Evaluation and Management of Pediatric Trauma

Anatomical and Physiological Factors in Pediatric Trauma

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  Trauma is the leading cause of death among children >1 years of age.

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  Small body size

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    Multiple injuries can result from a single impact due to the proximity of multiple organs and the wide transmission of energy.

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  Small blood volume

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    Hemorrhagic shock can result even from small blood loss.

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  Large surface-area-to-body-mass ratio

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    High risk of hypothermia due to larger heat loss

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    High risk of hypovolemia due to larger insensible fluid loss

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    Higher caloric requirement

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  Cartilaginous skeleton, less fat, and more elastic connective tissue

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    Severe pulmonary injury can result without any rib fracture.

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    Severe brain injury can result without skull fracture.

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    There is less risk of extremities fractures.

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  Larger solid organs with thin abdominal wall with less subcutaneous fat predisposes to the following:

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    Liver injury

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    Spleen injury

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  High risk of head injury is due to the proportionately larger size of the head.

Initial Evaluation and Resuscitation

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  Follows the same algorithm as in adults, which includes the following:

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    Airway

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    Cervical spine protection

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    Breathing

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    Circulation

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    Disability

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    Exposure

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  Leading causes of cardiopulmonary arrest in children

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    Lack of airway resulting in hypoxia and hypoventilation

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    Tension pneumothorax

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    Hypovolemia

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    Cardiac tamponade

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    Cardiac contusion

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    Severe head injury

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    Cervical spinal cord injury

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    Hypothermia

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  Hypotension is a sign of significant blood loss.

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  The Broselow Pediatric Emergency Tape is an essential adjunct in pediatric resuscitation. It provides weight- and length-based information on the following:

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    Medication dose

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    Fluid volume

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    Equipment size

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  Pediatric vital functions depend on age and weight, as shown in the illustration.

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  Imaging in children

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    Potential risk of radiation-induced malignancy should be considered when evaluating with computerized tomography scan (CT).

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    Radiation must be kept as low as reasonably possible.

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    Selective CT is recommended to reduce radiation exposure.

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    Plain films are the initial imaging of choice.

Airway: Special Considerations

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  High risk of airway obstruction

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    Smaller diameter of airway

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    Large occiput causing flexion of the neck

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    Larger tongue

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    Funnel-shaped larynx in children <8 years of age: High risk of aspiration as secretions accumulate in the retropharyngeal area.

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  Characteristics of respiratory distress

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    Tachypnea

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    Nasal flaring

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    Use of accessory muscles

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    Inspiratory retractions (suprasternal, substernal, and intercostal)

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  Oropharyngeal airway

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    Should be inserted only in unconscious children because the intact gag reflex can result in vomiting and aspiration.

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    Correct size of the tube

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      Flange at the level of incisors and distal end at the angle of the mandible

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    Insertion technique

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      Gently and directly into the oropharynx

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      A tongue blade to depress the tongue may be helpful.

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      Inserting the airway backward and rotating it to 180 degrees, as in adults, is not recommended due to risk of injury to soft-tissue structures.

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  Nasopharyngeal airway

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    Correct size

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      Diameter of the patient’s little finger

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    Insertion depth

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      Nose to the tragus of the ear

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  Indications for definitive airways

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    Respiratory failure or arrest

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    Airway obstruction

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    Potential of airway obstruction

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    Severe brain injury (Glasgow Coma Scale [GCS] 8 or less)

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    Intrathoracic injury

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    Severe or multiple injuries

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    Shock

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  Types of definitive airways

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    Endotracheal tube

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    Surgical airway

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      Needle cricothyroidotomy

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      Open cricothyroidotomy

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  Rescue airway

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    Laryngeal mask airway (LMA)

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    Intubating LMA

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  Endotracheal intubation

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    Considerations during intubation

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      Larger tongue and tonsils may occlude visibility of the airway during intubation.

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      There is risk of injury with bleeding to the prominent nasopharyngeal adenoids.

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      The larynx is placed anteriorly and higher at the level of C2-C3 in young children and at the level of C6-C7 in older children and adults.

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      A very narrow airway at the level of the cricoid ring may make intubation difficult.

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      The epiglottis is floppy, narrow, and angled posteriorly.

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        A straight-bladed laryngoscope should be used during intubation in smaller children.

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        A short trachea may result in intubation in the right mainstem bronchus causing the following:

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          Inadequate ventilation

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          Hypoxia

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          Barotrauma

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    Steps of drug-assisted/rapid sequence (orotracheal) intubation (RSI)

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      Evaluation for difficult intubation

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        Examination of the mouth

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        Examination of the neck for range of movement

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        Examination for any loose teeth

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      Selection of the endotracheal tube (ETT)

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        Cuffed ETTs

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        Diameter of the ETT

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          Approximate diameter of the ETT should correspond to the diameter of the child’s external nares or the tip of the little finger.

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          ETT diameter: Age/4 + 4 or Age + 16/4

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      Preoxygenation

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        100% oxygen using face mask for 3 minutes

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        Displaces nitrogen from the lungs and replaces it with oxygen

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        An increased amount of oxygen in the lung during intubation prevents apneic hypoxia during the procedure.

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      Medications

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        Atropine

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          0.1–0.5 mg in children <1 year

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          Infants have a pronounced vagal response to endotracheal intubation, more so than do children and adults.

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          Helps prevent bradycardia due to direct laryngeal stimulation

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          Not required for children >1 year of age

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        Sedation

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          Hypovolemic: etomidate 0.1 mg/kg or midazolam 0.1 mg/kg

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          Normovolemic: etomidate 0.3 mg/kg or midazolam 0.1 mg/kg

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        Paralytics

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          Succinylcholine: <10 kg weight: 2 mg/kg, >10 kg weight: 1 mg/kg or

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          Vecuronium: 0.1 mg/kg or

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          Rocuronium: 0.6 mg/kg

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      Intubation

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        May be performed using a video laryngoscope or a regular laryngoscope

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        Straight laryngoscope blade is preferred in smaller children.

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        In-line stabilization of the neck

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        Cricoid pressure (Sellick maneuver)

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          Compression of the esophagus between the cricoid cartilage and the vertebral body to prevent regurgitation of stomach content into the oropharynx

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          Also helps by moving the larynx during intubation

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        Position of the ETT

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          Depth (in cm) of the ETT from the level of the gum: approximately the size of the tube × 3. For example, a size 4.0 ETT should be positioned 12 cm from the gums.

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      Confirmation of the ETT position

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        Auscultation

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          Presence of bilateral breath sounds

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          Absence of breath sound over the epigastrium (stomach)

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        Capnography

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          Sensitive and specific to detect ETT placement

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        Colorimetric end-tidal carbon dioxide detector

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          Color change from purple to yellow

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        Chest x-ray

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      Secure the tube in position

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        Because of the short trachea, any movement of the head can result in displacement of the ETT leading to the following:

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          Inadvertent extubation

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          Right mainstem bronchial intubation

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  Surgical airways

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    Indications

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      Failed endotracheal intubation

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    Needle cricothyroidotomy

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      Steps

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        Cricothyroid membrane is punctured with a large IV catheter with needle.

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        Puncture is confirmed with aspiration of air in the syringe.

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        Needle is withdrawn and catheter is advanced in the trachea.

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        Cannula is connected to the high-pressure oxygen source (needle-jet insufflation).

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      It does not provide adequate ventilation and leads to progressive hypercarbia.

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    Open cricothyroidotomy

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      Rarely indicated for infants or small children

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      Can be performed in older children (>12 years of age) where cricothyroid membrane is easily palpable

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  Recue airway

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    Used for failed ETT

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    Performed with:

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      laryngeal mask airway LMA.

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      intubating LMA.

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    Selection of LMA sizeSize of LMA in Children