Lecture 4 (Part 1)-Anesthesia Management Of The Pediatric Trauma Patient Flashcards
___ is the #1 cause of death in those age 1-19 years
Trauma
Primary causes of death/long-term disability—traumatic brain injury ___%, thoracic injury___%, abdominal injury ___%
TBI 70%, thoracic injury 20%, abdominal injury 10%
Categories of trauma—blunt trauma is ___% of non-burn trauma in children; penetrating trauma is ___% of non-burn trauma in children; burns
Blunt trauma is 90% of non-burn trauma in children; penetrating trauma is 10% of non-burn trauma in children; burns
Phases of trauma care—___ survey with concurrent resuscitation; ___ survey; definitive care
Primary survey; secondary survey
Primary survey—ABCDE’s
A—airway B—breathing C—circulation D—disability E—expose
ABCDE’s—airway—ensure ___ airway
Ensure patent airway
ABCDE’s—breathing—assess and provide adequate ___
Respiration
ABCDE’s—circulation—assess and assist the circulation with ___ and ___ as needed
IV fluids and CPR as needed
ABCDE’s—disability—assess ___ injury
Neurologic
ABCDE’s—expose—remove ___ for complete visual exam and then take appropriate steps to prevent/treat ___thermia
Remove clothing; to prevent/treat hypothermia
Secondary survey—complete ___ exam; ___—medical, surgical, family; ___ tests; ___ imaging
Complete physical exam; history—medical, surgical, family; laboratory tests; radiologic imaging
Secure the airway—intubation indications = ___ation; ___ation; ____ precaution
Ventilation; oxygenation; aspiration precaution
Provider should be experienced!
Pediatric airway—relatively ___ (small/large) tongue; larynx and glottic opening are more ___ (cephalad/caudal)
Relatively large tongue; larynx and glottic opening are more cephalad
Pediatric airway—most narrow point in the airway is the ___ cartilage; do NOT ___ an ETT
Most narrow point in the airway is the cricoid cartilage; do NOT force an ETT!!!
Pediatric airway—___ (longer/shorter) overall airway length and ___ (smaller/larger) diameter; ___ is more significant in this patient population; higher likelihood for ___ (left/right) mainstem; ___ endotracheal tubes are more commonly used now
Shorter overall airway length and smaller diameter; edema is more significant in this patient population; higher likelihood for right mainstem; cuffed ETT are more commonly used now
Initial airway management—___ ventilation with ___% oxygen +/- ___ maneuver
Bag-valve-mask ventilation with 100% oxygen +/- jaw thrust maneuver
Intubation is indicated for those with ___ compromise, ___ collapse, ___ level of consciousness
Respiratory compromise, cardiovascular collapse, altered level of consciousness
Alternatives to intubation—___ does NOT protect against aspiration of gastric contents and therefore should be replaced as soon as experienced hands are available
LMA
Head and neck protection—children are more likely (because of their neck musculature, their disproportionately large head size, and elasticity of their supporting structures) to sustain cervical neck injuries above C___
Above C3
It is frequently difficult to rule out a spinal cord injury because 50% of these injuries exist in the absence of radiographic findings—T/F?
True
Always assume a spinal cord injury is present until a ___ scan can be obtained confirming that there is not such injury
CT scan
Intubation with C-spine injury—patient ___; head/neck in ___ position; avoid head ___ or chin ___ maneuvers; ___-person job with ___ stabilization
Patient supine; head/neck in neutral position; avoid head lift or chin lift maneuvers; two-person job with manual inline axial stabilization
Intubation with C-spine injury—direct laryngoscopy with ___; ___ Bronchoscopy; ___ laryngoscope…all are options depending heavily on acuity and injuries; common to utilize ___ so that others can visualize the airway as well
Direct laryngoscopy with RSI; fiberoptic bronchoscopy; Bullard laryngoscope; common to utilize the glidescope so that others can visualize the airway as well
Post-intubation—confirm placement via ___ exam/___; ___ radiograph; ___ decompression with OGT; secure the ___, may need to be creative
Confirm placement via physical exam/ETCO2; chest radiograph; gastric decompression with OGT; secure the ETT, may need to be creative
Secondary airway considerations—head injury—increased ___ d/t injury + airway manipulation; ___ skull fracture—strong indications are rhinorrhea, otorrhea, periorbital ecchymosis…avoid ___ instrumentation
Increased ICP; basilar skull fracture—avoid nasal instrumentation
Secondary airway considerations—neck injury—___ may indicate tracheal or bronchial interruption; consider intubation via flexible ___ bronchoscope in a spontaneously ventilating patient to avoid false passage of the endotracheal tube
Crepitus; consider intubation via flexible fiberoptic bronchoscope
Difficult airway management—transport patient to ___ if feasible; attending ENT surgeon or general surgeon dedicated to the airway; ___ induction with care to maintain ___ ventilation; avoid ___ until airway is secure; ___ and ___ can be used to facilitate short-acting IV induction while blunting ICP responses and maintaining spontaneous ventilation
Transport patient to OR if feasible; inhalation induction with care to maintain spontaneous ventilation; avoid muscle relaxants until airway is secure; propofol and remifentanil can be used to facilitate short-acting IV induction while blunting ICP responses and maintaining spontaneous ventilation
Injuries affecting ventilation—simple ___ pneumothorax; ___ pneumothorax; massive ___thorax; ___ chest; pulmonary ___
Simple tension pneumothorax; open pneumothorax; massive hemothorax; flail chest; pulmonary contusion
___ = widespread inadequate organ and tissue perfusion
Shock
Prompt recognition of ___volemic and ___ shock is essential
Hypovolemic and hemorrhagic shock
___-___% of total blood volume can be lost prior to evidence of hypotension
25-35%
___ = early sign of cardiovascular compromise and impending shock; generally indicates at least ___% loss of circulating blood volume
Tachycardia; generally indicates at least 10% loss of circulating blood volume
Signs of inadequate peripheral perfusion—___cardia; ___ capillary refill (> 2 sec.); ___ or ___ pulses; ___ing or ___osis; ___ consciousness
Tachycardia; delayed capillary refill (> 2 sec.); weak or thready pulses; mottling or cyanosis; impaired consciousness
___ in a child should be recognized as a late sign of hypovolemia and hemorrhage; it is an ominous sign of impending cardiovascular collapse
Hypotension
Hypotension indicates ___% blood volume loss in children (approximately ___ml/kg)
25% (approximately 20 ml/kg)
___ is a dangerous sign in children, indicating hypoxemia, impending cardiac arrest, or increased ICP
Bradycardia
Stages of pediatric blood volume loss and associated clinical signs—<20% = CV—___cardia; ___, ___ pulses; skin is ___ to touch, capillary refill ___ to ___ seconds; renal—slight ___ (increases/decreases) in urine output, ___ (increase/decrease) in urine specific gravity; CNS—___, may be ___
CV—tachycardia; weak, thready pulses
Skin is cool to touch, capillary refill 2 to 3 seconds
Renal—slight decreases in urine output, increase in urine specific gravity
CNS—irritable, may be combative
Stages of pediatric blood volume loss and associated clinical signs—25% = CV—___cardia; ___, ___ distal pulses; skin—___ (warm/cold) extremities, ___osis and ___ing; renal—___ (increase/decrease) in urine output; CNS—___ion, ___gy
CV—tachycardia; weak, thready distal pulses
Skin—cold extremities, cyanosis and mottling
Renal—decrease in urine output
CNS—confusion, lethargy
Stages of pediatric blood volume loss and associated clinical signs—40%—CV—frank ___tension, ___cardia may progress to ___cardia; skin—___, ___ (warm/cold); renal—___ urine output; CNS—___tose
CV—frank hypotension, tachycardia may progress to bradycardia
Skin—pale, cold
Renal—no urine output
CNS—comatose
Volume resuscitation—the initial fluid bolus should be ___ solution; ___ ml/kg; ___ or ___
Warmed isotonic crystalloid solution; 20 ml/kg; Lactated Ringers or Normal Saline
Volume resuscitation—if no response or transient improvement from initial bolus, give ___
Second bolus of 20 ml/kg
Volume resuscitation—if necessary, a ___ bolus can be administered for maintenance
Third
Volume resuscitation—additional volume resuscitation should begin with ___ ml/kg of ___
10 ml/kg of blood
Persistent shock—if volume resuscitation does not show marked improvement, further investigation is required for other causes—T/F?
True
Other causes of persistent shock: ___ bone fractures; ___ fracture; pericardial effusion and tamponade occur more commonly with ___ than ___ trauma; ___ pneumothorax; intra-___ injuries to solid organs and vessels; ___ hemorrhage in infants with expandable fontanelles can lead to significant unrecognized blood loss
Long bone fractures; pelvic fracture; pericardial effusion and tamponade occur more commonly with penetrating than blunt trauma; tension pneumothorax; intra-abdominal injuries to solid organs and vessels; intracranial hemorrhage in infants with expandable fontanelles can lead to significant unrecognized blood loss
