ATLS 2021 Pediatric Surgery Update
With Dr. Rich Falcone · hosted by Dr. Rod Gerardo & Dr. Todd Ponsky & Dr. Ellen Ancisco · StayCurrentMD
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Trauma 5 items
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
The priorities when evaluating a small child with multi-system trauma are the same as for an adult patient: airway, breathing, circulation
Pediatric patients have more pliable chests so the ribs don't necessarily break, but they can have a lot of pulmonary contusions and other injuries
Pediatric patients are more susceptible to tension pneumothorax because their mediastinum is more mobile and will shift more easily in response to that tension
For pediatric airway management, start with simple maneuvers like a jaw thrust because children have big tongues and big heads
When children are laid on a backboard, their large occiput causes head flexion which can obstruct the airway; pediatric backboards have a cutout for the head or a bump to keep the torso higher and maintain ear in line with shoulder
Needle cricothyroidotomy is recommended for children under 10 years old, while surgical cricothyroidotomy is for children over 10, according to ATLS guidelines
Pediatric blood volume is calculated as weight in kilos times 80 mLs
A 12 kg child's entire blood volume is about a liter, and a 25 kg child has about 2 liters
Massive transfusion protocols have been proven to help, with more data in the adult world but also data in pediatrics
Once blood transfusion starts, it is advisable to keep track of TEG (thromboelastography) if the institution has it readily available
Glasgow Coma Scale can be performed in a nonverbal child; if they cannot talk normally, they do not lose points for the verbal component
For verbal GCS scoring in nonverbal children: if they babble and say nonsense normally, they get full score; if irritable and crying, they get a 4; if just moaning, a 2; if doing nothing, that is most concerning
A child who does not respond to IV stick or IO placement, or a child who is crying a lot and then suddenly stops crying, is most concerning from a neurostatus perspective in the trauma bay
Kids have more diffuse brain injuries in general than the adult population
Child abuse is the most common cause of severe head injury in kids less than 2 years old
Kids are more at risk for head injury because of big heads, soft skulls, and they often fall on their head
Trauma and trauma-related injuries are still the number one killer of pediatric patients
Rich Falcone is a pediatric surgeon and the director of trauma services at Cincinnati Children's Hospital Medical Center
MIST stands for mechanism of injury, injuries identified, Signs and symptoms, and Treatments
A cricothyroidotomy is not a definitive airway but buys time to get to the OR to do a formal tracheostomy
For needle cricothyroidotomy, a 10 mL syringe with IV catheter can be used and connects to the Ambu bag
When peripheral IV access cannot be obtained, the next step is intraosseous (IO) access
An IO can be placed in the tibia, the humeral head, or in the distal femur
The new ATLS guideline is to give one 20 cc/kg bolus of crystalloid, and if there is transient or no response, go right to blood (10 cc/kg) as the next step
For a child to start showing signs of hemorrhagic shock, they would have to lose about 50% of their total blood volume
Over 75% of pediatric trauma deaths are due to head injuries
There are validated clinical decision rules for when not to obtain head CT in pediatric trauma patients, with different criteria for children less than 2 years versus older than 2 years
For blunt abdominal trauma, a multi-institutional algorithm identifies patients at very low risk (0.6%) of intraabdominal injury if they answer no to: abdominal pain, abdominal wall trauma/tenderness/distension, abnormal chest X-ray, AST greater than 200, or abnormal pancreatic enzymes
Approximately 35% of blunt abdominal trauma patients meet low-risk criteria (all negative findings), and 0.0% of those required intraabdominal injury intervention