Approach to Pediatric Trauma:
The Unstable Child
Presented by:
Jonna Bobeck BSN, RN, CEN
Introduction
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Trauma is leading cause of death in children
Blunt injury cause for majority of cases
Children’s anatomy different from adult
Initial approach and management of major
trauma
Overview
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Standardized approach
ATLS/ENPC
Prevention
Golden hour
Injury Classification
• Injury extent
• Injury type
• Injury severity
Trauma Systems
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GCS
Trauma score
Pediatric trauma score
Age specific pediatric trauma score
Initial approach
• Rapid assessment
• Key principles
-Assessment and management
American Heart Association
• 2010 CPR updates:
A-B-C to C-A-B
Primary Survey
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A- airway
B - breathing
C- circulation
D - disability
E - exposure
Airway
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Airway Assessment
Proper padding
Cervical spine immobilization
Tracheal intubation
- pretreatment with lidocaine
- sedative agents
- paralytics
Breathing
• Assessment
- key findings
• Management
Circulation
• Assessment
• Management
Circulation
• Hemorrhage control
• IV access
- two large bore within 90 seconds
- intraosseous
- percutaneous central access
- venous cutdown
Circulation
• Fluid resuscitation
- 20ml/kg warmed normal saline
• PRBC
- 10 – 20ml/kg
• FFP
• Platelets
• Recombinant activated factor V11
Advanced Procedures
• Cardiac tamponade
• Open thorocotomy
Disability :Neurological Assessment
• Pediatric GCS
- severity of TBI
• Prevent secondary injury
Exposure
• Rapid exposure of patient to identify and treat
injuries
• Avoid hypothermia
Labs
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Hematocrit/Hemoglobin
Type and cross
Rapid blood glucose
ABG
PT/PTT
Serum electrolytes
Radiographs
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C-spine
AP chest
AP pelvis
Ultrasound - FAST
Urinary Catheter and Gastric Tube
• Monitor urine output
• Decompress
Secondary Survey
• History (SAMPLE)
S - subjective
A - allergies
M - medications
P - past medical history/pregnancy
L - last meal
E - events leading to injury
• Head to toe physical exam
Adjuncts to Secondary Survey
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Radiographs
Head CT
Neck CT
Abdominal CT
Orthopedic management
Wound care
Specialized Care
• Definitive care
• Pediatric trauma center
Summary
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Primary Survey
Resuscitation of vital functions
Secondary survey
Key principles
References
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American Heart Association, . "Highlights of the 2010 American Heart Association Guidelines for CPR and ECC."
American Heart Association Guidelines 2010 (2010): 2. Web. 21 Dec 2010.
Bolick, Beth. "Emergency Nurse Pediatric Course Third ed.." Ed. Harriet Hawkins . United States of America:
Emergency Nurses Association, 2004. Print.
American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors. American
College of Surgeons, Chicago 2004.
Slack, SE, Clancy, MJ. Clearing the cervical spine of paediatric trauma patients. Emerg Med J 2004; 21:189.
Sokolove, PE, Kuppermann, N, Holmes, JF. Association between the "seat belt sign" and intra-abdominal injury in
children with blunt torso trauma. Acad Emerg Med 2005; 12:808.
Shlamovitz, GZ, Mower, WR, Bergman, J, et al. Poor test characteristics for the digital rectal examination in
trauma patients. Ann Emerg Med 2007; 50:25.
Shlamovitz, GZ, Mower, WR, Bergman, J, et al. Lack of evidence to support routine digital rectal examination in
pediatric trauma patients. Pediatr Emerg Care 2007; 23:537.
Cervical spine immobilization before admission to the hospital. Neurosurgery 2002; 50:S7.
Blackwell, CD, Gorelick, M, Holmes, JF, et al. Pediatric head trauma: changes in use of computed tomography in
emergency departments in the United States over time. Ann Emerg Med 2007; 49:320.
Brenner, D, Elliston, C, Hall, E, Berdon, W. Estimated risks of radiation-induced fatal cancer from pediatric CT.
AJR Am J Roentgenol 2001; 176:289.
Frush, DP, Donnelly, LF, Rosen, NS. Computed tomography and radiation risks: what pediatric health care
providers should know. Pediatrics 2003; 112:951.
Brenner, DJ, Hall, EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med 2007;
357:2277.
Palchak, MJ, Holmes, JF, Vance, CW, et al. A decision rule for identifying children at low risk for brain injuries after
blunt head trauma. Ann Emerg Med 2003; 42:492