Pediatric trauma , saving every life is a compilation of most important apsect for saving life

1. NAME Dr NITIN CHAWLA
PRESENT
DESIGNATION:
• CHIEF OF PEDIATRICS, KIMS
CUDDLES ,GACHIBOWLI,
HYDERABAD
PRESENT
AFFILIATION:
• DNB PEDIATRICS, FACEE-PEM,
PGPFN ( BPNA-UK), MECMS
MAJOR
ACHIEVEMENTS:
(HONOURS)
(AWARDS)
(PUBLICATIONS)
• Awarded by Shamshabad Mandal for
work on Snake bite management and
saving precious life of boy from
backward tribe.
• Dr APJ Abdul Kalam Young innovator
award for Digital training
• Pediatric Trauma and Toxicology – Key
area of interest
Photo

2. Objectives
• To understand the structured approach to a
seriously injured child
• To learn clinical assessment sequence to
identify life-threatening injuries in a child
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3. • Pediatric patients are unique
• Literature on trauma care has focused on
adults but all issue may not be translated
from adults

4. VASCULAR ACCESS-unique challenges
• Obtaining the cooperativeness of the child
• potential for psychological trauma,
• smaller veins more subcutaneous fat

5. Pediatric Trauma patient-
additional issues
• Higher likelihood of hypovolemia
• Lower success rates of IVs by first responders
with consequent hematomas, bruises,
• Fractures in the extremity bones
• Hypothermia causing peripheral
vasoconstriction

6. Dosing
• Traditionally weight based and when an
accurate weight cannot be measured, using a
length based resuscitation tape can help
estimate the weight.

7. FLUID MANAGEMENT
• Goal-to provide adequate oxygen delivery to
vital organs and prevent shock.
• PIV access with two age-appropriate IV
cannula should be achieved in all polytrauma
patients

8. Clinical categories - Assessment
1. Compensated shock,
2. Hypotensive shock
3. Cardiopulmonary failure

9. • Assess heart rate
• Presence and strength of pulses
• Blood pressure
• Respiratory rate,
• Mental status
• Color and temperature of extremities, and
• Capillary refill.

11. ATLS Practise

12. Special care
• In resuscitation of infants, toddlers, and small
children <20 kg, the most efficient pump may
be a 10 cc syring, attached to traditional IV
pump tubing, provided a one-way valve is in
place.
• Infusion system may be harmful as blood can
be infused too fast leading to complications
such as pulmonary edema or hyperkalemia

13. Special care
• Glucose should be kept out of resuscitative
fluid to prevent hyperglycemia.
• Routine monitoring of glucose should be
done to target Normoglycemia
• Hyperglycemia is associated with increased
risk of infection and increased length of stay.
• Hypoglycemia increases chances of mortality

14. Resuscitation fluid
(crystalloid versus colloid )
• Lack of strong evidence justify the use of
more expensive non-blood product colloids
(e.g. albumin, starches)as compared
crystalloid solutions.
• In TBI patients, use of albumin has been
associated with worse outcome

15. 4-2-1 Rule of Maintainence fluid
• The rule recommends
• Patient up to 10 kg.
• Patients between 10
and 20 kg
• patients above 20 kg.
4 cc/kg/h
40 cc/hr + 2 cc/kg/h (for
every kg above 10 kg),
60 cc/h + 1 cc/kg/h (for
every kg above 20 kg)

16. BLOOD TRANSFUSION
• Use of blood products should be strongly
considered as the primary resuscitative fluid
until haemorrhage can be controlled in
patient non responsive to crystalloids
• ATLS recommends transfusion if a patient still
has signs of shock after two boluses of 20
cc/kg of a crystalloid

17. Right blood product
• Pediatric trauma patient should preferentially
receive blood that has been recently
collected, freshly irradiated, and is “CMV-
safe.”
• Emergency uncross matched O-negative
blood until the appropriate units can be
delivered is a better alternative than delaying
transfusion in such a patient

18. Massive transfusion
• Defined as the transfusion of blood components
equalling one or more blood volumes within a
24-hour time frame or half of a blood volume in
12 hours.
• Accepted blood volume conversion factors
100 mL/kg premature neonates
90 mL/kg mature neonates
80mL/kg infants
70 - 80 mL/kg older children
>10 U of PRBCs adult-sized children

19. Coagulopathy of trauma
“Lethal triad” of Hypothermia ,hemodilution
and acidosis lead to worsening of
coagulopathy,
• Hypothermia is the result of shock, exposure,
and large-volume resuscitation using room
temperature fluids, which decreases platelet
activation and adhesion

20. • Hemodilution , caused by the infusion of
crystalloid solutions or PRBC units without
sufficient co-infusion of FFP and platelet,
dilutes clotting factors and also worsens
hypothermia.

21. • Acidosis resulting from shock further inhibits
proper clotting factor function and leads to
worsening coagulopathy.
• Massive transfusion protocol (MTP) have
been adopted worldwide to minimize the
effects of the lethal triad.

22. Massive haemorrhage Transfusion Practise

23. • Before routine use of rFVIIa can be
recommended in children, more studies
should be undertaken to look at the potential
complications, specifically in children, but
potential benefit cannot be debated.

24. COMPLICATIONS
Under-resuscitation
• Lead to multiple-organ
dysfunction, with the
kidney and liver being the
most susceptible organs
Over-resuscitation
• Lead to pulmonary and/or
peripheral edema,
especially in children with
pre-existing cardiac or
renal disease

25. COMPLICATIION
Procedure related
• Extravasation
• Infection
• Pneumothorax
• Perforation of the heart
Iatrogenic complications
• Hypothermia
• Air embolism
• Transfusion reactions when
blood products are used,
• Subcutaneous infiltration of
IV fluid
• Hyperkalemia ,
Hypocalcemia, and
Hypothermia (if blood
products are not sufficiently
warmed during transfusion).

27. Guide to Tetanus Prophylaxis in
Wound Management

28. Guide to tetanus prophylaxis in
wound management

29. • The recommended dose for TIG is 250 IU,
given by IM injection.
• If more than 24 hours have elapsed, 500 IU
should be given.
• For children, it can be given slowly using a 23
gauge needle due to its viscosity

30. • Individuals with a humoral immune
deficiency (including HIV-infected persons
who have immunodeficiency) should be given
TIG if they have received a tetanus-prone
injury, regardless of the time since their last
dose of tetanus-containing vaccine.

31. Case 1
• 12 month old female child brought by relative
h/o pain and swelling in right upper arm .
• h/o fall from bed 2 days back
• Swelling present over right forearm
erythematous and bruises +
• Not moving the limb
• How you will approach this child??

32. Management
• X ray
• Analgesics
• Ortho opinion
/splinting
• Follow up after 2
week
• ??

33. • Q-1 What should be our provisional diagnosis
an how should we proceed.
• Q-2 What are risk factors which make
children more prone for abuse
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34. The Problem
• One billion children globally – over half of all
children aged 2–17 years – have
experienced emotional, physical or sexual
violence in the past year
• Serious impact on the victims’ physical and
mental health, well-being and development
throughout their lives – and, by extension, on
society in general.
Pediatrics.

35. Risk factors of child
abuse

36. • Q-3 What is the role of emergency physician
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37. Role of Emergency care provider
• D/D of any injury or any physical or
psychological complaint that does not have
an obvious etiology
• Protect the child
• Legal requirements for reporting abuse to the
proper social service or police authority

38. • When should we suspect Non accidental
Trauma
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39. When to Suspect?
• Is the history one of inflicted injury?
• Does the history over- or underestimate the injury?
• Is there an absence of history, a “magical” injury?
• Are there inconsistencies or changes in the history?
• Is there a history of repeated injury or hospitalization?
• Was there a delay in seeking medical care?
• Is there a medical history of prematurity, failure to thrive,
and/or failure to receive adequate medical care, such as
immunization?
• Is this a high-risk history (e.g., fall down stairs, dropped
baby)?
• Could the injury have been avoided by better care and
supervision?

40. • As Physical Abuse being most visible form of
abuse, what are tell tale signs of physical
abuse
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41. Signs of physical abuse
• Bruises
• Bites
• Burns
• Fractures
• Abusive Head Trauma
• Retinal Haemorrhages

42. • Q-How common are fractures as presenting
complaint in children with abuse.
• Q-2 Which fractures are very specfic for child
abuse
• Q-3 Is these any guideline to do skeletal
survey for victim
• Q-4 Should we do other investigations as well
for affected child.
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43. Fractures
• Most common among abusive injuries where
medical help is sought
• Second most common findings of child abuse
after dermatologic findings (bruises, contusions,
burns)
• Age and distribution of fractures distinguishes
abusive from the accidental.
• Abusive fractures are uncommon in children
over 36 months of age.
• Always rule out nutritional and metabolic bone
disorders before coming to conclusions.

44. Fractures
• Posterior rib fractures
highest specificity for
child abuse followed by
metaphyseal corner
fractures.
• Multiple fractures of
different ages, with
associated findings in
history and physical
examination may
attribute to child abuse.

45. Fractures
• Femoral fractures and
fracture of humerus in
non-ambulatory
infants have a high
specificity.
• Fractures of scapula,
sternum and spinous
process of vertebrae
should also alert a
physician.

46. Guidelines for performing a skeletal
survey in children with bruising
Pediatrics, Vol. 135, Pages e312-e320

47. The standard skeletal survey

48. How to do documentation for such cases and
what all information we should not miss to
mention.
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49. Documentation
• Detailed hand written notes
• Simple diagrams and body charts for inflicted
injuries
• Photographic evidence are utmost important
in the medico-legal aspect
• Each injury should be photographed
separately.
• Ensure that both the injury and the body
part are captured in the frame.

50. • Size of all bite marks should be measured &
documented.
• All bite marks should be photographed.
• A swab should be collected from acute bites
for forensic analysis

51. • How do we assess any patient of trauma in
ED
• What should be the purpose of this
assessment.
51

52. Primary survey-ABCDE
Airway maintenance with restriction of cervical spine
motion
Breathing and ventilation support
Circulation with hemorrhage control
Disability with prevention of secondary insult
Exposure with temperature control

53. 53
PURPOSE OF “ PRIMARY
SURVEY ”
• Identification of “LIFE-THREATENING ”
emergencies
• Initiation of “LIFE-SAVING ” measures
Treat what kills first !!

54. Q-1 What are associated injury in MVA cases
which can be deterimental and we should take
due precaution.
Q-2 How should we maintain spine immobility
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55. AIRWAY AND CERVICAL SPINE
• Always assume that patient has cervical
spine injury
• Restrict cervical spinal motion until
spine injury is cleared
• Manually stabilise initially followed
by application of cervical collar

56. 56
CERVICAL SPINE STABILIZATION –
KEEP IMMOBILISED
• Maintain neck midline with “manual
in line” stabilization (MILS)”
• Use pediatric cervical collar
• Side rolls and Head straps /
• Soft collars & Sandbags alternatives

57. • Q- Should we do CT Scan in all cases of Head
injuy or is there a rule to follow
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58. • The PECARN rule suggests a CT head in a child = 2
years for multiple findings; a history of loss of
consciousness, a severe form of injury, history of
vomiting, severe headache.
• • The CHALICE clinical decision rule considers the
loss of consciousness of more than 5 minutes and a
fall from a height of more than 3 meters as high-risk
criteria
• • The CATCH clinical decision rule proposes that a
dangerous mechanism of injury such as a motor
vehicle crash, a fall from an elevation of 3 ft, five
stairs, or a fall from a bicycle with no helmet is a
medium risk for brain injury on CT scan.
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59. Primary Survey
Airway
• LOOK
– For the chest movements
• LISTEN
– For the breath sounds
• FEEL
– For exhaled air

60. Resuscitation
Airway
• Positioning
• Clearance
• Simple adjuncts
• Intubation
• Surgical intervention

61. Airway

62. Resuscitation
Airway
• HEAD TILT CHIN
LIFT IS
CONTRAINDICATE
D IN TRAUMA

64. Resuscitation
Cervical spine
• Hard Collar
• Sandbags/head
blocks and tape

65. Primary survey
Breathing
• Effort of breathing
• Efficacy of breathing
• Effects of respiratory inadequacy

66. Resuscitation
Breathing
• High flow Oxygen
• Ventilatory support as necessary

67. • What are indication for Intubation
67

68. Indication for Intubation and Ventilation
• Impending airway compromise
• Inadequate support form bag/mask
• Prolonged ventilation needed
• Controlled ventilation needed

69. • How do we assess Circulation
• What are different causes of shock in Trauma
patients
• How do we treat Shock
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70. Primary survey
Circulation
• Cardiovascular signs
• Effects of circulatory inadequacy
• Stop obvious exsanguinating hemorrhage

71. Circulation
• BP monitoring
• To assess perfusion, check
– Rate and quality of peripheral pulses
– Skin color, temp
– Capillary refill
– Level of consciousness

72. Causes of shock
• Hemorrhagic
– Blood loss
• Non
Hemorrhagic
– Tension
Pneumothorax
– Cardiac
tamponade
– Cardiogenic
– Neurogenic
– septic

74. Shock management
• Crystalloid /Colloid
10 ml/kg followed by 10
ml/kg
• Blood
Crystalloid /Colloid
10 ml/kg followed by 10
ml/kg
Surgery
Assess response
Assess response

75. • How can we quickly assess for disability
• Do Pupil give us good guide of Intracranial
status
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76. Primary Survey
Disability
• AVPU scale
• A lert
• Responds to Voice
• Responds to Pain ( GCS 8 or less)
• Unresponsive
• PUPILS

77. Pupillary

78. Primary Survey
• Exposure
• FULL
• Remember heat loss and embarrassment

79. • What all life threatening complications are
associated in such cases.
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80. Primary survey
Life threatening event
• Airway Obstruction
• Tension pneumothorax
• Massive heamothorax
• Open pneumothorax
• Shock
• Cardiac tamponade
• Decompensating Head injury

81. • How do we Differnentiate Between
Pneumothorax and Hemothorax Clinically
• How do we manage
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82. 82

83. 83

84. 84
• Needs immediate decompression with needle
• Successful needle decompression converts
tension pneumothorax to a simple
pneumothorax
• Tube thoracostomy is mandatory after needle or
finger decompression of the chest

85. • Results from large injuries to the chest wall that remain open
• Air passes preferentially through the chest wall defect with each
inspiration
• Effective ventilation is thereby impaired, leading to hypoxia and
hypercarbia
• Signs include - Pain, difficulty breathing, tachypnea, decreased
breath sounds on the affected side, and noisy movement of air
through the chest wall injury
• Close the defect with a sterile dressing on only three sides to
provide a flutter-valve effect
• As the patient breathes in, the dressing occludes the wound,
• Preventing air from entering. During exhalation, the open end of
the dressing allows air to escape
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86. PRIMARY Survey
• Post-resuscitation History
– Details of mechanism of injury
– Status at the site of accident
– Response to intervention
– Last meal
• Blood tests
– glucose
• Gastric tube
• Urinary catheter

87. Secondary survey
• COMPLETE THE PRIMARY
SURVEY AND RESUSCITATION

88. Secondary survey
• In case of deterioration
• ABANDON
&
• REPEAT THE PRIMARY SURVEY

89. Secondary survey
• Head to toe
• Front to back

90. Take home Points
• Maintaining Airway and breathing is of utmost
importance in pediatric trauma
• Anticipate difficult airway during intubation
• Protect cervical spine during airway
maintenance -MILS
• Identify life threatening thoracic trauma and
treat immediately
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91. • Examine children in a structured way – Focus on ABCDE
• Consider any child to have spinal injury until cleared
clinically
• Primary survey is to look for life threatening conditions
• Resuscitate immediately if you find problems before
proceeding with further examination
• Do not investigate if transfer is planned
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92. QUESTIONS ?????
Drnitinchawlapeder@gmail.com
7093801410
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