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
Peripheral IV access is useful but usually difficult in the child in shock—check the ___ first
AC
Central lines should be placed in the ___ vessels; subclavian and neck vessels offer too many possible complications in the acute phase of resuscitation
Femoral vessels
___ needle access is viable in all ages when placed properly
Intraosseous needle access
Disability/diagnostic evaluation—plain film x-ray is generally limited to ___, ___, and lateral ___; further radiographs are directed to specific physical findings
Plain film x-ray is generally limited to chest, pelvis, and lateral c-spine
Disability/diagnostic evaluation—CT scans can be done on ___ (loss of consciousness, altered mental status, focal neurologic deficits); ___ (to supplement plain film x-ray); and ___/___ (abdominal injuries or tenderness, as a screening in obtunded patients)
Head; neck; and abdomen/pelvis
Disability/diagnostic evaluation—FAST = ___; less valuable in ___ patients as less free fluid is generated
FAST = focused abdominal sonogram for trauma; less valuable in smaller patients as less free fluid is generated
Disability and diagnostic evaluation—laboratory testing—as most trauma patients are generally healthy prior to injuries, laboratory data is focused to ___ information—CBC, type & screen, ABG, urinalysis
Needed information
Disability—neurologic assessment—AVPU (completed in ___ survey) = ___; GCS is completed during ___ survey
AVPU (completed in primary survey) = alert, responds to voice, responds to pain, unresponsive
GCS is completed during secondary survey
Exposure—___ all of patient’s clothing, using shears if necessary to avoid additional injury; ___ the patient for direct assessment of the patient’s posterior surfaces; immediately upon completion of the assessment, ensure initiation of ___thermia treatment/prevention
Remove all of patient’s clothing, using shears if necessary to avoid additional injury; log-roll the patient for direct assessment of the patient’s posterior surfaces; immediately upon completion of the assessment, ensure initiation of hypothermia treatment/prevention
Facial trauma categories—___ tissue, ___, ___ fractures
Soft tissue, dental, facial fractures
For all categories of facial trauma, they occur more frequently in ___ (males/females)
Males
Generally, facial trauma is less severe in children less than ___ years of age; ___% of children with facial injuries are less than ___ years of age; most common facial trauma = ___ injuries
Less than 5 years of age; 42% of children with facial injuries are less than 5 years of age; most common = soft tissue injuries
Facial trauma mainly occurs d/t ___
Falls
Increased incidence of facial trauma in ___ (what age group?)
Adolescence
“Falling zone” — ___ to ___ is where most injuries are concentrated
Nose to mentum
Dental trauma—___ (increasing/decreasing) rate throughout childhood
Decreasing
Loss of dentition or severe injury can hinder airway security/intervention—T/F?
True
Dental trauma patients may require ___scopy to clear debris from lower airways
Bronchoscopy
___ are the least common type of facial injury in children
Facial fractures
___ fractures are the most common type of facial fracture in children, followed by ___ and ___ fractures
Nasal fractures, followed by mandibular and maxillary fractures
Oropharyngeal lacerations/impalement occur d/t falls complicated by objects in the mouth (i.e.: pencils, pens, toothbrushes, sticks, etc.); this creates complicated airways (difficult to work around foreign body); ___ should precede removal of objects, depending on the location
Angiogram
___ injuries can be immediately life threatening because they impair ___ or ___
Chest because they impair breathing or circulation
Generally, pediatric chest injuries can be treated with ___ or ___ tube
Observation or thoracotomy tube
Signs and symptoms of ___ = diminished breath sounds, tracheal deviation to the opposite side, hypotension, decreased lung compliance (increased pulmonary artery pressure)
Tension pneumothorax
Tension pneumothorax etiology = air trapping in ___ space from the injured lung; each breath increases the ___
Pleural space; each breath increases the pressure
Treatment of tension pneumothorax = needle decompression at the ___ intercostal space, ___ line
Needle decompression at the second intercostal space, mid-clavicular line
___ pneumothorax = defect in the chest wall equalizes pressure of the lung/pleural space with the outside environment
Open
Treatment of open pneumothorax = cover the defect with an ___ dressing and secure on ___ sides with tape
Cover the defect with an occlusive dressing and secure on three sides with tape
Abdominal injuries are the cause of death in ___% of trauma fatalities
10%
___ trauma is the most common cause of abdominal injuries
Blunt
Careful ___ management is usually the treatment of choice for abdominal injuries in pediatric patients
Medical
Solid organ injuries always require surgical intervention in blunt trauma—T/F?
False—rarely require surgical intervention
___ is the leading cause of mortality in the pediatric trauma patient— > ___% of deaths
TBI— > 70% of deaths
TBI is mainly caused by ___, but in children < 4 years of age, 30-50% of TBI cases are attributed to ___ or ___ (non-accidental trauma)
TBI is mainly caused by motor vehicle accidents, but in children < 4 years of age, 30-50% of TBI cases are attributed to falls or abuse (non-accidental trauma)
Multisystem trauma is almost always associated with ___ in children
TBI
Disproportionately large head and weak neck musculature, added to a high center of gravity yields a high risk of ___ injury, even at a low velocity
Coup-contrecoup
Children are at increased risk for TBI because they have ___ (thinner/thicker) cranial bones and ___ (more/less) myelinated nerve tissue
Thinner cranial bones and less myelinated nerve tissue
Phases of TBI—primary injury; secondary injury—___ response to trauma; secondary injury—___ response to trauma
Primary injury; secondary injury—cerebral response to trauma; secondary injury—systemic response to trauma
Goal of care for the patient with TBI = minimize effects of ___ injury
Secondary
TBI patients have a ___ (high/low) threshold for intubation
Low threshold
Recall that a suspected basilar skull fracture is a contraindication for ___ intubation, ___ airway, ___ suction tube
Nasal intubation, nasal airway, gastric suction tube
TBI—prompt treatment of systemic abnormalities such as ___, ___tension, ___emia, ___carbia
Shock, hypotension, hypoxemia, hypercarbia
Cervical spine fractures occur in ___-___% of children with TBI
7-10%
Assume ___/___ injury in the pediatric trauma patient
Vertebral/cord injury
Fulcrum of cervical mobility in children is C___-C___, while it is C___-C___ in adults; for this reason, 60-70% of pediatric cervical fractures occur in C___-C___ in children vs. 16% in adults
C2-C3 in children, C5-C7 in adults; 60-70% of pediatric cervical fractures occur in C1-C2 in children
Lawnmower injuries—___x injury rate with riding mowers vs. walk behind mowers
3x
Skeletal injuries are rarely ___ threatening but may be ___ threatening d/t neurovascular compromise
Rarely life threatening but may be limb threatening d/t neurovascular compromise
Skeletal injuries—control of ___ should occur as part of the primary survey
Hemorrhage
Skeletal injuries—urgent or emergent surgical intervention is required for ___/___ fractures; fracture complicated by ___ impairment; fracture complicated by limb ___; ___ fractures; joint dislocations that cannot be ___; ___ syndromes
Complex/displaced fractures; fracture complicated by neurovascular impairment; fracture complicated by limb ischemia; open fractures; joint dislocations that cannot be reduced; compartment syndromes
Vascular involvement typically with these types of fractures: supracondylar distal ___ fractures; distal ___; proximal ___; displaced ___ fractures; ___ dislocations
Supracondylar distal humerus fractures; distal femur; proximal tibia; displaced pelvic fractures; knee dislocations
Perioperative management of the pediatric trauma patient—___ status; anesthetic agents; patient ___; ___ and ___ resuscitation
NPO status; anesthetic agents; patient monitoring; fluid and blood resuscitation
NPO status—assume ___ stomach and take ___ precautions in all maneuvers
Assume full stomach and take aspiration precautions in all maneuvers
Every trauma experiences delayed ___
Gastric emptying
Anesthetic agents for the pediatric trauma patient—thiopental—___ protective; direct ___ depressant
Neuro protective; direct myocardial depressant
Anesthetic agents for the pediatric trauma patient—propofol—___ protective; profound vaso___
Neuro protective; profound vasodilator
Anesthetic agents for the pediatric trauma patient—etomidate—___ stability; ___ protective; ___ suppression
Hemodynamic stability; neuro protective; adrenal suppression
Anesthetic agents for the pediatric trauma patient—ketamine—___ outflow; not ___ protective; can caused marked ___tension with ___ (increased/decreased) CBF
Sympathetic outflow; not neuroprotective; can cause marked hypotension with increased CBF
Maintenance of anesthesia in the pediatric trauma patient is based on the nature and proposed ___ of the procedure; extent of ___; child’s ___tory, ___dynamic, and ___logic status; likelihood of postoperative ___
Based on the nature and proposed duration of the procedure; extent of injuries; child’s ventilatory, hemodynamic, and neurologic status; likelihood of postoperative mechanical ventilation
Patient monitoring—___ monitoring and prevention/treatment of ___thermia are extremely important in trauma care—___ exposure at scene; ___, open wounds; rapid infusion of ___ fluids; exposure of body cavities and ___ losses
Temperature monitoring and prevention/treatment of hypothermia are extremely important in trauma care—cold exposure at scene; large, open wounds; rapid infusion of cold fluids; exposure of body cavities and evaporative losses
Shock = a metabolic demand that exceeds either oxygen ___ or ___
Supply or delivery
Assess initial fluid resuscitation in ED and continue prior to induction; goal is to ___, then induce
Volume resuscitate, then induce
___volemia is end-point desired—achieve using ___ fluids (___ or ___); ___ is also acceptable; avoid ___ and ___
Normovolemia—achieve using isotonic fluids (LR or NS); 5% albumin is also acceptable; avoid dextrose and hetastarch
Purpose of blood administration in trauma patients is to restore/maintain ___ capacity
Oxygen carrying capacity
ABL up to ___% can usually be replaced with only crystalloids…evaluate carefully
40%
Individuals with preexisting conditions (i.e.: cyanotic heart disease, blood dyscrasias) may require blood administration prior to ___% ABL
40%
Type ___ non-crossmatched blood is preferred for emergencies
Type O-negative
PRBCs—approximately ___ ml volume; Hct ___-___%; citrate in PRBCs binds ___, so must have it ready to administer; usually begin with ___-___ml/kg of blood depending on rapidity of blood loss
Approximately 250 ml volume; Hct 60-80%; citrate in PRBCs binds calcium, so must have it ready to administer; usually begin with 10-20 ml/kg of blood depending on rapidity of blood loss
FFP—___ minute thaw time (from stored temp of -___C); must be used within ___ hours of thaw; provides ___ factors; transfuse when clotting studies become ___ (PT, aPTT prolonged); nonsurgical bleeding in children who receive more than one blood volume of PRBCs frequently require FFP d/t factor ___ and ___ deficiency; initial dose should be ___ to ___ ml/kg
45 minute thaw time (from stored temp of -18 C); must be used within 24 hours of thaw; provides clotting factors; transfuse when clotting studies become abnormal; nonsurgical bleeding in children who receive more than one blood volume of PRBCs frequently require FFP d/t factor V and VIII deficiency; initial dose should be 10 to 15 ml/kg
Platelets—derived from centrifugation and recentrifugation of ___; thrombocytopenia is usually ___ and most likely cause of nonsurgical micro vascular bleeding following massive transfusion; platelets are usually required prior to ___; transfusion of 0.1 units/kg will raise the platelet count by ___; do NOT ___
Fresh whole blood; thrombocytopenia is usually dilutional and most likely cause of nonsurgical micro vascular bleeding following massive transfusion; platelets are usually required prior to FFP; transfusion of 0.1 units/kg will raise the platelet count by 20,000; do NOT refrigerate!!!
