PEDIATRIC TRAUMA I: ABDOMINAL TRAUMA BURNS. December 19, 2012

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1 PEDIATRIC TRAUMA I: ABDOMINAL TRAUMA BURNS Niel F. Miele,, M.D. December 19, 2012

2 EPIDEMIOLOGY Major Trauma responsible for <50% of mortality in children 1-14 years Majority are blunt, not penetrating Motor Vehicle crashes Falls House Fires

3 ABDOMINAL BLUNT TRAUMA Difficult to assess Few signs of external injury Associated head injuries Should be suspected in any child who has multiple systems injuries

4 ABDOMINAL BLUNT TRAUMA APPROACH Primary Survey Airway Maintenance with C-Spine Protection Breathing Circulation with hemorrhage control Pulse and Perfusion BP drop is late sign Disability: Neurologic status Exposure/Environmental control Secondary Survey

5 CASE 4 year old, rear seat passenger in MVC, lap belt only, unconscious, intubated at scene, BP = 66/40 Fluids? Minimal BP: x Age What type and how much? After 2 boluses, consider blood loss What if no access?

6 EZ IntraOsseous

7 DIAGNOSTIC STUDIES CT scan of abdomen standard of care Ultrasound is adjunct IVP and UCG indicated if blood at urethral meatus Foley is contraindicated Diagnostic Peritoneal Lavage is rare House Fires

9 CASE 12 year old riding bicycle Flipped over front of bicycle; no LOC Handlebar hit below left rib cage Exam: Alert, awake No neck tenderness Slight LUQ tenderness

10 CASE Can you clear neck clinically?

11 CASE Clearing Clearing neck Awake, alert (not altered) Can answer questions No vertebral tenderness No distracting injuries

12 CASE Can you clear neck clinically? Do you image the abdomen? How? Abdominal series? Focused Abdominal Sonographic Technique? CT of abdomen with IV contrast?

14 SPLENIC LACERATION 5 Stages Consider non-operative management if: Grade I or II without a blush Stable hemoglobin over hours No clotting issues

15 CASE Same patient, but pain is over right upper quadrant Do same imaging rules apply?

17 HOLLOW VISCUS INJURY Difficult to detect Consider if increasing abdominal pain or distension Vast majority require operative intervention Duodenal hematoma may be managed nonoperatively Most resolve in 1-3 weeks using gastric decompression only

18 BURNS: EPIDEMIOLOGY 2/3 are scald burns 1/5 are contact with hot substances Remainder are flame burns 10-30% may be due to abuse Cigarette burns Scald burns with straight line demarcation

19 FIRST DEGREE BURN Superficial, dry, painful to touch Heals in 1 week

20 SECOND DEGREE BURN Partial thickness Bullae or weeping, painful Heals in 1 to 3 weeks

21 THIRD DEGREE BURN May appear similar to 2 nd degree, but not painful Charred, hard, parchment-like Full-thickness

22 The rule of nines altered for the anthropomorphic differences of infancy and childhood. Klein G L, Herndon D N Pediatrics in Review 2004;25: by American Academy of Pediatrics

23 PATHOGENESIS Burn Shock and Burn Edema Loss of fluid from intravascular space Fluid accumulation in interstital space Inhalation Injury Hypermetabolism? SIRS

24 MANAGEMENT < 10% TBSA outpatient management Occlusive dressing with daily change Protect sking from contamination Eliminate air movement (reduces pain) Decrease water loss Topical antibiotics Silvadene Bacitracin

25 MANAGEMENT OF EXTENSIVE BURN Remove from scene, extinguish burn Remove jewelry Chemical burn Remove clothing and irrigate with water ABC s

26 SMOKE INHALATION IN BURNS Consider thermal injury Intubate if any stridor or hoarseness Consider intubation for soot in nose or below cords Consider carbon monoxide poisoning 100% Oxygen

27 IMMEDIATE MANAGEMENT ABC S Cool sterile saline dressings? Debride blisters Cover with topical antibiotics Separate fingers Pain management Check tetanus status IV/IO access

28 FLUID MANAGEMENT Parkland Formula (for replacement) Wt (kg) x % TBSA x 4 1 st half in 8 hours, 2 nd half in 16 hours Don t forget maintenace fluids Further fluid management may be adjusted to keep urine > 1 ml/kg/hr

29 CRITERIA FOR BURN CENTER >20% TBSA, or >10% TBSA in children < 10 years 3 rd degree burns > 5% TBSA 2 nd or 3 rd degree burns in critical areas Hands, feet, perineum, genitalia, major joints Burns with associated inhalation injuries Electric or lightning burns

30 CRITERIA FOR BURN CENTER Severe burns complicated by trauma (may need trauma center first) Pre-existing disease that could complicate management Circumferential burns of extremities or chest

31 TRANSPORT TO BURN CENTER Cover patient with dry sheet Transport crews should be aware of hypothermia risks Avoid saline soaked dressings Avoid antimicrobial creams Will delay transfer Need to be removed at burn center

Pediatric Burn Management Justin D. Klein, MD Associate Burn Director Lisa C. Vitale, RN Burn Program Coordinator

Pediatric Burn Management Justin D. Klein, MD Associate Burn Director Lisa C. Vitale, RN Burn Program Coordinator Lecture Overview Burn statistics and etiologies Pre-hospital evaluation Anatomy of a burn