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Trauma - Pediatrics Amanda S. Cuda, MD,MPH Trauma - Pediatrics Amanda S. Cuda, MD,MPH

Trauma - Pediatrics Amanda S. Cuda, MD,MPH - PowerPoint Presentation

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Trauma - Pediatrics Amanda S. Cuda, MD,MPH - PPT Presentation

Learning Objectives Recognize common mechanism of pediatric trauma Demonstrate knowledge of ageappropriate physiology assessment equipment and dosing Demonstrate appropriate approach to resuscitation in a pediatric trauma patient ID: 749301

pediatric trauma airway age trauma pediatric age airway resuscitation injury learner patient rsi assessment signs approach case status abdominal

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Slide1

Trauma - Pediatrics

Amanda S. Cuda, MD,MPHSlide2

Learning Objectives

Recognize

common mechanism of pediatric trauma

Demonstrate

knowledge of age-appropriate physiology, assessment, equipment, and dosing

Demonstrate

appropriate approach to resuscitation in a pediatric trauma patient Slide3

Introduction: Pediatric Trauma

Leading cause of US mortality, ages 1-14

16 million ED visits per year

15,000 deaths

45

,000 permanent disability, brain injury

2:1 male to female ratio

Blunt trauma 90%, penetrating trauma 10%

F

alls, MVA, pedestrian, bicycle, assault (National Pediatric Trauma Registry, 1999)Slide4

Peitzman

, 2008)Slide5

Age Appropriate Assessment

Table summarizing age specific vital signs from

ATLS or CHOP

Benedum

Pediatric Trauma Program, Field

Reference (need permission)

Age

and weight

Vital Signs

Mental Status

Skin

Urine outputSlide6

Assessment in

Peds

Patients

Hypoventilation, hypoxia cause

cardiorespiratory

arrest

Poor end organ perfusion evidenced by hypotension, but also decreased cap refill, mental status change, and low urinary

output

GMC and GCS equivalent predictive for injury (Cicero, 2013)Slide7

Age Appropriate Equipment

Table summarizing age specific

equipment

from CHOP

Benedum

Pediatric Trauma Program, Field

Reference or ATLS

Age

and weight

ET tube

Foley

Broselow

tapeSlide8

Age-appropriate Dosing

Age and Weight

Rapid Sequence Intubation algorithm

PediStat

Broselow

TapeSlide9

Pediatric Resuscitation Approach

Approach airway—

Be prepared to secure airway with RSI

Enable patient to breath

in sniffing position

while

awaiting transport

Bottom line– Get the airway if it can’t waitSlide10

Pediatric Resuscitation Approach

Assess breathing–

Assess circulation–

Apply direct pressure to bleeding wounds

Fluid resuscitation:

Type

and

crossmatch

for multiple units

Place large bore

IVs, tibial

i

ntraosseous

(IO)Slide11

Diagnostic evaluation: imaging

Proceed to imaging if any

suspicion

of occult injury

Pediatric small frame more frequent multisystem injurySlide12

Diagnostic evaluation: lab

Proceed to imaging if any suspicion whatsoever of occult injury

Airway compromise or other injuries may have delayed presentationSlide13

Additional Management

Early consultation with surgeon

Transport to pediatric trauma center when possibleSlide14

Summary

Similar approach to

rescusitation

in adults

Age appropriate assessment, equipment, and dosing

Remember differences in cardiovascular responseSlide15

References

Cicero MX, Cross KP. Predictive value of initial Glasgow Coma scale score in pediatric trauma patients. Pediatric Emergency Care, 29(1):43-38, 2013.

American College of Surgeons, Advanced Trauma Life Support for Doctors (Student Manual), 8

th

Edition, Oct 2008.

Peitzman

A. The Trauma Manual: Trauma and Acute Care Surgery,

3

rd

Edition, 2008.

Lippincott Williams & Wilkins.Slide16

Simulation Training Assessment Tool (STAT)– Pediatric Trauma

Amanda

Cuda

, MPH, MDSlide17

CRITICAL

ACTIONS

MS

2

3

4

SUSTAIN

IMPROVE

Lead resuscitation at

bedside w/ clear coms

Assess airway–

GCS<8,

head injury

Proceed

to RSI

Assess breathing – clear BS, CXR

Assess circulation

– confirm

hypovolemia

, begin IVF resuscitation

Vital signs now 80/40,

HR 150; discover after RSI that IV is no longer functioning. If order fluids prior to RSI, then IV does not function. Process to

tibial

IO placement.

Assess

D

, E and Secondary Survey

Finish safety net–

incl

IV x 2 contra to

inj

, T&C multi units, post-

intub

CXR with RT, possible

abx

Disposition to medevacTOTAL

SCENARIO ALGORITHMSET UPTrauma room w/ IV, O2, trauma equipPediaSim or equivalent w/ bruising moulage to abdomen & bleeding from scalp, lying flat , in c collar and on back boardBroselow tape and bags/cart, Airway equip, RSI drugsBandagesPRE ARRIVALAs a family physician, you are working in a community hospital ER6 yo male; EMS s/p MVA, restrained in backseat, booster/seat belt, has bleeding scalp, decreased mental status, and abdominal bruising, IV establishedVSS BP100/50 HR120 RR12 POX92%PRIMARY SURVEYA- Slow breathing, no obvious obstruction, making moaning noises and occasionally speaking coherentlyB—BS CTA, no chest injuriesC– BP100/80 HR120 RR12 POX92D– PERRL, not moving extremities when arrives, speaking but not coherentE– Scalp laceration with some surrounding swelling of scalp; also has abdominal bruising in seat belt distributionSECONDARY SURVEYPatient with no other injuriesLABS & IMAGESPOC labs WNL. Post intubation CXR shows tube in adequate positionDISPOSITIONSurgeon arrives after intubation and IVF resusitation and secondary survey.

Simulation Training Assessment Tool (STAT)– Pediatric Trauma

Date:

Instructor(s):

Learner(s):

Learning Objectives:

1.

Recognize

common

mechanism of

pediatric trauma

2. Demonstrate knowledge of age-appropriate physiology, assessment, equipment, and dosing

3. Demonstrate

appropriate approach to resuscitation in a pediatric trauma patient

4. Demonstrate proper placement of

tibial

IO in pediatric patient.Slide18

Debriefing Notes

Approach to pediatric resuscitation is the same as for adults. Review each step and unique aspects of pediatric care

Airway

Breathing

Circulation

Disoability

Age appropriate decision making must be done. Use

Broselow

tape.

.

In approaching imaging,

remember multisystem trauma. Head CT – non contrast, abdominal CT – with and without contrast if

possilble

Early consultation with surgical trauma team

Remember to start broad spectrum antibiotics promptly if

aerodigestive

injury is suspected.

Review

age appropriate vital signs, equipment choice, and dosing of medications–

Beware—injuries

in one

area will often have other injuries.

This case is a

multisystem

injury with

decreased mental status and compromised

airway.

Head or

a

bdominal trauma, if present and with the following signs

indicate direct disposition to OR and include—

Unstable vital signs

Active bleeding

Hematemesis

or

hemoptysisLarge, expanding, or pulsatile hematoma Neurologic deficit Slide19

Additional Instructor Notes

Case Synopsis

6

yo

male suffered a

mild traumatic brain injury

and abdominal contusion as a result of being a restrained passenger in a high velocity (55mph) MVA. He

has decreased mental status and it has worsened since EMS arrival on scene and through transport to hospital. He is

able

to maintain

airway prior

to

arrival but on arrival, the

pt

is

somnolent and

should be intubated quickly with RSI drugs using IV that was placed by EMS.

Could consider

requirement of

intraosseous

placement with IV that now can’t flush

or IO may be attempted immediately.

Once

IO and intubation are

performed, VS will immediately stabilize. Learner must continue through the ABCs and the rest of the critical actions.

Consider telling the learner that the patient is moving around if post-RSI sedation not given by the end of the case.

If

intubation and fluid resuscitation are

not performed, the patient will die in about 5 minutes with falling Pox and other vital signs ending in

asystolic

arrest. The patient cannot be saved if this occurs.

Personnel and Roles

Instructor—Introduces case, switches to “EMS” as case begins, provides ancillary data as requested and plays

“Neurosurgeon” at the end of the caseAssistant (may be resident) —Acts voice of patient, manages respiratory distress in PediSIM and manages monitor (tell Primary Learner that the assistant will be the patient’s voice prior to entry)Primary learner (resident)—Is the responding doctor. May lead the Trauma Team response or act as sole provider, depending on how your institution manages traumaSecondary learners (residents)– Prompt primary learner to assign roles, e.g. Airway, Procedures, Nursing etc prior to beginning case. Props/Supply ChecklistPediSIM w/ ability to intubate and perform tibial IOMoulage for MVA with blood on scalp with laceration and bruising of the abdomen. Airway equipment–Broselow bag/tape, aryngoscope, suction, BMV, RSI drugsIO set – use IO that is available in your organization. Supporting StimuliEMS Run Sheet– give to learner at start of casePoint of care labs– give to learner only if ordered, after credible time lapsePost intubation CXR– give to learner only if ordered, after credible time lapseSlide20

EMS Run Sheet

6

yo

male

s/p

MVA with bleeding scalp, decreased mental status, abdominal bruising

BP 100/50

HR 120

RR 12

POX 92%Slide21

Point of Care Labs

Sodium:

140

Potassium

: 3.8

Chloride: 106

TCo2:

25

BUN

:

15Creatinine: 0.9Glucose

:

100

Hemoglobin 11.4

Hematocrit 32.5Slide22

Need

peds

non con head CT that is normal

Need

peds

abdominal CT that is also normal