ATLS APPROACH TO PEDIATRIC TRAUMA

PREPARE Room and equipment Staff: nursing, radiology, lab, RTs Discuss case/interventions Paramedic report

PRIMARY SURVEY (Assessment and Management)

Airway Breathing Circulation Disability Exposure Full vitals

ADJUNCTS TO PRIMARY SURVEY Pulsox, cardiac monitors, BP monitor, CO2 monitor NG tube Foley ECG Xrays: Cspine, CXR, pelvis Trauma blood work ABG DPL/ABUS if appropriate SECONDARY SURVEY AMPLE history H/N Chest Abd U/G Neuro Msk Roll pt ADJUNCTS TO SECONDARY SURVEY Xrays CT head, chest, pelvis, abd, spine ABUS DPL Contrast studies Endoscopy Angiography Esophagoscopy Bronchoscopy

PRIMARY SURVEY Airway and C-spine LOOK LISTEN FEEL MANAGE facial/neck trauma, trachea midline, crepitus, subQ emphysema put on C - collar maneuvers: jaw thrust, suction, foreign body removal devices: oropharyngeal airway, nasopharyngeal airway definitive airways: endotracheal intubation, jet insufflation, cricothyroidotomy, tracheostomy (nasotracheal intubation discouraged in peds) RR, depth of respirations, chest mvmts, flail segments breath sounds, heart sounds, bowel sounds in chest subQ emphysema, trachea midline, percussion, chest wall injury 100% 02: face mask with NRB at 10 - 12 L/min pulsoximeter, end tidal C02 ventilation as necessary thoracentesis for pneumo, chest tube for hemo/pneumo, seal open chest wounds with three sided dressing problems with intubated pt: Disloged, Distended stomach, Obstructed tube, Pneumothorax, Equipment failure identify external bleeding, skin color, diaphoresis, JVD, femur #s muffled heart sounds, murmur pulse rate, pulse quality, BP, cool/clammy skin cardiac monitor, BP monitor two large bore IVs, send blood for trauma panel and ABG intraosseous catheter or venous cutdown if cant get peripherals bolus 20 cc/kg NS or RL for hypotension packed rbcs 10 cc/kg if >2 boluses required direct pressure to bleeding sites; no clamping identify cause of hypotension: chest, belly, pelvis, external, SCI, MSK, head (rare): CXR and pelvic Xray should be done ASAP abdomenal ultrasound, DPL, thoracotomy, surgical consult prn speech clear, stridor, gurgling, hoarseness level of consciousness, agitated, cyanosis, retractions, AMU, evidence of facial or laryngeal injury, evidence of UAW burn (carbenaceous sputum, singed hairs, soot around mouth)

Breathing and Ventilation LOOK LISTEN FEEL MANAGE -

Circulation and Hemorrhage LOOK LISTEN FEEL MANAGE -

Disability PUPILS + GCS Manage: may include RSI intubation, hyperventilation/mannitol for herniation Exposure/Environment: Full exposure and prevent hypothermia with warmed solutions and blankets Full Vitals: Repeat vitals including core temp; are you stuck on primary survey b/c of poor

vitals??

ADJUNCTS TO PRIMARY SURVEY Most should already be done Monitors: Pulsox, BP and cardiac monitor, ET CO2 monitor Xrays: C-spine, CXR, and pelvic Xrays (TRY to get CXR and pelvis early; C-spine can wait until secondary survey) DPL, ABUS NG and urinary tubes if not contraindicated (foley after rectal) SECONDARY SURVEY AMPLE history and details of accident including condition of vehicle, ejection, other injured passengers, seat belts, blood loss at seen, vitals on route, interventions on route, etc Head and Neck Head: lacerations, contusions, fractures, burns Face: maxillofacial fractures, racoon eyes, battle signs, look in mouth, burns, carbenaceous sputum, soot, singed hairs, nose for CSF leak Eyes: pupil size and reactivity, EOM, visual acuity, hemorrhage, racoon eyes Ears: battle signs, hemotympanum, CSF leak Cranial nerves: II - XII if not already tested; occulocephalics and occulovestibular reflexes, corneal reflex, gag reflex Neck: inspect for blunt injury, penetrating injury, tracheal deviation, accessory muscle use; palpate for deformity, tenderness, swelling, subQ emphysema, tracheal deviation, symmetry of pulses; listen to carotids, palpate C-spine. Chest Look: blunt or penetrating trauma, acc muscle use, chest expansion, JVD Listen: breath sounds and heart sounds Feel: tenderness (AP and lateral compression), rib tenderness, crepitation, subcutaneous emphysema, percuss for hyperresonance or dullness Abdomen Look: blunt or penetrating trauma (look closely at sides re hepatic and splenic injury may be suspected by lower rib cage lateral abrasion) Listen: bowel sounds Feel: palpate for tenderness, guarding, rebound; percuss for tenderness DPL, ABUS, ABCT, pelvic Xrays as appropriate Urogenital Look: contusions, lacerations, urethral/vaginal/rectal bleeding Rectal: prostate position, bone fragments, wall integrity, sphincter tone, blood Vaginal: laceration, blood, bone fragments MSK Look, feel, move all joints of upper and lower limb looking for lacerations, contusions, deformities, crepitus, possible fractures Compress pelvis AP and lateral Assess limb pulses and neuro status distal to suspected fractures Obtain Xrays of injured parts Neuro Mental status and GCS

 Roll Pt

Cranial nerves Strength, Reflexes, Sensation, Coordination Look, feel for any injuries, lacerations, contusions, spine tenderness, rectal

PEDIATRIC VS ADULT TRAUMA

PATHOPHYSIOLOGY Smaller body mass of children thus the energy force per unit body areas is much higher in pediatrics than in adults resulting in more severe injuries Incomplete calcification of skeleton and growth plates make children more susceptible Internal organ damage without obvious overlying external fractures b/c of pliable skeleton: severe pulmonary contusions without rib fractures is an example Large surface area to body volume thus hypothermia more of a concern Increased physiological reserve allows near normal maintenance of vital signs even in the presence of severe shock: hypotension is a LATE sign of shock; kids crash quickly and LATE MUST keep in mind child abuse as a mechanism of injury MANAGEMENT ISSUES Fluid boluses: 20 cc/kg (compared to 2L in adults) Blood transfusion: 10 cc/kg Braslow tape essential equipment Intraosseous or venous cutdown if cant get iv access (3Xs or 90sec) Increased emphasis on gastric decompression re poor ventilation and vagal stimulation Hypothermia bigger issues in kids: make sure iv fluids warmed, blankets, etc AIRWAY MANAGEMENT Oral Airways: do not put in backwards and rotate 180 degrees; put straight in with depressor Orotracheal intubation: preferred route of definitive airway management; RSI preferred Nasotracheal intubation: not recommended b/c of increased risk of pharyngeal/adenoid bleeding and relatively acute angle of the posterior nasopharynx Cricothryoidotomy: rarely indicated, should only be done by surgeon, TTJV preferred TransTracheal Jet Ventilation (needle cricothyroidotomy): preferred over surgical cric AIRWAY EQUIPMENT Cuffed tubes NO cuffs < 8yo b/c of narrow cricoid ring provides functional cuff Uncuffed tubes should have small air lead @ peak inflation pressure (30mmHg) ETT sizes Age/4 + 4 Size of pinky or nostril Have size above and size below available Blade sizes

 Depth

Premie 0-2 2 - 10 > 10 ETT size (i.d.) X 3 Age/2 +12 Vocal cord marker

Miller 0 Miller 1 Miller/Mac 2 Mac 3

AIRWAY AND VENTILATION: ANATOMY/PATHOPHYSIOLOGY Head/Mouth/Pharynx Large head with prominent occiput: causes passive flexion of neck and airway obstruction (AWO) to poor position Large tongue which easily obstructs airway; also makes laryngoscopy more difficult b/c of large tongue in the way Loose teeth can easily be dislodged and cause AWO Relative poor tone of pharyngeal musculature thus passive AWO Relative prominence of adenoids: nasopharyngeal intubation not recommended Large, floppy epiglottis that doesnt lift up as well with the curved blade thus the use of the straight blade to raise the epiglottis Larynx/Trachea/Bronchial tree/Lungs Anterior larynx: harder to visualize; anterior larynx position makes the angle between the base of the tongue and glottic opening more acute thus the straight blades create a more direct visual plane from the mouth to the glottis Cricoid ring is the narrowest part of airway (compared to vocal cords in adults) and it forms a natural seal with the ETT hence uncuffed tubes < 8 yo; cuffed tubes risk pressure necrosis Short trachea: very easy to intubate the right mainstem bronchus Short airway: very easy to dislodge tube; minimal movement will dislodge ETT Narrow lumen: means using smaller ETTs which get blocked more easily with secretions, blood, etc Narrow lumen: small amounts of edema, bleeding, etc will cause obstruction Resistence varies with 1/radius^4 (any decreased radius increases resistence to the fourth power) High compliance of pediatric airway makes it very susceptible to dynamic collapse in presence of AWO: trachea will collapse in presence of upper airway obstruction like croup or epiglotitis Small lung volumes, especially in neonates/infants thus aggressive ventilation can easily cause pneumothoraces (most common cause of pediatric pneumos) Chest Wall Cartilaginous ribs very compliant thus chest retraction during respiratory distress decreases the ability to maintain FRC, prevents increase in tidal volume and increases work of breathing Any compromise of diaphragmatic excursion can increase respiratory distress due to reduced effectiveness of horizontal diaphragm contractions (gastric distension, abdominal masses, etc)

DETERIORATION OF INTUBATED PATIENT Displaced tube: listen, ETCO2, laryngoscopy to look, if in doubt, pull it out Distension: gastric distension can reduces ventilation and cause vagal response; NG/OG tube Obstruction: secretions, blood blocking the tube; pull tube Pneumothorax: listen to chest, CXR Equipment: check ventilator, bag, BVM, seal, hoses etc; d/c ventilator and bag, ?improvement

CHEST TRAUMA Same injuries as adult but different frequencies Injuries Rib fractures 50% Pneumothorax 20% Hemothorax 10% Pathophysiology Chest wall is less protective and transmits traumatic forces to the lung parenchyma and mediastinal structures; mediastinal structures are more mobile than in adults Children are diaphragmatic breathers Injury Patterns as a result of compliant chess wall Pulmonary contusion is more common Pulmonary contusion can occur without rib fractures Intrapulmonary hemorrhage more common in kids Tension pneumothorax more common in peds b/c mobility of mediastinum means that less pressure is required to compress and shift the mediastinal structures and contralateral lung Gastric distension easily compresses the lungs Diaphragmatic injury as profound affect on ventilation Less common injuries in pediatrics Bony chest injury: rib fractures less common b/c chest wall compliance Other: aortic disruption, diaphragmatic hernia, major tracheobronchial tears, flail chest, cardiac contusion Pneumothorax May not hear decreased BS b/c of easily transmitted sounds from other side See braslow for tube sizes Occult pneumos require chest tubes Signs of tension pneumothorax are often subltle: cant see tracheal deviation b/c of short neck, may still have bilateral breath sounds heard, hypotension late Hemothorax Indication for OR thoracotomy = initial drainage > 15 - 20 ml/kg or ongoing drainage > 5 ml/kg/hr or continued air leak Emergency Room Thoracotomy

Indications the same as adults Rarely needed but should be done if indicated Indicated in penetrating trauma only (NOT blunt) penetrating trauma + loss of vitals at scene penetrating trauma + loss of vital on transport penetrating trauma + loss of vitals in ED note: NOT indicated if NO vital signs at the scene Commotio cordis = myocardial concussion Sudden cardiac collapse after chest impact Results in brief dysrythmia, hypotension, or LOC NO lasting pathological changes May result in asystole or VF Explains sudden cardiac death after blow to chesst in which no hitolopathological changes are present on autopsy CASE: baseball to chest then Vfib arrest ABDOMINAL TRAUMA Injuries Spleen is MC Liver is 2nd MC Pathophysiology Less abdominal wall musculature protection Less abdominal fat protection Larger spleen and liver Large mobile kidneys Compliant lower chest wall thus easy compression of spleen and liver Patterns of injury Prone to liver and splenic injury Increased importance of gastric decompression (NG or OG tube) because of reduced effectiveness of ventilation and potential vagal response Duodenal hematomas, traumatic pancreatitis, duodenal/jejunal perforations, mesenteric and small bowel avulsion injuries are all more common in pediatrics: less developed abdominal musculature and common mechanism of injury (bike handles, epigastric blow, etc) Bladder rupture more common due to shallowness of pelvis Specific injuries Diaphragmatic rupture: common with lap belts Splenic injury: most common, evaluate with CT, delayed rupture also occurs, remember left shoulder tip pain Liver injury: 2nd most common injury, MOST COMMON cause of lethal hemorrhage in pediatrics, Renal: deceleration and vascular injuries Lap belt injuries in children Chance fracture Small bowel perf Mesenteric artery Pancreatic injuries Diaphragmatic rupture Similar approach to patient Generally emphasis is on non-surgical mx Clinical indication for laparotomy: to OR NO clinical indicator for laparotomy: abdominal investigation

-stable: CT scanning preferred -unstable: ultrasound or DPL (DPL in pediatrics should only be done by surgeon according to ATLS)