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Wirut phchiansatian , MD Emergency medicine

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Presentation on theme: "Wirut phchiansatian , MD Emergency medicine"— Presentation transcript:

1 Wirut phchiansatian , MD Emergency medicine
Pediatric trauma Wirut phchiansatian , MD Emergency medicine

2 Epidemiology 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

3 Pediatric VS Adult Anatomic and Physiologic differences

4 Anatomic Differences Body size Relative body surface Liver and spleen
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 Anatomic Differences Kidney Growth plates
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 Anatomic Differences Head injury Head-to-body ratio is greater
Brain less myelinated Cranial bones thinner

7 Body proportions

8 Anatomic Differences : Airway
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 Anatomic Differences : Airway
Epiglottis is floppy and more u-shaped Use of a straight blade


11 Anatomic Differences : Airway
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 Anatomic Differences : Airway
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

13 Needle cricothyroidotomy


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

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

17 Physiologic Differences
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 Subtle เข้าใจยาก,ลึกลับ


19 THE CONCEPT 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 Primary survey and resuscitation
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 A-Airway and Cervical Spine Stabilization
Possible airway obstruction clearing the oropharynx of debris jaw-thrust maneuver Stabilize neck

22 B-Breathing and Ventilation
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 B-Breathing and Ventilation
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 C-Circulation and Hemorrhage Control
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 CO=SV*HR BP=CO*SVR

25 C-Circulation and Hemorrhage Control

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


28 E-Exposure and Thorough Examination
Fully undressing Assess for hidden injury Hypothermia

29 F-Family Rapidly informing the family Caregiver is present
Explain the process

30 Secondary Survey 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 A - Allergies M - Medications P - Past medical history L - Last meal E - Environments and events

31 Specific Pediatric Injuries

32 Specific disorders/injuries
Leading cause of traumatic death Head injuries Thoracic injuries Abdominal injuries Cervical Spine Injury

33 Head Injury Cranial vault More pliable Less myelinated
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 pliable ยืดหยุ่น

34 Head Injury 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) Paradoxical irritability A child who is quiet at rest but who cries when moved or comforted

35 Head Injury 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 Head Injury Lucid interval Epidural hematomas
May be the result of venous bleeding Subtle and more subacute presentation over days Associated with overlying skull fractures Subtle เข้าใจยาก,ลึกลับ

37 Head Injury Subdural hematomas Shaken baby syndrome
Most commonly in < 2 years old 93% of cases < 1 year old Shaken baby syndrome Chronic subdural hematomas Retinal hemorrhages Subtle เข้าใจยาก,ลึกลับ

38 Head Injury Recommendations for CT scanning Children < 1 year
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 Subtle เข้าใจยาก,ลึกลับ

39 Anatomic Differences in the Pediatric Cervical Spine
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 Subtle เข้าใจยาก,ลึกลับ

40 C1-C2 Apical odontoid epiphyses fuses at 5-7 years of age
Posterior arch of C1 fuses at 4 years of age

41 C2 Basilar odontoid synchondrosis fuses at 3-7 years of age

42 Anatomic Differences in the Pediatric Cervical Spine
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 Preodontoid space Increased preodontoid space 4-5 mm (3 mm in an adult)

44 Pseudosubluxation of C2 on C3

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

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

47 Cervical Spine Injury 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

48 Line Of Swischuk

49 Line of Swischuk

50 Management 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 Management Neutral positioning

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

54 Cardiothoracic Injury
Mediastinum is mobile Tension pneumothorax Rapid ventilatory and circulatory collapse

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

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

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

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

62 Question

63 Thank you

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