Download - Catalyst

Pediatric Trauma
David Brown
August 2011
Epidemiology
• Leading cause of childhood (<19 yrs) death
#1 Motor vehicle accidents (46%)
#2 Homicide or suicide
#3 Drowning
Other: Falls, bicycles, ATVs
• Boys injured twice as often as girls
• Suffocation most common in infants <1 yr,
drowning in children yrs 1-4, MVAs in ages 5-19
Borse et al. (2008) CDC Childhood Injury Report 2001-2006. www.cdc.gov
Epidemiology
• 20 children die daily from preventable injury
(more than all medical conditions combined)
• 40 others hospitalized
• 1,120 others treated in ED
• 9.2 million emergency room visits annually for
unintentional injury
• Approximately $17 billion in medical costs
• 50,000 children acquire permanent disabilities each yr
Borse et al. (2008) CDC Childhood Injury Report 2001-2006. www.cdc.gov
Principles of Injury
• More elastic tissues → can absorb more energy
without external signs
• Closer proximity of vital organs to skin →
multiple injuries with single impact
• High surface area : volume ratio →
hypothermia more common,
warming more important
ATLS Primary Survey
• Same priorities for children:
•
•
•
•
•
Airway maintenance with c-spine protection
Breathing and ventilation
Circulation with hemorrhage control
Disability (neurologic status)
Exposure (prevent hypothermia)
Broselow Tape
• Widely-used length-based resuscitation scale
• Dosages & equipment based on predicted weight
• Divided into 8 colors corresponding to weight
• Recommended by PALS and ATLS
Broselow Tape
• Problem: 36% of U.S. population is overweight
(BMI 25-30) and 27% is obese (BMI >30)
• 17% of children < 19 are overweight
• Incidence has tripled for adolescents in last 20 yrs
• Broselow tape introduced in 1988
• 2 recent studies show under-prediction of dosages
using Broselow tape
• Ohio: Weight concordance 66%, dosages w/i 10% in 55%
• West VA: Weight concordance 33%
Knight et al. (2011) Ped Emerg Care 27:479. Nieman et al. (2006) Acad Emerg Med 13:1011.
Airway
• Failure to secure adequate airway is a major cause
of preventable pediatric death following trauma
• Children generally have shorter necks, smaller &
more anterior larynx, and floppier epiglottis
• ET tube size can be estimated by 5th finger width
• Needle cricothyroidotomy preferred over surgical
incision in patients < 10 yrs (14-16 g angiocatheter)
*Tuggle D, Garza J. Pediatric Trauma. In:Trauma, 6th Edition. Feliciano et al.
Breathing
• Infants and toddlers are primarily diaphragmatic
breathers – ventilation more susceptible to injury
• More elastic ribs and more mobile mediastinum
• Allows more energy transfer to lung
• More lung contusions without overlying rib Fx
• Higher propensity for tension PTX
*Tuggle D, Garza J. Pediatric Trauma. In:Trauma, 6th Edition. Feliciano et al.
Chest Tubes
• Similar indications & procedure as for adults
• Initial blood return of >15 cc/kg or >2-3 cc/kg/hr
for >3 hours warrants thoracic exploration
Age
Weight
Tube Size (Fr)
Premie
1-2.5 kg
10-14
Neonate
2.5-4 kg
12-18
6 mo
6-8 kg
14-20
1-2 yrs
10-12 kg
14-24
5 yrs
16-18 kg
20-32
8-10 yrs
24-30 kg
28-28
Connors KM. Tube thoracostomy (1997). In: Textbook of Pediatric Emergency Procedures. Henretig et al.
Circulation
• Know normal vitals:
AGE GROUP
WEIGHT RANGE
(in kg)
HEART RATE
(beats/min)
BLOOD PRESSURE
(mm Hg)
RESPIRATORY RATE
(breaths/min)
Infant 0–1
0–10
<160
>60
<60
Toddler 1–3
10–14
<150
>70
<40
Preschool 3–5
14–18
<140
>75
<35
School age 6–12
18–36
<120
>80
<30
Adolescent >12
36–70
<100
>90
<30
• Hypotension if >1 y/o: SBP < 70 + (age × 2)
*Advanced Trauma Life Support. 8th Edition. American College of Surgeons.
Venous Access
•
Recommended sequence for venous access:
1.
2.
3.
4.
5.
Peripheral veins x 2 attempts (AC preferred)
Intraosseous access
Percutaneous central venous access
Femoral vein
Venous cutdown (distal saphenous preferred)
Tuggle D, Garza J. Pediatric Trauma. In:Trauma, 6th Edition. Feliciano et al.
Hemorrhagic Shock
• Children have greater capacity to maintain blood
pressure during hemorrhage → hypotension in
shock may be sudden
MAP
Children
Adults
Hemorrhage
• Assess shock with pulse and capillary refill
Intraabdominal Injury
• Nonoperative management is standard for
pediatric blunt trauma
• Children generally fail nonop
management earlier (<72 hrs)
than adults (<5 days)
• Liver and spleen injuries*:
• Grade 1: No ICU, 2 days inpt, 3 wks activity restriction
• Grade 2: No ICU, 3 days inpt, 4 wks activity restriction
• Grade 3: No ICU, 4 days inpt, 5 wks activity restriction
• Grade 4: 1 ICU day, 5 days inpt, 6 wks activity restriction
*ASPS Recommendations. Based on Stylianos S. J Pediatr Surg. Mar 2002;37(3):453-6.
Intraabdominal Injury
• Common in MVAs, particularly if child < 100 lbs
is using adult seat belt (seat belt sign)
• Children more likely to have
solid organ injury without
hemoperitoneum
• Moore et al., Trauma: Support liberal use of CT
scans in children (acceptable to have more
negative scans than adults)
Tuggle D, Garza J. Pediatric Trauma. In:Trauma, 6th Edition. Feliciano et al.
FAST
• Advantages are relative lack of subcutaneous tissue,
reduced radiation, and no need for transport
• 2007 meta-analysis: 66-80% sensitivity of FAST
for detecting hemoperitoneum in kids
• Negative FAST does not
rule out intraabdominal injury
• CT is still diagnostic modality
of choice for trauma
Holmes et al. (2007). J Pediatric Surg 42:1588.
Radiation Risk
• Typical CT abdomen/pelvis in a child: 5 mSv
(another source: 3.5-23 mSv)
• Background radiation in U.S.: 2.4-3.5 mSv/yr
• Atomic bomb survivors data:
• Cancer risk is linear from 0-2500 mSv, p<0.05 at 20 mSv
• Children are 10-15× more radiosensitive than adults
• “Linear no-threshold model” & ALARA principle
Rice et al. (2007) J Pediatric Surg 42:603.
Child Abuse
• Represents 3-4% of all pediatric injuries
• Classic features:
• Discrepancies between history & injuries
• Long period of time before presentation
• History changes between caregivers
• Alarming exam findings:
• Bruises in various stages of healing
• Multiple subdural hematomas, retinal hemorrhages, long
bone fractures < 3 y/o
• Genital, perioral, or perianal trauma
Thank you!