The document discusses pediatric trauma care. Some key points: - Pediatric trauma is a leading cause of morbidity and mortality in children ages 1-40. Children are not just small adults and have anatomical and physiological differences. - Initial management of pediatric trauma involves a primary survey to evaluate life-threatening conditions like airway, breathing, circulation, disability, and exposure. - Airway management in children is challenging due to their anatomy and requires specialized equipment, medications, and expertise. Intubation carries risks and alternatives like LMA may be lifesaving. - Breathing can be subtly compromised in children with compliant chest walls. Pulmonary contusion can worsen and require aggressive ventilation support.

1. Pediatric Trauma CarePediatric Trauma Care
On CallOn Call
James G. Cain, MD
Past President, International Trauma, Anesthesia and Critical Care Society
Past President, West Virginia Society of Anesthesiologists
Director, Perioperative Medical Services, Children’s Hospital of Pittsburgh of UPMC
Director, Trauma Anesthesiology, Children’s Hospital of Pittsburgh of UPMC
Visiting Associate Professor, University of Pittsburgh School of Medicine
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2. DisclosureDisclosure
 Off label uses will be discussedOff label uses will be discussed
 Data Safety Monitoring Board (DSMB)Data Safety Monitoring Board (DSMB)
 HospiraHospira
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3. Pediatric trauma in USA
 Leading cause of morbidity & mortality in 1-40 yoLeading cause of morbidity & mortality in 1-40 yo
 30% of children annually require care due to trauma30% of children annually require care due to trauma
 40% of all deaths in 1-14 yo40% of all deaths in 1-14 yo
 Death & disability > than all others combinedDeath & disability > than all others combined
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4. Pediatric Trauma CategoriesPediatric Trauma Categories
Blunt traumaBlunt trauma
 Most commonMost common
 Majority motor vehicleMajority motor vehicle
relatedrelated
 PassengersPassengers
 PedestriansPedestrians
 BicycleBicycle
Penetrating traumaPenetrating trauma
 Increasingly commonIncreasingly common
 Primarily urbanPrimarily urban
 ““Knife and gun club”Knife and gun club”
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5. 8 year old restrained MVC8 year old restrained MVC
 AwakeAwake
 ResponsiveResponsive
 BP 80/45BP 80/45
 HR 136HR 136
 RR 32RR 32
 Abdominal painAbdominal pain
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6. Pediatric traumaPediatric trauma
 Kids aren’t “small adults”Kids aren’t “small adults”
 Differ anatomicallyDiffer anatomically
 Differ physiologicallyDiffer physiologically
 RequiresRequires
 Prepared personnelPrepared personnel
 ExpertiseExpertise
 MaterialsMaterials
 EquipmentEquipment
 MedsMeds
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7. Kids aren’t small adults!Kids aren’t small adults!
CharacteristicCharacteristic ResultResult
Large BSALarge BSA HypothermiaHypothermia
Poor neck musculaturePoor neck musculature Flex/ext injuryFlex/ext injury
Large blood vol in headLarge blood vol in head Cerebral edemaCerebral edema
Dec alveolar surf areaDec alveolar surf area Rapid desatsRapid desats
High metabolic rateHigh metabolic rate Rapid desatsRapid desats
Small airwaySmall airway Inc airway resistanceInc airway resistance
Heart high in chestHeart high in chest Injury/tamponadeInjury/tamponade
Small pericardial sacSmall pericardial sac Injury/tamponadeInjury/tamponade
Compliant skeletonCompliant skeleton Fractures less commonFractures less common
Thin walled, small abdThin walled, small abd Organs not protectedOrgans not protected
Poorly dev renal fnxPoorly dev renal fnx Risk renal failureRisk renal failure 700:32:37

8. Need specific peds suppliesNeed specific peds supplies
 MonitorsMonitors
 ETTETT
 LaryngoscopesLaryngoscopes
 BronchoscopesBronchoscopes
 IVIV
 IO trocarsIO trocars
 Central linesCentral lines
 Urinary cathetersUrinary catheters
 NGT/OGTNGT/OGT
 Resuscitation drugsResuscitation drugs
 Resuscitation devicesResuscitation devices
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9. Initial managementInitial management
 Primary surveyPrimary survey
 Evaluate life-threatening conditionsEvaluate life-threatening conditions
 Immediate interventionImmediate intervention
 Secondary surveySecondary survey
 Evaluate other injuries requiring treatmentEvaluate other injuries requiring treatment
 Pediatric trauma scorePediatric trauma score
 May be useful for triageMay be useful for triage
 9-12 Minor trauma9-12 Minor trauma
 6-8 Potentially life threatening6-8 Potentially life threatening
 0-5 Life threatening0-5 Life threatening
 < 0 Usually fatal< 0 Usually fatal
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10. Pediatric trauma scorePediatric trauma score
+ 2+ 2 + 1+ 1 - 1- 1
WtWt > 20 kg> 20 kg 10-20 kg10-20 kg < 10 kg< 10 kg
AirwayAirway PatentPatent MaintainMaintain UnmaintUnmaint
SBPSBP > 90> 90 50-9050-90 < 50< 50
PulsesPulses RadialRadial CarotidCarotid NonpalpNonpalp
CNSCNS AwakeAwake + LOC+ LOC UnrespUnresp
FrxFrx NoneNone ClosedClosed Mult/opMult/op
WoundsWounds NoneNone MinorMinor MajorMajor
TotalTotal -6 to +12-6 to +12
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11. Primary surveyPrimary survey
 Cornerstone of trauma careCornerstone of trauma care
 Life threatening conditionsLife threatening conditions
 EvaluateEvaluate
 StabilizeStabilize
 TreatTreat
 Moves forward on all fronts by teamMoves forward on all fronts by team
 Often listed sequentiallyOften listed sequentially ABCDEABCDE
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12. ABCDE of trauma careABCDE of trauma care
 AAirwayirway
 BBreathingreathing
 CCirculationirculation
 DDisabilityisability
 EExposurexposure
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13. Airway management prioritiesAirway management priorities
1.1. Ensure oxygenationEnsure oxygenation
2.2. Ensure ventilationEnsure ventilation
3.3. Protect cervical spineProtect cervical spine
4.4. Protect airwayProtect airway
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14. Initial airway managementInitial airway management
 Supplemental high flow oxygenSupplemental high flow oxygen
 Clear airway obstructionClear airway obstruction
 Large tongueLarge tongue
 ObtundationObtundation
 Foreign bodiesForeign bodies
 Maxillofacial traumaMaxillofacial trauma
 InflammationInflammation
 Consider oral or nasal airwaysConsider oral or nasal airways
 Caution with nasal in possible cribiform plate injuryCaution with nasal in possible cribiform plate injury
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15. Pediatric airwayPediatric airway
 Narrow oropharynxNarrow oropharynx
 Large tongueLarge tongue
 Stiff, short epiglottisStiff, short epiglottis
 Larynx anterior andLarynx anterior and
cephaladcephalad
 Cord view is difficultCord view is difficult
 Trachea shorterTrachea shorter
 Mainstem intubationMainstem intubation
more commonmore common
 Extubation moreExtubation more
commoncommon 1500:32:37

16. Intubation considerationsIntubation considerations
 Preparation is vital!Preparation is vital!
 Do not rush!Do not rush!
 Key pointsKey points
 Increased cardiac outputIncreased cardiac output
 Increased OIncreased O22 consumptionconsumption
 Overlapping FRC and closing capacityOverlapping FRC and closing capacity
 SOAPSOAP
 SuctionSuction
 OxygenOxygen
 AirwayAirway
 PharmacologyPharmacology
 Oral intubation typically easiestOral intubation typically easiest 1600:32:37

17. Trauma inductionTrauma induction
Induction medicationsInduction medications
 ThiopentalThiopental
 PropofolPropofol
 EtomidateEtomidate
 Adrenal suppressionAdrenal suppression
 KetamineKetamine
 Caution in brain injuredCaution in brain injured
Neuromuscular blockadeNeuromuscular blockade
 Faster onsetFaster onset
 Shorter circulation timeShorter circulation time
 RocuroniumRocuronium
 VecuroniumVecuronium
 CisatricuriumCisatricurium
 Succinyl cholineSuccinyl choline
 Transient inc ICP, IOP,Transient inc ICP, IOP,
intragastric pressureintragastric pressure
 HyperkalemiaHyperkalemia
 BradycardiaBradycardia
 AtropineAtropine
 GlycopyrrolateGlycopyrrolate
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18. IntubationIntubation
 PreoxygenationPreoxygenation
 Cricoid pressureCricoid pressure
 Support posterior neckSupport posterior neck
 Cervical spineCervical spine
 MAISMAIS
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19. Pediatric intubation viewPediatric intubation view
 LarynxLarynx
 AnteriorAnterior
 CephaladCephalad
 C 4 levelC 4 level
 Epiglottis long & UEpiglottis long & U
shapedshaped
 Trachea shortTrachea short
 Neonates → 2 cm cordsNeonates → 2 cm cords
to carinato carina
 Cricoid → NarrowestCricoid → Narrowest
point until 10 yopoint until 10 yo
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20. Increased risk of head an neckIncreased risk of head an neck
injuryinjury
Large headLarge head Weak neck musclesWeak neck muscles
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21. Cervical spine considerationsCervical spine considerations
 Upper cervical spine often involvedUpper cervical spine often involved
 Younger = higherYounger = higher
 Injury possible with minimalInjury possible with minimal
musculoskeletal effectmusculoskeletal effect
 Spine films and CTSpine films and CT
 May not confirm absence of injuryMay not confirm absence of injury
 SCIWORASCIWORA
 MRI neededMRI needed
 Symptoms and mechanism dictate careSymptoms and mechanism dictate care
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22. Difficult intubationDifficult intubation
 Up to 50% airway complicationsUp to 50% airway complications
 Severity increased in non pediatric centersSeverity increased in non pediatric centers
 Tracheal injuryTracheal injury
 Massive SQ emphysemaMassive SQ emphysema
 Post-extubation subglottic stenosisPost-extubation subglottic stenosis
 Vocal cord injuryVocal cord injury
 Massive aspirationMassive aspiration
 OptionsOptions
 LMA may be lifesavingLMA may be lifesaving
 King airwayKing airway
 Rescue technique of choice for Pittsburgh EMTsRescue technique of choice for Pittsburgh EMTs
 Needle cricothyroidotomy fallback techniqueNeedle cricothyroidotomy fallback technique
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23. BreathingBreathing
 Low residual lung volumes at expiration (FRC)Low residual lung volumes at expiration (FRC)
 FRC overlaps closing capacity → atelectesisFRC overlaps closing capacity → atelectesis
 Less alveoliLess alveoli
 Hgb P50 19 mm Hg contrasts to 26 Hg adultsHgb P50 19 mm Hg contrasts to 26 Hg adults
 Increased oxygen consumption → 7 ml/kg/minIncreased oxygen consumption → 7 ml/kg/min
 Higher minute ventilationHigher minute ventilation
 Higher blood flow to vessel rich groupHigher blood flow to vessel rich group
 Hypoxic/hypercapneic respiratory drives notHypoxic/hypercapneic respiratory drives not
well developedwell developed
 Oxygen reserve is limitedOxygen reserve is limited
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24. BreathingBreathing
 Supplemental OSupplemental O22 to allto all
trauma patientstrauma patients
 Airway and pulmonaryAirway and pulmonary
injuryinjury
 Signs may be subtleSigns may be subtle
 Compliant ribcageCompliant ribcage
 Airway managementAirway management
 Consider gastricConsider gastric
decompressiondecompression
 Auscultate breath soundsAuscultate breath sounds
 Pneumothorax?Pneumothorax?
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25. Chest injuriesChest injuries
 Mediastinum lessMediastinum less
well affixedwell affixed
 Compliant chest wallCompliant chest wall
 Fractures lessFractures less
commoncommon
 PTXPTX
 Pulmonary contusionPulmonary contusion
 HemothoraxHemothorax
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26. PneumothoraxPneumothorax
 SymptomsSymptoms
 JVDJVD
 Tracheal shiftTracheal shift
 Deviation of cardiac tonesDeviation of cardiac tones
 PEAPEA
 TreatTreat
 Angiocatheter 2Angiocatheter 2ndnd
intercostal space, midclavicularintercostal space, midclavicular
 Definitive tube thoracoscopyDefinitive tube thoracoscopy
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27. Pulmonary contusionPulmonary contusion
 Worsening oxygenation & ventilationWorsening oxygenation & ventilation
 Decreasing pulmonary complianceDecreasing pulmonary compliance
 Progressively more aggressive vent strategyProgressively more aggressive vent strategy
 Increase FiOIncrease FiO22
 Increase vent pressures and PEEPIncrease vent pressures and PEEP
 Volutrauma typically avoided with plateauVolutrauma typically avoided with plateau
pressures < 40.pressures < 40.
 Hemodynamic compromise possible withHemodynamic compromise possible with
increasing vent pressuresincreasing vent pressures
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28. CirculationCirculation
 Control blood lossControl blood loss
 ApparentApparent
 HiddenHidden
 Long bone fracturesLong bone fractures
 Pelvic fracturesPelvic fractures
 HemothoraxHemothorax
 HemoperitoneumHemoperitoneum
 ICH (prior to fontanelleICH (prior to fontanelle
closure)closure)
 Tissue perfusionTissue perfusion
 Shock symptomsShock symptoms
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 Vascular accessVascular access
 Early vascular accessEarly vascular access
 SupradiaphragmaticSupradiaphragmatic
 Alternatives to PIVAlternatives to PIV
 CentralCentral
 Surgical cutdownSurgical cutdown
 IntraosseousIntraosseous
 Consider A-lineConsider A-line

29. IntraosseousIntraosseous
 IO kit or bone marrow bxIO kit or bone marrow bx
needleneedle
 1-2 cm below tibial1-2 cm below tibial
tuberositytuberosity
 Insert with screwingInsert with screwing
motion until lack ofmotion until lack of
resistanceresistance
 Aspirate marrow toAspirate marrow to
confirm placementconfirm placement
 Secure needleSecure needle
 Volume replacementVolume replacement
 LabsLabs
 Drug administrationDrug administration
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30. Shock symptomsShock symptoms
 May not be apparent until > 25% blood lossMay not be apparent until > 25% blood loss
 Hypotension a late signHypotension a late sign
 Vaso-motor tone increasedVaso-motor tone increased
 Contractility increasedContractility increased
 Neonates limited ability to increase contractilityNeonates limited ability to increase contractility
 TachycardiaTachycardia
 Capillary refill > 3 secCapillary refill > 3 sec
 Diminished mental statusDiminished mental status
 OliguriaOliguria
 AcidemiaAcidemia
 Compensatory tachypneaCompensatory tachypnea
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31. Volume resuscitationVolume resuscitation
 Hallmark of intraoperative managementHallmark of intraoperative management
 Fluid warming is essentialFluid warming is essential
 Crystalloid 1Crystalloid 1stst
choicechoice
 No evidence for colloidsNo evidence for colloids
 EBVEBV
 Premies: 95 ml/kgPremies: 95 ml/kg
 Term neonates: 90 ml/kgTerm neonates: 90 ml/kg
 Up to 1 year: 80 ml/kgUp to 1 year: 80 ml/kg
 > 1 year old: 70 ml/kg> 1 year old: 70 ml/kg
 Acceptable Hg 7-8Acceptable Hg 7-8
 Higher Hg threshold in brain injuredHigher Hg threshold in brain injured
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32. Volume administrationVolume administration
 Bolus of 20 ml/kgBolus of 20 ml/kg
 Lactated Ringer’sLactated Ringer’s
 Lactate -> bicarbonateLactate -> bicarbonate
 0.9NS is OK0.9NS is OK
 May produce mildMay produce mild
acidemiaacidemia
 Repeat 20 ml/kgRepeat 20 ml/kg
bolus if inadequatebolus if inadequate
responseresponse
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33. Blood productsBlood products
 Acceptable Hg 7-8Acceptable Hg 7-8
 Higher Hg threshold in brain injuredHigher Hg threshold in brain injured
 Transfuse 10-20 ml/kg PRBC if inadequate response toTransfuse 10-20 ml/kg PRBC if inadequate response to
crystalloidcrystalloid
 Type specific preferred, Type O is OKType specific preferred, Type O is OK
 Freshest possibleFreshest possible
 KK++
> 8 noted, old blood may have as much as 33 meq/liter> 8 noted, old blood may have as much as 33 meq/liter
 Cardiac arrests notedCardiac arrests noted
 ECG monitoring in large volume transfusionsECG monitoring in large volume transfusions
 Citrate -> pH < 7Citrate -> pH < 7
 Metabolized to bicarbonate -> alkalosis possibleMetabolized to bicarbonate -> alkalosis possible
 Calcium supplement may be indicatedCalcium supplement may be indicated
 EBL 1 blood vol, 25% coag factors remainEBL 1 blood vol, 25% coag factors remain
 1 unit platelets/10 kg raises platelets by 101 unit platelets/10 kg raises platelets by 1055
 Consider FFP 10-15 ml/kgConsider FFP 10-15 ml/kg
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34. Disability (head injury)Disability (head injury)
 Head injury in 80% of major traumasHead injury in 80% of major traumas
 GCS modified for pedsGCS modified for peds
 Decreased emphasis on verbal performanceDecreased emphasis on verbal performance
 Improving neuro statusImproving neuro status
 Adequate resuscitationAdequate resuscitation
 Worsening neurologic statusWorsening neurologic status
 Global neurologic injuryGlobal neurologic injury
 Expanding intracranial massExpanding intracranial mass
 GCS < 8GCS < 8
 ICU admitICU admit
 Consider intubation and airway managementConsider intubation and airway management
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35. Significant neurologic injurySignificant neurologic injury
 Primary injuryPrimary injury
 Initial incidentInitial incident
 Secondary injurySecondary injury
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36. Limit secondary injuryLimit secondary injury
 Hypotension, hypoxemia & hypercarbiaHypotension, hypoxemia & hypercarbia
 Significantly increase mortalitySignificantly increase mortality
 Aggressive measures to maintain cerebralAggressive measures to maintain cerebral
perfusion and oxygenationperfusion and oxygenation
 CPP > 40 desiredCPP > 40 desired
 CPP = MAP - ICPCPP = MAP - ICP
 No current, reliable biochemical markersNo current, reliable biochemical markers
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37. Maintain cerebral perfusionMaintain cerebral perfusion
 Monitor ICPMonitor ICP
 Increase MAPIncrease MAP
 Alpha adrenergic or dopaminergic agentsAlpha adrenergic or dopaminergic agents
 Decrease ICPDecrease ICP
 HypocarbiaHypocarbia
 HyperosmolarHyperosmolar
 Drain CSFDrain CSF
 Fluid restrictFluid restrict
 DiuresisDiuresis
 Barbiturate comaBarbiturate coma
 Surgical decompressionSurgical decompression
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38. ExposureExposure
 Expose entirely to evaluate thoroughlyExpose entirely to evaluate thoroughly
 Hypothermia riskHypothermia risk
 ExposureExposure
 Large BSALarge BSA
 Thin skinThin skin
 Minimal fatMinimal fat
 Rapid loss of body heatRapid loss of body heat
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39. Hypothermia consequencesHypothermia consequences
 Increased risk in rural settingIncreased risk in rural setting
 Increased morbidity and mortalityIncreased morbidity and mortality
 Myocardial contractility decreasedMyocardial contractility decreased
 Oxyhemoglobin dissociation curve shifted leftOxyhemoglobin dissociation curve shifted left
 CoagulopathiesCoagulopathies
 DysrhythmiasDysrhythmias
 ArrestArrest
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40. Hypothermia precautionsHypothermia precautions
 Warm ORWarm OR
 Heating lampsHeating lamps
 Warming blanketsWarming blankets
 Heated humidifiedHeated humidified
circuitscircuits
 Warm fluidsWarm fluids
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41. Secondary surveySecondary survey
 More thorough evaluation of systemsMore thorough evaluation of systems
 Detailed head to toe examDetailed head to toe exam
 ROSROS
 PMHPMH
 MedsMeds
 AllergiesAllergies
 Diagnostic proceduresDiagnostic procedures
 Less invasive than in pastLess invasive than in past
 ConsultationsConsultations
 Surgery?Surgery?
 Solid organ injury routinely managed nonoperativelySolid organ injury routinely managed nonoperatively
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42. 8 year old to the OR8 year old to the OR
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43. Questions?Questions?
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