Download Secondary brain injury

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!”
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
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
Age
Weight
ISS
Direct
Referred
62.2%
8.6 years (std dev 4.5)
33.8 kg (std dev 18.1)
14 (std dev 11)
47.8%
52.2%
0
5
3
Other
10
Assault
20
Winter
Sport
25
ATV
40
Bike
Alone
Bike
vs. Car
60
Fall
95
MVC
100
Ped
Struck
No. Of Patients
Mechanism Of Injury
94
80
52
18
10
Intra-Abdominal Injuries
Bladder, 3
Pancreas, 5
Renal/Adrenal
16
Bowel &
Mesentery, 14
Liver, 31
Spleen, 32
0
5
10
15
20
# of Patients
25
30
35
Organ Requiring Surgical Intervention
3
Normal
2
Bladder
1
Spleen
2
Liver
10
Bowel
0
2
4
6
# of Patients
8
10
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.
 B.
 C.
 D.
 E.

Airway and C-spine control
Breathing
Circulation and hemorrhage control
Disability (rapid neurologic assessment)
Exposure and Environmental control
PREPARATION

Assemble team - define roles
 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
X1
 Arrival at primary hospital ~ 19:50
 Tachycardic
 Comatose – decorticate posturing –
GCS=5

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
Initial Treatment
ABC’s,
Needle decompression
Insert chest tube
Massive
hemothorax
ABC’s
Pleural decompression
Insert chest tube
Replace fluids
Uncommon Life-Threatening
Chest Injuries
Type
Flail chest
Initial Treatment
ABC’s
Positive-pressure ventilation
May require chest tube
Open pneumothorax
ABC’s
Occlusive dressing
Insert chest tube
Surface area

surface / volume ratio
 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

Why is evaluation of HR so important?
CO = HR x SV
 CO = HR x  SV
CO =  HR x  SV
Hypotension

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
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
 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 lifethreatening complications of major
trauma in pediatric age group.
QUESTIONS