MODULE IV - ucdenver.edu · SCENE IMMOBILIZATION . Small children have a proportionally larger...
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Pediatric Trauma MODULE IV
Transcript of MODULE IV - ucdenver.edu · SCENE IMMOBILIZATION . Small children have a proportionally larger...
Pediatric Trauma
MODULE IV
PRE-HOSPITAL HIGH RISK CRITERIA
• Blunt injury – Significant injury; physiologic compromise
• Penetrating injuries – Thorax, abdomen, head and neck
• High risk burns: > 10% second degree
> 5% third degree
Destination: specialized pediatric burn unit after stabilization on-
site/initial facility
Presenter
Presentation Notes
Two types of injuries constitute high risk criteria in pre-hospital assessment A significant BLUNT INJURY, which shows signs of physiologic compromise Penetrating INJURIES, particularly in thorax, abdomen, head and neck Assess also for: tachycardia and signs of hypo-perfusion, hypotension for age, altered mental status, and spinal cord injury with a neurological deficit Pre-hospital assessment should refer patients with high risk burns (>10% second degree or > 5% third degree) to a specialized facility after burn wound stabilization on-site.
SCENE IMMOBILIZATION
Presenter
Presentation Notes
Small children have a proportionally larger head, so increased neck flexion occurs when laid over a backboard, thus airway obstruction can occur. Use a backboard with a scooped-out head area or just a small roll of cloth placed under the shoulders. Do not keep the child on the backboard for more than a couple of hours. Primary goals for immobilization are easiest and safest transportation and spine protection.
TRAUMA PRIMARY SURVEY
A - Airway patency
B - Breathing and ventilation
C - Circulation with hemorrhage control
D - Disability: Mental status
E - Exposure: Completely undress patient
Presenter
Presentation Notes
Management of trauma requires a systematic approach. The initial ABCDE assessment is widely accepted. This approach prioritizes stabilization and giving immediate treatment for life threatening conditions, followed by secondary assessment and triage. All this is done before knowing in detail any personal background or data from a complete physical examination. Read A - Airway patency also includes cervical spine control E – If patients need to be undressed because of exposure issues, don’t let them get cold
A – AIRWAY (PRIMARY SURVEY)
• Midline positioning
• Do jaw thrust to open airway and protect c-spine
• Head tilt and chin lift are contraindicated
• Cervical spine immobilization
Presenter
Presentation Notes
The objective of airway clearing is to promote adequate gas exchange. Recognize and clear any obstruction, and try to prevent aspiration of gastric contents. Keep a midline position, do jaw thrust to open airway. Consider possible lesions in the cervical spine: in these cases, head tilt and chin lift are contraindicated. Spine immobilization must include a hard cervical collar.
Airway assessment in children
• Stable airway • If it is possible to keep the airway open - Airway opening maneuvers - Devices: oral or nasal airway • If it is NOT possible to keep the airway open - Bag-Valve-Mask (BVM) - Endotracheal tube (rapid sequence intubation) - Cricothyrotomy
Presenter
Presentation Notes
Airway evaluation determines if the airway is stable. If nessesary, airway opening manouvers should be performed. Remember that children under 3 months old are nasal breathers Ifit is not possible to keep the airway open, try with bag-valve- mask ventilation, endotracheal intubation or, as the last option, cricothyrotomy.
B - BREATHING
• Assess minute ventilation
• Assess chest expansion
• Breath sounds
• Heart sounds
• Chest percussion
BAG-VALVE-MASK VENTILATION
• Midline position
• “Open” airway
• Proper sized mask
• Proper sized bag
Presenter
Presentation Notes
Mask positioning is key for effective ventilation. Let’s see the picture: position the mask well on the midline, always keeping the airway open. Use a proper sized mask to achieve a good seal and a proper sized bag to ventilate effectively. Fingers securing the mask seal should fasten only on bony landmarks to avoid damage to the patient.
C - CIRCULATION
• Assess pulse, end organ perfusion (capillary refill, temperature/appearance of extremities, CNS) and blood pressure
• Control external hemorrhage using direct pressure to wounds
REMEMBER: Hypotension in children will not be evident until 25% to 30% of blood volume is lost. Begin aggressive fluid resuscitation immediately
Presenter
Presentation Notes
C stands for Circulation. Adequate circulation may be determined by examining pulse pressure and rate, both peripheral and central. Document blood pressure, but keep in mind that in children circulation might be compromised with normal BP. Hypotension in children will not be evident until 25% to 30% of blood volume is lost, so begin aggressive fluid resuscitation immediately. Tachycardia is an earlier marker for hypovolemia. Look for external hemorrhages and control them by applying direct pressure to wounds. Thin pressure dressings are advisable, rather than bulky dressings. Fluid expansion with intravenous liquids, although challenging and requiring special equipment, may save lives.
D - DISABILITY
• Determine mental status with rapid assessment
• Is the child responsive?
• Pupil and motor exam
• AVPN evaluation: (Alert, responsive to Voice, responsive to Pain, Nonresponsive)
Presenter
Presentation Notes
D stands for Disability. Rapidly assess mental status and carry out a minimal neurological exam (pupils, motor). Assess if the child is alert, responsive to verbal or painful stimuli, or unresponsive. In addition, the pupils should be assessed for size, equality, and response to light. A quick motor exam can determine if all four extremities show motor activity. To determine conscious level, use the AVPN evaluation (Alert, responsive to Verbal stimuli, responsive to Pain, Non responsive). One at the hospital, you can determine the score for the Glasgow coma scale.
E - EXPOSURE
• Completely undress the patient
• Perform a complete examination
• Don’t let the patient get cold
• Glucose, lab tests
Presenter
Presentation Notes
E stands for exposure. Completely undress the patient and perform a complete physical examination. Do not let the patient get cold. Infants may quickly become hypothermic, especially if they are wet.
Polytrauma: Secondary survey • Vital signs assessment
• Head- to- toe examination
• Laboratory and radiologic
• studies
• Splinting fractures and
• applying wound dressings
Presenter
Presentation Notes
The secondary survey starts after the ABCDE assessment has been completed and initial management of life-threatening conditions has taken place
SHOCK RELATED TO TRAUMA
• Spinal cord injury Distributive
• Massive hemothorax • Tension pneumothorax • Tamponade
Obstructive
• Myocardial contusion Cardiogenic
• Hemorrhage • Burns
Hypovolemic
Cause Classify
PEDIATRIC TRAUMA SCORE
Pediatric trauma score
Presenter
Presentation Notes
This table shows the items included in the Pediatric Trauma Score. This system is used to rapidly assess the severity of the injury, and also to classify children according to the level of care needed. If possible refer children with a score 8 to a specialized pediatric trauma centre. Mortality con be predicted based on the trauma score, as follows: >8: <1% mortality predicted <8: Suggests referal to trauma center 4: predicts 50% mortality <1:predicts >98% mortality
TRAUMATIC BRAIN / HEAD INJURY
• Primary injury - Blunt or penetrating - Concussion, cerebral contusion, diffuse axonal injury, intracranial hemorrhage
ASSESSMENT: AVPN
• Secondary injury - Result of metabolic events
- Cerebral ischemia, brain edema
Presenter
Presentation Notes
Traumatic brain injuries can be classified as either primary or secondary. Primary brain injuries are those produced during trauma. They may be blunt or penetrating, and may include brain concussion or contusion, diffuse axonal injury, or intracranial hemorrhage. Assessment includes AVPN (Alert, responsive to Verbal stimuli, responsive to pain stimuli, Nonresponsive) with the GCS. Secondary brain injuries include those that present later in time as a result of metabolic effects such as cerebral ischemia and cerebral edema. These injuries are usually seen hours to days after the traumatic event and can be minimized with proper medical care.
CLINICAL ASSESSMENT OF SEVERITY TRAUMATIC BRAIN INJURY (TBI)
• Vital signs
• Level of consciousness (AVPN)
• Muscular strength/ tone
• Cranial nerve exam
Presenter
Presentation Notes
Assess the severity of TBI based on vital signs, level of consciousness (AVPN), motor strength, cranial nerve exam. For a TBI diagnostic assessment, if possible, obtain a computerized tomography of the head, or a lateral image of the spine.
MANAGEMENT HEAD INJURY
• Maintain head in neutral position, use rigid cervical collar
• Administer short-term sedation and analgesia – Midazolam (0.1 mg/kg) and Fentanyl (1-2 mcg/kg)
• If there are clinical signs of ICP – Sedation, Mannitol (0.5-1 gm/kg), and hyperventilation
(to PCO2 of 25-30) until clinical signs improve – Consider elevating the head of the bed 30 degrees
• Consider a foley and nasogastric tube
Presenter
Presentation Notes
Short-term sedation and analgesia may be needed. If there are clinical signs of intracranial hypertension, such as an unequal pupil dilation, abnormal posturing, or Cushing’s triad, indicate additional therapeutic measures until clinical signs improve. Hyperventilation should be limited to serious injuries with no adequate response to other interventions. Finally, consider placement of a Foley tube and a nasogastric or oral-gastric tube in patients with severe posttraumatic brain injuries. If patients get cold, they will shiver, increasing their metabolic rate, so aim to keep patient normothermic. Do not administer seizure prophylaxis, but administer meds if the patient develops seizures.
THORACIC INJURIES
• Pulmonary contusion/laceration (53%)
• Pneumothorax/hemothorax (38%)
• Rib/sternal fractures (36%)
• Other injuries – Cardiac (5%) – Diaphragm (2%) – Major blood vessels (1%)
Presenter
Presentation Notes
In children, thoracic injuries are associated with a high mortality rate. Injuries include pulmonary contusion/laceration, pneumothorax/hemothorax, and others. The greater elasticity of the ribs and sternum make fractures less common than in adults, however there is a higher rate of energy transfer to the underlying structures.
PNEUMOTHORAX
• Simple vs Tension – Tracheal shift
• Air into pleural space – Loss of negative pressure – Collapse of lung
• Open pneumothorax – Occlusive dressing
Presenter
Presentation Notes
In pneumothorax, air enters the pleural space through a hole in the chest wall or a hole in the lung, bronchus, or trachea. This results in loss of negative pressure and collapse of the lung. Tension pneumothorax is a clinical diagnosis made by tracheal shifts AWAY from the side of the pneumothorax, absent breath sounds, hypotension and possibly distended neck veins. In children, it may be difficult to clinically determine jugular venous distention and tracheal shifting. Tension pneumothorax requires immediate needle decompression. An open pneumothorax exists when there is an opening in the chest wall. Immediately place an occlusive dressing (plastic wrap, petroleum gauze, etc.)
HEMOTHORAX
• Blood accumulates in the pleural space – Lung compression
• Type of injury – Large pulmonary injury – Large vessels injury
• Hypovolemia
Presenter
Presentation Notes
Hemothorax occurs when blood accumulates in the pleural space, which can then compress the lung. A massive hemothorax indicates a large lung injury with potential involvement of large vessels. Drain the blood from the chest with a chest tube and treat the hypovolemia.
PERICARDIAL TAMPONADE
• Beck’s triad: narrow pulse pressure, neck vein distention, muffled heart tones
• Fluid in the pericardial sac
• Compresses heart and ↓ cardiac output
• Impairs venous return
• Arrhythmias
• Pericardiocentesis
Presenter
Presentation Notes
Pericardial tamponade occurs when fluid accumulates in the pericardial sac. In trauma, this fluid is blood and usually develops over minutes to hours. Heart is compressed and cardiac output (as well as venous return) reduced. Clinically, Beck’s triad suggests pericardial tamponade. Arrhythmias can be present including bradycardia, pulseless electrical activity (PEA), and asystolia. Treatment includes pericardiocenthesis and IV fluids.
ABDOMINAL INJURIES
• Third leading cause of death in children, after head and thoracic injuries
• Silent hypovolemia
• Solid organ vs hollow viscous – Spleen most common
• Unique features of children’s abdomen
Presenter
Presentation Notes
Abdominal injuries are the third leading cause of death due to trauma in children, after head and thoracic injuries. They may affect solid or hollow organs, particularly the spleen. Typically, the abdomen represents a site of “silent” hypovolemia. There are unique abdominal features in children Thinner wall Smaller AP-diameter Increased lordosis Proportionately larger spleen and liver exposed below the rib cage Kidney more anterior; less perinephric fat
BONE AND EXTREMITY INJURIES INITIAL MANAGEMENT
• Splint, splint, splint… – Clean and cover wound – Different types of splints – Splint distally and
proximally to joint
• Pain management
Presenter
Presentation Notes
Initial management of bone and extremity injuries includes extensive splinting after cleaning and covering the wounds. If the ideal materials are not available at the disaster scene, use what is available. If at the Emergency Department: fiberglass makes a stronger and water resistant splint. Provide pain treatment as needed.
OPEN FRACTURES
• Implies significant force
- Look for other injuries
• Increased complications
- Infections, nerve impingement
• Management - Clean, cover, do not suture - IV antibiotics, keep NPO, and immobilize
• Will need OR surgical debridement
Presenter
Presentation Notes
Open fractures imply a significant force has been involved, and add the concern of infection. It is important to look for other injuries. Other complications include nerve entrapment and compression. Treatment of an open fracture includes cleaning, covering without suturing the opening, IV antibiotics, and immobilization. Ideally, these injuries will benefit from OR surgical debridement.
PELVIC FRACTURES
• Associated with high energy accidents – Blood loss can be significant
• Pelvic ring fracture: single fracture usually stable
• Multiple fractures: unstable – Genitourinary injuries – Abdominal injuries – Vascular abnormalities (pelvic vein section)
Presenter
Presentation Notes
Pelvic fractures cause concern because they are typically the result of high-impact blunt trauma; blood loss can be significant. The pelvic ring may be fractured in a single place, usually stable fractures, or more commonly in multiple places, usually unstable fractures. Additional injuries associated with pelvic fractures include genitourinary and abdominal lesions, and vascular abnormalities (i.e., pelvic vein section or laceration). A sheet tightly wrapped around the pelvis may be the only temporary measure for the unstable, bleeding pelvic fracture until operative treatment is arranged
BURN CLASSIFICATION
• Minor – < 10% body surface area (BSA) second-degree,
< 1% third-degree
• Moderate – 10-30% BSA second-degree, 1-10% third-degree – No hands, feet or genitalia
• Critical – Inhalational injury – > 30% BSA second-degree, > 10-20% third-degree – Complicating fracture – Extensive electric or chemical burns
Presenter
Presentation Notes
Burns cause both local lesions and systemic alterations, based on the type and degree of the burn. The local response involves not only direct tissue coagulation, but also microvascular reactions in the surrounding dermis, resulting in extension of the injury. Burn can be caused by heat, aggressive chemicals or radiation. Systemic response involves the release of vasoactive mediators. Burns can be classified according to depth. First-degree are red, dry, and painful; second-degree are red, wet, and very painful; third-degree are leathery, dry, with sensorial loss, and waxy, and fourth-degree involve underlying tissues, tendons, and bones. Assess burn wounds according to the percentage of body surface affected and burn degree. Inhalational injury, a complicating fracture, and extensive electric or chemical burns are high risk factors. The extent of necrosis is correlated to temperature and duration of contact with offending agent.
• Dilute and wash away offending chemicals
• Remove clothing
• Cover burns with clean dressing or sheet – Prevents contamination, decreases pain
• Keep warm
• Give pain medications
• Replace fluids – Rule of Nines… – >10% BSA in children – IV vs. oral (may attempt up to 25%BSA)
BURNS MANAGEMENT
Presenter
Presentation Notes
This slide reviews the steps for initial management of burns. Clean, remove clothing, cover, keep warm, give pain relievers, and replace fluids. Fluid replacement is one of the most important issues in burns treatment. There are two main formulas to estimate the amount of fluids needed: Parkland: 4ml/kg x % burn (2nd y 3rd grades): Half in first 8hs, the other half in the next 16h. Add maintenance fluids. Carvajal: 5000 mL/m2 x % burn. Half in first 8hs, the other half in the next 16h. Add maintenance fluids 2000 ml/m2 SCT/día Parkland formula is used more frecuently, though Carvajal is recomended for smaller children, as it estimates the amount of fluids needed according to corporal surface (which is calculated by height and weight), while Parkland calculates it according only to weight.
RULE OF NINES
Presenter
Presentation Notes
The slide shows the rule of nines. It divides body surface areas in 9% sections. The rule assumes adult body proportions but is adapted to children.
Surface of the palm
Presenter
Presentation Notes
The surface of the palm can also be used. The palm surface area of second degree (or greater) burns equals 0.5-1.0% of BSA
INHALATION INJURY
The patient faints…
• Fire or smoke present in a closed area
• Evidence of respiratory distress or upper airway obstruction
• Soot around the mouth or nose
• Singed eyebrows, eyelashes
• Burns around the face or neck
Upper airway edema is commonly seen during the first 6 to 24 hours after injury
Management: – Remove the patient from the gas and allow him to breathe air or oxygen – Keep airway open: Early obstruction of the upper airway is managed with
intubation – Oxygen 100%
Presenter
Presentation Notes
The patient with inhalation injury faints, so medical personnel need to identify clinical signs clearly. If patients have clinical findings of inhalational injury, perform endotracheal intubation early because increasing edema will make later intubation more difficult, if not impossible. First remove the patient from the gas, and then assess. If airway is obstructed, intubate. We must also consider carbon monoxide exposition as well as cyanide. They both have additive effects as they result in tissue and cellular hipoxia. In the disaster scene, management of the burned patient must always include oxygen as a part of the initial treatment. These issuess will be reviewed in module 10 as well.
EXPLOSIONS AND BLAST INJURIES
• Bombs and explosives cause unique injuries
• Among survivors: – Injuries include penetrating and blunt trauma – Blast lung is the most common lethal injury
• Half of all initial casualties will seek medical care over a one-hour period
• Upside down triage triangle ▼ Initial patients: Less injured
Later patients: More injured
Presenter
Presentation Notes
Explosives can be classified as either high-order (HE) or low-order (LE). High-order explosives such as TNT, C-4, nitroglycerin, or ammonium cause a supersonic over-pressurization shock wave. Low-order explosives such as black powder or nitrocellulose cause a subsonic explosion. You can see the Friedlander curve in the slide, describing the physics of blasts: a millisec brief over-pressurization is followed by a longer negative pressure phase. Bombs and explosives can cause distinctive injuries. Soft-tissue, orthopedic, and head injuries dominate in most larger series. Survivors of an explosion typically present both penetrating and blunt trauma injuries. The most common lethal injury is blast lung. Half of all initial casualties will seek medical care over a one-hour period. The upside-down triage triangle (▼) is a reminder that the least sick will arrive first, whereas those who are more sick, trapped, closer to the explosion site, or unable to ambulate will arrive later after EMS rescue and in smaller numbers.
BLAST INJURIES
• Primary mechanism: (Over-pressurization blast
wave)
• Secondary mechanism: (Flying debris)
• Tertiary mechanism: (Blast wind throwing the
individual)
– Affects air filled cavities (lungs, ears)
– Air embolism (stroke, acute abdomen, spinal cord injury)
– Penetrating or blunt injuries i.e. (eye injuries 10%)
– Fractures, brain injuries,
traumatic amputations…
Miscellaneous: Burns, crush injuries, respiratory (dust/ toxins)
Presenter
Presentation Notes
There are 4 types of blast injuries according to the injury mechanism: Primary injury mechanism: Primary injury is the result of the excessive pressure generated by the blast wave. It affects all air- or fluid-filled cavities (lungs, ears, GI tract). It may cause air embolism resulting in a stroke or in acute abdominal or spinal cord injury. Secondary injury mechanism: Secondary injuries are caused by pieces of flying debris that act as projectiles, resulting in penetrating or blunt injuries. About 10% are eye injuries. Tertiary injury Tertiary injuries occur when the body is thrown by the blast wind and may include fractures, brain injuries, traumatic amputations, etc. Miscellaneous Other blast trauma injuries may include burns, crush injuries, respiratory (dust/ toxins) injuries, etc.
“BLAST LUNG”
• Over-pressurization wave
• Most common fatal injury
• Can be found 48 hours later
• Triad: apnea, bradycardia, hypotension
• Suspect if: dyspnea, cough, hemoptysis, CP, hypoxia
• CXR: butterfly pattern
.
Presenter
Presentation Notes
The slide shows a chest radiograph of a patient with lung blast injury, day 1: Endotracheal tube, chest drainage, fracture of second and third ribs, and bilateral basal consolidation. Blast lung is the most common primary blast injury in explosion situations. It may appear up to 48 hours after the explosion. The initial triad of apnea, bradycardia, and hypotension may occur. Pulmonary injuries that may occur vary from petechiae to pulmonary hemorrhage. Symptoms include dyspnea, cough, hemoptysis, chest pain, and hypoxia.
BLAST BRAIN INJURIES
• Severe head injury is a leading cause of death – Subarachnoid, subdural hemorrhage most common
(fatalities)
• Mild TBI’s are common, but may be occult
• Signs and symptoms may be subtle – Memory problems, headaches, dizziness, uneven gait,
blurred vision, irritability, confusion…
Presenter
Presentation Notes
Blast fatalities associated with head injuries are basically related to subarachnoid and subdural hemorrhages. Although most of traumatic brain injuries are usually easily identified, mild traumatic brain injuries are common and may be overlooked. Other injuries may also serve as distractor to the health-care provider, making the diagnosis of subtle neurologic findings more difficult. Take into consideration subtle signs and symptoms of potential mild traumatic brain injury such as memory problems, headaches, fainting, uneven gait, blurred vision, irritability, and confusion.
BLAST ABDOMINAL INJURY • GI gas-containing structures
• Petechiae, hemorrhages, large intramural hematomas – Severe overpressure leads to intestinal laceration, bowel
perforation
• Colon: most common site of injury
• Ruptures may occur acutely several days after stretching, ischemia, and subsequent weakening of the bowel wall
• Tension pneumoperitoneum
Ann Emerg Med 2001
Presenter
Presentation Notes
Primary intestinal blast injury is uncommon and depends on exposure to a very high air pressure. Injuries may include intestinal petechiae, hemorrhages, large intramural hematomas, intestinal laceration, or bowel perforation. The colon, where gas accumulates, is the most common site of injury. Ruptures may occur acutely or several days after due to stretching, ischemia, and subsequent weakening of the bowel wall. A tension pneumoperitoneum may also occur. Mesenteric, retroperitoneal or scrotal hemorrhages are other potential injuries.
CRUSH SYNDROME CAUSES OF DEATH
• Highly severe hypovolemic shock
• Metabolic and electrolitic disorders: Hyperkalemia, Hypocalcemia, Metabolic acidosis
• Acute myoglobinuric renal failure
• Compartment syndrome
Treatment: massive volume replacement and alkaline solute (mannitol) diuresis
Detection of metabolic abnormalities
Presenter
Presentation Notes
Crush syndrome is characterized by hypovolemic shock and hyperkalemia. It is crucial to initiate volume expansion as soon as possible. The crush syndrome can result in several potential medical conditions that can be associated with significant morbidity or mortality. Associated clinical entities are hypocalcemia, metabolic acidosis, acute myoglobinuric renal failure and compartment syndrome. Some research suggests that intravenous hypertonic mannitol is protective to the injured muscle and can be used as a noninvasive adjunct in the management of compartment syndrome. Mannitol increases the urinary elimination of nephrotoxic metabolites (myoglobin urate and phosphate).
COMPARTMENT SYNDROME
• ↑ Intracompartment pressure→ ischemia → muscle necrosis and nerve palsies
• Anterior compartment of lower leg is the most frecuent
• Trauma does not have to be severe – Severe trauma interrupts the compartment
• ↑ Pain, especially with passive extension
• Absent Pulse, Paresthesia, Pallor, Paralysis/Paresis
• Direct measurement of compartment pressure
Presenter
Presentation Notes
Compartment syndrome occurs with an increase of pressure in a muscle compartment. This can lead to ischemia with eventual muscle necrosis and nerve damage (palsies). The anterior compartment of the lower leg is the most commonly affected as there are four susceptible compartments in this commonly injured location. In severe trauma the compartment integrity may actually be disrupted preventing high intracompartment pressures from being reached. Clinically, increasing and severe pain should be looked for, especially pain associated with passive extension of the compartment. The compartment syndrome examination is geared toward the classic description of the “five Ps”: 1. Pain out of proportion for the injury or pain to passive movement of the fingers or toes 2. Pallor of the extremity 3. Paralysis/paresis 4. Paresthesias 5. Pulseslessness or reduced pulse. Confirmation of elevated pressures may be obtained by direct measurement of the compartment pressure.
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