They re not little adults, but they are little humans Pearls for your next pediatric trauma patient Alisa McQueen MD, FAAP, FACEP Associate Professor of Pediatrics The University of Chicago Alisa McQueen MD, FAAP, FACEP Associate Professor of Pediatrics The University of Chicago I have no relevant financial relationships to disclose. Children are not little adults Children are little humans 1
Objectives Objectives Identify anatomic differences between the adult and pediatric airway and apply your knowledge to the management of the pediatric airway in trauma. Describe the physiologic differences between adult and pediatric circulation and apply this knowledge to the management of hypovolemic shock in pediatric trauma. Case 6 month old found unresponsive at home. Apneic, pulseless Asystole on monitor HR 0 R 0 BP 0 CPR initiated Predictors of Difficult Airway At a cardiac arrest, the first procedure is to take your own pulse. Law #3 The House of God Facial hair Restricted neck mobility Restricted mouth opening Obesity Pregnancy 2
These are adult problems You are experts in the emergent management of the difficult airway Neonatal Airway Anatomy How do you modify your approach in the pediatric patient? Tongue Vocal cords Epiglottis Cricoid ring Neonatal Airway Differences Neonatal Airway Modifications More prominent occiput Large tongue Large #1 tongue blade Airway is anterior Epiglottis is floppy Narrowest portion is below the cords Airway Look up is anterior Straight Epiglottis blade is floppy Make Narrowest sure your portion cuff is below is down the cords 3
Neonatal Airway Modifications Neonatal Airway Modifications More prominent occiput Towel roll beneath the shoulders Size matters Infants are small 4
But they are not that small! Atropine? Atropine for protection against bradycardia Infants have exaggerated parasympathetic tone Laryngoscopy can make them bradycardic Succinylcholine can make them bradycardic 5
Hypoxia makes them bradycardic The treatment for hypoxia is not atropine Successfully intubated Vitals remain 0-0-0 Back to our case IO established Epi given A word on securing that IO Source: http://mdnxs.com/topics 2/procedures/intraosseous vascular access/ 6
Source: https://www.aliem.com/2016/trick-securing-intraosseous-needle/ Successfully intubated Vitals remain 0-0-0 IO established Epi given ROSC HR 160 BP 50/20 Children are highly responsive to epinephrine Children are highly responsive to volume expansion Push Pull method to bolus IV fluids 7
Back to our case Two months ago ED visit for crying Normal vitals Normal exam except for a few bruises on the legs AAP Committee on Child Abuse and Neglect. Evaluating children with fractures for child physical abuse. Pediatrics 2014;133:e477 e489. 8
TEN 4 Rule Pilot study of children age 3 and under admitted to PICU for injury Mechanism (abuse vs accidental) determined by expert child abuse review Characteristics of abused vs accidentally injured children compared Identified high risk features: bruising on torso, ears, neck, or any bruise in infant < 4 months Pierce MC et al. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics 2010;125:67 74. Pierce MC et al. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics 2010;125:67 74. TEN 4 Rule Torso, ears, neck in a child less than four years old Any bruise in a child less than four months old Consider child abuse Fractures in Child Abuse Avoid the trap of thinking certain fractures are pathognomonic for non accidental trauma. Pierce MC et al. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics 2010;125:67 74. 9
Parietal skull fracture Spiral fracture Murphy R et al. Transverse fractures of the femoral shaft are a better predictor of nonaccidental trauma in young children than spiral fractures are. J Bone and Joint Surgery 2015;97:106-11. Parietal skull fracture Corner fracture bucket handle fracture Classic metaphyseal lesion Corner fracture bucket handle fracture Classic metaphyseal lesion Back to our case 10
Sibling study Infant has a 2 year old sibling at home Household contacts of abused children evaluated If age < 5: physical exam If age < 2: physical exam + skeletal survey If age < 6 months: physical exam + skeletal survey + neuroimaging 479 household contacts Lindberg D et al. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics 2012;130:193 201. 12% with fractures 25% with fractures None of these fractures had associated physical exam findings A twin is 20 times more likely to have a fracture Take home points Lindberg D et al. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics 2012;130:193 201. Avoid the tiny blades Optimize oxygenation to prevent bradycardia 11
Secure your IO with the mask from an ambu bag Don t rely on atropine Use the Push Pull method to bolus IV fluids Bruising on the torso, ear, or neck or anywhere <4 months Consider abuse Get a skeletal survey on household contacts of abused children Children are little humans 12