Pediatric Trauma Life Support for Prehospital Care Providers

ThoracicAbdominal Trauma 3rd Edition 1

Thoracic-Abdominal • Objectives – Describe major signs and symptoms, pathophysiology, and initial management of pediatric thoracic trauma – Compare the clinical presentation of massive hemothorax and tension pneumothorax – Identify indications for emergency needle decompression of the chest in children 2

Thoracic-Abdominal • Objectives – Describe how undetected abdominal trauma can lead to shock and death – Discuss why abdominal trauma in children is usually associated with other injuries – Describe the assessment and management of a child with abdominal trauma

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Thoracic-Abdominal • Case Study Scenario – A 2-year-old child was backed over by the family van in the driveway – The driver (the child’s father) immediately stopped and found child under car

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The approach to this patient requires the rescuer to be aware of the surroundings and scene safety. Be sure the scene is safe, including securing the vehicle, and that someone on the rescue team is available to talk to the parents. This would be a devastating event for the driver and a liaison is needed specifically to attend to the driver’s psychological needs.

Thoracic-Abdominal • You arrive on the scene – How would you approach this patient? – What are the concerns about the mechanism of injury? – Is this patient in shock? – Is this a priority patient? – What interventions should be performed?

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Knowledge of normal age-specific vital signs and an organized approach are crucial in this case. Refer to the ITLS Primary Survey and Patient Assessment as methods to answer these questions and determine the order in which interventions should be done.

Thoracic-Abdominal • Pediatric vs. Adult Thoracic Trauma – Energy is the same – “Target” is different • Much more compact

– Energy absorption is different – Blood loss triggers shock more easily in children

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Although mechanisms may not differ, the target of the mechanism for the pediatric patient is smaller. Thus, the energy is the same, but is absorbed by a smaller body. Blunt trauma such as an automobile bumper striking the thorax of a young child can cause multisystem trauma, whereas the same injury may cause injury to the rib cage or to an extremity only in an adult. Multisystem injury that includes chest or abdominal injuries also commonly includes head, neck or extremity injury. The child's lower reserve causes earlier decompensation and shock from blood loss.

Thoracic-Abdominal • Pediatric Anatomy and Pathophysiology – Ribs smaller, incompletely calcified – Liver, spleen often project below ribs – Thinner chest and abdominal walls – Abdominal muscles less developed – Mediastinum more mobile 7

The ribs of a child are more pliable because they are incompletely calcified. As a result, pediatric patients are more likely to develop underlying injury without rib fracture. Additionally, the fracture of one rib may negatively impact respiratory effort to the same degree as a flail segment in an adult. Because the ribs are smaller and do not protect the abdomen from injury as well as in adults, the liver and spleen are more prone to injury. The child’s thinner chest wall makes it more difficult to assess breath sounds. Breath sounds may be transmitted across the entire chest wall, making unilaterally decreased breath sounds more difficult to accurately evaluate. Rescuers should listen to lung sounds peripherally as well as anteriorly. They must also be able to recognize respiratory distress found commonly with chest injuries and maintain a high index of suspicion, close monitoring, and frequent reassessment of respiratory status. Signs of respiratory distress include tachypnea, nasal flaring, retracting, grunting, and apnea. The thinner muscle wall of the abdomen should make the pediatric abdomen easier to assess than that of a child; however, abdominal muscles tighten when children cry, making assessment more difficult. Children also tend to swallow air when they cry, distending the abdomen. This may cause the diaphragm to be displaced up into the thorax. Less developed abdominal muscles in children and infants account for their pot-bellied appearance. The mobility of the medastinum makes early detection of tension pneumothorax difficult.

Thoracic-Abdominal • Prehospital priorities – Scene Size-Up – Airway with LOC and spinal motion restriction – Anticipate and recognize respiratory distress – Anticipate and recognize early signs of shock – Proper spinal motion restriction and packaging – Rapid transport – Ongoing Exam 8

Thoracic-Abdominal • Scene Size-Up – Note mechanism of injury, restraints – Subtle scene clues

• Initial Assessment – Airway with LOC and spinal control • Modified jaw thrust, oral airway • Maintain open airway • BVM with 100% oxygen, saturation above 95% – Intubate only if you cannot oxygenate or maintain airway

• Capnography if available 9

The Scene Size-up is important because subtle scene clues increase suspicion toward an abdominal and or chest injury. Remain alert for signs of abuse. Begin the Initial Assessment by noting the general impression and level of consciousness. Remember, children with decreased LOC may not display common signs and symptoms such as pain and tenderness. Airway and spinal motion restriction are key in the presence of chest and abdominal injuries, as vomiting is common and pain often decreases the volume of respirations. Administer 100% oxygen to any patient with a suspected chest or abdominal injury. Assess breathing, observing closely for signs of respiratory distress that may include: tachypnea, flaring, retractions, grunting, apnea, shortness of breath, and/or pain.

Thoracic-Abdominal • Recognize respiratory distress – Tachypnea – rate is age-specific – Grunting, retractions, paradoxical movement – Close the open pneumothorax – Decompress tension pneumothorax – Stabilize mobile chest wall segments

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What are some of the signs and symptoms of respiratory distress? What can be done to maximize ventilations and oxygenation?

Thoracic-Abdominal • Recognize early signs of shock – Tachycardia – rate is age-specific – Compare central and peripheral pulses – Skin temperature, color, capillary refill

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What are the early signs of shock? How does the treatment of shock differ in the child versus the adult? If the child is showing signs of shock, initiate fluid resuscitation.

Thoracic-Abdominal • Thoracic Trauma “Deadly Dozen” – Life-threatening injuries – 6 detected during ITLS Primary Survey: • Airway obstruction • Open pneumothorax • Tension pneumothorax • Massive hemothorax • Flail chest and rib fracture • Cardiac tamponade 12

Observe closely for paradoxical chest movement and respiratory distress.

Thoracic-Abdominal • Thoracic Trauma “Deadly Dozen” – 6 that may be detected during ITLS Secondary Survey: • Traumatic aortic rupture • Tracheal or bronchial tree disruption • Myocardial contusion • Diaphragmatic tear • Esophageal injury • Pulmonary contusion

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Diaphragmatic tears and esophageal injury are difficult to diagnose, even in the hospital.

Thoracic-Abdominal • Open pneumothorax – Caused by penetrating injury – Sucking chest noise – Respiratory distress

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An open pneumothorax is typically caused by penetrating injury. This may be characterized by a sucking or blowing sound and respiratory distress. An open pneumothorax (sucking chest wound) is uncommon in the preadolescent child. Treatment should be standard airway management, oxygen supplementation, and BVM ventilation if needed. In addition, a nonocclusive dressing taped on three sides or a commercial device such as an Asherman chest seal should be used. The Asherman has a flutter valve to present development of tension pneumothorax.

Thoracic-Abdominal • Tension Pneumothorax

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A tension pneumothorax results when a lung leak due to trauma fails to seal. A one-way valve effect may be produced, leading to air buildup in the pleural space. This results in the mediastinum shifting to the side opposite the tension pneumothorax, causing compromise of pulmonary and cardiac function. The increasing air pressure in the pleural space prevents blood return to the heart. This is particularly problematic for young children due to their mobile mediastinum that allows for compromise to occur more rapidly.

Thoracic-Abdominal • Tension Pneumothorax – Caused by chest injury – Increasing pressure in the pleural space impairs blood return to the heart, decreasing stroke volume and cardiac output – Indicators • Airway compromise • Severe respiratory distress • Signs of circulatory collapse – Hypotension, cyanosis, traumatic cardiopulmonary arrest

• Shock • Subtle changes 16

– JVD

The development of tension pneumothorax in the field will likely require needle decompression in order to save the child’s life. Early diagnosis is critical. A tension pneumothorax is not a true tension until shock is present. A true tension pneumothorax has respiratory distress, decreased breath sounds and shock. Late findings in a child include hypotension, distended neck veins, tracheal deviation, and finally, complete cardiovascular collapse and cardiac arrest. Hyperresonance to percussion is a particularly unreliable indicator in the pediatric population.

Thoracic-Abdominal • Needle Decompression – Over-the-needle catheter inserted into midclavicular line in second or third intercostal space – “Walk” needle upward on the rib until it slides off upper edge and penetrates into pleural space 17

The appropriate sizes of needles for decompression can be found on the length-based resuscitation tape. ITLS teaches placement of the catheter in the mid-clavicular line of the second or third intercostal space (above the third or fourth rib). When the needle penetrates the pleural space, the air will exit under pressure. Remove the needle and tape the catheter into place, using a one-way valve to prevent air from entering the chest. If you are performing the procedure on teens or larger children, be sure the catheter is long enough to enter into the pleural space. Instructors: Note that the image in this slide has been corrected to show correct placement of the puncture site. The illustration that appears in the Pediatric Trauma Life Support for Prehospital Care Providers textbook erroneously shows the puncture site above the second rib instead of above the third rib.

Thoracic-Abdominal • Rib fracture and flail chest – Caused by blunt injury – Respiratory distress – Paradoxical chest wall movement

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Rib fractures and flail segments are normally caused by blunt injury. Stress the potential of underlying organ injury, such as pulmonary contusions, as the fractures themselves are rarely fatal. Particularly in children, pulmonary contusions may follow chest trauma even when the ribs are not fractured. A flail occurs when three or more adjacent ribs are fractured in at least two places, resulting in a segment of chest wall that isn’t mechanically contiguous with the rest of the thorax. It is unusual for a “true” flail to occur in children because of the flexibility of their ribs. Treatment should include BVM ventilation to ensure adequate oxygenation and external stabilization for pain control. For massive flails or severe respiratory distress, it may be necessary to internally stabilize the flail with endotracheal intubation and positive-pressure ventilation.

Thoracic-Abdominal • Paradoxical motion Expiration

Inspiration 19

On inspiration, the flail sucks in while the rest of the chest expands. On expiration, the flail flutters out while the rest of the chest contracts.

Thoracic-Abdominal • Hemothorax and Cardiac Tamponade – No specific field care – Treat for shock • Maintain airway with spinal control • Fluid resuscitation

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Hemothorax and cardiac tamponade are less common in children. Hemothorax is difficult to assess in the prehospital setting. Typically, signs of shock are present first and then respiratory distress, but this is not always true in children. It is difficult to differentiate tension pneumothorax and hemothorax in the field. Cardiac tamponade is also difficult to assess. Treat fshock with supportive care, airway management, oxygenation, and rapid transport to the hospital. Initiate IV boluses en route and monitor for changes.

Thoracic-Abdominal • Abdominal injuries – Splenic injury – Liver injury – Restraint-related injury – Mechanisms may vary

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Thoracic-Abdominal • Abdominal injuries – Splenic injury • Most frequently injured organ • Usually blunt injury • Tenderness, rigidity, pain

– Liver injury • Second most frequently injured organ • Most common fatal abdominal injury – Second only to head injury as most common cause of traumatic death in children

• Pain, tenderness, rigidity, shock 22

The spleen is the most commonly injured abdominal organ and is usually caused by blunt trauma. Potential splenic injury can be suspected with the appropriate mechanism together with pain, tenderness on abdominal palpation, and rigidity as a late finding. It can also produce referred pain to the left or right shoulder through diaphragmatic irritation. Children may benefit from fluid resuscitation en route. Treatment with fluid is more common than surgery for an encapsulated splenic hematoma. The liver is the second most frequently injured organ, but the most likely to be fatal. Liver injury should be suspected with any abdominal pain, tenderness or rigidity after abdominal or chest trauma in a child.

Thoracic-Abdominal • Restraint injury – Note position of restraints during extrication – May see external bruising – Usually from improperly worn restraint – Pain, tenderness, rigidity

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Children are more prone to restraint injuries due to their size and inability to fit properly into standard vehicle restraint devices. Bruising, as from a seatbelt (as shown above) may be noticeable.

Thoracic-Abdominal • ITLS Secondary Survey – Rapid transport immediately • Almost all are load-and-go • Most management at hospital

– Assess for 2nd half of “Deadly Dozen” – En route to hospital: • Initiate IV or IO • Continual reassessment • Changes can be subtle 24

When should IV access be obtained in the child with thoracic or abdominal injury? Don’t forget that the second half of the Deadly Dozen may be identified during the ITLS Secondary Survey: traumatic aortic rupture, tracheal or broncial tree injury, myocardial contusion, diaphragmatic injury, esophageal injury, and pulmonary contusion. As noted previously, diaphragmatic and esophageal injury can be very difficult to identify in the prehospital setting.

Thoracic-Abdominal • Case Study Continued – Initial Assessment: • Poor general impression – child unresponsive • Rapid, shallow, labored respirations at fast rate • Carotid pulse present, faintly palpable at fast rate • No radial pulses palpable

– Load-and-go priority patient – Spinal motion restriction instituted – Airway opened – BVM ventilation started with high-flow oxygen 25

Thoracic-Abdominal • Case Study Continued – Rapid Trauma Survey: • Trachea midline with neck veins flat • Tire marks extending to sternum on left chest • Crepitus in left upper chest • No subcutaneous emphysema present upon palpation • Breath sounds very diminished in left lung • Insufficient response to BVM with high-flow, high-concentration oxygen • Pulse oximetry readings persistently