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Pediatric Trauma. CPT James R. Rice Emergency Medicine Physician Assistant Interservice Physician Assistant Program. References. Objectives. Identify the concepts associated with evaluating and resuscitating the pediatric trauma casualty Introduction to the Broselow/Hinkle system.

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pediatric trauma

Pediatric Trauma

CPT James R. Rice

Emergency Medicine Physician Assistant

Interservice Physician Assistant Program

objectives
Objectives
  • Identify the concepts associated with evaluating and resuscitating the pediatric trauma casualty
  • Introduction to the Broselow/Hinkle system
pediatric trauma6
Pediatric Trauma
  • Basic same approach as with adults
    • Requires a team approach
    • Same injury patterns
      • May see slightly more blunt trauma
  • Children are NOT little adults
vital signs
Vital Signs
  • Use as a rough guide to your clinical decision making
  • The pulse is much more sensitive than B/P
    • Children often maintain a normal B/P until vascular collapse
airway
Airway
  • Nasal breathers
    • Be careful not of occlude the nasal passages
  • Relatively large occiput
    • Do not pad under the head-may cause excessive flexion
    • Keep in the “sniffing” position
  • Relatively larger tongue
    • May make intubation difficult
  • Narrow larynx in the subglottic region
    • Uncuffed ET tubes only
airway12
Airway
  • Intubate VERY early in the case of facial burns
  • Surgical airway
    • Surgical cricothyroidotomy is NOT recommended in children under 12
    • Needle cricothyroidotomy can be performed-but is temporary!
airway13
Airway
  • Intubation
    • The child may become bradycardic during stimulation of the posterior pharynx
      • Pre-medicate with atropine
        • 0.015-0.20 mg/kg IV
        • 0.02 mg minimum dose
breathing
Breathing
  • Look for respiratory distress
    • Tachypnea
    • Stridor/wheezing
    • Grunting
    • Nasal flaring
  • Auscultate in both axillae
    • Lung sounds are easily transmitted across the small chest
circulation
Circulation
  • Venous access can be VERY difficult
    • Will require small IV catheters
    • Go IO early!!
    • Use central lines (femoral) as a second choice
      • If you have a pediatric central line kit
    • Venous cut down may be a real option
circulation16
Circulation
  • For shock
    • Crystalloid fluid bolus of 20mL/kg
      • If an inadequate response is noted you may repeat a 20mL/kg bolus
      • If there is still a poor response start a third 20mL/kg bolus and initiate 0-neg whole blood transfusion at 10-20mL/kg IV bolus
circulation17
Circulation
  • Once you have stabilized with fluids
    • Start a fluid maintenance
      • 24hr fluid requirements:
        • 100ml/kg for the first 10kg of body wt.
        • 50ml/kg for the next 10kg of body wt.
        • 10ml/kg for each kg over 20kg
        • Patients weighing over 40kg should be managed as an adult
          • 2000-2500ml/day
      • Watch the urine output
        • Minimum should be 1.0ml/kg/hr
secondary survey
Secondary Survey
  • Your approach should be the same as with the adult casualty
    • Thorough head-to-toe exam
head injury
Head Injury
  • Leading cause of death due to injury
    • Blunt MOI
    • S/S
      • Vomiting
      • Lethargy
      • Headache
      • Asymmetric pupils
      • Asymmetric motor movement
      • Decreased mentation
      • Irritability
head injury20
Head Injury
  • Evaluation
    • GCS
    • AVPU
      • Considering communication problems with the casualty, the AVPU system will probably be the best approach.
      • A-Alert
      • V-responds to Verbal stimuli
      • P-responds to Painful stimuli
      • U-Unresponsive
head injury22
Head Injury
  • Management
    • Elevate head of bed to 20-30 degrees
    • Give IV mannitol at 1g/kg
    • Lasix at 1mg/kg may help as well
    • Mild hyperventilation
    • EVAC
head injury23
Head Injury
  • Post traumatic seizure
    • Relatively uncommon
    • Prophylactic seizure management is controversial and has not been shown to be beneficial
    • Acute seizure management
      • Lorazepam, Midazolam or Diazepam
spine
Spine
  • C-spine
    • Apply an appropriately sized collar
    • Place a towel under the shoulders to keep the spine in a neutral position
  • SCIWORA
    • Spinal Cord Injury Without Radiographic Abnormality
      • Neurologic deficit c/w spinal injury, but no abnormality seen with radiographic studies
      • Can have a delayed presentation
heat loss
Heat Loss
  • Children are much more susceptible to hypothermia than adults
  • Be very aggressive in preventing and managing hypothermia
burns
Burns
  • Airway management is the biggest concern
  • Remember the rule of nines is different for a child
  • A relatively mild burn in an adult can very serious in a child
  • Take no chances…plan on evacuating all burns
pediatric resuscitation equipment
Pediatric Resuscitation Equipment
  • Problem:
    • This equipment can be found in the WHO/Humanitarian Augmentation Set
    • We currently don’t have an allocation for pediatric trauma equipment in the standard SKO
pediatric resuscitation equipment32
Pediatric Resuscitation Equipment
  • What can we use that is light, appropriate for the mission and easy to use?
    • The Broselow/Hinkle System
broselow hinkle system
Broselow/Hinkle System
  • Small, portable kit based on the Broselow tape
  • Has been used successfully on the battlefield
  • Will require traditional re-supply utilizing NSNs
broselow hinkle system35
Broselow/Hinkle System
  • Eliminates Memorization 􀂃
  • Eliminates Mathematics􀂃
  • Promotes Standardization
  • Provides Redundancy and Universality
broselow hinkle system37
Broselow/Hinkle System
  • Place on flat surface next to supine child…
  • Hand running along the length of the tape from head to patient’s heel.
broselow hinkle system38
Hand on tape adjacent to patient’s

heel identifying patients weight and heel identifying patients weight and color zone

Broselow/Hinkle System
broselow hinkle system39
Broselow/Hinkle System
  • Measure Child and Assign Color Zone
  • Child measures in Broselow “red”
  • I need the “red” Ambu mask
broselow hinkle system40
Broselow/Hinkle System
  • We are currently working on developing a tactical prototype
    • The future plan is to have 2 complete tactical systems added to the standard SKO
  • Until then, we recommend 2 per BAS at unit cost of $1600.00ea.