of healing

• Assess behavior concern child and

caregiver and incongruent history about

injuries


Quick guide for pediatric head trauma

Kinematics Altered mental statusSuspect or evidences of Fractures or penetrating injuries in head.

Continuous Seizures


Quick guide for pediatric head trauma

Signs of increase in intracraneal pressure

Persistent emesis Amnesia Abnormal Neurological exam

(AVPU or Glasgow)


IS INDISPENSABLE THAT INJURIED CHILD RECEIVE

EXPERT MANEGEMENT ON SCENE, ON TRANSPORT AND IN

HOSPITAL

Trauma pediátrico

PreHospitalSetting.comAntonio Sánchez González EMT-I

Pediatric Head Trauma

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