Pediatric Trauma in the Under 5 yr. old: Nuances in Resuscitation and Stabilization

1. Pediatric Trauma in the Under 5 yr. old: Nuances in Resuscitation and Stabilization Allan de Caen MD FRCP Pediatric Critical Care Medicine Stollery Children's Hospital Edmonton, Canada

2. Objectives • Airway Control in the traumatized child • Cautions and pitfalls in management • Management of Pediatric Traumatic Shock • When and how aggressively to treat • Intracranial Hypertension in pediatric trauma • Beyond just the ABCs • Pediatric Traumatic Cardiac Arrest • How (and how long) to approach it

3. Conflicts of Interest Financial and Academic • None relevant to this topic • This talk balances current science/ EBM with my personal practice (tainted by personal experience and bias)

4. Airway Management in the Traumatized Child Indications for Intubation • Altered LOC/ airway reflexes: aspiration risk • Intrinsic airway trauma • Failures (real or potential/ future) of effective ventilation (hypercarbia) or oxygenation (hypoxia) • Central drive • Lung parenchyma (pneumothorax, hemothorax, contusions) • Chest wall (flail chest) • Ongoing hemodynamic compromise • Patient movement into the ‘uncontrolled’ setting • CT scanner • transport

5. Preparation for Intubation • Best available airway expert • Stable/ secure intravenous access • Pediatric-specific airway equipment • Pre-oxygenation • Adequate monitoring (HR/ 02 sat/ BP/ EtC02) • A plan B for airway management • Preparation for hemodynamic changes… Do I have to intervene now, or can it wait for…

6. What makes the pediatric airway particularly difficult… Difficulties positioning the relatively ‘anterior’ airway in the setting of the immobilized pediatric cervical spine

7. What makes the pediatric airway particularly difficult… • Short neck (and higher larynx)

8. What makes the pediatric airway particularly difficult… • Large tongue and relatively small mouth • Large and floppy epiglottis

9. What makes the pediatric airway particularly difficult… • Large head and the inability to extend the neck/ place rolls under shoulders

10. Recognizing (in advance) the high risk pediatric trauma airway Thyromental distance Mallampati assessment Flexion/ Extension of neck

11. Securing the pediatric trauma airway • Am I comfortable with intubating this child? • Intubation without drugs only in cardiac arrest • The comatose patient needs a neuro-RSI !! • The apneic child can still go into laryngospasm during intubation • If you are comfortable with the skill of endotracheal intubation, the incidence of complications is reduced when facilitated by drugs (RSI/ rapid sequence intubation) • Bradycardia/ hypoxia/ hypotension/ emesis/ aspiration

12. Modified RSI of Children • Pre-oxygenation • 100% 02 (NRBM) X 5 min or assisted ventilation with 100% 02 X 30-60 sec if severe respiratory distress and hypoxia, or reduced respiratory effort • Atropine 0.02 mg/ kg IV • Wait for onset of tachycardia • Anesthetic/ paralytic rapid push • Start assisting ventilation (slow rate, small volumes), exception being suspected severe TBI (peri-RSI) • Wait for flaccidity/ no movement (vs. laryngospasm) • Laryngoscopy and endotracheal intubation • Airway confirmation (EtC02 monitoring rules!!)

13. Atropine and RSI Atropine as an anti-sialogue • Need 15-30 minutes prior to laryngoscopy Bradycardia with intubation can occur due to: • Hypoxia or ischemia • Drug-related (eg. Fentanyl or sux) • Vagal reflexes with laryngoscopy (even if baseline tachycardic) • Positive pressure ventilation (PPV) in infants Shepherd , Circulation, 1981 Suggestion that atropine creates survival advantage in emergent pediatric intubation Jones, PLoS One, 2013 Give it even in the presence of underlying tachycardia)

14. What drugs for RSI? • Propofol/ benzodiazepines • Vasodilation combined with occult hypovolemia !! • Fentanyl • good analgesic but poor anesthetic/ sedative • Etomidate • potential hypoadrenalism and hypotension(sepsis+) • Ketamine • Maintains BP (usually) and lowersICP if C02 ‘N’ • Repeated boluses of 0.5 mg/ kg better than a large (2 mg/ kg) dose • Paralytic • Rocuronium 1mg/ kg • Succinylcholine: risks outweigh advantages (if Roc available)

15. Strategies to Enable Visualizing the Pediatric Trauma Airway • Time for laryngoscopy/ good view: pre-oxygenation • Anteriorly opened C-spine collar • ETT with stylet • Straight laryngoscope blade (long, but not too long…) • Don’t laryngoscope the esophagus: start at base of tongue • Pre-endoscopy suctioning • Gentle anterior laryngeal pressure • Not cricoid pressure: worsens view! • Failed intubation?: BVM and OPA; laryngeal mask • Don’t depend upon fancy airway adjuncts (especially if you don’t routinely use them)

16. Hypotension Surrounding Intubation • Hemodynamic preparation pre-RSI • Code dose epinephrine and NS boluses at bedside • Treat hypotension/ shock prior to starting RSI (start with volume) • Reduce anesthetic/ sedative doses, or withhold in setting of refractory severe hypotension • Hypotension post-RSI is common but is usually fluid responsive • PPV reduces venous return to heart (slower IMV!) • RSI drugs vasodilate and reduce preload • PPV (pre-atropine) can reduce HR in small infants due to CNS reflexes

17. Traumatic Shock Hypovolemic (hemorrhagic) Shock • Intra-abdominal • Intrathoracic • Sub-galeal vs. intracranial (prem) • External Obstructive shock • Pericardial hemorrhagic tamponade • Tension pneumothorax/ hemothorax Myocardial contusion Brainstem injury (late finding)

18. Traumatic Shock Assessment Shock? • Tachycardia • Pulses (perif vs. central/ strength) • Perfusion (cap refill and skin temp) • Narrowing in pulse pressure (BPs/BPd) • Fall in BP is a late finding • The more of the findings that are present, the more likely that they are specific for a diagnosis of shock What is the threshold to treat shock? • PALS teaches keep BPs> 70 + (ageX2), but is that what we really want?

19. Low Volume Fluid Resuscitation for Trauma • In traumatized adults with lower blood pressures/ flow, the body may effectively tamponade hemorrhage (especially venous injuries) • In adults with uncontrolled hemorrhagic shock (which refers to an injury that can only be managed operatively, such as intrathoracic or intraabdominal trauma), the use of LVFR might be indicated • IV fluid boluses, under these circumstances, raise central venous pressure, disrupt clots, dilute clotting factors, and worsen on-going hemorrhage

20. NICE Recommendations (2004) for Management of Traumatic Shock • It is recommended that in the pre-hospital management of adults and older children, IV fluid should not be administered if a radial pulse can be felt (or, for penetrating torso injuries, if a central pulse can be felt). • In the absence of a radial pulse (or a central pulse for penetrating torso injuries) in adults and older children, it is recommended that IV fluid should be administered in boluses of no more than 250 ml. The patient should then be reassessed, and the process repeated until a radial pulse (or central pulse for penetrating torso injuries) is palpable.

21. NICE Recommendations (2004) for Management of Traumatic Shock • There is inadequate evidence on which the Institute can base recommendations on when pre-hospital use of IV fluid in young children and infantsfollowing trauma is appropriate, or on the volumes of fluid to use. • However, there is a broad consensus that transfer to hospital should not be delayed by attempts to administer IV fluid.

22. Accuracy of palpation of a pulse? Pediatric OR (non-CPB, infant) study Sarti, Ped Anesthesia, 2006

23. Hypotension and Severe Pediatric Head Injury • A single episode of hypotension (BPs<90) in children with traumatic brain injury is associated with a fourfold decreased survival rate Pigula, 1993 • Adult literature has shown that early correction of hypotension in the traumatic brain injury improves outcome Bouma, 1990 Bottom Line: Avoid Hypotension (BP 70 + (ageX2)

24. Intravenous access • Larger is better than smaller, but 2-24G IVs are better than nothing • An intraosseous needle will be the equivalent of a 12-14G IV; consider using it early, especially in severe trauma • Place 2 IVs, with one above and one below the diaphragm

25. Pediatric Traumatic Shock Resuscitation: What kind of fluid to give? SAFE Study, NEJM, 2004 • Multi-centre double-blinded RCT comparing crystalloid (NS) to colloid (4% albumin) in fluid resuscitation of adults upon admission to ICU (n= 6997) • no difference noted in morbidity or mortality Subset of SAFE patient population with TBI • Increased mortality rate with the use of albumin when compared to NS • 41.8% mortality vs. 22.2% mortality (P<0.001) Don’t use dextrans/ starches/ hypertonic saline!

26. Pediatric Traumatic Fluid Resuscitation NS for fluid resuscitation • Efficacious for survival and cost • Risks? • Hyperchloremic metabolic acidosis: following the BE as marker of success • Hyperchloremia: possible association with need for CCRT (adult literature) • Alternatives: • Ringers lactate (relatively hyponatremic) • Plasmalyte (expensive; available?) • Bottom Line: NS is still the standard of care for the first 40cc/ kg

27. Persistent shock in pediatric trauma • On-going bleeding • On-going bleeding • On-going bleeding • On-going bleeding • Hypoglycemia in the small child • Hypocalcemia if transfusing blood • Cardiorespiratory effects… • Other causes of shock

28. Traumatic Shock Hypovolemic (hemorrhagic) Shock • Intra-abdominal • Intrathoracic • Sub-galeal vs. intracranial (prem) • External • Multiple sites (ped trauma is multi-system!) Obstructive shock • Pericardial hemorrhagic tamponade • Tension pneumothorax Myocardial contusion Brainstem injury (late finding) Multi-factorial

29. * * * Hyperventilation and the Cardiovascular SystemThe Hemorrhagic shock victim Pepe et al, J Trauma, 2003 • Reduced preload due to increased ITP and reduced venous return

30. How do you know when enough fluid has been given? Systolic Wave Variation/ Pulse Pressure Variability:check your pulse oximetry tracing (audio or visual)

31. Inotropes/ vasopressors in Pediatric Trauma: When and what to use Inotrope indications: • Hypotension not responding to first 20cc/ kg crystalloid: prepare the inotrope • Hypotension despite 40cc/ kg crystalloid: give 10-20 cc/ kg O-neg blood • Persistent hypotension despite 60cc/ kg fluid: start inotrope (or earlier if falling pressure) • Unless post-sedation, dopamine (5-15 mcg/ kg/ min) or epinephrine (0.1 mcg/ kg/ min): run dilute (rule of 6s) • ?needle the chest bilaterally to r/o pneumothorax? • Post-sedation: consider phenylephrine if you have it • Echo the heart if you have US (r/o tamponade)

32. Increased Intracranial pressure (ICP) in the Pediatric Trauma Patient How do we recognize the patient as potentially having increased ICP? • On-going reduced level of consciousness (without sedation) • Pupillary asymmetry • Focal motor abnormalities • Abnormal (decerebrate or decorticate)positioning • Cushings (ICP and HR) is a VERY late finding of increased ICP, and sometimes does not accompany increased ICP in small children

33. Increased ICP in the Pediatric Trauma Patient Basic management for all increased ICP patients • Secure the airway • Keep 02 saturations >94% and EtC02 30-40 • Maintain BPs> 70 + (ageX2) • Avoid fever (T>38C), but avoid hypothermia (intentional or accidental) • Appropriate sedation/ analgesia (including for ETT tolerance) • (Paralysis does not control ICP) What else should be considered for ICP control?

34. Increased Intracranial pressure (ICP) in the Pediatric Trauma Patient Osmolar therapy: Mannitol • Never well studied/ validated in adults and especially in children • Potentially nephrotoxic with repeated doses (S osm>330); limited dosing ceiling • Soon after dosing, osmolar diuresis can lead to (worsened) hypovolemia and hypotension • Replace urine output 1:1 with NS • 0.25-0.5 G/ kg IV slow bolus

35. Increased ICP in the Pediatric Trauma Patient Osmolar therapy: Hypertonic (3%) Saline • Potentially has anti-inflammatory effects • Reduces intracranial pressure when given as bolus, as well as when run as infusion (ICU tool) • Potentially good volume expander in shocky TBI patients (controversial), mobilizing interstitial fluid: • Does not lead to hypotension • 3-5 cc/ kg IV slow bolus • No upper limited to dosing ceiling (at least up to S Na 160-170)

36. Pediatric Traumatic Cardiac Arrest:Why do children arrest? • Specific anatomic causes of death are only rarely mentioned in published articles • blunt trauma to the brain and spinal cord • penetrating injuries to head/brain, liver, spleen, heart, and aorta • 78% have severe TBI

37. Pediatric Traumatic Cardiac Arrest(OOH)

38. Pediatric OHCA Donoghue, 2006

40. Immediate transportation to an ED should be considered for children who exhibit witnessed signs of life before traumatic CPR and have CPR ongoing or initiated within 5 minutes in the field, with resuscitation maneuvers including airway management and intravenous or intraosseous line placement planned during transport • After blunt and penetrating trauma in victims in whom there is anunwitnessed traumatic cardiopulmonaryarrest, a longer period of hypoxia may be presumed to haveoccurred, and an acceptable durationof CPR (including bystanderCPR) of less than 30 minutes maybe considered with medical director input.

41. Objectives • Airway Control in the traumatized child • Cautions and pitfalls in management • Management of Pediatric Traumatic Shock • When and how aggressively to treat • Intracranial Hypertension in pediatric trauma • Beyond just the ABCs • Pediatric Traumatic Cardiac Arrest • How (and how long) to approach it

42. Thanks for your attention.Questions?