Pediatric Trauma. Andrea L. Williams, PhD, RN
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1 Pediatric Trauma Andrea L. Williams, PhD, RN Clinical Associate Professor UW School of Nursing Emergency Education Specialist UW Emergency Education Center
2 Why Are Traumatic Injuries Different in Children than Adults? Energy/force is transmitted through: - More pliable bones - Incompletely calcified bones - Limited connective tissues - Weaker abdominal walls - Organs in closer proximity to other organs - Smaller physical stature
3 Types of MOI s in Infants & Children Falls cause the majority of all pediatric injuries Most common causes of death: - Motor vehicle-associated injuries are the most common cause of death - Drowning - House fires - Homicides - Traumatic brain injury Organ most associated w/i fatality - Sports related injuries - Greatest majority in infants (< 12 months) are from maltreatment - Firearms are the mechanism of injury & death in children & adolescents
4 Patterns of Injury in Infants & Pedestrian Struck Children Low speed: Lower extremity fractures High speed: Multiple trauma, head, neck, lower extremity fractures Automobile Occupant Unrestrained: Multiple trauma, head, neck, scalp & facial fractures
5 Patterns of Injury in Infants & Fall from Height Children Low Lower extremity fracture Medium Head, neck, upper & lower extremity fractures High Multiple trauma, head, neck, upper & lower extremity fractures
6 Patterns of Injury in Infants & Fall from Bicycle Children Without Helmet Head, neck, scalp& face (lacerations) & upper extremity fractures With Helmet Upper extremity fracture Striking Handlebar Internal abdominal injuries Straddle Injuries
7 Unique A & P - Airway Larger soft tissues tongue Obligate nose breather Pharynx buckle from passive flexion Funnel shaped larynx/c-shaped cricoid cartilage More cephalad & anterior coal cords difficult to visualize Short trachea Smaller airway diameter Heavy head
8 Unique A & P- Head Head Disproportionately large until age 4-6. Tend to fall or be ejected & land head, resulting in head &TBI (traumatic brain injury), diffuse>focal Soft tissues of skull & brain are more compliant Fontanels & sutures are open mos - Tolerant of high ICP
9 Unique A & P - Spine Spinal Column (SCIWORA) ~50% of spinal cord injuries occur w/o fracture, may be partial - Weak neck muscles & spine ligaments with heavy head lead to high cervical spine injuries (70% injuries C1-C2) - Facets are flatter - Mid to lower thoracic spinal injuries - Lap belt alone injuries w/i compression of L2
10 Unique A & P - Chest Pliable compressible ribs primarily composed of cartilage Chest wall, smaller, thinner with less muscle mass Diaphragm can rise to nipple line & flatten out Uncommon rib or sternal fractures or flail chest Energy transmitted to lungs with resultant pulmonary contusions
11 Unique A & P - Abdomen Solid organ of the abdomen are disproportionately large and exposed or poorly protected by the thin chest wall The most frequent site of injury in children causing shock The liver is the most injured abdominal organ in young children. The spleen is also commonly injured\ Pelvic fractures are more common in adolescence.
12 Unique A & P - Extremities More flexible bones Muscles less developed At risk for fractures at the weak, cartilaginous growth plates Fractures may only involve the periosteum on one side. Greenstick or buckle fractures occur from axial loading
13 Assessment Findings Extremity Injuries Suspect extremity fracture with point tenderness Injuries to the physeal plage can permanently injure a limb Compartment syndrome concerns Pallor Pain Parasthesia - Pressure - Pulses - Paralysis
14 Unique A & P - Skin Thinner Less subcutaneous fat Greater surface area Cover the head! At risk for hypothermia Young infants unable to shiver to generate heat
15 Developmental Characteristics Easily distracted Impulsive Lack of experience Focused on single object Separation anxiety 15
16 Triage Pediatric Assessment Triangle
17 PAT General Appearance Muscle tone Normal, limp, floppy Interactiveness Recognize & interact Consolability Look or gaze Visual contact, turn toward voice or person entering the room Speech or cry Normal, high pitch or no crying
18 PAT Work of Breathing Inadequate or excessive Nasal flaring Retractions Accessory muscle use Abnormal upper airway sounds Respiratory rate too fast or too slow Position of comfort (tripod, sitting)
19 PAT Circulation to the Skin Color Mottling Diaphoresis
20 Primary Assessment Airway & Alertness AVPU Loose or missing teeth Bleeding tooth sockets Cyanosis of oral mucous membranes
21 Dental Trauma Assessment Jagged, broken, loose, or missing tooth Sensitivity to cold or fluids Bleeding Soft tissue lacerations Obstruction Treatment Airway patency Treatment of avulsed tooth 21
22 Airway Interventions Airway maintained in in-line or neutral position Do not rotate oral airways to insert, causes bleeding. Use a tongue blade and direct oral airway curving downward Suction 100% NRB Intubation followed by gastric tube Crichothyroidotomy is rare Intubate for severe brain injury, ventilatory failure, severe shock as well as to maintain an airway.
23 Primary Assessment Cervical Spine & Intervention Inspect position of occiput in relation to body on spine board. Pad upper back to align auditory meatus to the shoulders. Mid-face parallel to surface Based on mechanism assess appropriate size of rigid cervical collar
24 Spine Immobilization Child safety seat Long spine board Padding Pediatric immobilization devices Cervical rigid collar Straps, cravats Tape Towel/blanket roll/sandbag Vest type/short spine boards
25 Primary Assessment Breathing Work of breathing Nasal Flaring Head bobbing & Ventilation Retractions & Severity Substernal, Intercostal, suprasternal, supraclavicular Mild, moderate, severe Accessory muscle use Sternocleidomastoid or trapezius Expiratory grunting
26 Primary Assessment Breathing Work of breathing Nasal Flaring Head bobbing & Ventilation Retractions & Severity Substernal, Intercostal, suprasternal, supraclavicular Mild, moderate, severe Accessory muscle use Sternocleidomastoid or trapezius Expiratory grunting
27 Breathing Interventions Blow-by oxygen does not meet oxygen requirements. Need a tight fitting NRB Gastric distension requires a gastric tube
28 Primary Assessment Circulation Base heart rate & BP assessment on age related tables Palpate central & peripheral pulses Capillary refill normal 2 seconds or less Assess color, mottling, skin temperature, diaphoresis Serial pulse assessments Assess for JVD difficult to assess in young children & infants
29 Circulation Interventions Rapid vascular access Intravenous access Not necessary to attempt before inserting an Interosseous line IV Bolus 20 ml/kg warmed isotonic crystalloid solution asap/over 5-10 minutes Assess for fluid overload after each bolus Assess for continued shock 3 fluid boluses then switch to blood at 10 ml/kg
30 Circulation- Return toward Hemodynamic Normality Slowing of heart rate Clearing of sensorium Return of peripheral pulses Return of normal skin color Increased warmth in extremities Improved BP ( x age) Increased pulse pressure. 20 mm Hg Urinary output 1-2 ml/kg/hour
31 Primary Assessment Disability Level of consciousness Restlessness, anxiety, fussiness, crying, irritability & combativeness. Could be a sign of hypoxia Pupils AVPU Pediatric GCS calculation
32 Pediatric GCS
33 Pediatric GCS
34 Pediatric GCS
35 Disability Interventions Consider a blood glucose Prepare for endotracheal intubation for changes in LOC Hyperventilation is only initiated as a temporary rescue measure for brain herniation
36 Primary Assessment Exposure & Temperature Regulation Remove clothing Check for injuries & patterns of injuries Keep warm Blankets/mylar sheets Warm fluids Cover head Bair Hugger pad/blanket Warm rig
37 Primary Assessment History SAMPLE Care giver perceptions Changing description of event by caregiver
38 Secondary Assessment Head-to-Toe Assessment
39 Head & Facial Trauma The scalp is so vascular that venous bleeding can cause shock! Don t forget to check the eyes & vision Hyphema Globe rupture Blurred, double, loss of vision
40 Closed & Open Head Injuries Battle Signs Raccoon Eyes Blood/fluid from nose or ears Posturing Loss of consciousness Temporary amnesia Headache Inability to recognize caregiver Nausea or emesis Abnormal behavior agitation, irritability, listlessness Decreased activity level Seizure following injury
41 Life Threats Airway Obstruction Tension Pneumothorax Pulmonary Contusion Hemorrhage Cardiac Tamponade Severe Closed Head Injury Contusion Subdural, Epidural, Intracerebral bleeding Ischemia/edema High spinal cord injury
42 Pulmonary Contusion Bruising over the ribs Tachycardia Tachypnea SOB Wheezing Hypoxemia Hemoptysis
43 Severe Head Injury Elevate the head of the bed degrees Keep the head midline Prepare to intubate in decreased GCS (less than 8) Follow the trends Neurologic status Vital signs Medicate Maintain BP low normal range
44 Pain Relief - QUESTT
45 QUESTT Q Question the child in age appropriate language about their pain U Use pain rating scale for child s age E Evaluate behavior S Secure the caregiver or parent s involvement T Take cause of pain into account T Take action and provide comfort & pain relief
46 Have a Great Weekend!
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