CCP 346 Single and Multi-System Trauma Flashcards
In what neonatal/infant/paediatric patient cohorts do experts suggest atropine as pretreatment for RSI
- Children ≤1 year
- Children in shock
- Children <5 years receiving succinylcholine
- Older children receiving a second dose of succinylcholine
Atropine Dose: 0.02 mg/kg IV without a minimum dose (maximum single dose 1 mg; if no IV access, can be given IM).
Succinycholine dosing for neonatal/infant/paediatric patients
- Infants and children ≤2 years: 2 mg/kg IV
2. older children and adolescents: 1 to 1.5 mg/kg IV (if IV access unobtainable, can be given IM, dose: 4 mg/kg)¶.
DOPES mnemonic for decompensation after intubation
D: Dislodgement/displacement of the tube O: Obstruction of tube P: Pneumothorax E: Equipment failure (ventilator malfunction, oxygen disconnected or not on) S: stacked breaths
The “7 P’s” of RSI
- Preparation: 10 minutes before intubation
- Pre-oxygenation: 5 minutes before intubation
- Pre-intubation optimization: 3 minutes before intubation (may be longer depending on necessary interventions and time available)
- Paralysis with induction: Induction
- Protection: 30 seconds after induction
- Placement (Intubation): 45 seconds after induction
- Post-intubation management: 60 seconds after induction
Age-based formula for selecting UNCUFFED endotracheal tube size (internal diameter in mm)
4 + (age in years/4)
Age-based formula for selecting CUFFED endotracheal tube size (internal diameter in mm)
*this formula only valid for children 2 years of age and older
3.5 + (age in years/4)
for children <1 years of age Use 3.0 mm internal diameter cuffed endotracheal tube
for children 1 to <2 years of age Use 3.5 mm internal diameter cuffed endotracheal tube
flow rate for apneic oxygenation via NC in peds RSI
1 L/kg (max 15 L/min)
what is the importance/significance of Preoxygenation in pediatric RSI
- Preoxygenation is tres important for infants and children
- Compared with adults, young patients have a ↑ oxygen consumption rate with ↓FRC and alveolar volume
- oxygen desaturation occurs much more rapidly in apneic kids
describe the considerations of head injury in neonates/infants
- Infants have relatively larger heads and are more likely to land head-first after a fall.
- Open fontanels provide a “release” for ↑ ICP such that symptoms may be a less reliable indicator of severe injury.
- Incomplete ossification of the skull and overlap with birth-related cephalohematomas complicates physical exam and radiograph interpretation.
- Unlike older patients, a young infant can lose enough blood from an intracranial hemorrhage to result in shock.
- Abusive head trauma (previously known as shaken baby syndrome) is associated with subdural hemorrhage
describe the considerations of Thoracic Injury in neonates/infants
- Due to their flexible, cartilaginous skeleton, significant internal thoracic trauma can occur without external signs or rib fractures.
- Pulmonary contusions are more common than other chest injuries
describe the considerations of Abdominal Injury in neonates/infants
- The liver and spleen are located below the protective rib cage, and a lack of protective fat and musculature results in ↑ injury to these organs
MSK fracture patterns concerning for non-accidental injury in neonates/infants
- Classic metaphyseal lesions (“corner fractures” or “bucket handle fractures” = injury to the growth plate at end of a long bone)
- posterior rib fractures
- multiple unexplained fractures
- any unexplained fracture in a non-ambulatory infant
simple trick for calculating appropriate SBP for children 1-10 y old
💎💎💎 MEGA PEARL 💎💎💎
70 mm Hg + (2 age in years)
blood pressure values (fifth percentile) for SBP at various ages
These are the minimal systolic blood pressures allowed head-injured patients
SBP 70 mm Hg in children <1 y old.
SBP 70 mm Hg + (2 age in years) for children 1-10 y old.
SBP 90 mm Hg in children ≥10 y old.
most common MOI of pediatric head injury-related deaths
MVA’s
describe The Monro-Kellie doctrine
don’t hate, i know you think you’re too good for this but you’re not
- The Monro-Kellie doctrine states that once the fontanelles are closed, the cranial vault volume is fixed, and changes in volume only occur at the expense of another source.
- The volume of the skull comprises CSF (10%), blood (10%), and brain parenchyma (80%).
- Cerebral perfusion pressure (CPP) must be maintained to ensure that there is no resultant ischemic brain injury, where: CPP = MAP - ICP.
Discuss BP goals in peds TBI
👊👊👊CORE CONTENT👊👊👊
- targeting an age-appropriate SBP or MAP goal ensures adequate cerebral perfusion.
- The Brain Trauma Foundation guidelines and the American College of Surgeons define pediatric (age 1-10) hypotension as SBP <70 + (age in years 2)
- for peds >10yo target a SBP of 90mmHg per BTF guidelines
TARGET NORMAL SBP/MAP FOR AGE AS YOUR GOAL
discuss vasopressor choice for maintaining MAP goals in Peds TBI (assuming they are adequately fluid loaded)
- no large studies comparing the effectiveness of different vasopressors.
- In one single-center retrospective cohort study of children 0-17 y old with moderate-to-severe TBI norepinephrine was associated with a higher CPP and lower ICP at the 3-hour mark.
discuss hyperosmolar therapy in Peds TBI
- Provide hyperosmolar therapy with HTS or mannitol
- HTS is superior to mannitol in adult patients with severe TBI and should primarily be used for pediatric patients
- 3% HTS 2-5 mL/kg intravenously over 10-20 min can be given through a peripheral IV
- Mannitol 0.5-1.0 g/kg IV works indirectly to ↑ serum osmolarity by causing osmotic diuresis. This approach can potentially ↓ the patient’s hemodynamic status and should be avoided in patients who are hypotensive
- Avoid serum Na+ >170 mEq/L
- Serum osmolarity should be maintained <360 mOsm/L.
discuss NODESAT/APOX for peds RSI
- apneic oxygenation can ↓ peri intubation hypoxemia
2. flow rate of 1L/kg to max 15L via NC
discuss Compensatory mechanisms (tachycardia and vasoconstriction) in peds hypovolemic shock
- Compensatory mechanisms (tachycardia and vasoconstriction) may maintain blood pressure in pediatric trauma patients until 40% of the blood volume has been lost, at which point decompensation abruptly occurs.
- DO NOT RELY ON HYPOTENSION ALONE TO IDENTIFY SHOCK
discuss the utility of emergency department (ED) thoracotomy following blunt traumatic arrest in children <15 y of age
- There are ZERO documented survivors from emergency department (ED) thoracotomy following blunt traumatic arrest in children <15 y of age.
- DON’T TRANSPORT PEDIATRIC BLUNT TRAUMATIC ARRESTS, THEY ARE DEAD
discuss the E (exposure) component of your paediatric ABCDE trauma evaluation
- Undress to assess completely for injuries.
- Log roll to evaluate back while maintaining spinal immobilization.
- Children have a large surface area-to-volume ratio and high metabolic demand, placing them at greater risk for hypothermia and coagulopathy. Therefore, remove wet clothing and warm up the child as soon as possible.
“HEENT” component of the secondary survey assessment in peds trauma
- Evaluate for: Bulging fontanel, scalp hematomas, lacerations, midface instability, auricular and septal hematomas, hemotympanum, cerebrospinal fluid leak, loose teeth
- Young children with open sutures and fontanelles may have delayed signs of ↑ ICP after significant head injury.
“neck” component of the secondary survey assessment in peds trauma
- Evaluate for: Tracheal deviation, penetrating wounds, seatbelt sign, crepitus, midline c-spine tenderness, step-offs
- Due to their relatively large head and high cervical fulcrum, children <8 y of age are prone to upper c-spine injuries, which may present without neurologic deficit.
“chest” component of the secondary survey assessment in peds trauma
- Evaluate for: Breath sounds, tenderness, instability, crepitus, abnormal breathing pattern
- Compliant chest walls make pulmonary contusions without rib fractures common in children.
“abdominal” component of the secondary survey assessment in peds trauma
- Evaluate for: Tenderness, peritonitis, seatbelt sign
- The pediatric spleen and liver are large, anterior, poorly protected, and thus prone to injury (even without external signs of trauma).
“renal” component of the secondary survey assessment in peds trauma
- Evaluate for: Perineal lacerations/hematomas, blood at urethral meatus, pain on palpation of pelvic ring, priapism
- Children’s kidneys are less protected, more mobile, and more susceptible to deceleration injury than adult kidneys
“MSK” component of the secondary survey assessment in peds trauma
- Evaluate for: Deformity, pain with palpation or range of motion, firm compartments
- Fractures are more common than ligamentous injuries in children
“Neurologic” component of the secondary survey assessment in peds trauma
- Evaluate for: Motor or sensory deficits, pupil size and reactivity, mental status
- Elasticity of the vertebral column predisposes children to spinal cord injury without fracture.
“Skin” component of the secondary survey assessment in peds trauma
Evaluate for: Lacerations, bruises, thermal injuries
when do you initiate massive transfusion protocol in Peds trauma
- Initiate pediatric MTP when 40 mL/kg of blood products have been, or are expected to be, transfused within 24 h.
- The optimal ratio of blood products is unknown. A ratio of 1:1:1 or 1:1:2 of plasma, platelets, and pRBCs is reasonable
discuss analgesia in peds trauma
Pain control is often overlooked in pediatric trauma; treat pain early and aggressively
discuss family engagement during paediatric resuscitation
- Allow parents to be at the bedside during resuscitation, with a team member explaining interventions.
- this leads to better psychosocial outcomes for family
Waddell’s Triad
occurs when a child is struck by an automobile at high speed and consists of a femur fracture, intra-aortic or intra-thoracic injury, and head injury
discuss the role of CXR in peds trauma
CXR is indicated for an abnormal thoracic examination, hemodynamic instability, or severe injury mechanism or for after endotracheal intubation or thoracostomy tube placement.
formula for calculating ETT size (cuffed and uncuffed)
([Age/4] + 4) = uncuffed
([age/4] + 3.5) = cuffed
discuss the role of Focused assessment with sonography for trauma (FAST) in children
- FAST is less accurate in children than adults, with a reported sensitivity of 20-80% and specificity of 80-95%
- (FAST) should not be used in isolation to screen for intra-abdominal injury in children
- despite this, E-FAST is still recommended in the evaluation of an unstable child following trauma
discuss the role of Permissive (or controlled) hypotension as part of a damage control resuscitation approach in children
- No data exist to support the use of permissive hypotension in children.
- In contrast, volume expansion with 10-40 mL/kg of crystalloid until blood products are available is recommended for children in compensated shock
- resuscitate to normal targets
discuss the optimal ratio of blood products in pediatric trauma transfusion
- The optimal ratio of blood products is unknown.
2. A ratio of 1:1:1 or 1:1:2 of plasma, platelets, and pRBCs is reasonable
discuss the role of TXA in paediatric trauma
- CRASH-2 excluded children <16 y of age.
- A retrospective study of early TXA use in pediatric trauma showed a similar mortality benefit with no adverse events
- This preliminary evidence supports the use of TXA in children with ongoing severe hemorrhage, although further study is needed.
discuss the role of pediatric trauma centers in caring for the injured child
- Severely injured children should receive definitive care in pediatric trauma centers when possible.
- Multiple studies have shown better outcomes when injured children receive care within an organized trauma system, at higher level (1 or 2) centers compared with lower level centers or non-designated facilities
- Thus, severely injured children should be transported to pediatric trauma centers from the field when possible
Sizing an uncuffed ETT
age/4 + 4
Sizing a cuffed ETT
age/4 + 3.5
PALS Estimation for ETT Depth (for >1yo)
(age in yrs/2) + 12
how to calculate appropriate in-line suction catheter size
- Multiply the ETT size (ID) by 3 to find a sxn catheter that will occlude 100% of the ETT.
- Multiply that by 2/3 to acquire the appropriate sxn catheter [ie: for a 4.0 ETT, 4.0 x 3 = 12Fr (occludes 100% of the ETT) 12Fr x 2/3 = 8Fr (for 2/3rd occlusion of the ETT)]
- In short, ETT size x 2 = appropriate sxn catheter size in Fr
What are the indications of emergency C-section in maternal trauma?
- Severe fetal distress.
2. Loss of maternal pulse, with C-section initiated within 4 minutes.
needle cric procedure
- place a large needle catheter (eg, 14-gauge) into the cricothyroid membrane.
- The needle is then removed, and the catheter can either be connected to a commercially available oxygen tubing set-up (eg, ENK modulator, Cook Inc.) with oxygen flow set at 1 L/min for every year of age, or to the adaptor from a 3.0 mm ETT, which is then connected to BVM
discuss FAST in obstetrical trauma
The FAST is less sensitive for free fluid in the pregnant patient than in non-pregnant patients.
Sensitivity decreases with increasing gestational age, likely due to altered fluid flow within the abdomen
FAST is most sensitive in the 1st trimester and least in the 3rd. thought to be d/t compression of the paracolic gutters and altered intra-abdominal fluid flow in late pregnancy
Oxygen saturation goals in pregnant trauma patients
O2 supplementation to maintain saturation >95%.
main goal in obstetric trauma
stabilize the mother first, as fetal outcomes are directly correlated with maternal resuscitation
timeline for perimortem cesarean delivery
ideally within 4 min if the fetus is viable.
discuss thoracostomy in obstetric trauma
consider placing the thoracostomy tube one rib space higher because of diaphragm elevation from the gravid uterus
this also applies to angiocaths/Turkell caths for chest decompression at the mid-axillary line
2nd intercostal space mid clavicular is still fine
1 and 2 most common causes of trauma in pregnancy
1 = Domestic violence (estimated incidence of 8,307 per 100,000 live births)
discuss the risk of retroperitoneal hemorrhage in pregnant trauma patients
Increased pelvic blood flow during pregnancy results in an increased risk of retroperitoneal hemorrhage
discuss Placental abruption in pregnant trauma patients
- <0.4% of minor trauma cases and 4.4%-9.4% of pregnant women with more significant trauma
- one of the most significant determinants of maternal morbidity (increased risk of cesarean delivery, postpartum hemorrhage, and transfusion) and fetal morbidity and mortality (preterm birth, intrauterine growth retardation, low birth weight, cerebral palsy)
- Increased risk (up to 40%) in patients with severe trauma requiring hospitalization and severe trauma as defined by ISS ≥12
- In MVCs, shear force, coup-contrecoup, and maternal body folding can result in a marked increase in intra-abdominal pressure, leading to placental abruption
discuss changes to location of intra abdominal organs in the pregnant trauma patient
The gravid uterus pushes the liver and spleen against the ribs and elevates the bladder, rendering these organs more prone to injury in trauma
discuss vital sign changes in maternal hemorrhagic shock in trauma
- Tachycardia and hypotension may be late signs due to increased maternal blood volume.
- Maternal vital signs and perfusion may be preserved to maintain uterine perfusion.
- signs of shock may not be as obvious in maternal hemorrhagic shock, and fetal distress may be the first indicator
Discuss considerations for airway management in the pregnant trauma patient
All pregnant patients are considered a “difficult airway” from both an anatomical and physiological perspective
- more difficult airway visualization d/t hormonal effects → increased vasculature and edema in the upper airway
- decreased FRC (almost 40% near term) d/t the higher oxygen demand and upward displacement of the diaphragm (>20 wk of gestation), which → rapid desaturation during periods of apnea
- reduced esophageal sphincter tone and delayed gastric emptying → increased risk of aspiration
ADEQUATE PRE-OX IS ESSENTIAL during preparation for intubation! Pregnant pt’s are at increased risk of hypoxemia d/t ↓FRC and ↑O2 consumption resulting from demands of the fetus and maternal metabolic processes.
Intubation should be performed by THE MOST EXPERIENCED laryngoscopist. Prolonged intubation attempts should be AVOIDED.
Discuss considerations for the assessment and management of hemorrhagic SHOCK in the pregnant trauma patient
- The assessment of hemorrhagic shock in a pregnant patient is complicated by the presence of physiological anemia, which reduces the hematocrit level by 30%.
- Traumatic injury to the pelvic vasculature can → rapid exsanguination d/t the dilated pelvic vasculature during pregnancy.
- Because the uterine blood flow is not autoregulated, maternal hypotension can lead to fetal distress.
- During resuscitation, manual left uterine displacement should be performed to minimize the effect on cardiac output d/t compression of the IVC by the gravid uterus. Manual left uterine displacement should be used rather than a lateral tilt of the patient for optimal resuscitation
golden rule of resuscitating a pregnant trauma patient
the best fetal resuscitation is good maternal resuscitation
discuss compression of the great vessels by the gravid uterus
- The weight of the gravid uterus falls posteriorly in the supine patient, and may compress the IVC and aorta causing reduced venous return and resultant hypotension.
- placing the patient in 15 – 30 degrees of left lateral tilt may improve CO by 30-50%,
- In one study of manual leftward displacement versus lateral tilt in patients undergoing cesarean section, leftward displacement was associated with less hypotension and decreased pressor requirements
