pediatric trauma

Management principles of pediatric trauma patients

Management principles of pediatric trauma patients are similar to those of adults, but modified according to the age group of the child. Children are not just small adults. Their unique, developing psychologic, anatomic, and physiologic characteristics pose special challenges to anesthesiologists and the entire trauma care team. Optimal management of the pediatric trauma patient depends on adequate knowledge and

understanding of these unique characteristics.

INITIAL ASSESSMENT AND MANAGEMENT

Primary Survey

The main goal of the primary survey is to rapidly find all potentially life-threatening injuries to prioritize management for efficient resuscitation and achieve hemodynamic stability. This requires immediate assessment of the “ABCDEs” of the Advanced Trauma Life Support (ATLS) protocol and constant reevaluation of the adequacy of resuscitation strategies.

Airway with C-Spine Control

Evaluation of the airway in an injured child can be complex. Injury to the airway or nearby structures may distort normal anatomy and render mask ventilation and tracheal intubation difficult.Preexisting conditions thatmay complicate emergency

airway management include congenital abnormalities, such as micrognathia (mandibular hypoplasia), macroglossia, and cleft palate and the presence of obstructive sleep apnea with or without obesity.

Inspection of the airway includes the face, mouth, mandible, nose, and neck. Look for edema, foreign bodies, secretions, blood, loose or missing teeth, and fractures of the jaw, mandible, and cervical spine. Any trauma victim, especially one with a closed-head injury, is presumed, until proved otherwise, to have cervical spine (C-spine) injury and a full stomach.

C-spine precautions

should be maintained and techniques that minimize the risk of pulmonary aspiration should be taken at all times.

Healthy neonates and young infants have large heads, including prominent occiputs relative to body size, so that, in the supine position, the infant neck is naturally flexed on the chest and the supine infant headmay be flexed on the neck]. This has several important implications.

The natural head and neck flexion of the obtunded or sedated young infant often results in significant airway obstruction that may be relieved by gently lifting the chin up and forward (anteriorly) to slightly extend the head on the neck. Otherwise, an

oral airway can be inserted with no relative movement of head and neck. In suspected C-spine injury, a more neutral, straight head and neck position should be achieved by placing a blanket or pad under the supine infant or young child’s torso.

Neonatesandyounginfants areobligate nose breathers until three to five months of age so that any secretions or blood in their relatively narrow nasal passages can lead to airway obstruction.

The larynx in infantsandchildren ismore cephalad, approximately at the level of the C3–C4 vertebrae in infants compared with the C5–C6 level in adults. This may give the impression that the infant larynx is more anterior during direct laryngoscopy.

The length of the trachea is only 4–5 cm in infants and approximately 7 cm by 18 months of age, so right mainstem intubation or ETT dislodgement can occur with correspondingly small movements of the infant’s head. extubation.When choosing the appropriately sized ETT, keep in mind that in children less than 5 years old, the narrowest part of the upper airway is at the level of the cricoid cartilage, not at the glottis, as in adults. The size of the ETT appropriate for the patient’s age may

be estimated by comparing the tube size with that of the infant or child’s fifth finger, or by using the formula: ETT tube size (diameter in mm) = 4 + (1/4) age .

An air leak around the ETT at 15–20 cmH2Opressure and easy passage of the tube into the trachea clinically suggests that the ETT size is appropriate. The following formula may be used as a guide to determine the appropriate depth of the ETT placement (in centimeters from lips to tip of ETT) for children older than 2 years: 13 + (1/2) age); for under 1 year old: 8 + weight in kilograms [20].

The appropriate depth of ETT insertion may also be approximated bymultiplying the internal diameter (millimeters) of the ETT by 3.

Indications for Endotracheal Intubation

a. Loss of consciousness or altered level of consciousness with inability to protect the airway

b. Inability to maintain patency of airway or clear secretions

c. Provide positive pressure ventilation and adequate oxygenation

d. Significant burn with airway injury.

TRAUMA IN GERIATRICS

TRAUMA IN GERIATRICS

Ahmad Mohamed Shafik MD, Rafik Magdy Abdou, M.B.B.Ch.

Dept. of Anesthesiology, intensive care, and Pain Management, faculty of medicine, Ain shams university.

W.H.O definition of elderly

Most developed countries accepted that:

- Elderly = over age 65 years.

- Young old = 65 – 80 years.

- Old old = over age 80 years.

However this definition is different in developing

countries with less life expectancy.

Trauma in the elderly poses special challenges.

Physiologic changes impact morbidity and mortality.

Trauma is the fifth leading cause of death in patients

over the age of 65. [1]

Mechanism of trauma :

1. Falls

Low-level falls (falls from a standing height) are the

most common reason for injury in geriatric patients.

Major risk factors are

falls, cognitive impairment and neuromuscular

disorders.[2]

; old age, living alone, previous

2. Motor vehicle collisions :

Motor vehicle accidents are the second most common

mechanism of injury, 28% of all injuries, in persons 65

years and older

account for the third most common mechanism of

injury in the geriatric patient, representing 10% of all

injuries in the elderly.[3]

. Pedestrians hit by motor vehicles

3. Burns :

Burns are the cause of approximately 8% of all trauma

deaths in the elderly. Cigarettes are the primary cause

of fire-injury death for those over 65. Other home fires

are attributed to food left on the stove and other kitchen

fires. Hot water scalds due to fragile skin and decreased

peripheral sensation in the elderly can also cause

burns

4. Accidental hypothermia :

.[3]

Geriatric patients are at an increased risk for accidental

hypothermia. Acute and chronic medical conditions

predispose the elderly to hypothermia, especially when

ambient temperatures are low. Dementia can result in a

patient getting lost in cold weather with inadequate

protective clothing. Financial limitations may lead to

insufficient heating of the home, and ultimately to

homelessness. Medical conditions that predispose to

hypothermia include hypoglycemia, hypothyroidism,

hypopituitarism, hypoaldosteronism, sepsis, and

substance abuse.

5. Elder abuse and neglect :

[4]

Violence is an increasing cause of injury in elders.

Pa

A. Musculoskeletal injury

ttttern off iinjjury

Most frequently injured organ system. Fractures of the

hip are the second most common (after wrist) fractures

in elderly patients who sustain injures after a fall

.[5]

Vertebral fractures are common in the elderly even

after minor trauma. [6]

Pelvic fractures in the elderly carry high morbidity and

mortality. [7]

B. Traumatic brain injury

Patients older than 65 years have mortality rates two to

five times those of younger patients with matched GCS

and intracranial pathology

.[8]

C. Thoracic injury:

It is an important injury in the elderly and a marker of

severity.

The elderly have twice the morbidity & mortality of

younger patients with similar injuries.

.[9]

D. Abdominal injury:

Similar injury rates to younger people. The spleen is

smaller & less prone to injury. Organs are more fragile,

so when injury does occur it is more severe.

Abdominal examination is less reliable in the

elderly.

[10]

Special considerations in management of trauma in

the elderly.

A. Head injury and Anticoagulants:

In the elderly, the chronic therapy with oral

anticoagulants & antiplatelets became common. These

drugs worsen the outcome of severe head injury.

Treatment options for these patients need to be

individualized and balanced between the need for

warfarin therapy (i.e., mechanical valve) and the need

for immediate reversal ( intracranial bleeding),

nonurgent reversal (preoperative), simple withdrawal

of warfarin (subsequent risk of falls), or no change in

therapy.For patients requiring immediate reversal the

administration of prothrombin complex concentrate or

fresh frozen plasma can be used.

B. Rib fractures in the elderly

[11]

In the elderly, even the presence of a single rib fracture

carries significant morbidity & mortality. Pain control

Trauma in Geriatrics Shafik AM and Abdou RM

ventilation. Significant decrease in mortality &

pulmonary complications were found with the use of

epidural analgesia compared with parenteral

analgesia.[10]

is of critical importance in improving mechanical

The management of trauma

In the elderly

Management of trauma has improved significantly due

to an integrated approach :-

Prehospital stabilization.

Rapid transport to definitive care.

Emergency resuscitation.

Timely operative intervention.

Comprehensive rehabilitation

A. Prehospital stabilization:

1) Assessment of scene and patient:

..[12]

As you arrive at a scene, take a moment to conduct an

overall assessment. Are there any obvious indicators of

trauma? If bystanders are available, ask what was

observed during the event. If the patient was

discovered "down" and there are no witnesses, the

combination of scene and patient assessment and

bystander reports may prove to be invaluable in

determining the possibility of trauma and potential

injuries.[13]

Attention to vital signs is particularly important in the

elderly. Although abnormal vital signs clearly warrant

further investigation and direct resuscitation, normal

vital signs should not necessarily reassure the

physician. [14]

2) Airway :

Supplemental oxygen should be placed on all elderly

trauma patients. This practice provides the needed

oxygen reserves if rapid sequence intubations is needed

and contributes to cellular oxygenation.

Adjuncts, such as nasopharyngeal and oropharyngeal

airways, are useful with the obtunded trauma patient.

Elderly often have friable nasal mucosa and care

should be taken when using the nasal passage for

airway support or gastric decompression.[15]

3) Breathing :

Physical examination findings, such as paradoxical

chest wall movement, chest wall tenderness, crepitus,

or ecchymosis, should prompt immediate action. The

elderly have blunted responses to hypoxia, hypercarbia

and acidosis that may delay the onset of clinically

apparent signs of impending distress. Therefore,

arterial blood gas measurements are an important

component of the trauma assessment in geriatric

patients. [14]

4) Circulation :

Elderly patients are particularly susceptible to the

effect of shock. The elderly have poor chronotropic

response to hypovolemia.Normal blood pressure may

actually indicate significant hypovolemia due to

baseline hypertension. Internal bleeding must be

excluded by ultrasound and diagnostic peritoneal

lavage, before declaring the patient hemodynamicaly

stable. Blood and fluid resuscitation shouldn’t be

delayed. [16]

B. Rapid transport to definite care :

Trauma triage:

patients with injuries at the scene of the accident.

The purpose of the triage procedure is to ensure that

major trauma patients are transported to the most

appropriate facility. Standard triage criteria for trauma

patients include age> 55 as a determinant of trauma

center disposition.[12]

Trauma triage tools include injury severity score,

revised trauma score, prehospital index & Glasgow

coma score. While the exact effectiveness of these

tools has been debated, they are an option that you may

want to incorporate into your trauma practices.

C. Emergency department resuscitation :

It is the process of sorting multiple[17]

The elderly have high mortality and in-hospital

complications. So , aggressive resuscitation , liberal

radiographic examination and early intensive

monitoring are essential for reducing early mortality in

the elderly trauma patient. Crystalloids are the initial

resuscitation fluid, but no evidence to recommend

either normal saline or lactated ringer as superior to the

other.[14]

Resuscitation monitoring should be done with urine

output, ABG, serum lactate & pulmonary artery

catheter (specialy In patients with occult

hypotension).These patients should be resuscitated

with fluid and supported with pressor medications, as

needed, to maintain a cardiac index of at least 4 L /min

per square meter or an oxygen consumption of 170 mL

/min per square meter. [10]

D. Timely operative intervention :

1. Solid organ injury:

of non operative management for blunt abdominal

trauma in the elderly. Recent studies show that in

properly selected patients the success of non operative

management is 62-85%

There is controversy on the use. [18]

2. Pelvic injuries:

fracture focus on control of hemorrhage, stabilization

of the fracture and pain control.

3. Traumatic brain injury:

rates two to five times that of younger patients with the

same Glasgow Coma Scale. All suspected patients with

TBI should have cranial CT and INR. Patients with

elevated INR and signs of intracranial hemorrhage

need immediate reversal of anticoagulation. Patients

with elevated INR , isolated head trauma and normal

CT, only observation is needed. [19]

Treatment of the elderly pelvic[14]The elderly have mortality

E. Comprehensive rehabilitation :

Patients hospitalized for acute episodes are at risk of

experiencing significant loss of functioning as a result

of inactivity, immobility and, in some cases, prolonged

bed rest. Early identification of rehabilitation needs and

early start of rehabilitation can reduce healthcare costs,

length of stay and help to prevent disability. [20]

Anesthesia of the elderly

A. pre-operative assessment:

1. History & examination

diseases

2. Preoperative investigations

functional capacity of different organs

3. Risk assessment: according

; to assess preexisting.; to assess the.to ASA classification.

4. Polypharmacy;

of different medications with increased incidence of

drug interactions with anesthetics.

The elderly tend to be on a number[21]

5

Communication difficulties, delirium ,malnutrition ,

dehydration , immobility and frailty.

. Special preoperative issues in the elderly are:

B. Intraopertive management :

1) Regional versus general anesthesia

suggests little, if any difference in outcome between

regional and general anesthesia in the elderly.

However, specific effects of regional anesthesia may

provide some benefits; decrease incidence of DVT,

decrease blood loss in pelvic surgeries and doesn’t

need airway instrumentation.

: Most evidence[22]

2) Airway management

elderly can prove difficult. So good preoperative

airway assessment should be done .The elderly are at

risk as ; they may be dentureless .The elderly have

greater risk of aspiration . Arthritis can restrict joints

movement. Osteoporosis can increase risk of cervical

fracture.

: Airway management in the[23]

3) Thermoregulation in the elderly

do not respond as young adults to hypothermia.

Inhibition of the thermoregulatory responses is

exaggerated by anesthetics in the elderly leaving them

more prone to intraoperative hypothermia. Effects of

hypothermia include hemodynamic disturbances,

bleeding, decreased immune function, reduced wound

strength and infections. Measures to prevent

hypothermia include warming the operating room ,

warming blankets & infusing warm intravenous

fluids.[24]

: Elderly patients

C. Post operative care for

1) Pulmonary complications (e.g.; atelectasis )

2) Post operative sepsis.

3) Post operative deep venous thrombosis.

4) Acute pain management. [22]

:

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