Trauma Pediatric - part 2 pot

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54 Sherman HF, Landry VL, Jones LM Should level I trauma centers be rated NC-17?

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63 Teach SJ, Antosia RE, Lund DP, et al Prehospital fluid therapy in pediatric traumapatients Pediatr Emerg Care 1995; 11:5–8

64 Herzenberg JE, Hensinger RN, Dedrick DK, et al Emergency transport and ing of young children who have an injury of the cervical spine J Bone Joint Surg 1989;71-A:15–22

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68 Jaffe DM, Binns H, Radkowski MA, et al Developing a clinical algorithm for earlymanagement of cervical spine injury in child trauma victims Ann Emerg Med 1987;16:270–276

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70 Hoffman JR, Mower WR, Wolfson AB, et al Validity of a set of clinical criteria to ruleout injury to the cervical spine in patients with blunt trauma N Engl J Med 2000;343:94–99

71 Viccellio P, Simon H, Pressman BD, et al A prospective multicenter study of cervicalspine injury in children Pediatrics 2001; 108:e20

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74 Tepas JJ, Mollitt DL, Talbert JL, et al The pediatric trauma score as a predictor ofinjury severity in the injured child J Pediatr Surg 1987; 22:14–18

75 Kaufmann CR, Maier RM, Rivara FP, et al Evaluation of the pediatric trauma score.JAMA 1990; 263:69–72

76 Jubelirer RA, Agarwal NN, Beyer FC, et al Pediatric trauma triage: review of 1,307cases J Trauma 1990; 30:1544–1547

77 Phillips S, Rond PC, Kelly SM, et al The need for pediatric-specific triagecriteria: results from the Florida Trauma Triage Study Pediatr Emerg Care 1996; 12:394–399.

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86 National Highway Traffic Safety Administration National Standard Curriculum forEmergency Medical Technician-Paramedics Washington: National Highway TrafficSafety Administration, 1998

87 National Highway Traffic Safety Administration EMS Education Agenda for theFuture Washington: National Highway Traffic Safety Administration, 2001

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of Surgeons, McSwain NE, Frame S, Salomone JP, eds PHTLS: Basic and AdvancedPrehospital Trauma Life Support, 5th ed St Louis: Mosby, 2003

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92 Kanter RK, Boeing NM, Hannan WP, et al Excess morbidity associated with pital transport Pediatrics 1992; 90:893–898

interhos-93 Edge WE, Kanter RK, Weigle CGM, et al Reduction of morbidity in interhospitaltransport by specialized pediatric staff Crit Care Med 1994; 22:1186–1191

94 Smith DF, Hackel A Selection criteria for pediatric critical care transport teams CritCare Med 1983; 11:10–12

95 MacNab AJ Optimal escort for interhospital transport of pediatric emergencies

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ambu-101 National Highway Traffic Safety Administration/Emergency Medical Services forChildren/Health Resources and Services Administration Do’s and Don’ts of Trans-porting Children in an Ambulance: Fact Sheet Washington: National Highway TrafficSafety Administration/Emergency Medical Services for Children/Health Resources andServices Administration, 1999

Organizing the Hospital for Pediatric

Trauma Care

Max L Ramenofsky

Geisinger Medical Center, Danville, Pennsylvania, U.S.A

HISTORY OF TRAUMA CENTERS

The development of trauma centers in the United States has a varied background,which takes its origins from many of the wars this country has fought Many aspects,which are now considered to be integral parts of any trauma center, originated onthe battlefield Aspects such as immediate availability of surgeons who can provideimmediate surgical care to trauma victims, facilities capable of providing anyindicated treatment (Mobile Army Surgical Hospital units), pre-hospital personnel

to identify and stabilize the victim in the field and transport the patient to an gency room capable of providing the indicated therapy, transport systems such asground ambulances and helicopters to transport the victims, just to mention afew All of these components originated in the U.S military

emer-The civilian trauma system originated in the State of Illinois in 1967 withthe inception of the first ‘‘adult’’ trauma center at Cook County Hospital underthe leadership of Drs Robert Freeark and Robert Baker Shortly after this,

Dr R Adams Cowley initiated the ‘‘Shock Trauma’’ Unit (Maryland Institure forEmergency Medical Services System) at the University of Maryland in Baltimore.Following closely on the heels of the first two ‘‘adult’’ trauma centers, the U.S.Congress passed a number of ‘‘emergency medical services systems acts,’’ whichdefined many aspects of the things needed by a trauma system in the prehospitalarena These included the makeup of ambulances (equipment), the necessity for com-munications systems, which would allow pre-hospital personnel to speakwith either an individual distant from or in a trauma receiving facility, and the train-ing necessary for personnel in an ambulance unit, i.e., emergency medical technicians(EMTs), paramedics, etc It is an interesting sidelight to note that prior to thepassage of the various emergency medical services systems acts, many ambulancedrivers were, in fact, funeral home directors

33

PEDIATRIC TRAUMA CENTERS

It is of interest to note that in 1962 the first Pediatric Trauma Center was established

by Dr Peter Kottmeier at the Kings County Hospital, in Brooklyn, New York, fiveyears before the first adult trauma center opened its doors

Trauma care was further advanced in the United States by the AmericanCollege of Surgeons (ACS), which in the early 1920s started the Committee on Trauma(COT) The purpose of the COT was to improve the care of the trauma victim byeducation In February of 1984, the COT developed the first resources or standardsmanual, which defined the standards of care necessary to treat trauma patients (1).These standards were primarily focused on the hospital resources necessary for thistask Not including the 1984 pamphlet, there have been four editions of this manual,the most current being entitled, Resources for the Optimum Care of the Injured Patient(2–5) The next edition is tentatively scheduled for publication in 2005

The ACS COT established the Verification Subcommittee in February of

1987 This subcommittee’s purpose was to verify compliance by hospitals wishing

to become ACS-verified trauma centers, with the standards of care promulgated bythe resources manual

The first document describing the resources necessary to treat the injured childwas published in the Journal of Trauma in 1982 (6) The COT first included anappendix on Pediatric Trauma Care in their original 1984 pamphlet, Appendix J(1) The first pediatric chapter in the ACS resource manual appeared in the 1987edition (3)

The COT has defined what is meant by the term ‘‘pediatric trauma center’’ bydividing trauma centers into levels The highest level is a Level-I Pediatric TraumaCenter located in a children’s hospital A similar designation and quality of caremay be present in a Level-I Adult Trauma Center with pediatric expertise Children’shospitals can also apply to become a Level-II Pediatric Trauma Center By ACSstandards, all trauma centers, regardless of their designation level, must have theability to stabilize and transfer injured children when received in their institution

PREPLANNING

Before the first patient is seen and treated in any institution that desires to become atrauma center or have a trauma unit, there is a great deal of organization that must beaccomplished The decision to apply for such a designation is the first priority Thisdecision is not one that can be made by a single individual or department The deci-sion is one that must be embraced by the entire institution for the simple reason thattrauma, by its very nature, is extremely disruptive to any hospital’s schedule Trauma

is a disease that can and does occur at any and all times The orderly carrying out of abusy operating room schedule can be disrupted because of the necessity of bringing aninjured patient to the operating room at any time Other resources such as laboratoryand radiology are similarly disrupted due to the need for immediate results from thelaboratory as well as immediate access to a computerized tomography scanner, mag-netic resonance imaging, and/or interventional radiological procedures The require-ment for a designated and immediately available trauma team is similarly disruptive.Thus, it should be apparent that the decision to seek designation as a trauma center isone that requires agreement of many, if not all, departments within a busy hospital.The hospital’s administration must agree and support this decision

The single most important component for any institution seeking a trauma tion is commitment Commitment to provide the personnel, equipment, space, andall other resources necessary for treatment of the injured patient, 24 hours a day,seven days a week

designa-Facilities

The injured patient generally enters an institution through its emergency department(ED) Often the ED is very busy and crowded An injured patient should not beexpected to wait until a room opens before being seen Thus a ‘‘trauma room’’ orresuscitation bay must always be available This is an expense for the institution,but assessment and resuscitation must be available without delay

The makeup of such a room should include appropriate IV fluids, catheters, gical instrument sets, warming equipment, including a method to rapidly warm theentire room, medications and enough space for an entire team of physicians, nurses,and technicians to have easy access to the patient Often a hospital that constructs anew trauma room will include a ceiling-mounted X-ray unit in the room If not, theremust be sufficient space for a portable X-ray machine to be wheeled into the space.For any institution that treats injured children, the Broselow System is areasonable method of organizing the trauma room This system provides color-coded equipment such as airways, laryngoscopes, endotracheal tubes, suction cathe-ters, vascular access devices, nasogastric (NG) tubes, urinary catheters, and chesttubes The color-coding is based on the child’s weight In addition, the Broselow tape

sur-is a clever method of rapidly determining the child’s weight based on height and can

be used in the trauma room for quick determination of weight, IV-fluid bolus sion amounts, and emergency medications The Broselow tape can be mounted in aLucite holder and kept permanently in the room When so mounted it measuresroughly five feet in length and does not have a tendency to be lost

infu-The facilities necessary for an institution to become a trauma center are notlimited to the emergency room The institution must have immediate availability

to CT scanning, angiography, interventional radiology, operating rooms, intensivecare units, and patient floors Another requirement is the availability of rehabilita-tion medicine

Radiology

In addition to routine radiographic procedures such as chest, abdominal, extremity,and spine X rays, the institution must provide immediate access to CT scanning forthe injured child The CT scan is the major diagnostic modality utilized in both chil-dren and adults, and must always be available to the trauma patient

Operating Room

An operating room must always be available for the trauma patient In a busyhospital this is difficult because this requirement decreases by one the number ofrooms available for routine elective surgery In addition to having an ORimmediately available, personnel, including nurses, technicians, and anesthesiolo-gists, must be immediately available 24/7

Pediatric Intensive Care

Intensive care must be available for the injured child, preferably in a pediatric sive care unit (PICU) with appropriately trained and trauma credentialed nurses.Should a PICU not be present, an intensive care unit may meet this requirement withappropriately trained and credentialed pediatric nurses The equipment necessary forPICU care is well documented in the ACS resources manual

of players

Physicians

The group of physicians immediately responsible for the care of an injured child ismade up of the surgical specialties Pediatric general surgery includes within its train-ing the care of the injured child The pediatric surgical team must include a leader ofthat team whose responsibility it is to organize the team In the ED, this trauma team

is expected to meet the patient on arrival Once the patient has been placed in theresuscitation room, the team begins its work Hopefully, the ED has been notified

by the pre-hospital personnel of the cause of the injury, e.g., motor vehicle crash,gunshot wound, stab wound, fall, and is prepared to start the resuscitation phase.Occurring simultaneously with the resuscitation phase is the diagnostic phase How-ever, the team should be trained to the important fact that the diagnosis is lessimportant than saving the life of the injured child Thus, the team should be awarethat the lack of a diagnosis should never impede the application of an indicatedtreatment For example, if the patient cannot maintain their airway, the airwayshould be secured before the diagnosis of the cause of the unstable airway is deter-mined To reverse the process, and first determine the cause of the unstable airwaybefore treating, may result in the death of the patient

The composition of the team, in addition to the leader, is generally two othersurgeons, an anesthesiologist or emergency medicine physician, and at least twonurses, one of who acts as the scribe

Absolute responsibility for the patient rests with the team leader The teamleader will have assigned specific duties to other members of the team For example,the leader may assign the physician at the head of the patient and either theanesthesiologist or emergency medicine physician to manage the airway The sur-geon on the patient’s right side may be assigned the responsibility of evaluatingthe neck, chest, right-sided extremities, and the patient’s back The surgeon on theleft side may be assigned the duties of evaluating the abdomen and perineum,

left-sided extremities, and neurological status Such a setup provides for rapid andaccurate initial assessment of the injured patient.

Other physicians will be part of the trauma team but not necessarily part of thephysician group who initially responds upon the patient’s arrival Clearly, OrthopedicSurgery and Neurosurgery must be included in this group Also, Plastic Surgery, EarNose Throat, Urology, and Ophthalmology will be required in specific cases Theseindividuals must be available on short notice at the behest of the trauma team leader.Nonsurgical physicians are also included in the requirements Pediatric emer-gency medicine and pediatric intensive care physicians are included in this group,

as are radiologists Others whose expertise may be required include enterologists, cardiologists, neurologists, infectious disease specialists, and generalpediatricians

gastro-Nurses

The nurses in the resuscitation room have established duties One will serve the tion of the scribe and will record everything that occurs with the patient The secondnurse prepares the room before the patient arrives, and makes sure that appropriatefluids, chest tubes and chest evacuation apparatus, IV fluids, urinary cathe-ters, suture material, surgical trays, etc., are available and in the room It is also thisnurse’s responsibility to make sure that the room temperature is adequate so thathypothermia does not supervene

func-Intensive care nurses with education, training and/or experience, and expertise

in pediatrics are required in the PICU setting Methods of training are discussed later

in this chapter

Laboratory and Radiological Technicians

These technicians are an integral part of the trauma team meeting the patient in the ED.Most trauma centers have a routine laboratory panel that is ordered on every patient.Technicians being present at the time the patient arrives shortens the length of timethe team must wait for various laboratory results As with laboratory studies, mostinjured patients require, at a minimum, a specific group of X rays, including lateral cer-vical spine, chest, and abdominal films The presence of the X-ray technician with theX-ray machine shortens waiting time When more sophisticated studies are warranted,such as CT scans or angiography, the technicians are helpful in organizing them

Social Work

The stress on a family resulting from a serious injury or death of a child is significant.The presence of social services in the ED, should either occur, is comforting for thefamily and can function as a bridge for information when the trauma surgeons arebusy providing the necessary care

the injured Clearly, pediatric surgical training has a trauma component as mandated

by the Residency Review Committee for Surgery Most other surgical specialtieshave a similar requirement

The ACS Advanced Trauma Life SupportÕ (ATLS) Course for Physicians is,

in many states, a requirement to participate in the care of injured children or injuredpatients in general (7) This course is a scaffold by which an injured child, or anyinjured patient, can be thoroughly evaluated and life-threatening injuries identifiedand treated This requirement for ATLS has never been mandated by the ACSbut has been mandated by many government agencies responsible for the individualstates’ emergency medical services (EMS) or trauma laws

Nurses caring for the trauma patient are often required to have experienceand/or training in trauma nursing There are a number of courses offered by variousorganizations for trauma nursing Advanced Trauma Care Nursing (ATCN) is thecourse provided by the Society of Trauma Nurses, and Trauma Nurse Care Course(TNCC) is provided by the Emergency Nursing Association As with physicians,nurses are required to have one of these courses in order to care for injured patients.EMTs and paramedics often provide pre-hospital trauma care The Pre-hospitalTrauma Life Support (PHTLS) course is a pre-hospital course provided by theNational Association of EMTs This particular course parallels the ATLS courseand provides physicians and pre-hospital personnel a common language by whichcare of the trauma patient can be expedited

The trauma center must take on the responsibility of educating its own nel, surrounding institutions’ personnel, the pre-hospital system, and the generalpopulace General education for the public can take the form of trauma or injuryprevention lectures, posters, and public service announcements

person-SEVERITY PREDICTORS AND THE TIERED RESPONSE

An essential element in organizing the hospital is to plan for what will actuallyhappen when a trauma patient arrives How is the commitment of the hospitaland its staff put into action? There are two key components to this The first is todefine the patient at risk and to determine what resources are required in individualcases The second is to define the relative roles and responsibilities of the members ofthe hospital staff in the care of trauma patients

For these purposes most trauma centers divide their patients into three maingroups (Table 1):

 Category 1—Patients with isolated, single-system injuries caused by energy mechanisms This group is by far the largest They have simple frac-tures, soft tissue injuries, etc They usually arrive by private conveyance.Rarely, these patients have significant occult injuries such as a spleniclaceration or an epidural hematoma The ED staff can assess them and seekconsultation when appropriate They do not require a trauma teamresponse

low- Category 2: Mechanism—Patients at increased risk for multisystem or threatening injuries without significant anatomic or physiologic derange-ment This group is defined mainly by mechanism of injury such as a fallfrom a great height or involvement in a high-energy motor vehicle collisionwith ejection, serious injuries or death of another occupant, rollover, or

significant intrusion into the passenger compartment These patientstypically arrive by ambulance Although most do not have life- or limb-threatening injuries, many do These patients demand careful assessment

by trained and experienced trauma staff

 Category 3: Physiologic derangement—Patients with obvious anatomic orphysiologic derangement such as an amputation; penetrating injury tothe head, neck, or trunk; coma; or shock These patients also typicallyarrive by ambulance These patients demand immediate careful assessment

by the most highly trained and experienced trauma staff

The exact details of the field triage criteria should be worked out locally.Engum et al have shown that a system of field triage based on anatomic andphysiologic variables plus mechanism of injury provides a ‘‘sensitive and safe system

of triage’’ (8) In Engum’s study, standard scoring systems such as the RevisedTrauma Score and the Pediatric Trauma Score had unacceptably low sensitivities,missing approximately one-third and one-half of ‘‘major’’ trauma cases, respectively

A system for activating the receiving hospital staff is also necessary Traumaresponses should be tailored to the expected needs of the individual patient and based

on objective information, either from the field or referring hospital, which places thepatient into one of the three categories described above The first category of patientswith low-energy, single-system injuries can be handled by the ED staff on duty withreferral to appropriate surgical services as required The second and third groupswith high-risk mechanisms or overt evidence of life-threatening injury both requiretrauma team activation and full assessment according to protocol A trained andexperienced trauma surgeon should direct the team, but the team should include otherphysicians, nurses, a respiratory therapist, a radiology technologist, a laboratory tech-nician, a pharmacist, a social worker, and a chaplain The roles of each member of theteam vary depending on local circumstances, but they must be clearly defined

Table 1 Criteria for Triaging Pediatric Trauma Patients

Category 1

Category 2:

Mechanism

Category 3: Physiologicderangement

Multiple injuries (3 systems)

Rollover Penetrating injury to head, neck,

chest, or abdomenProlonged extrication Paralysis post injury—spinal cord

injuryMajor extremity amputation

Many hospitals have revised or modified their team response for the secondcategory of patients that meet mechanism-only criteria to avoid inefficient use ofstaff time and resources, what might be called ‘‘false alarms.’’ Dowd et al haveshown that patients who meet mechanism-only criteria are less likely to require aresuscitative intervention than those who meet anatomic and physiologic criteria,and therefore do not require full trauma team activation (9) They concluded thatuse of anatomic and physiologic criteria only for the highest level of trauma teamactivation results in increased specificity without sacrificing sensitivity.

EMERGENCY MEDICAL SERVICES

No trauma center or institution can exist without emergency medical services (EMS)

By and large EMS is responsible for all pre-hospital care, including transportation tothe trauma center Pre-hospital personnel generally work under the medical license

of a physician who is charged with providing pre-hospital care guidelines The sician is often online with the in-field ambulance personnel, receiving data and pro-viding instructions to the emergency medical technicians in the field Other systemswork by off-line medical control where there are specific protocols developed before-hand EMS will generally transport a patient to a specific hospital or, in the case ofinjured child, to a pediatric trauma center There must be telephone or radio com-munication with the receiving institution so that the trauma team can meet thepatient in the ED on arrival

phy-There must also be a method for the ED to communicate with the trauma team

to alert them as to the mechanism of injury and types of injuries suffered by thevictim This can be accomplished in a variety of ways Walkie-talkies are used insome systems, as are beepers Most commonly today, cellular telephone communica-tion is the method of choice The various communication devices are, of course, anexpense for the hospital

For any trauma center to succeed in its mission of providing appropriate andrapid care to an injured patient, the institution must be on good terms with the EMSsystem The trauma center must always be aware of the fact that pre-hospital person-nel work in the most difficult and primitive emergency room of all, the field Theinstitution must provide appropriate feedback to these pre-hospital personnel so thatthe education of these individuals is steadily increased This is often accomplished byrun reviews, case studies, and lectures on specific topics

When ‘‘errors’’ are identified, alternatives should be suggested to help the hospital personnel improve their performance One common error is spending toomuch time in the field trying to stabilize a patient who would be better served byrapid and temporary stabilization and rapid transport to the trauma center Ambu-lances carry a limited amount of supplies The hospital should provide needed sup-plies to a pre-hospital unit when requested All of these courtesies will be rewarded

pre-by loyalty to the trauma center

SUMMARY

The decision to become a trauma center is one that takes significant commitmentfrom the entire institution Commitment is the single most important aspect inbecoming a trauma center The institution must determine the specific type of

trauma center it wishes to become based on the standards that apply to thatparticular state or region The ACS ‘‘resources’’ document is generally a good place

to start to put together all of the in-hospital systems that need to be in place prior to

a site survey to verify that the institution meets all of the applicable standards Inmost states, there is an entity in either the board of health or fire department thathas responsibility for verification There are necessary equipment, space, personnel,and educational requirements that the institution must meet in order to function as atrauma center It is neither cheap nor easy for an institution to meet the require-ments, but if the hospital has the commitment to become a trauma center, it can

The ABCs of Pediatric Trauma

Robert W Letton

Pediatric Trauma and Burns, Brenner Children’s Hospital, Wake Forest University

School of Medicine, Winston-Salem, North Carolina, U.S.A

INTRODUCTION

Pediatric multiple trauma victims present a unique set of problems to the emergencyphysician, pediatrician, or surgeon Children rarely sustain lethal injury; however,delayed recognition and inappropriate management of the common problems en-countered in the pediatric trauma patient can lead to a poor outcome The ultimatecommon pathway leading to death in the injured child is profound shock: the inade-quate delivery of oxygen to the tissues It is therefore the goal of the initial phase ofresuscitation to rapidly evaluate and treat any immediate life-threatening injuriesthat compromise tissue oxygenation This is known in Advanced Trauma LifeSupportÕ (ATLS) courses as the primary survey or the ABCs of trauma: airway,breathing, and circulation (1) Appropriate management of the ABCs is necessaryfor optimal outcome in pediatric trauma, regardless of whether it is managed in

an adult or pediatric trauma center (2) In fact, with a relatively limited number

of pediatric trauma centers, most improvements in pediatric trauma care are likely

to come from improvements at combined trauma centers (3)

When performing the primary survey of an injured child, one must keep inmind that frequent reassessment is mandatory Children have tremendous physiolo-gic reserve and may rapidly decompensate when their threshold level is crossed Only

by frequent evaluation and assessment can the physician detect and treat the childappropriately prior to decompensation Before a child leaves the trauma room for

a diagnostic procedure, they must have their ABCs assessed and stabilized Thecomputed tomography (CT) scanner is no place to lose an airway or require chesttube placement As the trauma workup proceeds into the secondary survey, any dete-rioration in an otherwise stable trauma patient, whether adult or child, shouldprompt a reassessment of the ABCs

Performance of the primary survey is divided into the three separate stages ofairway, breathing, and circulation only for discussion In practice, it is a dynamicprocess in which the clinician must be aware that all three aspects occur together

in real time The proficient physician managing pediatric or adult trauma must beable to evaluate all three simultaneously, not in sequence, and recognize thatproblems with the airway influence breathing and circulation, and vice versa It isPART II: GENERAL PRINCIPLES OF RESUSCITATION AND SUPPORTIVE CARE

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the goal of this chapter to provide a framework upon which to base the initialmanagement of the ‘‘Golden Hour’’ in pediatric trauma A MEDLINE search wasperformed with a restriction to articles dealing with children (ages 1 to 12) publishedsince 1990 Using the Eastern Association for the Surgery of Trauma guidelines, noclass-I articles could be found Mostly class-III articles and a few class-II articleswere used as a basis for this review Recommendations are based on current ATLSÕ

guidelines, with an attempt to include current evidence-based data as they relate tothe primary survey in children

ANATOMIC AND PHYSIOLOGIC CONSIDERATIONS

Children differ from adults in several specific areas relevant to trauma care Infants andyoung children, in particular, have a relatively large body-surface-area-to-body-cell-mass ratio and are thus prone to developing hypothermia This is particularly true whenexposed for resuscitation or operation or when given large volumes of intravenous fluids

or blood products To prevent hypothermia, it is important to keep injured children ered as much as possible and to have available warm blankets, heat lamps, room tem-perature controls, and fluid warmers in resuscitation areas and operating rooms (OR).The child’s vital signs and circulating blood volume also vary with age.This obviously affects the recognition and treatment of physiologic derangement.Young children have relatively large heads and are more likely to suffer headinjuries, especially with deceleration mechanisms such as falls and motor vehicletrauma Their craniums are also thinner and their brains are less completely myeli-nated, both of which tend to increase the severity of injury Infants with opencranial sutures, larger subarachnoid space and cisterns, and greater extracellular space

cov-in the bracov-in may tolerate expandcov-ing cov-intracranial hematomas and cerebral edema better.The glottis lies in a more superior and anterior position relative to the pharynx.This makes orotracheal intubation much easier than nasotracheal intubation,especially in an emergency In children up to about eight years of age, the airway

is narrowest at the level of the cricoid cartilage This is why uncuffed endotrachealtubes are generally used Because it is narrower foreign material, fluid or blood moreeasily occludes the child’s airway The fact that the trachea is relatively shortincreases the risk of malposition of endotracheal tubes because they are either toohigh or too low in the trachea Tube position must be checked carefully at the time

of intubation and monitored regularly thereafter

In children, the thorax is much more compliant to external forces and the vitalorgans are closer to the surface, both of which tend to increase the risk of blunt injury

to the tracheobronchial tree, the heart, and great vessels The elasticity of pediatricarteries and the normal absence of atherosclerosis offset this risk In children, themediastinum is more mobile so that an increase in pressure from a pneumothorax

or hemothorax on one side is more apt to compromise both lungs In the abdomen,the liver, spleen, and kidneys are less well protected by the ribs in children because theribs are more pliable and because these organs are less well covered by the ribs

AIRWAY

The main reason for ensuring a stable airway is to provide effective oxygenation andventilation while protecting the cervical spine and avoiding increases in intracranial

pressure Airway control is intimately related to cervical spine protection, but thescope of this chapter will be limited to managing the airway only Any child involved

in a significant trauma should be assumed to have a cervical spine injury until provenotherwise Movement of the neck, as is commonly employed to provide an airway,can convert a bony or ligamentous injury into a permanent disability C-spine pro-tection should be initiated at the scene and maintained in the emergency department.Any child that arrives without neck stabilization should be held with in-linetraction or have an appropriate sized rigid cervical collar applied while the airway

is evaluated

Anatomy and Assessment

Several anatomic features predispose the child to potential airway obstruction Thechild’s head is relatively large and causes flexion of the neck in the supine posi-tion The tongue is larger in proportion to the rest of the oral cavity and predisposesthe child to more rapid upper airway obstruction with posterior displacement

of the tongue Even a minimal amount of pressure on the submental soft tissueduring bag-valve-mask ventilation can displace the tongue posteriorly and occludethe airway The larynx is higher in the neck (C3-4) compared with that of the adult(C4-5); this alters the preferred angle of insertion of the laryngoscope blade andmakes the cords appear to be more anterior ‘‘Cocking’’ the laryngoscope, as is com-monly practiced in adult intubation, will only push the cords more anterior andmake intubation difficult The infant epiglottis is short and angled away from thelong axis of the trachea, increasing the difficulty of its control with the laryngoscopeblade Infant vocal cords are more cartilaginous and easily injured when passing theendotracheal tube The narrowest portion of the airway in the child is the subglottis,not the glottis, as in the adult A tube that readily passes the cords in an infant may

be too tight in the subglottis Uncuffed tubes are often used for this reason, and anacceptable air leak should be heard at a pressure that is neither too low to allow ade-quate tidal volumes nor too high The airways are much smaller and the supportingcartilage is less well developed, making the trachea more susceptible to obstructionfrom mucus, blood, or edema In addition, the pediatric trachea is much shorter thanthe adult trachea, and advancing the tube too far into the right main stem bronchus

is common

It can be difficult to recognize early airway obstruction in the child Certainlythe infant who is screaming or crying loudly and the older child who can conversewith you have airways that are not in immediate jeopardy The child who arrivescomatose (Glasgow Coma Score less than 8) or with obvious laryngeal trauma has

an airway that is in immediate danger Often the child is obtunded If spontaneousbreathing is absent, the airway should be opened with a jaw thrust maneuver takingcare to protect the C-spine A finger sweep to rule out a foreign body should beperformed If no breathing effort is seen after this maneuver, hand ventilation with amask should be initiated and preparation made to intubate the child During assistedmask ventilation, the operator must take care not to place undue pressure on the base

of the tongue, as this will occlude the airway It is the metastable pediatric traumapatient that can present difficulties in determining whether an airway is adequate.The patient may appear only slightly agitated, with nasal flaring, stridor, and airhunger The child with an innocent-appearing face and neck burn may have signifi-cant airway edema When in doubt, the following maneuvers should be attempted

to secure the airway

Managing the Airway

Studies investigating field intubation have demonstrated complication rates as high

as 25% (4) Appropriate mask ventilation can provide adequate gas exchange untilone skilled in the task can intubate the child (5) Newer airway techniques, includingthe laryngeal mask airway (LMA), have been shown to be an effective temporaryairway in children until secure endotracheal intubation can be performed in theemergency department (6) The LMA is placed in the posterior pharynx andadvanced until it seals over the vocal cords and larynx Excessive extension of theneck must be avoided in any airway technique Oral and nasal airways do not protectthe airway In fact, their insertion can induce emesis Nasal airways are too small to

be effective in the child An oral or nasal airway is, at best, a temporary technique

to improve bag ventilation in preparation for endotracheal intubation

Oral endotracheal intubation is the ‘‘gold standard’’ for airway control It iscritical to maintain neutral alignment of the cervical spine during all airway manip-ulation Even though nasotracheal intubation in adults requires less spine manipula-tion, in children it is difficult and time-consuming, and therefore has little role in theacutely injured child The size of the nares is often not large enough for an appro-priate-sized tube In addition, the path that the tube has to follow to the cords is at

a very acute angle, requiring direct laryngoscopy and forceps to accomplish Enlargedtonsils and adenoids can bleed if blindly injured with the endotracheal tube

Children less than six years of age should receive an appropriately sizeduncuffed endotracheal tube to minimize trauma to the cords and subglottic edema.Formulas exist for calculating endotracheal tube size (Table 1), but a quick reference

is the size of the middle phalanx of the fifth digit The Broselow tape, which basesdrug doses and weight on the child’s length, also estimates endotracheal tube size(7) Stylets are helpful for pediatric intubation to give the tube a gentle ‘‘J’’ curve.The tip of the stylet should never be extended beyond the end of the tube, and a thincoat of lubricating jelly can aid in removing the stylet without extubating the child

Endotracheal Intubation

The process of intubating a child can be harrowing for those not accustomed to it.Current ATLSÕ recommendations call for a rapid sequence induction of sedation

Table 1 Endotracheal Tube Size in Relation to Age

and paralysis, especially in those with closed head injury and possible elevated cranial pressure (1) Attempts to intubate a partially responsive, coughing, comba-tive child will cause further elevation of the intracranial pressure The use of drugs

intra-in rapid sequence intra-induction must intra-induce unconsciousness and paralysis, as well asblunt the intracranial pressure response (8) Our current choice of drugs for rapidsequence induction is listed in Table 2 Care should be taken if the patient is in shocknot to induce hypotension with too much sedative Paralysis should not be induced

in the spontaneously breathing patient until the physician is capable of visualizingthe cords

Gentle mask ventilation with cricoid pressure should be attempted to oxygenate the child In-line cervical immobilization with the collar opened anteriorlyshould provide adequate exposure Rapid sequence induction is initiated after properequipment is obtained and the child has been pre-oxygenated This should include abag and mask connected to high flow oxygen, suction, a laryngoscope with function-ing bulb, and an endotracheal tube with stylet of appropriate size as well as tubesthat are a half size larger and smaller than the estimated correct size A Miller(straight) blade is most often easiest to use and should be gently inserted intothe oropharynx and the tongue elevated anteriorly to visualize the cords Avoidthe temptation to ‘‘cock’’ the laryngoscope, as this will further displace the cordsanteriorly and increase the likelihood of breaking or loosening an incisor The tubeshould only be inserted a few centimeters past the vocal cords The trachea is shortand intubation of the right main stem bronchus can easily occur The tube should beplaced no deeper than three times the endotracheal tube size, in centimeters, fromthe lips The Broselow tape will also specify a depth of insertion (7) Endotrachealtube position should be confirmed with a disposable capnometer, as well as ausculta-tion of both lung fields and listening over the epigastrium for esophageal intubation.Breath sounds transmit easily in young children and listening in both axillae will givethe best point of auscultation to determine if the breath sounds are equal Symmetry

pre-of chest wall excursion with ventilation should be noted; diminished sounds andmovement of the left side should be treated by withdrawing the tube 0.5–1 cm Ifdiminished sounds persist, a left-sided pneumothorax should be considered Sincethe trachea is so short, movement of 1 cm in either direction can often displace thetube into an inappropriate position Vigilance in securing the tube and constantchecking of its position is mandatory Current ATLSÕ recommendations call forobtaining a chest X ray, as well as lateral C-spine and pelvis films, at the end ofthe primary survey to confirm tube position as well as rule out injury (1)

Table 2 Drugs and Doses Commonly Used for Rapid Sequence Induction

Note: Avoid propofol and ketamine in children with elevated intracranial pressure Sedatives and turates can aggravate hypotension.

Special Airway Situations

Any child with a severe burn to the face and neck should be assumed to have anairway at jeopardy Heat injury to the upper airway results in edema of the pharynx,larynx, and tongue that can rapidly occlude the airway As tissues become moredistorted, intubation can become more difficult Furthermore, children injured in aconfined space can have a compromised airway, even without obvious face and neckburns Inhaled toxic fumes and particles can irritate the airway and cause edema.Prophylactic intubation is appropriate whenever heat injury to the upper airway issuspected, or if transportation to another facility is expected It is much easier toremove a tube that is not needed than to obtain an airway emergently in a swollenburn victim In addition, carbon monoxide poisoning is difficult to detect, as thepulse oximeter will continue to read high saturation Tracheal intubation insures effi-cient delivery of oxygen under these circumstances

In the child with severe face or neck trauma, alternative maneuvers to cheal intubation may be necessary to secure the airway A child with severe facialtrauma that is able to maintain an airway should have a quick primary surveyand all immediate life-threatening injuries addressed The child should then be trans-ported to the operating room where a formal tracheostomy can be performed If thepatient is unable to maintain an airway, a needle cricothyrotomy is preferred to asurgical cricothyrotomy, especially if the child is less than 10 years of age Insertion

endotra-of a 14-gauge needle or angiocath requires less skill and can provide a temporary way until the child can have a formal tracheostomy in the operating room Needlecricothyrotomy provides good oxygenation, although normocarbia can be difficult

air-to maintain and therefore it should be converted air-to a surgical airway as soon aspossible Other alternatives, including fiber optic–assisted intubation and retrogradeintubation or tracheostomies, are institution- and operator-dependent

Laryngeal trauma is rare in children but may need to be addressed with trating trauma or ‘‘clothesline’’ injuries sustained on bicycles and ATVs Endotra-cheal intubation can potentially worsen the injury by causing complete separation

pene-of the trachea from the larynx and total loss pene-of the airway Signs and symptoms

of laryngeal fracture include stridor, subcutaneous emphysema of the neck, mothorax, and hoarseness If the child is able to maintain an airway, oxygen should

pneu-be provided until a surgical airway can pneu-be obtained in the OR Cricotracheal ration is an airway emergency that often requires immediate tracheostomy in theemergency department

sepa-BREATHING

Once an airway is secure, attention must next be directed toward injuries that affectventilation and oxygenation Most of these injuries comprise the immediate life-threatening injuries of the chest Although these will be discussed in detail elsewhere

in this textbook, they must be mentioned now, as an adequate primary survey can’t

be performed without including these injuries in the differential diagnosis tion and oxygenation must occur in an effective manner, and if they are not, correct-able causes should immediately be sought The intubated child with stable bloodpressure and good saturation likely does not have an immediately life-threateningchest injury, but can still have a potentially life-threatening chest injury Theintubated child that decompensates after intubation most likely has a life-threatening

chest injury and must be managed appropriately to preserve a good outcome Themajor life-threatening thoracic injuries include tension pneumothorax, open pneu-mothorax, massive hemothorax, flail chest, and cardiac tamponade Other poten-tially life-threatening injuries to consider are simple pneumothorax, hemothorax,pulmonary contusion, tracheobronchial tree injuries, cardiac contusion, traumaticaortic disruption, aerophagia, and traumatic diaphragmatic injury (Table 3).

Assessment and Monitoring

Assessing adequacy of ventilation and oxygenation in a busy trauma bay can beproblematic The child’s breathing should be observed, looking for symmetry of excur-sion or flail chest segments (rare in children) Auscultation can be difficult in a noisyemergency department, but the best point of auscultation to check for equality ofbreath sounds is in the axilla Pneumothorax will initially result in loss of expiratorybreath sounds, followed by the loss of inspiratory breath sounds To distinguish theloss of breath sounds associated with a hemothorax versus a pneumothorax, percus-sion can be attempted; however, dullness and resonance to percussion can be difficult

to appreciate in a noisy emergency department Fortunately, both are initiallytreated with placement of a chest tube and are easy to distinguish afterwards Ifthe child is stable, a chest X ray can be obtained prior to initiating therapy A decom-pensating child with decreased breath sounds should not wait for an X ray prior todecompression of the hemo/pneumothorax

Any child that has been intubated will require mechanical ventilation In infantsless than one year of age, pressure regulated ventilation is our preferred mode ofventilation in order to minimize iatrogenic barotrauma A peak pressure is chosen suchthat the resulting tidal volume is 7–10 cm3/kg, and a rate of 20 to 40 is chosenand adjusted based on the pCO2on an arterial blood gas If the child has a closed headinjury, the pCO2should be maintained at approximately 30–35 mmHg, otherwise apCO2of 40 mmHg is acceptable In children over one year of age, volume control venti-lation is our preferred method of ventilation However, pulmonary compliance should

be monitored closely, and if it acutely changes secondary to fluid resuscitation, ary contusion, or other causes, pressure control ventilation must be considered to mini-mize barotrauma as much as possible Initial settings in volume control are similar inthat a tidal volume of 7–10 cm3/kg is desired, but the older the child, the lower the ratenecessary to maintain adequate ventilation

pulmon-Most emergency departments are equipped with pulse oximeters, and manyhave capnometers to monitor end tidal CO2 Arterial blood gases are useful butcan be difficult to obtain If perfusion is adequate, arterial oxygen saturation can

Table 3 Potential Life-Threatening Injuries Addressed in Primary Survey

Immediate life-threatening injuries Potential life-threatening injuries

Massive hemothorax Tracheobronchial injury

Diaphragmatic rupture