Abstract
This chapter, provides an overview of the care and evaluation of pediatric trauma patients. The author presents the classification and evaluation of the trauma patient through the primary and secondary surveys. The anesthetic management and consideration from airway to vascular access are discussed.
You are called to assist in the evaluation and care of a seven-year-old boy who will be arriving to your emergency department following a head-on motor vehicle collision. The child was an unrestrained passenger in the backseat of an automobile. The first responders report positive loss of consciousness at the scene, with two failed attempts at intubation. There is adequate bag-mask ventilation. There is no additional medical or surgical history available, as the child’s parents were injured in the accident and taken to the nearest adult trauma center.
His current vital signs are: blood pressure 75/32 mmHg; heart rate 140/min; temperature 35.2ºC; SpO2 92% with bag-mask ventilation.
What Are the Demographics of Pediatric Trauma?
According to the Centers for Disease Control and Prevention, unintentional injury, suicide, and homicide comprise the top three causes of morbidity and mortality in children between the ages of 1–14 years. Unintentional injuries are the leading cause of childhood death, with motor vehicle collisions reported as the most common, followed by drowning, fires/burns, and accidental suffocation. Traumatic brain injury and thoracic trauma are the leading causes of death due to motor vehicle collisions in children.
Accidental suffocation is the leading cause of injury-related death in children under one year, while the overall leading cause of death in children under one year is secondary to congenital anomalies.
How Is Pediatric Trauma Care Organized?
In the United States, adult and pediatric trauma centers undergo a state and local designation as well as the American College of Surgeons (ACS) verification process. The ACS designates standardized criteria for hospital entities to ensure uniform resource capability. Pediatric trauma patients are typically routed to level I or level II trauma centers. A level I facility has the means to sustain the adult and/or pediatric patient, encompassing all aspects of injury-related care including but not limited to the vast emergency, perioperative, operative, intensive care, and rehabilitation settings. Both Level I and Level II pediatric centers require the presence of trauma and subspecialty surgeons, emergency medicine, radiology, anesthesiology, and critical care personnel (24-h in-house for level I and 24-h immediately available for level II).
What Is the Initial Evaluation and Classification of the Pediatric Trauma Patient?
Evaluating the pediatric trauma patient involves a stepwise continuum of information processing including the prehospital encounter, primary survey, resuscitation, secondary survey, resuscitation, re-evaluation, and anticipatory care. The Advanced Trauma Life Support guidelines recommend a primary and secondary survey be performed on all trauma patients.
What Are the Elements of the Primary Survey?
The primary survey is a systematic approach used to identify and treat life-threatening injuries. This evaluation often includes multiple medical personnel simultaneously assessing the trauma patient. The mnemonic ABCDE can be used to guide the primary survey.
A. Airway. The airway is evaluated for patency, obstruction, and secretions. In the pediatric population, careful inspection should be given to oral and facial anomalies that may alert the provider to the potential difficult airway associated with an underlying syndrome. Providers should quickly determine the patient’s level of consciousness and the ability to talk and/or protect the airway. Jaw-thrust, chin-lift, and airway adjuncts may assist in eliminating obstruction. Endotracheal intubation should be performed in those who cannot protect their airway. It is important to maintain cervical spine instability precautions with any head and neck manipulations during this assessment.
B. Breathing. Visual inspection of the oropharynx, neck, and chest for injuries and deviations, followed by an assessment of respiratory quality, auscultation, and palpation of the thorax should be accompanied with intervention if appropriate.
C. Circulation. During acute blood loss, children can compensate their blood pressure for a longer period of time when compared to adults. Tachycardia is often manifested as an initial sign of poor perfusion. Assessment of adequate perfusion in the pediatric patient should include palpation of the brachial and femoral pulses, capillary refill, and turgor. Two large bore intravenous catheters should be placed in the upper extremities if possible, to maintain resuscitation should the inferior vena cava be compromised. If intravenous access is difficult, pending no contraindications, intraosseous lines can also be placed. In children, hypotension becomes apparent when ~25% of the patients’ blood volume is depleted. If there is evidence of poor perfusion, resuscitation with 20–30 mL/kg of a balanced salt solution should be administered. If obvious hemorrhage is occurring, direct pressure should be applied, and type O negative blood can be administered.
D. Disability. Assessment of the patients’ neurological status includes the Glasgow coma scale (GCS) (Table 17.1). The pediatric modified GCS can be used in infants and nonverbal children. A GCS score ≤8 signals severe brain injury and endotracheal intubation with in-line stabilization is highly recommended. A GCS of 9–12 is classified as moderate, and a GCS ≥13 is considered minor brain injury. The next course of action in the management of a patient with a GCS in the mild to moderate range will depend on the nature of overall injury and the stability of their current clinical status.
E. Exposure. Removal of all patient clothing and accessories followed by careful inspection for further injury. During this evaluation, it is imperative to maintain patient normothermia.
| Adult and verbal children | Infants and nonverbal children | Score | |
|---|---|---|---|
| Eye opening | Spontaneous To speech To pain None | Spontaneous To speech To pain None | 4 3 2 1 |
| Verbal | Appropriate speech Confused speech Inappropriate words Incomprehensible words None | Coos, babbles Irritable, cries but consolable Cries, inconsolable Moans to pain, grunts None | 5 4 3 2 1 |
| Motor | Follows commands Localizes pain Withdraws to pain Decorticate posture to pain Decerebrate posture to pain None | Spontaneous movement Withdraws to touch Withdraws to pain Decorticate posture to pain Decerebrate posture to pain None | 6 5 4 3 2 1 |
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