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.