Pediatric Trauma 5/8/2019

Adventest Health Lodi MemorialCreated by; Todd Pelletier, MS, CCRN, CFRN, C-NPT, EMT-P

Edited and presented by; Troy Petersen, RN

Objectives

• Review Primary assessment

• Review Secondary assessment

• Review Airway Interventions

Pediatric Trauma

Trauma is the leading cause of

childhood death and disability in

the US. On average 12,175 deaths

annually! (CDC)

• Traumatic brain injury

(TBI) is the most common

cause.

• Chest Trauma ~ second.

• Abdominal injuries rank

third as a cause of traumatic

death.

0

10

20

30

40

50

60

70

80

90

Blunt Penetrating Crush Other

Blunt Force Trauma

1. Falls

2. Motor Vehicle Crashes

3. Car vs. Pedestrian Crashes

4. Bicycle Crashes

5. Skateboarding Injuries

6. Infant Walker – Related Injuries

7. Sledding Injuries

Mechanism of Injury

Knowledge of the Mechanism of Injury allows for a

high index of suspicion for the resultant injuries in the

child.

Initial Trauma Assessment and Intervention

Primary Assessment

Identify life-threatening injuries to the airway,

breathing, circulatory and neurologic systems

Secondary Assessment

Identify injuries to the remaining body systems.

Primary Assessment

1. Assess the Airway and Cervical Spine

2. Assess Breathing

3. Assess Circulation

4. Assess Disability (Neurologic System)

Airway

• Oral airway

• Nasopharyngeal airway

• Endotracheal intubation

• Needle cricothyroidotomy

Breathing

• Rate and depth of respiration

• Breath sounds, exhaled air

• Crepitus, tracheal position

• Oxygen saturation

Circulation

• Tachycardia early

• Capillary refill

• External blood loss

• Hypotension late finding

– Kids lose 25% of blood volume before

hypotension

• O2 sat probe not reading

IV access

• Peripheral vein

– Largest bore possible

• Intraosseous line

Secondary Assessment

5. Expose the patient.

6. Fahrenheit – keep patient warm.

7. Get vital signs with pain scale.

8. Head-to-Toe Assessment/ History.

9. Inspect the Back.

Traumatic Brain Injury

• #1 cause of trauma death

• 30% of childhood trauma deaths

• 30,000 permanent disabilities

Head CT’s

Spinal Cord Injury

Bony Structures

Spinous process

Lamina

Transverse process

Pedicle

Vertebral foramen

Posterior Arch

Superior articulating process

Spinous process

Inferior articular process

Transverse process

Superior articular process

McQuillan, K., Von Rueden, K., Hartsock, R., Flynn, M., & Whalen, E. (eds.).

(2002). Trauma Nursing: From Resuscitation Through Rehabilitation.

Philadelphia: W. B. Saunders Company. Reprinted with permission.

Spinal Nerves

Spinal Nerve Area Innervated

– C4 Diaphragm

– C5 Deltoids and biceps

– C6 Wrist extensors

– C7 Triceps

– C8 Hands

– T2 – T7 Chest muscles

Types of Spinal Injury

• Fracture

• Fracture with subluxation

• Subluxation alone

• SCIWORA ~ Spinal cord injury without

radiographic abnormality

Mechanism of Injury

• Hyperflexion

• Hyperextension

• Axial loading or vertical compression

• Rotation

• Penetrating trauma

Cervical Spine Fractures

• All patients involved in traumatic injury must be

immobilized

– Assume injured unless cleared

– Hard collar – Miami-J

– Log roll, Circulation, Motor, Sensory (CMS) exams

– No high dose steroids

– Spinal cord center for children

• The upper cervical spine C-1 and C-2 accounts for

20% of all c-spine fractures and the lower C-3 thru C-

7 accounts for 80%.

Spinal Alignment

Full Spine Immobilization

Cervical Spine ~ Immobilization

Cervical Spine Clearance

• Conscious patient– Alert, cooperative, no neck pain, no neck tenderness,

distracting injury?

• Unconscious patient– Plain film - Lateral c-spine with collar on

• If unable to visualize to T1 on lateral film, obtain multi-detector complete cervical spine CT

– Maintain in collar

– Follow guideline: "Routine Management of the Patient in a cervical collar”

– MRI if not expected to awaken

Neurological Assessment

• Sensorimotor exam

• Reflex function

Spinal Shock

• Spinal shock is manifested by

– Flaccid paralysis

– Absence of cutaneous and/or

proprioceptive sensation

– Loss of autonomic function

– Cessation of all reflex activity below the

site of injury

Neurogenic Shock

Loss of sympathetic innervation Increase in venous capacitance

Decrease in venous return

Injury to T6 and above

Hypotension

Bradycardia

Decreased cardiac output

Decreased tissue perfusion

Cardiovascular Implications

• Hypotension

– Maintain SBP > 90 mmHg for transport

– establish adequate pressure for systemic perfusion

• Bradycardia

– Treat only if symptomatic

• Temperature regulation

– Will become hypothermic

– Frequent to continuous monitoring

– Warming strategies

Abdominal and Thoracic Trauma

Thoracic & Abdominal Injuries

• Musculature of the child’s chest and abdomen is less developed than in the adult.

• Ribs are flexible and more anterior, thus are less protective of underlying organs.

• Child’s protuberant abdomen along with its thin abdominal wall places organs close to impacting forces during a traumatic event.

• Child’s small body size is predisposed to multiple injuries rather than isolated injury.

Mechanism of Injury

• Should heighten

suspicion regarding

certain injuries

• Blunt injury and types

of forces

• Use of restraint devices

• Penetrating trauma

Thoracic Trauma

• Penetrating verses Blunt

– Pulmonary Contusion

– Pneumothorax

– Open Pneumothorax

– Hemothorax

– Flail Chest

– Pericardial Tamponade

– Traumatic Asphyxia

– Traumatic Diaphragmatic Hernia

Tension Pneumothorax

Pericardial Tamponade

Abdominal Trauma

Abdominal Trauma

Physical assessment:

Abdominal distention or pain

Dermal evidence of trauma

Abdominal Trauma

Injury to the Solid Organs

Dense and less strongly held together

Prone to contusion

Bleeding

Fracture (rupture)

Unrestricted hemorrhage if organ capsule is

ruptured

Spleen: pain referred to left shoulder

Liver: pain referred to the right

shoulder

Abdominal Injury

• Most common MOI is blunt trauma from an MVC-related event whether as an occupant, pedestrian or bicycle rider

• Other causes include sports injuries, falls and child abuse

• Organs usually involved are the liver, spleen, kidneys and GI tract

• Injuries to the major vessels and the pancreas are less common

Splenic Injury

Liver Trauma

Kidney Injuries

Bowel Injury

Traumatic Diaphragmatic Hernia

Reporting

• Verbal Report immediately upon suspicion

– Police or Sheriff’s Department (Does not include a

school policy or security department)

– County Probation Department (If County

Designated)

– County Welfare/County CPS Department

• Follow up in writing

– General Standard within 48 hours or as soon as

possible

– California Form 8572

Mandated Reporting

• Good Faith reporters are protected under the law

from civil or criminal liability

• Failure to report may result in fine up to $1,000

Additional Information and Training:

http://mandatedreporterca.com

Handtevy

handtevy.com

The Three Way Stopcock…

• Great for small doses

• 4.5kg

Medication Concentration Order/Desired

Dose

Dose in MLs

EPI 1:10,000 1mg/10ml 0.01mg/kg 0.45ml =

0.045mg

Atropine 1mg/10ml 0.02mg/kg 0.9ml = 0.09mg

Fentanyl 250mcg/5ml 2mcg/kg 0.18ml = 9mcg

Versed 10mg/10ml 0.1mg/kg 0.45ml = 0.45mg

Airway/Ventilation

RSI

– Meds, Apneic oxygenation

– Correct size ETT

– Cuff or no cuff?

– Pediatric Airway anatomy

– Ventilator settings

Questions

Credits

• Reid AB. Letts RM. Black GB. Journal of

Trauma. [JC:kaf] 30(4):384-91, 1990 Apr

• Diagnostic Imaging in Infant Abuse, Am J

Roentgenol, Kleinman 155 (4):703

• The metaphyseal lesion in abused infants; a

radiologic-histopathologic study, PK

Kleinman, SC Marks, and B. Blackbourne,

AM J Roentgenol., May 1986; 146; 895-905.