Trauma

1. Pediatric Trauma- An area of concern
CNE- Trauma Care Nursing: Newer modalities perspectives and
Challenges
Venue- Base hospital , Delhi
cantonment Feb 9-10 , 2019
Prof. (Dr.) Smriti Arora
Amity College of Nursing
Amity University, Gurugram, Haryana
smritiamit@msn.com

2. Introduction
• Injury is the leading cause of death and disability in children
• accounts for a significant burden on countries with limited resources.
• There are anatomical, physiological, and emotional differences
between adults and children.
• The initial assessment and management of the injured child
follows
• primary survey and resuscitation, followed by
• secondary survey.

3. Causes of pediatric trauma
• Road traffic incidents , hit by vehicle
• Fall injuries – at home
• Interpersonal violence
• Submersion injury
• Homicide
• Suicide
• Fires

4. Types
• Abdominal/pelvic trauma
• Head /face/chest
trauma
• Lacerations
• Fractures

5. Primary and secondary survey
• Primary survey is quick, initial patient assessment to identify life
threatening injuries and involves active resuscitation.
• Secondary survey identifies other injuries, such as intra-abdominal
injuries and long-bone fractures, which can result in significant
hemorrhage.
• The relief of pain is also an important part of the treatment of an
injured child.

6. Primary
survey
• starts at the injury scene and aims to ensure a patent airway, adequate
breathing, circulatory support, and to assess major neurologic
disability.
• address life-threatening injuries that compromise oxygenation and
circulation.
• The priority of this initial phase is evaluation of the child's ABCDE.
• Every trauma patient should arrive boarded and C-spine
immobilized.
• Collar for school-age/adolescents and
• Rolls and tape for infants/toddlers

7. AIRWAY
• Airway control is the first priority.
• Unlike in adults, the cause of childhood cardiac arrest is an initial
respiratory arrest. A child's airway is anatomically different from
an adult’s.
• A child has a shorter neck, smaller and anterior larynx, floppy
epiglottis, short trachea, and large tongue.
• classic sign of upper airway partial obstruction- inspiratory
stridor
• complete airway obstruction- Respiratory effort with no air
flow

9. Airway
• If the airway is obstructed, inspect the mouth for a foreign body and remove it,
but do not perform a blind finger sweep, which may push it further into the
airway.
• Suction to clear blood, secretions, or vomitus.
• oral intubation- , use the jaw-thrust maneuver to improve airway patency.
• All pediatric trauma patients must be assumed to have cervical spine injury until
proven otherwise. Thus, if oral intubation is indicated, in-line cervical spine
immobilization must be performed.
• Size of the ET tube- by the child’s 5th digit or by the formula (age + 16)/4.
• The subglottic trachea is the narrowest portion of the pediatric airway and
provides a "physiologic cuff," so use uncuffed ET tubes in children <8 years
in order to minimize tracheal trauma.
• Use a rapid-sequence intubation technique to facilitate successful
intubation.

11. • Broslow tape - A reference at each color bar on the tape informs you
of equipment sizes to perform emergency resuscitation on the child.
A reference at each weight zone on the tape shows pre-calculated
medication dosages. Designated resuscitation equipment is contained
in corresponding, color coded equipment pouches.

13. BREATHING
• Once a patent airway is established, carefully assess the child's breathing. If
respiration is inadequate, provide ventilatory assistance.
• Infants and small children are primarily diaphragmatic breathers; their ribs
lack the rigidity and configuration present in adults.
• As a result, any compromise of diaphragmatic excursion significantly limits
the child's ability to ventilate.
• Direct injury to the diaphragm, disruption and herniation of intra-
abdominal contents, or gastric distension (aerophagia) can severely
compromise the infant or small child's ability to breathe.
• The mediastinum of a child is very mobile; therefore, mediastinal
structures can shift into the contralateral hemithorax as a result of a simple
pneumothorax, hemothorax, or tension pneumothorax.

15. Breathing
Anticipate respiratory failure if any of the following signs is present:
• an increased respiratory rate, nasal flaring, retractions, seesaw
breathing, or grunting;
• an inadequate respiratory rate, effort, or chest excursion (e.g.
diminished breath sounds or gasping), especially if mental status is
depressed;
• cyanosis with abnormal breathing despite supplementary oxygen.
• absent or asymmetric breath sounds - pneumothorax

17. CIRCULATION
• Assess for hypovolemic shock.
• Tachycardia is usually the earliest measurable response to
hypovolemia.
• Other signs- mental status change, respiratory compromise, absence
of peripheral pulses, delayed CRT, skin pallor, and hypothermia are
all possible early signs of shock that must be immediately
recognized.
• Children maintain a near-normal blood pressure even in the face of
25% to 30% of blood volume loss. In these situations, subtle
changes in the HR and extremity perfusion may signal impending
cardiorespiratory failure.

18. Circulation
• Obvious signs of shock such as
• hypotension
• decrease in urinary output
may not occur
until more than
30% of blood
volume has been
lost

19. Circulation
ABC
• Make vascular access the next priority once adequate ABCs are
established.
• If possible, place 2 percutaneous IV catheters in the upper
extremities.
• If peripheral venous access cannot be obtained after 3
attempts or in
< 90 seconds, establish IO access in children <6 years.
• A saphenous vein cutdown and cannulation of central veins are other
options, but these techniques should be reserved for stable
patients and skilled personnel.

21. Circulation
• Initial fluid resuscitation- warm isotonic crystalloid solution (RL
or isotonic NS solution) at a bolus of 20
mL/kg.
• The goals of the initial resuscitation should be to achieve
hemodynamic normality and to restore adequate tissue perfusion as
soon as possible.
• Children with evidence of hemorrhagic shock who fail to response to
fluid resuscitation should also receive blood (10 mL/kg) and be
evaluated by a pediatric surgeon for possible operative
intervention.

22. Disability
ABCD
• Causes of decreased level of consciousness in injured children include
traumatic brain injury (TBI), hypoxemia, and poor cerebral
perfusion.
• Assess Neurologic status
• [AVPU] system
• pediatric Glasgow Coma Scale [GCS]- describes level of consciousness in TBI,
categorize head injury

23. • E4V5M6
• Max score – 15
• Min 3 – coma
• <8 – intubate

24. Environment and Exposure
ABCDE
• larger body surface area to body mass ratio predisposes them to larger
heat and insensible fluid loss than adults, resulting in higher fluid and
caloric requirements.
• Avoid accidental hypothermia during the initial phase of resuscitation.
• Hypothermia results in vasoconstriction, low-flow state, acidosis, and
consumptive coagulopathy.
• To prevent hypothermia:
use warm intravenous fluids.
Once the patient is exposed, cover the patient with a warm blanket.
Connective air rewarmers and warmed, humidified ventilation can help maintain
core body temperature if hypothermia is detected (< 35°C/95°F).
Peritoneal lavage with warm saline
Extracorporeal circulatory rewarming- for patients with severe
hypothermia (< 28°C/82°F) in association with ventricular fibrillation or arrest or
with drowning in cold water.

25. Pain management

26. Pain control
• Once the primary survey has been completed, address the issue of
pain control.
• Pain relief can be provided with morphine (0.1 mg/kg) or a
combination of fentanyl (1 mcg/kg) and midazolam (0.5-0.1 mg/kg).
• Definitive treatment can be accomplished safely once hypoxia,
tachycardia, hypotension, and hypothermia have been managed.
The secondary survey involves a more detailed systemic evaluation and
initiation of diagnostic studies.

27. Adjuncts to Primary Survey
• Access: IV vs. IO
• Monitor: Cardiorespiratory/Pulse oximetry.
• Bloodwork - CBC, electrolytes, ABG, creatinine, BUN, PT/PTT,
crossmatch, LFT, lipase or amylase, BHCG if female of child-
bearing age

28. Imaging Prior to Secondary Survey
• Chest X rays: (AP only) , Pelvis (AP only) , C-spine: lateral,
AP
• FAST- Focused assessment with sonography in trauma

29. Secondary evaluation
• Complete history taking
• Head to toe physical examination
• Neurological- LOC, Pupils, GCS
• Head, neck , spine
• Chest
• Abdomen
• Orifices, Rectum
• Musculoskeletal
• Reassessment of vital signs

30. Secondary
survey
1. Head trauma
Management :
• Airway
• Cardiovascular and circulatory status
• Intracranial pressure and cerebral perfusion
• Bleeding, Seizures
• Temperature
• Analgesia, sedation, and neuromuscular blockade
Surgery: Surgical intervention in pediatric patients with head trauma may be required and includes
the following:
• Surgical decompression, Craniotomy and surgical drainage
• Surgical debridement and evacuation, Decompressive craniotomy with duraplasty

32. 2. Chest Injuries
• Children have relatively elastic ribs, that fracture rarely, despite that lungs
contusion is common without ribs fracture.
• Major thoracic injuries may coexist despite normal radiographic findings
like
1) Tension pneumothorax 2) Massive Haemothorax 3) Cardiac Tamponade
• In all cases airway should be secured, O2 is given and hypovolemia is
corrected
with IV – fluid. Diaphragmatic rupture after blunt abdominal trauma can
be
detected by chest x-ray or CT-scan, surgical repair is undertaken once the
pt
become stable
• Tension Pneumothorax: Tension pneumothorax requires prompt
clinical diagnosis
and immediate needle thoracocentesis. Site- 2nd ICS , “midclavicular
line”.
Thoracocentesis is followed by chest tube drainage.
• Massive Haemothorax: it is treated by chest tube drainage via “fifth

35. 3. Abdominal Trauma
►Blunt abdominal trauma is generally more common than
penetrating injury.
►In children more vulnerable organs are liver and spleen because they
are not protected by pliable rib cage.
Fluid resuscitation - 20 ml/kg of RL as bolus, may repeat 1-2 times.
Investigations used In Abdominal Trauma
►The definitive radiological investigation of major abdominal trauma
in haemodynamically stable child is CT – scan with IV – contrast.
►Expert ultrasound scanning is readily available it can demonstrate
free abdominal fluid and solid organ injuries but it is not valuable as CT
►Exp. Laparotomy is indicated for bowel perforation and
penetrating trauma.

36. 4. Burn/Thermal Injury
Management :
• ABCDE
• Consider early intubation if airway involvement
• Tetanus prophylaxis and ANALGESIA
• Fluid resuscitation mainstay of treatment
• Parkland Resuscitation Formula: using Ringer’s Lactate, Give 4ml/kg/%TBSA
• First half of resuscitation fluids (AS WELL AS MAINTENANCE FLUIDS) over
first 8 hours and Second half over following 16 hours
• Urine output goal: 1-2 ml/kg/hour

37. Prevention of pediatric trauma
• Supervision of children during play
• Commitment by healthcare workers to the pediatric trauma
population.
• Public education regarding automobile safety, firearm safety, and
burn prevention
• Pediatric life-support courses for providers of care
• Legislation regarding establishment and enforcement of seat belt
laws, increased enforcement of drunk driving statutes, firearm
registration, establishment of trauma registry.

38. Preventing falls
• Evaluating mental status, Call light within reach
• Environment clear of hazards and unused equipment
• Orientation to the room
• Bed in low position with brakes on
• Side rails raised as necessary based on the child’s age and cognition
• Nonskid footwear and appropriate-size clothing
• Child and family education
• Checks of the child at least every hour
• Accompaniment of the child during ambulation
• Assessment of the need for 1:1 supervision

39. Nursing responsibilities
• Maintaining calm approach
• Reassuring patients
• Focussed assessment- age, weight, vitals, spO2, investigations
• Maintaining ABCDE
• Preventing complications
• Educating caregivers
• Team approach

40. Summary
• Experiences with accidents, injuries, physical abuse, or
hospitalization can leave a lasting impact on
children's minds. Thus psychosocial support .
• ABCDE
• Age appropriate assessment, equipment, and
dosing

41. THANK YOU