Pediatric Trauma. Sept 2nd, Patrick Murphy Neil Merritt

Transcription

1 Pediatric Trauma Sept 2nd, 2015 Patrick Murphy Neil Merritt

2 Objectives

3 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

4 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

5 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

6 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

7 Objectives - Scholar 1. Identify and understand the implications of one recent sentinel paper in pediatric trauma care

8 Case 1

9 Patient LK 7 yo, biking and hit by car Wearing a helmet Unresponsive on arrival, tachypnea with pale, dusky extremities HR 144; RR 38; BP 84/60; GCS 5 (E = 1; V = 2; M = 2)

10 Patient LK What is the most common cause of cardiac arrest in pediatric trauma? Inability to secure airway! (Hypoxia)

11 ET Tube Predicted Size Uncuffed Tube = (Age / 4) + 4 Predicted Size Cuffed Tube = (Age / 4) + 3

12 Drugs in Peds Trauma

13 Case 2

14 Patient BA 9 yo, unsupervised on ATV; collisions with tree; no helmet No LOC at scene PMx: Fragile X Syndrome

15 Patient BA - Arrival C-Spine Collar 2IVs HR 69; BP 123/58; RR 18; 100% NRB O/E Trachea Midline, GAEBL Fast is Negative GCS 8

16 Patient BA - Arrival Pan CT Liver Lac Right Epidural, left subdural, right frontal bone # To PCCU

17 Pediatric Trauma

18 Facts 50% of childhood deaths result from preventable injury Injury prevention through awareness and increased safety measures = 1/3 reduction in death from trauma in Canada Seatbelts Vehicle Design Car seats

19 Mortality Incident Change Motor vehicle 3,587 2,431 32% crash Drowning 1, % Pedestrian 1, % injury Fire and/or 1, % burn injury Suffocation % Falls % Poisoning % Firearm %

20 Etiology - Mortality UNDER 1 1 to 4 5 to 9 10 to to 19 Breathing (50%) MVC (22%) MVC (60%) MVC (55%) MVC (70%) MVC (18%) Drowning (20%) Drowning/Fa ll/flame (18%) Drowning (13%) Poisoning (7%) Drowning (15%) Breathing (20%) Breathing (5%) Fall (7%) Drowning (6%)

21 Etiology - Hospitalization UNDER 1 1 to 4 5 to 9 10 to to 19 Fall (46%) Fall (39%) Fall (56%) Fall (39%) Fall (24%) Breathing, Burns (15%) Poisoning (15%) Poisoning (15%) Hit by object/cyclin g (15%) Hit by something (15%) Burns (7%) MVC (7%) MVC/Cycling (15%) MVC (20%) Hit by something (15%)

22 How are kids different? ANATOMY

23 Airway Compared to adult, 3 major differences 1) Smaller (Foreign bodies/teeth) 2) Larger tongue (risk of obstruction) 3) Epiglottis (project posterior)

24 Airway Where is the narrowest point in the pediatric airway? Cricoid ring Cuffed or uncuffed tube? Why?

25 Airway

26 Breathing Which way do the ribs move? Horizontally More or less compliant than adult? More!

27 Diaphragmatic Breathing Infants and young children have very compliant chest walls which explains intercostal retraction in airway obstruction Need to decompress the stomach to reduce pressure on diaphragm

28 Diaphragmatic Breathing

29 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

30 Abdomen Thin abdominal wall Which two organs are more likely to be injured in children Liver and Spleen Which organ is intra-abdominal in infants but not adults? Bladder

31 Bones When do children reach skeletal maturity Post-puberty Why is this important Growth plate fractures Interpretation of X-Rays

32 Bones What is a green stick fracture? Why do they occur in children and not adults?

33 Skull When do the anterior fontanelle close? months.

34 General Smaller size = more likelihood for multiple organ systems injured Higher metabolic rate and larger surface area to body-mass ratio = greater heat loss

35 How are kids different? PHYSIOLOGY

36 Circulation Blood volume is larger but absolute volume is smaller Small volume loss = significant % of total blood volume Need to record even small volume loses you might ignore in an adult SVR is lower

37 Circulation Fixed Stroke Volume in infants Why is this important? Is hypotension an early or late sign? LATE! Best method is U/O 1-2 ml/kg/hr in children/infants

38 Normal Vitals

39 Shock

40 Access/Fluids Typically more challenging in pediatrics I/O IV How much fluid to give? What kind?

41 Access/Fluids

42 Case 2

43 Patient HI 6 mo infant sitting in carrier on top of a stroller Fell approximately 3 ft to pavement No loss of conscious, crying HR 120; RR 18; BP 92/50 Swelling over right temporal region

44 Patient HI

45 Head/Spinal Injury

46 Head Leading cause of death from trauma Significant lifelong disability >80% are mild TBI Classified similarly to adults Mild (Ped-GCS 13-15) Moderate (Ped-GCS 9-12) Severe (Ped-GCS <8)

47 Head - Management Principles are same as adult Secure airway Avoid hypoxia give O2 Avoid hypotension Ensure adequate resuscitation ICP monitoring in those with severe head injury Correct raised ICP Hypertonic saline 0.1-1cc/kg Mannitol cc/kg

48 Spine Very rare in children < 17 yo, prevalence < 5% 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) MRI Important Neurologic Recovery Likely better compared to adult population No evidence for hypothermia/steroids

49 Cardiothoracic

50 Thoracic Much less common secondary to small size Approximately 6%, almost all blunt Highly fatal second only to head injury Male:Female 3:1 ratio Greater flexibility = pulmonary contusion of pneumatocele without rib fractures Miss 30-40% of injuries on initial CXR Vast majority only require observation +/- chest tube

51 Thoracic Hemo/Pneumothorax Clinical findinds of a tension may be impressive (mobile mediastinum) What size tube? How much output for OR? Nipple Level (R5/6); Do not use sharp trocar

52 Thoracic Rib # Marker of energy transfer OR child abuse (20% of all thoracic trauma) particularly in young (< 3 yo) 1 st /2 nd rib raise suspicion of vascular injury Management Analgesia (discussed later) Suspect pulmonary contusion if deteriorating

53 Abdominal

54 Abdominal Solid Organ 8-12% of pediatric trauma Similar to adults, spleen and liver most common Management largely Non-operative now (>90% success even in high grade injuries) Management Non-operative Continued instability = OR similar principles to adult, damage control lap, control bleeding and pack

55 Abdominal Solid Organ

56 Abdominal Hollow Viscus Crush, burst and sheer injuries Rapid contamination of abdominal cavity Frequent physical exam is more sensitive than CT Management Early recognition and repair are key High index of suspicion in unwell patient

57 Pain Management

58 Pain

59 Pain

60 Pain Assess and adjust regularly, start with low doses. Multimodal is key MEAC = minimum effective analgesia concentration Non-Pharmacologic Breathing, distraction (movies, video games)

61 THANKS!!