Initial Evaluation Of The Pediatric Trauma Patient

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INITIAL EVALUATION OF THEPEDIATRIC TRAUMA PATIENTRio Grande Trauma ConferenceDecember 5, 2019Grace Ng, MD

Disclosures I have no financial affiliations to disclose

Objectives Review current pediatric trauma statistics at UMC/EPCH Understand why children are not small adults Discuss tools to evaluate the pediatric trauma patient How to perform an initial evaluation of the pediatrictrauma patient Discuss special considerations during initial evaluation

Introduction Trauma is the number one cause of morbidity and mortality inchildren. 1 in 4 children sustain an unintentional injury requiring medicalcare each year. An estimated 17.4 million children do not have access to apediatric trauma center within 60 minutes.Management of Pediatric Trauma Pediatrics Volume 138 No 2 August 2016

2018 Pediatric Trauma StatisticsLevelNumber ofActivationsPercentage ofTotal ActivationsFull (Level 1)8815%Limited (Level 2)9516%Consultation (Level 3)40068%Direct Admits71%Total590100%

Pediatric Mechanism of InjuryMechanism of InjuryPercentageFalls40%MVC19%Assaults5%Auto vs Pedestrian4%Burns3%GSW2%MCC1%SW1%Other (animal, water, machinery,sports)20%

Pediatric Admissions By Age 8509084511ISS 1511118691055**79 pts not admitted (post ED Home, LAMA, Burn Center, Mental Health/Psychiatric Hospital and Morgue)

Children areNOTsmall adults

Children are not small adults Larger body surface area to body mass ratio Higher respiratory rate Less fluid reserve Less circulating volume Less fat, more elastic connective tissue, pliable skeleton Developmental vulnerabilitiesWathen et al. Pediatric Trauma Module 4. University of Colorado

Pediatric Normal Vital Signs

Broselow Tape

The Trauma Evaluation Airway Breathing Circulation Disability Exposure Family PresenceAmerican Academy of Pediatrics: Module 4 of the Pediatric Education in Disasters Manual

Airway Larger occiput Smaller airway Larger tongue Floppy epiglottis Vocal cord slanted Larynx is higherand more anteriorQuick Hits for Pediatric Emergency Medicine pp 1-5 Airway: PediatricAnatomy, Infants and Children

Airway Jaw thrust - maintain c-spine precautions BVM LMA Needle cricothyroidotomy– jet insufflation Surgical cricothyroidotomy:age 12 years IntubationThe Pediatric Airway and Rapid Sequence Intubation in Trauma. Sulton et al. 2017

Breathing Hypoventilation bradycardia cardia arrest Rib position more horizontal Abdominal musculature usediaphragm use Fewer type 1 muscle fibers Higher oxygen demand higher respiratory ratesMarr S. (2017) Respiratory Monitoring. In: Dabbagh A., Conte A., Lubin L. (eds) Congenital Heart Disease in Pediatric and Adult Patients. ual/how-are-children-different

Circulation Check perfusion Capillary refill Peripheral pulses No utility of permissive hypotension in pediatric trauma Do not equate pediatric blood loss to that of adult Total blood volume 75-80 ml/kg Initial fluid bolus 20 ml/kg NS Blood bolus: 10 ml/kg PRBC Tachycardia is an EARLY marker of hypovolemia Hypotension is a LATE identifier

Shock Index Pediatric-AdjustedSIPA maximum heart rate/minimum systolic blood pressureAgeSIPA4–6 years7–12 years13-16 years 1.22 1.00 0.90Risk of blunt injuryif SIPA is elevated22.0%25.1%32.0%

Disability Check hypoglycemia Quick neurologic assessment Alert Responsive to verbal/painful stimuli Unresponsive Pupillary exam Gross movement of all 4 extremities Glasgow coma scale for pediatricsHead Injury GCS 13-15: Mild GCS 9-12: Moderate GCS 8: Severe

Glasgow Coma Scale- EyeInfant ( 2 year)Pediatric ( VoiceVoiceVoice3PainPainPain2NoneNoneNone1

Glasgow Coma Scale- VerbalInfant ( 2 years) Pediatric ( 2 years)AdultScoreCoos, babblesAppropriate word/phraseOriented5Irritable ent grunts topain; eNoneNone1

Glasgow Coma Scale- MotorInfant ( 2 year)Pediatric ( 2 year)AdultScoreSpontaneousObeysObeys6Localizes painLocalizes painLocalizes 4Flexion/decorticateFlexion/decorticateAbnormal flexion(decorticate)3Abnormal extension(decerebrate)2None1Extension/decerebrate Extension/decerebrateNoneNone

Exposure Promptly evaluate for external signs ofinjury WARM THE ROOM, WARM THEPATIENT Higher basal metabolic rate andsurface area Higher oxygen consumption Higher respiratory rates and heartrates Larger surface area to body massration greater heat loss

Secondary Survey Once the primary survey is adequately assessed Perform a detailed head to toe exam Let’s revisit pediatric vital signs

Pediatric Normal Vital Signs

Adjuncts CXR Pelvic XR FAST exam

Common Traumatic Injuries Thinner/moreflexible skull Disproportionatelylarger head C -spine injuryusually higher Ribs/sternummore elastic Underlyinginjury withoutoutward signs Radius/ulnar/femur mostcommon Splint/reduce Thin wallDecreased AP diameterIncreased lordosisProportionately largerspleen/liver Organs below the rib cage Kidney more anterior/less fat

Special Circumstances Non accidental trauma Child maltreatment refers to acts of commission (deliberate orintentional inflicted injury referred to as child abuse or nonaccidental trauma (NAT) or omission in children under 18 years ofage 674,000 children classified as victims of maltreatment in 2017 Estimated 1,720 child deaths from maltreatment in 2017, 11%increase from 2013 Look for sentinel injuries: injuries suspicious for physical abuse Apply clinical screening vigilantly and follow up with appropriatelaboratory testing, radiographs, and appropriate consultingservicesACS Trauma Quality Programs Best Practices Guidelines For Trauma Center Recognition of Child Abuse, Elder Abuse, and Intimate Partner Violence

Non Accidental Trauma A thorough history and physical is key Delay in seeking care At risk social factors in the immediate family Lack of correlation between history and observed injury Note interactions/affect/responses of caretakers Injury of mechanism inconsistent with appropriate development Note Bruising patterns (frenulum, torso, ear, neck, jaw, cheek,eyelids, subconjunctiva, patterned bruising related to an object) Note fracture patterns (Ribs, Femur, Humerus)ACS Trauma Quality Programs Best Practices Guidelines For Trauma Center Recognition of Child Abuse, Elder Abuse, and Intimate Partner Violence

Children are not small adultsTHANK YOU!

Objectives Review current pediatric trauma statistics at UMC/EPCH Understand why children are not small adults Discuss tools to evaluate the pediatric trauma patient How to perform an initial evaluation of the pediatric trauma patient Discuss

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