Presentation on theme: "Julie Williamson, DO Clinical Assistant Professor of Anesthesia and Pediatrics Lucile Packard Children’s Hospital."— Presentation transcript:
Julie Williamson, DO Clinical Assistant Professor of Anesthesia and Pediatrics Lucile Packard Children’s Hospital
Epidemiology of trauma The Primary Survey (ABCs) Fluid resuscitation and massive transfusion Non-Neurologic Injury Traumatic Brain Injury
Trauma is the leading cause of death in children and young adults in the US (ages 1-44 years old) Most pediatric deaths from trauma involve motor vehicles Brain injury is most common cause of death In children, about half involve multiple organs or body regions
Rank<11-45-910-1415-2425-3435-4445-5455-6465+ All Ages 1 Congenital Anomalies 724 Unintention al Injury 171 Unintention al Injury 109 Unintention al Injury 117 Unintention al Injury 1,540 Unintention al Injury 1,355 Unintention al Injury 1,741 Malignant Neoplasms 4,914 Malignant Neoplasms 9,438 Heart Disease 53,330 Heart Disease 64,871 2 Short Gestation 428 Congenital Anomalies 76 Malignant Neoplasms 63 Malignant Neoplasms 71 Homicide 986 Homicide 645 Malignant Neoplasms 1,549 Heart Disease 3,610 Heart Disease 6,322 Malignant Neoplasms 37,317 Malignant Neoplasms 54,140 3 Maternal Pregnancy Comp. 157 Malignant Neoplasms 53 Congenital Anomalies 29 Homicide 50 Suicide 408 Malignant Neoplasms 475 Heart Disease 1,155 Unintention al Injury 2,259 Unintention al Injury 1,282 Cerebro- vascular 12,766 Cerebro- vascular 15,039 4 SIDS 137 Homicide 36 Homicide 13 Congenital Anomalies 26 Malignant Neoplasms 253 Suicide 468 Suicide 589 Liver Disease 1,160 Cerebro- vascular 1,140 Chronic Low. Respiratory Disease 11,167 Chronic Low. Respiratory Disease 12,829 5 Placenta Cord Membranes 109 Influenza & Pneumonia 17 Heart Disease 10 Heart Disease 21 Heart Disease 82 Heart Disease 291 Liver Disease 387 Suicide 752 Chronic Low. Respiratory Disease 1,136 Alzheimer's Disease 8,054 Unintention al Injury 11,375 WISQARS TM Produced By: Office of Statistics and Programming, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention Data Source: National Center for Health Statistics (NCHS), National Vital Statistics System
MechanismIncidence (%)Mortality (%) Blunt923 Fall27<1 MVA - occupant214 MVA – peds struck125 Bicycle92 Penetrating85 Gunshot Wound210 Stabbing33 Crush<11 From Roger’s Textbook of Pediatric Intensive Care, fourth edition
Type of IncidentNumber of Deaths in Year 1987 Number of Deaths in Year 2004 Percent Decrease/Increase Motor vehicle crash3,5872,431 32% Drowning1,363761 44% Pedestrian injury1,283583 55% Fire and/or burn injury 1,233512 58% Suffocation690963 28% Falls149107 28% Poisoning10086 14% Firearm24763 74% National Center for Health Statistics. Centers for Disease Control and Prevention. National Vital Statistics System. WISQARS Injury Mortality Reports, 1987 to 2004. Hyattsville (MD): National Center for Health Statistics, 2007 http://www.usa.safekids.org
Smaller bodies mean more kinetic injury into a smaller space impact on multiple organs Larger BSA heat loss Anterior liver and spleen, mobile kidneys Immature bone has increased elasticity more soft tissue injury (misleading lack of fractures) Head:body greater, cranial bones thinner More robust response to catechol driven vasoconstriction preserved blood pressure until catastrophic shock ensues More likely to suffer a respiratory than cardiac arrest
“Scoop and run” vs. “stay and play” Out of hospital airway management Improved outcomes associated with care in a pediatric trauma center/hospital with PICU Loss of airway and IV access twice as common during transport, 10 times more common if not a specialized team
Relatively larger tongue – most common cause of airway obstruction Larger adenoids Floppy omega shaped epiglottis Larynx appears more cephalad and anterior Cricoid ring is narrowest part of airway Narrow tracheal diameter, smaller distance between rings Shorter tracheal lengths ( 4 cm newborn, 7 in 18 month old) Large airways more narrow
Assume C spine injury in pediatric trauma Jaw thrust, oral airway Assume full stomach/RSI indicated Induction agents – risks of propofol, ketamine, etomidate and succinylcholine Pre-oxygenation Avoid nasal intubation with severe facial/head trauma. Blind NI less successful in children Consider cuffed ETT Needle cricothyroidotomy (no slash trachs in kids) Orogastric tube to decompress stomach
More likely to have high cervical trauma under 8 years old (OA fulcrum) Radiographs are over and under-read SCIWORA Harder to immobilize CT scan vs. MRI Tuggle David W, Garza Jennifer, "Chapter 46. Pediatric Trauma" (Chapter). Feliciano DV, Mattox KL, Moore EE: Trauma, 6th Edition: http://www.accesssurgery.com.laneproxy.stanford.edu/content.aspx?aID=169962.
Apply 100% oxygen immediately while doing primary survey Watch for age-appropriate respiratory rates Hypercarbia/inadequate ventilation often under appreciated Pneumothorax more difficult to diagnose by auscultation due to transmitted breath sounds. If hemodynamically unstable, needle chest early Respiratory arrest from C spine injury
Intravenous access 3 attempts, 90 seconds, or obtunded IO Large bore PIV is optimal CVL or cut down PIV Control of hemorrhage Direct pressure over bleeding Tourniquets? Hemorrhage into thorax, retroperitoneum, thigh or intracranial in infants More then 3cc/kg/hour from chest tube is an indication for operation Aortic injury is 2 nd cause of death after TBI
Hypotension is a late finding correlating to loss of 30% of circulating blood volume Monitor for poor perfusion or confusion 20cc/kg warmed isotonic solution X 2 then PRBC Crystalloid vs. colloid? 0.9 NS or LR Colloid 3% saline Albumin Hetastarch coagulopathy Blood products Over-resuscitation Edema, abd compartment syndrome, ARDS, hypothermia
Emergency release blood – O neg or O pos ABO & Rh type specific uncrossmatched blood Dilutional thrombocytopenia after replacement of ½ blood volume After replacement of one blood volume with type O, stick with O Early coagulopathy MTP protocols: 1:1:1 PRB to FFP to Platelets “Storage lesion” Whole warmed blood Activated factor VII in children?
Pediatric GCS or AVPU EyesVerbalMotor 1No openingNone 2Opens to painInconsolable, agitatedExtension 3Opens to speechInconsistently inconsolable, moans Flexion 4 Opens spontaneously Cries but consolableWithdraws to pain 5Appropriate, interactiveWithdraws to touch 6Purposeful or spontaneous movement Check pupil size and reactivity
Orthopedic injuries Primary cause of operative intervention in pediatric trauma Greenstick and buckle fractures Growth plate injury Supracondylar fractures Immobilize and monitor vascular status Vascular injury 95% limb salvage
Fully undress patient – keep warm Look under collar and splints Log roll patient, exam back Rectal exam
Complete visual inspection Maintain normothermia Platelet inhibition below 34 C 100% mortality below 32 C Hyperthermia causes secondary injury in TBI
Perfusion and mentation Lactate or base deficit Do NOT wait for labs or radiographs to indicate need to evacuate pneumothorax or transfuse
Continuously resuscitate and reassess – vital signs every 5 to 15 minutes Easy to miss orthopedic injuries Plain films FAST CT
4 – 25% of pediatric trauma, up to 40% mortality Low SBP, elevated RR, external thoracic injury or femur fracture associated with intrathoracic injury Compliant chest wall Mobile mediastinum Pneumothorax Hemothorax Aortic injury accounts for 14% of mortality
Thin body wall and closely spaced organs Any external markings or tenderness are ominous Gastric decompression to benefit ventilation Diaphragmatic rupture Gastric rupture Bowel injury injury Splenic or hepatic injury Renal injury
Among children ages 0 to 14 years, TBI results in an estimated: 2,685 deaths; 37,000 hospitalizations 35,000 emergency department visits annually What causes TBI? Falls (28%); Motor vehicle-traffic crashes (20%); Struck by/against events (19%); and Assaults (11%) Langlois JA. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2004.
Vascular injuries – SAH and IVH serve as markers of severity
Mass effect Parenchyma CSF Blood Hypoxia Ischemia Target thresholds in children?
Normothermia vs. hypothermia (why doesn’t this work in kids??) Normoventilation: PCO2 < 25 ischemia Osmolar therapy - rheology Mannitol Hypertonic Saline ICP and CPP mangement – what numbers are adequate in children? Decompressive craniotomy CSF drainage Glycemic control – not a simple answer Coagulopathy -30% incidence of DIC in children with severe TBI
Bleeding and hypercoagulability DVT/PE Infection 2002, Albierti at al examine over 14,000 ICU patients, finding 17% admitted for trauma have proven infection (8% hospital-acquired). 2001 Bochicchio et al. find 1/3 of blunt trauma patients with an Injury Severity Score (ISS) >16 suffer invasive infection. Hospital aqcuired infections (BSI, VAP)
ARDS White et all 2004 examine 7192 patients Posttraumatic ARDS observed in 3% if laparotomy required for surgical intervention and up to 10% if three or more body regions sustained injury Patients with an ISS 16–24 had an eightfold increased risk for developing ARDS. Survival improved in trauma (about 25% mortality)
Post traumatic stress disorder Rehabilitation Prevention
Avarello JT and Cantor RM, Pediatric Major Trauma: An approach to evaluation and management. Emerg Med Clin N Am 25 (2007) 803-836. Tuggle David W, Garza Jennifer, "Chapter 46. Pediatric Trauma" (Chapter). Feliciano DV, Mattox KL, Moore EE: Trauma, 6th Edition: http://www.accesssurgery.com.laneproxy.stanfor d.edu/content.aspx?aID=169962. http://www.accesssurgery.com.laneproxy.stanfor d.edu/content.aspx?aID=169962 Letarte Peter, "Chapter 20. The Brain" (Chapter). Feliciano DV, Mattox KL, Moore EE: Trauma, 6th Edition: http://www.accesssurgery.com.laneproxy.stanfor d.edu/content.aspx?aID=157936.
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