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Trauma: Stabilization and Transport. Division of Critical Care Medicine Children’s Healthcare of Atlanta Atlanta, Georgia. Trauma : Stabilization and Transport Objectives. Discuss the epidemiology of pediatric trauma Review the primary survey Identify priorities in care

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trauma stabilization and transport

Trauma:Stabilization and Transport

Division of Critical Care Medicine

Children’s Healthcare of Atlanta

Atlanta, Georgia

trauma stabilization and transport objectives
Trauma:Stabilization and TransportObjectives
  • Discuss the epidemiology of pediatric trauma
  • Review the primary survey
  • Identify priorities in care
  • Discuss differences between adult & pediatric trauma
  • Discuss pediatric trauma management
  • Review the development of andguidelines for transport
slide3

Neurosurgeon

Trauma Surgeon

Resuscitation Team

OrthopedicSurgeon

ALWAYS OPEN

TRAUMA CENTER

Anesthesia

SurgicalSpecialties

MedicalSpecialties

OR

Nursing

ICU

trauma initial stabilization stats
Trauma:Initial StabilizationStats
  • 22 million children/yr
  • 1 in 4 suffer serious injury/year
  • More children die from trauma than all other causes combined!
trauma initial stabilization the golden hour
Trauma:Initial StabilizationThe Golden Hour
  • R. Adams Cowley, MD
  • Care within 60 min.
  • mortality if care given > 60 min.
trauma initial stabilization

Trauma:Initial Stabilization

"You live or die depending on

where you have your accident

because they take you to the

nearest hospital!"

R. Adams Cowley, MD

“In the Blink of an Eye”

trauma
Trauma

A-M-P-L-E History

A - Allergies

M - Medications

P - Previous history

L - Last ate

E - Events of accident

trauma initial stabilization management of multiple trauma
Trauma:Initial Stabilization Management of Multiple Trauma
  • Primary survey
  • Initial stabilizationand resuscitation
  • Secondary survey
  • Definitive care
trauma initial stabilization the primary survey
Trauma:Initial Stabilization The Primary Survey
  • A rapid initial assessment
  • An "ABC" approach
  • Resuscitation done simultaneously
trauma initial stabilization the secondary survey
Trauma:Initial Stabilization The Secondary Survey
  • After the "ABCs"
  • Head to toe examination
trauma initial stabilization definitive care phase
Trauma Initial StabilizationDefinitive Care Phase
  • Overall management
  • Fracture stabilization
  • Stabilization/transport
  • Emergent surgery
trauma initial stabilization pediatric considerations
Trauma:Initial Stabilization Pediatric Considerations
  • ABCs
  • Differences: 1) Size 2) Injury pattern 3) Fluids 4) Surface area 5) Psychological 6) Long term effects
trauma initial stabilization1

Trauma:Initial Stabilization

In pediatric trauma, you don’t just have and injured child, you have an injured family

M. Eichelberger, MD

“In the Blink of an Eye”

trauma initial stabilization the primary survey1
Trauma:Initial Stabilization The Primary Survey

A - Airway and C-Spine

B - Breathing

C - Circulation (with hemorrhage control)

D - Disability

E - Exposure

trauma initial stabilization the primary survey2
Trauma:Initial Stabilization The Primary Survey
  • Airway:
    • Establish patency
    • Beware C- Spine
    • Do not:
      • Flex
      • Hyperextend
trauma initial stabilization the primary survey3
Trauma: Initial StabilizationThe Primary Survey
  • Oxygen
    • treat potential hypoxemia
    • all trauma patients get O2
trauma initial stabilization pediatric considerations1
Trauma:Initial Stabilization Pediatric Considerations
  • Craniofacial disproportion
  • "Sniffing" position
  • Obligate nose breathers
  • Anatomy
    • tongue
    • larynx
    • trachea
trauma initial stabilization suspected airway obstruction
Trauma:Initial Stabilization Suspected Airway Obstruction
  • Stridor
  • Cyanosis
  • Absence of breath sounds
  • Dysphagia, snoring, gurgling
  • Altered mental status
  • Trauma to head, face, neck
trauma initial stabilization cervical spine differences
Trauma:Initial Stabilization Cervical Spine Differences
  • Flexible interspinous ligaments
  • Underdeveloped neck muscles
  • Poorly developed articulations
  • Anterior vertebral bodies
  • Flat facet joints
  • Large head to BSA
trauma initial stabilization cervical spine
Trauma:Initial Stabilization Cervical Spine
  • Predisposed to serious high cervical injuries
  • Assume its presence in:
    • Blunt injury above clavicle
    • Multisystem trauma
    • Significant injury - MVA, fall
    • Altered sensorium
trauma initial stabilization cervical spine radiographs
Trauma:Initial Stabilization Cervical Spine: Radiographs
  • Pseudosubluxation
  • distance dens and C-1
  • Growth plate fracture
  • SCIWORA
trauma initial stabilization airway management
Trauma:Initial Stabilization Airway Management
  • Clear airway
  • Jaw thrust/stabilization maneuver
  • Oral/nasal airway
  • Oxygenate/ventilate
  • Intubation
  • Cricothyroidotomy
trauma initial stabilization c spine immobilization
Trauma:Initial Stabilization C-Spine Immobilization
  • Backboard
  • Appropriate C-collar
  • Snadbags or towel
  • Tape
  • Torso immobilization
trauma initial stabilization primary survey breathing
Trauma:Initial Stabilization Primary Survey: Breathing
  • Assess via
    • Exposure
    • Rate/depth of respiration
    • Inspection/palpation
    • Quality/symmetry of breath sounds

NB: An intact airway Does Not assure adequate ventilation!!

trauma initial stabilization primary survey breathing1
Trauma:Initial Stabilization Primary Survey: Breathing
  • Oxygen
  • Assisted ventilation
  • Alleviate life threatening injuries
thoracic injury heart lung mediastinum
Thoracic InjuryHeart, Lung, Mediastinum
  • Penetrating
    • Sucking, Bubbling
    • Hemopneumothorax
    • Tamponade
  • Blunt
    • Flail Chest
    • Contusion (lung, heart)
    • Aortic Dissection
    • Tracheal Rupture
    • Diaphram Rupture
trauma initial stabilization chest trauma
Trauma:Initial Stabilization Chest Trauma
  • Tension pneumothorax
  • Hemothorax
  • Flail chest
  • Cardiac tamponade
trauma initial stabilization chest trauma1
Trauma:Initial Stabilization Chest Trauma
  • Blunt injury common
  • More compliant chest wall
  • Sensitive to flail segment
  • Mobile mediastinum
  • Major vascular injury uncommon
trauma initial stabilization tension pneumothorax
Trauma:Initial Stabilization Tension Pneumothorax
  • Air in the pleural space without exit
  • Collapse of ipsilateral lung
  • Compressed contralateral lung
  • Mediastinal shift
trauma initial stabilization tension pneumothorax signs and symptoms
Trauma:Initial Stabilization Tension Pneumothorax: Signs and Symptoms
  • Respiratory distress
  • Unilaterally diminished breath sounds
  • Hyperresonance on affected side
  • Tracheal deviation
  • Distended neck veins
  • Cyanosis
trauma initial stabilization tension pneumothorax treatment
Trauma:Initial Stabilization Tension Pneumothorax: Treatment
  • Needle decompression
    • 2nd intercostal space mid-clavicular line
  • Chest tube
    • 4-5th intercostal space mid-axillary line
trauma initial stabilization hemothorax signs and symptoms
Trauma:Initial Stabilization Hemothorax: Signs and Symptoms
  • breath sounds on affected side
  • Dullness to percussion
  • Hypovolemia
  • Flat vs distended neck veins
trauma initial stabilization hemothorax treatment
Trauma:Initial Stabilization Hemothorax: Treatment
  • Fluids/blood
  • Decompression
  • Chest tube
  • Autotransfusion
trauma initial stabilization flail chest
Trauma:Initial Stabilization Flail Chest
  • Boney discontinuity of the chest wall
  • Major problem = underlying injury
  • Signs and symptoms
    • respiratory distress
    • paradoxical chest wall movement
    • severe chest pain
trauma initial stabilization flail chest treatment
Trauma:Initial Stabilization Flail Chest:Treatment
  • Oxygen
  • Stabilize segment
  • Re-expand lung
  • + intubation
  • Give fluids cautiously
trauma initial stabilization abdominal trauma
Trauma: Initial Stabilization abdominal trauma
  • Following the head and extremities, the abdomen is the third most commonly injured anatomic region in children
  • significant morbidity and may have a mortality rate as high as 8.5%
  • abdomen is the most common site of initially unrecognized fatal injury in traumatized children
trauma initial stabilization abdominal trauma1
Trauma: Initial Stabilization abdominal trauma
  • Why more prone to abdominal injury
    • child has thinner musculature
    • ribs are more flexible in the child
    • solid organs are comparatively larger in the child
    • fat content and more elastic attachments leading to increased mobility
    • bladder is more exposed to a direct impact to the lower abdomen
intraperitoneal hemorrhage
Intraperitoneal Hemorrhage

Management

  • Immediate surgical exploration
  • Non-operative protocols
    • successful in more than 95% of blunt abdominal trauma in appropriately selected cases
intraperitoneal hemorrhage1
Intraperitoneal Hemorrhage

Immediate Surgical Exploration

  • Abdominal distention + “shock”
  • Transfusion requirement > 40 cc/kg
  • Peritonitis
  • Pneumoperitoneum
  • Bladder rupture
intraperitoneal hemorrhage2
Intraperitoneal Hemorrhage

CT Scan

  • Hemodynamically stable
  • Unreliable exam
  • Immediate non-abdominal surgery
  • Specific Indicators

Hematuria (any)

SGOT 200, SGPT > 100

Hyperamylasemia

intraperitoneal hemorrhage3
Intraperitoneal Hemorrhage
  • FAST
    • standard part of the initial evaluation of bluntly injured abdomens in adults
    • rapid assessment of the peritoneal cavity and can detect free fluid
intraperitoneal hemorrhage4
Intraperitoneal Hemorrhage
  • Pediatrics role of FAST is still up for debate
    • Detailed information regarding the grade of organ injury is not provided by the FAST
    • operator-dependent and lacks specificity
    • FAST examination produces a significant number of false-negative results
intraperitoneal hemorrhage5
Intraperitoneal Hemorrhage
  • American Association for the Surgery of Trauma (AAST) has established grading classifications for all solid organs based on anatomic descriptive criteria
  • Grading used to determine treatment pathway
intraperitoneal hemorrhage6
Intraperitoneal Hemorrhage

Diagnostic Peritoneal Lavage

  • Rarely used in children
  • Indicators
    • Hollow viscous injury suspected
    • CT scanner not available
    • “Screen” for CT scan
  • Technique
    • Mini-laparotomy (midline)
    • 15 cc/kg Lactated Ringer’s
trauma initial stabilization circulation
Heart rate

Pulses

Perfusion

capillary refill

temperature

Color

Sensorium

Urine output

Blood pressure

Trauma:Initial Stabilization Circulation
trauma initial stabilization frequent reassessment of vital signs
Trauma:Initial Stabilization Frequent Reassessment of Vital Signs

What Are Normal Pediatric Vital Signs?

trauma initial stabilization pediatric vital signs

Blood

Pulse

Respirations

Pressure

Infant

160

80

40

Preschool

140

90

30

Adolescent

80

100

20

Trauma:Initial Stabilization Pediatric Vital Signs
trauma initial stabilization circulation vital signs
Trauma:Initial Stabilization Circulation:Vital Signs
  • Normal blood pressure:
    • Lower limit of systolic BP mmHg =

70 + 2 x age in years

trauma initial stabilization circulation shock
Trauma:Initial StabilizationCirculation: Shock
  • Altered vital signs:
    • tachycardia (early)
    • tachypnea
    • narrow pulse pressure
    • hypotension (late)
trauma initial stabilization circulation shock1
Trauma:Initial Stabilization Circulation: Shock
  • Physical findings:
    • cool, pale extremities
    • capillary refill
    • altered mental status
trauma initial stabilization circulation fluid therapy
Trauma:Initial Stabilization Circulation:Fluid Therapy
  • When?
  • What kind?
  • How much?
  • Time period?
trauma initial stabilization circulation fluid therapy1
Trauma:Initial Stabilization Circulation:Fluid Therapy
  • Goal: restore vascular volume
    • amount: 20 cc/kg
  • Initial bolus given rapidly
  • Crystalloids as effective as colloids
  • Isotonic, balanced salt solution preferred
  • Reassess response additional boluses?
trauma initial stabilization circulation blood replacement
Trauma:Initial Stabilization Circulation: Blood Replacement
  • Based on:
    • response to initial fluids
    • continued blood loss
  • Products:
    • Type Specific O, Rh-Negative
    • Warmed fluids/blood
trauma initial stabilization circulation pediatric considerations
Trauma:Initial Stabilization Circulation:Pediatric Considerations
  • Vascular access
    • peripheral I.V.
      • two large bore catheters
    • intraosseous
    • central venous line
    • venous cutdown
trauma initial stabilization disability
Trauma:Initial Stabilization Disability
  • Rapid, brief neurological assessment
  • Level of consciousnessA - AlertV - responds to Vocal stimuliP - responds to Painful stimuliU - Unresponsive
  • Assess pupillary size, symmetry, reactivity
trauma initial stabilization disability children s glasgow coma scale
Trauma:Initial StabilizationDisability:Children's Glasgow Coma Scale
  • Sum of
    • eye opening
    • verbal response
    • motor response
  • Minimum score = 3
  • Maximum score = 15
trauma initial stabilization disability children s glasgow coma scale1
Eye Opening

4 spontaneously

3 to Speech

2 to Pain

1 none

Best verbal

5 coos, babbles

4 cries irritably

3 cries to pain

2 moves to pain

1 none

Best Motor

6 spontaneously

5 withdraws to touch

4 withdraws to pain

3 abnormal flexion

2 abnormal extension

1 none

Trauma:Initial StabilizationDisability:Children's Glasgow Coma Scale
trauma initial stabilization pediatric trauma score
Trauma:Initial StabilizationPediatric Trauma Score

PTS +2 +1 -1Weight > 44lbs 22-44 lbs < 22 lbs (>20 kg) (10-20 kg) (<10kg)

Airway Normal Oral or nasal Intubated, tracheostomy

Blood Pressure >90mmHg 50-90mmHg < 50mmHg

  • Level of Completely Obtunded ComatoseConsciousness awake or any LOC
  • Open Wound None Minor Major or PenetratingFractures None Minor Open or Multiple Fractures Totals
trauma initial stabilization expose pediatric considerations
Trauma:Initial Stabilization Expose: Pediatric Considerations
  • Completely disrobe the patient
  • Thermoregulation
    • prone to hypothermia
    • protect from environment
      • overhead warmers
      • blankets
trauma initial stabilization cathertization
Trauma:Initial StabilizationCathertization
  • Gastric
    • stomach decompression
    • NGT vs. OGT
      • consider cribform plate fracture
  • Urinary
trauma initial stabilization definitive care
Trauma:Initial StabilizationDefinitive Care
  • Continued reassessment for:
    • deterioration
    • unrecognized Injury
  • Transport patients with injuries requiring facilities and personnel beyond those locally available
trauma initial stabilization definitive care1
Trauma:Initial StabilizationDefinitive Care
  • Continued monitoring and stabilization
  • Further diagnostic studies
  • Treatment or repair of identified injuries as necessary
references
References
  • Wegner S, Colletti JE, Van Wie D: Pediatric blunt abdominal trauma. Pediatr Clin North Am 2006 Apr; 53(2): 243-56
  • Baka AG, Delgado CA, Simon HK: Current use and perceived utility of ultrasound for evaluation of pediatric compared with adult trauma patients. Pediatr Emerg Care 2002 Jun; 18(3): 163-7
  • Clark P, Letts M: Trauma to the thoracic and lumbar spine in the adolescent. Can J Surg 2001 Oct; 44(5): 337-45
  • Chen MK, Schropp KP, Lobe TE: The use of minimal access surgery in pediatric trauma: a preliminary report. J Laparoendosc Surg 1995 Oct; 5(5): 295-301
questions
Questions:
  • 1. Increased Mortality if care given
    • A. > 90 minutes
    • B. > 45 minutes
    • C. > 30 minutes
    • D. > 60 minutes
questions1
Questions
  • 2. True or False?
    • Children are more prone to cervical spine injury because they have a smaller head to body surface area ratio
questions2
Questions
  • 3. Lower limit for systolic blood pressure can be calculated by:
    • 50 + 2x age in years
    • 60 + 3x age in years
    • 70 + 2x age in years
    • 40 + 3x age in years
questions3
Questions
  • 4. All the following are true except:
    • Children have thinner abdominal musculature as compared to adults
    • The ribs are less flexible in the child as compared to the adult
    • Solid organs are comparatively larger in the child as compared to the adult
    • The bladder sits relatively higher in the abdomen as compared to adults
questions4
Questions
  • 5. Correct placement of a chest tube
    • A. 2nd intercostal space mid clavicular line
    • B. 2nd intercostal space mid axillary line
    • C. 5th intercostal space mid axillary line
    • D. 5th intersostal space mid clavicular line