Approach to traumathe paeds emerg perspective

Stephen C. Porter MD MPH MScDivision Chief, Pediatric Emergency Medicine

The Hospital for Sick ChildrenAssociate Professor of Paediatrics

University of Toronto School of Medicine

Outline for today

• “Children are not little adults”• General concepts in pediatric trauma• Multiple trauma – major trauma/ ATLS• Quick hits: body parts and bones

How do injuries happen…

Children versus adults in trauma

• More energy from trauma distributes across more surface area

• The bony skeleton is less calcified, has active growth centers, and is more pliable

• Ratio of surface area to volume means thermal losses are a concern

You are called to the trauma bay…

• A 2 year old who was run over by a heavy delivery truck when she dashed out in front of the truck. She fell forward as she was struck by the bumper. The front tire rolled over her body prone on the pavement from the buttocks toward her left shoulder. She was crying and her parents who noticed what happened immediately drove to the hospital in their own car.

• VS T37, P140, R40, BP 100/65, oxygen saturation 94% in room air.

The exam• She is crying, alert and cooperative. Her head and face show no

tenderness, bruising or abrasions. Pupils are reactive. TM's are normal. Teeth are intact without evidence of oral injury. Her neck is non-tender. Her neck range of motion is not restricted. Heart regular. Lungs clear, with an occasional grunting sound. Anterior chest shows no bruises. Her abdomen is soft, not tender with active bowel sounds. There is extensive bruising over her anterior pelvis. There is no bleeding. Her labia are bruised but no bleeding or tears are noted. Her lower extremities are non-tender distal to the pelvis. Her back shows mild bruising in the upper chest and the buttocks. She can move all her fingers and toes well. She does not move her lower extremities spontaneously. No extremity deformities noted. Color and perfusion are good.

Describe and treat this patient• Nature and seriousness of injuries

– Multiple or local– Blunt/penetrating– Severity

• ATLS principles

Primary assessmentResuscitationComprehensive secondary assessmentTransition to definitive care

Describe and treat this patient• Nature and seriousness of injuries

– Multiple or local– Blunt/penetrating– Severity

• ATLS principles

Primary assessmentResuscitationComprehensive secondary assessment

Transition to definitive care

Describe and treat this patient• Nature and seriousness of injuries

– Multiple or local– Blunt/penetrating– Severity

• ATLS principles

Primary assessment AND resuscitationComprehensive secondary assessmentRepeat exams and monitoring for changes

Transition to definitive care

Major trauma: important questions

• Is the airway stable?• Is respiratory effort

sufficient?• Is the patient in shock?• Is there a neurologic

deficit?• What are the extent of

the injuries?

Crew resource management

Trauma team activation

• Physiologic criteria– Cardiac arrest– Hypotension per age– Respiratory distress– Neurologic failure– Trauma score < 12

• Anatomic criteria– Penetrating wound to

head, chest, abdomen– Facial/tracheal injury

with potential for airway compromise

– Burn > 30% BSA– Major electrical injury

Pediatric Trauma Score

Predicting mortality from trauma• The trauma BIG score

– Admission Base deficit– INR– Glasgow Coma Scale

• Score = (base deficit + [2.5*INR] + [15-GCS])• Predicted mortality =

1 / (1 + e-x) where x = 0.2 * BIG – 5.208• Mortality of 50% is predicted for a child with

– Base deficit 10, INR 3.6, GCS of 6

Borgman et al Pediatrics 2011

Observed and predicted mortality by the BIG score quintile in the derivation set

Pediatric trauma: Airway and C spine

Pediatric trauma: Shock

• Up to 30% loss of circulating volume may be required to influence systolic BP in a child

• If more than 2 fluid boluses of 20 cc/kg have been given to support perfusion, PRBC are needed and surgeon’s involvement is key

Systemic response to blood loss: childrenSystem <30%

blood loss30-45% blood loss

>45% blood loss

CV Nl BP Low BP Absent peripherals

CNS Anxious irritable

Lethargic Comatose

Skin Cool, mottled

Cyanotic, delayed refill

Pale, cold

UO Low Minimal None

Pediatric trauma: neurologic disability

• Neurologic assessment occurs in both primary and secondary survey phases– Primary survey - a “quick scan” for disability

• Pupils, GCS, lateralizing signs, level of spinal cord injury– Secondary survey - comprehensive assessment

• Repeat of pupils and GCS• Full assessment of cranial nerves and distal motor and

sensory function as able to given age of patient

Loss of vital signs in the trauma bay

• Children who suffer blunt trauma and then develop cardiac arrest are known to have poor outcomes

• 10/10 patients with blunt trauma died despite thoracotomies in the trauma bay

• 1 patient with penetrating injury and stable vital signs on arrival who underwent emergent thoracotomy survived

Hofbauer et al Resuscitation 2011

Back to our 2 year old patient

• Pertinent history– She fell forward as she was struck by the bumper. The

front tire rolled over her body prone on the pavement from the buttocks toward her left shoulder.

• Vitals – T37, P140, R40, BP 100/65, O2 saturation 94% in room air

• Exam– Bruising over her anterior pelvis, labia are bruised – Back shows bruising, upper chest and buttocks– No spontaneous movement of lower extremities

A pain in the neck

Swischuk and his line

Neurotrauma

• Key facts, current thinking– Cerebral perfusion pressure

depends on a normal MAP – Goal for ventilation in

neurotrauma is normocarbia

– When increased ICP is suspected,

• Elevation of head of bed• Sedation• Mannitol• Hypertonic saline

Thoracic trauma

• Lung contusion is the most common pediatric thoracic injury

• Pediatric patients are more sensitive to mediastinal shifts from air/fluid in pleural space

• Risk of intraabdominal injury higher in setting of thoracic trauma

Abdominal Trauma

• CT is the preferred diagnostic imaging modality to identify abdominal injury

• Chief indication for operative exploration in a child is a transfusion requirement that exceeds 40cc/kg in first 24 hours of care

Orthopedic trauma

http://radiographics.rsnajnls.org/content/vol24/issue4/images/large/g04jl21g15a.jpeg

Anterior humeral line

Anterior humeral line

• Line drawn from anterior cortex of humerus intersects middle third of capitellum

More lines and figuresRadio-capitellar line• Line drawn along axis of

the radius passes through centre of capitellum in all projections

Figure- of- eight• Seen on true lateral

elbow X-ray• If disrupted, may indicate

fracture

Summing up

Main themes• Blunt trauma is the

hallmark of pediatric injury

• Special considerations for pediatric trauma– anatomy and physiology– equipment

• Teamwork is needed for optimal trauma care

Main tasks• Is the airway stable?• Is respiratory effort

sufficient?• Is the patient in shock?• Is there a neurologic

deficit?• What are the extent of

the injuries?

Haddon MatrixExample of a phase-factor matrix for motor vehicle injury

Pre-event Event Post-event

Host Amount of sleep Use of safety belt Bystander care

Vehicle Antilock brakes Air bag deployment Crash scene audit

Environment Speed limits Impact-absorbing barriers

Access to trauma system

A free and good PEM resource

http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html