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1##Hot Topics in Pediatric Trauma CareTodd NickolesManager, Pediatric Trauma and Injury Prevention#2##

3DisclosuresNo disclosures or financial conflicts of interest4 ObjectivesCervical spine clearanceTraumatic brain injuryConcussionLap belt complexMassive transfusionNon-accidental traumaRegional trauma system care

5Case Study #110 month old boy falls down the stairs, landing on his head6

Pediatric TBISpecial considerations:Large headsThinner pliable skullFontanelsLess myelinationChanges in cerebral blood flow

7Brain injuryPrimary injuryDiffuse vs focalDAI, mTBI, EDH, SDH, SAH, IPH, etc.Secondary injuryEdema and cell death following primary injurySecond insultHypotension, hypoxia, ICH, seizures, hyperthermia

*Goal of most of our interventions is to decrease secondary insult/injuryOptimize balance of energy in brain tissue

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Case Study #110 month old boy falls down the stairs, landing on his head. No loss of consciousness, cries immediately.9Mild (GCS 13-15)Do well; may have radiographic abnormalitiesMay have headaches, seizures, vomitingModerate (GCS 9-12)Severe (GCS 3-8)LOC, posturing, combative, abnormal neuro exam

Brain injuryDiffuse injuries:

mTBI DAI

10Brain injury11Case Study #110 month old boy falls down the stairs, landing on his head. No loss of consciousness, cries immediately. Remains fussy through dinner and overnight. Brought to the ED. GCS 1312

From Contemporary PediatricsCase Study #110 month old boy falls down the stairs, landing on his head. No loss of consciousness, cries immediately. Remains fussy through dinner and overnight. Brought to the ED. GCS 13. CT head shows bilateral subdural hematomas13

Cervical spineSpecial considerations:Large headsFlexible joint capsules/ligamentsWeak musclesVertebral body wedgingFlat facets

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Mechanisms of injury15

McQuillan, K., Von Rueden, K., Hartsock, R., Flynn, M., & Whalen, E. (eds.). (2002). Trauma Nursing: From Resuscitation Through Rehabilitation. Philadelphia: W. B. Saunders Company. Reprinted with permission.

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Case Study #110 month old boy falls down the stairs, landing on his head. No loss of consciousness, cries immediately. Remains fussy through dinner and overnight. Brought to the ED. GCS 13. CT head shows bilateral subdural hematomas. CXR shows healed rib fracture

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Non-accidental trauma3 categories of red flag findings:Medical HistoryPhysical ExamRadiological Exam22

Medical History:Self reportNo history of traumaInconsistent story/injury/eventNot developmentally capableLacking details

Delay in treatment/multiple sitesInappropriate parent/child interactionSigns of medical neglectCaregiver under the influence

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Physical exam:Unusual bruise patternsInconsistent burnsIntra-oral injuries, frenulum tearsMacrocephalyGenital/anal injuries not adequately explained

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Radiographic:Metaphyseal fractures (bucket-handle, corner, chip)Rib fractures (esp. post)Fractures in non-ambulating childrenMultiple fractures

Unexpected finding of healing fractureComplex skull fractures/intracerebral injuries not well explainedStages of brain injuryAny other significant injury not well explained

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ReportingChildren's Protective Services Phone: 855-444-3911Fax: 616-977-1154 or 616-977-1158dhs-cps-cigroup@michigan.govCCP consult26

Prevention?27

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Case Study #212 year old boy riding in back seat of midsize car29

29##12 year old boy riding in back seat of midsize car, head on collision with tree. Presents to ED via EMS with abrasions to abdomen matching seat belt distribution.

Case Study #23030##12 year old boy riding in back seat of midsize car, head on collision with tree. Presents to ED via EMS with abrasions to abdomen matching seat belt distribution.Case Study #231

31##Lap belt complex32Lap belt complexInjury pattern:Linear ecchymosisChance fracture of lumbar spineHollow viscus (bowel > bladder), free air

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Mechanism- lap seat belt improperly placed over abdomen, hyperflexionPattern associated with delays in diagnosis of other injuries

33##Lap belt complexInjury pattern:Linear ecchymosisChance fracture of lumbar spineHollow viscus (bowel > bladder), free air

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Hyperflexion of spine. Particularly associated with car accidents when the occupant is restrained with a lap belt (also known as the seat-belt fracture) Transverse fracture through a vertebral body and neural arch. Usually occurring at the thoracolumbar junction

34##Lap belt complexInjury pattern:Linear ecchymosisChance fracture of lumbar spineHollow viscus disruption (bowel > bladder), free air

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36Mesenteric free air due to bowel perforation36##12 year old boy riding in back seat of midsize car, head on collision with tree. Presents to ED with abrasions to abdomen matching seat belt distribution. To OR for repair of injuries.

Case Study #237

37##Case Study #212 year old boy riding in back seat of midsize car, head on collision with tree. Presents to ED with abrasions to abdomen matching seat belt distribution. To OR for repair of injuries.Hospital course- 5 separate operations to closure. Withdrawn, poor eye contact, wakes up with nightmares

3838##Acute Stress ReactionFindings:Persistent frightening thoughts/memoriesNightmares, flashbacks, intrusive thoughtsHyperarousal symptoms, sleep disturbancesAvoidance symptoms, detachment or dissociation39Case Study #212 year old boy riding in back seat of midsize car, head on collision with tree. Presents to ED with abrasions to abdomen matching seat belt distribution. To OR for repair of injuries.Hospital course- 5 separate operations to closure. Withdrawn, poor eye contact, wakes up with nightmares. Discharged on PTD 24 to home.

4040##Injury Prevention Opportunity?

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4243?

Case Study #315 year old boy doing boy things for 5 seconds44

4 fatalities per every 100,000 athletes (5x football)Devastating injuries 9.5 vs 0.8 per 100,00044##Some physicsKinematicsFirst law of thermodynamicsForce = Weight X Speed2 2

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Case Study #315 year old boy in a rodeo is stepped on by a bull. Initially unconscious, transferred emergently to the local ED.464 fatalities per every 100,000 athletes (5x football)Devastating injuries 9.5 vs 0.8 per 100,00046##47

Solid organ injuries liver & spleen48

Grading by CT48##49 CT grade I II III IVICU stay (d) 0 0 0 1Hospital stay (d) 2 3 4 5Predischarge imagingnone none none nonePostdischarge imaging none none none noneActivity restriction (wk) 3 4 5 6

APSA guidelines for children with isolated spleen or liver injuryOur Compliance withStolen from Dr DeCou49##Management goalsSerial H&HPain medsBowel restBed restPrevent constipationIncentive spirometry

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Frequently managed non-operativelyH&H q6, then 8 or 12 until plateausIV, working toward oral pain meds, premedicate activity, splintingNPO until not vomiting, passing gasBedrest until Hgb levels, pain controlled with meds, different for each organStart miralax and/or bisacodyl if bowel function without BM- 3-4 daysPrevent pleural effusions, significant complication d/t reactive inflammationWhen should you call the MD?50##

Damage control surgery51

Case Study #315 year old boy in a rodeo is stepped on by a bull. Initially unconscious, transferred emergently to the local ED. Damage control laparotomy, transfusion, air medical transport to Level 1 Trauma Center.

1 FFP2 PlateletsTXA52

4 fatalities per every 100,000 athletes (5x football)Devastating injuries 9.5 vs 0.8 per 100,00052##53

Case Study #315 year old boy in a rodeo is stepped on by a bull. Initially unconscious, transferred emergently to the local ED. Damage control laparotomy, transfusion, air medical transport to Level 1 Trauma Center. On arrival, immediately back to OR. Massive transfusion protocol initiated.

Arrival: BP 51/28, HR 94, Hgb 8.5, LA 9.8544 fatalities per every 100,000 athletes (5x football)Devastating injuries 9.5 vs 0.8 per 100,00054##Shock in pediatricsClass IClass IIClass IIIClass IVBlood lossUp to 15%15%30%30%40%40%PulseNormalMild tachy.Mod. tachy.Severe tachy.BPNormal/ increasedNormal/ decreasedDecreasedDecreasedMental StatusSlightly anxiousMildly anxiousAnxious/ confusedConfused/ lethargicFluidCrystalloidCrystalloidCrystalloid & bloodCrystalloid & blood55Goals of massive transfusionAccurate assessment of blood lossSize-appropriate goals for resuscitationClear start and stop pointsPatient safety blood compatibility and availabilityEarly FFP to treat/prevent coagulopathyBalanced ratio of products (1:1:1)Provision of transfusion-related medications Calcium, Factor VIIa, TXA

56Estimates of blood lossBased on volume of blood product given to maintain hemodynamic stabilityActual OR anticipatedOther relevant clinical parameters:HR, BP, CVPBD, lactate, pHHgb/Hct not a reliable indicator57Estimates of blood lossAt physicians discretion, MTP can be initiated for either:Actual or anticipated transfusion of blood products AND other IV fluids greater than the patients estimated blood volume within 24 hour period Need for transfusion equal to half of the patients estimated blood volume at one time58Estimates of blood loss59AgeEst blood volumePremature infant90-100 ml/kgTerm infant to 3 months80-90 ml/kgChildren older than 3 months70 ml/kgObese children65 ml/kgSoa 6 year old non-obese child, weighing 22 kg22kg X 70ml/kg =__________2 units of PRBC given so far, with fluid resuscitationMTP?1540 kgClarify definitionsPacked Red Blood Cells (PRBC): 1 bag = 1 unit = 350 mlFresh Frozen Plasma (FFP): 1 bag = 1 unit = 250 mlPlatelets (PLT): 1 bag =1 pack = 5 units = 250 mlCryoprecipitate: 1 bag = 10 units = 200 mlVolumes are approximate and vary60Weight-based algorithmEach MTP Pack =25ml/kg PRBC20ml/kg FFP10ml/kg Platelets4ml/kg Cryoprecipitate

These products must be ordered specifically for any child 25mmHg decompression recommended, 20-25 strongly consider69##Case Study #315 year old boy in a rodeo is stepped on by a bull. Initially unconscious, transferred emergently to the local ED. Damage control laparotomy, transfusion, air medical transport to Level 1 Trauma Center. On arrival, immediately back to OR. Massive transfusion protocol initiated. Closure, to IR for embolization. To ICU for supportive care. Elevated ventilator pressures and low blood pressure. Decompression surgery. Discharged PTD #25.704 fatalities per every 100,000 athletes (5x football)Devastating injuries 9.5 vs 0.8 per 100,00070##Prevention?71

72Regionalized trauma care

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ObjectivesCervical spine clearanceTraumatic brain injuryConcussionLap belt complexMassive transfusionNon-accidental traumaRegional trauma system care

74Thank You!75

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