Pediatric Trauma Review
Focus on chest trauma and a JumpSTART Review
Silver Cross Hospital EMS
May 2014 CE
Epidemiology - General
Trauma is the leading cause of death between the ages of 1-18
Injury accounts for 5% of infant deaths
47% of these deaths are related to MVCs
With rates higher in those >13yo
13% of deaths in those 1-14yo were a result of homicide
In the school age group
Pedestrian injuries and bike injuries predominate
Pediatric Head Injury
#1 cause of death due to
trauma
~2700 deaths/year
450,000 children present to
EDs each year with head
injury
90% suffer from minor injuries
Perinatal period
Birth injuries
1-4 years old
Falls
School age
Pedestrian or bike injuries
Adolescence
MVA
Children have larger heads than
adults in relation to their body
The chance that it is hit in a traumatic
event is larger
Head is heavy
Different acceleration dynamics
At birth, face to cranium ratio is 1:8,
adult ratio is 1:2.5
Makes it more likely skull is hit in
younger children
Lack of pneumatization of sinuses is
associated with more rigidity and
less plasticity of facial skeleton
Increases transfer of forces directly to
brain
Pediatric Spine Injury
18.1 spinal cord injuries per million
children
1300 new cases a year
60-80% of injuries occur at the
cervical level
Adults have a 30-40% incidence
Children <8 yo
More likely to sustain high cervical (C1C3) injuries
Pediatric Thoracic Trauma
#2 cause of trauma related
mortality
In isolation, thoracic trauma carries
a 5% mortality
25% when combined with abdominal
injury
40% with head and abdominal injury
Anatomic Considerations
Incomplete ossification of ribs
allows anterior ribs to be
compressed to meet posterior
Pulmonary contusions are common, rib
fractures uncommon
Pulmonary contusions are most
common thoracic injury in
traumatized children
Trachea is narrow, short, more
compressible
Great vessel and cardiac injury are
rare in children
Anatomic Considerations
Commotio Cordis is a
unique consequence of
pediatric thoracic trauma
Abrupt strike to the chest
leads to V-Fib and arrest
Pericardial tamponade:
Pericardial tamponade is caused by blunt or penetrating trauma to the heart.
Blood leaks into the pericardial sac, causing compression of the heart. As the
volume of blood in sac increases, the compression of the heart becomes more
pronounced. This causes cardiac output to fall dramatically and leads to a backup
of volume in the venous system.
Pericardial Tamponade
Signs of pericardial tamponade are:
Broken ribs or penetrations to chest wall.
Dyspnea/Cyanosis
Neck vein distention
Weak, thready pulse
Decreasing blood pressure
Shock
Narrowing pulse pressure
Pericardial Tamponade
Treatment:
Oxygenation
Assisted ventilation as necessary
IV therapy
EKG monitoring
Rapid transport to nearest I Trauma facility
Cardiac Contusion:
Cardiac contusion is a common injury following severe
blunt trauma to the chest. It usually occurs when the
heart is compressed between the sternum and the spinal
column. Severe contusions may include rupture of the
heart wall. Most commonly, the right ventricle is injured,
as it lays directly beneath the sternum.
Cardiac contusion
Signs of cardiac contusion are:
Bruising, swelling, crepitus or deformity to chest
wall
Tachycardia
Irregular heart rhythm
Cardiac Contusion
Treatment:
Oxygenation
Assisted ventilation as necessary
IV therapy
EKG monitoring
Treatment of arrhythmias as necessary
Transport to nearest appropriate trauma facility
Commotio Cordis:
Commotio cordis, or “concussion” of the heart, is generally
described as “instantaneous cardiac arrest produced by nonpenetrating chest blows in the absence of heart disease or
identifiable morphologic injury to the chest wall or heart.”
Commotio Cordis represents one of the most common mechanisms
of sudden death in sports seen in young athletes.
Commotio Cordis—
Review of Condition
Classic presentation is a blow to the chest during a sporting
activity that precipitates sudden collapse, followed by death if
prompt resuscitation is not available.
Most commonly occurs during baseball, but can occur during
hockey, lacrosse, karate, and recreational activities such as
sledding or biking.
Case Study
You are called to a baseball game for a child hit with a baseball
that is now unresponsive. Bystanders initiated CPR.
Case Study
CPR is initiated and the Cardiac monitor is applied.
•Initial rhythm is:
1.What rhythm do you see?
2.What is your treatment priority?
Case Study
After delivering 3 shocks, the patient remains
unresponsive, pulseless,
and apneic with the rhythm shown below.
What is your next intervention?
Case Study
The patient has been intubated with a 6.0 ETT,
and is being ventilated
with high FiO2 via BVM.
An IV of NS is initiated.
— What is your next intervention?
Case Study
Epinephrine 1:10,000 is determined to be the next
intervention.
Continuation of CPR and PALS/SMO protocol
Case Study
Journal of the American Medical Association,
2002;287:1142-1146
In a study of 128 confirmed cases of commotio
cordis, a 15% survival
rate was reported when resuscitative
measures were initiated within 3
minutes of the event.
In cases where resuscitation was delayed, >3
minutes, the survival rate
was noted to be <1%.
Pediatric Abdominal Trauma
Third leading cause of pediatric
traumatic death
Blunt causes in 85%, penetrating
trauma in 15%
Blunt trauma related to MVC’s
causes more than 50% of
abdominal injuries in children
Boogie board related injury..!
Anatomic Considerations
Proportionally larger solid organs
Less subcutaneous fat
Less protective abdominal
musculature
Relatively larger kidneys that
predispose them to renal injury
Anatomic Considerations
Splenic injuries are the largest
proportion of pediatric abdominal
trauma
Liver is second most injured solid organ
Lap Belt Injury
Sudden increase in bowel intraluminal
pressure can result in intestinal
perforation
Chance fracture of the lumbar spine
Anatomic Considerations
The compliant chest wall, poor
thoracic musculature and weak
diaphragm can lead to considerable
respiratory difficulty with gastric
distention
Epinephrine
Generic Name: Epinephrine
Trade Name: Adrenalin®
Therapeutic Class: Sympathomimetic
Mechanism of Action:
—Alpha: Bronchial, cutaneous, renal & visceral arterial constriction.
—Beta 1: Positive inotropic & chronotropic actions, increase in
cardiac automaticity.
—Beta 2: Bronchial smooth muscle relaxation and dilation of
skeletal vasculature, blockage of histamine release.
Epinephrine
Pharmacokinetics: Onset with IV injection is immediate and
intensified. SC or IM injection gives a rapid onset with longer duration.
Half-life is 1-4 minutes.
Prehospital Indications:
Cardiac arrest
Bradycardia with profound hypotension
Severe bronchospasm
Anaphylaxis
Contraindications:
Hypertension
Narrow angle glaucoma
Pulmonary edema
JumpSTART review
The following is a PowerPoint from Dr. Lou Romig.
She developed jumpstart as a tool for evaluation and
triaging pediatric MCI.
JumpSTART Review
Please note that JumpSTART
was designed for use in
disaster/multicasualty
settings, not for daily EMS or
hospital triage.
Jump
START
Pediatric Multicasualty Triage System
Lou Romig MD, FAAP, FACEP
Miami Children’s Hospital
Miami Dade Fire Rescue
South Florida Regional DMAT/IMSuRT South
Medical Director, South Florida Area National Parks
Earthquake, Algeria
Earthquake, Iran
Earthquake, Italy
Tsunami, Indonesia
Building collapse, Jerusalem
Tornado, Kansas
Bus crash, Michigan
Beslan school siege
Moscow theater siege
OKC Bombing
We must assume each MCI
will include children.
We must be able to assess
and treat victims of all ages
with equal confidence and
competence.
What’s your call?
Photos by Bryan Patrick, The Sacramento Bee, 2000
What’s your call?
A bus carrying school children of various
ages and their chaperones on a field trip
loses control, slams into a median, then
rolls.
You are the triage officer.
What’s your call?
A young school aged boy is found lying on the roadway 10 ft from the bus.
Breathing 10/min
Good distal pulse
Groans to painful stimuli
What’s your call?
An adult kneels at the side of the road, shaking his head. He says he’s too dizzy to
walk.
RR 20
CR 2 sec
Obeys commands
What’s your call?
A school aged girl crawls out of the wreckage. She’s able to stand and walk toward
you crying.
Jacket and shirt torn
No obvious bleeding
What’s your call?
A toddler lies with his lower body trapped under a seat inside the bus.
Apneic
Remains apneic with modified jaw thrust
No pulse
What’s your call?
Adult female driver still in the bus, trapped by her lower legs under caved-in dash.
RR 24
Cap refill 4 sec
Moans with verbal stimulus
What’s your call?
A toddler lies among the wreckage.
RR 50
Palpable distal pulse
Withdraws from painful stimulus
What’s your call?
A woman is carrying a crying infant. She is able to walk.
RR 20
CR 2 sec
Obeys commands
What’s your call?
An infant is carried by the previous victim.
He’s screaming but the woman quiets him to RR of 34
Good distal pulse
Focuses on rescuer, reaches for mom.
No obvious significant external injuries.
What’s your call?
A young school aged boy props himself up on the road.
RR 28
Good distal pulse
Answers question and commands.
Has obvious deformity of both lower legs.
What’s your call?
A toddler is found outside the bus, lying on the ground in a heap.
Apneic
Remains apneic with jaw thrust
Faint distal pulse palpable
What’s your call?
A school aged girl lies among the wreckage.
RR 40
Absent distal pulse
Withdraws from painful stimulus
What’s your call?
A screaming infant is found among the bushes at the side of the road.
RR 38
Good distal pulse
Focuses and reaches for you.
Has a partial amputation of the foot without active bleeding.
What’s your call?
An adult male lies inside the bus.
Apneic
Remains apneic with jaw thrust
What’s your call?
A youngster is up and walking around but is
limping
Alert, crying hysterically for his mother
What’s your call?
A school aged boy lies close to the bus.
RR 36
Absent distal pulse
Sluggishly looks at you when you talk to him
What’s your call?
A young teen girl lies among the wreckage, crying for someone to help her up. A man
with her says she needs her wheelchair.
RR 22
Palpable distal pulse
Alert
Has minor cuts and bruises
What’s your call?
An adult male lies on the ground
RR 20
Good distal pulse
Obeys commands but cries that he can’t move his legs
What’s your call?
An older school aged child is found sitting outside the bus.
RR 28
Good distal pulse
Groggy, confused and slowly follows commands but won’t get up and walk.
Goal of Multicasualty Triage
“To do the best for the most
using the least.”
Primary Disaster Triage
Goal: to sort patients based on probable
needs for immediate care. Also to
recognize futility.
Assumptions:
Medical needs outstrip immediately
available resources
Additional resources will become available
with time
Primary Disaster Triage
Triage based on physiology
How well the patient is able to utilize
their own resources to deal with their
injuries
Which conditions will benefit the most
from the expenditure of limited
resources
The physiology of adults and children
are not the same.
Why do we need a pediatric tool?
To optimize triage effectiveness to
the benefit of all victims, not just
children.
Photo by Bryan Patrick, The Sacramento Bee, 2000
Why do we need an objective pediatric
tool?
The pediatric knowledge base and confidence levels of many
EMS providers are not as good as they can and should be.
Pediatric multicasualty triage may
be
affected by the emotional state of
triage officers.
Ambulatory = Green
START Triage
RESPIRATIONS
NO
Dead or
Expectant
PERFUSION
Over 30/min
Position Airway
NO
Under 30/min
YES
Immediate
YES
Immediate
Cap refill
> 2 sec
Control
Bleeding
Immediate
Cap refill
< 2 sec.
MENTAL
STATUS
Failure to follow
simple commands
Can follow
simple commands
Immediate
Delayed
START:
Potential Problems with Children
An apneic child is more likely to have a primary respiratory problem than an adult.
Perfusion may be maintained for a short time and the child may be salvageable.
RR +/- 30 may either over-triage or under-triage a child, depending on age .
START:
Potential Problems with Children
Capillary refill may not adequately reflect peripheral
hemodynamic status in a cool environment.
Obeying commands may not be an appropriate gauge of
mental status for younger children.
JumpSTART Goals
Modify an existing tool for use with children
Utilize decision points that are flexible enough to serve
children of all ages and reflective of the unique points of
pediatric physiology
Minimize over- and under-triage
Accomplish triage within 30 second/pt goal
JumpSTART: Age
Initially ages 1-8 years chosen
Less than one year of age is less likely to be ambulatory.
The pertinent pediatric physiology (specifically, the airway)
approaches that of adults by approximately eight years of
age.
I’m 10!
JumpSTART: Age
Current recommendation:
If a victim appears to be a child, use
JumpSTART.
If a victim appears to be a young adult,
use START.
JumpSTART: Ambulatory
Identify and direct all ambulatory patients
to designated Green area for secondary
triage and treatment. Begin assessment
of nonambulatory patients as you
come to them.
Modification for nonambulatory children
All children carried to the GREEN area by other ambulatory
victims must be the first assessed by medical personnel in
that area.
JumpSTART: Breathing?
If breathing spontaneously, go on to the next step, assessing
respiratory rate.
If apneic or with very irregular breathing, open the airway
using standard positioning techniques.
If positioning results in resumption of spontaneous
respirations, tag the patient immediate and move on.
The “Jumpstart” Part
If no breathing after airway opening, check for
peripheral pulse. If no pulse, tag patient
deceased/nonsalvageable and move on.
If there is a peripheral pulse, give 5 mouth to
barrier ventilations. If apnea persists, tag patient
deceased/nonsalvageable and move on.
If breathing resumes after the “jumpstart”, tag
patient immediate and move on.
JumpSTART: Respiratory Rate
If respiratory rate is 15-45/min, proceed to assess perfusion.
If respiratory rate is <15 or >45/min or irregular, tag patient as immediate and move
on.
JumpSTART:Perfusion
If peripheral pulse is palpable, proceed to assess mental
status.
If no peripheral pulse is present (in the least injured limb),
tag patient immediate and move on.
JumpSTART: Mental Status
Use AVPU scale to assess mental status.
If Alert, responsive to Verbal, or appropriately responsive to
Pain, tag as delayed and move on.
If inappropriately responsive to Pain or Unresponsive, tag as
immediate and move on.
Modification for nonambulatory children
Infants who normally can’t walk yet
Children with developmental delay
Children with acute injuries preventing them from walking
before the incident
Children with chronic disabilities
Modification for nonambulatory children
Evaluate using the JS algorithm
If any RED criteria, tag as RED.
If pt satisfies YELLOW criteria:
YELLOW if significant external signs of injury are found (ie.
deep penetrating wounds, severe bleeding, severe burns,
amputations, distended tender abdomen)
GREEN if no significant external injury
Individuals with special health
care needs may also be MCI
victims!
Note for Black Category Victims
Unless clearly suffering from injuries incompatible with life, victims tagged in the
BLACK category should be reassessed once critical interventions have been completed
for RED and YELLOW patients.
Putting it into practice
What’s your call?
A young school aged boy is found lying on the roadway 10 ft from the bus.
Breathing 10/min
Good distal pulse
Groans to painful stimuli
What’s your call?
An adult kneels at the side of the road, shaking his head. He says he’s too dizzy to
walk.
RR 20
CR 2 sec
Obeys commands
What’s your call?
A school aged girl crawls out of the wreckage. She’s able to stand and walk toward
you crying.
Jacket and shirt torn
No obvious bleeding
What’s your call?
A toddler lies with his lower body trapped under a seat inside the bus.
Apneic
Remains apneic with modified jaw thrust
No pulse
What’s your call?
Adult female driver still in the bus, trapped by her lower legs under caved-in dash.
RR 24
Cap refill 4 sec
Moans with verbal stimulus
What’s your call?
A toddler lies among the wreckage.
RR 50
Palpable distal pulse
Withdraws from painful stimulus
What’s your call?
A woman is carrying a crying infant. She is able to walk.
RR 20
CR 2 sec
Obeys commands
What’s your call?
An infant is carried by the previous victim.
He’s screaming but the woman quiets him to RR of 34
Good distal pulse
Focuses on rescuer, reaches for mom.
No obvious significant external injuries.
What’s your call?
A young school aged boy props himself up on the road.
RR 28
Good distal pulse
Answers question and commands.
Has obvious deformity of both lower legs.
What’s your call?
Toddler found outside the bus, lying on the ground in a heap.
Apneic
Remains apneic with jaw thrust
Faint distal pulse palpable.
OR
What’s your call?
A school aged girl lies among the wreckage.
RR 40
Absent distal pulse
Withdraws from painful stimulus
What’sA screaming
your infant
call?
is found among the bushes at the side of
the road.
RR 38
Good distal pulse
Focuses and reaches for you.
Has a partial amputation of the foot without active bleeding.
What’s your call?
An adult male lies inside the bus.
Apneic
Remains apneic with jaw thrust
What’s your call?
A youngster is up and walking around but is
limping
Alert, crying hysterically for his mother
What’s your call?
A school aged boy lies close to the bus.
RR 36
Absent distal pulse
Sluggishly looks at you when you talk to him
What’s your call?
A young teen girl lies among the wreckage, crying for
someone to help her up. A man with her says she needs her
wheelchair.
RR 22
Palpable distal pulse
Alert
Has minor cuts and bruises
What’s your call?
An adult male lies on the ground
RR 20
Good distal pulse
Obeys commands but cries that he can’t move his legs
OR
What’s your call?
An older school aged child is found sitting outside the bus.
RR 28
Good distal pulse
Groggy, confused and slowly follows commands but won’t get up and walk.
JumpSTART’s reception
In use throughout the US and Canada
Being taught in Germany, Switzerland, Japan, Polynesia and
other countries
Included in the NDMS Core Curriculum
Incorporated into the PDLS and APLS courses
Feature article, July 2002 JEMS magazine
Included in Brady’s Prehospital Emergency Care, 7th ed
Publication in other texts pending
Advantages
JumpSTART provides a rapid triage system specifically
designed for children, taking into consideration their unique
physiology.
The algorithm is modified from an existing system widely
accepted for adult triage.
For most patients, triage can be accomplished within the 30
second goal.
Advantages
Objective triage criteria for children will help
to eliminate the role of emotions in the triage
process.
Objective triage criteria will provide emotional
support for triage personnel forced to make
life or death decisions for children in the MCI
setting.
For more information on JumpSTART:
www.jumpstarttriage.com
Lou Romig MD
LouRomig@bellsouth.net
Thank you for your time and
attention!
If you have any questions, please
contact Silver Cross EMS Education
at 815-300-2909