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
Download Presentation The PPT/PDF document "Trauma - Pediatrics Amanda S. Cuda, MD,M..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
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