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PEDIATRIC TRAUMA STANDARDIZING CARE !/? DAVID A. LISTMAN, MD DIRECTOR PEDIATRIC EMERGENCY MEDICINE ST. BARNABAS HOSPITAL LEARNING OBJECTIVES • EPIDEMIOLOGY/ HISTORY • ATLS • PRIMARY SURVEY/RESUSCITATION • SECONDARY SURVEY • PEDIATRIC SPECIFIC ISSUES • REFERENCES EPIDEMIOLOGY/ HISTORY • 5 million trauma related deaths worldwide in 2000 • Age <20 in US visits for injuries • 10 million ED visits and • > 10 million primary care office visits • 300,000 pediatric hospitalizations annually • 11,090 injury related pediatric deaths per year INTRODUCTION • Trauma - # 1 cause of death in children older than 1 year • Effective initial resuscitation can reduce mortality by 25-30% (Stafford et al 2004) • National Pediatric Trauma Databank 2008 (≤ 19 yrs): • 474 Trauma Centers (127 Level 1) • 108,863 cases from 2007 record NATIONAL PEDIATRIC TRAUMA DATA BANK 2008 Incidents by Mechanism of Injury 35.00 30.00 Percent 25.00 20.00 15.00 10.00 5.00 0.00 Motor Vehicle Traffic Fall Struck by, Transport, against other Mechanism of Injury Firearm Cut/pierce NATIONAL PEDIATRIC TRAUMA DATA BANK 2008 Case Fatality Rate by Mechanism of Injury Case Fatality Rate (%) 14.00 12.00 10.00 8.00 6.00 4.00 2.00 0.00 M otor Vehicle Traffic Fall Struck by, Transport, against other Mechanism of Injury Firearm Cut/pierce MECHANISM OF INJURY • Motor vehicle/traffic: 31.5% of injuries • Increases at 14 years of age with a peak at 19 years of age • Associated with largest number of hospital/ICU days • 47% of all mortalities • Falls: 26.6% of injuries • Peak at 19 years • 2nd highest hospital/ICU days • 4.2% of all mortalities • Firearms 5.7% of injuries • Peak at 19 years • 26% of all mortalities TRI- MODAL DISTRIBUTION OF DEATHS • First peak- within seconds to minutes of injury • Second Peak- within minutes to several hours of injury • Third Peak- days to weeks after the injury TRI- MODAL DISTRIBUTION OF DEATHS • First peak- within seconds to minutes of injury • Apnea- brain or spinal cord injury • Rupture of the heart or great vessels • Treatment- prevention • Second Peak- within minutes to several hours of injury • Third Peak- days to weeks after the injury TRI- MODAL DISTRIBUTION OF DEATHS • First peak- within seconds to minutes of injury • Second Peak- within minutes to several hours of injury • • • • • Subdural and epidural hematomas Hemopneumothorax Ruptured spleen/ liver Pelvis fx’s and other sources of major blood loss Treatment- golden hour and ATLS • Third Peak- days to weeks after the injury TRI- MODAL DISTRIBUTION OF DEATHS • First peak- within seconds to minutes of injury • Second Peak- within minutes to several hours of injury • Third Peak- days to weeks after the injury • Sepsis • Multi organ system failure • Treatment- maximize care during preceding stages, Hospital/ ICU care Friday Sept 30, 2005 HOW DO WE IMPROVE SURVIVAL DURING SECOND PEAK? • Standardize evidence based best practices • A 1976 crash of a private plane piloted by an Orthopedic surgeon. His wife and children were on board. • Hospital care in rural Nebraska was substandard • 1978- 1st ATLS course to standardize initial care of trauma patients by doctors who do not manage major trauma regularly. CASE • • • • • • 4 year old female in stroller Mother and stroller hit by car Child ejected from stroller No LOC C-spine immobilized at scene Minor contusions and abrasions of scalp CASE • 4 year old female in stroller • Does patient require trauma evaluation? • What if any radiologic workup should be done? Who requires trauma evaluation? ACTIVATION OF TRAUMA TEAM • Level of activation determined by • Physiologic parameters • Anatomic location/type of injury • Mechanism of injury • Options: code, alert, consultation ACTIVATION OF TRAUMA TEAM • Trauma Alert • Anatomic Significant injuries above and below the diaphragm • 2 or more proximal long bone fractures • Burn of 15-30% BSA (second/third degree burn) • Traumatic amputation of limb proximal to wrist or ankle • Crush injury of torso • Spinal injury with paralysis • ACTIVATION OF TRAUMA TEAM • Trauma Alert • Mechanism Ejection from automobile Extrication > 20 minutes Fatality of another passenger Intrusion of vehicle by collision Unrestrained passenger or vehicle traveling > 20 mph • Fall 20 feet • Pedestrian struck at significant rate of speed • Lightning • • • • • ACTIVATION OF TRAUMA TEAM • Trauma Code • Physiologic • • • • Cardiopulmonary arrest Hypotention (by age) Respiratory distress Neurologic failure (GCS8) ACTIVATION OF TRAUMA TEAM • Trauma Code • Anatomic Penetrating wound to head, chest or abdomen (prox to knees/ elbows) • Burn > 30% BSA, inhalation airway burn • Major electrical injury • Who requires trauma evaluation? • All patients with significant or potentially significant injury should have a systematic evaluation Standard Precautions ● ● ● ● ● ● Cap Gown Gloves Mask Shoe covers Goggles / face shield INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES • Primary Survey • Airway • Breathing • Circulation • A,B,C’s with special trauma concerns INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES • Primary Survey • Airway maintenance, with cervical spine control • Breathing, with special concern for pneumothorax • Circulation- control bleeding • Disability- neurologic deficits • Exposure- expose (examine) all of patient & prevent hypothermia • Resuscitation • Oxygenation, airway management, ventilation • Shock management • Intubations – urinary tract, gastrointestinal tract INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES • As you perform the Primary Survey, stop and intervene as needed • Airway maintenance, with cervical spine control • • • • • Airway positioning Oxygen Airway adjuncts- nasopharyngeal airway, oral airway Endotracheal intubation Surgical Airway CHIN LIFT MANEUVER • Airway obstruction by tongue and epiglottis • Relief by headtilt/chin-lift Airway Management Basic Techniques Chin-lift Maneuver Airway Management Basic Techniques Jaw-thrust Maneuver INDICATIONS FOR INTUBATION • Shock • Cardiac arrest • Respiratory distress or failure • Severe head injury • GCS < 8 RAPID SEQUENCE INTUBATION I • Preoxygenate with 100% O2, insert IV lines, attach cardiac/respiratory monitor • Prepare equipment for possible emergency surgical airway • Inline manual immobilization of cervical spine • Lidocaine 1.5 mg/kg (for elevated ICP) • Atropine 0.02 mg/kg (minimum of 0.1 mg, maximum 0.5 mg) to prevent bradycardia • Begin Sellick maneuver (cricothyroid pressure to prevent vomiting and aspiration) RAPID SEQUENCE INTUBATION II • Paralyzing agent • Rocuronium (0.6 – 1.0 mg/kg) or • Vecuronium (0.1 mg/kg) • Succinyl Choline (1mg/kg) • Sedative agent: problem specific • Hypotension: Etomidate (0.3 mg/kg) • Head injury without hypotension: Thiopental mg/kg) • Severe asthma: Ketamine (1-2 mg/kg) (3-5 • Oral intubation • Confirm location of ET tube with end-tidal CO2 measurement SURGICAL AIRWAY • RARELY needed in children • AVOID in children < 12 years due to small target size and risk of damage to surrounding structures (Reamy 2004) • Indications: failure to intubate, apneic with c-spine injury, facial trauma with c-spine injury, severe facial and neck trauma • Needle cricothyroidotomy with needle jet insufflation is a short term solution SURGICAL AIRWAY SURGICAL AIRWAY COMPLICATIONS OF SURGICAL AIRWAY • • • • • • • Hemorrhage Laceration of surrounding structures Subcutaneous emphysema Hypoxia after failed/prolonged attempts Aspiration Infection Tracheal stenosis or cricoid cartilage damage INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES • Primary Survey • Breathing, with special concern for pneumothorax • • If pneumothorax suspected and patient unstable- needle decompression If pneumothorax suspected and patient stable- x-ray and chest tube • Pt may require intubation and mechanical ventilation • Prevent hypoxemia INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES • Primary Survey • Circulation- control bleeding • Control Bleeding • • • External- direct pressure Bony- align and splint fractures Internal- surgery/ interventional radiology • Establish 2 large bore IV’s • • Crystalloid fluid O neg blood SHOCK I • Early recognition of shock critical • Tachycardia, pain, anxiety • Decreased pulse pressure (<20mm Hg) • Mottled skin, warm/cool extremities • Most common cause is hypovolemic shock due to hemorrhage • BUT beware of: • Spinal cord injury can cause distributive shock • Cardiac tamponade or tension pneumothorax can cause obstructive shock SHOCK II • Minimum systolic BP: [70 + 2 (age in years)] • Compensated shock • • • • • • • Normal BP (may see orthostatic changes) Tachycardia Tachypnea Bounding pulses, widened pulse pressure Altered mental status Warm and dry extremities Delayed capillary refill (> 2 seconds) • Uncompensated shock • • • • Hypotension Severe tachypnea Cold extremities Capillary refill > 4 seconds SHOCK MANAGEMENT I • 20cc/kg infused rapidly • 0.9% NaCl or Lactated Ringer’s solution • 2 large bore IV’s • If severe shock 10cc/kg type specific or O- packed red blood cells • Identify and treat source of bleeding SHOCK MANAGEMENT II • Maintain urine output 2cc/kg/hour • Monitor urine output with catheter/feeding tube placed in urethra 1- • Contraindications to catheter placement • • • Pelvic fracture Blood at urethral meatus Blood in the scrotum VENOUS ACCESS • 2 attempts peripheral vein • Intraosseous needle • Central line • Complications: arrhythmias, thrombosis, and embolism • Locations • Subclavian vein • Femoral vein • Jugular vein • Cutdown VENOUS ACCESS: INTRAOSSEOUS NEEDLE PLACEMENT VENOUS ACCESS: INTRAOSSEOUS NEEDLE PLACEMENT INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES • Primary Survey • Disability- neurologic deficits • Level of consciousness- GCS Glasgow Coma Scale • Eye Opening • • • • • Best Motor Response • • • • • • • Spontaneous – 4 To speech – 3 To pain – 2 No Response – 1 Obeys -6 Localizes – 5 Withdraws – 4 Abnormal flexion – 3 Extension response – 2 No Response – 1 Verbal response • • • • • Oriented – 5 Confused conversation – 4 Inappropriate words – 3 Incomprehensible sounds – 2 No response - 1 GLASCOW COMA SCORE Glasgow Coma Scale A strong predictor of outcome 13: mild brain injury 9-12: Moderate brain injury < 8: Severe brain injury (coma) INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES • Primary Survey • Exposure- expose (examine) all of patient & prevent hypothermia • Remove all clothing • Roll Patient • Examine axillae, groin, rectum • Cover patient with warm blankets etc… INITIAL ASSESSMENT AND MANAGEMENT • Primary Survey • • • • • Airway Breathing Circulation Disability Exposure • Adjuncts to primary survey • • • • • Labs Cardiopulmonary Monitoring Urinary and Gastric Catheters X-rays- chest and pelvis FAST/ DPL SECONDARY SURVEY • Begins after primary survey is completed • Resuscitation in place • Vital signs improving • Head/toe complete evaluation of trauma patient • Complete history/physical exam • Reassessment of ALL vital signs SECONDARY SURVEY HISTORY • Obtain AMPLE history: allergies, medications, past illnesses, last meal, events related to injury • Mechanism of injury – blunt vs penetrating • Motor vehicle/pedestrian: head injury, traumatic aortic disruption, abdominal visceral injuries, fractured lower extremities/pelvis • Injury due to burns/cold INITIAL ASSESSMENT AND MANAGEMENT • Secondary Survey- head to toe exam • Head/ Face • Neck/ C-spine • Chest • Abdomen • Perineum • Extremities/ Musculoskeletal • Neurologic • Adjuncts to secondary survey INITIAL ASSESSMENT AND MANAGEMENT • Secondary Survey- head to toe exam • Adjuncts to secondary survey • Additional studies that may include X-rays of c-spine CT scans of head, c-spine, chest, abdomen/ pelvis • Angiography • Extremity x-rays • • UNIQUE PEDIATRIC CHARACTERISTICS • Compared to adults, children have… • Smaller body mass to surface area ratio increased susceptibility to insensible fluid and heat loss • More elastic connective tissue; less rigid skeleton protecting tightly packed thoracic and abdominal structures • Transmitted energy delivers greater force/volume; multisystem injuries • Thoracic and spinal injuries rare RESUSCITATION EQUIPMENT FACILITIES/EQUIPMENT REQUIREMENTS • Designated “Trauma Area” with essential pediatric equipment always ready • Full range of pediatric endotracheal tubes, chest tubes, blood drawing equipment – angiocatheters, butterfly needles • Heated air, warming blankets, heat lamps, room temperature 85°F • Ultrasound available for “Focused Abdominal Thoracic Sonography for Trauma” (FAST Scan) • Broselow Tape UNIQUE PEDIATRIC CHARACTERISTICS; THERMOREGULATION • Critical in children • High evaporative heat loss/caloric expenditure in children • High body surface area/mass • Little subcutaneous tissue • Hypothermia can affect coagulation time, CNS recovery • Management focus • Overhead heat lamps • Warm room • Warm fluids, blood products PEDIATRIC AIRWAY AIRWAY I • Larger occiput results in neck flexion with obstruction of the posterior pharynx • Larynx more anterior orienting midface slightly superior and anterior for protection of airway • Need to protect cervical spine • Large tongue may obstruct airway AIRWAY II • Cricoid cartilage at level of C6 in adults, but C4 in children • Cricoid ring – most narrow anatomic site until 8 years of age • Trachea is short – increases risk of mainstem bronchial intubation SCIWORA • Spinal Cord Injury WithOut Radiologic Abnormality • Accounts for up to 2/3 of severe cervical spine injuries in children • Elasticity in cervical spine allows severe spinal cord injury to occur • Diagnosis of exclusion; MRI useful • Watch for pseudosubluxation; anterior displacement may be up to 4mm Radiation Exposure • Increasing concern in literature for malignancies secondary radiation exposure • CNS lymphoma • Thyroid cancers • Unshielded radiation to genitals Radiation Exposure • Use of Abdomino-pelvic CT scans is more common • C-spine scanning done as a routine in adults if scanning the head to replace plain film Radiation Exposure • Pediatricians have championed injury prevention • “Kids are not small adults” Radiation Exposure • Attempt to decrease plain pelvis films as routine part of trauma series • Review of all blunt trauma 2002-2006 at SBH age </= 25 • 579 patients, 580 trauma evaluations • 22 pelvis fractures (4%) • Can we identify low risk for pelvis fx? Radiation Exposure • Can we identify low risk for pelvis fx? • No lower extrem injury (NPV 98.3%) • Normal Exam of pelvis (NPV 99%) • No clinical need for abdomino-pelvic CT (NPV 99.5%) • If all three are absent (NPV 100%). • Retrospectively applying criteria to study group would eliminate 45% of pelvis xrays. Wong et al. Pediatric Emerg Care in Publication Radiation Exposure • Trend in trauma care towards routine CT scan of cspine if head CT is to be done (replacing plain films). • CT c-spine exposes the thyroid to 90-200 times the radiation dose of plain films. (Jimenez et al Pediatr. Radiol) • Rate of c-spine injuries is very low in children 1-2%, 0.8 % in SBH • Ligamentous injuries are more common • NEXUS criteria are valid in children • • • • • Absence of midline tenderness Not intoxicated Normal level of alertness Normal neurologic exam Absence of painful distracting injury • Develop new protocols for Peds specific concerns SUMMARY • Practice routines in ”Mock Code” • Primary survey (ABCs, emergency conditions), resuscitation • Secondary survey • Consider unique characteristics of children (temperature requirements, anatomy) • Prepare protocols, dedicated area, equipment REFERENCES • Yamamoto LG. Multiple trauma in a 2 year old. Radiology Cases in Pediatric Emergency Medicine Volume 7, Case 8. http://www.pediatriconcall.com/fordoctor/ DiseasesandCondition/Multiple_Traumadia.asp • DeRoss AL and Vane DW. Early evaluation and resuscitation of the pediatric trauma patient. Sem Pediatric Surgery. 13(2); May, 2004, 74-79. • National Trauma Data Bank. Pediatric Section. http://www.facs.org/trauma/ntdbpediatric2004. pdf • Stafford PW et al. Practical points in evaluation and resuscitation of the injured child. Surg Clin North Amer 82:273-301, 2002. • Prince JS et al. Unusual seat belt injuries in children. J Trauma 56(2);420-427, Feb 2004. REFERENCES • Arensman RM and Madonna MB. Initial management and stabilization of pediatric trauma patients http//www.childsdoc.org/fall97/trauma/trauma.as p • Reamy RR and Losek JD. Pediatric trauma and initial resuscitation. Jour South Carolina Med Assn 100(12); Dec 2004: 317-321. • Advanced Trauma Life Support 6th edition. American College of Surgeons, Chicago, Illinois, 1997. • Nguyen D et al. Considerations in pediatric trauma.http://www.emedicine.com/med/topic 3223.htm • Ruddy RM and Fleisher G. An approach to the injured child. In Textbook of Pediatric Emergency Medicine, Fleisher G et al., Ed. Lippincott, Philadelphia, 5th edition, 2006. • Walzman M and Mooney DP. Major trauma. In Textbook of Pediatric Emergency Medicine, Fleisher G et al., Ed. Lippincott, Philadelphia, 5th edition, 2006.