Approach to pediatrics trauma according to ATLS

Approach to pediatric trauma and key differences to adult trauma management

1. Pediatric Trauma 

2. Outline  Preparation 1 Airway & Breathing 2 Circulation 3 Disability 4 Secondary Survey 5

3. Introduction While the general ATLS approach to trauma is similar in both adults and pediatrics, there are anatomic and physiologic differences to consider in the pediatric trauma patient. Children have unique anatomy and physiology compared with adults.  3

4. Preparation is the key 

5. Preparation is the key  Use a  Broselow tape to draw up all anticipated medications in advance of patient arrival Prepare all equipment needed for resuscitation Assemble your team and brief, assign roles  3 1

6. Preparation is the key  3 1

7. Airway and Breathing 

8. Important considerations in the pediatric trauma while managing airway. Airway and Breathing 2

9. 3 P's in Pediatric Trauma Airway : Patency –  use an oral airway to prevent obstruction by the tongue, suction any blood, secretions, foreign bodies Position – towel under torso, occiput on bed Protection – cuffed ETT ( age/4 + 3.5 ) in all trauma patients Airway and Breathing 2

10. RSI : PEARLS Have your weight based drugs drawn up in advance Airway and Breathing 2

11. RSI : PEARLS Have your weight based drugs drawn up in advance Airway and Breathing 2

12. RSI : PEARLS Pre-induction:  Consider atropine 0.02 mg/kg (minimum 0.1 mg, maximum 0.5 mg) in patients <1 year of age and have it drawn up in case of bradycardic response to intubation in older patients.  Airway and Breathing 2

13. RSI : PEARLS Use a straight blade laryngoscope:  Children have a floppy, U-shaped epiglottis which is easier to pick up to allow a view of the vocal cords with a straight blade, especially during c-spine immobilization. Airway and Breathing 2

14. RSI : PITFALLS  Inadequate pre-oxygenation time:  Children have lower functional residual capacity and shorter apnea times, so consideration should be given to a modified RSI with apneic oxygenation/NIPPV. Consider early NG tube placement for stomach decompression to allow for full diaphragmatic excursion. A rule of thumb to estimate accurate depth of ETT placement:  3 x  tube size  to prevent right mainstem endobronchial intubation due to shorter trachea Airway and Breathing 2

15. RSI : PITFALLS Consider  external laryngeal manipulation (ELM ) instead of cricoid pressure. Overbagging :  To prevent barotrauma all pediatric BVM units should be equipped with a safety pop-off valve along with a manometer, which limits peak inspiratory pressures between 35 and 40 cm H20 per breath. Each breath should be just enough to make chest rise and no more. Counting out loud can prevent our natural tendency to overbag in stressful situations Airway and Breathing 2

16. Circulation

17. Circulation Blood volume is relatively larger, but absolute volume is smaller Neonates 85-90ml/kg  Infants 75-80ml/kg   Children 70-75ml/kg  Adults : 65-70ml/kg 3 3

18. Circulation Relatively small volumes of blood will constitute significant blood loss in small children a 100ml haemorrhage experienced by a 5 kg child represents the loss of approximately 10% of their total blood volume.  Monitor and record all blood loss, including amounts that would be insignificant in the adult patient.  3 3

19. Circulation Shock in pediatric Trauma : Hypotension is a Late Sign Look for secondary signs which are often present while the patient is still normotensive ( compensated shock ).   Hypovolemia is the most common cause of shock, with tachycardia being the first manifestation.  Blood pressure is maintained until 30-40% blood loss due to great cardiac reserve, and      so hypotension is an ominous sign ( decompensated shock ). 3 3

20. Circulation Volume Resuscitation PALS recommends early IO placement (after 90 seconds or 2 attempts at IV placement). the maximum flow rate is usually around 25 mL/min.   temporary; get a large peripheral IV or central access once adequately resuscitated. 3 3

21. Circulation How much crystalloid before blood? While this a controversial topic, experts suggest that 10-40 ml/kg of warmed crystalloid prior to blood is reasonable in pediatric polytrauma patients in  compensated shock ,  but that early administration of blood components is vital in patients who present in  decompensated shock .  The principle of permissive hypotension in adult trauma can only be applied to adolescent pediatric patient and is not recommended in younger pediatric patients. 3 3

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23. Disability

24. Diasbility   A rapid assessment of the neurologic status can be obtained through use of the  AVPU scale A lert responsive to  V oice responsive to  P ain U nresponsive ​ 4

25. D isability 4

26. Secondary Survey 

27. The goal in pediatric severe head injury is to prevent secondary brain injury, minimize raised ICP, and maintain cerebral perfusion pressure. Pediatric Head Injury

28. There are 5 parameters that must be aggressively avoided in the pediatric patient with severe head injury: Hypotension  – maintain normal SBP and euvolemia Hypoxia  – maintain SaO2 > 90% and PaCO2 35-40mmHg Hypothermia  – warmed crystalloid and blood, warmed room, overhead warmer or Bair hugger Hypoglycemia  – Raised ICP  – keep head of bed at 30 degrees, remove collar, pain and anxiety control, treat seizures aggressively, normocapnea Pediatric Head Injury

29. Children have compliant chests and thus sustain musculoskeletal thoracic injuries far less frequently (5% of traumas). However, due to this elasticity, the most common injury is a pulmonary contusion. Obvious chest injuries are a red flag for more serious trauma as they are indicate a huge force. Pediatric Chest Trauma 

30. PEARLS Deflating the stomach can help patient breathing and with chest tube insertion. POCUS is highly sensitive for pneumothorax Pigtail Catheters have been shown to be as effective as large bore chest tubes in children with traumatic pneumothorax . Pediatric Chest Trauma 

31. PITFALLS Don’t expect traditional adult injury findings: Absence of chest tenderness, crepitus and flail chests does not preclude injury. CXR may miss early findings: Pulmonary contusions may only appear days later Pediatric Chest Trauma 

32. The vast majority of pediatric patients with abdominal trauma are treated conservatively with only 5% requiring surgery as most present with solid organ injuries. Any polytrauma patient with hemodynamic instability should be considered to have a serious abdominal injury until proven otherwise. The abdominal physical exam can be misleaded as 20-30% of pediatric trauma patients with a “normal” exam will have significant abdominal injuries on imaging. Pediatric Abdominal Trauma 

33. TXA use is  not  standard of care in pediatric polytrauma it was previously not studied in pediatric trauma.  Role of Tranexemic Acid  

34. Pediatric Trauma Score  

35. Take Home Message:  Keep in mind important differences in physiology and anatomy of pediatrics when managing pediatric trauma Know the imporatant calculations needed in pediatric resuscitation  Manage the airway promptly– indicated for almost all severe TBI, any hypoxia Appreciate and treat shock early  – do not wait for hypotension which is a sign of pre-arrest Injuries can present subtle in pediatrics without obvious signs or symptoms. Have a high index of suspicion and monitor closely.  

36. References :  Helman, A, Beno, S, Alnaji , F. Pediatric Trauma. Emergency Medicine Cases. May, 2017. https://emergencymedicinecases.com/episode-99-highlights-emu-2017/. Accessed [date].  Florian Hoffmann, Michael Schmalhofer , Markus Lehner, Sebastian Zimatschek , Veit Grote & Karl Reiter (2016) Comparison of the AVPU Scale and the Pediatric GCS in Prehospital Setting, Prehospital Emergency Care, 20:4, 493-498, DOI:  10.3109/10903127.2016.1139216 Uptodate : Trauma management : Unique pediatric considerations MTLS ATLS PALS TLSM

37. Thank you