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PEDIACTRIC TRAUMA
Core Knowledge and Skills
• Know the common life-threatening complications of major trauma in the pediatric age group
• Understand the principles of airway management in the injured pediatric patient
• Recognize and manage shock in the injured pediatric patient
Trauma
Pediatric Trauma
Injury• Leading cause of death and disability in
children• Often produces respiratory failure and shock• Organized system of pediatric trauma care
improves outcomes
Trauma
Pediatric Trauma (cont.)
Blunt injury is more common than penetrating injury• Head (CNS) injury present in 55% of blunt
trauma victims• Internal injuries present in 15% of blunt trauma
victims
Trauma
Pediatric Trauma (cont.)
Trauma
Isolated head (CNS) injury
Airway compromise
Respiratory failure
Multiple trauma
Shock
Cardiopulmonary arrest (final common pathway)
Basic and Advanced Life Support in Pediatric Trauma
• The general principles of resuscitation are the same as for all resuscitation
• Certain traumatic injuries affect resuscitation priorities� Possible cervical spine injury� Hemorrhage� Chest trauma
Trauma
Rapid Cardiopulmonary Assessment and Support--“Primary Survey”
ABCs
Rapid cardiopulmonary assessment
(includes thoracoabdominal assessment)
plus
Rapid brief neuologic assessment
D=Disability
plus
Temperature control
E=Exposure
Trauma
Rapid Cardiopulmonary Assessment and Support--“Secondary Survey”• Head-to-toe assessment
• Unique to trauma care
• Requires special training beyond the scope of the PALS course
Trauma
Rapid Cardiopulmonary Assessment and Support
Airway• Immobilize the cervical spine when assessing
and controlling the airway
Trauma
Cervical Spine Immobilization
Head in Neutral Position
Picture
Trauma
Combined Jaw Thrust--Cervical Spine Stabilization Maneuver
» picture
Trauma
Rapid Cardiopulmonary Assessment and Support
Breathing
• All trauma patients� Provide oxygen
• Neurologic or respiratory compromise� Intubate the trachea� Hyperventilate� Insert nasogastric or orogastric tube
Trauma
Rapid Cardiopulmonary Assessment and Support
Indications for Endotracheal Intubation
• Respiratory arrest
• Respiratory failure
• Airway obstruction
• Significant alteration of mental status
• Suspected increase in intracranial pressure
• Need for prolonged ventilatory support
Trauma
Intubation With Cervical Spine Immobilization
» Picture
Trauma
Common Life-Threatening Chest Injuries
Type Initial Treatment
Tension ABCs, needle
pneumothorax decompression
Massive ABCs, pleural
hemothorax decompression
Trauma
Uncommon Life-Threatening Chest Injuries
Type Initial Treatment
Flail chest ABCs, positive-
pressure ventilation
Open ABCs, occlusive
pneumothorax dressing
Trauma
Rapid Cardiopulmonary Assessment and Support
Circulation• Examine for hemorrhage
• Direct pressure to external hemorrhage sites
• Replace volume at first signs of shock
• Consult surgeon
• Transfuse with blood if the child is� Hypotensive� Poorly responsive to crystalloid boluses
• Reassess
Trauma
Special Adjuncts to Trauma Resuscitation
• Needle cricothyrotomy
• Pericardial decompression
• Pneumatic antishock trousers
Trauma
Rapid Cardiopulmonary Assessment and Support
Neurologic Evaluation
Trauma
Case Scenario
A 6-year-old by is struck by a car while riding his bicycle. On physical examination, he is unconscious and pale. You hear stridor with infrequent labored respirations. Breath sounds are slightly decreased bilaterally. Distal pulses are very weak; the pulse rate is rapid and regular. You see an obvious deformity of his left thigh.
Trauma
Case Scenario Questions
What is your assessment?
Is the child in respiratory failure?
Is the child in shock?
Trauma
Case Scenario Questions (cont.)
What other information would you like?
Trauma
Case Scenario Questions (cont.)
What would you do for this patient while this information is being gathered?
Trauma
Case Scenario -- Airway
1 Open the airway with combined jaw thrust-spine stabilization maneuver
2 Intubate as necessary
Trauma
Case Scenario -- Breathing
• Provide 100% oxygen
• Awake: Nonrebreathing mask
• Altered mentalstatus or breathing
difficulty: Bag-Valve mask
• Unresponsive or
respiratory failure: Endotracheal intubation
Trauma
Case Scenario -- Breathing (cont.)
• Examine the chest for tension/open pneumothorax. Treat if found.
• Look for gastric dilation. Treat once airway is controlled.
Trauma
Case Scenario -- Reevaluation
Heart rate 150 bpm
Respiratory rate 12 breaths per minute
Blood Pressure 80 mm Hg
Pulse quality Thready
Capillary refill time 5 seconds
External hemorrhage none
Thoracoabdominal No pneumothorax,
inspection hemothorax, flail chest,
or open wounds
Trauma
Case Scenario -- Circulation -- Treatment
1 Look for external hemorrhage. Apply direct pressure if found.
2 Place two large-bore vascular lines.
3 Obtain blood for type and crossmatch
4 If signs of decreased perfusion:• Rapidly infuse 20 mL/kg crysalloid
5 Notify the surgeon.
Trauma
Case Scenario -- Circulation (cont.)
• Reassess
• Infuse pepeat fluid bous and blood as necessary
Trauma
Summary
• Advanced life support for the traumatized pediatric patient includes assessment and support of� Ventilation (with cervical spine immobilization)� Oxygenation� Perfusion
• Rapid cardiopulmonary assessment, basic airway maneuvers, and vascular access skills are required.
Trauma