Escolar Documentos
Profissional Documentos
Cultura Documentos
Denise Watt
Oct. 25, 2001
Outline
Background
Trauma scores
Principles and Approach
ABCs
Specific injuries
Head, C-Spine, Chest, Abdominal, Burns
Abuse
Background
multi-system
unstable
axial skeleton #
neurovascular injury
acute cord injury
complicated TBI
low trauma score
Trauma Scores
+2 +1 -1 score +12 to -4
Size (Kg) >20 10-20 <10 0% mortality 8
SBP >90 50-90 <50
45% = 2
Airway N secure tenuous
100% = 0
CNS awake obtund coma transfer to
Open Wound none minor major
pediatric trauma
Fractures none closed open center if PTS <8
Principles (according to me)
ATLS
VS: plus BS, temp, weight
Broselow tape
ABCs, C-spine, NG
consent?
Airway
2 x O2 demands
resp failure #1 cause of arrest
no surgical airway < 10yr
ET tube size: (16 + age)/4
LMA as rescue if >4 ft tall
Anatomical airway issues in kids
big tongue, soft tissue short trachea
obstruction narrowest at subglottis
soft trachea no cuff nose breathers < 6 mos
soft VC no stylet big occiput
anterior larynx big epiglottis
straight blade
RSI
Pre-treat atropine 0.02 mg/kg all < 6yr
no defasciculating dose < 5 yr
induction:
ketamine 1-2 mg/kg
midaz 0.2-0.3 mg/kg
propofol 2 mg/kg
thiopental 3-7 mg/kg
etomidate 0.3 mg/kg
sux 2 mg/kg
no evidence for lidocaine in kids
Breathing
Case:
5 yr old boy, hit by car while walking. Father
picks him up and brings to ED
initial vitals: P 110, BP 110/70, RR 24, T 63
Head Injury
Protective Susceptible
fontanelles big head torque
open sutures soft cranium injury w/o
plasticity fracture
less myelin more shearing
forces
prone to reactive hyperemia
Head Injury: Types of injury
20 x risk ICH
50% of parietal #, 75% of occipital #
linear > depressed > basilar
X-rays not sensitive nor specific
90% linear # have overlying hematoma
growing skull #:diastatic dural tear
meninges herniate, prevents closure: NSx F/U
depressed #: may miss on CT
Interpretation?
Growing Skull Fracture
Predictors of ICH
Children < 2
hard to assess
prone to ICH, skull #
asymptomatic ICH (4-19%)
low threshold
various algorithms, no consensus
CT Head Algorithms
Savitsky, Am J Emerg Med. 2000
16-50% SCI!!
< 9 years
transient neuro symptoms (parasthesias)
recur up to 4 days later
bottom line:
CT/MRI if abn neck/neuro exam, distracting
injuries, alt. LOC, high risk mech DESPITE
normal 3-views
Case
6 yo girl fell off bike
Whats the
abnormality?
C-Spine Imaging
Who?
Vicellio. Pediatrics 2001 (NEXUS)
30 pediatric CSI inconclusive
What?
3-views 94% sensitive - but SCIWORA
Flexion-extension?
Ralston Acad Emerg Med 2001
no added info if 3 views normal
Chest Trauma
Traumatic asphyxia
Sudden compression elastic chest wall against closed
glottis intrathoracic pressureobstruction of
SVC/IVC capillary extravasation: petechiae face,
neck ,chest, periorbital edema, retinal hemorrhages,
resp distress, hemoptysis, pulmonary/cardiac
contusions, liver injuries, pneumothorax
Treat: chest tube prn, ventilate, PEEP,
elevate head
Abdominal Trauma
Case:
7 yo boy on bicycle collides with slow moving
car. Thrown onto hood of car.
Vitals: HR 158, RR 45, BP 100/65
Vitals: HR 176, RR 60, BP 80/35, sat 93%
Abdominal Trauma
FP 5-14%
15% kids with hemoperitoneum need lap
? solid organs, retroperitoneum, intestine
+ve:
>100,000 RBC (blunt, stab)
>5,000 (GSW)
use: unstable, going to OR anyway
Abdominal Trauma: FAST
blunt, acceleration/decceleration
31% missed, 28% re-injured
fractures:
bilateral, cross sutures, diastatic, non-parietal
IC injuires:
SAH, subdural, ICH, edema
CT if suspect
Child Abuse: Management
DOCUMENT
full P/E (rectal, genital)
photograph
B/W: CBC, PT/PTT, LFTs, lipase, U/A
skeletal survey
CT head, abd prn
Child Protection
Bottom Lines