Trauma - Pediatrics

Amanda S. Cuda, MD,MPH

Learning Objectives• Recognize common mechanism of

pediatric trauma • Demonstrate knowledge of age-

appropriate physiology, assessment, equipment, and dosing

• Demonstrate appropriate approach to resuscitation in a pediatric trauma patient

Introduction: Pediatric Trauma

• Leading cause of US mortality, ages 1-14• 16 million ED visits per year• 15,000 deaths• 45,000 permanent disability, brain injury• 2:1 male to female ratio • Blunt trauma 90%, penetrating trauma 10% • Falls, MVA, pedestrian, bicycle, assault

(National Pediatric Trauma Registry, 1999)

Peitzman, 2008)

Age Appropriate Assessment

• Table summarizing age specific vital signs from ATLS or CHOP Benedum Pediatric Trauma Program, Field Reference (need permission)

• Age and weight• Vital Signs• Mental Status• Skin• Urine output

Assessment in Peds Patients• Hypoventilation, hypoxia cause cardiorespiratory

arrest• Poor end organ perfusion evidenced by

hypotension, but also decreased cap refill, mental status change, and low urinary output

• GMC and GCS equivalent predictive for injury (Cicero, 2013)

Age Appropriate Equipment

• Table summarizing age specific equipment from CHOP Benedum Pediatric Trauma Program, Field Reference or ATLS

• Age and weight• ET tube• Foley• Broselow tape

Age-appropriate Dosing

• Age and Weight• Rapid Sequence Intubation algorithm• PediStat• Broselow Tape

Pediatric Resuscitation Approach

• Approach airway—• Be prepared to secure airway with RSI• Enable patient to breath in sniffing position

while awaiting transport • Bottom line– Get the airway if it can’t wait

Pediatric Resuscitation Approach

• Assess breathing– • Assess circulation–

• Apply direct pressure to bleeding wounds• Fluid resuscitation: • Type and crossmatch for multiple units• Place large bore IVs, tibial intraosseous (IO)

Diagnostic evaluation: imaging

• Proceed to imaging if any suspicion of occult injury

• Pediatric small frame more frequent multisystem injury

Diagnostic evaluation: lab

• Proceed to imaging if any suspicion whatsoever of occult injury

• Airway compromise or other injuries may have delayed presentation

Additional Management

• Early consultation with surgeon• Transport to pediatric trauma center when

possible

Summary

• Similar approach to rescusitation in adults• Age appropriate assessment, equipment,

and dosing • Remember differences in cardiovascular

response

References

1. Cicero MX, Cross KP. Predictive value of initial Glasgow Coma scale score in pediatric trauma patients. Pediatric Emergency Care, 29(1):43-38, 2013.

2. American College of Surgeons, Advanced Trauma Life Support for Doctors (Student Manual), 8th Edition, Oct 2008.

3. Peitzman A. The Trauma Manual: Trauma and Acute Care Surgery, 3rd Edition, 2008. Lippincott Williams & Wilkins.

Simulation Training Assessment Tool (STAT)– Pediatric Trauma

Amanda Cuda, MPH, MD

CRITICAL ACTIONS MS 2 3 4 SUSTAIN IMPROVE

Lead resuscitation at bedside w/ clear coms

Assess airway– GCS<8, head injury

Proceed to RSI

Assess breathing – clear BS, CXR

Assess circulation – confirm hypovolemia, begin IVF resuscitation

Vital signs now 80/40, HR 150; discover after RSI that IV is no longer functioning. If order fluids prior to RSI, then IV does not function. Process to tibial IO placement.

Assess D, E and Secondary Survey

Finish safety net– incl IV x 2 contra to inj, T&C multi units, post-intub CXR with RT, possible abx

Disposition to medevac

TOTAL

SCENARIO ALGORITHM

SET UP•Trauma room w/ IV, O2, trauma equip•PediaSim or equivalent w/ bruising moulage to abdomen & bleeding from scalp, lying flat , in c collar and on back board•Broselow tape and bags/cart, Airway equip, RSI drugs•Bandages

PRE ARRIVAL•As a family physician, you are working in a community hospital ER•6 yo male; EMS s/p MVA, restrained in backseat, booster/seat belt, has bleeding scalp, decreased mental status, and abdominal bruising, IV established•VSS BP100/50 HR120 RR12 POX92%

PRIMARY SURVEY•A- Slow breathing, no obvious obstruction, making moaning noises and occasionally speaking coherently•B—BS CTA, no chest injuries•C– BP100/80 HR120 RR12 POX92•D– PERRL, not moving extremities when arrives, speaking but not coherent•E– Scalp laceration with some surrounding swelling of scalp; also has abdominal bruising in seat belt distribution

SECONDARY SURVEYPatient with no other injuries

LABS & IMAGESPOC labs WNL. Post intubation CXR

shows tube in adequate position

DISPOSITIONSurgeon arrives after intubation and IVF

resusitation and secondary survey.

Simulation Training Assessment Tool (STAT)– Pediatric TraumaDate: Instructor(s): Learner(s):

Learning Objectives:1. Recognize common mechanism of pediatric trauma 2. Demonstrate knowledge of age-appropriate physiology, assessment, equipment, and dosing 3. Demonstrate appropriate approach to resuscitation in a pediatric trauma patient 4. Demonstrate proper placement of tibial IO in pediatric patient.

Debriefing Notes Approach to pediatric resuscitation is the same as

for adults. Review each step and unique aspects of pediatric care Airway Breathing Circulation Disoability

Age appropriate decision making must be done. Use Broselow tape. .

In approaching imaging, remember multisystem trauma. Head CT – non contrast, abdominal CT – with and without contrast if possilble

Early consultation with surgical trauma team Remember to start broad spectrum antibiotics

promptly if aerodigestive injury is suspected.

Review age appropriate vital signs, equipment choice, and dosing of medications–

Beware—injuries in one area will often have other injuries.

This case is a multisystem injury with decreased mental status and compromised airway. Head or abdominal trauma, if present and with the following signs indicate direct disposition to OR and include— Unstable vital signs Active bleeding Hematemesis or hemoptysis Large, expanding, or pulsatile hematoma Neurologic deficit

Additional Instructor NotesCase Synopsis

6 yo male suffered a mild traumatic brain injury and abdominal contusion as a result of being a restrained passenger in a high velocity (55mph) MVA. He has decreased mental status and it has worsened since EMS arrival on scene and through transport to hospital. He is able to maintain airway prior to arrival but on arrival, the pt is somnolent and should be intubated quickly with RSI drugs using IV that was placed by EMS. Could consider requirement of intraosseous placement with IV that now can’t flush or IO may be attempted immediately. Once IO and intubation are performed, VS will immediately stabilize. Learner must continue through the ABCs and the rest of the critical actions.

Consider telling the learner that the patient is moving around if post-RSI sedation not given by the end of the case. If intubation and fluid resuscitation are not performed, the patient will die in about 5 minutes with falling Pox and other vital

signs ending in asystolic arrest. The patient cannot be saved if this occurs.

Personnel and Roles Instructor—Introduces case, switches to “EMS” as case begins, provides ancillary data as requested and plays

“Neurosurgeon” at the end of the case Assistant (may be resident) —Acts voice of patient, manages respiratory distress in PediSIM and manages monitor (tell

Primary Learner that the assistant will be the patient’s voice prior to entry) Primary learner (resident)—Is the responding doctor. May lead the Trauma Team response or act as sole provider,

depending on how your institution manages trauma Secondary learners (residents)– Prompt primary learner to assign roles, e.g. Airway, Procedures, Nursing etc prior to

beginning case.

Props/Supply Checklist PediSIM w/ ability to intubate and perform tibial IO Moulage for MVA with blood on scalp with laceration and bruising of the abdomen. Airway equipment–Broselow bag/tape, aryngoscope, suction, BMV, RSI drugs IO set – use IO that is available in your organization.

Supporting Stimuli EMS Run Sheet– give to learner at start of case Point of care labs– give to learner only if ordered, after credible time lapse Post intubation CXR– give to learner only if ordered, after credible time lapse

EMS Run Sheet

• 6 yo male s/p MVA with bleeding scalp, decreased mental status, abdominal bruising• BP 100/50• HR 120• RR 12• POX 92%

Point of Care Labs

• Sodium: 140• Potassium: 3.8• Chloride: 106• TCo2: 25• BUN: 15• Creatinine: 0.9• Glucose: 100• Hemoglobin 11.4• Hematocrit 32.5

• Need peds non con head CT that is normal

• Need peds abdominal CT that is also normal