Pediatric Trauma Drill PTFD 7 14
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Transcript of Pediatric Trauma Drill PTFD 7 14
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Pediatric Trauma
ptfd7/14
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Objectives
• Review pediatric assessment• Review pathophysiology of pediatric trauma• Review of child abuse • Review PTFD protocols
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Pediatric Trauma
• Pediatric trauma is the leading cause of death among children older than 1 year.– MVC’s cause most deaths– Falls and submersions are next– Homicides and suicides are also common among
adolescents
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Pediatric Patient Assessment
• Differs from adult assessment• Adapt your assessment skills.• Have age-appropriate equipment.• Review age-appropriate vital signs.
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Scene Size-Up
• Take appropriate standard precautions.• Note child’s position.• Note pills, medicine bottles, alcohol, drug
paraphernalia, or household chemicals.• Do not discount the possibility of abuse.
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Primary Assessment
• Use the Pediatric Assessment Triangle to form a general impression.
Used with permission of the American Academy of Pediatrics, Pediatric Education for Prehospital Professionals, © American Academy of Pediatrics, 2000
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Primary Assessment• Appearance
– A child with a grossly abnormal appearance requires immediate life-support interventions and transportation.
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Primary Assessment• Work of breathing
– Reflects attempt to compensate for abnormalities in oxygenation, ventilation
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Primary Assessment• Circulation to skin
– Determine adequacy of cardiac output and core perfusion.
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Primary Assessment
• Stay or go– Use findings from PAT to determine whether the
patient requires urgent care.• Assess ABCs.• Treat life threats.• Transport.
– If condition is stable, finish assessment.
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Hands-on ABCs
• Manage threats to ABCs as you find them.• Steps are the same as with adults.• Estimate child’s weight.
– Best method is pediatric resuscitation tape measure.
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Hands-on ABCs
• Airway– Determine whether airway is open and patient has
adequate chest rise with breathing.– If there is potential obstruction, position airway
and suction as necessary.
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Hands-on ABCs
• Breathing– Calculate the respiratory rate.– Auscultate breath sounds.– Check pulse oximetry for oxygen saturation.
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Hands-on ABCs
• Circulation– Integrate information from PAT.– Listen to the heart or feel pulse for 30 seconds.
• Double the number to get pulse rate.
– After checking the pulse rate, do a hands-on evaluation of skin CTC.
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Hands-on ABCs
• Disability– Use the AVPU scale or Pediatric Glasgow Coma
Scale to assess level of consciousness.• Assess pupillary response.• Evaluate motor activity.
– Assessment of pain must consider age.
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Hands-on ABCs
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Hands-on ABCs
• Exposure– Perform a rapid exam of the entire body.– Avoid heat loss, especially in infants.– Cover child as soon as possible.
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Transport Decision
• Transport immediately for trauma with:– Serious MOI– Physiologic abnormality– Significant anatomic abnormality– Unsafe scene
• Attempt vascular access en route.
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History Taking• Can conduct en
route if condition is unstable.
• Goals:– Elaborate on chief
complaint.– Obtain history.
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Secondary Assessment
– Head– Pupils– Nose– Ears– Mouth– Neck
– Chest
– Back– Abdomen– Extremities– Capillary refill– Level of hydration
• May include a full-body examination or a focused assessment
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Secondary Assessment
• Attempt to take the child’s blood pressure on the upper arm or thigh.– Minimal systolic blood pressure =
80 + (2 × age in years)
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Reassessment
• Includes the following:– PAT– Patient priority– Vital signs– Assessment of interventions– Reassessment of focused areas
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Pediatric Trauma Emergencies
• Leading cause of death among children older than 1 year
• Anatomy and physiology make injury patterns and responses different from those seen in adults.
• Developmental stage will affect response.
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Shock
• Inadequate delivery of oxygen and nutrients to tissues to meet metabolic demand
• Three types:– Hypovolemic– Distributive– Cardiogenic
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Shock
• Compensated shock– Critical abnormalities of perfusion– Body is able to maintain adequate perfusion to
vital organs. – Intervention is needed to prevent child from
decompensating.
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Shock
• Decompensated shock– State of inadequate perfusion
• Child will be profoundly tachycardic and show signs of poor peripheral perfusion.– Hypotension is a late and ominous sign.
• Start resuscitation on scene.
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Hypovolemic Shock
• Hypovolemia: most common cause of shock in infants and young children– Loss of volume due to illness or trauma– Signs may include:
• Listless or lethargic• Pale, mottled, or cyanotic
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Hypovolemic Shock
• Management– Position of comfort– Supplemental oxygen– Keep the child warm.– Direct pressure to stop external bleeding– Volume replacement
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Hypovolemic Shock• With compensated
shock, you can attempt IV or IO access en route.– Many of the sites
are the same in adults and children.
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Hypovolemic Shock
• Once IV access is established, begin fluid resuscitation with isotonic fluids only.
• In decompensated shock with hypotension, begin initial fluid resuscitation on scene.– Evaluate sites for IV access.
• If this is unsuccessful, begin IO infusion.
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Distributive Shock
• Decreased vascular tone develops.– Vasodilation and third spacing of fluids occurs.– In a trauma setting, it is due to spinal cord injury
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Pathophysiology of Traumatic Injuries
• Blunt trauma is the MOI in more than 90% of pediatric injury cases.– Less muscle and fat mass leads to less protection
against forces transmitted.
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Pathophysiology of Traumatic Injuries
• Falls are common. – Injury will reflect anatomy and height of fall.
• Falls from a standing position usually result in isolated long bone injuries.
• High-energy falls result in multisystem trauma.• Injuries from bicycle handlebars typically produce
compression injuries.
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Pathophysiology of Traumatic Injuries
• Motor vehicle crashes can result in a variety of injury patterns depending on restraints and position in car.– For unrestrained passengers, assume multisystem
trauma.– Suspect spinal fractures with chest or abdominal
bruising in a seat belt pattern.
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Assessment and Management of Traumatic Injuries
• Begin with a thorough scene size-up.• Use PAT to form a general impression.
– If findings are grossly abnormal, move to ABCs.• Initiate life support interventions.
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Assessment and Management of Traumatic Injuries
• Pneumothorax may be present with penetrating trauma of the chest or upper abdomen.– Perform needle decompression.– Signs and symptoms may include:
• Tachycardia• Jugular vein distention • Pulsus paradoxus
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Assessment and Management of Traumatic Injuries
• Any trauma patient should be considered to be at risk for developing shock.– Assess circulation.– The only sign might be an elevated pulse rate.
• Once ABCs are stabilized, continue assessment of disability with AVPU.
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Assessment and Management of Traumatic Injuries
• Place a cervical collar, and immobilize on a long backboard as indicated.
• Perform rapid exam to identify all injuries.• Cover the child with blankets.• Treat any fractures.
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Transport Considerations
• Some traumas are load-and-go because of severe injuries and unstable condition.
• For these situations:– Perform lifesaving steps on scene or en route.– Transfer quickly per local trauma protocols.
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Transport Considerations• All trauma victims
with suspected spinal injury require spinal stabilization. – Do not place a collar
that is too big on a child.
© Mark C. Ide
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History Taking and Secondary Assessment
• If patient is stable:– Obtain additional history. – Perform a more thorough physical exam.
• Look for bruises, abrasions, other subtle signs of injury that may have been missed.
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Fluid Management
• Airway management and ventilatory support take priority over circulation management.– Tachycardia is usually the first sign of circulatory
compromise in a child.– Hypotension is a late finding.
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Fluid Management
• Establishing vascular access:– Large-bore IV catheters should be inserted into a
large peripheral vein.– 20 or 22 gauge needles may be considered “large
bore.”– Definitive care can only be provided at the ED.– To maintain perfusion, administer a bolus of 20
mL/kg of isotonic crystalloid solution.
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Pain Management
• Pain is often undertreated in children.– Use tools to elicit child’s self-report of pain level.– Use a calm, reassuring voice, distraction
techniques, and medications when appropriate.
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Pathophysiology, Assessment, and Management of Burns
• Assessment and management are similar to that of adults, with a few key differences. – Larger skin surface–body mass ratio
• More susceptible to heat and fluid loss
– Worrisome patterns of injury or suspicious circumstances should raise concerns of abuse.
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Assessment and Management of Burns
• Scene safety is important.
• Estimate the percentage of BSA burned may affect decisions on fluids and transport.
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Assessment and Management of Burns
• Burns suggestive of abuse: – Mechanism or pattern observed does not match
history or child’s capabilities• Remove burning clothing; support ABCs.
– Give 100% supplemental oxygen.
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Assessment and Management of Burns
• Clean burned areas minimally.• Avoid lotions or ointments.• Cover burn and patient as needed.• Analgesia is a critical part of management.• Transport to an appropriate medical facility.
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Child Abuse and Neglect
• Child abuse: Any improper or excessive action that injures or harms a child or infant – Physical abuse– Sexual abuse– Emotional abuse – Neglect
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Risk Factors for Abuse
• Risk factors for abuse:– Younger children– Children who require extra attention– Lower socioeconomic status– Divorce, financial problems, and illness– Drug and alcohol abuse– Domestic violence in the home
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Suspecting Abuse or Neglect• If you suspect
abuse, trust your instincts.
• Look for “red flags” that could suggest maltreatment.
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Assessment and Management of Abuse and Neglect
• Carefully document what you see.– Child’s environment– Condition of home– Interactions among caregivers, child, EMS crew
• Prehospital personnel are legally obligated to report suspicion of abuse.
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Assessment and Management of Abuse and Neglect
• Involve police early to secure the scene.• Approach ED staff with concerns.• Be aware of local regulations.• Focus on assessment and management.
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Assessment and Management of Abuse and Neglect
• Be alert for a history that is inconsistent with the clinical picture.
• Look for bruises.
Courtesy of Moose Jaw Police Service
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Mimics of Abuse• Can be difficult to
distinguish some normal skin findings from inflicted injuries
• Mongolian spots may be mistaken for bruises.
© Dr. P. Marazzi/Photo Researchers, Inc.
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Mimics of Abuse
• Medical conditions can mimic bruises.– Purpura– Petechiae
• Exposure to sun can cause reactions with certain medications or fruits. – Phytophotodermatitis
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Mimics of Abuse• Certain cultural
customs produce skin markings.– Coining – Cupping
Used with permission of the American Academy of Pediatrics, Pediatric Education for Prehospital Professionals, © American Academy of Pediatrics, 2000
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Reference Material• AAOS Emergency Care in the Streets, 7th Ed., Jones & Bartlett, 2014• PTFD Medical Protocols, Dr. Boggs, 2014