Pead Trauma

Pediatric Trauma

Objectives of Learning  Identify the unique characteristics of the

child as a trauma patient  Types

of injury  Patterns of injury  Anatomic and physiologic differences in children as compared with adults.  Long-term effects of injury.

Objectives of Learning  Discuss the primary management of the

following critical injuries in children based on the anatomic and physiologic differences as compared with adults.      

Airway management. Shock and maintenance of body heat Fluid and electrolyte management Medications and dosages Central nervous system and cervical spine injuries Psychological support

Objectives of Learning -Skills Demonstrate in a simulated situation the following procedures for the pediatric trauma victim.  Endotracheal

intubation.  Intravenous / intraosseous access.  Fluid and drug administration.  Management of extremity trauma.

Introduction  Injury continues to be the most common cause of death and

disability in childhood. Although falls are a very common cause of injury, they infrequently result in death. Children with multisystem injuies can deteriorate rapidly and develop serious complications. Therefore, such patients should be transferred early to a facility capable of managing the child with multisystem injuries.  Unique anatomic characteristics of children require special consideration in assessment and management.  Size and shape  Skeleton  Surface Area  Psychologic Status  Long-term effects  Equipment

Airway: Evaluation and management  Anatomy  The

infant’s trachea is approximately 5 cm long and grows to 7 cm by about 18 months. Failure to appreciate this short length may result in intubation of the right mainstem bronchus, inadequate ventilation, and/ or mechanical barotrauma to the delicate bronchial tree.

Airway: Evaluation and management  Management  

Before attempts are made to mechanically establish an airway, the child should be oxygenated. Oral airway 



The oral airway should only be inserted when a child is unconscious. If placed when the child is awake, vomiting is likely.

Orotracheal intubation   

Child with significant head injury requiring hyperventilation. The child who cannot maintain an airway. The child suffering significant hypovolemia who requires operative intervention.

Airway: Evaluation and Management  Orotracheal intubation  Uncuffed tubes of appropriate size should be used to avoid subglottic edema, ulceration, and disruption of the infant’s fragile airway.  The smallest area of the child’s airway is at the cricoids ring, which forms a natural seal with the endotracheal tube.  Orotracheal intubation under direct vision with adequate immobilization and protection of the cervical spine is the preferred method of obtaining initial airway control.  Auscultation of both hemithoraces in the qxillae should be performed.  A chest x-ray may be obtain to accurately identify the position of the endotracheal tube.

Airway: Evaluation and Management  Cricothyroidotomy  Surgical

cricothyroidotomy is rarely indicated for the infant or small child, and if absolutely necessary, it should be performed by a surgeon.  Needle cricothyroidotomy

Breathing Evaluation and management  Breathing and Ventilation  An infant requires 40 to 60 breaths per minute, whereas the older child breathes 20 times per minute.  Hypoventilation is the most common cause of cardiac arrest in the child.  In the absence of adequate ventilation and perfusion, attempting to correct an acidosis with sodium bicaarbonate results in further hypercarbia and worsened acidosis.  Tube Thoracostomy 

Same as in adults except the size.

Circulation and Shock  Recognition  Early

assessment of the child by a surgeon is essential to the appropriate management of the injured child.  A 25% diminution in circulating blood volume is required to manifest the minimal signs of shock.

System

<25% Blood Volume loss

25%-45% Blood Volume Loss

>45% Blood Volume Loss

Cardiac

Weak, thready pulse, incresed heart rate

In creased heart rate

Hypoten-sion, tachycar-dia to bradycar-dia

CNS

Lethargic, irritable confuse Change in level of consiousn-ess, dulled response to pain

Comato-s

Skin

Cool, clammy

Cyanotic, decreased capillary refill, cold extremitie-s

Pale, cold

Kidneys

Minimal decrease in urinary output; increased specific gravity

Minimal urine output

No urinary output

Circulation and Shock: Evaluation and management  Fluid Resuscitation  Goal in fluid resuscitation in the child is to rapidly replace the circulating volume.  When shock is suspected, a fluid bolus, using warmed fluid, of 20 ml/ of crystalloid solution is required.  It may be necessary to give three boluses of 20 ml/kg or a total of 60ml/kg to achieve a replacement of the lost 25%.

Circulation and Shock: Evaluation and management  A return toward hemodynamic normality is

indicated by:       

Slowing of the heart rate (<130 beats/minute with improvement of other physiologic signs) Increased pulse pressure (>20 mm Hg) Return of normal skin color Increased warmth of extremities Clearing of sensorium (improving GCS score) Increased systolic blood pressure (>80mm Hg) Urinary out put of 1 to 2ml/kg/hour (age-dependent)

Circulation and Shock: Evaluation and management  Blood Replacement  When

starting the third bolus of crystalloid fluid or if the child’s condition deteriorates, consideration must be given to the use of 10 ml/kg of type specific or O-negative warmed PRBCs.

Circulation and Shock: Evaluation and management  Venous Access  The sites for venous access in children are: Percutaneous peripheral (two attempts)  Intraosseous (children <6 years of age)  Venous cutdown-----Saphenous vein at the ankle  Percutaneous placement -------Femoral vein  Percutanceeous placement-----Subclavian vein  Percutaneous placement-------- External jugular vein (do not use if cervical collar applied  Internal jugular vein Intraosseous infusion, cannulating the marrow cavity of a long bone in an uninjured extremity, is an emergentaccess procedure for the critically ill or injured child. 

Circulation and Shock: Evaluation and management  Urinary Output  Urinary output for the newborn and infant, up to 1 year, is 2ml/kg/hour.  The toddler has a urinary output of 1.5 ml/kg/hour, and the older child has urinary output of 1ml/kg/ hour through adolescence.  Urinary output combined with urinary specific gravity is an excellent method of determining the adequacy of of volume resuscitation.

Circulation and Shock: Evaluation and management  Thermoregulation  The high ration of body surface area to body mass in children increases heat exchange with the environment, and directly affects the child’s ability to regulate core temperature.  While the child is exposed during the initial survey and resuscitation phase, overhead heat lamps or heaters or thermal blankets may be necessary to maintain body temperature to preserve body heat, warm the room as well as the intravenous fluids, blood products,and inhaled gases.

Chest Trauma  Ten percent of all injuries involve the chest  Chest injury also is a marker for other organ

system injury since more than two thirds of children with chest injury have been shown to have other organ system injuries.  Mobility of mediastinal structures makes the child more sensitive to tension pneumothorax and flail segments.

Abdominal Trauma  Assessment  Talk quietly and calmly  Palpate the abdomen gently  Pass N/G tube before palpation  Diagnostic Adjuncts   

Computed tomography (CT) Diagnostic peritoneal lavage (DPL) Ultrasound

Nonoperative Management  The presence of intraperitoneal blood

on CT,DPL, or ultrasound does not necessarily mandate a celiotomy.  It has been well demonstrated that bleeding from an injured spleen, liver, and kidney generally is self-limiting.

Nonoperative Management  If the child cannot be normalized

hemodynamically and if the diagnostic procedure performed is positive for blood, a prompt celiotomy to control hemorrhage is indicated.  Nonoperative management of confirmed abdominal, visceral injuries is a surgical decision made by surgeons, just as is the decision to operative. Therefore, the surgeon must provide the management of thepediatric trauma patient

Head Trauma  Outcome in children suffering severe head

injury is better than in adults. However, the outcome in children less than 3 years of age is worse than a similar injury in the older child.  Although an infrequent occurrence, infants may become hypotensive from blood loss into either the subgaleal or epidural space.

Head Trauma  Vomiting and even amnesia are common after head

injury in children and do not necessarily imply increased intracranial pressure.  Seizures occurring shortly after head injury are more common in children and are usually self-limited.  Children tend to have fewer focal mass lesions than do adults, but elevated intracranial pressure due to cerebral edema is more common. In children, a lucid interval may be prolonged, and the onset of neurologic deterioration delayed

Head Trauma Verbal Response

V-score

Appropriate words or social smile, fixes and follow Cries, but consolable Persistenly irritable Restless, agitated None

5 4 3 2 1

Head Trauma  Drugs  Phenobarbital 2 to 3 mg/kg  Diazepam 0.25 mg/kg, slow IV bolus  Phenytoin 15 to 20 mg/kg, administered at 0.5 to 1.5 ml/kg/minute as a loading dose, then 4 to 7 mg/kg/day for maintenance  Mannitl 0.5 to 1.0 g/kg 9rarely required). Diuresis with the use of mannitol or furosemide may worsen hypovelemia and should be withheld early in the resuscitation of the child with a head injury.

Head Trauma  Management  Rapid, early assessment and management of the child’s ABCDEs.  Appropriate neurosurgical involvement from the beginning of treatment.  Appropriate sequential assessment and management of the brain injury with attention director toward to prevention of secondarybrain injury.  Continuous reassessment of all parameters

Spine Cord Injury  Anatomic difference  Interspinous ligaments joints capsules are more flexible.  Vertebral bodies are wedged anteriorly and tend to slide forward with flexion.  The facet joints are flat.  The child has a relatively large head compared to the neck. Therefore, the force applied to the neck is relatively grater than it is in the adult.

Spine Cord Injury  Radiologic Consideration  Pseudosubloxation----- About 40% of children younger than 7 years of age show anterior displacement of C-2 C-3 and 20% of children up to 16 years of age exhibit this phenomenon.  Children may sustain spinal cord injury without radiographic abnormality (SCIWORA) more commonly than do adults.  When in doubt about the integrity of the cervical spine, assume that an unstable injury exists, maintain immobilization of the child’s head and neck, and obtain appropriate consultation.

Musculoskeletal Trauma  History  Blood loss  Special considerations of the immature

skeleton  Principles of immobilization

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Summary  Unique characteristics of children include  airway anatomy & management  Fluid requirements  Recognition of CNS, as well as thoracic and abdominal injuries  Extremity #  Resuscitate child appropriately to avoid

secondary brain damage from hypovolemia  Non operative management of abdominal visceral injuries only in facilities equipped to handle any contigencies quickly