Download Pediatric Trauma

Pediatric Trauma
And Triage
Overview of the Problem
and Necessary Care for
Positive Outcomes…
Presented by: Jim Morehead, BS, NREMT-P
2003
Oklahoma EMSC Resource Center
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OBJECTIVES
•
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Increase awareness of issues specific to
children & trauma.
Improve pediatric trauma Assessment &
Intervention skills.
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2003
Identify Mechanisms of Injury & key
Assessment components
Recognize differences btw adult & child
priorities
Identify & avoid common errors in the
pediatric trauma care
Provide appropriate interventions
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NATURE OF “BEAST”
•
Pediatrics account for 15-25% of total
•
Trauma is approximately 50% of all
pediatric emergencies
emergent care patients.
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Injury is the leading cause of death in
children
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2003
Usually > 2 years old
More medical cases < 2 years old
MVC = 50%
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NATURE OF “BEAST”
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Almost 70% of major pediatric trauma
cases die due to severity of injury.
•
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NOT a deficit in emergent care
When a child is injured, the whole
family is injured too!
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2003
cont’d
> 40% divorce rate within 1 year after a
major trauma
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Clinical Pearls
2003
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Consider Possibility of
Child Abuse
When you see an injured child
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2003
Common cause of injuries in children.
50% of second hospital visits for
these children result in death
Awareness of signs & symptoms of
abuse helps identify cases
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General Principles of
Pediatric Trauma
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Priorities are similar to adults
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Children have certain key differences
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All roads lead to the A-B-C (D-E)’s
Start with “A”, not the most obvious
Different energy transfer due to size
Metabolism
Ability to respond to words & give history
History of accident may be critical in
determining intervention plan
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Physical Differences
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HEAD Is Larger
• Brain injury increased during impacts
• More leverage on neck
• Occiput forces neck into flexion while
lying flat
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NECK Is Shorter
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2003
Airway tends to buckle & close on adult spine
board without proper shoulder support
Causes different injury patterns
C2-C4 more common injuries
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Physical Differences
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CHEST More Pliable
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Pulmonary contusion more likely
Diaphragm motion essential for
ventilation
Energy transmitted to chest organs
ABDOMINAL ORGANS Less Protection
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2003
cont’d
Liver not covered by the rib cage
Less abdominal wall muscle mass
Less Sub-Q tissue to absorb energy
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Energy Transfer Effects of Size
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Children are Smaller
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More force per square inch of body
Organs are closer together=multi-system
injury rule
Children are Softer
(More Flexible / Bouncy)
Bones don’t break but instead pass on
energy
• Internal organ damage without fractures
is more common
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Larger Surface Area to Size Ratio
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Lose heat more rapidly
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Metabolic Differences in Kids
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Have Higher Metabolic Rates
Nearly Twice as Rapid O2 Consumption
• Increased Blood Flow
• More Frequent Feedings
• More Fluid Intake per Size Ratio
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2003
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Metabolic Differences
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cont’d
Children “SHOCK OUT” Differently
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Children Compensate Better INITIALLY
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May show minimal signs & symptoms
Children have less reserves than adults
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Platinum Half-Hour in Trauma Resuscitation
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Rapid Intervention Critical
Once Reserves Exhausted
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BAD THINGS HAPPEN!!!
2003
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THE BAD THINGS
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Decompensation can be rapid
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A conscious, crying child can become
pulseless and apneic in less than 2
minutes
Once decompensated, may be too late
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Limited Reserves are gone; whole system
collapses
RAPID & EARLY RECOGNITION &
INTERVENTION ARE CRITICAL!!!
2003
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ASSESSMENT
For Survival
2003
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Safety First
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Bodily Substance Isolation
Potential Hazards on, around, or with
Patient
Available Resources
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Prepare Yourself
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The first step in a cardiac arrest or
other critical situation is to:
Take your own pulse!!!
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Assign roles ahead of time
Respiratory Management
• Spine Management
• Circulatory Management
• Hx, Equipment, etc.
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2003
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Careful Attention
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Initial Assessment CRUCIAL
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Don’t be distracted by the
blood and screams
A QUIET KID SHOULD
SCARE the @$% of
YOU!!!
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2003
If practical, keep parents
with child to help reduce
child's fear
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Clinical Pearls
2003
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Brilliance vs. Basics
For every “BRILLIANT”
maneuver/diagnosis you
make which saves a life,
you’ll save 10 by just
doing a good, solid job.
STAY FOCUSED ON THE
BASICS IN THE HEAT OF
THE MOMENT!!!
2003
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Consider MOI
2003
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Clinical Pearls
2003
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Remember
‘s
“Proper basic airway management is
often performed inadequately if at all,
apparently due to fear and panic.”
Theodore M. Barnett, M.D.
Children's Mercy Hospital, Kansas City, MO
2003
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Pediatric Assessment Triangle
Appearance
Work of
Breathing
Circulation to Skin
2003
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Appearance
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2003
Look at the patient from a slight
distance - What do you see?
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Mental Status
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Color
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Interaction / Movement
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Recognition
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STOP
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Remember
Quiet Kid is one that
should, SCARE You!!!
A
2003
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Respiratory
AIRWAY: Patent with Precautions
• BREATHING: Respiratory Rate; too fast vs
too slow, Abnormal Sounds
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A slow or irregular respiratory rate in a child is
an OMINOUS SIGN. (Bad JU JU)
Watch for the EFFORT NEEDED to BREATHE
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Chest, neck, or abdominal muscle retractions
Flaring of the nostrils
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Adventitious Sounds -Crackles, Crows, Grunts
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(Rice Krispies, Rosters, Pigs)
2003
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A=Airway: Control C-Spine
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Unconscious kids can’t protect their
airway
Tongue most common obstruction
• Little airways are easily blocked
• JAW THRUST: Neutral Alignment for kids
includes Pad under the Shoulders
• May need Oral/Nasal Airway
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Infants in first 30 days of life are
obligate nasal breathers
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2003
May need to suction out blood/mucus
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B=Breathing
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All Children get Oxygen & LOTS OF IT
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May need to assist with B-V-M
Good mask seal is the KEY to bagging
• Two people should bag when possible
• Avoid distending the stomach
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Cricoid pressure / Easy does it
Distended stomach = less room for air in
lungs
Blue BAD 2003
Oxygen GOOD
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C=Circulation:
Peripheral vs Central
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Pulse
Color , Temperature, Texture of Skin
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CAPILLARY REFILL
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< 2 seconds GOOD NEWS
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2-4 seconds WATCH OUT
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> 4 seconds
DEEP DOODOO NOW!!!
2003
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Clinical Pearls
2003
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Pediatric Trauma Messages
1. A little bleeding is a lot the smaller you are.
2. BP often maintained until very late in
hemorrhage by young patients because of
their overactive vasoconstrictive responses.
Tom Terndrup, MD
Director of Pediatric Emergency Medicine
University Hospital / Syracuse, N.Y.
2003
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D=Disability: Neuro Eval
• Use the AVPU system first
– Avoid "lethargic“, "semi-conscious“, etc.
because everyone has different meanings
with these terms.
• Use the Pediatric Glasgow Coma Scale
– If time and circumstance permit
– Age and behavior adjusted
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TBI’s need adequate oxygen !
Hyperventilate only if they deteriorate
• Otherwise High Flow O2
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2003
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E=Exposure
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Kids lose heat quickly
Keep them COVERED UP
Expose only as you need
If YOU are COMFORTABLE,
it’s probably TOO COLD for
them
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S-A-M-P-L-E Hx
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S=Signs and Symptoms
A=Allergies
M=Medications currently taken
P=Pertinent Past/ Present Illnesses
L=Last Meal
E=Events/environment related to the
injury
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Positive Outcomes
Resulting from early & rapid
recognition, assessment, &
management of shock…
2003
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Pediatric Trauma Score (PTS)
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All components are scored:
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Total score can range
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2003
+2
+1
-1
+12, the best
- 6, the worst
The threshold score is 8
Anyone scoring < 8 send to Pediatric
Trauma Center
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PTS Components
• SIZE
– The most obvious of all the components
– Automatically weights the infant-toddler
due to increased mortality associated to
their smaller size
• AIRWAY
– Assesses functionability and management
parameters
– The more toys it takes, the lower the
score
2003
Oklahoma EMSC Resource Center
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PTS Components
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SYSTOLIC B/P: Weighted to find the
evolving shock patient (50-90 mmHg).
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New DOT EMT Basic uses capillary refill
as an indicator of cardiovascular status.
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2003
cont’d
< 2sec, 2-4 sec, > 4 sec
Central vs Peripheral
PALS recommends use of peripheral and
central pulses as an indicator
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PTS Components
cont’d
• MENTAL STATUS
– Any change in Mental Status warrants a lower
score
• SOFT TISSUE INJURY
– Surface Area / Volume Issue
• MUSCULO-SKELETAL INJURY/FX
– High incidence in kids
– Energy transmission instead of localized fracture
MULTI-SYSTEMS TRAUMA IS RULE
2003
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Recognizing Signs of Shock
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Early signs can be subtle
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May be minimal signs with under 20%
blood loss
50% and over blood loss usually
pulseless and unconscious (Read as DEAD)
Any injured kid who is Cool &
Tachycardic is in SHOCK until proven
otherwise!!!
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Shock Recognition
cont’d
Altered mental status may be first sign of
shock
• Another early sign is DELAYED CAPILLARY
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REFILL
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Next comes a decrease in pulse pressure
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Drop in Blood Pressure is a LATE SIGN
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2003
Systolic minus Diastolic
Systolic should be > [ 70 + 2(age in years)] but
it rarely falls below this until 25-30% blood loss
Oklahoma EMSC Resource Center
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Shock Recognition
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cont’d
Anxiety, fear, and cold weather can all
mimic early shock
Increased heart rate
• Decreased capillary refill
• Pale, cool extremities
• Weak peripheral pulses
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History alone can be a good enough
reason
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2003
Remember the MOI
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Shock Intervention
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O2 (shoot the juice)
Protection
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Hemorrhage Control
Volume Replacement
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Spinal Stabilization/Immobilization
Preserve Body Temperature
Crystalloids (NS/LR) 20 mL/kg
Length-Based Resuscitation Tape
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Clinical Pearls
2003
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Infant Transport by EMS
• “Keep infants in car seats unless treatment
of injuries requires removal (IV, ETT, BVM,
control of hemorrhage). If they survived
the crash in an intact car seat, they are
usually better off to stay in it for the ride to
the hospital.”
William E. Hauda, II, MD
Pediatric Emergency Medicine Fellow
Attending Emergency Medicine Physician
Fairfax Hospital, Falls Church, VA
2003
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Trauma Management
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Kids are large headed and may have
cervical spine injury without evidence
Ideal immobilization is a hard collar,
spine board with pads & head-straps.
TBI’s need adequate oxygen!
Hyperventilate only if they deteriorate
• Otherwise High Flow O2
•
2003
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Pediatric Trauma Triage
Identifying a possible tool
to accomplish task…
2003
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Pediatric Problems in Triage
• Children often not
triaged as well as adults
in traumatic MCI’s
• Currently no published
or widely utilized MultiCasualty Triage Tools
that take into account
physiology differences
between children &
adults
2003
Oklahoma EMSC Resource Center
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Triage Problems
cont’d
• Pediatric Multi-Casualty triage may be
affected by the emotional states of
providers
• May be tendencies to upgrade triage
categories out of compassion or lack
of confidence in pediatric assessment
& intervention skills
2003
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May 3, 1999
2003
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May 3, 1999
2003
cont’d
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Multi-Casualty Triage Goal
“To do the
BEST for the
MOST with the
LEAST.”
2003
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Simple Triage And Rapid Tx
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Triage categories
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Green (ambulatory)
Red (immediate)
Yellow (delayed)
Black (dead or non-salvageable)
Components of Assessment
Ambulation
• Respirations
• Perfusion
• Mental status
•
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START Triage
RESPIRATIONS
PERFUSION
NO
Over 30/min
Position Airway
NO
Nonsalvageable
Under 30/min
YES
YES
Immediate
Immediate
Radial Pulse
Absent
Control
Bleeding
MENTAL
STATUS
Immediate
Failure to follow
simple commands
Immediate
2003
Radial Pulse
Present
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Can follow
simple commands
Delayed
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Pediatric Problems with START
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2003
Apneic child more likely to have a
primary respiratory problem than
adult
Perfusion may be maintained for a
short time & child may be salvageable
RR +/- 30 may either over-triage or
under-triage a child, depending on
age
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Problems with START
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Capillary refill may not adequately
reflect peripheral hemodynamic status
in a cool environment
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2003
cont’d
In fact START has changed to reflect
peripheral pulse checks instead of cap
refill
Obeying commands may not be an
appropriate gauge of mental status
for younger children
Oklahoma EMSC Resource Center
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JUMPSTART Goals
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2003
Modify an existing tool for use with
children
Utilize decision points that are flexible
enough to serve children of all ages &
reflective of the unique points of
pediatric physiology
Reduce over- and under-triage
Accomplish triage for most patients
within 15 second/pt goal
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The JumpSTART Field Pediatric Multi-Casualty Triage System ©
(Patients aged 1- 8 years)
Identify and direct all ambulatory patients to designated
Green area for secondary triage and treatment. Begin
assessment of nonambulatory patients as you come to them.
Proceed as below:
Black
Red
Yellow
Green
MINOR
Spontaneous respirations?
= Deceased/expectant
= Immediate
= Delayed
= Minor/Ambulatory
YES
NO
Check resp. rate
Open airway
Spontaneous respirations?
YES
< 15/min
or
> 40/min
or irregular
NO
Peripheral pulse?
15 - 40/ min,
regular
NO
Peripheral pulse?
IMMEDIATE
IMMEDIATE
NO
YES
YES
DECEASED
Perform 15 sec.
Mouth to Mask
Ventilations
IMMEDIATE
Check mental status
(AVPU)
Spontaneous respirations?
YES
NO
IMMEDIATE
DECEASED
© Lou Romig 1995
2003
Oklahoma EMSC Resource Center
P (inappropriate)
U
A
V
P (appropriate)
IMMEDIATE
DELAYED
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JUMPSTART Age
Ages 1-8 years chosen
• <1 year of age is less likely to be
ambulatory
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–
–
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2003
These children can be triaged using JUMPSTART
but should be fully screened
If all “DELAYED” criteria satisfied & without
significant external injuries, the child may be
classified as “AMBULATORY”
Pertinent pediatric physiology (specifically
airway) approaches that of adults by
approximately eight years of age
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JUMPSTART Ambulatory
• Identify & direct all ambulatory
patients to designated GREEN area
for secondary triage & treatment
• Begin assessment of non-ambulatory
patients as you come to them
2003
Oklahoma EMSC Resource Center
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JUMPSTART Breathing
• If breathing spontaneously, go on to
the next step, assessing respiratory
rate
• If apneic or with very irregular
breathing, open the airway using
standard positioning techniques
• If positioning results in resumption of
spontaneous respirations, tag the
patient IMMEDIATE & move on
2003
Oklahoma EMSC Resource Center
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JUMPSTART Part
• If no breathing after airway open, check
peripheral pulse
– If no pulse, move on after tagging patient
DECEASED/NONSALVAGEABLE
• If peripheral pulse present, give 15 sec of
Mouth-to-Mask ventilations (about 5
breaths)
– If apnea persists, move on after tagging patient
DECEASED/NONSALVAGEABLE
• If breathing resumes after “JUMPSTART”,
tag patient IMMEDIATE & move on
2003
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JUMPSTART Respiratory Rate
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2003
If respiratory rate is 15-40/min (1
breath every 2-4 sec) assess perfusion
If respiratory rate is <15 or >40/min
(<1 breath every 4 sec or >1 breath
every 2 sec) or irregular, tag patient
as IMMEDIATE & move on
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JUMPSTART Perfusion
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2003
If palpable peripheral pulse, proceed
to assess mental status
If no peripheral pulse present (in the
least injured limb), tag patient
IMMEDIATE & move on
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JUMPSTART Mental Status
• Use AVPU scale to assess
• If Alert, responsive to Verbal, or
appropriately responsive to Pain, tag
as DELAYED and move on
• If inappropriately responsive to Pain
or Unresponsive, tag as IMMEDIATE &
move on
2003
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START/JUMPSTART Similarities
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2003
As soon as a definitive triage category
determined further assessment STOPS
Ambulatory patients are immediately
moved away for secondary triage
To be in the DELAYED category pt’s
must have adequate respirations &
perfusion & mental status that is
unlikely to compromise the airway
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START/JUMPSTART
Differences
•
Apneic children are rapidly assessed for
sustained circulation
•
•
•
Respiratory rates are adjusted
Peripheral pulse is substituted for Cap
Refill
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2003
Apneic children with circulation receive a
brief ventilatory trial as an additional airway
opening & stimulating maneuver
This is now done in START too
AVPU is used to assess mental status
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POTENTIAL
JUMPSTART
DISADVANTAGES
2003
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Disadvantages
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•
•
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2003
Extra steps for apneic children add
time to the triage process
Mouth-to-Mask ventilation increases
the risk of cross-contamination
between patients
Additional equipment must be carried
by triage personnel
TOO COMPLICATED
NO PROOF IT WILL WORK
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POTENTIAL
JUMPSTART
ADVANTAGES
2003
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Advantages
•
•
•
2003
Provides rapid triage system
specifically designed for children,
taking into consideration their unique
physiology
Algorithm modified from an existing
system widely accepted for adult
triage
For most patients, triage can be
accomplished within the 15 sec goal
Oklahoma EMSC Resource Center
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Advantages
•
•
2003
cont’d
Objective criteria for children will help
eliminate role of emotions in triage
process
Objective criteria will provide
emotional support for personnel
forced to make life or death decisions
for children in the MCI setting
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Transport Decisions
Oklahoma ‘s Trauma Triage
and Transport Guidelines
2003
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Air Medical Services
MEDIFLIGHT OF OKLAHOMA
•
1-800-522-0212
AIR EVAC LIFE TEAM
•
1-918-426-4081
TULSA LIFE FLIGHT
•
1-888-4TRAUMA
EAGLEMED
•
2003
1-800-525-5220
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Pediatric Special Care Facilities
Children’s Hospital at OU Med Center, OKC
(405) 271- 4876
University Hospital at OU Med Center, OKC
(405) 271- 4363
Children’s Center of St. Francis Hospital,
Tulsa
(918) 584-5433
2003
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Summary
• The more critical the patient, the
more important it is to focus on the
basics
IN ORDER
•
•
•
•
•
Rapid Recognition & Intervention for
Shock
Airway
Oxygen
Proper Immobilization
Keep Warm
• Assign roles ahead of time
2003
Oklahoma EMSC Resource Center
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OK-EMSC Resource Center
To Contact Us:
Phone: 405-271-3307
Fax: 405-271-8709
e-mail: [email protected]
Web Page: http://emsc.ouhsc.edu/
2003
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