Pediatric Trauma: An Overview of the Problem

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Pediatric Trauma- An Overviewof the Problem
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• Presented by
• Oklahoma EMSC Resource Center

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Objectives

• Upon completion of this presentation the
  participant will have
• Increased awareness of issues specific to
  children and trauma.
• Improved skills in assessing pediatric trauma
• Mechanisms of injury

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Objectives (Continued)

• Identify key components of the assessment process
• Recognize differences between adult and child
  priorities
• Identify and avoid common errors in the care of
  the traumatized pediatric patient
• Implement appropriate treatment plans

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Nature of the Beast

• Pediatrics account for 5-15 of total EMS calls.
• but up to 33 of these calls require ALS.
• Trauma is 50 of pediatric EMS calls
• usually over 2 years old
• (more medical calls under 2.)
• Injury is the leading cause of death in children
• MVC 50

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Nature of the Beast contd

• Up to 70 of major Pediatric trauma cases die
  because of the severity of injury.
• NOT because of deficit in pre-hospital care
• When a child is injured, the whole family is
  injured too!
• gt40 divorce rate within 1 year after a major
  trauma.

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General PrinciplesPediatric Trauma

• Priorities are similar to adults
• All roads lead to the ABC (DE)s
• Start with A, not the most obvious

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General Principles (Continued)

• Children have certain key differences
• size different types of energy transfer
• metabolism
• ability to respond to words and give history
• History of accident may be critical in
  determining treatment plan

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Physical Differences Children

• Larger Head
• More leverage on neck and to brain during impacts
• Forces neck into flexion while lying flat
• airway tends to buckle and close on adult spine
  board without shoulder support
• Shorter neck
• causes different injury patterns
• (C2-C4 more common injuries)

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Physical Differences in Childrencontd

• Chest more pliable
• Pulmonary contusion more likely
• Diaphragm motion essential for ventilation
• Energy transmitted to chest organs
• Abdominal organs less well protected.
• Liver is not covered by the rib cage.
• Less muscle mass to abdominal wall.
• Less Sub-Q tissue to absorb the injury.

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Effects w/Size Energy Transfer

• Children are smaller
• more force per square inch of body.
• organs are closer together multi-system injury
  is the rule.
• Children are softer ( more flexible, bouncy)
• Bones dont break but instead pass on energy
• Internal organ damage without fractures is more
  common.
• Larger surface area to size ratio
• Lose heat more rapidly

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Metabolic Differences in Kids

• Children have a higher metabolic rate
• Nearly twice as rapid O2 consumption
• Need more blood flow
• More frequent feedings
• More fluid intake per size ratio

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Metabolic Differences contd

• Children shock out differently
• Children compensate better initially
• May show minimal signs and symptoms.
• Children have less reserves than adults
• Platinum half-hour in trauma resuscitation
• Rapid intervention critical
• Once reserves are exhausted,
• Bad Things Happen

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The Bad Things

• Decompensation can be rapid
• A conscious, crying child can become pulseless
  and apneic in less than 2 minutes.
• Once decompensated, it may be too late
• Limited Reserves are gone whole system collapses
• Early recognition and intervention are critical

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ASSESSMENT is the
for SURVIVAL!!!
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Approaching the Scene

• The first step in a cardiac arrest or other
  critical situation is to
• Take your own pulse!!!

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Prepare Yourselves

• Assign roles ahead of time
• History taker
• Spine Management
• Airway management
• Equipment

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On the Scene

• SAFETY FIRST!!!!

• BSI
• Scene Hazards
• Resources

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On the Scene

• Careful Attention to the Initial assessment is
  CRUCIAL
• Dont be distracted by the blood and screams
• A quiet Kid should scare the _at_ out of you
  !!!!
• If practical, keep the parents with the child to
  help reduce the child's fear.

Lots of blood
Cant breathe
crying
Fxs
Everyone scared
Uncon.
Quiet
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Brilliance vs. Basics

• For every brilliant maneuver or diagnosis you
  make which saves a life, youll save 10 by just
  doing a good, solid job stay focused on the
  basics in the heat of the moment.

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On the Scene contd

• Consider the mechanism of injury

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Initial AssessmentQuickie ABCs
APPEARANCE
BREATHING
Pediatric Assessment Triangle
CIRCULATION
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Appearance

STOP
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Remember the
s
...the biggest failure among the basic services
is to call for an ALS ground or air unit and
ignore the basics while they are
waiting. Proper basic airway management is
often performed inadequately if at all,
apparently due to fear and panic. Theodore M.
Barnett, M.D. Children's Mercy Hospital, Kansas
City, MO
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Airway Assessment - LOOK

• Is the patient breathing? How well?
• Respiratory Rate
• A slow or irregular respiratory rate in a child
  is an OMINOUS SIGN

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LOOK contd

• Watch for the effort needed to breathe
• chest, neck, or abdominal muscle retractions
• flaring of the nostrils
• Level of Awareness
• Agitated child could lack oxygen
• Obtunded/ gorked could be excessive CO2
• How does the child respond to its parents??

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Assessment 2 - Listen

• Observe the skin
• pale and clammy - ??shocky
• cyanosis - inadequate oxygen
• Listen -
• anything loud is a good sign, airway-wise,but a
  noisy airway may be partly obstructed
• Snoring, gurgling, crowing upper airway
• Grunting
• Wheezing - lower airways
• Hoarseness - voicebox affected

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RAPID ASSESSMENT and SUPPORTSIGNS OF DEEP
DOO-DOO

• Respiratory rate gt 60
• Heart Rate
• Less than 5 years lt80 or gt180 per minute
• Over 5 years lt60 or gt160 per minute
• Increased work of breathing
• retractions nasal flaring grunting
• Cyanosis
• Altered level of consciousness
• Failure to recognize parents Lethargy Irritable

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Airway w/C-Spine Protection

• Failure to secure airway is major preventable
  cause of death in Peds trauma
• Must protect spine
• Avoid flexing or extending neck
• Use jaw thrust to open airway
• Suspect possible neck injury if
• Any injury to head or above clavicles
• Ejected, thrown, rollover
• Unconscious trauma case

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AAirway w/C-spine Control

• Unconscious patients often cant protect their
  airway
• Tongue most common obstruction
• Little airways are easily blocked by blood, teeth
  - have rigid suction available
• Jaw thrust to open airway
• May need oral/nasal airway
• Do not rotate in children
• Infants need to breathe through their noses-
• may need to suction out blood/mucus

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Airway Adjuncts

• Use of oral and nasal-pharyngeal airways. How to
  insert (e.g do not invert OPA in younger child to
  insert, and directing NPA directly posterior,
  not up into nasal turbinates).
• Also contraindications to OPA/NPA use.
• If neck is OK, allow the child to be in position
  of comfort - they open their own airway.
• Sniffing position is an option

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Immobilization
I am a pediatric ICU fellow at Mass. General
Hospital. I have been teaching a one hour
segment on pediatric trauma, and have found these
to be some of the more common questions or
misconceptions 1. Practical aspects of
stabilizing a c-spine. Particularly in infants
and toddlers for whom there are no C-collars
(because at this age they don't have necks
yet!). We have also emphasized the fact that two
points are necessary to stabilize a c-spine when
doing in line stabilization. When doing case
scenarios with mannequins, I was surprised to see
that in-line stabilization was consistently
provided by holding the patient at the ears,
allowing the body to continue to move relative
to the position of the head. I imagine this
problem is greater with children who tend to kick
and scream and resist immobilization more. I
have tried to emphasize that the head/C-spine
need to be immobilized relative to the body in
order to be effective. Most BLS providers have
felt more comfortable doing this from above the
head and stabilizing against the shoulders, much
as a c-collar does. I have also demonstrated
stabilizing with forearms against the chest,
hands around the head and occiput as a second
option, particularly if they are assisting a
paramedic who can provide intubation or advanced
airway maneuvers.
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Proper Immobilization
3. commercial cervical collars often do not fit,
stabilization best provided by smaller collar (if
you have to choose one evil over another) NO SOFT
COLLARS !!!!! 4. when placed on an extrication
board, most children under 5 years will be in
cervical flexion, unless you elevate their upper
thoracic region by 1 inch (say with a few
towels) or use a peds board with head well.
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Infant immobilization

• Immobilization
• 1) Keep infants in car seats unless treatment of
  injuries requires removal (IV, ETT, BVM, control
  of hemorrhage). If they survived the crash in an
  intact car seat, they are usually better off to
  stay in it for the ride to the hospital.
• William E. Hauda, II, MD
• Pediatric Emergency Medicine Fellow
• Attending Emergency Medicine Physician
• Fairfax Hospital, Falls Church, VA

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B Breathing

• All children get Oxygen
• May need to assist with bag-valve-mask
• Good mask seal is the KEY to bagging
• Proper fit of mask.
• Watch your fingers and your jaw thrust
• Two people should bag whenever possible
• If the chest doesnt rise, you aint doing it
  right
• Avoid distending the stomach
• Cricoid pressure
• Easy does it
• Distended stomach less room for air in lungs

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Breathing advice
Having given this talk many times to EMS
providers at George WashingtonUniversity and
through the Maryland PALS courses I can offer a
few hints. Airway 1) Remember to mention all
those anatomic differences, but stress the large
tongue. Good airway positioning is crucial. 2)
All children can be ventilated with a bag valve
mask. This most common reasons that providers
have difficulty is a) partially obstructed
airway because of poor positioning, b) poor
technique in getting the mask to seal,.. c)
gastric distension from crying or vigorous
bagging 4) All injured children get oxygen.
Always. Everytime. No exceptions.
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Recognizing early signs of shock, and suspecting
it sooner if significant mechanism of injury A
few pediatric trauma messages for EMT's 1. a
little bleeding is a lot the smaller you are (I
use e.g. of a 10 kg child with a 30 hemorrhage
only 210 ml of blood, all too easily obtained
with a scalp lac extremity fracture) 2. BP
often maintained until very late in hemorrhage by
young patients because of their overactive
vasoconstrictive responses Good luck. Tom
Terndrup, MD Director of
Pediatric Emergency Medicine University Hospital
Syracuse, N.Y.
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What is shock??

• Any abnormality of the circulation which causes
  inadequate blood flow or oxygen to the tissues of
  the body.
• BLOOD LOSS most common type of shock in trauma
• Can occur from open bleeding, internal bleeding,
  into fractures

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Recognizing Possible Shock

• Early signs can be subtle
• May be minimal signs with under 20 loss
• 50 and over blood loss usually pulseless and
  unconscious
• Any injured patient who is cool and tachycardic
  is in shock until proven otherwise!!!

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Shock recognition 2

• Anxiety, fear, and cold weather can all mimic
  early shock.
• Increased heart rate
• Decreased capillary refill
• Pale, cool extremities
• Since the consequences of preventing
  decompensated shock are so high, sometimes all
  you have is the history.

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Shock 3

• First sign is loss of capillary refill
• Hold for 5 release for 3
• gt 4 critical gt 2 but lt 4 transition to critical
• Next comes a decrease in pulse pressure
• (Systolic - diastolic)
• May feel this as a rapid, thready pulse
• Drop in Blood Pressure is a late sign
• Systolic should be gt 70 2(age in years) but
  it rarely falls below this until 25-30 blood
  loss
• Altered mental status may be from shock
• Should recognize parents!!!!
• Shock may cause irritability or lethargy

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C Circulation and Shock Control

• If cool, clammy, thready pulse, then already over
  25 of blood volume lost
• External Bleeding - usually obvious
• Use a little gauze and a big finger
• Internal Bleeding
• Mechanism of injury very important
• Physical findings not clear
• Need definitive treatment (IVs Surgery)

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Stopping Bleeding

• Failure to control external hemorrhage using
  direct pressure. I have seen any number of
  cases, particularly with scalp lacerations (but
  also extremity arterial hemorrhages) where
  prehospital personnel apply "mounds and mounds"
  of gauze. I have seen many patients lose
  excessive amounts of blood into these dressings,
  sometimes to the point of developing
• hypotension. I like to emphasize the importance
  of using a small amount of gauze, and firm
  continuous direct pressure. I tell them to
  assign one
• person to this job .
• Michael A. Shapiro MD Vice Chairman
• Dept of Emergency Medicine
• Women's Christian Association Hospital
• Jamestown, NY 14701

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Treating Shock

• 1) Hypotension means the child is in shock, but
  children are often in shock without hypotension.
  An agitated child with cool skin is in shock
  until proven otherwise at the hospital.
• 2) Any signs of shock require fluid
  administration. For Basic EMTs this means rapid
  transport or meeting an ALS crew en route.
• 3) PASG or MAST are out, no good, dangerous in
  children, especially if the abdominal compartment
  is inflated because of impingement upon the
  diaphragm. The leg compartments can be used for
  stabilizing femur fractures or air splints.

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WORK QUICKLY Let me say that I have been
in EMS for three years, and have been a paramedic
since March. One of the strongest points people
forget to about trauma is time. (Platinum 10
Minutes, and the Golden Hour are the phrases used
to describe the time criteria'.) In any trauma,
pediatric or adult, the ideal setting is for the
patient to be in surgery within one hour (The
Golden Hour) of their injuries. It is stressed
in our training that scene time be less than 10
minutes to remain under the curtain of that
hour. I think that you need to stress that. In
many medical settings, the ambulance can do
almost as much as an ED, but in trauma, the
patient needs more than what we can provide -
namely surgery. Time is the most critical factor
in patient survival.
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D Disability

• Downs syndrome and large headed children may
  have cervical spine injury from apparently
  minimal trauma.
• Ideal immobilization is hard collar, full spine
  board with soft spacers and head straps.
• Secure child across forehead, collar, shoulders
  and pelvis
• Make sure chest can rise!!
• May need blunt under torso under age 8 to prevent
  neck flexion on the spine board.
• Injured brains need adequate oxygen !

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Quickie neuro eval - D

• Assessment
• 1) Reassess, reassess, reassess. The only way to
  know if your patient is getting better or worse
  is to be diligent in evaluation.
• 2) Use the AVPU system (alert, responds to
  verbal, responds to pain, unresponsive) in
  children. The GCS score is time consuming if
  you're using your memory and doesn't "paint a
  picture" of the patient. Avoid "lethargic"
  "semi-conscious" etc.. because everyone has
  different meanings with these terms.
• 3) Remember what children of various stages are
  capable of doing (a two year old may not talk
  yet, especially if frightened).

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E Exposure

• Children lose heat quickly
• Keep them covered
• If you are comfortable, its probably too cold
  for them

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Exposure- Staying Warm
5. Keeping the patient warm. (especially if
this winter is at all like last winter) 6. To
emphasize the above point in burn victims. Cool
wet dressings may feel good on a small isolated
burn, but with involvement of greater body
surface area, priorities become maintaining
temperature and preventing fluid loss which can
be best accomplished with a dry sterile dressing.
Many of our local EMTs have asked about the new
"gel-packs" that are available. To be honest,
they sound great, but I have little information
about them specifically and am in the process of
reading up on them.
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SAMPLE History for Trauma

• S Signs and Symptoms
• A Allergies
• M Medications currently taken
• Grab pill bottles
• P Pertinent Past/ Present Illnesses
• L Last Meal
• E Events/ environment related to the
  injury

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Always think about child abuse when you see an
injured child.
. Many EMTs have asked about child abuse. They
feel that those of us in the hospital and ED are
leaving them out in the cold, particularly at
smaller hospitals where they do not have a "Child
protective services team" who become involved.
Many tell me they have heard comments such as
"Oh, good. You are filing the DSS report, so I
don't have to". This is something that needs to
be addressed at individual hospitals and ED's.
Hopefully we can assure our EMS providers that
they will not be alone in filing and following up
with these cases. Common cause of
injuries in children. 50 of second hospital
visits for these children result in death
EMT awareness of signs and symptoms of abuse
would help identify cases.
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Summary

• The more critical the patient, the more important
  it is to focus on the basics IN ORDER
• Airway
• Oxygen
• Good mask and bagging
• Proper immobilization
• Keep them warm
• Speed of transport is a key issue.
• Assign roles ahead of time to keep
  responsibilities clear.

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Rewards from the job

• Thank you for your time and attention

External rewards are scarce in this
field. Knowing you did right by your patients
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Where to get more information

• Other training sessions
• Andrew W. Stern
• NYSDOH Emergency Medical Services
• 1 Commerce Plaza, Room 1126 (518)
  474-2219
• Dr. Jane Ball 301-650-8066 peds EMS
• NERA 310-328-0720
• SafeKids 202-884-4993
• Web sites
• Global Emergency Medicine Archives
• Website of Trauma

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Resources

• For anyone interested, the Pediatric Airway
  Management Project headed by Dr. Marianne Gausche
  just completed a curriculum for a 2-day pediatric
  airway management course for paramedics (ALS),
  and another course for EMT's (BLS), complete with
  slides for lectures and videos. This is the
  curriculum used to train all of LA and Orange
  county's paramedics airway management in children
  by the project. The curriculum emphasizes many
  facets of ALS, not just intubating.
• The curriculum is available through the National
  EMSC Resource Alliance (NERA) at 310-328-0720
• Kelly D. Young, MD Dept of
  Emergency Medicine
• Harbor-UCLA Medical Center, Box 21
  
• Fax [phone] West Carson
  Street
• Torrance, CA 90509 mail ekyoung_at_harbor4.hum
  c.edu

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Acknowledgements

• This presentation has been adapted from a
  powerpoint presentation developed by
• Bruce Nayowith MD
• Ellenville Community Hospital ER
• We gratefully acknowledge his willingness to
  share this information with others.