Week 12: Pediatric Trauma, Burns, Syndromes

Question 1

Pediatric Trauma

Injuries are the most common cause of death within the US for children older than _____ year of age.

________ injuries are the leading cause of death among children.

Most traumatic injuries in children result from:

Answer 1

• 1
• Head

• MVA
• Falls
• Nonaccidental trauma
• Drowning
• Extremes of temperature

Question 2

Trauma Scoring Systems

Glasgow Coma Scale (GCS) and the modified GCS

Pediatric Trauma Score (PTS)

Answer 2

Question 3

ABCs of Resuscitation

A =
B =
C =
D =
E =

Answer 3

A = Airway with cervical spinal control
B = Breathing & Ventilation (O2 & SaO2)
C = Circulation with hemorrhage control
D = Disability and neurologic control
E = Exposure & environmental control

Question 4

Surveys

Primary survey –

Secondary survey –

ATLS course (Advanced Trauma Life Support)

Answer 4

1. incorporates the “ABC’s” and life-threatening injuries are identified and treated
   * Airway
   * Breathing
   * Circulation and Access
   * Disability (Neurologic Assessment)
   * Exposure
2. other injuries that contribute to significantly to illness and deaths are identified and treatment is instituted

Question 5

SAMPLE Report

S
A
M
P
L
E

Preoperative Evaluation

Answer 5

SYMPTOMS
ALLERGIES
MEDICATIONS
PAST MEDICAL HISTORY
LAST MEAL
EVENTS LEADING TO INJURY

Vital signs
Airway/cervical spine evaluation
Planned surgical procedure
List of known injuries
Management since arrival
Relevant laboratory/imaging results
Past medical/surgical history/family history
Allergies/current medications
Fasting time

Question 6

Figure 39-1

Management of pediatric trauma patients

Answer 6

Question 7

CV
Skin
Renal
CNS

Answer 7

Question 8

review

Answer 8

Question 9

Criteria for Early Intubation

Answer 9

• Cardiac arrest
• Clinical signs of shock
• Hypoxia
• Hypercarbia
• Signs of developing airway obstruction
• Head injury with decrease in mental status
• Burn injury with airway involvement
• Combativeness
• Chest trauma with dyspnea

Question 10

Fasting Duration

It is common to consider all trauma patients at _________ regardless of the time of last oral intake.

Delayed gastric emptying & distention
Major injury
Pain
Anxiety
Opioids

Answer 10

• risk for aspiration

Question 11

Causes of airway abnormalities

Congenital syndromes

Acquired conditions

Answer 11

Question 12

Fluid Resuscitation

• Goal is to maintain _______ in the presence of ongoing blood loss and/or third-spacing
• Colloids, such as _________
• PRBCs, FFP, Platelets and Cryoprecipitate and _______

Answer 12

• normovolemia
• 5% albumin
• Factor VIIA

Question 13

Fluid Management

• Consider ______ solutions
• Avoid _______ solutions, especially when concerned with CNS injury
• Monitor blood glucose
• Per current literature, blood glucose should be maintained less than _____-_________, depending upon your facility protocol

Answer 13

• isotonic
• dextrose-containing
• 130-200

Question 14

Vascular Access

Establish IV access ASAP!
Intraosseous (IO) access if IV cannot be established

Answer 14

Question 15

Induction: Trauma

1. Rapid sequence induction
2. Consider hemodynamic status

• If less than 10% volume deficit (normotensive), then consider ______&_________
• If 10-20% blood loss (normotensive and HR <110), then consider _____ or _____ and______.
• If your patient has > 25% blood loss (hypotensive, tachycardia, respiratory distress, anuria, cold extremities) then you must be extremely cautious with the aforementioned agents because of hemodynamic instability!

Answer 15

• propofol & SCh
• Ketamine (1 – 2 mg/kg) or Etomidate (0.2 - 0.3 mg/kg) and SCh

-

Question 16

Specific Injuries

• Head injuries
• Cervical spine injuries
• Facial trauma
• • __________ (68% of all bites > ____ years of age)
• Soft-tissue neck trauma
• Chest trauma
• Abdominal trauma
• Lawnmower related injuries
• Skeletal injuries
• Abuse

Answer 16

Dog bites; 5

Question 17

______________ is the leading cause of morbidity and mortality resulting from trauma in children.

Results in life long disability and significant expense.

Answer 17

Traumatic Brain Injury (TBI)

Question 18

Head Injuries

• Adequate venous drainage (_____ degree, heads up position)
• Adequate oxygenation
• Avoidance of hypotension
• +/- Maintenance of slight hypocarbia (PaCO2 of ____ to ____)
• Monitor ICP (intraventricular catheters and subarachnoid bolts) and CBF (SVO2)
• Remember that fontanelles allow for expansion to a point.

Answer 18

• 30
• hypocarbia (35 to 38)

Question 19

Answer 19

Question 20

Answer 20

Question 21

Child Abuse

• Laws mandating the report of suspected abuse and neglect exist in all 50 states
• In order to recognize child abuse, anesthesia providers must acknowledge that victimization occurs in all segments of society and must be considered as part of a differential diagnosis

Answer 21

Question 22

Anesthesia For Burn Injuries

Children younger than 5 years of age account for _____% of all burns with most children burned in their homes.

Mortality rates from burn injuries have declined over the past decades but almost _______ children still die from fire and burn injuries each year.

Answer 22

• 19
• 1100

Question 23

Burn-Wound Assessment

• _____, _____ and ______ are the three components that contribute to the overall severity of burn wounds.
• May be caused by thermal, chemical, electrical, ultraviolet and radiologic sources.
• Burn wounds are dynamic (evolve over time).

Answer 23

Injury depth, size and location

Question 24

Burn Injuries: Pathophysiology

• Mediators released from burn areas activate local and systemic ________ responses.
• Abnormal _________ values may persist for years after injury.
• ___________ are detected immediately after the burn, correlate with burn size, and are predictive of multiorgan failure.
• Shortly after injury massive fluid volumes shift from the vascular compartment to burned tissues and nonburned areas resulting in ___________.
• Systemic BP is initially maintained by vasoconstriction secondary to an outpouring of catecholamines and ADH.
• Days 1-4 of a moderate size burn will result in an ______ loss equal to twice the total body plasma content through the wound.
• Changes in vascular integrity result in widespread ___.

Answer 24

1. inflammatory
2. cytokine
3. Endotoxins
4. hemoconcentration
5. albumin
6. edema

Question 25

Mortality increases when ____ or more organ systems fail. * Respiratory failure occurs in the first _______ primarily * Cardiac and renal failure in first ______ * Hepatic failure as the duration of hospital stay continues

Answer 25

- 3 - 5 days - 3 weeks

Question 26

# Burn Injuries: Cardiac * _______ is reduced immediately after an injury. Inotropes are used to improve CO while avoiding volume overload acutely. * 3-5 days post injury, children are ___________. * CO may increase 2-3 fold and persists for weeks to months. Some children may develop a reversible ________and _.

Answer 26

* CO * hypermetabolic * cardiomyopathy and hypertension

Question 27

# Burn Injuries: Pulmonary * Upper airway injury is usually a ________ insult. * Lower airway injury is usually _________ insult. * Overall effect is necrotizing bronchitis, bronchial swelling, alveolar destruction, exudation of protein, loss of surfactant, loss of bronchial lining and ciliary function, bronchospasm leading to bronchopulmonary pneumonia. * Mortality from inhalation injury is _______% *Carbon monoxide binds well to hemoglobin, replacing oxygen molecules * Oxygen molecules can not be transported causing hypoxemia * * Leftward shift of oxyhemoglobin curve * * Peak airway edema occurs between ___ to ______ hours

Answer 27

* thermal * chemical or toxic * 16 * 12 and 24

Question 28

Answer 28

Question 29

# Burn Injuries: Indicators of Lower Airway Injury

Answer 29

* Victim extricated from an enclosed environment * Burns noted on face, lips, nares, or intraoral cavities * Carbon debris in mouth, nose, sputum * Stridor or hoarseness * Dyspnea, retractions, or nasal flaring * Hypoxia * Carbon monoxide levels confirmed by co-oximetry on the ABG

Question 30

# Burn Injuries: Renal * Acute tubular necrosis may result from: * Fluid retention is common ____-____ days post injury followed by diuresis. | Burn Injuries: Liver ## Footnote The liver may be damaged by hypoxemia, hypoperfusion, drug toxicity, sepsis, hypermetabolic response to burns, blood transfusion, reperfusion injury

Answer 30

- Myoglobinuria, - Hemoglobinuria, - Hypoxemia, - Hypotension, - Inhaled toxins. ## Footnote 3-5

Question 31

# Burn Injuries: CNS Chemicals inhaled may be neurotoxic, hypoxic encephalopathy, sepsis, hyponatremia, hypovolemia all contribute to CNS dysfunction. | Hematology Problems: ## Footnote Gastrointestinal problems:

Answer 31

Hemoconcentration Hemolytic anemia Thrombocytopenia DIC ## Footnote Gastric stasis Intestinal ileus Stress ulcers

Question 32

# Burn Injuries: Metabolic * Altered _______ responses * Impaired _______ control * Impaired temperature control and increased potential for infection due to loss of skin integrity. * Increased use of glucose, fat, protein leads to greater O2 demand and CO2 production. * _____,______,______ * Psychiatric trauma

Answer 32

* hormone * glucose ## Footnote * Hypocalcemia, * hypophosphatemia, * hypermagnesemia

Question 34

# “Hyperdynamic” State * The hyperdynamic, hypercatabolic response is related to ________ burned and the duration of time patients are exposed to elevated levels of _______and______. * Strategies used to ameliorate the hypermetabolic response include early surgical intervention, normothermia, nutritional support to replenish catabolic losses, and pharmacological agents such as _______ and _______. * Early excision and grafting of burn eschar attenuates the hypermetabolic response by preventing further net ______, _______ and the development of sepsis.

Answer 34

* TBSA; catecholamines and stress hormones. * Insulin and b-antagonists * Protein loss, catabolism,

Question 35

Answer 35

Question 36

Answer 36

Question 37

Systemic effects of therm

Answer 37

Question 38

# Neuromuscular blockade: burns * In the context of acute burns, there is an increased risk of severe hyperkalemia. * Excessive SCh-induced potassium efflux may be observed as early as _______ hours post-injury and for up to ____ years. * In general, SCh okay within < _____ hours of burn injury; avoid if > _____ hours and for at least ____ months after burn injury.

Answer 38

* 12; 2 * 24, 24, 18

Question 39

# Neuromuscular blockade: burns * Nondepolarizing agents: ↑ dose frequency and requirements (2- to 5-fold) during _________, reversal agent requirements are ________. * Consider ________ for rapid-sequence induction if > 24 hours after burn injury.

Answer 39

* hyperdynamic phase; unchanged * rocuronium (up to 1.2 mg/kg)

Question 40

# General Anesthetics: burns Intravenous agents * ______ dose requirements during early phase. * _______ requirements during hyperdynamic phase of injury. Inhalation agents * ________ MAC during early phase of burn injury * _________ MAC during hyperdynamic phase of burn injury

Answer 40

* Decreased, Increased * Decreased, Increased

Question 41

# Volume Resuscitation: burns * The most widely accepted fluid protocols are the Parkland and Brooke formulas. * Infants weighing less than _______ should have ___________ fluid requirements calculated and then added to the Parkland or Brooke formula. * Fluid therapy is goal directed. * Restrict glucose containing solutions at all times.

Answer 41

10kg hourly maintenance

Question 42

# Volume Resuscitation: Burns Parkland Memorial Hospital (Dallas, TX) * Recommends _____mL/kg of crystalloid x the percentage of burn * Administer ½ of the volume in first ______ hours * Administer remainder over the next ___hours * No ________

Answer 42

* 4 * 8 * 16 * colloids

Question 43

# Volume Resuscitation: Burns Brooke Army Medical Center at Fort Sam Houston (San Antonio, TX) * Recommends _____ mL/kg of crystalloid and _____ mL/kg of colloids x the % of burn * Administer ½ of the volume in first _____ hours * Administer remainder over the next _____ hours

Answer 43

- 1.5, 0.45 - 8, 16

Question 44

# Volume Resuscitation: Burns Clinical Endpoints for Volume Resuscitation

Answer 44

* Normothermia * Age-appropriate hemodynamics * Sustained urine output (0.5- 1 ml/kg/hr; negative glucose or protein) * Minimal systemic acidosis

Question 45

# Anesthetic management: Burns * Psychological aspects * NPO guidelines and post pyloric feeds * Adequate IV access and monitoring * Monitor ABG to assess degree of shunting and dead space ventilation. * Correct blood losses. * Patients are chronically ______. * Remember, pharmacokinetic responses are altered. * Methehemoglobinemia secondary to use of _______ dressings (treat with _____ and ______). * Airway control * Continue hyperalimentation. * Infusions of opioids, benzodiazepines, ketamine, dexmedetomidine. * Attempt to modulate nociceptive pathways

Answer 45

* hypocalcemia * silver nitrate * Methylene blue and high fiO2