BIG T PED 1
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[00:00:00] Welcome back to Behind the Knife. I'm Patrick Geoff, and I'm happy to say that this is another big T trauma episode. They happen to be my favorite, and today we're taking a swing at a topic that's essential, but often anxiety provoking, and that's pediatric trauma.

Kids are not just little adults. They crash harder. They hide shock better, and they will certainly humble you. Today we're joined by my co-host Dr. Teddy Puzio, who is staff at UT Houston. He's a regular on our Big T series, and we have two special guests.

First is Dr. Chuck Cox, professor of pediatric surgery at UT Houston, and a true expert in the world of pediatric trauma and Dr. Paul Ramche, who is a second year trauma fellow at UT Houston.

Welcome y'all to the show.

Yeah, thanks Patrick. I've been a huge fan since intern year. You guys have definitely gotten me out of a ton of sticky situations.

And so in today's one of two part episode we're gonna dive into pediatric trauma pitfalls. And we're [00:01:00] gonna do this through some real life case scenarios. Today, particularly, we're gonna focus on the ABCs of p trauma as well as some of the unique anatomy and physiology that they have.

Let's get started with this first case.

A toddlers dropped off in the ambulance bay after reportedly being involved in a high speed rollover. MVC. He was unrestrained in the backseat was ejected from the vehicle. Your vitals, Paul heart rate's one 20. BP is 98 over 60. They have cool extremities and no external bleeding. You complete a rapid and complete primary survey.

They start having some difficulty breathing. Nasal cannula and a non-rebreather mask aren't cutting it.

So the ED moves to intubate him. Everyone's getting ready to do the thing and everyone starts asking him about RSI med dosing. Have we gotten the weight? What's the patient's age again? How tall are they? And someone went running off to find the brassel tape as well. Unfortunately during that time, the patient starts to desaturate and [00:02:00] really begins to drop precipitously.

Paul, what Could we have done differently in this scenario to prevent this patient's respiratory issues?

This one makes me anxious. Just hearing it. I'm not gonna lie it's real. We can all feel it. I think even hearing you describe the vitals, people are probably going, wait, are those normal in a kid?

Right? Yeah.

Yeah. In adults, there's a lot more leeway with estimating or standardized dosing, but in peds, every single medication or almost every medication is weight-based. And so you need to know the dosing and more importantly the weight or the estimated weight of your patient.

And so if you're not ready with a system in place before they roll in through the door, you're already behind.

Yeah.

Such

an important part of trauma, right? Huddle, your team, assign roles, get your equipment ready.

So what could we have done before this kid even got to the bay, especially knowing pediatric trauma makes us all nervous.

Yeah, I think it's really exactly what you just said. Get your system in place and [00:03:00] get your team ready.

And particularly for this scenario, it's having something that you can refer to immediately for pediatric patients, whether it's a brass low tape, or using the hand heavy system that we have in Houston. Just having something ready and it helps to have the code carts with all the critical meds you need that are already categorized by weight.

How does that work? Tell us how you apply that in real life scenario.

Yeah, of course. So there's two major ways to estimate weight-based dosing in peds, and it's either the brass tape or the hand TAVI system. They're both used for kids that are up to age 12 or. 36 kilos. And so with the bras low tape, it's a physical color coded tape that gets laid next to the patient, usually on the stretcher that they get rolled over to.

And whatever color the heels measure to, gives you the common medication doses for that height as well as the appropriate [00:04:00] catheters and tubes for that patient size. And the recess carts are also color coded, so whatever color that corresponds to on the patient's height is the drawer that you open and it has all your meds with the appropriate doses for that.

The hand TVI is similar to the brass tape in the sense that it's color coded and corresponds. However, the main difference is that it's age-based instead of height based.

Yeah. Here we use the hand heavy and it is age-based and so if a level one's.

Paged out we can use that age to get the room ready. Gives you pre-calculated drug doses, fluid volumes, equipment sizes, like endotracheal tubes, Foley catheter size, all that. So that, that part of the initial activity isn't taken up by just that chatter of trying to what size NG tube should we put in?

Yeah. And the SLO tape works well too. It's a color coded [00:05:00] scheme when the patient's laid down on the stretcher, it gives you a quick estimate and on it, it has the doses laid out already. And a lot of emss will use one or the other of these.

So in this case, had we known that, we would've had the right medication doses, the right equipment available for intubation and potentially could have avoided this episode of Desaturation. Let's go on Paul to the next case. EMS rolls in with a five-year-old pedestrian who is struck by an F-150.

He has devastating midface trauma profuse, oral pharyngeal bleeding and swelling as well. And EMS says they tried to secure the airway but got lost in bleeding and soft tissue swelling. GCS is six, SATs are 88%, and bagging is difficult and once you get into the bay, attempts are made to visualize the cords.

You can't see anything and between multiple suctions bag valve mass we're losing the fight. And oxygen saturations hovering the load in mid eighties.

And [00:06:00] now the patient drops precipitously. They become bradycardic with that hypoxia and arrest. Terrible situation. A frightening one. What went wrong here?

Yeah. It's such a scary situation and this is a true can't ventilate, can't oxygenate problem and it really requires immediate, what's called front of neck access.

I think the team probably spent a little too long trying to get orotracheal access and now the child's coding and decompensating rather quickly. I think we should have opted for a CRI or cricothyroid. Otomy pretty early on. And not just any crike. This is a five-year-old, so he needs a needle. C cri ba

right?

Crazy talking about needle Cris with adult trauma surgeons. We're gonna get into that. And break that down. So let's reset here. Work through the pediatric airway one step at a time because again, this is where a lot of folks freeze, especially when you're thinking about [00:07:00] a non-standard or non-adult approach to a crike

yeah, so hypoxia is the number one cause of pediatric arrests and trauma, and it's hard because everything's just different in kids. The Occi puts larger, the epiglottis is a lot floppier and the airway is positioned in such a way that it's much more anterior as opposed to adults. And obviously the trachea is a lot shorter.

Yeah. So with intubating, the real key here is to follow a checklist, and I use the six Ps. First one's preparation, have all the equipment you need, yank hour meds like we talked about earlier. Multiple sizes of ET tubes multiple different laryngoscopes, preferably a video bougie, all the adjuncts you could think of, and definitely an extra set of hands After you have all this preparation done.

Preoxygenate, get the adjuncts in. Start using your bag valve [00:08:00] mask, suction if you need to. And remember, these are kids, so they need small tidal volumes or else you'll really over bag them. Once they're preoxygenated, then you start thinking about pretreatment and paralysis. These kids need rapid sequence intubation, and like we talked about, the doses are weight-based.

Finally, with placement, this should be the most experienced person in the room getting the tube in. Use the bougie if the airway's too anterior. And when you're passing the bougie, always be sure to feel the clicks of the tracheal rings as you're passing it through to make sure you're in the trachea.

The video scope is certainly your best friend, and when you're worried about a floppy epiglottis, you should reach for the Miller blade. And then finally, the last important thing to know is the tongue is a lot larger in kids and it will cause your airway to get obstructed. And then once you've got all of this done, you're high fiving.

You gotta make sure that you [00:09:00] verify post intubation with either end tidal chest x-ray auscultation, or really any combination of those.

Paul, you mentioned the six Ps. I like to preach and I remember the seven Ps that I learned way back when I did EMS training. So proper pre-planning prevents piss poor performance, right?

And I think it, it's important, it applies to a lot of these things that we talk about. You can't in the moment, go through this checklist if you've never preemptively thought about it. Right? And that leads to the next scenario or the next phase of this scenario. So let's say you do all this stuff and the kid codes, and now you have to do a needle crike.

How do you do a needle crike and that, and an important. Part of this is talking through it and thinking through it ahead of time, and that's why we're having this discussion. So Dr. Cox you're the most qualified by far of all of us to walk us through this. So help us understand how you do one of these.

Yeah. I, you can call it needle [00:10:00] cri. You can also be needle trach as well. I don't think there's any I don't think you lose any points if it, if the needle goes into the trachea you're not gonna hurt anything with that. The, but the reality is cricothyroid, autotomies are impractical in children just due to the very small membrane and space that makes it , especially in an emergency situation, just impractical.

And so that. Idea is to access the airway with a 14 gauge angio c angled at 45 degrees coddly aspirating as you, insert it, it's not far. And then you connect to an oxygen source that and different places have different setups, but the idea is that you have quick bursts of oxygen with passive exhalation.

Practically speaking, is there an age, you often hear eight years old is a cutoff, is there roughly an age that you follow or [00:11:00] a,

I think that's a of a child where you say, stay small.

Think that's a fair, I think that's a fair cut point for doing that. The and even the smallest even the smallest ET tube would get you over the hump. Even a 2.5 or three French ET tube would get you over the hump for that brief period of time.

Alright so with that, this is, , trans tracheal jet ventilation, not that common. Dr. Cox, can you describe some of the more common setups and help paint a picture for people listening on the podcast, because it may not be something that most folks have seen.

Yep.

There's two common pieces of gear that you'll run across in managing. This one has a pressure regulated line that comes out of the off the wall or an oxygen tank and has a handheld triggering device that you can connect to the angiocath with a three-way stop cock and you squeeze and release.

And it's a short burst of gas in and a longer [00:12:00] exhalation. So your I to e ratio is, one to four or some, maybe even potentially longer than that because it's a rapid influx of gas and then exhalation.

And then the other is just the oxygen coming straight off the wall or off of a tank that's connected to your three-way stock cock that's connected to your angio cath. And then you can either manually control that with the tube and then in the inflow outflow with your thumb on the three-way stop cock.

Yeah. So you just putting your finger over that third piece at the lure lock connector there. And if you have your finger on top of it, gas is gonna flow at that high pressure, pure oxygen into the airway, into your catheter. When you take it off, it'll preferential flow outta your stopcock as opposed to the higher resistance catheter and into the lungs.

Correct. And that allows for excalation to occur. Alright, great. So with that, don't forget your six Ps for pediatric airway, for all airways, really preparation, oxidation, paralysis, placement, and, post intubation confirmation. And remember that you're looking at [00:13:00] roughly eight years old as a cutoff for airways that are too small to do a classic open CRI and where you might want to consider a needle cricothyrotomy for gen ventilation.

Let's go on to the next scenario. You have a 6-year-old boy. They're brought in after being struck by a car while crossing the street. EMS reports that the patient was awake at the scene crying and had a few abrasions on the legs. There's no loss of consciousness now though in the trauma bay. He's quiet, but alert.

Heart rate's 1 42. Blood pressure's 90 over 60. Respiratory rate is 26. Cap refill is four seconds, and the child's not moving much. They're a bit lethargic. They're not crying. He's got some gauze wrapped around his head. EMS said there's quite a bit of blood loss at the scene. And when it's taken down, there's a large scalp plaque, fastest negative.

There's two IVs. The patient gets 250 ccs ofr, and a pan scan is ordered. However, the Patient codes. Paul, what did we miss here? There's a big bad miss. This is a unfortunate one.

Yeah, [00:14:00] definitely. This is hard to hear. I think this is, it is uncomfortable reading it, to be honest with you.

I'm reading that stem going the whole time. Like it hurts my soul. Yeah. It's classic for compensated shock, especially in a pediatric patient. And it got missed completely. Everything about this case tells you that the kid's in trouble, but it's really subtle 'cause they compensate and compensate.

But some of the subtleties, he's tachycardic, he's cool. He had delayed cap refill. , But the whole time his blood pressure was quote unquote normal. And that is the trap. Kids are really good at maintaining perfusion until they suddenly come off the cliff and crash.

And by the time hypotension is showing up, you're late in the game.

So I think, if we talk about things as black and white, that's a core difference, right? Adults show early signs of shock with hypotension, but in kids, they compensate way longer like a machine, [00:15:00]

right? Pediatric patients, they, they just have an incredible sympathetic reserve and they are really good at vasoconstricting, selectively shunting blood and maintaining an adequate cardiac output

but when they decompensate, it is rapid and catastrophic. So one minute they're talking and unfortunately, the next minute they're coding.

Yeah. I think that's exactly right. Why don't we go into a little deeper dive in terms of what makes their physiology unique?

Sure

first and foremost, their blood volume is higher per kilo. It's about 80 mls per kilogram. So that makes the absolute volume smaller. For example, a 20 kilogram child only has about 1.61 and a half liters of total blood. And so losing a few hundred ccs is equivalent to losing basically a liter of blood in an adult.

Also, when you think about their cardiac output, it's very rate dependent. They can't, for lack of better [00:16:00] term, stroke volume, their way out of shock. And so their heart rate goes up, their perfusion takes a major hit and drops. That also means though, that when you start to see the things that are augmentation, decreased cap refill, certainly hypotension.

And you're already behind the eight ball.

So remember, blood is king, right? So the best thing that we can do for a bleeding patient, child or adult, is to get blood products into them as quickly as possible. And when we talk about balance resuscitation in adults, it's the same in kids, right? One to one-to-one ratio, until you hit the endpoints like hemodynamics and pegs improve.

Or that bleeding's controlled if you don't have rapid access to blood and the child is crashing. You can start with a 20 ml per kg bolus of crita. But remember when giving blood, the amount you need to replace their entire blood volume is proportional to their [00:17:00] weight. And that's an important point.

We'll put a link to a table at the end of this podcast with our UT Pediatric massive transfusion protocol algorithm that can help guide you. But before we move on this topic before I forget, let's talk a little bit about TXA or that's part of our MTP protocol.

So in this patient population of bleeding hemorrhagic shock, they get 15 milligrams per kilogram ID of TXA in a bolus form over 10 minutes. And that's followed by two milligrams per kilogram an hour over eight hours. And we also, we always try to give it within three hours of injury.

Sure. And this raises the ultimate point.

What about IV access? Dr. Cox, what kind of tips and tricks do you have for access in an pediatric trauma patient

now? So the same principles, the two large bore IVs obviously apply. But just recognize that large in an infant can be a 22 gauge . [00:18:00] And the toughest kids are the kind of chunky six month old, eight month old rolly, poy kid, who has these fat arms and thighs, and then it's skin dives down to their wrist, and they have these big fat hands and it's, yeah.

Super cute. Yeah. It is just not easy. And then if they're in shock, it's even harder. And the in children's hospitals the number of people are really good at getting those with ultrasound guided, even in. Trauma resuscitation, but without that. And the child is decompensating. The IO line and the tibia is your friend.

There are IO kits for that paying for infants, blue for larger kids. I think that tibia is superior, but sometimes they have fractures there, or proximal fractures. So that's not a viable option. The humerus is right here in, in humerus is a, on the, like, where you get a, where you get to immunization is a [00:19:00] similar next best site.

I think the third central access can be a little bit more tedious. But I think that even a less recognized site as a saphenous vein in terms of saphenous vein cut down even, which is a durable and predictable anatomic location of a decent size vessel that takes a little bit longer, but is something that works really well with almost zero real morbidity associated with it.

IJ I think is much more difficult than the smaller kid to be done in a trauma room. Femoral vein is reasonably straightforward, but in a hypotensive small child, then that can be a especially with a lot of activity on, in that space can be difficult.

Yeah, iOS can be lifesavers here and practically speaking, once your cutoff between the pink and blue.

Intraosseous catheters, you said pink for infants, blue for kids.

Oh, [00:20:00] six, six months to 12 months. , I don't know what the actual a package insert says, but if you have a greater than a five to 10 kilo kid, you would go to the blue.

Sure. Alright, Teddy, for this scenario, what's the key takeaways?

Kids crash hard and fast. So pediatric patients in shock, they look fine look fine, and then boom, they're, suddenly per arrests. So we need to pick up on those subtle findings like tachycardia, cool extremities, delayed cap refill, altered mental status.

These are all red flags that should start triggering your spidey senses. Right? There's other. Adjuncts to look for. So a drop in end tidal CO2 and increased lactite. These are sometimes early markers of hemorrhage. You have to recognize the signs of compensated shock early. Escalate to blood, right blood.

Blood. Activate your MTP protocol. Hopefully there's a role for TXA in your protocols. And [00:21:00] then if you wait for hypotension, you've already missed a boat you shouldn't wait to get to that point before you start intervening.

All right, Dr. Cox, you have another scenario for us?

Yeah, let's do a quick scenario highlighting some, in management of pediatric thoracic trauma. So a 2-year-old girl comes in after a fall with a second story balcony. She's nik oxygenating poorly, has diminished breath sounds on the left. Fast shows a left-sided hemothorax chest X-ray confirms a moderate hemothorax with some media style shift.

The trauma team decides to place a chest tube and then al cue the scramble for size, sedation and setup.

And so some of the nuances first obviously is size right? So it's not a 36 French chest tube for everybody that is, mandated in some,

so this day and age, you're talking 28 French or smaller, but that's a, oh geez. That's for us, that's for us to worry about

hope. Let's not go down that no rabbit hole.

Wow. I, I've always recognized that the adult trauma team has gotten softer over the years. [00:22:00] Now I've got a number to put on it, and so that's been helpful for me.

Thank you. The first thing is size and usually a 12 to 20 French chest tube. These are obviously smaller bore in the smallest kids smaller bore surgical tubes or pigtail catheters are popular.

The landmark's the same except for a few differences. The pleura, thinner and thoracic cavity is smaller, which means, your margins for error are less you don't insert your finger into the chest. That's called a thoracotomy on an infant. And so it can be a little bit more tedious to get the tube between the rib spaces especially if the child's awake and or moving with.

That's the attractiveness of the pigtail catheters. Sure.

What about pain control and sedation when you're doing these procedures? Paul, do you have a approach

you use? Yeah, that's huge, especially in [00:23:00] young kids. They're just, they're not able to stay still. They don't know what's going on. And so what I frequently reach for is sedation in the form of ketamine and definitely having plenty of lidocaine available.

If you're the one doing it, it's really prudent to have your ED colleagues at the head of the bed just doing airway monitoring in case they crash from the sedation or the rapid lung re expansion. Sure. And

oftentimes these children present with their parents, right? And you're about to do a major procedure on them.

So how do you communicate with them?

Yeah, perhaps this is one of the most important parts of a chest tube. It's important to not blow that off. Chest tube is something that we've all done hundreds of times, and to us it's a simple, straightforward procedure and usually pretty clearly indicated. But to parents, a tube sticking outta their child's chest, it's a big deal [00:24:00] and it should be.

And so you've gotta explain what you plan to do. Talk about what you're going to do to mitigate pain, the purpose of the tube, how long you expect it to be in what you're going to do to monitor. And although it's a rule for every procedure, it's that much more important in a pediatric patient. Yeah.

Dr. Cox, anything else you have to add over, years of placing these and watching residents place 'em that you wanna share?

Yeah. I think for the smaller kids even though the silicone tubes arelike for certain circumstances, there are some there that you need to consider when you're placing those meaning the way the tubes are secured to the chest, the reason is a lot of these kids they go upstairs and they're in their bed and they do this alligator roll in their bed, and then you come around out on rounds and the chest tube is in a knot.

And so that's a dangerous. Potentially dangerous situation where [00:25:00] you've got this twisted chest tube that's no longer draining either the air or fluid that you're trying that for, presumably was placed. And it's a a preventable problem.

Yeah, it's good stuff. All right, let's bring this home.

Next scenario, Paul, you're back in the hot seat, a 3-year-old girl spills a pot of hot tea on her upper chest and arm. She's screaming in the trauma bay. Nurses estimate she has around a 9% TBSA burn. Her heart rate is one 50. Her blood pressure's 92 over 60. She gets some morphine. The burns are dressed and she's sent to the pediatric floor with maintenance fluids.

Two hours later the intern goes around on them and she's lethargic. She's cold to the touch, she's hypotensive. Oliguric. What happened?

Sounds like we underestimated her burn wounds and overestimated her, I guess physiologic reserve pediatric patients.

They have a high [00:26:00] surface area to volume ratio and so they lose heat and fluids a lot faster than adults. Then you combine that with some thin skin and poor or less advanced, thermo regulation. You've got the perfect storm for shock and hypothermia and that could precipitate even from just a small burn.

Yeah. So what's the optimal approach in this scenario? I think it's first important to have. Good estimation tool. The rule of nines, which we frequently use in adults, is a little harder to apply to kids because their heads and arms are larger than in adults. And so the London Broder chart is what I go to frequently because they have a pediatric specific one.

For burns that are greater than 10%, you need aggressive fluid resuscitation. That's different than in the adult population where that cutoff is usually about 20%. Now, there's a lot of different [00:27:00] formulas when it comes to resuscitation, but I think the takeaway for any institution or anybody that's working in pediatric trauma is to pick one and stick with it.

And in addition to that, use your end markers of resuscitation. So frequently for burn patients, it's urine output, which by the way is greater than. One cc per kilo per hour. But using other adjuncts for that such as lactate, their heart rate their blood pressure. And so in addition for young kids, it's easy for them to get hypoglycemic and hypothermic when you're giving them large volumes of cold crystal solutions.

So make sure you're watching their temperatures like a hawk and when they inevitably become hypoglycemic, have a protocol or have dextrose ready or dextrose containing fluids for them.

I agree with the estimating, with lung broader charts and 'cause they're always, whatever [00:28:00] the initial assessment was, it's almost inevitably not right.

And so take the time to do that. With the medical records now, it's also a lot with pictures being able to be put into the records. It's so much more. Objective, after they're all dressed up, you can really map that out. But I think the piece of it in terms of NPO status hypoglycemia is, I think a critical component of that is if the patient has greater than a 10% burn even we place a do off to a feeding tube and they get interal nutrition begun just almost immediately, even during their resuscitation.

And so we we loathe having them NPO for if they're going back and forth to the or because they can end up spending, half of their first two weeks in the hospital. Being NPO, which is a disaster [00:29:00] for them in terms of physiologic stress, et cetera. We may that, that, that's part of their resuscitation is their internal access.

The EMIA is important, but also EU hermia, right? So warmed fluids, warming blankets, warming everything is important.

Yeah. So in pediatrics, burn wounds aren't about the sole percentages so much so as it is an adult, it also depends on who it's happening to, how small that child is.

We don't wanna be fooled by a small looking burn any other take on points, Dr. Cox

yeah, I think that the good news is the vast majority of the ones that we deal with are scald burns. Right. It's not hot tea or hot. It's ramen noodles and cup of soup.

Wow. That's 80% of our it's 80% of them. And I think that there's a small but real number of those that, that, when you're talking about letting [00:30:00] them fully, a small number of them convert and become deep partial thickness or full thickness burns. And so that's a important thing to keep an eye on.

Alright, so that wraps us up on episode one of two looking at pediatric trauma on the Big T trauma series.

Paul, thanks for joining. Yeah, thanks for having me. It's pediatric trauma is tough. Yeah, high stress. We appreciate Dr. Cox having you on as well. We look forward to our next episode discussing some additional scenarios.

Thanks. I appreciate the invite. Great cases and great discussion.

All right, before we end, just to remind everyone my favorite quote, the eyes did not see what the mind does not know.

Thanks everybody for listening. Yeah.

Thanks for joining. Dominate the Day