Pediatric Trauma Practice. Guideline for Management of the Child in Shock. Background

Transcription

1 Pediatric Trauma Practice Guideline for Management of the Child in Shock Background Guideline for Management Trauma is the leading cause of death in children and adolescents in the United States. Although most injuries are mild to moderate, trauma team members should be prepared to rapidly assess and manage those children with serious and life-threatening trauma. Clinicians are trained in and should follow the processes and protocols of Advanced Trauma Life Support (ATLS). Goal: The following guideline has been established to facilitate standardized, evidence-based management of the pediatric trauma patient in shock. Shock in children Hemorrhagic shock is the most common cause of shock in the pediatric trauma patient. However, the clinician should not exclude other causes of shock, including blunt cardiac injury, spinal cord injury, adrenal insufficiency and anaphylaxis. Children who have been injured and present in hemorrhagic shock may also have associated injuries that require stabilization and management including C-spine stabilization and treatment for pneumothorax. Hemorrhagic volume loss in children is categorized into four classes based on severity. Most children with Class II hemorrhage and all children with Class III and IV hemorrhage are in shock. Management approaches to hemorrhage by class follows: Class I Class I hemorrhage occurs with an acute blood loss of up to 15 percent of the child s blood volume and is usually associated with minimal physiologic changes. Patients usually respond to crystalloid fluid replacement. Class II Class II hemorrhage occurs with percent blood loss and is associated with mild tachycardia, mild tachypnea, narrowed pulse pressure, slightly delayed capillary refill, decreased UOP and mild anxiety. Patients can usually be stabilized with crystalloid fluids, but may require blood products. Class III Class III hemorrhage occurs with an acute blood loss of percent. Signs of shock including tachycardia, tachypnea, hypotension, delayed CRT, altered mental status and oliguria are present. Prompt resuscitation with crystalloid solution is necessary and most patients will require blood products.

2 Class IV Class IV hemorrhage occurs with more than 40 percent acute blood loss. Signs of shock are obvious and immediately life threatening. Patients will be cold and pale with profoundly decreased mental status, marked tachypnea and tachycardia and anuria. These children should receive prompt administration of blood products to treat shock, and may often require operative intervention to control hemorrhage. Massive Transfusion Protocol should be considered. Vasopressors should not be considered in the child in hemorrhagic shock until hemostasis and adequate volume resuscitation with blood products and warmed crystalloid solution has been achieved.

3 Initial Assessment and Management of the Multiple Trauma Patient Timeline Assessment Management Immediate/On Arrival Mobilize trauma resources Immobilize C-spine Airway Obstruction Midface fractures/difficult airway OR Direct airway injury Breathing Tension Pneumothorax Massive Hemothorax Open Pneumothorax Flail Chest Impaired oxygenation/ventilation Circulation Absent circulation External hemorrhage Signs of shock Cardiac tamponade Pelvic fracture Disability Level of consciousness (GCS) Assess Vital Signs Open airway, suction secretions, Administer 100% O2 Surgical Airway Needle decompression; place chest tube Place chest tube Apply 3-sided occlusive dressing Assist breathing - consider intubation for increased WOB Rapid sequence endotracheal intubation Cardiac compressions; thoracotomy IF witnessed arrest Control external hemorrhage --> consider tourniquet Secure IV acccess; obtain lab studies; Fluid resuscitation* Pericardiocentesis followed by thoracotomy Wrap or bind pelvis Endotracheal intubation for rapidly declining GCS, GCS 8 or herniation s/s

4 Pupillary Response Elevate HOB to 30⁰ if no signs of shock Signs of spinal cord injury Logroll and maintain MAP > 60 Signs of impending herniation ** Moderate hyperventilation (pco ); Neurosurgical Consultation; Administer osmotic agents if normotensive 5 minutes Exposure Hypothermia Remove clothing; initiate rewarming 15 minutes Repeat vital signs every 5 minutes Reassess response to interventions Intubated patients: Monitor ETCO2 Obtain blood gas Continue care of airway, breathing, circulation and disability Proceed to IO of central venous access if peripheral IV access unsuccessful Gastric tube placement Perform thoracotomy in patients who lose vital signs during resuscitation 20 minutes Reassess response to interventions Reassess level of consciousness Examine head, neck, chest, abdomen, pelvis and extremities Obtain screening radiographs (lateral c-spine, AP chest, AP pelvis per CHOG Pediatric Trauma Imaging Guidelines) Persistently hypotensive patients: FAST examination Continue care of airway, breathing, circulation and disability Logroll patient and remove spine board Provide analgesia; Place urinary catheter if no signs of urethral disruption Operative management for patients who remain hemodynamically unstable despite rapid blood infusion per trauma surgeon Reassess response to interventions Reassess level of consciousness Splint fractures Update tetanus immunization as needed

5 Perform complete PE (Secondary Survey) Repeat selected laboratory studies (eg, hematocrit, blood gas, glucose). Antibiotics for open fracture, contaminated wounds, or suspected bowel perforation Determine need for emergent life or limbsaving operative procedures CT of head, neck, chest, abdomen or pelvis as indicated by clinical findings and per CHOG Pediatric Trauma Imaging Guidelines) Disposition - OR, PICU, floor * Administer 20 ml/kg of warmed normal saline or Ringers lactate over minutes. In children with severe head injury, the aim is to ensure normal but not excessive circulating volume. ** Signs of impeding herniation include coma, unilateral pupillary dilation with outward deviation followed by hemiplegia, hyperventilation, Cheyne-Stokes respirations, and/or flexion/extension posturing. Key points for Pediatric Shock Management 1. Perform ATLS Primary Survey (A, B, C, D, E) and treat injuries needing intervention immediately. a. Consider activation of Massive Transfusion Protocol in child with penetrating trauma to chest, abd/pelvis or extremities proximal to knee or elbow PTA if EMS report indicates this may be needed. Register the child PTA using Trauma ID s and MRN s and activate MTP using that MRN. b. Consider activation of MTP in child requiring a second fluid bolus to maintain BP or treat tachycardia in setting of trauma. After the second warmed crystalloid bolus (or total of 40 ml/kg), blood/blood products are the resuscitation fluid of choice. c. Consider vasopressors for children with evidence of shock related to possible spinal cord injury (SCI). 2. Perform Secondary Survey per ATLS standards. 3. If a patient becomes unstable, repeat Primary Survey and address any issues. 4. Order resuscitation adjuncts as needed according to pt status, ATLS standards and CHOG guidelines. a. FAST for children with mechanism suggestive of abdominal injury or instability (Should consider FAST early during the assessment of the unstable or coding child) b. X-ray/CT per CHOG Imaging Guidelines. c. OR as indicated d. ICP monitoring as indicated e. Gastric decompression as indicated

6 f. Indwelling Urinary Catheter as indicated g. Aggressively manage temperature/protect against hypothermia References: Bixby, SD, Callahan, MJ, Taylor, GA. Imaging in Pediatric blunt abdominal trauma. Semin. Roetgenol 2008; 43:72. Carlotto, JR, Lopex-Filho Gde, J. Colleoni-Neto, R. (2016). Main Controversies in the Non-operative Management of Blunt Splenic Injuries. Arq Bars Cir Dig. 29(1) Gaines, BA. Intra-abdominal solid organ injury in children: diagnosis and treatment. J Trauma 2009; 67: S135. Holms, J.F., Lillis, K., Monroe, D, et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med 2013: 62: 107. London, J.A., Parry, L., Galante, J., Battistella, F. Safety of Early Mobilization of Patients with Blunt Solid Organ Injuries. Arch Surg, 2008; McVay, M., Kokoska, E., Jackson R. (2008). Throwing out the grade book: management of isolated spleen and liver injury based on hemodynamic status. Journal of Pediatric Surgery, 42, Notrica, DM, Eubanks, JW 3 rd, Tuggle, DW, Maxson, RT, Letton, RW, et. al. (2015). Nonoperative management of blunt liver and spleen injury in children: Evaluation of the ATOMAC guideline using GRADE. J. Trauma Acute Care Surg. 79(4) Pediatric Trauma Society. (2018). Guidelines in Focus: Blunt Liver and Spleen Injury. Retrieved from: St. Peter, S., Aguayo, P., Juang, D., Sharp, S., Snyder, C., Holcomb III, G., Ostile, D. (2013). Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. Journal of Pediatric Surgery, 48, St. Peter, S., Keckler, S., Sprilde, T., Holcombe, G., Ostile, D. (2007). Justification for an abbreviated protocol in the management of blunt spleen and liver injury in children. Journal of Pediatric Surgery, Vol. 43, St. Peter, S., Sharp, S., Snyder, C., Sharp, R., Andrews, W., Murphy, P., Ostile, D. (2011). Prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. Journal of Pediatric Surgery, 46,