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Trauma in special Populations

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Trauma in special Populations

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Trauma in special Populations

  1. 1. Trauma in Special population Dr Rashid A. M. Abuelhassan, MBBS R3 Emergency Medicine Resident Secretary of SEMS
  2. 2. Objectives • Variations in 1ry assessment : • Pediatric • Geriatric • Pregnant • Variations in the management and intervention in the three main
  3. 3. Trauma in Pediatrics
  4. 4. 1RY SURVY • Airway • Breathing • Circulation • Disability • Expose • Fast & Family • Continuous monitoring of vital signs • Provision of analgesia, and continuous reassessment of pain • Antibiotics and tetanus as appropriate • Ensure urine output of 1 mL/kg/hr • If patient is intubated, ensure adequate sedation and analgesia • If head injury is present, frequent neurologic assessment To be kept in mind always
  5. 5. Statistics • Mostly blunt • Penetrating injury 10-20% of all admissions • leading cause of death 1-17 years.
  6. 6. Difference • head-to-body ratio is greater • brain is less myelinated • cranial bones are thinner • internal organs are more susceptible to injury • ↓ cardiac output primarily through ↑ HR and systemic vascular resistance. • kidney is less well protected and more mobile, • pulmonary injury without skeletal injury due to elastic chest wall . • Salter-type fractures with possible resultant limb- length abnormalities. • more tenuous spinal cord blood supply and a greater elasticity of the vertebral column, predisposing them to spinal cord injury without radiographic abnormality (SCIWORA)
  7. 7. Airway • Increased vagal response to laryngoscopy • Relatively larger tongue • Larger mass of adenoidal • Epiglottis floppy and more U shaped • Larynx more cephalad and anterior • Cricoid ring the narrowest portion of the airway • Narrow tracheal diameter and distance between the rings • Shorter tracheal length (4-5 cm in newborns and 7-8 cm in 18-month-olds) • Large airways more narrow
  8. 8. C-Spine • C- spine fulcrum : from C2-C3 in toddlers to C5-C6 by 8 to 12 yr. • larger head size, in greater flexion and extension injuries. • large occiput in <2 years flexion of cervical • Smaller neck muscle mass with ligamentous injuries • Anterior wedge of cervical vertebral bodies is common. • Increased flexibility of interspinous ligaments. • Flatter facet joints with a more horizontal orientation. • Incomplete ossification,difficult interpretation (synchondrosis). • Uncinate processes do not calcify until 7 years. • Basilar odontoid synchondrosis fuses at 3 to 7 • Apical odontoid apparent at 7 yr may fuse on 12 yr . • Posterior arch of C1 fuses at 4 years of age. • Ant C1 arch visible on 1 year , fuses at 7 to 10 yr • Neural arches fuse to body by approximately 7 years • Posterior arches fuse by 3 to 5 years of age. • Epiphyses of spinous process tips may mimic fractures. • Preodontoid space 4 to 5 mm in those <8 years of age and <3 mm in those 8 years or older. • Pseudosubluxation of C2 on C3 seen in 40% of children 8 to 12 yr. • Prevertebral space size varies with phase of respiration
  9. 9. Breathing • Respiratory rate • Chest wall movements • Percussion and breath sounds • drainage > 15 mL/kg or output > 2 mL/kg/hr  OR • Tracheal deviation The use of end-tidal CO2 capnography allows better ventilatory management during head injury
  10. 10. Circulation and Hemorrhage Control • Vital signs should be monitored Q5 min during the initial assessment. • Continuous oximeter and cardiac monitor. • 2x large-bore intravenous sites • Bolus with 20 mL /Kg of warmed normal saline • Transfuse 10-20 mL/kg for decompensated shock secondary to blood loss. • Intraosseous placement in a fractured extremity is contraindicated. • Umbilical vein cannulation can be achieved in infants up to approximately 2 weeks of age; • With vasopressors or highly osmotic agents are to be used, a more formal umbilical venous line placed above the liver should be considered to avoid hepatic injury. • massive transfusion ≈ 80 mL/kg • FFP 15-25 ml/Kg : plat 10ml/Kg : cryo 0.1- 0.2bag/Kg
  11. 11. Disability Assessment • Thorough Neurologic Examination & Glucocheck if deteriorated at any moment
  12. 12. Exposure • Thorough Examination is always needed even for simple injury • Keep always low threshold for unexplained injuries
  13. 13. FAST and Family • Allowing family members to be present during resuscitations is acceptable and often preferred by families. • assign a staff member to be with him or her during the trauma resuscitation to explain the process.
  14. 14. Pain Control • Fentanyl is a good choice • advantage hemodynamic profile. • Advantage of short action
  15. 15. Specific injuries • concussion is a brain insult with transient alteration of consciousness. • Simple =<10 d • complex >10 days • Scalp injury • Caput succedaneum hematoma in the connective tissue layer. This is freely mobile and crosses suture lines. • subgaleal hematoma is subgaleal within the loose areolar tissue above the periosteum. • cephalohematoma is a collection of blood under the periosteum.
  16. 16. • Skull Fractures • Linear  benign, no intervention unless of a fracture overlying a vascular channel, a depressed fracture, a diastatic fracture (leptomeningeal cyst) , or a fracture that extends over the area of the middle meningeal artery. • Cerebral contusions • Epidural Hematoma • Subdural Hematoma.
  17. 17. To CT or not ?
  18. 18. Sens 100% in <2yrs ( NPV 100%) 96.8% in > 2yrs ( NPV 99.95%) but 100% for TBI need NS
  19. 19. Abdominal Trauma
  20. 20. Professor Karim Brohi
  21. 21. Trauma in Geriatrics
  22. 22. Who are they ? • Who: aged 65 to 80 or 85 years • oldest old older than 80 or 85 years.
  23. 23. • In 2008, there were 2.1 million ED visits for falls among those 65 and older—10 times more common than motor vehicle collisions (MVCs).1 • one third of elders sustain a significant fall each year, and serious injuries occur in up to a quarter.2 • Most falls are from standing and occur at the elder’s place of residence.19 Centers for Disease Control and Prevention (CDC): Injury Prevention and Control: Data and Statistics (WISQARS). Available at www.cdc.gov/ injury/wisqars/index.html. Accessed December 21, 2011 Centers for Disease Control and Prevention (CDC): Fatalities and injuries from falls among older adults—United States, 1993-2003 and 2001-2005. MMWR Morb Mortal Wkly Rep 2006; 55:
  24. 24. Risk factors for falling include : • weakness, • balance or gait deficit, • visual deficit, • mobility limitation, • cognitive impairment, • impaired functional status, • postural hypotension Bergen G, Chen LH, Warner M, Fingerhut LA, eds: Injury in the United States: 2007 Chartbook. Hyattsville, Md: National Center for Health Statistics; 2008
  25. 25. Elders are more likely to be struck by a motor vehicle than younger pedestrians, because of poor eyesight, limited mobility, and slower reaction time. Pedestrians struck sustain significant injury patterns have the highest fatality rate among injuries, 30 to 55%.19 Bergen G, Chen LH, Warner M, Fingerhut LA, eds: Injury in the United States: 2007 Chartbook. Hyattsville, Md: National Center for Health Statistics; 2008
  26. 26. ↓ Brain mass Eye disease ↓ Depth of perception ↓ Discrimination of colors ↓ Pupillary response ↓ Respiratory vital capacity ↓ Renal function 2- to 3-inch loss in height Impaired blood flow to lower leg(s) ↓ Degeneration of the joints Total body water Nerve damage (peripheral neuropathy) Stroke Diminished hearing ↓Sense of smell and taste ↓Saliva production ↓Esophageal activity ↓Cardiac stroke volume and rate Heart disease and high blood pressure Kidney disease ↓Gastric secretions ↓Number of body cells ↓Elasticity of skin, thinning of epidermis 15 – 30% body fat
  27. 27. Difference in management • Early intubation(Cricothyrotomy is more likely to be complex) • signs of shock • altered mental status • significant chest trauma • videolaryngoscopy is recommended.32 • dosages of induction agents should be reduced • High risk for succinylcholine hyperkalemia, • High-flow supplemental oxygen should be applied to all patients, including those with chronic pulmonary disease.
  28. 28. Disability • Traumatic Brain Injury • Vertebral Fractures and Spinal Cord Injuries • Central Cord Syndrome • Cervical Extension-Distraction Injury • Odontoid Fractures • Thoracic Trauma • Abdominal Trauma • Extremities
  29. 29. Hyperextension with superimposed spondylosis • 90-year-old male who tripped and fell on his back and the back of his head. He had immediate quadriparesis after the event with no loss of consciousness The findings are: • Widening of the disc space C5C6 in the front and narrowing in the back. • called 'an open book'.  hyperextension injury.
  30. 30. END-OF-LIFE DECISIONS
  31. 31. ● A 79-year-old male is brought to the ED after he was found at the base of the stairs by his wife. ● Initial vital signs: RR 32, Pulse 64, BP 110/60, GCS score 12
  32. 32. ( geriatric Trauma ) • are prone to significant injuries with low-force trauma such as falls from standing. • Vigilance for occult injuries, including TBI, cervical spine injuries, hip and pelvis fractures, and solid organ injuries, should be maintained. • Vital signs, are unreliable to detect hemodynamic instability in older adults. Clinicians should expand their assessment for shock by including alterations in mental status, urine output, and skin perfusion and should have a low threshold for considering shock in elderly trauma patients. • Resuscitation should be rapid but should include frequent reassessments of vitals signs, respiratory status, and other potential indicators of shock. Invasive hemodynamic monitoring may be beneficial. • A low threshold is advised for imaging in older adults with trauma. • Fluid resuscitation should be initiated with defined boluses • PCC is recommended for reversing warfarin • to consider tranaxemic acid
  33. 33. Trauma in Pregnancy
  34. 34. Pregnancy Epidemiology: • complicates 6% to 10% of all US pregnancies. • It is the leading cause non obstetric maternal death • According to a study published by Gazamarian et al there is a prevalence of 0.9% to 20% when it comes to violence in pregnancy. • There is an increasing trend with each trimester • 8% of violence occurs in first trimester, 40% in second trimester and 52% in the third trimester Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
  35. 35. Pregnancy • Trauma, relatively minor or major, is associated with increased risk of: • Preterm Labor • Placental abruption • Fetal-Maternal Hemorrhage • Pregnancy loss • The majority of the times when gravid women seek care, it is the result of: • Motor vehicle collision (MVC) • Assaults and falls • There are several normal anatomic and physiologic changes in pregnancy that need to be considered in the trauma patient Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
  36. 36. Pregnancy Physiology CARDIOVASCULAR • Plasma ↑45% @ 6-8wks • SV↓30% • Chest comp. ↓ • BP ↓ in 1st  ↑ in 2nd • CO ↑ 30 to 50% • “Supine Hypotensive Syndrome”@ 20 wks Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course Pulmonary • ↓ oxygen reserve • ↓ airway “swelling of tissues” • chest tube should be placed one or two interspaces highe • ↓ gastric emptying • ↓ GI injuries if lower abdominal trauma • Dilated pelvic Vasculature ↑ retroperitoneal hemorrhage • Respiratory Alkalosis and compensatory metabolic acidosis. • e ligaments of the symphysis pubis andsacroiliac joints are loosened during pregnancy. As a result, a base-line diastasis of the pubic symphysis may exist that can be mis-taken for pelvic disruption on a radiograp Ecg CHANGES , flat-tened T waves or Q waves in leads III and augmented voltageunipolar left limb lead may be seen.
  37. 37. Complications • Preterm Labor • Preterm delivery • Uterine rupture • Feto-maternal hemorrhage • placental abruption. Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
  38. 38. Complications Vaginal bleeding  abruption watery discharge  rupture of membranes - Abruption is a clinical diagnose - 25% separation carries a 5.5-fold increased risk of preterm delivery - Contractions that are not self-limited are often induced by some pathologic condition DIC pathophysiology . The injured placenta can release thromboplastin into the maternal circulation, resulting in DIC, whereas the damaged uterus can disperse plasminogen activator and trigger fibrinolysis
  39. 39. Blunt threefoldto fourfold increase in force transmission through the uterus Penetrating Pelvic and acetabular fractures during pregnancy  high maternal(9%) and a higher fetal (38%) mortality rate . lap belt should be placed under the gravid abdomen, snugly overthe thighs, with the shoulder harness off to the side of the uterus,between the breasts and over the midline of the clavicl
  40. 40. Evaluation
  41. 41. To X-RAY or to other? • risk of 1-rad = 0.003%, thousands of times smaller than the spontaneous risks of malformations, abortions, or genetic disease • Ultrasonography: accuracy of 97% for detecting intra- abdominal injuries in blunt trauma • CT can miss diaphragm and bowel injurie • DPL can be done in any trimester by an open technique above the uterus • DPL is limited in detecting bowel perforations and does not assess retroperitoneal and intrauterine pathology.
  42. 42. Management • No tocolytics if cervical dilated 4 cm • No Vasopressors. • ? Fluid  look for ferning (amniotic fluid not urine) • If amniotic fluid leak • group B streptococci • Neisseria gonorrhoeae • Chlamydia • FMH is usually of more concern after 12 weeks’ gestation but can be in 4 weeks •
  43. 43. Management • 4 hour CTG • Extend to 24 h if • > 3 contraction/h • Uterine tenderness • Worisome strips • Vaginal bleeding • Membrane rupture • Serious maternal injury • On d/c to record Fmfor 1wk if < 4/h to come to hospital • +ve FHS GA >= 26 wk infant survival is 75% • penetrating uterine wounds  laparotomy Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
  44. 44. Rhesus immune globulin • (RhIG) within 72 hours of the incident • 1st trimester 50-µg ( Total baby blood volume 4.2 mL) • 50 µg ( covers 5 mL of bleeding). • 2nd & 3rd  300-µg (30 mL of FMH) • Tetanus Prophylaxis • Tetanus toxoid and immune globulin have no detrimental effecton the fetu
  45. 45. • Perimortem Cesarean Section • within 4 min of maternal cardiac arrest • most experienced physician available as cardiopulmonaryresuscitation is continuing. • A midline vertical incision from the epigastrium to the symphysis pubis. midline vertical incision for the uterus. • is advisable to monitor the fetal heart during maternalcardioversion.
  46. 46. Perimortem Cesarean Section video
  47. 47. Take Home Points • requires a multidisciplinary team approach. • The need for diagnostic imaging outweighs radiation risk to fetus, due to low risk. • Time is life: No fetus with absent tones survived emergency delivery while 75% with FHTs and age >26wks survived. • The fetus is viable at 24 weeks’ gestation. This usually corresponds to when the fundus is at or above the umbilicus. • Stable pregnancies with a viable fetus should be monitored continuously for a minimum of 4 hours after trauma. • Keeping the mother tilted 30 degrees to the left or in the left lateral decubitus position may alleviate hypotension and improve perfusion for the mother and fetus. • Perimortem cesarean section should be considered only for a viable fetus with signs of life. • If available, nonionizing radiation, including ultrasound and MRI, is preferred for the evaluation of pregnant trauma patients. Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course
  48. 48. Thank you..
  49. 49. Injury Severity Score • ISS = A2 + B2 + C2 where A, B, C are the AIS scores of the three most injured ISS body regions • The ISS scores ranges from 1 to 75 (i.e. AIS scores of 5 for each category

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