Pediatric Trauma

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Pediatric Trauma

• EMS Professions
• Temple College

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Pediatric Trauma

• 1 Killer of children after neonatal period
• Priorities same as adult ? ABCs
• Children not small adults

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Pediatrics

• Prehospital providers often have
• Limited pediatric patient contacts
• Limited knowledge, training, and experience
  specifically directed towards pediatrics
• Many other healthcare providers are similarly
  affected
• Children are not little adults!!!

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Age Classification

• Neonate Birth to 1 month
• Infant 1 - 12 months
• Toddler 1 - 3 years
• Preschooler 3-6 years
• School age 6 - 12 years
• Adolescent 12 - 18 years

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How Does Serious Injury Occur in Children?

• Function of Age Development
• Does not yet understand harm or risk
• Does not yet understand cause and effect
• Feeling of invincibility
• Injury is the leading cause of death in children
  and young adults
• 1/2 of the injuries result from motor vehicles

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Common Emergencies By Age

• Neonate Infection, Neglect
• Infant Infection, Neglect, Abuse
• Toddler Poisoning, Fall
• Preschool Poisoning, Fall, Pedestrian
• School Age Pedestrian Fall, Recreation
• Adolescent MV, OD/Poison, Recreation

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Pediatric Trauma

• Traumatic injuries often involve blunt trauma to
  the head
• Drowning leading cause of death
• Pedestrian leading cause of death 5 - 9 years
• Injuries from Falls, Motorized vehicles,
  Bicycles, Sports
• Mechanism Kinematics are critical
• serious injuries in a child may not be evident
  initially

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Mechanisms of Pediatric Injury
Waddells Triad
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Mechanisms of Pediatric Injury
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Pediatric AssessmentFirst Impression

• Pediatric Assessment Triangle
• Appearance - mental status, body position, tone
• Breathing - visible movement, effort
• Circulation - color

Appearance
Breathing
Circulation
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First Impression

• Consider the possibility of serious injury if
• the injured child has altered mental status or
  appears behaving inappropriately initially
• there is significant mechanism regardless of
  whether there are obvious injuries
• the injured child has evidence of poor systemic
  perfusion

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Pediatric AssessmentInitial Assessment

• Pediatric Assessment Triangle
• Appearance - AVPU
• Breathing - airway open, effort, sounds, rate,
  central color
• Circulation - pulse rate/strength, skin
  color/temp, cap refill, BP (? use at early ages)

Appearance
Breathing
Circulation
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General Assessment

• Observations of the child, family and environment
  are critical!
• Form a first impression of the childs status
• Maintain distance
• Talk to parents. Keep child with parent
• Is the behavior appropriate for the childs age?
• Mental status and ABCs are critical!

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Focused Exam

• Vitals signs are age dependent
• Use pediatric vital signs charts
• Systemic perfusion
• Best evaluated by presence and volume of
  peripheral pulses and mental status
• Low output shock weak, thready, narrow PP
• High output shock bounding, wide PP
• Loss of central pulses is a premorbid sign

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Focused Exam

• Skin
• ? skin perfusion may be early sign of shock
• Skin/cap refill dependent on ambient temp
• Mottling, pallor, delayed cap refill and
  peripheral cyanosis often indicate poor skin
  perfusion
• Severe vasoconstriction gray/aschen in newborns
  and pallor in older children

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Focused Exam

• Mental Status
• Lost muscle tone, Seizure, ? Pupil size
• Confusion, Irritability/Agitation, Lethargy
• Tachycardia may be an unreliable sign
• BP Estimates ( 1 year)
• Median BP 90 mm Hg (2 x age years)
• Lower Limit BP 70 mm Hg (2 x age yrs)

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Focused History Exam

• History of the Present Injury
• Family/Witness/Caretaker
• Older child
• Pertinent Past Medical History
• Often none or not obtainable
• Immediately Treat Life-Threats
• Some exceptions (epiglottitis, febrile seizure)

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Anatomical Differences

• Larger occipit increases neck flexion
• Large, floppy epiglottis
• Larger tongue relative to size of oropharynx
• Children younger than 10 have narrowest portion
  of airway below vocal cords (subglottic)
• Larynx is anterior

• As a result
• Due to airway angles, straight blade is more
  useful
• difficult to lift and control epiglottis with
  blade
• Subglottic edema, constriction or compression
  results in significant airway compromise
• Need to position yourself very low during
  intubation

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Pediatric Intubation Considerations

• Equipment ( 2 years old)
• ET tube size mm I.D. (Age in years ? 4) 4
• Term Newborn 3.0 or 3.5
• Premie 2.0, 2.5 or 3.0
• 1 year 3.5 or 4.0
• 2 years 4.0 or 4.5
• Uncuffed tubes at approx. 8 years and younger
• straight blade
• ET tube depth (Age in years ? 2) 12
• OR, 3 x tube size

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Pediatric Intubation Considerations

• Place in the sniffing position
• Manually immobilize head in suspected C-spine
  injury
• A small folded towel may need to be placed
• Under the head of the child 2 years
• Under the shoulders of the child
• Move the tongue out of the way!
• Lift the epiglottis directly with the blade

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Pediatric Intubation Considerations

• If bradycardia ensues, ventilate adequately
  before re-attempting intubation
• Pretreat with Atropine 0.02 mg/kg if using
  neuromuscular blockers or sedation
• Consider NG or OG tube if excessive gastric
  distention was created by BVM ventilations

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Pediatric Intubation Considerations

• Intubation complications - DOPE
• D Dislodgment
• O Obstruction
• P Tension Pneumothorax
• E Equipment failure
• FREQUENTLY Reassess!
• Little movement is required to inadvertently
  extubate the pediatric patient

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Pediatric Intubation Considerations

• Tubes migrate with head movement
• Secure tube well
• Immobilize head in neutral position
• Never let go of tube
• ET tubes wind up in mainstem bronchi, due to
  short trachea

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Surgical Airways

• Surgical cricothyrotomy is not recommended in
  children
• Needle cricothyrotomy is preferred for children,
  if required at all

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C-Spine Immobilization

• Many experts now oppose the transport of an
  injured child in his/her car seat
• The car seat may have been damaged in the
  accident
• It is difficult to adequately examine the child
• It is difficult to adequately immobilize the
  C-spine
• KED is frequently used for this purpose
• A rolled towel may be used when a properly sized
  C-collar is not available
• Remember the large occiput of the small child

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Breathing

• High metabolic rates Low reserve capacity
  result in high sensitivity to airway/breathing
  problems
• Oxygenate and ventilate aggressively

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Breathing

• Adequate ventilation and oxygenation are crucial
  to the seriously injured child
• Higher demand for oxygen normally as compared to
  adults
• Head injuries require adequate oxygenation to
  minimize secondary injury
• At a minimum, supplemental oxygen is indicated

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Airway Management

• Simple supplemental oxygen is usually adequate in
  the spontaneously breathing child
• If the child does not tolerate a mask or nasal
  cannula, blow-by oxygen is better than no oxygen
• Proceed slowly in the anxious or distrusting child

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Airway Management

• BVM ventilation often is sufficient and
  preferable over ETT
• Complication of BVM ventilation gastric
  distention
• May interfere with diaphragm movement
• Increase risk of emesis aspiration

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Circulation

• Assessment of the BP is seldom useful
• Assess BP last. Use other assessment findings.
• Hypotension will be a very late sign in the
  pediatric shock patient
• Hypertension may be subtle in the head injured
  patient
• Serious injuries may not be obvious externally

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Circulation

• Rapid control of external bleeding
• Essential due to small blood volume
• Efficient compensation for shock may lead to
  sudden decompensation and onset of irreversible
  shock

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Circulation

• BP monitoring - poor way to detect shock
• Assess rate, quality of peripheral pulses
• Skin color and temperature
• LOC (Silence is not Golden)
• Capillary refill

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Shock

• Children will not tolerate respiratory failure or
  shock
• Shock may be seen as tachycardia and poor skin
  perfusion or mental status
• Children have excellent compensatory mechanisms -
  UP TO A POINT!
• Then they crash
• Hypotension is an ominous sign

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Shock

• Bradycardia, hypotension or irregular
  respirations are late and ominous signs!!!
• Treatment
• Oxygenation/Ventilation
• Fluids 20 cc/kg as a bolus (not wide open
  infusion)
• Additional vascular access options intraosseous
  and umbilical vein (newborn)

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Head Trauma

• Major cause of pediatric trauma
• Large heads
• Thin skulls
• Poor muscle control
• Diffuse edema more common than intracranial
  hematomas

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Head Trauma

• Monitor for Signs of ICP
• AVPU
• Pupils
• Vomiting
• Cushing Response
• Controlled hyperventilation if ? ICP
• Resuscitate hypovolemic shock aggressively

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Spinal Trauma

• Rare. Usually at C1, C2, C3. Dislocations more
  common.
• Suspect if trauma involves
• Sudden deceleration
• Head injuries
• Decreased LOC
• If Spinal immobilization is thought, then do it.
• Resist temptation to pick up child and run.

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Chest Trauma

• Second only to head trauma as cause of trauma
  death
• 90 of pedi chest trauma - blunt trauma
• Chest wall is pliant. Rib fracture is uncommon
• Extensive intrathoracic injury without rib Fx

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Chest Trauma

• Mobile mediastinum - do not tolerate tension
  pneumothorax well
• Limited respiratory reserve
• Poor tolerance of chest injury

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Abdominal Trauma

• Most common from of pediatric trauma.
• Usually blunt
• Liver, spleen injury more common than in adults
• High, broad costal arch
• Relatively larger organs

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Abdominal Trauma

• Tenderness
• Significant trauma UPO
• Distention
• Significant trauma UPO
• May also be due to air swallowing
• Early NG tube placement may avoid unnecessary
  surgery

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Extremity Trauma

• Priorities ABCs
• Orthopedic trauma never severe enough to warrant
  attention before head, chest, abdominal injury
• Pliant pedi bones absorb/ dissipate significant
  force.
• Greenstick Fx common
• Treat painful, tender or favored extremities as Fx

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Extremity Trauma

• Epiphyseal plate frequently involved
• 50 have growth abnormalities
• Neurovascular injury - most common injury
• Humerus
• Femur
• Assess distal pulse, skin color, temp, cap
  refill, motor/sensory function

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Burns

• 50 burn admissions
• 33 burn deaths
• Large BSA increases fluid loss
• Large BSA increases heat loss - hypothermia
• Smaller airway - increased airway burn difficult

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Burn Resuscitation

• LR with 4cc/kg/BSA
• 50 in first 8 hours
• 25 in second 8 hours
• 25 in third 8 hours

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NG Tube

• Need to be placed early
• Shock may be secondary to decreased venous return
  from distended stomach pressing under diaphragm

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Management

• Airway
• 100 O2. Consider early ventilation.
• Prevent Hypothermia
• Large surface/volume ratio - increase heat loss
• Cover with blanket
• Consider effects of cold IV fluids

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Fluid Replacement

• IVs should be enroute to hospital
• Warm fluids
• After 60cc/kg without reversal, need blood
  replacement

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Management

• MAST/PASG
• Legs only initially
• If child needs abdominal compartment also
  intubate and ventilate
• Elastic ace bandages or air splints can be used
  on legs if child too small for MAST