pals - trauma

PEDIACTRIC TRAUMA

Core Knowledge and Skills

• Know the common life-threatening complications of major trauma in the pediatric age group

• Understand the principles of airway management in the injured pediatric patient

• Recognize and manage shock in the injured pediatric patient

Trauma

Pediatric Trauma

Injury• Leading cause of death and disability in

children• Often produces respiratory failure and shock• Organized system of pediatric trauma care

improves outcomes

Trauma

Pediatric Trauma (cont.)

Blunt injury is more common than penetrating injury• Head (CNS) injury present in 55% of blunt

trauma victims• Internal injuries present in 15% of blunt trauma

victims

Trauma

Pediatric Trauma (cont.)

Trauma

Isolated head (CNS) injury

Airway compromise

Respiratory failure

Multiple trauma

Shock

Cardiopulmonary arrest (final common pathway)

Basic and Advanced Life Support in Pediatric Trauma

• The general principles of resuscitation are the same as for all resuscitation

• Certain traumatic injuries affect resuscitation priorities� Possible cervical spine injury� Hemorrhage� Chest trauma

Trauma

Rapid Cardiopulmonary Assessment and Support--“Primary Survey”

ABCs

Rapid cardiopulmonary assessment

(includes thoracoabdominal assessment)

plus

Rapid brief neuologic assessment

D=Disability

plus

Temperature control

E=Exposure

Trauma

Rapid Cardiopulmonary Assessment and Support--“Secondary Survey”• Head-to-toe assessment

• Unique to trauma care

• Requires special training beyond the scope of the PALS course

Trauma

Rapid Cardiopulmonary Assessment and Support

Airway• Immobilize the cervical spine when assessing

and controlling the airway

Trauma

Cervical Spine Immobilization

Head in Neutral Position

Picture

Trauma

Combined Jaw Thrust--Cervical Spine Stabilization Maneuver

» picture

Trauma

Rapid Cardiopulmonary Assessment and Support

Breathing

• All trauma patients� Provide oxygen

• Neurologic or respiratory compromise� Intubate the trachea� Hyperventilate� Insert nasogastric or orogastric tube

Trauma

Rapid Cardiopulmonary Assessment and Support

Indications for Endotracheal Intubation

• Respiratory arrest

• Respiratory failure

• Airway obstruction

• Significant alteration of mental status

• Suspected increase in intracranial pressure

• Need for prolonged ventilatory support

Trauma

Intubation With Cervical Spine Immobilization

» Picture

Trauma

Common Life-Threatening Chest Injuries

Type Initial Treatment

Tension ABCs, needle

pneumothorax decompression

Massive ABCs, pleural

hemothorax decompression

Trauma

Uncommon Life-Threatening Chest Injuries

Type Initial Treatment

Flail chest ABCs, positive-

pressure ventilation

Open ABCs, occlusive

pneumothorax dressing

Trauma

Rapid Cardiopulmonary Assessment and Support

Circulation• Examine for hemorrhage

• Direct pressure to external hemorrhage sites

• Replace volume at first signs of shock

• Consult surgeon

• Transfuse with blood if the child is� Hypotensive� Poorly responsive to crystalloid boluses

• Reassess

Trauma

Special Adjuncts to Trauma Resuscitation

• Needle cricothyrotomy

• Pericardial decompression

• Pneumatic antishock trousers

Trauma

Rapid Cardiopulmonary Assessment and Support

Neurologic Evaluation

Trauma

Case Scenario

A 6-year-old by is struck by a car while riding his bicycle. On physical examination, he is unconscious and pale. You hear stridor with infrequent labored respirations. Breath sounds are slightly decreased bilaterally. Distal pulses are very weak; the pulse rate is rapid and regular. You see an obvious deformity of his left thigh.

Trauma

Case Scenario Questions

What is your assessment?

Is the child in respiratory failure?

Is the child in shock?

Trauma

Case Scenario Questions (cont.)

What other information would you like?

Trauma

Case Scenario Questions (cont.)

What would you do for this patient while this information is being gathered?

Trauma

Case Scenario -- Airway

1 Open the airway with combined jaw thrust-spine stabilization maneuver

2 Intubate as necessary

Trauma

Case Scenario -- Breathing

• Provide 100% oxygen

• Awake: Nonrebreathing mask

• Altered mentalstatus or breathing

difficulty: Bag-Valve mask

• Unresponsive or

respiratory failure: Endotracheal intubation

Trauma

Case Scenario -- Breathing (cont.)

• Examine the chest for tension/open pneumothorax. Treat if found.

• Look for gastric dilation. Treat once airway is controlled.

Trauma

Case Scenario -- Reevaluation

Heart rate 150 bpm

Respiratory rate 12 breaths per minute

Blood Pressure 80 mm Hg

Pulse quality Thready

Capillary refill time 5 seconds

External hemorrhage none

Thoracoabdominal No pneumothorax,

inspection hemothorax, flail chest,

or open wounds

Trauma

Case Scenario -- Circulation -- Treatment

1 Look for external hemorrhage. Apply direct pressure if found.

2 Place two large-bore vascular lines.

3 Obtain blood for type and crossmatch

4 If signs of decreased perfusion:• Rapidly infuse 20 mL/kg crysalloid

5 Notify the surgeon.

Trauma

Case Scenario -- Circulation (cont.)

• Reassess

• Infuse pepeat fluid bous and blood as necessary

Trauma

Summary

• Advanced life support for the traumatized pediatric patient includes assessment and support of� Ventilation (with cervical spine immobilization)� Oxygenation� Perfusion

• Rapid cardiopulmonary assessment, basic airway maneuvers, and vascular access skills are required.

Trauma