Course Pediatric Trauma

Assessment of pediatric trauma includes an ABCDE approach adapted to pediatric characteristics. This approach encompasses the identification and treatment of pediatric trauma, such as traumatic brain injury, respiratory and thoracic trauma, and blunt abdominal trauma (Box 4).

Primary Survey

The primary survey is the initial evaluation of the patient, where life-threatening problems are identified and treated. It is designed to assess each of the following items in a given order (Nichols et al, 1996):

A Airway maintenance

B Breathing and ventilation

C Circulation with hemorrhage control

D Disability: neurologic status

E Exposure/environment

Airway

The goals of airway management are recognition and relief of obstruction, prevention of gastric content aspiration, and promotion of adequate gas exchange. In managing a trauma patient's airway it is important to take potential cervical spine injuries into consideration. Maintain midline positioning and perform a jaw thrust maneuver to open the airway and protect the cervical spine. In these cases, tilting the head or lifting the chin is contraindicated. Cervical spine immobilization should include a hard cervical collar.

Airway assessment determines whether the airway is stable. If necessary, perform airway maneuvers such as jaw thrust maneuvers and nasal or oral suctioning to keep the airway open. Despite these maneuvers, it may be impossible to maintain the airway. In this case, placing an ETT with rapid sequence intubation to secure the airway would be the first option, followed by a cricothyrotomy as last resort (Box 5).

Breathing

During the primary survey, once the airway has been assessed and kept open, assessment of breathing follows for the evaluation of oxygenation and ventilation (thoracic movements, air influx, proportion of oxygen in inspired air, skin color). Some patients, such as those with pulmonary contusions, will need positive pressure ventilation. This can initially be provided using BVM ventilation until a definitive airway is obtained. New standards for assessing ventilation include the use of CO2 monitors. Finally, inspect the chest wall looking for signs of pneumothorax or evidence of other chest wall trauma.

Circulation

After airway and breathing assessment and stabilization have been completed, the next step is the assessment of circulation. Adequate circulation can be determined by assessing the pulse strength and rate both centrally and peripherally. Capillary refill, although potentially affected by environmental factors such as temperature, can also help to determine peripheral perfusion. Measure blood pressure, keeping in mind that in children compromised circulation may occur despite a normal blood pressure. Hypotension in children will not be evident until 25% to 30% of blood volume is lost.

Tachycardia is an early marker of hypovolemia in children. It represents a compensatory mechanism to blood loss and is more marked in children than in adults. Once hypotension occurs, the child is in very serious condition.

Use direct pressure on wounds to control for external hemorrhage. This includes assessing the back of the patient, as scalp injuries can be associated with significant bleeding. In general, use thin compression dressings rather than bulky dressings, so that adequate pressure to the bleeding site can be delivered. Intravenous fluid resuscitation with isotonic fluid such as lactated Ringer’s solution or normal saline should begin immediately. If blood loss has been substantial, anticipate the need for blood products such as O negative packed red blood cells, fresh frozen plasma, etc, and begin type and cross of patient and potential donors. If IV access can not be obtained, insert an intraosseous line for fluid administration.

State of Consciousness

State of consciousness is evaluated through a quick neurologic assessment. Assess whether the child is alert, responsive to verbal or painful stimuli, or unresponsive (AVPN). In addition, assess the pupils for size, equality, and response to light. A quick motor exam can determine if all four extremities show motor activity. A detailed neurologic exam can wait until the secondary survey. Some medical facilities will assign the child a score at this point using the adult/child and infant versions of the Glasgow Coma Scale (GCS) (Box 6, Tables 1 and 2). A score of 8 or lower indicates a significant neurologic disability and the risk of respiratory compromise. If your patient has a low GCS score, consider endotracheal intubation, but keep in mind the risks of tube dislodgement in transport and the resources to maintain ventilation.

Adapted from: American College of Surgeons, Advanced Trauma Life Support: Course for Physicians, 1993.

Exposure/Environment

Removing clothing allows for a complete exposure and evaluation for other injuries. 

Among the concerns related to environment is proper body temperature regulation. It is important to bear in mind that infants can rapidly become hypothermic, due to their large surface area-to-volume ratio. This is particularly true if the child is wet. Hypothermia alone has been shown to be an independent risk factor for mortality following major trauma (Gentilello et al, 1997). Effectiveness of rewarming has been studied; only patients treated with hot packs had an increase in body temperature, compared to passive rewarming with blankets and warmed IV fluids (Watts et al, 1999).