Presentation on theme: "Pediatric Trauma: - An Overview of the Problem - Presented by: Oklahoma EMSC Resource Center."— Presentation transcript:
Pediatric Trauma: - An Overview of the Problem - Presented by: Oklahoma EMSC Resource Center
Objectives: Upon completion of this presentation the participant will have: b Increased awareness of issues specific to children and trauma. b Improved skills in assessing pediatric trauma: Mechanisms of injuryMechanisms of injury
Objectives: (Continued) Identify key components of the assessment processIdentify key components of the assessment process Recognize differences between adult and child prioritiesRecognize differences between adult and child priorities Identify and avoid common errors in the care of the traumatized pediatric patientIdentify and avoid common errors in the care of the traumatized pediatric patient Implement appropriate treatment plansImplement appropriate treatment plans
Nature of the Beast b Pediatrics account for 5-15% of total EMS calls. but up to 33% of these calls require ALS.but up to 33% of these calls require ALS. b Trauma is 50% of pediatric EMS calls usually over 2 years old usually over 2 years old (more medical calls under 2.) (more medical calls under 2.) b Injury is the leading cause of death in children MVC = 50%MVC = 50%
Nature of the Beast contd b Up to 70% of major Pediatric trauma cases die because of the severity of injury. NOT because of deficit in pre-hospital careNOT because of deficit in pre-hospital care b When a child is injured, the whole family is injured too! >40% divorce rate within 1 year after a major trauma.>40% divorce rate within 1 year after a major trauma.
General Principles: Pediatric Trauma b Priorities are similar to adults All roads lead to the ABC (DE)sAll roads lead to the ABC (DE)s Start with A, not the most obviousStart with A, not the most obvious
General Principles (Continued) b Children have certain key differences size = different types of energy transfersize = different types of energy transfer metabolismmetabolism ability to respond to words and give historyability to respond to words and give history b History of accident may be critical in determining treatment plan
Physical Differences: Children b Larger Head More leverage on neck and to brain during impactsMore leverage on neck and to brain during impacts Forces neck into flexion while lying flatForces neck into flexion while lying flat –airway tends to buckle and close on adult spine board without shoulder support b Shorter neck causes different injury patternscauses different injury patterns (C2-C4 more common injuries) (C2-C4 more common injuries)
Physical Differences in Children contd b Chest more pliable Pulmonary contusion more likelyPulmonary contusion more likely Diaphragm motion essential for ventilationDiaphragm motion essential for ventilation Energy transmitted to chest organsEnergy transmitted to chest organs b Abdominal organs less well protected. Liver is not covered by the rib cage. Liver is not covered by the rib cage. Less muscle mass to abdominal wall.Less muscle mass to abdominal wall. Less Sub-Q tissue to absorb the injury.Less Sub-Q tissue to absorb the injury.
Effects w/Size: Energy Transfer b Children are smaller more force per square inch of body.more force per square inch of body. organs are closer together = multi-system injury is the rule.organs are closer together = multi-system injury is the rule. b Children are softer (= more flexible, bouncy) Bones dont break but instead pass on energyBones dont break but instead pass on energy Internal organ damage without fractures is more common.Internal organ damage without fractures is more common. b Larger surface area to size ratio Lose heat more rapidlyLose heat more rapidly
Metabolic Differences in Kids Metabolic Differences in Kids b Children have a higher metabolic rate Nearly twice as rapid O2 consumptionNearly twice as rapid O2 consumption Need more blood flowNeed more blood flow More frequent feedingsMore frequent feedings More fluid intake per size ratioMore fluid intake per size ratio
Metabolic Differences contd Metabolic Differences contd b Children shock out differently Children compensate better initiallyChildren compensate better initially –May show minimal signs and symptoms. Children have less reserves than adultsChildren have less reserves than adults –Platinum half-hour in trauma resuscitation –Rapid intervention critical –Once reserves are exhausted, Bad Things Happen
The Bad Things b Decompensation can be rapid A conscious, crying child can become pulseless and apneic in less than 2 minutes.A conscious, crying child can become pulseless and apneic in less than 2 minutes. b Once decompensated, it may be too late Limited Reserves are gone; whole system collapsesLimited Reserves are gone; whole system collapses b Early recognition and intervention are critical
ASSESSMENT is the for SURVIVAL!!!
Approaching the Scene b The first step in a cardiac arrest or other critical situation is to: Take your own pulse!!!
Prepare Yourselves b Assign roles ahead of time History takerHistory taker Spine ManagementSpine Management Airway managementAirway management EquipmentEquipment
On the Scene SAFETY FIRST!!!! b BSI b Scene Hazards b Resources
On the Scene b Careful Attention to the Initial assessment is CRUCIAL Dont be distracted by the blood and screamsDont be distracted by the blood and screams A quiet Kid should scare the out of you !!!! b If practical, keep the parents with the child to help reduce the child's fear. Lots of blood Cant breathe Uncon. Everyone scared Fxs crying Quiet
Brilliance vs. Basics b For every brilliant maneuver or diagnosis you make which saves a life, youll save 10 by just doing a good, solid job; stay focused on the basics in the heat of the moment.
On the Scene contd Consider the mechanism of injury
Remember the...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. 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 s
Airway Assessment - LOOK b Is the patient breathing? How well? b Respiratory Rate A slow or irregular respiratory rate in a child is an OMINOUS SIGNA slow or irregular respiratory rate in a child is an OMINOUS SIGN
LOOK contd b Watch for the effort needed to breathe chest, neck, or abdominal muscle retractionschest, neck, or abdominal muscle retractions flaring of the nostrilsflaring of the nostrils b Level of Awareness Agitated child could lack oxygenAgitated child could lack oxygen Obtunded/ gorked could be excessive CO2Obtunded/ gorked could be excessive CO2 How does the child respond to its parents??How does the child respond to its parents??
Assessment #2 - Listen b Observe the skin – pale and clammy - ??shocky – cyanosis - inadequate oxygen b Listen - anything loud is a good sign, airway-wise,but a noisy airway may be partly obstructedanything loud is a good sign, airway-wise,but a noisy airway may be partly obstructed –Snoring, gurgling, crowing = upper airway –Grunting –Wheezing - lower airways –Hoarseness - voicebox affected
RAPID ASSESSMENT and SUPPORT [SIGNS OF DEEP DOO-DOO ] b Respiratory rate > 60 b Heart Rate –Less than 5 years 180 per minute –Over 5 years 160 per minute b Increased work of breathing retractions nasal flaring gruntingretractions nasal flaring grunting b Cyanosis b Altered level of consciousness Failure to recognize parents Lethargy IrritableFailure to recognize parents Lethargy Irritable
Airway w/ C-Spine Protection b Failure to secure airway is major preventable cause of death in Peds trauma b Must protect spine Avoid flexing or extending neckAvoid flexing or extending neck Use jaw thrust to open airwayUse jaw thrust to open airway b Suspect possible neck injury if: Any injury to head or above claviclesAny injury to head or above clavicles Ejected, thrown, rolloverEjected, thrown, rollover Unconscious trauma caseUnconscious trauma case
A=Airway w/ C-spine Control b Unconscious patients often cant protect their airway Tongue most common obstruction Little airways are easily blocked by blood, teeth - have rigid suction available Jaw thrust to open airway May need oral/nasal airway –Do not rotate in children b Infants need to breathe through their noses- may need to suction out blood/mucus
Airway Adjuncts Use 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
Immobilization I am a pediatric ICU fellow at Mass. General Hospital. I have been teaching 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 and toddlers for whom there are no C-collars (because at this age they don't have necks yet!). We have also emphasized the fact that two points are necessary to stabilize a c-spine when doing in line stabilization. When doing case scenarios with mannequins, I was surprised to see that in-line stabilization 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 scream and resist immobilization more. I have tried to emphasize that the head/C-spine need to be immobilized relative to the body in order to be effective. Most BLS providers have felt more comfortable doing this from above the head and stabilizing against the shoulders, much as a c-collar does. I have also demonstrated stabilizing with forearms against the chest, hands around the head and occiput as a second option, particularly if they are assisting a paramedic who can provide intubation or advanced airway maneuvers.
Proper 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.]
Infant immobilization 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, MD Pediatric Emergency Medicine Fellow Attending Emergency Medicine Physician Fairfax Hospital, Falls Church, VA
B = Breathing b All children get Oxygen b May need to assist with bag-valve-mask Good mask seal is the KEY to baggingGood mask seal is the KEY to bagging –Proper fit of mask. –Watch your fingers and your jaw thrust Two people should bag whenever possibleTwo people should bag whenever possible b If the chest doesnt rise, you aint doing it right b Avoid distending the stomach Cricoid pressureCricoid pressure Easy does itEasy does it Distended stomach = less room for air in lungsDistended stomach = less room for air in lungs
Breathing advice Having given this talk many times to EMS providers at George WashingtonUniversity and through the Maryland PALS courses I can offer a few hints. Airway 1) 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 is a) partially obstructed airway because of poor positioning, b) poor technique in getting the mask to seal,.. c) gastric distension from crying or vigorous bagging 4) All injured children get oxygen. Always. Everytime. No exceptions.
Recognizing 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 responses Good luck. Tom Terndrup, MD Director of Pediatric Emergency Medicine University Hospital Syracuse, N.Y.
What is shock?? b Any abnormality of the circulation which causes inadequate blood flow or oxygen to the tissues of the body. b BLOOD LOSS most common type of shock in trauma b Can occur from open bleeding, internal bleeding, into fractures
Recognizing Possible Shock b Early signs can be subtle May be minimal signs with under 20% lossMay be minimal signs with under 20% loss b 50% and over blood loss usually pulseless and unconscious b Any injured patient who is cool and tachycardic is in shock until proven otherwise!!!
Shock recognition #2 b Anxiety, fear, and cold weather can all mimic early shock. Increased heart rateIncreased heart rate Decreased capillary refillDecreased capillary refill Pale, cool extremitiesPale, cool extremities b Since the consequences of preventing decompensated shock are so high, sometimes all you have is the history.
Shock #3 b First sign is loss of capillary refill Hold for 5; release for 3Hold for 5; release for 3 > 4 critical; > 2 but 4 critical; > 2 but < 4 transition to critical b Next comes a decrease in pulse pressure (Systolic - diastolic)(Systolic - diastolic) May feel this as a rapid, thready pulseMay feel this as a rapid, thready pulse b Drop in Blood Pressure is a late sign Systolic should be >[ (age in years)] but it rarely falls below this until 25-30% blood lossSystolic should be >[ (age in years)] but it rarely falls below this until 25-30% blood loss b Altered mental status may be from shock Should recognize parents!!!!Should recognize parents!!!! Shock may cause irritability or lethargyShock may cause irritability or lethargy
C = Circulation and Shock Control b If cool, clammy, thready pulse, then already over 25% of blood volume lost b External Bleeding - usually obvious Use a little gauze and a big finger b Internal Bleeding Mechanism of injury very important Physical findings not clear Need definitive treatment (IVs Surgery…)
Stopping Bleeding b Failure 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 developing b hypotension. I like to emphasize the importance of using a small amount of gauze, and firm continuous direct pressure. I tell them to assign one b person to this job. b Michael A. Shapiro MD Vice Chairman b Dept of Emergency Medicine b Women's Christian Association Hospital b Jamestown, NY 14701
Treating Shock 1) 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.
WORK QUICKLY Let me say that I have been in EMS for three years, and have been a paramedic 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, the ambulance 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.
D = Disability b Downs syndrome and large headed children may have cervical spine injury from apparently minimal trauma. b Ideal immobilization is hard collar, full spine board with soft spacers and head straps. Secure child across forehead, collar, shoulders and pelvis Make sure chest can rise!! May need blunt under torso under age 8 to prevent neck flexion on the spine board. b Injured brains need adequate oxygen !
Quickie 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).
E = Exposure b Children lose heat quickly b Keep them covered b If you are comfortable, its probably too cold for them
Exposure- Staying Warm Exposure- 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.
SAMPLE History for Trauma b S= Signs and Symptoms b A= Allergies b M = Medications currently taken –Grab pill bottles b P = Pertinent Past/ Present Illnesses b L = Last Meal b E = Events/ environment related to the injury
Always think about child abuse when you see an injured child. Always 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 death EMT awareness of signs and symptoms of abuse would help identify cases.
Summary b The more critical the patient, the more important it is to focus on the basics IN ORDER AirwayAirway Oxygen Oxygen Good mask and baggingGood mask and bagging Proper immobilizationProper immobilization Keep them warmKeep them warm Speed of transport is a key issue.Speed of transport is a key issue. b Assign roles ahead of time to keep responsibilities clear.
Rewards from the job b Thank you for your time and attention External rewards are scarce in this field. Knowing you did right by your patients
Where to get more information b Other training sessions b * Andrew W. Stern b * NYS*DOH Emergency Medical Services b * 1 Commerce Plaza, Room #1126 # (518) b Dr. Jane Ball peds EMS NERA NERA SafeKids SafeKids b Web sites Global Emergency Medicine ArchivesGlobal Emergency Medicine Archives Website of TraumaWebsite of Trauma
Resources b For 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. b The curriculum is available through the National EMSC Resource Alliance (NERA) at b Kelly D. Young, MD Dept of Emergency Medicine b Harbor-UCLA Medical Center, Box 21 b Fax: (310) West Carson Street b Torrance, CA mail:
Acknowledgements This presentation has been adapted from a powerpoint presentation developed by: Bruce Nayowith MD Ellenville Community Hospital ER We gratefully acknowledge his willingness to share this information with others.