What determines better outcome in acute ishemic stroke patients treated with thrmbolysis
DELIVERY OUTSIDE HOSPITAL
Lili Steblovnik, Erika Tuta
The frequence of psychiatric disorders in poisoning with drugs treated at the department of toxicology, clinical centre Niš
Designed & developed by
FLUID AND ANALGESIC MANAGEMENT IN A TRAUMATIZED CHILD
NADOKNADA TEČNOSTI I ANALGEZIJA KOD POLITRAUMATIZOVANOG DETETA
Vesna Marjanović, Ivana Budić
Center for anesthesiology and resuscitation, Clinical Center Nis, Serbia
Summary: Every traumatized child requires the identification as high-
Keywords: Multiple trauma, children, analgesia, fluid resuscitation
Traffic accidents are still the main cause of death in children. Traumatic head injury, uncontrolled bleeding and hemorrhagic shock play a significant role in increasing mortality of traumatized children. Timely and adequate transport to an appropriate institution, first aid in such clinical conditions are reflected in an early reimbursement of lost blood and pain relief have great importance . Fluid resuscitation must be critically applied only in traumatic head injury. Sometimes rapid fluid resuscitation can cause early coagulopathy in the traumatized children as well as increased incidence of Multi Organ Dysfunction (MOF) and mortality . Every traumatized child requires rapid transport to an appropriate regional pediatric trauma center, providing basic and advanced reanimation procedures, identification of high-
The review, recommendations and controversies about access to care of poly-
MATERIALS AND METHODS
A retrospective analysis of databases PubMed and Kobson using the keywords: poly-
The duration of prehospital transport, which is for the city estimated that it may take around 31 minutes, while in the rural area transportation to the hospital takes approximately 43 minutes is particularly important . Regional trauma centers are very important in the survival of children with trauma, especially because of the opportunity to adequately define patients at the increased risk of death. Engum et al.  defined five criteria to determine poor outcome in patients, such as: systolic blood pressure <90 mm Hg, Glasgow Coma Score (GCS) <12, respiratory frequency <10/min or> 29/min, burns more than 15% of the total body surface of second or third degree. Newgard et al.  analyzed the 6-
SALVE THE PAIN IN TRAUMATIZED CHILDREN
Giving analgesic to traumatized children is important to cure these patients. During the last 3 decades it has been observed that the administration of analgesics is less common in children than in adults in similar clinical conditions and that usually the administered dose is 50% lower than it is needed in regard to weight regardless of the intensity of pain .
In a retrospective study of 696 patients, the pain has been detected pain in 81% of children in the prehospital setting, where 64% of children had a documented pain, while 15% of the children had some kind of intervention, which was the reason for the occurrence of pain. Given that the pain does not correlate with the extent of injuries in children, pain relief is applied to all children in the pre-
REIMBURSE FLUID -
Physiologically, children better compensate hemodynamic instability in the initial phase of trauma; hypotension may therefore be a late sign of hemorrhage in children, when they are already have the blood loss of 25 to 35% of circulating volume . Tachycardia is the first sign of hypovolemia in children and is important to note, given that children have little overall circulating volume (80 ml / kg for infants ages 1 to 3 months, while children older than 3 months have circulating volume of 70 ml / kg). Metabolic acidosis due to hypoperfusion and oliguria or concentrated urine are additional indicators of hypovolemia. If the fluids are not given timely, the signs of hypovolemia are then quickly observed .
Major problem with traumatized children is to establish venous access, due to the physiological specificity (veins small diameter, increased range of adipose tissue) and the presence of hypovolemia. In adult for setting of IV line it is enough 7.8 minutes, while in children it can take 10 minutes . The current standard in traumatic shock is an early and rapid fluid resuscitation with the placement of 2 venous line . Some studies show that the majority of children come into the regional trauma center with set venous line, although others suggest that 59% of children come to the hospital with non-
Side effects are manifested in the form of hemodilution, hypothermia, applying larger amounts of blood derivatives thereafter, the deterioration of the coagulation system (prolonged prothrombin time) and the increase of death in traumatized children . However, the early application of larger amounts of isotonic crystalloid quickly corrects hypotension in children and it is proposed for achieving hemodynamic stability . Hypertonic solutions enhance hemodynamic stability among adults and reduce the overall amount of liquid for initial compensation, without the effect to the final outcome of the patients . The use of hypertonic saline in children with closed head injury has not shown positive effects on child survival, and there is the need for new studies . Hydroxyethyl starch and albumin can also be used for fluid resuscitation in children without significant side effects . Other studies indicate that colloids do not show advantages compared to crystalloid, as shows in the studies that have been done on adults. Colloids are much more expensive and cause side effects therefore cannot be considered essential in the treatment of children with trauma . Glucose is usually avoided because hypotonic solutions can cause edema of the brain and increase the risk of hyperglycemia, which exacerbates the ultimate outcome of children with head injury. Hypoglycaemia should also be avoided in head injuries . In the meta-
Conclusion: Each of the stages in the management of multiple trauma is still controversial in the pediatric population, and it is necessary to consult the literature data to determine local protocol for the management of these patients. Prehospital care of children have great importance for their survival since this period also constitutes a period of "golden hour". The current findings suggest that early identification of high-
1. Kiraly L, Schreiber M: Management of the crushed chest. Crit Care Med 2010; 38: S469-
2. Schneider CP, Faist E, Chaudry ICH, Angele MK: Therapy of hemorrhagic shock. New strategies based on experimental results. Notfall Rettungsmed 2009; 12: 193-
3. Carr BG, Caplan JM, Pryor JP, et al. A meta-
4. Engum SA, Mitchell MK, Scherer LR, et al. Prehospital triage in the injured pediatric patient. J Ped Surg 2000; 35(1): 82-
5. Newgard CD, Cudnik M, Warden CR, et al. The predictive value and appropriate ranges of prehospital physiological parameters for high-
6. Newgard CD, Rudser K, Atkins DL, et al. The availability and use of out-
7. Lewis FR. Ineffective therapy and delayed transport. Prehosp Disaster Med 1989; 4: 129-
8. Bankole S, Asuncion A, Ross S, Aghai Z, Nollah L, Echols H, et al. First responder performance in pediatric trauma: A comparison with an adult cohort. Pediatr Crit Care Med 2011; 12: e166–70.
9. Schechter NL. The undertreatment of pain in children: An overview. Pediatr Clin North Am 1989; 36: 781–94.
10. Clark E, Plint AC, Correll R, Gaboury I, Passi B authors. A randomized, controlled trial of acetaminophen, ibuprofen, and codeine for acute pain relief in children with musculoskeletal trauma. Pediatrics 2007; 119: 460–7.
11. Schwaitzberg SD, Bergman KS, Harris BH authors. A pediatric trauma model of continuous hemorrhage. J Pediatr Surg 1988; 23: 605–9.
12. Barcelona SL, Thompson AA, Cote CJ authors. Intraoperative pediatric blood transfusion therapy: A review of common issues. Part II: Transfusion therapy, special considerations, and reduction of allogenic blood transfusions. Paediatr Anaesth 2005; 15: 814–30.
13. Kanter RK, Zimmerman JJ, Strauss RH, et al. Pediatric emergency intravenous access: evaluation of a protocol. Am J Dis Child 1986; 140: 132– 4.
14. Paul TR, Marias M, Pons PT. Adult versus pediatric prehospital trauma care: is there a difference? J Trauma 1999; 47: 455–9.
15. Lillis KA, Jaffe EM. Prehospital intravenous access in children. Ann Emerg Med 1992; 21: 1430–4.
16. Tighe SQ, Rudland SV, Kemp PM, et al. Paediatric resuscitation in adverse circumstances: a comparison of three routes of systemic access. J R Nav Med Serv1993; 79: 75–79.
17. Cassey JG, Armstrong PJ, Smith GE, Farrell PT authors. The safety and effectiveness of a modified convection heating system for children during anesthesia. Paediatr Anaesth 2006; 16: 654–62.
18. Bernardo LM, Gardner MJ, Lucke J, Ford H authors. The effects of core and peripheral warming methods on temperature and physiologic variables in injured children. Pediatr Emerg Care 2001; 17: 138–42.
19. Hussmann B, Lefering R, Kauther MD et al. Influence of prehospital volume replacement on outcome in polytraumatized children. Crit Care 2012; 16(5): R201.
20. Kwan I, Bunn F, Chinnock P et al. Timing and volume of fluid administration for patients with bleeding. Cochrane Database Syst Rev 2014; 3: CD002245.
21. Bulger EM, May S, Kerby JD, Emerson S, Stiell IG, Schreiber MA, et al. authors. Out-
22. Morrow SE, Pearson M authors. Management strategies for severe closed head injuries in children. Semin Pediatr Surg 2010; 19: 279–85.
23. Sumpelmann R, Kretz FJ, Gabler R, Luntzer R, Baroncini S, Osterkorn D, et al. authors. Hydroxyethyl starch 130/0.42/6:1 for perioperative plasma volume replacement in children: preliminary results of a European Prospective Multicenter Observational Postauthorization Safety Study (PASS). Paediatr Anaesth 2008; 18: 929–33.
24. Perel P et al. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database of Systematic Reviews 2012, 6.
25. Cochran A, Scaife ER, Hansen KW, Downey EC authors. Hyperglycemia and outcomes from pediatric traumatic brain injury. J Trauma 2003; 55: 1035–8.
26. Boluyt N, Bollen CW, Bos AP, Kok JH, Offringa M. Fluid resuscitation in neonatal and pediatric hypovolemic shock: A Dutch Pediatric Society evidence-
27. Dehmer JJ and Adamson WT. Massive transfusion and blood product use in the pediatric trauma patient. Semin Pediatr Surg. 2010; 19:286–91.
28. Paterson NA author. Validation of a theoretically derived model for the management of massive blood loss in pediatric patients -
Center for anesthesiology and resuscitation, Clinical Center Nis, Serbia
Rad primljen: 01.07.2016.
Rad prihvaćen: 12.08.2016.
Elektronska verzija objavljena 07.01.2017.:
|A Word From The Editor|