Discuss broadly anatomical and physiological difference in paediatric population in trauma compared to adults
Force is more widely distrubted through the body of child making multisystem trauma more likley.
The younger the patient the greater the surface area to weight ratio and greater potential for heat loss leading to acidosis and coagulopathy
Child physiological to injury is robust and can maintain BP despite 30% volume loss. CO is increased almost solely by HR so trauma or hypovolaemia should be thought of in a tachycardic child
Child head to body ratio is greater, the brain is less myelinated and cranial bones are thinner resulting in more serious head injury
Abdominal
- The Childs internal organs are more susceptible to injury due to a more anterior placement of liver and spleen
- Diaphragm is flatter placing the liver and spleen further into the abdomen
- Less protected from ribs
- less protective musculature and sub cut tissue mass
- the Childs kidney is less well protected and more mobile making it susceptible to deceleration injury
- Bladder is an intra-abdominal organ in young children
Respiratory
- The elasticity of the child chest wall allows for pulmonary injury without skeletal injury
- More horizontal ribs - limits potential for thoracic expansion
- o2 consumption is high 7ml/kg/min (3-4ml in adults)
- Alveolar minute volumeis greater and the FRC is realativly low
- physiological dead space is similar to adult but the absolute volume is small so that any increase caused by apparatus dead space is proportionally greater
MSK
-Growth plates are not yet closed in the paediatric population leading to salter type fracutres with possible resultant limb length abnormalitlis
Neuro
-Children have a more tenuous spinal cord blood supply and greater elasticity of the vertebral column predisposing them to spinal cord injury without radiographic abnormality (sciwora)
Discuss equipement size estimate in children
Cuffed ETT (age/4)+4 uncuffed ETT (age/4) +3.5 Depth of ETT = (tube size) x3 or (Age/2) + 12 Largest size of ICC = ETT size x4 OGT, NGT or foley diameter = 2x ETT
Femoral line <3kg = 3f 3-10 = 4F 10-20 = 5F >20 = 6 F
Discuss management of the airway and c-spine in trauma in paeds
Look at Paeds airway cards for anatomical and physiological difference in intubation
Spinal motion restriction should be maintained with signifiacnt mechanisms of injury or increased risk of spinal injury with trauma (Downs, Ehlers danlos) or any signs of neurological deficit
Safe apnoea is reduced in children due to increased o2 demand 7ml/kg and reduced FRC
Discuss management of breathing and circulation in children
Breathing:
Be careful of insufflation of the stomach with BVM as this can impair diaphragmatic movement lead to respiratory embarrassment and potential hypotension
C:
-Child may be profoundly shocked from blood loss resulting from trauma well before the occurence of hypotension.
-60-90 seconds to achieve IV otherwise IO
-20ml/kg
Blood volume is 75-80ml/kg
Discuss assessment of neurology - S
Level of conciousness can be assessed using AVPU or modified GCS - AVPU easiest with scores of P or U correleating relatively well to GSC 8 and below indicated need for ETT
Pupil size and reactivity
Extremity movement and tone
Posturing and reflexes
Discuss modified GCS for paeds
Eye and motor similar to adults
Voice 0-2 5-bables, coos 4- cires but consolable 3-persistnet crying or screaming to pain 2- grunts or moans to pain 1 - none
Voice 2-5 5-appropraite words or phrases 4- inappropriate words 3-persistnet crying or screaming to pain 2- grunts or moans to pain 1 - none
Voice >5 5-oriented and converses 4- confused conversation 3-inapprorppaite words 2- incomprehensible sounds 1 - none
Discuss ATMIST and AMPLE
A:- age name and DOB
T: time of incident or onset of symptoms
M: mechanism of injury and medical complaint
I: injuries/exam finding
S: signs
T: treatment given
A: allergies M:medications P: Past medical L: last ate E: Event and environment
Discuss locations of IO insertion
Proximal tibia just below growth plate Flattened part of distal femur Proximal humerous Distal TIb Sternum
Discuss anatomical difference in children in regards to head injury
Cranial vault is larger and heavier in proportion to the total body mass.
Sutures lead to a more pliable skull but allow forces to be generated internally which can lead to parenchymal injury in the absence of fracture
Paeds brain is less myelinated with higher water content predisposing it to acceleration and deceleration + sheraring forces further injury and post traumatic seizures. Seizures that occur at time of impact “impact seizures” are less likley to correlate to signifiacnt brain injury comapred to delayed seizures of 20minutes or more\
Unfused sutures and an open fontanelle can expand to accomodare intracrnail haemorrhage and oedema
Discuss imaging rules in peadiatric head trauma
Pecarn and Chalice and Catch
Discuss Pecarn rule
Age of child <2
1) GCS 14 or above without signs of AMS or skull fracture
- AMS (agitation, somnolence, repetitive questioning or slow verbal communication)
- If yes to above CT head If no next question
2)Occipital parietal or temporal scalp haemtoma;, history of LOC >5 sec, not acting normal per parent or severe mechanisms of injury
-Sever mech ( MVC with patient ejection, death of another passenger, rollover, pedestrian or bicyclist w/o helmet struck by vheicle, fall > 3 ft, head struck by high impact object)
If no for observation but exceedingly low risk of injury
If yes observation over CT with a 0.9% risk of clinically significant TBI depending on physician comfort
Age of child >2
1) GCS 14 or above without signs of AMS or skull fracture
- AMS (agitation, somnolence, repetitive questioning or slow verbal communication)
- If yes to above CT head If no next question
2)history of LOC >5 sec, or recurrent vomoiting or severe headache or severe mechanisms of injury
-Sever mech ( MVC with patient ejection, death of another passenger, rollover, pedestrian or bicyclist w/o helmet struck by vheicle, fall > 3 ft, head struck by high impact object)
If no for observation but exceedingly low risk of injury
If yes observation over CT with a 0.9% risk of clinically significant TBI depending on physician comfort
Discuss signs and symptoms of increased intracranial pressure in infants and children
Infants
- full fontanel
- split sutures
- altered level of consciouness
- paradoxical irritability
- persistent emeisis ‘
- “setting sun” sign
Children -headache -stiff neck -photophobia -altered state of consciouness persistent emesis -cranial nerve invovlement -papilloedema -HTN, brady and hypoventilation -decorticate or decerebrate posturing
Discuss emegent management of increased ICP
General neuroprotection
- Head elevation to 30 degrees
- Hyperventilation to pco2 26-30 if signs of significant ICP (short term for acute until definitive management) or low normal for prevetnion
- Normal glucose
- normal sodium
- maintenance of CCP
- normal temp
- manage seizures agressively
- Neuromuscular blockade helps reduce ICP
Hypertonic saline bolus (3%)
- 6.5-10ml/kg bolus
- does not cause hypovolaemia or fluid depletion safer in trauma than mannitol
- better reflection coeffecient
Discuss anatomical difference in the paeds C-spine
- Cervical spine fulcrum changes from c2-3 in toddles to c5-6 by 8-12
- Relatively larger head size resulting in greater flexion and extension injury
- Relatively large occiput in children younger than 2 years old leads to flexion of c-spine if they are laid flat on standard backboard without support under thier scapular and pelvis
- smaller neck muscle mass with ligamtentous injury more common than fracture
- Anterior wedge appearance of vertebral bodies is common
- growth plates
- pseudosubluxation of c2-3 seen in 40% of children 8-12 years of age
All of the above can lead to SCIWORA (spinal cord injury without obvious radiogrpahic eveidence)
Discuss NEXUS
Can be used to clear a c-spine
3000+ children in the study as apposed to canadian c-spine rule which excluding patient under 16
If all the follow-up are absent can clear c-spine
1) focal neurolgoical deficit present
2) midline spinal tenderness
3) altered level of conciouness
4) intoxication
5) distracting injury
Discuss swischuks line
Used to evaluate pseudosubluxation from true dislocation
A line drawn from the anterior aspect of the posterior arch of c1 to the anterior aspect of posterior arch of c3
- the anterior aspect of posterior arch of c2 should be within 1-2 mm of this line
- if>2mm true subluxation
- even if not cannot exclude hangmans fracture
Discuss evaulation of plain c-spine films - and
Should have AP, lateral and dens views
include all 7 c-spine bodies to the c7 T1 junction
-predental space should be less than 5mm ]
-prevertebral space should be half the adjacent body to c4 and than a whole body c5-7
three lines
Discuss management of spinal injury in children
Two phases of injury
- direct (initial phase) results in largely irreversible injury to the spinal cord.
- indirect injury (secondary) preventable or reversible injury to the spinal cord secondary to ischaemia hypoxemia and tissue toxicity
ABCD aimed at preventing indirectinjury
A: secure as indicated
B: patients with spinal cord injury may hypoventilate due to loss of diaphragmatic inervation or intercostal muscle paralyiss- supplemental o2 should be given as a routine
C: Can result from hypovolaemai, spinal shock, neurogenic shock or other less common causes.
Differentiate spinal and neurologcial shock
- Spinal shock usually results from injury above the level of t1 and manifest with lower extremity finding of spinal cord injury with flaccid paralysis of skeletal and smooth muscle leading to he appearance of relative hypovolemia caused by diminished vascular resistance
- generally resolves in hours to 24 hours
Neurological shock typically occurs after injury to the cord above the level of t6. They lose their sympathetic tone and demonstrate hypotension in the face of unopposed parasympathetic action
- Demonstrate hypotension and bradycardia
- respond to vaso and inotropes
Discuss management of massive haemothorax and indication for thoracotomy
Rare in children
Should have blood avialble for infusion
Cell salvage from ETT
Indications for thoracotomy in OR in children include
- 15ml/kg of blood after initial chest tube placement
- persistent blood loss exceeding 2-4ml/kg/hr over 3 hours
- persistent air leak
ED thoracotoamty is reserved for pateint with thoracic trauma who deteriatae to CPR despite maximal resuscitation in the out of hospital setting or in the ED
Discuss indication for laparotomy in paeds trauma
1) HD instability depite agressive resus and appropraite ED provedures
2) HD instability despite resuscitiave efforts and evidence of intraperitoneal free fluid on FAST
3) transfusion of>50% of ttoal blood volume due to massive intraperitoneal bleeding
4) Radiographic evidence of pneumoperitoneum, intraperitoneal bladder rupture or grade V renovascular injury
5) Gunshot to abdo
6) evisceration of intraperitoneal or stomach contents
7) signs of peritonitis
Discuss the difference evidence behind the Percarn, chalice and catch decision making tools
PECARN trial
- initial included 42412 children <18 uears old rpesenting to 1 of 25 North American emergency departments with 33785 (8502 <2) in the derivtion cohort and 8627 (2216 <2) in the validation cohort.
- In patients < 2years if age that were -ve for any PECARN risk factors the aid was 100% sensitive with NPV of 100% for ruling out ciTBI
- In patient > 2 years of age negative for any PECARN risk factors the aid was 96.8% sensitive with NPV of 99.95%
- Specificity of 53-60%
- Has been externally validated in 2 seperate studies found both times to be 100% sensitive
CHALICE predicts death need for neurosurigal intervention or CT abnormality in children with head trauma
- 22772 chidren recruited
- 91% sensitive on external validation
- Most specific 85%
Catch predicts clinically signifiacnt head injuries in chidlren
-3866 patient enrolled
-only 277 of the patient were under 2 year of age
-not separateed into subgroups
-missed three patients who did not require intervetion
Sensivity for high risk in realtion for neurolgocial intevertion
- 100% sensitive and 70.2% specific
Sensitivity for high and medium risk factors to presence of brain injury
- 98.1% sensitivt and 50.1% specific
-84% sensitive on external validation
Discuss major trauma predictors at high risk of life threatening injury
Mechanism
- Motocylcist, bicyclist or pedastrian impact at >30kph
- Crash speed >60 KMH
- Ejection
- Vehicle roll over
- Fall greater than 3m or more than twice the child height
- fatality in the same vehicle
- explosion and suspected inhalational burns
- extrication >30 mintues
Signs -RR <10 or >30 -SBP >75' -GCS >15 o2 >90
INjury
- serious or suspected serious blunt or penetrating injury to head neck or torso
- signifaicnt injury to two or more body areas
- bursn >20%
- two or more long bone fractures
- evisceration, severe crush injury, amputation, suspected spianl injury pelvic fracture
discuss problems associated with spinal immobilisation with hard collar in children
Hard collar
- Incorrect fit c -spine collar causing distraction of the spine or allowing excessive movement
- flexion of the spine in children under the age of 8
- Reduction in tidal volume and limitations of resp effort
- airway obsturction
- increased ICP due to reduction in venous drainage
- discomfort
- distress
