Pediatric Critical Care Study Guide || Trauma/Burn

896

Trauma/Burn

CHAPTER 41

LEARNING OBJECTIVES Understand the Advanced Trauma Life Support (ATLS) ■

approach to evaluation and initial treatment of the injured child. Understand the role of the Pediatric Critical Care ■

Medicine specialist in the ATLS evaluation. Be able to evaluate and clear the axial skeleton in an ■

injured child. Know the current treatment of common thoracic, ■

abdominal and orthopedic injuries in children. Be able to initiate treatment of a child with burn injury ■

CHAPTER OUTLINELearning ObjectivesOverview of Pediatric Trauma SystemsDemographics of Childhood InjuryInitial Evaluation of the Traumatically Injured Child/Role

of the PICU and PCCMEvaluation of the Airway in a Multiply Injured ChildEstablishing Vascular Access in the Injured ChildHemodynamic Monitoring as a Guide to Therapy in the Multiply Injured ChildStabilization and Evaluation of the Axial SkeletonSupportive Care and Treatment for Cervical Spine InjurySupportive Care/Treatment of Pediatric Patients with Injures to the Chest

Pulmonary ContusionCardiac ContusionFlail ChestInjury to the Great Vessels

Supportive Care/Treatment of Pediatric Patients with Abdominal Injuries

Spleen InjuryLiver InjuryPancreatic InjuryRenal InjuryIntestinal Injury

Special Problems Associated with Orthopedic InjuriesFat Embolus and Long Bone FractureCompartment SyndromeRisk of Deep Venous Thrombosis and Prevention of Pulmonary Embolism

Approach to the Multiply Injured Child Who May Be the Victim of Non-accidental Injury

ROBERT E. CILLEY AND ERIC H. BRADBURN

Head InjuryInitial Evaluation, Fluid Resuscitation, and Care of the Severely Burned Child

First PrioritiesCarbon Monoxide PoisoningTypes of Burns and Extent of Burn InjuryFluid ResuscitationCriteria for Transfer

SummaryReview QuestionsAnswersSuggested Readings

897 C HAPTER 41 • TRAU MA/ B U R N

OVERVIEW OF PEDIATRIC TRAUMA SYSTEMS

Trauma centers improve outcome in seriously injured patients. Although the evidence has been controversial, trauma centers with dedicated resources for injured children have better outcomes in childhood injury compared to other trauma centers. Highest quality pediatric trauma care requires the availability of multidisciplinary services for the injured child. These services must be coordinated within a supportive organizational structure, with stakeholders working across traditional organizational boundaries, assuring that the primary concern is the well-being of the injured child. Optimal outcomes occur when the entire trauma system functions in a coordinated fashion facilitated by the engaged leaders and the involved par-ticipants (Table 41-1 ). The pediatric intensive care unit (PICU) and Pediatric Critical Care Medicine (PCCM) play crucial roles in attaining optimal outcomes for the injured child.

DEMOGRAPHICS OF CHILDHOOD INJURY

Penetrating injury mechanisms (fi rearms, stab injuries) account for fewer than 10% of child-hood injuries. The majority of serious childhood injuries result from blunt trauma. Motor vehicle occupant, pedestrian vs. motor vehicle, and falls account for the overwhelming major-ity of injuries. Many injuries are associated with bicycle and all-terrain vehicle use. Effective injury prevention strategies target the areas of highest injury risk, with attention to the most prevalent mechanism of injury in the region. For example, urban areas may want to focus injury prevention strategies on falls from windows, whereas rural trauma programs may be more effective if injury prevention efforts focus on injuries that result from farming.

INITIAL EVALUATION OF THE TRAUMATICALLY INJURED CHILD/ROLE OF THE PICU AND PCCM

Emergency Medical Services systems are designed to bring the correct responders to injury victims as rapidly as possible. Triage decisions are made and care initiated, including extrica-tion if required. Priorities include establishing and maintaining an airway, avoiding hypoxia, establishing vascular access and treatment/prevention of hypotension. Wounds are controlled to avoid further blood loss and contamination. The axial skeleton is stabilized and protected. Environmental exposures such as thermal burns, chemical burns and hypothermia are addressed. Evacuation and transportation decisions are made. A receiving facility is chosen based on predetermined criteria. Geography and facility expertise, as well as capacity, are

Optimal care of the injured child requires a coordinated multidisciplinary team

Pre-hospital care/EMS/Air and ground transport Emergency Medicine/Emergency Department Pediatric Trauma Service (pediatric Surgeons, case managers, advanced practice nurses,

physician assistants) Pediatric Critical Care Medicine/Pediatric ICU Neurosurgery/Orthopedics Otolaryngology/Plastic Surgery/Ophthalmology/Urology Anesthesia Radiology Nursing from all units caring for pediatric trauma patients Social Work/Child Life Services/Chaplaincy Pediatric Rehabilitation (occupational/physical/speech Therapy) Nutrition support Support services (lab Services, abstractors, coders, hospital administration) Comprehensive follow-up after discharge Performance improvement program Injury prevention program

TABLE 41-1

CONTRIBUTORS TO THE MULTIDISCIPLINARY CARE OF THE INJURED CHILD

898 R.E. C I LLEY AN D E.H. B RADB U R N

considered. Established criteria should be in place to determine the correct receiving facility (nearest hospital, nearest trauma center, pediatric trauma center). Non-pediatric trauma cen-ters need to have established criteria for transfer to a pediatric trauma center. Prearranged transfer agreements with pediatric trauma centers facilitate these decisions.

The treatment of the multiply injured child in the trauma resuscitation room can be cha-otic. There are often many people present, each with a different set of priorities. Coordinating the multidisciplinary response to the injured child is the responsibility of the trauma surgeon. A skilled, effective trauma team leader manages people and resources to address the needs of the injured child permitting the resuscitation to proceed in an orderly fashion. The Advanced Trauma Life Support (ATLS) approach is used. For seriously injured children, the early involvement of PCCM is particularly important. The skills and expertise of PCCM physicians in airway management, vascular access, ventilator management, and initiating protocols for treating severe head injury are particularly helpful. The trauma resuscitation room should be viewed as an extension of the operating room (OR) and/or the PICU depend-ing on patient needs. A patient-focused multi-disciplinary care model de-emphasizes tradi-tional geographic and service boundaries.

The ATLS model addresses life-threatening problems with simultaneous diagnosis and treatment (primary survey), rapidly assesses the patient for other injuries (secondary survey) and utilizes obligatory high yield diagnostic tests (chest, cervical spine and pelvis radio-graphs) to create an initial catalogue of injuries. Supplemental testing usually in the form of computerized tomography permits the rapid diagnosis of other injuries. The evaluation is modifi ed to the needs of the particular patient, and experienced practitioners eliminate unnecessary tests and procedures without compromising thoroughness or patient safety. As the catalogue of injuries is developed, a plan is created for each problem. Decisions regard-ing disposition (OR, PICU, intermediate unit, general care unit, observation unit) are made. Resuscitation continues in order to avoid secondary injury by maintaining hemodynamic stability and avoiding hypoxia. Treatment for intracranial pressure (ICP) abnormalities is begun according to established protocols while addressing other injuries as needed. Safety in transport is critical. Endotracheally intubated children must always be accompanied by personnel capable of establishing and replacing the airway, intubation equipment and neces-sary pharmacologic agents. Seriously injured children are brought rapidly to either the OR or the PICU. Each hospital needs criteria for PICU admission, but injuries that require intu-bation and mechanical ventilation account for the majority of PICU admissions. Patients with respiratory distress, hemodynamic instability or those with injuries that have the poten-tial to deteriorate require continuous monitoring and are often admitted to the PICU. Head injury is the most common reason for admission to many PICUs and for many pediatric patients is the main determinant of outcome.

Preventable problems in injured children are most often associated with inadequate or unstable airway, diffi cult vascular access and with the under-appreciation of shock. Hypothermia is a danger in all injured children. Prevention and treatment involves warming the trauma resuscitation room, use of warmed intravenous solutions and blood products, and external warming devices (radiant warming lights, warm air circulation devices, application of warmed blankets, exothermic chemical reaction devices). High volume fl uid warming devices are particularly helpful. Warmed intra-cavitary (thoracic or peritoneal) solution cir-culation or extra-corporeal circulation may reverse profound hypothermia. With the use of hypothermia as a neuroprotective measure in children and adults with traumatic brain injury undergoing renewed study, care should be take to avoid iatrogenic hyperthermia, which has the potential to cause secondary injury to the injured brain.

EVALUATION OF THE AIRWAY IN A MULTIPLY INJURED CHILD

If the airway is compromised or breathing is impaired, endotracheal intubation should be performed. Prehospital personnel may have established a stable airway, but it is the fi rst and foremost responsibility of the Trauma Team Leader to confi rm the adequacy of the airway and breathing. Expertise in pediatric intubation at the Pediatric Trauma Center is critically

The ATLS model allows life-threatening injuries to be simultaneously diagnosed and treated.


important. Anesthesiologists, Pediatric Surgeons, Emergency Medicine physicians and Pediatric Critical Care Medicine specialists may provide expertise in airway management in children. The cervical spine must be maintained in axial stabilization, but achieving success-ful intubation is the highest priority. Craniofacial injuries may increase the diffi culty, but with adequate personnel and appropriate equipment, including suction, it is rarely necessary to establish a surgical airway in an injured child. Surgical cricothyroidotomy is the method of choice when endotracheal intubation is impossible.

ESTABLISHING VASCULAR ACCESS IN THE INJURED CHILD

A systematic approach to vascular access is needed to avoid unnecessary delay in fl uid and drug administration. After two failed attempts at peripheral access, placement of an intra-osseous device in infants and smaller children should be considered. Percutaneous central venous access may be attempted in the trauma room if appropriately trained personnel are available, but in hypo-volemic patients, valuable time may be wasted in unsuccessful attempts. Surgical cutdown on the saphenous vein performed at the ankle or on the femoral vein below the inguinal crease can be implemented rapidly and should be used when peripheral attempts fail. After initial resuscitation, clean central venous catheter placement may performed in the trauma room, OR or PICU.

HEMODYNAMIC MONITORING AS A GUIDE TO THERAPY IN THE MULTIPLY INJURED CHILD

Initial hemodynamic monitoring is provided by the vital signs and physical exam in a criti-cally injured child. Knowledge of normal heart rates for infants and children of various ages is necessary to determine if tachycardia is present. Pain, fear and anxiety may cause tachy-cardia and must be considered in the evaluation. Hypotension is a grave sign and often indicates that complete cardiovascular collapse is imminent. Although hourly urine output, central venous pressure, and continuous arterial blood pressure are very important in the ongoing management of the critically injured child, these measurements rarely help during the initial resuscitation. A bladder catheter should be placed in multiply injured patients, but central venous access is not critical in the initiation of the resuscitation. It is usually best to wait until after the initial resuscitation to attempt to place central venous catheters, as long as stable peripheral venous access has been obtained.

After initial resuscitation, stabilization and operative treatment, critically injured children are cared for in the PICU. Invasive monitoring including urinary catheters, central venous catheters and arterial catheters are used routinely in patients with hemodynamic instability and/or severe head injury. In less severely injured patients, the risks of invasive monitoring must be weighed against the benefi ts. Central venous catheters can usually be placed very safely and their use carries the added benefi t of reducing discomfort associated with blood sampling.

STABILIZATION AND EVALUATION OF THE AXIAL SKELETON

Since all trauma victims are at risk for injury to the axial skeleton, the cervical spine is main-tained in a neutral rest position by means of a properly fi tting cervical collar at the injury scene and maintained during transport. Similarly, the remainder of the axial skeleton is stabilized by maintaining in-line positioning and log-rolling the patient when it is necessary to move the patient side-to-side. Infants and small children have cranial and occipital prominence dispro-portionate to that of adults. They may require elevation of the rest of the body while the cervi-cal spine is maintained in a collar to avoid excessive fl exion of the neck. All guidelines for the clearance of the axial skeleton represent an attempt to balance safety and practicality.

Every injured child must have a secure airway and vascular access


Children at low risk for injury, without distracting injuries (other painful injuries) who are calm enough to be examined and are free of neck pain may safely have their collars removed after a normal physical exam (no spinal tenderness and no pain on fl exion, exten-sion, rotation). Radiographs (typically lateral view from C1 to T1, AP view and “open mouth” odontoid view) are obtained in other children to assist with clearance of the cervical spine. The role of computerized tomography (CT) as a replacement for standard radiographs is evolving. CT scanning is frequently used to supplement ordinary radiographs in the evalu-ation of the upper and lower cervical spine. If radiographs are normal and there is minimal clinical suspicion of injury (no pain, or neurological fi ndings), the collar is removed with confi rmation by a negative physical exam. When there is a high suspicion of injury (neck pain, tenderness, physical fi ndings, highly suspicious mechanism), it is necessary to assure that the protective cervical collar remains on. Active fl exion and extension views may be helpful to assess injury. For patients who remain unevaluable (comatose, distracting injury), MRI may be required. Pediatric neurosurgeons and pediatric orthopedic surgeons may pro-vide valuable assistance in diffi cult cases. Subspecialty consultation is mandatory when injury is present.

The thoracic and lumbar spine must also be evaluated in multiply injured patients. Awake, conscious patients that can cooperate for a good physical examination may be cleared. Symptomatic, unconscious or unevaluable patients should undergo AP and lateral thoracic and lumbar radiographs for clearance of the thoracic and lumbar spine. The role of comput-erized tomography as a replacement for standard radiographs is evolving. Factors such as adequacy of images, ease, cost and radiation exposure are considered. Log-roll precautions are used until the axial skeleton is cleared. As with the cervical spine, subspecialty consulta-tion is mandatory when injury is present.

SUPPORTIVE CARE AND TREATMENT FOR CERVICAL SPINE INJURY

Although every injured child must be considered “at risk” for cervical spine injury, very few (<2%) will actually have a cervical spine injury. Of those children with a spinal injury, one-third with have a neurologic defi cit. The neurologic defi cit will be complete in the majority of patients. There will be no radiographic abnormalities in half of the children with neuro-logic defi cits (SCIWORA, spinal cord injury without radiographic abnormality). The goal of spinal evaluation is to identify patients with unstable spines (either bony or ligamentous injury) who are at risk for spinal cord injury with movement of the axial skeleton. The patient is then protected from spinal cord injury through judicious handling, supportive externally-applied devices and operative stabilization if needed. Patients who have already sustained a spinal cord injury will be recognized by an abnormal physical examination, abnormalities on diagnostic imaging studies and abnormal physiology due to spinal shock. Spinal shock results from the loss of vasomotor tone in portions of the body below the injury. Patients with spinal shock benefi t from hemodynamic monitoring to guide intravenous fl uid administration and the use of vaso-active drugs. Although the scientifi c support behind this practice has been questioned, immediate use of high dose steroids may play a role in improv-ing recovery after spinal cord injury.

SUPPORTIVE CARE/TREATMENT OF PEDIATRIC PATIENTS WITH INJURES TO THE CHEST

Pulmonary Contusion Pulmonary contusions are common in multiply injured children and are diagnosed by chest radiographs or CT. Most are not clinically signifi cant and resolve with supportive care. Severe pulmonary contusions may result in respiratory failure, which will require

The cervical spine and remainder of the axial skeleton is stabilized and subsequently cleared using established guidelines

Children may sustain spinal cord injuries in spite of normal radiographs of the cervical spine.

Although pulmonary contusions are common in children, they are rarely clinically signifi cant.


mechanical ventilation support until the contusion resolves. Associated pneumothorax and hemothorax are treated with tube thoracostomy. Ongoing bleeding or uncontrolled airleaks (which may result from a tear in the tracheobronchial tree) may require operative repair.

Cardiac Contusion Cardiac contusions are recognized by arrhythmias, EKG changes and elevated cardiac enzymes. Monitoring is required and echocardiography is performed when contusion is sus-pected. Evaluation by a pediatric cardiologist is required. Sequelae are usually minimal, but occasionally a contusion creates an injury equivalent to a myocardial infarction in a child. Most cardiac contusions will be self-limited, and treatment is mainly supportive. Rarely a child will require inotropic support to maintain cardiac output based solely on a cardiac contusion.

Flail Chest Multiple rib fractures with mechanical instability of the chest are unusual in children due to the fl exibility of thorax. Intubation and mechanical ventilation may be required, and treat-ment is supportive in nature.

Injury to the Great Vessels Severe decelerative injuries that disrupt the great vessels are usually fatal, and often children will not even survive to arrive at a pediatric trauma center. Older teenagers may have “adult” type injuries with aortic disruption near the ligamentum arteriosum . Widening of the medi-astinum on the chest radiograph is the best indicator of vascular injury. CT scanning, echocar-diography, and arteriography are used to confi rm diagnosis and plan surgical treatment. Occasionally a non-fatal great vessel injury is diagnosed in a younger child (Fig. 41-1 ). A high index of suspicion must be maintained in any child with abnormal radiographs, physical fi ndings or suspicious mechanism of injury. This represents a surgical emergency, and immediate consultation with a pediatric cardiothoracic surgeon and the pediatric cardio-pulmonary bypass team is critical.

SUPPORTIVE CARE/TREATMENT OF PEDIATRIC PATIENTS WITH ABDOMINAL INJURIES

Solid organ injuries are common in children. Spleen, liver, kidney, pancreas and adrenal may be injured. Mechanisms of injury include motor vehicle crash, pedestrian, bicycle, motor-ized vehicles (all-terrain vehicles, motorcycles), falls, team sports and snow sports among others. Most solid organ injuries may be managed non-operatively with good preservation of organ function. Control of bleeding is the most common need for operation. Adrenal hemor-rhage is an indicator of signifi cant abdominal injury, but requires no specifi c treatment unless the child develops symptoms of cortisol defi ciency, at which point corticosteroid replace-ment should be considered.

Spleen Injury Direct blows or decelerations into the left upper quadrant and fl ank are responsible for most splenic injuries. Diagnosis is made by CT scanning. Injuries are graded by severity from I to V, with the higher numbers signifying more severe injury (Table 41-2 ). There is no absolute correlation between injury grade and need for operation, however higher grade injuries and those with evidence of arterial contrast extravasation are more likely to require operation. Most injuries stop bleeding with supportive measures. Non-operative

Under the care of a surgeon, solid organ injuries of the spleen, liver, kidney and pancreas can often be treated without operation.


management is successful approximately 85% of the time (Fig. 41-2 ). Patients with ongoing hemodynamic instability or the requirement for blood replacement in excess of one-half of the patient’s total blood volume will likely require operation. Multiple injuries may make assessment diffi cult, necessitating operation. If operation is needed, splenic salvage (sple-norrhaphy) is preferred over splenectomy, if at all feasible. Antibiotic prophylaxis, as well as pneumococcal and meningococcal vaccination is required. Patients who do not require operation are restricted in activities while healing takes place. Recommendations are not uniform, but a conservative approach severely limits activities for 1– 2 weeks from injury (bedrest with bathroom privileges) and moderately restricts activity for 1–2 months from

a

b

FIGURE 41-1

( a ) Cross-sectional computerized tomography of the chest demonstrating a disruption of the transverse aortic arch in an 8 years old ejected motor vehicle crash victim. Injury was successfully repaired using cardiopulmonary bypass. ( b ) Three-dimensional reconstruction demonstrates injury between left common carotid and left subclavian arteries


injury (walking allowed, no “contact activities”). Recent trends in care include shorter PICU stays, earlier discharge and elimination of follow-up imaging studies in asymptom-atic patients.

Liver Injury Management of liver injuries is similar in principle to spleen injuries. However, the grading system utilized is different, and ranges from one (minor injury) to six (severe injury) (Table 41-3 ). If operation is required, major intra-operative bleeding should be anticipated. Bile leaks are unique to liver injuries and result in biliary ascites. Drain placement and endo-scopic sphincterotomy and stenting may obviate the need for operative correction.

FIGURE 41-2

Cross-sectional computerized tomography of the abdomen demonstrating a high-grade spleen injury in a 15 years old motor vehicle crash victim ( top ), with complete healing 2 months after injury ( bottom )

Grade I Subcapsular hematoma of less than 10% of surface area ■

Capsular tear of less than 1 cm in depth ■

Grade II Subcapsular hematoma of 10–50% of surface area ■

Intraparenchymal hematoma of less than 5 cm in diameter ■

Laceration of 1–3 cm in depth and not involving trabecular vessels ■

Grade III Subcapsular hematoma of greater than 50% of surface area or expanding and ruptured ■

subcapsular or parenchymal hematoma Intraparenchymal hematoma of greater than 5 cm or expanding ■

Laceration of greater than 3 cm in depth or involving trabecular vessels ■

Grade IV Laceration involving segmental or hilar vessels with devascularization of more than 25% of ■

the spleen Grade V

Shattered spleen or hilar vascular injury ■

TABLE 41-2

GRADING SYSTEM FOR TRAUMATIC SPLEEN INJURIES (AS DETERMINED BY THE ORGAN INJURY SCALING COMMITTEE OF THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA)


Pancreatic Injury Major pancreatic contusions and lacerations may heal with conservative management con-sisting of bowel rest and parenteral nutrition. Healing may be complicated by pseudocyst formation and recurrent pancreatitis. Some pseudocysts will resolve spontaneously while persistence, progression or infection may indicate that aspiration or drainage is needed. Complete pancreatic transaction is traditionally treated with spleen-preserving pancreatec-tomy. However, even complete transactions can heal without sequelae. An experienced pedi-atric surgical team is required to manage these complex injuries.

Renal Injury Avulsion of the renal hilum associated with complete devascularization of the kidney usually results in loss of the kidney. Occasionally, immediate revascularization may result in renal salvage. Penetrating injury, ongoing blood loss and hemodynamic instability are the most common reason for immediate operation; however, renal salvage is possible in most cases of blunt injury. Even high grade injuries with urinary extravasation may heal or be corrected with delayed surgery. If the patient is hemodynamically stable, even with severe organ injury, there is no need for immediate surgical exploration. Urinomas may be drained either percu-taneously or by transureteral stenting. Long term function, although reduced, can be antici-pated even in severe injuries. Renal function and blood pressure should be monitored closely in the acute post-trauma period.

Intestinal Injury Penetrating injuries to the peritoneal cavity require operative assessment and repair of intes-tinal injury if found. Blunt injuries are unlikely to cause hollow viscus rupture. However, when such injuries occur, they must be recognized and treated promptly. Lap-belt fl exion injuries (with the possibility of associated lumbar spine fractures) are particularly associ-ated with intestinal injury. Diagnosis is suggested by the fi nding of intraperitoneal fl uid on CT scan in the absence of solid organ injury. However, the presence of a solid organ injury does not eliminate the possibility of intestinal injury. Based on initial examination, CT scan fi ndings, and serial exams during the fi rst 24 h after injury, the pediatric trauma surgeon decides if exploration is needed. Diagnostic peritoneal lavage may be helpful if intestinal contents are found in the effl uent, but is rarely used by pediatric surgeons today. Serial exams that indicate increased peritoneal irritation along with fever and other early signs of sepsis or systemic infl ammatory response syndrome (SIRS) mandate evaluation. Traditional laparotomy was the standard in the past if an operation was deemed necessary. More recently, diagnostic laparoscopy has been useful in evaluating children for intestinal injury.

The presence of intra-peritoneal fl uid on a CT scan in the absence of solid organ injury increases the likelihood of intestinal perforation.

Grade 1 Subcapsular hematoma <1 cm in thickness; capsular avulsion; superfi cial parenchymal ■

laceration <1 cm deep; isolated periportal blood Grade 2

Parenchymal laceration 1–3 cm deep; parenchymal/subcapsular hematomas 1–3 cm thick ■

Grade 3 Parenchymal laceration >3 cm deep; parenchymal or subcapsular hematoma >3 cm in ■

diameter Grade 4

Parenchymal/subcapsular hematoma >10 cm in diameter; lobar destruction, or ■

devascularization Grade 5

Global destruction or devascularization of the liver ■

Grade 6 Hepatic avulsion ■

TABLE 41-3

GRADING SYSTEM FOR TRAUMATIC LIVER INJURIES (AS DETERMINED BY THE ORGAN INJURY SCALING COMMITTEE OF THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA)


Some injuries may be repaired laparoscopically, or a small “mini-laparotomy” may suffi ce, obviating the need for a traditional trauma laparotomy.

SPECIAL PROBLEMS ASSOCIATED WITH ORTHOPEDIC INJURIES

Fat Embolus and Long Bone Fracture Although some fat is likely released into the systemic circulation after long bone fractures and surgical manipulation, symptomatic fat embolism syndrome (FES) is uncommon. FES refers to respiratory failure (primarily hypoxia), neurologic deterioration, and petechiae that occur after long-bone and pelvic fractures often in association with orthopedic fracture manipulation. Symptoms usually occur within 24–48 h after injury. FES may account for sudden deterioration in patients admitted to the PICU after trauma. It may also be respon-sible for symptoms that necessitate an upgrade in care to the PICU from lower acuity set-tings. Care is primarily supportive. Long-term neurologic sequelae are possible and severe, fatal, respiratory failure may result. High levels of clinical suspicion, early recognition and aggressive physiologic support including intubation and mechanical ventilation are required to improve outcome. An additional concern in the pediatric trauma patient is the potential of signifi cant hemorrhage to occur with a femur fracture. The femur is very vas-cular, and care must be taken to observe the child with a long bone fracture to assure that hemorrhagic shock does not occur secondary to bleeding into the soft tissue components of the thigh.

Compartment Syndrome Extremity fractures, crush injuries, thermal injuries and prolonged ischemia are risk factors associated with the development of compartment syndrome (CS). CS results from elevated tissue pressures within a confi ned fascial space, compromising blood fl ow and resulting in ischemia. The presence of pain, pallor, paresthesia, paralysis, and pulselessness (the 5 “Ps”) indicates severe and likely irreversible ischemia. Diagnosis is based on awareness of the situations that result in elevated compartment pressures, clinical signs including worsening pain and increasing analgesic requirements, and objective measures of compartment pres-sures by invasive monitoring. In contrast to adults, tissue damage may be caused by lower compartment pressures. Compartment pressures must be interpreted in relation to the blood pressure of the child. Treatment is by decompressive fasciotomy of all affected compartments.

Risk of Deep Venous Thrombosis and Prevention of Pulmonary Embolism There is a paucity of adequate outcome data to support any of the possible methods of dealing with the risk of venous thrombo-embolism in injured children. Risks are thought to be very low in infants and small children. Compression devices and prophylactic anti-coagulation are not used. Many injury victims have contraindications to anticoagulation as well. Older children, especially “adult-sized” teenagers, present more of a management dilemma in the PICU. Sequential compression devices may be used, but have limited benefi t in prevention of venous thrombosis. Prophylactic low-dose anticoagulation is like-wise safe in patients without a contraindication. There is no proven benefi t to prophylactic inferior vena cava fi lter placement in high risk teenage patients (pelvis and lower extrem-ity fractures) who cannot be anticoagulated, although “adult” practices are often used in these patients. Even the use of retrievable temporary inferior vena cava fi lters is not with-out risk and long-term follow-up as to the safety and effi cacy of these devices in children is lacking.

The diagnosis of compartment syndrome should be suspected and treated before the typical signs of ischemia are present.


APPROACH TO THE MULTIPLY INJURED CHILD WHO MAY BE THE VICTIM OF NON-ACCIDENTAL INJURY

Intentional injury is the leading cause of death secondary to trauma in children between age 1 month and 1 year. Intentional injury is suspected on the basis of both the details of the event related by caregivers as well as by physical fi ndings and patterns of injury. The suspi-cion of injury must be based on objective grounds. Abuse occurs in children from all socio-economic and cultural backgrounds. Historical clues include: discrepancy between history and degree of physical injury, history that is inconsistent over time or among care-givers, delay in seeking medical attention, repeated injuries requiring medical attention, and neglect/inattention to injuries. Injuries that raise the concern of abuse include retinal hemorrhages, multiple subdural hematomas, perioral injuries, perineal injuries, rib fractures in infants, multiple fractures at different stages of healing, long bone fractures in children less than 3 years of age, and immersion burns. Bite marks, cigarette burns, rope marks and “pattern” injuries (e.g. in the shape of a hand) indicate abuse. Although highly uncommon, coagula-tion and metabolic disorders may mimic abusive injury and should be tested for. The fi rst priority is always the treatment of acute injuries, and the same resuscitation protocols as outlined by the ATLS guidelines should be implemented in abused children. Photographic documentation of injuries is critical. In every state mandatory reporting laws exist that require physicians to notify government agencies of suspected abuse. Hospital based social services and Child Protection Teams help coordinate these activities and should become immediately involved.

HEAD INJURY

(For a more detailed discussion of head injury, please refer to Chap. 31 of this text). Treatment of severe head injury begins at the scene of the accident. Pre-hospital personnel have crucial roles in establishing and maintaining a secure airway, initiating vascular access, and provid-ing hemodynamic support using intravenous fl uids. Treatment continues in the trauma room where mechanical ventilation is initiated and arterial blood gas analysis can be used to adjust ventilation. Hemodynamic support continues, and blood products and inotropic and vasoac-tive agents are used as needed. Hyperosmolar therapy with either mannitol or hypertonic saline may be given. The primary diagnostic goal is assessment by a neurosurgeon and CT scanning of the head to determine immediate surgical needs. Other potentially life-threaten-ing injuries must be diagnosed and treated.

Patients with severe head injury that do not require operative intervention should be rap-idly transported to the PICU from the trauma resuscitation area. In order to reach the goal of avoiding secondary injury, the most critical need is to maintain respiratory and hemody-namic stability and to institute support of cerebral perfusion. Central venous access, arterial access, intra-ventricular drainage or other types of intra-cranial pressure monitoring can be performed in the PICU. Transport to the PICU should not be delayed for suturing wounds or placement of monitoring devices. Non-operative fracture management should not delay transfer to the PICU. If there are other immediate operative needs that cannot be delayed, treatment of the severe head injury must continue from the trauma resuscitation room to the operating room and then to the PICU. Pediatric Critical Care Medicine can provide valuable input during the period of time between ED arrival and admission to the PICU. Communication among pediatric trauma surgeon, neurosurgeon, anesthesia and PCCM is essential. Computerized medical record systems that provide remote access to laboratory information and digital radiographs facilitate this process. Protocols for management of severe head injury facilitate consistency in care and provide a framework upon which individual patient management decisions are based.

Non accidental injury/abuse must be considered in childhood injury.

Intensive therapy to support cerebral perfusion offers the best chance for recovery in severe head injury in children.


INITIAL EVALUATION, FLUID RESUSCITATION, AND CARE OF THE SEVERELY BURNED CHILD

World-wide, millions of children are victims of burn injury every year. In countries with comprehensive health care systems, approximately 5% of burned children require intensive hospitalization. Despite the many advancements in the care of severely burned children, there are over 500 pediatric deaths from burn injury in the U.S. each year, making mortality from burns the tenth most common cause of death in the pediatric population. Initial resuscitation of the burned child follows the usual priorities of any trauma evaluation with special refer-ence to unique problems associated with burns. While the burn itself may be obvious, second-ary effects of blast injury, such as pneumothorax, associated injuries from falls (leaping to escape the fi re) or injuries sustained in a vehicular crash must be discovered and treated.

First Priorities The initial evaluation of any burn victim follows ATLS protocols beginning with the ABC’s (airway, breathing, circulation). If signifi cant inhalation injury has occurred, endotracheal intubation should be performed before airway swelling progresses. Burns and singeing of the face and neck, burn debris in the oropharynx, carbonaceous sputum, enclosed burn environ-ment, and elevated carboxyhemoglobin levels indicate inhalation injury. Stridor and circum-ferential burns to the neck are particularly ominous signs of impending airway loss. All clothing and chemical contamination must be removed. Medical personnel must be protected from contamination from chemical injury. Intravenous access is established, using areas of burned skin if necessary. Intra-osseous access may be life-saving. Clean, warm, dry linens are used to cover the patient. There is no need for the immediate application of topical anti-biotics or cumbersome dressings during the resuscitation. The extent and depth of the burn injury are estimated (see below). Rarely, immediate surgical escharotomy may be required to relieve circulatory or respiratory compromise. Narcotics and sedatives are judiciously used to relieve pain and anxiety. Agitation and restlessness may be a sign of hypoxia or shock.

Carbon Monoxide Poisoning Burns from fi re, especially those occurring in enclosed spaces (house fi res or car fi res) carry the potential for carbon monoxide (CO) poisoning. The majority of the immediate fatalities in the burned population are from CO poisoning. Carbon monoxide has 200 times the affi nity for hemoglobin as oxygen. Pulse oximetry cannot distinguish the difference between oxygenated hemoglobin and carboxyhemoglobin (COHb) and is therefore unreliable. Arterial blood gas determination with measurement of COHb is essential in all burn victims. Until this lab value is available, empiric treatment is indicated using 100% oxygen via a non-rebreather mask or endotracheal intubation. CO elimination is 4–5 times faster with 100% oxygen compared to room air. The role of hyperbaric oxygen therapy in CO poisoning remains controversial, and many fully operational pediatric trauma centers do not have hyperbaric oxygen capabilities, making delay in therapy and the risk of transportation to another facility important variables in determining whether this therapy would be benefi cial. In addition to CO, other potential noxious gases are produced by the combustion of common materials such as polyurethane, acrylonitriles, nylon, wool, and cotton. Cyanide poisoning should be considered in an appro-priately resuscitated burn patient with a persistent metabolic acidosis, apnea, and depressed level of consciousness. Antidote kits utilize sodium thiosulfate and amyl nitrate.

Types of Burns and Extent of Burn Injury First degree burns do not penetrate the epidermis. They are painful and characterized by blanching erythema. First degree burns do not require fl uid resuscitation. Partial thickness burns (second degree burns) penetrate the dermis, weep, and form blisters. They are red or mottled and are very painful (hypersensitive to air currents). Full thickness burns (third


degree burns) appear leathery and dry. Due to complete destruction of dermis and to some extent subcutaneous tissues (where nerves are present) these burns are non painful. Deeper burns involving muscle, tendon and bone have been termed “fourth degree”. Partial and full thickness burns require fl uid resuscitation, wound care and dressing. Surgical debride-ment, skin grafting or surgical wound coverage may be needed. The “rule of nines”, adapted to child body proportions, is used to guide the estimation of the extent of the burn and cal-culation of early fl uid resuscitation. Modifi cation of the Lund-Browder chart is a more age appropriate method to estimate burn size and is preferred in pediatric burns (Fig. 41-3 ).

Fluid Resuscitation Large quantities of isotonic intravenous fl uids are required to support circulating blood volume and prevent shock in burned patients. Adequate fl uid resuscitation decreases the risk of multi-ple organ failure and restores perfusion to burned tissue areas, minimizing the extent of local tissue damage. Adequate resuscitation is indicated by urine output of at least 1 ml/kg/h in chil-dren. The “Parkland Formula” is a method of estimating early fl uid requirements and may be used to calculate initial intravenous fl uid rates. Using this method, the fl uid requirements for the fi rst 24 h after the burn are estimated as 4 ml/kg for each percent of total body surface area

Intravenous fl uid resuscitation of burn victims requires very large quantities of isotonic fl uids.

Add 1/2% to each lower limb for each year >1yr. of ageSubtract 1% from head for each year >1 yr. of age

AREAAge:

15

18

15

13

15

1817

1991/2

91/2

91/2

91/2

18%

Burn EvaluationSeverity of Burn

13 13

19

99

91/2

91/2

17

OtherElectrical Voltage

Scald Steam GreaseFlameChemical Agent

Sex:

Tetanus Status:

Type of Bum

Time of Bum:Date:Weight:inf.

192 2 2 2

13 1313 13

13 131313

13

31/2

31/2 31/2 31/2 31/2

31/231/231/2

61/2

61/2

total

TOTAL

fullpart%%3˚

5–9 10–141–4

%2˚

3°=

2°=

1°=

1

32

32

32

10–145–9AGE–YEAR

1–41117

66

88

81/2

81/261/2

61/2

51/2

5551/2

51/2

51/2

21/2

21/2

21/2

21/2 21/2 21/2

21/221/221/2

21/2 21/2 21/2

21/221/221/2

21/2

1 1 1 14 4 4 4

44443 3

3 33 3

33

HeadNeckAnt. trunkPost. TrunkR. ButtockL. ButtockGenitaliaR.U.ArmL.U. ArmR.L. ArmL.L. ArmR. HandL. HandR. ThighL. ThighR. LegL. LegR. FootL. Foot

FIGURE 41-3

Body surface area chart used to estimate initial burn injury in pediatric patients


of burn (partial thickness + full thickness). One half of the estimate is given in the fi rst 8 h and the remainder in the subsequent 16 h. Lactated Ringers solution is used. Maintenance fl uids containing glucose may be needed as well. The calculation of fl uid requirement may seem large to those not accustomed to caring for burn victims. [E.g. 20 kg child with 50% burn: (4)(20)(50)/2/8 = 250 ml/hr for the fi rst 8 h ] It is crucial for the trauma and critical care teams to frequently reassess the burned child to assure that adequate fl uid resuscitation is appropriate.

Criteria for Transfer Following systematic initial assessment, the decision to treat or transfer must be made. Although minor burns may be treated as outpatients, specialized multidisciplinary care is required to achieve optimal outcomes in serious burn injury. The American Burn Association has developed guidelines for transfer to specialized burn centers. All trauma centers must have transfer/referral arrangements with regional burn centers (Table 41-4 ).

SUMMARY

Pediatric trauma centers improve outcomes in seriously injured children. Motor vehicle occupant, pedestrian vs. motor vehicle, and falls account for the overwhelming majority of injuries. The pediatric intensive care unit and Pediatric Critical Care Medicine play crucial roles in optimal outcomes for the injured child. The Advanced Trauma Life Support (ATLS) approach is used to guide resuscitative efforts and initiate treatment. The airway is secured, vascular access is obtained, and circulation is supported. The axial skeleton is stabilized. The axial skeleton is “cleared” using guidelines that incorporate both radiographic and clinical parameters. Seriously injured children with head, chest, abdominal and extremity injuries are treated by a multidisciplinary team that includes surgeons and critical care specialists. Head injury is the most common cause of death and disability due to injury in children. The most critical need is to maintain respiratory and hemodynamic stability and to institute sup-port of cerebral perfusion. Intentional injury/abuse is suspected based on historical fi ndings or suggestive patterns of injury. Despite many of the recent advancements in the care of severely burned children, mortality from burns is the tenth most common cause of death in the pediatric population. Large quantities of isotonic intravenous fl uids are required to sup-port circulating blood volume, and prevent shock in burned patients. Adequate fl uid resusci-tation decreases the risk of multiple organ failure and restores perfusion to burned tissue areas, minimizing the extent of local tissue damage. The American Burn Association has developed guidelines for transfer to specialized burn centers.

Partial-thickness burns greater than 10% total BSA Burns that involve the face, hands, feet, genitalia, perineum, or major joints Full-thickness burns Electrical burns, including lightning injury Chemical burns Inhalation injury Burn injury in patients with preexisting medical disorders that could complicate management,

prolong recovery, or affect mortality Any burn injury patient with concomitant trauma (e.g., fractures) in which the burn injury poses

the greatest risk of morbidity or mortality. In such cases, if the injury poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being trans-ferred to a burn center. The doctor’s judgment is necessary in such situations and should be in concert with regional medical control plans and triage protocols

Any burn-injury children who are seen in hospitals without qualifi ed personnel or equipment to manage their care should be transferred to a burn center with these capabilities

Burn injury in patients who will require special social, emotional, or rehabilitative intervention

Adapted from American Burns Association transfer criteria protocol ( http://www.ameriburn.org/ )

TABLE 41-4

BURN INJURIES THAT MAY REQUIRE TRANSFER TO A BURN CENTER

http://www.ameriburn.org/


1. In the Trauma Bay, the fi rst and foremost responsibility of the Trauma Team Leader is which of the following? A. To assure appropriate warming of the patient B. To assure establishment of secure intravenous access C. To confi rm the adequacy of the airway and breathing D. To identify any injuries requiring emergent surgical

intervention E. To maintain crowd control and facilitate a coordinated team

effort

2. Which of the following statements is true regarding the man-agement of spleen trauma? A. Blood replacement requirements exceeding one-half of the

total blood volume identify patients who will likely require surgery.

B. Grade IV splenic injuries are characterized by a shattered spleen or hilar vascular injury.

C. If surgery is needed, splenectomy is preferred over splenic salvage (splenorrhaphy) because of the risk for rebleeding.

D. In children requiring splenectomy, antibiotic prophylaxis is recommended, but pneumococcal vaccination is not required.

E. Non-operative management is successful approximately 60% of the time.

3. Which of the following intra-abdominal injuries cannot be treated without an operative evaluation? A. Hepatic lacerations B. Pancreatic injuries C. Renal injuries D. Small bowel injuries E. Splenic lacerations

4. Which of the following abdominal injuries is MOST likely to be able to be managed without surgical intervention? A. A 7 years old, febrile, hemodynamically stable child who

sustained a Grade IV splenic laceration 24 h ago and has required a red blood cell transfusion (10 mL/kg)

B. A 9 years old, afebrile, hemodynamically stable unrestrained passenger in a motor vehicle collision who sustained avul-sion of the right renal hilum with complete devascularization of the kidney

C. A 12 years old, febrile, hemodynamically child with evi-dence of intraperitoneal fl uid, but no solid organ injury on abdominal CT scan who was a restrained back seat passenger in a motor vehicle collision 24 h ago

D. A 13 years old, afebrile, hemodynamically stable child who fell while running with scissors and incurred a penetrating intraabdominal injury

E. A 16 years old, afebrile, hemodynamically stable, gunshot wound victim with an entry wound in the periumbilical region

5. A 16 years old male was involved in a motor vehicle collision in which he sustained a right femur fracture and multiple pelvic fractures. He sustained no other obvious injuries and computer tomography of his head, chest, and abdomen were reported as unremarkable. He has been awake and interac-tive throughout. The day after the injury, and shortly after orthopedic manipulation of his fracture, he becomes acutely hypoxic, confused and combative. Given the most likely expla-nation for his clinical deterioration, what other physical exam fi nding is MOST likely to be noted? A. Absence of a pulse in his right foot B. Absent breath sounds on the right C. Anisocria D. Murmur E. Petechiae

6. A 5 years old girl fell out of a second story window and sustained a minimally depressed skull fracture with a small subdural hematoma and a displaced right ulnar and radius fracture. She had an open reduction, internal fixa-tion, and cast placement on her extremity fractures. Al-though she is hemodynamically stable and remains awake and alert, her bedside nurse is concerned because she is beginning to complain more and more of right arm pain. The MOST appropriate response to her concern is which of the following? A. Assess the arm and order three view radiographs to assess for

malalignment of the fractures B. Assess the perfusion of the hand and contact the orthopedics

service to exclude a compartment syndrome C. Calmly reassure both the nurse and young girl that pain is

common after such an injury and it is likely worsening because the anesthetic effects are waning

D. Increase the dose and frequency of her pain medications and consider beginning a patient controlled analgesia morphine infusion

E. Perform a repeat computerized axial tomogram of her brain to exclude an expanding subdural hematoma or another form of intracranial pathology

7. In the setting of a potential compartment syndrome, the fi ve “Ps” refer to the classic signs and symptoms associated with severe ischemia. Which of the following lists of signs and symptoms correctly identifi es the fi ve “Ps” associated with severe ischemia? A. Pain, pallor, paralysis, paresthesia, and pulselessness B. Pallor, paralysis, paresthesia, pulselessness, and purpura C. Pain, pallor, paralysis, pulselessness, and purpura D. Pain, pallor, paresthesia, pulselessness, and purpura E. Pain, paralysis, paresthesia, pulselessness, and purpura

REVIEW QUESTIONS


8. Which of the following statements is true regarding the pedi-atric burn patient? A. Fluid resuscitation should consist of 0.225 or 0.45 normal

saline to account for the free water lost from the burn sites and to prevent hypernatremia.

B. Most immediate fatalities from burns result from carbon monoxide poisoning.

C. Surgical escharotomy should be performed only at qualifi ed burn centers.

D. The priorities for burn resuscitation differ from those of other forms of trauma.

E. Third degree burns are extremely painful and require the judicious use of analgesia.

9. A 4 years old, 20-kg child was involved in a house fi re in which he sustained partial thickness burns to 20% of his body and full thickness burns to an additional 30% (total partial and full thickness burns equals 50%). He is currently he-modynamically stable and intravenous access has just been established in the Emergency Department. In determining his initial intravenous fl uid requirements, a decision is made to utilize the Parkland formula. Using that formula, which of the following correctly identifi es the initial hourly rate of isotonic fl uid needed? A. 100 mL/h B. 150 mL/h C. 167 mL/h D. 250 mL/h E. 300 mL/h

10. Which of the following statements BEST describes the ser-vices NEEDED for a successful pediatric trauma program? A. Pediatric trauma surgeons, emergency medicine physicians,

anesthesiologists, surgical subspecialists, and nursing B. Pediatric trauma surgeons, emergency medicine physicians,

anesthesiologists, surgical subspecialists, pediatric intensiv-ists, and nursing

C. Pediatric trauma surgeons, anesthesiologists, surgical sub-specialists, pediatric intensivists, radiologists, nursing, social work, nutritional support, chaplains, child life specialists, radiology services, laboratory services, and injury prevention specialists

D. Pediatric trauma surgeons, emergency medicine physicians, anesthesiologists, surgical subspecialists, pediatric intensiv-ists, radiologists, nursing, social work, nutritional support, chaplains, child life specialists, radiology services, labora-tory services, and medical coders

E. Pediatric trauma surgeons, anesthesiologists, surgical sub-specialists, pediatric intensivists, radiologists, nursing, social work, nutritional support, chaplains, child life specialists, radiology services, laboratory services, injury prevention specialists, and medical coders

1. C 2. A 3. D 4. A 5. E

6. B 7. A 8. B 9. D 10. E

ANSWERS

American College of Surgeons, editor. Advanced trauma life support for doctors; student course manual. 7th ed. Chicago: American College of Surgeons; 2004. First Impression.

Azu MC, McCormack JE, Scriven RJ, Brebbia JS, Shapiro MJ, Lee TK. Venous thromboembolic events in pediatric trauma patients: is prophylaxis necessary? J Trauma. 2005;59(6):1345–9.

Bae DS, Kadiyala RK, Waters PM. Acute compartment syndrome in children: contemporary diagnosis, treatment, and outcome. J Pediatr Orthop. 2001;21(5):680–8.

Buckley JC, McAninch JW. The diagnosis, management, and out-comes of pediatric renal injuries. Urol Clin North Am. 2006;33(1):33–40.

Keller MS, Eric Coln C, Garza JJ, Sartorelli KH, Green CM, Weber TR. Functional outcome of nonoperatively managed renal inju-ries in children. J Trauma. 2004;57(1):108–10. discussion 110.

Potoka DA, Schall LC, Ford HR. Improved functional outcome for severely injured children treated at pediatric trauma centers. J Trauma. 2001;51(5):824–34.

Sherman HF, Landry VL, Jones LM. Should level I trauma centers be rated NC-17? J Trauma. 2001;50(5):784–91.

Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Pediatric Critical Care Medicine. 2003;4(3)Suppl:S1-S75.

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Documents

Pediatric Critical Care Study Guide || Trauma/Burn