PAEDIATRIC TRAUMA

Learning outcomes Approach to patient Approach to patient Differences compared to adult trauma Differences compared to adult trauma Specific injuries Specific injuries Head injuries Head injuries Spinal injuries Spinal injuries Abdominal injuries Abdominal injuries Extremities Extremities Burns Burns Children are not just little adults!

Trauma No 1 killer of after neonatal period No 1 killer of after neonatal period 50% of childhood deaths 50% of childhood deaths

Cause of trauma 0-1 yrs – falls, burns, drowning, suffocation 0-1 yrs – falls, burns, drowning, suffocation 1- 4yrs – RTC (occupant), burns, falls, drowning 1- 4yrs – RTC (occupant), burns, falls, drowning 4-15yrs – RTC (occupant, pedestrian), bicycle injuries, burns, drowning 4-15yrs – RTC (occupant, pedestrian), bicycle injuries, burns, drowning

Pediatric Trauma Same PRIORITIES as adults Same PRIORITIES as adults ABC’s first ABC’s first Parents may want to be present Parents may want to be present Remember analgesia Remember analgesia

Airway - problems At increased risk of obstruction At increased risk of obstruction Large head Large head Short neck Short neck Small oral cavity Small oral cavity Large tongue Large tongue <6mths nasal breathers <6mths nasal breathers

Airway - management Neutral position in infants Neutral position in infants Suction Suction Jaw thrust Jaw thrust Adjuncts Adjuncts

Breathing Respiratory Failure Leading Cause of Pediatric Cardiac Arrest

Breathing Increased respiratory rate Increased respiratory rate What is normal for 8 month old? What is normal for 8 month old? Slow rate = impending arrest Slow rate = impending arrest AGENORMAL RR <1 YEAR YEARS YEARS20-25 >12 YEARS<20

Breathing 3 Es: Effort – grunting, RR, nasal flaring, recession, use of accessory muscles Effort – grunting, RR, nasal flaring, recession, use of accessory muscles Efficacy – chest expansion, breath sounds Efficacy – chest expansion, breath sounds Effect – cyanosis, oxygen sats, mental status Effect – cyanosis, oxygen sats, mental status

Breathing Trauma specific: contusions contusions wounds wounds subcutaneous emphysema subcutaneous emphysema

Breathing Pliant chest walls Pliant chest walls Rib fractures rare Rib fractures rare Pulmonary contusions common Pulmonary contusions common

Breathing - management Oxygen Oxygen Ventilate / intubate if required Ventilate / intubate if required Analgesia Analgesia Treat pneumothorax if present Treat pneumothorax if present

Circulation Silence is not Golden Silence is not Golden

Circulation Small blood volume Small blood volume Good initial compensation for hypovolemia Good initial compensation for hypovolemia

Circulation BP monitoring BP monitoring Poor method Poor method To assess perfusion, check: To assess perfusion, check: Pulse rate, quality of peripheral pulses Pulse rate, quality of peripheral pulses Skin temperature Skin temperature Capillary refill Capillary refill Level of consciousness Level of consciousness

Shock Management Keep warm Keep warm Fluid Resuscitation- Fluid Resuscitation- Volume weight based Volume weight based Reassess Reassess Repeat boluses as indicated by response Repeat boluses as indicated by response

Special circumstances

Head Trauma Major cause of deaths Major cause of deaths Unfused sutures allow significant intracranial haemorrhage which can lead to shock Unfused sutures allow significant intracranial haemorrhage which can lead to shock Scalp wounds can lead to anaemia Scalp wounds can lead to anaemia

Head Trauma Key symptoms – headache, vomiting, irritability or drowsiness Key symptoms – headache, vomiting, irritability or drowsiness Neurological examination varies with age - Observation key Neurological examination varies with age - Observation key

Severe Head Trauma May need to intubate to scan May need to intubate to scan Controlled ventilation Controlled ventilation Maintain normal BP Maintain normal BP CPP = MAP - ICP

Spinal Trauma SCIWORA – Spinal cord injury without radiographic abnormality X-rays and CT look normal X-rays and CT look normal Usually affects spine Usually affects spine Due to elasticity of spine Due to elasticity of spine Abnormalities now usually seen on MRI Abnormalities now usually seen on MRI

Abdominal Trauma Primarily blunt Primarily blunt Organs are vulnerable Organs are vulnerable Spleen, liver = Most common injuries Spleen, liver = Most common injuries High costal arch High costal arch Relatively larger organs Relatively larger organs Poor abdominal muscle development Poor abdominal muscle development

Abdominal Trauma Contusions Contusions Tenderness Tenderness Unexplained hypovolemic shock Unexplained hypovolemic shock

Extremity Trauma Never warrants attention before head, chest, abdomen injury Never warrants attention before head, chest, abdomen injury Think of neurovascular supply Think of neurovascular supply Evaluate distal extremity for: Evaluate distal extremity for: Skin color, temperature Skin color, temperature Motor, sensory function Motor, sensory function Capillary refill Capillary refill Pulses Pulses

Burns Pediatric patients Pediatric patients 50% of burn admissions 50% of burn admissions 33% of burn deaths 33% of burn deaths Challenges due to Challenges due to Immature immune system Immature immune system Small airways – increased complications Small airways – increased complications Fluid and heat loss Fluid and heat loss

REMEMBER IN ALL CASES TO CONSIDER POSSIBLE NON ACCIDENTAL INJURY

Questions

Summary Same PRIORITIES as treating adults Same PRIORITIES as treating adults ABCs ABCs Neutral head position in infants Neutral head position in infants Prone to intra-thoracic and abdominal organ injury Prone to intra-thoracic and abdominal organ injury Will compensate until fall off cliff Will compensate until fall off cliff