International Trauma Life Support for Prehospital Care Providers Sixth Edition for Prehospital Care Providers Sixth Edition Patricia M. Hicks, MS, NREMTP Roy Alson, PhD, MD, FACEP Donna Hastings, EMT-P John Emory Campbell, MD, FACEP and Alabama Chapter, American College of Emergency Physicians Patricia M. Hicks, MS, NREMTP Roy Alson, PhD, MD, FACEP Donna Hastings, EMT-P John Emory Campbell, MD, FACEP and Alabama Chapter, American College of Emergency Physicians Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Chapter 17 Trauma in Children Chapter 17 Trauma in Children

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Trauma in Children

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Overview Effective techniques to gain confidence Injuries based on mechanisms of injury ITLS Primary and Secondary Surveys Consent and the need for immediate transport Pediatric equipment needs Various methods of SMR on child EMS involvement in prevention programs 2Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Trauma in Children Different from adults Different patterns of injuries Different responses to those injuries Special equipment required Assessment equipment and treatment equipment Difficult to assess and communicate Come with caregivers and other family members 3Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Communicating Family-centered care is critical. Caregiver not always parent. Involve caregivers as much as possible in care. Give explanations and careful instructions. Inclusion and respect will improve stabilization. Keep caregivers in physical and verbal contact. Demonstrate competence and compassion. 4Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Assessing Mental Status Consoled or distracted Most sensitive indicator of adequate perfusion Caregivers best at detecting subtle changes Initial level of consciousness Preschool child: sleeping vs. unconscious Most will not sleep through arrival of ambulance Ask caregivers to wake child Suspect hypoxia, shock, head trauma, seizure 5Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ 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 caregiver to accompany child 6Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Caregiver 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 7Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Pediatric Equipment Length-based tape Weight estimate Fluid and medication doses precalculated Common equipment size estimates 8Trauma in Children - Photo courtesy of Kyee Han, MD

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Mechanisms of Injury Falls Usually land on head Serious head injury unusual from <27 inches Protective gear MVCs Seat-belt syndrome Liver, spleen, intestines, lumbar spine Auto-pedestrian crashes 9Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Mechanisms of Injury Burns Airway obstruction Foreign body Child abuse Suspect if history does not match injury Story keeps changing 10Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Airway in Children Signs of obstruction Apnea Stridor “Gurgling” respiration Contribute to obstruction Hyperextension Hyperflexion 11Trauma in Children - Courtesy of Bob Page, NREMT-P

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Airway in Children 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 12Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Breathing in Children Work of breathing Retractions, flaring, grunting Persistent grunting requires ventilation Respiratory rate Fast, then periods of apnea or very slow Minor blunt neck trauma can be critical. 13Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ 20, 15, 10 Ventilation Rate 14Trauma in Children - 10 per minute for adolescent 20 per minute for <1 year 15 per minute for >1 year

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Breathing Management 15 Effective BVM ventilation— intubation is elective. Effective BVM ventilation— intubation is elective. Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ 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 16Trauma in Children age in years = size of tube (mm) 4

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Circulation in Children 17 Persistent tachycardia is most reliable indicator of shock. Persistent tachycardia is most reliable indicator of shock. Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Circulation in Children 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 18Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Shock in Children 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 19Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Pediatric Trauma Center Criteria Obstructed airway Need for airway intervention Respiratory distress Shock Altered mental status Dilated pupil Glasgow Coma Scale score <13 Pediatric Trauma Score <8 20Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Pediatric Trauma Center Mechanism that predicts severe injury Fall from height >10 feet Motor-vehicle collision MVC with fatalities Ejection from an automobile in a MVC In MVC, significant intrusion into compartment Hit by a car as a pedestrian or bicyclist Fractures in more than one extremity Significant injury to more than one organ system 21Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Pediatric Trauma Center Recommended Burns Near-drowning Head injuries with loss of consciousness Notify hospital as early as possible. 22Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Life-Threatening Injuries Head injury Most common cause of death Level of consciousness change best indicator Pupil assessment important Treatment High-flow oxygen Hyperventilate only with cerebral herniation syndrome Fluid administration titrated to systolic BP –Preschool child: 80 mmHg; older child: 90 mmHg Be prepared to prevent aspiration 23Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Life-Threatening Injuries Chest injury Respiratory distress common Pneumothorax or tension pneumothorax Difficult to assess Needle thoracostomy can be life-saving Pulmonary contusion Rare injuries Rib fractures, flail chest, aortic rupture, pericardial tamponade 24Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ 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. 25Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Life-Threatening Injuries Spinal injury Uncommon before adolescence <9 years usually upper cervical-spine injuries >9 years usually lower cervical-spine injuries Higher incidence of SCIWORA spinal-cord injury without radiographic abnormality SMR Pad under torso for neutral position May have to secure without cervical collar Do not restrict chest movement 26Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Child Restraint Seats 27Trauma in Children - Child in car seat Serious injury Remove from car seat Apply SMR No apparent injury Secure and transport in car seat

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Child Neglect and Abuse A leading cause of death in U.S. Be alert to signs Transport if suspected Know local laws 28Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Summary Good trauma care for children Proper equipment Interact with frightened caregivers Know normal vital signs for various ages Reference chart Be familiar with common injuries in children Be active in prevention programs 29Trauma in Children -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Discussion 30Trauma in Children -