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C L I N I C A L
Pediatric Emergency Medicine Editor Steven E. Krug, MD, FAAP
Feinberg School of Medicine, Northwestern University, Children’s Memorial Hospital, Chicago, IL
Voll 11, No 1 Vo
March 2010
Advances In Pediatric Trauma Harold K. Simon, MD, MBA Guest Editor
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GUEST EDITOR’S PREFACE Pediatric iatric Trauma: Trauma: A Roadmap for Evidence-Based, Evidence-Based, Patie Patient-Cente nt-Centered red Coordination Coordination and Care . . . . . . . . . . . Ped Harold K. Simon
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Opportunity: Early Management of Pediatric Pediatric Trauma Trauma . . . . . . . . . . Golden Hour or Golden Opportunity: Wendalyn K. Little
C L I N I C A L
Pediatric Emergency Medicine Editor Steven E. Krug, MD, FAAP
Feinberg School of Medicine, Northwestern University, Children’s Memorial Hospital, Chicago, IL
Voll 11, No 1 Vo
March 2010
Advances In Pediatric Trauma Harold K. Simon, MD, MBA Guest Editor
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GUEST EDITOR’S PREFACE Pediatric iatric Trauma: Trauma: A Roadmap for Evidence-Based, Evidence-Based, Patie Patient-Cente nt-Centered red Coordination Coordination and Care . . . . . . . . . . . Ped Harold K. Simon
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Opportunity: Early Management of Pediatric Pediatric Trauma Trauma . . . . . . . . . . Golden Hour or Golden Opportunity: Wendalyn K. Little
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. . . . . . . . . Prehospital Management of Pediatric Trauma Trauma Manish I. Shah
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. . . . . . . . . Do Routine Laboratory Test Testss Add to the Care of the Pediatric Trauma Patient? Jeffrey F. Linzer Sr
22 . . . . . . . . . Radiographic Evaluation of the Pediatric Trauma Patient and the Risk for Ionization Radiation Exposure Ricardo R. Jiménez
28 . . . . . . . . . Analgesia for the Pediatric Pediatric Trauma Trauma Patient: Primum Non Nocere? Michael Greenwald
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. . . . . . . . . When There Are no Inpatient Inpatient Beds: Pediatric Intensive Intensive Care Level Management Management of Traumaa Patients in the Emergency Department Traum Toni Petrillo-Albarano and Wendalyn K. Little
48 . . . . . . . . . Pediatric Patients in the Adult Trauma Bay—Comfort Bay—Comfort Level and Challenges Kimberly P. Stone and George A. Woodward
Consequences of Trauma Trauma:: The Unseen Scars Scars 57 . . . . . . . . . Mental Health Consequences Michael Finn Ziegler W.B. Saunders
www.clinpedemergencymed.org
GUEST EDITOR'S PREFACE
Pediatric Trauma: A Roadmap for EvidenceBased, Patient-Centered Coordination and Care By Harold K. Simon, MD, MBA
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or children younger than 14 years, there has been be en a dr dram amat atic ic an and d st stea eady dy de decli cline ne ov over er the pa past st 2 dec decade adess in inju injuryry-rel related ated mor mortali tality ty fro from m 942 9427 7 deaths in 1986 (age-adjusted rate of 18.04/100 000) to 65 6530 30 in 20 2006 06 (a (age ge-a -adj djus uste ted d ra rate te of 10 10.5 .59/ 9/ 1 100 000). Many factors contribute to this improvement including injury prevention strategies as well as tr treat eatmen mentt and aft afterc ercar are e of tra trauma uma pat patien ients. ts. Altho Although ugh tre tremen mendous dous str stride idess hav have e bee been n mad made, e, injury inj ury rem remain ainss a lead leading ing cau cause se of mor morbid bidity ity and morta mor tali lity ty in th the e Un Unit ited ed St Stat ates es an and d is es espe peci cial ally ly concerning within the pediatric population where trauma can rob years of happiness and productivity. This issue of Clinical Pediatric Emergency Medicine focu fo cuses ses on th the e co comp mplet lete e sp spect ectru rum m of pe pedi diat atri ric c trau tr auma ma ca care re,, be begi ginni nning ng wi with th th the e in init itia iall golden hour, em emer erge genc ncy y med medic ical al se serv rvic ices es ca care re at th the e scene, through critical care management. It incorporate por atess per perspe specti ctives ves fro from m ped pediat iatric ric eme emerge rgency ncy medicine medicin e physici physicians, ans, emerge emergency ncy medica medicall service servicess prov pr ovid ider ers, s, an and d cr crit itic ical al ca care re ph phys ysic icia ians. ns. It wi will ll address present state of care, improvement strategies, and potential areas that can help us not only decr de crea ease se mo mort rtal alit ity y bu butt do so in a co cost st-e -effe ffect ctiv ive e manne man nerr co cogn gniza izant nt of fa faci cilit lity y an and d ma manp npowe owerr re re-source limitations. Unlike many previous antholo“
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Depart Dep artmen ments ts of Pedi Pediatr atrics ics and Eme Emergen rgency cy Medi Medicin cine, e, Emo Emory ry University School of Medici University Medicine, ne, Child Children's ren's Healthcare Healthcare of Atlant Atlanta, a, Atlanta, GA.
gies on the subject, it will also take into perspective a more patient-centered approach to what can be done with new and emerging technologies, taking into account long-term implications when considering what interventions are most beneficial to the patient in the immediate care situation. It will look at qu ques esti tion onss su such ch as th the e ri risk sk vs be bene nefi fits ts of computed tomographic scanning in light of radiation exposure. exposure. This issue will address topics such as coordination of care between subspecialties, transitions of care, and care of pediatric trauma patients in adult-based centers. It will, however, go beyond the traditional bounds and will touch on the more holistic approach to care that can and should be part of our broader perspective on pediatric trauma managem mana gement. ent. This will inc include lude sections sections on pai pain n contro con troll as well as pos posttra ttrauma umatic tic str stress ess dis disord order er recognition recogn ition and preve prevention. ntion. Trauma care has emerged from its infancy in the latter part of the 21st century as a focus of modern medicine. medici ne. Militar Military y experi experiences ences have helped push the envelope of trauma care and continues to help us mold our our perspectives, p erspectives, knowledge, and treatment 2,3 of trauma. Trauma centers have been proven to have ha ve a po posit sitiv ive e im impa pact ct on pa pati tien entt ma man nagement, ultimately ultimat ely leading to decre decreased ased mortality.4 Pediatric trauma care has, however, as is the case in most areas are as of ped pediat iatric ric med medici icine, ne, tak taken en a bac backse kseat at to much of the initia initiall focus that has been adult patient base ba sed. d. It wa wass not unt until il th the e de deve velo lopme pment nt of th the e
PEDIATRIC TRAUMA: A ROADMAP FOR COORDINATION AND CARE / SIMON • VOL. 11, NO. 1
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VOL. 11, NO. 1 • PEDIATRIC TRAUMA: A ROADMAP FOR COORDINATION AND CARE / SIMON
Emergency Medical Services for Children program in 19 1984 84 an and d th the e In Inst stit itute ute of Me Medi dici cine ne re repo port rt on Emergen Emer gency cy Med Medica icall Ser Service vicess for Chil Children dren tha that t pediatric trauma care began to se par parate ate itself out 5,6 as a functio functionally nally distinct discipline. Evidence has mounted over the years that regionalized liz ed cen cente ters rs wit with h ped pediat iatri ric c equ equip ipmen ment, t, pe perso rsonne nnel, l, and exper exp ertis tise e hav have e con contri tribut buted ed to the ove overall rall improvement in pedi pediatri atric c traum trauma a manag management ement..7-9 In addit addition, ion, coordina coor dinated ted afte aftercar rcare e in cent centers ers with pedi pediatri atric c surgeons geo ns and ped pediat iatri ric c cri critic tical al car care e phy physic sician ianss has improve imp roved d out outcome comes. s. Dif Differ ferenc ences es in ope operat rative ive vs support supp ortive ive tre treatm atment ent of the ped pediat iatric ric pat patien ientt as compared with the adult trauma patient, especially for blunt abdominal trauma, and comfort levels and expertise wit h t he he pediatric patient may contribute to these effects.10 Consensus opinion and present standards dar ds for fie field ld tr triag iage e of ped pediat iatric ric tra trauma uma pat patien ients ts suppor sup portt the thedir direc ectio tion n of tho those se chi childr ldren en mee meetin tingg t rauma rauma 11 criteria to a pediatric capable trauma center. Man Many y co comm mmun unit itie iess do no nott ha have ve th the e vo volu lume me of patients or resources required to support designated pediatric trauma centers. Facilities within communitiess tha tie thatt do ha have ve thi thiss vol volume ume ar are e oft often en str stret etche ched d beyond their functional capacity given the prevalence of eme emerge rgency ncy de depar partme tment nt ove overc rcrow rowdi ding ng an and d the use of emergency departments as the safety net for medical care for many unde underser rserved ved popu populati lations. ons.12,13 These factors, along with the shear cost of keeping trauma centers available 24/7 in communities that may not have ha ve th the e re requ quir ired ed re resou sourc rces es,, ma make ke it ev even en mo more re impor imp ortan tantt to dev develo elop p tr traum auma a cen center terss wit within hin wel welllcoordinated regional systems to best transport, stabilize, and defi definiti nitively vely care for crit critica ically lly inju injured red chil chil-dren.11,14 Howev However, er, toda today, y, fewe fewerr than 200 ped pediatr iatric ic trauma centers exist in the United States; and more than 28% of children younger than 15 years are more than 1 hour from such centers by ground or by air transport. This disparity is even greater in rural areas, wher wh ere e 77% of ch chil ildr dren en ar are e mo more re th than an 1 ho hour ur fr from om su such ch 15 centers. Giv Given en the crit critical icalimpo importan rtance ce of stab stabiliz ilizatio ation n within the golden opportunity for care, we have a long lo ng wa way y to go in co coor ordi dina nati ting ng su such ch ca care re an and d es esta tabl blis ishhing centers capable of providing optimal management to this vulnerable population. This points to a need to expand expa nd acc access ess to ped pediatr iatric ic trau trauma ma care for gre greater ater number num berss of chi childr ldren en and to con contin tinue ue to gr grow ow and enhanc enh ance e the net networ works ks ava availa ilable ble.. Th Those ose cen center terss th that at do exist exi st nee need d to ful fully ly co coord ordina inate te ca care re ove overr lar large ge ca catch tchmen ment t areas with the necessary support systems and transfer protocols to best serve the children throughout their regions. These items will be among those addressed in this th is se seri ries es of ar arti ticl cles es an and d ar are e so some me of th the e mo most st challe cha lleng nging ing iss issues ues fac faced ed as we see seek k to con contin tinue ue to expand and enhance pediatric trauma networks. “
Even when we are fortunate enough to have an abundance of resources or tertiary care pediatric faci fa cili liti ties es in a re regi gion on,, we mus mustt al also so de dete term rmineif ineif we ar are e using our resources appropriately and, in doing so, delivering deliveri ng evidence evidence-based, -based, highest-q highest-quality uality care. Technology simply for technology's sake may not alway al wayss le lead ad to th the e be best st out outco comes mes.. We mus mustt th ther eref efore ore critically evaluate the sensitivities and specificities of such advancements as well as balanc balance e the longterm effects and costs (financial and even adverse medical) medica l) that can come from their usage. Examples such as focused assessment sonography in trauma examinations and their use in the pediatric population, screening laboratories, and radi radiologic ologic studies 16-20 must all be cri critic tically ally eva evaluat luated. ed. The prese present nt state of knowledge and risks vs benefits of each will be addressed. Lastly, patient- and family-centered care needs to be at th the e fo fore refr fron ontt of wh what at di dist st inguis in guishes hes the 21 manage man agemen mentt of ped pediat iatric ric tra trauma uma.. Having Hav ing the prop pr oper er eq equip uipme ment nt an and d pe pers rsonn onnel el fo forr th the e ba basic sic trau tr auma ma ne need edss of ch chil ildr dren en of al alll ag ages es re rema main inss essential. However, recognition of the need to treat both patients and their families can help bring a more holistic approach to meeting the needs of our most vulnerable patients and their families. Consideration eratio n of the entire child and his or her family, and not just the injury (eg, the fracture in room one ), remains a crucial part of the challenge set forth in pediatric trauma care. Health care providers tend to underrecognize, undertreat, and fail to prevent pain and an d an anxie xiety ty in ch chil ildr dren en,, an and d li limit mit theimpa theimpact ct of th these ese 21 stressors related to trauma. This issue will therefore also address pain management of the pediatric trauma patient, posttraumatic stress disorder recogniti ogn ition, on, and pre prevent vention ion str strate ategie gies. s. Alth Although ough we stil stilll have a long way to go to optimi optimize ze the care of injured children, childr en, this series should act as a roadma roadmap p for the broad bro ad ran range ge of car care e pro provid viders ers tre treati ating ng ped pediat iatric ric trauma patients. “
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REFERENCES National Cent National Center er for Inju Injury ry Prev Preventi ention on and Cont Control. rol. WISQA WISQARS RS Injury Mortality Reports, 1999 - 2006. Available at: http:// webapp.cdc.gov/sasweb/ncip webapp.cd c.gov/sasweb/ncipc/mortrate10_ c/mortrate10_sy.html sy.html.. Accessed 1/15/10. 2. Mullins RJ. A historical perspective of trauma system development in the United States. J Trauma 1999;47(Suppl 3): S8-S14. 3. Ber Berger ger E. Le Lesson ssonss fro from m Afg Afgha hanis nistan tan an and d Ira Iraq: q: the cos costly tly benefits bene fits from the battle battlefield field for emer emergenc gency y medi medicine cine.. Ann Emerg Med 2007;49:486-8. MacKenzi enzie e EJ, Rivara FP, Jurk Jurkovic ovich h GJ, et al. A nati national onal 4. MacK evaluation of the effect of trauma center care on mortality. N Engl J Med 2006;354:366-78. 1.
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The Preventive Health Amendments of 1984, Pub. L. 98-555 § 7, 98 Stat. 2854, 2856 (1984) (codified as amended at 42 U. S.C. § 300w-9). Institute tute of Medic Medicine ine Comm Committe ittee e on Pedi Pediatri atric c Emer Emergenc gency y 6. Insti Medical Services. In: Durch JS, Lohr KN, editors. Emergency medical medi cal servi services ces for child children. ren. Wash Washingt ington, on, DC: Natio National nal Academy Press; 1993. 7. Ha Hall ll JR JR,, Re Reye yess HM HM,, Me Melle llerr JT JT,, etal. Ou Outc tcom ome e fo forr bl blun untt tr trau aumais mais best at a pediatric trauma center. J Pediatr Surg 1996;31:72-7. Potoka oka DA, Sc Schal halll LC, For Ford d HR. Imp Improv roved ed fun functi ctiona onall 8. Pot outcome for severely injured children treated at pediatric trauma centers. J Trauma 2001;51:824-34. 9. Bensard DD, McIntyre RC, Moore EE, et al. A critical analysis of acu acutel tely y inj injure ured d ch child ildrenmana renmanagedin gedin an ad adult ult lev level el I tra trauma uma center. J Pediatr Surg 1994;29:11-8. Farrell ell LS, Hann Hannan an EL, Coop Cooper er A. Seve Severity rity of inju injury ry and 10. Farr mortality associated with pediatric blunt injuries: hospitals with pedi pediatric atric inte intensiv nsive e care unit unitss vs. other other hospi hospitals. tals. Pedi Pediatr atr Crit Care Med 2004;5:5-9. 11. Centers for Disease Control and Prevention. Guidelines for field triage of inju injured red patients: patients: reco recommen mmendati dations ons of the national expert panel on field triage. MMWR 2009;58:RR-1. 12. O Conn Connor or RE. Spec Specialty ialty coverage coverage at nonnon-tert tertiary iary care centers. Prehosp Emerg Care 2006;10:343-6. 13. Mil Millin lin MG, He Hedge dgess JR JR,, Bas Basss RR. The eff effect ect of am ambul bulan ance ce diversions on the development of trauma systems. Prehosp Emerg Care 2006;10:351-4. 5.
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Taheri PA, Butz DA, Lottenberg L, et al. The cost of trauma center readiness. Am J Surg 2004;187:7-13. Nance ML, Carr BG, Branas CC. Access to pediatric trauma care in the United States. Arch Pediatr Adolesc Med 2009; 163:512-8. Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonograp ultrasonography hy in pedi pediatri atric c blunt trauma patients: patients: a meta-analysis. J Pediatr Surg 2007;42:1588-94. Holmes JF, Mao A, Awasthi S, et al. Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Ann Emerg Med 2009;54: 528-33. Blackwell CD, Gorelick M, Holmes JF, et al. Pediatric head trauma: changed tomography in emergency departments in the Uni United ted Sta States tes ove overr tim time. e. Ann Emerg Med 200 2007;4 7;49: 9: 320-4. Brenner DJ, Hall EJ. Computed tomography - an increasing source sourc e of radi radiatio ation n expos exposure. ure. New Engl J Med 2007;357: 2007;357: 2277-84. Jimenez RR, DeGuzman MA, Shiran S, et al. CT versus plain radiog rad iograp raphs hs for eva evalua luatio tion n of c-s c-spin pine e inj injury ury in you young ng children: do benefits outweigh risks? Pediatr Radiol 2008; 38:635-44. Ziegler M, Grenwald MH, DeGuzman DeGuzman MA, et al. Posttraumatic Posttraumatic stresss respo stres responses nses in children: children: awar awarenes enesss and practice practice amon amongg a sample samp le of pedi pediatri atric c emer emergenc gency y care prov provider iders. s. Pedi Pediatri atrics cs 2005;115:1261-7.
Abstract: The concept of a golden hour is a fixture in trauma care. There is a dearth of scientific proof for this concept but an abundance of controversy around how this concept should be inter interpreted, preted, especially especially for pediatric trauma patients. Health care providers should instead focus on the golden opportunity, different for each patient, to provide the best care in the most appropriate environment environ ment for all injured childr children. en. “
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Keywords: pediatric pediatric trauma; golden hour; pediatric emergency; trauma systems; interfacility transport
Golden Hour or Golden Opportunity: Early Management of Pediatric Trauma Wendalyn K. Little, MD, MPH
There is a golden hour between life and There
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death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be Pediatrics and Emergency Medicine, Division of Pediatri Pediatric c Emergency Emergency Medicine, Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA.
Reprint requests and correspondence: Wendalyn Little, MD, MPH, Pediatric Emergency gen cy Medi Medicine cine,, 164 1645 5 Tul Tullie lie Circl Circle, e, Atlan Atlanta, ta, GA 30329.
[email protected]
three days or two weeks later — b —but ut some- thing has happened in your body that is irreparable.” R Adams Cowley MD 1
1522-8401/$ - see front matter © 2010 Elsevier Elsevier Inc. All rights reserved.
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VOL. 11, NO. 1 • GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE
GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE • VOL. 11, NO. 1
THE GOLDEN HOUR The term golden hour is a fixture in the lexicon of trauma care. The phrase refers to a critical period in th the e ca care re of tr trau auma ma pa pati tien ents ts du duri ring ng wh whic ich h appropriate care may limit morbidity and increase survival. The origin of this term is difficult to trace. It may have evolved from an early description of the relationship between survival and time from injury to tr trea eatme tment nt on th the e ba batt ttlef lefie ields lds of Wo Worl rld d Wa Warr I. This Th is an anal alysi ysiss of Fr Fren ench ch mil milit itary ary da data ta sh showe owed d a decrease in mortality from battle wounds from 10% within 1 hour of treatment to 75% at 8 hours postinjury.2 More More rec recent ent medi medical cal lite literat rature ure oft often en attribut attr ibutes es the phra phrase se “gold golden en hour” to tra trauma uma surge sur geon on R. Ad Adams ams Cowley Cowley,, MD MD,, one of th the e ea earl rly y champio cha mpions ns of org organiz anized ed tra trauma uma car care. e. Dr Cow Cowley ley conduct cond ucted ed tra trauma uma res resear earch ch and wrot wrote e and spo spoke ke extensively on the subject of trauma care, and the coining of the term golden hour is often attri attributed buted to his speeches, yet none of his publications mentions or test test s th the e th theo eory ry of a go gold lden en ho hour ur in tr trau auma ma 2,3 care. Modern support for the golden hour concept began in the 1960s when trauma care in the United Stat St ates es wa wass in it itss in infa fanc ncy y an and d ci civi vili lian an tr trau auma ma systems were nonexistent. Military data from each of the world wars, the Korean Conflict and the war in Vietnam, show decreased combat mortality with the development of faster, more organized systems forr th fo the e tr tran ansp spor ortt of in injur jured ed tr troo oop p s fr from om th the e 3,4 battle bat tlefie field ld to med medica icall car care e fac facili ilitie ties. s. This Th is in in-crease cre ased d surv surviva ivall was att attrib ribute uted d in par partt to fas faster ter evacuation of wounded soldiers from the battl efield to the hospital by way of helicopter transport. 4 The 1960 19 60ss an and d 19 1970 70ss sa saw w an in incr crea eased sed in inte tere rest st in civilia civ ilian n tra trauma uma car care. e. Fed Federa erall leg legisla islation tion led the way for funding emergency medical services (EMS) standar sta ndards ds and tra traini ining. ng. The Ame Americ rican an Col Colleg lege e of Surgeons published t he first of many guidelines for trauma care in 1976. 4 Pioneers such as Dr Cowley championed champio ned trauma care as a sp spec ecia ialty lty with its roots roo ts in gen genera erall sur surger gery. y.5 Helico Helicopter pter trans transport port bega be gan n to be se seen en as a me mean anss of qu quic ickly kly moving moving injured patients to hospitals; some hospitals began to devote specialized resources and teams to care for trauma victims, and the concept of regionalized trauma tra uma syst systems ems gai gained ned supp suppor ortt f rom rom hea health lth car care e 4,6 providers provid ers and gover governing ning bodies.
TRAUMA SYSTEMS AND TRANSPORT TO TRAUMA CENTERS Early st Early studi udies es of tr trau auma ma pa patie tient ntss ap appe pear ared ed to show inc increa reased sed sur surviv vival al with the dev develo elopme pment nt of these early trauma systems and continue to show
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improved improv ed outc outcomes omes for sev severe erely ly inj injure ured d patients 7,8 cared car ed for in ded dedica icated ted tra trauma uma cen center ters. s. A cor core e principal in many of these systems is the belief that crit cr itic ical ally ly in injur jured ed pa pati tien ents ts ar are e be best st ca care red d fo forr in designated trauma centers, even if transport from the field to these centers bypasses closer medical facilities. The combination of the concepts of the golden hour and the importance of trauma centers has been the impetus for the development of EMS policies such as rapid scene triage, minimization of on-scene treatment interventions in favor of rapid transport to emergency departments, and air evacuation cuatio n of severely injured patients directly from the sit site e of in injur jury y to de desig signa nate ted d tr trau auma ma ce cent nter ers. s. These practices are not without cost, in money for equipment and staffing of helicopter transport and EMS resources. They are also not without risk to EMS teams, patients, and bystanders when priority is pl plac aced ed on ra rap pid tra transpo nsport, rt, some sometime timess acr across oss 9 greatt dista grea distances. nces. A co commo mmon n de deba bate te in tr trau auma ma system syst em dev develo elopmen pmentt cen center terss on whet whether her pat patien ients ts should shou ld be tra transfe nsferre rred d long longer er dist distanc ances es to tra trauma uma center cen terss or to the closest available available fac facilit ility, y, wher where e initial init ial sta stabili bilizat zation ion may be per perform formed, ed, and the then n those patients determined determined to need furthe furtherr specia specialty lty care are then transferred to a trauma center. Much of the current literature supports a varied approach based on geographic location. In urban areas, where level I trauma centers are often readily available, it may ma make ke se sense nse to by bypa pass ss cl close oserr fa faci cilit litie iess to reach the trauma facility, as differences in transport timess are likel time likely y to be minor. minor. In rur rural al areas, areas, how howeve ever, r, tran tr ansp spor ortt ti time mess to tr trau auma ma ce cent nters ers ma may y be pr proolonged, long ed, and pat patien ients ts may ben benefit efit from sta stabili bilizazation ti on in a cl clos oser er fa facil cilit ity y fol follow lowed ed by tr tran ansfe sferr to a trauma center after initia initiall stabil stabilization ization.. Effecti Effective ve trauma systems must therefore take into account the location and capabilities of the facilities within a geographic catchment area, as well as any traffic or geogra geo graphi phical cal feat feature uress tha thatt may imp impact act tra transpo nsport rt times. tim es. Thi Thiss app approa roach ch to est establ ablish ishing ing eff effect ective ive trauma tra uma syst systems ems is per perhap hapss bes bestt cha charac racter terize ized d by the “3R ” rul rule e att attrib ribute uted d to pio pionee neerin ringg tra trauma uma surgeon surg eon Dr Don Donald ald Tru Trunkey nkey of get gettin tingg th the e “right patient to the right place at the right time. ”10 Some patients may have only minutes to survive without appropriate approp riate intervention, intervention, whereas some may survive vi ve the their ir in initi itial al inj injur uries ies but ne need ed sp spec ecia ializ lized ed care and rehabilitation to achieve maximum postinjur inj ury y fun funct ctio ion. n. Th This is co conc ncep eptt mig might ht we well ll be th the e best guiding principle of trauma management, and the im immed media iate te po posti stinju njury ry pe perio riod d mig might ht be best st be thou th ough ghtt of as a “golden opport opportunity unity” to ensu ensure re prompt, appropriate treatment for each and every injured patient.
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VOL. 11, NO. 1 • GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE
PEDIATRIC TRAUMA AND TRAUMA CENTERS If th the e co conc ncep eptt of a go gold lden en ho hour ur an and d it itss re rela lati tion onsh ship ip to trauma systems is controversial and unproven in adult ad ults, s, it is ev even en mor more e so fo forr pe pedi diat atri ric c tr trau auma ma patients. The development of pediatric emergency medic med icine ine as a sp spec ecia ialty lty ha hass pr promo omote ted d th the e cr crea eati tion on of pedi pe diat atri ric c tr trau auma ma ce cent nter ers, s, so some me as pa part rt of fr free ee-standi sta nding ng chi childr ldren' en'ss hos hospit pitals als and oth others ers wit within hin general/adult facilities. Pediatric trauma care continues to evolve as a distinct facet of trauma care that recognizes the differ different ent anatomi anatomical, cal, physiol physiologogic, and developmental developmental reali realities ties of pedia pediatric tric patients as well as the different injury patterns seen in these patien pat ients. ts. The dev develop elopment ment and con concen centra tratio tion n of pediatric expertise has improved the management of in inju jure red d ch chil ildr dren en,, wi with th pa pati tien ents ts ca care red d fo forr in pediatric trauma centers appearing to have equal or be bett tter er out outco come mess ov over eral alll wh when en co comp mpar ared ed to pediatric pediat ric patie patien nts car ared ed fo forr in ge gene nera rall or ad adul ult t 11-17 trauma cente centers. rs. Many factors likely contribute to this positive effect including the availability of appropri appr opriatel ately y sized equi equipmen pmentt and monit monitorin oring g capabi cap abilit lities ies for pe pedia diatr tric ic pat patien ients, ts, hea health lth car care e provid pro viders ers cap capable able of rec recogni ognizin zingg and tre treati ating ng the early, ear ly, oft often en sub subtle tle,, sig signs ns of sho shock ck in pe pedia diatri tric c patien pat ients, ts, and man manage agemen mentt str strate ategie giess uni unique que to pediatric injuries. Despite evidence to suggest better outcomes for pediat ped iatric ric tra trauma uma victims victims tre treated ated in ped pediat iatric ric tra trauma uma center cen ters, s, most ped pediat iatric ric tra trauma uma vic victim timss are car cared ed for, at least initially, in nonpediatric centers, as the number numb er and geo geogra graphi phic c loca location tion of ded dedica icated ted pediat ped iatric ric cen center terss lea leaves ves man many y ch chil ildr dren en ou outt of reach rea ch for imme immedia diate te car care. e.12,13 The que questi stion on tha that t therefore arises is not only does a golden hour exist for the treatment of pediatric trauma patients, but also, al so, wha whatt sho should uld oc occu curr du duri ring ng th that at in init itia iall ti time me frame. One aspect of this debate centers on whether pediat ped iatric ric tra trauma uma pat patient ientss shou should ld be tra transpo nsporte rted d direct dir ectly ly to ped pediat iatric ric cen center ters, s, pos possibl sibly y byp bypassi assing ng other oth er eme emerge rgency ncy fac facilit ilities ies or tra trauma uma cen center terss on the way to specialized pediatric care, or should they be stabilized at the closest capable capable facility and then transferred to specialized pediatric centers if their condition warrants. It is worrisome that pediatric patients may be subjected to longer transport times, possibly bypassing “adult ” trauma facilities to reach pediat ped iatric ric centers, centers, as EMS pro provid viders ers often do not have hav e gre great at fam familia iliarit rity y or exp experie erience nce wit with h cri critic tically ally ill or injured children. The EMS pedia pediatric tric volumes are often quoted as around 10% of EMS calls, with less than 1% of these patients meeting the definition of critically critic ally ill. The EMS personn personnel el may have difficulty difficulty
performing procedures such as intra performing intravenous venous access, endotr end otrach acheal eal int intuba ubation tion,, and app approp ropria riate te ca cardiordiopulmonary resuscitation on pediatric patients. 14,15 There is literature to suggest similar outcomes for pediat ped iatric ric pat patien ients ts ven ventil tilate ated d by mean meanss of bag baggin ging g inste in stead ad of en endo dotr trac achea heall in intu tuba bati tion on in ca case sess of respirat resp iratory ory fail failure, ure, sugg suggesti esting ng that intu intubati bation on should not be attempted in the field for pediatric patients in urban locations where transport times to hospita hosp itall emer emergen gency cy dep depart artment mentss is fai fairly rly sho short. rt.15 Anot Another her stu study dy exa examini mining ng the eff effect ective ivenes nesss of pediat ped iatric ric hel helico icopte pterr tra transp nsport ort show showed ed no ben benefit efit for patients transported directly from the scene of injury inju ry to a ped pediat iatric ric trauma center center as com compar pared ed with thos those e initially stabilized at the closest medical 17 facility. All All of th this is in info forma rmati tion on co could uld be in inte terrpreted that time spent in EMS transport of critically ill and injured children should be minimized, and these patients should be transported to the closest facility able to provide stabilizing, if not definitive, care.
EMERGENCY DEPARTMENT READINESS FOR CHILDREN If pediatric patients patients are to be transp transported orted to non – pediatric-specific hospitals, the emergency departments men ts at th these ese fa faci cilit litie iess mus mustt be ca capa pabl ble e of as asse sessi ssing ng pediatric trauma patients and providing stabilizing care (also see article “Pediatric Patients in the Adult Trauma Tra uma Bay—Comf Comfort ort Lev Level el and Cha Challen llenges ges,,” in this issue). Although most emergency department visits in the United States involving children occur in nonpediatric nonpediatric facilities, facilities, many of these facilities facilities are underprepared to deal with critically ill or injured chil ch ildr dren en.. In 20 2001 01,, th the e Ame Ameri rica can n Ac Acad adem emy y of Pediatrics and the American College of Emergency Physi Phy sici cian anss es esta tabl blish ished ed a set of gu guid idel elin ines es f or or pediatric pediat ric emerge emergency ncy depar department tment prepa preparedness. redness.18 These guidelines, which were recently updated in 2009, 20 09, ad addre dress ss equ equipm ipment ent,, tra traini ining, ng, and qua qualit lity y review for ped pediatr iatric ic car care e in emer emergen gency cy dep depart art-ments.19,21 Surveys evaluating preparedness preparedness continue to show inadequate preparat preparat ion ion in equipment 13,20,22 and training for pediatric patients. Nonpediatric tri c cen center terss oft often en tra transfe nsferr ser serious iously ly ill or inju injured red patients to pediatric centers for definitive care. The prese pr esenc nce e of a se seri rious ously ly in inju jure red d ch chil ild d ma may y en enge gend nder er a sense of anxiety in the emergency department and hass th ha the e po pote tent ntial ial to cr crea eate te a str stress ess-la -lade den n at atmomosphere in which recognition and treatment of lifethreatening shock and respiratory failure go unaddressed and untreated in attempts to get the patient outt of th ou the e fa faci cili lity ty an and d en enro rout ute e to a pe pedi diat atri ric c
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specialty specia lty cen center ter as qui quickl ckly y as pos possib sible. le. Mis Missed sed injuries on an initial trauma survey are a common proble pro blem, m, and there is some evidence evidence from adu adult lt studies that seriousl seriously y injure injured d patie patients nts transfe transferred rred from rural hospitals to trauma centers frequently have unrecognized injuries.23,24 This suggests that patients may have injuries overlooked in favor of rapid transport to a trauma center. This problem may be even more widespread for pediatric patients in simi similar lar situ situatio ations. ns. Rece Recent nt lit litera erature ture supp supports orts early ear ly re recog cogni nitio tion n an and d tr treat eatmen mentt of sho shock ck an and d respiratory failure as important in improving ultimate survival and outcome of critically critica lly ill ill or injured 25,26 patien pat ients, ts, bot both h adu adult lt and ped pediat iatric. ric. Similarly, neurolo neu rologic gic outcome outcome has bee been n show shown n to imp improv rove e with early appropriate resuscitation and monitoring of children with traumatic brain injury.27 Unfortunately, studies of pediatric patients transferred to pediatric centers describe deficiencies in the detection ti on an and d tr trea eatm tmen entt of sh shoc ock, k, hypote ypotensi nsion, on, an and d respiratory failure before transfer. 18,25,26
INITIAL STABILIZATION OF INJURED CHILDREN So what should be the scope of the evaluation and stabilization stabili zation of pedia pediatric tric trauma patien patients ts in genera generall trauma facilities or community hospitals? A primary sur surve vey y fo focu cusin singg on ai airw rway ay,, br brea eath thin ing, g, an and d circul cir culat ation ion sho should uld be und under erta take ken n and any lif lifeethreate thre atening ning cond conditi itions ons corr correct ected. ed. All pat patient ientss should sho uld be pla place ced d on sup suppl pleme ementa ntall oxy oxyge gen. n. Ad Ad-vanced airway management in the form of endotracheal che al int intuba ubation tion may be nee needed ded in pat patien ients ts with severe traumatic brain injury, thoracic injuries, or shock. shoc k. Ade Adequat quate e oxyg oxygena enatio tion n and ven ventila tilatio tion n shou should ld be ensured. A portab portable le chest radiograph radiograph to evalua evaluate te for pneumothorax may be helpful. Placement of a thora tho raco cost stomy omy tu tube be sh shoul ould d be pu pursu rsued ed fo forr mo most st ca cases ses of pneumothorax. Close attention should be paid to the child's hemodynamic status. Health care providers must keep in mind that the strong compensatory mechanisms in children and teenagers allow them to increase their systemic vascular resistance and an d ma main intai tain n blo blood od pr pre essur ssure e un unti till a sub subst stan anti tial al 19,28 amount of blood is lost. Early Ear ly sig signs ns of shoc shock k such as tac tachyca hycardi rdia, a, ment mental al sta status, tus, and cap capilla illary ry refi re fill ll ti time me ar are e mor more e sen sensit sitiv ive e an and d sho should uld be monitored closely. An initial fluid bolus of isotonic saline sal ine sho should uld be ad admin minist ister ered ed and re repea peate ted d as needed nee ded.. Bloo Blood d com compone ponent nt tra transfu nsfusion sion shou should ld be considered for patients not responding to crystalloid resuscitation or for those with evidence of ongoing hemorrhage.27 Pat Patien ients ts with imme immedia diatel tely y life life--
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threatening hemorrhage would seem to be candidates dat es for imme immedia diate te trans transfer fer to to a tra trauma uma center center wit with h pediat ped iatric ric sur surgeo geons ns and a ped pediat iatric ric int intensi ensive ve car care e unit un it bu butt at ti times mes may re requ quir ire e th the e se serv rvic ices es of a generall surgeon genera surgeon,, if availa available, ble, to control hemorrhage hemorrhage before transport. Most pediatric trauma is caused by blunt bl unt me mech chan anism ism of in inju jury ry su such ch as fa falls lls,, mot motor or vehicle vehicl e collisio collisions, ns, assault, and sporti sporting ng activ activities. ities. Most Most pat patien ients ts wil willl not req requir uire e eme emerge rgent nt surg surgica icall intervention. Pediatric trauma specialists have led the development of protoc protocols ols for expectant, nonoperativ era tive e mana managem gement ent of some con condit ditions ions,, nam namely ely liver and splenic injuries. In adult-oriented systems, these thes e injur injuries ies are gene generall rally y tre treated ated surg surgical ically, ly, whereas children cared for in pediatric centers are usually managed nonoperatively. Therefore, pediatric patients undergo fewer laparotomi laparo tomies es and sple29,30 nectomies than do adult patients. The golden hour for these patients might best be spent ensuring adequate oxygenation and ventilation, securing an airway air way if nee needed ded,, obt obtain aining ing vas vascula cularr acc access, ess, and provid pro viding ing ini initia tiall flu fluid id res resusci uscitat tation ion if nee needed ded.. Patien Pat ients ts wit with h tra trauma umatic tic bra brain in inj injury ury mus mustt be carefully monitored, and hypotension and hypoxia avoi av oide ded d as bo both th of th thes ese e st stat ates es ha have ve be been en fo foun und d to be indepe ind epende ndent nt pre predic dictor torss of inc increa reased sed mor mortal tality ity in patien pat ients ts with tra traumat umatic ic bra brain in inj injury ury.. Pedi Pediatr atric ic patien pat ients ts wit with h isol isolate ated d bra brain in inj injurie uriess may best be stabili sta bilized zed at the clos closest est med medica icall fac facili ility ty in whi which ch these conditions may be recognized and corrected as needed. Transport could then be undertaken in a controlled fashion and preferably with a specialized pediatric critical care transport team. Time should not be spent obtaining computerized tomography and other extensive imaging studies if the facility lacks the surgical capabilities to provide definitive care for injuries detected on imaging or if obtaining scans will delay transport. transport. Scans may inadvertently inadvertently fail to be transp transported orted with the patient or, in the case of di digit gital al ima images ges,, tra transf nsferr erred ed by com compac pactt dis disk, k, inaccessible at the receiving facility, thus, necessitatin ta tingg re repe peat at ima imagi ging ng wit with h in incr creas eased ed cos costs ts and unnecessary radiation exposure to the patient. In fact, fac t, one stu study dy foun found d tha thatt alm almost ost all rad radiogr iograph aphss performed at referring facilities were later rep r epeated eated 31 when patients arrived to the trauma center. Once critically ill or injured children are stabilize li zed d an and d th the e de deci cisi sion on is ma made de to tr tran ansf sfer er to a pediat ped iatric ric tra trauma uma cen center ter,, att attenti ention on must the then n be turned tur ned to the best mode of tra transfe nsfer. r. One recent recent study showed signif significantly icantly more complic complications ations and deaths dea ths (23 (23% % mor mortal tality ity vs 9% mor mortal tality ity)) amo among ng pediatric patients transferred from referring facilities ti es to a pe pedi diat atri ric c tr trau auma ma ce cent nter er by “general ” helicop heli copter ter tea teams ms vs spe specia cialize lized d ped pediat iatric ric tea teams. ms.
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This remained true even when corrected for patient mix and the greater average time from referral to arriva arr ivall in the ped pediat iatric ric cen center ter amo among ng pat patien ients ts transpo tra nsporte rted d by the spe specia cialty lty tea teams. ms. The aut author horss speculat spec ulate e that desp despite ite ove overall rall long longer er tran transpor sport t times, the patients transported by the specialized team tea m ac actua tually lly ben benefi efited ted fr from om an ove overa rall ll longer period per iod in the car care e of ped pediat iatric ric spe specia cialist lists. s.18 This concept conc ept of “br bring inging ing the ho hospi spita tall to th the e pa pati tien ent t ” may in fact be a critical piece of care that is currently lacking lac king in man many y tra trauma uma syst systems. ems. Sev Severa erall stud studies ies have hav e sho shown wn tha thatt tra transp nsport ort by spe specia cialty lty-tr -train ained ed mobile ile int intensi ensive ve car care e unit ” tea teams ms is asso associa ciated ted “mob with improved improved out outcome comes, s, eve even n if such tra transp nsport ort delays ulti ultim mate patient arrival at the tertiary care 18,19 , 28-44 center.
THE GOLDEN OPPORTUNITY So wha whatt is th the e be best st ca care re fo forr pe pedi diat atric ric tr trau auma ma patien pati ents ts? ? Ho How w ca can n a sy syst stem em ca capi pita tali lize ze on th the e “golden opportunity” to provide the right care in the th e ri righ ghtt pl plac ace e at th the e ri righ ghtt ti time me? ? Cr Crea eati tion on of region reg ionali alized zed tra trauma uma syst systems ems to ens ensure ure tim timely ely acc access ess to basic evaluation and stabilization for all patients is vit vital al..45 Th This is may re requi quire re ini initi tial al tr tran anspo sport rt of pediat ped iatric ric tra trauma uma pat patien ients ts to gen genera erall eme emerge rgency ncy facilities, especially in rural areas without immediately ate ly ava availa ilable ble ped pediat iatri ric c tra trauma uma cen center ters. s. The These se facilities facilit ies must be capable of evaluat evaluating ing and stabili stabilizzing pediatric trauma patients. Appropriately sized equipmen equi pmentt and moni monitori toring ng cap capabi abiliti lities es must be present pre sent.. Sta Staff ff must have ski skills lls in the assessment assessment and stabilization of pediatric patients, especially in the management management of shoc shock k and real or imp impend ending ing respiratory respir atory failure. Pediat Pediatric ric patien patients ts with severe or life life-thr -threat eatenin eningg inju injurie ries, s, espe especia cially lly thos those e in need of intensive care unit-level care, should then be transfe transferred rred to appro appropriate priate pediatric pediatric trauma facilities as rapidly as possible after initial stabilization of any immedia immediately tely life-threatening life-threatening conditions. The criter cri teria ia for tra transfe nsferr and mec mechan hanisms isms for ref referr erral al and transfer must be put in place and maintained. Transfer agreements between general and pediatric trauma centers must be well designed with prompt, easily easi ly acc accesse essed d comm communic unicati ation on rea readily dily ava availa ilable ble between betw een fac faciliti ilities es to expe expedite dite tran transfer sfers. s. Car Careful eful cons co nsid ider erat atio ion n sho shoul uld d be gi give ven n to th the e mo mode de of transfe tra nsferr and com composi position tion of the tra transp nsport ort tea team. m. For many pediatric patients, this may mean awaiting the arrival of specialized transport teams from the rec receiv eiving ing inst institut itution ion.. In the these se situ situati ations ons,, per per-sonnel at the referring facility must be capable and remain rem ain comm committe itted d to car caring ing for the patient patient unt until il the team arrives. They must adopt a mentality of
ongoing tre ongoing treatm atment ent vs “awaitin awaitingg transf transfer er” an and d be capable of recognizing and responding to evolving clinicall change clinica changess in pediat pediatric ric patients.
SUMMARY Certainly, no one would argue that timely care is best for critically ill and injured persons. However, the exact meaning and significance significance of a golden hour in tr trau auma ma ca care re is th the e su subj bjec ectt of de deba bate te an and d controversy. So is there a golden hour? If there is, then what should occur during this time? Should this time be spent transferring a patient from the scene to a major trauma center, even if it is not the closest facility? Or should patients be stabilized at the clos closest est med medica icall fac facilit ility y bef before ore tra transf nsfer? er? Fur Fur-thermore, how do the concepts of a golden hour and trauma tra uma syst system em car care e app apply ly to ped pediat iatric ric pat patien ients? ts? Perhap Per haps, s, the ans answer werss lie some somewhe where re in bet betwee ween, n, and an d ra rath ther er th than an a go gold lden en ho hour ur,, he heal alth th ca care re providers should focus on the “golden opportunity” to provide stabilization of immediately life-threatening conditions at the closest appropriate facility followed by safe transfe transferr when neede needed d for definitive care. car e. Tr True ue rea realiz lizati ation on of thi thiss op oppor portun tunity ity for pediatric pediat ric trauma patients requir requires es indivi individualize dualized d conside con siderat ration ion for eac each h pat patien ientt wit within hin well well-es -estab tab-lished and well-coo well-coordinat rdinated ed systems of region regionalized alized trauma care.
REFERENCES www.umm.edu/shocktrauma/history.htm. Acce Accessed ssed Dec Decemember 10, 2009. 2. Trauma.org. Trauma resuscitation. Available at: http://www. trauma.org/archive/hist trauma.org/a rchive/history/resuscitati ory/resuscitation.html on.html.. Acc Accesse essed d August 11, 2009. 3. Lerner EB, Moscati RM. The golden hour: scientific fact of medical “urban legend”. Acad Emerg Med 2001;8:758-60. Mackersi ersie e RC. Histo History ry of trau trauma ma fieldtriage deve developme lopment nt and 4. Mack the American College of Surgeons criteria. Prehosp Emerg Care 2006;10:287 2006;10:287-94. -94. Cowley y RA. Acci Accident dental al deat death h and disa disabilit bility: y: the negl neglecte ected d 5. Cowle disease dise ase of mode modern rn socie society ty—wher where e is the fifth comp compone onent. nt. Ann Emerg Med 1982;11:582-5. 6. Sasser SM, Hunt RC, Sullivant EE, et al. Guidelines for field triage of injured patients. MMWR 2009;58:1-35. 7. MacK MacKenzi enzie e EJ, Rivara FP, Jurk Jurkovich ovich GJ, et al. A nati national onal evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006;354:366-78. 8. Nathens AB, Jurkovich GJ, Rivara FP, et al. Effectiveness of state trauma systems in reducing injury-related mortality: a national evaluation. J Trauma 2000;48:25-31. AM, Abdessalam SF, et al. Effective Effective use of 9. Larson JT, Dietrich AM, the air ambulance for pediatric trauma. J Trauma 2004;56: 89-93. 10. Traumafoundation.org. Trauma's golden hour. Available at: http://www.traumafoundation.org/r http://www.trauma foundation.org/restricted/tinym estricted/tinymce/ ce/ 1.
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jscripts/tinymce/plugins/filemanager/files/About%20Trauma %20Care_Golden%20hour.pdf . Accessed 10/27/2009. 11. Potoka DA, Schall LC, Gardner MJ, et al. Impact of pediatric trauma centers on mortality in a statewide system. J Trauma 2000;4:237-45. Potoka oka DA DA,, Sch Schall all LC LC,, For Ford d HR. Imp Improv roved ed fun functi ctiona onall 12. Pot outcome for severely injured children treated at pediatric trauma centers. J Trauma 2001;51:824-34. 13. Odetola FO, Miller WC, Davis MM, et al. The relationship between the location of pediatric intensive care unit facilities and child death from trauma: a county-level ecologic study. J Pediatr 2005;147:74-7. 14. Osler TM, Vane DW, Tepas JJ, et al. Do pediatric trauma centers have better survival rates than adult trauma centers? An exam examinat ination ion of the nati national onal pediatric pediatric trau trauma ma regis registry. try. J Trauma 2001;50:96-101. Farrell ell LS, Hann Hannan an EL, Coop Cooper er A. Seve Severity rity of inju injury ry and 15. Farr mortality associated with pediatric blunt injuries: hospitals with pediatric pediatric inte intensiv nsive e care units vers versus us other hospitals. hospitals. Pediatr Crit Care Med 2004;5:5-9. 16. Naka Nakayam yam DK, Cope Copess WS, Sacco W. Diff Differen erences ces in trau trauma ma care among pedi pediatri atric c and nonp nonpedia ediatric tric trau trauma ma cen centers. ters. J Pediatr Surg 1992;27:427-31. 17. Hall JR, Reyes HM, Meller JL, et al. The outcome for children with blunt trauma is best at a pediatric trauma center. J Pediatr Surg 1996;31:72-7. 18. American Academy of Pediatrics, Committee on Pediatric Emergenc Emerg ency y Medic Medicine, ine, Amer American ican Colle College ge of Emer Emergenc gency y Physician Physi cians, s, Pedi Pediatri atric c Comm Committe ittee. e. Care of chil children dren in the emergency department: guidelines for preparedness. Pediatrics 2001;107:77 2001;107:777-81. 7-81. 19. Gausche-Hill M, Krug SE, American Academy of Pediatrics Committee Commi ttee on Pedia Pediatric tric Emerg Emergency ency Medic Medicine ine Amer American ican College Colle ge of Eme Emergen rgency cy Phy Physici sicians ans Ped Pediatr iatric ic Comm Committe ittee, e, Emergency Nurses Association, Pediatric Committee. Guideliness for the chi line childre ldren n in the eme emerge rgency ncy dep depart artmen ment. t. Pediatrics 2009;124:123 2009;124:1233-43. 3-43. NanceML, ceML, Car Carrr BG,Bran BG,Branas as CC CC.. Acc Accessto essto ped pediat iatrictrau rictraumacare macare 20. Nan in the Unite United d State States. s. ArchPediatrAdolesc Med 2009; 2009;163:5 163:512-8. 12-8. 21. Athey J, Dean M, Ball J, et al. Ability of hospitals to care for pediatric emergency patients. Pediatr Emerg Care 2001;17: 170-4. 22. Gausc Gausche he M. Diff Differen erences ces in the out-o out-of-ho f-hospita spitall care of child children ren and adults: more questions than answers. Ann Emerg Med 1997;29:776-9. 23. Kumar VR, Bachman DT, Kiskaddon RT. Children and adults in cardiopulmonary arrest: are advanced life support guidelines followed in the prehospital prehospital setting. setting. Ann Emerg Med 1997;29:743-7. Seide dell JS, Hor Hornb nbein ein M, Yos Yoshiy hiyama ama K, et al. Eme Emerge rgenc ncy y 24. Sei medical medi cal services services and the pedi pediatri atric c pati patient: ent: are the needs being met. Pediatrics 1984;73:769-72. Seidel el JS. Emer Emergenc gency y medi medical cal serv services ices and the pediatric pediatric 25. Seid patient: are the needs being met? II. Training and equipping emergenc emer gency y medi medical cal serv services ices prov provider iderss for pedi pediatri atric c emer emer-gencies. Pediatrics 1986;78:8081986;78:808-12. 12. 26. Gau Gausch sche e M, Lew Lewis is RJ, Stratto Stratton n SJ, et al. Effect Effect of out out-of -of-hospital pediatric endotracheal endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA 2000; 283:783-90.
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Larson JT, Die Larson Dietric trich h AM, Abd Abdessa essalam lam SF, Wer Werman man HA. Effective use of the air ambulance for pediatric trauma. J Trauma 2004;56:89-9 2004;56:89-93. 3. Schmitz C, Lewis Lewis RJ. Pediatric Pediatric preparedn preparedness ess 28. Gausche-Hill M, Schmitz of US emer emergenc gency y depa departme rtments: nts: a 2003 survey. Pedi Pediatri atrics cs 2007;120:1229-37. 29. Aaland MO, Smith K. Delayed diagnosis in a rural trauma center. Surgery 1996;120:77 1996;120:774-9. 4-9. 30. Robertson R, Mattox R, Collins T, et al. Missed injuries in a rural area trauma center. Am J Surg 1998;12:564-8. 31. Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of pediatric-neonatal septic shock by community physicians is associate assoc iated d with impr improved oved outc outcome. ome. Pedi Pediatri atrics cs 2003 2003;112: ;112: 793-9. 32. Carcillo JA, Kuch BA, Han YY, et al. Mortality and functional morbidity after use of PALS/APLS by community physicians. Pediatrics 2009;124:50 2009;124:500-8. 0-8. 33. Zebrack M, Dandoy C, Hansen K, et al. Early resuscitation of children chil dren with mode moderate rate-to-s -to-sever evere e trau traumati matic c brai brain n inju injury. ry. Pediatrics 2009;124:56 2009;124:56-64. -64. RA,, Fel Felmet met KA, Han Y, et al. Ped Pediat iatric ric speciali specialized zed 34. Orr RA transport tran sport teams are assoc associate iated d with improved outcomes. outcomes. Pediatrics 2009;124:40 2009;124:40-8. -8. 35. American Heart Association. PALS provider manual. Dallas (Tex): American Heart Association; 2002. America rican n Colle College ge of Surg Surgeon eons. s. Adv Advanc anced ed Trau Trauma ma Life 36. Ame Support for Doctors. 7th ed. Chicago (Ill): American College of Surgeons; 2004. 37. Davis DH, Localio AR, Stafford PW, et al. Trends in operative management of pediatric splenic injury in a regional trauma system. Pediatrics 2005;115:89-94. 38. Moo Mooney ney DP, Rot Rothst hstein ein DH, For Forbes bes PW. Var Varia iatio tion n in the manage man agemen mentt of ped pediat iatric ric spl spleni enic c inj injuri uries es in the Uni United ted States. J Trauma 2006;61:330-3. 39. Keller MS, Vane DW. Management of pediatric blunt splenic injury: comparison of pediatric and adult trauma surgeons. J Pediatr Surg 1995;30:221-5. 40. Hall JR, Reyes HM, Meller JL, et al. The outcome for children with wit h blu blunt nt tra trauma uma is bes bestt at a pe pedia diatri tric c tra trauma uma ce cente nter. r. J Pediatr Surg 1996;31:72-7. 41. Thomas SH, Orf J, Peterson C, et al. Frequency and costs of laborator labor atory y and radi radiograp ograph h repe repetitio tition n in traum trauma a pati patients ents undergoing interfacility transfer. Am J Emerg Med 2000;18: 156-8. 42. Bellingan G, Oliver T, Batson S, Webb A. Comparison of a speciali spec ialist st retr retriev ieval al team with cur current rent Unit United ed King Kingdom dom practice for the transport of critically ill patients. Intensive Care Med 2000;26:740-4. 43. Valenzuela TD, Criss EA, Copass MK, et al. Critical care air transport tran sportation ation of the severely injured: injured: does long dista distance nce transport adversely affect survival. Ann Emerg Med 1990;19: 169-72. 44. McPherson ML, Graf JM. Speed isn't everything in pediatric medical transport. Pediatrics 2009;124:381-3. 45. Tuggle D, Krug SE, American Academy of Pediatrics, Section on Orthopedics, Committee on Pediatric Emergency Medicine, cin e, Se Secti ction on on Cri Critic tical al Ca Care,Secti re,Section on on Sur Surger gery, y, Sec Sectio tion n on Transport Medicine, Pediatric Orthopedic Society of North America. Management of pediatric trauma. Pediatrics 2008; 121:849-54. 27.
Abstract: A limited body of literature about pediatric prehospital trauma care exists to date. Topics that have been studied include delaying transport to initiate treatment on-scene, the use of advanced life support or basic life support resources, identifying high-risk pediatric trauma patients, optimal airway management, obtaining intravenous or intraosseous access, immobilization of the cervical spine, optimal management of traumatic brain injury, and the assessment and management of pain. Translating the best available evidence into clinical practice is important to providing quality prehospital pediatric trauma care. This article will review the literature regarding the risks and benefits of various aspects of pediatric trauma care in the prehospital setting.
Keywords: pediatric trauma; intravenous access; intraosseous access; cervical spine immobilization; traumatic brain injury; prehospital care; airway; emergency medical services
Depart Departmen mentt of Pedia Pediatri trics, cs, Sectio Section n of Emergency Emergency Medicine, Medicine, Baylor College College of Medicine, Houston, TX. Reprint requests and correspondence: Manish I. Shah, MD, Texas Children’s Hospital, 6621 Fannin Street, MC 1-1481, Houston, TX 77030.
[email protected]
Prehospital Management of Pediatric Trauma Manish I. Shah, MD
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ecent estimates from the National Hospital Ambulatory Med Medic ical al Ca Care re Su Surv rvey ey da data taba base se no note te tha thatt 27 27% % of al alll emergency department (ED) visits in the United States are by children younger than 19 years, and 13% of all patients transported via Emergency Medical Services (EMS) are children. Although the percentage of children who require EMS is small relative to adults, the acuity of pediatric EMS patients is often of ten hi high gher er tha than n th that at of ad adul ults ts.. Th This is is es espe pecia cially lly tr true ue wi with th trauma, in wh which ich 54 54% % of pe pedi diat atri ric c tr trau auma ma pa pati tien ents ts ar arri rive ve to th the e ED via EMS. 1 As the EMS system in the United States was originally designed to meet the needs of adults, the integration of the unique needs of children into the existing EMS infrastructure has been one of the main goals of the federally funded Emerg e Emerg ency Medical Services Servi ces for Childre Children n progra program m for th the e past 25 years. 2 Twenty Twent y years ago, Ramen Ramenofsky ofsky3 descr described ibed esse essential ntial compo compo-nents of an integrated pediatric trauma system that addressed system design, prevention, education, standards of care, research and develo development, pment, quality assu assurance, rance, and fundi funding. ng. Succ Successfu essfully lly integrating the needs of children into the existing EMS infrastructure involves initiating high-quality high-quality preho prehospital spital care that uses preest pre establ ablish ished ed prot protocol ocols. s. Thes These e pro protoc tocols ols mus mustt the then n be app applie lied d by skilled skille d emer emergency gency medical technicians technicians (EMTs (EMTs)) with the assi assisstance of online medical control until ultimate transport to an appropriate facility capable of providing definitive care. Although much has been accomplished in each of these areas for pediatric trauma, there are still many areas that have not been adeq ad equat uately ely ad addr dres esse sed. d. On One e of the these se is th the e in inco corpo rporat ration ion of eviden evi dencece-bas based ed pra practi ctices ces int into o pre prehos hospita pitall car care. e. Thi Thiss con concep cept t was highlighted in the recent Institute of Medicine (IOM) report, The Fu Futur ture e of Eme Emerge rgency ncy Car Care, e, whi which ch des descri cribes bes the imp importa ortance nce of ext extend ending ing evi eviden dencece-bas based ed pra practi ctices ces int into o pre prehos hospit pital al car care. e.4 Although the prehospital pediatric literature is limited to date, evalua eva luatin tingg the lit litera eratur ture e for ris risks ks and ben benefi efits ts of var variou iouss asp aspect ectss of pediatric trauma care in the prehospital setting is an important “
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way to determine the value of certain decisions in the fie field. ld. The These se inc includ lude e del delayi aying ng tra transp nsport ort to ini initia tiate te treatm tre atment ent on-s on-scen cene, e, the use of adv advanc anced ed life sup suppor port t (ALS) or basic life support (BLS) resources, identifying high-risk pedia pediatric tric trauma patient patients, s, optima optimally lly managing manag ing the airwa airway, y, obtaini obtaining ng intra intravenous venous (IV) or intraos intr aosseo seous us (IO) acce access, ss, imm immobili obilizat zation ion of the cervical cervic al spine spine,, optim optimal al manag management ement of traum traumatic atic brain injury, and the assessment and management of pain. Each of these areas has been controversial in the man manage agemen mentt of ped pediat iatric ric tra traum uma a pat patien ients, ts, and examination of the literature is important in determining local protocols.
PREHOSPITAL CARE TIME Some lite Some literat rature ure sug sugges gests ts tha thatt pre prehos hospit pital al car care e time has a significant impact on survival in severely injured patients and is a major majo r component of the golden hour of trauma care. 5 Yet the impact of response respon se time interv intervals als on morb morbiidity and morta mortality lity 6 of all trauma patients is unclear. In a meta-analysis design des igned ed to des descri cribe be ave averag rage e tim time e int interv ervals als of prehospital care, 4 time intervals were defined and analy an alyze zed: d: (1 (1)) an ac acti tiva vatio tion n ti time me in inte terv rval al (A (ATI TI)) in th the e prealarm period defined as the time from receiving the call to the time of alarm, (2) a response time interval (RTI) defined as the time from alarm to arriv ar rival al onon-sc scene ene,, (3) an onon-sce scene ne tim time e int inter erva vall (OSTI) defined as the time from on-scene arrival to departure, and (4) a transport time interval (TTI) defined as the time from scene departure to arrival at a hospital. Average urban and suburban ground ambulance time intervals were similar to each other (ATI (A TI = 1 mi minu nute te;; RT RTII = 5 mi minu nute tes; s; OS OSTI TI = 14 minutes; and TTI = 11 minutes) and significantly shorte sho rterr than tho those se for rur rural al gro ground und amb ambulan ulances ces (ATI = 3 minutes; RTI = 8 minutes; OSTI = 15 minu mi nute tes; s; an and d TT TTII = 17 mi minu nute tes) s).. Th The e av aver erag age e ov over erall all prehospital prehos pital care time for urban/ urban/subur suburban ban setti settings ngs was 31 minutes compared to 43 minutes in the rural setting. Helicopter transport times were significantly longer than those for ground ambula ambulances as a whole but were not compared by setting. 7 Using Usi ng the these se nat nation ional al ave averag rages es as a ben benchm chmark ark may be us usefu efull in ev evalu aluat ating ing the qu quali ality ty of pe pedia diatri tric c prehospital trauma care. Although standards exist for tim time e to def defini initiv tive e ca care re for ac acut ute e cor corona onary ry syndrome and stroke patients the impact of similar prehospital care time standards for trauma patients is still unclear. The American College of Surgeons does strongly encourage rapid transport to a trauma center cen ter and min minimi imizat zation ion of onon-sce scene ne tim time e for tra trauma uma patients, and there is evidence to support supp ort improved improved 5,8 outcomes with shorter on-scene times. “
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PREHOSPITAL TRIAGE AND TRANSPORT Regionalizi Regiona lizing ng tra trauma uma care has dem demonst onstrat rated ed improved improv ed outcom outcomes es in pediat pediatric ric tra traum uma a an and d ha hass 4,9 been be en re reco comm mmen ende ded d by the IO IOM. M. Determining which patients are at high risk for mortality or need specialized treatment that can only be provided at a trauma center with pediatric capabilities is important. Using prehospital triage criteria that balances sensitivity and specificity to transport patients with the most severe injuries to trauma centers, while transporting those with less severe injuries to the closest hospital, is essential in regionalizing trauma care for children children.. Engum et al 10 performed a retrospective analysis of the predictive value of certain physiologic and anatomical criteria in determining pediatric trauma patien pat ients ts who sub subseq sequen uently tly die died d in the ED, wer were e admitt adm itted ed to the ped pediat iatric ric int intens ensive ive car care e uni unit, t, or required a major surgical procedure. Their findings showed sho wed tha thatt 5 cri criter teria ia had a pos positi itive ve pre predic dictive tive value val ue of 50% or hig higher her,, a sys systol tolic ic bloo blood d pre pressu ssure re (SBP) of less than 90 mm Hg (86%), Glasgow Coma Score (GCS) of 12 or less (78%), respiratory rate (RR) (R R) of le less ss th than an 10 10/m /min in or mo more re th than an 29 29/m /min in (73%), (73 %), a sec second ond-- or thi thirdrd-deg degree ree bur burn n inv involvi olving ng more than 15% total body surface area (79%), or paralysis (50%). Yet this analysis did not take into account varying normal vital sign values by age group, thus drawing some criticism on the utilization of SBP less than 90 mm Hg and RR of more than 29/min as predictors of poor outcomes in young children. Newgard et al 11 analyzed a retrospective cohort of injured children in the Oregon state trauma registry over a 6-year period per iod and inc includ luded ed age age-ba -based sed phy physio siolog logic ic par paraameters to identify children at high risk for major nonorthoped nonort hopedic ic opera operative tive interv intervention ention,, intens intensive ive care unit stay of 2 days or longer, or in-hospital mortality. They found that the GCS was the most importa imp ortant nt pre prehosp hospital ital pred predict ictor or foll followed owed by (in order) ord er) air airway way int interv erventi ention, on, RR, hea heart rt rat rate e (HR (HR), ), SBP, and shock shock ind index. ex. Exa Examin mining ing the fin findin dings gs of New gard gard et al11 in re refe fere renc nce e to th thos ose e of En Engu gum m 10 et al, a RR of more than 29/min had no predictive valu va lue e in ch chil ildr dren en yo youn unge gerr th than an 5 ye year arss of ag age e an and d HR was significantly significantly more predictive of poor outcomes in comparison to SBP or shock index. Yet, Ye t, Ne Newg wgar ard d et al12 perfor performed med a subs subsequent equent analysis on pediatric patients using the American College Coll ege of Su Surge rgeons ons Com Commit mittee tee on Tra Traum uma a fie field ld deci de cisi sion on cr crit iter eria ia to de deve velop lop a cli clini nica call de deci cisi sion on ru rule le to identif ide ntify y hig high-ri h-risk sk inj injure ured d chi childr ldren. en. The dec decisi ision on rul rule e placed pla ced the these se cri criter teria ia in the foll followi owing ng ord order er to ide identi ntify fy high-risk high-r isk injur injured ed childre children: n: need for assis assistance tance with
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ventilatio ventila tion n via end endotr otrach acheal eal int intuba ubatio tion n (ET (ETI) I) or bag bag-valve-mask ventilation (BVM), GCS of less than 11, pulse oximetry of less than 95%, and SBP of more than tha n 96 mm Hg Hg.. Of Of no note te,, HR an and d RR di did d not not pr prov ove e to be important predictors in the model. In addition, the finding finding of a hi high gh SB SBP P as asso soci ciat ated ed wi with th po poor or outcom out comes es may be pla plausi usible ble wit with h tra traum umatic atic bra brain in injury but otherwise did not seem to be expected. Therefore, Theref ore, pedia pediatric tric patien patients ts with prehos prehospital pital findings of a low GCS, the need for airway airway interv interventions entions,, hypox hyp oxia ia,, an and d hyp hyper erte tens nsion ion se seem em to be at hig high h ri risk sk fo forr poor outcomes. These predictors should potentially be incorporated into decision-making protocols f or or transport of pediatric patients to a trauma center. 12 The use of ALS vs BLS for the transport of trauma patien pat ients ts in the pre prehosp hospita itall set settin tingg has sti stirre rred d deb debate ate,, given giv en the res resour ource ce imp implica licatio tions ns of usi using ng ALS for each patient, the lack of adequate ALS staffing in rural rur al are areas, as, and the ass assump umptio tion n tha that t pre prehospital hospital 13,14 ALS AL S dec decrea reases ses mor morbid bidity ity and mor mortal tality. ity. Staffing an ALS unit compared to a BLS unit is esti ma mated ted to 15 cost co st an ex extr tra a $9 $94 4 92 928 8 pe perr ye year ar pe perr un unit it.. Also, procedures performed by ALS units take additional time, tim e, whi which ch ma may y de dela lay y ult ultim imat ate e tr trans anspo port rt to 16 definitive definit ive care. A met meta-an a-analys alysis is eva evalua luating ting 15 studie stu dies, s, inc includi luding ng pat patient ientss of all age ages, s, conc conclud luded ed that ALS ALS-tr -treate eated d tra trauma uma pat patien ients ts ove overal ralll had an increas incr eased ed odd oddss of mor mortal tality ity ove overr BLS BLS-tr -treat eated ed patients (odds ratio [OR], 2.92). Interpretation of the confid confidence ence intervals (CIs), howeve however, r, reveal revealed ed only one study that favored ALS. The other studies had CIs that included 1, therefore did not show a significant signif icant diffe difference. rence.17 One stu study dy fro from m Fin Finlan land d reported slightly improved outcomes in ALS units staffed by a phys ph ysician, ician, but this model is rare in the 18 United State States. s. Th Thus us,, it se seem emss tha thatt th ther ere e is no diffe di ffere renc nce e in mo mort rtal ality ity be betw twee een n AL ALS S an and d BL BLS S trauma tra uma care whe when n pro provid vided ed by EMT EMTs, s, but there are sig signifi nificant cant dif differe ferences nces in cos costt wit with h pos possib sible le benefi ben efitt only in sit situat uation ionss of pro prolong longed ed tra transp nsport ort times or physician-staffed ALS units.
AIRWAY MANAGEMENT One of the most controversial topics in prehospital care is the method of airway management that reduces morbidity and mortality while optimizing safe sa fety. ty. Th This is is al also so an is issu sue e in ad adul ultt trau trauma ma car care, e, an and d a retrospective cohort analysis of trauma patients older than 14 years demonstrated that prehospital care time for patients undergoing rapid sequence intubation (RSI) was 10.7 minutes longer (95% CI, 7.7-13. 7.7 -13.8) 8) tha than n pat patient ientss who wer were e not int intuba ubated ted.. Also, prehospital care time for patients undergoing conventional convent ional ETI withou withoutt induc induction tion medic medications ations
was still 5.2 minutes long lo ng er er than that for patients 19 who were not intubated. Thus, intubation clearly increases on-scene time, which may result in poorer outcomes for patients. In a se sepa para rate te an anal alys ysis is of th the e sa same me co coho hort rt,, adju ad just stin ingg for the pr prop opens ensity ity to be in intu tuba bate ted, d, prehospital ETI was associated with an increased oddss of mor odd mortali tality ty (OR (OR,, 2.7 2.70; 0; 95% CI, 1.6 1.63-4 3-4.46 .46)) when ground transport distances were short ( b10 miles) mil es) com compar pared ed to non nonintu intubat bated ed pat patien ients. ts. Thi Thiss risk ris k gra gradua dually lly dec decline lined d as gro ground und tra transp nsport ort dis dis-tance increased, such that the 95% CI included an OR of 1 fo forr tr tran ansp spor ortt di dist stan ance cess gr grea eater ter th than an 20 miles. Intubated patients transported transported by helico helicoppter, however, had decreased mortality (OR, 0.36; 95% CI, 0.24-0.56). This finding may be due to the more mor e adv advanc anced ed air airway way man manage agemen mentt ski skills lls of air transport providers, but the evidence suggests that ETII in ad ET adul ults ts by gro groun und d cr crew ewss ne near ar a hos hospi pita tall 20 increases mortality. In a controlled trial of pediatric patients in the urban setting who either received BVM or ETI for prehospital prehos pital airwa airway y manag management, ement, intent intention-toion-to-treat treat analysi ana lysiss rev reveale ealed d tha thatt the there re was no dif differ ferenc ence e between the 2 interventions for both survival and neurolo neu rologic gic out outcom come, e, eve even n in the sub subgro group up ana analys lysis is of variou var iouss cat catego egorie riess of tra trauma uma pat patien ients ts inc includ luding ing submersion injury, head injury, and multiple trauma. The subgroup of child maltreatment patients demons dem onstra trated ted imp improv roved ed sur surviv vival al wit with h BVM com com-pare pa red d to ET ETII (O (OR, R, 0.0 0.07; 7; 95 95% % CI CI,, 0. 0.01 01-0. -0.58 58), ), bu butt th ther ere e was no significant difference in neurologic outcome. This Th is st stud udy, y, ho howe weve ver, r, di did d not ex exam amin ine e po pote tent nt ial effect eff ect mea measur sure e mod modifi ificat cation ion by tra transp nsport ort dis distanc tance. e.21 Maint Maintena enance nce of the rar rarely ely enc encoun ounter tered ed tas task k of prehosp pre hospita itall ped pediat iatric ric ETI ETI,, the ana anatom tomica icall dif differ fer-ences of the pediatric airway relative to an adult, and the limited pediatric continuing education for prehosp pre hospita itall pro provid viders ers mak make e ped pediat iatric ric ETI a cha challlenging task for the prehos prehospital pital provider, especially especially in th the e ru rura rall se sett ttin ing. g. In ru rura rall pe pedi diat atri ric c tr trau auma ma patient pat ients, s, fiel field d int intuba ubation tion suc succes cesss rat rates es by bot both h EMT-pa EMT -param ramedi edics cs and fli flight ght reg regist istere ered d nur nurses ses are significantly poorer (45%-70%) when compared to rates ra tes by ED ph physi ysici cian anss an and d anest anesthesiolo hesiologists gists at 22 trauma centers (89%-100%). Theref The refore ore,, the ris risk k of inc increa reased sed onon-sce scene ne tim time e and pot potent ential ial com compli plicat cation ionss wit with h ETI mus mustt be weighed against the benefit of rapid transport to an appropriate trauma center when deciding whether to intubate or use less invasive means to manage the airway of a pediatric trauma patient. This may be especially true for ground transport distances less than 10 miles, in which higher mortality has been demonstrated in the adult population.
PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH • VOL. 11, NO. 1
INTRAVENOUS AND IO ACCESS AND INFUSIONS Because many time intervals in prehospital care are sys system tem dep depend endent ent,, the mos mostt eff effect ective ive way to decrease prehospital times is to decrease the onscene sce ne dur duratio ation. n. Pro Proced cedure uress in the fie field ld may inc increa rease se the likelihood of survival or may increase mortality by delaying definitive definitive care. care. In a retros retrospecti pective ve review of IV placement in trauma patients of all ages, this procedure ad adde ded d an ad addi diti tion onal al 5 mi minu nute tess of on on-scene time.16 Becaus Bec ause e thi thiss stu study dy did not inc includ lude e a sub subgro group up analysis of pediatric patients, however, the time to place an IV in a child may actually be longer. A retrospective chart review of prehospital IV placement in pediatric patients, with subgroup analysis for trauma patients, showed a 57% success rate for IV placement in patients less than 6 years of age and 74% success rate in age 6 years or higher. Average time to IV placement in trauma patients was 14 minutes (range, 7-24 minutes) in age less than 6 years and 12 minute minutess (range, 1-43 minutes) in age more than 6 years. 23 For some patients, decreasing on-scene time may be essential to survival, but for other oth ers, s, the ben benef efit it of ini initia tiatin tingg IV ac acces cesss ma may y outweigh outwe igh the risks risks.. Theref Therefore, ore, the deter determinati mination on of whether to place an IV needs to be based on the individual patient with respect to expected transport po rt ti time me an and d an antic ticip ipat ated ed ti time me to co comp mplet lete e th the e procedure. Altho Although ugh obt obtain aining ing IV acc access ess in ped pediatr iatric ic patients may prolong on-scene time by up to 14 minutes, placement of an IO needle may provide more mo re ti time mely ly ac acce cess ss fo forr tr trau auma ma pa pati tien ents ts wi with th hemorrhagic shock. In a prospective observational study of paramedics after a brief training session on the placement of IO needles, 28 (84%) of 33 of the attempted IO infusions were successfully started in less than 1 minute in a simulated ambulance ambulanc e setting s etting 24 at a sp spee eed d of 25 to 35 mi mile less pe perr ho hour ur.. In a retrospective cohort of pediatric trauma patients in whom who m an IO was att attemp empted ted for car cardio diopul pulmon monary ary arrest arr est,, hypo hypovole volemic mic sho shock, ck, or neu neurolo rologic gic ins insult ult,, successful succe ssful placem placement ent by prehos prehospital pital profes professional sionalss was noted in 13 (93%) of 14 cases. These IO needles were used both in the prehospital and emergency department settings to successfully administer both colloi col loid d and cry cryst stall alloid oid inf infus usion ionss and mu multi ltiple ple pharm pha rmaco acolog logic ic ag agent entss in pa patie tients nts 3 mon months ths to 10 ye year arss of ag age, e, wi with th on onlly one reported reported cas case e of minor tissue extravasation. 25 Rega Re gard rdle less ss of wh whet ethe herr an IV or IO is pl plac aced ed,, controversy exists about whether administration of fluids in the prehospital setting actually improves
13
patient outcomes. Computer modeling to evaluate the potent potential ial benef benefit it of admin administeri istering ng preho prehospital spital fluid flu idss for ma major jor he hemor morrha rhage ge su sugg gges ests ts tha thatt onl only y trauma patients who had a bleeding rate of more than 25 mL/min and prehospital time greater than 30 minutes would benefit.26 Yet these findings have not been validated in children in the prehospital setting set ting.. The only study eva evalua luating ting the eff effica icacy cy of prehos pre hospit pital al IV flu fluid id adm admini inist strat ration ion to ped pediat iatric ric trauma tra uma pat patien ients ts was a ret retros rospec pectiv tive e rev review iew in which whi ch it was inconsequ inconsequent ential ial in 94% of pat patient ients, s, potentially beneficial in 4% of cases cases,, and potent potentially ially harmful in 2% of cases. 27 It seems evident that adult trauma protocols may not be ap appl plic icab able le to ch chil ildr dren en,, pr preho ehosp spita itall IV placement prolongs on-scene time, and the benefit of pre prehos hospit pital al flu fluid id th ther erapy apy in ped pediat iatric ric tra traum uma a 28 patients is still unclear. Yet given the physiologic differences between children and adults, IV/IO fluid administration for hemorrhage secondary to trauma may be warranted. For some patients, decreasing on-scene time may be essential to survival, but for other oth ers, s, the ben benefi efitt of ini initia tiati ting ng IV acc access ess ma may y outweigh outwe igh the risks risks.. There Therefore, fore, the deter determinati mination on of whether to place an IV or IO needs to be based on the ind indivi ividua duall pat patien ientt wit with h res respec pectt to exp expect ected ed transp tra nsport ort tim time e and ant antici icipat pated ed tim time e to com complet plete e the procedure.
CERVICAL SPINE IMMOBILIZATION Common pra Common practi ctice ce amo among ng pre prehos hospit pital al pro profes fes-siona si onals ls is to im immo mobi biliz lize e th the e ce cerv rvic ical al sp spin ine e of a patientt who has had a traum patien traumatic atic injury. Once these patients arrive at the hospital, the cervical immobili bi liza zati tion on de devi vice ce mi migh ghtt be re remo move ved d ba base sed d on clinic cli nical al cr crit iter eria, ia, or the pa patie tient nt mi migh ghtt un unde derg rgo o further imaging. The National Emergency X-Radiograph ogr aphy y Uti Utiliza lization tion Stu Study dy (NE (NEXUS XUS)) der derive ived d and vali va lida date ted d a de deci cisi sion on ru rule le to de dete term rmin ine e wh who o ca can n safely have a cervical spine immobilization device remov rem oved ed in the ED wit withou houtt rad radiog iograp raphic hic eva evalua lua-29 tion. Although these data apply to patients who have already been immobilized, it is plausible that some som e EMS agencies agencies may attempt attempt to app apply ly the these se findings to the prehospital setting. To date, there are no publis published hed studies that provid provide e evide evidence nce that prehospital professionals can forego cervical spine immobilization using the NEXUS criteria. Because only 10% of the patients in NEXUS were children, applying these findings to the prehospital care of children childr en would be even more difficult. difficult.29,30 Analysis of the NEXUS pediatric patient data demonstrates thatt no ce tha cerv rvic ical al sp spin ine e in inju jury ry wo woul uld d ha have ve be been en missed if the NEXUS criteria had been applied to
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this population.30 Yet due to the low cervical spine injury rate of 0.98% in pediatric trauma patients in this study, it would be difficult to safely apply this rule ru le to ch child ildre ren n in t he h e ED se sett tting ing,, le lett al alon one e th the e 30 prehospital prehos pital settin setting. g. Until Unt il th this is is issu sue e is st stud udie ied d further, children with a significant mechanism of injury should have their cervical spine immobilized using age-ap age-appropr propriate iate equip equipment ment before trans transport port to the hospital.
TRAUMATIC BRAIN INJURY Traumatic brain injury (TBI) in children results from a variety of causes, including nonacc nona ccidental idental 31 injury, falls, and motor vehicle collisions. In the young you ng ath athlete lete,, TBI occ occurs urs with act activi ivities ties such as football, soccer, cheerleading, basketball, and field hockey. 32 Bec Becaus ause e athl athleti etic c inju injuries ries and mot motor or vehicle collisions are common causes of pediatric TBI, the prehos prehospital pital professional professional must be equipped equipped to manage these common mechanisms of injury. 33 In addition, because 50% of the mortality due to TBI occurs in the first 2 hours after injury, prehosp preho spital ital 34 assessment and management of TBI is crucial. Yet variation varia tion exists in asses assessing sing and managi managing ng childr children en with TBI in the prehospital environme environment, and an evidence-based approach is necessary. 31 Early correction of hypoxemia and hypotension, accurate assessment of the GCS and pupils, airway management, manag ement, and appro appropriate priate transport decis decision ion maki ma king ng is vi vita tal, l, ac accor cordi ding ng to the Br Brai ain n Tr Trau auma ma Foundation's evidence-based guidelines on prehospital management of TBI. Most of these guidelines are ar e ba base sed d on ad adul ultt st stud udies ies,, how howev ever er,, du due e to relativ rela tively ely lim limite ited d stu studie diess on ped pediat iatric ric TBI in the prehospital setting. Regardless, modifying the GCS for a pediatric patient is essential essenti al due to differences in preverbal children (Table (Table 1). 1).35 In add additi ition, on, the ass assess essmen mentt of pot potent ential ial TBI shou sh ould ld in inclu clude de as aski king ng th the e ve verb rbal al ch chil ild d ab abou outt a rece re cent nt pr prior ior he head ad in inju jury ry an and d sy symp mpto toms ms of a concussion, concus sion, such as headac headache, he, dizzine dizziness, ss, naus nausea, ea, and blurred vision. In addition, it is also important to ask bystanders about loss of consciousness and the mec mechani hanism sm of inju injury. ry. Phy Physic sical al ass assess essmen ment t should include evaluation of the face and scalp for hematomas, ecchymoses, or palpable skull fracture; drai dr aina nage ge of bl blood ood from the ea ears rs or no nose se;; an and d a thorough neurologic examination, examination, including an ageadjusted assessment of the GCS. 31 In a recent analysis of a prospective cohort of childre chi ldren n wit with h hea head d inj injuri uries, es, pat patien ients ts 2 yea years rs or older with altered mental status, any suspected or confirmed loss of consciousness, history of vomiting,, sev ing severe ere mec mechan hanism ism of inj injury ury (mo (motor tor veh vehicle icle
collision collisi on wit with h pat patien ientt eje ejecti ction, on, dea death th of anot another her pass pa sseng enger er or ro rollo llover ver,, ped pedes estri trian an or bi bicyc cyclis list t witho wi thout ut he helm lmet et st stru ruck ck by a mo moto tori rize zed d ve vehi hicl cle, e, falls fa lls of N5 fe feet et,, he head ad st stru ruck ck by a hi high gh-i -imp mpac act t object obj ect), ), cli clinic nical al si sign gnss of ba basi silar lar sk skull ull fr fract actur ure e (poster (pos terior ior aur auricul icular ar or per periorb iorbital ital ecch ecchymos ymoses, es, hemotympanu hemoty mpanum, m, or cerebr cerebrospinal ospinal fluid otorrhe otorrhea/ a/ rhinorrhea), or a severe headache were at risk for a cl clin inic icall ally y si sign gnif ific icant ant TB TBI, I, wh whic ich h ma may y re requ quir ire e neurosurgic neuros urgical al interv intervention ention or hospit hospital al admis admission. sion. Patients younger than 2 years with altered mental status, occipital/parietal/temporal scalp hematoma, loss lo ss of co cons nsci ciou ousn snes esss fo forr 5 se seco cond ndss or mo more re,, severe mechanism of injury, palpable or equivocal skull fracture, or abnormal behavior according to the car caregi egiver ver w ere e re al also so at ri risk sk fo forr cl clin inic ical ally ly important TBI.36 Being aware of what makes a pediatric patient high risk for complications from TBI is especially esse es sent ntia iall fo forr EM EMS S sy syst stem emss in wh whic ich h EM EMTs Ts ca can n determ det ermine ine pat patien ientt dis dispos positi ition on in the pre prehos hospit pital al setting set ting.. Thi Thiss is als also o tru true e in the case of pot potent ential ial nontran nont ranspo sport rt of pat patien ients ts aft after er spo sports rts inj injuri uries es because providers must be aware of the sequelae of TBI and recommendatio recommendations ns to return to play after sports-related injuries. 31 For example, sports-related TBI can result in a clinica clin icall ent entity ity cal called led second impact syndrome, in wh whic ich h a se seco cond nd co conc ncus ussi sion on in a pa pati tien entt wh who o is st stil illl symptomatic from a first concussion can result in cerebra cereb rall ed edem ema, a, br brain ain he herni rniati ation, on, co coma ma,, an and d 37 death. To prevent second impact syndrome, the Concussion in Sport Group has published recommendations on short-term management and when to return to play. These recommendations state that any pla player yer tha thatt sho shows ws sy symp mptom tomss of hea headac dache, he, dizziness, nausea, or double vision should refrain from fro m the cur current rent spo sports rts act activi ivity, ty, und under er med medica icall evalua eva luation tion,, and should only ret return urn to pla play y whe when n asymptomatic w it it h a normal neurologic and cognitive evaluation.38 Also, patients who experience a loss of consci consciousnes ousnesss should be tra transp nsport orted ed to a 39 hospital for further evaluation. The prehospital management of TBI focuses on minimizing secondary injury, essentially through handling the compromised airway and intervening to prevent hypotension. Hypoxemia (oxygen saturation, b90%) should be avoided by managing the airway by the most appropriate means, which may be supplem supplemental oxyge oxygen, n, BVM, ETI, or other airw airway ay 35 adjuncts. There is no evidence to support ETI over BVM in pediatric patients with TBI, however, and pediatric trauma patients as a whole may have fewer co comp mplic licati ations ons fro from m BV BVM M whe when n com compar pared ed 21 to ETI.
PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH • VOL. 11, NO. 1
TABLE 1. Comparison of pediatric GCS with standard GCS GCS Eye opening Spontaneous Speech Pain None Verbal response Oriented Confused Inappropriate Incomprehensible None Motor response Obeys command Localizes pain Flexor withdrawal Flexor posturing Extensor posturing None
Pediatric Pediatric GCS
4 3 2 1 5 4 3 2 1 6 5 4 3 2 1
Eye opening Spontaneous Speech Pain None Verbal response Coos, babbles Irritable cries Cries to pain Moans to pain None Motor response Normal, spontaneous Withdraws to touch Withdraws to pain Abnormal flexion Abnormal extension None
4 3 2 1 5 4 3 2 1 6 5 4 3 2 1
Data from Badjatia. 35
Children Childr en wit with h sus suspec pected ted TBI sho should uld hav have e the their ir cervical cervi cal spine (C-spine) immobili immobilize zed d in th the e fi field eld due to risk for concurrent injury. 31 If ETI is going to be att attemp empted ted,, ma manua nuall C-s C-spin pine e sta stabil biliza izatio tion n is necess nec essary ary to pre preven ventt sec second ondary ary inj injury ury.. For EMS agencies that use RSI medications for intubation, premedication with 1.5 mg/kg of lidocaine followed by 0.3 mg/kg of etomidate for sedation and either 1.5 mg/kg of succinylcholine or 1 mg/kg of vecuronium are preferred to protect against increases in intracrania intrac raniall press pressure. ure. Otherwise, Otherwise, the decis decision ion to intubate should be made in consultation with online medica med icall con contro troll if the these se RSI med medica icatio tions ns are not available for use in the prehospital setting. Signs of increased intracranial pressure are represented by Cushing's Cushi ng's triad of hypert hypertensio ension, n, brady bradycardi cardia, a, and irregular breathing.31 The EMS systems that use RSI protocols should monitor blood pressure, oxygenation, and end-tidal CO2 (ETCO2). Patients should be maintained with normal breathing rates (ETCO2 = 35-40 mm Hg), and hyperv hyperventilat entilation ion (ETCO2 b 35 mm Hg) should be av avoid oided ed un unles lesss the there re are si sign gnss of ce cere rebr bral al herniation. The evidence for the latter, however, is lacking in pediatrics, and this recom recommendation has been extrapolated from adult data. 35 Beca Be caus use e hy hypo pote tens nsio ion n wi with th TB TBII in pe pedi diat atri ric c patients has been associated with poor outcomes,
15
blood bloo d pr pres essu sure re sh shou ould ld be mo moni nito tore red d wi with th an approp app ropria riately tely siz sized ed ped pediat iatric ric cuf cufff and pre preven vented ted by gi givi ving ng bo bolu luse sess of 20 mL mL/k /kgg of is isot oton onic ic crystalloid crysta lloid (Table 2). 2).31,35 Prehospital providers should determine the GCS and pupil size after airway, breathing, and circulation have been assessed and stabilized. The most appropriate airway should be established in patients patien ts with severe TBI, defined as a GCS less than 9. 35 Also, Al so, bec becaus ause e hyp hypogl oglyce ycemia mia can res result ult aft after er TBI TBI,, blood glucose should be checked and t reated reated when serum glucose is less than 80 mg/dL. 31 Prehospita Preho spitall provid providers ers shoul should d direc directly tly trans transport port child ch ildre ren n wi with th se seve vere re TB TBII to a pe pedi diat atri ric c tr trau auma ma cente ce nterr or an ad adult ult tr trau auma ma ce cente nterr wi with th ad adde ded d 35 qualifications to treat children. Because nonaccidental head injury is also a common cause of death in infants, prehospital providers should thoroughly document findings at the scene and report unclear or imp implau lausib sible le mec mechan hanism ismss to law enf enforc orceme ement, nt, child protective services, and ED personn perso nnel, el, while being cautious cautious to mainta maintain in scene safety.31
PAIN ASSESSMENT AND MANAGEMENT Pain assessment and management in trauma is important importa nt for pat patien ientt com comfor fortt and pot potent ential ially ly for patient healing. In a retrospective chart review of 696 pediatric trauma patients, prehospital personnel documented a pain assessment in 81% of cases, but only 0.1% actually used a pain assessment tool. Of the 64% of patients with documented pain, only 15% received some sort of intervention to address their pain. For all patients, both pharmacologic and nonpharmacologic nonpharmacologi c interv nterventions entions were used equally in 13.4% of cases. 40 Because pain does not necessarily correlate with injury severity, severity, pain assessment assessment should occur in all children childr en in the prehos prehospital pital setting with a traum traumatic atic injury. In addition, parental report of pain is often
TABLE 2. Definition of pediatric hypotension by age Age 0-28 days 1-12 months 1-10 years N10 years
Data from Badjatia. 35
SBP 60 mm Hg 70 mm Hg b70 + (2 × age in years) b90 mm Hg b b
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VOL. 11, NO. 1 • PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH
comparabl compar able e to a chi child' ld'ss rep report ort and shou hould ld be 41 incorp inc orpora orated ted int into o a pai pain n ass assess essmen ment. t. Although pediatric pain scales that have been validated in the hospi hos pital tal se sett tting ing hav have e not be been en va valid lidate ated d in th the e prehos pre hospit pital al set settin ting, g, the use of sta standa ndardi rdized zed and age-appropriate pain assessment tools by prehospital professional professionalss is more likely to lead to management of pain. 42
SUMMARY Prehospit Prehos pital al pro provid viders ers pla play y an ess essenti ential al rol role e in the th e ini initi tial al ma mana nage geme ment nt of pe pedi diat atri ric c tr trau auma ma patien pat ients ts by mi minim nimizi izing ng se secon condar dary y inj injur ury y and transporting injured children to definitive care in a ti time mely ly ma mann nner er.. As th the e IO IOM M ha hass re rece cent ntly ly recommended, it is essential for the United States to ha have ve an EM EMS S sy syst stem em th that at is re regi giona onali lized zed an and d coordinated to provide optimal care in a seamless fashion along the continuum from the prehospital to ED set setting tings. s.4 Althou Although gh the evi eviden dence ce bas base e for pediat ped iatric ric pre prehosp hospita itall tra trauma uma car care e is lim limite ited, d, transl tra nslati ating ng the bes bestt ava availa ilable ble inf inform ormati ation on int into o clinical practice is important to providing quality care. car e. In add additi ition, on, con conduc ducting ting fur furthe therr res resear earch ch in prehos pre hospit pital al ped pediat iatric ric tra trauma uma car care e wil willl be vit vital al to providing the best care possible in the future.
REFERENCES Shah MN, Cushman JT, Davis CO, et al. The epidemiology epidemiology of emergency medical services use by children: an analysis of the Nat Nation ional al Hos Hospit pital al Ambu Ambulat latory ory Med Medica icall Car Care e Sur Survey vey.. Prehosp Prehos p Emerg Care 2008;12: 2008;12:269-76. 269-76. Twenty y years of emergency medical 2. Krug S, Kuppermann N. Twent services for children: a cause for celebration and a call for action. Pediatrics 2005;115:1089-91. 3. Ramenofsky ML. Emergency medical services for children and pediatric trauma system components. J Pediat Pediatrr Surg 1989;24:153-5. Institute ute of Medici Medicine ne of the National Academies. Emergency 4. Instit medical medi cal ser service vices: s: at the cro crossr ssroads oads.. Was Washing hington ton,, DC: Nat Nation ional al Academies Press; 2006. 5. Sampalis JS, Lavoie A, Williams JI, et al. Impact of on-site care, car e, pre prehosp hospita itall tim time, e, and leve levell of inin-hos hospit pital al car care e on sur surviv vival al in severely injured patients. J Trauma 1993;34:252-61. 6. Lerner EB, Moscati RM. The golden hour: scientific fact or medical urban legend . Acad Emerg Med 2001;8:758 2001;8:758-60. -60. Carrr BG, Caplan Caplan JM, Pryor JP, et al. A met meta-a a-analy nalysis sis of 7. Car prehospital prehospi tal care times for traum trauma. a. Prehos Prehosp p Emerg Care 2006; 10:198-206. 8. American College of Surgeons. Advanced trauma life support forr doc fo docto tors rs.. 8t 8th h ed. Chi Chicag cago o (I (Ill) ll):: Ame Ameri rican can Co Colle llege ge of Surgeons; 2008. Haller ler JA, Sho Short rter er N, Mil Miller ler D, et al. Or Organ ganiz izati ation on and 9. Hal functi fun ction on of a reg region ional al ped pedia iatri tric c tra trauma uma cen center ter:: doe doess a system management improve outcome. J Trauma 1983;23: 691-6. 1.
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Engum SA, Mitchell MK, Scherer LR, et al. Prehospital triage in the inj injure ured d pedi pediatr atric ic pati patient ent.. J Ped Pediat iatrr Sur Surgg 2000 2000;35: ;35: 82-7. 11. Newgard CD, Cudnik M, Warden CR, et al. The predictive value and appropr appropriate iate ranges of prehosp prehospital ital physiological physiological parameters paramet ers for high-r high-risk isk injur injured ed childr children. en. Pediat Pediatrr Emerg Care 2007;23:450-6. Newgard d CD, Rudser K, Atkins DL, et al. The availab availability ility and 12. Newgar use of out-of out-of-hospi -hospital tal physiol physiologic ogic information information to identi identify fy high-risk highrisk injured childr children en in a multis multisite, ite, population-based population-based cohort. Prehosp Emerg Care 2009;13:420-31. Trunkey y DD. Is ALS necessar necessary y for pre-ho pre-hospita spitall traum trauma a care. 13. Trunke J Trauma 1984;24:86-7. 14. Lewis FR. Ineffective therapy and delayed transport. Prehosp Disaster Med 1989;4:129-30. Orna natoJP, toJP, Ra Rach chtt EM EM,, Fi Fitc tch h JJ JJ,, et al al.. Th The e ne need ed fo forr AL ALS S inurb inurban an 15. Or and subu suburbanEMS rbanEMS syst systems. ems. Ann Emer Emergg Med 1990 1990;19: ;19:1469 1469-70. -70. Carrr BG, Bra Brachet chet T, Guy D, et et al. al. The tim time e cost cost of preh prehospi ospital tal 16. Car intubat int ubations ions and intr intraveno avenous us acce access ss in trau trauma ma pati patients ents.. Prehosp Emerg Care 2008;12:327-32. 17. Liberman M, Mulder D, Sampalis J. Advanced or basic life support for trauma: meta-analysis and critical review of the literature. J Trauma 2000;49:584-99. 18. Suominen P, Baillie C, Kivioja A, et al. Prehospital care and survival of pediatric patients with blunt trauma. J Pediatr Surg 1998;33:1388-92. Cudn dnik ik MT MT,, New Newga gard rd CD CD,, Wa Wang ng H, et al. En Endot dotra rach cheal eal 19. Cu intubation increases out-of-hospital time in trauma patients. Prehosp Emerg Care 2007;11:224-9. 20. Cudnik MT, Newgard CD, Wang H, et al. Distance impacts mortality mortal ity in traum trauma a patien patients ts with an intuba intubation tion attempt. Prehosp Emerg Care 2008;12:459-66. Gausche sche M, Lew Lewis is RJ, Stratton Stratton SJ, et al. Effect of out out-of -of-21. Gau hospital pediatric endotracheal intubation on survival and neurologic outcome. JAMA 2000;283:783-90. Ehrlic lich h PF, Seidman Seidman PS, Atallah Atallah O, et al. Endo Endotra trache cheal al 22. Ehr intuba int ubatio tions ns in rur rural al pedi pediatr atriactraumapatien iactraumapatients. ts. J Ped Pediat iatrr Sur Surg g 2004;39:1376-80. Lilli lliss KA, Jaf Jaffe fe DM. Pre Prehos hospit pital al int intrav raveno enous us acc access ess in 23. Li children. childr en. Ann Emerg Med 1992;21:1430-4. Fuchs chs S, La LaCov Covey ey D, Pa Pari riss P. A pr preho ehospi spital tal model of 24. Fu intraosseous infusion. Ann Emerg Med 1991;20:371-4. Guy y J, Ha HaleyK, leyK, Zu Zusp span an SJ SJ.. Useof in intr trao aosse sseou ouss in infu fusi sion on in th the e 25. Gu pediatric trauma patient. J Pediatr Surg 1993;28:158-61. 26. Wears RL, Winton CN. Load and go versus stay and play: analys ana lysis is of pre prehos hospit pital al IV flu fluid id the thera rapy py by com comput puter er simulation. Ann Emerg Med 1990;19:163-8. Teach h SJ, Antosia Antosia RE, Lund DP, et al. Prehospit Prehospital al flu fluid id 27. Teac therapy in pediat pediatric ric trauma patien patients. ts. Pediatr Emerg Care 1995;11:5-8. Prehospital spital intra intravenous venous fluid therapy in 28. Sadow KB, Teach SJ. Preho the pedi pediatr atric ic tra trauma uma pat patien ient. t. Cli Clin n Pedi Pediatr atr Eme Emerg rg Med 2001 2001;2: ;2: 23-7. 29. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patientss with blunt trauma. N Engl J Med 2000;343:94-9. patient 2000;343:94-9. Viccell cellio io P, Sim Simon on H, Pre Pressma ssman n BD, et al. A pros prospect pective ive 30. Vic multicen mult icenter ter stu study dy of cerv cervical ical spine inju injury ry in chi children ldren.. Pediatrics 2001;180:e20. Atabaki aki SM. Pre Prehos hospit pital al eva evaluat luation ion and mana manageme gement nt of 31. Atab traumatic brain injury in children. Clin Pediatr Emerg Med 2006;7:94-104. Covassi ssin n T, Swa Swanik nik CB, Sac Sachs hs ML. Epi Epidemi demiolog ologica icall con32. Cova siderations sidera tions of concuss concussions ions among interc intercollegi ollegiate ate athlet athletes. es. Appl Neuropsychol 2003;10:12-22. 10.
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NCCSIR. Eight NCCSIR. Eighteenth eenth Annual Report, Fall 1982-S 1982-Spring pring 2000. Chapel Hill (NC): Univer University sity of North Caroli Carolina; na; 2000. Baxt WB, Moody P. The impact of advanced prehospital care on the mortality of severely brain-injured patients. J Trauma 1987;27:365-9. Badj Ba djat atia ia N, Car Carney ney N, Cr Croc occo co TJ TJ,, et al. Gu Guid idel elin ines es fo forr prehospital management of traumatic brain injury, 2nd ed. Prehosp Emer Care 2007;12:S1-S52. Kupperm Kup permann ann N, Hol Holmes mes JF, Dayan PS, for the Pediatric Pediatric Emergenc Emer gency y Care Appl Applied ied Rese Research arch Netw Network ork (PEC (PECARN) ARN).. Identif Iden tifica icatio tion n of chi childr ldren en at ver very y low ris risk k of clin clinica icallyllyimportant import ant brain injur injuries ies after head trauma: a prospec prospective tive cohort study. Lancet 2009;374:1160-70. CantuR, Can tuR, VoyR. Se Secon cond d im impac pactt sy syndr ndrom ome: e: a ri risk sk in an any y spo sport rt.. Phys Sport Med 1995;23:27 1995;23:27-36. -36.
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Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement statem ent of the First Intern International ational Symposium Symposium on Concussion in Sport Sport.. Vienna 2001. Phys Sport Med 2002;30:57 2002;30:57-63. -63. Collins M, Stump J, Lovell MR. New developments in the management managem ent of sports concussion. concussion. Curr Opin Orthop 2004; 15:100-7. Izsak Izs ak E, Moo Moore re JL, Str String ingfel fellow low K, et al. Pre Prehos hospit pital al pai pain n assessment in pediatric trauma. Prehosp Emerg Care 2008;12: 182-6. Baxt C, Kassam-Adams N, Nance M, et al. Assessment of pain after aft er inj injur ury y in the ped pediat iatri ric c pat patien ient: t: chi child ld and par parent ent perceptions. J Pediatr Surg 2004;39:979-83. Zempsky Zemp sky WT, Cra Craver vero o JP. Relief of pai pain n and anxiety anxiety in pediatric patients in emergency medical systems. Pediatrics 2004;114:1348-56.
Abstract: Laboratory studies are often routiLaboratory nely obtained in the injured child. How broad a range of studies are needed and do they impact on the child's management? This article reviews the literature and makes recommendations for a simplified, cost-effective laboratory testing strategy.
Keywords: pediatric trauma; laboratory studies; intraabdominal injury
Do Routine Laboratory Tests Add to the Care of the Pediatric Trauma Patient? Jeffrey F. Linzer Sr, MD
L Reprint requests and correspondence: Jeffrey F. Linzer Sr MD, Departments of Pediatrics and Emergency Medicine, Emory University University Schoo Schooll of Medici Medicine, ne, Children’s Child ren’s Healthcare Healthcare of Atlant Atlanta, a, GA 30322.
1522-8401/$ - see front matter © 2010 Elsevier Elsevier Inc. All rights reserved.
aboratory tests are often obtained on children who have aboratory had ha d tr trau auma mati tic c in inju juri ries es.. Th Thes ese e te test stss ra rang nge e fr from om a comple com plete te blo blood od co coun untt (C (CBC BC)) to ser serum um che chemi mist stri ries es,, liver and pancreatic enzymes, coagulation studies, and urinalysis (UA). The primary purpose for obtaining these tests in the emergency department is either to (1) manage and monitor the unstable patient or (2) scree screen n the stable patient to determine the need for imaging studies. In som some e cir circu cums mstan tances ces,, the ind indica icatio tion n for sp speci ecific fic te testi sting ng is straig str aightf htforw orward ard.. Fo Forr exa examp mple, le, a typ type e and cro cross ss ma match tch for blo blood od would be indicated for the hemodynamically unstable patient. The decisi dec ision on to pro provid vide e ad addit dition ional al tre treatm atment ent or to obt obtain ain a com compu puter terize ized d tomographic (CT) study is often based on clinical evaluatio evaluation n and is made before these laboratory results are made available. 1,2 It is the patient who has had blunt trauma without obvious injury inj ury,, how howeve ever, r, whe where re the use of rou routin tine e lab labora orator tory y tes testing ting comes into question. Screening laboratory tests are most often used in these patients to determine the need for CT imaging. As ther th ere e is no now w gr grea eate terr re reco cogn gnit ition ion of th the e po pote tenti ntial al ri risk skss fr from om ionizing radiation, especially in younger children, the question of the use of laboratory testing to determine who needs imaging has become becom e a larger issue. A revie review w of the literature literature shows that there is no simple answer as to what test(s) may be of benefit. The routine use of trauma panels in pediatric trauma vic v ictims tims does 1-5 not appear to provide any significant clinical benefit. “
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LABORATORY TESTS IN PEDIATRIC TRAUMA CARE / LINZER • VOL. 11, NO. 1
URINALYSIS Alth Althou ough gh no te test st ha hass be been en sh show own n to be 10 100% 0% sensitive and specific, the UA appears to have some use in determining the presence of intraabdominal injury (IAI) in blunt trauma. There is controversy, however, as to the quantity of blood that needs to be present to determine the need for a CT scan. In adults who are not hypotensive and who have not had a decele deceleration ration entry, imagin imagingg is only indicate indicated d if there is frank hematuria. In a ret retros rospec pectiv tive e stu study dy by Qu Quinla inlan n and Gear6 hart, frank hematuria along with a low hematocrit correlated w ith severe renal injury. In a review by Stei St ein n et al al,,7 an any y de degr gree ee of he hema matu turi ria a wa wass an indication f or or radiographic imaging. Isaacman and colleagues8 found that there was a low prevalence of laboratory laborat ory abnormalities abnormalities in childr children en with mild to moderate trauma. Using a cutoff of greater than 5 red blood cells per high-power field (RBC/hpf), they found the physical examination, in a patient with a Glasgow Coma Score (GCS) of 12 or higher, along with the UA, had a sensi sensitivity tivity of 100%, specificity specificity of 64%,, and a negative predictive value of 100% for 64% IAI.8 In a prospective prospective study of children with blunt trauma, Holmes et al 9 also found an association of IAI with a UA with more than 5 RBC/hpf (odds ratio, 4.8; 95% confid confidence ence interval [CI], 2.7-8. 2.7-8.4). 4). 10 Tayl Ta ylor or et al fou found nd an ass associ ociati ation on bet betwe ween en abdominal symptoms and a UA with greater than 10 RBC/hpf, but noted that asymptomatic hematuria would have a low yield as an indicator f or or CT of the abdomen. Whereas Lieu and colleagues 11 found that more than 20 RBC RBC/hpf /hpf was ass associa ociated ted with higher high er yield intravenous pyelography, Abou-Jaoude et al12 found that using that same value missed 28% of genit genitourina ourinary ry tract injuries injuries or anomalies. Both groups of investigators believed that clinical judgment me nt wa wass va valu luab able le in de dete term rmin inin ingg th the e ne need ed fo forr radiographic imaging. Seve Se vera rall st stud udies ies,, how howev ever er,, hav have e sh show own n th that at a baseline of 50 RBC/hpf can be used to determine the need for acute radiog radi og raphic raphic imaging to evaluate for renal injury. Morey13 found that a CT scan was not indi indicat cated ed in pat patien ients ts wit with h min minor or abd abdomin ominal al trau tr auma ma if th ther ere e we were re le less ss th than an 50 RB RBC/ C/hp hpf. f. Th The e likelihood of significant genitourinary injuries w as as 2% in that group of patients. Perez-Brayfield et al14 also found that a CT was indicated in children with more than 50 RBC/hpf, who were hypotensive or had had a significant mechanism of injury (eg, highspeed deceleration injury). Stalker and colleagues15 found a direct relationship between the severity of renal injury and the degree of hematuria in that the higher the grade of injury the more RBCs that were
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seen in the UA. In that same study, children with blunt abdominal abdominal trauma who were not in shock and had ha d le less ss th than an 50 RB RBC/ C/hp hpff di did d not be bene nefi fitt fr from om radiographic imaging.
HEMATOLOGY A CBC, on the whole, provides little predictive informa info rmation tion reg regard arding ing the tra traum uma a pat patient ient.. Whi White te blood cell elevation is often encountered, usually due to the stress of the injury.3 However, there is no correl cor relati ation on bet betwee ween n ele elevat vation ion and the deg degree ree of injury. inju ry. In one study, study, 1% of pat patient ientss had platelet platelet coun co unts ts le less ss th than an 10 100 0 000 000/hpf /hpf,, but non none e req requir uired ed 1 platelet transfusions. Monito Monitoring ring platelet counts in hemodynamic hemod ynamically ally unsta unstable ble patie patients, nts, espec especially ially those who are receiving massive transfusions, may be of value. A low in init itia iall he hema matoc tocri ritt ma may y wa warn rn of ong ongoi oin ng hemorr hem orrhag hage e fro from m an occ occult ult ble bleed. ed. Hol Holmes mes et al9 foun fo und d an ini initi tial al va valu lue e of le less ss th than an 30% to be a predictor of IAI, whereas Cotton et al 5 found each unit decrease resulted in an 11% increase risk for IAI. Although a low hematocrit may imply the need for transfusion, patients will usually have signs of hemodynamic hemodynam ic ins instab tabilit ility y suc such h as tac tachyc hycard ardia ia or 1 hypotension. One must however keep in mind that hypote hyp otensi nsion on is a lat late e sign sign of sho shock ck in chi childr ldren. en. Ser Serial ial hematoc hem atocrit ritss may help in the monitorin monitoringg of sol solid id organ injuries.
SERUM CHEMISTRIES Liver transaminases (aspartate aminotransferase [AST] and ala [AST] alanin nine e ami aminot notran ransfer sferase ase [AL [ALT]) T]) are ofte of ten n us used ed as a sc scre reen en fo forr li live verr in inju jury ry.. Us Using ing recurs recu rsive ive partitioning partitioning retrospective analysis, Cotton 5 et al fo foun und d th that at 88 88% % of pa pati tient entss wi with th IA IAII we were re correctly identified when they had an AST more than 131 U/L with a hematocrit of less than 39% (sensi (se nsitiv tivity ity 100 100% % [95 [95% % CI, 90% 90%-100 -100%] %] and spe specif cifici icity ty of 87% [95% CI, 83%-91%]). An ALT of more than 105 U/L had similar findings. As other solid organ inju in jury ry,, su such ch as ki kidn dney ey an and d pa panc ncre reas as,, can al also so 16 produce elevated transaminases, Chu et al found that a higher value, AST of more than 200 U/L or ALT of more than 125 U/L, were predictors of liver injury. Holmes et al9,17 also identi identified fied these elevated elevated valu va lues es as am amon ongg the high-risk va vari riab ables les us used ed in th the e decision to image childre children for IAI. Keller and colleagues1 found that children with elevat ele vated ed tra transa nsamina minases ses wer were e mor more e lik likely ely to hav have e liver injury compared to children with normal levels (elevated vs normal: AST 12% vs 0%, ALT 17% vs 0%; P b .05). However, he determined that only levels of “
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VOL. 11, NO. 1 • LABORATORY TESTS IN PEDIATRIC TRAUMA CARE / LINZER
more than 400 U/L were predictive of liver injury. Because these levels were associated with patients who had other indications for imaging (eg, physical exami exa minat natio ion), n), th the e va value lue did no nott in influ fluen ence ce th the e decision for imaging studies or other interventions. In a review of various trau trauma ma panel studies, 3 Capraro Caprar o et al did not find either the AST or ALT to be of any value in predicting IAI or in determining the need for CT imaging. They found that AST had a sensit sen sitivi ivity ty of 63% (95% CI, 51% 51%-74 -74%), %), a neg negati ative ve predictive value of 71% (95% CI, 67%-82%), and a positive positi ve predictive value of 38% (95% CI, 29%-47%). Alanine aminotransaminase fared no better with a sensit sen sitivi ivity ty of 52% (95% CI, 41% 41%-64 -64%), %), a neg negati ative ve predictive value of 75% (95% CI, 67%-82%), and a positive predictive value of 4 of 48% (95% CI 37-60%). In the study by Isaacman et al,8 elevated AST and ALT levels lev els did not mak make e a sig signifi nifican cantt con contri tribut bution ion in predicting the presence of IAI or in determining the need for imagi imaging. ng. The use use of ser serum um amyl amylase ase and lip lipase ase for scre screeni ening ng of pancreatic injury in child hildren ren app appear earss to car carry ry 18 little use. Adamson et al found that although these values were elevated in pancreatic injury, there was no cost-benefit in using them as screening tests to determine the need for CT scanning. Simon et al 19 found fou nd tha thatt pan pancre creati atic c enz enzyme yme scr screen eening ing was of limit lim ited ed va valu lue e in th the e ini initi tial al as asse sess ssme ment nt of bl blun unt t 2 abdomi abd ominal nal tra traum uma. a. In add additi ition, on, Nam Namias ias et al di did d not find any correlation between serum amylase elevation and pancre pancreatic atic injury. Serum electrolytes also contribute very little in the eva evalua luatio tion n of the hem hemody odynam namica ically lly st stabl able e patient. pati ent. Altho Although ugh tran transient sient abno abnormal rmalities ities may occur, they are not usually clin clinically ically relevant and do not impact manag management. ement.2,4,8 “
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When When co comp mpare ared d to oth other er coa coagu gula latio tion n stu studie diess (activa (act ivated ted par partial tial thro thrombo mbopla plastin stin tim time e [PT [PTT], T], thromb thr ombin in tim time, e, ble bleedi eding ng tim time, e, pla platel telet et cou count, nt, fibrinogen, fibrin deg deg radation radation products, and hematocrit), Hymel et al20 found that prolongation of the prothrombin time (PT) was associated with parenchy ch ymal brain injury. In the review by Vavilala et al,22 a fibrin degradation product of more than 1000 μg/ g/mL mL wa wass as asso soci ciat ated ed wi with th a po poor or ou outc tcom ome e in children with a GCS betw een een 7 and 12. Holmess and colleag Holme colleagues ues25 ascer ascertained tained that children with a GCS of 13 or lower had an odds ratio of 8.7 8. 7 (9 (95% 5% CI CI,, 4. 4.33-17 17.7 .7)) of ha havi ving ng an el elev evat ated ed international intern ational normal normalized ized ratio ratio (INR) of 1.5 1.5 or higher or a PTT of 40 seconds or more. Keller et al 24 used PT, INR, and PTT in finding that 43% of the children in his review with intracranial injuries had coagulation abnormalities.
COST Based on the Centers for Medicare and Medicaid Servi Se rvices ces 200 2009 9 me media dian n for lab labora orator tory y tes testt cod code e fee schedule sche duless (Ta Tabl ble e 1), a traditional trau trauma ma pane panell consisting of a CBC, comprehensi comprehensive ve metabolic metabolic profile, amylase, amyl ase, lipas lipase, e, PT (incl (includin udingg INR) INR),, PTT TT,, an and d UA 26 (with microscopy) would cost $84.45. Hematocrit, AST, and UA would cost $21.12, whereas hematocrit and UA alone would cost $10.92. “
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SUMMARY AND RECOMMENDATIONS In the unstable trauma patient, hematocrit, type and cross match, PT, INR, and PTT are useful tests in managing the critically injured patient. Transamina mi nase ses, s, pa panc ncre reat atic ic en enzy zyme mes, s, an and d UA ar are e no not t
COAGULATION COAGUL ATION STUDIE STUDIES S Coagulopathy has been sho shown wn to be associated 20 with significant hea significant head d injuries and is a predictor of 21,22 poor out outcom come e. In a met meta-an a-analy alysis sis,, Har Harhan hangi gi 23 and colleag colleagues ues fo foun und d th that at 1 in 3 pa pati tien ents ts wi with th traumatic brain injury was at risk for developing a coagul coa gulopa opathy thy and tha thatt the pre presen sence ce abn abnorm ormal al coagulation studies was an independent predictor of prognosis (odds ratio of mortality 9.0 [95% CI, 7.3-11.6] and unfavorabl unfavorable e outcome 36.3 [95% CI, 18.7-70.7]). Keller et al24 found that children with a GCS of less than 14 after traumatic brain injury appeared to be at the greatest risk of developing a coagulopathy (7% for a G CS CS of 15 vs 67% for GCS 14; P b .05). Keller et al24 also found an inverse relationship between decreasing GCS and the risk of coagu coagulopath lopathy. y.
TABLE 1. Laboratory charges. CBC without differential Hematocrit Basic metabolic profile Comprehensive metabolic profile Hepatic function profile AST ALT Amylase Lipase PT PTT Urinalysis (dip) UA (automated with microbiology)
$12.77 $4.67 $16.70 $20.86 $16.12 $10.20 $10.44 $12.79 $13.59 $7.75 $11.84 $6.25 $6.25
Based on mid Based midpoi point nt val value ues s pu publi blishe shed d by Ce Cente nters rs fo forr Medicare and Medicaid Services, revised January 2009.26
LABORATORY TESTS IN PEDIATRIC TRAUMA CARE / LINZER • VOL. 11, NO. 1
necessary in determining the need for a CT scan becaus bec ause e ima imagin gingg dec decisi isions ons are typ typica ically lly bas based ed on the physical status of the patient. Holding blood for later use (eg (eg,, bloo blood d sam samples ples obta obtaine ined d dur during ing vas vascul cular ar access acc ess)) if the CT sca scan n sho shows ws liv liver er or panc pancrea reatic tic injury is cost-effective cost-effective and does not adversely affect patient management.27 In th the e he hemo mody dyna nami mica call lly y st stab able le ch chil ild, d, no labo la bora rato tory ry te test stss ar are e ne need eded ed to de dete term rmin ine e th the e need ne ed fo forr ra radi diog ogra raph phic ic im imag agin ingg if the there re ar are e an any y physica phys icall fin finding dingss of abd abdomi ominal nal inju injury, ry, inc includ luding ing tendern tend erness ess and con contus tusion, ion, or a pos positiv itive e Foc Focus used ed Ass Asses essm smen entt by So Sonog nogra raph phy y in Tr Trau auma ma (F (FAS AST) T) examin exa minati ation. on. The phy physic sical al exa examin minati ation on alo alone ne is clearly the best dete determinant rminant for the need for CT imaging ima ging for IAI IAI..5,8,28 In th the e ch chil ild d wi with th bl blun untt tr trau auma ma to th the e th thor orax ax with wi thou outt an any y ph physi ysica call fi find nding ingss an and d a ne nega gati tive ve FA FAST ST,, a hematoc hem atocrit rit and UA should be obt obtain ained. ed. It is not unre un reas ason onab able le to ob obta tain in an AS AST T or AL ALT T in th this is scenario. Imaging is indicated if the hematocrit is less than 30%, UA has 50 RBC/hpf or more, AST is more than 200 U/L, and/or ALT is more than 125 U/ L. A pr preg egna nanc ncy y te test st (u (uri rine ne or se seru rum) m) sh shou ould ld be obtaine obta ined d on eve every ry fem female ale pat patient ient of rep reprod roduct uctive ive potential age. Prothrombin time, INR, and PTT have demonstrated value in monitoring patients with a GCS of less than 14.
10.
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Keller MS, Coln CE, Trimble JA, et al. The utility of routine trauma laboratories in pediatric trauma resuscitations. Am J Surg 2004;188:671-8. 2. Namias N, McKenney MG, Martin LC. Utility of admission chemist chem istry ry and coag coagulat ulation ion pro profil files es in tra trauma uma pati patient ents: s: a reappraisal of traditional practice. J Trauma 1996;41:21-5. 3. Capraro AJ, Mooney D, Waltzman ML. The use of routine laboratory studies as screening tools in pediatric abdominal trauma. Pediatr Emerg Care 2006;22:480-4. laboratory 4. Tasse JL, Janzen ML, Ahmed NA, et al. Screening laboratory and radiology panels for trauma patients have low utility and are not cost effective. effective. J Trauma 2008;65:1114-6. 2008;65:1114-6. Cotton ton BA, Lia Liao o JG, Burd RS. The utility utility of cli clinica nicall and 5. Cot laboratory labora tory data for predic predicting ting intraabdominal intraabdominal injury among children. childre n. J Traum Trauma a 2005;58:13 2005;58:1306-7. 06-7. Quinlan nlan D, Gea Gearha rhart rt J. Blu Blunt nt ren renal al tra trauma uma in chi childho ldhood. od. 6. Qui Feat Fe atur ures es in indi dica cati ting ng sev sever ere e in inju jury ry.. Br J Ur Urol ol 19 1990; 90;66 66:: 526-31. 7. Stein J, Kaji D, Eastham J, et al. Blunt trauma in the pediatric population: indications for radiographic evaluation. Urology 1994;44:406-10. 8. Isaacman DJ, Scarfone RJ, Kost SI, et al. Utility of routine laboratory testing for detecting intra-abdominal injury in the pediatric trauma patient. Pediatrics 1993;92:691-4. 9. Holmes JF, Sokolove PE, Brant WE, et al. Identification of children childre n with intra-abdominal intra-abdominal injuries after blunt trauma trauma.. Ann Emerg Med 2002;39:5 2002;39:500-9. 00-9.
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Taylor GA, Eic Taylor Eichelb helberg erger er MR, Pot Potter ter BM. Hem Hematu aturia ria:: a mar marker ker of abdominal injury in children after blunt trauma. Ann Surg 1988;208:688-93. Lieu Lie u TA, Fleisher Fleisher GR, Mah Mahboub boubii S, et al. Hematuria Hematuria and clinical clinic al findi findings ngs as indica indicators tors for intrav intravenous enous pyelography in ped pediat iatri ric c blu blunt nt re renal nal tra trauma uma.. Ped Pediat iatric ricss 1988 1988;82 ;82:: 216-22. Abou-Jao Abou -Jaoude ude WA, Sug Sugarm arman an JM, Fal Fallat lat ME, et al. Indi Indicato cators rs of genitourinary tract injury or anomaly in cases of pediatric blunt trauma. J Pediatr Surg 1996;31:88-90. Morey AF, Bruce JE, McAninc McAninch h JW. Effic Efficacy acy of radiog radiographic raphic imaging in pediatric blunt renal trauma. J Urol 1996;156: 2014-8. Perez-Brayf PerezBrayfield ield MR, Gatti Gatti JM, Smith Smith EA, et al. Blunt Blunt dramat dramatic ic hematuria and children. Is a simplified algorithm justified. J Urol 2002;167:2543-7. Stalker Sta lker HP, Kau Kaufma fman n RA, Ste Stedje dje K. The sig signif nifica icance nce of hematuria hematu ria and childr children en after blunt abdominal trauma. Am J Roentgenol 1990;154:569-71. Chu FY, Lin HJ, Guo HR, et al. A reliable screening test to pre predict dict liver inj injury ury in pedi pediatr atric ic blu blunt nt tor torso so tra trauma uma.. Eur J Trauma Emerg Surg 2009; doi:10.1007/s00068-009doi: 10.1007/s00068-0099034-z.. 9034-z Holmes JF, Mao A, Awasthi S, et al. Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Ann Emerg Med 2009;54: 528-33. Adamson WT, Hebra A, Thomas PB, et al. Serum amylase and lipase alone are not cost-effective cost-effective screening methods for pedi pediatr atric ic panc pancreat reatic ic tra trauma uma.. J Ped Pediat iatrr Sur Surgg 2003 2003;38: ;38: 354-7. Simon Si mon HK HK,, Mu Muehl ehlbe berg rg A, Li Linak nakis is JG. Se Seru rum m amy amylas lase e determination determi nationss in pediatric patients presenting presenting to the ED with wi th acu acute te abd abdomi ominalpain nalpain or tr trau auma ma.. Am J Eme Emerg rg Me Med d 199 1994; 4; 12:292-5. Hymel Hym el KP, Abshire Abshire TC, Luckey DW, et al. Coagulopa Coagulopathy thy in pedi pediatr atric ic abus abusive ive head tra trauma uma.. Ped Pediat iatric ricss 1997 1997;99: ;99: 371-5. Miner ME, Kaufman HH, Graham SH, et al. Disseminated intravascular intra vascular coagul coagulation ation fibri fibrinolyti nolytic c syndrom syndrome e follow following ing head injury in children: frequency and prognostic implications. J Pediatr 1982;100:687-91. Vavilala Vavi lala MS, Dun Dunbar bar PJ, Riv Rivara ara FP, et al. Coag Coagulo ulopat pathy hy predic pre dicts ts poo poorr out outcom come e fol follow lowing ing head inj injury ury in chi childre ldren n less than 16 year yearss of age. J Neu Neuros rosurg urg Anesth Anesth 2001 2001;13: ;13: 13-8. Harhangi BS, Kompanje EJ, Leebeek FW, et al. Coagulation disorders after traumatic brain injury. Acta Neurochir 2008; 150:165-75. Keller Kell er MS, Fendya DG, Web Weber er TR. Glasgow Glasgow Coma Scale predicts coagulopathy in pediatric trauma patients. Semin Pediatr Surg 2001;10:12-6. Holmes Hol mes JF, Goo Goodwi dwin n HC, Land C, et al. Coa Coagul gulati ation on tes testin tingg in pediatr pedi atric ic blun bluntt tra trauma uma pat patien ients. ts. Ped Pediat iatrr Eme Emerg rg Car Care e 2001 2001;17: ;17:324324-8. 8. Centers Cente rs for Medi Medicare care and Medic Medicaid aid Serv Services. ices. Medicare Medicare clinical clinic al labora laboratory tory fee schedul schedule e (09CLA (09CLAB.Zip). B.Zip). Available at: http://www.cms.hhs.gov/ClinicalLabFeeSched/02_clinlab. asp#TopOfPage.. Accessed October 12, 2009. asp#TopOfPage Bryant MS, Tepas JJ, Talbert JL, et al. Impact of emergency room laboratory studies on the ultimate triage and disposition of the injured child. Am Surg 1988;54:209-11. 1988;54:209-11. Miller D, Garza J, Tuggle D, et al. Physical examination as a reliable reliab le tool to predic predictt intraintra-abdomi abdominal nal injur injuries ies in braininjured injur ed children. Am J Surg 2006;192:738-42. 2006;192:738-42.
Abstract: With the introduction of faster computerized tomography (CT), this radiographic modality has become widely used for the evaluation of the pediatric trauma patient. There is a substantially increased increa sed dose of ionizi ionizing ng radiat radiation ion associated associ ated with CT compare compared d to plain radiography. Multiple studies have demonstrated that the younger the patient at the time of exposure, the higher the radiation dose to the organs org ans.. Hig Higher her org organ an rad radiat iation ion dos doses es have been linked with an increased cancer can cer ris risk. k. The ind indisc iscrim rimina inate te use of CT in the evaluation of the pediatric trauma patient is therefore associated with an increased risk for cancer in this population. population. This article's articl e's objective is to review the relative risks and benefits associated with this radiographic modality.
Radiographic Evaluation of the Pediatric Trauma Patient and Ionizing Radiation Exposure
Keywords: CT scan; pediatric trauma; radiation risk
Ricardo R. Jiménez, MD
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Reprint requests and correspondence: Ricardo R. Jiménez, MD, Pediatric Emergency Medicine Attending, University of South Florida Affiliated Faculty, All Children's Hospital, 801 6th St South, Saint Petersburg, FL 33701.
[email protected] 1522-8401/$ - see front matter © 2010 Elsevier Elsevier Inc. All rights reserved.
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can th can them em un unti till th they ey gl glow ow sai said d the sur surge gery ry atte at tend nding ing on my fi firs rstt tr trau auma ma ca case se dur durin ingg my medical school surgery rotation. What he meant was that when dealing with a trauma patient, the overuse of computerized tomography (CT) was acceptable. But what about the glow part? Trauma is a leading cause of death in the pediatric population. A systema systematic tic detailed evaluation is necessa necessary ry in the management of th the e pe pedi diat atri ric c tr trau auma ma pa pati tien ent. t. Th The e go goal al of th the e tr trau auma ma eval ev alua uati tion on is th the e ac accu cura rate te an and d ea earl rly y id iden enti tifi fica cati tion on of li life fe-threatening injuries while ensuring the safety of the patient. A larg la rge e pa part rt of th the e tr trau auma ma ev eval alua uati tion on is im imag agin ing, g, an and d it ha hass revol re voluti utioni onized zed th the e wa way y we pr prac actic tice e me medi dicin cine. e. Th The e im imag aging ing eval ev aluat uatio ion n ca can n ra rang nge e fr from om pl plai ain n ra radi diog ogra raph phy y of an inj injur ured ed extremity to a head, neck, and/or abdominopelvic CT scan. In the last decade, with the invention of faster CT technology and with the widespread availability of CT in most hospitals, there has been a substantial increase in its use as part of the trauma evaluation. evaluat ion. In a recent study, the use of CT increased from 12.8%
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to 22.4% from fro m 1995 to 2003 in the evaluation of head trauma.1 Furthermore, 11.2% of the CTs done in the U nited nited States were on patients 0 to 15 years 2 of age. Howeve How ever, r, rad radiog iograp raphic hic eva evalua luatio tion n is not an innocuo inn ocuous us pro proced cedure ure and bea bears rs some ris risk. k. Dia Diaggnostic radiography carries an exposure to ionizing radiat rad iation ion,, ran rangin gingg fro from m fai fairly rly low dos doses es in pla plain in radi ra diog ogra raph phy y to mu much ch hi high gher er do dose sess wi with th CT CT.. Exposu Exp osure re to hi high gh le leve vels ls of ion ioniz izing ing ra radi diat atio ion n is proven to increase the risk for cancer development later in life, especially leukemia, leukemia, breas breastt cance cancer, r, and thyroid thyr oid can cancer cer.. Unf Unfort ortunat unately, ely, chi childre ldren n are more susce sus cepti ptible ble to ra radia diati tion on eff effec ects ts tha than n ad adult ults. s.2-5 Chernob Che rnobyl yl and Hir Hiroshi oshima ma surv survivo ivorr stud studies ies hav have e demon de monst stra rate ted d an in incr crea ease se ca canc ncer er ri risk sk in t he he pediat ped iatric ric pop populat ulation ion whe when n comp compare ared d to adu adults. lts.6,7 Furthermore, an association has been shown with age at the time of exposure and cancer risk; the youn you nge gerr th the e pa pati tient ent at ex expo posur sure, e, th the e hi highe gherr th the e risk.8 Conside Considerr this, actively replic replicating ating cell lines willl ha wil have ve a hi high gher er ri risk sk of mu mutat tatio ion; n; th this is ri risk sk is increased by ionizing radiation. It is important to be aware that the radiation dose to an organ is energy deposit dep osited ed div divide ided d by mass mass;; the theref refore ore,, the gre greate aterr the mass, the lower the dose to the organ. Now, also consi co nside derr th that at th the e ac actu tual al do dose se of ra radi diat ation ion to an organ is affected by the distance to the radiation source, for example, if an organ is proximal to the radi ra diat atio ion n sou sourc rce, e, th the e do dose se wi will ll be hi high gher er;; as th the e source rotates and the organ is now distal and is partially shielded by body tissue, the dose to that organ org an wil willl be low lower er.. Be Beca cause use ch chil ildre dren n ar are e sti still ll undergoing underg oing development, they carry more repli replicatcating cells lines than adults, and because children are often oft en thin thinner ner tha than n the their ir adu adult lt cou counte nterpa rparts rts,, it is easy ea sy to und under ersta stand nd wh why y th they ey ha have ve a hi highe gherr ri risk sk associated associa ted with ionizing radiation radiation exposur exposure. e. In th the e pa past st ye year ars, s, th the e ma main in so sour urce ce of th this is ra radi diat atio ion n was env enviro ironme nmenta ntal, l, ave avera ragin gingg 3 mSv an annua nually lly depending on where the person lives. The typical single singl e CT radiation exposure ranges from 1 to 14 mSv.9 With the increased use of imaging studies, medical diagnostic evaluation has become a major source with CT accou acco unting for 67% of the diagnostic radiation radiatio n exposur exposure. e.2 Comp Compute uted d tomo tomogra graphy phy has become for many the imaging study of choice in the ev evalu aluat ation ion of the ped pedia iatri tric c tr traum auma a pat patien ient, t, takin ta kingg the pla place ce of pla plain in ra radi diogr ograp aphy hy in th the e evaluation evaluat ion of head and neck injuri injuries es and perito peritoneal neal lava la vage ge in th the e ev evalu aluat atio ion n on ab abdo domin minal al inj injur urie ies. s. Although other modalities such as ultrasound and magneti magn etic c res resonan onance ce ima imagin gingg car carry ry no ioni ionizing zing radiation exposure, their use in the evaluation of the pediatric trauma patie patient nt remains unclear.
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Recentl Rece ntly, y, the there re ha hass be been en inc incre reas ased ed con conce cern rn regard reg arding ing the asso associat ciation ion of dia diagnos gnostic tic rad radiat iation ion expo ex posur sure e an and d th the e ri risk sk fo forr ca canc ncer er.. Wi With th th the e in incr creas eased ed use of CT in the care of children, we have to ask if this risk outweighs the benefits and consider shortterm benefits vs long-term effects. Lastly, is it really necessary to scan them until they glow?
HEAD INJURY EVALUATION Trauma Trau ma is a le lead adin ingg ca caus use e of de deat ath h in th the e pe pedi diat atri ric c population, and head trauma is i s the most common reason rea son for dea death th or disa disabili bility. ty.10 Ac Accor cordin dingg to the Center for Disease Control and Prevention, there are ar e ro roug ughly hly 65 650 0 00 000 0 ho hosp spit ital al vi visi sits, ts, 30 3000 00 de deat aths, hs, an and d 50 000 0 00 hospitalizations associated with head injuries.11 Most head injuries are classified as mild. In the absence of validated clinical criteria that can identif ide ntify y wit with h 100 100% % sens sensiti itivit vity y tho those se pat patien ients ts wit with h intracranial injury (ICI), the trauma physician often relies on imaging studies to assess the extent of the head injury. Initially, skull radiography was used to detect fractures after a head injury, followed with a CT if the x-ray detected a fracture. The presence of skull fractures in a skull rad radiograph iograph is one of the 12 stronge str ongerr pre predict dictors ors of ICI ICI.. Sku Skull ll x-r x-ray ayss ha have ve a sensitivity of 65% and 83% negative predictive value and are better better for detecting detecting horizontal horizontal fractur fractures es that the CT can miss. Unfort Unfortunately unately,, skull x-rays cannot detec de tectt und under erlin lining ing bra brain in inj injury ury.. Hea Head d CT ha hass beco be come me th the e te test st of ch choic oice e fo forr th the e ev eval aluat uation ion of head hea d inj injury, ury, esp especi ecially ally sin since ce the int introd roduct uction ion of helical CT, which is much faster and minimizes the need for sedatio sedation. n. Computed tomography is clearly a better tool for the evaluation of head injury, as it detects not only skull fractures but also ICI. Of course, it carries a higher level of ionizing radiation exposure and an increase in cancer risk. In the absence of a set of validated criteria that could reliably identify those patients with very low risk for ICI, the use of head CT has increased dramatically for the past decade. The problem lies in the overuse of CT in those head injured patients who have a very low risk for ICI, which some studies suggest range range from 40% to 60% of patients with head trauma.13-16 When comparing ionizing radiation exposure associated with skull xrayss vs CT, there is a not ray notice iceable able differen difference ce wit with h doses from plain radiographs ranging from 0.02 to 10 mGy and doses from CT ranging from 5 to 20 mGy.5 To pu putt th this is in pe pers rspe pect ctiv ive, e, we sh shou ould ld remembe rem emberr tha thatt the annu annual al bac backgr kground ound rad radiat iation ion exposure in the Unit Uni t ed ed States averages 3 mSv and 9 that 1 mSv = 1 mGy. Therefore, radiation exposure
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associated with head CT is not only higher but is also additive to backg backgroun round d radiation. Brenner and colleagues3,4 have estimated organ doses associated associated with CT use; the dose is depend dependent ent on th the e ac actua tuall mi milli lliam ampe pere re se sett ttin ingg us used ed in th the e scanner. The relationship between dose and milliampere is linear. When the setting used was 200 mAs, the organ radiation dose to the brain from one head he ad CT ra rang nged ed fr from om 15 to 65 mG mGy; y; th the e hi high ghes estt do dose se wass as wa asso socia ciate ted d wi with th th the e you young nges estt pa pati tien ents. ts. Th The e organ dose remained the same after 15 years of age and incre increased ased directly propor proportional tional to decre decreasing asing pati pa tient ent age. Conversely, in a study by Jimenez et 17 al whe where re ant anthro hropomo pomorph rphic ic pha phantom ntomss wer were e use used d to quantify the organ doses after head and neck CT, the pituitary organ radiation dose in the 1-year-old phantom was 21.25 mGy, whereas in the 5-year-old 5-year-old phan ph anto tom, m, it wa wass 33 33.8 .8 mG mGy. y. It is im impo port rtan antt to recognize that there are data supporting an incre as ase e 18 in individ individu ual cancer risk with these dose ranges. Brenner3 wa wass ab able le to ex extr trap apol olat ate e a li life feti time me attrib att ributa utable ble can cancer cer ris risk k asso associa ciated ted to the org organ an doses from a single head CT. The attributable risk was estimated to be highest in those younge youngerr than 2 year ye ars, s, wi with th a on one e in 20 2000 00 ri risk sk fo forr th the e de deve velo lopm pmen entt of canc ca ncer er as assoc socia iate ted d wi with th a si sing ngle le he head ad CT CT.. It is importa imp ortant nt to und underst erstand and tha thatt rad radiat iation ion dose dosess are cumulative and will increase with the number of exposu exp osure res, s, and als also, o, the at attri tribut butab able le ri risk sk is a function of the scanner setting used (in this case 200 mAs). When evaluating for the pediatric trauma vict vi ctim im fo forr he head ad in inju jury ry,, we ne need ed to as ask k if th the e diagn dia gnost ostic ic be bene nefit fitss of CT ima imagin gingg out outwe weigh igh th the e radiation risk. For those children with a mechanism of injury or clinical findings indicative of a higher risk for ICI, the answer is yes. As discussed earlier, 40% to 60% of the children who wh o re rece ceiv ive e a CT as pa part rt of th the e he head ad in inju jurry evaluation are considered minor trauma, and only about abo ut 10% of the these se ch child ildre ren n wil willl ha have ve a pos positi itive ve findin fin ding. g. Th This is lar large ge dis discr crepa epancy ncy in the lar large ge num number ber of CTs an and d the small num numbe berr of pos positi itive ve fin findin dings gs in children with minor head trauma is associated with the lac lack k of va valid lidate ated d cr crite iteri ria a tha thatt wil willl ide identi ntify fy pat patien ients ts with a very low risk for ICI. Recent data obtained by the Ped Pediat iatri ric c Eme Emerge rgency ncy Ca Care re App Applie lied d Res Resea earch rch Networ Net work k (PE (PECARN CARN)) pre presen sented ted a ver very y pro promisi mising ng prediction rule for identifying children at very low risk of ICI. This prospective cohort study analyzed more than 42 000 children with minor head injury divi di vidi ding ng th them em in 2 gr grou oups ps,, yo youn unge gerr th than an 2 ye year arss an and d2 to 18 yea years rs of ag age. e. PEC PECARN ARN investig investigat ator orss use used d a pred pr edic icti tion on ru rule le to id iden enti tify fy th thos ose e wi with th ve very ry lo low w ri risk sk fo forr ICI. IC I. Fo Forr th thos ose e yo youn unge gerr th than an 2 ye year ars, s, th the e ru rule le in incl clud uded ed normal norm al ment mental al stat status, us, no scal scalp p hema hematoma toma except “
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frontal, no loss of consciousness or loss of consciousness less than 5 seconds, nonsevere injury mechanism, no palpable skull fracture, and acting normally as pe perr pa pare rent nts. s. In th the e 2 to 18 ye year arss gr grou oup, p, th this is decision rule included normal mental status, no loss of consciousness, no vomiting, no severe headache, nonsevere injury mechanism, and no signs of basilar skull fracture. The younger-than-2-year-old rule had a negative predictive value and sensitivity of 100% and an d th the e 2- to 18 18-y -yea earr-ol old d ru rule le ha had d a ne nega gati tive ve predicti predi ctive ve va valu lue e of 99 99.9 .95% 5% an and d se sens nsit itiv ivit ity y of 96.8%.19 This is the largest and most comprehensive study evaluating minor head injury. The study was able to validate a prediction rule that would serve to identify those children at very low risk of ICI and those for whom a head CT may be obviated for the trauma evaluation as the risk for ionizing radiation will outweigh the benefits.
NECK INJURY EVALUATION The evaluation of the cervical spine for cervical spine injury (CSI) is an integral part of the pediatric trauma patient evaluation. Cervical spine injuries can have severe deleterious deleterious effects if left untreated, untreated, from fro m per permane manent nt neu neurolo rologic gic def defect ectss to dea death. th. Because ca use CS CSIs Is ar are e ve very ry ha hard rd to ev eval aluat uate e cl clini inica cally lly,, radiographic radiog raphic evaluation evaluation has been an integr integral al part of the tra traumat umatic ic cer cervic vical al spin spine e eva evaluat luation. ion. Con Conven ven-tional tio nal 3-v 3-view iew (an (anter teropo oposte sterior rior,, lat latera eral, l, odo odonto ntoid) id) cervical cervic al spine plain radiographs radiographs are a standa standard rd part of th the e ne neck ck in inju jury ry ev eval alua uati tion. on. Bot Both h ad adult ult an and d pediatric literature supports the use of neck CT for the evaluation of CSI as it yields a hig her her detection rate rat e and is mor more e cost cost-ef -effec fectiv tive. e.20-23 Cer Cervic vical al CT alon al one e ha hass be been en sh show own n to ha have ve a se sens nsit itiv ivit ity y of 98 98% % fo forr CSIs;; in con CSIs contra trast, st, con conven ventio tional nal rad radiiogra ograph phy y ha hass 24,25 been shown to miss up to 57% of CSIs. Keenan et al22 and Blackmore et al23 both support the use of cervical CT for the evaluation of high-risk patients, which whi ch in inclu clude de alt alter ered ed men mental tal sta status tus or foc focal al neuro ne urolo logi gic c de defi fici cit. t. An in incr creas ease e in the use of CT and its use without the use of plain radiog ra diog raphy raphy has been noted in the evaluation of CSIs. 19,26 The adult literature recommendations for clearing the cervical spine after a traumatic injury seem to agree that those patients classified as high risk should be evaluated with a cervical spine CT. The most common criteria used in the adult literature to classify a patient as high risk are focal neurologic defici def icitt and alt altere ered d men mental tal sta status tus.. A ped pediat iatric ric 27 literature review by Slack and Clancy suggested a similar approach in clearing the cervical spine in children as that in adults. Cervical spine injuries are rare rar e in the ped pediat iatric ric tra trauma uma pat patien ient. t. The lar largest gest
RADIOGRAPHIC EVALUATION AND IONIZING RADIATION EXPOSURE / JIMÉNEZ • VOL. 11, NO. 1
study eva study evaluat luating ing CSI in the ped pediat iatric ric pop popula ulation tion,, The Th e Na Nati tiona onall Emerg ergenc ency y X-r X-ray ay Util Utiliza izatio tion n Stud Study y (NEXUS) group,28 fou found nd a CS CSII inc incide idenc nce e ra rate te of 0.98% 0.9 8% in th the e pe pedi diatr atric ic pop popula ulati tion on com compa pare red d to 2.54% 2.5 4% in adu adults. lts. The difference difference in pre prevale valence nce of CSI between the pediatric and adult population is probably associated with the anatomical and physiologic iolo gic dif differ ferenc ences es that exi exist st amo among ng the them. m. Thes These e differences are more prominent in those younger than 8 y ea ears rs bu butt pe pers rsis iste tent nt in th thos ose e 8 to 12 29,30 years. The Th e NE NEXU XUS S de deci cisi sion on ru rule le ha hass be been en shown to be 100% sensitive in the detection of CSI in the pediatric population. The decision rule used by the NEXUS group includes changes in sensorium, intoxication, intoxic ation, focal neurolo neurologic gic defici deficits, ts, distra distraction ction injury, and midline cervical tenderness. With the low incidence of CSI in the pediatric population and a decision rule that can potentially identify those pedi pe diat atri ric c pa pati tien ents ts at lo lowe werr ri risk sk,, is th ther ere e a ne need ed to us use e CT as a scr scree eenin ningg to tool ol to cle clear ar th the e ce cerv rvic ical al spi spine ne an and d if so what is the risk? Once again, the risk has to be measured against the ben benefi efits. ts. It has alr alread eady y bee been n est establi ablishe shed d tha that t there is a substantial increase in ionizing radiati on exposure associated with CT use. Jimenez et al17 studied the amount of radiation exposure between plain neck radiography and neck CT using anthropomorphic phantoms representing a 1-year-old and a 5-year-old. This study directly collected the dose received by certain organs in the neck, specifically the thyroid which is recognized as one of the most radiosensitiv radiosensi tive e or orga gans ns in th the e bo body dy.. Ji Jime mene nezz an and d 17 colleagues found that in the 1-year phantom, the radiat rad iation ion received received to the thyroid thyroid fro from m a CT was 385 times (59.28 mGy) that from a 3-view neck xray, ra y, an and d in th the e 55-ye year ar ph phan anto tom, m, th the e ne neck ck CT provided a dose 164 times greater (52. 3 mGy) than that fro from m con conven ventio tional nal rad radiog iograp raphy. hy.19 Again, Again, it appear app earss tha thatt the you younge ngerr the pat patien ient, t, the hig higher her the ra radi diat ation ion or orga gan n dos dose. e. Int Inter erest esting ingly ly en enoug ough, h, 17 Jimenez et al also found that the organ dose to the thyroid from a head CT was higher than that of a 3-view conventional neck x-ray, which is concerning as some patients receive both a h ea ead d and neck neck 19 CT as part of the trauma evaluation. Brenner3,4 hass al ha also so co confi nfirm rmed ed tha thatt th the e or orga gans ns th that at re rece ceiv ive e most of the radiation secondary to a head CT are the brain and thyroid. Studies Stu dies abo about ut Che Chernob rnobyl yl and Hir Hirosh oshima ima surv survivo ivors rs have reported an increase in thyroid cancer in the pediatric population with a significant linear association between radi radiation ation dose and cancer risk.6,7,31 Furthermore, Ron32 repor reported ted that the age at time of exposure was strongly linked to the risk for thyroid cancer, with those younger than 15 years having the
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strongest associa strongest association. tion.33 With the increased use of CT for the evaluation of neck injury, it is important to evalu evaluate ate the the risk for thyr thyroid oid canc cancer er lat later er in lif life e for those patien patient t s who are exposed. In the study by Jimenez et al,17 the excess relative risk for thyroid cancer was calculated. Those younger than 5 years appear to have a higher risk of developing thyroid cancer can cer,, with those you younger nger than 1 year doublin doubling g 19 their cancer risk with only one CT.
ABDOMINAL EVALUATION Bluntt tr Blun trau auma ma ac acco coun unts ts fo forr 90 90% % of ch chil ildh dhoo ood d injurie inju ries, s, and alt althoug hough h onl only y 10% of the these se inj injuri uries es involve the abdomen, abdominal abdominal injuries are one of those thos e most comm commonly only miss missed. ed.33 The gen genera erall approach for the evaluation of pediatric blunt abdominal trauma is based upon the clinical status of the patien pat ient. t. Abd Abdomi ominal nal CT is wel welll acc accep epted ted as the standa sta ndard rd dia diagno gnosti stic c too tooll for the eva evaluat luation ion of abdomi abd ominal nal inj injuri uries. es. Thi Thiss woul would d sig signif nify y tha thatt most children childr en evalua evaluated ted for intraintra-abdomin abdominal al injuri injuries es will undergo a CT, which of course is associated with radiati rad iation on exp exposur osure e to the abd abdomi ominal nal org organs. ans. Rec Recent ent-ly, a prediction rule for the identification of children with intra-abdominal injury has been validated; it showed good sensitivity but was unable to identify 100% 100 % of the chi childr ldren en wit with h int intrara-abd abdomin ominal al inj injuu34,35 ry. In this same study, the authors estimated that when these 6 high-risk variab variable le predi prediction ction rules were used appropriately, it would decre decrease ase the 34,35 number of ab of abdomina dominall CTs by one third third.. 3,4 Brenner evalua eva luated ted the rad radiat iation ion exp exposu osure re associa asso ciated ted with an abd abdomin ominal al CT and found that the organs that were most affected were the liver and the stomach. The doses range ranged d between 12 and 25 mGy at 200 mAs. Once again, this relation is linear and can be scaled up or down depending on the mAs use used d in a spe specifi cific c sca scanne nner/e r/exami xaminati nation. on. The relationship between organ radiation dose and age were again inversely proportional, putting the youngest children at highest risk. When the estimated risk risk for developing developing cancer cancer was calculated, calculated, the digest dig estive ive org organs ans wer were e the most affected, affected, and the canc ca ncer er ri risk sk in incr crea ease sed d as th the e ag age e at ex expo posu sure re decrea dec reased sed.. The est estimat imated ed life lifetim time e ris risk k was fou found nd to be small, ranging ranging from 1/2000 to 1/1000 in the youngest patients.3,4 In the last decade, the use of focused assessment with sonography for trauma (FAST) by emergency physicians for the evaluation for abdominal trauma of the adult patient has become more accepted. The use of FAST has been shown to shorten the time to the th e opera peratin tingg ro room om in the uns unsta table ble tr trau auma ma pa pa-35,36 tient. The Ame Americ rican an Col Colleg lege e of Eme Emerge rgency ncy “
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Physician Physici an has issu issued ed gui guideli delines nes tha thatt str strongl ongly y encourage cour age the ava availa ilabili bility ty and use of FA FAST ST in th the e 36,37 evaluation of the trauma patient. It is understand sta ndabl able e tha thatt FAS FAST T co could uld de decr crea ease se th the e use of abdominal CT, reducing the organ radiation exposure. However, the use of FAST for the evaluation of the pediatric trauma patient has not been widely accepted, and there are no clear guidelines for its use in children. The reported sensitivity of FAST in the pediatric population ranges from 31% to 100%, and it appears to perform well in the detect d etect ion ion of 37-39 free fre e flu fluid id in the hyp hypote otensi nsive ve pa patie tient nt.. More studies are needed that support the use of FAST in the pediatric trauma patient before guidelines can be dev devised ised for its reg regular ular implementa implementatio tion n in the pedia pe diatr tric ic po popu pulat lation ion.. Th This is is a too tooll th that at wil willl hopeful hope fully ly help reduce reduce the use of abd abdomin ominal al CT, thus, reducing the risk for cancer.
SUMMARY Computed Compute d tomo tomogra graphy phy has bec become ome one of the most frequently used diagnostic tools in the evaluation tio n of the pediatric pediatric trauma trauma pat patien ient. t. The There re is an inhere inh erent nt ris risk k ass associ ociate ated d wit with h ion ionizi izing ng rad radiat iation ion exposur exp osure e seco seconda ndary ry to CT use, and chi childr ldren en are more susceptible than adults to the development of radiation-induced cancer. Although the risk may be low an and d th the e be bene nefit fitss ma may y gr grea eatl tly y out outwei weigh gh th the e ri risk sk in certai cer tain n cas cases, es, such as thos those e chi childre ldren n with more sever sev ere e in inju juri ries, es, it is im impo porta rtant nt to we weig igh h th the e ri risk sk vs th the e bene be nefi fitt fo forr ev ever ery y pa pati tien ent. t. Exp Exposi osing ng a ch child ild to a radiat rad iation ion dos dose e tha thatt inc increa reases ses the ris risk k for can cancer cer without a proven diagnostic advantage is no longer acceptable. accept able. This practice is also contrary to ALARA (as low as rea reasona sonably bly achi achieva evable) ble) that ack acknowl nowledg edges es that no level of diagno diagnostic stic radiation is without risks. Scan Sca n the them m unti untill the they y glo glow w vio violate latess the ALAR ALARA A concept and is not an appropriate approach to the evaluation of the pediatric trauma patient. “
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Health risks from exposure to low levels of ionizing radiation: BEIR VII Phase 2. Washington, DC: The National Academic Press; 2001. American ican Acad Academy emy of Pedi Pediatri atrics cs Comm Committe ittee e on Envi Environron6. Amer mental men tal He Healt alth. h. Ris Risk k of ion ionizi izing ng rad radiat iation ion exp exposu osure re to children chil dren:: a subje subject ct revi review. ew. Pedi Pediatri atrics cs 1998 1998;101( ;101(4 4 Pt 1):717-9 1):717-9.. 7. Kazakov VS, Demidchik EP, Astakhova LN. Thyroid cancer after Chernobyl. Nature 1992;359:21. 8. Her Herna nande ndezz JA, Ch Chupi upik k C, Swi Swisch schuk uk LE. Cer Cervic vical al spi spine ne traum tra uma a in chi childr ldren en und under er 5 yea years: rs: pro produc ductiv tivity ity of CT. Emerg Radiol 2004;10:176-8. 9. Ionization radiation exposure of the population of the United States Sta tes.. Rep Report ort no. 93: Nat Nation ional al Cou Counci ncill on Rad Radiat iation ion Protecti Prot ection on and Mea Measure suremen ments. ts. Bet Bethesd hesda a (Md (Md): ): Nati Nationa onall Council on Radiation Protection and Measurements; 1987. National nal Cen Center ter For Inju Injury ry Prev Preventi ention on and Control. Trau10. Natio matic Brain Injury in the United States: a report to Congress. Atlanta Atlanta (Ga) (Ga):: Cen Center ter for Dise Disease ase Contr Control ol and Prev Preventi ention; on; 1999. 11. Centers for Disease Control and Prevention. 2000 National Ambulatory Medical Care Survey, Emergency Department File Fil e 200 2002. 2. Hya Hyatts ttsvil ville le (Md (Md): ): Nat Nation ional al Ce Cente nterr for Hea Health lth Statistics; 2002. Schutz utzma man n SA, Bar Barne ness P, Duh Duhaim aime e AC. Eva Evalua luatio tion n and 12. Sch manageme mana gement nt of chil children dren younger younger than two year yearss old with apparently minor head trauma: proposed guidelines. Pediatrics 2001;107:983 2001;107:983-93. -93. Dunnin nings gs J, Dal Daly y JP, Lomas Lomas JP, et al. De Deriv rivati ation on of the 13. Dun child ch ildren ren's 's he head ad inj injury ury alg algori orith thm m for th the e pre predic dictio tion n of importan impo rtantt clin clinical ical events decision decision rule for head injury in children. Arch Dis Child 2006;91:885-91. 14. Greenes DS, Schuztman SA. Clinical indicators of intracranial inju injury ry in head head-inj -injured ured infa infants. nts. Pedi Pediatri atrics cs 1999 1999;104: ;104: 861-2. 15. Palchak MJ, Holmes JF, Vance GW, et al. A decision rule for identifying children at low risk for low brain injuries after blunt head trauma. Ann Emerg Med 2003;43:493-506. 16. Quayle KS, Jaffe DM, Kuppermann N, et al. Diagnostic testing for acu acute te he head ad inj injury ury in chi childr ldren: en: wh when en are com comput puted ed tomograp tomo graphy hy and skul skulll rad radiogr iograph aphss indi indicate cated. d. Ped Pediat iatrics rics 1997;99:1-8. 17. Jimenez RR, DeGuzman MA, Shiran S, et al. CT versus plain radiog rad iograp raphs hs for eva evalua luatio tion n of c-s c-spin pine e inj injury ury in you young ng children chil dren:: do bene benefits fits outwe outweigh igh risks risks.. Pedi Pediatr atr Rad Radiol iol 2008 2008;; 38:635-44. 18. Pie Pierce rce DA, Shi Shimiz mizu u Y, Pre Presto ston n DL, et al. Studies Studies of the mortal mor tality ity of ato atomic mic bom bomb b sur surviv vivors ors.. Re Repor portt 12, par partt 1. Cancer: 1950-1990. Radiol Res 1996;146:1-27. 19. Kupperman N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injures after head trauma: a prospective cohort study. Lancet 2009; 374:1160-70. 20. Nuñez DB, Zuluaga A, Fuentes-Bernardo DA, et al. Cervical spine spi ne tra traum uma: a: how muc much h mor more e do we lea learn rn by rou routin tinely ely usi using ng helical CT. Radiographics 1996;16:1307-18. Nuñe ñezz DB DB,, Qu Quen ence cerr RM RM.. Th The e ro role le of he heli lica call CT in th the e 21. Nu assessment of cervical spine injuries. AJR Am J Roentgenol 1998;171:951-7. Keenan an HT, Hollin Hollingshe gshead ad MC, Chun Chungg CJ, et al. Using CT 22. Keen of the ce cervi rvica call spi spine ne for ea early rly eva evalua luatio tion n of ped pediat iatric ric patients pati ents with head trau trauma. ma. AJR Am J Roen Roentgen tgenol ol 2001 2001;; 177:1405-9. 23. Blackmore CC, Ramsey SD, Mann FA, et al. Cervical spine screening with CT in trauma patients: a cost-effectiveness analysis. Radiology 1999;212:117-25. 5.
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Borock EC, Sheryl GA, Lenworth MJ, et al. A prospective analysis of a two-year experience using computed tomography as an adjunct for cervical spine clearance. J Trauma 1991;31:1001-6. Nuñez BA, Adel A. Clearing the cervical spine in multiple trauma tra uma vic victim tim:: a tim time-e e-effe ffecti ctive ve pro protoc tocol ol usin usingg hel helica icall computed tomography. Am Soc Emerg Radiol 1994;1:273-7. Shiran S, Jimenez R, Altman D, et al. Evaluation of C-spine HRCT. Pediatr Radiol 2005 [abstr]. Slack SE, Clancy Clancy MJ. Clearing Clearing the cervical cervical spine of paediatri paediatric c trauma patients. Emerg Radiol J 2004;21:273-7. Viccel Vic cellio lio P, Sim Simon on H, Pre Pressm ssman an BD, et al. A pro prospe specti ctive ve multice mul ticente nterr stud study y of cer cervic vical al spi spine ne inj injury ury in chi childre ldren. n. Pediatrics 2001;108:e20 2001;108:e20.. d'Amato C. Pediatric spinal trauma: injuries in very young children. Clin Orthop Related Res 2005:34-40. Fesmir Fes mire e FM, Lut Luten en RC RC.. The ped pediat iatric ric cer cervic vical al spi spine: ne: developmental anatomy and clinical aspects. J Emerg Med 1989;7:133-42. Sadetzki S, Chetrit A, Lubina A, et al. Risk of thyroid cancer after aft er chi childh ldhood ood exp exposu osure re to ion ionizi izing ng rad radiat iation ion for tin tinea ea capitis. J Cli Endocrinol Metab 2006;91:4798-804. Ron E. Let's not relive the past: a review of cancer risk after diagnostic or therapeutic irradiation. Pediatr Pediatr Radiol 2002;32: 739-44.
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Saladino RA, Lund DP. Abdominal trauma. In: Fleisher GR, Ludwig S, eds. Textbook of pediatric emergency medicine, 5th ed. Phila Philadelp delphia hia (Pa): Lipp Lippinco incott tt Willia Williams ms & Wilki Wilkins; ns; 2006. p. 1453-62. Holm lmes es JF JF,, Ma Mao o A, Aw Awas asth thii S, et al al.. Va Vali lida dati tion on of a 34. Ho prediction rule for the identification of children with intraabdomina abdo minall inju injuries ries after blunt torso trau trauma. ma. Ann Emerg Med 2009;54:528-33. 35. Rozycki GS, Feliciano DV, Schmidt JA. The role of surgeonperform per formed ed ultr ultrasou asound nd in pat patien ients ts wit with h poss possible ible car cardia diac c wounds. Ann Surg 1996;223:737-46. 36. Amer American ican College of Emer Emergenc gency y Physi Physician cians. s. Use of ultra ultra-sound imaging by emergency physicians. Ann Emerg Med 2001;38:470-81. Mateer eer JR JR.. Ped Pediatr iatric ic app applic licati ations. ons. In: Pri Price ce DP, 37. Ma OJ, Mat Peterson MA, eds. Emergency ultrasound, 2nd ed. Columbus (Ohio): McGraw-Hill Companies; 2003. p. 464-89. 38. Mut Mutab abag agan anii KH KH,, Co Cole ley y BD BD,, Zu Zumb mber erge ge N. Pr Prel elim imin inar ary y experience with focused abdominal sonography for trauma (FAST) (FA ST) in ch child ildren ren is it use useful ful.. J Ped Pediat iatrr Sur Surgg 199 1999;3 9;34: 4: 48-52. Holmes es JF, Bra Brant nt WE, Bon Bond d WF. Eme Emerge rgency ncy dep depart artmen ment t 39. Holm ultrasonograph ultrason ography y in the evalua evaluation tion of hypote hypotensive nsive and normotensive children with blunt abdominal trauma. J Pediatr Surg 2001;36:968-73. 33.
Abstract: The acutely injured child poses unique clinical challenges in many respects. Our understanding of these unique characteristic differences and ability to care for pediatric trauma patients patien ts has greatly improved over recent decad decades; es; however, however, one one area in pediatric pediat ric trauma care continues to suffer from relative neglect in research and shows few signs of improvement improve ment in clinical practice: practice: analgesia. Studies of analgesia practices continue to describ describe e pervas pervasive ive undertreatment of pain in the pediatric trauma patient. A growing body of evidence evidenc e suggests that poorly controlled tro lled acu acute te pai pain n (olig (oligoan oanalge algesia) sia) not only causes suffering suffering but may lead l ead to both immediate complications that worsen outcomes as well as debilitating chronic pain syndro syndromes mes that are often refractory to available treatments. This article will provide a review of pain in injured children with respectt to its pathophysiology, respec pathophysiology, clinical ramifications, and patterns of analgesia analge sia practic practices. es. Impedim Impediments ents to analgesia are examined regarding multiple providers of care for the acutelyy injured child including preacutel hospitall person hospita personnel, nel, nurses, and physicians sici ans.. Fin Finally ally,, the arti article cle will pro provide vide analgesia recommendations with an approach to pain relief and sedation for the injure injured d pediat pediatric ric patient.
Keywords:
Analgesia for the Pediatric Trauma Patient: Primum Non Nocere? Michael Greenwald, MD
E
valuati valua ting ng pai pain n in the tr traum auma a pat patie ient nt po poses ses uni unique que challe cha llenge ngess as it may sim simult ultane aneous ously ly inv involv olve e bot both h somatic and visceral pain from a variety of origins. The pain response is a complicated process that may evolve from fro m acu acute te (no (normal rmal)) to chr chronic onic (ma (malad ladapt aptive ive)) pai pain n with per persist sistent ent or repetitive exposure to injury-provoked pain. This is true for patients of any age; however, children appear especially vulnerable to the harmful effects of oligoanalgesia. Understanding how both acute and chronic pain occurs may help us better control and prevent the pain responses that can cause harmful changes after injury. A comprehensive description of pain physiology in the pediatric trauma patients is beyond the scope of this article. Instead, Instea d, we will focus focus on select select concep concepts ts of the pain response response,, how the pediatric patient's response to injury and pain are unique, and how chronic pain syndromes are thought to occur. These painrelat re lated ed iss issues ues inc includ lude e vi visce scera rall vs som somat atic ic pa pain, in, the str stress ess response, hypersensitivity vs habituation, central nervous system (CNS) plastic plasticity, ity, hyper hyperalgesia algesia,, and centra centrall sensiti sensitization. zation.
oligoanalgesia; oligoanalgesia; pain; pediatric; pediatric; trauma Pediatrics and Emergency Medicine, Emory Univer University sity School School of Medicine Medicine,, ChilChildren’s Health care of Atlanta, Atlanta, Atlanta, GA. Reprint requests and correspondence: Michael Greenwald, MD, 1604 Clifton Rd NE, Atlanta, GA 30322 30322..
[email protected] 1522-8401/$ - see front matter © 2010 Published by Elsevier Inc.
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KEY CONCEPTS OF PAIN PATHOPHYSIOLOGY IN THE INJURED CHILD Visceral vs Somatic Pain Somatic and vis Somatic viscera cerall pai pain n syst systems ems hav have e dis distinc tinctt phy physiol siologic ogic and clinical features. Cutaneous somatic innervation is more dense and an d li limi mite ted d to a fe few w sp spina inall se segm gment ents; s; th ther eref efor ore, e, cu cutan taneo eous us som somati atic c pain is better localized and characterized by specific sensations. Deep somatic pain (muscles, joints) resembles resembles visceral pain in its dull nature and poor localization. Visceral organs are innervated
ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
by 2 sets of nerves: vagal and spinal nerves nerves or pelvic and spinal nerves. Most internal organs are innervate va ted d by th the e va vagu guss ne nerv rve; e; ho howe weve ver, r, it itss ro role le in tran tr ansmi smitt ttin ingg pa pain in si sign gnals als is not ye yett cl clea ear. r. Mo Most st viscera visc erall aff affere erent nt fib fibers ers are thi thinly nly myel myelina inated ted or unmye unm yelin linat ated ed pr prov ovid idin ingg a du dull ll and dif diffic ficult ult to describe sensation. Visceral pain has poor localization tio n as inp input ut is typi typical cally ly dis distri tribut buted ed ove overr seve several ral spinal segments. This leads to similar pain sensations from nociceptive activity in unrelated organs (eg,, uri (eg urinar nary y bla bladde dderr and colon, gal galll bla bladde dderr and heart). Visceral nerves receive convergent somatic input (skin, muscle) resulting in referred pain to unrelated sites (eg, retrosternal pain to the neck, cardiac ischemic pain to neck, shoulder, or jaw). The str stronge ongerr emot emotiona ionall and aut autonom onomic ic rea reacti ctions ons seen with visceral pain may reflec reflectt the involv involvement ement of the ant anteri erior or cing cingula ulated ted gyr gyrus, us, amyg amygdal dala, a, and insular cortex. Last, visceral nociceptor activation can occur even in the absence absen ce of tissue damage (eg, functional abdominal pain).1,2
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investigators found that the control group demonstrat str ated ed hig highe herr lev levels els of str stress ess hor hormon mones es (e (eg, g, hyperglycemia, lactic acidemia), greater incidence of sepsis and dissemi disseminated nated intravascular intravascular coagulopathy, and had a 27% mortality rate. The intervention ti on (m (med edic icat ation ion)) gr group oup ha had d no in incr crea ease se in pulmonar pulm onary y or cir circula culatory tory comp complica lication tionss and no deaths. The results starkly contradicted prevailing wisdo wi sdom m at th the e ti time me an and d we were re so re rema marka rkable ble the study was ended prematurely as it was considered too ri risky sky to co cont ntinu inue e pr prac acti tici cing ng th the e st stan anda dard rd of ca care re.. Finally, behavioral changes seen in patients with poorly controlled pain include crying, agitation, and sleep disturbance. In one study, children in a burn unitt wer uni were e fou found nd to hav have e pos posttr ttraum aumati atic c str stress ess disorder symptoms inversely related to the amount of morphine adminis administered tered 6 months prior at their 6 initiall present initia presentation. ation. Thus, many physiologic, biochemical, and behavioral changes associated with poorly controlled pain are the very consequences of injury we hope to prevent and control to facilitate healing and preve prevent nt harmful outcomes.
The Stress Response Acu Acute te pa pain in re resul sults ts in a st stre ress ss re resp spon onse se th that at manifests in physiologic, biochemical, and behavioral changes associated with hemodynamic instabilit bi lity y an and d po poor or wo wound und he heali aling ng.. In Infa fant ntss ar are e particularly partic ularly vulnerable to chang changes es in intracr intracranial anial pressures related to fluctuations in systemic vascular pressures because of an immature blood brain barrier. Autonomic responses to acute pain lead to fluctuations in heart rate and blood pressure. These respo re spons nses es ma may y di dimi minis nish h wi with th pe pers rsist isten entt pa pain in an and d ar are e often not a reliab reliable le marker for the presen presence ce of pain. Pain is also ass associa ociated ted wit with h hyp hypove oventi ntilati lation on tha that t may ma y le lead ad to hy hypo poxi xia. a. Th This is ma may y ex expl plai ain n th the e seemingly paradoxical effect of improving respiratory function in critically ill patients when wh en treating their pain with effective doses of opioids. 3,4 Persis Per siste tent nt or sev sever ere e pa pain in is ass assoc ociat iated ed wit with h eleva ele vated ted lev levels els of “ str stress ess horm hormone oness” su such ch as catech cat echolam olamines ines,, gluc glucago agon, n, gro growth wth hor hormone mone,, and lacta lac tate te and ke keton tones, es, whe where reas as ins insuli ulin n le level velss ar are e suppressed. suppres sed. Neonat Neonatal al catec catecholamine holamine and metabo metabolic lic responses are 3 to 5 times greater than those in adults undergoing similar types of surgery. One of the most significant clinical studies on the harmful effects of poorly control controlled acute pain was reported by Ana Anand nd and Hickey Hickey 5 in 1992. At the time the standard of care in anesthesia held that neonates would woul d exp experi erienc ence e wor worse se outc outcomes omes if pro provid vided ed a compar com parabl able e lev level el of ane anesthe sthesia sia dur during ing sur surger gery. y. 5 Anand and Hickey conducted a trial with neonates requirin requ iringg cong congenit enital al hea heart rt dise disease ase rep repair. air. The
Hypersensitivity vs Habituation One of the clinical hallmarks of a healthy adult's response to pain is the ability to habituate. That is, with repeated or prolonged exposure to a similar stimulus, the the autonomic autonomic responses responses tend to lessen. lessen. In contrast, contra st, younger patie patients nts tend to demonstrate just the opposite. This is classically found with the heel prick of a neonate. With repeated exposures, the infan inf antt ex exhib hibit itss a low lower er pa pain in th thre resho shold ld (i (ie, e, mo more re br brisk isk 7 flexor response) and autono autonomic mic labilit lability. y. Similarly, older children report increased perception of pain if preceded by repeated painful experiences. 8 On a co conc ncep eptua tuall le leve vel, l, the re reaso ason n why in infan fants ts may differ in a pain experience lies in the difference in underst und erstand anding ing and pro process cessing ing the mea meaning ning of a painful experience. This is one of the most challenging areas to explore; it is unlikely we will ever know kno w how inf infant antss per percei ceive ve a pain painful ful exp experie erience nce.. Pain experiences experiences have both physic physical al and emotional components that affect the reaction. Our cognitive maturity allows us to attenuate the emotional and neurophysiologic response of a non–life-threatening injur inj ury. y. On One e ex exam ample ple is the pa pain in fr from om a per percu cuta tane neous ous needle nee dle ins insert ertion. ion. The pai pain n exp experi erience enced d fro from m tra trauma uma assoc ass ocia iate ted d wi with th a ne need edle le in inser serti tion on is li like kely ly sim simila ilarr on an ana anatomi tomical cal lev level el in dif differ ferent ent age aged d ind indivi ividua duals. ls. The pain stimulates the same nociceptors, results in the release of similar neurotransmitters, and travels on the same neural pathways to similar areas of the brain. A healthy, mature individual should recognize the source of the pain as something that has a
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ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
positive purpose (to improve health) and a limited duration and intensity. Even the adult with needle phobia will recognize that the pain experienced will dissipate dissipa te and and not recur recur without warning warning.. Infants Infants and to a le lesse sserr ex exte tent nt ch chil ildr dren en la lack ck th this is pe pers rspe pect ctiv ive. e. Th This is may also help explain why the stress response to the same pain stimulus is more brisk brisk and and intense in less mature or adapti adaptive ve individ individuals. uals.7 There are severa severall possibl possible e physiolo physiologic gic explanations for this phenomenon. One of the important components of pain physiology is modulation. Pain respo re spons nses es ar are e ei eith ther er amp amplif lifie ied d or at atte tenua nuate ted d at the th e le leve vell of th the e do dors rsal al ho horn rn of th the e sp spin inal al co cord rd through thro ugh the rele release ase of exc excitat itatory ory and inh inhibit ibitory ory neurotr neur otransmi ansmitte tters. rs. Less mat mature ure pat patien ients ts hav have e a relative deficiency of inhibitory neurotransmitters and some inh inhibi ibitor tory y neu neurotr rotransm ansmitte itters, rs, such as -Aminobutyric yric acid (GABA), (GABA), hav have e an exc excitat itatory ory γ-Aminobut 7 effect in the premature infant. Anot Anothe herr ex expl plan anat ation ion lie liess at hig highe herr lev levels els in a process pro cess kno known wn as int integr egrati ation. on. Whe When n pai pain n sig signals nals ascend to the brain, they are distributed distributed to multiple supraspinal centers including the reticular activating system, olivary, paraventricular, and thalamic nuclei; nuc lei; limb limbic ic syst system; em; cin cingula gulate te and post postcent central ral gyrus; frontal and parieto-occipital areas. At these levels, the pain signal is integrated and processed. Pain is identified by its localization and characteristics. The information is matched with memories of past pa st ex expe peri rien ence cess th that at in tu turn rn me medi diat ate e le leve vels ls of arousal, attention, attention, and sympathetic responses. responses. In laborat lab oratory ory stu studie dies, s, less mat mature ure subj subject ectss dem demononstrate less inhibitory pathway activation compared to more mature mature subj subject ects. s. It is hyp hypoth othesiz esized ed tha that t recognition recogn ition of nonharmful painful stimuli can aid in blunting the pain signal. This ability logically relates to experiences and and age and is inherently deficient in younger patients.9
Central Nervous System Plasticity One of the gre greate atest st con concer cerns ns reg regard arding ing olig oligoaoanalg na lges esia ia in yo youn ungg pa pati tien ents ts is th the e po pote tent ntia iall fo forr altering the developing CNS. The plasticity of the nervous system is now recognized in all age groups butt is th bu thoug ought ht to ha have ve a pa part rticu icula larly rly pr prof ofou ound nd impac imp actt on you young ng ch child ildre ren n be beca cause use the they y hav have e rapidly rapidl y develo developing ping nervous systems. Pain resea researchrchers have demonstrated that poorly controlled and repetitive repeti tive exposure to pain has a unique and lasting negative impact on the CNS of young patients and that this eff effect ect is pot potent entiall ially y mor more e pro profoun found d with less maturity. In lab labora oratory tory studies studies of rat pups, the rep repeat eated ed exposure to pain results in morphologic changes at
the site of injury and the dorsal horn of the spinal column. These changes may be temporary or long lasting. They are seen at a variety of levels including change cha ngess in pro protei tein n phos phospho phoryla rylatio tion, n, alt altere ered d gen gene e expre ex pressi ssion, on, los losss of neu neuron rons, s, for format mation ion of ne new w synaps syn apses, es, and los losss of inh inhibi ibitor tory y int intern erneur eurons ons.. Local tissue damage in the early postnatal period results in profound and lasting sprouting of sensory nerv ne rve e te term rmina inals ls (A & C fi fibe bers) rs) an and d sp sprou routi ting ng of neighboring dorsal root ganglia cells in the spinal cord cor d lea leadin dingg to ina inappr ppropr opriat iate e fun functio ctional nal con connec nec-tions tio ns and hyp hyperi erinnn nnnerv ervati ation. on. Cli Clinic nicall ally, y, the these se change cha ngess res result ult in allod llodynia ynia and oth other er fea featur tures es of 10 neuropathic pain. Repeti Rep etitiv tive e pai pain n also app appear earss to acc accele elerat rate e apo apo-ptosis. This refers to the “pruning ” of unused neural pathways. Although this is a normal phenomenon durin dur ingg in infa fanc ncy, y, it app appea ears rs to be ac acce cele lera rate ted d in labora lab orator tory y ani animals mals subj subject ected ed to rep repeat eated ed pai painful nful stimuli. Finally, pain is associat associated ed with activ activation ation of -methyl methyl -aspartate -aspart ate (NMDA) receptors recept ors located on N D neurons neu rons.. The rec recept eptor or is act activa ivated ted by glut glutama amate te ++ + resulting in an influx of Ca and Na activating a Ca++–calmodulin complex. This leads to production of hea heatt sho shock ck pr prote oteins ins tha thatt ca cause usess lys lysoso osome me degranulation and necrosis of the nerve cell. The activation of NMDA receptors is thought to contribute to the development of chronic pain syndromes. Intere Int eresti sting ngly, ly, thi thiss pr proc ocess ess is in inhib hibite ited d wi with th the administration of opioids as well as “NMDA receptor antagonists” such as ket ketami amine, ne, met methad hadone one,, and 11,12 nitrous oxide. Clinical evidence of these changes is found in the association of chronic conditions conditio ns with exposure to pain pa infu full st stim imul uli. i. An Anan and d et al13 descr described ibed how functional abdominal pain is seen in higher rates in for former mer pr prema ematur ture e in infan fants ts who ex expe perie rienc nced ed freque fre quent nt gas gastri tric c suc suctio tionin ning. g. Stud Studies ies usi using ng PET scans sc ans ha have ve re reve veal aled ed th that at th the e an ante teri rior or ci cing ngula ulate te cortex is particularly affected by pain. This area is associa asso ciated ted wit with h con control trol of emo emotio tion n and att attent ention ion and may help explain why premature infants who experience experi ence more medica medicall complic complications ations exhibit a highe hig herr ra rate te of ps psych ychoso osocia ciall dis disord order erss suc such h as attention atten tion defic deficit it hyper hyperactiv activity ity disord disorder er (ADHD (ADHD)) and low lower er ac acad ade e mic ac achie hieve vemen mentt com compar pared ed to 14 matched controls.
Pathways to Chronic Pain: Hyperalgesia, Central Sensitization, and Sympathetically Mediated Pain Multip Mu ltiple le pat pathway hwayss are desc describ ribed ed to exp explain lain the developme develo pment nt of chr chronic onic pai pain n aft after er inju injury. ry. The These se mechanisms include hyperalgesia from local inflammatory markers, sensitization of neurons proximal
ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
to and sur surroun roundin dingg dam damage aged d ner nerves ves,, and symp sympaathetically thetic ally mediate mediated d pain. After After an inj injury ury,, inf inflam lammat matory ory med mediat iators ors ar are e re re-leased that may cause the pain response to increase even ev en in th the e ab abse senc nce e of ad addi diti tion onal al in inju jury ry.. Th This is sensitization of nociceptors results in primary hyperalgesi alg esia a at the sit site e or inj injury ury.. Pri Primar mary y hyp hypera eralge lgesia sia manifests clinically as a more intense pain response than expected from stimuli. Secondary hyperalgesia may ma y de deve velo lop p in th the e ar area ea su surr rrou ound ndin ingg th the e ar area ea of in inju jury ry as a result of sensitization of neurons in the CNS. This centra cen trall sen sensiti sitizat zation ion occ occurs urs whe when n rec recept eptors ors tha that t normal nor mally ly con conduc ductt non nonpai pain n sig signal nalss (eg (eg,, tou touch) ch) now transm tra nsmit it pa pain in sig signal nals. s. Whe When n non nonpai painfu nfull sti stimul mulii suc such h as touch result in a pain response the condition is called allodynia. Clinical examples of this include the severe and diffuse pain associated with burns (light touch), pharyngi phar yngitis tis (swal (swallowin lowing), g), arth arthriti ritiss (move (movement) ment),, and in more unusual conditions conditions such as compl complex ex regi regional onal pain pai n syn synd d r ome (for (formerl merly y refle reflex x sympa sympathet thetic ic dystrophy).15 Hypera Hyp eralge lgesia sia may also res result ult fro from m dam damage aged d or severed nerves. Instead of a diminished pain signal, Wallerian Wallerian degeneration degeneration of the severed nerve may result res ult in sens sensiti itizati zation on of noc nocice icepto ptors rs in adj adjace acent nt nerves (primary hyperalgesia) and increase spontaneous activity of adjacent nociceptors resulting in central sensitization (secondary hyperalgesia). This paradoxical pain response manifests in the clinical syndrome of neuropathic pain. Symptoms include intense burning and electrical sensations sensation s that are often refractory to opioids in usual doses. 15 As noted above, nociceptor stimulation is often associated with a resulting increase in sympathetic activi act ivity. ty. In some cir circums cumstan tances ces,, the rea reacti ction on revers rev erses: es: noci nocicep ceptor torss may dev develop elop sens sensiti itivit vity y to catecholamines. This is known as sympathetically maintained maintai ned pain. In these condit conditions, ions, trauma (even seemingly trivial trauma) provokes a pain response that features not only hyperalgesia but also allodynia. The classic example is complex regional pain syndrome synd rome tha that, t, in the ped pediat iatric ric pat patien ient, t, typ typica ically lly involves the lower extremity of school-age girls and is of ofte ten n as asso soci ciat ated ed wit with h ed edem ema a an and d dr dram amat atic ic 15 changess in cutaneous perfu change perfusion. sion.
Summary of Neurophysiologic Reponses to Pain Pain resp responses onses appear heig heighten htened ed in young younger er patien pat ients ts whose whose CNS is more vuln vulnera erable ble to phy physiol siologogic stress. Repetit Repetitive ive and persistent persistent pain is associated associated with morphologic changes of the nervous system at multiple levels. Analgesics have a neuroprotective effect effe ct by dec decrea reasing sing exhi exhibit bitory ory neu neurotr rotransm ansmitte itterr activity, increasing inhibitor inhibitory y neurotran neurotransmitters, smitters,
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and stab stabiliz ilizing ing neur neurons. ons. The cli clinic nical al res result ult may includ inc lude e a low lower er inc incid idenc ence e of sep sepsis sis,, met metab aboli olic c acidosis, disseminated intravascular coagulopathy, and death. Given this information, it appears that pain pa in co cont ntro roll is im impo port rtan antt fo forr al alll pa pati tien ents ts an and d particularly the youngest. Ironically, studies of our clinical practice reflect just the opposite.
ANALGESIC PRACTICE FOR PEDIATRIC TRAUMA PATIENTS Most of the information available regarding pain management for pediatric trauma patients focuses on iso isola late ted d in inju juri ries es an and d bur burns ns.. Th Ther ere e ar are e mor more e studie stu diess ad addr dress essing ing pai pain n man manag ageme ement nt for ad adult ult trau tr auma ma pa pati tien ents ts th than an fo forr ch child ildre ren. n. In ge gener neral al,, studies on analgesia practice in medicine over the pastt sev pas severa erall dec decade adess rev reveal eal per pervas vasive ive pat patter terns ns of appare app arent nt und undert ertrea reatmen tment. t. In thi thiss sec section tion,, we will examine the following aspects of clinical practice. What What are the patterns patterns of ana analge lgesia sia for ped pediat iatric ric patien pat ients? ts? Wha Whatt are the pat patter terns ns of ana analge lgesia sia for trau tr auma ma pa pati tien ents ts? ? Wh What at ar are e som some e of th the e imp imped edim iment entss to pro provid viding ing ana analge lgesia sia for ped pediat iatric ric tra trauma uma pat patien ients? ts?
Analgesia for Children This ye This year ar ma mark rkss a de deca cade de si sinc nce e th the e Jo Join int t Commissi Comm ission on on the Acc Accred redita itatio tion n of Hea Healthc lthcare are Organi Org anizat zations ions cit cited ed ina inadeq dequat uate e ana analge lgesia sia as the first fi rst no nond ndise iseas ase e he healt althc hcar are e cr cris isis is in th the e Uni Unite ted d States Sta tes.. Its re respo sponse nse to thi thiss pr probl oblem em inc includ luded ed numerous guidelines, resources, and requirements to assess and tre treat at pain. Despite Despite this effo effort, rt, it is unclear whether we have seen improvement in the clinical practice of pain management for children. Pain Pai n re resea searc rch h sin since ce th the e 19 1970 70ss de descr scrib ibes es how children are given analgesics less often than adults for similar conditions and prescr prescribed ibed approximateapproximately 50% of the wei weight ght-ba -based sed equ equiva ivalen lentt of ana analge lge-16-18 sics. Furthermore, the milligram per kilogram dosing of analgesics is generally directly related to age, that is, younger patients receive lower milligram gr am pe perr kil kilogr ogram am dosi dosing ng reg regar ardle dless ss of cl clin inic ical al 19 20 situation. In 1996, Broome et al reported that younger children received inconsistent pain assessmentt and mana men managem gement ent and tha thatt ins instit tituti utiona onall standa sta ndards rds reg regard arding ing pai pain n cont control rol wer were e oft often en ignored. That same year, Cummings et al 21 reported on children admitted to a Canad Canadian ian hospital, noting that 21% had uncontrolled pain and that children were offered analgesics analgesics less than prescribed prescribed (ie, prn medications available but not provided). Interestingly, some studies have shown that those with pediatric subspecialty training may provide less
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analgesia than th their eir generalist counterparts. In 2004, 22 Cimpello et al described this in a review of more than 700 children with fractures seen in 3 emergency departments (EDs) for 2 years. In this study, general emergenc emer gency y physi physician cianss presc prescribe ribed d more anal analgesi gesics cs and recomm rec ommend ended ed pa pain in tre treatm atment ent and adv advice ice on dis dis-charg cha rge e mor more e oft often en tha than n the their ir ped pedia iatr tric ic emer emergenc gency y medicine-trai medici ne-trained ned colleagu colleagues. es. Quinn23 des descri cribed bed a comparison of the use of local anesthetic for lumbar puncture in children and found an even more striking contrast contr ast betw between een those with and with without out pedi pediatri atric c subspe sub speci cialt alty y tra traini ining ng.. In thi thiss stu study dy of ch child ildren ren pres pr esen enti ting ng to di diff ffer eren entt ED EDss in Ba Balt ltim imor ore, e, 93 93% % of children treated by those without pediatric training receive rece ived d loca locall lido lidocai caine ne bef before ore lumb lumbar ar punc puncture ture,, wher wh erea eass on only ly 4. 4.5% 5% of ch chil ildr dren en pr pres esen enti ting ng to th the e childr chi ldren' en'ss hos hospit pital al ED rec receiv eived ed lid lidocai ocaine. ne. At the pediatric institution, those receiving lidocaine included 0 of 168 infants, 1 of 18 toddlers, and only 8 of 12 children older than 4 years. The treating physicians were we re as aske ked d wh whet ethe herr pa pain in wa wass ex expe peri rien ence ced d to th the e sa same me degree degr ee reg ardl ardles esss of ag age e an and d 51 51% % ag agre reed ed wi with th th this is 23 statement. In ad addi diti tion on to th the e pa patt tter erns ns fo found und in ped pedia iatr tric ic patients, studies of other specific demographic groups have also demo demonstra nstrated ted patt patterns erns of oligo oligoanalg analgesia esia.. Elder Eld erly ly pa patie tients nts (N70 yea years rs old old)) als also o re recei ceive ve les lesss 24 analgesia in the ED. Analgesia research by Todd et al25 has des descri cribed bed sign signific ificant ant ethn ethnic ic and rac racial ial dispar dis pariti ities es in the ad admin minist istrat ration ion of ana analge lgesia sia.. His Hispa panic nic patie pat ients nts in Los An Angel geles es wi with th iso isolat lated ed lon longg bon bone e fractures were twice as likely to receive no analgesia compared to non-Hispanic white patients, and black pati pa tien ents ts in At Atla lant nta a we were re le less ss li like kely ly to re rece ceiv ive e adequate analgesia analg esia comp compared ared with white pati patients ents..26 Finally, patte pat terns rns of sex di disc scri rimin minat atio ion n ar are e rep repor orte ted d wi with th women wom en oft often en re recei ceivin vingg les lesss ana analge lgesia sia tha than n men men..27 The Th e re reas ason onss fo forr th thes ese e pa patt tter erns ns of di disp spar arit itie iess ar are e difficult to elucidate but important to examine; they are addressed later in this article.
therapeut therap eutic ic dos dosing ing,, and wit with h ana analge lgesic sic adv advice ice given at 74% of visits. Children with burns received analgesics even less often (26% of visits), with 70% therap the rapeut eutic ic dos dosing, ing, and with only 27% rec receivi eiving ng 28 analgesia analge sia instru instructions ctions at dischar discharge. ge. O'Donnell29 found that 49% of 172 children with musculoskeletall inj eta injuri uries es pre presen sentin tingg to an ED wer were e pro provid vided ed analgesics. Another 2002 study noted only 50% of burn victims rec received eived adequate analgesia in EDs. 30 Neighbor et al31 described opioid use for severely injured patients in a level I trauma center over the course of 1 year. Of more than 500 cases, only 48% rece re ceiv ived ed in intra trave venou nouss opi opioid oidss wit withi hin n the fi first rst 3 hour ho urss wi with th th the e me mean an ti time me to fi firs rstt do dose se of 95 minute min utes. s. Ris Risk k fac factor torss for rec receiv eiving ing les lesss opi opioid oid included younger age ( b10 years old), intubation, lower low er re revis vised ed tra traum uma a sc scor ore, e, or no nott re requ quir irin ing g 31 fracture manipulation. Studies of prehospital care demonstrate 2 patterns. In general, prehospital personnel tend to undertreat pain in trauma patients; however, when analgesia is provid pro vided ed by pre prehos hospi pital tal per person sonnel nel,, it mak makes es a significa signi ficant nt diff differen erence ce in the time to anal analgesia gesia compare pa red d to pa pati tien ents ts wh who o re rece ceiv ive e th thei eirr fi firs rstt do dose se of analge ana lgesia sia by hos hospit pital al per person sonnel nel.. A 200 2000 0 rep report ort on preho pr ehospi spital tal ana analge lgesia sia in mor more e tha than n 100 1000 0 pat patien ients ts showed that only 1.5% of pa patients tients received analgesia 32 after an extremity injury. A 2002 study on transportss of patients port patients with isola isolated ted lower lower extr extremity emity inju injuri ries es showed sho wed ana analge lgesic sic use in jus justt 18. 18.3% 3% of tra transp nsport orts. s.33 Sever Sev eral al stu studie diess on the use of pre prehos hospit pital al ana analge lgesia sia protoco pro tocols ls for inj injure ured d pat patien ients ts have dem demons onstra trated ted safety, effectiveness, effectiveness, and increased use of prehospital opioid analgesia.34-38 In a 2005 review of emergency medica med icall ser servic vices es (EM (EMS) S) tra transp nsport ortss by 20 dif differ ferent ent EMS agencies in Michigan, analgesia was provided by EMS for 22% of chi childr ldren en hav having ing fra fractu cture ress or bu burns rns;; how howeve ever, r, these the se ch child ildren ren re recei ceive ved d the their ir med medica icatio tions ns 1 hou hourr sooner than than those who had to wait for a dose provided by the ED.39
Impediments to Analgesia Analgesia in Trauma Research Resea rch on ana analge lgesia sia pr prac actic tice e for tr traum auma a patients patien ts revea reveals ls similar patterns of undert undertrrea eatment, tment, 28 partic par ticula ularly rly for chi childr ldren. en. Fri Friedl edland and et al compared analgesia provided for 215 children presenting to Ci Cinc ncinn innat atii Chi Child ldre ren's n's Hos Hospi pita tall (Oh (Ohio io). ). Children with vaso-occlusive crisis from sickle cell disease received analgesics at 100% of visits, within 52 min minutes utes (mea (mean), n), with 78% the therap rapeut eutic ic dosi dosing ng (avera (av erage) ge),, and wit with h ana analge lgesia sia gui guidan dance ce giv given en on discharge dischar ge at 100% of visits. In compar comparison, ison, children with fractures received analgesics at 31% of visits, at 1.5 ho hours urs (me (mean) an) af after ter pr prese esenta ntati tion, on, wit with h 69 69% %
Effortss to understand the causes of oligoan Effort oligoanalgesia algesia have revealed a wide array of possible explanations. Influences may come from the patient, family, and society as well as the medical profession. profession. For health care professionals, professionals, these explanations explanations include (1) fear of masking signs of serious injury or illness, (2) fearr of cau fea causing sing or exa exacer cerbati bating ng hem hemodyn odynamic amic or respiratory respir atory insufficiency, insufficiency, (3) inadeq inadequate uate pain assessment skills or efforts, (4) lack of understanding about pain and analgesics, and (5) concerns about creating addictive behavior by providing analgesia. One of the pur purpor ported ted rea reasons sons for with withhold holding ing analgesics in the trauma patient is the belief that
ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
pain rel pain relie ieff ac achie hieved ved by ana analge lgesic sicss cou could ld mas mask k symptom symp tomss of an und underl erlying ying pat patholo hologic gic cond conditi ition. on. The Th e imp implic licat atio ion n is th that at out outco comeswill meswill wor worsen sen du due e to a delay in diagnosis and progression of symptoms. A study stu dy of 21 215 5 ph physi ysici cians ans an and d nu nurs rses es in 9 Is Israe raeli li trauma tra uma uni units ts rep report orted ed tha thatt ana analges lgesics ics wer were e fre freque quentnt40 ly (78%) withheld to assist diagnosis. Most providers in this study believed believed that analg analgesics esics should be withhe wit hheld ld in cas cases es of abd abdomi ominal nal or mul multis tisyst ystem em injury; however, 75% reported that they had h ad inadequate knowledge about pain management. 40 Althoug Although h see seeming mingly ly log logica ical, l, the par paradi adigm gm tha that t analgesia worsens outcomes is not substantiated in the th e li lite tera ratu ture re.. Th The e ba basi siss fo forr th this is be beli lief ef ma may y li lie e in pa part rt with a classic surgical text originally authored by Cope, Early Diagnosis of the Acute Abdomen . The text states that in the setting of acute abdominal pain of unclear etiology analgesia will (1) mask signs and symptoms of a surgical condition causing a (2) delay in diagnosis with resulting (3) increase morbidity and mor mortal talit ity. y. Alt Althou hough gh th these ese ass asser ertio tions ns we were re replicated replic ated in subseq subseque uent nt editions, they do not offer 41 supporting evidence. In recent years, researchers have attempted attempted to test this assumption with respec respect t to the patient with possible acute appendicitis. More than a half dozen studies have examined the use of morphine morphin e (typica (typicallly 5-mg 5-mg dose doses) s) in pat patien ients ts with 42,43 signs of peritonitis. None of the studies revealed a de dela lay y in di diag agnos nosis is or a ne nega gati tive ve ou outc tcome ome at attr trib ibute uted d to the the mor morphi phine. ne. One stud study y demonstrat d emonstrat ed ed improved localization of tenderness.44 Kim et al 45 published the first pediatric study on this issue and also found no false-negative evaluations and no complications attributed to opioid used for children with an acute abdomen. Opioid use in trauma patients has received close examin exa minati ation on in the lit liter eratu ature. re. The 3 pr prima imary ry con concer cerns ns in acute pain management are altered mental status (ie,, mas (ie maskin kingg dis disord orders ers inv involv olving ing the CNS or CNS perfusion), respiratory depression, and masking serious injuries by blocking the pain response. Although exce ex cessi ssive ve do dosi sing ng of op opio ioid idss ca can n ce cert rtai ainl nly y ca caus use e CN CNS S or respir res pirato atory ry dep depres ressio sion, n, re resea search rch in cli clinic nical al use of opioi op ioids ds in tr traum auma a pat patie ient ntss do does es no nott sup suppo port rt the presumpti presump tion on that analgesia worsens outcomes. Budu46 han et al studied more than 500 trauma patients and found fou nd no cor corre relat lation ion w ith ith op opio ioid id us use e an and d mi miss ssed ed 47 injuries. Lazarus et al reported a study of adverse drug events in more than 4000 trauma patients and found fou nd no ser seriou iouss eve events nts due to opi opioid oids. s. Fin Finall ally, y, sev severa erall large studies have demonstrated safety and efficacy of fentanyl used by EMS EMS for trauma patients 48 including one pediatric study.49 Improving pain assessment is a prim pri mary focus for reducing oligoanalgesia. Whipple et al 50called atten-
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tion to this issue in a 1995 study that described a strikingg contrast in perce strikin perceptions ptions among patien patients ts with multisystem injury in a critical care setting. Ninetyfive fi ve pe perc rcen entt of ho house usest staf afff an and d 81 81% % of nu nurs rses es re repo port rted ed adequate analgesia provided for patients who simultaneously rated pain moderate or severe 74% of the time.. It is log time logica icall tha thatt imp improv roved ed pai pain n asse assessme ssment nt would wou ld lea lead d to imp improv roved ed ana analge lgesia sia.. In a 200 2004 4 prospective study of 150 adult trauma patients, 60% of those with pain scores received analgesics compared to 33% without pain scores. The mean time to analgesia was 68 minutes in this study. 51 Howe However ver,, a recent pediatric study on pain assessment failed to show a change in analgesia administration rates and time to analge analgesia sia with improved documentation of 52 pain scores. Barriers to analgesia likely occur at multiple steps beginning with pain assessment and then the response to that information. A st study udy of 35 355 5 ED nu nurse rsess re reve veal aled ed de defi fici cits ts in understanding underst anding pharma pharmacologic cologic analge analgesic sic princi principles ples and conc concept ept s such as add addict iction, ion, tole toleran rance, ce, and dependence.53 Scor Scores es cor correla related ted with educ educati ation on level lev el and improved improved aft after er a 1-d 1-day ay semi seminar nar.. Fif Fiftytythree thr ee pe perce rcent nt of nur nurses ses ci cited ted the po poten tentia tiall for analgesics to mask signs of injury or illness as a barrier to providing treatment. Forty-eight percent reported report ed inadeq inadequate uate pain assessme assessment nt skills.53 In a 2004 study of prehospital personnel, Hennes et al54 found significant differences in the comfort level of EMS providers in administering analgesics depending depend ing on a patie patient's nt's condition. Of the subjects, 93% to 95% reported feeling comfortable providing analge ana lgesic sicss to pat patient ientss with pai pain n fro from m fra fractur ctures, es, burns, or nonspecific chest pain if the patient was older than 17 years. Much fewer respondents felt comfortable if similar patients were 7 to 17 years old (chest pain, 36%; extremity injury, 70%; burn, 77%) and even less if younger than 7 years (chest pain, pai n, 24% 24%;; ext extremi remity ty inju injury, ry, 38% 38%;; bur burn, n, 44% 44%). ). In this th is stu study dy,, re resp spon onde dent ntss ci cite ted d th the e fol follow lowin ingg as barriers to providing analgesia to pediatric patients: inabili ina bility ty to ass assess ess pai pain n (87 (87%), %), dif diffic ficult ult vas vascula cularr acce ac cess ss (8 (80% 0%), ), de dela lay y of tr tran anspo sport rt (66 (66%) %),, fe fear ar of compl co mplic icat ation ion (68 (68%) %),, re reco cord rd ke keepi eping ng (3 (30% 0%), ), and possible drug seeking (65%). 54 Although attention to pain in the adult medical literature liter ature has incre increased ased exponentially exponentially in recent years, a focus on analgesia for children and trauma patients remains sparse. Much of the research in pediat ped iatric ric pai pain n cen center terss on ani animal mal mod models els.. Maj Major or pediatrics and pediatric emergency medicine texts still provide relatively little attention to pain. The advanced adva nced trau trauma ma life suppo support rt cours course e prac practical tically ly ignore ign oress the subject. subject. In pre previo vious us edi editio tions ns of the advanced trauma life support provider manual, pain
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was bri brieflyaddre eflyaddresse ssed d in a par paragr agra aph thatfollow thatfollowed ed the 55 section on the secondary survey. The most recent editionhasomittedeventhisbriefmention.Theindex cites just 2 pages where pain is addressed in the current manual: as part of C-spine evaluation and under musculoskeletal trauma. In the latter section, the authors' guidance states “ Whenever analgesics, muscle musc le rel relaxa axants, nts, or sed sedativ atives es are admi adminis nister tered ed to an injured patient, the potential exists for respiratory arrest. ”56 In comp comparis arison, on, the Emer Emergenc gency y Nurs Nurses es Associa Association tion cours course, e, Adva Advanced nced Traum Trauma a Nursi Nursing: ng: A Conceptual Approach, ha hass an entire chapter on pain pa in in the tr trau auma ma pa pati tien ent. t.57 This contra contrast st highli highlights ghts the differing emphasis emphasis on pain manage management ment seen in the nur nursin singg and med medica icall pro profess fession ions. s.
RECOMMENDATIONS FOR ANALGESIA IN THE PEDIATRIC TRAUMA PATIENT The dictum “First do no harm ” seems to conflict with wi th ef effo fort rtss to ef effe fect ctiv ivel ely y co cont ntro roll pa pain in;; bu butt as explained explain ed in the preceding pages, there is conside considerrable harm inf inflic licted ted by allo allowing wing pain to con continu tinue e unchec unc hecke ked. d. Thi Thiss fin final al sec sectio tion n wil willl cov cover er sel select ect modali mod aliti ties es fo forr bo both th pa pain in an and d an anxie xiety ty.. Alt Althou hough gh there is no panacea for traumatic pain, the treating clinic cli nician ian wil willl fin find d succ success ess with ant antici icipat pation ion of analge ana lgesia sia nee needs, ds, an und unders erstan tandin dingg of bot both h the patient and available treatments, and an approach of titrating to effect.
Pain Management Approach for the Injured Child Whe W hen n tr trea eati ting ng pa pain in,, ph physi ysici cians ans oft often en te tend nd to th thin ink k only of medications (“when you have a hammer, all the world's a nail”), however, effective pain management relies first on the skilled use of nonpharmacologic macolog ic appro approaches. aches. The first key interv intervention ention is pain assessment and reassessment. Just as shock is overlooked if capillary refill, heart rate, and blood pressur pre ssure e mea measure surement mentss are neg neglec lected ted,, untr untreat eated ed pain pa in usu usual ally ly oc occu curs rs be beca cause use it is not re reco cogn gniz ized ed.. Th The e challenge lies not only in finding effective tools to measure pain but simply payin payingg attention to pain in the clinica clinicall settin setting. g. Using our most validated instruments (eg, WongBakerr Fac Bake Faces es scal scale), e), pai pain n asse assessme ssment nt is gen genera erally lly conside cons idered red to be unr unreli eliable able in chi childr ldren en youn younger ger tha than n 3 years and the visual analog scale is generally not useful in children younger than 6 years ( Table 1). 1). Furthermore, acutely injured patients may require intubation and therefore lose the ability to vocalize discomfort. When a patient is unable to perform a pain pai n sco score re,, the cli clinic nician ian is lef leftt wit with h sec second ondar ary y assessmentt measure assessmen measures. s. Vocaliza Vocalizations tions such as crying,
TABLE 1. Pain assessment scales. Patient Description
Recommended Scale
Scoring Range
Infants
NIPS: Neonatal Infant Pain Scale
0-21
Preschool
Wong Wo ng-B -Bak aker er Fa Face cess Sc Scal ale e
0-5 05
School age School adolescent
Visual Analog Scale
0-10
Intubated/ noncommunicative
Comfort Scale
8-40
—
grunting, grunti ng, or moa moaning ning may ref reflec lectt pai pain; n; how howeve ever, r, children with painful injuries may make no sound simply simp ly bec becaus ause e the they y fea fearr tha thatt voc vocali alizati zations ons will prompt an injection. Heart rate and blood pressure are often elevated in acute pain; however, hemodynamic changes are not always reliable markers in painfu pai nfull set settin tings. gs. Vag Vagal al res respon ponses ses to pai pain n may decrease decre ase heart rate, whereas some patie patients nts demonstrate stra te a more att attenua enuated ted symp sympathe athetic tic resp response onse,, partic par ticular ularly ly whe when n pai pain n is pro prolong longed. ed. Whe When n unc uncert ertain ain one should ask a simple rhetorical question: Is this a painfull condition/situati painfu condition/situation? on? If so, examine the effect effect of a small dose of analgesia on vital signs, muscle tone, respiratory effort, and overall affect. Justt as imp Jus import ortant ant as “doi doing ng the rig right ht thi thing ng ” is caution not to do the “wrong thing.” Anxiety and pain are magnified in children when they feel a loss of control and lack psychosocial support. This, of course, is also true for adults; the difference lies in the ability to recognize and express these feelings. How we speak with vulnerable children can make a tremen tre mendou douss posi positiv tive e or neg negati ative ve imp impact act on the their ir experi exp erienc ence e and reaction reaction to the car care e we pro provid vide. e. Children may be scared by either a poor choice of words wor ds (“we'll give this a shot ”) or lan langu guag age e the they y either do not understand or misunderstand. Making unrealistic promises (“this won't hurt ”) or invalidating feelings ( “that doesn't really hurt ”) only serves to und underm ermine ine your rel relati ationsh onship ip with the pat patien ient. t. Painful treatments should never be used as threats or pu puni nishm shment ents. s. Ta Take ke ca care re to ke keep ep ne need edle less or needle nee dle/syr /syringe inge ima images ges out of vie view w when pos possib sible. le. When possible, keep the patient close to eye level and let them sit up whenever feasible. Last, children are ar e usu usuall ally y ve very ry co conc ncer erned ned ab abou outt los losing ing bl blood ood.. When they see their own blood, they may benefit from reassurance that the amount of blood loss is not harmful to them.
ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
Keys to an op Keys opti timal mal ra rapp pport ort wit with h yo your ur pa pati tien ent t include honesty, clarity, and empower empowerment. ment. Give them choices wherever possible. The key is recognizin ni zingg whi which ch pa pati tient ent ma may y be bene nefit fit fr from om de deta taile iled d informa inf ormation tion and whic which h pat patient ient cop copes es bet better ter with distrac dis traction tion.. Whi While le man many y chi childre ldren n are ext extrem remely ely frighte frig htened ned of nee needle dles, s, some hav have e wor worse se anxi anxiety ety when they cannot see what is happening to them. Distrac Dist raction tion is a pot potent entiall ially y powe powerful rful int interv ervent ention ion and generally easier to implement at younger ages. Hypnosis, an advanced form of distraction, has a long track record of effective pain control in many acute and chronic pain situations. There is considerable evidence in the literature that th at sup suppo port rtss fa fami mily ly pr pres esen ence ce in th the e med medic ical al setting set ting.. Rese Researc archer herss hav have e fou found nd tha thatt with cle clear ar guidelines and support, patients and family members report greater preference for family presence even eve n in cr criti itical cal sit situat uation ions. s. Cli Clinic nician ianss in th these ese studies stud ies rep report ort no inc increa rease se in adv advers erse e outc outcomes omes when family members are present and experts in the fi fiel eld d re repo port rt a low lower er med medic icole olega gall ri risk sk whe when n family members are present at end of life settings. The Th e ke key y to fa fami mily ly pr prese esenc nce e is pr prov ovid idin ingg sk skil illed led pers pe rson onne nell su such ch as cl cler ergy gy,, nu nurs rses es,, or ch chil ild d li life fe services to guide the family members about where they should be in a trauma room and under what circumstances they may be asked to leave. If your institution does not already have a policy describingg ho in how w to pr prov ovid ide e sa safe fe an and d ef effe fect ctiv ive e fa fami mily ly prese pr esenc nce, e, th ther ere e ar are e mu multiple ltiple resourc resources es availa available ble 58-63 to develop such a policy. The Th e co conc ncep epts ts li liste sted d ab abov ove e do no nott re requ quir ire e a medicall license or sophisti medica sophisticated cated understanding understanding of pharmacology. Rather, they require a basic understanding of child development and a willingness and ability to pay attention to verbal and nonverbal cues of distress. When practiced and performed well they can ca n mak make e th the e di diff ffer eren ence ce be betw twee een n an op opti tima mall situation and one that is unmanageable.
Pharmacologic Interventions In a se sens nse, e, al alll an analg algesi esics cs ar are e “nerve blocks blocks..” Whether a pain signal is interrupted by a local or generalized anesthetic, systemic opioid, or effective distraction, each intervention works by attenuating the pain signal at some level. The keys to safe and effective effect ive use of medic medications ations include an underst understandanding of the characteristics of the medications and a willingness willingn ess to carefu carefully lly titrate to effect effect.. This section is no nott in inte tend nded ed to pr provi ovide de an ex exha haust ustiv ive e li list st of avai av ailab lable le tr trea eatm tment ents. s. Att Atten enti tion on wil willl fo focus cus on genera gen erall con concep cepts ts with add added ed det detail ail abo about ut sele select ct and an d co commo mmonly nly av avai aila labl ble e med medic icat atio ions. ns. A mor more e
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complete review of both pharmacologic and complementary approach approaches es to analgesia is found in the references cited. 64-66
Acute Pain The immediate goal of acute pain management is to ge gett pa pain in un unde derr co cont ntrol rol an and d th then en ma main inta tain in thatt cont tha control rol.. Eve Even n whe when n the former is ach achiev ieved, ed, we of ofte ten n end up “chasing ” th the e pa pain in wh when en we neglec neg lectt to rea reasses ssesss and treat until the pat patien ientt is agai ag ain n in se seve vere re di dist stre ress ss.. Th This is re resu sult ltss in bo both th ineffective analgesia and more medication administered iste red.. A sec seconda ondary ry goa goall in acu acute te pai pain n mana managegement is the preventio prevention n of chr chroni onic c pai pain. n. Thr Throug ough h the careful titration of medication and attention to nonpain nonp ainful ful str stresso essors rs tha thatt wor worsen sen pai painful nful exp experi eri-ence en ces, s, cl clin inic ician ianss ca can n pr provi ovide de sa safe fe an and d ef effe fecti ctive ve pain control in most patients. Opio Op ioid idss ar are e us usua ually lly th the e ce cent ntra rall th ther erap apy y fo forr managing severe acute pain. There is considerable variab var iabilit ility y of opi opioid oid res respons ponsive ivenes nesss in some pat patient ients, s, and they may require significantly significantly higher dosing. Such patients may either have differ differences ences in opioid rece re cept ptors ors (of (ofte ten n a fa famil milial ial pa patt tter ern) n) or a hig higher her toleran tole rance ce due to chr chronic onic exposure exposure to opi opioid oids. s. Of the numerous potential side effects of opioids, the most common are gastrointestinal dysmotility (nausea, pai pain, n, and con consti stipat pation) ion),, sed sedati ation, on, and tol tolera erance nce/ / dependence. depend ence. Proactive treatment of constip constipation ation is strongl str ongly y rec recomm ommende ended d for pat patient ientss rec receiv eiving ing reg regular ular doses of opioid opioids. s. Morphine, Morphine, the “gold standa standard rd” anal analges gesic, ic, has a relatively slow onset of action and a half-life of 2 to 3 hours. It is typically dosed as 0.05 to 0.1 mg/kg for the opioid-naïve patient in severe pain. Subsequent dosing of 0.02 to 0.05 mg/kg should take place every 10 minutes to desired level of analgesia. Although morphine is perhaps the most familiar opioid, it is somet som etime imess no nott th the e id idea eall me medi dica cati tion on fo forr tr trau auma ma patien pat ients. ts. Di Disad sadvan vanta tages ges inc includ lude e a slo slower wer ons onset et,, highe hi gherr in incid ciden ence ce of al aller lergi gic c re reac acti tions ons du due e to histami hist amine ne rel release ease,, more ven venodi odilat lation ion and ris risk k of hypotension, hypote nsion, and greate greaterr effec effects ts on gastr gastrointesti ointestinal nal motility than other commonly used opioids. For the ac acute utely ly inj injure ured d pa patie tient nt who whose se ini initia tiall eval ev aluat uation ion is sti still ll in pr progr ogress ess,, fe fenta ntanyl nyl of offe fers rs a number of advantages. Fentanyl is metabolized in the liver to inactive compounds; however, this is not significantly signifi cantly altered in liver disease. Onset is within 5 minutes and therapeutic levels are achieved for 20 to 60 minutes. Typically, the opioid-naïve patient in severe pain is safely and effectively treated with an initial dose of 2 to 3 μg/kg of fentanyl. A continuous infusion infu sion can sust sustain ain the therap rapeut eutic ic lev levels els and allo allow w
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ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
careful titration. In addition, the literature shows growing grow ing inte interest rest in intr intranas anasal al admi administ nistrati ration on of fenta fe ntanyl nyl.. Th This is off offer erss th the e ob obvi vious ous ad adva vanta ntage ge of analgesia analge sia without intravenous intravenous access. Some studies suggest that a dose of 1.7 μg/kg of intranasal fentanyl is equ equiva ivalen lentt to 0.1 mg/ mg/kg kg of mor morphi phine. ne.67 In this author's experience, a higher dose of fentanyl (2-3 g/kg kg)) is re requ quir ired ed fo forr mil mildd-mod moder erat ate e pa pain in.. Or Oral al μg/ transmucosal fentanyl is another option; however, effective effect ive doses by this route are associa associated ted w ith i th hi high gh 68 rates (25%-50%) of nausea and vomiting. Finally, hydromorphone hydromo rphone offers sever several al potent potential ial advant advantages ages to morphine and fentanyl including fewer allergic reactions, longer duration of action, and somewhat less tolerance when used for prolonged periods. Opioid Opi oidss are ideally ideally dos dosed ed to main maintai tain n a stea steady dy state sta te ser serum um con concent centrat ration ion and avo avoid id pea peaks ks and trou tr ough ghs. s. On Once ce pa pain in co cont ntro roll is ac achi hiev eved ed,, it is import imp ortan antt to an anti tici cipa pate te the ne need ed fo forr bo bolus luses es of analge ana lgesia sia.. Eve Even n sma small ll mov movem ement ents, s, tur turni ning ng the patient or inadvertently bumping a chest tube or endotracheal tube can cause significant exacerbations of pain. The patie patient nt with a femur fracture fracture may appe ap pear ar to ha have ve go good od pa pain in co cont ntro roll wh when en ly lyin ing g motio mot ionle nless ss bu butt qu quick ickly ly los loses es th that at co cont ntro roll whe when n moved mov ed.. Be Befo fore re mov movin ingg th the e pa pati tient ent for x-r x-ray ayss or other oth er re reaso asons, ns, con consid sider er a sma small ll (1(1-2 2 μg/ g/kg kg of fentany fen tanyl) l) bolu boluss adm admini iniste stered red seve several ral minu minutes tes in advanc adv ance e of anti anticip cipate ated d move movement ment.. If the pat patien ient t seemss exc seem excessi essivel vely y sed sedate ated d fen fentan tanyl yl also has the advant adv antage age of a rel relati atively vely short hal half-li f-life. fe. If opi opioid oid revers rev ersal al is nec necess essary ary in a sta stable ble but excessive excessively ly sedated patient physicians should begin cautiously with small doses of naloxone (0.001 mg/kg per dose) to avoid excessive blockade of opioid and resulting severe pain. Although not commonly used in the ED setting, some ped pediat iatric ric EDs are usin usingg pat patien ient-c t-contr ontrolle olled d analgesia (PCA) for select patients (eg, sickle cell pain pai n cr crisi isis) s) wit with h goo good d re resul sults ts.. In ge gener neral, al, PCA requi re quire ress a pa pati tient ent wit with h at lea least st a 5-y 5-yea earr-old old develop dev elopment mental al lev level. el. Alth Althoug ough h not all pat patient ientss pre prefer fer thiss app thi approa roach, ch, man many y pat patien ients ts ach achiev ieve e gre greate aterr control with lower doses of opioid when they have immedia imme diate te con contro troll of the their ir ana analge lgesia sia with a PCA PCA.. Typically, a basal infusion of opioid is provided with a li limit mited ed nu numb mber er of PC PCA A do doses ses pr prog ogra ramme mmed d in into to th the e PCA pump. Nonsteroidal Nonster oidal antiinf antiinflammator lammatory y medica medications tions such as ibu ibuprof profen en and ket ketoro orolac lac are pot potent entiall ially y usef useful ul treatments either alone for mild pain or as adjuncts for mod moderat erate e pai pain. n. Effi Efficac cacy y stud studies ies comp compari aring ng ketoro ket orolac lac to morp morphin hine e an and d ace acetam taminop inophen hen hav have e 69,70 yielded yie lded mixe mixed d res results ults.. Give Gi ven n th the e ri risk sk of de de-creased platelet function and gastritis, the role for
regular use of nonsteroidal antiinflammatory medications in the acutely injured patient is therefore limit lim ited ed to si situ tuati ation onss whe where re th the e ri risk sk fo forr sur surge gery ry is low and pain levels are not severe. Finally Fin ally,, ner nerve ve bloc blockad kade e at the spinal cord can provid pro vide e eff effect ective ive ana analge lgesia sia wit with h a fra fractio ction n of the dose req requir uired ed for syst systemic emic tre treatme atment. nt. Lon Long-t g-term erm use of epidural analgesia is possible and can offer appropriate approp riate candidates unique benefi benefits. ts. Although commonly used for labor pain, cesarean delivery, and thoracic and abdominal surgery in adults, many pediatric institutions do not yet routinely use this approach as it requires close observation from those trained traine d in this proced procedure. ure.
Sedation of the Trauma Patient Sedation Sedati on of the ped pediat iatric ric tra trauma uma pat patien ientt pos poses es uniqu un ique e ch chal allen lenge gess du due e to th the e ri risk sk of sho shock ck fr from om blood loss and CNS injury due to altered cerebral perfusion pressures secondary to intracranial swelling. in g. In ad addi diti tion on,, th thes ese e pa pati tien ents ts of ofte ten n re requ quir ire e analgesia for pain. Although multiple studies have shown sho wn th that at pr prepr eproce ocedur dural al fas fastin tingg tim times es do not corre cor relat late e wit with h asp aspira iratio tion, n, the cli clinic nician ian sho should uld consider th the e risks of nausea and vomiting in each situation.71 The ide ideal al sed sedati atives ves for the nec necessa essary ry proced pro cedure ure in an acut acutely ely inj injure ured d ped pediat iatric ric pat patient ient include the following properties: analgesia, minimal alterat alte ration ion in syst systemi emic c and int intrac racran ranial ial per perfusi fusion on pressures, and short acting or reversible. No single agent offers the ideal combination of benefits for all situations; therefore, clinicians must rely on differentt op en optio tions ns oft often en wit with h a co comb mbina inati tion on of ag agent ents. s. Exper Exp erti tise se in a ha handf ndful ul of mo moda dalit litie iess is a be bett tter er investment than marginal familiarity with a broad array of treatme treatments. nts. Before Bef ore sta starti rting ng sed sedati ation, on, one shou should ld ver verify ify that equipment, medications, and personnel are in place to re respo spond nd ef effec fectiv tively ely to a sud sudde den n de decr creas ease e in ventilation ventila tion or oxygena oxygenation, tion, emesis, hypoten hypotension, sion, or seizure sei zure.. Hav Have e an air airway way tec techni hnicia cian n imme immedia diatel tely y available availa ble if your intention is to provide moderate to deep sedation. Recall that in light sedation (previously ousl y con conscio scious us sed sedati ation), on), the pat patient ient res respond pondss approp app ropria riately tely to phys physica icall and ver verbal bal stim stimuli. uli. In deep sedation, the patient is not easily aroused, may have partial or complete loss of protective reflexes, and an d los loses es th the e ab abili ility ty to re respo spond nd pu purp rpose osefu fully lly to physical or verbal stimuli. Last, anticipate when you might stop a procedure. Take for example a child who appears deeply sedated when untouched but screams during a painful orthopedic procedure. The orthopedist is focused on completing the procedure. The physician in charge of sedation should decide
ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD
whether it is reasonable to attempt or complete the procedure or defer to another setting such as the operating operat ing room with general anesth anesthesia. esia. The following strategy may be helpful in choosing optimal sedation medications for a given scenario or proced pro cedure ure.. The These se are gen genera erall rec recomme ommenda ndation tions, s, and each case requir requires es an indivi individual dual assessment by a phy physici sician an tra traine ined d and exp experie erience nced d in sed sedati ating ng children. First, determine if the analgesia requirement will be low (eg, laceration repair) or high (eg, reducing a fracture). Next, determine if the procedure du re is li like kely ly to be le less ss th than an or gr grea eate terr th than an 5 minut min utes. es. Th The e ke key y is to pr provi ovide de ef effe fect ctiv ive e se seda dati tion on an and d analgesia with the least amount of medication. In all cases, local or regional anesthetic is recommended where wher e pos possibl sible e to limi limitt the dose and dur durati ation on of systemi syst emic c med medica ication tions. s. Las Last, t, str strong ongly ly cons conside iderr an amnestic agent (eg, benzodiazepine) as an adjunct for fright frightening ening situations/procedu situations/procedures. res. Do not proceed with a painful procedure until assured that the patient's patien t's sedati sedation on and analgesia is adequa adequate. te. For lowe lowerr ana analge lgesia sia req requir uiremen ements, ts, fen fentan tanyl yl or nitrou nit rouss oxi oxide de is rec recomm ommend ended. ed. Adv Advant antag ages es of nitrous oxide include its rapid on o nset and recovery time tim e and exc excell ellent ent anx anxiol iolysi ysis; s;72 fenta fentanyl nyl offers superior analgesia. Nitrous oxide requires specific apparatus appara tus includi including ng a scaveng scavenging ing system and familiarity with administr administration. ation. Contrai Contraindicatio ndications ns against aga inst sed sedati ation on with nit nitrou rouss oxi oxide de inc include lude fir first st trimester pregnancy, pneumothorax, chronic respiratory rat ory dis disease ease,, bowe bowell obst bstruc ruction tion,, CNS inj injury ury or 73 depression, depres sion, and shock. Forr mor Fo more e pa pain infu full pr proc oced edur ures, es, it is som someti etime mess challenging to find a safe therapeutic window with fentanyl. In these cases, ketamine is often a good alternative as it can provide effective analgesia a nd sedation without loss of spontaneous respirations. 74
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Ketamine Ketami ne ten tends ds to inc increa rease se secr secreti etions ons and has a positive chronotropic and inotropic effect that can result in an increase in systemic pressures. Ketamine adm admini inistr stratio ation n is asso associa ciated ted with inc increa reased sed intracranial pressure; however, this effect is attenuated uate d with ben benzodi zodiaze azepin pine e adm adminis inistra tration tion or hyperventilation. Interestingly, one study of patients with traumatic traumatic brain injury found a dec decrea rease se in intracrania intracran iall pressu pressure re in pat patient ientss giv given en keta ketamine mine and 75 propofol. In ad addi ditio tion, n, ket ketami amine ne of ofte ten n ca cause usess emesis eme sis an and d dy dysp spho hori ria a up upon on wa waki king ng (“emergence reaction”). Th The e fo form rmer er is ass assoc ocia iate ted d wi with th hi high gher er dosin do singg an and d th the e lat latte terr wit with h ol olde derr ch child ildre ren n an and d 11 adults. The Theref refore ore,, it is pru prudent dent to pre premed medicat icate e with atropine if increased secretions pose a problem, con conside siderr an anti antieme emetic tic suc such h as onda ondanse nsetro tron n and an d wa warn rn th the e fa fami mily ly of th the e po poss ssib ibil ilit ity y of an emergence reaction (estimated to occur in 50% of older old er ch child ildre ren n an and d ad adul ults) ts).. Wh When en a pr proce ocedur dure e requires requir es more than 5 minutes, propofol is a useful agent.76 Propofol can provide deep sedation without losss of spo los spont ntan aneo eous us re resp spir irat atio ions ns an and d we wear arss of offf wi with thin in minutes minu tes of dis discon continu tinuati ation. on. Sid Side e eff effect ectss inc include lude negati neg ative ve ino inotro tropy, py, so spe specia ciall att attent ention ion sho should uld be paid pa id to th the e blo blood od pr pres essur sure e in pa pati tien ents ts re rece ceiv ivin ing g fentanyl and propofol. Propofol is typically bolused with wi th a st star arti ting ng do dose se of 1 to 3 mg mg/k /kgg and th then en maintained with an infusion at 5 mg/kg per hour titrated titr ated to effe effect. ct. Cont Contrain raindica dication tionss to prop propofol ofol include soy or egg allergy. Alternatives to propofol include inclu de mida midazolam, zolam, etomi etomidate date,, or metho methohexit hexital al (Table 2). 2).
Prolonged Acute Pain Mana Managi ging ng pro prolon longed ged or chron chronic ic pa pain in is qui quite te diff di ffer eren entt th than an ac acut ute e pa pain in an and d gene genera rally lly no nott th the e
TABLE 2. Treatment options for procedural sedation of the trauma patient. Analgesia Need
Duration
37
Recommendation
a
Alternatives
Mild-moderate
Short (b5 min)
Fentanyl (IV, IN)
Nitrous oxide (when anxiety
Mild-moderate (eg, long laceration repair)
Long (N5 mi min) n)
Fent Fe ntan anyl yl (I (IV, V, IN IN)) + pr prop opof ofol ol
Fentan Fent anyl yl in infu fusi sion on;; Fe Fent ntan anyl yl + mi mida dazo zola lam, m, etomidate, OR methohexital
Moderate-severe
Short (b5 min)
Ketamine
Moderate-severe
Long (N5 min in))
Keta Ke tam min ine e + pr prop opo ofo foll
a
N
pain)
Ketam Keta min ine e in inffus usio ion; n; ke keta tami mine ne + mid idaz azol olam am,, etomidate, OR methohexital
Local Loc al or reg region ional al blo blocks cks wit with h an anest esthet heticsare icsare rec recomm ommen ende ded d wh wherepossib erepossible le to dec decrea rease se therequi therequirem rement ent for sys system temic ic med medica icatio tions. ns. IV indicates intravenous; IN, intranasal.
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responsibility of those in the emergency or acute care setting. As a result, acute care providers are generally less familiar with approaches to chronic pain. Nevertheless, the acute care provider will care for patients having prolonged or chronic pain and will need an understanding of these issues. Usually, patients transition from intra intravenous venous to oral opioids within days after injury or surgery. Oral opioids are sometimes necessary for 1 to 2 additional weeks. When patients have difficulty weaning from fr om op opio ioid idss on one e sho shoul uld d co cons nsid ider er th the e po possi ssibl ble e causes and alternative treatments. Opioid tolerance typically develops within a week of continuous use of the same opioid. Patients will exhibit a decreasing effect of similar doses of the medication. Although increased dosing can address this temporarily, it is usually more effective (ie, better analgesia with less medicat medi cation) ion) to swit switch ch to ano another ther opi opioid oid.. Pat Patien ients ts with wit h in incre creasi asing ng ne need edss for bol boluse usess of an analg algesi esics cs (breakthrough pain) should be reassessed for both the causes of the pain and effectiveness of the pain plan pl an.. Alt Altho houg ugh h at atte tent ntio ion n to th the e po possi ssibi bilit lity y of evolvin evo lvingg org organ an dama damage ge is the pri priori ority, ty, the there re are other common causes of increased opioid use in this setting set ting.. Sle Sleep ep dep depriv rivatio ation n is oft often en an ove overlo rlooke oked d source sour ce of poo poorly rly cont control rolled led pai pain. n.77 Anxiet Anxiety y may build buil d with rep repeti etitiv tive e pai painfu nfull pro proced cedure ures, s, gre greate aterr awareness of injuries, and a sense of lack of control over the situati situation. on. Assuming more aggressive analgesia is not contraindicat indi cated ed one may con conside siderr cha changin ngingg the opi opioid oid.. Frequ Fre quent ent nee need d fo forr a sho shortrt-act actin ingg op opioi ioid d sho should uld prompt a consideration to add a long-acting opioid such as methadone or long-acting formulations of morphin morp hine, e, oxy oxycod codone one,, or hyd hydrom romorp orphon hone. e. The objec ob jecti tive ve is to fi find nd an ef effe fect ctive ive do dose se an and d do dosin sing g schedule that minimizes the peaks and troughs of medication level and pain control. Any changes in treatme tre atment nt str strate ategy gy for pat patien ients ts with chr chronic onic pai pain n must mu st in invo volv lve e th the e ad advi vice ce an and d on ongo goin ingg ca care re of a knowledgeable physician. Nonopioid adjuncts may have an opioid-sparing effect and control the develop development ment of chroni chronic c pain. Unfortu Unfo rtunate nately, ly, ped pediat iatric ric tri trials als for most of thes these e adjuncts adju ncts are lack lacking ing,, part particul icularly arly for ped pediatr iatric ic trauma tra uma pat patien ients. ts. A wide arr array ay of ant antico iconvul nvulsan sant t medicat medi cations ions hav have e demo demonst nstrat rated ed eff effecti ectiven veness ess for various vari ous chron chronic ic pain syndr syndromes. omes. Gaba Gabapent pentin's in's possibl poss ible e eff effect ective ivenes nesss for pha phanto ntom m limb pai pain n and spinal cord injury pain in addition to its relatively benig be nign n si side de ef effe fect ct pr prof ofile ile ma make ke it a re reaso asona nable ble 78 consideration for some trauma patients. Cannaboid therapy may offer some analgesia in addition to effectiv effe ctivene eness ss as an anxi anxiolyt olytic ic and anti antiemet emetic. ic.79 Ketamin Ket amine e is a pot potent ent NMDA rec recept eptor or ant antago agonis nist t
that has demonstrated effectiveness in suppressing postsurg post surgica icall cen centra trall sensi sensitiza tizatio tion n and seco secondar ndary y hyper hyp eral alge gesia sia af afte terr bu burn rns. s. It ha hass al also so be been en use used d effecti effe ctively vely in the tre treatme atment nt of post postamp amputat utatii on stump pain and complex regional pain syndrome. 80 Tricyc Tri cyclic lic ant antide idepre pressan ssants ts such as ami amitri triptyl ptyline ine hav have e a long track record of effectiveness in a variety of chronic chroni c pain syndromes. Amitrip Amitriptyline's tyline's sedative effects may also help treat insomnia. More recent serotonin seroton in select selective ive reupt ak ak e inh inhibi ibitor torss hav have e also 81 shown some effectiveness.
SUMMARY Analgesia Analge sia for the ped pediat iatric ric tra trauma uma pat patient ient rem remain ainss a challenging and important area of research and clinical care. The relative infrequency of cases and multidimensional nature of injuries makes clinical resear res earch ch dau daunti nting. ng. Und Undert ertrea reatmen tmentt of the these se pat patien ients ts continues due to a variety of influences including excessive fears about adverse effects of analgesics, a lack of attention to pain, and underappreciation of the har harmful mful eff effect ectss of poo poorly rly con contro trolled lled pai pain. n. Med Medica icall education educat ion and train training ing still under underserves serves the issue of pain pa in in th the e co cont ntex extt of pa pati tien entt ca care re.. Nu Nume mero rous us nationall and institutional guidelines nationa guidelines and requi requirerements have modest impact as the standards of care for analgesia are usually locally based. Fort Fo rtun unat atel ely, y, th the e to tool olss to im impr prov ove e ca care re ar are e withi wi thin n ou ourr gr gras asp. p. Co Commo mmon n ph phar armac macolo ologi gic c an and d nonpha non pharma rmacol cologi ogic c int interv ervent ention ionss are saf safe e and effective if used in a judicious manner. Analgesia protoc pro tocols ols for pre prehosp hospita itall and hos hospita pital-b l-base ased d car care e can imp improv rove e the per percen centag tages es of pat patient ientss tre treate ated; d; ultima ult imatel tely, y, the at atti titu tudes des and un unde derst rstan andin dingg of provi pr ovide ders rs re rega gardi rding ng ana analge lgesia sia mus mustt ev evolv olve e to achieve achiev e signifi significant cant improvements improvements in pain control. The emergency physician's responsibility in caring for a pat patien ientt inc include ludess eff effect ective ive pai pain n rel relief ief dur during ing their care and until the patient is transferred to a subsequent physician. Once we recognize that the potent pot ential ial harm in “pri primum mum non noc nocere ere” li lies es as much in und undert ertrea reatme tment nt as in ove overtr rtreat eatment ment of pain pa in,, ch child ildre ren n ha havi ving ng in injur jury y wi will ll re rece ceiv ive e mor more e effective effect ive analge analgesia. sia.
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Pasero C, Portenoy RK, McCaffery M. Opioid analgesics. In: McCaffery M, Pasero C, editors. Pain clinical manual. 2nd ed. St Louis (MO): Mosby; 1990. p. 271-2. 4. Hedderich R, Ness TJ. Analgesia for trauma and burns. Crit Care Clin 1999;15:167-84. Halothane-morphine orphine compared 5. Anand KJS, Phil D, Hickey P. Halothane-m with high dose sufentanil for anesthesia and post operative analge ana lgesia sia in neo neonat natal al car cardia diac c sur surger gery. y. N Eng Engll J Med1992; Med1992;326 326:: 1-9. 6. Saxe G, Stoddard F, Courtney D, et al. Relationship between acute morphine and the course of PTSD in children with burns. J Am Acad Adolesc Psychiatr 2001;40:915-21. 7. Beggs S, Fitzgerald M. Development of peripheral and spinal nociceptive systems. In: Anand KJS, Stevens BJ, McGrath PJ, editors. Pain in neonates and infants. 3rd ed. New York (NY): Elsevier; 2007. p. 11-24. Schechte chterr NL, Zeltz Zeltzer er LK. Pedi Pediatricpain: atricpain: new dire direction ctionss from 8. Sche a developmental perspective. J Develop Behav Pediatr 1999; 20:209-10. 9. Anand KJS, Al-Chaer ED, Bhutta AT, Hall RW. Development of supra suprapina pinall pain processin processing. g. In: Anand KJS, Stev Stevens ens BJ, McGrath PJ, editors. Pain in neonates and infants. 3rd ed. New York (NY): Elsevier; 2007. p. 25-44. 10. Woolf CJ, Salter MW. Plasticity and pain: role of the dorsal horn. In: McMahon SB, Koltze Koltzenbur nburgg M, edit editors. ors. Wall and Melzb Melzback ack's 's tex textbo tbook ok of pai pain. n. 5th ed. Phi Philad ladelp elphia hia (PA (PA): ): Elsevier; 2006. p. 91-105. Duriex M. Ketamine: Ketamine: teac teaching hing an old dog new tricks. 11. Kohrs R, Duriex Anesth Anal 1998;87:1186 1998;87:1186-93. -93. Fitzge zgeral rald d M, de Lim Lima a J. Hyp Hypera eralge lgesia sia and all allody odynia nia in 12. Fit infan inf ants. ts. In: Fin Finley ley GA GA,, McG McGrat rath h PJ, edi editor tors. s. Ac Acute ute and procedural pain in infants and children. Seattle (WA): IASP Press. 2001. p. 1-12. 13. Anand KJS, Runeson B, Jacobson B, et al. Gastric suction at birth associated with long term risk for functional intestinal disorders in later life. J Pediatr 2004;144:449-54. Gruna nau u RE, Tu MT. Lon Long-t g-term erm conseque consequence ncess of pa pain in in 14. Gru human neonates. In: Anand KJS, Stevens BJ, McGrath PJ, editors. Pain in neonates and infants. 3th ed. New York (NY): Elsevier; 2007. p. 45-55. 15. Meyer RA, Ringkamp M, Campbell JN, Raja SN. Peripheral mechanis mech anisms ms of cuta cutaneous neous nociception nociception.. In: McMa McMahon hon SB, Koltzen Kolt zenbu burg rg M, ed edito itors. rs. Wal Walll an and d Mel Melzba zback' ck'ss tex textbo tbook ok of pai pain. n. 5th. ed. Philadelphia (PA): Elsevier; 2006. p. 3-34. 16. Schechter NL. The under-treatment of pain in children: an overview. Pediatr Clin North Am 1989;36:781-93. 17. Selbst SM. Analgesic use in the emergency department. Ann Emerg Med 1990;19:1010-3. 18. Petrack EM, Christopher NC, Kriwinsky J. Pain management in the eme emerge rgency ncy dep depart artmen ment: t: pat patter terns ns of uti utiliza lizatio tion. n. Pediatrics 1997;99:7111997;99:711-4. 4. 19. Friedland LR, Kulick RM. Emergency department analgesic use in pediatric trauma victims with fractures. Ann Emerg Med 1994;23:203-7 1994;23:203-7.. 20. Bro Broome ome ME, Ric Richts htsme meier ier A, Mai Maikle klerr V, Ale Alexan xander der M. Pediatric pain practices: a national survey of health professionals. J Pain Symptom Manage 1996;11:312-20. 21. Cummings EA, Reid GJ, Finley GA, et al. Prevalence and source of pain in pediatric inpatients. Pain 1996;68:25-31. 22. Cimpello L, Khine H, Avner JR. Practice patterns of pediatric vs gene general ral emer emergenc gency y physi physician cianss for pain management management of fractures in pediatric patients. Pediatr Emerg Care 2004;20: 228-32. 23. Quinn M, Carraccio C, Sacchetti A. Pain, punctures, and pediatricians. Pediatr Emerg Care 1993;9:12-4. 3.
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EMSC Grant Panel (Writing Committee) on Pharmacologic Agent Agentss Use Used d in Ped Pediat iatric ric Sed Sedati ation on and An Analg algesi esia a in the Emergenc Emer gency y Dep Departm artment. ent. Clini Clinical cal polic policy: y: evid evidence enced d base based d approach to pharmacologic agents in the emergency department. Ann Emerg Med 2004;44:342-77. 67. Borland M, Jacob I, King B, et al. A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in the emergency department. Ann Emerg Med 2007;49:335-40. 68. Sharar SR, Bratton SL, Carrougher GJ, et al. A comparison of oral trans-mucosal fentanyl citrate and oral hydromorphone for inpa inpatien tientt pedi pediatric atric burn wound care analgesia. analgesia. J Burn Care Rehab 1998;19:5161998;19:516-21. 21. Rusy y LM, Hou Houck ck CS CS,, Sul Sulliv livan an LJ, et al. A dou double ble-bl -blind ind 69. Rus evaluation of ketorolac tromethamine versus acetaminophen in pedi pediatric atric tonsillectomy tonsillectomy:: anal analgesia gesia and blee bleeding ding.. Anes Anesth th Analag 1995;80:226 1995;80:226-9. -9. 70. Burd RS, Tobias JD. Ketorolac for pain management after abdominal surgical procedures in infants. S Med J 2002;95: 331-3. 71. Roback MG, Bajaj L, Wathen JE, et al. Pre-procedural fasting and adverse events in procedural sedation and analgesia in a pediatri pedi atric c eme emergenc rgency y depa departmen rtment: t: are they relat related. ed. Ann Emerg Med 2004;44:454-9. Luhman man J, Ken Kenned nedy y RM, Porter Porter FL, et al. A ran random domize ized d 72. Luh clinical trial of continuous flow nitrous oxide and midazolam for sedation of young children during laceration repair. Ann Emerg Med 2001;37:20-7. 73. Clark M, Brunick A. N 2O and its interaction with the body. Handbook of nitrous oxide and oxygen sedation. 2nd ed. St Louis (MO): Mosby; 2003. p. 89-98. 74. Park Parker er RI, Maha Mahan n RA, Giugliano Giugliano D. Safety of intr intraven avenous ous midazolam mida zolam and keta ketamine mine as seda sedation tion in ther therape apeutic utic and diagnost dia gnostic ic proc procedur edures es in chi childre ldren. n. Pedi Pediatri atrics cs 1997 1997;99: ;99: 427-31. Albane anese se J, Arn Arnaud aud S, Re Rey y M, et al. Ket Ketami amine ne dec decrea reases ses 75. Alb intracra intr acranial nial press pressure ure and elec electroe troence ncephalo phalograp graphic hic acti activity vity in traumati trau matic c brai brain n inju injury ry pati patients ents duri during ng prop propofol ofol seda sedation. tion. Anesthesia 1997;87:132 1997;87:1328-34. 8-34. 76. Gottschling S, Meyer S, Krenn T. Propofol versus midazolam/ ketamine keta mine for proc procedur edural al seda sedation tion in pedi pediatric atric oncology. oncology. J Pediatr Hematol Oncol 2005;27:471-6. 77. Lamb Lamberg erg L. Pati Patients ents in pain needround-th needround-the-c e-clock lock care care.. JAMA 1999;281:689-90. 78. Sang C, Hayes K. Anticonvulsant medications in neuropathic pain. pai n. In: McM McMaho ahon n SB, Kolt Koltzen zenbu burg rg M, ed edito itors. rs. Wal Walll and Melzba Melzback ck's 's tex textbo tbook ok of pai pain. n. 5th ed ed.. Phi Philad ladelp elphia hia (Pa (Pa): ): Elsevier; 2006. p. 499-506. 79. Rice ASC. Cannabinoids. In: McMahon SB, Koltzenburg M, editor edi tors. s. Wal Walll an and d Mel Melzba zback' ck'ss tex textbo tbook ok of pai pain. n. 5th ed. Philadelphia (PA): Elsevier; 2006. p. 521-40. 80. Hill RG. Analgesic drugs in development. In: McMahon SB, Koltze Kol tzenbu nburg rg M, edi editor tors. s. Wal Walll andMelzb andMelzbac ack's k's tex textbo tbook ok of pai pain. n. 5th ed. Philadelphia (PA): Elsevier; 2006. p. 544. 81. Pet Peter er C, Wat Watson son N, Chi Chipma pman n ML, et al. Ant Antide idepre pressa ssant nt analgesics: a systematic review and comparative study. In: McMahon SB, Koltzenburg M, editors. Wall and Melzback's textbook of pain. 5th ed. Philadelphia (PA): Elsevier; 2006. p. 481-97. 66.
Abstract: The continued growth in emergency department (ED) use combined with limited limit ed inpati inpatient ent bed availab availability ility often leads to boarding of patients needing inpatient or intensive care unit admission in the ED. Emergency department personnel are experie exp erience nced d in the rap rapid id ass assess essmen mentt of trauma patients but may be less prepared prepar ed or comfor comfortable table with providing providi ng ongoing management management of trauma patients, especially critically injured pediatric patients. This article reviews management principles princi ples of traum traumatic atic brain injury injury,, mechanical ventilation, and shock in the pediatric trauma patient and is intended to guide ED management of these patients until they can be transferred to an appropriate level of inpatient care.
Keywords: pediatric critical care; traumatic brain injury; shock; trauma; mechanical ventilation
*Division *Division of Pediatric Pediatric Critical Critical Care, Emory Emory Universi University ty School School of Medicin Medicine, e, Children’s Healthcare of Atlanta, Atlanta, GA; †Divisi †Division on of Pediatr Pediatric ic Emergenc Emergency y Medicine, Medicine, Emory University University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA.
Reprint requests and correspondence: Wendalyn K. Little, MD, MPH, Pediatric Emergency Medicine, 1645 Tullie Circle, Atlanta, GA 30329.
[email protected] ,
[email protected] 1522-8401/$ - see front matter © 2010 Elsevier Elsevier Inc. All rights reserved.
When There Are No Inpatient Beds: Providing Pediatric Critical Care for Trauma Patients in the Emergency Department Toni Petrillo-Albarano, MD, FAAP*, Wendalyn K. Little, MD, MPH†
I
n an ideal world, the emergency department (ED) would be easily eas ily acc accesse essed d by tho those se tru truly ly nee needin dingg eme emerge rgency ncy car care. e. Seriously injured and ill patients would arrive and be cared for rar rarely ely and dis disposi position tioned ed in a tim timely ely fas fashio hion. n. Pat Patien ients ts needing surgery or hospital admission would move through the ED exp expedi edient ently ly to thei theirr fin final al des destina tinatio tion. n. Unfo Unfortu rtunat nately, ely, that idea id eall ra rare re,, ex exis ists ts in to toda day' y'ss ED ED.. Mo More re th than an 10 100 0 mi mill llio ion n Americans,, 30 mi Americans mill llio ion n of th them em ch chil ildr dren en,, pr pres esen entt to th the e ED each year.1 A persistent rise in ED visits over the last several decade dec adess has led to an overcrowding crisis in many communities.2,3 This increase is often attributed to overuse of the ED for minor illnesses, but there is also evidence that EDs are seeing steadily increasing numbers of patients with serious illness and injuries. injuri es. Lack of availa available ble inpati inpatient ent hospital beds, particularly particularly intensive care unit (ICU) beds, also contributes to ED crowding
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and ex and exte tend nded ed ED le leng ngth th of st stay ay.. 1 Emergency department physicians and staff may be challenged not only with seeing large numbers of patients, but also with pro provid viding ing car care e for ext extend ended ed per periods iods of time to seriously ill and injured patients awaiting inpatient or ICU admission. Although ED care providers are trained to provide initial ini tial asse assessme ssment nt and sta stabil bilizat ization ion for acu acutely tely ill and an d in inju jure red d pa pati tient ents, s, th they ey ma may y be und under erpr prep epar ared ed,, in terms of training and resour resou rces, to provide ongoing critic cri tical al car care e man manage agement ment.. 4 De Delay lay in tr tran ansfe sferr of critically ill patients to the ICU has been associated with in increased hospital length of stay and mortality rates.5 In an ideal world, patients needing ICU level care would be quickly evaluated and transferred to an IC ICU. U. Wh When en a cr crit itic icall ally y il illl pa pati tien entt ca canno nnott be immediately transferred to an ICU, they must be prov pr ovid ided ed wi with th ap appr prop opri riat ate e ca care re in an ED or transpo tra nsport rt set setting ting,, in ess essence ence bringing bringing the ICU to the patient. The purpose of this article is to review some of the more common elements of ICU level trau tr auma ma ca care re that may be re requi quire red d in th the e ED or transport setting.
TRAUMATIC BRAIN INJURY Traumatic brain injury (TBI) is a leading cause of Traumatic morbidity and mortality for pediatric patients in the United States, accounting for more than 400 000 E D visit vi sitss an and d mo more re tha than n 20 2000 00 de deat aths hs an annu nuall ally. y.6 Throug Thr ough h the yea years, rs, man many y the therap rapies ies hav have e bee been n prop pr opose osed d fo forr th the e tr trea eatme tment nt of TB TBI; I; fe few w of the these se have been studied studied or proven in pediatric pediatric patients. patients. In 2003, a multidisciplinary group convened a set of guideliness7 for the man guideline manage agement ment of ped pediat iatric ric pat patien ients ts 4 with TBI. A major focus of these guidelines is good support supp ortive ive care care of the cri critic tically ally injur injured ed pat patien ient, t, with particular partic ular attention to preve prevention ntion and treat treatment ment of shock shoc k and res respira piratory tory fai failure lure.. Rece Recent nt lite literat rature ure contin con tinues ues to sup suppor portt the these se gui guidel deline ines, s, wit with h a growin gro wingg bod body y of evi eviden dence ce dem demonst onstrat rating ing tha that t hypoten hypo tension sion and hyp hypoxi oxia, a, esp especi ecially ally if unr unreco ecogni gnized zed and untreated, are independent predictors of poor outcome in TBI.8-11 Careful attention should be paid to the ability to maintain an airway and adequate oxygenation and ventilation in patients with TBI. Hypoxia has been shown to negative negatively ly affect morbidity and mortality in th this is gr group oup..7,10 In ca case sess of mi mild ld to mo mode dera rate te isolated TBI, patients may require only supplementall ox ta oxyg ygen. en. If a pa pati tient ent's 's abi abili lity ty to ma main intai tain n an adequa ade quate te air airway way and con contro troll of ven ventil tilati ation on is compromi comp romised, sed, endo endotra trachea cheall intu intubat bation ion may be required. Ventilation should be provided to maintain ta in a pa part rtial ial pr pres essur sure e of ca carb rbon on di diox oxid ide e (PCO2)
within normal limits (35-45 mm Hg). Both hyperand hypoventilation may be deleterious to patients with TBI TBI.. Hyp Hypove oventi ntilati lation on may inc increa rease se cer cerebr ebral al blood flow, leading to increased intracranial pressure (ICP) if cereb cerebral ral autoregulation autoregulation of blood flow is impair imp aired ed by inju injury. ry. Hype Hyperve rventil ntilati ation on lowe lowers rs PCO2 and causes subsequent cerebr cerebral al vasocon vasoconstricti striction, on, with the potential for ischemia and secondary insult to th the e al alre read ady y in inju jure red d br brai ain. n. On Only ly in ca case sess of persistently elevated ICP refractory to other medical management should consideration be given t o maintaining a lower level of P CO2 (30-35 mm Hg).7 Further discussion of specific ventilation strategies will be covered later in this article. Careful Car eful att attenti ention on to vol volume ume stat status us and per perfusi fusion on is impor imp orta tant nt in th the e ma manag nagem emen entt of TB TBI. I. Me Medi dica call person per sonnel nel some sometim times es wor worry ry abo about ut giv giving ing intr intrave ave-nous (IV) fluids to TBI patients; patients; there is a myth that the administration of any IV volume may worsen cerebr cer ebral al ede edema. ma. Ade Adequa quate te bloo blood d pre pressur ssure e is req require uired d to maintain cerebral perfusion, and ensuring adequate intravascular volume is important for maintain ta iningbloo ingblood d pr pres essur sure e an and d pe perf rfusi usion on to th the e br brai ain n an and d other oth er vit vital al org organs ans.. Cer Cerebr ebral al per perfusi fusion on pre pressur ssure e (CPP) (CP P) can be est estima imated ted by sub subtra tracti cting ng ICP from the th e me mean an ar arte teri rial al pr pres essur sure e (M (MAP) AP).. Id Idea eall CP CPP P in infants and children has not been well established, but targeting a range between 40 (infants) and 65 mm Hg (adults) seems reasonable.12 A normal MAP is ag age e de depe pend nden entt an and d ca can n be es esti tima mate ted d by th the e formula (50 + 2× age in years) for any child older than 1 year. 13 Often, ICP monitoring is not immediat di atel ely y av avai aila lablein blein th the e ED ED.. It is the there refor fore e ad advi visa sabl ble e to attemptt to maintai attemp maintain n normal to slightl slightly y high MAPs in pati pa tien ents ts wi with th TB TBI. I. If IC ICP P mo moni nitor torin ingg is av avai aila lable ble,, CP CPP P shou sh ouldbe ldbe ta targ rget etedto edto st stay ay in th the e ra rang nge e of 40to 65mm Hg. Hyp Hypote otensi nsion, on, if pr prese esent, nt, sho should uld ini initi tiall ally y be treate tre ated d wit with h flui fluid d res resusc uscitat itation ion.. If bloo blood d pre pressur ssure e remains low or low-normal in the setting of persistently ten tly ele elevate vated d ICP ICP,, vas vasopr opresso essorr age agents nts such as dopa do pamin mine e or nor norep epin inep ephr hrin ine e may be ne need eded ed to maintai main tain n a nor normal mal to hig high-no h-norma rmall MAP and ade ade-quate CPP. In add additi ition on to ens ensurin uringg ade adequa quate te oxyg oxygena enatio tion, n, ventilation, and blood pressure, a few other basic princ pr incip iple less sh shoul ould d be ob obser serve ved d in ma mana nagi ging ng TB TBII patients. The patient's head should be kept midline and an d el elev evat ated ed to 30 30°° if po possi ssibl ble e be beca caus use e th this is pr promo omote tess veno ve nous us re retur turn n an and d may he help lp co cont ntro roll IC ICP. P. One ca cave veat at to remember is that patients with TBI may have associated spinal injuries, and any positioning of the head must be done while maintaining strict spinal precautions preca utions until an injury of the spine is exclud excluded, ed, but slight angulation of the entire bed, if possible, may be hel helpful pful.. Oth Other er man manage agemen mentt str strate ategie giess in
PROVIDING PEDIATRIC CRITICAL CARE FOR TRAUMA PATIENTS IN THE ED / PETRILLO-ALBARANO AND LITTLE • VOL. 11, NO. 1
treating patients with TBI involve decreasing cerebral br al me meta tabo boli lic c de deman mands ds to he help lp ma mana nage ge the el elev evat ated ed ICP, which oft often en acc accompa ompanie niess TBI TBI.. One of thes these e strateg str ategies ies is to main maintai tain n ade adequa quate te ana analge lgesia sia and sedation, particularly in patients with concomitant injuries or those requiring mechanical ventilation. Altho Al thoug ugh h th the e ab abil ilit ity y to mo monit nitor or an and d fo follo llow w a pa pati tien ent' t'ss neurolo neu rologic gic exa examina minatio tion n is imp import ortant ant,, it must be balance bala nced d with the ben benefit efitss of ens ensurin uringg ade adequa quate te analg ana lgesi esia a and se seda datio tion. n. In ca cases ses of pe persi rsiste stentl ntly y elevat ele vated ed ICP ICP,, con consid sidera eratio tion n sho should uld be gi given ven to deeper dee per sed sedati ation, on, such as pen pentob tobarb arbita itall com coma a and 7 even the use of neuromuscular paralysis. Maintaining a normal body temperature is also important in the man manag agem emen entt of TB TBI. I. Hyp Hyper erthe therm rmia ia ma may y in in-crease cre ase cer cerebr ebral al met metabo abolic lic dem demand andss and lea lead d to increased ICP. Although some studies support the use of mild hypothermia hypothermia in the management management of TBI, there is currentl currently y no strong evidence to support its 14-16 routine rou tine use. Finally, hyperosmolar fluid therapy may be used to manage elevated ICP. Both mannitol and hyp hypert ertoni onic c sal saline ine have be been en sh show own n to be 16,17-19 effect eff ective ive in this reg regard ard.. These The se age agents nts wor work k by altering the osmotic gradient across the bloodbrai br ain n ba barr rrie ier, r, i n eff ffec ect, t, pu pulli lling ng flu fluid id fro from m th the e edematous edemat ous brain.7,12 There have been no definitive comp co mpari ariso son n st stud udies ies of th the e 2 ag agen ents ts,, an and d th the e ch choic oice e of whic wh ich h to us use e ma may y be ba base sed d on av avai aila labi bili lity ty or physician preference. Hypertonic (3%) saline may be administered in 5 to 10 mL/kg aliquots as needed until a serum sodium of 170 mEq/dL or a serum seru m osmola osm olari rity ty of 36 360 0 mOs mOsm m ha hass be been en rea reach ched ed.. 19 Mannitol should be given in 0.5 to 1 g/kg aliquots as ne need eded ed un unti till a maxi ximu mum m ser serum um osm osmola olari rity ty of 32 320 0 mOsm is reached.12
VENTILATOR MANAGEMENT Many pediatric trauma patients may be managed without intubation and mechanical ventilation. Intubation bat ion may be req requir uired ed for air airway way pro protec tectio tion n in cas cases es of cra cranio niofa facia ciall inj injury ury or hea head d inj injury ury wit with h alt alter ered ed mental status, to ensure oxygenation and ventilation with wit h tho thorac racic ic inj injuri uries, es, or to ena enable ble ade adequa quate te sed sedati ation on and ana analge lgesia sia and to dec decre rease ase met metabo abolic lic dem demand andss for patien pat ients ts wit with h sev sever ere e or mul multis tisyst ystem em tra trauma uma.. Although thoug h multip multiple le model modelss of mech mechanic anical al vent ventilat ilators ors exist,, with multi exist multiple ple modal modalitie itiess for deliv deliverin eringg mecha mechannicall ve ica venti ntilat lation ion,, the mos mostt imp import ortant ant con consid sider erati ations ons in the mecha mechanica nicall vent ventilat ilation ion of pedi pediatri atric c pati patients ents is close attention to initial choice of ventilator settings and an d cl close ose mo monit nitor orin ingg of th the e pa patie tient nt to en ensur sure e adequate oxygenation and ventilation. Previo Pre viousl usly y hea health lthy y tra trauma uma pat patien ients ts wit withou hout t thoracic or lung injury should have fairly compli-
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ant lu ant lung ngss an and d be ab able le to be ma main inta tain ined ed on relatively relati vely low ventil ventilator ator settings. Initia Initiall ventila ventilator tor setti se tting ngss ar are e ba base sed d on no norm rmal al ph physi ysiolo ologi gic c pa para ra-meter met erss fo forr a he heal althy thy ch chil ild d of sim simila ilarr we weig ight ht an and d age. A positive end-expiratory pressure (PEEP) of 5 cm is a goo good d star startin tingg poi point. nt. Many ven ventila tilator torss are desi de sign gned ed to de deliv liver er bo both th pr pres essur sure e an and d vo volum lumeecontrol modes of ventilation. Either may be used, with the goal of delivering a tidal volume (TV) of 6 to 8 mL mL/k /kg. g. Ta Targ rget et re respi spira rato tory ry ra rate te va vari ries es wi with th patient age. Good starting points are a rate of 30 forr in fo infa fant nts, s, 20 fo forr ch chil ildr dren en,, an and d 16 fo forr ol olde derr childr chi ldren en and tee teenag nager ers. s. Ins Inspir pirato atory ry tim time e (Ti (Ti)) should be set between 0.5 and 1 second to target an insp inspira irator tory/ex y/expir pirato atory ry rat ratio io of 1:3 and allo allow w adeq ad equa uate te ti time me in th the e ex exha hala lati tion on ph phas ase e of th the e respir res pirato atory ry cyc cycle le for car carbon bon dio dioxid xide e elim eliminat ination ion.. Using these guideli guidelines, nes, initial ventil ventilator ator settings for a previ previously ously healthy 5-year 5-year-old -old patient weighing 20 kg should be TV of 160 mL (8 mL/kg), PEEP of 5 cm, rate of 20, and inspiratory time of 1 second. Patients undergoing mechanical ventilation should be moni monitor tored ed with con contin tinuous uous pul pulse se oxim oximetr etry. y. A blood gas measurement should be obtained shortly after instituting mechanical ventilation and the pH and PCO2 values used to gauge the effectiveness of ventilat vent ilation. ion. Afte Afterr this measu measureme rement, nt, endend-tida tidall carbon dioxide monitoring, if available, augmented with wi th pe peri riod odic ic bl blood ood ga gass mea measur sureme ements nts,, ma may y be used to monitor and adjust ventilation. Capillary or venous blood gas measurements may be adequate for monitoring pH and P CO2 in some patients, but placement of an arterial line may also be necessary for fre freque quent nt bloo blood d samp samplin lingg and blo blood od pre pressur ssure e monitoring in critically ill patients. Ventilator adjustment may be required to correct difficulties with oxygenation or ventilation. Ventilation ti on di diff ffic icul ulti ties es re requ quir ire e an inc incre reas ase e in mi minut nute e ventil ven tilati ation on to rem remove ove car carbon bon dio dioxid xide. e. Min Minute ute ventilation (MV) is defined as TV times respiratory rate ra te (M (MV V = TV × RR RR)) an and d ca can n be chang changed ed by manipu man ipulat lating ing eit either her of the these se par parame ameter ters. s. Tid Tidal al volu vo lume me ma may y be ad adju just sted ed by in incr crea easi sing ng th the e TV setting set ting in volu volume-c me-contr ontrol ol mod mode e or inc increa reasing sing the peak inspiratory pressure in pressure control mode. An An im impo port rtan antt po poin intt to re reme memb mber er is tha thatt th the e TV delivered to the patient may differ from that set on the ventilator if there is a large air leak around the endotra end otrache cheal al tube tube.. Anot Another her impo importa rtant nt con conside siderratio at ion n is th the e po pote tent ntia iall fo forr sec secon onda dary ry lun lungg in inju jury ry from positiv positive-pre e-pressure ssure ventil ventilation. ation. Althoug Although h patients with TBI may benefit from keeping P CO2 levels in a low-norm low-normal al range for ICP contro control, l, trauma pati pa tien ents ts wi with thou outt TB TBII ma may y be ma mana nage ged d wi with th a strate str ategy gy of permi permissive ssive hyper hypercapne capnea a in wh whic ich h “
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PCO2 levels are allowed to remain above normal as long as an acceptable pH level (generally considered pH N7.2) is mainta maintained. ined.20 Ventilator adjustment may also be necessary to improve imp rove oxy oxygena genatio tion. n. The eas easiest iest par parame ameter ter to manip man ipula ulate te is th the e fr frac acti tion on of in insp spir ired ed oxy oxyge gen n (F IO 2). De Deli live verry of FIO 2 gr grea eate terr th than an 60 60% % fo forr prolong pro longed ed per period iodss has bee been n asso associat ciated ed with fre free e radica rad icall for formati mation on and sec seconda ondary ry lung inj injury ury.. In patients requiring more than 60% F IO2, or in those diff di ffic icul ultt to ox oxyg ygen enat ate e on hi high gher er le leve vels ls of FIO2, conside cons iderat ration ion sho should uld be giv given en to inc increa reasing sing the PEEP delivered by the ventilator. Increasing PEEP increa inc reases ses the fun functio ctional nal res residu idual al cap capaci acity ty of the lungss and may ser lung serve ve to rec recrui ruitt add additi itiona onall alv alveoli eoli and imp improv rove e oxy oxygen genati ation. on. How Howeve ever, r, inc increa reasin sing g PEEP PE EP ma may y al also so ha have ve th the e de dele lete teri riou ouss ef effe fect ct of decreasing venous return to the heart and decreasing systemic blood pressure. This effect can often be overcome by the provision of additional intravascu va scula larr vo volum lume e in the fo form rm of iso isoto toni nic c flu fluid id or blood bloo d pro produc ductt adm admini inistra stration tion.. A fin final al ven ventila tilator tor adjus ad justm tment ent th that at ma may y be co consi nside dere red d to im impr prov ove e oxygena oxyg enatio tion n is leng lengthe thening ning the ins inspir pirator atory y tim time e (Ti) (T i).. In do doin ingg so so,, ca care re mu must st be ta take ken n to al allo low w adequate time in the respiratory cycle for expiration. Failure to do this may compromise ventilation ventilation and lead to the development of respiratory acidosis from carbon dioxide retention.
MANAGEMENT AND RECOGNITION OF SHOCK Shock is a state of inadequate delivery of oxygen and an d sub substr strat ate e to ti tissu ssues. es. Any se serio rious us in injur jury y or il illne lness ss can cause a state of shock if circulatory function is significantly impaired. In compensated shock, autonomic reflex mechanisms are activ activated ated to maintai maintain n vital organ perfusion. These include massive catecholamine release, leading to increased heart rate and systemic vascula vascularr resist resistance. ance. These compensa compensa-tory tor y mec mechan hanisms isms are par partic ticular ularly ly act active ive in pre previviously healthy children and young adults and may make early phases of shock difficult to recognize in this popul populatio ation. n. If unrec unrecogni ognized zed and untr untreate eated, d, these compensatory mechanisms are overwhelmed, cellular function function deteriorates, deteriorates, and a state of progressive siv e org organ an dys dysfun functi ction on and met metabo abolic lic ac acido idosis sis heralds the development of uncompensated shock. Finally, terminal or irreversible shock implies organ damage to a degre degree e that death is inevitable. inevitable. 21-24 Shock may be broadly categorized as hypovolemic, distributive, cardiogenic, or obstructive. In the trauma patient, the most common cause is hypovo-
lemic shock in which acute blood loss leads to an inadequate inadeq uate circu circulating lating intra intravascula vascularr volume. Trauma patients may also experience obstructive shock in which cardi cardiac ac output is mechan mechanically ically obstructed obstructed by tension pneumothorax or by hemopericardium leading leadi ng to peric pericardia ardiall tampon tamponade. ade. Distr Distributi ibutive ve shock, characterized by systemic vasodilation leading to functional or relative hypovolemia, may be seen after spinal cord inj injurie uriess and is some sometim times es termed spinal shock. Finally, myocar myocardial dial contusion may cau cause se myo myocar cardia diall dys dysfun functi ction on and cau cause se cardiogenic shock. Rapid Rap id rec recogni ognitio tion n of shoc shock, k, esp especi ecially ally ear early ly or compensated shock, is crucial to limiting morbidity it y an and d mo mort rtal alit ity y af afte terr tr trau auma ma.. Ca Care refu full an and d repeated physical examinations may give valuable information as to the nature and cause of shock. The Th e ph physi ysica call ex exam amina inati tion on sh shoul ould d st star artt wi with th an obser obs erva vatio tion n of the pa pati tien ent's t's men menta tall st statu atuss an and d respons res ponsive iveness ness to the surr surround ounding ing env enviro ironmen nment. t. Agitation, restlessness, and inability to be consoled by known caregivers may be an early sign of shock in infants and children. Even more concerning is the quiet, withdrawn child that does not make eye cont co ntac actt or re resp spon ond d to pa pain infu full st stim imul uli. i. Clo Close se atte at tent ntio ion n sh shou ould ld ne next xt be pa paid id to ai airw rway ay an and d breathing. Effortless tachypnea is an early sign of shock as the patient attempts to compensate for an increasing increa sing metab metabolic olic acido acidosis sis throu through gh respi respiratory ratory elimination of carbon dioxide.13,21,22 The next step in the rapid assessment of patients in sho shock ck is to ev eval aluat uate e th the e ci circ rcul ulato atory ry st stat atus us by assessing skin perfusion, temperature, and capillary refill time. Healthy patients in a warm envir environment onment should have pink, warm skin with brisk ( b2 second) capillary refill time. An early sign of hypovolemic and cardiogenic shock is the presence of cool distal extrem ext remiti ities es and pro prolon longed ged cap capilla illary ry ref refill ill tim time. e. Conversely, patients with early distributive shock may hav have e flus flushed hed ski skin n and bri brisk sk cap capilla illary ry ref refill. ill. Heart Hea rt rat rate e and pulse qua quality lity are oth other er imp importa ortant nt elements of the cardiovascular assessment. Tachycardia is one of the earliest signs of shock and must also be interpreted in context to age-specific normal values. Hypovolemic or cardiogenic shock leads to narrow pulse pressure and weak thready pulses. In contrast, patients in early distributive shock may have widened pulse pressure with readily palpated bounding pulses.18,19,21,22 Ur Urin ine e ou outp tput ut is a sensiti sens itive ve ind indica icator tor of ren renal al per perfusi fusion on and shou should ld be mo monit nitor ored ed cl clos osely ely as an in indi dica cato torr of in intr trav avas ascu cular lar volume status. Diminished urine output may be an early ear ly sig sign n of int intrav ravasc ascular ular volu volume me dep deplet letion ion and may ma y pr prog ogre ress ss to a st stat ate e of comp complet lete e an anur uria ia in 18,21-25 patients patien ts with severe shock. “
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PROVIDING PEDIATRIC CRITICAL CARE FOR TRAUMA PATIENTS IN THE ED / PETRILLO-ALBARANO AND LITTLE • VOL. 11, NO. 1
Blood pressure pressure should also be measure measured d as part of the car cardiov diovascu ascular lar asse assessmen ssment. t. Many refe referenc rences es differ dif ferenti entiate ate comp compensa ensated ted vs unco uncompen mpensate sated d shock by the presence or absence of hypotension. Overrelia Overr eliance nce on bloo blood d pres pressure sure measur measurement ement,, however, may lead to missed cases of shock. This is especially true in previously healthy children and young you ng ad adult ultss wi with th hyp hypov ovole olemi mic c sho shock ck,, in wh whom om arte ar teri rial al bl bloo ood d pr pres essur sure e may be no norm rmal al or ev even en slightly elevated during early stages of shock due to strong compensatory compensatory responses. With acute hemorrhage rha ge,, blo blood od pr press essur ure e may be ma maint intai ained ned in a norm no rmal al ra rang nge e un unti till ap appr prox oxim imat atel ely y 30 30% % of th the e circula cir culatin tingg blo blood od vol volume ume has been lost lost,, at whic which h point uncompensated shock ensues and may progress re ss rap rapidly idly to ter termin minal al sho shock ck unr unres espon ponsiv sive e to therapy.13,25 Health care providers must therefore realize that hypotension is a late and ominous sign of sho shock ck in pe pedi diat atri ric c pa pati tient ents, s, an and d ev ever ery y ef effo fort rt should be made to recognize and treat tre at shock states before such decompe decompensation nsation occurs.13,21,22,25 Certain principles apply regardless of the etiology of shoc shock k and shou should ld be inst institu ituted ted imme immedia diately tely for all patients presenting with signs of shock. Attention should first be directed toward airway and breathing. All patients should be placed on supplemental oxygen, oxyg en, pre prefer ferabl ably y by hig high h flo flow, w, non non-re -rebre breath ather er mask. Patients with a patent airway and spontaneous respirations respirations may still benef benefit it from early intubation ti on to re redu duce ce me meta tabo boli lic c de dema mand nd an and d as assur sure e adequa ade quate te oxyg oxygenat enation ion and ven ventil tilati ation, on, es especi pecially ally 26-28 in cases of severe or decompensated shock. Establ Est ablish ishing ing vas vascul cular ar acc access ess is ano anothe therr ear early ly priority in the management of shock. This is best accomplished through the placement of as large a caliber peripheral IV catheter as is possible for the patien pat ient's t's siz size. e. Sev Severe erely ly inj injure ured d pat patien ients ts sho should uld idea id eall lly y ha have ve at le leas astt 2 fu func ncti tion onin ingg IV IVs. s. Th The e maximum rate of flow through any given catheter is pro propor portio tional nal to the dia diamet meter er and inv inver ersel sely y proportional to the length; therefore, short, largecaliber cal iber cat cathet heters ers are pre prefer ferred red ove overr long long cen centra trall 24,25 venous lines for initial resuscitation. When IV access cannot be quickly established, consideration should sho uld be gi give ven n to pla placin cingg an int intrao raosseo sseous us (IO (IO)) 13,25 access acce ss devi device. ce. Histor His torica ically lly,, IO acc access ess was limited limi ted to inf infant antss and young chi childr ldren. en. New Newer er IO drill dri ll dev device icess allo allow w t his h is route route to be used in older children childre n and adults.29,30 Flui Fluid d the therap rapy y shou should ld be initiat ini tiated ed imm immedia ediately tely aft after er acc access ess is est establi ablishe shed. d. Initial fluid therapy should consist of a 20 mL/kg bolus of isotonic crystalloid fluid given as quickly as pos possib sible. le. If hea heart rt rat rate, e, lev level el of con conscio sciousne usness, ss, and capillary capillary refill do not improve, a second 20 mL/ kg bolus should be rapidly administered. If system-
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ic perfusion does not respond to administration of 40 to 60 mL mL/k /kgg of cr crys ysta tall lloi oid d in pa pati tien ents ts wi with th suspect susp ected ed hemo hemorrh rrhagi agic c shoc shock, k, 10 to 15 mL/ mL/kg kg of packed pac ked red bloo blood d cell cellss (PRB (PRBCs) Cs) sho should uld be tra transnsfused and repeated as needed. Type-specific crossmatc ma tche hed d bl blood ood is pr pref efer erre red; d; ho howe weve ver, r, ty type pe O negative blood may be used in emergency circumstance sta ncess unt until il cr cross oss-ma -matc tched hed blo blood od is ava availa ilable ble.. Patie Pat ients nts ex exhib hibit itin ingg sig signs ns of sho shock ck sho should uld ha have ve emerge eme rgent nt cons consulta ultation tion by a tra trauma uma surg surgeon eon because they may require explorati expl oration on to identify and correctt ongoing hemorrhage.13,25 correc Treatment Treat ment of obstruc obstructive tive shock requir requires es identi identifification and specific therapy for the type of obstruction.. Peri tion Pericar cardia diall tam tampona ponade de may pre present sent with muffled heart sounds, diminished pulses, and distended neck veins. Chest radiograph and bedside ultraso ultr asound,when und,when ava availab ilable, le, may be help helpful ful in mak making ing the diagnosis. If time permits, pericardial drainage under ultrasound guidance is the preferred treatment.. In pat ment patien ients ts wit with h sev severeshock ereshock or car cardio diovas vascula cularr collapse, collaps e, emerge emergent nt peric pericardioc ardiocentesis entesis may be life saving sav ing and sho should uld be per perfor formed med wit without hout delay. Tensi Te nsion on pn pneum eumot othor horax ax is a co commo mmon n ca cause use of obstructiveshockintraumapatientsandmaypresent with hypoxia, hypotension, diminished pulses, diminished or absent breath sounds on the affected side,, and dist side distend ended ed neck veins and and/or /or tra trache cheal al deviat dev iation ion.. Che Chest st rad radiog iograp raphs hs may be help helpful ful in makin mak ingg th the e di diag agnos nosis is bu butt sho should uld no nott de dela lay y tr trea eatme tment nt in cri critic ticallyill allyill tra trauma uma pat patient ients. s. The These se pat patien ients ts shou should ld haveimmediatedecompressionofthepneumothorax by pla placem cement ent of an ove over-t r-thehe-nee needle dle cat cathet heter er in the second intercostal space in the th e midclavicular midclavicular line fol followe lowed d by tub tube e tho thorac racosto ostomy. my.13,24,25,31 Distributive shock may be seen in acute spinal cord injuries when loss of systemic vascular tone creates a state sta te of rel relati ative ve vas vascul cular ar vol volume ume dep deplet letion ion.. Ini Initia tiall treat tre atmen mentt of dis distri tribut butive ive sho shock ck is sim simila ilarr to tha thatt of hypovo hyp ovolemi lemic c sho shock. ck. Vas Vascula cularr acc access ess shou should ld be obtained and crystalloid boluses of 20 mL/kg should be del delive ivere red d unt until il sys system temic ic per perfus fusion ion imp improv roves. es. If systemic perfusion does not improve after 2 to 3 such boluses bolus es and occult hemor hemorrhag rhage e has been excluded, excluded, vasoactive medications such as dopamine or norepinephri nep hrine ne may be nee needed ded.. The α-adrenergic properties of these medications cause systemic vasoconstriction and may impr improve ove perfusion perfusion in case casess of distributive distributive shock sho ck.. The These se inf infusi usions ons are ide ideall ally y giv given en thr throug ough h a central cent ral veno venous us cath catheter eter beca because use extr extravas avasation ation may cause significant tissue necrosis. Ongoing management of trauma patients involves frequen fre quentt rea reasse ssessme ssment nt to gau gauge ge the ade adequa quacy cy of resuscitation and to recognize any need for further intervention. Some patients may respond to initial
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VOL. 11, NO. 1 • PROVIDING PEDIATRIC CRITICAL CARE FOR TRAUMA PATIENTS IN THE ED / PETRILLO-ALBARANO AND LITTLE
volume resuscitation resuscitation with improvement of tachycardia car dia,, cap capill illary ary ref refill, ill, or blo blood od pre pressur ssure, e, onl only y to retu re turn rn to an un unst stab able le sh shoc ock k st stat ate e if th they ey ar are e experiencing ongoing hemorrhage. The often mentioned leth lethal al tri triad ad of tr trau auma ma re refe fers rs to th the e development develop ment of hypoth hypothermia, ermia, metab metabolic olic acidosi acidosis, s, and coa coagulo gulopat pathy hy tha thatt may dev develo elop p in ser seriou iously sly injured patients. Pediatric patients are particularly suscept susc eptible ible to hypo hypothe thermia rmia giv given en the their ir rel relati ativel vely y larger surface to body mass ratio, as compared with adults. Warming measures such as heate heated d blanke blankets, ts, removal of wet clothing and bedding, and warming lights lig hts shou should ld be inst institut ituted ed and bod body y tem temper peratu ature re closely monitored. Serial measures of serum hemoglobi glo bin n and he hemat matocr ocrit it ma may y aid in re reco cogn gnizi izing ng ongoing hemorrhage hemorrhage and ident identifying ifying patients needing emerg emergent ent surgic surgical al interv intervention. ention. Patients requi requirring mas massive sive or ong ongoing oing volume res resusci uscitat tation ion may develop coagulopathy from consumption and dilution of clotting factors. factors. This may manifest exter externally nally as mucosal bleeding or oozing from skin sites such as nee needle dlesti sticks cks and cut cutane aneous ous wou wound nds. s. The These se patien pat ients ts may req requir uire e tra transfu nsfusion sion of fre fresh sh fro frozen zen plasma and platelets in addition to PRBCs. Traditionally tion ally,, tra trauma uma pat patient ientss were tra transfu nsfused sed with PRBCs alone until coagulopathy coagulopathy becam became e manife manifest st as eit either her exc excessi essive ve ble bleedi eding ng or abn abnorma ormaliti lities es in laborat lab oratory ory valu values es for pla platel telet et lev levels, els, pro prothr thrombi ombin n time,, and act time activa ivated ted par partia tiall thro thrombo mboplas plastin tin tim time. e. Recent literature literature suggest suggestss that patients requiring massive transfusion, usually defined as more than 10 U of PRBCs for adult patients, should receive closer to a 1:1:1 1:1:1 ratio of red blood cells, plasma, and 32-34 platelets. Evidence-base Eviden ce-based d pediat pediatric ric guide guidelines lines for massive transfusion have not been well established, but it seems prudent to provide plasma and platelet replenishment in addition to PRBCs to any patient requiring massive transfusion. “
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SUMMARY AND RECOMMENDATIONS Optimal ear Optimal early ly int interv erventi ention on has bee been n show shown n to improve patient outcomes outcom es in many medical conditions includi including ng trauma trauma..28 Unfortu Unfortunately nately,, EDs are often overcrowded and understaffed, and inpatient and intensive care beds are often in short or limited supply. As a consequence, increasing numbers of crit cr itica ically lly il illl pa pati tient entss ar are e bo boar arde ded d in ED EDss whi while le awaiting inpatient bed availability. 2,3,5,31 Seriously injured pediatric trauma patients must be car careful efully ly moni monitor tored ed and fre freque quently ntly asse assessed ssed,, whether in the ED, the radiology department, the pediatr ped iatric ic ICU ICU,, or in-t in-tran ransit sit bet between ween loca location tions. s. Care Ca refu full at atte tent ntio ion n mu must st be pa paid id to th the e ai airw rway ay,, breathing, and adequacy of oxygenation and venti-
lation. Caregivers should be comfortable with bagmask ven ventila tilatio tion, n, tra trachea cheall int intubat ubation, ion, and eve even n ventila ven tilator tor mana managem gement ent for pat patien ients ts who may remain in the ED awaiting an ICU bed or transfer to a tertiary care center. Alll pat Al patient ientss sho should uld hav have e ade adequa quate te vasc vascula ularr acc access. ess. Often, IV access can be difficult to obtain in infants and sma small ll chi childr ldren. en. Equi Equipme pment nt for int intraos raosseou seouss access acc ess shou should ld be rea readily dily ava availab ilable le and car caregi egiver verss familia fam iliarr wit with h the their ir use. Cen Central tral ven venous ous cat cathet heter er plac pl aceme ement nt may al also so be ne need eded ed,, esp espec ecia iall lly y in patients requiring vasopressor infusion or administration tratio n of multiple medications. The most commonly used site for central line insertion in pediatric patients is the femoral vein. This site is often chosen due to relative ease of access and because placement does not require removal of the cervical collar in trauma patients or interfere with airway manipulation. However, in patients with intra-abdominal hemor he morrh rhag age, e, a fe femor moral al lin line e ma may y not be th the e be best st choice;; in these patients, choice patients, a subclavian line may be a more optimal choice. Pati Pa tien ents ts mus mustt be ca care reful fully ly mon monito itore red d fo forr the subtle early signs of shock and every effort made to rever reverse se shock before compensatory mechanisms are overwhelmed. overwhelmed. Placement of an arterial line may be helpful for both blood pressure monitoring and freque fre quent nt lab labora orator tory y dra draws; ws; esp espec ecial ially ly in sma small ll children in whom central access is not established. Placement Placeme nt should be consider considered ed for any patient patient who is on vasopressors, has an ICP monitor in place, or has persistent hypotension hypotension or other signs of clinic clinical al instability. If an appropriately sized arterial line kit is not available, a 24- or 22-gauge catheter may be plac pl aced ed in the ra radi dial, al, do dors rsali aliss pe pedi dis, s, or po post steri erior or ti tibi bial al artery. A single-lumen, 3 French, 5- or 8-cm-long central venous catheter may also be placed in the femoral artery of infants or children. Maint Ma intain aining ing air airway, way, bre breath athing ing,, and cir circul culatio ation n are always top priorities in the management of trauma patien pat ients. ts. Con Contro troll of pai pain n and anxiety anxiety is anot another her important component of trauma care that may be overloo ove rlooked ked in the cri critic tically ally inj injured ured ped pediat iatric ric pat patien ient. t. Small doses of opiates and/or benzodiazepines may be give given n and repeated repeated as nee needed ded,, wit with h con consta stant nt monitoring for the depression of level of consciousness, respiratory drive, and blood pressure that may occu oc curr wi with th th these ese me medi dica cati tion ons. s. If th the e ch child ild is intubated, ensuring adequate sedation is paramount to mai mainta ntaini ining ng con contro troll of the air airway. way. Ina Inadeq dequat uate e sedation may lead to a host of secondary issues from airway edema to aspiration and may increase ICP in patients with TBI. Intubated patients may benefit from fro m con continu tinuous ous lowlow-dose dose inf infusio usions ns of nar narcoti cotics cs and and/ / or benzodiazepines to maintain adequate levels of
PROVIDING PEDIATRIC CRITICAL CARE FOR TRAUMA PATIENTS IN THE ED / PETRILLO-ALBARANO AND LITTLE • VOL. 11, NO. 1
sedation. On occasion, it may also be necessary to use neuromuscular blocking agents (paralytics) to assist ventilation ventilation or contro controll ICP. These medica medications tions may ma y be gi give ven n as ei eith ther er in inte term rmit itte tent nt do dose sess or contin con tinuous uous inf infusio usions. ns. It is vit vitally ally imp import ortant ant to maintai main tain n ade adequa quate te sed sedati ation on in pat patien ients ts rec receiv eiving ing neuromuscular blockade. Close monitoring of blood press pr essur ure e an and d he hear artt ra rate te,, esp espec ecia ially lly ch chan ange gess in respons res ponse e to pos positio itionin ning, g, suct suctioni ioning, ng, or othe otherr nox noxious ious stimuli, may provide valuable information about the patient's level of sedation. While While awa awaiti iting ng tra transf nsfer er to an app approp ropria riate te ICU setting, every effort should be made to bring the ICU to the patient by providing close monitoring, freque fre quent nt rea reasse ssessme ssment, nt, and rap rapid id cor correc rectio tion n of probl pr oblems ems as the they y ar arise ise.. Eme Emerg rgen ency cy de depa partm rtmen ent t personnel should also keep in mind that consultation tio n with colleagues colleagues in cri critic tical al car care e med medici icine ne or anesthesia is often available to help guide patient management, even if an ICU bed is not physically available availa ble for a critic critically ally injured patie patient. nt. “
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REFERENCES American America n Acad Academy emy of Pedi Pediatri atrics cs Comm Committee ittee on Pedi Pediatri atric c Emergen Emer gency cy Medi Medicine cine.. Over Overcrowd crowding ing crisi crisiss in our nati nation's on's emergenc emer gency y depa departme rtments: nts: is our safe safety ty net unra unraveli veling? ng? Pediatrics 2004;144:878 2004;144:878-88. -88. Richar hardson dson LD, BR Asp Asplin lin BR, Low Lowe e RA. Eme Emerge rgency ncy 2. Ric crowding crow ding as hea health lth polic policy y issue issue:: past development, development, future direction. Ann Emerg Med 2002;40:388-93. 3. Derlet R, Richards J, Kravitz F. Frequent overcrowding in U.S. emer emergenc gency y depa departme rtments. nts. Aca Acad d Emer Emergg Med 2001 2001;8:15 ;8:151-5. 1-5. 4. Cowan RM, Treciak S. Clinical review: emergency department overcrowding and the impact on the critically ill. Crit Care 2005;9:291-5 2005;9:291-5.. 5. Chalfin DB, Trzeciak S, Likourezos A, et al. Impact of delayed transfer tran sfer of crit criticall ically y ill pati patients ents from the emer emergenc gency y depa departme rtment nt to the intensive care unit. Crit Care Med 2007;35:1477-83. 6. Curry R, Hollingworth W, Ellbogen RG, et al. Incidence of hypo- and hype hypercar rcarbia bia in seve severe re trau traumati matic c brai brain n inju injury ry before and after 2003 pediatric guidelines. Pediatr Crit Care Med 2008;9:141-6 2008;9:141-6.. 7. Carney NA, Chestnut R, Kochanek P, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Pediatr Crit Care Med 2003;4(Suppl):S1-S75. Pigu gula la FA FA,, Wa Wald ld SL SL,, Sh Shac ackf kfor or SR SR,, et al al.. Th The e ef effe fect ct of 8. Pi hypotension and hypoxemia on children with severe head injury. J Pediatr Surg 1993;28:310-4. Coat ates es BM, Va Vavi vila lala la MS, Ma Mack ck CD CD,, et al al.. In Influ fluen ence ce of 9. Co definition and location of hypotension on outcome following severe pediatric traumatic brain injury. Crit Care Med 2005; 33:2645-50. Michaud aud LJ, Riva Rivara ra FP, Grady Grady MS, et et al. Pred Predicto ictors rs of surviv survival al 10. Mich and disability after severe brain injury in children. Neurosurgery 1992;31:254 1992;31:254-64. -64. 11. Ong L, Selladurai BM, Dhillon MK, et al. The prognostic value of the Gla Glasco scow w com coma a sca scale, le, hyp hypoxi oxia, a, and com comput puteri erized zed tomography in outcome prediction of pediatric head injury. Pediatr Neurosurg 1996;24:285 1996;24:285-90. -90. 1.
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Mansfield RT. Severe traumatic brain injuries in children. Clin Pediatr Emerg Med 2007;8:156-64. 13. American Heart Association. Pediatric advanced life support provider manual. Dallas (Tex): American Heart Association; 2002. 14. Marion DW, Obrisr DW, Carlier PM, et al. The use of moderate therapeutic hypothermia for patients with severe head injuries: a preliminary report. J Neurosurg 1993;79:354-62. 15. Bi Bisw swas as AK AK,, Br Bruc uce e DA DA,, Sk Skla larr FH FH,, et al al.. Tr Trea eatm tmen entt of acute acut e trau traumati matic c brai brain n inju injury ry with mode moderate rate hypot hypotherm hermia ia improves intracranial hypertension. Crit Care Med 2002;30: 2742-51. Shio ioza zaki ki T, Hi Hisa sash shii S, Ta Tane neda da M, et al al.. Ef Effe fect ct of mi mild ld 16. Sh hypotherm hypot hermia ia on unco uncontrol ntrollable lable intr intracra acranial nial hyper hypertensi tension on after severe head injury. J Neurosurg 1993;79:363-8. 17. Muizelaar JP, Lutz HA, Becker DP. Effect of mannitol on ICP and CBP and corr correlati elation on with pressure autoregulat autoregulation ion in several head injured patients. J Neurosurg 1984;61:700-6. 18. Khanna S, Davis D, Peterson B, et al. Use of hypertonic saline solutions in the treatment of cerebral edema and intracranial hypertension. Crit Care Med 2000;28:1144-51. 19. Qureshi AI, Suarez JI. Use of hypertonic saline solutions in the treatment of cerebral edema and intracranial hypertension. Crit Care Med 2000;28:3301-13. Nathen henss AB, Johnson Johnson JL, Min Minei ei JP, et al. Gui Guide delin lines es for 20. Nat mechanic mech anical al vent ventilati ilation on of the trau trauma ma pati patient. ent. J Traum Trauma a 2005 2005;; 59:764-76. 21. McConnell MS, Perkin RM. Shock states. In: Zimmerman JJ, Furman BP, editors. Pediatric critical care. St Louis (Mo): Mosby; 1998. p. 293-306. 22. Vanore M, Perks D. Early recognition and treatment of shock in the pediatric patient. J Trauma Nurs 2006;13:18-21. 23. Hameed SM, Aird WC, Cohn SM. Oxygen delivery. Crit Care Med 2003;31:S65 2003;31:S658-67. 8-67. 24. Cheatham ML, Block EJ, Smith HG, et al. Shock: an overview. In:RippeJM, Irw Irwin in RS,edito RS,editors.Irwinand rs.Irwinand Rip Rippe pe's 's int intens ensivecare ivecare medicine. Philadelphia (Pa): Wolters Kluwar; 2007. p. 1831. 25. American College of Surgeons. Advanced trauma life support for doc doctor tors. s. 7th ed. Chi Chicag cago o (Il (Ill): l): Am Ameri erican can Col Colleg lege e of Surgeons; 2004. 26. Maar SP. Emergency care in pediatric septic shock. Pediatr Emerg Care 2004;20:6172004;20:617-24. 24. 27. Welch SB, Nadel S. Treatment of meningococcal infection. Arch Dis Child 2003;88:608-14. Parker er MM, Haze Hazelzet lzet JA, Carc Carcillo illo JA. Pedi Pediatri atric c consi considera dera-28. Park tions. Crit Care Med 2004;32:S591-594. 29. Buck MI, Wiggins BS, Sesler JM. Intraosseous drug administration tra tion in chi childre ldren n and adu adults lts dur during ing car cardiop diopulmo ulmonar nary y resuscitation. Ann Pharmacoth Pharmacother er 2007;41:167 2007;41:1679-86. 9-86. 30. Blumberg SM, Gorn M, Crain EF. Intraosseous infusion: a review of methods and novel devices. Pediatr Emerg Care 2008;24:50-9. Gregory ory JC, Marcin Marcin JP. Golden Golden hours hours waste wasted: d: the huma human n cost 31. Greg of intensive care unit and emergency inefficiency. Crit Care Med 2007;35:161 2007;35:1614-5. 4-5. Lawson n JH. The coag coagulopa ulopathy thy of trau trauma ma versus 32. Hess JR, Lawso disseminated intravascular coagulation. J Trauma 2006;60: S12-9. 33. Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood prod products ucts tran transfuse sfused d affe affects cts mort mortalit ality y in pat patient ientss receiving massive transfusions at a combat support hospital. J Trauma 2007;63:805-13. 34. Ketchum L, Hess JR, Hiippala S. Indications for early fresh frozen froze n plasm plasma, a, cryop cryopreci recipita pitate, te, and plate platelet let tran transfusi sfusion on in trauma. J Trauma 2006;60:S51-8. 12.
Abstract: Most pediatric trauma patients are cared for in non-chil non-children's dren's hospitals by providers without pediatric specialty training and in facilities that may not be used to caring for children. Children have different physiologic and psychologic responses to injury than adults. Children have differ different ent service servi ce and evaluative needs. Several studies have shown that pediatric pediat ric trauma patients have improved impro ved outcom outcomes es with lower mortality, fewer operations, and improved function when cared for in pediatric pediat ric facilities or adult trauma centers with pediatric expertise. Differences Differ ences between injured adults and injured children need to be understood, unders tood, recognized, and acted upon by care providers to optimize treatment treat ment for injured children. Limitations in the availability of pediatric pediat ric specialists require that all hospitals hospit als be prepar prepared ed to effectively and success successfully fully treat pediat pediatric ric trauma patients.
Keywords: pediatric pediatric trauma; trauma; injured children; trauma systems; outcomes
Reprint requests and correspondence: Kimberly P. Stone, MD, MS, MA, Department of Pediatrics, Division of Emergency Medicine, Seattle Children's Hospital, 4800 Sand Point Way NE, M/S B-5520, Seattle, WA 98105.
[email protected] ,
[email protected] 1522-8401/$ - see front matter © 2010 Elsevier Elsevier Inc. All rights reserved.
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Pediatric Patients in the Adult Trauma Bay — Comfort Level and Challenges Kimberly P. Stone, MD, MS, MA, George A. Woodward, MD, MBA
C
hildre hild ren n re repr pres ese ent alm lmos ostt 20 20% % of al alll em emer erg g ency depa de part rtme ment nt (E (ED) D) vi visit sitss in th the e Un Unit ited ed St Stat ates. es.1 In any giv given en yea year, r, an est estimat imated ed 13. 13.5 5 mill million ion ped pediat iatric ric ED vi visi sits ts ar are e fo forr in inte tent ntio iona nall an and d un unin inte tent ntio iona nall 2 injury. Of th thes ese e 13 13.5 .5 mi mill llio ion n vi visi sits ts,, on only ly 23 23% % of ch chil ildr dren en will be tre treate ated d by a ped pediat iatric ric emergenc emergency y phy physici sician an and only 7% of pedi at ric r ic pa pattie ient ntss wi will ll be tr trea eate ted d in a se sep par arat ate e 3 pediatric pediat ric ED. Despi De spite te no nott ha havi ving ng a pe pedi diat atri ric c ED or in inpa pati tien entt pe pedi diat atri ric c resources, resource s, 76 76% % of hos hospi pita tals ls wil willl ad admi mitt ch child ildre ren n to th thei eirr ow own n facilities.2 A rec recent ent rev review iew of hosp hospita itall dis discha charge rgess for inju injured red children identified that 15% of injured children were discharged from fro m hosp hospita itals ls wit with h low ped pediat iatric ric tra trauma uma exp experi erienc ence e and low overall pediatric experience. Of those 15% of injured children, 6% had injury sever severity ity scores of 9 or higher indicating moderate to 4 severe sever e injur injury. y. Almo Almost st hal halff of all ped pediat iatric ric tra trauma uma-re -relat lated ed 5 discharges in the review by Segui-Gomez and colleagues were from fro m non nontra trauma uma cen center ters, s, eve even n in sta states tes wit with h ped pediat iatric ric tra trauma uma designation systems in place. Despit Des pite e the rec recent ent pro prolife liferat ration ion of ped pediat iatric ric eme emerge rgency ncy medicin medi cine e spec special ialists ists,, most inj injure ured d chil childre dren n are tre treate ated d by providers provid ers without pediatric specialty traini training ng an and d in fac facilit ilities ies 2,6-8 that th at ma may y not be use used d to ca cari ring ng fo forr ch child ildre ren. n. Tremendous variability exists across the country with some geographic areas having availability of pediatric EDs and pediatric trauma services, whereas other areas still do not. Emergency departments, both
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PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD • VOL. 11, NO. 1
within trauma centers and nontrauma centers, cente rs, need to be prepared to care for injured children. 2,8 This article will discuss pediatric-specific challenges that face fac e all prov provide iders rs and rev review iew the lite literat rature ure reg regard arding ing how in inju jure red d pe pedi diat atri ric c pa pati tien ents ts fa fare re whe when n ca care red d fo forr in the non–pediatric-specific trauma system.
CHALLENGES POSED BY THE PEDIATRIC TRAUMA PATIENT By now everyo everyone ne has heard the phrase, “children are not little adults. ” However, how they differ and why it matters, especially as it pertains to trauma, is not necessa necessarily rily univers universally ally appre appreciated ciated.. Childr Children en have hav e dif differ ferent ent phy physio siolog logic ic and psy psycho cholog logic ic responses respons es to injury. Children have different service and evaluative needs. These differences need to be understood, recognized, and acted upon by treating providers provid ers to provid provide e optimal treatment.
Assessment of the Child and Recognition of Injury The first step in any treatment algorithm is the skilled assessment assessment of the patient. The assessment of the injured child is inherently different than that of an adu adult. lt. Ped Pediatr iatric ic pat patien ients ts may be non nonver verbal bal or developmentally incapable of communicating their nonappa nona pparen rentt inj injuri uries es to hea health lth car care e pro provid viders. ers. Providers will need to use nonverbal cues in young children to assess pain and injury sites. Pediatric trauma tra uma pat patien ients ts (an (and d the their ir par parent ents) s) wil willl ofte often n be scared scar ed and anx anxious ious;; thi thiss anx anxiet iety y may aff affect ect vital signs and limit the overall assessment. Assessment of vital signs requires knowledge of age-based norms and an d co conf nfoun ounde ders rs th that at may not be as fa fami milia liarr to nonpediatric providers. Rapid identification of early signs sig ns of sh shock ock both by vi vita tall si sign gnss an and d ph physi ysica call examination examina tion are crucia cruciall for optimal resusc resuscitation itation of seriously seriousl y injured children.
Anatomical and Physiologic Differences A ch child ild's 's bod body y siz size e an and d hab habitu ituss af affec fectt how tr traum aumat atic ic energy forces are absorbed and distributed. Knowledge of anatomical differences can lead to pattern recognition and aid in timely diagnosis of injuries. A thorough thor ough review of the anat anatomic omical al diff differen erences ces in children is beyond the scope of this article, but a few important variations variations are highlighted here: •
A ch chil ild' d'ss bo body dy si size ze is sm smal alle lerr an and d ha hass proportionally less body fat leading to energy forces for ces bei being ng mor more e wid widely ely dis dispe perse rsed d tha that t results res ults in mult multipl iple e inj injuri uries es and pot potent ential ially ly less visibi visibility lity on physica physicall examina examination. tion.
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A child's airway is more anteriorly located and easily eas ily obs obstru tructe cted d by poo poorr pos positi itioni oning. ng. The ability to successfully manage a child's airway requires specific advanced airway skill. child's ld's pro propor portio tionall nally y lar larger ger ton tongue gue can • A chi cause upper airwa airway y obstru obstruction. ction. Child ildre ren n hav have e lar large ge hea heads, ds, esp espec ecial ially ly as • Ch comp co mpar ared ed to the re rema maind inder er of th thei eirr bo body dy size. Young children “lead with their head ” during falls resulting in more head injuries. The e ex expa pand ndab able le sk skul ulll in yo youn ungg ch chil ildr dren en • Th (b1 yea year) r) with ope open n fon fontan tanelle elless pro provid vides es spa space ce to accommodate a large intracranial bleed. As compared compare d to adults and older children, young children can present with or develop hemorrhagic shock from closed head trauma. • Children have a higher fulcrum in the neck resulting in higher spinal cord injuries (above C4) in younger children. These injuries may not be as obvious on x-rays due to the large amount of cartilage present, but the effects can be devast devastating. ating. • Laxity of the vertebral column along with the cartila car tilage ge art artifa ifacts cts can res result ult in spi spinal nal cor cord d injury inju ry with without out rad radiogr iographi aphic c abno abnormal rmality ity (SCIWORA). • A child's chest wall is pliable, allowing more internal inte rnal for force ce with litt little le to no no ext extern ernal al sign signss of injury. Children have fewer rib fractures, flail chest, and more pulmonary contusions. Cardiovascular injuries can be initially silent and challenging to diagnose. Abdomin ominal al org organs ans in chi childr ldren en are less well • Abd protected by the bony rib cage allowing for more solid organ injury. The infant liver and spleen are palpable below the costal margin. The kid kidney neyss are also more vulnerabl vulnerable e secondary to decrea decreased sed abdomi abdominal nal musculat musculature. ure. • A child's growing bones result in vulnerable growth plates leading to a high incidence of growth plate fractures. Childr ldren en hav have e pro propor portio tional nally ly lar larger ger ski skin n • Chi surfa sur face ce ar area ea all allowi owing ng th them em to mor more e ea easil sily y become hypothermic hypothermic with result resultant ant acido acidosis. sis. • Children have an overall smaller total blood volume that increases the risk for rapid onset of sh shoc ock. k. Th They ey al also so ha have ve th the e ab abil ilit ity y to increase their heart rate and stroke volume to te temp mpor orize ize fo forr ac acute ute vo volum lume e los loss. s. Vi Vital tal signs, sign s, and par partic ticula ularly rly bloo blood d pre pressur ssure, e, may not indicate the true level of volume loss in these children. •
These anato These anatomica micall and phys physiolog iologic ic diff differen erences ces may be less familiar to medical providers without
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pediatric train pediatric training ing or signifi significant cant ongoing experience experience in caring for children but are vital to be recognized by anyone caring for a pediatric trauma patient.
Equipment Children Childr en com come e in dif differ ferent ent ages and sizes, and therefore, the equipment needed to treat them (and sometimes the skills required) also need to come in differ dif ferent ent size sizes. s. Sev Severa erall rec recent ent stud studies ies hav have e ide identi ntifie fied d that few nonpediatric hospitals are fully equipped with wi th al alll th the e necess cessary ary equ equipme ipment nt to hand handle le ped pediat iatric ric emergencies.1 In its review of the emergency care system for children, the Institute of Medicine noted that only 6% of EDs in the United States had all the supplies deemed essential by the American Academy of Ped Pediatr iatrics ics and Amer America ican n Col Colleg lege e of Emer Emergen gency cy Physicians Physicia ns to handle pediatric pediatric emerge emergencies. ncies. Only half of the ho hospital spitalss had at least 85% of the essential essential 6 equipment. A similar study in Canada also found essential pediat ric equipment unavailable in most of Canadian Canadi an EDs.9 Th The e mat mater eria ials ls mos mostt li like kely ly to be missin mis singg ar are e equ equip ipme ment nt an and d sup suppli plies es ne need eded ed fo forr neonates and young infants. A 2003 20 03 survey of EDs by Gau Gausch sche-H e-Hill ill and col collea league guess10 found simil similar ar levels lev els of rea readine diness ss com compar pared ed to pub publish lished ed gui guideli delines nes.. Childr Chi ldren' en'ss hos hospit pitals als wer were e pre predic dictab tably ly the bes best t prepared, though hospitals with inpatient pediatric care car e res resour ources ces and lar larger ger ped pediat iatric ric pat patien ientt ED volumes were typica typically lly bette betterr prepa prepared. red. Regardless of hospital size, the presence of a physician and/or nurse coordinator for pediatric emergency ca care re was 10 predictive of a higher level of preparedness. A recently updated reference for recommended equipment (as well as other resources) for all EDs cari ca ring ng fo forr pe pedi diat atri ric c pa pati tien ents ts ca can n be fo found und in th the e 20 2009 09 joint jo int Amer America ican n Aca Academy demy of Ped Pediat iatric rics, s, Amer America ican n College of Emergency Physicians, and Emergency Nurses Association policy statement, Guidelines Guidelines fo forr Care of Children in the Emergency Department. 1 Any ED caring for pediatric trauma patients should make it a priority to have the appropriate range and spectrum of equipment outlined.
Medications and Errors Just as the equipm Just equipmen entt siz size e ne need edss to be sc scal aled ed down to child proportions, proportions, so too do the medica medication tion dosages. The need for weight-based dosing and lack of sta stand ndard ardize ized d do dosi sing ng fo forr ch child ildre ren n le lead adss to in in-creased medi medication cation errors in children as compared 11,12 to adu adults. lts. Medic Me dicati ation on err errors ors in chi childr ldren en are most 11 associated with intraven intrave nous fluids, and pain and sedative medications,13 medications frequently used in ped pediat iatric ric tra trauma uma pat patien ients. ts. Pro Provid viders ers not routinel rout inely y admi administ nisterin eringg medi medicati cations ons to chil children dren
may be less familiar with the subtleties of weightbased dosing and the complex calculations that may be required. Providers caring for pediatric trauma patie pa tients nts sho should uld see seek k to imp improv rove e hos hospi pital tal-wi -wide de systems to decrease pediatric medication errors as partt of a com par compre prehen hensive sive ped pediat iatric ric pat patient ient saf safety ety 11 program. Establis Establishing hing a weight in kilograms for all pedia pe diatr tric ic pa patie tients nts an and d th the e use of pre preca calcu lculat lated ed weight-based dosing tools will assist in the reduc reduction tion 12 of medication errors for all pediatric patients.
Evaluation Tools The diagnostic tools used to evaluate intraabdominal injuries in pediatric trauma patients differ from those used for adult trauma patients. For pediatric trauma patients, abdominal computed tomography (CT) remains the standa standard rd for evalua evaluating ting suspected abdomina abdo minall inj injury ury in the hem hemody odynami namical cally ly sta stable ble 14-17 child. The acc accepte epted d sta standar ndard d for a hemo hemodydynamicall nami cally y unst unstabl able e chi child, ld, howe however ver,, rem remains ains in evolution with decreasing use of diagnostic peritoneal lavage (DPL), increasing use of focused abdominal sonography for trauma (FAST), and continued reliance on initial and serial physical examinations. In hem hemody odynam namica ically lly uns unstab table le ad adult ults, s, DPL remains rem ains a too tooll used to det determi ermine ne int intrap raperi erito toneal neal 18,19 hemor he morrh rhag age e or a ru rupt ptur ured ed ho holl llow ow vi visc scus us.. However, DPL is now rarely used or recommended in ch chil ildr dren en be beca cause use of it itss inv invasi asive ve na natur ture e an and d unacceptab unac ceptably ly high rate of nontherapeutic laparot14,16,17 omy. In addition, because most solid organ injuries are managed nonoperatively, the presence of blood may not determine therapeutic interventions. DPL in pediatric trauma patients should be reserved for critically ill children with concerning CT fi find ndin ings, gs, in who whom m in init itia iall an and d se seri rial al ph physi ysica call examination is unreliable and for whom laparotomy pose posess subs substan tantia tiall ris risk k 14 and for pat patien ients ts who require requir e immedia immediate te surgic surgical al interv intervention entionss for nonabdomi abd ominal nal issu issues es whe where re a subt subtle le or lat latent ent injury could prove proble problematic. matic. In the adult trauma population, FAST examinations have been well studied and are now routinely used use d to ident ify i fy hem hemope operit ritone oneum um in unst unstabl able e 16,20,21 patients. Studies Stud ies on FAST examinati examinations ons in pediatric trauma populations have been be en mixed m ixed with 16,22 high specificity (as high as 95%-100%) but w ider ider ranges of sensitivity sensitivity (from 30% to 100%) 100%).. 16,20,22 The FAST examinations have the distinct advantage of bein be ingg a be beds dsid ide e to tool ol th that at ca can n ra rapi pidly dly id ident entif ify y hemopericardium and hemoperitoneum in an unstable sta ble tra trauma uma pat patien ient. t. Howe However ver,, chi childre ldren n hav have e a higher incidence of solid organ injury without free fluid flu id mak makin ingg a ne nega gati tive ve FAS FAST T ex exam amina inati tion on les lesss
PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD • VOL. 11, NO. 1
predictive in this population. More recent studies have hav e fou found nd FAST exa examina minati tions ons,, when com combin bined ed with la laboratory boratory assessments23 or physical examination,24 ha have ve hi highe gherr sen sensit sitiv ivity ity and ac accur curacy acy in pediat ped iatric ric tr traum auma a pa patie tients nts.. Man Many y adu adult lt tr traum auma a center cen terss tha thatt rel rely y on FAST examinati examinations ons in the their ir adult trauma also use the FA ST ST examina examination tion for their pediatric trauma patients. 25 Provid Providers ers need to understand the limitations of the FAST examination in chi childre ldren n to app approp ropria riatel tely y int interp erpret ret the res results ults and provid pro vide e opt optima imall dir direct ection ion and car care e to ped pediat iatric ric blunt trauma patien patients. ts. The his histor tory, y, ini initia tiall exa examina minatio tion, n, and seri serial al physic phy sical al exa examin minati ation on of the ped pediat iatric ric tra trauma uma patien pat ientt rem remain ain the cor corner nerston stone e of dia diagno gnosis. sis. Although children have classica classically lly been conside considered red unreli unr eliabl able e wit with h re regar gard d to phy physic sical al exa examin minati ation on findings, more recent studies have found that the initial and subsequ subsequent ent physical examina examinations tions will most often identify those pediatric trauma patients requiring requir ing operat ive ive intervention for their intraab26-28 dominal organs. Familiarity and comfort with examining examini ng pediat pediatric ric patients and interpreting interpreting pediatric vital signs, combined with an understanding of injury inj ury mec mechan hanisms isms,, is fun fundam damenta entall to rel relying ying on and trusting the physical examination examination as part of the diagnostic diagno stic evaluation of a pediat pediatric ric trauma patie patient. nt.
Radiation Exposure Trauma eval Trauma evaluati uations ons ofte often n inclu include de diag diagnost nostic ic radi radioologic logi c eval evaluati uation. on. Pedi Pediatri atric c trau trauma ma pati patients ents req require uire additionall considera additiona consideration tion regarding the total radiation dose whe when n dec decidi iding ng upo upon n ra radio diolog logic ic ass assess essmen ment. t. Potential future risks of accumulated radiation are unknown unknow n and dispr disproport oportionate ionately ly affec affectt younge youngerr pediatric patients who have a longer lifespan during which radiation-related radiation-related cancers could evolve.29 One review of pediatric trauma patients admitted to a level I trauma center found that 78% of patients underwen unde rwentt at leas leastt one radi radiolog ologic ic exam examina ination tion.. In this study stu dy,, CT sca scans ns ac accou counte nted d for 97.5% of the total effect ive ive radiation dose experienced by these children.30 The recent concern about potential radiation radiation risk from CT sca s cans ns led to a scientific review by Rice 31 and colle colleague agues. s. A Acc ccor ordi ding ng to th thei eirr re revi view ew,, th ther ere e is a potent pot ential ial inc incre reas ased ed ris risk k of can cance cerr fro from m low low-le -leve vell radiation (such as with CT); the calculated risk may be as high as 1 fatal cancer fo forr every 1000 CT scans performed in a young child.31 Appropr Appropriate iate decisionmaking regarding use of CT scan evaluation requires an understanding of the traumatic event and risk for injury inj ury,, an awa aware renes nesss of the ra radia diatio tion n ri risk, sk, the availability of alternate means of radiologic assessment (eg, ultrasound and magnetic resonance imag-
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ing whe where re app approp ropria riate) te),, and com compet petenc ency y wit with h ongoing clinical assessment of the pediatric trauma patient. pati ent. Although one shou should ld not with withhold hold critical critical diagnost diag nostic ic imag imaging ing for chil children dren with pote potentia ntially lly serious ser ious inj injuri uries, es, con conside siderat ration ion of rad radiat iation ion risk riskss 32 should be included in protocol development. The recently rece ntly publ publishe ished d deci decision sion rule by the Pedi Pediatr atric ic Emergen Emer gency cy Car Care e Appl Applied ied Rese Researc arch h Net Network work (PECARN) (PEC ARN) for the eval evaluati uation on of ped pediatr iatric ic head headtrau trauma ma is a good example example of an evid evidence ence-bas -based ed dec decisio isionnsupport tool that when used appr appropriately opriately can limit unnecessary unnecessar y radiati radiation on exposure.33 When CT scans are indicated in the evaluation of a pediatric trauma patient, patient, steps should be taken to minimi min imize ze th the e ra radi diat ation ion ex expo posur sure. e. The ALA ALARA RA (ass lo (a low w as re reas ason onab ably ly ac achi hiev evab able) le) co conc ncep eptt is a philoso phi losophy phy of rad radiati iation on dose management management tha thatt is bein be ingg pr pro o mo mote ted d by th the e So Soci ciet ety y fo forr Pe Pedi diat atrr ic 32 Radiology and the Nat Nation ional al Can Cancer cer Ins Instit titute ute34 and has been embraced by numerous professional organizations and many pediatric care facilities. A firs fi rstt st step ep in re redu duci cing ng ra radi diat atio ion n ex expo posu sure re is to decr de crea ease se the ra radi diati ation on se sett ttin ingg fo forr pe pedi diat atric ric CT scans. Children will receive a higher dose than is necessary for image quality when adult CT settings are used. Rad Radiat iation ion set setting tingss can be adj adjuste usted d for pediatric size yet maintain reliability of the study. Radiologists and all care providers treating pediatric ri c tr trau auma ma pa pati tien ents ts ne need ed to be aw awar are e of th the e principles of ALAR A and work toward minimizing radiation exposure.29,32,34
Nonaccidental Trauma Child abuse remains a leading cause of death and morbidi morb idity, ty, esp especi ecially ally amon amongg youn youngg chi childr ldren. en. In 2005, 353 children younger than 4 years died as a result of injuries sustained from an assault, making it the fourth lead le ading ing national cause of mortality in 35 this age gro group. up. Far more children children hav have e ser serious ious injuries, as a result of their abuse, with an estimated 1.3% to 15% of pediat ric ric inju injurie riess res resulti ulting ng in ED 36 visits caused by abuse. Severall factor Severa factorss can influence the identi identificati fication on of patien pat ients ts who hav have e inj injuri uries es fro from m susp suspect ected ed chi child ld abuse. The diagnosis of child abuse is often missed on initial medical visits due to erroneous histories, variable variab le physica physicall examina examinations, tions, and psychos psychosocial ocial issues.37 Identification and reporting of suspected child abuse is linked linked with provid provider er education about 38,39 child abuse. Pediatric residency programs have been found to provide more training and resources for child abuse education than general emerge emer gency ncy 40 medici med icine ne and fam family ily med medici icine ne pro progra grams. ms. In addition, nonchildren's hospitals have been found
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to less fr frequently equently identify victims of potential child 41 abuse. Provide Prov iders rs car caring ing for ped pediat iatric ric tra trauma uma patie pa tients nts mus mustt be di dilig ligent ent in con consid sider ering ing ch child ild abuse in their differential diagnosis and be aware of in inju juri ries es an and d pa patt tter erns ns th that at ar are e co conc ncer erni ning ng fo forr inflicted injury, including unexplained apnea, injuries with suspicious etiologies, or incidents blamed on unlikely perpetrators.
Family-Centered Care In 2006, the American Academy of Pediatrics and the Ame Americ rican an Col Colleg lege e of Eme Emerg rgen ency cy Phy Physic sicia ians ns publis pub lished hed a joi joint nt pol policy icy sta statem tement ent cal callin lingg for patientpatien t- and family-c family-center entered ed care when providing 42 care ca re to ch chil ildr dren en in ED EDs. s. Patien Pat ientt- and fam familyilycenter cen tered ed car care e rec recogn ognize izess the int integr egral al rol role e of the fami fa mily ly whe when n tr trea eatin tingg an il illl or in injur jured ed ch chil ild d an and d encoura enc ourages ges mut mutuall ually y ben benefi eficia ciall col colla laborati boration on among 42 the patient, family, and providers. Alth A lthoug ough h in inclu cludi ding ng fa famil milie iess in th the e ca care re of ch chil ildr dren en has lon longg bee been n und unders erstoo tood d an and d ap appr preci eciate ated d by pediat ped iatric rician ians, s, thi thiss con concep ceptt is rel relati ativel vely y new in trauma, tra uma, spe specif cifica ically lly wit with h reg regard ard to tra trauma uma res resusci uscitatations. A survey of trauma surgeons' attitude toward family presence during trauma resuscitation found that although 38% of respondents knew about the push toward family presence during trauma resuscita ci tati tion, on, on only ly 50 50% % wou would ld ev ever er al allo low w the their ir pr prese esenc nce. e.43 Of tho those se res respon ponde dents nts who wou would ld all allow ow fam family ily presence, only only 8% would permit it during the entire resuscitation.43 These results are similar to those found by Helmer et al44 who surveyed members of the Eme Emerge rgency ncy Nur Nurses ses Asso Associa ciatio tion n (EN (ENA) A) and Americ American an Asso Associa ciatio tion n for the Surg Surgery ery of Tra Trauma uma (AAST) regarding their opinions on family presence during trauma resuscitations. Almost 98% of AAST members felt that family presence during all phases of tra trauma uma res resusci uscitat tation ion was ina inappr ppropr opriat iate, e, and many beli believed eved that fami family ly pre presenc sence e inte interfer rfered ed with patient care ca re and inc increa reased sed str stress ess of tra trauma uma 44 team members. Several recent studies of family presence during pediatri pedi atric c trau trauma ma resus resuscita citat t ions io ns di disp spro rove ve th thes ese e 45 46 attitudes. Both O'Connell et al and Dudley et al performed perfor med prospective studies of family presence during pediatric pediatric trauma resuscitations resuscitations and found little to no negative impact on the care pro vi vided ded to pediatric pediat ric patien patients. ts. O'Conne O'Connell ll and collea colleagues gues45 found medical decision making, institution of care, team communication, and communication to the family to be the same or even ev en easier with family presence. presence. Dudley and Hansen46 found no clinically relevant difference in time to CT or resuscitation time with and without family presence. In their study, families
felt that their presence was helpful to both themselves and their child. Family involvement is a crucial element in providing well-rounded, sensitive care to injured children. Providers caring for injured children need to be well-versed in pediatric and family-centered care and seek to imp improv rove e comm communic unicati ation. on. Inv Involve olvement ment of family members of pediatric patients will serve t o improve care quality and promote patient safety. 12
Environment and Interactions Hospita Hospi tals ls an and d ED EDs, s, in pa part rtic icula ular, r, ca can n be fe fear ar-provoking entities for any young child. The inherent anxie an xiety ty wi with th a ch chao aoti tic, c, lou loud d ED ma may y be fu furt rthe herr compounded for an injured child by being strapped to a backb backboard, oard, surrounded by strange strangers, rs, separa separated ted from fro m car caregi egiver vers, s, and sub subjec jected ted to pai painful nful eva evalualuations tio ns and int interv erventi entions. ons. Ped Pediat iatric ric EDs and chil chil-d re re n' n' s h os os pi pi ta ta ls l s a re re a cu cu te te ly l y a wa w a re re o f t he he enviro env ironmen nment's t's imp impact act on a chi child's ld's psyc psycholo hologic gic stress. str ess. Walk int into o any children' children'ss hosp hospita itall and you see se e th the e mut muted ed lig light hting ing,, op open en sp spac aces, es, an and d ch chil ilddfriendly artwork all geared toward making children and their parents feel more comfortable. In add additi ition on to chi child-f ld-frie riendly ndly env enviro ironmen nments, ts, in jured children need age-appropriate interaction and attent att ention ion.. Chi Childr ldren en re refle flect ct the emo emotio tions ns of the adults and caregivers around them. Care providers need to be cognizant of their own potential stress and/or highly charg charged ed emotion emotionss when interacting with ped pediat iatric ric tra trauma uma pat patient ients. s. Ped Pediatr iatric ic tra trauma uma patients and their families need calm reassurance and positive attitudes. When appropriate, providers caring for injured children need to create environments and interactions that reduce a patient's fear and stress. Soft lights and quiet, calm providers and environments should be the rule.
Psychologic Impact on Children Pediatr Pedia tric ic tra trauma uma pat patie ients nts may suf suffer fer con consesequences beyond what is visible from their physical injurie inju ries. s. Pos Posttr ttrauma aumatic tic stre stress ss diso disorde rderr (PTS (PTSD) D) is high hig h amo among ng ch chil ildre dren n wh who o sus susta tain in ev even en mi mild ld or moderat mode rate e tra traumat umatic ic inju injury. ry. In thei theirr long longitud itudinal inal study stu dy of pe pedi diatr atric ic tra trau u ma pa patie tients nts and PTS PTSD, D, 47 Schreier Schrei er and colleag colleagues ues fo found und that 69% of th the e patients patien ts they interv interviewed iewed between the ages of 7 and 17 had at least mild symptoms of PTSD immediately afte af terr a tr trau aumat matic ic in inju jury ry.. Th The e pr pres esen ence ce of PT PTSD SD symptoms was still present in 38% of the cohort 18 months after the initial injury. Care providers for pediatric trauma patients need to be aware of these high rates of PTSD symptoms after even mild and moderat mode rate e inj injury ury.. Syst Systems ems need to be in pla place ce to
PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD • VOL. 11, NO. 1
identi iden tify fy th thos ose e ch chil ildr dren en at ri risk sk an and d as assi sist st wi with th managing managi ng the symptoms.
Learning Opportunities The ability to stay current with pediatric trauma patient patie nt evalu evaluation ation and trea treatment tment requi requires res a commi committmentt to ong men ongoin oingg edu educat cation ion and opp opport ortuni unitie tiess to lea learn rn new ski skills lls and pra practi ctice ce rou routin tine e one ones. s. Ped Pediat iatric ric trauma centers make this commitment with their focus on the assessment and treatment of pediatric trauma patients. Because of their higher pediatric volumes, providers in pediatric trauma centers are able to maintain their skills. In a survey of EDs by Gausche-Hil Gausc he-Hilll and collea colleagues, gues,10 50% of res respon pondin ding g hospi hos pital talss pr provi ovide de ca care re fo forr le less ss th than an 6 pe pedi diat atri ric c patients per day in the ED. The median volume of pediatric patients cared for by all respondents was 3700 37 00 pa pati tien ents ts pe perr ye year ar,, wi with th le less ss th than an 25 25% % of responding EDs caring for more than 7000 patients per year. With relatively few pediatric patients seen, provid pro viders ers in tho those se EDs may sim simply ply not hav have e ade adequa quate te ongoing exposure to critically ill or injured children to mai mainta ntain in the their ir ass assessm essment ent and res resusci uscitat tation ion skills ski lls.. Wi With th lim limite ited d exp exposu osure, re, the there re is an ev even en greate gre aterr nee need d for add additi itiona onall ong ongoin oingg lea learni rning ng and skill maintenance experiences, such as with medical simulatio simul ation, n, case rev reviews iews,, and othe otherr educ educatio ational nal sessions sess ions.. Unfo Unfortu rtunate nately, ly, con continu tinuing ing edu educat cation ion in pediatric pedia tric resusc resuscitat itation ion is infre infrequent quently ly requi required red of ED staff in nonpediatric trauma centers and adult hospitals (i.e i.e., ., gen genera erall hosp hospita itals ls or nonp nonpedi ediatri atric c 6 hospitals). Such ong ongoing oing ped pediatr iatric ic edu educat cation ion is important not only for physicians but also for nonphysician physi cian prov provider iderss (nurse (nurses, s, medic medical al assis assistants tants,, support staff), who may be called upon to care for pediatric trauma patients. In add additi ition, on, tra trauma uma cent centers ers car caring ing for chi childr ldren en need to learn from the pediatric patients they care for with pedia pediatrictric-specif specific ic quali quality ty improv improvement ement activities. Pediatric trauma centers are required to have processes in place to critically review pediatric mortality, mortali ty, morbid morbidity, ity, and functio functional nal outcome. All providers caring for injured children should implement such progra programs ms to improve performance and 1,8,48 patient safety.
Injury Prevention A disc discussio ussion n of ped pediat iatric ric trauma would not be complete without mentioning the important role of prevention. Injury prevention programs have been proven to be eff effect ective ive in red reducin ucingg chi childho ldhood od injuries,8,49 and numerous prevention recommendations are available through the American Academy of Pediatrics, Committee on Injury and Poison
53
Prevention.50 Despite widespread knowledge of the importa imp ortance nce of inj injury ury pre preven ventio tion, n, most ped pediat iatric ric trauma remai remains ns prev revent entabl able. e. In a rec recent ent rev review iew,, Joffe and Lalani51 identified that 77% of unintentional injuries sustained by children in a pediatric intensive care unit were from a mechanism that had a proven strategy to reduce significant injury and was therefore, preventable. Med M edic ical al pr prov ovid ider erss in invol volve ved d in th the e ca care re of pe pedi diat atri ric c trauma patients have an opportunity and obligation to cont contrib ribute ute to inj injury ury pre preven vention tion thr throug ough h dat data a collection that seeks to understand the causes of injurie inju riess and by par partic ticipa ipatio tion n in edu educ c at ional ional and 8 community injury-prevention activities.
EXPERIENCE AND OUTCOMES Several studie Several studiess and compr comprehensiv ehensive e revie reviews ws have attemp att empted ted to ans answer wer the que questi stion on “Do pedi pediatri atric c traum tr auma a pa patie tient ntss tr treat eated ed at pe pedia diatr tric ic hos hospi pital talss or adult hospitals with pediat pediatric ric special specialty ty exper experience ience have hav e bet better ter outcomes outcomes tha than n tho those se tre treate ated d at adu adult lt hospitals?” Alt Althou hough gh no com compr prehe ehensi nsive ve stu study dy of pediatric trauma centers vs adult trauma centers or pediat ped iatric ric hosp hospita itall vs adu adult lt hos hospit pitals als has yet bee been n perfor per formed med,, ther there e are ind indivi ividual dual stud studies, ies, as bel below, ow, that begin beg in to add addres resss por portio tions ns of thi thiss comp complica licated ted que questi stion. on.
Mortality of Pediatric Trauma Patients Two separate studies using large databases have found fou nd tha thatt inj injure ured d chil childre dren n tre treate ated d by ped pediat iatric ric specialists, specia lists, especially younger and more severe severely ly injured children, have improved mortality as comc ompare pa red d to th those ose tr trea eate ted d by ad adult ult sp spec ecia iali list sts. s.7,52 Densmor Den smore e and coll colleag eagues ues7 us used ed th the e 20 2000 00 Ki Kids ds'' Inpati Inp atient ent Dat Databa abase se to rev review iew mor more e tha than n 79, 79,000 000 cases cas es of ped pediat iatri ric c inj injury ury tr treat eated ed at chi childr ldren' en'ss hospitals and adult hospitals. They found that 89% of inj injured ured children children in thi thiss dat databa abase se wer were e tre treate ated d outside childr children's en's hospita hospitals. ls. Importa Importantly, ntly, in-hosp in-hospital ital mortality, length of stay, and hospital charges were all higher in the adult hospitals, even after controlling for injury severity scores. The Kids' Inpatient Database Databa se does not include trauma hospital designation tio n so add additi itional onal inf informa ormatio tion n bas based ed on tra trauma uma designation design ation is not available. The fin findin dings gs of Den Densmor smore e and col colleag leagues ues complement the the findings in a 2000 study by Potoka and colleagues.52 They retro retrospectiv spectively ely analyze analyzed d more than 13,000 injured children from the Pennsylvania Trauma Outcome Study database to compare mortality data across trauma-designated hospitals. In their study, injured children children who were treated at a pe pedi diat atri ric c tr trau auma ma ce cent nter er or an ad adul ultt tr trau auma ma
54
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center with added qualifications to treat children had ha d lo lowe werr mo mort rtal alit ity y ra rate tess (1 (11. 1.9% 9% an and d 12 12.4 .4%, %, respe re spect ctiv ivel ely) y) as co comp mpar ared ed to le leve vell I an and d lev level el II adultt tra adul trauma uma cen center terss (21. (21.6% 6% and 16. 16.2%, 2%, res respec pec-tively) tiv ely).. Simi Similar larly, ly, mor more e sev severe erely ly inj injured ured chi childr ldren en had the best overall outcomes when treated at a pediatric trauma center. 52
Blunt Trauma Patients An estimated 90% 90% of trauma trau ma in pediatric patients 14,17,20,52 is blu blunt nt tra trauma uma.. Less Le ss th than an 5% of al alll pediat ped iatric ric tra trauma uma pat patien ients ts with blun blunt t ab abdominal dominal trauma requi require re opera operative tive interv intervention ention.. 53 Several studies looking at the outcome of this large subset of injured children have identified improved outcomes and increased likelihood of successful nonoperative treatment when children are treated by pedi pediatric atric 54-57 specialists or at a pediatric trauma center. In a re revi view ew at one Chi Chicag cago o ped pediat iatric ric tra trauma uma 54 center, Hall et al revie reviewed wed almost 1800 records of injured inj ured chi childre ldren n and comp compare ared d pat patient ient out outcom comes es for this institution to outcomes reported in the Major Trau Tr auma ma Out Outco comes mes St Stud udy. y. Mo Most st ch child ildren ren in th this is sample had blunt trauma (75%) and had improved survivall rates and increa surviva increased sed successful nonoperative treatment of blunt abdominal injuries. Splenectomy rates after spleen injuries have been well we ll st stud udie ied d as a pr proc oces esss of ca care re me meas asur ure e fo forr pediat ped iatric ric tra trauma uma pat patien ients. ts. Sev Severa erall ind indepe epende ndent nt studies stud ies hav have e ide identi ntifie fied d that inj injured ured chi childr ldren en with blunt spleen injury are more likely to be managed successfully successf ully in a nonope nonoperative rative fashion when tr treated eated 56 55 by pediatric surgeons, ped pediatri iatric c specialists, or in 54,57 a pedia pediatric tric trauma center center.. Thiss aff Thi affect ectss acu acute te management as well as potential lifetime morbidity.
Functional Outcomes A few stu studi dies es ha have ve be begun gun to mov move e bey beyond ond mor mortal tality ity outcomes outc omes and eva evalua luate te fun functi ctiona onall out outcome comess in pediatri pedi atric c tra trauma uma pati patients. ents. One such study, using data from the Pennsylvan Pennsylvania ia Trauma Outcome Study, S tudy, found foun d tha thatt chi childr ldren en tre treate ated d in ped pediat iatric ric tra trauma uma centers had improved functional outcomes, as demonstrat onst rated ed by decr decrease eased d dep depend endence ence on feed feeding, ing, locomot loco motion ion,, or tra transf nsfer er dev device ices, s, whe when n com compar pared ed with injured children treated at adult trauma centers with add addition itional al qual qualific ificatio ations ns for trea treating ting chil childre dren n and an d adu dult lt tr traum auma a ce cente nters rs wit withou houtt the ad adde ded d qua quali lific ficaations.58 Certainly, more studies evaluating quality of life and functional outcomes are needed. The improved outcomes of injured children when treated by pediatric specialists should come as no surprise. Pediatric trauma patients are different from
adult trauma patients. Access to pediatric specialty care in the form of pediatric emergency medicine physicians,, pediatr physicians pediatric ic surgeons, pediatric anesthesiologists, ogis ts, ped pediatr iatric ic cri critica ticall care spec special ialists, ists, pedi pediatr atric ic nurses, child life specialists, pediatric rehabilitation specialists, and pediatric social workers is critical in the assessment, stabilization, treatment, and rehabilitation of pediatri pediatric c trauma patients patients..8 The findings described above also mirror similar findings find ings in othe otherr field fields. s. A rece recent nt stud study y comp compari aring ng the survival surv ival rates and morb morbidit idity y of pedi pediatr atric ic pat patient ientss transpor tran sported ted betw between een faci faciliti lities es by pedi pediatr atric ic crit critical ical care spec speciali ialized zed team teamss vs nons nonspeci pecialize alized d team teamss identified increased mortality and more unplanned events among patients transported with nonsp non speciaecia59 lized liz ed te teams ams,, re regar gardle dless ss of the sev severi erity ty of ill illnes ness. s. The autho au thors rs in th this is stu study dy hyp hypot othes hesiz ized ed th that at lim limit ited ed pediatric critical care experience, limited pediatric procedural experience, and lack of ongoing continuing education education in pediatr pediatric ic critical critical care contribute contributed d to the difference differencess between nonspecialized and specialized teams.59 It is reasonable to assume that these same conclusions can be applied to adult hospitals with wit h lim limite ited d pe pedia diatr tric ic exp exposu osure re an and d few few,, if any any,, requirements requirem ents for ongoing pediatric education.
IMPROVING QUALITY OF CARE TO PEDIATRIC TRAUMA PATIENTS Pediatric trauma centers should be used whenev Pediatric whenev-er feasible for pediatric trauma patients. However, because beca use of geog geographi raphic c limita limitations, tions, nonpe nonpediatr diatric ic trau tr auma ma ce cente nters rs ma may y ne nee ed to pro provide vide the ini initia tiall care car e to inj injured ured chi childre ldren. n.2,8 Standa Standardize rdized d courses such as Pediatric Advanced Life Support (PALS), Adva Advance nced d Ped Pediat iatric ric Lif Life e Sup Suppor portt (APL (APLS), S), and Advanced Advan ced Trauma Life Support (ATLS) will expand nonpediatric nonped iatric provid providers' ers' assessmen assessment, t, manage management ment skills, ski lls, and com comfor fortt with ped pediat iatric ric pat patien ients. ts. Non Non-pediatric trauma centers should partner with local/ regional region al pediat pediatric ric specialists and identify physic physician ian and nur nurse se coo coordi rdinat nators ors for ped pediat iatric ric eme emerge rgency ncy medicine to create pediatric-specific trauma protocolss and pediatric provider resources where needcol ed.8 Ong Ongoin oingg edu educat cation ional al act activi ivitie tiess foc focused used on pediatric-sp pediat ric-specific ecific trauma care should shou ld be provided to all members of the trauma team. 8,48 Measurable improvements in quality and outcomes are found when nonpediatric trauma cent ce nt ers ers make a commit60 ment to pediat pediatric ric excellence.
SUMMARY Trauma remains the leading cause of mortali mortality ty in children. Most injured children are treated in adult
PEDIATRIC PATIENTS IN THE ADULT TRAUMA BAY / STONE AND WOODWARD • VOL. 11, NO. 1
hospitals hospita ls and adu adult lt tra trauma uma cen center ters. s. Alth Although ough not conclu con clusiv sive, e, sev severa erall stu studie diess hav have e ide identi ntifie fied d tha that t injured inj ured chi childr ldren en hav have e imp improv roved ed outc outcomes omes,, with lowerr mort lowe mortalit ality, y, few fewer er ope operat rations ions,, and imp improv roved ed functi fun ction, on, whe when n tre treate ated d by ped pediat iatri ric c spe speci ciali alists sts.. However, limitations in the availability of pediatric trauma tra uma cen center terss and ped pediat iatric ric spec special ialists ists req requir uire e tha that t all hospitals be prepared to effectively and successfully treat pediatric patients.
14. 15. 16. 17. 18.
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Abstract: Psychological issues are common overlays with all forms of illness and injury, but the extent to which these problems proble ms are associated with trauma is becoming better understood. Emergency Emerg ency care provide providers rs will deal with the causes and consequences of these posttraumatic difficulties. The practice of medicine, such as illness itself, is dynamic and always changing. We must prepare ourselves to the best of our abilities if we are to be successful in facing this challenge. challeng e. This article offers suggestions for physicians and other acute care providers for ways to accomplish this task by relying on skills we already possess as we increase increa se our level of unders understanding tanding..
Keywords: posttraumatic stress disorder (PTSD); acute stress disorder (ASD); emergency medicine; trauma; pain management
Reprint requests and correspondence: Michael Finn Ziegler, MD, Department of Pediatrics and Emergency Medicine, Emory University Children s Healthcare of Atlanta 1405 Clifton Road NE Atlanta, GA 30322.
[email protected] ’
1522-8401/$ - see front matter © 2010 Elsevier Elsevier Inc. All rights reserved.
Mental Health Consequences of Trauma: The Unseen Scars Michael Finn Ziegler, MD
T
rauma ha rauma happ ppen ens; s; it is pa part rt of lif life. e. In Inju juri ries es ar are e ve very ry common in children and adolescents, almost a right of passage. In its most innocuous form, it is a whimsical story of “remembe rememberr the time …,” but in some instances, it is life-changing and disrupting not only to the patient but for everyone around them. As emergency medicine (EM) physicians, especially those taking care of children and families, we see the enti en tire re ga gamu mut. t. We do ou ourr be best st to pr prov ovide ide in inte terve rvent ntion ionss tha that t preserve and improve the quality of that life. Upon the completion of em emer erge genc ncy y ca care re,, we ma make ke di dispo sposi siti tion on de deci cisi sions ons,, tu turn rn th the e ca care re of injured children over to someone else and wish them well. We then move on to see the next patient, a child with 6 months of abdominal pain and poor school performance who has no primary care physician. He has been very healthy with only one other visit to an emergency department (ED) last year after a car accident, but thankfully, he was not hurt as severely as his brother. One might pause to feel the frustration of another “nonemergency” wrongly presenting to an ED. Or, one might also wish they had spent just a few more minutes talking with that last family about what happens after trauma. A growing body of knowledge now exists that sheds light on our understanding of the psychological consequences of trauma and illnes ill nesss in ch child ildhoo hood. d. As our un unde derst rstan andi ding ng gr grow ows, s, so do does es our ne need ed to add addres resss the these se seq sequela uelae e thr throug ough h edu educat cation, ion, dir direct ect int interv ervent ention ions, s, appropriate referrals, and advocacy. Many EM physicians may not be exc excite ited d when faced wit with h stil stilll ano anothe therr res respon ponsibi sibilit lity y in the increasingly overcrowded and time and resource-constrained ED. However,, rather than seeing this as a new skill set and knowledge However base bas e to acq acquir uire, e, eme emerge rgency ncy car care e pro provid viders ers alr alread eady y hav have e the expertise as well as the opportunity to become effective advocates for children with mental health consequences of trauma. MENTAL HEALTH CONSEQUENCES OF TRAUMA / ZIEGLER • VOL. 11, NO. 1
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BACKGROUND For the sake of discussion, this article will focus primar pri marily ily on acu acute te and pro prolong longed ed pos posttr ttrauma aumatic tic stress disorders disorders (PTSDs (PTSDs)) and subsyndromal presentations, but it should be understood that depression, anxiety anxi ety,, and oth other er psyc psycholo hologic gic pro proble blems ms are als also o associated with acute traumatic events. An understandingg of posttra standin posttraumatic umatic behavioral behavioral change changess has been around for a long time, at least in reference to militar mili tary y con conflic flict. t. Dur During ing the Amer America ican n Civ Civil il War War,, soldiers were described as having “soldier's heart ” or “irrit irritable able heart ” when the they y dis display played ed alt altere ered d behavi beh avior or aft after er con conflic flict. t. Dur During ing Wor World ld War I, the terms shell shock or the effort syndrome were used to describe the same behaviors. “Combat stress reaction” was first described among veterans of World War II. Posttraumatic stress disorder was formally described and given diagnostic criteria in response to behavioral prob pro blems experienced by veterans of the Vietnam War.1 During this same period, childhood trauma as a predictor of future psycholo psycho logical gical problems such as 2-5 PTSD was first described. Eventually, Eventu ally, investi investigagators turned their attention to acute stress disorder (ASD) and PTSD in the pediatric population and found foun d tha thatt chi childre ldren n wer were e more susc suscept eptibl ible e tha than n adults in develo developing ping these disord disorders ers after trauma traumatic tic experiences. experi ences. Overal Overall, l, preva prevalence lence rates fo forr PTSD in adul ad ults ts is es esti tima mate ted d to be 8% to 9% 9%;;6-8 however, depe de pend ndin ingg on th the e ty type pe of st stre ress ssor ors, s, st stud udie iess in children childre n demonst demonstrate rate the prevalence rate to range between 13% and 45%. 9-13 Diagnostic dilemmas also exist in children that may miss subsyndromal presentations that still may lead to sig signifi nifican cantt disa disabili bility. ty. The Diag Diagnostic nostic a nd Statistical Manual of Mental Disorders, Fourth Edition ,14 requires coexisting symptom clusters of reexperiencing, avoidance, and hypera hyperarousal rousal in conjun conjunction ction with an inc inciti iting ng str stresso essorr or tra traumat umatic ic eve event nt and disability for 1 month or more to meet diagnostic crit cr iter eria ia fo forr PT PTSD SD.. Th The e sa same me cr crit iter eria ia wi with th th the e addition additi on of dissocia dissociation tion for less than 1 month define ASD. It is difficult for children to meet these criteria because they often alternate symptom clusters of reexperi reexpe rienc encing ing an and d av avoid oidanc ance e (ie (ie,, no coe coexis xis-15 tence), or the avo avoida idance nce symp symptoms toms are miss missed ed because t hey h ey ar are e mo more re di diff ffic icul ultt to as asse sess ss in children.16 Reexperiencing symptoms includes recurren cur rentt and int intrus rusive ive tho though ughts ts oft often en dis displa played yed through playacting, intrusive distressing dreams of the events, and intense psychological and physiological distress at reminders of the events. Avoidance symptoms include efforts to avoid thoughts or activities that arouse memories, apparent amnesia
to events, withdrawal, and a sense of a foreshortened future. Hyperarousal symptoms are often the most easily identified and include insomnia, emotional lability, poor concentration, concentration , hypervigilance, and exagg exaggerate erated d startle response.14 The These se symp symp-toms and subsequent somatizations are often what bring children and their families back to the ED. Other diagnostic challenges challenges include the depen depen-denc de nce e of you young ng ch chil ildr dren en on th thei eirr ca care regi give vers rs to expres exp resss the their ir symp symptoms toms.. Sev Severa erall stud studies ies have have show shown n that caregivers often minimize children's symptoms and rarely seek help for these problems unless they are assisted by a medical professional pro fessional who recognizess the symp nize symptom tom clu cluster sters. s.13,15,17-19 Sur Surveys veys of emerge eme rgency ncy car care e and pri primary mary care pro provid viders ers not only on ly sh show ow th that at ph phys ysic icia ians ns ar are e aw awar are e of th this is tendency of caregivers to minimize symptoms but also show that the same providers underestimate the prevalence of the disorder and lack an understanding stand ing of of the risks asso associa ciated ted with its dev develo eloppment.20,21 The reason these diagnostic difficulties are so important is exemplified by studies that show thatt subs tha subsynd yndroma romall stat states es of str stress ess dis disord orders ers hav have e similar posttrau posttraumatic matic disabilities as those meeting 22 full spectrum. Therefore, a missed diagnosis is a missed miss ed opp opportu ortunit nity y to inte interve rvene ne and pote potenti ntially ally change what could become a bad outcome.
SINGLE INCIDENT TRAUMA Early literature about childhood stress reactions consid con sidere ered d inc inciti iting ng eve events nts such as com commun munity ity violence, physical and/or sexual abuse, wars, and domesti dom estic c vio violen lence, ce, but mor more e rec recent ent stud studies ies hav have e found fou nd sig signif nifica icant nt rat rates es of ASD and PTS PTSD D amon among g victimss of accidental single incident trauma as well. victim Children who sustain motor vehicle-related injuries have ha ve a 27 27% % to 36 36% % ch chan ance ce of de deve velop loping ing a fu fullllfledged fled ged ASD or a clin clinica ically lly sig signifi nifican cantt imme immedia diate te stress reacti reaction on wi with thin in da days ys to we week ekss af afte terr th the e 18,23,24 injury. Similarly, children who have injuries from motor motor vehiclevehicle-relate related d incidents incidents will have have a 25% to 33% chance chance of developing full diagnostic criteria for PTSD.17,23 Victims of single incident dog attacks were we re st stud udied ied an and d fo found und to ha have ve fu full ll di diag agno nosti stic c criter cri teria ia for PTSD PTSD in 5 of 22 child children ren at 7 months months and and an additional 7 of 22 children had subs su bsyndromal yndromal 25 presentations in the same time frame. A recent study looking at single incident orthopedic injuries found that 33% met full diagnostic criteri riteria a for PTSD 26 at follow-up psychological psychological testin testing. g. As many as 80% of children will develop at least one sym sympto ptom m of an im immed media iate te st stre ress ss re reac acti tion on wi with thin in the th e fi firs rstt mo month nth aft after er a mo moto torr ve vehi hicl clee-re rela late ted d 27 injury. It is likely that similar high rates of isolated
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symptoms sympto ms wou would ld exi exist st aft after er oth other er acc accide identa ntall traumas. Do we need to worry about all of these patients? Actually, most affected children will see these symptoms disappear or become part of their coping strategy. strategy. These acute stress-r stress-related elated symptoms to ms mig might ht ac actu tual ally ly he help lp ch chil ildr dren en ad adju just st to th the e trau tr auma. ma. It ha hass lo long ng be been en th theo eori rized zed th that at som some e asp aspec ects ts of tra trauma umatic tic str stress ess are ada adapti ptive. ve. Sing Single le inc incide ident nt adaptive adapti ve learning is essenti essential al to surviv survival al by allowing us to generalize the lesson to other similar circumstances sta nces.. Inj Injury ury or thr threat eat lea leads ds to neu neuroho rohormon rmonal al adaptive responses that provide emotional, behavioral, cogni cogniti tive, ve, and physiologic changes necessary for survi survival. val.28 Unfor Unfortunat tunately, ely, somet sometimes imes these adaptive adapti ve response responsess “lock ” neuroche neurochemical mical and microarchitectural organization and function leading to a lack of return to preevent homeosta si siss and 29 possibly to a clinical disorder such as PTSD.
the ree reexpe xperie rienci ncing ng symp symptom tomss of PTS PTSD. D.41 Th This is is furthe fur therr supp support orted ed by fin findin dings gs tha thatt ele elevat vated ed hea heart rt rates ra tes an and d ur urin inar ary y co cort rtis isol ol le leve vels ls at th the e ti time me of prehosp pre hospita itall tra transpo nsport rt and ED pre presen sentati tation on for trauma tra umatic tic inj injury ury are more lik likely ely to be fo foun und d in 42-44 patien pat ients ts who lat later er dev develop elop PTS PTSD. D. Therefore, appropriate pain control is essential in taking care of the child with trauma. Surprising to many is the lack of an association between betwe en severity severity of injury and risk of developing 17,31,45 PTSD. Perception of injury tends to be more important to future psychiatric disability than the actual injury itself. This is important because failure to unders understand tand the patien patient's t's intern internal al conce concerns rns could wrongly assign risk to patients who may otherwise do well. A lack of concern on the provider's part toward tow ard chi childr ldren en wit with h min minor or inj injuri uries es may mis misss otherwise high-risk patients.
UNDERSTANDING RISK
ASSESSING RISK
If these isolated symptoms are so prevalent, how do we as asce cert rtai ain n wh who o is at ri risk sk fo forr de deve velo lopi ping ng disa di sabi bili lity ty an and d wh who o is go goin ingg to co cope pe we well ll an and d recov re cover? er? Und Under ersta stand nding ing wha whatt ri risk sk fa facto ctors rs ex exist ist may he help lp us de deci cide de wha whatt lev level el of in inte terv rven enti tion on may be necessary. It has been shown that the loss or injury of a loved one during a traumatic event is highly associa associated ted with the the ris risk k of tha thatt ind indivi ividua duall developing develo ping PTSD.17,19,27,29 Likewi Likewise, se, paren parental tal posttraumatic st ress ress is associated with children developing PTSD.30 This is likely due to parents being less emo emotio tionall nally y ava availa ilable ble to the chi child ld and the themmselv se lves es un unab able le to co cope pe wi with th th the e tr trag aged edy. y. Th This is suggest sugg estss tha thatt simp simple le par parent ental al sep separa aration tion dur during ing and after trauma may also be associated with the risk for PTSD PTSD.. Dem Demogr ograph aphic ic fac factor torss aff affecti ecting ng ris risk k include female sex; this has been consistently found as a ri risk sk fa fact ctor or in mos mostt ty type pess of tr trau auma ma ex exce cept pt motorr veh moto vehicle icle-re -relate lated d inj injuri uries. es. In add additio ition, n, an inverse inv erse rel relati ationsh onship ip exi exists sts be betw twee een n ag age e an and d th the e 17,31 risk of developing PTSD. Especia Esp ecially lly imp import ortant ant to eme emerge rgency ncy car care e prov proviiders de rs is th the e as assoc socia iati tion on be betw twee een n PT PTSD SD an and d pa pain in management. Several studies and reviews point to inadeq ina dequat uate e pai pain n con contro troll as an ind indepe epende ndent nt ris risk k factor fac tor for dev develop eloping ing tra trauma uma-rela -related ted str stress ess dis disoror32-37 ders such as ASD and PTSD. Hyperadrenergic states sta tes occ occur ur wit with h pai pain n an and d st stre ress. ss. Th These ese st state atess 38,39 enhance enhanc e memory, especi esp ecially ally if occur ccurrin ringg in 40 conjunction conjunc tion with negati negative ve emotions emotions.. A positi positive ve feedback mechanism exists where hyperadrenergic states from trauma and pain lead to overconsolidation of traumatic memory with subsequent release of str stress ess hor hormon mones es and cat catech echola olamine miness link linked ed to
The mental health community is actively pursuing bet better ter dia diagno gnostic stic stan standar dards ds to imp improv rove e bot both h sensitivit y and specificity of the diagnostic criteria for PTSD.46 The new Diagnostic and Statistical Manual expe pect cted ed to of Men Mental tal Dis Disord orders ers,, Fif Fifth th Ed Editi ition on , is ex include developmental developmental consid consideratio erations ns in childhoo childhood d PTSD PT SD an and d wil willl ac ackn knowl owled edge ge th the e di diff fficu iculty lty in recogni rec ognizing zing avo avoidan idance ce symp symptoms toms,, whic which h shou should ld loos lo osen en th the e cr crit iter eria ia fo forr fu full ll di diag agno nost stic ic PT PTSD SD in children. Mental health professionals who work in conj co njunc uncti tion on wit with h ED EDss ha have ve al also so de deve velop loped ed an and d tested screening tools that could be used for rapid assessment of risk stratification in the ED setting. One On e su suc ch to tool ol is th the e Sc Scrree eeni ning ng To Tool ol fo forr Ea Early rly 47 Predictors of PTSD (STEPP) (Figure 1). 1). This tool consists of 4 brief questions addressed to parents of child ch ildre ren n an and d an ad addi diti tion onal al 4 qu quest estio ions ns fo forr th the e childr chi ldren en the themsel mselves. ves. Thi Thiss too tooll also inc incorp orpora orates tes demographic data that could be obtained from the record or the physician. Usin Us ingg th the e ST STEP EPP, P, a sc scor ore e wa wass as assi sign gned ed th that at yielde yie lded d a ne nega gativ tive e pr pred edict ictive ive v al alue ue of 0. 0.95 95 fo forr childr chi ldren en and 0.9 0.99 9 for par parent ents. s.47 A subse subsequent quent study assessed the viability of the tool in an active ED and found that that it i t was relat relatively ively well accepted by 48 staff and familie families. s. These findings indicate that the STEPP is a potentially valuable screening tool for risk assessment in trauma traumatized tized children. Another tool is the Univers University ity of California Los Angeles PTSD 49 Reaction Index, which demonstrated demonstrated a sensitiv sensitivity ity of 0.93 and a specificity of 0.87 for detecting PTSD. The Reaction Index has been proposed as a rapid screening tool for EDs and primary care offices. Its greate gre atest st use may be in ide identif ntifyin yingg childr children en with with high high
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Figure 1. Screening Tool for Early Predictors of PTSD (STEPP). Instructions for completion were as follows: ask questions 1 to 4 of the parent and questions 5 to 8 of the child, and record answers to questions 9 to 12 from the acute care medical record. Circle 1 for yes and 0 for no. Instructions for scoring were as follows: the child STEPP score is the sum of responses to questions 4 to 10 and 12. A child score of 4 or higher indicates a positive screen. The parent STEPP score is the sum of responses to questions 1 to 4, 9, and 11. A parent score of 3 or higher indicates a positive screen. ((C)2003, The Children's Hospital of Philadelphia. Reproduced with permission.)
scores that are considered to be at high risk and therefore theref ore may requir require e close follow-up.
THE ROLE OF EMERGENCY CARE PROVIDERS So, what does this have to do with emergency care providers? Perhaps a review of the sequelae of untre unt reate ated d po postt sttra rauma umati tic c str stress ess may hel help p us to better understand why this is, in part, our problem to de deal al wi with th.. Af Affe fect cted ed ch chil ildr dren en ha have ve a hi high gher er rela re lati tive ve ri risk sk fo forr po poor or sc scho hool ol pe perf rfor orma manc nce e an and d other functional impairments, somat ization, ization, substance sta nce abu abuse, se, and suic suicide ide att attempt empts. s.1,17,18,33,50-54 Many of these patients will present to EDs during their sequelae, and we must understand that these morbidities carry not only an acute component, but additionally, a risk of long-term disability and an added burden on society in health care cost and resource use. There is also the loss of productivity
experienced by the patien experienced patientt and family members. As is true for all aspects of emergency care, a primary goall shou goa should ld be to limi limitt mor morbid bidity ity and mortality mortality.. This is typica typically lly achieved with immedia immediate te interventions, education, anticipatory anticipatory guidanc guidance, e, and followup pl plan ans. s. Wh Why y sho should uld we loo look k at th this is par parti ticu cular lar problem proble m any diffe differently? rently? Emergency health care providers may see stress disorders as beyond the scope of their practice. By defin de finit itio ion, n, we ma may y be una unable ble to ma make ke th thes ese e diagnos dia gnoses es dur during ing a shor short-te t-term rm enc encount ounter. er. Men Mental tal health professionals professionals who underst understand and the diagno diagnostic stic criteria and who are highly skilled with interview techniques are best suited to do this. These same professionals are also in a position to recommend and initiate successful treatment modalities modalitie s such such as 55-57 cogniti cogn itive ve ther therapy apy and phar pharmaco macother therapy apy.. As previously discussed, it may be difficult to identify those at risk in an initial encounter. Yet we also do not wa want nt to ov over erre refe ferr th these ese pa pati tien ents. ts. Th The e mos most t sensible sens ible course course of act action ion woul would d be to enc encour ourage age
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follow-up follow -up wit with h th the e pr prim imar ary y ca care re or pos postt ttrau rauma ma mental health care systems available to the patient where further evaluation and referral can occur. Unfortu Unf ortunat nately, ely, man many y of the pat patient ientss rec receiv eiving ing care ca re in th the e ED ha have ve li limi mite ted d or no ac acce cess ss to a me medi dica call 45,58 home. In addition, few mental health resources exist in many communities, making referrals problematic lema tic eve even n aft after er str stress ess dis disord orders ers are ide identi ntified fied.. Justt as di Jus distu sturb rbing ing is the the lack lack of use of suc such h re reso sourc urces es when concer concerted ted effort effortss are mad made e to mak make e the them m 58 avail av ailab able le to th the e pa patie tient nt.. The eme emerge rgency ncy car care e system may be the only point of contact for many of the these se pat patient ients. s. Howe However ver,, sur survey veyss of phy physici sician an knowled know ledge ge and pra practi ctice ce in bot both h eme emerge rgency ncy and primary care settings have shown that physicians feel fe el ti time me co const nstra rain ined ed in de deal alin ingg wi with th suc such h iss issue ues, s, ar are e poorly reimbursed for their efforts, may be penalized in manage managed d care systems for referring, referring, and and feel 20,21,59 unprepared unprep ared to handle these proble problems. ms. These same studies confirm that mental health resources are ar e sca scarc rce e in man many y co commu mmuni niti ties es.. A di disc sconn onnec ect t clearly cle arly exists between between wha whatt we are beginning beginning to understand underst and about posttra posttraumatic umatic stress and what we actua ac tuall lly y do do.. On One e ca cann nnot ot ig ignor nore e co conc ncer erns ns ab about out barriers to effective practice if we wish to provide optimal care for our patients.
EMERGENCY MEDICINE SOLUTIONS The fi The firs rstt th thin ingg to rea eali lize ze is th that at no on one e is suggesting that the ED is the only place to address PTSD, PT SD, bu butt as th the e ED of ofte ten n re repr pres esen ents ts th the e fi first rst conta co ntact ct fo forr th thes ese e ch child ildren ren,, we ar are e in a uni uniqu que e positi pos ition on to imp implem lemen entt int inter erven venti tions ons tha thatt mig might ht positively affect outcomes and advocate for better prima pr imary ry an and d tr trau auma ma ca care re fo follo llow-u w-up, p, as we well ll as as,, support the improvement improvement of acces accesss to mental heath resou re sourc rces es.. No None ne of the these se ta task skss ar are e be beyon yond d our abilities, and in fact, we are already very skilled in their application; even if we do not realize it.
COMPASSION Compas Comp assi sion on is de defi fine ned d as a fe feel elin ingg of de deep ep sympathy and sorrow for another who is stricken by misfortune, acco accompanied mpanied by a strong desire to 60 alleviate the pain. Compassion is at the center of what we do each and every day. Perhaps we can improve imp rove our comp compassi assion on for the these se chi childr ldren en and theirr fam thei familie iliess thro through ugh our und underst erstand anding ing of the problem. Nancy Kassam-Adams, PhD, in an introduction to a special issue on pediatric stress in the Journal of Pediatric Psychology reports that as health care professionals we have compassion fatigue and seco se cond ndar ary y tr trau auma mati tic c st stre ress ss as a re resu sult lt of our
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practice practi ce of car caring ing for tra trauma uma pa patie tients nts.. 61 She enco en cour urag ages es us to br broad oaden en ou ourr un unde derst rstan andi ding ng of the problem both as a way not only to improve our comp co mpass assion ion fo forr pat patie ient ntss bu butt al also so fo forr our ourse selve lves. s. Unders Und erstan tandin dingg may in an and d of its itself elf inc incre rease ase comp co mpas assi sion on fo forr ou ourr pa pati tien ents ts le lead adin ingg to mo more re attent att ention ion to pai pain n mana managem gement ent and oth other er com comfort fort issues issu es dur during ing our ini initia tiall eva evaluat luation. ion. This has the added benefit of helping us to check our own biases about mental health issues by bette betterr underst understanding anding the th e ph phys ysio iolo logi gic c ba basi siss fo forr th thes ese e pr prob oble lems ms an and d avoidi avo iding ng the fal false se dic dichot hotomy omy of dra drawing wing dis distin tincctions tio ns bet betwee ween n so-c so-calle alled d org organi anic c vs nono nonorga rganic nic disease. This helps us to advocate for the benefit of men mental tal hea health lth foll follow-u ow-up p when nec necess essary. ary. The need ne ed for co comp mpas assio sion n an and d und unders ersta tand nding ing ca can n be impart imp arted ed to fam famili ilies es by ed educa ucati ting ng the them m ab about out posttraumatic stress reactions including the likelihood they will resolve. We can encourage families to pay a little extra attention to their children both as a form of anticipatory guidance and as therapy. Encou Enc oura ragi ging ng he healt althy hy ha habit bitss suc such h as go good od sle sleep ep patter pat terns, ns, goo good d eat eating ing pat patter terns, ns, and exe exercis rcise e can give gi ve th the e fa famil mily y a re rega gaine ined d sen sense se o f control after feeling a significant loss of control. 57 I like to tell families that this is a good time for a few extra hugs as a wa way y to en enco coura urage ge th thei eirr le leve vell of co comp mpas assio sion n both for their children and themselves.
EDUCATION AND UNDERSTANDING Education both for our patients and ourselves is likely to improve clinical outcomes. The ability to inform families about likely posttraumatic posttraumatic stressrelate rel ated d symp symptoms toms and the their ir exp expect ected ed res resolut olution ion might mig ht be com comfort forting ing and can help avo avoid id fur furthe therr stress for the family when such symptoms occur. Furthermore, this gives the family a framework in which to observe for more concerning or prolonged reacti rea ctions. ons. Thi Thiss is emp empowe owerin ringg and may inc increa rease se the likelih likeliho ood the they y will seek profession professional al help in 62 the futu future. re. Ther Th ere e is ev even en so some me ev evid iden ence ce to suggest that that anticipatory anticipatory guidance may help reduce symptoms,63 bu butt fur furthe therr inv invest estig igati ation on ne need edss to occur to best understand and maximize the effect of such interventions. Ourr own und Ou unders ersta tand nding ing ca can n he help lp us to ri risk sk st stra rati tify fy injured injure d patie patients. nts. Physici Physicians ans have expressed desires to l ear earn n m or ore e an and d be pr prep epar ared ed fo forr int inter erve venn20,21,45 tions. This inte interes rest, t, in conj conjunct unction ion wit with h screening tools, may allow us to target anticipatory guidance provided during an ED encounter toward those who may need it the most, offering needed reassurance and/or strongly emphasizing the purpose of follow-up assessments assessments through primary primary care
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or tra trauma uma car care e foll follow-u ow-up p syst systems. ems. Adv Advoca ocatin tingg for the presence of staff in the ED that are trained in mental health and the use of screening tools can help to make the process more efficient and effective. In a survey of emergency care providers, only h al alff could 20 identify such staff within their institutions. As our understanding of the mental health consequences of trau tr auma ma imp impro rove vess so too ca can n our ab abil ilit ity y to do ef effi fici cien ent t screening of affected patients. For this reason, we need to advocate for further research into screening tools and ED assessmen assessments. ts.
PAIN AND ANXIETY REDUCTION Anothe Anotherr are area a whe where re eme emerge rgency ncy car care e pro provide viders rs posses pos sesss gr great eat exp exper erien ience ce is pai pain n man manage agemen ment. t. Multiple studies have shown that attention to pain manag man ageme ement nt ca can n re redu duce ce th the e ri risk sk fo forr PT PTSD SD.. 32-37 Recognizing this, we should continue our efforts to be aggressive in our control of pain and anxiety in trauma tra uma pat patien ients. ts. Dr Mic Michae haell Gre Greenw enwald ald off offers ers guida gu idanc nce e on pa pain in ma mana nage geme ment nt in th this is iss issue ue of Clinical Clinical that at is we well ll wo wort rth h Pediatricc Emergenc Pediatri Emergencyy Medicin Medicinee th reviewing. revie wing. In additi addition on to pharmac pharmacologic ologic interveninterventions, numerous initiatives have begun within the EM comm communit unity y to pro promote mote fam familyily-cent centere ered d car care e and parental presence whenever possible during painful or stressful procedures as a way to further reduce distress and as a means to promote coping. Previous publications suggest family presence presence to be helpful in the secondary prevention of PTSD. 56
PSYCHOLOGICAL FIRST AID The American Red Cross has proposed psychologi lo gica call fi firs rstt ai aid d as a me mean anss to de deal al wi with th me ment ntal al he heal alth th issue iss uess t hat ha t ar aris ise e in th the e af afte term rmat ath h of a ma mass ss 64 casualty. These The se rec recomme ommenda ndation tionss cou could ld eas easily ily be ad adap apte ted d an and d ap appl plii ed to ind indivi ividua duall eve events. nts. Schonfeld Schonfe ld and Gurwitch56 propo propose se that emerge emergency ncy providers are uniquely skilled in supporting families and patients in these disasters who have emotional and psychological problems related to their crisis. This psyc psycholog hological ical fir first st aid incl includes udes prov providin iding g appropriate approp riate informati information on without overbur overburdening dening the alr alrea eady dy str stress essed ed fa famil mily, y, cr crea eatin tingg a ca calmi lming ng supportive support ive enviro environment nment wheneve wheneverr possible possible,, minimizing mizi ng pat patien ientt sep separa aration tion fro from m fam family ily mem member bers, s, minimizing pain, and emphasizing positive coping strategies and communication.
ADVOCACY I propose that the knowledge and understanding gained from caring for injured children and their
families makes emergency care providers uniquely equipped to advocate for our patients at the system level. lev el. We sho should uld fir first st adv advoca ocate te for an acc accessi essible ble medicall home for all children, as this would offer all medica children timely follow-up after acute trauma care provided in the ED and allow for further screening for mental health disorders and referral as indicated. We should also advocate for improved mental health resources and expanded insurance coverage. We might also advocate for EDs to have adequate staffingg both at the provider and ancilla staffin ancillary ry staff levels and for appropriate reimbursement when we take the time to address the mental health concerns of ourr pa ou pati tien ents ts in the ED ED.. Me Menta ntall he healt alth h di diso sord rder erss should receive just as much attention as any other medicall issue and without stigma. Further research medica and continuing education designed to continually improve the quality of emergency care should be encouraged through funding and academic support.
SUMMARY Trauma has cons Trauma consequ equenc ences es tha thatt are bot both h sho shortrtterm and delayed. Some of these consequences are nott ea no easi sily ly see seen n or un unde ders rsto tood od.. Me Ment ntal al hea healt lth h sequela seq uelae e of tra trauma uma will impact the wel well-be l-being ing of ourr pa ou pati tien ents ts an and d th thei eirr fa fami milie lies. s. Fa Failu ilure re on our pa part rt to recogni rec ognize ze the these se con concer cerns, ns, the risk riskss tha thatt inc increa rease se their the ir lik likeli elihood hood,, or fai failin lingg to pro provide vide imme immedia diate te interve inte rventi ntions ons des design igned ed to red reduce uce the these se ris risks ks is a missed opportunity to improve the well-being of our patients and their families. To inadequately address these issues at the time of acute traumatic event may likely place a burden on our already overtaxed emergency medical resources in the future. Policy stateme sta tements nts fro from m bot both h the Amer America ican n Aca Academ demy y of Pediatrics and the American College of Emergency Physi Phy sicia cians ns ch char arge ge us to be re respo spon nsible fo forr th the e 65-67 We can mental ment al hea health lth nee needs ds of our pat patien ients. ts. meet this challenge with expertise, understanding, and an d co comp mpas assi sion on ju just st li like ke we me meet et a my myri riad ad of challenges challen ges every day. In this way, we truly serve the needs of our patients and, maybe, ourselves.
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