1 Pediatric ABC Emergencies in the Combat or Austere Environment Matthew Martin, MD, FACS, FASMBS Trauma Medical Director, Madigan Army Medical Center Director of Informatics, Legacy Emanuel Med Center Associate Professor of Surgery, USUHS contact email: [email protected] Summary: The care of emergency problems involving the airway, breathing, or circulatory systems (ABC) can be challenging in any patient population or setting. These can be particularly challenging when managing pediatric patients in an austere environment. The recent combat operations in Iraq and Afghanistan have provided a generation of military surgeons with a large body of experience in providing care for severely ill or injured pediatric patients. Many of these issues are not specific to the combat environment, and may be encountered at any facility or setting not ideally equipped and staffed for high-level pediatric care. Although the general approach to these emergent problems should follow a similar approach to that outlined for adults, there are many subtleties that must be appreciated in pediatric patients that can greatly impact the efficacy, risk of complications, and ultimate outcomes. This syllabus highlights the key issues, concerns, and practical advice for the provider who is faced with managing ABC problems in the emergency pediatric. Specific focus will be paid to high yield "tips and tricks" and also to "potential pitfalls" in each area. The Setting: A Desert is a Desert Ø Remote, rural location Ø Limited personnel and resources Ø No pediatric specialists (YOU are the peds doc) Ø Not equipped or supplied for pediatric care Ø Limited options for immediate transfer or help Ø Severe injury/illness that needs immed intervention Ø Co-existing malnutrition, other diseases Is this atGlobal all Health Centerapplicable to the U.S.? 17.4 Million children without access White areas = no pediatric trauma center w/in 1 hour Most pediatric urgent care NOT Plenty of "pediatric deserts" in the US at pediatric hospitals Pediatric ABC Emergencies in Austere Setting Austin Trauma & Critical Care Conference 2016 2 I. Key Points and Pitfalls for Pediatric ABC Emergencies AIRWAY 1. A patent airway is hard to improve upon – if the patient is moving air and maintaining oxygen saturation, don’t rush to attempt intubation unless you are fully prepared 2. Don’t forget simple maneuvers first – suction, chin lift/jaw thrust, and oral/nasal airway 3. Bag-valve-mask ventilation works great in almost all pediatric patients and can provide completely adequate temporary oxygenation and ventilation 4. Don’t compromise exposure, evaluation, and ability to intubate due to c-spine concerns. Remove the collar and do what you have to do to secure the airway 5. Expect bradycardia with intubation, and either give atropine or have it ready 6. A surgical airway will fail without adequate lighting and a good assistant to retract/expose 7. A needle cricothyrotomy can buy you time with oxygenation but will not provide good ventilation. Avoid open cricothyrotomy in children if at all possible 8. Have a “difficult airway” cart prepared and available for airway emergencies 9. A Broselow tape is one of the most important aids to emergency pediatric care BREATHING 1. Assessment for breathing emergencies in children is challenging – look for tachypnea, nasal flaring, intercostal retractions, and abdominal breathing 2. Lung sounds can be present even with a significant pneumothorax, particularly in intubated patients receiving positive pressure ventilation 3. Suspected tension physiology should prompt immediate decompression with either a needle thoracostomy or chest tube 4. The treatment for a “sucking chest wound” is a chest tube first, then deal with the wound 5. A normal upright chest x-ray effectively rules out a pneumothorax or hemothorax as the source of any respiratory distress or hemodynamic instability 6. Ultrasound for pneumo and hemothorax is easily integrated into the FAST exam, and can be more reliable than even chest x-ray 7. Chest tubes can kink, clog, or be in the wrong position (or even wrong body cavity); always confirm position on xray and troubleshoot to endure adequate function CIRCULATION 1. Hypotension is a very late finding in children with circulatory shock; do not rely on a normal blood pressure as a marker of stability 2. Marked or worsening tachycardia is a red flag that there is ongoing bleeding or volume losses 3. A rapid prioritized search for the source of shock can be done in minutes (see Appendix A) 4. Control of active bleeding is the top priority in combat trauma injuries 5. Bradycardia indicates the patient is about to arrest; intervene immediately 6. Start resuscitation in synchrony with the diagnostic workup for patients with signs of shock 7. A balanced resuscitation with plasma, PRBCs, and PLTs will help avoid major coagulopathy and may carry a survival benefit 8. Tamponade is readily identified with ultrasound, and should prompt either immediate drainage or open surgical exploration Pediatric ABC Emergencies in Austere Setting Austin Trauma & Critical Care Conference 2016 3 II. Priorities of Care in the Pediatric Trauma or Emergency A. Is it as easy as ABC? Ø Standard ATLS teaching emphasizes primary importance of A – airway first Ø Reasoning is that death from hypoxia typically more rapid than hemorrhage Ø Is somewhat artificial as a team approach may do A, B, and C simultaneously Ø Will also be highly dependent on the mechanism of injury, the setting, the number of other casualties, and the local resources/equipment/expertise Ø For most civilian settings, blunt trauma or acute surgical illness, Airway comes first Ø For combat trauma, explosions, amputations, active external bleeding, C comes first! B. Is there a "golden hour" in children? Ø Time to critical interventions for life-threatening A, B, or C issues are clearly associated with outcomes and the chance of survival. This is reflected in many of the terminology and expressions we use: Ø Significantly less cardiorespiratory reserve in children vs adults Ø Also a function of age and size, with reserve in infants < toddlers < children Ø Children have "golden minutes" if a major ABC issue C. How is the workup/evaluation different than adults? Ø Basic workup and flow is the same, but need awareness of the unique issues Ø Differences in injury patterns, key anatomy, and physiologic response Ø Particularly important with ABC issues to avoid the common pitfalls Pediatric ABC Emergencies in Austere Setting Austin Trauma & Critical Care Conference 2016 4 III. Airway/Breathing Management and Avoiding Pitfalls A. What are the key Airway-related differences in kids? Ø Many anatomic differences (see Table below), some more important than others Ø All structures are smaller/shorter – so much less room for error and easier to injure Ø Smaller diameter = can obstruct with small amount of edema/swelling/foreign bodies Ø Nasal breathers, large tongue that can obstruct airway Ø Narrowest point is at cricoid cartilage, and cricoid right at vocal cords, therefore: • avoid crichothyroidotomy in children, particularly younger children/infant • can result in subglottic stenosis and/or vocal cord injury – both devastating Ø Airway more anterior than in adults, need more anterior retraction when intubating Ø Less physiologic reserve and will desaturate quickly B. High-yield tips and techniques for pediatric Airway management Ø May look or sound worse than it is Ø It they are talking, they have an airway Ø Often respond to suctioning and positioning Ø A patent airway is hard to improve upon Ø Can delay intubation until fully prepared If not in immediate respiratory distress: v Focus on adequate oxygenation and keeping airway clear of blood, debris, etc. v Completion of primary survey and assessment for other life-threatening problems v Put on supplemental oxygen immediately on arrival v Continuous pulse oximetry and telemetry v Little role for an immediate arterial blood gas in children Pediatric ABC Emergencies in Austere Setting Austin Trauma & Critical Care Conference 2016 5 If current or impending respiratory distress: v All hands on deck: call for help, and most experienced help available v Should have a difficult airway cart, make sure it has some pediatric supplies as well v Look for an immediately reversible non-airway cause (Breathing or Circulation problem) v Try simple maneuvers first, but rapidly escalate as the clock it ticking v Focus on OXYGENATION! Ventilation not as critical or immediately life-threatening Ø There is often a scramble to get intubation equipment, meds, ET tube, etc., while the patient is in distress or unconscious and not moving air Ø Bag-valve-mask (BVM) ventilation should be the FIRST method to rescue the patient Ø Almost ALL children can be fully oxygenated & ventilated with good BVM technique: • lift face into mask, don't push mask into face; suction airway well • small breaths appropriate to age – watch chest rise and fall • augment patient breaths if spontaneously breathing • if unconscious or chemically paralyzed, give full tidal volume support Ø If not moving air, then either improper technique or airway physically obstructed Ø Don't forget the TONGUE – oral (OP) or nasopharyngeal (NP) airway will solve this ü OPA length – measure from lower lip to angle of mandible ü Pull tongue anteriorly while inserting ü Avoid in awake kids ü NPA length – measure from nares to angle of mandible ü Avoid if major facial trauma/fractures ü Avoid in infants/smaller children If BVM solves the problem, then take a deep breath: v You have control of the airway, now have time to get fully prepared or to move patient v Zoom out: Look for other immediately life-threatening injuries/problems (back to ABCDE) v Intubate or surgical airway if everything and everyone ready to go v If difficult airway anticipated or massive facial trauma, can move to OR and do it there Pediatric ABC Emergencies in Austere Setting Austin Trauma & Critical Care Conference 2016 6 C.