PEDIATRIC TRAUMA STANDARDIZING CARE !/?

PEDIATRIC TRAUMAPEDIATRIC TRAUMASTANDARDIZING CARE !/?STANDARDIZING CARE !/?

DAVID A. LISTMAN, MDDAVID A. LISTMAN, MDDIRECTOR DIRECTOR PEDIATRIC EMERGENCY PEDIATRIC EMERGENCY MEDICINEMEDICINEST. BARNABAS HOSPITALST. BARNABAS HOSPITAL

LEARNING OBJECTIVES

• EPIDEMIOLOGY/ HISTORYEPIDEMIOLOGY/ HISTORY• ATLSATLS

• PRIMARY SURVEY/RESUSCITATIONPRIMARY SURVEY/RESUSCITATION• SECONDARY SURVEYSECONDARY SURVEY

• PEDIATRIC SPECIFIC ISSUESPEDIATRIC SPECIFIC ISSUES• REFERENCESREFERENCES

EPIDEMIOLOGY/ HISTORY

• 5 million trauma related deaths 5 million trauma related deaths worldwide in 2000worldwide in 2000

• Age <20 in US visits for injuriesAge <20 in US visits for injuries• 10 million ED visits and 10 million ED visits and • > 10 million primary care office visits> 10 million primary care office visits

• 300,000 pediatric hospitalizations 300,000 pediatric hospitalizations annuallyannually

• 11,090 injury related pediatric deaths 11,090 injury related pediatric deaths per yearper year

INTRODUCTION• Trauma - # 1 cause of death in Trauma - # 1 cause of death in

children older than 1 yearchildren older than 1 year• Effective initial resuscitation can Effective initial resuscitation can

reduce mortality by 25-30% reduce mortality by 25-30% (Stafford et al 2004) (Stafford et al 2004)

• National Pediatric Trauma National Pediatric Trauma Databank 2008 (≤ 19 yrs):Databank 2008 (≤ 19 yrs):• 474 Trauma Centers (127 Level 1)474 Trauma Centers (127 Level 1)• 108,863 cases from 2007 record108,863 cases from 2007 record

NATIONAL PEDIATRIC TRAUMA DATA BANK 2008

Incidents by Mechanism of Injury

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

Motor Vehicle

Traffic

Fall Struck by,

against

Transport,

other

Firearm Cut/ pierce

Mechanism of Injury

Perc

ent

NATIONAL PEDIATRIC TRAUMA DATA BANK 2008

Case Fatality Rate by Mechanism of Injury

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

Motor Vehicle

Traffic

Fall Struck by,

against

Transport,

other

Firearm Cut/ pierce

Mechanism of Injury

Cas

e F

atal

ity

Rat

e (

%)

MECHANISM OF INJURY• Motor vehicle/traffic: 31.5% of injuriesMotor vehicle/traffic: 31.5% of injuries

• Increases at 14 years of age with a peak at Increases at 14 years of age with a peak at 19 years of age19 years of age

• Associated with largest number of hospital/ICU Associated with largest number of hospital/ICU daysdays

• 47% of all mortalities47% of all mortalities• Falls: 26.6% of injuriesFalls: 26.6% of injuries

• Peak at 19 yearsPeak at 19 years• 22ndnd highest hospital/ICU days highest hospital/ICU days• 4.2% of all mortalities4.2% of all mortalities

• Firearms 5.7% of injuriesFirearms 5.7% of injuries• Peak at 19 yearsPeak at 19 years• 26% of all mortalities26% of all mortalities

TRI- MODAL DISTRIBUTION OF DEATHS

• First peak- within seconds to minutes of First peak- within seconds to minutes of injuryinjury

• Second Peak- within minutes to several Second Peak- within minutes to several hours of injuryhours of injury

• Third Peak- days to weeks after the Third Peak- days to weeks after the injuryinjury


• First peak- within seconds to minutes of First peak- within seconds to minutes of injuryinjury• Apnea- brain or spinal cord injuryApnea- brain or spinal cord injury• Rupture of the heart or great vesselsRupture of the heart or great vessels• Treatment- preventionTreatment- prevention


• Third Peak- days to weeks after the Third Peak- days to weeks after the injuryinjury



• Second Peak- within minutes to several Second Peak- within minutes to several hours of injuryhours of injury• Subdural and epidural hematomasSubdural and epidural hematomas• HemopneumothoraxHemopneumothorax• Ruptured spleen/ liverRuptured spleen/ liver• Pelvis fx’s and other sources of major blood Pelvis fx’s and other sources of major blood

lossloss• Treatment- golden hour and ATLSTreatment- golden hour and ATLS

• Third Peak- days to weeks after the injuryThird Peak- days to weeks after the injury




• Third Peak- days to weeks after the Third Peak- days to weeks after the injuryinjury• SepsisSepsis• Multi organ system failureMulti organ system failure• Treatment- maximize care during preceding Treatment- maximize care during preceding

stages, Hospital/ ICU carestages, Hospital/ ICU care

Friday Sept 30, 2005

HOW DO WE IMPROVE SURVIVAL DURING SECOND PEAK?

• Standardize evidence based best Standardize evidence based best practicespractices

• A 1976 crash of a private plane piloted by A 1976 crash of a private plane piloted by an Orthopedic surgeon. His wife and an Orthopedic surgeon. His wife and children were on board.children were on board.

• Hospital care in rural Nebraska was Hospital care in rural Nebraska was substandardsubstandard

• 1978- 11978- 1stst ATLS course to standardize ATLS course to standardize initial care of trauma patients by doctors initial care of trauma patients by doctors who do not manage major trauma who do not manage major trauma regularly.regularly.

CASE

• 4 year old female in stroller4 year old female in stroller• Mother and stroller hit by carMother and stroller hit by car• Child ejected from strollerChild ejected from stroller• No LOCNo LOC• C-spine immobilized at sceneC-spine immobilized at scene• Minor contusions and abrasions of scalp Minor contusions and abrasions of scalp

CASE

• 4 year old female in stroller4 year old female in stroller• Does patient require trauma evaluation?Does patient require trauma evaluation?• What if any radiologic workup should be What if any radiologic workup should be

done?done?

Who requires trauma evaluation?

ACTIVATION OF TRAUMA TEAM

• Level of activation Level of activation determined by determined by • Physiologic parametersPhysiologic parameters• Anatomic location/type of injuryAnatomic location/type of injury• Mechanism of injuryMechanism of injury

• Options: code, alert, Options: code, alert, consultationconsultation


• Trauma Trauma AlertAlert• AnatomicAnatomic

• Significant injuries above and below Significant injuries above and below the diaphragmthe diaphragm

• 2 or more proximal long bone fractures2 or more proximal long bone fractures• Burn of 15-30% BSA (second/third Burn of 15-30% BSA (second/third

degree burn)degree burn)• Traumatic amputation of limb proximal Traumatic amputation of limb proximal

to wrist or ankleto wrist or ankle• Crush injury of torsoCrush injury of torso• Spinal injury with paralysisSpinal injury with paralysis


• Trauma Trauma Alert• MechanismMechanism

• Ejection from automobileEjection from automobile• Extrication > 20 minutesExtrication > 20 minutes• Fatality of another passengerFatality of another passenger• Intrusion of vehicle by collisionIntrusion of vehicle by collision• Unrestrained passenger or vehicle Unrestrained passenger or vehicle

traveling > 20 mphtraveling > 20 mph• Fall Fall 20 feet 20 feet• Pedestrian struck at significant rate of Pedestrian struck at significant rate of

speedspeed• LightningLightning


• Trauma Trauma Code• PhysiologicPhysiologic

• Cardiopulmonary arrestCardiopulmonary arrest• Hypotention (by age)Hypotention (by age)• Respiratory distressRespiratory distress• Neurologic failure (GCSNeurologic failure (GCS8)8)


• TraumaTrauma Code• AnatomicAnatomic

• Penetrating wound to head, chest Penetrating wound to head, chest or abdomen (prox to knees/ or abdomen (prox to knees/ elbows)elbows)

• Burn > 30% BSA, inhalation airway Burn > 30% BSA, inhalation airway burnburn

• Major electrical injuryMajor electrical injury

Who requires trauma evaluation?

• All patients with significant or All patients with significant or potentially significant injury should have potentially significant injury should have a systematic evaluationa systematic evaluation

Standard Precautions

● Cap● Gown● Gloves● Mask● Shoe covers● Goggles / face shield

INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES

• Primary SurveyPrimary Survey• AAirwayirway• BBreathingreathing• CCirculationirculation

• A,B,C’s with special trauma concernsA,B,C’s with special trauma concerns


• Primary SurveyPrimary Survey• AAirway maintenance, with cervical spine irway maintenance, with cervical spine

controlcontrol• BBreathing, with special concern for reathing, with special concern for

pneumothoraxpneumothorax• CCirculation- control bleedingirculation- control bleeding• DDisability- neurologic deficitsisability- neurologic deficits• EExposure- expose (examine) all of patient & xposure- expose (examine) all of patient &

prevent hypothermiaprevent hypothermia• ResuscitationResuscitation

• Oxygenation, airway management, ventilationOxygenation, airway management, ventilation• Shock managementShock management• Intubations – urinary tract, gastrointestinal Intubations – urinary tract, gastrointestinal

tracttract


• As you perform the Primary Survey, As you perform the Primary Survey, stop and intervene as neededstop and intervene as needed• AAirway maintenance, with cervical spine irway maintenance, with cervical spine

controlcontrol• Airway positioningAirway positioning• OxygenOxygen• Airway adjuncts- nasopharyngeal Airway adjuncts- nasopharyngeal

airway, oral airwayairway, oral airway• Endotracheal intubationEndotracheal intubation• Surgical AirwaySurgical Airway

CHIN LIFT MANEUVER

• Airway obstruction by tongue and epiglottis

• Relief by head-tilt/chin-lift

Airway Management

Chin-lift Maneuver

Basic Techniques

Airway Management

Jaw-thrust Maneuver

Basic Techniques

INDICATIONS FOR INTUBATION

• ShockShock• Cardiac arrestCardiac arrest• Respiratory distress or Respiratory distress or

failurefailure• Severe head injury Severe head injury

• GCS GCS << 8 8

RAPID SEQUENCE INTUBATION I

• Preoxygenate with 100% OPreoxygenate with 100% O22, insert IV lines, , insert IV lines, attach cardiac/respiratory monitorattach cardiac/respiratory monitor

• Prepare equipment for possible emergency Prepare equipment for possible emergency surgical airway surgical airway

• Inline manual immobilization of cervical Inline manual immobilization of cervical spine spine

• Lidocaine 1.5 mg/kg (for elevated ICP) Lidocaine 1.5 mg/kg (for elevated ICP) • Atropine 0.02 mg/kg (minimum of 0.1 mg, Atropine 0.02 mg/kg (minimum of 0.1 mg,

maximum 0.5 mg) to prevent bradycardiamaximum 0.5 mg) to prevent bradycardia• Begin Sellick maneuver (cricothyroid Begin Sellick maneuver (cricothyroid

pressure to prevent vomiting and pressure to prevent vomiting and aspiration)aspiration)

RAPID SEQUENCE INTUBATION II

• Paralyzing agentParalyzing agent• Rocuronium (0.6 – 1.0 mg/kg) orRocuronium (0.6 – 1.0 mg/kg) or• Vecuronium (0.1 mg/kg)Vecuronium (0.1 mg/kg)• Succinyl Choline (1mg/kg)Succinyl Choline (1mg/kg)

• Sedative agent: problem specific Sedative agent: problem specific • HypotensionHypotension: Etomidate (0.3 mg/kg): Etomidate (0.3 mg/kg)• Head injury without hypotensionHead injury without hypotension: Thiopental (3-: Thiopental (3-

5 mg/kg)5 mg/kg)• Severe asthmaSevere asthma: Ketamine (1-2 mg/kg): Ketamine (1-2 mg/kg)

• Oral intubationOral intubation• Confirm location of ET tube with end-tidal COConfirm location of ET tube with end-tidal CO22

measurementmeasurement

SURGICAL AIRWAY• RARELYRARELY needed in children needed in children

• AVOID in children < 12 years due to AVOID in children < 12 years due to small target size and risk of damage small target size and risk of damage to surrounding structures to surrounding structures (Reamy 2004)(Reamy 2004)

• IndicationsIndications: failure to intubate, : failure to intubate, apneic with c-spine injury, facial apneic with c-spine injury, facial trauma with c-spine injury, severe trauma with c-spine injury, severe facial and neck traumafacial and neck trauma

• Needle cricothyroidotomy with Needle cricothyroidotomy with needle jet insufflation is a short needle jet insufflation is a short term solutionterm solution

SURGICAL AIRWAY

SURGICAL AIRWAY

COMPLICATIONS OF SURGICAL AIRWAY

• HemorrhageHemorrhage• Laceration of surrounding structuresLaceration of surrounding structures• Subcutaneous emphysemaSubcutaneous emphysema• Hypoxia after failed/prolonged Hypoxia after failed/prolonged

attemptsattempts• AspirationAspiration• InfectionInfection• Tracheal stenosis or cricoid cartilage Tracheal stenosis or cricoid cartilage

damagedamage


• Primary SurveyPrimary Survey• BBreathing, with special concern for reathing, with special concern for

pneumothoraxpneumothorax

• If pneumothorax suspected and patient If pneumothorax suspected and patient unstable- needle decompressionunstable- needle decompression

• If pneumothorax suspected and patient If pneumothorax suspected and patient stable- x-ray and chest tube stable- x-ray and chest tube

• Pt may require intubation and Pt may require intubation and mechanical ventilationmechanical ventilation

• Prevent hypoxemiaPrevent hypoxemia


• Primary SurveyPrimary Survey• CCirculation- control bleedingirculation- control bleeding

• Control BleedingControl Bleeding• External- direct pressureExternal- direct pressure• Bony- align and splint fracturesBony- align and splint fractures• Internal- surgery/ interventional Internal- surgery/ interventional

radiologyradiology

• Establish 2 large bore IV’sEstablish 2 large bore IV’s• Crystalloid fluidCrystalloid fluid• O neg bloodO neg blood

SHOCK I• Early recognitionEarly recognition of shock critical of shock critical

• Tachycardia, pain, anxietyTachycardia, pain, anxiety• Decreased pulse pressure (<20mm Hg)Decreased pulse pressure (<20mm Hg)• Mottled skin, warm/cool extremitiesMottled skin, warm/cool extremities

• Most common cause is hypovolemic Most common cause is hypovolemic shock due to hemorrhageshock due to hemorrhage

• BUT beware of:BUT beware of:• Spinal cord injury can cause distributive Spinal cord injury can cause distributive

shockshock• Cardiac tamponade or tension Cardiac tamponade or tension

pneumothorax can cause obstructive pneumothorax can cause obstructive shockshock

SHOCK II• Minimum systolic BP: [70 + 2 (age in Minimum systolic BP: [70 + 2 (age in

years)]years)]• CompensatedCompensated shock shock

• Normal BP (may see orthostatic changes)Normal BP (may see orthostatic changes)• TachycardiaTachycardia• TachypneaTachypnea• Bounding pulses, widened pulse pressureBounding pulses, widened pulse pressure• Altered mental statusAltered mental status• Warm and dry extremitiesWarm and dry extremities• Delayed capillary refill (> 2 seconds)Delayed capillary refill (> 2 seconds)

• UncompensatedUncompensated shock shock• HypotensionHypotension• Severe tachypneaSevere tachypnea• Cold extremitiesCold extremities• Capillary refill > 4 secondsCapillary refill > 4 seconds

SHOCKMANAGEMENT I

• 20cc/kg infused rapidly20cc/kg infused rapidly• 0.9% NaCl 0.9% NaCl oror Lactated Ringer’s Lactated Ringer’s

solutionsolution• 2 large bore IV’s2 large bore IV’s• If severe shock If severe shock 10cc/kg type 10cc/kg type

specific or O- packed red blood specific or O- packed red blood cellscells

• Identify and treat source of Identify and treat source of bleedingbleeding

SHOCKMANAGEMENT II

• Maintain urine output Maintain urine output 1-2cc/kg/hour1-2cc/kg/hour

• Monitor urine output with Monitor urine output with catheter/feeding tube placed in catheter/feeding tube placed in urethraurethra• Contraindications to catheter Contraindications to catheter

placementplacement• Pelvic fracture Pelvic fracture • Blood at urethral meatusBlood at urethral meatus• Blood in the scrotumBlood in the scrotum

VENOUS ACCESS• 2 attempts peripheral vein2 attempts peripheral vein• Intraosseous needleIntraosseous needle• Central line Central line

• Complications: arrhythmias, Complications: arrhythmias, thrombosis, and embolism thrombosis, and embolism

• LocationsLocations• Subclavian veinSubclavian vein• Femoral veinFemoral vein• Jugular veinJugular vein

• CutdownCutdown

VENOUS ACCESS: INTRAOSSEOUS NEEDLE

PLACEMENT

VENOUS ACCESS: INTRAOSSEOUS NEEDLE

PLACEMENT


• Primary SurveyPrimary Survey• DDisability- neurologic deficitsisability- neurologic deficits

• Level of consciousness- GCSLevel of consciousness- GCS

Glasgow Coma Scale• Eye OpeningEye Opening

• Spontaneous – 4Spontaneous – 4• To speech – 3To speech – 3• To pain – 2To pain – 2• No Response – 1No Response – 1

• Best Motor ResponseBest Motor Response• Obeys -6Obeys -6• Localizes – 5Localizes – 5• Withdraws – 4Withdraws – 4• Abnormal flexion – 3Abnormal flexion – 3• Extension response – 2Extension response – 2• No Response – 1No Response – 1

• Verbal responseVerbal response• Oriented – 5Oriented – 5• Confused conversation – 4Confused conversation – 4• Inappropriate words – 3Inappropriate words – 3• Incomprehensible sounds – 2Incomprehensible sounds – 2• No response - 1No response - 1

GLASCOW COMA SCORE

Glasgow Coma Scale

A strong predictor of outcomeA strong predictor of outcome13: mild brain injury13: mild brain injury9-12: Moderate brain injury9-12: Moderate brain injury< 8: Severe brain injury (coma)< 8: Severe brain injury (coma)


• Primary SurveyPrimary Survey• EExposure- expose (examine) all of patient xposure- expose (examine) all of patient

& prevent hypothermia& prevent hypothermia

• Remove all clothingRemove all clothing• Roll PatientRoll Patient• Examine axillae, groin, rectumExamine axillae, groin, rectum

• Cover patient with warm blankets etc…Cover patient with warm blankets etc…

INITIAL ASSESSMENT AND MANAGEMENT

• Primary SurveyPrimary Survey• AAirwayirway• BBreathingreathing• CCirculationirculation• DDisabilityisability• EExposurexposure

• Adjuncts to primary surveyAdjuncts to primary survey• LabsLabs• Cardiopulmonary MonitoringCardiopulmonary Monitoring• Urinary and Gastric CathetersUrinary and Gastric Catheters• X-rays- chest and pelvisX-rays- chest and pelvis• FAST/ DPLFAST/ DPL

SECONDARY SURVEY• Begins after primary survey is Begins after primary survey is

completed completed • Resuscitation in placeResuscitation in place• Vital signs improvingVital signs improving• Head/toe complete evaluation of Head/toe complete evaluation of

trauma patienttrauma patient• Complete history/physical examComplete history/physical exam• Reassessment of ALL vital signsReassessment of ALL vital signs

SECONDARY SURVEY - HISTORY

• Obtain AMPLE history: Obtain AMPLE history: aallergies, llergies, mmedications, edications, ppast illnesses, ast illnesses, llast ast meal, meal, eevents related to injuryvents related to injury

• Mechanism of injury – blunt vs Mechanism of injury – blunt vs penetratingpenetrating• Motor vehicle/pedestrian: head Motor vehicle/pedestrian: head

injury, traumatic aortic disruption, injury, traumatic aortic disruption, abdominal visceral injuries, abdominal visceral injuries, fractured lower extremities/pelvisfractured lower extremities/pelvis

• Injury due to burns/coldInjury due to burns/cold


• Secondary Survey- head to toe Secondary Survey- head to toe examexam• Head/ FaceHead/ Face• Neck/ C-spineNeck/ C-spine• ChestChest• AbdomenAbdomen• PerineumPerineum• Extremities/ MusculoskeletalExtremities/ Musculoskeletal• NeurologicNeurologic

• Adjuncts to secondary surveyAdjuncts to secondary survey


• Secondary Survey- head to toe Secondary Survey- head to toe examexam

• Adjuncts to secondary surveyAdjuncts to secondary survey• Additional studies that may includeAdditional studies that may include

• X-rays of c-spineX-rays of c-spine• CT scans of head, c-spine, chest, CT scans of head, c-spine, chest,

abdomen/ pelvisabdomen/ pelvis• AngiographyAngiography• Extremity x-raysExtremity x-rays

UNIQUE PEDIATRIC CHARACTERISTICS

• Compared to adults, children Compared to adults, children have…have…• Smaller body mass to surface area ratio Smaller body mass to surface area ratio

increased susceptibility to insensible fluid increased susceptibility to insensible fluid and heat lossand heat loss

• More elastic connective tissue; less rigid More elastic connective tissue; less rigid skeleton protecting tightly packed skeleton protecting tightly packed thoracic and abdominal structuresthoracic and abdominal structures

• Transmitted energy delivers greater Transmitted energy delivers greater force/volume; force/volume; multisystem injuries multisystem injuries

• Thoracic and spinal injuries rareThoracic and spinal injuries rare

RESUSCITATION EQUIPMENT

FACILITIES/EQUIPMENT REQUIREMENTS

• Designated “Trauma Area” with Designated “Trauma Area” with essential pediatric equipment essential pediatric equipment alwaysalways readyready• Full range of Full range of pediatricpediatric endotracheal tubes, endotracheal tubes,

chest tubes, blood drawing equipment – chest tubes, blood drawing equipment – angiocatheters, butterfly needlesangiocatheters, butterfly needles

• Heated air, warming blankets, heat Heated air, warming blankets, heat lamps, room temperature 85°Flamps, room temperature 85°F

• Ultrasound available for “Focused Ultrasound available for “Focused Abdominal Thoracic Sonography for Abdominal Thoracic Sonography for Trauma” (FAST Scan)Trauma” (FAST Scan)

• Broselow TapeBroselow Tape

UNIQUE PEDIATRIC CHARACTERISTICS; THERMOREGULATION

• Critical in childrenCritical in children• High evaporative heat loss/caloric High evaporative heat loss/caloric

expenditure in children expenditure in children • High body surface area/massHigh body surface area/mass• Little subcutaneous tissueLittle subcutaneous tissue

• Hypothermia can affect coagulation Hypothermia can affect coagulation time, CNS recoverytime, CNS recovery

• Management focus Management focus • Overhead heat lampsOverhead heat lamps• Warm roomWarm room• Warm fluids, blood productsWarm fluids, blood products

PEDIATRIC AIRWAY

AIRWAY I

• Larger occiputLarger occiput results in neck results in neck flexion with obstruction of the flexion with obstruction of the posterior pharynxposterior pharynx

• Larynx more anteriorLarynx more anterior orienting orienting midface slightly superior and midface slightly superior and anterior for protection of airwayanterior for protection of airway

• Need to protect cervical spineNeed to protect cervical spine• Large tongueLarge tongue may obstruct may obstruct

airwayairway

AIRWAY II• Cricoid cartilage at level of C6 in Cricoid cartilage at level of C6 in

adults, but C4 in childrenadults, but C4 in children• Cricoid ring – most narrow Cricoid ring – most narrow

anatomic site until 8 years of anatomic site until 8 years of ageage

• Trachea is short – increases risk Trachea is short – increases risk of mainstem bronchial of mainstem bronchial intubationintubation

SCIWORA• SSpinal pinal CCord ord IInjury njury WWithithOOut ut

RRadiologic adiologic AAbnormalitybnormality• Accounts for up to 2/3 of severe Accounts for up to 2/3 of severe

cervical spine injuries in childrencervical spine injuries in children• Elasticity in cervical spine allows Elasticity in cervical spine allows

severe spinal cord injury to occursevere spinal cord injury to occur• Diagnosis of exclusion; MRI usefulDiagnosis of exclusion; MRI useful• Watch for pseudosubluxation; Watch for pseudosubluxation;

anterior displacement may be up anterior displacement may be up to 4mmto 4mm

Radiation Exposure• Increasing concern in literature for Increasing concern in literature for

malignancies secondary radiation malignancies secondary radiation exposureexposure• CNS lymphomaCNS lymphoma• Thyroid cancersThyroid cancers• Unshielded radiation to genitals Unshielded radiation to genitals

Radiation Exposure• Use of Abdomino-pelvic CT scans is Use of Abdomino-pelvic CT scans is

more commonmore common• C-spine scanning done as a routine C-spine scanning done as a routine

in adults if scanning the head to in adults if scanning the head to replace plain filmreplace plain film

Radiation Exposure• Pediatricians have championed Pediatricians have championed

injury preventioninjury prevention• ““Kids are not small adults” Kids are not small adults”

Radiation Exposure• Attempt to decrease plain pelvis Attempt to decrease plain pelvis

films as routine part of trauma films as routine part of trauma seriesseries

• Review of all blunt trauma 2002-Review of all blunt trauma 2002-2006 at SBH age </= 252006 at SBH age </= 25

• 579 patients, 580 trauma 579 patients, 580 trauma evaluationsevaluations

• 22 pelvis fractures (4%)22 pelvis fractures (4%)• Can we identify low risk for pelvis Can we identify low risk for pelvis

fx?fx?

Radiation Exposure• Can we identify low risk for pelvis fx?Can we identify low risk for pelvis fx?

• No lower extrem injury (NPV 98.3%)No lower extrem injury (NPV 98.3%)• Normal Exam of pelvis (NPV 99%)Normal Exam of pelvis (NPV 99%)• No clinical need for abdomino-pelvic CT No clinical need for abdomino-pelvic CT

(NPV 99.5%)(NPV 99.5%)• If all three are absent (NPV 100%).If all three are absent (NPV 100%).

• Retrospectively applying criteria to Retrospectively applying criteria to study group would eliminate 45% of study group would eliminate 45% of pelvis x-rays.pelvis x-rays.

Wong et al. Pediatric Emerg Care in PublicationWong et al. Pediatric Emerg Care in Publication

Radiation Exposure• Trend in trauma care towards routine CT scan Trend in trauma care towards routine CT scan

of c-spine if head CT is to be done (replacing of c-spine if head CT is to be done (replacing plain films).plain films).• CT c-spine exposes the thyroid to 90-200 times the CT c-spine exposes the thyroid to 90-200 times the

radiation dose of plain films. radiation dose of plain films. (Jimenez et al Pediatr. Radiol)(Jimenez et al Pediatr. Radiol)

• Rate of c-spine injuries is very low in children 1-2%, Rate of c-spine injuries is very low in children 1-2%, 0.8 % in SBH0.8 % in SBH

• Ligamentous injuries are more commonLigamentous injuries are more common• NEXUS criteria are valid in childrenNEXUS criteria are valid in children

• Absence of midline tendernessAbsence of midline tenderness• Not intoxicatedNot intoxicated• Normal level of alertnessNormal level of alertness• Normal neurologic examNormal neurologic exam• Absence of painful distracting injuryAbsence of painful distracting injury

• Develop new protocols for Peds specific Develop new protocols for Peds specific concernsconcerns

SUMMARY• Practice routines in ”Mock Code”Practice routines in ”Mock Code”• Primary survey (ABCs, emergency Primary survey (ABCs, emergency

conditions), resuscitationconditions), resuscitation• Secondary surveySecondary survey• Consider unique characteristics of Consider unique characteristics of

children (temperature requirements, children (temperature requirements, anatomy)anatomy)

• Prepare protocols, dedicated area, Prepare protocols, dedicated area, equipmentequipment

REFERENCES• Yamamoto LG. Multiple trauma in a 2 year old. Yamamoto LG. Multiple trauma in a 2 year old.

Radiology Cases in Pediatric Emergency Radiology Cases in Pediatric Emergency Medicine Volume 7, Case 8. Medicine Volume 7, Case 8. http://www.pediatriconcall.com/fordoctor/ http://www.pediatriconcall.com/fordoctor/ DiseasesandCondition/Multiple_Traumadia.aspDiseasesandCondition/Multiple_Traumadia.asp

• DeRoss AL and Vane DW. Early evaluation and DeRoss AL and Vane DW. Early evaluation and resuscitation of the pediatric trauma patient. resuscitation of the pediatric trauma patient. Sem Pediatric Surgery. 13(2); May, 2004, 74-Sem Pediatric Surgery. 13(2); May, 2004, 74-79.79.

• National Trauma Data Bank. Pediatric Section. http://www.facs.org/trauma/ntdbpediatric2004.pdf

• Stafford PW et al. Practical points in evaluation Stafford PW et al. Practical points in evaluation and resuscitation of the injured child. Surg Clin and resuscitation of the injured child. Surg Clin North Amer 82:273-301, 2002.North Amer 82:273-301, 2002.

• Prince JS et al. Unusual seat belt injuries in Prince JS et al. Unusual seat belt injuries in children. J Trauma 56(2);420-427, Feb 2004.children. J Trauma 56(2);420-427, Feb 2004.

REFERENCES• Arensman RM and Madonna MB. Initial Arensman RM and Madonna MB. Initial

management and stabilization of pediatric management and stabilization of pediatric trauma patients trauma patients http//www.childsdoc.org/fall97/trauma/traumahttp//www.childsdoc.org/fall97/trauma/trauma.asp.asp

• Reamy RR and Losek JD. Pediatric trauma and Reamy RR and Losek JD. Pediatric trauma and initial resuscitation. Jour South Carolina Med initial resuscitation. Jour South Carolina Med Assn 100(12); Dec 2004: 317-321.Assn 100(12); Dec 2004: 317-321.

• Advanced Trauma Life Support 6Advanced Trauma Life Support 6thth edition. edition. American College of Surgeons, Chicago, American College of Surgeons, Chicago, Illinois, 1997.Illinois, 1997.

• Nguyen D et al. Considerations in pediatric Nguyen D et al. Considerations in pediatric trauma.http://www.emedicine.com/med/topic trauma.http://www.emedicine.com/med/topic 3223.htm3223.htm

• Ruddy RM and Fleisher G. An approach to the Ruddy RM and Fleisher G. An approach to the injured child. In Textbook of Pediatric injured child. In Textbook of Pediatric Emergency Medicine, Fleisher G et al., Ed. Emergency Medicine, Fleisher G et al., Ed. Lippincott, Philadelphia, 5Lippincott, Philadelphia, 5thth edition, 2006. edition, 2006.

• Walzman M and Mooney DP. Major trauma. In Walzman M and Mooney DP. Major trauma. In Textbook of Pediatric Emergency Medicine, Textbook of Pediatric Emergency Medicine, Fleisher G et al., Ed. Lippincott, Philadelphia, Fleisher G et al., Ed. Lippincott, Philadelphia, 55thth edition, 2006. edition, 2006.

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PEDIATRIC TRAUMA STANDARDIZING CARE !/?