Trauma Resource Guide for the PICU RN

1. Trauma Resource Guide for the PICU RN By: Marci Mechtel RN, BSN Michigan State University MSN Ed student March 2004

2. Trauma History • The Johns Hopkins Children's Center serves as the Trauma center for children < 15 yo in the state of Maryland. US statistics show that the Central Nervous System is a factor in 60-70% of all trauma-related injuries in children. This accounts for approximately 200,000 hospital admissions annually. Of that number, 4000 will die with 50% of the deaths occur in the first few hours after injury; and 15,000 will go on to require prolonged care. The most common head injury in all ages in seen with blunt trauma. The result, in infants and children is diffuse brain swelling and in adolescents the result, is a focal mass or lesion. Primary injury occurs at the time of the insult involving destruction of brain tissue, the goal is the prevention or limitation of secondary injury which involves the destruction of viable brain tissue due to hypoxia, hypotension and cerebral edema. . Trauma Resource Guide on Quickplace

3. Trauma History • The presents of severe neurological injury in a child < 1 yo without a consistent significant history of trauma should be consider child abuse until proven otherwise. Shaken Baby Syndrome is the leading form of child abuse as a cause of death in children < 1 yo accounting for about 50,000 cases annually with 1 in 4 children will die. The finding is the presence of a subdural hematoma (caused by the whip-like motion that tears the bridging veins from the accelerant forces) or parenchymal hemorrhage. Frequently bilateral retinal hemorrhages are present. Skull fractures or only present if the child's head struck a surface during the incident. Trauma Resource Guide on Quickplace

4. General Principles • The head is the largest portion of body mass and is more malleable, making it easily deformed in infants and children. The neck muscles aren’t well developed and the mylenation of nerve fibers isn’t complete until 10 years of age. • 1° injury: occurs at the time of incident and severity depends on amount of brain tissue involved. Types include: • Concussion-there is a transient LOC, with occasional amnesia to event, HA, N/V dizziness but no long term sequale. • Diffuse Axonal Injury (DAI) it is a non focal injury where there is no obvious tissue damage but the shearing force causes an physiological or anatomical disruption of the axon (portion of the nerve cell). It results in prolonged coma with cerebral edema. DIA • Focal injuries include: laceration or contusion that is an area of bruising or microscopic hemorrhage caused by coup (direct trauma) or contrecoup (indirect trauma-impact of the brain on the opposite side of the brain) injury. • 2°injury: occurs as the result of the damage of the 1° injury such as  in size of hematoma or  blood supply to the injured area  compression  development of cerebral edema or ischemia  ICP   brain compliance Trauma Resource Guide on Quickplace

5. General Guide • General Head Injury Information Link Great Ormand Street Hospital Information Sheet • Parent/Family Guide Link Virtual Hospital: Acute Brain Injury - A Guide for Family and Friends • Basic Concepts Neurological System Basic concepts of the nervous system anatomy and physiology • JHH policy and procedure manual Trauma Resource Guide on Quickplace

6. Skull Fractures Types of Skull Fractures: • Linear Non-Depressed- Look for underlying brain injury otherwise no treatment required • Depressed- Management is directed at any underlying brain injury. Consult NUS if fracture depressed more than the thickness may need to be surgically elevated. • Compound-There is a communication with the underlying brain. NUS involved as pt needs to go to the OR for elevation, debridement of the brain and closure of the dura. Pt placed on post-op oxacillin. • Basilar S/S: raccoon eyes (cause by orbital roof fx causes interorbital bleed), battle sign (bruise behind ear), presence of blood or CSF in ears or nose. NO NGT for this population. • Link:eMedicine - Skull Fracture : Article by Nazer H Qureshi, MD Trauma Resource Guide on Quickplace

7. Epidural Hematoma • Occurs most often from a tear in the middlle meningeal artery. In 60-80% of the cases it is associated with a skull fracture over the parietal or temporal bones. Up to 20% can be a venous bleed that may arise from a tear in the dural sinus or posterior fossa. • Bleeding occurs in the potential space between the skull and the dura. This creates a mass effect, resulting in shifting and compression of brain tissue. It is a true neurosurgical emergency because it can be fatal because 2° injury can occur rapidly. Small bleeds may require PICU observation with follow-up CT and the blood will reabsorb on its own in 2-4 weeks • S/S: Early- initial LOC noted by a lucid interval followed by a rapid  in LOC. Headache, seizures. Pt is never symptom free. With 2nd LOC there may be hemiparesis of the opposite side. Late-Hallmark sign in 50% of the patients is a fixed or dilated pupil on the same side as the bleed. Signs of herniation. Trauma Resource Guide on Quickplace

8. Subdural Hematoma • Bleeding occurs between the dura and arachnoid membranes due to the tearing of the bridging veins, small cerebral arteries or from lacerations of the brain. A skull fracture may be present, if so the underlying brain injury is severe, the prognosis is dismal even with early evacuation, mortality is high. The bleed will not be reabsorbed. It can be acute, subacute or chronic (classification depends on when symptoms progress). It will create a mass effect that results in shifting any compressed brain tissue. • S/S may be slow to develop include: HA, fluctuations in LOC, hemiparesis, seizures (chronic), chocked optic disc (chronic), signs of herniation. Trauma Resource Guide on Quickplace

9. Intracerebral Hematoma • Bleeding occurs in the cerebral tissue, it is usually small and multifocal. Any significant bleeding is the result of penetrating injury and occurs most often in the temporal and frontal lobes. It can create a mass effect. • S/S early HA and decreased LOC and late signs of herniation. Late complications depend on size and location and is usually seizures and learning disabilities. Trauma Resource Guide on Quickplace

10. Hematomas • UNC Case #2 Epidural • CNS Pathology Epidural • Head Trauma Epidural • CNS Pathology Subdural • UNC Case#1 Subdural • Sudural Hematoma • Picture –Can you identify the bleeds? Trauma Resource Guide on Quickplace

11.  ICP/ICP waveforms • Link to general information Increased Intracranial Pressure • 3 types of Cerebral Edema: • Cytoxic: affects the gray matter and there is an increase in intracellular space associated with hypoxia, anoxia, hypo-osmolar solutions, electrolyte imbalance (SIADH), bacterial menegitis. • Vasogenic: affects the white matter and is the most common. It is caused by the increase in the capillary permeability which lead to a breakdown of the Blood Brain Barrier (BBB). It causes the fluid to leak extracellular and is seen in trauma, cerebral ischemia and hemorrhage. • Intersititial: Increase in intersititial fluid due to movement of CSF out of the ventricules associated with hydrocephalus (communicating/noncommunicating) • ICP waveforms Intracranial pressure / waveforms Trauma Resource Guide on Quickplace

12. Camino Catheter for ICP monitoring • The neurosurgeon will decide between the ICP monitor catheter and the ICP monitor with drain. They are located in the supply room with the cranial access kit . The Codman Subarachnoid bolt is in the 1st big room top shelf. The procedures are done sterilely, need hats, masks, gowns and gloves. • Pt has to have PT/PTT documented. Be prepared to give FFP if bleeding times prolonged. • REMEMBER THE CATHETER NEEDS TO BE ZEROED WITH THE SMALL SCREW INCLUDED IN THE KIT BEFORE THE SURGEON INSURTS INTO THE PT. • To zero to the Marquette monitor, Press cal step on the front of the camino, cal step 0.20,40,100,200 then simultaneously press the zero button on the Marquette monitor as you cal step to 0 again. • See Camino Resource Guide for further details. Trauma Resource Guide on Quickplace

13. Treatment of  ICP • Hyperventilation PaCO CBF(cerebral blood flow) ICP . Goal CO= 35. This works in the 1st 72 hours after that you see a rebound effect, once you stop bagging ICP. Works best with PaO > 100. • Use of thiopental1-5 mg/kg/dose IV as needed last for ~ 5 min/pentobarbitalIV bolus (1-5 mg/kg) or gtt at 1-4 mg/kg/hr for sedation. SE: Use with caution as may cause hypotension. • Use of 3% NS or mix of NS and acetate (avoids hyperchoridemia) to  Serum Na/serum osmolarity. Dose 6 cc/kg given IV over 20-30 min. • No dextrose unless hypoglycemia-hyperglycemia can cause further injury • Lasix- loop diuretic used to increase urine output also inhibits CSF formation. Dose 0.5-1 mg/kg IV q 4-6 hr. side effects (SE): electrolyte imbalance, prerenal azotemia and ototoxicity. • Mannitol-osmotic diuretic helps to move fluid from extracellular to intravascular space excreted by the kidneys overall dehydration. Dose 0.25-1 gm/kg/doseSE hypovolemia, hypotension,use with caution if serum osm > 310 can lead to a breakdown in BBB and deposit mannitol into brain parenchyma may lead to accumulation of H2O in the effected area. Need to draw up via filter needle and don’t inject air into bottle leads to crystalization. • Phenytoin/Fospheytoin- Given prophalatically to prevent seizures Dose: Load 15-20 mg/kg and maintenance 4-7 mg/kg/day.SE: may cause profound hypotension with rapid administration, can cause tissue damage if infiltrates. Give fospheytoin (same dose) if pt only has PIV or having issue with BP. • Lidocaine-used as an anesthetic to suppress cough reflex during suctioning. Dose is 1 mg/kg need to follow lidocaine level to prevent toxicity • Hypothermia- decrease pt temperature to 36.0° C rectally as a way to control ICP last attempt measure watch for shivering as it can cause  ICP. • Operative craniotomy has shown no true benefit. Trauma Resource Guide on Quickplace

14. Supratentorial-displacement of tissue normally located above the tentorium cerebelli can be: Central-downward displacement of cerebral hemisphere,basal ganglia,diencephalon and mid brain through the tentorial notch. S/S  LOC, altered resp. pattern, small pupils, babinski present  loss of oculocephalic reflex (Doll’s eyes), Cheyne-Stokes resp. and decoticate posturing. Uncal-downward displacement of inner edge of temporal lobe-most common. Causes compression of diencephalon & midbrain S/S in dilation of same side pupil, hemiparesis, decorticate/decerebrate posturing altered resp. pattern, untreated  fixed, dilated pupils, flaccid extremities and respiratory arrest. Cingulate-a unilateral lesion in the supratentorial space forces tissue laterally causes compression of the local blood supply. It is hard to identify Infratentorial-downward displacement through tentorial notch or downward displacement through foramen magnum  brain stem compression  damage to the cardiac and respiratory center. This causes a rapid deterioration in status  death Link Herniation Syndrome Herniation Syndrome Trauma Resource Guide on Quickplace

15. Systemic Effects of Neurological System Failure • Respiratory- Can lead to an altered respiratory pattern, Neurogenic pulmonary edema due to autonomic effects on the pulmonary vasculature, potential for aspiration pneumonia due to loss of protective mechanisms (cough/gag), V-Q mismatch due to sympathetic nervous stimulation. • Cardiovascular-  Cardiac output 2° to bradycardia, arrhythmias with brain stem injury, potential inhibition of autonomic nervous system leads to an inability to vary HR. • GI: potential for GI ulceration/hemorrhage. Pt on Zantac or protonix to prevent. • Metabolic DI-Diabetes insipidus results from damage to the hypothalamus leads to impaired production/release of ADH, so kidney is unable to concentrate urine and conserve H2O. S/S: U/O > 5 cc/kg/hr, specific gravity < 1.005, Na > 145, Serum Osm > 295 leads to dehydration and pot hypovolemic shock. Remember Pt is high (Na) and dry (due to high urine output).Tx: Urine replacement as ordered and Vasopressin gtt to titrate urine to 1-2 cc/kg/hr.SIADH-Syndrome of inappropriate Anti-diuretic hormone. Results from the damage to the feedback loop regulating ADH release causes dilutional hyponatremia and H2O toxicity S/S: minimal U/O specific gravity> 1.030 N/V, change in LOC,seizures ( w/ Na < 120), twitching, Na< 130, Serum osm < 275 (can calculate by 2* Na + (glucose/18) + (BUN/2.8).Tx: restrict fluid, replace Na with hypertonic solutions, and lasix. Goal U/O= 2 cc/kg/hr. Trauma Resource Guide on Quickplace

16. Non accidental trauma/Shaken Baby Syndrome • Links for Shaken Baby Syndrome (SBS) inflicted head injury – intro Virtual Children's Hospital: Intentional Head Trauma in Infants NursingCenter –SBS • Hallmark is + retinal hemorrhage (pictured) • Part of work-up is skeletal survey (child < 2), ophthalmology consult, child protection team notification. Trauma Resource Guide on Quickplace

17. Management of the Patient with Acute Spinal Cord Trauma • Injury is caused by fracture of the vertebral bodies, subluxation of the vertebra that results in cord compression, and direct cord injury or compromise of spinal cord perfusion. • HIGH CORD INJURY PRESENTS AS A RESPIRATORY ARREST. • Traumas need C-spine immobilization until there is documented evidence that no cord trauma exists. • S/SComplete injury is loss of movement and/or sensation and loss of sphincter tone. • S/S Partial Injury: • Brown-Sequard-hemisection (North/South) results in ipsilateral loss motor function/non painful sensation and contralateral loss of pain/temperature • Central Cord-usually cervical motor deficits/sensory loss UE>LE. • Anterior Cord-pain/temp/motor function is lost below level of lesion-vibration, position,& sensation intact. • Posterior Cord-rare results in loss of position, vibration and sensation Trauma Resource Guide on Quickplace

18. Management of the Patient with Acute Spinal Cord Trauma • Tractions system in place with 5# weight until pt can be placed in a Halo jacket or cervical spinal fusion done. • May require long term ventilation • Infections common particularly pulmonary and UTI • Spinal Shock may occur in cervical and high thoracic injuries loss of sympathetic tone distal to the level of the injury may last from hrs to weeks. S/S hypotension(due to vasodilation of vascular beds), bradycardia,hypothermia (neurogenic shock), flaccidity, bowel/bladder disfunction. Change positions with care because normal compensation for postural changes is lost. Tx: Phenylephrine gtt to start at 0.5 mcg/kg/min titrate to effect. It is used as a vasoconstrictor as an adrenergic antagonist needed for the hypotension. • Autonomic dysreflexia-it is seen in patients with injuries T6 and above. It is cause by nerve impulses from noxious stimuli below the lesion. Some causes can be: bladder distention, constipation, pressure sore or infection. hypertension, bradycardia, diaphoresis, chills. If untreated it can lead to CVA. Tx-is to identify and treat the cause and treat the hypertension. • Methylpredisolone-most beneficial if started within 8 hours after injury-decrease the edema around the cord. Dose is 30 mg/kg load IV over 15 min. After 45 min begin gtt at 5.4 mg/kg/hr x 23 hr. SE: hyperglycemia, hypokalemia, alkalosis, N/V, and peptic ulcer Trauma Resource Guide on Quickplace

19. Management of the Patient with Thoracic Trauma-Lung • Lung injury-caused by massive blunt trauma • Pulmonary Contusion-is a laceration of lung tissue with interstital hemorrhage. It is the most common parenchymal injury after trauma. V-Q mismatch leads to hypoxia leads to a R to L shunt through the contused, underventilated pulmonary parenchyma may lead to ARDS. Complicated by presents of aspirated gastric contents, flail chest or pneumothorax. S/S Bloody ETT secretions, Resp distress, persistent air leak after CT placement. SQ emphysema present. Tx. ABC’s, O2 to maintain O2 sats if hypoxic on > 50% intubate/ventilate. CPT to atelectatic area and avoid over hydration. • Flail Chest-seen in multiple rib fractures with underlying parenchymal injury. Segment of chest wall has no continuity with main thoracic cage. V-Q mismatch occurs leads to hypoxia. S/S paradoxical breathing noted on affect side due to the change in intrathoracic pressure. Palpable crepitus and rib fractures. Tx. Is intubation with use of PEEP, positive pressure stabilizes the chest wall, narcotics for the pain and avoid over hydration-will worsen contusion. Trauma Resource Guide on Quickplace

20. Management of the Patient with Thoracic Trauma-Cardiac • Cardiac Tamponade- Rarely seen in blunt trauma. It is commonly seen when a rib fracture or another object penetrates the heart. The heart is compressed due to the accumulation of blood in the pericardial sac. This pressure then exceeds the intracardiac pressure with leas to decreased filling of heart and cardiac output. S/S narrow pulse pressure, muffled heart sounds, neck vein distension, pulses paradoxes with a > 10 mmHg gradient.Intubate, ventilate, IVFs including PRBC’s. Pericardialcentesis to drain blood may see PVC’s if needle is to far into myocardium. Watch also for ST changes and widening QRS. Pt need to go to OR after to repair site and drain pericardium. • Myocardial Contusion-blunt trauma causing cardiac musc le injury. There is a disruption in myocardial blood flow leads to ischemia. S/S Elevation of CPK-MB, risk for dysrhthmias esp. PAC/PVC. Rarely will hear new murmur. Tx: EKG monitoring, adequate oxygenation. Serial CPK’s and ECHO if you see ischemic changes on EKG. Trauma Resource Guide on Quickplace

21. Management of the Patient with Abdominal Trauma • Liver/Spleen lacerations, Intestinal Tears, and renal hematomas- 90% of abdominal injury is due to blunt trauma. Liver and splenic lacerations are due to the rapid deceleration forces and intestinal tears are due to seat belt injury. They are graded I-IV. It is diagnosed by CT or by the presence of free air on an abdominal x-ray. • S/S bruising abrasions, lacerations or seat belt marks on the abdomen. Abdominal distension or mass palpated. Presence or absence of bowel sounds and pt c/o pain anteriorly and flank pain for renal injury. • Tx. ABC’s. good IV access for fluid resuscitation, OG Tube for gastric decompression, Foley if no uretheral injury to monitor U/O. Serial hemogloblins may need Surgical intervention if pt has sudden drop in hemoglobin or becomes hemodynamically unstable. • Links Peds Trauma • Virtual Children's Hospital: Pediatric Case 17 Trauma Resource Guide on Quickplace

22. End of Resource Guide • Please fill out the evaluation rubric, so that this site may be as useful as possible. Thank You. • Home Trauma Resource Guide on Quickplace