Pediatric Trauma Pediatric Trauma CareCare

On CallOn CallJames G. Cain, MD

Past President, International Trauma, Anesthesia and Critical Care Society Past President, West Virginia Society of Anesthesiologists

Director, Perioperative Medical Services, Children’s Hospital of Pittsburgh of UPMC

Director, Trauma Anesthesiology, Children’s Hospital of Pittsburgh of UPMC

Visiting Associate Professor, University of Pittsburgh School of Medicine

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DisclosureDisclosure

Off label uses will be discussedOff label uses will be discussed Data Safety Monitoring Board Data Safety Monitoring Board

(DSMB)(DSMB) HospiraHospira

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Pediatric trauma in USA

Leading cause of morbidity & mortality in 1-40 yoLeading cause of morbidity & mortality in 1-40 yo 30% of children annually require care due to trauma30% of children annually require care due to trauma 40% of all deaths in 1-14 yo40% of all deaths in 1-14 yo Death & disability > than all others combinedDeath & disability > than all others combined

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Pediatric Trauma Pediatric Trauma CategoriesCategories

Blunt traumaBlunt trauma Most commonMost common Majority motor Majority motor

vehicle relatedvehicle related PassengersPassengers PedestriansPedestrians BicycleBicycle

Penetrating traumaPenetrating trauma Increasingly commonIncreasingly common Primarily urbanPrimarily urban

““Knife and gun club”Knife and gun club”

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8 year old restrained 8 year old restrained MVCMVC

Awake Awake ResponsiveResponsive BP 80/45BP 80/45 HR 136HR 136 RR 32RR 32 Abdominal pain Abdominal pain

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Pediatric traumaPediatric trauma

Kids aren’t “small adults”Kids aren’t “small adults” Differ anatomically Differ anatomically Differ physiologicallyDiffer physiologically

Requires Requires Prepared personnelPrepared personnel

Expertise Expertise

MaterialsMaterials Equipment Equipment MedsMeds

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Kids aren’t small adults!Kids aren’t small adults!CharacteristicCharacteristic ResultResultLarge BSALarge BSA HypothermiaHypothermia

Poor neck musculature Poor neck musculature Flex/ext injuryFlex/ext injury

Large blood vol in head Large blood vol in head Cerebral edemaCerebral edema

Dec alveolar surf areaDec alveolar surf area Rapid desatsRapid desats

High metabolic rateHigh metabolic rate Rapid desatsRapid desats

Small airway Small airway Inc airway resistanceInc airway resistance

Heart high in chestHeart high in chest Injury/tamponadeInjury/tamponade

Small pericardial sacSmall pericardial sac Injury/tamponadeInjury/tamponade

Compliant skeletonCompliant skeleton Fractures less commonFractures less common

Thin walled, small abd Thin walled, small abd Organs not protectedOrgans not protected

Poorly dev renal fnxPoorly dev renal fnx Risk renal failureRisk renal failure 717:54:10

Need specific peds Need specific peds suppliessupplies

MonitorsMonitors ETTETT LaryngoscopesLaryngoscopes BronchoscopesBronchoscopes IVIV IO trocarsIO trocars

Central linesCentral lines Urinary cathetersUrinary catheters NGT/OGTNGT/OGT Resuscitation Resuscitation

drugsdrugs Resuscitation Resuscitation

devicesdevices

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Initial managementInitial management Primary surveyPrimary survey

Evaluate life-threatening conditions Evaluate life-threatening conditions Immediate interventionImmediate intervention

Secondary surveySecondary survey Evaluate other injuries requiring treatmentEvaluate other injuries requiring treatment

Pediatric trauma scorePediatric trauma score May be useful for triageMay be useful for triage

9-12 Minor trauma9-12 Minor trauma 6-8 Potentially life threatening6-8 Potentially life threatening 0-5 Life threatening0-5 Life threatening < 0 Usually fatal< 0 Usually fatal

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Pediatric trauma scorePediatric trauma score

+ 2+ 2 + 1+ 1 - 1- 1

WtWt > 20 kg> 20 kg 10-20 10-20 kgkg

< 10 kg< 10 kg

AirwayAirway PatentPatent MaintaiMaintainn

UnmainUnmaintt

SBPSBP > 90> 90 50-9050-90 < 50< 50

PulsesPulses RadialRadial CarotidCarotid NonpalNonpalpp

CNSCNS AwakeAwake + LOC+ LOC UnrespUnresp

FrxFrx NoneNone ClosedClosed Mult/opMult/op

WoundsWounds NoneNone MinorMinor MajorMajor

TotalTotal -6 to -6 to +12+12

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Primary surveyPrimary survey

Cornerstone of trauma care Cornerstone of trauma care Life threatening conditions Life threatening conditions

EvaluateEvaluate StabilizeStabilize Treat Treat

Moves forward on all fronts by teamMoves forward on all fronts by team Often listed sequentially Often listed sequentially ABCDEABCDE

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ABCDE of trauma careABCDE of trauma care

AAirwayirway BBreathingreathing CCirculationirculation DDisabilityisability EExposurexposure

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Airway management Airway management prioritiespriorities

1.1. Ensure oxygenation Ensure oxygenation

2.2. Ensure ventilationEnsure ventilation

3.3. Protect cervical spineProtect cervical spine

4.4. Protect airwayProtect airway

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Initial airway Initial airway managementmanagement

Supplemental high flow oxygenSupplemental high flow oxygen Clear airway obstructionClear airway obstruction

Large tongueLarge tongue ObtundationObtundation Foreign bodiesForeign bodies Maxillofacial traumaMaxillofacial trauma InflammationInflammation

Consider oral or nasal airwaysConsider oral or nasal airways Caution with nasal in possible cribiform plate Caution with nasal in possible cribiform plate

injury injury

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Pediatric airwayPediatric airway Narrow oropharynx Narrow oropharynx Large tongueLarge tongue Stiff, short epiglottis Stiff, short epiglottis Larynx anterior and Larynx anterior and

cephaladcephalad Cord view is difficultCord view is difficult Trachea shorterTrachea shorter

Mainstem intubation Mainstem intubation more commonmore common

Extubation more Extubation more commoncommon

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Intubation Intubation considerationsconsiderations

Preparation is vital!Preparation is vital! Do not rush!Do not rush! Key points Key points

Increased cardiac outputIncreased cardiac output Increased OIncreased O22 consumption consumption Overlapping FRC and closing capacityOverlapping FRC and closing capacity

SOAPSOAP SuctionSuction OxygenOxygen AirwayAirway PharmacologyPharmacology

Oral intubation typically easiestOral intubation typically easiest

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Trauma inductionTrauma induction

Induction medicationsInduction medications ThiopentalThiopental PropofolPropofol EtomidateEtomidate

Adrenal suppressionAdrenal suppression KetamineKetamine

Caution in brain injuredCaution in brain injured

Neuromuscular blockadeNeuromuscular blockade Faster onsetFaster onset

Shorter circulation timeShorter circulation time RocuroniumRocuronium VecuroniumVecuronium CisatricuriumCisatricurium Succinyl cholineSuccinyl choline

Transient inc ICP, IOP, Transient inc ICP, IOP, intragastric pressureintragastric pressure

HyperkalemiaHyperkalemia BradycardiaBradycardia

Atropine Atropine GlycopyrrolateGlycopyrrolate

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Intubation Intubation

PreoxygenationPreoxygenation Cricoid pressureCricoid pressure

Support posterior neck Support posterior neck Cervical spineCervical spine

MAISMAIS

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Pediatric intubation viewPediatric intubation view Larynx Larynx

Anterior Anterior CephaladCephalad C 4 levelC 4 level

Epiglottis long & U Epiglottis long & U shapedshaped

Trachea shortTrachea short Neonates → 2 cm Neonates → 2 cm

cords to carinacords to carina Cricoid → Narrowest Cricoid → Narrowest

point until 10 yopoint until 10 yo

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Increased risk of head an Increased risk of head an neck injuryneck injury

Large headLarge head Weak neck musclesWeak neck muscles

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Cervical spine Cervical spine considerationsconsiderations

Upper cervical spine often involvedUpper cervical spine often involved Younger = higherYounger = higher

Injury possible with minimal Injury possible with minimal musculoskeletal effectmusculoskeletal effect

Spine films and CT Spine films and CT May not confirm absence of injuryMay not confirm absence of injury

SCIWORASCIWORA MRI neededMRI needed

Symptoms and mechanism dictate Symptoms and mechanism dictate carecare

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Difficult intubationDifficult intubation Up to 50% airway complicationsUp to 50% airway complications Severity increased in non pediatric centersSeverity increased in non pediatric centers

Tracheal injuryTracheal injury Massive SQ emphysemaMassive SQ emphysema Post-extubation subglottic stenosisPost-extubation subglottic stenosis Vocal cord injuryVocal cord injury Massive aspirationMassive aspiration

OptionsOptions LMA may be lifesavingLMA may be lifesaving King airwayKing airway

Rescue technique of choice for Pittsburgh EMTsRescue technique of choice for Pittsburgh EMTs Needle cricothyroidotomy fallback techniqueNeedle cricothyroidotomy fallback technique

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BreathingBreathing

Low residual lung volumes at expiration (FRC)Low residual lung volumes at expiration (FRC) FRC overlaps closing capacity → atelectesisFRC overlaps closing capacity → atelectesis

Less alveoliLess alveoli Hgb P50 19 mm Hg contrasts to 26 Hg adultsHgb P50 19 mm Hg contrasts to 26 Hg adults Increased oxygen consumption → 7 ml/kg/minIncreased oxygen consumption → 7 ml/kg/min

Higher minute ventilationHigher minute ventilation Higher blood flow to vessel rich groupHigher blood flow to vessel rich group

Hypoxic/hypercapneic respiratory drives not Hypoxic/hypercapneic respiratory drives not well developedwell developed

Oxygen reserve is limitedOxygen reserve is limited

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BreathingBreathing

Supplemental OSupplemental O22 to all to all trauma patientstrauma patients

Airway and pulmonary Airway and pulmonary injuryinjury Signs may be subtleSigns may be subtle

Compliant ribcageCompliant ribcage Airway managementAirway management Consider gastric Consider gastric

decompressiondecompression Auscultate breath soundsAuscultate breath sounds

Pneumothorax?Pneumothorax?

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Chest injuriesChest injuries

Mediastinum less Mediastinum less well affixedwell affixed

Compliant chest Compliant chest wallwall

Fractures less Fractures less commoncommon

PTXPTX Pulmonary Pulmonary

contusioncontusion HemothoraxHemothorax

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PneumothoraxPneumothorax

SymptomsSymptoms JVDJVD Tracheal shiftTracheal shift Deviation of cardiac tonesDeviation of cardiac tones PEAPEA

TreatTreat Angiocatheter 2Angiocatheter 2ndnd intercostal space, intercostal space,

midclavicularmidclavicular Definitive tube thoracoscopyDefinitive tube thoracoscopy

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Pulmonary contusionPulmonary contusion

Worsening oxygenation & ventilationWorsening oxygenation & ventilation Decreasing pulmonary complianceDecreasing pulmonary compliance

Progressively more aggressive vent Progressively more aggressive vent strategystrategy

Increase FiOIncrease FiO22

Increase vent pressures and PEEPIncrease vent pressures and PEEP Volutrauma typically avoided with plateau Volutrauma typically avoided with plateau

pressures < 40.pressures < 40. Hemodynamic compromise possible with Hemodynamic compromise possible with

increasing vent pressuresincreasing vent pressures

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CirculationCirculation Control blood lossControl blood loss

ApparentApparent HiddenHidden

Long bone fracturesLong bone fractures Pelvic fracturesPelvic fractures HemothoraxHemothorax HemoperitoneumHemoperitoneum ICH (prior to ICH (prior to

fontanelle closure) fontanelle closure) Tissue perfusionTissue perfusion

Shock symptomsShock symptoms

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Vascular accessVascular access Early vascular accessEarly vascular access SupradiaphragmaticSupradiaphragmatic

Alternatives to PIVAlternatives to PIV CentralCentral Surgical cutdownSurgical cutdown IntraosseousIntraosseous

Consider A-lineConsider A-line

IntraosseousIntraosseous IO kit or bone marrow IO kit or bone marrow

bx needlebx needle 1-2 cm below tibial 1-2 cm below tibial

tuberosity tuberosity Insert with screwing Insert with screwing

motion until lack of motion until lack of resistanceresistance

Aspirate marrow to Aspirate marrow to confirm placementconfirm placement

Secure needleSecure needle Volume replacementVolume replacement LabsLabs Drug administrationDrug administration

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Shock symptomsShock symptoms May not be apparent until > 25% blood lossMay not be apparent until > 25% blood loss

Hypotension a late signHypotension a late sign Vaso-motor tone increasedVaso-motor tone increased Contractility increasedContractility increased

Neonates limited ability to increase contractilityNeonates limited ability to increase contractility TachycardiaTachycardia Capillary refill > 3 secCapillary refill > 3 sec Diminished mental statusDiminished mental status OliguriaOliguria AcidemiaAcidemia

Compensatory tachypneaCompensatory tachypnea

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Volume resuscitation Volume resuscitation Hallmark of intraoperative managementHallmark of intraoperative management Fluid warming is essentialFluid warming is essential Crystalloid 1Crystalloid 1stst choice choice No evidence for colloidsNo evidence for colloids EBVEBV

Premies: 95 ml/kg Premies: 95 ml/kg Term neonates: 90 ml/kgTerm neonates: 90 ml/kg Up to 1 year: 80 ml/kgUp to 1 year: 80 ml/kg > 1 year old: 70 ml/kg> 1 year old: 70 ml/kg

Acceptable Hg 7-8Acceptable Hg 7-8 Higher Hg threshold in brain injuredHigher Hg threshold in brain injured

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Volume administrationVolume administration

Bolus of 20 ml/kg Bolus of 20 ml/kg Lactated Ringer’sLactated Ringer’s

Lactate -> Lactate -> bicarbonatebicarbonate

0.9NS is OK0.9NS is OK May produce mild May produce mild

acidemiaacidemia

Repeat 20 ml/kg Repeat 20 ml/kg bolus if inadequate bolus if inadequate responseresponse

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Blood productsBlood products Acceptable Hg 7-8Acceptable Hg 7-8

Higher Hg threshold in brain injuredHigher Hg threshold in brain injured Transfuse 10-20 ml/kg PRBC if inadequate response Transfuse 10-20 ml/kg PRBC if inadequate response

to crystalloidto crystalloid Type specific preferred, Type O is OK Type specific preferred, Type O is OK Freshest possible Freshest possible

KK++ > 8 noted, old blood may have as much as 33 meq/liter > 8 noted, old blood may have as much as 33 meq/liter Cardiac arrests notedCardiac arrests noted ECG monitoring in large volume transfusionsECG monitoring in large volume transfusions

Citrate -> pH < 7Citrate -> pH < 7 Metabolized to bicarbonate -> alkalosis possibleMetabolized to bicarbonate -> alkalosis possible Calcium supplement may be indicated Calcium supplement may be indicated

EBL 1 blood vol, 25% coag factors remainEBL 1 blood vol, 25% coag factors remain 1 unit platelets/10 kg raises platelets by 101 unit platelets/10 kg raises platelets by 1055

Consider FFP 10-15 ml/kgConsider FFP 10-15 ml/kg

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Disability (head injury)Disability (head injury) Head injury in 80% of major traumasHead injury in 80% of major traumas GCS modified for pedsGCS modified for peds

Decreased emphasis on verbal performanceDecreased emphasis on verbal performance Improving neuro statusImproving neuro status

Adequate resuscitationAdequate resuscitation Worsening neurologic statusWorsening neurologic status

Global neurologic injury Global neurologic injury Expanding intracranial massExpanding intracranial mass

GCS < 8GCS < 8 ICU admitICU admit Consider intubation and airway managementConsider intubation and airway management

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Significant neurologic Significant neurologic injuryinjury

Primary injuryPrimary injury Initial incidentInitial incident

Secondary injurySecondary injury

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Limit secondary injuryLimit secondary injury

Hypotension, hypoxemia & Hypotension, hypoxemia & hypercarbiahypercarbia Significantly increase mortalitySignificantly increase mortality

Aggressive measures to maintain Aggressive measures to maintain cerebral perfusion and oxygenationcerebral perfusion and oxygenation

CPP > 40 desiredCPP > 40 desired CPP = MAP - ICP CPP = MAP - ICP

No current, reliable biochemical No current, reliable biochemical markersmarkers

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Maintain cerebral Maintain cerebral perfusionperfusion

Monitor ICPMonitor ICP Increase MAPIncrease MAP

Alpha adrenergic or dopaminergic agentsAlpha adrenergic or dopaminergic agents Decrease ICPDecrease ICP

HypocarbiaHypocarbia HyperosmolarHyperosmolar Drain CSFDrain CSF Fluid restrictFluid restrict DiuresisDiuresis Barbiturate comaBarbiturate coma Surgical decompressionSurgical decompression

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ExposureExposure

Expose entirely to evaluate Expose entirely to evaluate thoroughlythoroughly

Hypothermia riskHypothermia risk ExposureExposure Large BSALarge BSA Thin skinThin skin Minimal fatMinimal fat Rapid loss of body heatRapid loss of body heat

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Hypothermia Hypothermia consequencesconsequences

Increased risk in rural settingIncreased risk in rural setting Increased morbidity and mortalityIncreased morbidity and mortality

Myocardial contractility decreasedMyocardial contractility decreased Oxyhemoglobin dissociation curve Oxyhemoglobin dissociation curve

shifted leftshifted left CoagulopathiesCoagulopathies DysrhythmiasDysrhythmias ArrestArrest

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Hypothermia precautionsHypothermia precautions

Warm ORWarm OR Heating lampsHeating lamps

Warming blanketsWarming blankets Heated humidified Heated humidified

circuitscircuits Warm fluidsWarm fluids

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Secondary surveySecondary survey More thorough evaluation of systemsMore thorough evaluation of systems

Detailed head to toe examDetailed head to toe exam ROSROS PMHPMH MedsMeds AllergiesAllergies

Diagnostic proceduresDiagnostic procedures Less invasive than in pastLess invasive than in past

ConsultationsConsultations Surgery?Surgery?

Solid organ injury routinely managed Solid organ injury routinely managed nonoperativelynonoperatively

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8 year old to the OR8 year old to the OR

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Questions?Questions?

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