Paediatric Trauma
Paediatric Trauma
The primary survey follows the 'ABCDE' sequence and involves a rapid physiological assessment to identify immediate threats to life in a structured order.
The first priority in managing a child with acute trauma is to ensure a patent airway. Special airway considerations include the possibility of cervical spinal injuries, head injury, and the presence of a full stomach. The larger head and relatively smaller mid-face make airway obstruction more common in children than in adults. This together with increased respiratory rate and increased oxygen consumption makes establishing and maintaining the airway in children more urgent. Cervical spine injury is uncommon in children (<2% of trauma cases) compared with the large number (75%) with traumatic brain injury (TBI). The need to avoid a further hypoxic insult to the child with TBI while protecting the C-spine remains particularly challenging. In many cases, simple jaw thrust or insertion of an oral airway may relieve airway obstruction. In the trauma setting, orotracheal intubation is preferred to the nasal route. Indications for intubation are similar to adults.
Orotracheal intubation with manual in-line immobilization after rapid sequence induction should be used to secure the airway in blunt trauma with an uncleared C-spine. The circulatory state and the conscious level must be taken into account when choosing the induction agents and their dose. The goal of drug usage is to produce unconsciousness, improve intubating conditions, and blunt haemodynamic responses in children with head injury and possible raised ICP. Suitable induction agents include thiopental 2–5 mg kg, etomidate 0.3 mg kg, or ketamine 1–2 mg kg combined with fentanyl 0.5–1.0 µg kg.
In cases of circulatory inadequacy, the dose of thiopental should be reduced. Succinylcholine is widely used in children and is not contraindicated in the initial resuscitation phase, unless there has been a major crush injury. Once successful intubation has been performed, a naso/orogastric tube should be passed to prevent gastric dilation which can seriously compromise oxygenation and ventilation in the child. It is important to provide ongoing sedation, analgesia, and muscle relaxation to prevent coughing on the tube and alterations in ICP in children with significant head injury.
Breathing and ventilation need to be rapidly assessed. Children have greater oxygen consumption, smaller functional residual volume, and increased chest wall compliance, predisposing to airway collapse and hypoxia. The diaphragm is both easily fatigued and easily displaced. Urgent intervention may be needed to treat tension pneumothorax, open pneumothorax, haemothorax, or flail chest.
Circulation should be assessed by evaluating heart rate, capillary refill time, skin colour, arterial pressure (AP), and mental status. Particular attention should be paid to peripheral perfusion. Children compensate well after major haemorrhage as vasculature readily constricts and increases systemic vascular resistance to maintain perfusion pressure.
AP is well maintained until hypovolaemia is quite severe, >25–40% of blood volume loss. Hypotension in a child is a sign of decompensated shock and may be abruptly followed by bradycardia. Tachycardia is a more useful sign of hypovolaemia, but may also reflect pain and fear. In small children, i.v. access is often easier in the hands and feet than in the antecubital fossae. If no i.v. access is achieved within 90 s in a severely injured child <6 yr of age, intraosseous access is appropriate. Initial fluid resuscitation should consist of warm isotonic crystalloid solution (Ringer's lactate or isotonic saline) and should be administered in 20 ml kg boluses guided by heart rate, peripheral perfusion, AP, and mental status. If failure to improve with >40 ml kg of crystalloid, then blood 10 ml kg boluses should be given followed by frequent reassessments. In the face of ongoing haemorrhage, fresh frozen plasma and platelets will be required.
The trend in adult trauma resuscitation is to give smaller boluses of fluid 10 ml kg followed by reassessment and further 10 ml kg boluses as required. A recent Cochrane systematic review concluded that there is no evidence from randomized clinical trials for or against early or larger volumes of fluids in uncontrolled haemorrhage. Fluid loading may be harmful in the face of uncontrolled haemorrhage particularly after penetrating trauma. It can exacerbate bleeding and contribute to coagulopathy and hypothermia. Permissive hypotension (systolic AP=80 mm Hg) may be appropriate in this situation, providing that it is combined with immediate surgical intervention to control the bleeding. In children without a TBI, a systolic AP of 80 mm Hg is more than adequate to maintain organ perfusion. 'Best' fluid remains controversial in the initial treatment of the bleeding trauma patient. Both crystalloids and colloids are effective in correcting hypovolaemia. Large volumes of normal saline can lead to hyperchloraemic acidosis (Table 1).
The assessment of disability during the primary survey consists of a brief neurological examination to determine conscious level, and assessment of pupil size and reactivity. Conscious level is rapidly assessed using the AVPU score:
The aim of the neurological assessment is to identify severe head injury which may require urgent neurosurgical intervention and neuroprotective intensive care strategies. Analgesia should be considered at this stage if not already given before intubation. Morphine is the drug of choice and should be given in a dose of 0.1–0.2 mg kg.
X-rays: CXR, pelvis, C-spine.
Investigations: ABG, FBC, cross-match, glucose, U&Es. Urinary catheter if required.
Allergies
Medications
Past medical history
Last oral intake
Environment in which the injury occurred
Primary Survey and Resuscitation
The primary survey follows the 'ABCDE' sequence and involves a rapid physiological assessment to identify immediate threats to life in a structured order.
Airway
The first priority in managing a child with acute trauma is to ensure a patent airway. Special airway considerations include the possibility of cervical spinal injuries, head injury, and the presence of a full stomach. The larger head and relatively smaller mid-face make airway obstruction more common in children than in adults. This together with increased respiratory rate and increased oxygen consumption makes establishing and maintaining the airway in children more urgent. Cervical spine injury is uncommon in children (<2% of trauma cases) compared with the large number (75%) with traumatic brain injury (TBI). The need to avoid a further hypoxic insult to the child with TBI while protecting the C-spine remains particularly challenging. In many cases, simple jaw thrust or insertion of an oral airway may relieve airway obstruction. In the trauma setting, orotracheal intubation is preferred to the nasal route. Indications for intubation are similar to adults.
Criteria for Intubation/Ventilation
Respiratory inadequacy
Glasgow Coma Scale (GCS) <8
Suspected raised intracranial pressure (ICP)
Need for prolonged ventilation
Need for transport to tertiary centre
Orotracheal intubation with manual in-line immobilization after rapid sequence induction should be used to secure the airway in blunt trauma with an uncleared C-spine. The circulatory state and the conscious level must be taken into account when choosing the induction agents and their dose. The goal of drug usage is to produce unconsciousness, improve intubating conditions, and blunt haemodynamic responses in children with head injury and possible raised ICP. Suitable induction agents include thiopental 2–5 mg kg, etomidate 0.3 mg kg, or ketamine 1–2 mg kg combined with fentanyl 0.5–1.0 µg kg.
In cases of circulatory inadequacy, the dose of thiopental should be reduced. Succinylcholine is widely used in children and is not contraindicated in the initial resuscitation phase, unless there has been a major crush injury. Once successful intubation has been performed, a naso/orogastric tube should be passed to prevent gastric dilation which can seriously compromise oxygenation and ventilation in the child. It is important to provide ongoing sedation, analgesia, and muscle relaxation to prevent coughing on the tube and alterations in ICP in children with significant head injury.
Breathing
Breathing and ventilation need to be rapidly assessed. Children have greater oxygen consumption, smaller functional residual volume, and increased chest wall compliance, predisposing to airway collapse and hypoxia. The diaphragm is both easily fatigued and easily displaced. Urgent intervention may be needed to treat tension pneumothorax, open pneumothorax, haemothorax, or flail chest.
Circulation
Circulation should be assessed by evaluating heart rate, capillary refill time, skin colour, arterial pressure (AP), and mental status. Particular attention should be paid to peripheral perfusion. Children compensate well after major haemorrhage as vasculature readily constricts and increases systemic vascular resistance to maintain perfusion pressure.
AP is well maintained until hypovolaemia is quite severe, >25–40% of blood volume loss. Hypotension in a child is a sign of decompensated shock and may be abruptly followed by bradycardia. Tachycardia is a more useful sign of hypovolaemia, but may also reflect pain and fear. In small children, i.v. access is often easier in the hands and feet than in the antecubital fossae. If no i.v. access is achieved within 90 s in a severely injured child <6 yr of age, intraosseous access is appropriate. Initial fluid resuscitation should consist of warm isotonic crystalloid solution (Ringer's lactate or isotonic saline) and should be administered in 20 ml kg boluses guided by heart rate, peripheral perfusion, AP, and mental status. If failure to improve with >40 ml kg of crystalloid, then blood 10 ml kg boluses should be given followed by frequent reassessments. In the face of ongoing haemorrhage, fresh frozen plasma and platelets will be required.
The trend in adult trauma resuscitation is to give smaller boluses of fluid 10 ml kg followed by reassessment and further 10 ml kg boluses as required. A recent Cochrane systematic review concluded that there is no evidence from randomized clinical trials for or against early or larger volumes of fluids in uncontrolled haemorrhage. Fluid loading may be harmful in the face of uncontrolled haemorrhage particularly after penetrating trauma. It can exacerbate bleeding and contribute to coagulopathy and hypothermia. Permissive hypotension (systolic AP=80 mm Hg) may be appropriate in this situation, providing that it is combined with immediate surgical intervention to control the bleeding. In children without a TBI, a systolic AP of 80 mm Hg is more than adequate to maintain organ perfusion. 'Best' fluid remains controversial in the initial treatment of the bleeding trauma patient. Both crystalloids and colloids are effective in correcting hypovolaemia. Large volumes of normal saline can lead to hyperchloraemic acidosis (Table 1).
Disability
The assessment of disability during the primary survey consists of a brief neurological examination to determine conscious level, and assessment of pupil size and reactivity. Conscious level is rapidly assessed using the AVPU score:
A: Alert
V: Responds to voice
P: Responds to pain
U: Unresponsive
The aim of the neurological assessment is to identify severe head injury which may require urgent neurosurgical intervention and neuroprotective intensive care strategies. Analgesia should be considered at this stage if not already given before intubation. Morphine is the drug of choice and should be given in a dose of 0.1–0.2 mg kg.
Investigations
X-rays: CXR, pelvis, C-spine.
Investigations: ABG, FBC, cross-match, glucose, U&Es. Urinary catheter if required.
Detailed History of Accident and Medical History
Allergies
Medications
Past medical history
Last oral intake
Environment in which the injury occurred
Source...