Hey there, listeners. This is Rod Gerardo, research resident at Cincinnati Children's Hospital. And today, we're gonna talk about pediatric trauma, specifically, the ATLS guidelines and potential updates for 2021. And if you're thinking, Rod, why do we need to go over this like every year? Is it important? Well, just keep in mind that Trauma and trauma-related injuries are still the number one killer of pediatric patients. That's Doctor Rich Falcone. He's a pediatric surgeon and the director of trauma services at Cincinnati Children's Hospital Medical Center. And we're gonna walk you through his grand rounds that talks about pediatric surgery updates for ATLS. And, you know, I, I keep saying we, you know, I had to bring the whole team in here. I'm Todd Ponsky, a pediatric surgeon at Cincinnati Children's Hospital. And I'm Ellen Ancisco, a research resident at Cincinnati Children's Hospital. Awesome. The gang's all here, including you. Welcome to the State Current Pediatric Surgery podcast. All right, Ellen, why don't you start us off? Let's jump right into a case. And we're gonna give you the case in the MIST format. Wait, Ellen, why is the case laid out like that? And what does MIST mean? Oh, good question, Todd. MIST stands for mechanism of injury, injuries identified, Signs and symptoms, and Treatments. OK, got it. Thanks. Keep going with the case. M or mechanism of injury. A 3 year old boy falls 10 m out of an apartment window onto the pavement. Eye or injuries identified. The patient does not open his eyes, moans incomprehensibly, and extends abnormally when stimulated. S or signs and symptoms. He is unresponsive on arrival to the emergency department at a small rural hospital. His pupils are unequal. He is Blood coming from the right ear. He's breathing rapidly, he's pale, he has mottled extremities, and his vital signs are a blood pressure of 74/57, heart rate of 156, respiratory rate of 49. Lastly, T. And there are no reported treatments so far. And that left Dr. Falcone asking us, what are, what are you worried about with just that scenario? Or in other words, what are the priorities when evaluating a small child with multi-system trauma? Well, The answer is actually a lot more simple than you think. Just go back to your ABC's. The key message though is it's the same. It's the same as you would do for an adult patient. Don't get hyper, you know, acute that, well, this is a 3 year old and not a 30-year-old, you know, drunk guy who was in an a car accident. Your, your priorities are going to be, it's going. be the same. You're gonna make sure the kid has an airway, you're gonna make sure the kid's breathing, you're gonna check for circulation. But it's still like, you know, a good idea to keep thinking like, which injuries in particular, are you gonna be focused on throughout this initial survey for this specific patient. So, both head injury, shock, and, you know, who knows why, you know, what else could be going on to give this kid the shock cause we don't always see this degree of shock with just an isolated head injury either, so kind of keeping all things in mind. So you kinda move on, you got, in this case, you got breath sounds that are symmetrical, um, but SATs are, are low. And by low, let's say he means like 85% oxygen saturation. All right. So the initial rules of trauma still apply. You have to check your ABCs. But are there differences between pediatric and adult chest injury? Right, so they're more pliable chests, right? So the, the ribs don't necessarily break, but what do you have to worry about then? Well, they can have a lot of pulmonary contusions and, and other injuries. With all your adult, I feel a lot of creptence and uh, you know, I, you know, there's a lot of chest wall pain and bruising and stuff, but they can still have a lot. What about, are they more or less susceptible to tension pneumothorax? Well, based on And the way he said it, my gut tells me, yes. I don't know why though. It's a little less reserved. They also their mediastinum is more mobile, so it'll, it'll shift more easily in response to that tension, whereas you get a little older. And then it takes a lot more pressure to kind of move the trachea, you know, put pressure on the, the cava and things like that. All right, let's keep the case moving. So, all right, so we said breath sounds in this kid are symmetrical, but we still have low sacs. So what else can you do to kind of, is this, this may be an airway problem, right? How are you gonna deal with this 3 year old's airway? So let's say they're on a, they're on a backboard already in a seat collar and they're having this, some airway concerns. So how are you gonna address it? All right. I know that we're, you know, surgeons at heart, and we wanna jump to the, the most interesting thing, but really it's a stepwise approach. So think simple, like a jaw thrust. Right, they got, they got big tongues. Their heads are big too. You lay them on their backboard and that already starts flexing their head forward, um, because they're big oxfoot which starts to, in obstruct. Their airway as well. So some of the real true pediatric backboards have a, a cutout for the head or, or a bump already built in to keep the, the torso a little higher so you keep your ear in line with your shoulder. I love that rule, ear in line with the shoulder because little kids like this, they just got big heads. Some adults have big heads too, but it's different, different story altogether. Yeah, that's probably a whole different podcast. Anyway, let's say you try the simple maneuvers, they don't work. We keep moving up in the stepwise approach, and now we have to intubate, but we failed twice. What should we do next? Uh, good question, Ellen. I guess a surgical airway. Yes, but Rod, this is a 3 year old child. Would you do a surgical cricothyroidotomy or a needle cricothyroidotomy? So, needle crike and the, the small airway, um, usually say under 10, um, would be for the needle versus over 10 before. Surgical Craig, that's what ATLS will tell you. But at the same time, some of it is what you're most comfortable with. I mean, we're, we're also fortunate here that we have, you know, amazing ENT folks. So you save the kid's life, but you give them a little, you know, tracheal ring damage and Subglottic stenosis, well, that's a lot better choice than being dead because you didn't do something. Um, so we've seen kids come in that have been saved from an in the field surgical cripe that according to ATLS should have had a needle, crike, but Well, they're alive and they got their trachea fixed and they're fine. And keep in mind, that's not your definitive airway, that's a buy you time to get to the OR to do a formal tracheostomy. OK, yeah, that makes sense, but how do you perform a needle crake? You can actually use a 10 mL syringe, then once you have that IV in, it actually connects to the Abu bag, it'll fit um into that. So there's a little way to do that versus the. You know, connecting an oxygen tubing directly to it and cutting a little side hole, cause you gotta remember, you can't just keep blowing things up, you have to let them, uh, you know, you have to ventilate them as well. Now, once you get that needle, cricothyroidotomy, the next step is that you have to, you know, talk to, based on your institution, you know, the ENT team or whoever it is that we have to get a definitive airway because this ain't it. Now, let's keep moving down the pathway, we're at C as in Charlie, circulation, we still have the patient hypotensive and tachycardic. We kind of need to get IV access. Let's say hypothetically in this kid you've had several failed attempts at peripheral IV access while you were, while you were struggling to do the, do the airways someone was trying to stick for IVs, um, and did not get them. So what are you gonna do when you can't get access? Well, when you can't get IV access, then the next step is intraosseous or an IO access. So, One, where would you put IOs? Ellen, where, where can the IO be placed? Ah, he called on me. Well, you can place an IO in the tibia, the humeral head, or in the distal femur. Some people talk about placing external IO in adults, but we usually try to avoid this in children. Now, again, this isn't your definitive access, but it's the access that we have right now in the trauma bay. So, there we are, we can start infusing, but How much do you infuse? And, and on top of that, what are you gonna infuse? The old ATLS was you give 20 per kilo, you see how they respond, then you give another 20 per kilo and see how they respond, and then you can just, you know, and only after that can you use blood. The, the teaching even in ATLS, ATLS is a little soft on saying go straight to blood, although I think that's the right thing in a situation like this if you have blood available, um, but they They're very clear on now saying it's one, and if you get either transient or no response, you can go right to blood as the next, as the next step. All right, got it. So, in these hypotensive tachycardic patients where you're worried about shock, do 1 L bolus at 20 ccs per kg of crystalloid. Then if they don't respond or they're transiently respondent, Move on to blood, that's gonna be 10 cc's per kg. This is a new update in ATLS. So, this patient is 3 years old, and I know that vital signs change as the child ages, but this kid's like definitely in shock, right? This hypotension, that's tachycardia even for a 3 year old, so he's got both. So how bad is this shock? What do you mean? Like small, medium, large? How much blood does a kid have to lose to be both tachycardic and hypotensive? What percentage? For a child to start showing signs of hemorrhagic shock, they would have to lose about 50% of their total blood volume. Whoa, that's like way more than I thought. And their total blood volume is a lot smaller than you would think. Let's put it into some perspective. Yes, infants are a little different and there's some difference in the blood volume, but weight, weight in kilos times 80 mLs is the blood volume, right? So let's do some math here. A 12 kg kid's entire blood volume is gonna be about a liter. Let's keep this going. 25 kg kid is a 2 L bottle, right, just to kind of frame of reference, so. That then means that shock is going to be seen in a 15 kg kid after you lose. One can of Coca-Cola. I mean, like, you know, the, the volume in one can of Coca-Cola, not literally a can of Coke. Massive transfusion protocols, um, you know, they're, they're definitely been proven to help. Certainly more data in the adult world, but there's definitely data in pediatrics as well. Um, ours is made up, you know, based on, on weights and, and once you activate the massive transfusion protocol, you don't have to keep calling. They're gonna, the blood. The, the key is remembering to call and stop it once you think you're in a good spot, but they're gonna keep sending coolers. And once you start transfusing blood, it's not a bad idea to keep track of a tag or thromboelastography, as long as your institution has it readily available. Great point, Todd. So, basically, the exact massive transfusion protocol that you use is gonna be determined by your institution. Same with the tag, or, you know, whether or not you're even using tag or if you're using Rotem or How that information's getting to you and how that's guiding your management. A lot of that is institution-based. So, look it up for your specific hospital, make sure that you have those guidelines readily available for you or those orders or whatever you need to do. All right, let's keep the case moving. The next step we have to evaluate this patient's neuro status. And this neuro evaluation is critical because over 75% of pediatric trauma deaths are due to head injuries. Don't forget that you can do it. GCS in a child that's nonverbal, right? It's they don't, they don't automatically get a 0 or a 1 for verbal just because they can't talk, right? If you can't talk normally, you don't, you don't lose points, right? So you got to think about what, what's a normal baby or normal kid this age do if, if they're just going to kind of babble and say nonsense, well, you can't say, well, you lose all your points. You give them the full score. If they're irritable and crying, you get a 4. They're just moaning at a 2. If they're doing nothing, that's That's when you really have to be worried. I mean, I'm most scared when you have a kid this age that's not crying, right? I mean, a kid that doesn't respond to their IV stick or their IO is, or a kid that's crying a lot and then suddenly stops crying, that's who I'm most worried about in the trauma bay from a neurostatus. And the same goes for the motor assessments. I mean, keep in mind the age of the patient and what they can or can't do physically. Kids have more diffuse brain injuries in general than your adult population. Um, child abuse said. is the most common cause of severe head injury in kids less than, less than 2. and kids are more at risk because of big heads, soft skulls, and they often fall on their head. Um, you know, they're, they topple over onto their head, um, and like start diffuse rather than focal, uh, injuries. Now, despite the emergency department stereotype of everyone going through and getting a scan, as concerning as a head injury is, we try to refrain from scanning absolutely every trauma that comes through the door. So there actually are recommendations on when not to scan. Scroll down under the media player, we'll give you some resources for that, but really, the rule of thumb when you're looking at it is, if you're less than 2, your patient's less than 2, and the answer to all of these questions are no, then you don't need a head CT. And those questions for the younger than 2 year old, it's stuff like, you know, are they, are they acting different per the parents' report? Was there a skull fracture? And then if they're older than 2, there are a couple of differences, like, is there a history of vomiting, are there signs of a basil or skull fracture. Like I said, we'll give you all of it down under the media player, click on the links there. And the same goes for blunt abdominal trauma. We have great algorithms that will help us determine who will or will not get an abdominal CT scan. Do they complain of abdominal pain? No. Keep moving. Do they have abdominal wall trauma or tenderness or distension? No. Do you have an abnormal chest X-ray? No. Do we have an AST greater than 200? No. Or you have abnormal pancreatic enzymes? No. This is an algorithm based on a multi-institutional study that You guessed it, we're gonna link it below, but the punchline is, if, if you say no to all of these, and that's about 35% of this population, then you are at a very, very low risk of intraabdominal injury. It's, it's actually about 0.6% of those patients ended up with an intraabdominal injury, and then on top of that, it says 0.0% of those had an intraabdominal injury intervention, and that could even just be blood. It's not necessarily just surgery. But the flip side is if you have one, yes, doesn't mean you have to CTM, but it starts giving you some, some risk groups of how likely are they to have it. And the data would also support, you have more than one of these, your risk goes up. You have all four of them, your risk is even higher. So, there you have it, a 2021 ATLS pediatric surgery update from Doctor Rich Falcone. Did you hate this? Did you love it? Either way, leave us a comment below, rate us if you're listening to us on Apple Podcasts, Stitcher, Spotify, SoundCloud, or the best way to listen, to stay current pediatric surgery app. It's available in the Apple App Store or the Google Play Store. Download it today, but until then, I'm Rob Gerardo from Cincinnati Children's, and remember, knowledge should be free.
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