T he y re no t little a dults, b ut Pe a rls fo r yo ur ne xt pe - - PDF document

3/7/2018 1

T he y’ re no t little a dults, b ut the y a re little huma ns

Alisa Mc Que e n MD, F AAP, F ACE P Asso c ia te Pro fe sso r o f Pe dia tric s T he Unive rsity o f Chic a g o

Pe a rls fo r yo ur ne xt pe dia tric tra uma pa tie nt

Alisa Mc Que e n MD, F AAP, F ACE P Asso c ia te Pro fe sso r o f Pe dia tric s T he Unive rsity o f Chic a g o

I have no re le vant financ ial re latio nships to disc lo se .

Childre n a re no t little a dults Childre n a re little huma ns

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Ob je c tive s

I de ntify a na to mic diffe re nc e s b e twe e n the a dult a nd pe dia tric a irwa y a nd a pply yo ur kno wle dg e to the ma na g e me nt o f the pe dia tric a irwa y in tra uma .

Ob je c tive s

De sc rib e the physio lo g ic diffe re nc e s b e twe e n a dult a nd pe dia tric c irc ula tio n a nd a pply this kno wle dg e to the ma na g e me nt o f hypo vo le mic sho c k in pe dia tric tra uma .

Ca se

6 mo nth o ld fo und unre spo nsive a t ho me . Apne ic , pulse le ss Asysto le o n mo nito r HR 0 R 0 BP 0 CPR initia te d

“At a c a rdia c a rre st, the first pro c e dure is to ta ke yo ur

• wn pulse .”

L a w # 3 T he Ho use o f Go d

Pre dic to rs o f Diffic ult Airwa y

• F

a c ia l ha ir

• Re stric te d ne c k mo b ility
• Re stric te d mo uth o pe ning
• Ob e sity
• Pre g na nc y

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T he se a re a dult pro b le ms Yo u a re e xpe rts in the e me rg e nt ma na g e me nt o f the diffic ult a irwa y Ho w do yo u mo dify yo ur a ppro a c h in the pe dia tric pa tie nt?

Tongue Vocal cords Cricoid ring Epiglottis

Ne o na ta l Airwa y Ana to my

Large tongue Airway is anterior Narrowest portion is below the cords Epiglottis is floppy More prominent occiput

Ne o na ta l Airwa y Diffe re nc e s

Large tongue #1 blade Epiglottis is floppy Straight blade Airway is anterior Look up Narrowest portion is below the cords Make sure your cuff is down

Ne o na ta l Airwa y Mo dific a tio ns

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More prominent occiput

Ne o na ta l Airwa y Mo dific a tio ns

Towel roll beneath the shoulders

Ne o na ta l Airwa y Mo dific a tio ns

Size matters Infants are small

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But they are not that small!

Atro pine ?

Atro pine fo r pro te c tio n a g a inst b ra dyc a rdia

I nfa nts ha ve e xa g g e ra te d pa ra sympa the tic to ne L a ryng o sc o py c a n ma ke the m b ra dyc a rdic Suc c inylc ho line c a n ma ke the m b ra dyc a rdic

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Hypo xia ma ke s the m b ra dyc a rdic T he tre a tme nt fo r hypo xia is no t a tro pine Ba c k to o ur c a se

Suc c e ssfully intub a te d Vita ls re ma in 0-0-0 I O e sta b lishe d E pi g ive n

A wo rd o n se c uring tha t I O

Source: http://mdnxs.com/topics‐2/procedures/intraosseous‐vascular‐access/

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So urc e : https:/ / www.a lie m.c o m/ 2016/ tric k-se c uring -intra o sse o us-ne e dle /

Suc c e ssfully intub a te d Vita ls re ma in 0-0-0 I O e sta b lishe d E pi g ive n ROSC HR 160 BP 50/ 20

Childre n a re hig hly re spo nsive to e pine phrine Childre n a re hig hly re spo nsive to vo lume e xpa nsio n “Push – Pull” me tho d to b o lus I V fluids

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Ba c k to o ur c a se

AAP Committee on Child Abuse and Neglect. Evaluating children with fractures for child physical abuse. Pediatrics 2014;133:e477‐ e489.

T wo mo nths a g o … E D visit fo r “c rying ” No rma l vita ls No rma l e xa m e xc e pt fo r a fe w b ruise s o n the le g s

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T E N – 4 Rule

• Pilo t study o f c hildre n a g e 3 a nd unde r

a dmitte d to PI CU fo r injury

• Me c ha nism (a b use vs a c c ide nta l)

de te rmine d b y e xpe rt c hild a b use re vie w

• Cha ra c te ristic s o f a b use d vs a c c ide nta lly

injure d c hildre n c o mpa re d

• I

de ntifie d hig h risk fe a ture s: b ruising o n to rso , e a rs, ne c k, o r a ny b ruise in infa nt < 4 mo nths

Pierce MC et al. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics 2010;125:67‐74. Pierce MC et al. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics 2010;125:67‐74.

T E N – 4 Rule

• T
• rso , e a rs, ne c k in a c hild le ss tha n

fo ur ye a rs o ld

• Any b ruise in a c hild le ss tha n fo ur

mo nths o ld

Pierce MC et al. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics 2010;125:67‐74.

Co nside r c hild a b use

F ra c ture s in Child Ab use Avo id the tra p o f thinking c e rta in fra c ture s a re pa tho g no mo nic fo r no n a c c ide nta l tra uma .

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Spira l fra c ture

Murphy R e t a l. T ra nsve rse fra c ture s o f the fe mo ra l sha ft a re a b e tte r pre dic to r o f no na c c ide nta l tra uma in yo ung c hildre n tha n spira l fra c ture s a re . J Bo ne a nd Jo int Surg e ry 2015;97:106-11.

Pa rie ta l skull fra c ture Pa rie ta l skull fra c ture Co rne r fra c ture “b uc ke t ha ndle ” fra c ture Cla ssic me ta physe a l le sio n Co rne r fra c ture “b uc ke t ha ndle ” fra c ture Cla ssic me ta physe a l le sio n

Ba c k to o ur c a se

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I nfa nt ha s a 2 ye a r o ld sib ling a t ho me

Sib ling study

• Ho use ho ld c o nta c ts o f a b use d

c hildre n e va lua te d

– I f a g e < 5: physic a l e xa m – I f a g e < 2: physic a l e xa m + ske le ta l surve y – I f a g e < 6 mo nths: physic a l e xa m + ske le ta l surve y + ne uro ima g ing

• 479 ho use ho ld c o nta c ts

Lindberg D et al. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics 2012;130:193‐201. Lindberg D et al. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics 2012;130:193‐201.

12% with fra c ture s 25% with fra c ture s

A twin is 20 time s mo re like ly to ha ve a fra c ture

No ne o f the se fra c ture s ha d a sso c ia te d physic a l e xa m finding s

T a ke ho me po ints

Avoid the tiny blades

Optimize oxygenation to prevent bradycardia

3/7/2018 12 Don’t rely on atropine Se c ure yo ur I O with the ma sk fro m a n a mb u b a g Use the “Push–Pull” me tho d to b o lus I V fluids

Bruising o n the to rso , e a r, o r ne c k

• r a nywhe re <4 mo nths

Co nside r a b use

Ge t a ske le ta l surve y o n ho use ho ld c o nta c ts o f a b use d c hildre n

Childre n a re little huma ns