TRAUMA

1. TRAUMA Pediatric Critical Care Medicine Emory University Children’s Healthcare of Atlanta

2. Epidemiology • 22 million children/yr • 1 on 4 suffer serious injury/year • More children die from trauma than other causes combined

3. Management • Like any other critical patient: it’s all about the ABC

4. Trauma • ABCs • Differences: • Size • Injury pattern • Fluids • Surface area • Psychological • Long term effects

5. Trauma • A= airway • B= breathing • C= circulation • D = D’Brain • E= electrolytes • F= fluids • G= GI • H= heme • I= ID • J= Joints • K= kidney

6. Airway • Usually secured in ER but occasional mental status or respiratory effort changes & adjuncts necessary

7. Airway Intervention • Control of ventilation • Circulatory failure (shock) • Upper airway obstruction • Acute respiratory failure

8. Airway Intervention • Size of tongue, oral cavity & upper airway • Position of the larynx • Anatomy of the epiglottis • Position of the vocal cords • Narrowest portion of the airway

9. B- breathing • Trauma can lead to difficulty with both oxygenation & ventilation

10. B- breathing • Pulmonary contusion • Injury to lung parenchyma, leading to edema & blood collecting in alveolar spaces • Poor gas exchange, increased resistance & decreased compliance

11. B- breathing • Pulmonary contusions • 50-60% w/ significant contusions will develop ARDS • approximately 20% of blunt trauma patients with an Injury Severity Score over 15 • is the most common chest injury in children

12. B- breathing • Pulmonary contusion • Worsens over 24-48 hours • Resolves 3-5 days • Pneumonia is also a common complication of pulmonary contusion • Care is supportive

13. B- breathing • Pneumothorax • Pneumothorax is the collection of air in the pleural space. Air may come from an injury to the lung tissue, a bronchial tear, or a chest wall injury allowing air to be sucked in from the outside

14. B- breathing • Pneumothorax • Treatment depends on size • Small pneumothorax can be watched • Large require chest tube

15. B- breathing • Also other injuries may effect the way one controls the breathing • TBI keep PCO2 normal to low normal

16. C- circulation • Most often difficulty with BP is related to hypovolemia • Volume , volume, volume • Normal SBP 70 + (2x age) • Normal MAP 50 + (2x age)

17. C- circulation • Unless blood loss no acute benefit of crystalloid over colloid

18. C- circulation • Cardiac contusion • hypotension and arrhythmia • diagnosis of a cardiac contusion and identification of patients at risk remain a challenge

19. C- circulation • Cardiac tamponade • caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise • Cardiac tamponade • Narrow pulse pressure • increased jugular venous pressure, hypotension, and diminished heart sounds • Give volume • Pericardiocentesis

20. C- circulation

21. C- circulation • TBI • Need to maintain CPP (age dependent) • CPP= MAP-ICP • May need pressors to maintain • Most often Dopa or NE

22. D= D’Brain • Wide array of injuries from contusion and DAI to bleeds • Intervention depends on injury • Most common difficulties in PICU are AMS, ICP issues and SZ

23. D= D’Brain • Traumatic seizures • incidence of PTS for all types of head injuries is 2-2.5% • increases to 5% in hospitalized neurosurgical patients • Glasgow Coma Scale score <9 the incidence is 10-15% for adults and 30-35% for children • Duration of treatment of traumatic seizures is a bit controversial

24. D= D’Brain • ICP • HOB 30 degrees and midline • Normal temp • Normal CO2 • Good pain and sedation control • 3% or mannitol • EVD

25. D= D’Brain – spinal cord • Flexible inter spinous ligaments • Underdeveloped neck muscles • Poorly developed articulations • Anterior vertebral bodies • Flat facet joints • Large head to BSA

26. D= D’Brain – spinal cord • Neurological injury represent 18% of pediatric injuries and accounted for 23% of pediatric traumatic deaths (Durkin, et al., 1998). • However, spinal cord injury in young children is rare accounting for only 5% of spinal cord injuries (Proctor et al., 2002)

27. D= D’Brain – spinal cord • Predisposed to serious high cervical injuries • Assume its presence in: • Blunt injury above clavicle • Multisystem trauma • Significant injury - MVA, fall • Altered sensorium

28. D= D’Brain – spinal cord • Kids less than 2 yrs more likely C1-C2 • As increase with age approach more adult pattern C5-C6 • Kids much more likely to have ligamentous injury • Fractures involving the thoracolumbar spine in tend to involve the junction between the thoracic and lumbar spine

29. D= D’Brain – spinal cord • spinal cord injury without radiographic abnormalities • flexion/extension films of the cervical spine and CT scans are also normal • Cervical and thoracic spinal levels are injured with almost equal frequency and lumbar levels are rarely involved • Consider MRI

30. D= D’Brain – spinal cord • mismatching of elasticity response between the spinal column and spinal cord is the major factor contributing to the high incidence of SCIWORA injuries in young children

31. D= D’Brain – spinal cord • Steroids • No good pediatric studies • Evidence in adults now controversial and leading toward non use (Spine. 26(24S) Supplement:S39-S46) • Dosing if used: 30 mg/kg i.v. bolus within 8 hours followed by 5.4 mg/kg/hour for 24 hours

32. D= D’Brain – spinal cord • Children with spinal cord injury may have autonomic instability and hypotension • Fluid resuscitation • pressors

33. E= Electrolytes/Fluids • Glucose • w/TBI usually no dextrose • Maintain 80-140 • Stress may cause hyperglycemia • Adult lit increase mortality w/ hyperglycemia

34. E= Electrolytes/Fluids • Sodium • If head injury use NS • Keep high end of normal up to 160’s if having cerebral edema • Calcium • If cardiac contusion make sure with in normal range • Low Calcium can promote arrhythmias

35. GI • Liver/Splenic Laceration • most common injuries in blunt abdominal trauma • Often supportive care • Follow HCT q4-6 hours • Transfuse HCT < 20-24 or hemodynamic instability

36. GI • 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

37. GI • 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

38. GI Immediate Surgical Exploration • Abdominal distention + “shock” • Transfusion requirement > 40 cc/kg • Peritonitis • Pneumoperitoneum • Bladder rupture

39. Heme • Often trauma can lead to blood loss • Use conservative management in giving blood • If necessary consider losing whole blood and replacing PRBC

40. Heme • If significant amount of PRBC (generally > 3 transfusions) think about replacing factor and platelets • If using the massive transfusion protocol this will happen automatically • Additionally Blood will cause chelation and may need to give calcium

41. Heme • DIC • Inappropriately accelerated systemic activation of coagulation • Both the coagulation and the fibrinolytic systems are activated in trauma • DIC • Widespread areas of tissue damage (particularly the brain). • Head Injury common cause of DIC in infants and children • Because of the high thromboplastin content of the brain • Proportionately increased ratio of surface area of the head to total BSA.

42. Heme • DIC • Replacement therapy is helpful until the primary problem is controlled • Fresh frozen plasma (FFP) • Cryoprecipitate • Platelet concentrates • The use of heparin in DIC controversial and not indicated in patients w/ trauma

43. ID • Routine use of antibiotics is not standard • Occasionally with facial fractures will prophylactically treat • Sepsis • Sepsis occurred in 2% of all adult patients • Respiratory tract infections are the most common cause of sepsis • Severity Score, Revised Trauma Score, lower admission Glasgow Coma Scale score, and preexisting diseases as significant independent predictors of sepsis Critical Care Medicine. 32(11):2234-2240, November 2004

44. ID • Sepsis • Injury Severity Score was associated with increased incidence of sepsis • Moderate (Injury Severity Score 15-29) and severe injury (Injury Severity Score >=30) had a six-fold and 16-fold

45. Joints • Occult fractures are sometimes missed on initial survey • Watch for signs of decreased movement and increased swelling

46. Kidney • Renal contusions/lacerations • Increased Creatinine • Bloody UOP • HTN • Usually supportive care

47. MODS/SIRS • MODS is a clinical syndrome of progressive physiologic dysfunction of organ systems • Trauma high risk because of circulatory shock with tissue hypoxemia, tissue injury, and infection • Management requires control/elimination of the source of inflammation, maintenance of tissue oxygenation, nutritional/metabolic support, support for individual organs, and effective pain control.

48. MODS • Preditors in adults • Preexisting chronic illness • Acidosis • > 1L blood loss • ISS >24 • Labs • Lactate, transferrin, CRP