Pediatric Prehospital Trauma for the SOF Provider

Transcription

1 Pediatric Prehospital Trauma for the SOF Provider LTC GUYON J. HILL, MD, FACEP,FAAP MADIGAN ARMY MEDICAL CENTER The weight of a sick child in kg is inversely proportional to the number of medical providers standing around the patient doing nothing - Mike Simpson, MD, 18D 1

2 Disclosure Opinions or assertions contained herein are the private views of the speaker and are not to be construed as official or as reflecting the views of the TCCC committee or the Department of Defense Resus basics what to use for peds needle decomplression Look at other peds prehospital trauma stuff Look at drafts move to blast file other peds trauma lecs on desktop or drafts to include mine pictures 2

3 Objectives Discuss unique challenges in caring for pediatric trauma patients in the deployed combat environment Provide guidance for areas of controversy Review new literature and recommendations from both civilian and military studies related to the prehospital setting Why Should I Care? 3

4 Why Should I Care? Approximately 8% of trauma patients seen in combat theaters are pediatric (Schauer, 2017) Pediatric patients have higher mortality rates than adult patients and have twice the hospital stay (Borgman, 2012) Humanitarian and civilian emergency care accounts for 1/3 of CSH admissions ½ of these are children Why Should I Care? Patterns of injury are different than in adults Younger children (< 8 yo) present more severely injured than older children or adults (Matos, 2008) In-hospital mortality (18% vs 4%) 4

5 Why Should I Care? Most deployed medical providers lack specific peds trauma/resuscitation training Building rapport By, with, and through Lifesaving information CIVCAS (Civilian casualties as a result of military operations) Provider supervision and cross training Department of Defense Trauma Registry (DODTR) Data repository for DOD trauma-related injuries Formerly known as the Joint Theater Trauma Registry (JTTR) Includes documentation of care for US and non-us military, and US and non-us civilian personnel in wartime and peacetime Care is included from point of injury onward if they are admitted to a Role 3 facility or FST 5

6 Overview Hemorrhage is the leading cause of preventable death in pediatric trauma Pediatric patients have a higher physiologic reserve Maintain SBP longer possibly until 40-50% blood loss Tachycardia is usually the first sign of shock Other signs Cool or mottled extremities Decreased level of consciousness Not crying or crying regardless of stimulus Overview Body Surface Area Larger relative BSA/smaller muscle mass Maintaining body temperature more difficult Thermal energy loss a significant stressor Hypothermia develops quickly 6

7 Differences Between Civilian and Wartime Pediatric Trauma Patients ~80% of injuries are penetrating Blast injuries GSWs Approximately 60% ICU admission rate Approximately 30% receive transfusions Blast Injuries Same kinetic injury dissipated in smaller body mass Most adult blast injury patients have lower extremity injuries Pediatric patients have higher rates of head and neck injuries Pediatric patients suffer more thermal burns Predictors of mortality Head injuries Burns Transfusion 7

8 Rapid Weight Estimation Tourniquets in Pediatric War Casualties Retrospective observational review of 88 casualties (Kragh, 2012) Ages 4-17 Survival rate of 93% 7% had no indication for use No pediatric-specific issues noted Commercially available tourniquets should work on most children 8

9 Tourniquets Airway Management Many anatomic variants from adult airway More mucosal tissue and secretions Have a plan! Broselow, apps, PALS card, etc. BVM, suction, adjuncts, diff size ETTs and blades? PALS defines pediatric airway as < 8 Common errors Poor positioning Poor sealing of BVM and no chest rise Right mainstem intubation 9

10 Airway Management Airway Management 10

11 Igel sizing chart Out-of-Hospital Intubation Prospective study comparing endotracheal intubation and BVM in 830 consecutive pediatric patients suffering out-of-hospital cardiac arrest Patients received either endotracheal intubation or BVM followed by intubation No significant difference in survival or neurologic outcome between the BVM group or the intubation group Gausche Hill, et al., JAMA (2000) 11

12 Association of Prehospital Intubation with Decreased Survival Among Pediatric Trauma Patients in Iraq and Afghanistan Airway compromise is the third leading cause of preventable death on the battlefield Intubating pediatric patients is challenging for those with limited experience Prehospital intubations had higher median composite injury severity scores and lower survival rates When controlling for confounders prehospital intubation increased mortality odds Schauer, et al., Am J Emerg Med (2017) Association of Prehospital Intubation with Decreased Survival Among Pediatric Trauma Patients in Iraq and Afghanistan Prehospital intubations had higher median composite injury severity scores and lower survival rates When controlling for confounders prehospital intubation increased mortality odds Schauer, et al., Am J Emerg Med (2017) 12

13 Hypertonic Saline Head injuries are the leading cause of mortality for children admitted to CSHs (Creamer, 2009) 5 mg/kg (same as adults) No max dose Stop at Na of 160 Prehospital Ketamine Administration to Pediatric Trauma Patients with Head Injuries in Iraq and Afghanistan Head injuries occur frequently in combat due to the high prevalence of IEDs ACEP guidelines have removed head injury as a contraindication for ketamine use in both children and adults TCCC guidelines recommend the prehospital use of ketamine for analgesia Can these guidelines be extrapolated safely for use in pediatric patients with head injuries? 13

14 Prehospital Ketamine Administration to Pediatric Trauma Patients with Head Injuries in Iraq and Afghanistan No significant difference in: Survival to hospital discharge Median ICU days Median hospital days Median composite injury scores No significant difference in subgroup analyses Age Intubated prehospital Severe head injury (GCS 3-8) FAST 14

15 FAST In adults Decreased time to the OR Reduced rates of abdominal CTs Decreased hospital length of stay Kessler, JAMA (2017) FAST in Children After Blunt Abdominal Trauma: a Multi-institutional Analysis Prospective study of 2,188 children < 16 at 14 pediatric Level I trauma centers Intraabdominal injury 27.8% sensitive Intraabdominal intervention 44.4% sensitive 15 children with a negative FAST required acute intervention 12/27 patients with a true positive FAST required intervention Calder, et al. J Trauma Acute Care Surgery,

16 Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children with Blunt Torso Trauma: A Randomized Clinical Trial Prospective randomized study of 925 HDS pediatric blunt trauma patients < 18 years old Results No change in rate of abdominal CT scans No difference in missed intrabdominal injuries No change in ED length of stay No change in hospital charges Conclusion: You shouldn t automatically perform a FAST exam on a pediatric trauma patient Holmes, et al., JAMA (2017) Pediatric Resuscitation Volumes Initial crystalloid bolus in a neonate: 10 ml/kg Initial crystalloid bolus in an infant or child: 20 ml/kg Packed Red Blood Cells: 10 ml/kg Fresh Frozen Plasma: 10 ml/kg Platelets: 10 ml/kg or 1 unit/10kg Warm all fluids if possible! 16

17 Tranexamic Acid (TXA) FDA approved in 1986 for hemophiliacs Established role in pediatric spinal surgery, craniofacial surgery, and in the care of hemophiliacs requiring surgery Reduction in transfusion rates reported as high as 85% Effects lasting up to POD 4 Indications Likely patients to receive massive transfusions Any life-threatening hemorrhagic injury and high potential for development of coagulopathy or outright presence of coagulopathy TXA Early administration has been associated with a decrease in mortality and blood product utilization in severely injured adults (CRASH-2 trial, 2013) Lower mortality in TXA group despite being more severely injured, requiring more blood and having lower SBP and GCS (MATTERS trials, 2012) 17.4% vs. 23.9% overall 14% vs. 28% in those receiving massive transfusion 17

18 PED-TRAX Study TXA Administration to Pediatric Trauma Patients in a Combat Setting: the Pediatric Trauma and Tranexamic Acid Study Patients who received TXA had greater injury severity, hypotension, acidosis, and coagulopathy TXA use was independently associated with decreased mortality after controlling for confounders No significant increase in thromboembolic complications Propensity analysis showed improvement in discharge neurologic status and decreased ventilator dependence Eckert, MJ, et al., J Trauma Acute Care Surg (2014) TXA Bolus of mg/kg (max 1g) over 10 minutes Give < 3 hours from injury Follow by gtt of 2 mg/kg/hr over next 8 hours 18

19 PECARN TXA Study Little prospective data for TXA in pediatric hemorrhagic trauma Multicenter placebo-controlled double-blinded RCT in initial stages IO Placement 19

20 Humeral IO Placement Demonstrated higher flow rates than for proximal tibia and distal femur (Lairet, et al., Prehosp Emerg Care, 2013) Surgical neck becomes skeletally immature before age 10 Some sources suggest as young as 5 years of age (Tintinalli s Emergency Medicine, 7 th ED) > 11 suitable for humeral IO placement Outcomes in Out-of-Hospital Pediatric Cardiac Arrest Prospective study of 599 consecutive pediatric out-of-hospital arrests Evaluated survival rates and neurologic outcomes Results 8.6% survived to hospital discharge No patients with > 3 doses of epinephrine or > 31 minutes of resuscitation in the ED had a good neurologic outcome Young, et al. Pediatrics (2004) 20

21 Spinal Motion Restriction No evidence that it limits neurologic injury with some evidence of worse outcomes Potential for non-physiologic positioning In critically injured Impairs airway management and ventilation Increases ICP Can cause pressure ulcers Causes increased pain Causes increased reliance on imaging for clearance Leonard, Prehospital Emergency Care, 2012 Spinal Motion Restriction Recommendations in children Minimize the time on backboards and consider padding Don t mandate just because of age or if nonverbal Consider use of additional padding under the shoulders to avoid excessive c-spine flexion Consider deferring in case of penetrating injury 21

22 Spinal Motion Restriction C-collars should be applied for the following patients: Complaint of neck pain Torticollis Neurologic deficits AMS, GCS < 15, intoxication or other concerning signs (hypopnea, somnolence, apnea, agitation) Most Common Interventions Children Received? Vascular access (87%) Fluids (85%) Prehospital External warming (44%) Antibiotics 6% Schauer, et al.,

23 Intranasal Medications Intranasal midazolam mg/kg Max dose 10mg Intranasal fentanyl 2 mcg/kg Intranasal ketamine 1 mg/kg 50 mg max dose Antibiotic Recommendations Ertapenam 3 mo 12 years 30 mg/kg/day IM/IV divided BID 15 mg/kg single dose Max dose 1gm/day > 13 1mg/day IM/IV QD Ceftriaxone 50 mg/kg/day IM/IV 100 mg/kg/day (meningitis dose) 23

24 Biggest Areas for Improvement Only 44% of pediatric patients were externally warmed Only 17% received pain medication Only 10% received antibiotics (prehospital and ED) Additional Resources Borden Institute Pediatric Surgery and Medicine for Hostile Environments (2017) 24

25 Summary Commercially available tourniquets should work on most children Prehospital intubation may worsen outcome No evidence of harm when ketamine is given to pediatric patients with head injuries Remember to warm your pediatric trauma patients and treat their pain Medical resuscitation of children is unlikely to be effective if greater than 31 minutes of 3 doses of epinephrine Questions guyon.j.hill.mil@mail.mil guyonhill@gmail.com 25

26 extra Airway Smaller, more mucosal tissue and more secretions though Kids devour o2 twice as much as adults, especially when sick, put oxygen on them early Thoracic cavity is tiny, kids can go into tension physiology very easily so little space so much mucous Conclusions TXA given early after trauma saves lives Reduce the risk of death due to bleeding by 15% Clinical benefit if use within 3 hours of injury and greatest benefit if given within 1 hour Reduces transfusion requirements No increase in vascular occlusive events between the two arms Increased risk of death if initiated after three hours 26