Week 12: Pediatric Trauma, Burns, Syndromes Flashcards

1
Q

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:

A
  • 1
  • Head

  • MVA
  • Falls
  • Nonaccidental trauma
  • Drowning
  • Extremes of temperature
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2
Q

Trauma Scoring Systems

Glasgow Coma Scale (GCS) and the modified GCS

Pediatric Trauma Score (PTS)

A
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3
Q

ABCs of Resuscitation

A =
B =
C =
D =
E =

A

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

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4
Q

Surveys

Primary survey –

Secondary survey –

ATLS course (Advanced Trauma Life Support)

A
  1. incorporates the “ABC’s” and life-threatening injuries are identified and treated
    * Airway
    * Breathing
    * Circulation and Access
    * Disability (Neurologic Assessment)
    * Exposure
  2. other injuries that contribute to significantly to illness and deaths are identified and treatment is instituted
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5
Q

SAMPLE Report

S
A
M
P
L
E

Preoperative Evaluation

A

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

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6
Q

Figure 39-1

Management of pediatric trauma patients

A
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7
Q

CV
Skin
Renal
CNS

A
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8
Q

review

A
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9
Q

Criteria for Early Intubation

A
  • 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
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10
Q

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

A
  • risk for aspiration
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11
Q

Causes of airway abnormalities

Congenital syndromes

Acquired conditions

A
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12
Q

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 _______
A
  • normovolemia
  • 5% albumin
  • Factor VIIA
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13
Q

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
A
  • isotonic
  • dextrose-containing
  • 130-200
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14
Q

Vascular Access

Establish IV access ASAP!
Intraosseous (IO) access if IV cannot be established

A
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15
Q

Induction: Trauma

  1. Rapid sequence induction
  2. 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!
A
  • propofol & SCh
  • Ketamine (1 – 2 mg/kg) or Etomidate (0.2 - 0.3 mg/kg) and SCh

-

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16
Q

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
A

Dog bites; 5

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17
Q

______________ is the leading cause of morbidity and mortality resulting from trauma in children.

Results in life long disability and significant expense.

A

Traumatic Brain Injury (TBI)

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18
Q

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.
A
  • 30
  • hypocarbia (35 to 38)
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19
Q
A
20
Q
A
21
Q

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
A
22
Q

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.

A
  • 19
  • 1100
23
Q

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).
A

Injury depth, size and location

24
Q

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 ___.
A
  1. inflammatory
  2. cytokine
  3. Endotoxins
  4. hemoconcentration
  5. albumin
  6. edema
25
Q

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

A
  • 3
  • 5 days
  • 3 weeks
26
Q

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 _.
A
  • CO
  • hypermetabolic
  • cardiomyopathy and hypertension
27
Q

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
A
  • thermal
  • chemical or toxic
  • 16
  • 12 and 24
28
Q
A
29
Q

Burn Injuries: Indicators of Lower Airway Injury

A
  • 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
30
Q

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

A
  • Myoglobinuria,
  • Hemoglobinuria,
  • Hypoxemia,
  • Hypotension,
  • Inhaled toxins.

3-5

31
Q

Burn Injuries: CNS

Chemicals inhaled may be neurotoxic, hypoxic encephalopathy, sepsis, hyponatremia, hypovolemia all contribute to CNS dysfunction.

Hematology Problems:

Gastrointestinal problems:

A

Hemoconcentration
Hemolytic anemia
Thrombocytopenia
DIC

Gastric stasis
Intestinal ileus
Stress ulcers

32
Q

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
A
  • hormone
  • glucose

  • Hypocalcemia,
  • hypophosphatemia,
  • hypermagnesemia
33
Q
A
34
Q

“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.
A
  • TBSA; catecholamines and stress hormones.
  • Insulin and b-antagonists
  • Protein loss, catabolism,
35
Q
A
36
Q
A
37
Q

Systemic effects of therm

A
38
Q

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.
A
  • 12; 2
  • 24, 24, 18
39
Q

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.
A
  • hyperdynamic phase; unchanged
  • rocuronium (up to 1.2 mg/kg)
40
Q

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

A
  • Decreased, Increased
  • Decreased, Increased
41
Q

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.
A

10kg
hourly maintenance

42
Q

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 ________

A
  • 4
  • 8
  • 16
  • colloids
43
Q

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

A
  • 1.5, 0.45
  • 8, 16
44
Q

Volume Resuscitation: Burns

Clinical Endpoints for Volume Resuscitation

A
  • Normothermia
  • Age-appropriate hemodynamics
  • Sustained urine output (0.5- 1 ml/kg/hr; negative glucose or protein)
  • Minimal systemic acidosis
45
Q

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
A
  • hypocalcemia
  • silver nitrate
  • Methylene blue and high fiO2
46
Q
A