Pediatric Trauma Case Studies:Assessment and Intervention

Ankush Gosain, MD, PhD, FACS

Medical Director, Pediatric Trauma Program

American Family Children’s Hospital

University of Wisconsin – Madison

06 December 2012

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.

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

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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

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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

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Children are NOT just small adults

Anatomic considerations

Physiology responds differently to trauma

Injury patterns differ from adults

Anatomy - Airway

Larger head

Smaller jaw

Short, narrow airway

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Anatomy – Head/Spine

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Anatomy - Head

Soft cranium Open fontanelle –

easy estimate of fluid status/intracranial pressure

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Anatomy - Spine

Spine–SCIWORA

Flexible ligaments

Pseudo-subluxation

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Anatomy - Chest

Soft flexible chest wall

Weak muscles Significant force

required to fracture ribs

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Anatomy - Abdomen

Liver and spleen project farther below the costal margin

Thin abdominal wall

Multiple injuries common

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Physiology – Vital Signs

Different normal range

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Physiology

Blood volume

About 70-80 mL/Kg

Resuscitation/Blood Loss need to be Weight-based

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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

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Physiology

Sudden cardiovascular collapse

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Physiology – Blood Loss

System < 25% Loss 25-45% Loss >45% Loss

Cardiac Increased heart rate

Weak pulse, increased heart rate

Hypotension, tachycardia or bradycardia

CNS Lethargic, irritable

Change in level of consciousness, dulled response to pain

Comatose

Skin Cool, clammy Cyanotic, decreased capillary refill, cold extremities

Pale, cold

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Physiology - Thermoregulation

Higher body surface area to mass ratio

Thin skin Limited subcutaneous fat

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Physiology – Hypothermia

Keep them dry Keep them covered Keep the heat on Warmed fluids and blankets if

available

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Differences Between Adults and Children

Difference Impact

Large tongue Easy to obstruct airway

High anterior larynx Straight blade for intubation

Proportionately larger head Padding under torso

Proportionately larger head CNS/head injuries more common

Proportionately smaller torso Fewer chest and abdominal injuries

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Differences Between Adults and Children

Difference Impact

Body more compact Multiple injuries more common

Softer/thinner outer shell Underlying organ injury

Thin skin, less fat Hypothermia!

Vigorous compensatory response Sudden deterioration/arrest

Medications/fluids Broselow tape

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Injury Prevention

Helmets Window locks Seat belts/car seats Motorized vehicles

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Abuse/ Non-accidental trauma

About 7% of admissions to a pediatric trauma center

More severe injuries Younger Higher mortality (9%)

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NAT – History

Delay in care Repetitive injuries Discrepancies Inappropriate responses Medical neglect

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NAT – Physical Exam

Multicolored bruises Femur fractures Unusual scald/contact burns Bilateral subdural hematoma Retinal hemorrhage

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Response to abuse

Document the “story” Don’t ask too many questions Treat the trauma Report, report

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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

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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

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.

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AAST Spleen Injury Scale

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Non-operative Management Rate

Splenic Salvage LOS

Mortality Transfusion Rate

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- 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

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- 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

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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

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

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Ankush Gosain, MD, PhD, FACSMedical Director, Pediatric Trauma Program

gosain@surgery.wisc.edu(608) 263-9419 (office)

Questions?

Mary Anderson, RN, MSN, CEN, CPEN, SANE-AProgram Manager, Pediatric Trauma ProgramMAnderson4@uwhealth.org(608) 890-8328(office)