Paediatric Trauma - Emergency Management

Paediatric Trauma

·        Most common cause of death < 14 years (way out in front)

·        Under 1 year: cause of death – congenital abnormalities > infection > trauma

·        Trauma: poisoning > suffocation > MVA

·        What makes kids different:

o   Large, poorly supported head. Always land head first 

o   Thin skin ® ­evaporative skin losses and burn at a lower temperature

o   ­Surface area: mass ration ® ­rate of heat loss

o   Relatively large, poorly attached spleen

o   Renal function, conserves water, secretes sodium

o   Greenstick fractures 

o   Child abuse: differential diagnosis in all cases of trauma (do history and physical findings correlate)

·        Dealing with children:

o   Never lie – say if it‟s going to hurt

o   Kid that is injured will almost always have been injured doing something they were told not to do – child will consider you part of the punishment

o   Parents will get mad at you because they feel guilty.  Wear it – this is not the time to deal with it

o   Child will regress

Resuscitation

·        Summary:

o  A. and cervical spine

o  B.C.

o  Exsanguinating haemorrhage (if it‟s not bleeding, ignore it)

·        Get help early

·        Airway and cervical spine immobilisation: Look/listen/feel

o  Airway opening: Jaw thrust

o  Suction of foreign material under direct vision

o  Airway devices:

§  Oropharyngeal/nasopharyngeal airways, ET tube, surgical airways. 

§  Oropharyngeal: Right size: should reach from midline of lips to angle of the jaw. Use tongue depressor to help insert oropharyngeal (cf adult)

·        Breathing:

o  Monitor:

§  Work of breathing: rate, noises, recession, accessory use, grunting

§  Effectiveness of breathing: breath sounds, chest expansion, SpO2

§  If inadequate commence assisted ventilation

o  Indications for intubation:

§  Inadequate O2 via bag mask

§  Inability to protect airway (eg do they have gag reflex, muscle tone in jaw, etc)

§  Prolonged ventilation required, or control required (eg in transport)

§  Flail chest

§  Inhalational burn injury

o  Intubating 

§  If using sedating drugs, must be confident you can completely manage ventilation, do surgical airway if necessary, etc

§  Pre-oxygenate if possible with high flow O2

§  Need: working, correctly sized laryngoscope, suction, bag valve mask, syringe

§  Take collar off to intubate

§  Tube size = (age/4) + 4 (or size of kids little finger)

§  Must secure tube or it will slide out

§  Ausciltate the chest to check air entry and check end-tidal CO2

o  Identify and treat life-threatening problems: 

§  Tension pneumothorax: ¯sounds on affected side, trachea shifts to good side ® needle decompression in 2^nd intercostal space, midclavicular line, then chest drain. Little harm if they don‟t have a pneumothorax. 

§  Open pneumothorax: 3 sided sealed dressing then chest drain

§  Massive haemothorax: chest drain and cardiothoracic consult 

§  Flail chest: intubate and ventilate. Rare in kids as ribs too spongy – but can get very severe injury without breaking ribs 

§  Cardiac tamponade: Urgent cardiothoracic consult

·        Circulation: 

o  Assess: heart rate, pulse volume, central capillary refill < 2 secs (eg over sternum after 5 secs pressure), skin temperature

o  Identify and treat life threatening problems:

§  Shock

§  Stop uncontrolled haemorrhage

§  Stabilise pelvis

o  Initial management of shock:

§  O2 

§  Large IV line placement. If can‟t then inter-osseous needle. 1 cm medial and distal to tibial tuberosity. Have to squeeze in fluid 

§  Crystalloid 20 mls/kg bolus. Reassess and repeat if needed. After that, warmed blood. After transfusion of > ½ blood volume then FPP.

§  If still unstable consider blood and urgent surgical opinion

·        Keep them warm

·        Disability (ie simplified coma scale):

o   A: Alert

o   V: Responds to voice

o   P: Response to pain

o   U: unresponsive

o   Pupils and posture (decorticate/decerebrate)

·        Exposure:

o   Uncover to inspect for injuries

o   Keep warm and minimise embarrassment

·        Glucose: all severely injured children at risk of hypoglycaemia: check during primary survey 

·        Assessment:

o   Monitors: Pulse/BP/RR/SpO2/Temperature + EtCO2 if intubated 

o   History taking: parents/ambulance crew/child, past medical history, medications, allergies, last meal 

o   Blood tests: baseline FBC and U&Es, cross matching, glucose 

o   X-rays: Trauma series – AP chest, AP pelvis, lateral C-spine. NB Soft bones are less likely to break despite strong force Þ ­chance of internal organ damage in absence of breaks than in an adult (eg ribs) 

o   Urinary catheterisation/naso-gastric tube placement

o   Analgesia: morphine, 0.1 – 0.2 mg/kg IV (not IM) 

o   NG tube to empty stomach: kids graze all day so stomach never empty. Also, swallow lots of gas when in pain ® tube lets air out ® ¯risk of aspiration due to pressure in stomach and less pressure on thorax

·        Then secondary survey: head to toe inspection

Traumatic Injury

·        Head injury almost never causes shock

·        Frequency of visceral injury: spleen > liver > kidney 

·        Splenectomy. The younger the child the greater the risk of fatal post-splenectomy sepsis (adults have greater previous antigenic exposure so less susceptible). Leave it in if vital signs stable

·        Kidney trauma: most common injury is contusion ® mild haematuria

·        Bladder: easily ruptured

·        Closed head injury:

o   Full neuro exam

o   Level of consciousness: Awake, responds to Voice, to Pain, or is Unresponsive

o   Localising signs: can be very subtle, watch for changes

o   Pupils

o   Can rupture middle-meningeal artery without fracturing skull

·        Pain management: early – consider regional blocks (eg femoral nerve block in fractured femur)

Car crash

·        Without seat belt, risk of death is ­10 times.  All children being held in the front seat die

·        Assessment of severity:

o   Speed of crash

o   Was seatbelt on

o   Was child thrown from car

o   Was any other child killed

Burns

·        > 50 % of burn admissions are children

·        Full thickness burns don‟t hurt (nerves are dead)

·        Partial thickness burns blister and heal

·        Rule of 9‟s doesn‟t work – needs age adjustment

·        Fluid resuscitation: Ringer‟s 4ml/kg/% of burn (half in 1^st 8 hours) + maintenance (ie pour it in till they urinate)