Pediatric Trauma :Pediatric Trauma EMS Professions Temple College


Pediatric Trauma :Pediatric Trauma #1 Killer of children after neonatal period Priorities same as adult  ABC’s Children not small adults


Pediatrics :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!!!


Age Classification :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


How Does Serious Injury Occur in Children? :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


Common Emergencies By Age :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


Pediatric Trauma :Pediatric Trauma Traumatic injuries often involve blunt trauma to the head Drowning leading cause of death < 4 years 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


Mechanisms of Pediatric Injury :Mechanisms of Pediatric Injury Waddell’s Triad


Mechanisms of Pediatric Injury :Mechanisms of Pediatric Injury


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


First Impression :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


Pediatric Assessment:Initial Assessment :Pediatric Assessment:Initial 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


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


Focused Exam :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


Focused Exam :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


Focused Exam :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)


Focused History & Exam :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)


Anatomical Differences :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


Pediatric Intubation Considerations :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


Pediatric Intubation Considerations :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 < 2 years Move the tongue out of the way! Lift the epiglottis directly with the blade


Pediatric Intubation Considerations :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


Pediatric Intubation Considerations :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


Pediatric Intubation Considerations :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


Surgical Airways :Surgical Airways Surgical cricothyrotomy is not recommended in children < 8 - 10 years of age Needle cricothyrotomy is preferred for children, if required at all


C-Spine Immobilization :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


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


Breathing :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


Airway Management :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


Airway Management :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


Circulation :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


Circulation :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


Circulation :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


Shock :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


Shock :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)


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


Head Trauma :Head Trauma Monitor for Signs of ICP AVPU Pupils Vomiting Cushing Response Controlled hyperventilation if  ICP Resuscitate hypovolemic shock aggressively


Spinal Trauma :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.


Chest Trauma :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


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


Abdominal Trauma :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


Abdominal Trauma :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


Extremity Trauma :Extremity Trauma Priorities ABC’s 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


Extremity Trauma :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


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


Burn Resuscitation :Burn Resuscitation LR with 4cc/kg/%BSA 50% in first 8 hours 25% in second 8 hours 25% in third 8 hours


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


Management :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


Fluid Replacement :Fluid Replacement IV’s should be enroute to hospital Warm fluids After 60cc/kg without reversal, need blood replacement


Management :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