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Approach to trauma the paeds emerg perspective. Stephen C. Porter MD MPH MSc Division Chief, Pediatric Emergency Medicine The Hospital for Sick Children Associate Professor of Paediatrics University of Toronto School of Medicine. Outline for today. “Children are not little adults” - PowerPoint PPT Presentation
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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
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