Pediatric Trauma Patient Flashcards
List the three primary causes of death/long term disability from trauma?
TBI - 70%
Thoracic Injury - 20 %
Abdominal Injury 10%
What are the categories for trauma?
- Blunt - 90% of non-bun trauma in children
- Penetrating 10% of non-burn trauma
- Burns
What are the phases of trauma?
Primary Survey with concurrent resuscitation
- Secondary Survey
- Definitive care
What does the primary survey consist of?
ABCDE’s
Airway: Ensure patient airway
Breathing: Assess and provide adequate respiration
Circulation: Circulation IVF, CPR
Disability: Neurologic Injury
Expose: Remove clothing for complete visual exam and then are appropriate steps to prevent/treat hypothermia
What are the 4 parts to a second survey?
1-Complete physical exam
2-PMH, surgery and family
3-Labs
4-Radiologic Imaging
As experienced providers what should be do?
Secure the airway
Intubation indications:
Ventilation
Oxygenation
Aspiration Precautions
Pediatric Airway considerations?
Large Tongue
Larynx and glottic opening are more cephalic
-**Most narrows point in the airway is the cricoid cartilage DO NOT force the ETT
-Shorter airway length and smaller diameter
–Edema more significant
–Higher R mainstem%
–Now using cuffed ETT
What is our initial airway management ?
-BVM - 100% O2 +/- jar thrust maneuver
When is intubation indicated?
Respiratory Compromise
CV collapse
Altered LOC
-Alternative airways
What are children more likely to sustain due to their disproportionately large head size compared to the elasticity of their supporting structures and neck musculature?
Cervical injury above C3
*Difficult to rule out spinal cord injury b/c 50% of these injuries exists in the absence of radiographic findings
T/F: Always assume a spinal cord injury until a Ct scan can be obtains conforming there is not such injury
True
Place in aspen collar
What are the steps for intubating a patient with C-spine precautions?
- Supine
- Head/neck neutral
- AVOID head lift or chin maneuvers
- Two person job
- -Direct laryngoscopy, bullard laryngoscope, etc, depend on acuity of injuries
How do we confirm success intubation with a C-spine injury?
Placement via ETCO2
- Chest xray
- Gastric decompression with OG
- Secure ETT
Head injuries may have increase ICP from injury and airway manipulation, as well as with basilar skull fractures, what do we want to avoid?
- *NASAL instrumentation
- Strong indications of injury are rhinorrhea, otorrhea, periorbital ecchymosis
What signs and symptoms may indicate a neck injury?
Crepitus - can indicate tracheal or bronchial interruption
-Consider fiberoptic, spont vent. to avoid false passage of the endotracheal tube
How do we manage a difficult airway?
- Transport to OR table only if feasible
- ENT or gen. sx dictates airway
- Inhalation induction with care to maintain SV
- Avoid muscle relaxants until airway is secure
- Propofol/ Remifentanil can be used to facilitate short acting IV induction while blunting ICP repossess and maintain spontaneous ventilation
What injuries can affect SV?
1-Simple tension pneumo 2-Open Pneumo 3-Massive hemothorax 4-Flail Chest 5- Pulmonary contusion
What is the definition of shock?
Wide spread perfusion inadequate organ and tissue perfusion
What is essential in treating shock?
Prompt recognition of hypovolemic and hemorrhagic shock essential
-25-35% loss of total blood volume can be lost prior to evidence of hypotension
What is the early sign of circulatory shock?
*****TACHYCARDIA
Sign of CV compromise and impending shock, generally indicates at least 10% loss of circulating blood volume
What are other signs of inadequate peripheral perfusion in circulatory shock ?
1-**TACHYCARDIA 2- Delayed capillary refill ( > 2seconds) 3- Weak or thready pulses 4- Mottling or cyanosis 5- Impaired consciousness
T/F: Hypotension in a child should be recognized as a late of hypovolemia?
***TRUE
- This was underlined - all the *** mean she had it bolded or underlined
- It is an ominous sign of impending CV collapse
**Hypotension indicates what percent blood volume loss in children?
** 25%
~ 20ml/kg
With less than 20% blood loss what clinical signs do we see in CV, Skin, Renal, and CNS?
CV: Tachycardia, weak/thready pulse
Skin: Cool to touch, cap refill 2-3 seconds
Renal: Slight decrease in urine output, increase in specific gravity
CNS: Irritable, may be combative
What are systemic signs of blood loss greater than 25%?>
CV: Same as , 20%
Skin: cool extremities, cyanosis and mottling
Renal: Decrease urine output
CNS: Confusion, lethargy
Signs of pediatric blood volume loss 40%
CV: Frank hypotension, tachycardia-> bradycardia
Skin: Pale, cold
Renal: NO urine output
CNS: Comatose
How much should the initial fluid bolus be in volume resuscitation ?
20 ml/kg
LR or NS
WARMED and ISOTONIC crystalloid
- If no response transient improvement
- -second 20ml/kg bolus
- -If necessary 3rd bolus
- -Following volume resuscitation 10ml/kg
If shock persist and volume resuscitation does not show marked improvement , we need to investigate further and look for what other causes?
- Long bong fractures
- Pelvic fracture
- Pericardial effusion and tamponade occur more commonly with penetrating than blunt trauma
- Tension Pneumo
- Intra-abdominal injuries to slid organs and vessels
- Intracranial hemorrhage in infants with expandable fontanelles can lead to significant unrecognized blood loss
What do we need to access quickly in a child undergoing circulatory shock?
Large bore IV access
-Peripheral, useful but difficult to obtain, check AC first
-Central lines, FEMORAL
Subclavians and neck offer too many possible complications in the acute phase of resuscitation
-Intraosseous needle is viable in all ages
What do we obtain for disability and diagnostic evaluation ?
- Plain film x-ray
- -chest, pelvis, lateral c-spine
- CT
- –head: LOC, AMS, focal defects
- -Neck
- -ABD/Pelvis: ABD injuries tenderness, obtunded
- Sonogram
- -FAST: focused abdominal sonogram for trauma, LESS valuable in smaller patients as LESS free fluid is generated
What laboratory testing should we obtain ?
- Focused on need to now info
- CBC
- Type and Screen
- ABG
- Urinanalysis
What does our disability assessment consist of?
AVPU-primary -Alert -Voice responsiveness -Pain-responds only -Unresponsive GSC - 2nd survey
How do you expose the patient to get a good assessment?
- Remove all patients clothing using shears if necessary to avoid additional injury.
- Log-rolling the patient for direct visual and palpation assessment of the posterior side.
- Immediately after assessment ensure initiation hypothermia treatment/prevention
What are different facial injuries?
- soft tissue
- dental
- facial fractures
T/F: ALL facial traumas are more frequent in males than females
True.
What is the most common facial trauma in children less than 5 years old?
Soft Tissue
*facial traumas are generally less severe in children less than 5 years of age
Facial traumas are mainly due to what and increased incidence in what age group?
Mainly due to falls and increased incidence in adolescence
While dental trauma is a decreasing rate throughout childhood, loss of dentition or severe injury can hinder what?
Airway security/ intervention
-May require bronchoscopy to clear debris from lower airways
Of all facial traumas, facial fractures are the least common type. However what is the most common type of facial fracture?
- Nasal fractures
- Followed by mandibular and maxillary fx
How do oropharyngeal lacerations/impalements happen?
Falls complicated by objects in the mouth (pencil, pens, toothbrush, stick, etc)
Why are oropharyngeal lacerations/impalements complicated airways?
Difficult to work around foreign body, angiogram should proceed removal of objects depending on location
How are chest injury patients treated?
With observation or a thoracotomy tube.
*potentially life threatening, impalement of breathing or circulation
What are the signs and symptoms of a tension pneumothorax? (These were underlined!!)
Diminished breath sounds, tracheal deviation to the opposite side, hypotension, decreased lung compliance (increased PAP)
What is the etiology and treatment for Tension Pneumo?
- etiology: air trapping in pleural space from injured lung, each breath increases the pressure
- treatment: needle decompression at the second intercostal space/mid-clavicular line
What is the etiology and treatment of an open pneumo?
Etiology: defect in chest wall equalizes pressure of the lung/pleural space with outside environment
-Treatment: cover the defect with an occult I’ve dressing and secure in three sides with tape
Abdominal injuries cause death in 10% in trauma fatalities. What kinda of abdominal injuries is the most common?
Blunt trauma
- careful medical management usually treatment of choice for pediatrics
- solid organ injuries require surgical intervention in blunt trauma
What is the leading cause of mortality in pediatrics trauma patients?
Traumatic Brain Injury (>70% of the deaths)
-Mainly MVAs but in children less than 4yrs 30-50% are attributed to falls or abuse
Why are children at risk for TBIs?
Disproportionately large head and weak neck musculature added to a high center of gravity yields a high risk of coup-countercoup injury even at low velocity
-also have thinner cranial bones and less myelinated nerve tissue
What are the phases of TBIs?
- Primary Injury
- Secondary Injury (cerebral response to trauma)
- Secondary Injury (systemic response to trauma)
What is the goal with TBIs? (This is underlined!!)
- Minimize effects of secondary injury
- Low threshold for intubation
- Recall suspected basilar skull fix is contradiction for nasal intubation/nasal airway/gastric tube
- prompt treatment of systemic abnormalities such as shock, hypotension, hypoxemia, hypercarbia
What occurs in 7-10% of children with TBIs?
- Cervical slime fractures
- assume vertebral/cord injury in the pediatric trauma patient
Where is the fulcrum of cervical mobility in children?
- C2-3 (adult C5-7)
- for this reason, 60-70% of pediatric fractures occur in C1-2 in children v 16% in adults
- ligamentous laxity also accounts for decreased incidence of Fx in kids
T/F: >9400 injuries in those <18yrs of age annually
True.
More stats:
-25% of the 9400 are <5yrs of age
-3x Injury rate with riding mowers vs walk behind mowers
What are the 4 basic mechanisms of lawnmower injuries?
- Lower of mower stability
- Blade contact
- Layout and function of mower and mower controls
- Running over/backing over
What are the types of lawnmower injuries and treatments?
Types: lacerations, and amputations and avulsions
Treatment: surgical control/treatment of injures, repeated anesthetic of debridement, reconstruction/grafting and fx stabilization
What Skeletal fx need urgent or emergent surgical intervention?
- Complex/displaced fx
- Fx complicated by NV impairment
- Fx complicated by limb ischemia
- Open fx
- Joint dislocations that cannot be reduced
- Compartment syndromes
What skeletal injuries may have vascular involvement that need to be confirmed/evaluated before/after intervention with angiogram?
- Supracondylar distal humerus fx
- Distal femur
- Proximal tibia
- Displaced pelvic fracture
- knee dislocation
What does the preoperative management of the pediatric trauma include?
- NPO status
- Anesthetic agents
- Patient monitoring
- Fluid and blood resuscitation
You should assume a full stomach and take precautions in all maneuvers which include
- Major Injury
- pain and/of anxiety
- opioids
- bag/mask aspiration
- oral contrast
- recent meal
- delayed gastric emptying
Anesthetic agents and induction of anesthesia
- thiopental
- propofol
- etomidate
- ketamine
- review slide 50
Maintenance of anesthesia is based on what?
- nature and purpose of injury
- extent of injuries
- child’s ventilators, hemodynamic, and neurologically status
- likelihood of post-op mechanical ventilation
Patient monitoring
- Routine (EKG, SpO2, NIBP, temp, ETCO2, FiO2)
- Invasive (a-line, CVP)
- UOP
- Temp monitoring and prevention/treatment of hypothermia are extremely important in trauma care
What is shock?
A metabolic demand that exceeds either oxygen supply or demand
Assess initial fluid resuscitation in ED and continue prior to induction. What is the goal?
Volume resuscitate then induce
What fluid can you use and what should you avoid?
Use isotonic fluid (LR or NS)
5% albumin also acceptable
Avoid dextrose
Avoid hydoxyethyl start
Perioperative management of blood administration
- Purpose: restore/maintain oxygen carrying capacity
- ABL up to 40% can usually be replaced with only crystalloids
- individuals with preexisting conditions (cyanotic heart disease, blood dyscrasias) May require blood admin prior to 40% ABL
What type of blood is preferred for all emergencies?
-Type-O negative non-cross matched
Perioperative management of blood administration- PRBCs
- Approximately 250ml volume
- Hct 60-80%
- preservative CPD of CDP-A (citrate, phosphate, dextrose, adenine) with shelf lives of 21 and 35 days.
- Citrate binds to Ca, have Ca ready to admin
- Dose: usually begins with 10-2ml/kg depending on rapidity of blood loss
Perioperative management of blood administration- FFP
- 45min thaw time
- must be used within 24 hour of thaw
- provides factors II, V, VIII, IX, X, XI, and antithrombin III
- Transfuse when clotting studies become abnormal (PT, aPTT prolonged)
- nonsurgical bleeding in children who receive more than one blood volume of PRBCs frequently require FFP due to factor V and VII deficiency
- Dose: 10-15ml/kg
Perioperative management of blood administration- Platelets
- Derived via centrifugation and recentrifulgation of fresh whole blood
- Thrombocytopenia usually diluational and most likely cause of nonsurgical micro vascular bleeding following massive transfusion
- Platelets usually require prior to FFP
- Transfusion of 0.1 units/kg will raise the PLT count by 20,000
- DO NOT REFRIDERATE
