Update on Approach to Paediatric Trauma

PAEDIATRIC major TRAUMA: approach to evaluation n mx:

PAEDIATRIC major TRAUMA: approach to evaluation n mx Dr Nazhatul Muna Bt Ahmad Nasarudin

Outlines:

Outlines Epidemiology Principles of Disease Approach to Trauma: ATLS & PALS Specific Injuries Summary

Epidemiology:

Epidemiology Trauma - most common COD and disability in children 1 MV associated injuries – most common COD in children of all ages (>45%) Falls- majority of injuries but infrequently cause death. NAI – majority of homicides in infants. Each year, approximately 20,000 children and teenagers die as a result of injury Most common single organ injury: head trauma 2 ATLS 2005 Avarallo et al. Pediatric Major Trauma: An Approach to Evaluation and Management. Emerg Med Clin N Am 2007: 803-836

Mechanism of Injury:

Mechanism of Injury ATLS 2005

Principles of disease:

Principles of disease Different anatomy, physiology and psychology High body surface area to body volume ratio - prone to hypothermia Greater capacity to maintain BP despite significant acute blood loss (25-30%) Subtle changes in HR, BP and perfusion: impending cardiorespiratory failure Head: proportionately larger in young children – higher frequency of blunt head injuries.

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Bones incompletely calcified - fractures uncommon but should suspect internal organ injury. Rib fracture: should suspect more serious internal injuries Anterior placement of liver n spleen Kidney less protected n more mobile Significant multiple injuries: d/t - Smaller body mass : results in greater force applied per unit body area. - Less fat, less CT and close proximity of organs

Approach To Trauma:

Approach To Trauma ATLS 2005, PALS 2005 & 2010 Same as in adult. Special considerations compared to adult

ATLS 2005:

ATLS 2005 Triage Trauma team activation Primary Survey Secondary survey Adjuncts Treatment Disposal

PALS 2005:

PALS 2005 General Assessment : -overall appearance -work breathing -circulation Primary Assessment: -rapid ABCDE Secondary Assessment: -SAMPLE -Head-to-toe examination Tertiary Assessment

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General Appearance Work of breathing Circulation Possible shock? Resp failure or respiratory distress? Action: Triage Monitor IV Oxygen Or CPR/ Defib Primary Rapid ABCDE Hypotensive or compensated shock? Resp distress or failure? Action: Fluid: slow/bolus Relieve pneumothorax Defib Secondary SAMPLE Repeat vitals Head-to-toe Type of shock? Type of resp problem? Action: Specific treatment Tertiary Investigations

Primary survey:

Primary survey Rule out and treat life or limb threatening injury Must occur simultaneously with initial resuscitation effort Initial vitals should be every 5 min during primary survey, 15 min afterwards until stable High impact mechanism must activate trauma team

Broselow:

Broselow

Airway:

Airway Smaller the child, the greater the disproportionate between cranium and mid-face Larger occiput- passive flexion of cervical spine Flexion of neck on chest and extension of head on neck

airway:

airway Child’s larynx- funnel shape, more anterior and superior Vocal cord- more anterior and caudal Infant’s trachea- 5cm long. Grows to 7cm at 18 months Narrowest at cricoid

airway:

airway Endotracheal intubation: Inability to ventilate with BVM Need prolong control of airway GCS ≤ 8 Resp failure from hypoxemia Decompensated shock Loss of protective laryngeal reflex Prehospital : BVM as effective and safer than endotracheal intubation. Class IIa , LOE B 4

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Orotracheal is recommended. Estimate size of ETT- child external nares or little finger Safe to use cuffed ETT from 1 year onwards 4 Naso tracheal: should not be performed < 9 years d/t the ‘physiologic’ cuff, may increase ICP 1 Atropine- to clear secretion 0.02mg/kg (minimal dose 0.1mg, maximal dose 1.0mg) 1-2min before intubation 1 1. ATLS 2005 4. PALS 2010

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Cuffed ETT is preferable in infants beyond newborn: in poor lung compliance, h igh airway resistance, l arge glottic air leak 4 OT: lower reintubation rate ICU: risk of complication is same as non cuffed

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Uncuffed 0-1m : 3.0mm 1m-1y : 3.5mm 1y-2y : 4.0mm After 2y Uncuffed = 4 + age/4 Cuffed = 3.5 + age/4 Cuffed <1y : 3.0mm 1-2y : 3.5mm

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LMA – acceptable if BVM and ETT is unsuccessful, provided used by experienced providers (class IIa , LOE C) 4 Oropharyngeal airway – in unresponsive or no gag reflex Oral airway- inserted DIRECTLY into the oropharynx (otherwise trauma to soft tissue structure). May use tongue depressor. 3 Naso pharyngeal airway – can be used in normal gag

rsi:

rsi May use sedative, muscle relaxant and other meds Actual body weight rather than ideal body weight for non resuscitation drugs eg muscle relaxant 4

RSI:

RSI Preoxygenate Atropine 0.1-0.5mg Sedation Normovolaemic Etomidate 0.3mg/kg, or Midazolam 0.3mg/kg Hypovolaemic Etomidate 0.3mg/kg, or Midazolam 0.1mg/kg Cricoid pressure Paralysis * Suxa <10kg: 2mg/kg >10kg: 1mg/kg Intubate, Check tube

Breathing:

Breathing Assess chest rise Assess respiratory rate Tx is assisted ventilation with BVM Excessive volume n rate of ventilation: gastric intention n further impair ventilation Once ETT placed, ventilation rate: 1 breath every 6-8 seconds (8-10 breaths per minute) Oxygen: titrate so that oxyhemoglobin saturation ≥ 94% Use pulse oxymeter for initial adequacy Early nasogastric tube: decompress stomach

Circulation:

Circulation Increased physiologic reserve- allow maintenance of vital signs in normal range Tachycardia- primary response to hypovolaemia Assess pulse, skin colour , CRT, temp of extremeties < 2 yr old: assess pulse @ Brachial or femoral Delayed CRT is sign of shock even BP is maintained (Normal CRT ≤ 2 sec) Continuous cardiac monitoring 2 large bore IV lines

Systolic BP:

Systolic BP Age SBP Newborn 60 Infant 70 1y-10y 70 + 2 (Age in years) ≥ 10 y 90

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Palpable peripheral pulse = SBP > 80 mmHg Palpable central pulse = SBP 50-60 mmHg

Systemic Response To Blood Loss:

Systemic Response T o B lood Loss System Mild Blood Loss (<30%) Moderate (30-45%) Severe (>45%) Cardiovascular Increased HR Weak pulse Low BP, Narrow PP, Tachycardia, absent peripheral pulse Hypotension, tachycardia then bradycardia CNS Anxious, irritable Lethargic, dull response to pain Comatose Skin Cool, mottled, prolong CRT Cyanotic, markedly prolong CRT Pale, cold Urine output Minimal Minimal None

Fluid Resuscitation:

Fluid Resuscitation Child blood volume: 80 ml/kg Warm fluid Initial 20ml/kg crystalloid bolus Up to 3 boluses of 20ml/kg or total of 60ml/kg 3-for-1 rule: 3 rd fluid bolus should be followed by warmed PRBC. PRBC: bolus of 10ml/kg. PRBC: type specific or O-negative Consider IO after 2 failed percutaneous access (Class I, LOE C)

Disability and exposure:

Disability and exposure Quick assessment: AVPU system GCS Pupils size Rule out hypoglycemia Fully undress = keep normothermia

GCS:

GCS

Paediatric Verbal Score :

Paediatric Verbal Score For children < 4 years old (Preverbal) Verbal response V-Score Appropriate words/Social smile/ Fix and follow 5 Cries, but consolable 4 Persistently irritable 3 Restless, agitated 2 None 1

Secondary survey:

Secondary survey ‘SAMPLE’ history Head to toe examination Log roll and PR examination +/- Tetanus booster Antibiotic as indicated Continues vitals monitoring Urine output monitoring

Urine Output:

Urine Output Age Urine output Newborn -1 year 2ml/kg/hour Toddler 1.5ml/kg/hour Older child 1ml/kg/hour Adult 0.5ml/kg/hour

Paediatric Trauma Score:

Paediatric Trauma Score To predict mortality and severe disability PTS of 8 = mortality rate 0% PTS < 8 – aggressive monitoring and observation Lesser PTS, greater mortality/disability SBP < 50mmHg – serious jeopardy

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Component Score +2 +1 -1 Weight >20kg 10-20kg <10kg Airway Normal Oral/Nasal airway, Oxygen Intubated, Cricothy , Trachy SBP >90mmHg, good pulse and perfusion 50-90mmHg, carotid/femoral pulse palpable <50 mmHg, Weak/no pulse Level of Consciousness Awake Obtunded, any LOC Coma, unresponsive Fracture None seen/suspected Single/closed Open/Multiple Cutaneous None visible Contusion, abrasion, laceration <7cm not thru fascia Tissue loss, any GSW, stab wound thru fascia Totals:

Investigations/Adjuncts:

Investigations/Adjuncts Most important: CXR and pelvis for site of blood loss Pediatric Ultrasounds NAI : skeletal survey:- skull, chest, abdomen, long bones

Head injury:

Head injury

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Leading COD. 80% of all trauma Mostly from MVA, bicycle accident, and fall. Outcome in children suffering severe brain injury is better than adults. However, the outcome in less than 3 years is worse than older child.

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Lancet. October 2009 By Pediatric Emergency Care Applied Research Network (PECARN) Aim: to identify children at very low risk of clinically-important traumatic brain injuries ( ciTBI ) for whom CT might be unnecessary Method: child < 18 years presenting within 24 h of head trauma with GCS of 14-15 in 25 EDs. Follow up by admission record, phone call at 7 and 90 days, imaging results, medical records and county morgue record.

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They derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission ≥2 nights ). enrolled and analysed 42 412 children 10718 (25%) < 2 y CT scans done on 14 969 (35·3%); ciTBIs occurred in 376 (0·9%), and 60 (0·1%) underwent neurosurgery.

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the prediction rule for children < 2 years : had a negative predictive value for ciTBI of 1176/1176 (100·0%, 95% CI 99·7—100 0) sensitivity of 25/25 ( 100% , 86·3—100·0 ) 167 (24·1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group.

prediction rules for very low risk of ciTBI for < 2 y:

prediction rules for very low risk of ciTBI for < 2 y normal mental status acting normally (as per parental description) no scalp hematoma or only a frontal scalp hematoma (small < 1cm, medium 1-3cm, large >3cm) no loss of consciousness or loss of consciousness for < 5 seconds non-severe injury mechanism no palpable skull fracture

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The prediction rule for children ≥ 2 ): had a negative predictive value of 3798/3800 ( 99·95% , 99·81—99·99) sensitivity of 61/63 ( 96·8% , 89·0—99·6 ) 446 (20.1%) of 2223 CT-imaged patients ≥ 2 years were in this low-risk group.

prediction rules derived for very low risk of ciTBI for ≥ 2 y:

prediction rules derived for very low risk of ciTBI for ≥ 2 y normal mental status no loss of consciousness no vomiting non-severe injury mechanism no signs of basilar skull fracture no severe headache.

Clinically important TBI =:

Clinically important TBI = Death from traumatic brain injury Neurosurgical intervention for TBI Intubation > 24 hours for TBI Hospital admission ≥ 2 nights for TBI: -altered mental status -recurrent emesis -persistent headache -ongoing seizure

Tbi on CT =:

Tbi on CT = ICB/ Contussion Cerebral edema Traumatic infarct DAI Shearing injury Sigmoid sinus thrombosis Midline shift Depressed skull # Diathesis of skull pneumocephalus

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blunt head trauma who are at very low risk for a significant ICI Cranial CT seems unlikely to detect clinically important ICI in children who do not exhibit at least 1 of the following risk criteria: (1) evidence of significant skull fracture; ( 2) altered level of alertness; ( 3) neurologic deficit; ( 4) persistent vomiting; ( 5) presence of scalp hematoma; ( 6) abnormal behavior; and ( 7) coagulopathy.

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Concussion= Trauma-induced alteration in mental status with or without LOC . [American Academy of neurology] Mild head injury with transient LOC/amnesia with normal CT brain, can be discharged home after at least 6 h of uneventful observation. Post concussion syndrome= headache, memory loss, behavior disturbance, impaired concentration. Should repeat CT brain. Post concussion sy : may up to months but rarely beyond 3 months. Symptomatic n supportive tx .

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ICP monitoring with GCS 8 or less 30° head elevation Steroid - No role! Hypothermia (27-31°C) -very few studies and not very definite - In children with severe traumatic brain injury, hypothermia that is initiated within 8 hours after injury and continued for 24 hours does not improve the neurologic outcome and may increase mortality N Engl J Med 2008; 358:2447-2456 June 5, 2008 Hypertonic saline has been demonstrated to be effective at lowering ICP in both ICU and operating room settings, but with limited studies

Cervical spine injury:

Cervical spine injury Uncommon. Cervical spine injury must be presumed until proven otherwise. 40% due to MVA Common cervical # - C1 and C2 SCIWORA- more common than adult. 10-20%

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NEXUS Low Risk Imaging criteria (100%sensitivity and 100% negative predictive value) 5 : No Midline cervical tenderness No altered mental status No intoxication No neuro deficit No distracting pain However, use cautiously in < 2 years. Also in congenital or acquired abnormality If imaging indicated, 3 views – 89% sensitivity and 100% negative predictive value

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Pseudosubluxation – 40% of child < 7y shows anterior displacement of C2 on C3. 20 % of child up to 16 y. D/t increased ligamentous laxity. Versus true subluxation by post cervical line/ spinolaminar line/line of Swischuk Prevertebral space: ant line to pharynx: - C2 < 50% of body or less than 7mm -C6 < 14mm

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Pseudosubluxation : If Swischuk line crosses the anterior cortical margin of the spinous process at C2 or is off by less than 2mm, and no fractures are seen.

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Inadequate cervical xray : Swimmer’s view Failed Swimmer’s view: do not repeat plain Xray . May proceed CT Scan Unconscious child: continue immobilization. A strong case could be made for CT or MRI. 7

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NASCIS 3, USA 1997: Level 1 evidence from this data is that there is no difference between methylprednisolone and placebo in the outcome of spinal cord injury ATLS 2010 – methyl prednisolone is no longer advocated in SCI. No RCT study on pediatric population. .

Chest injury:

Chest injury

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2 nd leading COD in pediatric trauma Most blunt trauma from MVA Rib # uncommon due to bone pliability Pulmonary contusion and pneumothorax is more frequent If rib # is present, must suspect more serious internal injury >50% rib # in child < 3 y d/t child abuse 70% had abnormal initial CXR. But a normal CXR doesn’t rule out diagnosis.

PNEUMOTHORAX:

PNEUMOTHORAX Simple: Small (<20%), not ventilated, not in tension: may observe with 100% oxygen Chest tube size: 4 times the ETT diameter Tension: Relieved by needle thoracostomy

Abdominal trauma:

Abdominal trauma

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Mostly blunt trauma Solid organ esp spleen, followed by liver and kidney. DPL – in hemodynamic unstable child. But considered invasive compared to Ultrasound. Non operative mx has 90% success rate.

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Higher solid organ injury without free fluid FAST alone 100% specificity, 70 % sensitivity FAST + clinical = sensitivity 100% +LR = 17.35 -LR = 0.32 A negative FAST doesn’t rule out important injury

Splenic injury:

Splenic injury Relatively common LUQ pain radiating to left shoulder Successful rate non op mx for isolated injury: 90% Mortality rate from isolated injury: 0.7% Most do not need blood transfusion FAST CT abdo in stable pt , to define site and extent May opt for conservative mx provided pt is admitted to paeds ICU at least 48 hours with surgical team back up

Hepatic injury:

Hepatic injury Isolated hepatic injury, without disruption of portal vein, hepatic vein, or suprarenal IVC, behaves clinically like splenic injury Most responds to non operative mx Success rate for non operative mx of blunt injury is 85-90%. Exception massive hepatic injury or perihepatic vascular involvement who are not hemodynamic stable and transfusion requirement > 25-40ml/Kg/d

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Hemodynamic unstable: prompt op mx Mortality rate from isolated injury 2.5% Most death at first 48 hours. Hemorrhage: most common COD Combine hepatosplenic injury has higher risk and requires vigilance

Pancreatic injury:

Pancreatic injury Mostly blunt trauma Frequently falling into bicycle handlebars

Renal injury:

Renal injury Less common Dull back pain, ecchymosis in costovertebral region, hematuria Renal ultrasound May CT in stable patient Grade I-V Grade I-III: maybe conservative Absolute Op: expanding/pulsatile renal hematoma Relative: urinary extravasation, arterial injury

Renal injury classification:

Renal injury classification GRADE I: contusion or subcapsular hematoma GRADE II: confined perirenal hematoma or cortical laceration less than 1 cm deep GRADE III: parenchymal laceration extending more than 1 cm into the cortex GRADE IV: extending to corticomedullary junction and into the collecting system GRADE V: shattered kidney ; thrombosis of the main renal artery; avulsion of the main renal artery and/or vein.

Penetrating injury:

Penetrating injury Urgent referral to surgeon Stable pt : CT Unstable pt : Op DPL is controversial. Hugely replaced by FAST Arrival SBP < 90mmHg & core T < 34°C : predicts high mortality 2

Indications for surgery2 :

Indications for surgery 2 Hemodynamic instability despite resuscitative efforts Transfusion > 50% total blood volume Radiographic evidence of pneumoperitoneum , intraperitoneal bladder rupture, Grade V renovascular injury Gunshot wound to abdomen Evisceration of intraperitoneal or stomach contents Signs of peritonitis Fecal or bowel contamination on DPL

Child abuse:

Child abuse Injury during first year of life Should suspect if: Discrepancy between hx and degree of physical injury Prolong interval between time of injruy and seeking tx Hx of repeated trauma, treated in different ED Parents respond inappropriately Hx of injury changes or differs between parents and guardian

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Findings in NAI : Multiple subdural hematomas, esp without a fresh skull # Retinal hemorrhage Perioral injuries Ruptured internal viscera without antecedent major blunt trauma Trauma to genital/perianal area Evidence of frequent injuries on xray # of long bones in child < 3 years Bizarre injuries eg bites Sharply demarcated 2 nd and 3 rd degree burn/ unusual areas

Pitfalls in pediatric injury:

Pitfalls in pediatric injury Unique anatomy and physiology: produce pitfalls in the mx Small ETT promotes obstruction from secretions Uncuffed ETT can be dislodged esp during transportation Child’s ability to compensate in early stage of hypovolemia can mask the hemodynamic unstability Therefore, must reexamine frequently

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Internal injury, must involve the surgeon early A child who refuse to use an arm or bear weight, must carefully evaluated The doctor must remember the potential for child abuse

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The End

References:

References ATLS 2005 Avarallo et al. Pediatric Major Trauma: An Approach to Evaluation and Management. Emerg Med Clin N Am 2007: 803-836 ACLS 2005 PALS 2010 Vicello et al, NEXUS Group. A Prospective Multicentre study of cervical spine Injury in Children. Pediatrics 2001; 108 (2) E20 Kuppermann et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009;374(9696):1160-1170.

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7. Slack & Clancy. Clearing The Cervical Spine Of Paediatric Trauma Patients. Emerg Med J 2004;21:189-193 8. http://www.trauma.org/archive/spine/steroids.html#NASCIS_3.2C_USA_1997 9 . Levy & Noble. Bedside Ultrasound in Pediatric Emergency Medicine. Pediatrics 2008; 121: 1404-12 10 . http://www.med.umn.edu/peds/em/prod/groups/med/@pub/@med/@peds/@emergmed/documents/content/med_content_113682.pdf 11. Emedicine 12. http ://www.rch.org.au/paed_trauma/manual.cfm?doc_id=14075

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Paediatric Verbal Score :

Paediatric Verbal Score For children < 4 years old (Preverbal) Verbal response V-Score 5 4 3 2 1