Trauma Care After Resuscitation (TCAR) ALL MODULES COMBINED QUESTIONS BANK WITH EXPERT SOLUTIONS + RATIONALES(DIAGRAMS INCLUDED)

Trauma Scope & Impact

-Most frequent cause of childhood disability

-50,000 children acquire permanent disabilities yearly

-Most common are TBIs

Common Pedi Trauma Etiologies

Motor Vehicles

-over 460,000 U.S. children injured each year

-3,000 deaths

Falls

-most frequent cause

Firearms

-leading cause of childhood death

-63% homicides; 30% suicides

Field Triage: Red Criteria

Injury Patterns

- Penetrating injuries to head, neck, torse

- Skull deformities

- Suspected spinal, pelvic, fractures

-Active bleeding

Mental Status & Vitals Signs

- GCS <6

- Pulse Ox <90%

Field Triage: Yellow Criteria

Mechanism of Injury

- High-risk auto crash

- Partial/Complete ejection

- Death in passenger compartment

EMS Judgement

- anticoagulant use

- suspicion of child abuse

Trauma Center Classifications

Level I:

- full range of specialist available 24/7

- trauma residency program

Level II:

- comprehensive trauma care

- 24 hr availability of essential personnel

Level III:

- resources for emergency resuscitation

- general surgeon promptly available

Level IV:

- initial evaluation, stabilization, and diagnostic capabilities

Trauma Care Implications: Child Size

Due to different sizes IV fluid rates, blood product volumes, and medications are weight-based

urine output measured in mL/kg

Evaluate hemorrhage as a percentage of child's normal circulating volume rather than total milliliters of blood lost

Multisystem injury highly likely in peds

Pediatric Anatomic & Physiologic Difference: Cardiovascular

-Presume tachycardia is due to hypovolemia

-When their circulating blood volume is low, compensation is easier through tachycardia and vasoconstriction

-Maintain normal systolic blood pressure until more than 25-30% of circulating blood volume is lost

-Tachycardia is earliest indicator of hypovolemia

Pediatric Anatomic & Physiologic Difference: Respiratory

-In children ribs and weak intercostal muscles limit chest expansion, makes breathing less effective

-Higher chances of atelectasis, pneumonia, and respiratory failure

-High susceptibility to barotrauma from overinflation

-in small kids with no visible neck, tracheal deviation and jugular vein distention cannot be adequately assessed

Pediatric Anatomic & Physiologic Difference: Spinal Cord

-Large heads and weak neck muscles predispose to high c-spine injuries

-Most infant c-spine occur at C1-C2

Pediatric Anatomic & Physiologic Difference: Brain

-Due to lower BP at baseline, young children sustain fewer epidural hematomas than do older kids

-More likely to experience injuries that produce generalized edema such as contusions, anoxic damage, and diffuse axonal injuries

-Children have greater degree of neuroplasticity which allows non-injured areas of brain to compensate

Pediatric Anatomic & Physiologic Difference: Abdominal

-Asplenic children and those with severe spleen injuries require prophylactic antibiotics for at least one year after injury

-Lap belt injuries: bruising, redness, and abrasions across abdomen requires evaluation for intra-abdominal lower thoracic and lumbar injuires

Pediatric Anatomic & Physiologic Difference: Urine Output

-Children less than age 2 are unable to efficiently concentrate urine due to immature renal responses; continue to excrete urine even when hypovolemic

-Normal Infant Urine Output (1-2 mL/kg/hr)

-Young children urine output (1-1.5 mL/kg/hr)

-Adult urine output (0.5-1 mL/kg/hr)

Pediatric Anatomic & Physiologic Difference: Glycemic Control

-Limited glycogen stores and can quickly become hypoglycemic

Pediatric Anatomic & Physiologic Difference: Musculoskeletal

-higher chances of incomplete fractures as bones are softer and springier

-pulmonary contusions blossom over time (12-72 hours after injury). Anticipate onset of progressive ventilatory compromise in hours and days post injury

-

Calculation of pediatric drug doses and fluid bolus volumes

Calculated by weight or length

Broselow tape: reliable way to identify appropriate medication doses in an emergency

Trauma

Event or circumstance resulting in physical, emotional, and/or life-threatening harm that has lasting adverse effects on the individual's mental, physical, and emotional health and social and/or spiritual well-being

What is the Trauma Process?

1. Event

-Single Event

-Chronic

-Complex

2. Experience

-Positive Stress

-Tolerable Stress

-Toxic Stress

3. Effect

-Activation of the HPA axis

-Emotional regulation disturbances

-Hyperarousal

-Problem-solving and executive function impacts

-Impaired attachments and social skills

-Gene expression alteration

HPA Axis

Interaction between the nervous and endocrine systems to produce the body's response to stress. Elevated levels of one of these hormones may lead to depression

Why use the TIC Approach?

-Minimize potentially harmful traumatic experience, encourage positive coping, provide emotional support

-Improve therapy outcomes and process

-Improve health outcomes

OT Value and Role in TIC

-Knowledge of therapeutic interventions

-Focus on meaningful activities

-Evidence-based practice skills

-Understanding of environmental context

-Serve individuals, families, and communities

-Serve clients across the lifespan

TIC-OT Model

What are the guiding values of OT?

-Therapeutic Use of Self

-Evidence-Based Practice

-Holistic

-Humanistic

-Client Centered

-Cultural Competence

Therapeutic Use of Self

-Use empathy when working with client, family, and team

-Collaborate

-Build hope

-Build therapeutic alliance and trust

-Be aware of your verbal and non-verbal cues

-Help grow client's self-worth

-Respond to crisis points appropriately

Evidence-Based Practice

Use evidence for assessment and intervention

Holistic

-Include all domains of the individual in the assessment and intervention

-Allow flexibility in intervention

Humanistic

Support advocacy for needs

Client-Centered

-Client is the expert

-Encourage problem-solving

-Collaborate and offer choices

-Interventions reflect client's beliefs

Cultural Competence

-Respect cultural differences

-Be aware of cultural considerations

-Different cultures may require different therapeutic styles

-Recognize personal cultural biases and impact on therapeutic relationship

What are the Foundational Principles of TIC

1. Safety- physical and psychological security

2. Trust- strengthen therapeutic alliance with truth, reliability, and predictability

3. Choice- allow the client to have control of life by making decisions when faced with possibilities

4. Collaboration- client as a partner with shared power

5. Empowerment- encourage client to accomplish tasks of their own autonomy, encourage strength, and increase self-image

Safety- physical and psychological security

-Provide therapy in a safe and secure setting

-Ensure patient confidentiality

-Offer to address physiological needs

-Avoid shame inducing conversations/situations

-Ask before touching client

-Provide a safe place for client to express anger/frustrations without judgement

Trust- strengthen therapeutic alliance with truth, reliability, and predictability

-Use of Therapeutic Use of Self

-Follow through with what is said or promised

-Be transparent in therapy expectations and results

-Provide a vivid explanation of assessment and intervention

Choice- allow the client to have control of life by making decisions when faced with possibilities

-Have the client choose where, how, and when they will receive services, if possible

-Offer choices of interventions

-Offer choices ofthe order of activities during therapy

Collaboration- client as a partner with shared power

-Work with the client and family to set goals

-Work with the client and family to problem solve problems

-View and treat client as the expert in their understanding of themselves

-Encourage client feedback before, during and after

Empowerment- encourage client to accomplish tasks of their own autonomy, encourage strength, and increase self-image

-Encourage self-advocacy

-Identify and acknowledge strengths of the client

-Praise client for success in therapy

-Set realistic goals and acknowledge when they are met or need to be adjusted

Person-Environment Interaction

Community

-Connect with community supports to improve social and financial supports

-Reduce environmental stressors in the community as much as possible

-Refer client to other supports in the community

-Assist in prevention of future trauma by connecting to community support

Home/Family

-Educate household members about effects of trauma and how to limit future trauma

-Include siblings/caregivers

-Train/educate parents on effective parenting styles

School/Work

-Educate teachers and/or employers about the effects of trauma

-Support teachers and employers in adapting the environment to best meet the client's needs

What are the Four R's of TIC?

-Realize

-Recognize

-Respond

-Resist

Realize

Realize the prevalence of trauma and impact on health and well-being

-Observe escalated emotions/behaviors through trauma-informed lens

-Attend training on trauma-informed care in practice setting or community

Recognize

Recognize the presence of trauma and trauma's effect on occupation

-Advocate for the healthcare team to routinely screen/assess for trauma

-Interpret assessment results with trauma-informed lens

Respond

Respond appropriately by adapting approach to interacting with the client and communicate with the team effectively

-Provide emotional support and coping resources

-Emphasize continuity of care and collaboration among providers

-Refer to appropriate services

-Provide intervention as appropriate if trauma is impacting occupational participation

Resist

Resist Re-Traumatization

-Minimize potential triggers such as self-care activities, touching without asking, standing in close proximity

-Respond to trauma disclosures appropriately

End Goals and Results

-Resist Re-Traumatization

-Improve Therapeutic Alliance

-Collaborate with Healthcare team to provide trauma informed approach

-Provide referrals as appropriate

-Maximize participation in meaningful occupations

differential ddx: VINDICATED MEN

Vascular / Vessels

Infection

Neoplasm

Drugs & Diet (a.k.a. ingestions)

Idiopathic

Congenital

Autoimmune & Allergic

Trauma & Treatment SEs (a.k.a. idiopathic)

Endocrine (a.k.a. metabolic)

Deficiencies & Excesses

Musculoskeletal disorders

Environmental exposures

Neuropsychiatric disorders (a.k.a. neurologic, psychiatric)

differential ddx: VITAMINS ABCDEK

Vascular

Infectious / Inflammatory

Trauma / Toxic

Autoimmune

Metabolic

Iatrogenic / Idiopathic

Neoplastic

Social (e.g. child abuse, social deprivation)

Alcohol

Behavioral (psychosomatic)

Congenital

Degenerative / Drug

Endocrine / Exocrine

Karyotype (a.k.a. genetics)

ddx strategies: symptom complexes

ddx strategies: local anatomic approach

ddx strategies: systems approach

ddx strategies: mechanism approach

gross motor development: newborn

- limbs flexed, symmetrical pattern

- marked head lag on pulling up

gross motor development: 6 - 8 weeks

raises head to 45 degrees in prone position ("tummy time")

gross motor development: 6 - 8 months

sits without support (initially with a round back, the eventually with a straight back by 8 months)

By what age should infants be able to sit without support?

9 months

gross motor development: 8 - 9 months

crawling

gross motor development: 10 months

- stands independently

- cruises around furniture

gross motor development: 12 months

walks unsteadily (broad gait with hands apart)

By what age should infants be able to walk independently, even if unsteadily?

18 months

gross motor development: 15 months

walks steadily

gross motor development: 2.5 years

runs & jumps

vision & fine motor development: 6 weeks

follows moving object or face by turning the head (fixing & following)

By what age should an infant be fixing & following objects & faces?

3 months

vision & fine motor development: 4 months

reaches out for toys

By what age should infants be reaching out for toys?

6 months

When should an infant develop their palmar grasp?

4 - 6 months

vision & fine motor development: 7 months

transfers toys from one hand to another

By what age should infants be able to transfer toys from one hand to another?

9 months

When should an infant develop a mature pincer grip?

10 months

limit age: 12 months

vision & fine motor development: 16 - 18 months

makes marks with crayons

brick building: 14 months - 4 years

tower of three: 18 months

tower of six: 2 years

tower of eight or a train with four bricks: 2.5 years

bridge (from a model): 3 years

steps (after demonstration): 4 years

pencil skills: 2 - 5 years

drawn without seeing how it's done; copying can be done 6 months earlier

line: 2 years

circle: 3 years

cross: 3.5 years

square: 4 years

triangle: 5 years

hearing, speech & language development: newborn

startles to loud noises

hearing, speech & language development: 3 - 4 months

- vocalizes alone or when spoken to

- coos & laughs: aa, aa”

hearing, speech & language development: 7 months

- turns to soft sounds out of sight

- polysyllabic babble: “babababa, lalalalala”

Infants use sounds indiscriminately starting at _____ months & discriminately to parents at _____ months.

7, 10 (“Dada, Mama”)

hearing, speech & language development: 12 months

- two to three words other than "Dada" or "Mama"

- understands name “Drink”

hearing, speech & language development: 18 months

- 6 - 10 words

- is able to show two parts of the body (e.g. asking “Where is your nose?” & infant will point)

hearing, speech & language development: 20 - 24 months

joins two or more words to make simple phrases (e.g. “Give me teddy”)

hearing, speech & language development: 2.5 - 3 years

- talks constantly in 3 – 4-word sentences

- understands 2 joined commands (e.g. “Push me fast Daddy”)

social, emotional & behavioral development: 6 weeks

smiles responsively

By what age should infants smile responsively?

8 weeks

social, emotional & behavioral development: 6 - 8 months

puts food in their mouth

social, emotional & behavioral development: 10 - 12 months

- waves bye-bye

- plays peek-a-boo

social, emotional & behavioral development: 12 months

drinks from a cup with two hands

social, emotional & behavioral development: 18 months

holds spoon and gets food safely to mouth

social, emotional & behavioral development: 18 - 24 months

symbolic play

By what age should infants be engaging in symbolic play?

2 - 2.5 years

social, emotional & behavioral development: 2 years

- toilet training: dry by day

- pulls off some clothing

social, emotional & behavioral development: 2.5 - 3 years

- parallel play

- interactive play evolving

- takes turns

Shock

hypoperfusion= inadequate tissue perfusion

Aerobic metabolism

cell metabolism with O2

Anaerobic metabolism

cell metabolism without O2

Inadequate Volume (Hypovulimia)

loss of blood, loss of plasma

Inadequate Pumping

traumatic injury, heart attack, heart failure, obstruction

Inadequate Vessel Tone

Vessel Tone →systemic vascular resistance, BP= CO x SVR

Hypovolemic shock

inadequate volume (ex. burns, hemorrhage, dehydration)

Distributive shock

inadequate vessel tone (vasodilation and capillary permeability)

Neurogenic shock

caused by spinal cord trauma→lose sympathetic NS Signals→decreased heart rate and vasodilation→decreased CO and BP→decreased perfusion

Anaphylactic shock

extreme allergic reaction→systemic vasodilation and increase cap permeability →relative hypovolemia→decrease perfusion (swelling and constriction)

Psychogenic shock

fainting

Septic shock

exaggerated/systemic response to infection →systemic vasodilation and increase cap permeability→relative hypovolemia→decreased perfusion

Cardiogenic shock

inadequate pumping (ex. AMI, CHF, Dysrhythmia, cardiac meds, cardiac contusion)

Obstructive shock

inadequate pumping or blockage of flow (ex. Pulmonary embolism, Tension pneumothorax, Pericardial tamponade)