Pediatric Trauma

1. Pediatric Trauma CPT James R. Rice Emergency Medicine Physician Assistant Interservice Physician Assistant Program

3. References

4. Objectives • Identify the concepts associated with evaluating and resuscitating the pediatric trauma casualty • Introduction to the Broselow/Hinkle system

6. Pediatric Trauma • Basic same approach as with adults • Requires a team approach • Same injury patterns • May see slightly more blunt trauma • Children are NOT little adults

9. Vital Signs • Use as a rough guide to your clinical decision making • The pulse is much more sensitive than B/P • Children often maintain a normal B/P until vascular collapse

10. Vital Signs

11. Airway • Nasal breathers • Be careful not of occlude the nasal passages • Relatively large occiput • Do not pad under the head-may cause excessive flexion • Keep in the “sniffing” position • Relatively larger tongue • May make intubation difficult • Narrow larynx in the subglottic region • Uncuffed ET tubes only

12. Airway • Intubate VERY early in the case of facial burns • Surgical airway • Surgical cricothyroidotomy is NOT recommended in children under 12 • Needle cricothyroidotomy can be performed-but is temporary!

13. Airway • Intubation • The child may become bradycardic during stimulation of the posterior pharynx • Pre-medicate with atropine • 0.015-0.20 mg/kg IV • 0.02 mg minimum dose

14. Breathing • Look for respiratory distress • Tachypnea • Stridor/wheezing • Grunting • Nasal flaring • Auscultate in both axillae • Lung sounds are easily transmitted across the small chest

15. Circulation • Venous access can be VERY difficult • Will require small IV catheters • Go IO early!! • Use central lines (femoral) as a second choice • If you have a pediatric central line kit • Venous cut down may be a real option

16. Circulation • For shock • Crystalloid fluid bolus of 20mL/kg • If an inadequate response is noted you may repeat a 20mL/kg bolus • If there is still a poor response start a third 20mL/kg bolus and initiate 0-neg whole blood transfusion at 10-20mL/kg IV bolus

17. Circulation • Once you have stabilized with fluids • Start a fluid maintenance • 24hr fluid requirements: • 100ml/kg for the first 10kg of body wt. • 50ml/kg for the next 10kg of body wt. • 10ml/kg for each kg over 20kg • Patients weighing over 40kg should be managed as an adult • 2000-2500ml/day • Watch the urine output • Minimum should be 1.0ml/kg/hr

18. Secondary Survey • Your approach should be the same as with the adult casualty • Thorough head-to-toe exam

19. Head Injury • Leading cause of death due to injury • Blunt MOI • S/S • Vomiting • Lethargy • Headache • Asymmetric pupils • Asymmetric motor movement • Decreased mentation • Irritability

20. Head Injury • Evaluation • GCS • AVPU • Considering communication problems with the casualty, the AVPU system will probably be the best approach. • A-Alert • V-responds to Verbal stimuli • P-responds to Painful stimuli • U-Unresponsive

21. Glasgow Coma Scale

22. Head Injury • Management • Elevate head of bed to 20-30 degrees • Give IV mannitol at 1g/kg • Lasix at 1mg/kg may help as well • Mild hyperventilation • EVAC

23. Head Injury • Post traumatic seizure • Relatively uncommon • Prophylactic seizure management is controversial and has not been shown to be beneficial • Acute seizure management • Lorazepam, Midazolam or Diazepam

24. Spine • C-spine • Apply an appropriately sized collar • Place a towel under the shoulders to keep the spine in a neutral position • SCIWORA • Spinal Cord Injury Without Radiographic Abnormality • Neurologic deficit c/w spinal injury, but no abnormality seen with radiographic studies • Can have a delayed presentation

25. Heat Loss • Children are much more susceptible to hypothermia than adults • Be very aggressive in preventing and managing hypothermia

26. Burns • Airway management is the biggest concern • Remember the rule of nines is different for a child • A relatively mild burn in an adult can very serious in a child • Take no chances…plan on evacuating all burns

29. Rule of 9’s

30. Questions or comments at this point???

31. Pediatric Resuscitation Equipment • Problem: • This equipment can be found in the WHO/Humanitarian Augmentation Set • We currently don’t have an allocation for pediatric trauma equipment in the standard SKO

32. Pediatric Resuscitation Equipment • What can we use that is light, appropriate for the mission and easy to use? • The Broselow/Hinkle System

33. Broselow/Hinkle System • Small, portable kit based on the Broselow tape • Has been used successfully on the battlefield • Will require traditional re-supply utilizing NSNs

34. Broselow/Hinkle System

35. Broselow/Hinkle System • Eliminates Memorization 􀂃 • Eliminates Mathematics􀂃 • Promotes Standardization • Provides Redundancy and Universality

36. Broselow/Hinkle System

37. Broselow/Hinkle System • Place on flat surface next to supine child… • Hand running along the length of the tape from head to patient’s heel.

38. Hand on tape adjacent to patient’s heel identifying patients weight and heel identifying patients weight and color zone Broselow/Hinkle System

39. Broselow/Hinkle System • Measure Child and Assign Color Zone • Child measures in Broselow “red” • I need the “red” Ambu mask

40. Broselow/Hinkle System • We are currently working on developing a tactical prototype • The future plan is to have 2 complete tactical systems added to the standard SKO • Until then, we recommend 2 per BAS at unit cost of $1600.00ea.

41. Questions??