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A 5-year-old female presents after being struck by a vehicle in her driveway. She has multiple injuries, including a right femur fracture, and open book pelvis injury, and bilateral clavicle fractures. Peripheral IV access is not able to be obtained in the trauma bay after multiple attempts, and the patients blood pressure is 110/70. Which of the following is the most appropriate method to obtain vascular access in this patient?
Placement of an intraosseous infusion device
Peripherally inserted central catheter (PICC) placement in the upper extremity
Femoral venous cutdown
Subclavian central line placement
Continued attempts at obtaining peripheral IV access
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Intraosseous(IO) infusion (shown in Illustrations A and B) is the most appropriate method of obtaining venous access in a normotensive pediatric trauma patient who is unable to obtain a peripheral IV line. Intraosseous lines can be rapidly and easily inserted, have low complication rates, and are safe to use with resuscitation medications.
Guy et al evaluated intraosseous line indications, insertion sites, complications, and outcomes in 27 pediatric trauma patients. They reported minimal IO-related complications, and high success of obtaining peripheral access with this technique. They concluded that IO infusion is a rapid, safe, and simple method of obtaining short term vascular access in both critically ill and injured children when venous access is not rapidly obtainable.
Orlowski et al performed an animal study to determine the comparative pharmacokinetics of six emergency drugs administered through different routes (central intravenous, PIV, and IO) in randomized sequence. The authors found that the IO route of administration was comparable with the central and peripheral intravenous routes for all of the emergency drugs and solutions studied,and that it is a clinically feasible alternative when intravenous access will be critically delayed.
Guy J, Haley K, Zuspan SJ.
J Pediatr Surg. 1993 Feb;28(2):158-61. PMID: 8437069 (Link to Abstract)
Orlowski JP, Porembka DT, Gallagher JM, Lockrem JD, VanLente F.
Am J Dis Child. 1990 Jan;144(1):112-7. PMID: 1688484 (Link to Abstract)
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A 4-year-old child involved in a motor vehicle collision sustains multiple injuries including splenic rupture, bilateral open femur fractures, lumbar burst fracture with compression of the neural elements, and a closed head injury requiring a ventriculostomy. Of these injuries, which is likely to cause the greatest long-term morbidity?
Traumatic brain injury
Peripheral nerve injury
Vertebral column injury
Long-term morbidity from trauma in children is most commonly secondary to central nervous system injury, including traumatic brain injury.
Key et al reported closed head injuries are the most common cause of long-term disability in children following polytrauma. They also note that the death rate in pediatric polytrauma patients is most closely correlated with the presence and severity of traumatic brain injury.
Gladden et al emphasize that appropriate orthopaedic treatment is important to facilitate early mobilization and care of these injured children and discuss the current management recommendations for pediatric polytrauma patients.
Kay RM, Skaggs DL
J Pediatr Orthop. 2006 Mar-Apr;26(2):268-77. PMID: 16557148 (Link to Abstract)
Kay, JPO 2006
Gladden PB, Wilson CH, Suk M.
Semin Pediatr Surg. 2004 May;13(2):119-25. PMID: 15362282 (Link to Abstract)
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How many milliliters(mL) of intravascular blood volume are present per kilogram of body weight in a healthy 5-year-old child?
Pediatric patients have an approximate blood volume of 75-80 ml/kg.
Although blood volume estimations based on body weight lack precision compared to other invasive methods of measuring, a rough estimate of blood volume for pediatric patients of this age group is 75-80 mL/kg. In trauma patients, this most common type of shock is hypovolemic shock due to blood loss. A patient can lose up to 30% of blood volume before becoming hypotensive due to compensatory mechanisms that maintain blood pressure, such as peripheral vasconstriction and increased heart rate. One sign of early hypovolemia is a narrowed pulse pressure (decreased difference between systolic and diastolic blood pressure), which can be noted with only 15% blood loss.
Illustration A is a table describing signs and symptoms of hypovelmia based on percentage of blood loss. Note the precise mL values of blood loss in this table are estimates for an average sized adult. Illustration B is a table summarizing average blood volume, heart rate, and systolic blood pressure by age.
Kay et al. provide a review of the evaluation and management of pediatric trauma patients. They note that pediatric trauma is most commonly blunt trauma, and has a high incidence of internal bleeding. They recommend immediate assessment of circulation and initial resuscitation with crystallized solution. They caution against over hydrating patients with head injuries due to the possibility of increasing cerebral edema.
Answers 1, 3, 4, 5: These values do not accurately estimate the per kg blood volume of a pediatric patient.
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Which of the following injuries is associated with the highest risk of morbidity and mortality in a pediatric trauma patient?
Buckley et al reviewed 805 pediatric trauma patients who sustained 953 fractures and dislocations to determine the relationship between skeletal injury and trauma score, injury severity score, length of hospital stay, hospital charges, and mortality. The femur was the most commonly fractured bone, and overall mortality was 3% in the group studied. The trauma patients with associated scapula or pelvic fractures had an 11% mortality rate, whereas those patients with spine fractures had a 16% mortality rate. Femur and tibia fractures had a mortality rate of 2% and 1% respectively. The authors concluded that central musculoskeletal injuries (spine, clavicle/scapula, and pelvis) were associated with the longest hospital stays and intensive care unit admissions, as well as the highest Injury Severity Scores, hospital charges, and mortality rates. Tepas et al reviewed the records of 4,400 children with traumatic head injuries, and compared them to head injuries reported from an adult trauma registry. They found that overall children have a lower mortality than adults, and that CNS injury is the predominant and most common cause of pediatric traumatic death.
Buckley SL, Gotschall C, Robertson W Jr, Sturm P, Tosi L, Thomas M, Eichelberger M.
J Pediatr Orthop. 1994 Jul-Aug;14(4):449-53. PMID: 8077425 (Link to Abstract)
Buckley, JPO 1994
Tepas JJ 3rd, DiScala C, Ramenofsky ML, Barlow B.
J Pediatr Surg. 1990 Jan;25(1):92-5; discussion 96. PMID: 2299551 (Link to Abstract)
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