SlideShare a Scribd company logo
1 of 69
Download to read offline
PEDIATRIC TRAUMA
Presenter : Dr Subhankar Paul
INTRODUCTION
• The priorities & principals of assessment &
management of injuries in Children are same as in
adults.
• Unique Anatomical & Physiologival characteristics of
the Children & different mechanisms of Injury
results in MultiSystem Injury being the Rule rather
than the exception in Children . So, Aggressive
management accordingly is to be done.
• Many injuries can be managed initially in a general
hospital ED, but care of the most seriously injured
children requires prompt triage and transportation
to a designated pediatric trauma center
Unique Characteristics of Pediatric
patienets related to Trauma
1. SIZE & SHAPE :
 SMALLER BODY MASS in the children , the energy
imparted from the trauma results in a greater force
applied per unit of body surface area.
 This more intense energey is transmitted to a body
having LESS FAT, LESS CONNECTIVE TISSUE, & CLOSE
PROXIMITY to MULTIPLE ORGANS , resulting in severe &
multi-system injuries in children.
 Head in proportionately larger than the body , so high
frequency of Blunt Brain injuries is there.
• 2. SKELETON
Incomplete calcification
Multiple active growth centres
More pliable
Internal organ damage is frequent without
external skeletal damage.
If bony injury (e.g skull/rib # ) present : must have
underlying severe organ injury (e.g blunt brain
injury/ pulonary contusion etc.)
Diagnostic difficulty by Radiography
3. SURFACE AREA
(Child’s body surface area : Blood volume ) ratio is
Highest @ Birth & decreases with Age.
Thermal energy loss & thereby Hypothermia
develops quickly in children with
Hypovolemia/hypotension
4. PSYCHOLOGICAL STATUS :
• emotional unstability
• Regressive behaviour with pain/ stress
• Naturally more fear & Stranger anxiety
Difficulty in CLINICAL ASSESSMENT
PRINCIPLES of Pediatric Trauma Care
• Prehospital Care
• TRIAGE
• PRIMARY SURVEY (A/B/C/D/E)
• RESUSCITAION
• SECONDARY SURVEY
• POSTRESUSCITAION MONITORING & RE-
EVALUATION
• DEFINITIVE CARE
Prehospital Care
prehospital interventions should focus on
 airway and respiratory management ,
 spinal immobilization
 recognition of shock,
 rapid transport to an appropriate facility based
upon the predicted severity of injury as soon as
possible
 Shortening the time interval between injury and
definitive care remains a priority, and interventions
beyond lifesaving measures can be performed en
route to the hospital.
 Don’t delay in transport for ET intubation/ IV access
Primary Survey Goals
AIRWAY EVALUATION & MANAGEMANT
• inability to maintain a Patent airway asssoc
with lack of oxygenation & Ventilation is
the most common cause of cardiac arrest
in children .
• So, children’s airway is a priority.
• Assess for Obstruction due to , POSITION,
INJURY, BLOOD, TEETH, FOREIGN BODY,
VOMITUS,
Pediatric Anatomy Potential Implications Airway Maneuvers
Large head and occiput May push head forward, occluding
airway
Shoulder roll may be required
to align airway axes
Large tongue May occlude upper airway in
obtunded or paralyzed patient
Jaw thrust, oral or
nasopharyngeal airway, Miller
(straight) laryngoscope blade
Superior larynx and
anterior cords
May make visualization of cords
difficult
Shoulder roll may be required
to align airway axes, straight
laryngoscope blade to lift
epiglottis
Cricoid narrowing Subglottic space is narrowest
portion of the pediatric airway,
prone to inflammation and upper
airway obstruction
Monitor cuff insufflation
pressures in small children
Large adenoids and tonsils May cause upper airway
obstruction; may bleed with nasal
intubation
Avoid blind nasal intubation in
young children
Small cricoid cartilage Makes open cricothyrotomy
technically difficult
Needle cricothyrotomy
preferred in young children
Large stomach, low
gastroesophageal sphincter
tone, relatively small lungs
Insufflation of stomach with bag-
valve mask ventilation or swallowed
air, children are prone to vomiting
Consider early placement of
orogastric or nasogastric tube
to deflate stomach when using
positive pressure ventilation
Pediatric Trauma - Concepts & Management
Airway management
NON-INVASIVE
• Indication :
Spontaneously Breathing
Child with Partially
Obstructed airway
Methods :
1. Neutral Position
2. Jaw-thrust + Bi-manual In-
line stabilisation
3. Suction of Secretion
/vomitus /Blood
4. Bag-Mask Ventilation +/-
Oral Airway
INVASIVE
• Indication
1. Unconscious/ GCS <9
2. Lack of Patent airway
3. Impending loss of patent
airway
4. Inability to Oxygenate/
Ventilate
5. Full/Impending Cardiac
Arrest
PRE-REQUISITE : Fully Pre-
Oxygenation
Invasive Definitive Airway
ENDO-TRACHEAL INTUBATION
• Most reliable Method of
establishing definitive
Airway & administering
ventilation in a child
• Orotracheal Intubation
under direct Laryngoscopic
visualisation along with
Adequate immobilisation &
protection of C-Spine is
preffered
• Naso-tracheal route is NOT
PREFFERED in children
• Method : DAI (RSI )
CRICOTHYROIDOTOMY
• When Airway maintenance
/control can’t be achieved
by Bag-Mask Ventilation /
Orotracheal Intubation
• Needle Cricothyroidotomy
preferred over Surgical
Cricothyroidotomy (≤8yrs)
• Caution :
1. Temporary Technique
2. Inadequate ventilation
progressive Hypercarbia
Pediatric DAI / RSI PROTOCOL IN TRAUMA
Age
Et tube(mm
Internal Diameter)
Blade Size & shape
Premature 2.5 Uncuffed* 0 Straight
Newborn 3.0 Uncuffed* 1.0 Straight
1–6 mo 3.5 Uncuffed* 1.0–1.5 Straight
6–12 mo 4.0 Uncuffed* 1.5 Straight
1–2 y 4.5 Uncuffed* 1.5 Straight
3–4 y 5.0 Uncuffed* 1.5–2.0 Straight or
curved
5–6 y 5.5 Uncuffed* 2.0 Straight or
curved
7–8 y 6.0 Cuffed 2.0 Straight or
curved
9–10 y 6.5 Cuffed 2.0 Straight or
curved
11 y 7.0 Cuffed 3.0 Straight or
curved
Age-Based Airway Equipment Size
2-10yrs
UNCUFFED ETT SIZE
AGE(yrs)/4 + 4
CUFFED ETT SIZE
AGE (yrs)/4 + 3.5
Weight based
ET Tsize
< 1kg : 2.5 mm
1-2kg : 3 mm
2-3kg : 3.5 mm
>3kg : 3.5-4.0
mm
Cervical Spine Immobilization
• Criteria:
• spinal pain or tenderness,
• significant multisystem trauma,
• severe head or facial trauma,
• neurologic deficit in any extremity,
• loss of consciousness,
• significant distracting injury,
• altered mental status
• METHOD ( Immobilize C-Spine until such injury excluded)
• A properly fitting rigid Cervical collar should be used.
• Head should be secured to the spine board using towel rolls
• padding may be necessary behind the shoulders
• Secure the child's body to the board by straps or wide cloth tape
• prevent lateral movement of the child during log-rolling
BREATHING
• ASSESSMENT
1. RATE
2. CHEST WALL MOVEMENT ( PARADOXICAL
BREATHING/ FLAIL SEGMENT)
3. TRACHEAL DEVIATION
4. OPEN WOUNDS
5. OXYGEN STATUS
6. PERCUSSION NOTE
7. CREPITUS
Signs of hypoxemia
Cyanosis
Agitation
Poor capillary refill
Bradycardia
Desaturation measured by pulse oximetry
Signs of inadequate ventilation
Tachypnea
Nasal flaring
Grunting
Retractions
Stridor or wheezing
MANAGEMENT Of BREATHING &
VENTILATION
• WARM HUMIDIFIED O2
• GASTRIC DECOMPRESSION (To prevent Aspiration)
• Appropriate Mechanical Ventilation ( avoid
Barotrauma & Volutrauma )
• NEEDLE/ TUBE THORACOSTOMY (
pneumo/hemo/hemo-pneumothorax)
avoid using long 14-18 g over-the-needle catheters for
needle thoracostomy ( 2nd ICS, MCL)
Chest tubes (small size) inserted by Tunneling , site
same as adult ( 5TH ICS, JUST ANT to MAL )
CIRCULATION & SHOCK
• Child’s Increased Physiologic Reserve : allows
for maintenance of normal SBP even in shock
• Upto 30% diminuation in circulatory blood
volume may be required to manifest a
Decrease in Child’s SBP
• TACHYCARDIA & POOR SKIN PERFUSION are
often the Only Early recognising features for
hypovolemia
Pediatric Vitals
SYSTEMIC RESPONSE to BLOOD LOSS
MANAGEMENT
1. VASCULAR ACCESS
2. FLUID RESUSCITATION
3. BLOOD REPLACEMENT
4. CONTROL EXTERNAL HEMORRHAGE
5. SURGICAL INTERVENTION ( To
control INTERNAL HEMORRHAGE)
VASCULAR ACCESS
Ref : ATLS 10TH
OPTIMAL RESPONSE to RESUSCITATION
DISABILITY
• Level of consciousness can be assessed using
either the Glasgow Coma Scale (GCS) or the
AVPU system
• GCS <8 : prompt endotracheal intubation in
trauma patients
• In children, GCS < 5 : poor outcome.
• Examination of cranial nerves
• pupillary responsiveness
• motor strength of each limb
EXPOSURE
• to identify important injuries and to detect
and correct hypothermia.
• Control bleeding by direct pressure, using air
splints on the extremities if needed
• A rectal temperature should be obtained
• Whenever possible, keep the child covered
and use external warming devices
• Consider warming fluids to 40°C (104°F) if
large amounts of IV fluids or blood products
are used.
POST RESUSCITATION PRIORITIES
Secondary Survey
• to identify all other injuries in the patient
• The presence of family may often be helpful to
calm and console frightened and injured
children
• complete history ( “AMPLE” (allergies,
medications, past medical history, time of last
meal, and events leading up to the injury )
• Imaging, diagnostic, and laboratory studies
Stabilization
• stabilized sufficiently to allow transfer of the child to
the radiology suite or inpatient unit, or safe transfer
to HIGHER CENTRE
• Continual reassessment is crucial
• Endotracheal tube dislodgment,
• development of a pneumothorax,
• regurgitation of stomach contents,
• occult hemorrhage causing shock,
• Worsening neurologic function
• Careful monitoring of fluid administration,
• Analgesics and sedatives
Referral to a HIGHER Pediatric Center
• Use of trauma triage scores : identify a child
whose care requires a more experienced team
• commonly used systems
1. Pediatric Trauma Score
2. Revised Trauma Score .
• Higher numbers : greater likelihood of survival
and thus a reduced need for trauma center
care
• A child with a Revised Trauma Score of <12 or
a Pediatric Trauma Score of <8 should be
transferred to a trauma center.
Pediatric Trauma Score
–1 +1 +2
Size (kg) <10 10–20 >20
Airway Unmaintained Maintained Normal
Systolic blood
pressure (mm
Hg)
<50 50–90 >90
Level of
consciousness
Comatose Altered Awake
Wounds Major open Minor open None
Skeletal
trauma
Open/multiple Closed None
Revised Trauma Score
Number
Glasgow
Coma
Scale
Score
Systolic
Blood
Pressure
(mm Hg)
Respirator
y Rate
(breaths/
min)
4 13–15 >89 10–29
3 9–12 76–89 >29
2 6–8 50–75 6–9
1 4–5 1–49 1–5
0 3 0 0
Indications for Transfer to a Pediatric
Trauma Center
Mechanism of injury Ejection from motor vehicle
Fall from a height
Motor vehicle collision with prolonged
extrication
Motor vehicle collision with death of
another vehicle occupant
Anatomic injury Multiple severe trauma
More than three long-bone fractures
Spinal fractures or spinal cord injury
Amputations
Severe head or facial trauma
Penetrating head, chest, or abdominal
trauma
Pediatric Trauma - Concepts & Management
SPECIFIC PEDIATRIC INJURIES
PEDIATRIC HEAD TRAUMA
• Head trauma consists of INJURY to Bony Skeleton,
Soft Tissue , & IntraCranial Contents
• Traumatic Brain injury is the leading cause of death
due to pediatric trauma
• Concussion is term for mild traumatic brain injury
with trauma-induced alteration in mental status,
often manifested with amnesia / confusion
• Children are more susceptible to secondary brain
injury , triggered by hypovolemia, decreased CPP,
Hypoxia, Hyperthermia, Seizures. So, adequate &
early restoration of circulating blood volume &
avoidig hypoxia is necessary
ASSESSMENT
• AVPU SCALE ( CORTICAL FUNCTION )
• GCS
• PUPIL
• FONTANELLES
• EYE EXAMINATION (RETINAL HEMORRHAGES )
• MOTOR/ SENSORY DEFICITS
• SYMPTOMS ( vomiting, dizziness, headache,
irritability, and decreased level of
consciousness)
Pediatric considerations in Assessment
1. Infants & Young Child having Open fontanelle
& Mobile cranial sutures , more tolerant to
increasing IC SOL / Brain Edema. So even in a
Conscious child with bulging fontanelle/
suture diastasis indicate severe brain injury
Early neurosurgical intervention is essential.
2. Vomiting & Amnesia are common in children
after head injury , doesn’t necessarily imply
increased ICP. But, Persistant /more frequent
Vomiting is a concern & mandates CT HEAD
3. Impact Seizures is more common in Children &
usually self-limited, but REQUIRES CT Head(Only
50% of children with post-traumatic seizures
have abnormal findings on CT scan) least likely
to result in long-term sequelae.
4. Raised ICP due to Cerebral edema is more
common than focal mass lesions in children, so
early ICP Monitoring indicated with
GCS <8 or MOTOR SCORE 1 or 2
Co-existent Multiple Organ injuries requiring
major volume resuscitation
Cerebral haemorrrhage/ edema & brain
herniation in CT HEAD
RADIOLOGIC EVALUATION
• primary goal : to identify traumatic brain
injury and to detect intracranial injuries that
require surgical intervention
• No clinical criteria can reliably predict the
presence of an intracranial injury
• CT and MRI are necessary . CT is the imaging
modality of choice.
• Indications are different acc to age
0 to 2 Years of Age
• INDICATIONS
(1) any neurologic abnormality,
(2) any altered mental status,
(3) any scalp abnormalities (contusion, abrasion,
laceration, cephalohematoma),
(4) Persistent vomiting
• Maintain a lower threshold for imaging young infants
BECAUSE serious head injuries can produce findings
that are nonspecific and difficult to appreciate
• Children <2 years of age who have low-energy
mechanisms of injury and who have not experienced
signs or symptoms lasting >2 hours after injury may be
managed by observation alone
>2 Years of Age
Defined as applicable for patients aged 2–20 y, previously healthy, with isolated head injury
A child with a minor closed head injury is defined as a child with normal mental status, normal
findings on neurologic examination, and no signs suggestive of skull fracture
Pediatric Emergency Care Applied Research Network ( PECARN ) Criterias for Head CT
MANAGEMENT
• RAPID , EARLY ASSESSMENT & MANAGEMENT of
ABCDE
• NEUROSURGICAL CONSULTATION (from the beginning )
• Children in the negligible or low risk categories with
normal evaluation findings can be safely discharged
home (assuming there are no home-related risks) with
24-hour observation and follow-up with the primary
care provider. Discharge instructions should clearly
state the need to return to the ED if any symptoms in
the moderate-risk category occur
MANAGEMENT
• .
Pediatric Trauma - Concepts & Management
• ANTI-CONVULSANTS
• Children who experience two or more seizures, or seizures lasting
longer than a few minutes, should receive anticonvulsant therapy
• Prophylactic anticonvulsant therapy should also be strongly
considered in a child with a GCS score of <8, even if no seizures
have yet occurred, because the risk of developing acute post-
traumatic seizures is high, and many of these children already
have high intracranial pressures that will increase further with a
seizure
• MANNITOL
• Rarely indicated
• Diuresis may worsen hypovolemia
• Should be withheld during resuscitation unless there is signs of
Transtentorial herniation
• IV mannitol in a dose of 0.5 to 1.0 gram/kg can be used to lower
intracranial pressure, but the effect is temporary (a few hours
SPINAL TRAUMA
• Spinal trauma is relatively uncommon in young
children and is more commonly seen in adolescents
• Motor vehicle crashes (most common cause) , falls
and sports mishaps.
• 50% of spinal injuries and 67% of cervical spinal
injuries in children <12 years of age occur between
the occiput and C2
• Due to increased flexibility of the spine and spinal
column in younger children spinal cord injury
without radiographic abnormality (SCIWORA) can
occur
Anatomic differences of the Spinal Column in Children
and adults
Underdevelopment of supporting muscles
Partially ossified vertebrae
Wedge-shaped vertebrae
Horizontal facet joints
Higher fulcrum of flexion
Unstable atlanto-occipital joint
Children with spinal cord trauma have a higher mortality rate than
adults, and the mortality is frequently due to concomitant traumatic
brain injury
Because most spinal injuries fail to improve substantially, even in
children, the most important factor in prognosis is the initial neurologic
status
Assessment
1. Clinical Findings
1. Vertebral fractures
pain, tenderness, or overlying soft tissue injury
2. spinal cord injuries (with or without fracture)
paresthesias, paralysis, and other findings based
upon the level or type of spinal cord injury
3. SCIWORA
•In >50% of children onset of paralysis is delayed,
sometimes up to 4 days
•Many of these children have transient
paresthesias, numbness, or weakness at the time of
or shortly after the injury.
2. Radiography
• Considerations for Cervical Spine Imaging in
Children
• Moderate- or high-risk head injury
• Multiple trauma
• Signs or symptoms of spinal injury
• Direct mechanism for spinal injury
• Altered mental status or focal neurologic findings
• Distracting painful injury
• Agitation with possible mechanism for spinal
injury
• . Plain radiography ( remains a useful tool for
initial imaging of the child with a possible spinal
column injury)
• Plain radiographic imaging of the cervical spine
should include at a minimum three views:
lateral, anteroposterior, and odontoid
• if there is any doubt : CT scan
• CT scanning without plain radiographic imaging
of the cervical spine is also an acceptable
alternative if a head CT scan is also being
obtained,
• SCIWORA : MRI
Spinal Cord Injury without Radiographic
Abnormality (SCIWORA)
• Up to 66% of spinal cord injuries
• In children who have experienced transient or
persistent symptoms such as paresthesias or
weakness, with objective signs OF spinal injury , spinal
column imaging must be performed
• If findings on all radiographs are negative but the child
has signs or symptoms of a spinal cord injury, then MRI
should be performed emergently
• Any time the diagnosis of SCIWORA is considered, the
child requires a neurosurgical consultation in the ED
and admission to the hospital.
• Cervical spine immobilization should be maintained
throughout this entire procedure
MANAGEMENT
• prehospital and ED settings
immobilization,
diagnosis of the specific injury,
possibly, steroid administration.(Steroid therapy
should be considered if there is evidence of a
neurologic deficit,Though Debate continues )
• immediate neurosurgical consultation.
• If a spinal fracture is also present, a pediatric
orthopedist should be consulted .
CHEST TRAUMA
• 80% all Pediatric injuries
• Marker for other organ injury ( >2/3rd Pediatric Chest
Injuries assoc with Multiple Injuries)
• Mechanism : mainly, Blunt Trauma (penetrating trauma
more common after 10yrs)
• Rib # , Mediastinal Injuries , Diaphragmatic injury are
Uncommon,
• Mobility of mediastinal structures : more susceptible to
Tension Pneumothorax
• Treatment : Supportive Care +/- Thoracostomy+
Adequate Ventilation ( like Adults)
ABDOMINAL TRAUMA
• Mechanism : blunt trauma mainly,
• More susceptible to
 Solid organ Avulsion (liver, spleen,
Kidney)
 Bladder Injury
 Duodenal Hematoma
 Blunt Pancreatic injury
 Small Bowel perforation @/near the
ligament of Treitz, Avulsion, Mesenteric Avulsion
more common in Children
Clinical Examination
Clincal assessment becomes difficult @ times
 Frightened, Crying Conscious
infants/ young children having Voluntary
guarding
Upper Abdominal Distension due to
Aerophagia
Tenderness due to Gastric dilatation & Bladder
Distension
Diagnostic adjuncts
1. Abdominal CECT
• Gold Standard for Abdominal organ Injuries
even for Children
• Abdominal CT SCAN should be IMMEDIATELY
available , performed Early & Must Not delay
further treatment , & Should be accompanied by
Doctor skilled in Pediatric airway management &
vascular access.
• Indications : abdominal tenderness, abdominal
distention, abdominal bruising, hematuria,
vomiting, neurologic obtundation, falling or low
hematocrit, and absent bowel sounds
2. FAST
Advantage :
• Rapid
• Non-invasive
• Can be Repeated
• Can detect small-amount
of blood
Disadvantage:
Not Consistent to diagnose
Isolated Parenchymal
injury In Children (>1/3rd
solid organ injuries in
children)
• May be used in hemodynamically
unstable children with abdominal
trauma if CT/FAST not readily available
or who can’t be safely transported to
CT,
• By ONLY THE SURGEON who will care
for the child
In Children , Uncertain
Utility
Advantage :
Can be peformed by attending
doctor @ bedside
Disadvantage :
Invasive
•Uncontrolled penetration may
produce iatrogenic organ injury
•Retroperitoneal bleeding can’t be
assessed
•DPL interferes with subsequent
clinical examination
3. DPL
Abdominal trauma management
OPERATIVE
• PRESENCE of INTRAPERITONEAL
BLOOD, DOES NOT MANDATE
LAPAROTOMY in CHILDREN
• Indication :
1. Hemodynamically unstable even
after resuscitative efforts &
Diagnostics (+) for blood
2. Hemodynamically Stable but
transfusion requirement is >1/2
Child’s Blood Volume , or
>40ml/kg during 24hrs after
injury
3. HVP , most of the cases (DPL +
for feces/bile/vegetable
fibres/leococytosis)
NON-OPERATIVE
• Selective cases
• Decision taken by the Surgeon
only
• MUST be UNDER CONTINUOUS
MONITORING by SURGEONS
• Indication
1. Hemodynamically Stable ,
without requiring massive
transfusion
Pelvic and GU Trauma
• GU injuries are uncommon in children
• Trauma to the GU tract should be considered
in all children with multiple trauma, a pelvic
fracture, or injury to the flank, back, or groin
• Children are less likely to die of hemorrhage
from a pelvic fracture than are adults
CLINICAL ASSESSMENT
• often nonspecific
• back pain,
• abdominal pain,
• hypotension,
• abdominal wall trauma
• Pelvic fractures, particularly anterior ring fractures,
(associated with urethral and bladder injury)
• Hematuria is considered the hallmark finding in GU
trauma, although it is a nonspecific sign
• The degree of hematuria does not correlate with
the severity of injury, because renal pedicle
disruption can be associated with no hematuria
and minor injuries can be associated with gross
hematuria
RADIOGRAPHY
• based on clinical
presentation
• Asymptomatic microscopic
hematuria in children with
blunt trauma and no
apparent injuries is a low-
yield indication for emergent
abdominal CT
• Cystourethrography
all patients with suspected
lower urinary tract injuries
(blood at the urethral meatus
or severe anterior pelvic
fracture)
Pediatric Trauma - Concepts & Management
Pediatric Trauma - Concepts & Management
REFERENCES
• ATLS, 9th & 10th edition
• TINTINALLI , 7TH & 8th edition
• UNDERSTANDING PEDIATRIC
ANAESTHESIA, JACOB, 2ND
EDITION
• IAP PEDIATRIC ICU PROTOCOLS,
2ND edition
THANK
YOU

More Related Content

What's hot

Foreign body aspiration in children
Foreign body aspiration in childrenForeign body aspiration in children
Foreign body aspiration in childrenNoor alwiely
 
Advanced Trauma Life Support- An overview
Advanced Trauma Life Support- An overviewAdvanced Trauma Life Support- An overview
Advanced Trauma Life Support- An overviewSelvaraj Balasubramani
 
Congenital diaphragmatic hernia by Dr. Varsha Atul Shah
Congenital diaphragmatic hernia by Dr. Varsha Atul ShahCongenital diaphragmatic hernia by Dr. Varsha Atul Shah
Congenital diaphragmatic hernia by Dr. Varsha Atul ShahVarsha Shah
 
Approach to a trauma patient - Advanced Trauma Life Support
Approach to a trauma patient - Advanced Trauma Life SupportApproach to a trauma patient - Advanced Trauma Life Support
Approach to a trauma patient - Advanced Trauma Life SupportParthasarathi Ghosh
 
Presentation of atls 2018
Presentation of atls 2018Presentation of atls 2018
Presentation of atls 2018Novel Pokharel
 
INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELI...
INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELI...INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELI...
INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELI...Prerna Biswal
 
Approach to respiratory distress in children
Approach to respiratory distress in childrenApproach to respiratory distress in children
Approach to respiratory distress in childrenWasim Akram
 
Advanced trauma life support
Advanced trauma life supportAdvanced trauma life support
Advanced trauma life supportyakubuahmed1
 
Diaphragmatic hernia in children
 Diaphragmatic hernia in children  Diaphragmatic hernia in children
Diaphragmatic hernia in children Siddhi Koti
 
Surgical emergencies in newborn
Surgical emergencies in newbornSurgical emergencies in newborn
Surgical emergencies in newbornAbhijeet Deshmukh
 
Bronchopulmonary Dysplasia
Bronchopulmonary DysplasiaBronchopulmonary Dysplasia
Bronchopulmonary DysplasiaDr Anand Singh
 
Abdominal trauma
Abdominal traumaAbdominal trauma
Abdominal traumaFaiz Hmoud
 
Advanced trauma life support (atls)
Advanced trauma life support (atls)Advanced trauma life support (atls)
Advanced trauma life support (atls)Saleh Bakry
 
Damage control resuscitation
Damage control resuscitationDamage control resuscitation
Damage control resuscitationSCGH ED CME
 

What's hot (20)

Foreign body aspiration in children
Foreign body aspiration in childrenForeign body aspiration in children
Foreign body aspiration in children
 
Advanced Trauma Life Support- An overview
Advanced Trauma Life Support- An overviewAdvanced Trauma Life Support- An overview
Advanced Trauma Life Support- An overview
 
Foreign body aspiration
Foreign body aspirationForeign body aspiration
Foreign body aspiration
 
Foreign Body In Children
Foreign Body In ChildrenForeign Body In Children
Foreign Body In Children
 
Congenital diaphragmatic hernia by Dr. Varsha Atul Shah
Congenital diaphragmatic hernia by Dr. Varsha Atul ShahCongenital diaphragmatic hernia by Dr. Varsha Atul Shah
Congenital diaphragmatic hernia by Dr. Varsha Atul Shah
 
Approach to a trauma patient - Advanced Trauma Life Support
Approach to a trauma patient - Advanced Trauma Life SupportApproach to a trauma patient - Advanced Trauma Life Support
Approach to a trauma patient - Advanced Trauma Life Support
 
Presentation of atls 2018
Presentation of atls 2018Presentation of atls 2018
Presentation of atls 2018
 
Respiratory distress in newborn
Respiratory distress in newbornRespiratory distress in newborn
Respiratory distress in newborn
 
INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELI...
INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELI...INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELI...
INITIAL ASSESSMENT OF TRAUMA PATIENTS....(INSPIRED FROM CTLS AND ATLS GUIDELI...
 
Approach to respiratory distress in children
Approach to respiratory distress in childrenApproach to respiratory distress in children
Approach to respiratory distress in children
 
Atls presentation
Atls presentationAtls presentation
Atls presentation
 
Pediatric burns
Pediatric burnsPediatric burns
Pediatric burns
 
Advanced trauma life support
Advanced trauma life supportAdvanced trauma life support
Advanced trauma life support
 
Diaphragmatic hernia in children
 Diaphragmatic hernia in children  Diaphragmatic hernia in children
Diaphragmatic hernia in children
 
Surgical emergencies in newborn
Surgical emergencies in newbornSurgical emergencies in newborn
Surgical emergencies in newborn
 
Bronchopulmonary Dysplasia
Bronchopulmonary DysplasiaBronchopulmonary Dysplasia
Bronchopulmonary Dysplasia
 
Abdominal trauma
Abdominal traumaAbdominal trauma
Abdominal trauma
 
Advanced trauma life support (atls)
Advanced trauma life support (atls)Advanced trauma life support (atls)
Advanced trauma life support (atls)
 
Damage control resuscitation
Damage control resuscitationDamage control resuscitation
Damage control resuscitation
 
ATLS- Advanced Trauma Life Support
ATLS- Advanced Trauma Life SupportATLS- Advanced Trauma Life Support
ATLS- Advanced Trauma Life Support
 

Similar to Pediatric Trauma - Concepts & Management

ANESTHESIA MANAGEMENT OF CLEFT LIP & PALATE
ANESTHESIA MANAGEMENT OF CLEFT LIP & PALATEANESTHESIA MANAGEMENT OF CLEFT LIP & PALATE
ANESTHESIA MANAGEMENT OF CLEFT LIP & PALATEmadhu chaitanya
 
Neonatal resuscitation
Neonatal resuscitationNeonatal resuscitation
Neonatal resuscitationAhmad Aboaziza
 
neonatL resuscitation
neonatL resuscitation neonatL resuscitation
neonatL resuscitation KhodifadVijay
 
Choanal atresia
Choanal atresiaChoanal atresia
Choanal atresiaNibi Baby
 
neonatal resuscitation.pptx
neonatal resuscitation.pptxneonatal resuscitation.pptx
neonatal resuscitation.pptxVedVyas20
 
Pediatric Airway Anatomy Physiology and Management.ppt
Pediatric Airway Anatomy Physiology and Management.pptPediatric Airway Anatomy Physiology and Management.ppt
Pediatric Airway Anatomy Physiology and Management.pptssuser814a33
 
18basicsofpediatricairwayanatomyphysiologyandmanagement 100415234610-phpapp01
18basicsofpediatricairwayanatomyphysiologyandmanagement 100415234610-phpapp0118basicsofpediatricairwayanatomyphysiologyandmanagement 100415234610-phpapp01
18basicsofpediatricairwayanatomyphysiologyandmanagement 100415234610-phpapp01Dolores Malone
 
upper & lower airway obstruction
upper & lower airway obstructionupper & lower airway obstruction
upper & lower airway obstructionRamya Deepthi P
 
Anesthetic Concerns for Difficult Airway in a Child with Congenital Hydroceph...
Anesthetic Concerns for Difficult Airway in a Child with Congenital Hydroceph...Anesthetic Concerns for Difficult Airway in a Child with Congenital Hydroceph...
Anesthetic Concerns for Difficult Airway in a Child with Congenital Hydroceph...asclepiuspdfs
 
Paediatrics Resuscitation 2015
Paediatrics Resuscitation 2015Paediatrics Resuscitation 2015
Paediatrics Resuscitation 2015Kemi Dele-Ijagbulu
 
Acute_respiratory_diseses_in_Children___Croup.pptx
Acute_respiratory_diseses_in_Children___Croup.pptxAcute_respiratory_diseses_in_Children___Croup.pptx
Acute_respiratory_diseses_in_Children___Croup.pptxesicOrtho1
 
GIT for nursing school
GIT for nursing schoolGIT for nursing school
GIT for nursing schoolMukhtar Mahdy
 
Neonatal resuscitation
Neonatal resuscitationNeonatal resuscitation
Neonatal resuscitationMohd Maghyreh
 
anesthesia for obstructed inguinal hernia
anesthesia for obstructed inguinal herniaanesthesia for obstructed inguinal hernia
anesthesia for obstructed inguinal herniaPramod Sarwa
 

Similar to Pediatric Trauma - Concepts & Management (20)

ANESTHESIA MANAGEMENT OF CLEFT LIP & PALATE
ANESTHESIA MANAGEMENT OF CLEFT LIP & PALATEANESTHESIA MANAGEMENT OF CLEFT LIP & PALATE
ANESTHESIA MANAGEMENT OF CLEFT LIP & PALATE
 
Neonatal resuscitation
Neonatal resuscitationNeonatal resuscitation
Neonatal resuscitation
 
neonatL resuscitation
neonatL resuscitation neonatL resuscitation
neonatL resuscitation
 
pediatric emergency.ppt
pediatric emergency.pptpediatric emergency.ppt
pediatric emergency.ppt
 
ventilation in neonates
ventilation in neonatesventilation in neonates
ventilation in neonates
 
Choanal atresia
Choanal atresiaChoanal atresia
Choanal atresia
 
neonatal resuscitation.pptx
neonatal resuscitation.pptxneonatal resuscitation.pptx
neonatal resuscitation.pptx
 
Pediatric Airway Anatomy Physiology and Management.ppt
Pediatric Airway Anatomy Physiology and Management.pptPediatric Airway Anatomy Physiology and Management.ppt
Pediatric Airway Anatomy Physiology and Management.ppt
 
18basicsofpediatricairwayanatomyphysiologyandmanagement 100415234610-phpapp01
18basicsofpediatricairwayanatomyphysiologyandmanagement 100415234610-phpapp0118basicsofpediatricairwayanatomyphysiologyandmanagement 100415234610-phpapp01
18basicsofpediatricairwayanatomyphysiologyandmanagement 100415234610-phpapp01
 
Neonatal resuscitation
Neonatal resuscitationNeonatal resuscitation
Neonatal resuscitation
 
upper & lower airway obstruction
upper & lower airway obstructionupper & lower airway obstruction
upper & lower airway obstruction
 
Anesthetic Concerns for Difficult Airway in a Child with Congenital Hydroceph...
Anesthetic Concerns for Difficult Airway in a Child with Congenital Hydroceph...Anesthetic Concerns for Difficult Airway in a Child with Congenital Hydroceph...
Anesthetic Concerns for Difficult Airway in a Child with Congenital Hydroceph...
 
Paediatrics Resuscitation 2015
Paediatrics Resuscitation 2015Paediatrics Resuscitation 2015
Paediatrics Resuscitation 2015
 
Neonatal resuscitation
Neonatal resuscitationNeonatal resuscitation
Neonatal resuscitation
 
Acute_respiratory_diseses_in_Children___Croup.pptx
Acute_respiratory_diseses_in_Children___Croup.pptxAcute_respiratory_diseses_in_Children___Croup.pptx
Acute_respiratory_diseses_in_Children___Croup.pptx
 
GIT for nursing school
GIT for nursing schoolGIT for nursing school
GIT for nursing school
 
Neonatal resuscitation
Neonatal resuscitationNeonatal resuscitation
Neonatal resuscitation
 
Airway Management
Airway ManagementAirway Management
Airway Management
 
BIRTH ASPXIA, RDS.pptx
BIRTH ASPXIA, RDS.pptxBIRTH ASPXIA, RDS.pptx
BIRTH ASPXIA, RDS.pptx
 
anesthesia for obstructed inguinal hernia
anesthesia for obstructed inguinal herniaanesthesia for obstructed inguinal hernia
anesthesia for obstructed inguinal hernia
 

More from Subhankar Paul

Emergency Wound Management
Emergency Wound Management Emergency Wound Management
Emergency Wound Management Subhankar Paul
 
SEDATIVES & ANALGESICS in ICU
SEDATIVES & ANALGESICS in ICUSEDATIVES & ANALGESICS in ICU
SEDATIVES & ANALGESICS in ICUSubhankar Paul
 
violent patient in emergency department
 violent patient in emergency department violent patient in emergency department
violent patient in emergency departmentSubhankar Paul
 

More from Subhankar Paul (6)

Emergency Wound Management
Emergency Wound Management Emergency Wound Management
Emergency Wound Management
 
SEDATIVES & ANALGESICS in ICU
SEDATIVES & ANALGESICS in ICUSEDATIVES & ANALGESICS in ICU
SEDATIVES & ANALGESICS in ICU
 
Adult BLS & ACLS 2015
Adult BLS & ACLS 2015Adult BLS & ACLS 2015
Adult BLS & ACLS 2015
 
TRIAGE
TRIAGETRIAGE
TRIAGE
 
Pulse & JVP
Pulse & JVPPulse & JVP
Pulse & JVP
 
violent patient in emergency department
 violent patient in emergency department violent patient in emergency department
violent patient in emergency department
 

Recently uploaded

Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionkrishnareddy157915
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondSujoy Dasgupta
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.kishan singh tomar
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismusChandrasekar Reddy
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...Shubhanshu Gaurav
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE Mamatha Lakka
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisSujoy Dasgupta
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.aarjukhadka22
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptxNIKITA BHUTE
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project reportNARMADAPETROLEUMGAS
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfHongBiThi1
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024EwoutSteyerberg1
 

Recently uploaded (20)

Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung function
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and Beyond
 
American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismus
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE
 
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosis
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project report
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
 
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024
 

Pediatric Trauma - Concepts & Management

  • 1. PEDIATRIC TRAUMA Presenter : Dr Subhankar Paul
  • 2. INTRODUCTION • The priorities & principals of assessment & management of injuries in Children are same as in adults. • Unique Anatomical & Physiologival characteristics of the Children & different mechanisms of Injury results in MultiSystem Injury being the Rule rather than the exception in Children . So, Aggressive management accordingly is to be done. • Many injuries can be managed initially in a general hospital ED, but care of the most seriously injured children requires prompt triage and transportation to a designated pediatric trauma center
  • 3. Unique Characteristics of Pediatric patienets related to Trauma 1. SIZE & SHAPE :  SMALLER BODY MASS in the children , the energy imparted from the trauma results in a greater force applied per unit of body surface area.  This more intense energey is transmitted to a body having LESS FAT, LESS CONNECTIVE TISSUE, & CLOSE PROXIMITY to MULTIPLE ORGANS , resulting in severe & multi-system injuries in children.  Head in proportionately larger than the body , so high frequency of Blunt Brain injuries is there.
  • 4. • 2. SKELETON Incomplete calcification Multiple active growth centres More pliable Internal organ damage is frequent without external skeletal damage. If bony injury (e.g skull/rib # ) present : must have underlying severe organ injury (e.g blunt brain injury/ pulonary contusion etc.) Diagnostic difficulty by Radiography
  • 5. 3. SURFACE AREA (Child’s body surface area : Blood volume ) ratio is Highest @ Birth & decreases with Age. Thermal energy loss & thereby Hypothermia develops quickly in children with Hypovolemia/hypotension 4. PSYCHOLOGICAL STATUS : • emotional unstability • Regressive behaviour with pain/ stress • Naturally more fear & Stranger anxiety Difficulty in CLINICAL ASSESSMENT
  • 6. PRINCIPLES of Pediatric Trauma Care • Prehospital Care • TRIAGE • PRIMARY SURVEY (A/B/C/D/E) • RESUSCITAION • SECONDARY SURVEY • POSTRESUSCITAION MONITORING & RE- EVALUATION • DEFINITIVE CARE
  • 7. Prehospital Care prehospital interventions should focus on  airway and respiratory management ,  spinal immobilization  recognition of shock,  rapid transport to an appropriate facility based upon the predicted severity of injury as soon as possible  Shortening the time interval between injury and definitive care remains a priority, and interventions beyond lifesaving measures can be performed en route to the hospital.  Don’t delay in transport for ET intubation/ IV access
  • 9. AIRWAY EVALUATION & MANAGEMANT • inability to maintain a Patent airway asssoc with lack of oxygenation & Ventilation is the most common cause of cardiac arrest in children . • So, children’s airway is a priority. • Assess for Obstruction due to , POSITION, INJURY, BLOOD, TEETH, FOREIGN BODY, VOMITUS,
  • 10. Pediatric Anatomy Potential Implications Airway Maneuvers Large head and occiput May push head forward, occluding airway Shoulder roll may be required to align airway axes Large tongue May occlude upper airway in obtunded or paralyzed patient Jaw thrust, oral or nasopharyngeal airway, Miller (straight) laryngoscope blade Superior larynx and anterior cords May make visualization of cords difficult Shoulder roll may be required to align airway axes, straight laryngoscope blade to lift epiglottis Cricoid narrowing Subglottic space is narrowest portion of the pediatric airway, prone to inflammation and upper airway obstruction Monitor cuff insufflation pressures in small children Large adenoids and tonsils May cause upper airway obstruction; may bleed with nasal intubation Avoid blind nasal intubation in young children Small cricoid cartilage Makes open cricothyrotomy technically difficult Needle cricothyrotomy preferred in young children Large stomach, low gastroesophageal sphincter tone, relatively small lungs Insufflation of stomach with bag- valve mask ventilation or swallowed air, children are prone to vomiting Consider early placement of orogastric or nasogastric tube to deflate stomach when using positive pressure ventilation
  • 12. Airway management NON-INVASIVE • Indication : Spontaneously Breathing Child with Partially Obstructed airway Methods : 1. Neutral Position 2. Jaw-thrust + Bi-manual In- line stabilisation 3. Suction of Secretion /vomitus /Blood 4. Bag-Mask Ventilation +/- Oral Airway INVASIVE • Indication 1. Unconscious/ GCS <9 2. Lack of Patent airway 3. Impending loss of patent airway 4. Inability to Oxygenate/ Ventilate 5. Full/Impending Cardiac Arrest PRE-REQUISITE : Fully Pre- Oxygenation
  • 13. Invasive Definitive Airway ENDO-TRACHEAL INTUBATION • Most reliable Method of establishing definitive Airway & administering ventilation in a child • Orotracheal Intubation under direct Laryngoscopic visualisation along with Adequate immobilisation & protection of C-Spine is preffered • Naso-tracheal route is NOT PREFFERED in children • Method : DAI (RSI ) CRICOTHYROIDOTOMY • When Airway maintenance /control can’t be achieved by Bag-Mask Ventilation / Orotracheal Intubation • Needle Cricothyroidotomy preferred over Surgical Cricothyroidotomy (≤8yrs) • Caution : 1. Temporary Technique 2. Inadequate ventilation progressive Hypercarbia
  • 14. Pediatric DAI / RSI PROTOCOL IN TRAUMA
  • 15. Age Et tube(mm Internal Diameter) Blade Size & shape Premature 2.5 Uncuffed* 0 Straight Newborn 3.0 Uncuffed* 1.0 Straight 1–6 mo 3.5 Uncuffed* 1.0–1.5 Straight 6–12 mo 4.0 Uncuffed* 1.5 Straight 1–2 y 4.5 Uncuffed* 1.5 Straight 3–4 y 5.0 Uncuffed* 1.5–2.0 Straight or curved 5–6 y 5.5 Uncuffed* 2.0 Straight or curved 7–8 y 6.0 Cuffed 2.0 Straight or curved 9–10 y 6.5 Cuffed 2.0 Straight or curved 11 y 7.0 Cuffed 3.0 Straight or curved Age-Based Airway Equipment Size 2-10yrs UNCUFFED ETT SIZE AGE(yrs)/4 + 4 CUFFED ETT SIZE AGE (yrs)/4 + 3.5 Weight based ET Tsize < 1kg : 2.5 mm 1-2kg : 3 mm 2-3kg : 3.5 mm >3kg : 3.5-4.0 mm
  • 16. Cervical Spine Immobilization • Criteria: • spinal pain or tenderness, • significant multisystem trauma, • severe head or facial trauma, • neurologic deficit in any extremity, • loss of consciousness, • significant distracting injury, • altered mental status • METHOD ( Immobilize C-Spine until such injury excluded) • A properly fitting rigid Cervical collar should be used. • Head should be secured to the spine board using towel rolls • padding may be necessary behind the shoulders • Secure the child's body to the board by straps or wide cloth tape • prevent lateral movement of the child during log-rolling
  • 17. BREATHING • ASSESSMENT 1. RATE 2. CHEST WALL MOVEMENT ( PARADOXICAL BREATHING/ FLAIL SEGMENT) 3. TRACHEAL DEVIATION 4. OPEN WOUNDS 5. OXYGEN STATUS 6. PERCUSSION NOTE 7. CREPITUS
  • 18. Signs of hypoxemia Cyanosis Agitation Poor capillary refill Bradycardia Desaturation measured by pulse oximetry Signs of inadequate ventilation Tachypnea Nasal flaring Grunting Retractions Stridor or wheezing
  • 19. MANAGEMENT Of BREATHING & VENTILATION • WARM HUMIDIFIED O2 • GASTRIC DECOMPRESSION (To prevent Aspiration) • Appropriate Mechanical Ventilation ( avoid Barotrauma & Volutrauma ) • NEEDLE/ TUBE THORACOSTOMY ( pneumo/hemo/hemo-pneumothorax) avoid using long 14-18 g over-the-needle catheters for needle thoracostomy ( 2nd ICS, MCL) Chest tubes (small size) inserted by Tunneling , site same as adult ( 5TH ICS, JUST ANT to MAL )
  • 20. CIRCULATION & SHOCK • Child’s Increased Physiologic Reserve : allows for maintenance of normal SBP even in shock • Upto 30% diminuation in circulatory blood volume may be required to manifest a Decrease in Child’s SBP • TACHYCARDIA & POOR SKIN PERFUSION are often the Only Early recognising features for hypovolemia
  • 22. SYSTEMIC RESPONSE to BLOOD LOSS
  • 23. MANAGEMENT 1. VASCULAR ACCESS 2. FLUID RESUSCITATION 3. BLOOD REPLACEMENT 4. CONTROL EXTERNAL HEMORRHAGE 5. SURGICAL INTERVENTION ( To control INTERNAL HEMORRHAGE)
  • 25. Ref : ATLS 10TH
  • 26. OPTIMAL RESPONSE to RESUSCITATION
  • 27. DISABILITY • Level of consciousness can be assessed using either the Glasgow Coma Scale (GCS) or the AVPU system • GCS <8 : prompt endotracheal intubation in trauma patients • In children, GCS < 5 : poor outcome. • Examination of cranial nerves • pupillary responsiveness • motor strength of each limb
  • 28. EXPOSURE • to identify important injuries and to detect and correct hypothermia. • Control bleeding by direct pressure, using air splints on the extremities if needed • A rectal temperature should be obtained • Whenever possible, keep the child covered and use external warming devices • Consider warming fluids to 40°C (104°F) if large amounts of IV fluids or blood products are used.
  • 30. Secondary Survey • to identify all other injuries in the patient • The presence of family may often be helpful to calm and console frightened and injured children • complete history ( “AMPLE” (allergies, medications, past medical history, time of last meal, and events leading up to the injury ) • Imaging, diagnostic, and laboratory studies
  • 31. Stabilization • stabilized sufficiently to allow transfer of the child to the radiology suite or inpatient unit, or safe transfer to HIGHER CENTRE • Continual reassessment is crucial • Endotracheal tube dislodgment, • development of a pneumothorax, • regurgitation of stomach contents, • occult hemorrhage causing shock, • Worsening neurologic function • Careful monitoring of fluid administration, • Analgesics and sedatives
  • 32. Referral to a HIGHER Pediatric Center • Use of trauma triage scores : identify a child whose care requires a more experienced team • commonly used systems 1. Pediatric Trauma Score 2. Revised Trauma Score . • Higher numbers : greater likelihood of survival and thus a reduced need for trauma center care • A child with a Revised Trauma Score of <12 or a Pediatric Trauma Score of <8 should be transferred to a trauma center.
  • 33. Pediatric Trauma Score –1 +1 +2 Size (kg) <10 10–20 >20 Airway Unmaintained Maintained Normal Systolic blood pressure (mm Hg) <50 50–90 >90 Level of consciousness Comatose Altered Awake Wounds Major open Minor open None Skeletal trauma Open/multiple Closed None
  • 34. Revised Trauma Score Number Glasgow Coma Scale Score Systolic Blood Pressure (mm Hg) Respirator y Rate (breaths/ min) 4 13–15 >89 10–29 3 9–12 76–89 >29 2 6–8 50–75 6–9 1 4–5 1–49 1–5 0 3 0 0
  • 35. Indications for Transfer to a Pediatric Trauma Center Mechanism of injury Ejection from motor vehicle Fall from a height Motor vehicle collision with prolonged extrication Motor vehicle collision with death of another vehicle occupant Anatomic injury Multiple severe trauma More than three long-bone fractures Spinal fractures or spinal cord injury Amputations Severe head or facial trauma Penetrating head, chest, or abdominal trauma
  • 38. PEDIATRIC HEAD TRAUMA • Head trauma consists of INJURY to Bony Skeleton, Soft Tissue , & IntraCranial Contents • Traumatic Brain injury is the leading cause of death due to pediatric trauma • Concussion is term for mild traumatic brain injury with trauma-induced alteration in mental status, often manifested with amnesia / confusion • Children are more susceptible to secondary brain injury , triggered by hypovolemia, decreased CPP, Hypoxia, Hyperthermia, Seizures. So, adequate & early restoration of circulating blood volume & avoidig hypoxia is necessary
  • 39. ASSESSMENT • AVPU SCALE ( CORTICAL FUNCTION ) • GCS • PUPIL • FONTANELLES • EYE EXAMINATION (RETINAL HEMORRHAGES ) • MOTOR/ SENSORY DEFICITS • SYMPTOMS ( vomiting, dizziness, headache, irritability, and decreased level of consciousness)
  • 40. Pediatric considerations in Assessment 1. Infants & Young Child having Open fontanelle & Mobile cranial sutures , more tolerant to increasing IC SOL / Brain Edema. So even in a Conscious child with bulging fontanelle/ suture diastasis indicate severe brain injury Early neurosurgical intervention is essential. 2. Vomiting & Amnesia are common in children after head injury , doesn’t necessarily imply increased ICP. But, Persistant /more frequent Vomiting is a concern & mandates CT HEAD
  • 41. 3. Impact Seizures is more common in Children & usually self-limited, but REQUIRES CT Head(Only 50% of children with post-traumatic seizures have abnormal findings on CT scan) least likely to result in long-term sequelae. 4. Raised ICP due to Cerebral edema is more common than focal mass lesions in children, so early ICP Monitoring indicated with GCS <8 or MOTOR SCORE 1 or 2 Co-existent Multiple Organ injuries requiring major volume resuscitation Cerebral haemorrrhage/ edema & brain herniation in CT HEAD
  • 42. RADIOLOGIC EVALUATION • primary goal : to identify traumatic brain injury and to detect intracranial injuries that require surgical intervention • No clinical criteria can reliably predict the presence of an intracranial injury • CT and MRI are necessary . CT is the imaging modality of choice. • Indications are different acc to age
  • 43. 0 to 2 Years of Age • INDICATIONS (1) any neurologic abnormality, (2) any altered mental status, (3) any scalp abnormalities (contusion, abrasion, laceration, cephalohematoma), (4) Persistent vomiting • Maintain a lower threshold for imaging young infants BECAUSE serious head injuries can produce findings that are nonspecific and difficult to appreciate • Children <2 years of age who have low-energy mechanisms of injury and who have not experienced signs or symptoms lasting >2 hours after injury may be managed by observation alone
  • 44. >2 Years of Age Defined as applicable for patients aged 2–20 y, previously healthy, with isolated head injury A child with a minor closed head injury is defined as a child with normal mental status, normal findings on neurologic examination, and no signs suggestive of skull fracture
  • 45. Pediatric Emergency Care Applied Research Network ( PECARN ) Criterias for Head CT
  • 46. MANAGEMENT • RAPID , EARLY ASSESSMENT & MANAGEMENT of ABCDE • NEUROSURGICAL CONSULTATION (from the beginning ) • Children in the negligible or low risk categories with normal evaluation findings can be safely discharged home (assuming there are no home-related risks) with 24-hour observation and follow-up with the primary care provider. Discharge instructions should clearly state the need to return to the ED if any symptoms in the moderate-risk category occur
  • 49. • ANTI-CONVULSANTS • Children who experience two or more seizures, or seizures lasting longer than a few minutes, should receive anticonvulsant therapy • Prophylactic anticonvulsant therapy should also be strongly considered in a child with a GCS score of <8, even if no seizures have yet occurred, because the risk of developing acute post- traumatic seizures is high, and many of these children already have high intracranial pressures that will increase further with a seizure • MANNITOL • Rarely indicated • Diuresis may worsen hypovolemia • Should be withheld during resuscitation unless there is signs of Transtentorial herniation • IV mannitol in a dose of 0.5 to 1.0 gram/kg can be used to lower intracranial pressure, but the effect is temporary (a few hours
  • 50. SPINAL TRAUMA • Spinal trauma is relatively uncommon in young children and is more commonly seen in adolescents • Motor vehicle crashes (most common cause) , falls and sports mishaps. • 50% of spinal injuries and 67% of cervical spinal injuries in children <12 years of age occur between the occiput and C2 • Due to increased flexibility of the spine and spinal column in younger children spinal cord injury without radiographic abnormality (SCIWORA) can occur
  • 51. Anatomic differences of the Spinal Column in Children and adults Underdevelopment of supporting muscles Partially ossified vertebrae Wedge-shaped vertebrae Horizontal facet joints Higher fulcrum of flexion Unstable atlanto-occipital joint Children with spinal cord trauma have a higher mortality rate than adults, and the mortality is frequently due to concomitant traumatic brain injury Because most spinal injuries fail to improve substantially, even in children, the most important factor in prognosis is the initial neurologic status
  • 52. Assessment 1. Clinical Findings 1. Vertebral fractures pain, tenderness, or overlying soft tissue injury 2. spinal cord injuries (with or without fracture) paresthesias, paralysis, and other findings based upon the level or type of spinal cord injury 3. SCIWORA •In >50% of children onset of paralysis is delayed, sometimes up to 4 days •Many of these children have transient paresthesias, numbness, or weakness at the time of or shortly after the injury.
  • 53. 2. Radiography • Considerations for Cervical Spine Imaging in Children • Moderate- or high-risk head injury • Multiple trauma • Signs or symptoms of spinal injury • Direct mechanism for spinal injury • Altered mental status or focal neurologic findings • Distracting painful injury • Agitation with possible mechanism for spinal injury
  • 54. • . Plain radiography ( remains a useful tool for initial imaging of the child with a possible spinal column injury) • Plain radiographic imaging of the cervical spine should include at a minimum three views: lateral, anteroposterior, and odontoid • if there is any doubt : CT scan • CT scanning without plain radiographic imaging of the cervical spine is also an acceptable alternative if a head CT scan is also being obtained, • SCIWORA : MRI
  • 55. Spinal Cord Injury without Radiographic Abnormality (SCIWORA) • Up to 66% of spinal cord injuries • In children who have experienced transient or persistent symptoms such as paresthesias or weakness, with objective signs OF spinal injury , spinal column imaging must be performed • If findings on all radiographs are negative but the child has signs or symptoms of a spinal cord injury, then MRI should be performed emergently • Any time the diagnosis of SCIWORA is considered, the child requires a neurosurgical consultation in the ED and admission to the hospital. • Cervical spine immobilization should be maintained throughout this entire procedure
  • 56. MANAGEMENT • prehospital and ED settings immobilization, diagnosis of the specific injury, possibly, steroid administration.(Steroid therapy should be considered if there is evidence of a neurologic deficit,Though Debate continues ) • immediate neurosurgical consultation. • If a spinal fracture is also present, a pediatric orthopedist should be consulted .
  • 57. CHEST TRAUMA • 80% all Pediatric injuries • Marker for other organ injury ( >2/3rd Pediatric Chest Injuries assoc with Multiple Injuries) • Mechanism : mainly, Blunt Trauma (penetrating trauma more common after 10yrs) • Rib # , Mediastinal Injuries , Diaphragmatic injury are Uncommon, • Mobility of mediastinal structures : more susceptible to Tension Pneumothorax • Treatment : Supportive Care +/- Thoracostomy+ Adequate Ventilation ( like Adults)
  • 58. ABDOMINAL TRAUMA • Mechanism : blunt trauma mainly, • More susceptible to  Solid organ Avulsion (liver, spleen, Kidney)  Bladder Injury  Duodenal Hematoma  Blunt Pancreatic injury  Small Bowel perforation @/near the ligament of Treitz, Avulsion, Mesenteric Avulsion more common in Children
  • 59. Clinical Examination Clincal assessment becomes difficult @ times  Frightened, Crying Conscious infants/ young children having Voluntary guarding Upper Abdominal Distension due to Aerophagia Tenderness due to Gastric dilatation & Bladder Distension
  • 60. Diagnostic adjuncts 1. Abdominal CECT • Gold Standard for Abdominal organ Injuries even for Children • Abdominal CT SCAN should be IMMEDIATELY available , performed Early & Must Not delay further treatment , & Should be accompanied by Doctor skilled in Pediatric airway management & vascular access. • Indications : abdominal tenderness, abdominal distention, abdominal bruising, hematuria, vomiting, neurologic obtundation, falling or low hematocrit, and absent bowel sounds
  • 61. 2. FAST Advantage : • Rapid • Non-invasive • Can be Repeated • Can detect small-amount of blood Disadvantage: Not Consistent to diagnose Isolated Parenchymal injury In Children (>1/3rd solid organ injuries in children) • May be used in hemodynamically unstable children with abdominal trauma if CT/FAST not readily available or who can’t be safely transported to CT, • By ONLY THE SURGEON who will care for the child In Children , Uncertain Utility Advantage : Can be peformed by attending doctor @ bedside Disadvantage : Invasive •Uncontrolled penetration may produce iatrogenic organ injury •Retroperitoneal bleeding can’t be assessed •DPL interferes with subsequent clinical examination 3. DPL
  • 62. Abdominal trauma management OPERATIVE • PRESENCE of INTRAPERITONEAL BLOOD, DOES NOT MANDATE LAPAROTOMY in CHILDREN • Indication : 1. Hemodynamically unstable even after resuscitative efforts & Diagnostics (+) for blood 2. Hemodynamically Stable but transfusion requirement is >1/2 Child’s Blood Volume , or >40ml/kg during 24hrs after injury 3. HVP , most of the cases (DPL + for feces/bile/vegetable fibres/leococytosis) NON-OPERATIVE • Selective cases • Decision taken by the Surgeon only • MUST be UNDER CONTINUOUS MONITORING by SURGEONS • Indication 1. Hemodynamically Stable , without requiring massive transfusion
  • 63. Pelvic and GU Trauma • GU injuries are uncommon in children • Trauma to the GU tract should be considered in all children with multiple trauma, a pelvic fracture, or injury to the flank, back, or groin • Children are less likely to die of hemorrhage from a pelvic fracture than are adults
  • 64. CLINICAL ASSESSMENT • often nonspecific • back pain, • abdominal pain, • hypotension, • abdominal wall trauma • Pelvic fractures, particularly anterior ring fractures, (associated with urethral and bladder injury) • Hematuria is considered the hallmark finding in GU trauma, although it is a nonspecific sign • The degree of hematuria does not correlate with the severity of injury, because renal pedicle disruption can be associated with no hematuria and minor injuries can be associated with gross hematuria
  • 65. RADIOGRAPHY • based on clinical presentation • Asymptomatic microscopic hematuria in children with blunt trauma and no apparent injuries is a low- yield indication for emergent abdominal CT • Cystourethrography all patients with suspected lower urinary tract injuries (blood at the urethral meatus or severe anterior pelvic fracture)
  • 68. REFERENCES • ATLS, 9th & 10th edition • TINTINALLI , 7TH & 8th edition • UNDERSTANDING PEDIATRIC ANAESTHESIA, JACOB, 2ND EDITION • IAP PEDIATRIC ICU PROTOCOLS, 2ND edition

Editor's Notes

  1. Treatment of spinal cord injuries in the prehospital and ED settings consists of immobilization, diagnosis of the specific injury, and, possibly, steroid administration. Steroid therapy should be considered if there is evidence of a neurologic deficit. Debate continues regarding the benefit of steroid administration in spinal cord injury
  2. Because most morbidity and mortality in pediatric trauma is due to traumatic brain injury, prehospital interventions should focus on airway and respiratory management, recognition of shock, spinal immobilization, and rapid transport to an appropriate facility based upon the predicted severity of injury Shortening the time interval between injury and definitive care remains a priority; minimizing on-scene time is an important issue in prehospital management. Transport to the hospital should be initiated as soon as possible, and interventions beyond lifesaving measures can be performed en route to the hospital. Although establishment of IV access may be the prehospital ALS intervention that is most often performed, the beneficial effects of this intervention remain in doubt for the majority of pediatric trauma patients. Although airway management is crucial to prevent hypoxia, prehospital endotracheal intubation requires specialized skills and training, and it is not associated with better outcomes in children than is bag-valve mask ventilation.
  3. Injuries and conditions that require immediate lifesaving intervention should be identified and treated during the primary survey , The priorities in the management of children with traumatic injuries do not differ from those in the management of injured adults
  4. The most important step in trauma care for children is airway intervention
  5. Statistically validated criteria to predict which children require immobilization have not been developedCompleting the primary survey takes precedence over clearance of the child's cervical spine by clinical or radiographic methods.
  6. Signs of shock include tachycardia, cool extremities, altered level of consciousness, weak distal pulses, low urine output, and capillary refill time of >3 seconds. Measure capillary refill in children at the head or chest to minimize the influence of environmental factors. For shock, give rapid crystalloid fluid boluses of 20 mL/kg. If three boluses of crystalloid fail to correct signs of shock, then blood [packed red blood cells (RBCs)] should be given using 10 mL/kg boluses
  7. IO 18G INFANTS, 15 G YOUNG CHILD
  8. , because some injuries may only be manifested over time and complications from therapeutic interventions can occur
  9. Children with any loss of consciousness or any symptoms after head injuries from sports should be kept out of athletic activities for 1 week and reevaluated before return to athletic activities
  10. Furosemide (1.0 milligram/kg) may decrease edema as well. To date, no studies have shown steroid therapy to be helpful
  11. A single lateral cervical spine radiograph has been shown to miss fractures and result in a delay in diagnosis. The role of flexion and extension lateral cervical spine radiographs is controversial. Flexion-extension images should not be obtained if there are neurologic signs or symptoms In children, the need to limit exposure to ionizing radiation, immature development of the cervical spine, and uncooperative behavior of the child all affect the usefulness and diagnostic ability of radiographic imaging
  12. Up to 66% of spinal cord injuries in children produce no abnormal radiographic findings and thus fall under the umbrella of SCIWORA