CCP 346 Single and Multi-System Trauma

Question 1

In what neonatal/infant/paediatric patient cohorts do experts suggest atropine as pretreatment for RSI

Answer 1

1. Children ≤1 year
2. Children in shock
3. Children <5 years receiving succinylcholine
4. 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).

Question 2

Succinycholine dosing for neonatal/infant/paediatric patients

Answer 2

1. 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)¶.

Question 3

DOPES mnemonic for decompensation after intubation

Answer 3

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

Question 4

The “7 P’s” of RSI

Answer 4

1. Preparation: 10 minutes before intubation
2. Pre-oxygenation: 5 minutes before intubation
3. Pre-intubation optimization: 3 minutes before intubation (may be longer depending on necessary interventions and time available)
4. Paralysis with induction: Induction
5. Protection: 30 seconds after induction
6. Placement (Intubation): 45 seconds after induction
7. Post-intubation management: 60 seconds after induction

Question 5

Age-based formula for selecting UNCUFFED endotracheal tube size (internal diameter in mm)

Answer 5

4 + (age in years/4)

Question 6

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

Answer 6

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

Question 7

flow rate for apneic oxygenation via NC in peds RSI

Answer 7

1 L/kg (max 15 L/min)

Question 8

what is the importance/significance of Preoxygenation in pediatric RSI

Answer 8

1. Preoxygenation is tres important for infants and children
2. Compared with adults, young patients have a ↑ oxygen consumption rate with ↓FRC and alveolar volume
3. oxygen desaturation occurs much more rapidly in apneic kids

Question 9

describe the considerations of head injury in neonates/infants

Answer 9

1. Infants have relatively larger heads and are more likely to land head-first after a fall.
2. Open fontanels provide a “release” for ↑ ICP such that symptoms may be a less reliable indicator of severe injury.
3. Incomplete ossification of the skull and overlap with birth-related cephalohematomas complicates physical exam and radiograph interpretation.
4. Unlike older patients, a young infant can lose enough blood from an intracranial hemorrhage to result in shock.
5. Abusive head trauma (previously known as shaken baby syndrome) is associated with subdural hemorrhage

Question 10

describe the considerations of Thoracic Injury in neonates/infants

Answer 10

1. Due to their flexible, cartilaginous skeleton, significant internal thoracic trauma can occur without external signs or rib fractures.
2. Pulmonary contusions are more common than other chest injuries

Question 11

describe the considerations of Abdominal Injury in neonates/infants

Answer 11

1. 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

Question 12

MSK fracture patterns concerning for non-accidental injury in neonates/infants

Answer 12

1. Classic metaphyseal lesions (“corner fractures” or “bucket handle fractures” = injury to the growth plate at end of a long bone)
2. posterior rib fractures
3. multiple unexplained fractures
4. any unexplained fracture in a non-ambulatory infant

Question 13

simple trick for calculating appropriate SBP for children 1-10 y old

💎💎💎 MEGA PEARL 💎💎💎

Answer 13

70 mm Hg + (2 age in years)

Question 14

blood pressure values (fifth percentile) for SBP at various ages

These are the minimal systolic blood pressures allowed head-injured patients

Answer 14

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.

Question 15

most common MOI of pediatric head injury-related deaths

Answer 15

MVA’s

Question 16

describe The Monro-Kellie doctrine

don’t hate, i know you think you’re too good for this but you’re not

Answer 16

1. 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.
2. The volume of the skull comprises CSF (10%), blood (10%), and brain parenchyma (80%).
3. Cerebral perfusion pressure (CPP) must be maintained to ensure that there is no resultant ischemic brain injury, where: CPP = MAP - ICP.

Question 17

Discuss BP goals in peds TBI

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Answer 17

1. targeting an age-appropriate SBP or MAP goal ensures adequate cerebral perfusion.
2. The Brain Trauma Foundation guidelines and the American College of Surgeons define pediatric (age 1-10) hypotension as SBP <70 + (age in years 2)
3. for peds >10yo target a SBP of 90mmHg per BTF guidelines

TARGET NORMAL SBP/MAP FOR AGE AS YOUR GOAL

Question 18

discuss vasopressor choice for maintaining MAP goals in Peds TBI (assuming they are adequately fluid loaded)

Answer 18

1. no large studies comparing the effectiveness of different vasopressors.
2. 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.

Question 19

discuss hyperosmolar therapy in Peds TBI

Answer 19

1. Provide hyperosmolar therapy with HTS or mannitol
2. HTS is superior to mannitol in adult patients with severe TBI and should primarily be used for pediatric patients
3. 3% HTS 2-5 mL/kg intravenously over 10-20 min can be given through a peripheral IV
4. 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
5. Avoid serum Na+ >170 mEq/L
6. Serum osmolarity should be maintained <360 mOsm/L.

Question 20

discuss NODESAT/APOX for peds RSI

Answer 20

1. apneic oxygenation can ↓ peri intubation hypoxemia

2. flow rate of 1L/kg to max 15L via NC

Question 21

discuss Compensatory mechanisms (tachycardia and vasoconstriction) in peds hypovolemic shock

Answer 21

1. 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.
2. DO NOT RELY ON HYPOTENSION ALONE TO IDENTIFY SHOCK

Question 22

discuss the utility of emergency department (ED) thoracotomy following blunt traumatic arrest in children <15 y of age

Answer 22

1. There are ZERO documented survivors from emergency department (ED) thoracotomy following blunt traumatic arrest in children <15 y of age.
2. DON’T TRANSPORT PEDIATRIC BLUNT TRAUMATIC ARRESTS, THEY ARE DEAD

Question 23

discuss the E (exposure) component of your paediatric ABCDE trauma evaluation

Answer 23

1. Undress to assess completely for injuries.
2. Log roll to evaluate back while maintaining spinal immobilization.
3. 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.

Question 24

“HEENT” component of the secondary survey assessment in peds trauma

Answer 24

1. Evaluate for: Bulging fontanel, scalp hematomas, lacerations, midface instability, auricular and septal hematomas, hemotympanum, cerebrospinal fluid leak, loose teeth
2. Young children with open sutures and fontanelles may have delayed signs of ↑ ICP after significant head injury.

Question 25

“neck” component of the secondary survey assessment in peds trauma

Answer 25

1. Evaluate for: Tracheal deviation, penetrating wounds, seatbelt sign, crepitus, midline c-spine tenderness, step-offs
2. 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.

Question 26

“chest” component of the secondary survey assessment in peds trauma

Answer 26

1. Evaluate for: Breath sounds, tenderness, instability, crepitus, abnormal breathing pattern
2. Compliant chest walls make pulmonary contusions without rib fractures common in children.

Question 27

“abdominal” component of the secondary survey assessment in peds trauma

Answer 27

1. Evaluate for: Tenderness, peritonitis, seatbelt sign
2. The pediatric spleen and liver are large, anterior, poorly protected, and thus prone to injury (even without external signs of trauma).

Question 28

“renal” component of the secondary survey assessment in peds trauma

Answer 28

1. Evaluate for: Perineal lacerations/hematomas, blood at urethral meatus, pain on palpation of pelvic ring, priapism
2. Children’s kidneys are less protected, more mobile, and more susceptible to deceleration injury than adult kidneys

Question 29

“MSK” component of the secondary survey assessment in peds trauma

Answer 29

1. Evaluate for: Deformity, pain with palpation or range of motion, firm compartments
2. Fractures are more common than ligamentous injuries in children

Question 30

“Neurologic” component of the secondary survey assessment in peds trauma

Answer 30

1. Evaluate for: Motor or sensory deficits, pupil size and reactivity, mental status
2. Elasticity of the vertebral column predisposes children to spinal cord injury without fracture.

Question 31

“Skin” component of the secondary survey assessment in peds trauma

Answer 31

Evaluate for: Lacerations, bruises, thermal injuries

Question 32

when do you initiate massive transfusion protocol in Peds trauma

Answer 32

1. Initiate pediatric MTP when 40 mL/kg of blood products have been, or are expected to be, transfused within 24 h.
2. 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

Question 33

discuss analgesia in peds trauma

Answer 33

Pain control is often overlooked in pediatric trauma; treat pain early and aggressively

Question 34

discuss family engagement during paediatric resuscitation

Answer 34

1. Allow parents to be at the bedside during resuscitation, with a team member explaining interventions.
2. this leads to better psychosocial outcomes for family

Question 35

Waddell’s Triad

Answer 35

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

Question 36

discuss the role of CXR in peds trauma

Answer 36

CXR is indicated for an abnormal thoracic examination, hemodynamic instability, or severe injury mechanism or for after endotracheal intubation or thoracostomy tube placement.

Question 37

formula for calculating ETT size (cuffed and uncuffed)

Answer 37

([Age/4] + 4) = uncuffed

([age/4] + 3.5) = cuffed

Question 38

discuss the role of Focused assessment with sonography for trauma (FAST) in children

Answer 38

1. FAST is less accurate in children than adults, with a reported sensitivity of 20-80% and specificity of 80-95%
2. (FAST) should not be used in isolation to screen for intra-abdominal injury in children
3. despite this, E-FAST is still recommended in the evaluation of an unstable child following trauma

Question 39

discuss the role of Permissive (or controlled) hypotension as part of a damage control resuscitation approach in children

Answer 39

1. No data exist to support the use of permissive hypotension in children.
2. In contrast, volume expansion with 10-40 mL/kg of crystalloid until blood products are available is recommended for children in compensated shock
3. resuscitate to normal targets

Question 40

discuss the optimal ratio of blood products in pediatric trauma transfusion

Answer 40

1. 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

Question 41

discuss the role of TXA in paediatric trauma

Answer 41

1. CRASH-2 excluded children <16 y of age.
2. A retrospective study of early TXA use in pediatric trauma showed a similar mortality benefit with no adverse events
3. This preliminary evidence supports the use of TXA in children with ongoing severe hemorrhage, although further study is needed.

Question 42

discuss the role of pediatric trauma centers in caring for the injured child

Answer 42

1. Severely injured children should receive definitive care in pediatric trauma centers when possible.
2. 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
3. Thus, severely injured children should be transported to pediatric trauma centers from the field when possible

Question 43

Sizing an uncuffed ETT

Answer 43

age/4 + 4

Question 44

Sizing a cuffed ETT

Answer 44

age/4 + 3.5

Question 45

PALS Estimation for ETT Depth (for >1yo)

Answer 45

(age in yrs/2) + 12

Question 46

how to calculate appropriate in-line suction catheter size

Answer 46

1. Multiply the ETT size (ID) by 3 to find a sxn catheter that will occlude 100% of the ETT.
2. 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)]
3. In short, ETT size x 2 = appropriate sxn catheter size in Fr

Question 47

What are the indications of emergency C-section in maternal trauma?

Answer 47

1. Severe fetal distress.

2. Loss of maternal pulse, with C-section initiated within 4 minutes.

Question 48

needle cric procedure

Answer 48

1. place a large needle catheter (eg, 14-gauge) into the cricothyroid membrane.
2. 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

Question 49

discuss FAST in obstetrical trauma

Answer 49

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

Question 50

Oxygen saturation goals in pregnant trauma patients

Answer 50

O2 supplementation to maintain saturation >95%.

Question 51

main goal in obstetric trauma

Answer 51

stabilize the mother first, as fetal outcomes are directly correlated with maternal resuscitation

Question 52

timeline for perimortem cesarean delivery

Answer 52

ideally within 4 min if the fetus is viable.

Question 53

discuss thoracostomy in obstetric trauma

Answer 53

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

Question 54

1 and 2 most common causes of trauma in pregnancy

Answer 54

1 = Domestic violence (estimated incidence of 8,307 per 100,000 live births)

Question 55

discuss the risk of retroperitoneal hemorrhage in pregnant trauma patients

Answer 55

Increased pelvic blood flow during pregnancy results in an increased risk of retroperitoneal hemorrhage

Question 56

discuss Placental abruption in pregnant trauma patients

Answer 56

1. <0.4% of minor trauma cases and 4.4%-9.4% of pregnant women with more significant trauma
2. 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)
3. Increased risk (up to 40%) in patients with severe trauma requiring hospitalization and severe trauma as defined by ISS ≥12
4. In MVCs, shear force, coup-contrecoup, and maternal body folding can result in a marked increase in intra-abdominal pressure, leading to placental abruption

Question 57

discuss changes to location of intra abdominal organs in the pregnant trauma patient

Answer 57

The gravid uterus pushes the liver and spleen against the ribs and elevates the bladder, rendering these organs more prone to injury in trauma

Question 58

discuss vital sign changes in maternal hemorrhagic shock in trauma

Answer 58

1. Tachycardia and hypotension may be late signs due to increased maternal blood volume.
2. Maternal vital signs and perfusion may be preserved to maintain uterine perfusion.
3. signs of shock may not be as obvious in maternal hemorrhagic shock, and fetal distress may be the first indicator

Question 59

Discuss considerations for airway management in the pregnant trauma patient

Answer 59

All pregnant patients are considered a “difficult airway” from both an anatomical and physiological perspective

1. more difficult airway visualization d/t hormonal effects → increased vasculature and edema in the upper airway
2. 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
3. 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.

Question 60

Discuss considerations for the assessment and management of hemorrhagic SHOCK in the pregnant trauma patient

Answer 60

1. The assessment of hemorrhagic shock in a pregnant patient is complicated by the presence of physiological anemia, which reduces the hematocrit level by 30%.
2. Traumatic injury to the pelvic vasculature can → rapid exsanguination d/t the dilated pelvic vasculature during pregnancy.
3. Because the uterine blood flow is not autoregulated, maternal hypotension can lead to fetal distress.
4. 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

Question 61

golden rule of resuscitating a pregnant trauma patient

Answer 61

the best fetal resuscitation is good maternal resuscitation

Question 62

discuss compression of the great vessels by the gravid uterus

Answer 62

1. 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.
2. placing the patient in 15 – 30 degrees of left lateral tilt may improve CO by 30-50%,
3. 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