Management of the Pediatric Trauma Patient :1 Management of the Pediatric Trauma Patient Sass Elisha
Kaiser Permanente School of Anesthesia
Prevalence of Pediatric Trauma :2 Prevalence of Pediatric Trauma Trauma is the leading cause of death in infants and children
Trauma is the cause of 50% of deaths in people between 5 and 34 years of age
Motor vehicle related accidents account for 50% of pediatric trauma cases
$16 billion is spent annually caring for injuries to children less than 16 years of age
Mechanism of Injury and Associated Mortality :3 Mechanism of Injury and Associated Mortality
Slide 4:4
Slide 5:5
Organ Weight During Violent Impact at Various Velocities :6 Organ Weight During Violent Impact at Various Velocities
Seatbelt Injuries :7 Seatbelt Injuries
Child Passenger Restraints :8 Child Passenger Restraints Infants: 20 to 40 lbs and > 1 yr
Forward-facing, back seat
> 40 lbs or exceeds height requirements for child safety seats
Belt-positioning booster seat, back seat
> 80 lbs or 4’9”
Lap and shoulder straps fit
Knees bent over seats edge
LATCH: A Standardized Child Safety Seat System :9 LATCH: A Standardized Child Safety Seat System Simplify child safety seat installation
All new vehicles sold within the US by 2002
Upper and lower anchor points
Concerns About Airbags :10 Concerns About Airbags Car sensors
Speed of deployment
By products of combustion
Head, Neck and Thoracic injuries
Advances in Airbag Technology :11 Advances in Airbag Technology On-off switches
Disabled for:
Infants in rear facing position,
Forward facing children between 1 and 12 years of age
Smart Airbags?
Slide 12:12
Traumatic Brain Injury :13 Traumatic Brain Injury
Increased Intracranial Pressure :14 Increased Intracranial Pressure
Modified GCS for ChildrenEYE OPENING :15 Modified GCS for ChildrenEYE OPENING
Modified GCS for ChildrenMOTOR RESPONSE :16 Modified GCS for ChildrenMOTOR RESPONSE
Modified GCS for ChildrenVERBAL RESPONSE :17 Modified GCS for ChildrenVERBAL RESPONSE
Traumatic Brain Injury :18 Traumatic Brain Injury Primary Brain Injury
Results from what has occurred to the brain at the time of the injury Secondary Brain Injury
Physiologic and biochemical events which follow the primary injury
Examples of Primary Brain Injuries :19 Examples of Primary Brain Injuries
Factors that Effect Secondary Brain Injuries :20 Factors that Effect Secondary Brain Injuries Blood Pressure
Oxygenation
Temperature
Control of Blood Glucose
Fluid Volume Status
Increased Intracranial Pressure
Altered Cerebral Autoregulation :21 Altered Cerebral Autoregulation
Blood Pressure Control :22 Blood Pressure Control CPP=MAP-ICP
Birmingham, Edinberg, Lund
Pigula, et al (1993)
Vavilala, et al (2003)
Median 50th percentile SBP for children> 1year of age
90+(2 X age in years)
Hyperventilation and Hypocarbia? :23 Hyperventilation and Hypocarbia? PaO2 >60 mm/Hg or
Oxygen saturation >90%
Ong (1996)
PaCO2 35-38 mm/Hg
Exceptions when hyperventilation is warranted:
Hypothermia? :24 Hypothermia? Presently no controlled studies related to children and hypothermia
Adult head injury patients and hypothermia
Concerns and the hypothermic pediatric patient
Avoid hyperthermia (>38.5° C)
Blood Glucose :25 Blood Glucose Stress response
Hypoglycemia
Cochran (2003)
Fluid Volume Status :26 Fluid Volume Status Normovolemia?
Maintenance of hemoglobin
Isotonic crystalloids
Colloids
Vasopressors
Central diabetes insipidus
Intracranial Pressure Control :27 Intracranial Pressure Control Mannitol
3% sodium chloride
External ventricular drain (EVD)
Currently no standards for ICP control in the pediatric population
Mazzolla (2002)
Decreased mortality with ICP control
Slide 28:28
Hypotension, Hypercarbia and Hypoxia are Associated with Significantly Increased Mortality in the Pediatric Patient Presenting with a Traumatic Brain Injury :29 Hypotension, Hypercarbia and Hypoxia are Associated with Significantly Increased Mortality in the Pediatric Patient Presenting with a Traumatic Brain Injury
Acute Spinal Cord Injuries (ASCI) in the Pediatric Population :30 Acute Spinal Cord Injuries (ASCI) in the Pediatric Population C Spine injuries, although rare in the pediatric population are associated with a 60% mortality rate.
Differences in patterns of C spine injuries in children as compared to adults
Spinal Cord Injury Without Radiographic Abnormality (SCIWORA)
Dislocation/Relocation Injuries
Immobilization :31 Immobilization Neutral Position
Cervical Collars
Sand Bags and Tape
Clearance of Cervical Spine Injuries in the Pediatric Population :32 Clearance of Cervical Spine Injuries in the Pediatric Population Clinical Clearance
Normal mental status
Not intoxicated
Normal neurological examination
No tenderness to palpation of C spine
No pain with active range of motion
Cervical spine in alignment without deformation
Clearance of Cervical Spine Injuries in the Pediatric Population :33 Clearance of Cervical Spine Injuries in the Pediatric Population Radiographic Clearance
Anterior/Posterior View
Lateral View
Odontoid Radiograph
Cat Scan
MRI
Lateral Cervical Spine Injury :34 Lateral Cervical Spine Injury
National Emergency X-Ray Utilization Study :35 National Emergency X-Ray Utilization Study Viccellio (2001), Low Risk Criteria
Absence of midline cervical tenderness
Not intoxicated
Appropriate level of alertness
No neurologic deficits
No evidence of spinal column distraction
Airway Maneuver and Effect on Cervical Spine :36 Airway Maneuver and Effect on Cervical Spine
In Line Manual Axial Stabilization :37 In Line Manual Axial Stabilization
Anatomic Characteristics of the Pediatric Patient and Significance to Trauma Care :38 Anatomic Characteristics of the Pediatric Patient and Significance to Trauma Care
REFERENCES :39 REFERENCES Cochran, A. (2003). Hyperglycemia and outcomes from pediatric traumatic brain injury. Journal of Trauma, Injury, Infection, and Critical Care, 55(6), 1035-1038.
Cook, B. S., Kaaren, F., & Schweer, L. (2003). Pediatric cervical spine clearance: Implications for nursing practice. Emergency Nursing, 29(4), 383-386.
Elias-Jones, A. C., Punt, J. A., & Turnbull, A. E. (1992). Management and outcome of severe head inuries in the Trent region from 1985-1990. Archives of Disabled Children, 67, 1430-1435.
Fortune, J. B., Feustel, P. J., & Garcia, L. (1995). Effect of hyperventilation, mannitol and ventriculostomy drainage on cerebral blood flow after head injury. Journal of Trauma, Injury, Infection, and Critical Care, 39(6),
1091-1099.
REFERENCES :40 REFERENCES Hadley, M. N. (2002). Management of pediatric cervical spine and spinal cord injuries. Neurosurgery, 50(3), 85-99.
Hall, J. K., & Berman, J. M. (1996). Pediatric Trauma Anesthesia and Critical Care. Baltimore, Maryland: Futura Publishing Company.
Kamerling, S. N. (2002). Airbags & Children: Making correct choices in child passenger restraints. American Journal of Maternal/Child Nursing, 27(5), 264-273.
Kinder-Ross., A. (2001). Pediatric trauma: Anesthesia management. Anesthesiology Clinics of North America, 19(2), 200-226.
REFERENCES :41 REFERENCES Mattox, K. L., Feliciano, D. V., & Moore, E. E. (2000).Trauma (4th ed.).
New York: McGraw Hill.
Mazzola, C. A., & Adelson, D. P. (2002). Critical care management of head trauma in children. Critical Care Medicine, 30(11), 393-401.
McGwin, G., Metzger, J. & Rue, L. W. (2004). The influence of side aribags on the risk of head and thoracic injury after motor vehicle collisions. Journal of Trauma, Injury, Infection, and Critical Care, 56(3), 512-517.
Ong, L., Selladurai, B. M., & Dhillon, M. K. (1996). The prognostic value of Glasgow Coma Scale, hypoxia and computerized tomography in outcome prediction of pediatric head injury. Pediatric Neurosurgery, 24, 285-291.
REFERENCES :42 REFERENCES Pigula, F. A., Wald, S. L., & Shackford, S. R. (1993). The effect of hypotension and hypoxia on children with severe head injuries. Journal of Pediatric Surgery, 28, 310-316.
Vavilala, M. S., Bowen, A, & Lam, A. M. (2003), Blood pressure and outcome after severe pediatric traumatic brain injury. Journal of Trauma, Injury, Infection and Critical Care, 55(6) 1039-1044.
Viccellio, P., Simon, H., Pressman, B. D. (2001). A prospective multicenter study of cervical spine injury in children. Pediatrics, 108, 234-250.