1. Pediatric Trauma Case Studies: Assessment and Intervention Ankush Gosain, MD, PhD, FACS Medical Director, Pediatric Trauma Program American Family Childrens Hospital University of Wisconsin – Madison 06 December 2012

2. Disclosures I do not have any relationships with commercial interests to disclose. I do not intend to reference unlabeled or unapproved uses of drugs or products in my presentation.

3. Objectives 1. To understand the incidence and epidemiology of pediatric trauma. 2. To understand pediatric anatomic and physiologic factors relevant to pediatric trauma resuscitation. 3. To understand the current approach to management of pediatric solid organ injury 3

4. Objectives 1. To understand the incidence and epidemiology of pediatric trauma. 2. To understand pediatric anatomic and physiologic factors relevant to pediatric trauma resuscitation. 3. To understand the current approach to management of pediatric solid organ injury 4

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10. Objectives 1. To understand the incidence and epidemiology of pediatric trauma. 2. To understand pediatric anatomic and physiologic factors relevant to pediatric trauma resuscitation. 3. To understand the current approach to management of pediatric solid organ injury 10

12. Children are NOT just small adults Anatomic considerations Physiology responds differently to trauma Injury patterns differ from adults

13. Anatomy - Airway Larger head Smaller jaw Short, narrow airway 13

14. Anatomy – Head/Spine 14

15. Anatomy - Head Soft cranium Open fontanelle – easy estimate of fluid status/intracranial pressure 15

16. Anatomy - Spine Spine –SCIWORA Flexible ligaments Pseudo- subluxation 16

17. Anatomy - Chest Soft flexible chest wall Weak muscles Significant force required to fracture ribs 17

18. Anatomy - Abdomen Liver and spleen project farther below the costal margin Thin abdominal wall Multiple injuries common 18

19. Physiology – Vital Signs Different normal range 19

20. Physiology Blood volume About 70-80 mL/Kg Resuscitation/Blood Loss need to be Weight-based 20

21. Physiology Vigorous ability to compensate for blood loss – typically increased HR May see very little change in vital signs until loss of 30% of intravascular volume 21

22. Physiology Sudden cardiovascular collapse 22

23. Physiology – Blood Loss System< 25% Loss25-45% Loss>45% Loss CardiacIncreased heart rate Weak pulse, increased heart rate Hypotension, tachycardia or bradycardia CNSLethargic, irritable Change in level of consciousness, dulled response to pain Comatose SkinCool, clammyCyanotic, decreased capillary refill, cold extremities Pale, cold 23

24. Physiology - Thermoregulation Higher body surface area to mass ratio Thin skin Limited subcutaneous fat 24

25. Physiology – Hypothermia Keep them dry Keep them covered Keep the heat on Warmed fluids and blankets if available 25

26. Differences Between Adults and Children DifferenceImpact Large tongueEasy to obstruct airway High anterior larynxStraight blade for intubation Proportionately larger headPadding under torso Proportionately larger headCNS/head injuries more common Proportionately smaller torsoFewer chest and abdominal injuries 26

27. Differences Between Adults and Children DifferenceImpact Body more compactMultiple injuries more common Softer/thinner outer shellUnderlying organ injury Thin skin, less fatHypothermia! Vigorous compensatory responseSudden deterioration/arrest Medications/fluidsBroselow tape 27

28. Injury Prevention Helmets Window locks Seat belts/car seats Motorized vehicles 28

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30. Abuse/ Non-accidental trauma About 7% of admissions to a pediatric trauma center More severe injuries Younger Higher mortality (9%) 30

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32. NAT – History Delay in care Repetitive injuries Discrepancies Inappropriate responses Medical neglect 32

33. NAT – Physical Exam Multicolored bruises Femur fractures Unusual scald/contact burns Bilateral subdural hematoma Retinal hemorrhage 33

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37. Response to abuse Document the story Dont ask too many questions Treat the trauma Report, report 37

38. Objectives 1. To understand the incidence and epidemiology of pediatric trauma. 2. To understand pediatric anatomic and physiologic factors relevant to pediatric trauma resuscitation. 3. To understand the current approach to management of pediatric solid organ injury 38

39. Non-operative management of splenic trauma Prior to the 1960s – routine splenectomy for injury –not a vital organ Risk of OPSS recognized –Non-operative management championed in pediatric patients –Success led to adoption of practice by adult trauma surgeons in the late 1990s

40. Spleen Injury: Non- operative Management Hospital for Sick Children, Toronto –First proposed non-operative management in 1948 Upadhyaya & Simpson. Surg Gynecol Obstet. 1968. Douglas & Simpson. J Peds Surg. 1971. 40

41. AAST Spleen Injury Scale 41

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45. 45 Non-operative Management Rate Splenic SalvageLOS MortalityTransfusion Rate

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51. 51 - Grade of injury per AAST criteria - Grade I/II – Bedrest overnight - Grade III-V – Bedrest 2 nights - Night of bedrest = in hospital room by time of AM rounds, regardless of time of admission - Ambulate, with Hgb drawn 4 hours later - Discharge if stable Hgb - Time of obs reset if transfusion given - Resume normal activity in 6 weeks

52. 52 - 131 patients, 76 spleen, 59 liver - Mean grade of injury: 2.6 +/- 1.0 - Mean bedrest 1.6 +/- 0.6 nights - Mean LOS 2.2 +/- 1.3 days - If APSA guidelines had been used, bedrest 3.6 +/- 1.1 - 24 pts transfused (18%) - 2 deaths – TBI, grade V liver injury

53. AFCH Solid Organ Injury Protocol Grade of injury determined by radiologic (attending pediatric radiologist) and/or surgical evaluation (attending pediatric trauma surgeon) Bedrest definition – If the patient is in their room at the time of morning work rounds, regardless of time of admission, it isconsidered a night Bedrest observation –Grade I & II = One night –Grades III - V = Two nights –If both organs are injured the highest grade is used ICU admission only for hemodynamic change or other injuries requiring ICU monitoring (e.g. head injury) Period of observation reset to time zero if a transfusion is needed Ambulation begins after bedrest period –Patients that require ongoing hospitalization for other injuries are allowed to ambulate/move to chair using the protocol Serum Hgb level checked 4 hours after ambulation Discharge allowed for patients with stable hgb levels and no indication for ongoing hospital care Restriction from contact sports = 6 weeks 53

54. Objectives 1. To understand the incidence and epidemiology of pediatric trauma. 2. To understand pediatric anatomic and physiologic factors relevant to pediatric trauma resuscitation. 3. To understand the current approach to management of pediatric solid organ injury 54

55. Ankush Gosain, MD, PhD, FACS Medical Director, Pediatric Trauma Program gosain@surgery.wisc.edu (608) 263-9419 (office) Questions? Mary Anderson, RN, MSN, CEN, CPEN, SANE-A Program Manager, Pediatric Trauma Program MAnderson4@uwhealth.org (608) 890-8328(office)