Trauma: Stabilization and Transport

Trauma: Stabilization and Transport
Division of Critical Care Medicine
Children’s Healthcare of Atlanta
Atlanta, Georgia

Trauma:Stabilization and Transport
Objectives
* Discuss the epidemiology of pediatric trauma
* Review the primary survey
* Identify priorities in care
* Discuss differences between adult & pediatric trauma
* Discuss pediatric trauma management
* Review the development of and
guidelines for transport

Neurosurgeon
Resuscitation Team
Surgical Specialties
Medical Specialties
Nursing
ICU
OR
Anesthesia
Orthopedic Surgeon
Trauma Surgeon
ALWAYS OPEN TRAUMA CENTER

Trauma:Initial Stabilization
Trauma:Initial Stabilization
The Golden Hour
* R. Adams Cowley, MD
* Care within 60 min.
* mortality if care given > 60 min.
"You live or die depending on where you have your accident because they take you to the nearest hospital!"

R. Adams Cowley, MD
“In the Blink of an Eye”
A-M-P-L-E History

A - Allergies
M - Medications
P - Previous history
L - Last ate
E - Events of accident

Trauma:Initial Stabilization Management of Multiple Trauma
* Primary survey
* Initial stabilization
and resuscitation
* Secondary survey
* Definitive care

Trauma:Initial Stabilization The Primary Survey
* A rapid initial assessment
* An "ABC" approach
* Resuscitation done simultaneously

Trauma:Initial Stabilization The Secondary Survey
* After the "ABCs"
* Head to toe examination

Trauma Initial Stabilization Definitive Care Phase
* Overall management
* Fracture stabilization
* Stabilization/transport
* Emergent surgery

Trauma:Initial Stabilization Pediatric Considerations
* ABCs
* Differences:
1) Size
2) Injury pattern
3) Fluids
4) Surface area
5) Psychological
6) Long term effects

Trauma:Initial Stabilization
In pediatric trauma, you don’t just have and injured child, you have an injured family
M. Eichelberger, MD
“In the Blink of an Eye”
Trauma:Initial Stabilization The Primary Survey
A - Airway and C-Spine
B - Breathing
C - Circulation (with hemorrhage control)
D - Disability
E - Exposure

Trauma:Initial Stabilization The Primary Survey
* Airway:
o Establish patency
o Beware C- Spine
o Do not:
+ Flex
+ Hyperextend
* Oxygen
o treat potential hypoxemia
o all trauma patients get O2

Trauma:Initial Stabilization Pediatric Considerations
* Craniofacial disproportion
* "Sniffing" position
* Obligate nose breathers
* Anatomy
o tongue
o larynx
o trachea

Trauma:Initial Stabilization Suspected Airway Obstruction
* Stridor
* Cyanosis
* Absence of breath sounds
* Dysphagia, snoring, gurgling
* Altered mental status
* Trauma to head, face, neck

Trauma:Initial Stabilization Cervical Spine Differences
* Flexible interspinous ligaments
* Underdeveloped neck muscles
* Poorly developed articulations
* Anterior vertebral bodies
* Flat facet joints
* Large head to BSA

Trauma:Initial Stabilization Cervical Spine
* Predisposed to serious high cervical injuries
* Assume its presence in:
o Blunt injury above clavicle
o Multisystem trauma
o Significant injury - MVA, fall
o Altered sensorium

Trauma:Initial Stabilization Cervical Spine: Radiographs
* Pseudosubluxation
* distance dens and C-1
* Growth plate fracture
* SCIWORA

Trauma:Initial Stabilization Airway Management
* Clear airway
* Jaw thrust/stabilization maneuver
* Oral/nasal airway
* Oxygenate/ventilate
* Intubation
* Cricothyroidotomy

Trauma:Initial Stabilization C-Spine Immobilization
* Backboard
* Appropriate C-collar
* Snadbags or towel
* Tape
* Torso immobilization

Trauma:Initial Stabilization Primary Survey: Breathing
* Assess via
o Exposure
o Rate/depth of respiration
o Inspection/palpation
o Quality/symmetry of breath sounds

NB: An intact airway Does Not assure adequate ventilation!!

* Oxygen
* Assisted ventilation
* Alleviate life threatening injuries

Thoracic Injury Heart, Lung, Mediastinum
* Penetrating
o Sucking, Bubbling
o Hemopneumothorax
o Tamponade
* Blunt
o Flail Chest
o Contusion (lung, heart)
o Aortic Dissection
o Tracheal Rupture
o Diaphram Rupture

Trauma:Initial Stabilization Chest Trauma
* Tension pneumothorax
* Hemothorax
* Flail chest
* Cardiac tamponade

Trauma:Initial Stabilization Chest Trauma
* Blunt injury common
* More compliant chest wall
* Sensitive to flail segment
* Mobile mediastinum
* Major vascular injury uncommon

Trauma:Initial Stabilization Tension Pneumothorax
* Air in the pleural space without exit
* Collapse of ipsilateral lung
* Compressed contralateral lung
* Mediastinal shift

Trauma:Initial Stabilization Tension Pneumothorax: Signs and Symptoms
* Respiratory distress
* Unilaterally diminished breath sounds
* Hyperresonance on affected side
* Tracheal deviation
* Distended neck veins
* Cyanosis

Trauma:Initial Stabilization Tension Pneumothorax: Treatment
* Needle decompression
o 2nd intercostal space mid-clavicular line
* Chest tube
o 4-5th intercostal space mid-axillary line

Trauma:Initial Stabilization Hemothorax: Signs and Symptoms
* breath sounds on affected side
* Dullness to percussion
* Hypovolemia
* Flat vs distended neck veins

Trauma:Initial Stabilization Hemothorax: Treatment
* Fluids/blood
* Decompression
* Chest tube
* Autotransfusion

Trauma:Initial Stabilization Flail Chest
* Boney discontinuity of the chest wall
* Major problem = underlying injury
* Signs and symptoms
o respiratory distress
o paradoxical chest wall movement
o severe chest pain

Trauma:Initial Stabilization Flail Chest:Treatment
* Oxygen
* Stabilize segment
* Re-expand lung
* + intubation
* Give fluids cautiously

Trauma: Initial Stabilization abdominal trauma
* 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

Trauma: Initial Stabilization abdominal trauma
* Why more prone to abdominal injury
o child has thinner musculature
o ribs are more flexible in the child
o solid organs are comparatively larger in the child
o fat content and more elastic attachments leading to increased mobility
o bladder is more exposed to a direct impact to the lower abdomen

Intraperitoneal Hemorrhage Management
o Immediate surgical exploration
o Non-operative protocols
+ successful in more than 95% of blunt abdominal trauma in appropriately selected cases

Intraperitoneal Hemorrhage
Immediate Surgical Exploration
o Abdominal distention + “shock”
o Transfusion requirement > 40 cc/kg
o Peritonitis
o Pneumoperitoneum
o Bladder rupture

Intraperitoneal Hemorrhage
CT Scan
o Hemodynamically stable
o Unreliable exam
o Immediate non-abdominal surgery
o Specific Indicators
Hematuria (any)
SGOT 200, SGPT > 100
Hyperamylasemia

Intraperitoneal Hemorrhage
* FAST
o standard part of the initial evaluation of bluntly injured abdomens in adults
o rapid assessment of the peritoneal cavity and can detect free fluid

Intraperitoneal Hemorrhage
o Pediatrics role of FAST is still up for debate
+ Detailed information regarding the grade of organ injury is not provided by the FAST
+ operator-dependent and lacks specificity
+ FAST examination produces a significant number of false-negative results

Intraperitoneal Hemorrhage
Diagnostic Peritoneal Lavage
Trauma:Initial Stabilization Circulation
Trauma:Initial Stabilization Frequent Reassessment of Vital Signs
What Are Normal Pediatric Vital Signs?
Trauma:Initial Stabilization Pediatric Vital Signs
Trauma:Initial Stabilization Circulation: Vital Signs
Trauma:Initial Stabilization Circulation: Shock
Trauma:Initial Stabilization Circulation: Fluid Therapy
Trauma:Initial Stabilization Circulation: Fluid Therapy
Trauma:Initial Stabilization Circulation: Blood Replacement
Trauma:Initial Stabilization Circulation:Pediatric Considerations
Trauma:Initial Stabilization Disability
Trauma:Initial Stabilization Disability: Children's Glasgow Coma Scale
Trauma:Initial Stabilization Pediatric Trauma Score
Airway Normal Oral or nasal Intubated, tracheostomy
Trauma:Initial Stabilization Expose: Pediatric Considerations
Trauma:Initial Stabilization Cathertization
Trauma:Initial Stabilization Definitive Care
Questions ??
References
Trauma: Stabilization and Transport .ppt