Can I go to the first slide, please? Well, thank you. Good morning, everybody. What a great talk. My talk is going to be much less scientific and it's going to be a lot more about just general pediatric resuscitation in the form of what you do when you see a child in the emergency department, mainly because there's just not a lot of data on pediatric fluid resuscitation other than what we've taken from the adult side. But there is some. We're going to intersperse that through this talk, so hopefully you'll learn about resuscitation but also just how you take care of a pediatric trauma patient when they show up in your trauma bay. We'll talk about the ABCs of trauma resuscitation, secondary survey, a little bit about FAST exam and what the data shows. I'll touch on a few subjects like non-accidental trauma and then lat-belt complex because it's so misunderstood in our patient population. You probably know some of these facts, but 91% of pediatric trauma is blunt, nearly half of that is multi-organ, and then the rest is extremity injuries and head and neck injuries. Mortality rate is pretty low, about 3%, even lower in recent data. The mechanism of injury is pretty much falls and motor vehicle crashes as far as the majority of our patients. Pedestrians, struck by sickle axons also fill up that void. Unfortunately the unintentional gunshot wounds, although they make up a small percentage of our trauma victims, they still carry the highest mortality rate right behind assault, which in our case is usually non-accidental trauma. When I'm talking about kids in these slides, most of the time we're talking about patients that are less than 16 years of age. Head injury is a leading cause of death in our patients. It's a leading cause of long-term functional disability and they're usually disabilities in the areas of just daily living, walking, bathing, feeding, and it's estimated that half of the deaths from head injury occur from secondary head injury, which will be reflected when I talk about resuscitation approaches. So we're going to review these things, as I mentioned, and we'll talk a little bit about some emerging considerations in pediatric trauma resuscitation. As far as the ABCs are concerned, distracting injuries are not uncommon in children as they are in adults. In fact, in children, oftentimes when a child shows up in the emergency department of an adult hospital, the first thing you start thinking is, how do I quickly get this patient out of here? So you're distracted by two things. One is, when can we get the patient out? And two, what in the world happened to this child, what were they doing? As opposed to adult trauma, a lot of trauma in children is trauma of curiosity, trying to leap over something or trying to do something really cool and show their friends how awesome they are. Airway is important because a death occurs within three to four minutes. Just like in adults, we use rapid sequence intubation as our approach to securing the airway. If a laryngeal injury is suspected, fibroctobronchoscopy has been our go-to. Now we use something called a CMAQ in our hospital where we can actually visualize the vocal cords. Everybody in the room can see the vocal cords. The vocal cords are projected on screen so that everyone can see, and sometimes you'll have one person comment, there they are, and they say, no, that's a piriform sinus, move to the left. So it's great for teaching, but you always have to maintain C-spine stability during your intubation, obviously. This is a formula that I do not ever use, but it is the formula that's taught. The formula for deciding what endotracheal tube to use, 18 plus A is divided by 4, and that's the internal diameter. We basically just look at the fifth digit and make an estimate. If they're a little baby, we put a 3 and a 3 1⁄2. If they're an older child, like a toddler, a 4, and then move up from there. Breathing, obviously important. Death can occur within five minutes if you can't breathe. In children, usually you're dealing with pneumothorax, hemothorax, or pulmonary contusion. Most kids do not have significant flail chest or even rib fractures to speak of. Even if you run over a child with a car or a truck, ATV, you will often not even break a single rib, but you will cause significant pulmonary contusion and can cause a hemothorax. Obviously surgical intervention is needed immediately once this is identified, either in the form of a chest tube or even needle thoracostomy. A needle thoracostomy is not ideal, particularly in adult patients, but we have seen it occasionally be utilized to relieve a severe tension pneumothorax, and patients have survived those injuries. This is a photograph of one of our flight teams actually placing a needle thoracostomy in a secondary intercostal space. The challenges with this is those needles and the angiocast that they use tend to kink. They don't get into the space. They think they've relieved the problem, and they take off in the helicopter again when actually the patient still has a pneumothorax, so our flight team are trained on how to place chest tubes, and we do the training for them on that. The issue with circulation in children is significant. An old baby only has about 270 cc's of total blood volume. A one-year-old, about 700 cc's of total blood volume, and of course an adult's got five liters of total blood volume. So when you're dealing with children, it doesn't take a lot of blood on the floor. It shouldn't take a lot of blood on the floor to get your attention. Now sometimes my residents, when they come over from the Adult Trauma Center, which in my neck of the woods is Elvis Presley Trauma Center, they don't appreciate all the blood on the floor when they're dealing with a five-year-old, and I've gotten some calls to the emergency room about needing to educate my residents on replacing what's falling on the floor in children. The reason for that is because we know in pediatrics that they tend to, quote, fall off the table hemodynamically. So if you have a child that comes in with hypovolemia from blood loss, they can often maintain their heart rate and their blood pressure until they get to 40-45% of blood volume loss, in which case they kind of fall, quote, off the table. This is a great slide. It illustrates that they have such incredible vascular resistance, they can continue to raise their blood pressure until they get nearly half their blood volume lost before you then start to see signs, external signs, of shock in their vital signs. Now you can pick up things like a clammy nature of their body. You can pick up maybe some changes in their attitude, but a lot of kids come in fussy anyway. And so that's really subtle, and it takes someone who's had 10,000 hours to see that. So circulations are addressed the same in kids as it is adults. However, intraosseous lines have become a great standard because placing a peripheral IV in the field in a three-year-old is not easy. So the IOs have gotten so much better that we're able to resuscitate patients pretty quickly with those. So patients in the field often come in with an IO if they couldn't get an IV placed. We then try to place a peripheral IV, of course, in the emergency department and have done cut-downs on occasion. We tend to not do CT contrast, CTs do IOs, so that tends to be a problem. So very quickly, once we get the patient in our resuscitation bay, if we can get their blood pressure up, circulation better, we get an IV in, then we'll go to the CT scanner. We'll put a subclavian line in a trauma patient that's hemodynamically unstable, by the way. So this is the old algorithm for trauma resuscitation in adults. It has been still followed until fairly recently, and in children, we still kind of hang on to it, but we don't go three times on our 20-per-kilo saline resuscitation. If you have a patient that's a blunt trauma victim, they don't have any obvious source of bleeding. If we've given two 20-per-kilo boluses of saline, we're going to convert them to blood, either O-negative blood, or if we really think they have massive abdominal hemorrhage, we're going to start a massive transfusion protocol after one unit of blood. So that would put you at 30 cc's per kilo. So 40 cc's per kilo is kind of the cut-off for trauma resuscitation. If you have 40 cc's per kilo in kids, you probably need to go to the operating room and you should consider starting a massive transfusion protocol at that point. So at this point is when you're going to be deciding if the patient's failing resuscitation, whether to do an ED Thor Academy. And I mention this because in the data, in pediatric literature, I believe there have been two or three reported salvages from an ED Thor Academy, and I think two of those were the same patient reported in two different papers, which were knife stab wounds to the heart. This is our guideline for ED Thor Academy. The reason I stress this so importantly, because there's nothing more deflating to the emotional state of a trauma teen than to see a little kid come in and die from trauma. If you take a little kid that comes in and dies from trauma, and then you cut their chest open, that is impressively more deflating. And I've had to fight this battle with my residents from time to time, and so I'm just stressing this to you now, unless you have a patient that comes in with penetrating trauma who either loses vital signs in your presence, or loses vital signs en route, an ED Thor Academy is not the approach. The only other potential alternative is if you have blunt trauma and your echo shows, and they lose vitals en route, and your echo shows they have pericardial tamponade, then a pericardial window or ED Thor Academy would be appropriate. In our shop, Massive Transfusion Protocol gets started after a 40 per kilo of blood estimated loss in 24 hours. Normally this is the surgeon at the bedside seeing blood running on the floor, having given four boluses without a response, either two of saline or two of, excuse me, two of LR, or two of PAX cells, and then initiating the blood transfusion. And we try to maintain a ratio of one to one to one, although as Dr. Holcomb mentioned, it's difficult. So there have been a few papers, though. The Atomic group did a research paper where they looked at Massive Transfusion Protocol in pediatric trauma. I'm a member of that group, but this was not my paper. I was an author, but as you see, I was in the middle, only a small participant. But what we did find in this group of patients, which is at six level one trauma centers across the south and mainly southwest, was that if you did a Massive Transfusion Protocol, the closer you came to one to one to one, the lower the mortality rate. It was pretty impressive, the findings in this paper, which was not really necessarily expected, but was consistent with what had been identified in the adult literature. There's just not been a lot done in children in Massive Transfusion Protocol, but this is one paper that showed that, yes, we are doing the right thing. Most pediatric hospitals, big trauma centers, have just adopted the adult guidelines and just applied them. They haven't researched the question, they've just adopted those and applied them to their patients. TXA utilization in children, not done on a routine, has not really been studied in civilian pediatric population. I know it's been studied in adult population. It has been used some in pediatric population as part of a treatment for patients with congenital heart disease who undergo surgery and other, maybe spine surgeries and other major operations, but not in trauma patients. This is the biggest and probably the best paper that there is out there, but this was in a casualty zone, Camp Bastion in Afghanistan, and I believe they studied 700 and almost 800 pediatric patients that were casualties in war, and they applied TXA to these patients within three hours of the injury, and what they found was that the patients had a higher survival rate, and when they went home, they had a better GCS at the time of discharge. They did not find that they had any worsening thromboembolic events with utilization of this technique, but again, this has not been applied. I'm sure there's some pediatric centers that are using this, but it's not been studied in pediatric trauma, so I'm not suggesting this would be something that you do. Disability, so we're going to skip through, we're kind of going through this as you would make decisions seeing a child in your emergency department. Really is not the time to try to calculate a GCS, which pediatric GCS, you almost have to pull a book out to calculate it, because it's different based on age, but you just want to see at this point, what's their level of consciousness, what's their pupillary response, and just basically how they're doing neurologically, generally speaking. Keep in mind that, as I mentioned earlier, secondary head injury is estimated to cause 50% of deaths, and since it's the number one cause of killer in kids from trauma, it's particularly, you have to pay particular attention to it. One of our big concerns for children in talking about hypotensive resuscitation has been unintentionally causing secondary neurologic injury, and having said that, we as trauma surgeons, pediatric trauma surgeons, will do hypotensive resuscitation on patients that we know have massive abdominal hemorrhage, grade 4 or 5 livers or spleens, or have penetrating injuries. If we can get their blood pressure semi-stabilized, and they do not appear to have a neurologic injury, either based on their exam or the exam plus CT scan, we will kind of slow down the resuscitation, and it is a fight between me and the emergency department on this issue. We'll slow down the resuscitation and say, look, let's just get them stabilized, we'll get them in the operating room, we don't have to keep slamming them with 20 per kilo of saline, or even blood products at this point. The blood pressure's OK. They're doing all right. We'll get in the operating room and we'll complete the laparotomy and stop the hemorrhage at that point. You just have to be careful because you can't apply that to every patient. Most of our patients are blunt. Oftentimes, they have head injuries. And if you apply that to every patient in pediatrics, you have a lot more secondary head injury. Cerebral perfusion pressure in children is no different. We want to keep it as high as possible. So keeping the blood pressure as high as possible is obviously the goal. Exposure in kids is critical because kids don't have as much fat. They don't have the ability to maintain normally. They don't have as much fat. They don't have the ability to maintain their temperature as well. And mass body index is different than in adults. So we tend to lose temperature really quickly. So remove all the clothing, but also maintain their temperature as much as possible. We'll use bear huggers, heated fluids, turn the temperature really high in our trauma resuscitation room as well. Initial x-rays in kids seem pretty much similar in adults. Lateral c-spine chest x-ray is mandatory. Pelvic x-ray is only done if we have a hemodynamically unstable patient, we're worried about a massive pelvic fracture, or if there's a clear indication of a pelvic fracture, hematoma over that area, or a short left lower extremity or right lower extremity. One good thing about lateral c-spine film, we will resuscitate a kid until everybody's exhausted from CPR sometimes, and a lateral c-spine film oftentimes will show us they have a lateral occipital dislocation, and that's the reason they've been getting CPR for 20 minutes before they got here. They're not going to survive. So it does inform your resuscitation in children as much as anything else. It reforms your resuscitation. If you see that injury right there, and you've been doing CPR for 15 minutes, there's not really a lot you can do about it. I'm sorry, my chest x-ray shrunk down to really small, but you can probably still see the pneumothorax there on the left. 40% of the blood volume can hide in the chest, so it's an important part of our resuscitative effort to evaluate where the blood's going. Also, attention pneumothorax, obviously, can be missed on exam, although it shouldn't be. Pelvic x-ray is only really done, as I mentioned, when you think there's a severe pelvic fracture. You can hide all of your blood volume in the pelvis, and in this x-ray, this is a child who had a severe pelvic fracture and also had a cystogram done. This study just showed the compression by the hematoma bilaterally, and also there's extravasation of the chondrus, as you can see there. So I use pelvic x-rays not routinely, but specifically on specific patients. Labs are similar. In children, we always get type and cross. If we have ALT or AST elevation of above 125 to 200, those patients are going to get a CT scan of the adenine. If they have more than 50 cc's of red cells in their urine or gross blood, they're going to get a CT of the adenine or G.U. injury as well. And PT-PTT is becoming increasingly important. In fact, there's been some very good papers by Barb Gaines out of Pittsburgh looking at the issues with PT-PTT and the actual indication that that may be more important in predicting mortality in children than adults. So we always get that, and head injury being so severe in our patients and so common, we want to address that as soon as we possibly can. Second day of survey, just keep in mind, up to 10% of injuries in children are not picked up until after the initial assessment. They're usually picked up in the next 24 hours for evaluation. This is why we oftentimes will keep a child overnight, even though they may not have a high injury severity score. This is one of the reasons we do that. But basically, you do a head-to-toe evaluation of these patients. Always remember to look for a battle sign or sign of basic skull fracture. If you do have one, we would recommend screening for a BCVI. They do happen in children, and some studies have suggested it's pretty consistent with what you've seen in adults, although the literature is not finalized on that. Keep in mind that children often have spinal cord injuries without evidence seen on a radiology exam, and obviously getting a C-spine film is difficult in a kid, depending on the age, especially if you're not used to doing that at your center. We want to see four things clear of C-spine, and those four are listed there. Chest evaluation, obviously evaluating the chest is important, but always roll the patient over and look at the back. I'll mention a little bit later about lap belt injuries, but spine injuries are probably the most common things that are kind of missed or not seen, picked up on initial evaluation. And again, on the abdominal exam, you can occasionally determine, especially when it's massive, interabdominal solid organ injury. Holoviscus injury, unfortunately, is often missed initially on physical exam, and it's often not picked up on CT scan. So this is like a blunt trauma algorithm that we use. If a child is awake and alert, they're non-tender, we'll check labs. If their labs are not abnormal, they will not get a CT scan. We do not do PANS scans in children, and scanning in general in children is becoming less and less in favor. Unfortunately, we haven't found a better way to evaluate their abdomen, but we're working on it. If they are tender, they should get a CT scan, and if they're not awake and alert and have distracting injuries, they should get a CT scan as well. We don't CT scan the chest of a patient unless we have an indication of injury. So in a child, typically we're going to do CT head and abdomen and skip the chest altogether. Rectal exam is, or excuse me, perineal exam, the rectal exam is oftentimes inadequately used. I'm really going to use that to see if the patient had a spinal cord injury. Never put a Foley in if you see blood at the meatus. Keep in mind if you see extremity fractures in kids, you can have three to four units per extremity per fracture. So that's a source of blood loss. As far as head injuries are concerned in children, we tend to be less liberal in kids with CT scans of the head or CT scans of anything, but particularly CT scans of the head as well as CT scan of the abdomen. If we have a patient that's less than eight GCS, we're going to intubate them and then get a CT scan. If they have a nine to 13, they're going to get a CT scan of their head and then we're going to consult neurosurgery. If they're above a 13, unless they have some of those things you see in the far left-hand screen, they're not going to get a CT scan initially. We're going to evaluate them in the emergency department normally and then with serial exams and determine whether or not a CT scan needs to be done later. As far as FAST exam, three papers I'm going to mention here on FAST because this is kind of what we use to make decisions about resuscitation, including quickly resuscitating the operating room. Holmes did a study years ago looking at FAST exam in pediatric patients and what he identified was 80% of the patients, only 80% of the patients were identified that had intra-abdominal injuries, however, the ultrasound was accurate when the patient was hypotensive. So a severe, massive abdominal bleed can be identified on ultrasound in FAST, but that was really the only place that this study found a utility for the FAST exam. Although that is what this paper found and it was some years ago we continue to do it, our emergency department colleagues enjoy doing the FAST exam, our residents like doing FAST exam, I enjoy doing FAST exam. So we continue to look at FAST exam for utility in pediatric patients. It seems to be that we're not going to find a new utility for it. Emergent laparotomy, dictating whether emergent laparotomy should be done or not is really the only thing that we found to date and that was all that was found in that study. More recently, a couple of studies that were done, one by Chris Strick and his group out of Charleston, looked at the implication of a positive FAST, just all FAST exams, it's a multi-center study as you see many centers represented there across the country, the prospective study. They did FAST exam on all their patients and unfortunately what they found was that the FAST exam didn't help. Even centers that use FAST exam much more frequently, they were often not able to determine whether the patient had an injury and even determine whether the patient had an injury that needed intervention. So it was even less positive than the home study. What about negative FAST exam? Does that tell you anything? Well, the Atomic group looked at that in their solid organ injury study information. What they found was that a negative FAST exam actually does help and will predict that a patient will not fail a solid organ injury protocol, in particular this solid organ injury protocol which was developed through this multi-center study. So a negative FAST exam predicts lack of failure of solid organ injury management. A positive FAST exam really doesn't, really may not help you and may not pick up on when you need to intervene. Really quickly, non-accidental trauma, just because this is such a difficult thing to do and children to manage and you don't see it very often. This is our treatment algorithm for non-accidental trauma. Some of the red flags that you need to look for on history are an unwitnessed injury, a delay in seeking care, different stories from different caregivers, children that are premature, low birth weight or have chronic illnesses, oftentimes are at higher risk for non-accidental trauma. Some of the physical findings, bruising on a non-ambulatory child, it makes perfect sense now that you think about it, but oftentimes when you see a bruise on a child and you don't consider the fact that they're not even walking, how could they have fallen, they often roll off the couch. The story often says they rolled off the couch, rolled off the bed, unfortunately, for these patients. This happens way too often and it's really probably the thing that bothers me the most in what I do as a pediatric trauma surgeon. Lastly, on the bottom right, red flag radiologic findings, metaphyseal fractures, rib fractures, particularly posterior rib fractures, healing undisclosed fractures or a subdural or subarachnoid hemorrhage in a child less than one. In the case of suspected non-accidental trauma, we consult our social workers, we also consult what we call a CARES team, which is our non-accidental trauma evaluation team. They'll come and see the patient. They'll make recommendations. They'll actually go to the home. We'll keep the patient in the emergency department, send them home, send the social worker home, they'll check the home site to see if it matches up with the story. The worst thing that could ever happen to you, and it's happened to me, is when you have a child that goes home from a broken arm and they come back three months later beat to death. It's just, you don't want to have that happen. We can't stop them all, but we do the best we can. Real quickly, I'm going to go through lap belt complex and then that'll wrap up my talk. Lap belt injuries are pretty common in kids, most common in less than 10-year-old children. It's due to lack of proper restraint utilization. Either they're taking the shoulder strap off, they're not properly belted, or they're belted without a booster seat. Really a booster seat should be applied up to at least the age of eight, and the force that's applied from a 30-mile-an-hour accident is 1,200 pounds of force to a 40-pound child. The pathophysiology of a lap belt injury is a crush and a hyperflexion extension type of injury, so they have injuries to the solid organs of the abdomen, injury to the diaphragm, the bladder, and some major vessels as well. Unfortunately, bladder, small bowel, and colon injuries can be missed on just routine CT scan with IV contrast. This is just a cartoon of what typically happens in these patients. They crush their liver. They crush their spleen. They have missed fractures of the spine, which are extremely unstable spine injuries. They can come in completely neurologically intact, and so you want to really be careful of these, and I talk about this to all our emergency rooms that send us patients. If you have a patient that's less than 10 years old and they come in with a lap belt mark, even if they're older than that, but in particular in the young ones, because the lap belt mark usually slides right over the top of the pelvis, they can oftentimes have a missed chance fracture, and we see them sent in to us routinely where they're sent in for a, they've got a grade two liver injury, and when we get them, we evaluate them, and they say they've got a spine fracture. Most of the time, they don't progress their neurologic injury, but they could. So in these patients, you always want to look for a lateral C-spine injury because they get hyperflexion of their neck. This is a patient that had a very unstable fracture of C1, 2, and 3. This is an example of a chance fracture. Not very impressive, but if you drew a line across the anterior vertebral bodies there, you'll see one of those vertebral bodies has fallen back a little bit from the others. CT scans can miss these. They're much better now, the CT reconstruction. The key thing about this is if you think, and I mentioned to you earlier in children, we don't typically get CT of the chest. Someone comes in from a motor vehicle accident who would normally at an adult center get a CT head, chest, and abdomen. We'll only do the chest if we have x-ray findings of injury or we have suspicious injury of their chest. But in this case, it would be worth it because if you think they have a chance fracture from a lat belt injury and you do a CT of the chest, you can actually reconstruct the chest and abdomen and they can oftentimes find multiple injuries at multiple levels. This is a CT scan just demonstrating that you really can't see an injury. You can see free fluid around Morrison's pouch. This patient had a small bowel injury, had a lat belt mark. What we do on these patients is once the CT scan is done, we do serial exams. If they're tender at that time, they go to the operating room. If they're not tender at that time, we admit them to the hospital. We do serial exams. When they become tender, they go to the operating room. This is an example of what that looks like. Oftentimes, it's down around the terminal ilium. Sometimes, it could be a torn mesentery in the mid to genome. Sometimes, it could be colon injuries. Unfortunately, sometimes, the injuries can be instead of a hollow viscous injury, it can be an aortic injury. We've had aortic aneurysms, pseudoaneurysms develop. We've had transections of iliac artery and veins develop as well from these injuries. That's all I've got. I'm sorry there's not more literature on fluid resuscitation in children, but I'd be happy to answer any questions at the end of the session. Thank you.

pediatric resuscitation

emergency department

ABCs of trauma resuscitation

head injuries in children

C-spine stability

fluid resuscitation in children