Presentation on theme: "Pediatric Trauma: - An Overview of the Problem -"— Presentation transcript:
1Pediatric Trauma: - An Overview of the Problem - Presented by:Oklahoma EMSC Resource Center
2Objectives:Upon completion of this presentation the participant will have:Increased awareness of issues specific to children and trauma.Improved skills in assessing pediatric trauma:Mechanisms of injury
3Objectives: (Continued) Identify key components of the assessment processRecognize differences between adult and child prioritiesIdentify and avoid common errors in the care of the traumatized pediatric patientImplement appropriate treatment plans
4Nature of the “Beast” Pediatrics account for 5-15% of total EMS calls. but up to 33% of these calls require ALS.Trauma is 50% of pediatric EMS callsusually over 2 years old(more medical calls under 2.)Injury is the leading cause of death in childrenMVC = 50%
5Nature of the “Beast” cont’d Up to 70% of major Pediatric trauma cases die because of the severity of injury.NOT because of deficit in pre-hospital careWhen a child is injured, the whole family is injured too!>40% divorce rate within 1 year after a major trauma.
6General Principles: Pediatric Trauma Priorities are similar to adultsAll roads lead to the ABC (DE)’sStart with “A”, not the most obvious
7General Principles (Continued) Children have certain key differencessize = different types of energy transfermetabolismability to respond to words and give historyHistory of accident may be critical in determining treatment plan
8Physical Differences: Children Larger HeadMore leverage on neck and to brain during impactsForces neck into flexion while lying flatairway tends to buckle and close on adult spine board without shoulder supportShorter neckcauses different injury patterns(C2-C4 more common injuries)
9Physical Differences in Children cont’d Chest more pliablePulmonary contusion more likelyDiaphragm motion essential for ventilationEnergy transmitted to chest organsAbdominal organs less well protected.Liver is not covered by the rib cage.Less muscle mass to abdominal wall.Less Sub-Q tissue to absorb the injury.
10Effects w/Size: Energy Transfer Children are smallermore force per square inch of body.organs are closer together = multi-system injury is the rule.Children are softer (= more flexible, bouncy)Bones don’t break but instead pass on energyInternal organ damage without fractures is more common.Larger surface area to size ratioLose heat more rapidly
11Metabolic Differences in Kids Children have a higher metabolic rateNearly twice as rapid O2 consumptionNeed more blood flowMore frequent feedingsMore fluid intake per size ratio
12Metabolic Differences cont’d Children “shock out” differentlyChildren compensate better initiallyMay show minimal signs and symptoms.Children have less reserves than adultsPlatinum half-hour in trauma resuscitationRapid intervention criticalOnce reserves are exhausted,Bad Things Happen
13The Bad Things Decompensation can be rapid A conscious, crying child can become pulseless and apneic in less than 2 minutes.Once decompensated, it may be too lateLimited Reserves are gone; whole system collapsesEarly recognition and intervention are critical
15Approaching the Scene Take your own pulse!!! The first step in a cardiac arrest or other critical situation is to:Take your own pulse!!!
16Prepare Yourselves Assign roles ahead of time History taker Spine ManagementAirway managementEquipment
17On the SceneSAFETY FIRST!!!!BSIScene HazardsResources
18On the Scene Careful Attention to the Initial assessment is CRUCIAL Don’t be distracted by the blood and screamsA quiet Kid should scare the out of you !!!!If practical, keep the parents with the child to help reduce the child's fear.Lots of bloodCan’t breathecryingFx’sEveryone scaredUncon.Quiet
19Brilliance vs. BasicsFor every “brilliant” maneuver or diagnosis you make which saves a life, you’ll save 10 by just doing a good, solid job; stay focused on the basics in the heat of the moment.
20Consider the mechanism of injury On the Scene cont’dConsider the mechanism of injury
23Remember the‘s“...the biggest failure among the basic services is to call for an ALS ground or air unit and ignore the basics while they are waiting.”“Proper basic airway management is often performed inadequately if at all, apparently due to fear and panic.”Theodore M. Barnett, M.D.Children's Mercy Hospital, Kansas City, MO
24Airway Assessment - LOOK Is the patient breathing? How well?Respiratory RateA slow or irregular respiratory rate in a child is an OMINOUS SIGN
25LOOK cont’d Watch for the effort needed to breathe Level of Awareness chest, neck, or abdominal muscle retractionsflaring of the nostrilsLevel of AwarenessAgitated child could lack oxygenObtunded/ gorked could be excessive CO2How does the child respond to its parents??
26Assessment #2 - Listen Listen - Observe the skinpale and clammy - ??shockycyanosis - inadequate oxygenListen -anything loud is a good sign, airway-wise,but a noisy airway may be partly obstructedSnoring, gurgling, crowing = upper airwayGruntingWheezing - lower airwaysHoarseness - voicebox affected
27RAPID ASSESSMENT and SUPPORT [SIGNS OF DEEP DOO-DOO ] Respiratory rate > 60Heart RateLess than 5 years <80 or >180 per minuteOver 5 years <60 or >160 per minuteIncreased work of breathingretractions nasal flaring gruntingCyanosisAltered level of consciousnessFailure to recognize parents Lethargy Irritable
28Airway w/C-Spine Protection Failure to secure airway is major preventable cause of death in Peds traumaMust protect spineAvoid flexing or extending neckUse jaw thrust to open airwaySuspect possible neck injury if:Any injury to head or above claviclesEjected, thrown, rolloverUnconscious trauma case
29A=Airway w/C-spine Control Unconscious patients often can’t protect their airwayTongue most common obstructionLittle airways are easily blocked by blood, teeth - have rigid suction availableJaw thrust to open airwayMay need oral/nasal airwayDo not rotate in childrenInfants need to breathe through their noses-may need to suction out blood/mucus
30Airway AdjunctsUse of oral and nasal-pharyngeal airways. How to insert (e.g do not invert OPA in younger child to insert, and directing NPA directly posterior, not up into nasal turbinates).~ Also contraindications to OPA/NPA use.If neck is OK, allow the child to be in position of comfort - they open their own airway.Sniffing position is an option
31ImmobilizationI am a pediatric ICU fellow at Mass. General Hospital. I have beenteaching a one hour segment on pediatric trauma, and have found these to be some of the more common questions or misconceptions:1. Practical aspects of stabilizing a c-spine. Particularly in infants andtoddlers for whom there are no C-collars (because at this age they don'thave necks yet!). We have also emphasized the fact that two points arenecessary to stabilize a c-spine when doing in line stabilization. Whendoing case scenarios with mannequins, I was surprised to see that in-linestabilization was consistently provided by holding the patient at the ears,allowing the body to continue to move relative to the position of the head.I imagine this problem is greater with children who tend to kick and screamand resist immobilization more. I have tried to emphasize that thehead/C-spine need to be immobilized relative to the body in order to beeffective. Most BLS providers have felt more comfortable doing this fromabove the head and stabilizing against the shoulders, much as a c-collardoes. I have also demonstrated stabilizing with forearms against the chest,hands around the head and occiput as a second option, particularly if theyare assisting a paramedic who can provide intubation or advanced airwaymaneuvers.
32Proper Immobilization 3. commercial cervical collars often do not fit, stabilization best provided by smaller collar (if you have to choose one evil over another)NO SOFT COLLARS !!!!!4. when placed on an extrication board, most children under 5 years will be in cervical flexion, unless you elevate their upper thoracic region by 1 inch (say with a few towels)[or use a peds board with head well.]
33Infant immobilization 1) Keep infants in car seats unless treatment of injuries requires removal (IV, ETT, BVM, control of hemorrhage). If they survived the crash in an intact car seat, they are usually better off to stay in it for the ride to the hospital.William E. Hauda, II, MDPediatric Emergency Medicine FellowAttending Emergency Medicine PhysicianFairfax Hospital, Falls Church, VA
34B = Breathing All children get Oxygen May need to assist with bag-valve-maskGood mask seal is the KEY to baggingProper fit of mask.Watch your fingers and your jaw thrustTwo people should bag whenever possibleIf the chest doesn’t rise, you ain’t doing it rightAvoid distending the stomachCricoid pressureEasy does itDistended stomach = less room for air in lungs
35Breathing adviceHaving given this talk many times to EMS providers at George WashingtonUniversity and through the Maryland PALS courses I can offer a few hints.Airway1) Remember to mention all those anatomic differences, but stress the large tongue. Good airway positioning is crucial.2) All children can be ventilated with a bag valve mask. This most common reasons that providers have difficulty isa) partially obstructed airway because of poor positioning,b) poor technique in getting the mask to seal,..c) gastric distension from crying or vigorous bagging4) All injured children get oxygen. Always. Everytime. No exceptions.
36Recognizing early signs of shock, and suspecting it sooner if significant mechanism of injury A few pediatric trauma messages for EMT's:1. a little bleeding is a lot the smaller you are (I use e.g. of a 10 kg child with a 30% hemorrhage = only 210 ml of blood, all too easily obtained with a scalp lac & extremity fracture)2. BP often maintained until very late in hemorrhage by young patients because of their overactive vasoconstrictive responsesGood luck.Tom Terndrup, MD Director of Pediatric Emergency MedicineUniversity Hospital Syracuse, N.Y.
37What is shock??Any abnormality of the circulation which causes inadequate blood flow or oxygen to the tissues of the body.BLOOD LOSS most common type of shock in traumaCan occur from open bleeding, internal bleeding, into fractures
38Recognizing Possible Shock Early signs can be subtleMay be minimal signs with under 20% loss50% and over blood loss usually pulseless and unconsciousAny injured patient who is cool and tachycardic is in shock until proven otherwise!!!
39Shock recognition #2Anxiety, fear, and cold weather can all mimic early shock.Increased heart rateDecreased capillary refillPale, cool extremitiesSince the consequences of preventing decompensated shock are so high, sometimes all you have is the history.
40Shock #3 First sign is loss of capillary refill Hold for 5; release for 3> 4 critical; > 2 but < 4 transition to criticalNext comes a decrease in pulse pressure(Systolic - diastolic)May feel this as a rapid, thready pulseDrop in Blood Pressure is a late signSystolic should be >[ (age in years)] but it rarely falls below this until 25-30% blood lossAltered mental status may be from shockShould recognize parents!!!!Shock may cause irritability or lethargy
41C = Circulation and Shock Control If cool, clammy, thready pulse, then already over 25% of blood volume lostExternal Bleeding - usually obviousUse a little gauze and a big fingerInternal BleedingMechanism of injury very importantPhysical findings not clearNeed definitive treatment (IV’s Surgery…)
42Stopping BleedingFailure to control external hemorrhage using direct pressure. I have seen any number of cases, particularly with scalp lacerations (but also extremity arterial hemorrhages) where prehospital personnel apply "mounds and mounds" of gauze. I have seen many patients lose excessive amounts of blood into these dressings, sometimes to the point of developinghypotension. I like to emphasize the importance of using a small amount of gauze, and firm continuous direct pressure. I tell them to assign oneperson to this job .Michael A. Shapiro MD Vice ChairmanDept of Emergency MedicineWomen's Christian Association HospitalJamestown, NY
43Treating Shock1) Hypotension means the child is in shock, but children are often in shock without hypotension. An agitated child with cool skin is in shock until proven otherwise at the hospital.2) Any signs of shock require fluid administration. For Basic EMTs this means rapid transport or meeting an ALS crew en route.3) PASG or MAST are out, no good, dangerous in children, especially if the abdominal compartment is inflated because of impingement upon the diaphragm. The leg compartments can be used for stabilizing femur fractures or air splints.
44WORK QUICKLYLet me say that I have been in EMS for three years, and have been aparamedic since March. One of the strongest points people forget to about trauma is time. (Platinum 10 Minutes, and the Golden Hour are the phrases used to describe the `time criteria'.) In any trauma, pediatric or adult, the ideal setting is for the patient to be in surgery within one hour (The Golden Hour) of their injuries. It is stressed in our training that scene time be less than 10 minutes to remain under the curtain of that hour.I think that you need to stress that. In many medical settings, theambulance can do almost as much as an ED, but in trauma, the patient needs more than what we can provide - namely surgery. Time is the most critical factor in patient survival.
45D = DisabilityDown’s syndrome and large headed children may have cervical spine injury from apparently minimal trauma.Ideal immobilization is hard collar, full spine board with soft spacers and head straps.Secure child across forehead, collar, shoulders and pelvisMake sure chest can rise!!May need blunt under torso under age 8 to prevent neck flexion on the spine board.Injured brains need adequate oxygen !
46Quickie neuro eval - “D” Assessment:1) Reassess, reassess, reassess. The only way to know if your patient is getting better or worse is to be diligent in evaluation.2) Use the AVPU system (alert, responds to verbal, responds to pain, unresponsive) in children. The GCS score is time consuming if you're using your memory and doesn't "paint a picture" of the patient. Avoid "lethargic" "semi-conscious" etc.. because everyone has different meanings with these terms.3) Remember what children of various stages are capable of doing (a two year old may not talk yet, especially if frightened).
47E = Exposure Children lose heat quickly Keep them covered If you are comfortable, it’s probably too cold for them
48Exposure- Staying Warm 5. Keeping the patient warm. (especially if this winter is at all like last winter)6. To emphasize the above point in burn victims. Cool wet dressings may feel good on a small isolated burn, but with involvement of greater body surface area, priorities become maintaining temperature and preventing fluid loss which can be best accomplished with a dry sterile dressing. Many of our local EMTs have asked about the new "gel-packs" that are available. To be honest, they sound great, but I have little information about them specifically and am in the process of reading up on them.
49SAMPLE History for Trauma S= Signs and SymptomsA= AllergiesM = Medications currently takenGrab pill bottlesP = Pertinent Past/ Present IllnessesL = Last MealE = Events/ environment related to the injury
50Always think about child abuse when you see an injured child. . Many EMTs have asked about child abuse. They feel that those of us in the hospital and ED are leaving them out in the cold, particularly at smaller hospitals where they do not have a "Child protective services team" who become involved. Many tell me they have heard comments such as "Oh, good. You are filing the DSS report, so I don't have to". This is something that needs to be addressed at individual hospitals and ED's. Hopefully we can assure our EMS providers that they will not be alone in filing and following up with these cases.Common cause of injuries in children.50% of second hospital visits for these children result in deathEMT awareness of signs and symptoms of abuse would help identify cases.
51SummaryThe more critical the patient, the more important it is to focus on the basics IN ORDERAirwayOxygenGood mask and baggingProper immobilizationKeep them warmSpeed of transport is a key issue.Assign roles ahead of time to keep responsibilities clear.
52Rewards from the job Thank you for your time and attention External rewards are scarce in this field.Knowing you did right by your patients
53Where to get more information Other training sessions* Andrew W. Stern* NYS*DOH Emergency Medical Services* 1 Commerce Plaza, Room #1126 # (518)Dr. Jane Ball peds EMSNERASafeKidsWeb sitesGlobal Emergency Medicine ArchivesWebsite of Trauma
54ResourcesFor anyone interested, the Pediatric Airway Management Project headed by Dr. Marianne Gausche just completed a curriculum for a 2-day pediatric airway management course for paramedics (ALS), and another course for EMT's (BLS), complete with slides for lectures and videos. This is the curriculum used to train all of LA and Orange county's paramedics airway management in children by the project. The curriculum emphasizes many facets of ALS, not just intubating.The curriculum is available through the National EMSC Resource Alliance (NERA) atKelly D. Young, MD Dept of Emergency MedicineHarbor-UCLA Medical Center, Box 21Fax: (310) West Carson StreetTorrance, CA mail:
55Ellenville Community Hospital ER AcknowledgementsThis presentation has been adapted from a powerpoint presentation developed by:Bruce Nayowith MDEllenville Community Hospital ERWe gratefully acknowledge his willingness to share this information with others.