1. 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

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

3. 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

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

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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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

17. 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

18. 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.

19. 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

20. 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

21. Gastric distension

22. 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.

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

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

28. 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%

29. 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

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

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

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

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

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

35. 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

36. 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 ml/Kg/hour

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

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

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

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

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

42. 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

43. 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

44. Strange environment?

45. Strangers in environment?

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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

57. 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

58. 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

59. 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

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

61. 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

62. 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

63. 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.

64. QUESTIONS