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LTC Brenda Sowards, Chief Nurse
141st MDG
Washington Air National Guard

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  1. 1. PEDIATRIC TRAUMA LTC Brenda Sowards, Chief Nurse 141 st MDG Washington Air National Guard
  2. 2. Epidemiology <ul><li>Injuries are the number one cause of death and disability in children over one year of age </li></ul><ul><li>Deaths from natural causes have declined; not from traumatic injury </li></ul>
  3. 3. Mechanisms of Injury and Biomechanics <ul><li>Toddler/preschooler: Fires, burns, drowning, struck by vehicle, motor vehicle crashes, and child maltreatment </li></ul><ul><li>School age: Struck by vehicle, motor vehicle crashes, drowning, fires, and burns </li></ul><ul><li>Middle school age: Motor vehicle crashes, pedestrian versus motor vehicle, homicide </li></ul><ul><li>High school age: Motor vehicle crashes, homicide, suicide, drowning, and poisoning </li></ul>
  4. 4. Mechanisms of Injury and Biomechanics <ul><li>Motor vehicle crashes </li></ul><ul><li>Falls </li></ul><ul><li>Lap belt complex </li></ul><ul><li>Air bag injuries </li></ul>
  5. 5. Child Maltreatment <ul><li>Associated with: </li></ul><ul><ul><li>Head injuries </li></ul></ul><ul><ul><li>Burns </li></ul></ul><ul><ul><li>Abdominal injuries </li></ul></ul><ul><ul><li>Soft tissue injuries </li></ul></ul><ul><ul><li>Fractures </li></ul></ul>
  6. 6. Types of Injuries <ul><li>Blunt trauma: 80% </li></ul><ul><li>Order of frequency </li></ul><ul><ul><li>Head </li></ul></ul><ul><ul><li>Musculoskeletal </li></ul></ul><ul><ul><li>Abdomen, l iver and spleen most common abdominal injury </li></ul></ul><ul><ul><li>Thorax </li></ul></ul>
  7. 7. Anatomic and Physiologic Differences <ul><li>Tongue is larger when compared to oral cavity </li></ul><ul><li>Airway cartilage is soft; smaller diameter </li></ul><ul><li>Infants are obligatory nose breathers </li></ul><ul><li>Larynx is higher and more anterior; trachea is shorter </li></ul><ul><li>Cricoid cartilage is narrowest portion of trachea (under 8 years) </li></ul><ul><li>Diaphragm is positioned more horizontally (until 12 years of age) </li></ul><ul><li>Chest wall is more pliable </li></ul><ul><li>Lower glycogen stores </li></ul>
  8. 8. Cardiovascular <ul><li>Blood pressure is an unreliable indicator of shock </li></ul><ul><li>Tachycardia is one of the first signs of shock </li></ul><ul><li>Blood volume depends on size </li></ul><ul><ul><li>90 ml/kg in the infant </li></ul></ul><ul><ul><li>80 ml/kg in the child </li></ul></ul>
  9. 9. Temperature Regulation <ul><li>Children have less effective thermoregulatory mechanism </li></ul><ul><li>Greater body surface area to body mass </li></ul><ul><li>Less subcutaneous tissue </li></ul><ul><li>Hypothermia is not well tolerated </li></ul><ul><li>Infants and small children lose heat through their heads </li></ul>
  10. 10. Other Anatomic and Physiologic Characteristics <ul><li>Metabolic demands are twice that of adults </li></ul><ul><li>Neck is short, fat, with weaker muscles </li></ul><ul><li>Fontanelles are open in infants </li></ul><ul><li>Head is heavier and larger, cranium is thinner, occiput more prominent </li></ul>
  11. 11. Other Anatomic and Physiologic Characteristics <ul><li>White matter not well myelinated; sheaths around nerves less developed </li></ul><ul><li>Abdominal muscles are thinner, weaker </li></ul><ul><li>Liver is more anterior; kidneys more mobile </li></ul><ul><li>Spine more flexible; extremities more pliable </li></ul>
  12. 12. Nursing Care - Assessment <ul><li>History </li></ul><ul><li>Who is the caregiver? </li></ul><ul><li>Is immunization status current? </li></ul><ul><li>The child’s weight? </li></ul><ul><li>Mechanism of injury and associated factors? </li></ul>
  13. 13. Nursing Care - Physical Assessment <ul><li>Inspection </li></ul><ul><li>Assess breathing for nasal flaring and intercostal retractions </li></ul><ul><li>Assess circulation for pallor, mottled skin, or differences in central versus peripheral color </li></ul><ul><li>Inspect abdomen for abrasions or ecchymosis </li></ul>
  14. 14. Nursing Care - Physical Assessment <ul><li>Auscultation </li></ul><ul><li>Breath sounds: Auscultate at anterior axillary lines </li></ul><ul><li>Apical heart rate: Bradycardia is ominous sign </li></ul><ul><li>Blood pressure: Hypotension is a late sign of shock </li></ul>
  15. 15. Nursing Care - Physical Assessment <ul><li>Palpation </li></ul><ul><li>Fontanelles for fullness and bulging </li></ul><ul><li>Central and peripheral pulses </li></ul><ul><li>Capillary refill </li></ul><ul><li>Abdomen for distention </li></ul><ul><li>Neurological assessment is tailored to the age and developmental stage of the child </li></ul>
  16. 16. Pediatric Coma Scale Score <ul><li>Eye opening </li></ul><ul><li>Best motor response </li></ul><ul><li>Best verbal response </li></ul>
  17. 17. Diagnostic Procedures <ul><li>Radiographic Studies </li></ul><ul><ul><li>Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) </li></ul></ul><ul><ul><li>Extremity films may need comparison views </li></ul></ul><ul><li>Laboratory Studies </li></ul><ul><li>Other: Diagnostic peritoneal lavage (not commonly done) </li></ul>
  18. 18. Nursing Diagnoses <ul><li>Aspiration risk </li></ul><ul><li>Impaired gas exchange </li></ul><ul><li>Fluid volume deficit </li></ul><ul><li>Altered tissue perfusion </li></ul><ul><li>Hypothermia </li></ul><ul><li>Infection risk </li></ul><ul><li>Pain </li></ul><ul><li>Altered health maintenance </li></ul><ul><li>Anxiety and fear </li></ul><ul><li>Powerlessness </li></ul>
  19. 19. Planning and Implementation <ul><li>Administer oxygen via a pediatric nonrebreather mask </li></ul><ul><li>Assist with endotracheal intubation </li></ul><ul><li>Verify endotracheal tube placement </li></ul><ul><li>Stabilize and/or immobilize cervical spine </li></ul><ul><li>Initiate CPR as indicated </li></ul><ul><li>Insert a gastric tube </li></ul>
  20. 20. Child on a Backboard
  21. 21. Planning and Implementation <ul><li>Cannulate 2 veins with 22-gauge catheters </li></ul><ul><ul><li>Infuse warmed lactated Ringer’s solution </li></ul></ul><ul><ul><li>Infuse a bolus of 20 ml/kg </li></ul></ul><ul><ul><li>Reassess circulation </li></ul></ul><ul><ul><li>Give 2nd bolus, if indicated </li></ul></ul><ul><li>Anticipate blood replacement </li></ul><ul><ul><li>Red blood cells at 10 ml/kg </li></ul></ul>
  22. 22. Site for Intraosseous Infusion <ul><li>If peripheral venous access cannot be established within 3 attempts or 90 seconds, initiate intraosseous (IO) access with a 16- or 18-gauge bone marrow needle </li></ul>
  23. 23. Intraosseous Infusion <ul><li>In children under 6 years of age, use the proximal tibia </li></ul><ul><li>Verify placement by aspiration of bone marrow </li></ul><ul><li>Fluid, blood, and medications can be infused </li></ul>
  24. 24. Planning and Implementation <ul><li>Insert an indwelling catheter </li></ul><ul><ul><li>Infants: 2 ml/kg/hr </li></ul></ul><ul><ul><li>Children: 1 ml/kg/hr </li></ul></ul><ul><li>Keep the child warm </li></ul><ul><li>Get a complete set of vital signs, including temperature </li></ul><ul><li>Obtain a pediatric consult </li></ul>
  25. 25. Planning and Implementation <ul><li>Psychosocial support </li></ul><ul><ul><li>Utilize anxiety-reducing techniques </li></ul></ul><ul><ul><li>Provide family members with information; include them in care; refer them to support programs </li></ul></ul><ul><ul><li>Report suspected child maltreatment </li></ul></ul><ul><ul><li>Prepare for operative intervention, admission, or transfer </li></ul></ul><ul><ul><li>Provide injury prevention teaching </li></ul></ul>
  26. 26. Evaluation and Ongoing Assessment <ul><li>Monitor </li></ul><ul><ul><li>Vital signs </li></ul></ul><ul><ul><li>Urinary output </li></ul></ul><ul><ul><li>Level of anxiety of patient and family and their ability to cope </li></ul></ul>
  27. 27. Summary
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