Pediatric Trauma Management The Division of Paediatric Emergency Medicine Presents: Pediatric Trauma Management What You Need To Know Thanks to: Angelo Mikrogianakis MD, FRCPC Pediatric Emergency Physician and Trauma Team Leader Emergency Medicine & Critical Care The Hospital for Sick Children Pediatric Patch Physician Ornge

Objectives General overview of pediatric trauma Anatomy and patterns of injury Case Study

Why does pediatric trauma cause so much anxiety? Emotional impact Different equipment sizes Different drug and fluid calculations Differences in anatomy,physiology and pathophysiology specific to children Communication difficulties Lack of staff experience

We can all be better prepared for pediatric trauma! “We Forgot The Patient!”

Cardiopulmonary arrest PEDIATRIC TRAUMA Isolated head Multiple injury trauma Airway compromise Respiratory failure Shock Cardiopulmonary arrest

PEDIATRIC TRAUMA Blunt injury is much more common than penetrating injury Head (CNS) injury present in 55% of blunt trauma victims Internal injuries present in 15% of blunt trauma victims

ANATOMY & PHYSIOLOGY BODY small body mass with large surface area heat loss greater force per body unit area less protective muscle and fat high metabolic rate higher oxygen and glucose demands

ANATOMY & PHYSIOLOGY HEAD large compared to body size heat loss more prone to injury weak neck muscles prominent occiput sutures open until 18 months relatively larger tongue

PEDIATRIC HEAD TRAUMA Most common single organ system injury associated with 80% of all deaths Concussion common injuries Subdural bleeds common in infants Epidural bleeds less common than adults Acute neurosurgical intervention required less often than adults

CAUSES OF SECONDARY BRAIN INJURY Systemic Causes (Extracranial) hypotension hypoxemia anemia hypo/hypercarbia hyperthermia hypo/hyperglycemia hyponatremia Neurologic Causes (Intracranial) raised ICP herniation vasospasm hematoma seizures infection hyperemia Secondary brain injury compounds the initial damage and negatively affects the brain’s ability to autoregulate and compensate Intracranial versus extracranial causes

BREATHING FOR HEAD INJURED PATIENTS Controlled ventilation cerebral vasculature responds to PaCO2 maintain cerebral oxygenation PaO2< 60 mm Hg associated with  morbidity & mortality Hyperventilation with caution hyperventilation decreases CBF & worsens outcome hyperventilation NOT recommended unless herniation goal is PaCO2 = 35 mmHg

MANAGEMENT OF RAISED ICP Elevate HOB (unless  BP) Medication Mannitol: osmotic diuresis 3% Hypertonic saline: Early transfer to neurosurgical facility Hyperventilation only if impending herniation

ANATOMY & PHYSIOLOGY NECK shorter; supports more mass veins & trachea hard to see larynx - cephalad & anterior cricoid narrowest part epiglottis at 45o & floppy short trachea (5cm at birth) spine– elasticity of ligaments Less calcified

PEDIATRIC C-SPINE C-Spine injury is uncommon (1-4%) < 8 y.o.  10-15% 8-12 y.o.  20-25% > 12 y.o.  60-70% Anatomic fulcrum of spine at C2-C3 Fractures below C3 < 30% of spine lesions in children < 8 years of age *** Adult pattern of injury at 12 years old

CSI - pediatric differences  mobility at C2-C3 (pseudosubluxation) normal mobility 3 mm (children 4-5 mm) tip of odontoid < 1 cm from base of skull pre-dental space 3 mm (children 4-5 mm) retropharyngeal space 5-7 mm (children < 7-8 mm) vertebral bodies may be wedged anteriorly especially on their superior surfaces until  age 10

ANATOMY & PHYSIOLOGY CHEST ribs are cartilaginous and pliable greater transmitted injury rib fracture = massive force little protective muscle and fat mediastinum very mobile

PEDIATRIC THORACIC INJURIES Less serious thoracic injuries than adults Rarely will chest injuries occur in isolation Rarely are the sole cause of death Blunt cardiac & great vessel injuries are rare Management is mainly conservative: Assisting oxygenation and ventilation Chest tube insertion Replacing lost blood volume < 15% require a chest tube

PEDIATRIC THORACIC INJURIES U.S. data in pediatric blunt chest trauma 50% pulmonary contusions 20% pneumothorax 10% hemothorax Canadian incidence is most likely less Chest tube sized to occupy most of the intercostal space.

ANATOMY & PHYSIOLOGY ABDOMEN less protection from ribs and muscle liver and spleen vulnerable small forces can cause severe injury propensity for gastric distension abdominal pain respiratory distress GU organs well protected by pelvis

Gastric distension common after trauma from crying and swallowing air can interfere with respiration / ventilation limits diagphragmatic motion reduces lung volume increases the risk of vomiting difficult to discern abdominal findings

Gastric distension

PEDIATRIC ABDOMINAL INJURIES Gastric distention = OG/NG tubes Solid organs are most vulnerable. 8% of admissions to peds trauma centres 85-90% of all pts with hepatic & splenic injuries can be managed nonoperatively. Missed hollow viscus injury is uncommon.

SickKids Patient Population April 1998 – March 2001 Male 62.2% Age 8.6 years (std dev 4.5) Weight 33.8 kg (std dev 18.1) ISS 14 (std dev 11) Direct 47.8% Referred 52.2%

The more important requisite is the ability to evaluate hemodynamic stability.

AMBULANCE PATCH 7 y.o. male, pedestrian struck by truck while crossing street Witnesses describe LOC Now confused & agitated O2 applied IV access x 1 VITALS: HR=120, BP=105/69, RR=30, SATS=91%

RAPID CARDIOPULMONARY ASSESSMENT A. Airway and C-spine control B. Breathing C. Circulation and hemorrhage control D. Disability (rapid neurologic assessment) E. Exposure and Environmental control

PREPARATION Assemble team - define roles Prepare equipment for: physicians nurses RT radiology Prepare equipment for: airway management IV access & fluid resuscitation Broselow tape

PRIMARY SURVEY AIRWAY position - jaw thrust suction 100% oxygen oral airway ensure C-spine is immobilized

AIRWAY Bag & mask ventilaton C-spine precautions Intubating Criteria RSI meds

PRIMARY SURVEY BREATHING colour chest movement retractions breath sounds assess work of breathing oxygen saturations

PRIMARY SURVEY CIRCULATION heart rate capillary refill skin colour and temperature blood pressure peripheral pulses organ perfusion: brain, kidney

CIRCULATION IN THE TRAUMA VICTIM Assess for signs of hypovolemic shock: quiet tachypnea tachycardia prolonged capillary refill cool extremities thready pulses narrow pulse pressure altered mental status

RESPONSE TO FLUID BOLUS Slowing of heart rate increased systolic BP increased pulse pressure (>20mmHg) decrease in skin mottling increased warmth of extremities clearing of sensorium urinary output of 1 - 2 ml/Kg/hour

PRIMARY SURVEY DISABILITY pupils: size and reactivity level of consciousness A - Alert V - Verbal stimulus P - Painful stimulus U - Unresponsive

PRIMARY SURVEY EXPOSURE remove all clothes keep patient warm warm blankets warm fluids overhead warmer warm the room

SECONDARY SURVEY HEAD TO TOE EXAM systematic exam of all body organs look, listen & feel fingers & tubes in every orifice

SECONDARY SURVEY HISTORY A - Allergies M - Medications P - Past medical history L - Last meal E - Events/Environment

RE-ASSESS And ASSESS AGAIN If patient deteriorates, go back to ABC’s

KEY MESSAGES Prevention is the best defense Pediatric patients have special differences Recognize head-injured patients early Prevent secondary brain injury Be excellent airway managers Provide adequate fluid resuscitation Anticipate need for transfer ASAP Ensure appropriate transport personnel

Psychologic status impaired ability to interact unfamiliar individuals strange environment emotional instability fear / pain / stress parents often unavailable history taking and cooperation can be difficult

Strange environment?

Strangers in environment?

CASE STUDY: 7 year old, male Pedestrian struck by truck while crossing street On Arrival to Primary Hospital Moaning with bruising & swelling to face, large scalp laceration 100% O2 Cardio, Resp, BP & Sat monitors 2 large bore IV’s placed

CASE: 7 year old male Vitals: HR=160, BP=110/70, RR=24, SAT= 99 A - Patent, teeth loose, facial contusions B - Breath sounds decreased on RIGHT C - Heart sounds N, cap refill brisk D - Eyes open to speech, Verbally confused, Obeys commands (GCS=13), PERL ABDO - soft, tender RUQ, bruising R flank/hip

CASE: 7 year old Interventions: Broselow Tape Bolus 20 cc/kg NS rapidly Reassess Vitals: HR=140, BP=105/75, RR=14, SAT= 99 Resp effort decreased, BS decreased to R Eyes open to pain, no longer verbal, abnormal flexion to pain

Summary of Pitfalls Beware of hypothermia in systemic trauma especially if hemodynamic compromise Beware of unusual bleeding sites subgaleal hematomas long bone fractures Beware of the distended stomach

CASE 14 y.o. male, previously healthy Un-helmeted cyclist struck by truck ~ 19:00 Thrown & rolled Initially unconscious then agitated, Vx X 1 Arrival at primary hospital ~ 19:50 Tachycardic Comatose – decorticate posturing – GCS=5 Extension of extremities

CASE A - Intubated No maxillofacial trauma B - Trachea midline Good A/E bilaterally No subcutaneous air C – HR = 126, BP = 120/35 D - PERL – myosis, extension to painful stimuli Abrasion L chest & abdomen Abdomen distended

Common Life-Threatening Chest Injuries Type Tension pneumothorax Massive hemothorax Initial Treatment ABC’s, Needle decompression Insert chest tube ABC’s Pleural decompression Replace fluids

Uncommon Life-Threatening Chest Injuries Type Flail chest Open pneumothorax Initial Treatment ABC’s Positive-pressure ventilation May require chest tube Occlusive dressing Insert chest tube

Surface area surface / volume ratio thermal energy loss significant highest in infants diminishes as child matures thermal energy loss significant hypothermia may develop quickly may be good for isolated head injuries bad for hypotensive patients

Tachycardia CO = HR x SV  CO = HR x  SV CO =  HR x  SV Why is evaluation of HR so important? CO = HR x SV  CO = HR x  SV CO =  HR x  SV

Hypotension BP = CO x SVR  CO =  HR x   SV BP =  CO x  SVR Why is evaluation of BP so important? BP = CO x SVR  CO =  HR x   SV BP =  CO x  SVR

It’s “Shock” ing  BP @ 25% loss normal blood volume = 80 mL/kg 6 month old  7 kg 7 kg = 560 mL  25%  140 mL 140 mL  ½ cup

BP Rule of Thumb 70 mm Hg + (2 x age in years) Minimal acceptable systolic blood pressure: 70 mm Hg + (2 x age in years) Represents 5th %ile of normal BP Hypotension in children is a late and often sudden sign of cardiovascular decompensation

BP in head injuries Secondary brain injury = neuronal injury as a result of the pathological processes that are initiated as the body’s response to primary injury hypercarbia cerebral edema  ICP hypotension hypoxemia

BP in head injuries CPP = MAP - ICP    CPP =  MAP -  ICP

Long-term effects effect on growth and development growth deformity abnormal development children with severe multisystem trauma 60% residual personality changes at 1 year 50% show cognitive and physical handicaps

Long-term effects other disabilities social affective learning significant impact on family structure personality and emotional disturbances in 2/3 of uninjured siblings strain on marital relationship

CORE KNOWLEDGE & SKILLS 1.Understand the principles of airway management in the injured pediatric patient. 2.Recognize and manage shock in the injured pediatric patient. 3. Recognize and treat common life-threatening complications of major trauma in pediatric age group.

QUESTIONS