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Pediatric Anesthesia > Pediatric Trauma Patient > Flashcards

Pediatric Trauma Patient Flashcards

1
Q

List the three primary causes of death/long term disability from trauma?

A

TBI - 70%
Thoracic Injury - 20 %
Abdominal Injury 10%

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2
Q

What are the categories for trauma?

A
  • Blunt - 90% of non-bun trauma in children
  • Penetrating 10% of non-burn trauma
  • Burns
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3
Q

What are the phases of trauma?

A

Primary Survey with concurrent resuscitation

  • Secondary Survey
  • Definitive care
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4
Q

What does the primary survey consist of?

A

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

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5
Q

What are the 4 parts to a second survey?

A

1-Complete physical exam
2-PMH, surgery and family
3-Labs
4-Radiologic Imaging

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6
Q

As experienced providers what should be do?

A

Secure the airway

Intubation indications:

Ventilation
Oxygenation
Aspiration Precautions

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7
Q

Pediatric Airway considerations?

A

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

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8
Q

What is our initial airway management ?

A

-BVM - 100% O2 +/- jar thrust maneuver

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9
Q

When is intubation indicated?

A

Respiratory Compromise
CV collapse
Altered LOC

-Alternative airways

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10
Q

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?

A

Cervical injury above C3

*Difficult to rule out spinal cord injury b/c 50% of these injuries exists in the absence of radiographic findings

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11
Q

T/F: Always assume a spinal cord injury until a Ct scan can be obtains conforming there is not such injury

A

True

Place in aspen collar

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12
Q

What are the steps for intubating a patient with C-spine precautions?

A
  • Supine
  • Head/neck neutral
  • AVOID head lift or chin maneuvers
  • Two person job
  • -Direct laryngoscopy, bullard laryngoscope, etc, depend on acuity of injuries
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13
Q

How do we confirm success intubation with a C-spine injury?

A

Placement via ETCO2

  • Chest xray
  • Gastric decompression with OG
  • Secure ETT
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14
Q

Head injuries may have increase ICP from injury and airway manipulation, as well as with basilar skull fractures, what do we want to avoid?

A
  • *NASAL instrumentation

- Strong indications of injury are rhinorrhea, otorrhea, periorbital ecchymosis

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15
Q

What signs and symptoms may indicate a neck injury?

A

Crepitus - can indicate tracheal or bronchial interruption

-Consider fiberoptic, spont vent. to avoid false passage of the endotracheal tube

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16
Q

How do we manage a difficult airway?

A
  • 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
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17
Q

What injuries can affect SV?

A 
1-Simple tension pneumo
2-Open Pneumo
3-Massive hemothorax
4-Flail Chest 
5- Pulmonary contusion
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18
Q

What is the definition of shock?

A

Wide spread perfusion inadequate organ and tissue perfusion

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19
Q

What is essential in treating shock?

A

Prompt recognition of hypovolemic and hemorrhagic shock essential
-25-35% loss of total blood volume can be lost prior to evidence of hypotension

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20
Q

What is the early sign of circulatory shock?

A

*****TACHYCARDIA

Sign of CV compromise and impending shock, generally indicates at least 10% loss of circulating blood volume

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21
Q

What are other signs of inadequate peripheral perfusion in circulatory shock ?

A 
1-**TACHYCARDIA
2- Delayed capillary refill ( > 2seconds)
3- Weak or thready pulses 
4- Mottling or cyanosis 
5- Impaired consciousness
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22
Q

T/F: Hypotension in a child should be recognized as a late of hypovolemia?

A

***TRUE

  • This was underlined - all the *** mean she had it bolded or underlined
  • It is an ominous sign of impending CV collapse
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23
Q

**Hypotension indicates what percent blood volume loss in children?

A

** 25%

~ 20ml/kg

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24
Q

With less than 20% blood loss what clinical signs do we see in CV, Skin, Renal, and CNS?

A

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

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25
Q

What are systemic signs of blood loss greater than 25%?>

A

CV: Same as , 20%
Skin: cool extremities, cyanosis and mottling
Renal: Decrease urine output
CNS: Confusion, lethargy

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26
Q

Signs of pediatric blood volume loss 40%

A

CV: Frank hypotension, tachycardia-> bradycardia
Skin: Pale, cold
Renal: NO urine output
CNS: Comatose

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27
Q

How much should the initial fluid bolus be in volume resuscitation ?

A

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
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28
Q

If shock persist and volume resuscitation does not show marked improvement , we need to investigate further and look for what other causes?

A
  • 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
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29
Q

What do we need to access quickly in a child undergoing circulatory shock?

A

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

30
Q

What do we obtain for disability and diagnostic evaluation ?

A
  • 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
31
Q

What laboratory testing should we obtain ?

A
  • Focused on need to now info
  • CBC
  • Type and Screen
  • ABG
  • Urinanalysis
32
Q

What does our disability assessment consist of?

A 
AVPU-primary
-Alert
-Voice responsiveness
-Pain-responds only 
-Unresponsive 
GSC - 2nd survey
33
Q

How do you expose the patient to get a good assessment?

A
  • 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
34
Q

What are different facial injuries?

A
  • soft tissue
  • dental
  • facial fractures
35
Q

T/F: ALL facial traumas are more frequent in males than females

A

True.

36
Q

What is the most common facial trauma in children less than 5 years old?

A

Soft Tissue

*facial traumas are generally less severe in children less than 5 years of age

37
Q

Facial traumas are mainly due to what and increased incidence in what age group?

A

Mainly due to falls and increased incidence in adolescence

38
Q

While dental trauma is a decreasing rate throughout childhood, loss of dentition or severe injury can hinder what?

A

Airway security/ intervention

-May require bronchoscopy to clear debris from lower airways

39
Q

Of all facial traumas, facial fractures are the least common type. However what is the most common type of facial fracture?

A
  • Nasal fractures

- Followed by mandibular and maxillary fx

40
Q

How do oropharyngeal lacerations/impalements happen?

A

Falls complicated by objects in the mouth (pencil, pens, toothbrush, stick, etc)

41
Q

Why are oropharyngeal lacerations/impalements complicated airways?

A

Difficult to work around foreign body, angiogram should proceed removal of objects depending on location

42
Q

How are chest injury patients treated?

A

With observation or a thoracotomy tube.

*potentially life threatening, impalement of breathing or circulation

43
Q

What are the signs and symptoms of a tension pneumothorax? (These were underlined!!)

A

Diminished breath sounds, tracheal deviation to the opposite side, hypotension, decreased lung compliance (increased PAP)

44
Q

What is the etiology and treatment for Tension Pneumo?

A
  • 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
45
Q

What is the etiology and treatment of an open pneumo?

A

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

46
Q

Abdominal injuries cause death in 10% in trauma fatalities. What kinda of abdominal injuries is the most common?

A

Blunt trauma

  • careful medical management usually treatment of choice for pediatrics
  • solid organ injuries require surgical intervention in blunt trauma
47
Q

What is the leading cause of mortality in pediatrics trauma patients?

A

Traumatic Brain Injury (>70% of the deaths)

-Mainly MVAs but in children less than 4yrs 30-50% are attributed to falls or abuse

48
Q

Why are children at risk for TBIs?

A

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

49
Q

What are the phases of TBIs?

A
  • Primary Injury
  • Secondary Injury (cerebral response to trauma)
  • Secondary Injury (systemic response to trauma)
50
Q

What is the goal with TBIs? (This is underlined!!)

A
  • 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
51
Q

What occurs in 7-10% of children with TBIs?

A
  • Cervical slime fractures

- assume vertebral/cord injury in the pediatric trauma patient

52
Q

Where is the fulcrum of cervical mobility in children?

A
  • 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
53
Q

T/F: >9400 injuries in those <18yrs of age annually

A

True.
More stats:
-25% of the 9400 are <5yrs of age
-3x Injury rate with riding mowers vs walk behind mowers

54
Q

What are the 4 basic mechanisms of lawnmower injuries?

A
  • Lower of mower stability
  • Blade contact
  • Layout and function of mower and mower controls
  • Running over/backing over
55
Q

What are the types of lawnmower injuries and treatments?

A

Types: lacerations, and amputations and avulsions
Treatment: surgical control/treatment of injures, repeated anesthetic of debridement, reconstruction/grafting and fx stabilization

56
Q

What Skeletal fx need urgent or emergent surgical intervention?

A
  • Complex/displaced fx
  • Fx complicated by NV impairment
  • Fx complicated by limb ischemia
  • Open fx
  • Joint dislocations that cannot be reduced
  • Compartment syndromes
57
Q

What skeletal injuries may have vascular involvement that need to be confirmed/evaluated before/after intervention with angiogram?

A
  • Supracondylar distal humerus fx
  • Distal femur
  • Proximal tibia
  • Displaced pelvic fracture
  • knee dislocation
58
Q

What does the preoperative management of the pediatric trauma include?

A
  • NPO status
  • Anesthetic agents
  • Patient monitoring
  • Fluid and blood resuscitation
59
Q

You should assume a full stomach and take precautions in all maneuvers which include

A
  • Major Injury
  • pain and/of anxiety
  • opioids
  • bag/mask aspiration
  • oral contrast
  • recent meal
  • delayed gastric emptying
60
Q

Anesthetic agents and induction of anesthesia

A
  • thiopental
  • propofol
  • etomidate
  • ketamine
  • review slide 50
61
Q

Maintenance of anesthesia is based on what?

A
  • nature and purpose of injury
  • extent of injuries
  • child’s ventilators, hemodynamic, and neurologically status
  • likelihood of post-op mechanical ventilation
62
Q

Patient monitoring

A
  • 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
63
Q

What is shock?

A

A metabolic demand that exceeds either oxygen supply or demand

64
Q

Assess initial fluid resuscitation in ED and continue prior to induction. What is the goal?

A

Volume resuscitate then induce

65
Q

What fluid can you use and what should you avoid?

A

Use isotonic fluid (LR or NS)
5% albumin also acceptable
Avoid dextrose
Avoid hydoxyethyl start

66
Q

Perioperative management of blood administration

A
  • 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
67
Q

What type of blood is preferred for all emergencies?

A

-Type-O negative non-cross matched

68
Q

Perioperative management of blood administration- PRBCs

A
  • 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
69
Q

Perioperative management of blood administration- FFP

A
  • 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
70
Q

Perioperative management of blood administration- Platelets

A
  • 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

Pediatric Anesthesia (3 decks)

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