TRAUMA

TRAUMA

Pediatric Critical Care MedicineEmory University

Children’s Healthcare of Atlanta

2

Epidemiology• 22 million children/yr• 1 on 4 suffer serious injury/year• More children die from trauma than other causes

combined

3

Management• Like any other critical patient: it’s all about the

ABC

4

Trauma• ABCs• Differences:

– Size– Injury pattern– Fluids– Surface area– Psychological – Long term effects

Trauma• A= airway• B= breathing• C= circulation• D = D’Brain• E= electrolytes• F= fluids

• G= GI• H= heme• I= ID• J= Joints• K= kidney

5

6

Airway• Usually secured in ER but occasional mental

status or respiratory effort changes & adjuncts necessary

7

Airway Intervention• Control of ventilation• Circulatory failure (shock)• Upper airway obstruction• Acute respiratory failure

Airway Intervention• Size of tongue, oral cavity &

upper airway• Position of the larynx• Anatomy of the epiglottis• Position of the vocal cords• Narrowest portion of the

airway

8

9

B- breathing• Trauma can lead to difficulty with both

oxygenation & ventilation

B- breathing• Pulmonary contusion

– Injury to lung parenchyma, leading to edema & blood collecting in alveolar spaces

– Poor gas exchange, increased resistance & decreased compliance

10

11

B- breathing• Pulmonary contusions

– 50-60% w/ significant contusions will develop ARDS

– approximately 20% of blunt trauma patients with an Injury Severity Score over 15

– is the most common chest injury in children

12

B- breathing• Pulmonary contusion

– Worsens over 24-48 hours– Resolves 3-5 days– Pneumonia is also a common complication of pulmonary

contusion

– Care is supportive

B- breathing• Pneumothorax

– Pneumothorax is the collection of air in the pleural space. Air may come from an injury to the lung tissue, a bronchial tear, or a chest wall injury allowing air to be sucked in from the outside

13

14

B- breathing• Pneumothorax

– Treatment depends on size» Small pneumothorax can be watched» Large require chest tube

15

B- breathing• Also other injuries may effect the way one

controls the breathing– TBI keep PCO2 normal to low normal

16

C- circulation• Most often difficulty with BP is related to

hypovolemia– Volume , volume, volume– Normal SBP 70 + (2x age)– Normal MAP 50 + (2x age)

17

C- circulation• Unless blood loss no acute benefit of crystalloid

over colloid

18

C- circulation• Cardiac contusion

– hypotension and arrhythmia

– diagnosis of a cardiac contusion and identification of patients at risk remain a challenge

19

C- circulation• Cardiac tamponade

– caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise

• Cardiac tamponade– Narrow pulse pressure– increased jugular venous pressure, hypotension, and

diminished heart sounds

– Give volume– Pericardiocentesis

C- circulation

20

21

C- circulation• TBI

– Need to maintain CPP (age dependent)» CPP= MAP-ICP» May need pressors to maintain

• Most often Dopa or NE

22

D= D’Brain• Wide array of injuries from contusion and DAI to

bleeds• Intervention depends on injury• Most common difficulties in PICU are AMS, ICP

issues and SZ

23

D= D’Brain• Traumatic seizures

– incidence of PTS for all types of head injuries is 2-2.5%

– increases to 5% in hospitalized neurosurgical patients

– Glasgow Coma Scale score <9 the incidence is 10-15% for adults and 30-35% for children

• Duration of treatment of traumatic seizures is a bit controversial

24

D= D’Brain • ICP

– HOB 30 degrees and midline– Normal temp– Normal CO2– Good pain and sedation control– 3% or mannitol– EVD

25

D= D’Brain – spinal cord• Flexible inter spinous ligaments• Underdeveloped neck muscles• Poorly developed articulations• Anterior vertebral bodies• Flat facet joints• Large head to BSA

26

D= D’Brain – spinal cord•Neurological injury represent 18% of pediatric

injuries and accounted for 23% of pediatric traumatic deaths (Durkin, et al., 1998).

•However, spinal cord injury in young children is rare accounting for only 5% of spinal cord injuries (Proctor et al., 2002)

27

D= D’Brain – spinal cord• Predisposed to serious high cervical injuries• Assume its presence in:

– Blunt injury above clavicle– Multisystem trauma – Significant injury - MVA, fall– Altered sensorium

28

D= D’Brain – spinal cord• Kids less than 2 yrs more likely C1-C2

– As increase with age approach more adult pattern C5-C6

• Kids much more likely to have ligamentous injury • Fractures involving the thoracolumbar spine in

tend to involve the junction between the thoracic and lumbar spine

29

D= D’Brain – spinal cord• spinal cord injury without radiographic

abnormalities• flexion/extension films of the cervical spine and CT

scans are also normal• Cervical and thoracic spinal levels are injured with

almost equal frequency and lumbar levels are rarely involved

• Consider MRI

30

D= D’Brain – spinal cord• mismatching of elasticity response between the

spinal column and spinal cord is the major factor contributing to the high incidence of SCIWORA injuries in young children

31

D= D’Brain – spinal cord• Steroids

– No good pediatric studies– Evidence in adults now controversial and leading toward

non use (Spine. 26(24S) Supplement:S39-S46) » Dosing if used: 30 mg/kg i.v. bolus within 8 hours followed

by 5.4 mg/kg/hour for 24 hours

32

D= D’Brain – spinal cord• Children with spinal cord injury may have

autonomic instability and hypotension– Fluid resuscitation– pressors

33

E= Electrolytes/Fluids• Glucose

– w/TBI usually no dextrose– Maintain 80-140– Stress may cause hyperglycemia– Adult lit increase mortality w/ hyperglycemia

34

E= Electrolytes/Fluids• Sodium

– If head injury use NS– Keep high end of normal up to 160’s if having cerebral

edema

• Calcium– If cardiac contusion make sure with in normal range– Low Calcium can promote arrhythmias

35

GI• Liver/Splenic Laceration

– most common injuries in blunt abdominal trauma– Often supportive care

» Follow HCT q4-6 hours» Transfuse HCT < 20-24 or hemodynamic instability

36

GI• Following the head and extremities, the abdomen

is the third most commonly injured anatomic region in children

• significant morbidity and may have a mortality rate as high as 8.5%

• abdomen is the most common site of initially unrecognized fatal injury in traumatized children

37

GI• Why more prone to abdominal injury

– child has thinner musculature – ribs are more flexible in the child – solid organs are comparatively larger in the

child– fat content and more elastic attachments

leading to increased mobility– bladder is more exposed to a direct impact to

the lower abdomen

38

GIImmediate Surgical Exploration

– Abdominal distention + “shock”– Transfusion requirement > 40 cc/kg– Peritonitis– Pneumoperitoneum– Bladder rupture

39

Heme• Often trauma can lead to blood loss• Use conservative management in giving blood• If necessary consider losing whole blood and

replacing PRBC

40

Heme• If significant amount of PRBC (generally > 3

transfusions) think about replacing factor and platelets

• If using the massive transfusion protocol this will happen automatically

• Additionally Blood will cause chelation and may need to give calcium

41

Heme• DIC

– Inappropriately accelerated systemic activation of coagulation

– Both the coagulation and the fibrinolytic systems are activated in trauma

• DIC– Widespread areas of tissue damage (particularly the

brain).» Head Injury common cause of DIC in infants and children

• Because of the high thromboplastin content of the brain• Proportionately increased ratio of surface area of the head to

total BSA.

42

Heme• DIC

– Replacement therapy is helpful until the primary problem is controlled

» Fresh frozen plasma (FFP)» Cryoprecipitate » Platelet concentrates

– The use of heparin in DIC controversial and not indicated in patients w/ trauma

43

ID• Routine use of antibiotics is not standard• Occasionally with facial fractures will prophylactically treat

• Sepsis– Sepsis occurred in 2% of all adult patients– Respiratory tract infections are the most common cause

of sepsis– Severity Score, Revised Trauma Score, lower admission

Glasgow Coma Scale score, and preexisting diseases as significant independent predictors of sepsis

Critical Care Medicine. 32(11):2234-2240, November 2004

44

ID• Sepsis

– Injury Severity Score was associated with increased incidence of sepsis

» Moderate (Injury Severity Score 15-29) and severe injury (Injury Severity Score >=30) had a six-fold and 16-fold

45

Joints• Occult fractures are sometimes missed on initial

survey• Watch for signs of decreased movement and

increased swelling

46

Kidney• Renal contusions/lacerations

– Increased Creatinine– Bloody UOP– HTN– Usually supportive care

47

MODS/SIRS• MODS is a clinical syndrome of progressive

physiologic dysfunction of organ systems• Trauma high risk because of circulatory shock

with tissue hypoxemia, tissue injury, and infection • Management requires control/elimination of the

source of inflammation, maintenance of tissue oxygenation, nutritional/metabolic support, support for individual organs, and effective pain control.

48

MODS• Preditors in adults

– Preexisting chronic illness– Acidosis– > 1L blood loss– ISS >24– Labs

» Lactate, transferrin, CRP