Pediatric Trauma Ryan Donlin, BSN, RN, CCRN Edited by Diana Priego BSN, RN, CCRN Objectives • Review the current prevalence and leading types of Pediatric Trauma • Review and discuss the Pediatric trauma assessment - “Slow is smooth, smooth is fast” • Identify and evaluate Pediatric vs. Adult trauma differences • Examine injuries more commonly seen in the pediatric population • Analyze pediatric trauma prevention practices • Recognizing Child Abuse/Maltreatment Pediatric Trauma Trauma is the leading cause of childhood death and disability in the US. On average 12,175 deaths annually CDC Statistics – (2000-2006) Injury Deaths: • Death rate in Males were almost 2x that of females • #1 Leading cause of death for children were due to transportation related incidents (Occupant, Ped vs. Vehicle, Bicycle vs. Vehicle) • Leading cause of death by age group: < 1yr = Suffocation 1-4yr = Drowning 5-19yr = Occupant in MVC Death Rate Per 100,000 Population Buckle Up! And Buckle Up Correctly! More Nerd Stats • Blunt trauma accounts for more than 80% of all pediatric fatal injuries Body Part Rankings • #1 - Traumatic brain injury (TBI) • #2 – Thoracic • #3 – Abdominal Mechanism of Injury (MOI) Knowledge of the MOI allows for a high index of suspicion for the resultant injuries in the child. •MOI often reflects the age and developmental status of the child •External evidence of injury may be minimal as energy is often absorbed by underlying structures •MUST suspect underlying potential injuries!! Mechanisms of Injury The transfer of kinetic energy arises from several sources: • Blunt (injury to internal organs), • Penetrating (disruption of skin and organ integrity), • Acceleration-Deceleration (abrupt, forceful back and forth movement), • Crushing (direct compression of body structures). Pediatric Trauma Assessment Initial Trauma Assessment and Intervention Primary Assessment Identify life-threatening injuries to the airway, breathing, circulatory and neurologic systems Secondary Assessment Identify injuries to the remaining body systems. Primary Assessment 1. Assess the Airway and Cervical Spine 2. Assess Breathing 3. Assess Circulation 4. Assess Disability (Neurologic System) Airway Cervical Spine ~ Immobilization Full Spine Immobilization Spinal Alignment Breathing • Rate and depth of respiration – RR – Infants > Children > Adults – More reliance on diaphragm to breath – Newborns are obligatory nose breathers until approx 4-6mths • Breath sounds, Effort to move air - Accessory muscle use? • Crepitus, Tracheal position • Oxygen saturation Circulation • Tachycardia early • Capillary refill / Skin color • External blood loss – Control life threatening hemorrhage!!!!! • Hypotension is a late finding – Kids can lose up 25-30% of circulating blood volume before hypotension presents • Use SPO2 as a loose guide How’s the dome? (Disability) Secondary Assessment 5. Expose the patient / Environmental Control 6. Full Set of VS & Family presence! 7. Get ready for resuscitation measures • IV access – largest bore possible • IO access – don’t hesitate to use if IV unavailable 8. Head-to-Toe Assessment/ History. • SAMPLE, MIVT 9. Inspect the Back. General Vital Signs and Guidelines Head Injury – Quick Case vs. Case CASE #1 7YOF rear middle seat unrestrained passenger of a 4-door sedan who was involved in a single vehicle vs tree MVA traveling approx 35- 45mph. Per EMS the vehicle sustained significant front-end damage w/ starring of the windshield, and + airbag deployment, + LOC for unknown amount of time. Pt was mobile prior to BLS EMS arrival at scene. Pt began to vomit during primary assessment. Head Injury – Quick Case vs. Case CASE #2 3YOF s/p fall from a stationary motorcycle while playing on the seat. Immediately following the fall, the patient vomited w/ additional c/o head pain. Head Injury – Quick Case vs. Case CASE #1 + facial fractures and moderate concussion CASE #2 CT revealed ICH in the 3rd, 4th ventricles and temporal horns. Head Injury • Traumatic brain injury (TBI) is the most common cause of traumatic childhood death and disability in the US. • #1 cause of traumatic death for peds • Major cause of TBIs are motor vehicle related incidents in which the child is a passenger, a pedestrian or on a bicycle. • Other head injuries result from falls, sports/play injuries. TBI – Initial Management • Airway – Normo-ventilation vs hyperventilation? – ETCO2 = 35-40mmHg • Maximize cerebral perfusion (age appropriate goal) – SBP/MAP (age specific) + O2 (SPO2 > 90%) • Intracranial pressure monitor – Goal = REDUCE secondary brain injury Protecting the dome! Prevention Measures Spinal Cord Injury Babies and toddler are like lawn darts?... Cervical Spine Injury • Uncommon in young children and are associated with multiple injuries. • Child’s large head takes most of impact. • Highly elastic neck ligaments and incompletely calcified vertebral bodies allow for more pliancy of the neck. • Subluxation is more common in children. Mechanism of Injury Hyperflexion Hyperextension Axial loading or vertical compression Rotation Penetrating trauma Classification of SCI • Complete • Incomplete* A total motor and There is a partial sensory loss distal to preservation of sensory the injury and/or motor function below the level of the injury *classified as spinal cord syndromes Cervical Spine Fractures • All patients involved in traumatic injury must be immobilized – Assume injured unless cleared – Hard collar (Aspen) / Miami-J – Log roll, Circulation, Motor, Sensory (CMS) exams – Steroids? – Spinal cord center for children • The upper cervical spine C-1 and C-2 accounts for 20% of all C-spine fractures and the lower C-3 thru C-7 accounts for 80%. Cervical Spine Clearance • Conscious patient – Alert, cooperative, no neck pain, no neck tenderness, distracting injury? • Unconscious patient – Plain film – Lateral C-spine with collar on • If unable to visualize to T1 on lateral film, obtain multi-detector complete cervical spine CT – Maintain in collar – Follow guideline: "Routine Management of the Patient in a cervical collar” – MRI if not expected to awaken Shaking and spinal injuries… Spinal Shock • Spinal shock is manifested by – Flaccid paralysis – Absence of cutaneous and/or proprioceptive sensation – Loss of autonomic function – Cessation of all reflex activity below the site of injury Neurogenic Shock Cardiovascular component of Spinal Shock Injury to T6 and above Loss of sympathetic innervation Increase in venous capacitance Bradycardia Decrease in venous return Hypotension Decreased cardiac output Decreased tissue perfusion Cardiovascular Implications • Hypotension – Maintain age appropriate SBP transport – establish adequate pressure for systemic perfusion • Bradycardia – Treat only if symptomatic (result of vagus nerve unopposed) • Temperature regulation – Will become hypothermic – Requires continuous monitoring – Warming strategies Abdominal and Thoracic Trauma Thoracic & Abdominal Injuries • Musculature of the child’s chest and abdomen is less developed than in the adult. • Ribs are flexible and more anterior, thus are less protective of underlying organs. • Child’s protuberant abdomen along with its thin abdominal wall places organs close to impacting forces during a traumatic event. • Child’s small body size is predisposed to multiple injuries rather than isolated injury. Mechanism of Injury • Should heighten suspicion regarding certain injuries • Blunt injury and types of forces • Penetrating trauma • Use of restraint devices – Safety seat vs. seat-belt only Quick Case Study • 10YOM who was riding his BMX bicycle, when he went full send off a jump and landed on the handlebars. • Pt sustained penetrating trauma to the RLQ resulting in a deep laceration approximately 6"x3"x2" (LxWxD). • Not wearing a helmet at the time of injury, denies any LOC, able to recall all events leading up to TT arrival. • Rapid trauma assessment reveals no other injuries. • Pt able to MAE w/ CMS intact x4. VS stable @ scene Thoracic Trauma Penetrating Blunt Open Pneumothorax *Pulmonary Contusion Hemothorax *Pneumothorax Hemothorax Rib Fracture / Flail Chest Traumatic Asphyxia Traumatic Diaphragmatic Hernia / Rupture Pericardial Tamponade *most common Pulmonary Contusion • Results from blunt trauma to the chest that transmits energy to the underlying lung tissue. • Pulmonary edema, alveolar hemorrhage, desquamative alveolitis and subsequent RDS may result. – RDS generally within first few hours of injury • Impaired gas exchange • VQ mismatch • ↓ lung compliance • Positive pressure ventilation with PEEP and oxygen support may be required. Pneumothorax • Collection of air into the pleural space with partial or complete collapse of the lung. – Usually caused by blunt trauma to the chest causing alveoli rupture with a resultant escape of air, thus collapsing the lung. • This injury is closed and the lung seals, preventing further leakage. – May progress to tension pneumothorax. What do we have here? Abdominal Injury • Most common MOI is blunt trauma from an MVC-related event whether as an occupant, pedestrian or bicycle rider • Other causes include sports injuries, falls and child abuse • Organs usually involved are the Spleen, Liver, & Kidneys • Injuries to the major vessels and the Pancreas are less common Abdominal Trauma • Injury to the Solid Organs – • Dense and less strongly held together • Prone to contusion – bleeding – fracture (rupture) • Often referred to as “The Kill Zone” • Area is extremely vascular • At risk for unrestricted hemorrhage if organ capsule is ruptured