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Essentials of pediatric trauma care short september 2012


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Essentials of pediatric trauma care short september 2012

  1. 1. Pediatric Trauma CarePediatric Trauma CareOn CallOn CallJames G. Cain, MDPast President, International Trauma, Anesthesia and Critical Care SocietyPast President, West Virginia Society of AnesthesiologistsDirector, Perioperative Medical Services, Children’s Hospital of Pittsburgh of UPMCDirector, Trauma Anesthesiology, Children’s Hospital of Pittsburgh of UPMCVisiting Associate Professor, University of Pittsburgh School of Medicine100:32:36
  2. 2. DisclosureDisclosure Off label uses will be discussedOff label uses will be discussed Data Safety Monitoring Board (DSMB)Data Safety Monitoring Board (DSMB) HospiraHospira200:32:37
  3. 3. Pediatric trauma in USA Leading cause of morbidity & mortality in 1-40 yoLeading cause of morbidity & mortality in 1-40 yo 30% of children annually require care due to trauma30% of children annually require care due to trauma 40% of all deaths in 1-14 yo40% of all deaths in 1-14 yo Death & disability > than all others combinedDeath & disability > than all others combined300:32:37
  4. 4. Pediatric Trauma CategoriesPediatric Trauma CategoriesBlunt traumaBlunt trauma Most commonMost common Majority motor vehicleMajority motor vehiclerelatedrelated PassengersPassengers PedestriansPedestrians BicycleBicyclePenetrating traumaPenetrating trauma Increasingly commonIncreasingly common Primarily urbanPrimarily urban ““Knife and gun club”Knife and gun club”400:32:37
  5. 5. 8 year old restrained MVC8 year old restrained MVC AwakeAwake ResponsiveResponsive BP 80/45BP 80/45 HR 136HR 136 RR 32RR 32 Abdominal painAbdominal pain500:32:37
  6. 6. Pediatric traumaPediatric trauma Kids aren’t “small adults”Kids aren’t “small adults” Differ anatomicallyDiffer anatomically Differ physiologicallyDiffer physiologically RequiresRequires Prepared personnelPrepared personnel ExpertiseExpertise MaterialsMaterials EquipmentEquipment MedsMeds600:32:37
  7. 7. Kids aren’t small adults!Kids aren’t small adults!CharacteristicCharacteristic ResultResultLarge BSALarge BSA HypothermiaHypothermiaPoor neck musculaturePoor neck musculature Flex/ext injuryFlex/ext injuryLarge blood vol in headLarge blood vol in head Cerebral edemaCerebral edemaDec alveolar surf areaDec alveolar surf area Rapid desatsRapid desatsHigh metabolic rateHigh metabolic rate Rapid desatsRapid desatsSmall airwaySmall airway Inc airway resistanceInc airway resistanceHeart high in chestHeart high in chest Injury/tamponadeInjury/tamponadeSmall pericardial sacSmall pericardial sac Injury/tamponadeInjury/tamponadeCompliant skeletonCompliant skeleton Fractures less commonFractures less commonThin walled, small abdThin walled, small abd Organs not protectedOrgans not protectedPoorly dev renal fnxPoorly dev renal fnx Risk renal failureRisk renal failure 700:32:37
  8. 8. Need specific peds suppliesNeed specific peds supplies MonitorsMonitors ETTETT LaryngoscopesLaryngoscopes BronchoscopesBronchoscopes IVIV IO trocarsIO trocars Central linesCentral lines Urinary cathetersUrinary catheters NGT/OGTNGT/OGT Resuscitation drugsResuscitation drugs Resuscitation devicesResuscitation devices800:32:37
  9. 9. Initial managementInitial management Primary surveyPrimary survey Evaluate life-threatening conditionsEvaluate life-threatening conditions Immediate interventionImmediate intervention Secondary surveySecondary survey Evaluate other injuries requiring treatmentEvaluate other injuries requiring treatment Pediatric trauma scorePediatric trauma score May be useful for triageMay be useful for triage 9-12 Minor trauma9-12 Minor trauma 6-8 Potentially life threatening6-8 Potentially life threatening 0-5 Life threatening0-5 Life threatening < 0 Usually fatal< 0 Usually fatal900:32:37
  10. 10. Pediatric trauma scorePediatric trauma score+ 2+ 2 + 1+ 1 - 1- 1WtWt > 20 kg> 20 kg 10-20 kg10-20 kg < 10 kg< 10 kgAirwayAirway PatentPatent MaintainMaintain UnmaintUnmaintSBPSBP > 90> 90 50-9050-90 < 50< 50PulsesPulses RadialRadial CarotidCarotid NonpalpNonpalpCNSCNS AwakeAwake + LOC+ LOC UnrespUnrespFrxFrx NoneNone ClosedClosed Mult/opMult/opWoundsWounds NoneNone MinorMinor MajorMajorTotalTotal -6 to +12-6 to +121000:32:37
  11. 11. Primary surveyPrimary survey Cornerstone of trauma careCornerstone of trauma care Life threatening conditionsLife threatening conditions EvaluateEvaluate StabilizeStabilize TreatTreat Moves forward on all fronts by teamMoves forward on all fronts by team Often listed sequentiallyOften listed sequentially ABCDEABCDE1100:32:37
  12. 12. ABCDE of trauma careABCDE of trauma care AAirwayirway BBreathingreathing CCirculationirculation DDisabilityisability EExposurexposure1200:32:37
  13. 13. Airway management prioritiesAirway management priorities1.1. Ensure oxygenationEnsure oxygenation2.2. Ensure ventilationEnsure ventilation3.3. Protect cervical spineProtect cervical spine4.4. Protect airwayProtect airway1300:32:37
  14. 14. Initial airway managementInitial airway management Supplemental high flow oxygenSupplemental high flow oxygen Clear airway obstructionClear airway obstruction Large tongueLarge tongue ObtundationObtundation Foreign bodiesForeign bodies Maxillofacial traumaMaxillofacial trauma InflammationInflammation Consider oral or nasal airwaysConsider oral or nasal airways Caution with nasal in possible cribiform plate injuryCaution with nasal in possible cribiform plate injury1400:32:37
  15. 15. Pediatric airwayPediatric airway Narrow oropharynxNarrow oropharynx Large tongueLarge tongue Stiff, short epiglottisStiff, short epiglottis Larynx anterior andLarynx anterior andcephaladcephalad Cord view is difficultCord view is difficult Trachea shorterTrachea shorter Mainstem intubationMainstem intubationmore commonmore common Extubation moreExtubation morecommoncommon 1500:32:37
  16. 16. Intubation considerationsIntubation considerations Preparation is vital!Preparation is vital! Do not rush!Do not rush! Key pointsKey points Increased cardiac outputIncreased cardiac output Increased OIncreased O22 consumptionconsumption Overlapping FRC and closing capacityOverlapping FRC and closing capacity SOAPSOAP SuctionSuction OxygenOxygen AirwayAirway PharmacologyPharmacology Oral intubation typically easiestOral intubation typically easiest 1600:32:37
  17. 17. Trauma inductionTrauma inductionInduction medicationsInduction medications ThiopentalThiopental PropofolPropofol EtomidateEtomidate Adrenal suppressionAdrenal suppression KetamineKetamine Caution in brain injuredCaution in brain injuredNeuromuscular blockadeNeuromuscular blockade Faster onsetFaster onset Shorter circulation timeShorter circulation time RocuroniumRocuronium VecuroniumVecuronium CisatricuriumCisatricurium Succinyl cholineSuccinyl choline Transient inc ICP, IOP,Transient inc ICP, IOP,intragastric pressureintragastric pressure HyperkalemiaHyperkalemia BradycardiaBradycardia AtropineAtropine GlycopyrrolateGlycopyrrolate00:32:37 17
  18. 18. IntubationIntubation PreoxygenationPreoxygenation Cricoid pressureCricoid pressure Support posterior neckSupport posterior neck Cervical spineCervical spine MAISMAIS1800:32:37
  19. 19. Pediatric intubation viewPediatric intubation view LarynxLarynx AnteriorAnterior CephaladCephalad C 4 levelC 4 level Epiglottis long & UEpiglottis long & Ushapedshaped Trachea shortTrachea short Neonates → 2 cm cordsNeonates → 2 cm cordsto carinato carina Cricoid → NarrowestCricoid → Narrowestpoint until 10 yopoint until 10 yo1900:32:37
  20. 20. Increased risk of head an neckIncreased risk of head an neckinjuryinjuryLarge headLarge head Weak neck musclesWeak neck muscles2000:32:37
  21. 21. Cervical spine considerationsCervical spine considerations Upper cervical spine often involvedUpper cervical spine often involved Younger = higherYounger = higher Injury possible with minimalInjury possible with minimalmusculoskeletal effectmusculoskeletal effect Spine films and CTSpine films and CT May not confirm absence of injuryMay not confirm absence of injury SCIWORASCIWORA MRI neededMRI needed Symptoms and mechanism dictate careSymptoms and mechanism dictate care2100:32:37
  22. 22. Difficult intubationDifficult intubation Up to 50% airway complicationsUp to 50% airway complications Severity increased in non pediatric centersSeverity increased in non pediatric centers Tracheal injuryTracheal injury Massive SQ emphysemaMassive SQ emphysema Post-extubation subglottic stenosisPost-extubation subglottic stenosis Vocal cord injuryVocal cord injury Massive aspirationMassive aspiration OptionsOptions LMA may be lifesavingLMA may be lifesaving King airwayKing airway Rescue technique of choice for Pittsburgh EMTsRescue technique of choice for Pittsburgh EMTs Needle cricothyroidotomy fallback techniqueNeedle cricothyroidotomy fallback technique2200:32:37
  23. 23. BreathingBreathing Low residual lung volumes at expiration (FRC)Low residual lung volumes at expiration (FRC) FRC overlaps closing capacity → atelectesisFRC overlaps closing capacity → atelectesis Less alveoliLess alveoli Hgb P50 19 mm Hg contrasts to 26 Hg adultsHgb P50 19 mm Hg contrasts to 26 Hg adults Increased oxygen consumption → 7 ml/kg/minIncreased oxygen consumption → 7 ml/kg/min Higher minute ventilationHigher minute ventilation Higher blood flow to vessel rich groupHigher blood flow to vessel rich group Hypoxic/hypercapneic respiratory drives notHypoxic/hypercapneic respiratory drives notwell developedwell developed Oxygen reserve is limitedOxygen reserve is limited2300:32:37
  24. 24. BreathingBreathing Supplemental OSupplemental O22 to allto alltrauma patientstrauma patients Airway and pulmonaryAirway and pulmonaryinjuryinjury Signs may be subtleSigns may be subtle Compliant ribcageCompliant ribcage Airway managementAirway management Consider gastricConsider gastricdecompressiondecompression Auscultate breath soundsAuscultate breath sounds Pneumothorax?Pneumothorax?00:32:37 24
  25. 25. Chest injuriesChest injuries Mediastinum lessMediastinum lesswell affixedwell affixed Compliant chest wallCompliant chest wall Fractures lessFractures lesscommoncommon PTXPTX Pulmonary contusionPulmonary contusion HemothoraxHemothorax2500:32:37
  26. 26. PneumothoraxPneumothorax SymptomsSymptoms JVDJVD Tracheal shiftTracheal shift Deviation of cardiac tonesDeviation of cardiac tones PEAPEA TreatTreat Angiocatheter 2Angiocatheter 2ndndintercostal space, midclavicularintercostal space, midclavicular Definitive tube thoracoscopyDefinitive tube thoracoscopy2600:32:37
  27. 27. Pulmonary contusionPulmonary contusion Worsening oxygenation & ventilationWorsening oxygenation & ventilation Decreasing pulmonary complianceDecreasing pulmonary compliance Progressively more aggressive vent strategyProgressively more aggressive vent strategy Increase FiOIncrease FiO22 Increase vent pressures and PEEPIncrease vent pressures and PEEP Volutrauma typically avoided with plateauVolutrauma typically avoided with plateaupressures < 40.pressures < 40. Hemodynamic compromise possible withHemodynamic compromise possible withincreasing vent pressuresincreasing vent pressures2700:32:37
  28. 28. CirculationCirculation Control blood lossControl blood loss ApparentApparent HiddenHidden Long bone fracturesLong bone fractures Pelvic fracturesPelvic fractures HemothoraxHemothorax HemoperitoneumHemoperitoneum ICH (prior to fontanelleICH (prior to fontanelleclosure)closure) Tissue perfusionTissue perfusion Shock symptomsShock symptoms2800:32:37 Vascular accessVascular access Early vascular accessEarly vascular access SupradiaphragmaticSupradiaphragmatic Alternatives to PIVAlternatives to PIV CentralCentral Surgical cutdownSurgical cutdown IntraosseousIntraosseous Consider A-lineConsider A-line
  29. 29. IntraosseousIntraosseous IO kit or bone marrow bxIO kit or bone marrow bxneedleneedle 1-2 cm below tibial1-2 cm below tibialtuberositytuberosity Insert with screwingInsert with screwingmotion until lack ofmotion until lack ofresistanceresistance Aspirate marrow toAspirate marrow toconfirm placementconfirm placement Secure needleSecure needle Volume replacementVolume replacement LabsLabs Drug administrationDrug administration2900:32:37
  30. 30. Shock symptomsShock symptoms May not be apparent until > 25% blood lossMay not be apparent until > 25% blood loss Hypotension a late signHypotension a late sign Vaso-motor tone increasedVaso-motor tone increased Contractility increasedContractility increased Neonates limited ability to increase contractilityNeonates limited ability to increase contractility TachycardiaTachycardia Capillary refill > 3 secCapillary refill > 3 sec Diminished mental statusDiminished mental status OliguriaOliguria AcidemiaAcidemia Compensatory tachypneaCompensatory tachypnea3000:32:37
  31. 31. Volume resuscitationVolume resuscitation Hallmark of intraoperative managementHallmark of intraoperative management Fluid warming is essentialFluid warming is essential Crystalloid 1Crystalloid 1ststchoicechoice No evidence for colloidsNo evidence for colloids EBVEBV Premies: 95 ml/kgPremies: 95 ml/kg Term neonates: 90 ml/kgTerm neonates: 90 ml/kg Up to 1 year: 80 ml/kgUp to 1 year: 80 ml/kg > 1 year old: 70 ml/kg> 1 year old: 70 ml/kg Acceptable Hg 7-8Acceptable Hg 7-8 Higher Hg threshold in brain injuredHigher Hg threshold in brain injured3100:32:37
  32. 32. Volume administrationVolume administration Bolus of 20 ml/kgBolus of 20 ml/kg Lactated Ringer’sLactated Ringer’s Lactate -> bicarbonateLactate -> bicarbonate 0.9NS is OK0.9NS is OK May produce mildMay produce mildacidemiaacidemia Repeat 20 ml/kgRepeat 20 ml/kgbolus if inadequatebolus if inadequateresponseresponse3200:32:37
  33. 33. Blood productsBlood products Acceptable Hg 7-8Acceptable Hg 7-8 Higher Hg threshold in brain injuredHigher Hg threshold in brain injured Transfuse 10-20 ml/kg PRBC if inadequate response toTransfuse 10-20 ml/kg PRBC if inadequate response tocrystalloidcrystalloid Type specific preferred, Type O is OKType specific preferred, Type O is OK Freshest possibleFreshest possible KK++> 8 noted, old blood may have as much as 33 meq/liter> 8 noted, old blood may have as much as 33 meq/liter Cardiac arrests notedCardiac arrests noted ECG monitoring in large volume transfusionsECG monitoring in large volume transfusions Citrate -> pH < 7Citrate -> pH < 7 Metabolized to bicarbonate -> alkalosis possibleMetabolized to bicarbonate -> alkalosis possible Calcium supplement may be indicatedCalcium supplement may be indicated EBL 1 blood vol, 25% coag factors remainEBL 1 blood vol, 25% coag factors remain 1 unit platelets/10 kg raises platelets by 101 unit platelets/10 kg raises platelets by 1055 Consider FFP 10-15 ml/kgConsider FFP 10-15 ml/kg3300:32:37
  34. 34. Disability (head injury)Disability (head injury) Head injury in 80% of major traumasHead injury in 80% of major traumas GCS modified for pedsGCS modified for peds Decreased emphasis on verbal performanceDecreased emphasis on verbal performance Improving neuro statusImproving neuro status Adequate resuscitationAdequate resuscitation Worsening neurologic statusWorsening neurologic status Global neurologic injuryGlobal neurologic injury Expanding intracranial massExpanding intracranial mass GCS < 8GCS < 8 ICU admitICU admit Consider intubation and airway managementConsider intubation and airway management3400:32:37
  35. 35. Significant neurologic injurySignificant neurologic injury Primary injuryPrimary injury Initial incidentInitial incident Secondary injurySecondary injury3500:32:37
  36. 36. Limit secondary injuryLimit secondary injury Hypotension, hypoxemia & hypercarbiaHypotension, hypoxemia & hypercarbia Significantly increase mortalitySignificantly increase mortality Aggressive measures to maintain cerebralAggressive measures to maintain cerebralperfusion and oxygenationperfusion and oxygenation CPP > 40 desiredCPP > 40 desired CPP = MAP - ICPCPP = MAP - ICP No current, reliable biochemical markersNo current, reliable biochemical markers3600:32:37
  37. 37. Maintain cerebral perfusionMaintain cerebral perfusion Monitor ICPMonitor ICP Increase MAPIncrease MAP Alpha adrenergic or dopaminergic agentsAlpha adrenergic or dopaminergic agents Decrease ICPDecrease ICP HypocarbiaHypocarbia HyperosmolarHyperosmolar Drain CSFDrain CSF Fluid restrictFluid restrict DiuresisDiuresis Barbiturate comaBarbiturate coma Surgical decompressionSurgical decompression3700:32:37
  38. 38. ExposureExposure Expose entirely to evaluate thoroughlyExpose entirely to evaluate thoroughly Hypothermia riskHypothermia risk ExposureExposure Large BSALarge BSA Thin skinThin skin Minimal fatMinimal fat Rapid loss of body heatRapid loss of body heat3800:32:37
  39. 39. Hypothermia consequencesHypothermia consequences Increased risk in rural settingIncreased risk in rural setting Increased morbidity and mortalityIncreased morbidity and mortality Myocardial contractility decreasedMyocardial contractility decreased Oxyhemoglobin dissociation curve shifted leftOxyhemoglobin dissociation curve shifted left CoagulopathiesCoagulopathies DysrhythmiasDysrhythmias ArrestArrest3900:32:37
  40. 40. Hypothermia precautionsHypothermia precautions Warm ORWarm OR Heating lampsHeating lamps Warming blanketsWarming blankets Heated humidifiedHeated humidifiedcircuitscircuits Warm fluidsWarm fluids00:32:37 40
  41. 41. Secondary surveySecondary survey More thorough evaluation of systemsMore thorough evaluation of systems Detailed head to toe examDetailed head to toe exam ROSROS PMHPMH MedsMeds AllergiesAllergies Diagnostic proceduresDiagnostic procedures Less invasive than in pastLess invasive than in past ConsultationsConsultations Surgery?Surgery? Solid organ injury routinely managed nonoperativelySolid organ injury routinely managed nonoperatively4100:32:37
  42. 42. 8 year old to the OR8 year old to the OR4200:32:37
  43. 43. Questions?Questions?4300:32:37