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Pediatric Trauma

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1 Killer of children after neonatal period. Priorities same as adult ABC's ... OR, 3 x tube size. Pediatric Intubation Considerations. Place in the sniffing position ... – PowerPoint PPT presentation

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Title: Pediatric Trauma


1
Pediatric Trauma
  • EMS Professions
  • Temple College

2
Pediatric Trauma
  • 1 Killer of children after neonatal period
  • Priorities same as adult ? ABCs
  • Children not small adults

3
Pediatrics
  • Prehospital providers often have
  • Limited pediatric patient contacts
  • Limited knowledge, training, and experience
    specifically directed towards pediatrics
  • Many other healthcare providers are similarly
    affected
  • Children are not little adults!!!

4
Age Classification
  • Neonate Birth to 1 month
  • Infant 1 - 12 months
  • Toddler 1 - 3 years
  • Preschooler 3-6 years
  • School age 6 - 12 years
  • Adolescent 12 - 18 years

5
How Does Serious Injury Occur in Children?
  • Function of Age Development
  • Does not yet understand harm or risk
  • Does not yet understand cause and effect
  • Feeling of invincibility
  • Injury is the leading cause of death in children
    and young adults
  • 1/2 of the injuries result from motor vehicles

6
Common Emergencies By Age
  • Neonate Infection, Neglect
  • Infant Infection, Neglect, Abuse
  • Toddler Poisoning, Fall
  • Preschool Poisoning, Fall, Pedestrian
  • School Age Pedestrian Fall, Recreation
  • Adolescent MV, OD/Poison, Recreation

7
Pediatric Trauma
  • Traumatic injuries often involve blunt trauma to
    the head
  • Drowning leading cause of death
  • Pedestrian leading cause of death 5 - 9 years
  • Injuries from Falls, Motorized vehicles,
    Bicycles, Sports
  • Mechanism Kinematics are critical
  • serious injuries in a child may not be evident
    initially

8
Mechanisms of Pediatric Injury
Waddells Triad
9
Mechanisms of Pediatric Injury
10
Pediatric AssessmentFirst Impression
  • Pediatric Assessment Triangle
  • Appearance - mental status, body position, tone
  • Breathing - visible movement, effort
  • Circulation - color

Appearance
Breathing
Circulation
11
First Impression
  • Consider the possibility of serious injury if
  • the injured child has altered mental status or
    appears behaving inappropriately initially
  • there is significant mechanism regardless of
    whether there are obvious injuries
  • the injured child has evidence of poor systemic
    perfusion

12
Pediatric AssessmentInitial Assessment
  • Pediatric Assessment Triangle
  • Appearance - AVPU
  • Breathing - airway open, effort, sounds, rate,
    central color
  • Circulation - pulse rate/strength, skin
    color/temp, cap refill, BP (? use at early ages)

Appearance
Breathing
Circulation
13
General Assessment
  • Observations of the child, family and environment
    are critical!
  • Form a first impression of the childs status
  • Maintain distance
  • Talk to parents. Keep child with parent
  • Is the behavior appropriate for the childs age?
  • Mental status and ABCs are critical!

14
Focused Exam
  • Vitals signs are age dependent
  • Use pediatric vital signs charts
  • Systemic perfusion
  • Best evaluated by presence and volume of
    peripheral pulses and mental status
  • Low output shock weak, thready, narrow PP
  • High output shock bounding, wide PP
  • Loss of central pulses is a premorbid sign

15
Focused Exam
  • Skin
  • ? skin perfusion may be early sign of shock
  • Skin/cap refill dependent on ambient temp
  • Mottling, pallor, delayed cap refill and
    peripheral cyanosis often indicate poor skin
    perfusion
  • Severe vasoconstriction gray/aschen in newborns
    and pallor in older children

16
Focused Exam
  • Mental Status
  • Lost muscle tone, Seizure, ? Pupil size
  • Confusion, Irritability/Agitation, Lethargy
  • Tachycardia may be an unreliable sign
  • BP Estimates ( 1 year)
  • Median BP 90 mm Hg (2 x age years)
  • Lower Limit BP 70 mm Hg (2 x age yrs)

17
Focused History Exam
  • History of the Present Injury
  • Family/Witness/Caretaker
  • Older child
  • Pertinent Past Medical History
  • Often none or not obtainable
  • Immediately Treat Life-Threats
  • Some exceptions (epiglottitis, febrile seizure)

18
Anatomical Differences
  • Larger occipit increases neck flexion
  • Large, floppy epiglottis
  • Larger tongue relative to size of oropharynx
  • Children younger than 10 have narrowest portion
    of airway below vocal cords (subglottic)
  • Larynx is anterior
  • As a result
  • Due to airway angles, straight blade is more
    useful
  • difficult to lift and control epiglottis with
    blade
  • Subglottic edema, constriction or compression
    results in significant airway compromise
  • Need to position yourself very low during
    intubation

19
Pediatric Intubation Considerations
  • Equipment ( 2 years old)
  • ET tube size mm I.D. (Age in years ? 4) 4
  • Term Newborn 3.0 or 3.5
  • Premie 2.0, 2.5 or 3.0
  • 1 year 3.5 or 4.0
  • 2 years 4.0 or 4.5
  • Uncuffed tubes at approx. 8 years and younger
  • straight blade
  • ET tube depth (Age in years ? 2) 12
  • OR, 3 x tube size

20
Pediatric Intubation Considerations
  • Place in the sniffing position
  • Manually immobilize head in suspected C-spine
    injury
  • A small folded towel may need to be placed
  • Under the head of the child 2 years
  • Under the shoulders of the child
  • Move the tongue out of the way!
  • Lift the epiglottis directly with the blade

21
Pediatric Intubation Considerations
  • If bradycardia ensues, ventilate adequately
    before re-attempting intubation
  • Pretreat with Atropine 0.02 mg/kg if using
    neuromuscular blockers or sedation
  • Consider NG or OG tube if excessive gastric
    distention was created by BVM ventilations

22
Pediatric Intubation Considerations
  • Intubation complications - DOPE
  • D Dislodgment
  • O Obstruction
  • P Tension Pneumothorax
  • E Equipment failure
  • FREQUENTLY Reassess!
  • Little movement is required to inadvertently
    extubate the pediatric patient

23
Pediatric Intubation Considerations
  • Tubes migrate with head movement
  • Secure tube well
  • Immobilize head in neutral position
  • Never let go of tube
  • ET tubes wind up in mainstem bronchi, due to
    short trachea

24
Surgical Airways
  • Surgical cricothyrotomy is not recommended in
    children
  • Needle cricothyrotomy is preferred for children,
    if required at all

25
C-Spine Immobilization
  • Many experts now oppose the transport of an
    injured child in his/her car seat
  • The car seat may have been damaged in the
    accident
  • It is difficult to adequately examine the child
  • It is difficult to adequately immobilize the
    C-spine
  • KED is frequently used for this purpose
  • A rolled towel may be used when a properly sized
    C-collar is not available
  • Remember the large occiput of the small child

26
Breathing
  • High metabolic rates Low reserve capacity
    result in high sensitivity to airway/breathing
    problems
  • Oxygenate and ventilate aggressively

27
Breathing
  • Adequate ventilation and oxygenation are crucial
    to the seriously injured child
  • Higher demand for oxygen normally as compared to
    adults
  • Head injuries require adequate oxygenation to
    minimize secondary injury
  • At a minimum, supplemental oxygen is indicated

28
Airway Management
  • Simple supplemental oxygen is usually adequate in
    the spontaneously breathing child
  • If the child does not tolerate a mask or nasal
    cannula, blow-by oxygen is better than no oxygen
  • Proceed slowly in the anxious or distrusting child

29
Airway Management
  • BVM ventilation often is sufficient and
    preferable over ETT
  • Complication of BVM ventilation gastric
    distention
  • May interfere with diaphragm movement
  • Increase risk of emesis aspiration

30
Circulation
  • Assessment of the BP is seldom useful
  • Assess BP last. Use other assessment findings.
  • Hypotension will be a very late sign in the
    pediatric shock patient
  • Hypertension may be subtle in the head injured
    patient
  • Serious injuries may not be obvious externally

31
Circulation
  • Rapid control of external bleeding
  • Essential due to small blood volume
  • Efficient compensation for shock may lead to
    sudden decompensation and onset of irreversible
    shock

32
Circulation
  • BP monitoring - poor way to detect shock
  • Assess rate, quality of peripheral pulses
  • Skin color and temperature
  • LOC (Silence is not Golden)
  • Capillary refill

33
Shock
  • Children will not tolerate respiratory failure or
    shock
  • Shock may be seen as tachycardia and poor skin
    perfusion or mental status
  • Children have excellent compensatory mechanisms -
    UP TO A POINT!
  • Then they crash
  • Hypotension is an ominous sign

34
Shock
  • Bradycardia, hypotension or irregular
    respirations are late and ominous signs!!!
  • Treatment
  • Oxygenation/Ventilation
  • Fluids 20 cc/kg as a bolus (not wide open
    infusion)
  • Additional vascular access options intraosseous
    and umbilical vein (newborn)

35
Head Trauma
  • Major cause of pediatric trauma
  • Large heads
  • Thin skulls
  • Poor muscle control
  • Diffuse edema more common than intracranial
    hematomas

36
Head Trauma
  • Monitor for Signs of ICP
  • AVPU
  • Pupils
  • Vomiting
  • Cushing Response
  • Controlled hyperventilation if ? ICP
  • Resuscitate hypovolemic shock aggressively

37
Spinal Trauma
  • Rare. Usually at C1, C2, C3. Dislocations more
    common.
  • Suspect if trauma involves
  • Sudden deceleration
  • Head injuries
  • Decreased LOC
  • If Spinal immobilization is thought, then do it.
  • Resist temptation to pick up child and run.

38
Chest Trauma
  • Second only to head trauma as cause of trauma
    death
  • 90 of pedi chest trauma - blunt trauma
  • Chest wall is pliant. Rib fracture is uncommon
  • Extensive intrathoracic injury without rib Fx

39
Chest Trauma
  • Mobile mediastinum - do not tolerate tension
    pneumothorax well
  • Limited respiratory reserve
  • Poor tolerance of chest injury

40
Abdominal Trauma
  • Most common from of pediatric trauma.
  • Usually blunt
  • Liver, spleen injury more common than in adults
  • High, broad costal arch
  • Relatively larger organs

41
Abdominal Trauma
  • Tenderness
  • Significant trauma UPO
  • Distention
  • Significant trauma UPO
  • May also be due to air swallowing
  • Early NG tube placement may avoid unnecessary
    surgery

42
Extremity Trauma
  • Priorities ABCs
  • Orthopedic trauma never severe enough to warrant
    attention before head, chest, abdominal injury
  • Pliant pedi bones absorb/ dissipate significant
    force.
  • Greenstick Fx common
  • Treat painful, tender or favored extremities as Fx

43
Extremity Trauma
  • Epiphyseal plate frequently involved
  • 50 have growth abnormalities
  • Neurovascular injury - most common injury
  • Humerus
  • Femur
  • Assess distal pulse, skin color, temp, cap
    refill, motor/sensory function

44
Burns
  • 50 burn admissions
  • 33 burn deaths
  • Large BSA increases fluid loss
  • Large BSA increases heat loss - hypothermia
  • Smaller airway - increased airway burn difficult

45
Burn Resuscitation
  • LR with 4cc/kg/BSA
  • 50 in first 8 hours
  • 25 in second 8 hours
  • 25 in third 8 hours

46
NG Tube
  • Need to be placed early
  • Shock may be secondary to decreased venous return
    from distended stomach pressing under diaphragm

47
Management
  • Airway
  • 100 O2. Consider early ventilation.
  • Prevent Hypothermia
  • Large surface/volume ratio - increase heat loss
  • Cover with blanket
  • Consider effects of cold IV fluids

48
Fluid Replacement
  • IVs should be enroute to hospital
  • Warm fluids
  • After 60cc/kg without reversal, need blood
    replacement

49
Management
  • MAST/PASG
  • Legs only initially
  • If child needs abdominal compartment also
    intubate and ventilate
  • Elastic ace bandages or air splints can be used
    on legs if child too small for MAST
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