Pediatric Trauma Cases QPEM 2018 Barbara Blackie, MD, MEd, FRCPC
DISCLOSURE I do not have any relevant financial relationship with commercial interest to disclose.
Learning Objectives -Manage interactive cases involving pediatric trauma
To what percent blood volume loss will a child s blood pressure be maintained?
} A child s blood pressure may be maintained up to 30% acute blood loss Greater capacity to compensate by increasing heart rate, stroke volume and systemic vascular resistance
What do we know? Pediatric Trauma Patients have different injury profiles than adults, need to be treated accordingly taking into consideration developmental level
Question What is the average blood volume for an 11 year old boy?
Question Average 11 year old boy Weight 35 kg Blood volume 2.8 litres Average 11 year old girl 37 kg Blood volume almost 3 litres Roughly 80 ml/kg
Case 1 4 year old at crosswalk, hit by car at 40 km/hr EMS called by parent 10 min to scene Vitals on arrival: HR 120, RR 40, BP 110/60, Sats 98% Lying on his back on side of road
Case 1 Further history: Hit on left side, front of vehicle, thrown 6 feet No LOC, but dazed initially; GCS 14 Previously well, no meds, no allergies
Case 1 Physical Exam Abrasions right cheek, shoulder and flank Obvious deformity right thigh Abdomen slightly distended, tender Complaining of pain, grunting, distressed
What s the Plan? Grant 2006, Cordell 2002, Johnston 2005, Tanabe 1999, Todd 2007, Augarten 2006, Le May 2009, Zempsky 2004, Chan 1998, Taylor 2008
In Triage Title goes here Subtitle goes here
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What can we do? Title goes here Subtitle goes here
Prehospital Pain Management? Studies show that inadequate treatment of pain in children can lead to posttraumatic stress disorder, physiologic and psychologic changes in pain behavior responses, and a reduced response to appropriate weight-based doses of analgesia Most notably, when prehospital providers fail to treat pain in the out-of-hospital setting, there is a delay in pain relief Grant 2006, Cordell 2002, Johnston 2005, Tanabe 1999, Todd 2007, Augarten 2006, Le May 2009, Zempsky 2004, Chan 1998, Taylor 2008
Case Resolution Child is boarded, collared IV and fluids provided Transported to Level 1 Trauma Center Pain medication after arrival; none provided enroute Grant 2006, Cordell 2002, Johnston 2005, Tanabe 1999, Todd 2007, Augarten 2006, Le May 2009, Zempsky 2004, Chan 1998, Taylor 2008
Case Resolution Stabilized with 2 boluses IV fluids PICU admission No sequelae Discharged 6 days Grant 2006, Cordell 2002, Johnston 2005, Tanabe 1999, Todd 2007, Augarten 2006, Le May 2009, Zempsky 2004, Chan 1998, Taylor 2008
Case 2 7 year old on ATV, rolled over on a hill. Riding alone, found when parents went to look for him (1 hour after he left house) No helmet Unconscious Underneath ATV EMS called to scene Knowhownapaonline.com
Case 2 Vitals HR 160, BP 100/60 RR shallow and 8 Sats 90% T 35ºC Glucose 6.3 GS 10 Initial Assessment Airway patent, lots of secretions Breathing shallow, quiet breath sounds on left, trachea midline
Case 2 Initial assessment Abrasion/lacerations to face, scalp, chest Pelvis feels intact L thigh very swollen, externally rotated, shortened
What s the Plan? www.buzzfeed.com
Case 2 Enroute Deteriorates, BP now 50/P, HR 140 Abdomen distended GCS 8 What now?
Now what s the Plan? www.buzzfeed.com
Case 2 Resolution Intubation Fluid bolus, blood on arrival at ED Trauma team receives, CT and OR for splenic injury, fracture femur, fractured pelvis 10 days in PICU, prolonged hospitalization Neurologic sequelae
Case 2 Resolution Flags for impaired recovery Multiple injuries Prolonged downtime Difficult intubation Period of hypotension, hypoxemia
Question The bladder is an intraabdominal organ in young children making it easier to injure with blunt trauma True or False? Abdominal distension from aerophagia can be difficult to distinguish from distension due to bleeding True or False?
Case 3 12 year old on a trampoline Complicated jumps Missed the edge and landed on his neck and head Unconscious, EMS called No one present with BLS skills 12 minutes to the scene
Case 3 Initial assessment Lying unconscious, not moving GCS 3
Case 3 Initial assessment Airway patent but secretions Breathing shallow, RR 12 Pale, HR 110, BP 60/40
What s the Plan? www.buzzfeed.com
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Question During airway manipulation in the prehospital setting, what is the ideal method of spinal immobilization?
Spinal Immobilization with Airway Manipulation Airway management of acute SCI patients requiring intubation in the pre-hospital setting should include the use of manual in-line cervical spine traction Intubation of patients with acute SCI in the pre-hospital setting should not rely solely on cervical collar neck immobilization Indirect methods of intubation may cause less cervical movement than with direct laryngoscopy with a Miller blade (Gerling et al., 2000), Maruyama et al., 2008; Scannell et al., 1993
Question Does standard C spine immobilization work for all ages?
C Spine Differences 40 children aged < 8 years with nontraumatic presentations to the ED: mean torso elevation of 25 mm was needed to achieve neutral position for the spine 10 children with CSIs aged < 7 years had standard positioning on a backboard that produced anterior angulations or translation at the injured segment that resolved with neutral positioning
Question What is the role for pre-hospital care providers in cervical spine clearance and immobilization?
C Spine Clearance Pre hospital Pre-hospital emergency medical technicians can be trained to apply criteria to clear patients of cervical spinal injuries and immobilize patients suspected of having a cervical spinal injury to a level similar to that of emergency physicians Armstrong et al., 2007; Benner et al., 2006; Brown et al., 1998; Burton et al., 2005, 2006; Campbell, 1987; Domeier et al., 1997, 1999, 2002, 2005; Meldon et al., 1998; Muhr et al., 1999; Sahni et al., 1997; Stroh and Braude, 2001).
Case 3 Resolution Intubated, in line stabilization Collared, boarded, transported IO, fluid support Level 1 Trauma Center Armstrong et al., 2007; Benner et al., 2006; Brown et al., 1998; Burton et al., 2005, 2006; Campbell, 1987; Domeier et al., 1997, 1999, 2002, 2005; Meldon et al., 1998; Muhr et al., 1999; Sahni et al., 1997; Stroh and Braude, 2001).
Case 3 Resolution Prolonged hospital stay Some recovery of upper limbs Persistent paraplegia Persistent cognitive deficits
Questions?