International Trauma Life Support, 7e Trauma in Children 17 NOTE: Due to increasing demand for further training in management of injured children, ITLS has developed a one-day course (Pediatric ITLS) that covers this subject in detail. You can get more information about this course by calling ITLS International at 888-495-4875. (Outside the United States, call 630-495-6442.) Key Lecture Points Discuss the differences and similarities between the adult and pediatric patient regarding trauma management. Cover the various baseline vital signs expected for the different age groups. Note that the ITLS Primary Survey sequence is the same for pediatric and adult patients. Note that children will appear to be stable with fewer warning signs of deterioration, which can be followed by sudden disastrous decompensation. Mention that gastric distension in small children may cause hypotension. Mention that transport of small children in their car seats with appropriate additional stabilization may be acceptable under certain conditions.

Trauma in Children © Pearson

Overview Effective techniques to gain confidence Injuries based on mechanisms of injury ITLS Primary and Secondary Surveys Consent and the need for immediate transport The same basic ITLS principles apply to children as to adults. All ITLS Patient Assessment components apply to children. These slides emphasize differences and should supplement ITLS Patient Assessment, not replace it.

Overview Pediatric equipment needs Various methods of SMR on children EMS involvement in prevention programs The same basic ITLS principles apply to children as to adults. All ITLS Patient Assessment components apply to children. These slides emphasize differences and should supplement ITLS Patient Assessment, not replace it.

Trauma in Children Different from adults Anatomical differences Different patterns of injuries Different responses to those injuries Special equipment required Assessment equipment and treatment equipment Difficult to assess and communicate Come with parents and other family members Anatomical differences such as head and organ size, airway structures, etc. lead different injury patterns, responses to injury and the need for special equipment Children differ from adults in that they have different patterns of injuries, frequently have different responses to those injuries, require special equipment for assessment and treatment, are difficult to assess and communicate with, and come with parents and other family members. Doctors as well as EMTs are uncomfortable treating children because of these differences and the fact that they treat children less frequently. Health-care providers who are parents are often further hampered by intense emotions when treating a seriously injured child.

Communicating Family-centered care is critical Caregiver not always parent Involve parent as much as possible in care Give explanations and careful instructions Inclusion and respect will improve stabilization Keep parents in physical and verbal contact Demonstrate competence and compassion NOTE: Acknowledge that the primary caregiver may not be a parent; however, we will use the term parent throughout this presentation as it is in the chapter. A child is part of a family unit. To a child, family may serve as a constant factor in life. Best method to gain confidence is to demonstrate competence and compassion in managing the child. Parents are more likely to be cooperative if they see EMS as confident, organized, and using equipment designed for children. Parents can perform simple tasks such as holding a pressure dressing or holding child's hand. Parents can explain to child what is going on or sing his or her favorite songs. Show concern for child, remain calm and do not freeze.

Assessing Mental Status Consoled or distracted Most sensitive indicator of adequate perfusion Parents best at detecting subtle changes Initial level of consciousness Preschool child: sleeping vs. unconscious Most will not sleep through arrival of ambulance Ask parents to wake child Suspect hypoxia, shock, head trauma, seizure Since they are familiar with child's baseline mental status, caregivers are best resource for detecting subtle changes in child's level of consciousness. A child who can be consoled or distracted by a person or a toy has a normal mental status (most sensitive indicator of adequate perfusion). On other hand, a child who cannot be consoled or distracted may have a head injury, may be in shock, or may be experiencing hypoxia or severe pain. Changes in distractibility and ability to be consoled are important observations about level of consciousness of a child. Record and report them just as you would report changes in level of consciousness of an adult.

Communicating Interaction strategies Appropriate language for developmental level Speak simply, slowly, clearly Be gentle and firm Avoid “no” questions Get a favorite belonging Get on child's level Explain SMR necessity Allow parent to accompany child Be familiar with age and developmental level appropriate communications and behaviors of children Speak softly as children often associate loud talk or yelling with negativity © Pearson

Parental Consent Critical care should not be delayed. Emergency care needed Consent not available Transport before permission, document why, notify medical direction Consent denied Try to persuade, document actions, obtain signature Notify law enforcement and appropriate authorities Report suspected abuse NOTE: Adapt this information to what is required/expected in country where class is being taught.

Pediatric Equipment Length-based tape Weight estimate Fluid and medication doses precalculated Common equipment size estimates IMAGE: Figure 17-1 Broselow tape: length-based drug dose tape. IMAGE: Figure 17-2a SPARC system has color-coded tape and booklet. Ambulances should have specific pediatric bag with pediatric equipment so that everything for children is easily accessible. These devices allow focus on patient instead of trying to remember correct equipment size and drug dose. These tape systems estimate weight better than emergency medicine professionals, and endotracheal tube size as well as anesthesiologists. (NOTE: See Chapter 9: Fluid Resuscitation Skills.) Courtesy of James Broselow, MD Courtesy of Louis B. Mallory, MBA, REMT-P Photos courtesy of Kyee Han, MD

Mechanisms of Injury Falls MVCs Auto-pedestrian crashes Usually land on head Serious head injury unusual from <3 feet (1 meter) Protective gear MVCs Seat-belt syndrome Liver, spleen, intestines, lumbar spine Auto-pedestrian crashes Falls (most common in U.S.): Usually land on head, since head is largest and heaviest part of a small child's body. Serious head injury unusual from <3 feet (1meter). Study showed that serious head injuries usually did not occur from falling off of couch. Protective gear. Motor-vehicle collision, especially if protective devices not used: Motor-vehicle collisions, especially if lap belt restraints are improperly used, may result in seat-belt syndrome, and injury may occur to liver, spleen, intestines, or lumbar spine. Seat-belt syndrome (or seat-belt sign) is an abrasion, caused by seat-belt use, over abdomen and/or upper neck. Auto-pedestrian crashes.

General Assessment IMAGE: Figure 17-3 Pediatric Assessment Triangle. IMAGE: Figure 17-4 Steps in assessment. Develop a general impression of the injured child, usually from across the room or scene. Before ever touching an injured child, try to decide whether he or she appears to be severely injured or in distress. Make a mental note of the child's initial level of consciousness, work of breathing, and overall circulation as you begin your survey. (Copyright American Academy of Pediatrics. Used with permission.)

Airway Assessment Opening airway Tongue is large; tissue soft Jaw-thrust Oropharyngeal airway Nasopharyngeal airways Too small to work predictably Neonate obligate nose breather Clear nose with bulb syringe Courtesy of Louis B. Mallory, MBA, REMT-P IMAGE: Jaw-thrust maneuver. Note simultaneous in-line stabilization.

Airway Assessment Signs of obstruction Contribute to obstruction Apnea Stridor “Gurgling” respiration Contribute to obstruction Hyperextension Hyperflexion Courtesy of Bob Page, NREMT-P As with all patients, if mechanism exists, stabilize neck while checking airway. Be sure to look-listen-feel. Apply cervical collar after you complete ITLS Primary Survey. NOTE: Commercially available cervical collars may not accurately maintain positioning or may interfere with airway. If necessary, make cervical stabilization from towels or sheets. Children need different amounts of padding to maintain neutral position. Padding goes under torso, not just under shoulders and/or neck. Remember: SMR needs to be in an anatomically neutral position specific for each patient to be neutral for spinal cord and airway. Although texts often recommend age ranges (including ITLS), SMR is principle-driven. Appropriate padding should be used for all age groups and situations (elderly, American football shoulder pads, infants, obesity, etc.). © Pearson

Breathing Assessment Work of breathing Respiratory rate Retractions, flaring, grunting Persistent grunting requires ventilation Respiratory rate Fast, then periods of apnea or very slow Minor blunt neck trauma can be critical

Ventilation Give ventilations slowly Lowest pressure necessary 20, 15, 10 20 bpm < 1 year old 15 bpm > 1 year old 10 bpm adolescent Of course, all ventilation principles remain same. There must be an open patent airway. BVM should have reservoir with high-flow oxygen. A good mask fit is essential. Be careful with small children—large hands can easily obstruct airway or injure child's eyes. When using a bag-valve mask, it is best to monitor your ventilation with capnography. Look for adequate chest rise; do not overinflate (which may cause gastric distention).

Effective BVM ventilation— intubation is elective. Breathing Management Effective BVM ventilation— intubation is elective. If BVM ventilation is effective, then field intubation is elective. It is usually better not to intubate child in field. Intubation is extremely difficult to perform even in a dry, well-lighted Emergency Department. Courtesy of Louis B. Mallory, MBA, REMT-P

Endotracheal Intubation Oral endotracheal intubation No blind nasotracheal intubation for <8 years Uncuffed tube Length-based tape system Same diameter as tip of child's little finger Frequently reassess placement Alternative airways 4 + age in years = size of tube (mm) 4 As with all patients, always preoxygenate, stabilize cervical spine, visualize cords, confirm placement, and stabilize tube. The use of capnography is considered a standard of care for monitoring the airway patency of intubated patients. No blind nasotracheal intubation for <8 years due to nares too small and larynx too far anterior. Laryngeal mask airway and Kin LT available in pediatric sizes.

Circulation Assessment Early shock more difficult to determine Persistent tachycardia Rate >130 usually shock in all ages except neonates Prolonged capillary refill and cool extremities Level of consciousness Circulation can be poor even if child is awake Low blood pressure is sign of late shock BP <80 mmHg in child; <70 mmHg in young infant NOTE: Ranges for vital signs—see Table 17-2. Prolonged capillary refill and cool extremities may indicate decreased tissue perfusion. Although currently controversial, capillary refill should still be included as part of Initial Assessment for shock in a child. Individual variances may make some signs of shock normal for a particular child. Tachycardia—fear or fever. Mottling—normal in infant less than 6 months, but also may be sign of poor circulation, so note it. Extremities—nervousness, cold weather, poor perfusion. Capillary refill prolonged in child who is cold. In general, carefully evaluate and assume shock if persistent tachycardia or signs of poor peripheral perfusion. NOTE: The antishock garment (MAST or PASG) is no longer recommended for treatment of shock, except in special circumstances. AHA PALS refers to hypotension as “less than 70 + (age in years x 2).”

Bleeding Control immediately Blood volume 80-90 mL/kg Avoid large bulky dressings Constant direct pressure Hemostatic agents Tourniquets with caution Blood volume 80-90 mL/kg Example: 200-mL loss is approximately 20% in a 10 kg child Obvious bleeding sources must be controlled to maintain circulation. Remember, the child's blood volume is about 80–90 mL/kg, so a 10-kg child has less than 1 liter of blood. Three or four lacerations can cause a 200-mL blood loss, which is about 20% of the child's total volume. Unfortunately, the bulky dressings often do not provide enough direct pressure to stop the bleeding. Instead, they simply absorb large amounts of blood and disguise potentially serious bleeding. Your gloved hand and fingers in combination with a 4x4 sterile gauze pad is usually your best tool for applying constant firm pressure to the site of bleeding. Hemostatic agents also can be used to control hemorrhage in children. While tourniquets are not routinely recommended, in life-threatening bleeding that cannot be controlled by other means, the lifesaving benefits of a tourniquet outweigh the small potential risk of further limb injury and loss.

Critical Trauma Situation Perform only necessary procedures Control bleeding SMR Oxygenation Ventilation Rapid, safe transport Appropriate destination There are very few procedures that should be done in the field. Minutes count, especially in children. On-scene times of less than five minutes are desirable. Administer 100% oxygen to all potentially seriously injured pediatric patients. There is strong evidence to support the policy that bag-mask ventilation of the critical child is preferable to placing an endotracheal tube if the transport time to an appropriate emergency department is short. When considering transportation options, providers should be aware of local and regional resources and policies. This includes deciding the appropriate destination for a particular patient (the nearest emergency department versus a regional pediatric trauma center) as well as choosing the best transportation mode (BLS versus ALS versus air ambulance). See Table 17-3 for a partial list of mechanisms of injury that are criteria for transport to an emergency department that is approved for pediatrics or a pediatric trauma center.

Hemorrhagic Shock Strong compensatory mechanisms Appear surprisingly good in early shock “Crash” when deteriorate Be prepared Fluid administration 20 mL/kg in each bolus Consider intraosseous infusion Frequent Ongoing Exams Ability to maintain a normal blood pressure despite life-threatening bleeding. Persistent tachycardia is the most reliable early indicator of shock in a child. Low blood pressure is a late sign of shock (also called decompensated shock). If shock is present (compensated with a normal blood pressure or decompensated with a low blood pressure), the child requires fluid resuscitation. You should establish vascular / IO access quickly and give a fluid bolus. The initial bolus should be 20 mL/kg of normal saline given as rapidly as possible. If you cannot start an IV in two attempts or 90 seconds, you will need to insert an intraosseous needle.

Life-Threatening Injuries Head injury Most common cause of death Level of consciousness change best indicator Pupil assessment important Assessment of pupils is as important in child as in adult. Note also whether eyes are moving both left and right or whether they remain in one position. Do not move head to determine this!

Life-Threatening Injuries Head injury Treatment High-flow oxygen Hyperventilate only with cerebral herniation syndrome Monitor ventilation with capnography Fluid administration titrated to systolic BP Preschool child: 80 mmHg; older child: 90 mmHg Be prepared to prevent aspiration Children with head injury often fare much better than adults with same degree of injury. The head is primary focus of injury in child because child's head is proportionately larger than adult's. The force of impact does some damage to brain, but much of brain damage from head injuries comes after impact, from preventable causes.

Life-Threatening Injuries Chest injury Respiratory distress common Pneumothorax or tension pneumothorax Difficult to assess Needle thoracostomy can be lifesaving Pulmonary contusion Rare injuries Rib fractures, flail chest, aortic rupture, pericardial tamponade Abnormal breath sounds, neck-vein distension, tracheal deviation are difficult to assess due to thin chest wall and short, fat necks. Chest wall highly elastic.

Life-Threatening Injuries Abdominal injury Liver and/or spleen rupture Second leading cause of traumatic death Bleeding often contained within organ Difficult to diagnose Severe injury with minimal signs Suspect with any abnormal abdominal assessment Be prepared to prevent aspiration In children, liver and spleen both protrude below ribs, exposing organs to blunt trauma. This poor protection and relatively large size of liver and spleen in children allow these organs to be easily torn. Abnormal abdominal assessment, for example, seat-belt marks, bicycle handle-bar marks, or bruises to abdomen.

Life-Threatening Injuries Spinal injury Uncommon before adolescence <9 years usually upper cervical-spine injuries >9 years usually lower cervical-spine injuries SMR Pad under torso for neutral position May have to secure without cervical collar Do not restrict chest movement NOTE: Emphasize importance of neutral alignment/positioning specific for that patient (pediatrics, adults, and geriatrics). Commercially available cervical collars may not accurately maintain positioning or may interfere with airway. If necessary, make cervical stabilization from towels or sheets. Children need different amounts of padding to maintain neutral position. Padding goes under torso, not just under shoulders and/or neck. Remember: SMR needs to be in an anatomically neutral position specific for each patient to be neutral for spinal cord and airway. Although texts often recommend age ranges (including ITLS), SMR is principle-driven. Appropriate padding should be used for all age groups and situations (elderly, American football shoulder pads, infants, obesity, etc.).

Child Restraint Seats Child in car seat Serious injury Remove from car seat Apply SMR No apparent injury Secure and transport in car seat NOTE: Most car seat manufacturers recommend only transporting child in safety seat if there is no visible sign of damage to safety seat. Children who are involved in an MVC while restrained in a child safety seat but have no apparent injuries may be packaged in a safety seat for transport to hospital. Using towel or blanket rolls, cloth tape, and a little reassurance, you can secure child in a safety seat and then belt seat into ambulance. When child is in a car seat that is damaged, or in a built-in child-restraint seat that cannot be removed, child must be removed for SMR. Children in such situations will have to be carefully extricated onto a backboard or another pediatric SMR device, using manual stabilization. Courtesy of Louis B. Mallory, MBA, REMT-P

Child Neglect and Abuse A leading cause of death in U.S. Be alert to signs Transport if suspected Know local laws Child neglect and abuse: Be alert for signs. Suspect if history does not match injury. Story keeps changing. Pattern marks or injuries. Match object shapes. Clear lines without splatter or splash. History does not match developmental age. Follow local procedures in event of suspected child abuse. © Pearson

Summary Good trauma care for children Proper equipment Interact with frightened parents Know normal vital signs for various ages Reference chart Be familiar with common injuries in children Be active in prevention programs NOTE: Additional useful information in Appendix H: Injury Prevention and the Role of the EMS Provider.