Trauma in the child by A Scuola di Salute

Trauma in the child

Traumatic event characterized by injuries capable of determining an immediate or potential risk for survival

Trauma in the child

Pathophysiological criteria

• Glasgow Coma Scale ≤13 • PAS lower than the minimum age limits • Altered RR or need for ventilatory support

Trauma in the child

Anatomical criteria

• • • • • • • •

Trauma in the child

All penetrating wounds (except distal elbow and knee) Chest wall instability or deformity (mobile flap) ≥ 2 proximal long bone fractures Mangled extremities or with not appreciable pulse Proximal amputation at the wrist or ankle Pelvic fractures Open or depressed skull fractures Paralysis

Dynamic criteria

• Fall from a height > 3 meters or > 2-3 times the child’s height • High-risk car accident o Intrusion (including car roof): > 30 cm to the occupant seat, > 45 cm to any part of the car o Extrusion (partial or complete) from the car o Death of another passenger in the same car o Speed of the vehicles involved compatible with high-risk trauma o Hit by a car of a pedestrian or cyclist, with impact > 30 km/h and/or throwing of the invested person from the point of impact o Motorcycle accident at speed > 30 km/h

Trauma in the child

Special criteria

• Comorbidities due to chronic pathologies or drug intake • Coagulation disorders or patients on anticoagulant treatment • Pregnancy • Age < 5 years

Trauma in the child

Trauma is the leading cause of death and disabling sequele in children after the first year of life • •

• •

Falls and mistreatment are the main causes <5 years The severity of the clinical picture essentially depends on the extent of CNS involvement, respiratory compromise and the extent of blood loss In major trauma, the head is involved in 80% of cases Injuries to internal organs, even in the absence of obvious external lesions, are more frequent

In severe trauma, the timeliness (golden hour) and quality of care in the early stages after trauma are decisive in reducing long-term mortality and morbidity Trauma in the child

Mode of arrival

Hospital response in the Emergency Network 118 system (primary transfer) In the event of a serious trauma, 118 pre-alerts the reference Intensive Care Unit

Transfer from another health facility (Secondary transfer)

Led by parent/carer or came independently

Preparation of the Shock Room

Arrival of the patient in the ED Accesso immediato in Shock Room e contestuale triage

YES

Compromise of at least one of the vital functions (Respiratory, Cardiocirculatory, Neurological)

1. On the door assessment (at a glance) 2. Data collection (subjective and objective assessment) 3. Triage decisions (level assignment, Fast-Track…) 4. Revaluation

Patient access to the examination room Trauma in the child

Triage methodology

On the door assessment (at a glance): • • • • •

Overall appearance of the patient A(lert) V(erbal) P(ain) U(nresponsive) GCS/pGCS (if < 1 year) Degree of walking Presence of ongoing bleeding, amputations or obvious deformities • Access mode

Trauma in the child

Triage methodology

Data collection (patient/carer): • • • • • •

Trauma in the child

Personal data Type and modality of event Time elapsed since the event Means of protection (helmet, child seat, seat belt, etc.) Loss of consciousness and memory of the event Paresthesias, motor deficits and visual disturbances

Triage methodology

Data collection (patient/carer): • Dizziness and vomiting • Allergies • Treatments performed during the pre-hospital phase (clinical, TC, RX, ultrasound, etc.) and evolution of clinical parameters and clinical picture • Associated risk factors/diseases: age <5 years, coagulopathies, previous NCH surgery or chronic diseases • Taking alcohol, drugs of abuse or drugs (anticoagulants, anti platelet agents, anti epileptics, etc.)

Trauma in the child

Triage methodology

Vital parameters collection: • • • • • • • • •

Trauma in the child

Blood pressure Heart rate Respiratory frequency Body temperature HGT Pupil diameter RTS (Revised Trauma Score) SpO2% Pain (FLACC/VAS)

Triage code PV and indices

Airways

Obstructed

Patency

SpO2 %

< 90

90 < SpO2< < 92

93 < SpO2 < 95

>95

Airway 1 2

Breathing FR 3 a/m

4 5

mesi

anni

1 2

Circulation FC bpm

3 4 5 PAS

Disability

Trauma in the child

<60 (<6aa) <90 (>6aa)

normal

GSC

≤9

10-13

Pupils

Anisocoria

miosis/mydriasis

normal

mmHg

normal

Severe trauma (Codes 1 and 2)

SHOCK ROOM/ Red Room

• Correct positioning of the patient on the spinal board and cervical collar or, if absent, immediate application of protection systems • Maintaining venous access • Maintaining the correct position of the immobilization aids (limb immobilizers, «spider», etc.) In cranial trauma, even without apparent cervical impairment, evaluate the opportunity to place a rigid cervical collar

Trauma in the child

Triage 5 levels

Vital parameters

from code 1

from code 2

from code 3

from code 4

from code 5

Characteristics of the main symptom/sign

Major traumatic event Massive external bleeding in progress Intense pallor

Pallor, jaundice, lethargy, listlessness (child >2 years) Insomnia, irritability (infant) Dizziness, syncope

Minor dynamics, occurred <12 hours, with normal vital parameters, sensory intact, asymptomatic

Minor dynamics, occurred <12 hours, with normal vital parameters, sensory intact, asymptomatic , abrasions, excoriations, no other symptoms

Band/neck

Penetrating wound of the eyeball Motor/sensory deficits Deviation of the trachea Cervical trauma with myelic symptoms

Neck trauma with Orbital hematoma neurological symptoms Nose wound with Eyeball wound modest epitaxy Facial trauma with alteration of the physiognomy Nose wound with massive epitaxy Amputation of the auricle

Superficial wound Contracture symptoms

Chest - abdomen pelvis

Penetrating wound Spinal trauma with myelic symptoms Massive hemoptysis

Signs of fractures ribs or scapulae Subcutaneous crepitus on palpation (neck,

Superficial wound

Trauma in the child

Mild respiratory distress Vomit Streaks of blood in the stool

Limbs

Major amputations Burst wound of hands Absence of pulse Open fracture Multiple fractures

Skin

Associated symptoms/signs

chest, collarbone area) Abdomen distended, stiff, sore, jumping test positive Vomiting bile, blood, caffeine, rectal bleeding, gross blood in stool, hematuria Moderate respiratory distress Hemoptysis, hematemesis

Chest or abdominal trauma without symptoms Vaginal trauma

Single long bone fracture Large joint dislocation Penetrating wound of the limbs Weak peripheral pulses Phalanx amputation

Pain on palpation of limbs Suspected small bone fracture Small joint dislocation

Large loss of substance Animal (nonvenomous) or human bite with loss of substance Coagulation disorders (thrombocytopenia, hemophilia)

Superficial wounds

Excoriation and abrasion

Animal or human bite without loss of substance

Age <6 months Suspected or confirmed mistreatment

Specific scores: GCS Trauma score Pain

Trauma in the child

Revaluation CODE 1: EMERGENCY ▪ No revaluation CODE 2: URGENCY ▪ Direct observation ▪ Access to the visit within 15 minutes CODE 3: DEFERRABLE URGENCY ▪ According to the Nurse▪ At the request of the accompanying person ▪ After 60 minutes CODE 4: MINOR URGENCY ▪ According to the Nurse ▪ At the request of the accompanying person ▪ After 120 minutes CODE 5: NOT URGENCY ▪ According to the Nurse ▪ At the request of the accompanying person ▪ After 240 minutes Trauma in the child

The severe trauma Clinical cases

Trauma in the child

Clinical case 1

• 8 year old patient • 118 transport for falling backwards from the balcony of about 4 meters in height (occurred 30 minutes before arrival in PS) • Prolonged loss of consciousness reported • No episodes of vomiting

Trauma in the child

Clinical case 1

• • • • • • • •

Alert and responsive GCS 13 AVPU=A RTS 12 HGT 86 mg/dl Presence of cranial swelling in the occipital area Evident signs of thoracoabdominal trauma and of the right lower limb Isochoric pupils, isocyclic cells that react normally to the light stimulus

Trauma in the child

Vital parameters: • • • • • •

PA 102/54 FC 101 FR 23 TC 36.1 SpO2 98% in AA VAS 2

Clinical case 1 Triage 5 levels

Vital parameters

from code 1

from code 2

from code 3

from code 4

from code 5

Characteristics of the main symptom/sign

Major traumatic event Massive external bleeding in progress Intense pallor

Pallor, jaundice, lethargy, listlessness (child >2 years) Insomnia, irritability (infant) Dizziness, syncope

Minor dynamics, occurred <12 hours, with normal vital parameters, sensory intact, asymptomatic

Minor dynamics, occurred <12 hours, with normal vital parameters, sensory intact, asymptomatic , abrasions, excoriations, no other symptoms

Band/neck

Penetrating wound of the eyeball Motor/sensory deficits Deviation of the trachea Cervical trauma with myelic symptoms

Superficial wound Contracture symptoms

Chest – abdomen – pelvis

Penetrating wound Spinal trauma with myelic symptoms Massive hemoptysis

Signs of fractures ribs or scapulae Subcutaneous crepitus on palpation (neck)

Superficial wound

Trauma in the child

Mild respiratory distress Vomit Streaks of blood in the stool

Clinical case 2

• 12 year old patient • Accompanied by his grandmother due to a previous road accident (minor dynamic trauma) • Occurred 5 hours before arrival in PS • No loss of consciousness • No episodes of vomiting

Trauma in the child

Clinical case 2

• • • • • • • •

Alert and responsive GCS 15 AVPU=A RTS 12 HGT 98 mg/dl Absence of cranial swelling Presence of abrasions on the zygomatic level (no bleeding in progress) Isochoric pupils, isocyclic cells that react normally to the light stimulus

Trauma in the child

Vital parameters: • • • • • •

PA 110/60 FC 100 FR 21 TC 36.1 SpO2 100% in AA VAS 2

Clinical case 2 Triage 5 levels

Vital parameters

from code 1

from code 2

from code 3

from code 4

from code 5

Characteristics of the main symptom/sign

Major traumatic event Massive external bleeding in progress Intense pallor

Pallor, jaundice, lethargy, listlessness (child >2 years) Insomnia, irritability (infant) Dizziness, syncope

Minor dynamics, occurred <12 hours, with normal vital parameters, sensory intact, asymptomatic

Minor dynamics, occurred <12 hours, with normal vital parameters, sensory intact, asymptomatic , abrasions, excoriations, no other symptoms

Band/neck

Penetrating wound of the eyeball Motor/sensory deficits Deviation of the trachea Cervical trauma with myelic symptoms

Superficial wound Contracture symptoms

Chest – abdomen – pelvis

Penetrating wound Spinal trauma with myelic symptoms Massive hemoptysis

Signs of fractures ribs or scapulae Subcutaneous crepitus on palpation (neck)

Superficial wound

Trauma in the child

Mild respiratory distress Vomit Streaks of blood in the stool