PEDIATRIC HANDBOOK Eugene McGahren, MD
Professor of Pediatric Surgery/Pediatrics Chief, Division of Pediatric Surgery
Kelly B Mahaney, MD, MS
Assistant Professor, Neurological Surgery
Michael C. Spaeder, MD, MS
Assistant Professor, Pediatric Critical Care
William A. Woods MD
Director, Emergency Medicine Residency Program Department of Emergency Medicine
Contributions and Collaborations by:
Dr. Mark Abel, Jacqueline Brown, Jen Eccles, Wendy Petrohoy, Donna Shuler, Dr. James Gorham, Dusty Lynn, Esther McClure, & Meghan Winslow, Dr. William Woods
Special appreciation for major contributions: Dr. Kelly Mahaney, Dr. Eugene McGahren, Dr. Michael Spaeder
Final Editing by:
Eugene McGahren, MD Professor of Surgery and Clinical Pediatrics Division Chief, Pediatric Surgery
Level I Trauma Center October 2016
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PEDIATRIC TRAUMA GUIDELINES
The following guidelines were created from a consensus of content experts in the field of pediatric trauma at the University of Virginia Health System. These guidelines are a spring board off of the excellent work done initially under the direction of Drs. Bradley Rodgers, Julie Haizlip, and Eugene McGahren. Other major contributors to the previous edition include Drs. John Jane Jr., Mark Able and Bartholomew Kane. It is with great honor and respect we build on their excellent work to create this 2016 edition. Thank you to all the contributors who assisted with this edition. Your hard work is evident in the excellent product of your labor. Special thanks go out to Drs. Kelly Mahaney and Michael Spaeder; both recent welcomed additions to our faculty here at Uva. They took on the majority of responsibilities and created exemplary work. These guidelines are approved for patients UNDER 16 years of age, who are under the care of pediatric surgeons. There are guidelines, which should be used in coordination with expert analysis & input.
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PEDIATRIC TRAUMA GUIDELINES TABLE OF CONTENTS
Alert Criteria • Pediatric Alpha Alert • Pediatric Beta Alert • Pediatric Trauma Transfers Brain Injury Guidelines • Severe Traumatic Brain Injury Pathway • Severe Traumatic Brain Injury Guidelines Cervical Spine Protocol Pediatric Non Accidental Guidelines Pediatric Abuse Screening • NAT Guidelines Sedation Service Submersion Injury Tetanus Guidelines for Pediatric Trauma Patients References & PEARLS
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PEDIATRIC ALPHA ALERT CRITERIA (< 16 Y.O.) Any pediatric patient who arrives medically unstable and during the ED exam is found to have injuries consistent with non-accidental trauma/abuse, a trauma alert should be considered for full trauma workup to be done. I. AIRWAY / BREATHING: 1. Patients who are demonstrating ongoing respiratory compromise 2. All intubated patients transported to UVA directly from the field (e.g., SAO2 < 90, massive maxillofacial trauma, airway hemorrhage, stridor, or flail chest) II. CIRCULATION: Recognize any child with poor capillary perfusion and tachycardia is in shock, regardless of BP number
1. Weak central pulses or absent peripheral pulses 2. Dysrhythmia 3. Hypotension (SBP < 70mmHG+ 2x age in years) 4. Pre-hospital cardiac arrest (any mechanism) 5. Patient requires fluid or blood administration to maintain blood pressure
III. DISABILITY: 1. GCS < 9 with trauma mechanism or GCS declining by 2 with trauma mechanism 2. A V P U : Responsive only to pain or unresponsive 3. New paraplegia or quadriplegia
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IV. MECHANISM: 1. GSW or stab wound to neck, thorax or abdomen 2. GSW to extremities proximal to elbow or knee 3. Hangings, especially if any of the physiologic criteria above are present 4. Two or more proximal long- bone fractures humerus or femur 5. Burns > 25% TBSA or inhalation injury 6. Threatened limb or complete/partial amputation proximal to wrist or ankle, crushed, degloved or mangled extremity V. EM OR TRAUMA SERVICE PHYSICIAN DISCRETION
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PEDIATRIC BETA ALERT CRITERIA ( 10 4. Known fracture to a vertebral body from outside imaging IV. MECHANISM / INJURY: 1. Falls 10 feet or 2-3 times height of child 2. Pedestrian or bicyclist vs. car thrown, run over or significant > 20 MPH impact 3. Stable severe system injury (ie: Known SDH / EDH or pelvis fracture) 4. Concomitant thermal / multi-system injury 5. Burns with TBSA 10-15% (2nd and 3rd degree burns only) 6. High voltage electrical burns V. EM OR TRAUMA SERVICE PHYSICIAN DISCRETION
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PEDIATRIC TRAUMA TRANSFERS- (50
3-4 yrs
61-65
>55
5-8 yrs
67-72
>55
9-12 yrs
72-77
>55
13-17 yrs
77-84
>60
VTE prophylaxis: HOB 30 degrees, head/neck in neutral position, avoid obstruction of neck veins/inspect cervical collar for proper fit Place arterial line, EtCO2, CVP, foley, continuous EEG, start AED Place ICP monitor, consider whether EVD indicated
Fluids, Vasopressors, Na+: If Na 10mcg/kg/min, start norepinephrine or epinephrine or phenylephrine Sedation, Analgesia, and Paralytics: Fentanyl, 1-2 mcg/kg/hr Midazolam, 0.05-0.1 mg/kg/dose q1-2 hr prn Dexmedetomidine Vecuronium/cisatracurium gtt – titrate to 0 on train of 4 Avoid hypotension, titrate to effect
For Routine US screening for DVT?
Goals of Management: 1. ICP 140, where appropriate: Na+>150 5. Hgb>7, Hct>21 6. Adequate sedation, analgesia, (paralytics as appropriate) 7. Core temperature 36-37C (avoid fever, cooling blanket prn) 8. O2 sat>93%, pCO2 37±2mmHg 9. Seizure prophylaxis with Keppra. Promptly identify and treat seizures, clinical and subclinical 10. Glucose control (100-180) 11. Start enteral nutrition early - by HD3 if able
Seizures: Continuous EEG monitoring on all severe TBI for 48 hrs – if no seizures, may dc Prophylaxis: • Load Keppra 60 mg/kg IV once • Maintenance Keppra 30 mg/kg IV q12 hrs Treatment: IV lorazepam (0.1 mg/kg), ***If IV access unavailable: IN (intranasal) midazolam (0.2 mg/kg IN, max dose of 10 mg) or IM midazolam (0.2 mg/kg IM, max dose of 10 mg)*** Notify pediatric neurology service If numerous/continuous seizures, load 20 mg/kg of fosphenytoin
Start enteral nutrition early – by HD3 if patient stable and not contraindicated
Transfusion thresholds: pRBCs:
Hgb 40-45
Platelets:
platelet count 20 for > 5 min
Neurosurgical Intervention: Decompressive Craniectomy Will be considered early (within 24 hrs) by Neurosurgery Team in cases of severe cerebral edema/diffuse injury and early elevation in ICP Will be considered at any time point by Neurosurgery Team in patients with progression/worsening of neurologic condition: o ICP non-responsive to successive escalations in medical management o Diffuse or progressive cerebral edema or radiographic herniation o Secondary deterioration in neurologic exam o Clinical signs of herniation: unilateral dilated pupil, hypertension and bradycardia
1st Tier
Recent intervention – suctioning or nursing care? – intervention-related ICP peaks usually last < 5 min Cervical collar in place? Ensure that not compressive PaCO2 = 37±2 mm Hg (arterial blood gas) Exclude seizure activity (continuous EEG) Exclude fever Correction hypotension, which can cause cerebral vasodilation and elevate ICP Adequate sedation/analgesia/neuromuscular blockade? – sedation with fentanyl, midazolam, dexmedetomidine o Neuromuscular blockade as infusion - vecuronium drip – titrate to 0 on train of 4 o If ICP well-controlled, interrupt neuromuscular blockade q24hrs to evaluate sedation/ICP response o Maintain continuous EEG while administering continuous neuromuscular blockade 2nd Tier
If an EVD is present, begin intermittent drainage. If continuous EVD drainage required, consider whether separate ICP monitor indicated for continuous ICP monitoring If ICP > 20 and Na8mEq/24h o Account for 3%NS when calculating daily fluid intake PICU attending to be If ICP > 20 and Na >155, serum osmol
