Pediatric Trauma Ray Taylor Valencia Community College Department of Emergency Medical Services.
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Transcript of Pediatric Trauma Ray Taylor Valencia Community College Department of Emergency Medical Services.
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!