TRAUMA IN THE PICU.ppt
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1、TRAUMA IN THE PICU,Pediatric Critical Care Medicine Emory University Childrens Healthcare of Atlanta,2,Epidemiology,#1 cause of death in 1yr old Exceeds all other deaths combined 20,000/yr of children & teenagers 65% of all death 19 yrs old unintentional injury 1 death from trauma 40 hospitalized 1,
2、120 treated in ER Most pediatric trauma are blunt injury (vs penetrating in adults) More vulnerable to major abdominal injury from minor forces More immature musculoskeletal system Intra-abdominal organs are proportionally larger & closer together predisposed to multiple organ injury,3,Epidemiology,
3、MVC leading cause of death are unrestrained 2/3 riding with drunk drivers Pedestrian leading cause of death in 5-9 yrs old Bicycle injury increases with age most common is head trauma,4,Physiologic Differences,Larger head greater inertia, movement & transfer of energy to the head & brain Less soft t
4、issue & muscle greater energy transfer to internal organs Difference in center of gravity Infant above umbilicus 1 yr at the umbilicus Adults pubic symphysis Jack knife effect with 2 points restraint spinal and intestinal injury in forward collision,5,Resuscitation,Causes of early death in injury Ai
5、rway compromise Hypovolemic shock CNS injury ATLS : steps in trauma eval Primary survey Adjuncts to primary survey Secondary survey Adjunct to secondary survey (investigations) Definitive managementss,6,Resuscitation Primary Survey,A- Large head/occiput, large oropharyngeal soft tissue, short trache
6、a frequent Right stem intubation 12 yr: needle cricothyroidotomy because cricoid cartilage is the major support structure of airway Surgical tracheostomy 12 yr B Pneumothorax, tension pneumothorax, hemothorax C Normal physiologic status up to 30% loss of total blood vol; traumatic cardiac arrest or
7、penetrating with witnessed arrest poor outcome D Disability: CNS injury E Exposure: prevent further heat loss,7,Resuscitation Secondary Survey,Similar steps as primary survey,8,Resuscitation Investigations,Plain X-rays Lateral C-spine: screen but not adequate in diagnosis Supine chest: pulmonary of
8、mediastinal injuries, not good in diagnosing small pneumothoraces Pelvic: major pelvic disruption Ultra sound FAST: focused abdominal sonography for trauma, not very reliable in children as in adults CT: Chest abd. pelvis as indicated by injury,9,Trauma In PICU,Child abuse & neglect Head injury Spin
9、al cord injury Thoracic injury Abdominal injury,10,Child Abuse & Neglect,Abuse head trauma: most common in PICU causing more long term morbidity Neck is weaker with larger head larger CSF volume (move around), larger water contents increase in deformability More rotational : tear bridging veins (SDH
10、) & axons (DAI) Neurons and axons less protected due to less myelination Skeletal injury: posterior rib fractures, metaphyseal fracture, spinous process fractures,11,Child Abuse & Neglect,Abdominal trauma: 2nd leading cause of fatal injury, 40%-50% death rates Compression: crush solid viscera agains
11、t anterior spine burst injuries to solid viscera & perforation of hollow viscera Deceleration forces shear injuries at the site of fixed, ligamentous attachment with tear & hematoma formation Thermal burns Uniformed thickness closely replicate the objects Abuse scald burns immersion pattern with cir
12、cumferential & uniform depth, well defined edges, spares body creases,12,Severe Traumatic Brain Injury,Statistic230/100,000 3000-4000 deaths/yr; 10-15% are severe with GCS8 deaths or permanent brain damage 0-4 yr: worse outcome probably secondary to non-accidental trauma 5-15 yr: favorable outcome c
13、ompared to adults Goals: to prevent secondary injury Optimize substrate delivery & cerebral metabolism Prevent herniation Target specific mechanisms involved in the evolution of secondary injuries,13,TBI - Pathophysiology,Primary direct disruption of brain parenchyma Secondary cascade of biochemical
14、s, cellular amd molecular events Ischemia/excitotoxicity, energy failure cell deaths Secondary cerebral swelling Axonal injury,14,TBI Secondary Injury,Post-traumatic ischemia Extra cerebral insults hypotension/hypoxemia Early hypoperfusion are common” CBF 20ml/kg/min associated with poor outcome CBF
15、 recovered usually after 24 hrs Delayed in normalization of CBF does not associated with poor outcome,15,TBI Secondary Injury,Excitotoxicity Glutamate other txs- magnesium, glycine site antagonists, hypothermia, pentobarb NMDA antagonists may induce apoptotic neurodegeneration in children,16,TBI Sec
16、ondary Injury,Cerebral swelling: initial min to hrs of post-traumatic hypoperfusion & hypermetabolism metabolic depression (CMRO2 decreases by 1/3 of normal) Edema Vasogenic & BBB disruption Cellular swelling: astrocytes swelling uptake of glutamate,17,TBI ICP Monitoring,Parenchymal fiberoptic & mic
17、rotransducer system Subarachnoid, subdural, epidural- less reliable Ventricular- best monitoring with benefit of draining CSF Keep ICP 60: adolescents lidocaine: decrease catechol surge with direct laryngoscopy,18,TBI Advanced Monitors,Stable Xenon CT CBF monitor regional CBF Stable Xenon technique
18、Transcranial doppler: measured velocity rather than flow, mainly MCA distribution Jugular venous saturation: keep 50%, lower assoc. with mortality NIRS- near infrared spectroscopy: trace the oxidative state of cytochrome, more on trends PO2 microelectrode implantation to frontal parenchyma: also pro
19、vide sign metabolic information: glutamate, lactic acid, glucose, ATP PET: positron emission tomography,19,TBI ICH Management,CSF drain Osmolar therapy Mannitol: Rapid dec. ICP by dec. viscocity dec. bl vessel diameter. Depend on intact viscosity autoregulation. Transient (75 min) Osmotic: (onset 15
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