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Wirut phchiansatian, MD Emergency medicine. Half of all deaths in children Trauma Motor vehicle crashes (MVCs) Most fatalities occur in the field Most.

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Presentation on theme: "Wirut phchiansatian, MD Emergency medicine. Half of all deaths in children Trauma Motor vehicle crashes (MVCs) Most fatalities occur in the field Most."— Presentation transcript:

1 Wirut phchiansatian, MD Emergency medicine

2 Half of all deaths in children Trauma Motor vehicle crashes (MVCs) Most fatalities occur in the field Most common organ  Head trauma Multiple injuries are common Child abuse 25-35% in Some children's hospitals

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4 Body size Greater distribution Multiple trauma is common Relative body surface Greater heat loss area Liver and spleen More anterior placement Less protective musculature and subcutaneous tissue mass

5 Kidney Less well protected and more mobile Deceleration injury Congenital abnormalities Growth plates Not yet closed Salter-type fractures  possible limb-length abnormalities with healing

6 Head injury Head-to-body ratio is greater Brain less myelinated Cranial bones thinner

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8 Relatively larger tongue Most common cause of airway obstruction Head positioning or use of airway adjunct (oropharyngeal or nasopharyngeal airway) Larger mass of adenoidal tissues Nasotracheal intubation Nasopharyngeal airways Infants <1 year old

9 Epiglottis is floppy and more u-shaped Use of a straight blade

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11 Larynx more superior and anterior Difficult to visualize the cords Cricoid ring is the narrowest portion Uncuffed tubes Up to size 6mm or about 8 years old

12 Narrow tracheal diameter and distance between the rings Tracheostomy more difficult Surgical cricothyrotomy more difficult Needle cricothyroidotomy Emergent surgical airway of choice Younger than 8 to 10 years old

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15 Shorter tracheal length Intubation of right main stem Dislodgment Airways more narrow Airway resistance (R α 1/radius)

16 Maintenance requirements Water, trace metals, minerals Energy and caloric

17 Child's physiologic response to injury Great capacity Blood losses 25-30% of total blood volume  normal BP Subtle changes Heart rate, blood pressure, and extremity perfusion Impending cardiorespiratory failure

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19 Outline of ATLS consists of Primary survey & Resuscitation Adjuncts to primary survey Secondary survey Adjuncts to secondary survey Continued monitoring and reevaluation Definitive care

20 The primary survey in ATLS consist of. A : Airway maintenance with cervical spine protection. B : Breathing and ventilation. C : Circulation with hemorrhage control. D : Disability or Neurologicstatus. E : Exposure and environmental control

21 Possible airway obstruction clearing the oropharynx of debris jaw-thrust maneuver Stabilize neck

22 Adequacy of chest rise Bag valve mask device Gastric distention and impair ventilation diaphragm  ventilatory status cricoid pressure early placement of a nasogastric tube

23 Indications for endotracheal intubation Inability to ventilate by bag valve mask or need for prolonged control of the airway GCS score < 9 Respiratory failure hypoxemia (flail chest, pulmonary contusions) hypoventilation (injury to airway structures) Decompensated shock

24 Pediatric vasculature constrict and increase systemic vascular resistance Signs of poor perfusion cool distal extremities, decreases in peripheral versus central pulse quality, delayed capillary refill time

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26 Glasgow Coma Scale (GCS) AVPU System A - Alert V - Responds to Verbal stimuli P - Responds to Painful stimuli U - Unresponsive

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28 Fully undressing Assess for hidden injury Hypothermia

29 Rapidly informing the family Caregiver is present Explain the process

30 Complete head-to-toe examination Appropriate tetanus immunization Antibiotics as indicated Continued monitoring of vital signs Ensure urine output of 1 mL/kg/hr AMPLE History

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32 Leading cause of traumatic death 1.Head injuries 2.Thoracic injuries 3.Abdominal injuries Cervical Spine Injury

33 Cranial vault Larger and heavier in proportion to total body mass More pliable Parenchymal injury in the absence of skull fractures Less myelinated Shearing forces and further injury

34 Common Symptoms and Signs of Increased Intracranial Pressure in Infants Full fontanel Split sutures Altered state of consciousness Paradoxical irritability Persistent emesis “Setting sun” sign (inability to open eyes fully)

35 Common Symptoms and Signs of Increased Intracranial Pressure in Children Headache Stiff neck Photophobia Altered state of consciousness Persistent emesis Cranial nerve involvement Papilledema Hypertension, bradycardia, and hypoventilation Decorticate or decerebrate posturing

36 Lucid interval Epidural hematomas May be the result of venous bleeding Subtle and more subacute presentation over days Associated with overlying skull fractures

37 Subdural hematomas Most commonly in < 2 years old 93% of cases < 1 year old Shaken baby syndrome Chronic subdural hematomas Retinal hemorrhages

38 Recommendations for CT scanning Neurologic deficits GCS scores of less than 14 Major forcible insults Children < 1 year Special challenge  neuro sign Any loss of consciousness, protracted vomiting, irritability, poor feeding, or suspicion of abuse

39 Relatively larger head size, resulting in greater flexion and extension injuries Smaller neck muscle mass with ligamentous injuries more common than fractures Increased flexibility of interspinous ligaments Flatter facet joints with a more horizontal orientation Incomplete ossification making interpretation of bony alignment difficult Basilar odontoid synchondrosis fuses at 3-7 years of age Apical odontoid epiphyses fuses at 5-7 years of age Posterior arch of C1 fuses at 4 years of age Anterior arch fuses at 7-10 years of age Epiphyses of spinous process tips may mimic fractures

40 Apical odontoid epiphyses fuses at 5-7 years of age Posterior arch of C1 fuses at 4 years of age

41 Basilar odontoid synchondrosis fuses at 3-7 years of age

42 Increased preodontoid space 4-5 mm (3 mm in an adult) Pseudosubluxation of C2 on C3 seen in 40% of children Prevertebral space size may change because of variations with respiration

43 Increased preodontoid space 4-5 mm (3 mm in an adult)

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45  SCIWORA Elasticity of ligamentous structures 25-50% spinal cord injury (SCI) without radiographic abnormality

46 Anatomic fulcrum of the spine Underdeveloped neck musculature Head is disproportionately large and heavy C2 and C3 vertebrae

47 Pseudosubluxation of C2 on C3 Common in children up to adolescence Line of Swischuk Anterior cortical margin of the spinous process of C1 down through the anterior cortical margin of C3 crosses the anterior cortical margin of the spinous process at C2 within 2 mm No fractures

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50 Neutral positioning Large cranium in proportion to the rest of their body Absence of modified backboards with cutouts for the occiput of the child

51 Neutral positioning

52 83% blunt trauma Adequate oxygenation in a pediatric patient does not always ensure sufficiency of ventilation Important to rely on auscultatory and other physical findings rather than simple measurements of oximetry Infants, young children Diaphragm breathers Gastric distention

53 Compliance of the rib cage Significant injury Little apparent external signs of trauma Multiple rib fractures Serious injury Child abuse

54 Mediastinum is mobile Tension pneumothorax Rapid ventilatory and circulatory collapse

55 Pneumothorax Normal breath sounds Chest tube size Four times the endotracheal tube size Open pneumothorax Tension pneumothorax

56 Hemothorax Tube thoracostomy Indications for thoracotomy Evacuated blood > 10-15 ml/kg Blood loss > 2 to 4 ml/kg/hr Continued air leak

57 Pulmonary contusion Compliance of the rib cage Absence of external signs of chest trauma Treatment Careful evaluation for the presence of additional injuries Supplemental oxygen Close monitoring Acute respiratory distress syndrome

58 Most common cause of unrecognized fatal injury in children History is often limited Physical examination is difficult Repeated examination Prolonged observation Close attention to vital signs Radiologic and laboratory studies

59 Splenic Injury Most common in pediatric abdominal trauma sudden deceleration injuries Contact sports Typical findings LUQ pain radiating to the left shoulder

60 Liver Injury Second most commonly injured solid organ Most common cause of lethal hemorrhage Mechanisms of injury  splenic injury RUQ tenderness Pain in this region or in the right shoulder

61 Radiology Injury to solid organ CT abdomen  high sensitivity and specificity Bedside abdominal ultrasound

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