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PEDIATRIC TRAUMA

INTRODUCTION

Trauma is the leading cause of death in the pediatric population.  Motor vehicle accidents are the leading mechanism of injury.  Eleven percent of the EMS runs in Long Beach involve pediatric patients, of this eleven percent approximately 51% are trauma related.  Optimal patient care requires that the EMT-I understand important concepts to be utilized when dealing with pediatric trauma victims.  The following topics will be discussed during this lesson.

·                      Common mechanisms of injury

·                      Pediatric trauma assessment

·                      Unique pediatric characteristics

·                      Pediatric head/spinal injuries

·                      Pediatric torso injuries

·                      Pediatric extremity injury

·                      Field treatment priorities in pediatric trauma

LESSON OBJECTIVES

At the completion of this lesson the participants will be able to:

1.         Name the most common mechanism of injury for pediatric trauma

2.         Discuss preventative measures that the EMT-I should be aware of.

3.         Identify assessment priorities in pediatric trauma.

4.         Understand the significance of anatomical characteristics that are unique to         pediatric trauma victims.

5.         Verbalize assessment and treatment priorities in pediatric head/spinal, torso, and            extremity injuries.

6.         Discuss transport decisions for the pediatric trauma victim.

SKILLS

Pediatric cervical collar

Pediatric spinal immobilization

KEY CONCEPTS

The following section provides information and space for taking notes on the key concepts provided by the instructor

PEDIATRIC TRAUMA OVERVIEW

Mechanism of injury

·        Motor vehicle accident (#1 killer of children)

·        Falls (most frequently in children under 5 years)

·        Drowning/Sports-related injuries

·        Penetrating injuries (especially in urban area)

Trauma prevention

·        Statistics:  Head injury is the leading cause of death from trauma in the pediatric population.  Chest and abdominal trauma rank second.  20% to 40% of pediatric deaths from trauma are preventable.

·        Educational Activities:  helmet safety, CPR, cycle safety, seatbelt use, care seat use, pool safety, antiviolence campaigns, etc.

·        Parental awareness:  safety locks and gates, small toys, home safety, smoke detector awareness, etc.

SPECIAL CONSIDERATIONS FOR PEDIATRIC TRAUMA VICTIMS

Unique pediatric characteristics

Characteristic

Prehospital Considerations

Size:  smaller size leaves the child more susceptible to a wide range of injuries

The EMT-I should consider the mechanism of injury in relation to the relative size of the child.  Appropriate equipment must be selected for the child’s size.

Head size:  The child’s head is much larger in proportion to the rest of the body.

Children tend to land on their heads when they fall.  Spinal immobilization techniques may need to be modified to ensure proper alignment.  Extra padding may be needed under the shoulders.

More elastic connective tissue;  this allows for more stretching and tearing

Serious spinal cord injury can occur without any visible signs of trauma.  If the child has any signs of a deficit or if the mechanism of injury is serious, suspect serious injury and take appropriate precautions.

Organs are closer together: more organs can be injured when energy is released during a traumatic situation

Children may initially look uninjured and suddenly deteriorate.  The mechanism of injury and frequent reassessment of the patient can help the EMT-I recognize potentially serious pediatric trauma.

Less rigid skeletal structure:  The child’s skeleton is not fully calcified and has many active growth centers.  This allows the child  to withstand severe force without breaking bones.  The lack of outward injury can be deceptive.  There may be severe internal injury to the organs!

Initial and ongoing assessments are essential to detect subtle changes in the pediatric trauma victim.  EMT-Is should develop an acute index of suspicion based on the mechanism of injury.  Even minor injuries can result in damage to the growth plate and should be evaluated by a physician.  Remember that the E.R. nurses and physicians cannot see the scene - they rely on the EMT-I and EMT-P to relay significant details regarding the mechanism of injury.   For example:  vehicle speed, ejection, extrication, distance of falls, distance thrown, etc.

The child has less body fat and a larger surface area in relation to body weight: they can lose heat very rapidly.

Cover and maintain body temperature.

Observe for hypothermia.

Total circulating volume per unit of body weight is greater than an adult by 25%.  Approximately 80-90 ml/kg.

Estimated blood loss is significantly related to relative body weight.  For example:  A blood loss of 150 ml in a 25 kg child is approximately 10% of her/his circulating volume.

Blood pressure is an unreliable indicator of shock in the pediatric trauma victim

Children can maintain a normal blood pressure until the late stages of shock.  Careful observation for other indictors such as skin signs, capillary refill, tachycardia, and tachypnea.

PEDIATRIC TRAUMA ASSESSMENT

Initial Assessment

1).  Assess environment:  (may need to manipulate the environment)

·        Safety of rescuers and environment

  • Environmental factors
    • Patient location (home, street, convalescent, etc.)
    • Weapons (may indicate trauma mechanism)
    • Witnesses (may help to explain circumstances)
  • Mechanism of injury
  • Number of patients
 
 


Add Pediatric Assessment Triangle:

Develop a general impression:  The “across the room” assessment

Assess appearance

Work of breathing

Circulation to skin

 
 

2).  Airway  (determine responsiveness and patency of airway)

  • Initiate spinal precautions if indicated
  • Introduce self to patient
  • Obtain patient’s name and age
  • Determine LOC
  • Open the airway using jaw thrust maneuver
  • If the child is unresponsive, begin hyperventilation immediately (hyperventilation will help reduce cerebral edema)
 
 

3).  Breathing:  assess rate, rhythm, and tidal volume

  • If the patient is not breathing, begin rescue breathing using BVM
  • Is the breathing labored or unlabored
  • If labored, place the patient on oxygen
  • Suspect hemothorax or pneumothorax if there is increasing respiratory distress, increasing ventilatory resistance and diminished lung sounds
 
 

4).  Circulation:    

a).  Palpate for pulse noting: rate/rhythm/quality

b). Check capillary refill

c).  Control obvious bleeding

  • Increased or decreased heart rate may be an indication of shock
  • Increased or decreased heart rate may be an indication of head or spinal trauma
  • Character of the pulse (weak or strong) is an indicator of the pressure and volume within the arteries
  • Location of pulses can help to estimate blood pressure, generally:
    • Radial pulse not palpable if BP <80mm/hg
    • Femoral pulse not palpable if BP <70mm/hg
    • Carotid pulse not palpable if BP <60mm/hg
 
 

5). Skin signs:  assess color, temperature and moisture

  • Pale, cool, moist skin and delayed capillary refill are due to peripheral vasoconstriction
 
 

6).  Assess neurological status:  assess level of consciousness                

       (Glasgow Coma Score) and neuro deficits

  • Restlessness, agitation, and lethargy may be due to hypoxia and decreased cerebral perfusion.
  • Unconscious and coma may be due to prolonged hypoxia, shock

Head injury, metabolic disorders, or other causes

 
 

7. Determine chief complaint

 
 


GOLDEN RULE: 

Life-threatening conditions should be corrected during the initial assessment.  Transport should not be delayed; Focused history and detailed physical exam should be done enroute.

Focused History and Detailed Physical Examination

1).  Elicit history of chief complaint or problem
  • may be obtained enroute
 
 

2).  Elicit personal history (HAM)

  • H   medical history/under a doctors care
  • A   allergies/age
  • M   medications-current over the counter and prescription
  •  Generally obtained from the parents
  • Time of last meal (necessary if surgery will be required)                                           
 
 

3).  Vital Signs

·        Appropriate cuff size is essential for accurate BP measurement

  • Accurate heart rate and respiratory rate are necessary as base line VS
  • Children tend to compensate very well for blood loss and may have perfect VS in the late stages of shock
  • Watch for other indicators such as pallor, delayed capillary refill and declining  level of consciousness
 
 

4).  Special Questions

  • Ask questions specific to chief complaint:
 
 

5).  Pertinent Body Check:

  • Medical or minor trauma—perform body check pertinent to chief complaint
  • Major trauma—perform total body check
 
 

Complete Head to Toe Examination:

  • Note paralysis and parasthesia
  • Full spinal immobilization with notation of circulation, motor, and sensory function before and after immobilization
 
 

 


FIELD MANAGEMENT OF PEDIATRIC TRAUMA

Field treatment of head and spinal injuries

·        BLS procedures

·          Spinal immobilization/airway management

·          High flow oxygen

·          Hyperventilation with BVM if unresponsive (helps to reduce cerebral edema)

·          Elevate the head if possible (helps to reduce cerebral edema)

·          Assist with ALS procedures

·        ALS procedures

·          Rapid transport to PCCC if significant mechanism or suspicion of head or spinal injury

·          Venous access (large bore)

·          Monitor

·        NOTE:  If hypotension and shock are present in a child with a head injury it is from another cause.   SUSPECT INTERNAL BLEEDING!

Field treatment of pediatric torso trauma

·        BLS procedure

·          Airway management/spinal immobilization

·          High flow oxygen

·          Assist with ALS procedures

·        ALS procedure

·          Rapid transport to PCCC if significant mechanism of injury

·          Venous access (large bore).

·          Monitor

·          Needle thoracostomy if suspected tension pneumothorax

Field treatment of extremity injuries

·        BLS procedures

·          Airway management/spinal immobilization (if appropriate)

·          High flow oxygen

·          Extremity immobilization

·          Ice and elevate

·          Frequent check of circulation, sensation, and motor function

·        ALS procedure

·          Venous access

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