Pediatric Trauma. July 27 th, Suzana Buac, PGY4. Dr. Neil Merritt
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1 Pediatric Trauma July 27 th, Suzana Buac, PGY4 Dr. Neil Merritt
2 Case
3 5yoM fall from roof Fall from roof of home while father was shingling
4 5yoM fall from roof Fall from roof of home while father was shingling, 8 ft. high No loss of consciousness, ambulating immediately after injury, actual fall not witnessed Previously healthy No home meds, no allergies, immunizations up to date
5 Speaking, airway protected, patent GAEB, trachea midline, 98%SpO2 on RA HR 115, BP 111/65, FAST Positive, Abdomen tender diffusely, guarding Bilateral tenderness/edema/bruising at wrists
6 CT head, c-spine, C/A/P Head/C-spine/Thorax no injury Segment 7/8 Liver Grade 4 laceration, extravasation of contrast, free fluid
7 Objectives
8 Objectives Medical Expert 1. Describe the types of pediatric injuries sustained with a given mode of trauma, and identify the most common injuries occurring in various age groupings. 2. Identify unique anatomic or physiologic differences in children, when compared to adult patients. 3. Discuss the components of the primary survey in the pediatric trauma patient 4. Outline the secondary survey, and identify controversies in pediatric shock trauma management 5. Differentiate between mild, moderate, and severe head injuries in children
9 Objectives Medical Expert 6. Describe unique traumatic injuries to the spine that occur in children and measures to treat these injuries 7. Differentiate the types of cardiothoracic trauma, and list appropriate management of each type 8. Identify signs, symptoms, and management of pediatric abdominal and genitourinary trauma 9. Recognize the risks and appropriate management of traumatic amputation and soft tissue trauma in children 10. Recognize the risks and appropriate interventions in the management of orthopedic pediatric trauma
10 Objectives - Collaborator 1. Understand the post injury components of care for pediatric trauma patients 2. Describe the levels of pediatric trauma care and how to prepare an ER for treatment of the injured child
11 Objectives Health Advocate 1. Describe the impact of pediatric trauma on Canadian society and healthcare. 2. Identify the importance of pain management with practical strategies for managing pain in pediatric trauma patients 3. Outline the role of family centered care in pediatric trauma
12 Objectives - Scholar 1. Identify and understand the implications of one recent sentinel paper in pediatric trauma care
13 Pediatric Trauma
14 Background Trauma is the leading cause of death in children and adolescents Most due to preventable injuries For every injury mortality, estimated 25 hospitalizations and 925 emergency room visits Leading cause of years of life lost Leading cause of medical costs Emotional trauma for parents and families
15 Background Injury prevention through awareness and increased safety measures has lead to the reduction in death from trauma in Canada Seatbelts Vehicle Design Car seats Reduction in drunk driving Child resistant packaging Safety awareness Improved medical care
16
17 Mortality Incident Change Motor vehicle 3,587 2,431 32% crash Drowning 1, % Pedestrian injury 1, % Fire and/or burn 1, % injury Suffocation % Falls % Poisoning % Firearm %
18
19
20 Approach to injured child
21 ATLS Based on trimodal death distribution First peak seconds to minutes immediately after injury (only prevention can affect mortality) Second peak minutes to hours rapid assessment and treatment can improve mortality Third peak days to weeks multi-organ system failure definitive care at specialized pediatric center may mitigate delayed mortality
22 Injury classification Many pediatric trauma classification systems used to predict mortality, morbidity, resources, operative intervention, etc. GCS, Trauma Score, Revised Trauma Score, Pediatric Trauma Score, Age-specific pediatric trauma score, Anatomic systems, abbreviated injury scale, injury severity score, mechanism, etc. Objectives are in 1) triage decision support in prehospital setting and 2) predicting severity of illness and mortality
23 Injury classification Extent multiple (two or more body areas) vs. localized; may be obvious or evolve over time Type blunt vs. penetrating Severity mechanism of injury, vita signs, physical exam findings
24 Mechanism
25 Physical findings
26 Goals Rapidly assess injuries, determine management priorities, provide critical interventions Primary survey, resuscitation, adjuncts to primary survey, secondary survey, continued resuscitation and monitoring, adjuncts to secondary survey, transition to definitive care
27 What is different about children?
28 ANATOMY
29 Airway Differences from adult airways: 1. small oral cavity and large tongue - obstruction 2. large occiput, neck flexion obstruction, c-spine 3. larynx cephalad/anterior, floppy epiglottis 4. short narrow trachea, narrow distance between rings
30 Airway What is the narrowest point in the pediatric airway? Would you use a cuffed or un-cuffed tube?
31 Airway
32 Breathing More or less compliant than adult?
33 Diaphragmatic Breathing
34 Summary Anatomy PEDIATRIC ADULT Tongue Large Normal Epiglottis Shape Floppy, omega shaped Firm, flatter Epiglottis Level Level of C3 - C4 Level of C5 - C6 Trachea Smaller, shorter Wider, longer Larynx Shape Funnel shaped Column Larynx Position Angles posteriorly away Straight up and down from glottis Narrowest Point Sub-glottic region At level of Vocal cords Lung Volume 250ml at birth 6000 ml as adult
35 Abdomen Thin abdominal wall Which two organs are more likely to be injured in children? Which organ is intra-abdominal in infants but not adults?
36 Bones When do children reach skeletal maturity? Why is this important?
37 Bones What is a green stick fracture? Why do they occur in children and not adults?
38 Skull When do anterior fontanelles close?
39 General Smaller size increased likelihood for injury to multiple organ systems Higher metabolic rate and larger surface area to body-mass ratio increased heat loss
40 What is different about children?
41 PHYSIOLOGY
42 Circulation Blood volume is larger but absolute volume is smaller A relatively small amount of blood loss can be a significant % of total blood volume Need to record even small volume loses you might ignore in an adult
43 Circulation Fixed Stroke Volume in infants Hypotension is a late sign of shock. What s a better indicator?
44 Normal Vitals
45 Shock
46 Intravenous Fluids Access is typically more challenging in pediatrics How much fluid to give? What kind?
47 Access/Fluids
48 Head/Spinal Injury
49 Head Leading cause of death from trauma leading to significant lifelong disability However, over 80% are mild traumatic brain injury Classification: Mild (Ped-GCS 13-15) Moderate (Ped-GCS 9-12) Severe (Ped-GCS <8)
50 Head - Management Principles: Airway Avoiding hypoxia (02) Avoiding hypotension Ensuring adequate resuscitation ICP monitoring in those with severe head injury Raised ICP: Hypertonic saline 0.1-1cc/kg Mannitol cc/kg
51 Spine Very rare in children younger than 17 year olds C2 lesions in young, C4 in teen (A-O dislocation) Mechanism MVC in young, sports in teens SCIWORA need high suspicion of injury (PH Exam) Neurologic Recovery Likely better compared to adult population No evidence for hypothermia/steroids
52 Case
53 15 yom ATV crash from community Not helmeted, thrown off ATV, landed on right side No loss of consciousness, but amnesia Taken to community ER, HD stable, Chest Xray showed right pneumo/haemo, chest tube placed (750mL blood) Transferred to LHSC Peds Emerg
54 Healthy, allergy to penicillin Airway patent, protected, speaking Decreased AE on the right, midline trachea, no sub/q emphysema, 96% on 5L, continuous air leak No further blood drained on transfer, HR 110, BP 132/90, abdomen soft, no obvious long bone fractures, FAST negative, peripheral pulses palpable PEARL. GCS 15.
55 CT scan C/A/P Right pneumothorax Right lung contusion Grade 1 liver laceration Bilateral scapular fractures
56 Cardiothoracic
57 Thoracic Much less common secondary to small size Approximately 6%, almost all of which are blunt 3:1 male to female ratio Greater flexibility results in more pulmonary contusions or pneumatoceles with no rib fractures 30-40% of injuries are missed on initial CXR Vast majority only require observation or chest tube
58 Thoracic Hemothorax or Pneumothorax Clinical findings of a tension pneumothorax may be impressive (mobile mediastinum) Nipple Level
59 Thoracic Rib # Marker of energy transfer OR child abuse 1 st or 2 nd rib fractures raise suspicion for vascular injury Management Analgesia Suspicion of pulmonary contusion if deteriorating
60 Abdominal
61 Case
62 5yoM fall from 8 ft height Fall from roof of home while father was shingling No loss of consciousness, ambulating immediately after injury, actual fall not witnessed Previously healthy
63 Speaking, airway protected, patent GAEB, trachea midline, 98%SpO2 on RA HR 115, BP 111/65, FAST Positive, Abdomen tender diffusely, guarding Bilateral tenderness/edema/bruising at wrists
64 CT head, c-spine, C/A/P Head/C-spine/Thorax no injury Segment 7/8 Liver Grade 4 laceration, extravasation of contrast, free fluid
65 Abdominal Solid Organs 8-12% of pediatric trauma Spleen and liver most common Current management is largely non-operative (>90% success even in high grade injuries) Management Non-operative Continued instability operating room for laparotomy, control of bleeding and packing
66 Abdominal Solid Organs
67 Abdominal Hollow Viscous Injury Crush, burst and sheer injuries Rapid contamination of abdominal cavity Serial physical exams are more sensitive than CT Management Early recognition and repair are key High index of suspicion in unwell patients
68 Pain Management
69 Pain
70 Pain
71 Papers for Discussion
72
73 Sathya et al 2015 Retrospective cohort study of children 18 and younger in US from Jan 2010 to Dec 2013 of Abbreviated Injury Score 2 or higher from 252 Level I and II trauma centers participating in the Trauma Quality Improvement Program Compared in hospital mortality in children treated at adult trauma centers, mixed trauma centers, pediatric trauma centers
74 Sathya et al 2015 Performed multilevel regression analysis to evaluate association between center type and mortality Also did stratified analysis in different ages Secondary analyses in patients with severe injuries (ISS over 25)
75 Sathya et al 2015 After adjustment, children had higher mortality at ATCs and MTCs than PTCs Younger children had this association but not older children or adolescents Similar results for severely injured children
76
77 Webman et al 2016 Differences in mortality between different trauma centers have not previously been consistent for adolescents Data from National Trauma Bank using injured adolescents from 2010 in Level I and II trauma centers Multilevel models accounting for center specific effects Mortality was higher among adolescents treated at ATCs and MTCs rather than PTCs
78 Questions?
79 Drugs in Pediatric Trauma
80 Case 1
81 Case 1 8 yom helmeted cyclist struck by car Unresponsive on arrival, tachypnea with pale, dusky extremities HR 144 RR 38 BP 84/60 GCS 5 (E = 1; V = 2; M = 2)
82 What is the most common cause of cardiac arrest in pediatric trauma?
83 Endotrachial Tubes Predicted Size for Un-cuffed Tube = (Age / 4) + 4 Predicted Size for Cuffed Tube = (Age / 4) + 3
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