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PAEDIATRIC TRAUMA
Dave Ellis November 2011
Objectives • Define trauma
• Describe the anatomical and physiological features in children that influence their response to trauma
• Identify the phases of evaluation of the paediatric trauma patient
• Review the management of specific organ trauma
Definition Injury to human tissue and organs resulting from the
transfer of energy from the environment
the goal of trauma management is to provide an
organized and systematic approach to the assessment
and care of the pediatric trauma patient
Facts • Leading cause of death after 1 year
• 20-40% of deaths are preventable
• 3-500 major paediatric cases/year
Children Aren’t Small Adults
Airway • Airway more difficult to obtain/maintain
– Young infants obligate nasal breathers – Larger tongue relative to size of oropharynx – Narrow pharyngeal space – Smaller nares and mandible – Relatively larger T+A’s – Submandibular tissues softer, more compressible – Larynx more pliable collapses with neck hyper-extension. flexion – Relatively large occiput forces neck flexion – Small diameter: secretions significantly increase resistance
• Intubation more difficult – Larynx is more anterior and higher – Large, long, floppy epiglottis – Vocal cords lower anterior attachment – Narrowest point of larynx subglottic (funnel shaped <10 years) – Airway passages shorter (RMB intubation)
Cardiovasular • Wide variation in normal vital signs • Relatively fixed stroke volume
– Reliant on HR to maintain cardiac output • Tachycardia sensitive but not specific to shock • Small absolute circulating volume
– Small volume loss large % of absolute total • Children maintain BP until 25-30% CBV lost • Bradycardia produces significant drop in CO • Children relatively anaemic • Pulses awkward to feel
Cervical Spine • Lax interspinous ligaments • Shallow angled facet joints • Underdeveloped spinous processes • Physiologic anterior wedging of vertebral bodies • Relatively large head, shorter neck • Underdeveloped neck muscles • Flat facet joints • Large head to BSA • Fulcrum C2-C3 in child, C5-C6in adult • Incomplete ossification of odontoid process
Skeletal • Growth plates weakest point • Cortices of bones more porous • Periosteum thicker more plastic • Disability if growth plate involved • Proportionately greater blood loss
• Associations femur + abdominal humerus + thoracic
Thorax • Ribs more pliable
– Greater transfer of energy to thoracic organs – Rib fractures uncommon
• Flexible mediastinum – less vessel trauma – more visceral displacement
• Higher O2 demand + hmetabolic rate – more rapid development of hypoxemia
• Less alveoli irespiratory reserve • Immature respiratory muscles fatigue
faster
Head • Larger head-to-body ratio
– increased momentum with accel/decel • Soft calvarium
– Injury without fracture – Energy transfer to brain
• Large subarachnoid space – venous tearing • Unmyelinated brain tissue more prone to shearing • Higher brain water content -more prone to oedema • Brain more prone to reactive hyperaemia • Open fontanelles/sutures may mask signs of hICP
Abdomen
• Ribs do not protect the upper abdomen • Proportionately larger solid organs • Closer proximity • Less musculature and fat • Liver & spleen anterior • Bladder intra-abdominal • Viscera more mobile • Air swallowing splints the diaphragm
Trauma Management
Neurosurgeon
Resuscitation Team
Surgical Specialties
Medical Specialties
Nursing ICU AE
Anaesthesia
Orthopedic Surgeon
Trauma Surgeon
TRAUMA CENTER TRAUMA TEAM
AHP’s
Pre-‐arrival Resource iden7fica7on and alloca7on
1o Survey 2o Survey
Basic Studies Specialty Studies
Reevalua7on
Resuscita7on
1o Therapy Defini7ve Therapy
Trauma: Ini7al Management Priori7es
Components of Management
Time
Pediatric Assessment Triangle
Response Work of Breathing
Circulation to Skin
Primary Survey
Circulation: - assess - access - stop hemorrhage - resuscitate
Breathing: - assess - support
Airway: - assess - establish - maintain
“H”
Primary Survey • Airway obstruction • Tension pneumothorax • Open pneumothorax • Massive haemothorax • Flail chest • Cardiac tamponade. • Shock (haemorrhagic or otherwise) • Decompensating head injury
Airway and C-Spine Control • Oxygen • Suction • Jaw thrust • Oral guedel • OGT/NGT • Intubation
Manual in line stabilisa7on
C-Spine Immobilisation
• Proper size collar – Doesn’t impair ventilation – Doesn’t obstruct jugular venous return – Too small results in flexion – Too large doesn’t immobolise
• Blocks and tapes • Board
Breathing
• Oxygen
• Effort efficacy effect
• Look feel listen
Difficult intubation
• Decreased LOC • Head trauma • Facial trauma • Neck trauma • Upper chest trauma • Airway, facial burns
Indications for Intubation and Ventilation
• Persistent/predicted airway obstruction • Inability to adequately ventilate with B+M • Persistent hypoxia despite O2/adjuncts • Loss of airway reflexes (GCS<9) • Apnoea • Inadequate ventilatory effort or fatigue • Disrupted ventilatory mechanism, flail chest • Controlled ventilation for management of ICP • Fluid resistant shock • Suspected upper airway burn • Facial burns • Unstable midface fracture
Intuba7on
• Adequate pre-oxygenation • Adequate monitoring • Most experienced personnel • Cricoid pressure • RSI • Confirm position
– ETCO 2 – Colour (yellow ok , purple misplaced) – CARDIAC ARREST
Circulation • HR, pulse volume, temp
gradient • Compromise-consider hypoxia • Shock=hypovolaemia • Venous access a priority
– peripheral – IO – central – cut down
Venous Access
EZ-IO
Circulation
Disability • Conscious level
– GCS: age appropriate – AVPU
• Pupils – Symmetry – Size – Reactivity
• Posture • Manage suspected raised ICP
Expose and Examine
• Look to find • Find to treat • Remove ALL clothing • Cover patient with blanket when finished
Analgesia
• Opiates, simple analgesics • Splinting, immobilisation • Regional blocks
Secondary Survey
• Identify , treat non life threatening conditions • History
– Event – Previous medical
• Examination – Re-evaluation primary survey – Top to toe/front and back (log roll)
• Blood work, radiology • NGT/UC/invasive lines
Inves7ga7ons
• FBC, X-match/G+S • Blood glucose • Coagulation- severe trauma, HI • Gas- pulmonary injury, shock • Urinalysis • X-rays, C-spine, chest, pelvis • CT: head, c-spine, thorax, abdo, pelvis
– haemodynamically stable – able to deliver ongoing resuscitation, monitoring
C-‐Spine Injury
Cervical Spine Trauma
• Decreased level of consciousness • Blunt injury above clavicle • Multisystem trauma • Sudden deceleration • Ejection • Altered neurology
Cervical Spine Injury • 1-2% paediatric trauma • 80% traumatic paediatric spinal injuries • Usually C1-C3 • 5% spinal injuries second nonadjacent ♯ • 8% missed or delayed diagnosis
– Critical injuries, hypotension , decreased GCS – Increased secondary neurological injury
Immobilisation takes priority over clearance Consider steroids if confirmed injury < 8 24
C-Spine Investigations • Xrays
– 3 views: 94% sensitive if all normal – Open mouth (odontoid) :17% ♯ missed if intubated – Lateral (up to 15%♯ missed) – AP
• No benefit of flexion extension if all 3 normal – Xrays cannot exclude ligamentous instability – Normal anatomical variations mimic fracture
• CT: boney injury, soft tisue • MRI:ligaments, spinal cord
Spinal Cord Injury Without Radiological Abnormlities
• 16-50% SCI • CT and C-Spine xrays normal • Transient neuro symptoms (paraesthesias)
– recur up to 4 days • MRI
– abnormal neuro exam – distracting injuries – altered LOC – high risk mechanism irrespective of normal Xray/CT
Criteria for Clearing C-Spine
• No midline cervical tenderness on palpation • No focal neurological deficit • Normal alertness • No intoxication • No painful distracting injuries
Viccellio et al (2001) Pediatrics
Traumatic Head Injury
Traumatic Head Injury • Commonest trauma death in children • Aim to minimise secondary injury
– Hypoxia – Anaemia – Hypotension – hICP – Pyrexia – Glucose abnormalities – Seizures
• Scalp • Haemorrhagic shock in infants
Suspect Head Injury
• Mechanism of injury • Penetrating injury • Loss of conciousness • Fluctuating GCS, GCS< 8 AVPU • Seizures • Focal neurological signs • Significant facial trauma
To CT or not to CT… • GCS < 8, GCS variable since injury • Suspected/open depressed ♯ • Basal skull ♯ • Focal neurology • Persistent vomiting • Seizure • Amnesia > 30 minutes • Suspicion of non-accidental trauma • Concerning MOI • Children <2
CPP= MAP – ICP • i cerebral metabolic rate
– sedation analgesia normothermia anticonvulsants
• Maintain fuel – euglycaemia
• hmean arterial pressure – Volume pressors
• Maintain oxygen content – Ventilation – PEEP
• Reduce ICP – Osmotherapy avoid
hyponatraemia – Normocapnoea – Head of bed 30 deg
head midline – Remove hard-collar – Fentanyl/lignocaine for
suction – Rx seizures
Chest Trauma
Chest Trauma • 50% paediatric trauma • 2nd highest cause of death in trauma • Usually part of multisystem injury • 90% blunt deceleration • External signs often absent • Non specific signs-suspect from MOI • Major vascular injury uncommon • Mobile mediastinum
– Poorly tolerant of tension pneumothorax
Chest Trauma
6 Lethal Injuries • Airway obstruction • Open pneumothorax • Tension pneumothorax • Massive haemothorax • Flail chest • Cardiac tamponade
6 Hidden Injuries • Pulmonary contusion • Cardiac contusions • Aortic disruption • Tracheobronchial
disruption • Oesophageal disruption • Diaphragmatic tear
Tension Pneumothorax
• Can occur after intubation and PPV • Can occur with drains in situ • Air in the pleural space without exit
– Collapse of ipsilateral lung – Compressed contralateral lung – Mediastinal shift – Decreased venous return – Decreased cardiac output
• Symptoms and signs can be misleading • Rapid thoracentesis and chest drain insertion
Lethal Injuries • Cardiac Tamponade
– Beck’s triad • iBP, JV distension, muffled HS
• Haemothorax – Consider auto-transfusion
• Flail Chest – Paradoxical chest movement – High velocity impact – Multiple fractures – Major issue is underlying injury
• Open Pneumothorax – occlusive dressing sealed on 3 sides
Pulmonary Contusion • Most common chest injury • Usually blunt injury • High assossciation with with other injuries • 50% lack external signs, symptoms initially
– VQ mismatch, reduced lung compliance – Onset over 48 hours – Distress, pain, haemoptysis, hypoxia
• Serial CXR if severe MOI / rib fracture • Oxygen, analgesia, physiotherapy, intubation
Immediate life threatening chest injuries can be managed successfully by any clinician capable of performing
• needle thoracocentesis • chest drain insertion • intubation and ventilation • pericardiocentesis
Abdominal Trauma
Abdominal Trauma • 3rd commonest trauma • Usually blunt • Solid organ (liver>spleen) > hollow organ • High level of suspicion
– MOI (handlebars, lap belt), RTA – Head – Skeletal – Polytrauma
• Challenging-minimal external signs – up to 45% initial examination insignificant – sequential examinations essential
• Missed overlooked – Significant other trauma – Altered LOC – Unco-operative
Management
• Priority to airway and breathing • Immediate laparotomy
– Abdominal distention + >40ml/kg fluid • Early laparotomy
– Peritonitis – Pneumoperitoneum – Bladder rupture – Penetrating injuries
• Most solid organ injury conservative
Lap Belt Injury • Up to 75% have abdominal injury
• Solid • Hollow viscus
• Lumbar ♯ • Iliac, pubic rami ♯
Investigations
• CT is the modality of choice in stable patients – Does not exclude hollow viscous injury – Allows grading for visceral injury
• Focused Abdominal Sonography for Trauma (FAST) – Unstable patients
• DPL – Rarely needed in pediatric. – FP 5-14%
Renal Trauma • Haematuria
– only 88% with known injury – no correlation with degree of injury – significant if other abdominal injuries – marker for injury to other organs
• CT – Persistent microscopic haematuria – Gross haematuria – Injury to other organs + >50RBC /HPF
• IVP – normal in 20% of major injuries – urinary extravasation and non functioning kidney
Extremity Trauma • Priorities ABC’s • Life threatening injury
– Traumatic amputation – Crush injury pelvis/abdomen – Open long bone fracture – Multiple skeletal fractures
• Limb threatening – Supracondylar humeral – Femur – Fracture dislocation ankle
Acute Compartment Syndrome
• Iatrogenic – splints – MAST trousers – casts – tissued IO
• Trauma – crush injuries – fractures – burns
Pain- worse on passive stretching Pallor
Paralysis Decreased sensation
Pulselessness
CONCLUSIONS CHILDREN ARE NOT SMALL ADULTS
HYPOXIA AND HYPOVOLAEMIA ARE THE MOST IMMEDIATE THREATS TO
CHILDREN WITH TRAUMA
AN ORGANIZED AND SYSTEMATIC APPROACH TO THE ASSESSMENT AND
CARE OF THE PEDIATRIC TRAUMA PATIENT SAVES LIVES
Always pass on what you have
learned
Glasgow Coma Scale