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PEDIATRIC TRAUMA

EARLY MANAGEMENT
RESUSCITATION
OF SEVERELY INJURED CHILD
EDWIN BASYAR

Trauma the leading cause of death and


disability in children
Over all mortality rate for children with
trauma : 2,5%
More than 90% injuries in children: result
of blunt mechanism
NPTR (1997): multiple trauma 48%
Majority of injured children to ER: do not
have life threatening injuries
10 15% truly life threatening injuries

NPTR develop Pediatric Trauma Score


most predictive of death and disability
Score range from +12 (no or minor injury)
to -6 (fatal injury)

Trimodel of traumatic death :


First peak : injured patient die very soon
after the injury ( seconds or minutes ) :
CNS, central vasculature
Second peak : occurs minutes or hours
after the injury ( epidural hematoma, solid
organ injury, fluid in pleural / pericardial
space ) require rapid identification
and treatment during the golden
hour
Third peak : injury mortality occurs days
and weeks result of complication of
injury

The priorities and the protocol of trauma


management in children : the same as in
adult
Injured children are not small-injured
adult
Anatomy and physiology in children
require special considerations
Children : small, less fat and elastic
connective tissue, multiple organs in
close proximity to a very pliable skeleton

Smaller body mass : transmitted injury is


distributed all over the body multisystem injury
In children :

most seriously injury multiple organ injury


( including CNS )
thoracic injury are unusual ( significant cause
for mortality )
vulnerable for intraabdominal organ injury
(very pliable ribs injury to the liver and
spleen; pelvis fails to protect the bladder)

Initial assessment of the injured child:


ABCDEs of the primary survey (guarantee
the airway, ensure breathing, restore
circulation and control hemorrhage,
assessment of neurologic status and disability
Resuscitation phase ( ECG monitoring,
urinary and gastric catheters, blood and urine
studies )
Secondary survey ( a thorough head to toe
evaluation )

Assessment of circulatory status in


children :
evaluation of pulse, HR, perfusion, skin color,
capillary refill and blood pressure.

In children : BP is maintain until


hypovolemia is quite severe
Significant hemorrhagic injury may present
with a normal blood pressure (reflex
tachycardia and increase peripheral
vasoconstriction )
Children compensate 25 30% of circulating
volume blood loss with minimal initial
external signs
40% blood volume loss ability of vascular
constriction is totally lost BP rapidly falls
progressive bradycardia

Vascular access in injured children :


Percutaneous peripheral
Intraosseus access (< 6 years old )
Venous cut-down
Percutaneous ( femoral, subclavian, jugular
vein )

Initial fluid resuscitation in children with


circulatory failure
Warmed isotonic crystalloid solution (RL, NS)
bolus 20 ml / Kg ( may repeat 2 or 3 times )
PRC 10 ml / kg
Hemodynamic respons (-) OR
Hemodynamic respons (+) observation

Organs primary important in hypovolemic


shock : heart, brain, kidneys and skin

Indication of effective volume


resuscitation :
Slowing hearth rate (< 130 bpm) with
improvement other physiologic signs
Increase in pulse pressure
Return of normal skin color
Increase extremity warmth
Clearing of sensorium
Increase in systolic BP (> 80 mmHg)
Increase in urine output (1 to 2 ml/ Kg / hrs)

Abdominal injury
Abdominal wall in children is quite thin
minor force result in serious compression
and disrupting injury
Little protection for the upper abdominal
viscera high incidence splenic and hepatic
injury
90% of abdominal injury in children :
result of blunt trauma
Non operative management 80 - 90%
success rate and has become the standard of
care in the treatment of blunt abdominal
injury in children

Hemodynamic stable children with isolated


solid organ injury tolerate Hb to 7 gr%
(without blood transfusion)
CT preferred imaging technique for
hemodynamic stable injured children
FAST gaining acceptance reliable method
for evaluation trauma patient ( unstable )
DPL potentially a major procedure for
children, but infrequently necessary
Indication for operation in blunt abdominal
trauma:
Hemodynamic instability
Suspected associated injury
Excessive transfusion requirement ( > 0,5 BV )

Summary :
Resuscitation in severely injured children
should be aggressive to avoid irreversible
shock
Non operative management has become the
clear standard of care for pediatric blunt
trauma

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