Week 12: Pediatric Trauma, Burns, Syndromes Flashcards
Pediatric Trauma
Injuries are the most common cause of death within the US for children older than _____ year of age.
________ injuries are the leading cause of death among children.
Most traumatic injuries in children result from:
- 1
- Head
- MVA
- Falls
- Nonaccidental trauma
- Drowning
- Extremes of temperature
Trauma Scoring Systems
Glasgow Coma Scale (GCS) and the modified GCS
Pediatric Trauma Score (PTS)
ABCs of Resuscitation
A =
B =
C =
D =
E =
A = Airway with cervical spinal control
B = Breathing & Ventilation (O2 & SaO2)
C = Circulation with hemorrhage control
D = Disability and neurologic control
E = Exposure & environmental control
Surveys
Primary survey –
Secondary survey –
ATLS course (Advanced Trauma Life Support)
- incorporates the “ABC’s” and life-threatening injuries are identified and treated
* Airway
* Breathing
* Circulation and Access
* Disability (Neurologic Assessment)
* Exposure - other injuries that contribute to significantly to illness and deaths are identified and treatment is instituted
SAMPLE Report
S
A
M
P
L
E
Preoperative Evaluation
SYMPTOMS
ALLERGIES
MEDICATIONS
PAST MEDICAL HISTORY
LAST MEAL
EVENTS LEADING TO INJURY
Vital signs
Airway/cervical spine evaluation
Planned surgical procedure
List of known injuries
Management since arrival
Relevant laboratory/imaging results
Past medical/surgical history/family history
Allergies/current medications
Fasting time
Figure 39-1
Management of pediatric trauma patients
CV
Skin
Renal
CNS
review
Criteria for Early Intubation
- Cardiac arrest
- Clinical signs of shock
- Hypoxia
- Hypercarbia
- Signs of developing airway obstruction
- Head injury with decrease in mental status
- Burn injury with airway involvement
- Combativeness
- Chest trauma with dyspnea
Fasting Duration
It is common to consider all trauma patients at _________ regardless of the time of last oral intake.
Delayed gastric emptying & distention
Major injury
Pain
Anxiety
Opioids
- risk for aspiration
Causes of airway abnormalities
Congenital syndromes
Acquired conditions
Fluid Resuscitation
- Goal is to maintain _______ in the presence of ongoing blood loss and/or third-spacing
- Colloids, such as _________
- PRBCs, FFP, Platelets and Cryoprecipitate and _______
- normovolemia
- 5% albumin
- Factor VIIA
Fluid Management
- Consider ______ solutions
- Avoid _______ solutions, especially when concerned with CNS injury
- Monitor blood glucose
- Per current literature, blood glucose should be maintained less than _____-_________, depending upon your facility protocol
- isotonic
- dextrose-containing
- 130-200
Vascular Access
Establish IV access ASAP!
Intraosseous (IO) access if IV cannot be established
Induction: Trauma
- Rapid sequence induction
- Consider hemodynamic status
- If less than 10% volume deficit (normotensive), then consider ______&_________
- If 10-20% blood loss (normotensive and HR <110), then consider _____ or _____ and______.
- If your patient has > 25% blood loss (hypotensive, tachycardia, respiratory distress, anuria, cold extremities) then you must be extremely cautious with the aforementioned agents because of hemodynamic instability!
- propofol & SCh
- Ketamine (1 – 2 mg/kg) or Etomidate (0.2 - 0.3 mg/kg) and SCh
-
Specific Injuries
- Head injuries
- Cervical spine injuries
- Facial trauma
- __________ (68% of all bites > ____ years of age)
- Soft-tissue neck trauma
- Chest trauma
- Abdominal trauma
- Lawnmower related injuries
- Skeletal injuries
- Abuse
Dog bites; 5
______________ is the leading cause of morbidity and mortality resulting from trauma in children.
Results in life long disability and significant expense.
Traumatic Brain Injury (TBI)
Head Injuries
- Adequate venous drainage (_____ degree, heads up position)
- Adequate oxygenation
- Avoidance of hypotension
- +/- Maintenance of slight hypocarbia (PaCO2 of ____ to ____)
- Monitor ICP (intraventricular catheters and subarachnoid bolts) and CBF (SVO2)
- Remember that fontanelles allow for expansion to a point.
- 30
- hypocarbia (35 to 38)
Child Abuse
- Laws mandating the report of suspected abuse and neglect exist in all 50 states
- In order to recognize child abuse, anesthesia providers must acknowledge that victimization occurs in all segments of society and must be considered as part of a differential diagnosis
Anesthesia For Burn Injuries
Children younger than 5 years of age account for _____% of all burns with most children burned in their homes.
Mortality rates from burn injuries have declined over the past decades but almost _______ children still die from fire and burn injuries each year.
- 19
- 1100
Burn-Wound Assessment
- _____, _____ and ______ are the three components that contribute to the overall severity of burn wounds.
- May be caused by thermal, chemical, electrical, ultraviolet and radiologic sources.
- Burn wounds are dynamic (evolve over time).
Injury depth, size and location
Burn Injuries: Pathophysiology
- Mediators released from burn areas activate local and systemic ________ responses.
- Abnormal _________ values may persist for years after injury.
- ___________ are detected immediately after the burn, correlate with burn size, and are predictive of multiorgan failure.
- Shortly after injury massive fluid volumes shift from the vascular compartment to burned tissues and nonburned areas resulting in ___________.
- Systemic BP is initially maintained by vasoconstriction secondary to an outpouring of catecholamines and ADH.
- Days 1-4 of a moderate size burn will result in an ______ loss equal to twice the total body plasma content through the wound.
- Changes in vascular integrity result in widespread ___.
- inflammatory
- cytokine
- Endotoxins
- hemoconcentration
- albumin
- edema
Mortality increases when ____ or more organ systems fail.
* Respiratory failure occurs in the first _______ primarily
* Cardiac and renal failure in first ______
* Hepatic failure as the duration of hospital stay continues
- 3
- 5 days
- 3 weeks
Burn Injuries: Cardiac
- _______ is reduced immediately after an injury. Inotropes are used to improve CO while avoiding volume overload acutely.
- 3-5 days post injury, children are ___________.
- CO may increase 2-3 fold and persists for weeks to months. Some children may develop a reversible ________and _.
- CO
- hypermetabolic
- cardiomyopathy and hypertension
Burn Injuries: Pulmonary
- Upper airway injury is usually a ________ insult.
- Lower airway injury is usually _________ insult.
- Overall effect is necrotizing bronchitis, bronchial swelling, alveolar destruction, exudation of protein, loss of surfactant, loss of bronchial lining and ciliary function, bronchospasm leading to bronchopulmonary pneumonia.
- Mortality from inhalation injury is _______%
*Carbon monoxide binds well to hemoglobin, replacing oxygen molecules
- Oxygen molecules can not be transported causing hypoxemia
- Leftward shift of oxyhemoglobin curve
- Peak airway edema occurs between ___ to ______ hours
- thermal
- chemical or toxic
- 16
- 12 and 24
Burn Injuries: Indicators of Lower Airway Injury
- Victim extricated from an enclosed environment
- Burns noted on face, lips, nares, or intraoral cavities
- Carbon debris in mouth, nose, sputum
- Stridor or hoarseness
- Dyspnea, retractions, or nasal flaring
- Hypoxia
- Carbon monoxide levels confirmed by co-oximetry on the ABG
Burn Injuries: Renal
- Acute tubular necrosis may result from:
- Fluid retention is common ____-____ days post injury followed by diuresis.
Burn Injuries: Liver
The liver may be damaged by hypoxemia, hypoperfusion, drug toxicity, sepsis, hypermetabolic response to burns, blood transfusion, reperfusion injury
- Myoglobinuria,
- Hemoglobinuria,
- Hypoxemia,
- Hypotension,
- Inhaled toxins.
3-5
Burn Injuries: CNS
Chemicals inhaled may be neurotoxic, hypoxic encephalopathy, sepsis, hyponatremia, hypovolemia all contribute to CNS dysfunction.
Hematology Problems:
Gastrointestinal problems:
Hemoconcentration
Hemolytic anemia
Thrombocytopenia
DIC
Gastric stasis
Intestinal ileus
Stress ulcers
Burn Injuries: Metabolic
- Altered _______ responses
- Impaired _______ control
- Impaired temperature control and increased potential for infection due to loss of skin integrity.
- Increased use of glucose, fat, protein leads to greater O2 demand and CO2 production.
- _____,______,______
- Psychiatric trauma
- hormone
- glucose
- Hypocalcemia,
- hypophosphatemia,
- hypermagnesemia
“Hyperdynamic” State
- The hyperdynamic, hypercatabolic response is related to ________ burned and the duration of time patients are exposed to elevated levels of _______and______.
- Strategies used to ameliorate the hypermetabolic response include early surgical intervention, normothermia, nutritional support to replenish catabolic losses, and pharmacological agents such as _______ and _______.
- Early excision and grafting of burn eschar attenuates the hypermetabolic response by preventing further net ______, _______ and the development of sepsis.
- TBSA; catecholamines and stress hormones.
- Insulin and b-antagonists
- Protein loss, catabolism,
Systemic effects of therm
Neuromuscular blockade: burns
- In the context of acute burns, there is an increased risk of severe hyperkalemia.
- Excessive SCh-induced potassium efflux may be observed as early as _______ hours post-injury and for up to ____ years.
- In general, SCh okay within < _____ hours of burn injury; avoid if > _____ hours and for at least ____ months after burn injury.
- 12; 2
- 24, 24, 18
Neuromuscular blockade: burns
- Nondepolarizing agents: ↑ dose frequency and requirements (2- to 5-fold) during _________, reversal agent requirements are ________.
- Consider ________ for rapid-sequence induction if > 24 hours after burn injury.
- hyperdynamic phase; unchanged
- rocuronium (up to 1.2 mg/kg)
General Anesthetics: burns
Intravenous agents
* ______ dose requirements during early phase.
* _______ requirements during hyperdynamic phase of injury.
Inhalation agents
* ________ MAC during early phase of burn injury
* _________ MAC during hyperdynamic phase of burn injury
- Decreased, Increased
- Decreased, Increased
Volume Resuscitation: burns
- The most widely accepted fluid protocols are the Parkland and Brooke formulas.
- Infants weighing less than _______ should have ___________ fluid requirements calculated and then added to the Parkland or Brooke formula.
- Fluid therapy is goal directed.
- Restrict glucose containing solutions at all times.
10kg
hourly maintenance
Volume Resuscitation: Burns
Parkland Memorial Hospital (Dallas, TX)
* Recommends _____mL/kg of crystalloid x the percentage of burn
* Administer ½ of the volume in first ______ hours
* Administer remainder over the next ___hours
* No ________
- 4
- 8
- 16
- colloids
Volume Resuscitation: Burns
Brooke Army Medical Center at Fort Sam Houston (San Antonio, TX)
* Recommends _____ mL/kg of crystalloid and _____ mL/kg of colloids x the % of burn
* Administer ½ of the volume in first _____ hours
* Administer remainder over the next _____ hours
- 1.5, 0.45
- 8, 16
Volume Resuscitation: Burns
Clinical Endpoints for Volume Resuscitation
- Normothermia
- Age-appropriate hemodynamics
- Sustained urine output (0.5- 1 ml/kg/hr; negative glucose or protein)
- Minimal systemic acidosis
Anesthetic management: Burns
- Psychological aspects
- NPO guidelines and post pyloric feeds
- Adequate IV access and monitoring
- Monitor ABG to assess degree of shunting and dead space ventilation.
- Correct blood losses.
- Patients are chronically ______.
- Remember, pharmacokinetic responses are altered.
- Methehemoglobinemia secondary to use of _______ dressings (treat with _____ and ______).
- Airway control
- Continue hyperalimentation.
- Infusions of opioids, benzodiazepines, ketamine, dexmedetomidine.
- Attempt to modulate nociceptive pathways
- hypocalcemia
- silver nitrate
- Methylene blue and high fiO2
