Review articlePractical points in evaluation and resuscitation of the injured child
Section snippets
Primary survey
The primary survey in the ATLS protocol follows the “ABCDE” sequence with priorities that are the same for children and adults. The goal of treatment is the provision of adequate oxygen to maintain cellular function. The inability to establish and maintain a patient airway leading to hypoxia and inadequate ventilation is the most common cause of cardiorespiratory arrest in a child. Thus, control of the pediatric airway is of paramount importance, requiring an understanding of and familiarity
Intubation
Each trauma center must establish a protocol for emergency intubation referred to as a rapid sequence intubation (RSI). The ATLS manual includes an algorithm for RSI of the pediatric patient. Children should be preoxygenated using a ventilating mask and receive Atropine Sulfate (0.1–0.5 mg) to ensure that the heart rate remains high during intubation. The cardiac output of a child is rate dependent since small infants have a limited ability to increase stroke volume. The child thereafter should
Resuscitation phase
As the ABC's are finished, adjuncts to the primary survey and resuscitation must be initiated. These include electrocardiographic monitoring and placement of urinary and gastric catheters. The patient must be quickly assessed for mid-face fractures involving the nares and cribriform plate prior to placing a nasogastric tube. If there are any questions, gastric decompression can be accomplished using an oral gastric tube. Similarly, the perineum must be assessed prior to placement of a Foley
Secondary assessment
After completion of the primary survey and the resuscitation phase, the physician performs a secondary survey. Reevaluation of the initial resuscitation (ABC's) is an integral part of the ongoing resuscitation.
Neuroresuscitation
- 1.
Maintain adequate systemic oxygen delivery by keeping mean arterial oxygen tension >80 mm Hg, oxygen saturation >95%, and systolic arterial pressure >80 mm Hg. Restore circulating blood volume immediately to avoid hypotension, the most critical, single component of secondary brain injury.
- 2.
Utilize early controlled endotracheal intubation in children with a GCS <8 to keep the PCO2 regulated with moderate hyperventilation 30–35 mm Hg.
- 3.
Osmotic diuresis with mannitol (0.25 g/kg) will reduce ICP within
Abdomen
Penetrating abdominal injuries remain uncommon even in urban environments and generally involve injuries to the hollow viscera, primarily the small intestine. Blunt abdominal injuries predominate in 90% of children with abdominal injuries with injuries mainly to intraabdominal solid organs, generally the liver and spleen. Injury severity is low with a trauma score less than 12 and injury severity score more than 15 in less than 20% of injured children. Overall mortality is also relatively low
Extremities
The goal of initial assessment and management of extremity injuries during the secondary survey is to identify injuries that pose a threat to life (major pelvic disruption with hemorrhage, arterial injuries with hemorrhage, and crush syndrome) and limb (open fractures and joint injuries, vascular injuries, compartment syndrome, and peripheral nerve injury). Many orthopedic injuries in children are subtle and difficult to diagnose. Often the parents will notice the changes in the child's
Agonal protocols
Knowing when to resuscitate an injured child is difficult but can be learned from a variety of available resources; knowing when not to resuscitate an injured child is far more difficult, and there are very few resources available. Non-resuscitation protocols for adult trauma patients are well documented [108], [109], [110]. Adult trauma patients are declared dead on arrival (DOA) on admission to the ED if established parameters are met. For blunt trauma, pre-hospital cardiopulmonary
Summary
The ultimate goal of resuscitation of an injured child is delivery of oxygen to intracellular organelles in order to maintain aerobic metabolism. This can be obtained by following ATLS protocols with immediate attention to the “ABCDE's” and compulsive reevaluation of the adequacy of resuscitation maneuvers. After stabilization, seriously injured children should be transferred to trauma centers with established pediatric trauma programs utilizing preexisting transfer agreements and protocols.
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