Trauma

LPCH at Stanford Pediatric Trauma Guidelines

Overview

  • Trauma is the leading cause of death in children and adolescents (more than all other causes combined)
  • Trauma management guided by ATLS (developed in 1978 by an orthopedic surgeon)
  • Trauma response includes careful prehospital care with appropriate triage to centers capable of caring for trauma victim
  • ATLS includes the primary survey, focusing on Airway, Breathing, Circulation, Disability, and Exposure
  • The secondary survey is a more comprehensive head to toe examination that identifies any other injuries as well as an AMPLE (allergies, medications, past medical history, last meal, and events leading to the injury) focused history
  • Trauma resuscitation and management also involves appropriate disposition (varying from direct transport to the operating room, intensive care unit, another higher level facility, or discharge home)

Primary Survey

  • Focuses on treating the most life threatening injuries first
  • Iterative, in that it is repeated if the patient's clinical status changes
  • A-Airway: Establish a patent airway. Place oxygen on the patient and maintain cervical spine stabilization. 3 general categories: 1) Those with a patent airway requiring no further intervention 2) Those who have had intervention in the field or at a different institution 3) Those who will need an intervention to establish an airway. 
    • Ask patient's name
    • Inspect for voice changes or stridor
    • Assess for craniofacial injuries
    • Can inform team that "airway is patent" if all parameters met
    • If airway placed in field or outside hospital, evaluate tube size, position, adequacy of ventilation (with breath sounds, ETCO2), and radiographic confirmation
    • If impending respiratory failure, inability to protect the airway, or GCS <8, may require rapid seuence  endotracheal intubation.
    • If suspected cervical spine injury, only use jaw thrust and not chin lift. LMA can be used as a temporary rescue if intubation can not be successfully completed
    • Nasotracheal intubation generally not performed and is contraindicated with facial trauma, basilar skull fracture, or concern of CSF leak
    • In can't intubate/can't ventilate with BMV or LMA scenario, surgical or needle cricothyroidotomy may be necessary (extremely rare <1% of cases)
    • Needle cricothyroidotomy involves identifying the cricothyroid membrane, inserting a 12-18 gauge angiocatheter caudally at a 30-45 degree angle with a syringe to aspirate air and confirm entry into the trachea and connection to a oxygen source at about 10-12 L/min to insufflate oxygen. Temporizing measure as cannot BVM ventilate and respiratory acidosis ensues in ~30 minutes
  • B-Breathing: Ensure adequate ventilation/oxygenation via auscultation, pulse oximetry, and respiratory rate. 
    • Evaluate for pneumothorax, flail chest, and hemothorax
    • Decompression of tension pneumothorax (14-18 gauge needle above the rib in the 2nd intercostal space at the midclavicular line)
    • Definitive thoracotomy may be needed if hemothroax volume exceeds 20-25% estimated blood volume or if bleeding continues at a rate > 2-4 cc/kg/hr, or the rate of bleeding is increasing
  • C- Circulation: Focused on identifying and treating shock
    • HR, BP, pulses, capillary refill
    • Tx: control hemorrhage and give fluid (20 cc/kg boluses of NS or LR) via pressure bag, hand pump, or syringe
    • Blood transfusion (aliquots of 10 cc/kg) (Transfusion of platelets and FFP generally in 1:1:1 ratio with PRBC during massive transfusion protocols)
    • Consider IO access or CVL if PIV cannot be established
    • Sites of major blood loss include: intrathoracic, intraabdominal, pelvic/long bone, external (ie scalp laceration)
  • D-Disability: Neurologic assessment
    • Calculate GCS
    • Assess pupil responses
  • E-Exposure: CLothing removed to visually inspect all parts of the body to ensure no obvious external evidence of injuries have been missed
    • Coordinated log roll while maintaining C-Spine precautions allows assessment of the back and spine
    • Evaluate temperature
Figure 1: ATLS Algorithm


Secondary Survey

  • AMPLE history (allergies, medications, past medical history, last meal, events leading to injury)
  • Head to toe comprehensive examination (digital rectal examination can be omitted in children without blunt trauma or obvious signs of other injury)
  • Consider need for tetanus vaccine administration
  • Diagnostic testing: routine labs not particularly helpful
    • Blunt trauma: AST, ALT, UA, Hgb (>100 for AST or ALT and >5 RBC/hpf on UA suggest intraabdominal injury)
    • Coagulation studies, electrolytes, type and cross for significant head injuries, penetrating trauma, or significant mechanism of injury
    • Urine drug screen/tox screen as inidcated
    • C spine xray: If midline cervical tenderness, altered mental status, neurological symptoms, evidence of intoxication, or presence of distracting injury
    • CXR: major blunt injury, high speed MVC, or significant torso injury
    • CT head: Rules identified to identify children at low risk of clinically important brain injuries after head trauma. (100% sensitivity in <2 yrs, 96.8% in >2 yrs, and NPV of 100% in all ages)
      • <2 yrs: Palpable skull fracture, altered mental status or GCS =14: CT recommended
      • <2 yrs: Scalp hematoma, LOC >5 seconds, severe mechanism, not acting normal per parent: Observation or CT (based on physician experience, worsening symptoms, age <3 months, parental preference)
      • <2 yrs: None of the above: No CT
      • >2 yrs: GCS=14, altered mental status, basilar skull fracture: CT recommended
      • >2 yrs: History of LOC, emesis, severe mechanism, severe headache: Observation vs CT
      • >2 yrs: None of the above: No CT
    • CT Abdomen: based on screening lab tests (UA RBC >5/hpf, AST or ALT >100, of positive FAST)
    • FAST has unclear utility in excluding intraabdominal injury in children by itself (sensitivity for hemoperitoneum ~80%)

Disposition

  • Discharged from ER if no injuries requiring inpatient observation or care
  • General ward for observation/treatment
  • Direct to OR transfer for emergent operative intervention
  • Admission to PICU for ongoing stabilization and management


TBI


Hypothermia Trials for TBI in Children: 

  Cool Kids (Hypothermia after pediatric TBI)Adelson et al Lancet Neurology 2013 RCT of 77 pediatric patients with TBI (stopped for futility) demonstrated no significant difference in clinical outcomes comparing hypothermia vs. normothermia.
 Hypothermia after Pediatric TBI Hutchison et al NEJM 2008 Multicenter RCT of 225 children with TBI randomized to early (within 8 hours) hypothermia (32.5 C) for 24 hours or normothermia (37 C) demonstrated no improvement in neurologic outcome and may have increased mortality (21 vs. 12%, p=0.06)  
  • Hypothermia found not to be helpful for intracranial hypertension in the setting of traumatic brain injury in adults (Andrews et al, NEJM 2015)

Head Trauma CT Rules




References

1) Kuppermann N et al. Pediatric Emergency CareApplied Research Network (PECARN). Identification of children at very low risk ofclinically-important brain injuries after head trauma: a prospective cohortstudy. Lancet. 2009 Oct 3;374(9696):1160-70. doi: 10.1016/S0140-6736(09)61558-0.