TRAUMA ASSESSMENT/TREATMENT PEDIATRIC
INTRODUCTION
Pediatric trauma patients are stressful. Trauma is a leading cause of death among certain age groups. Like most trauma patients the scene time should be limited to those procedures that are clearly beneficial to the patient.
GENERAL GUIDELINES
1. Quickly determine if a life threat exists following the XABC paradigm.
a. Identify and manage any significant bleeding.
b. Airways are readily compromised in younger children and need to be carefully assessed and managed.
c. Circulation and perfusion should be assessed and managed where there are signs of inadequate perfusion like poor pulses, tachycardia, bradycardia, hypotension (see VITALS TABLES PEDIATRIC at end of PEDIATRIC section. Pediatric patients can maintain stable or normal vitals until late decompensation.
d. Evaluate for altered mental status or depressed level of consciousness.
e. Expose the patient to look for hidden injuries and to thoroughly evaluate.
f. Assess the integrity of the cervical spine and stabilize as needed.
g. Air transport to advanced trauma center should be considered for severe traumatic injuries. Local hospitals offer ER stabilization, blood products, and advanced airway management in smaller children. Limited in pediatric trauma care otherwise.
2. Interventions to consider
a. AIRWAY
i. Position head to optimize airway.
ii. Suction may be necessary
iii. Consider airway adjuncts including NPA, OPA, and LMA.
iv. Intubation is limited to children older than 12.
1. Consider post intubation pain management and sedation.
b. BREATHING
i. Assess the chest and obtain breath sounds
ii. In cases of inadequate ventilation assist with BVM.
iii. Oxygen should be considered by mask if tolerated to maintain pulse oximetry to approximately 94%.
1. If Traumatic Brain Injury (TBI) present push 100% oxygen to avoid any hypoxia.
2. Avoid hyperventilation keeping end tidal in the 35-45 range.
iv. In extreme cases where tension pneumothorax is suspected consider needle decompression of the chest in the 2nd anterior intercostal space or the 4th intercostal space in the anterior axillary line.
v. Obtain pulse oximetry and end tidal CO2 readings.
c. CIRCULATION
i. Control external bleeding with pressure, dressings, or hemostatic fabric.
ii. Tourniquets are sometimes indicated.
iii. TXA approved over 15 years old. 2 grams IV/IO over ten minutes.
iv. IV/IO access should be considered. Below or equal to 7 years old proximal tibia or distal femur only. In cases of decreased perfusion bolus crystalloid fluids at rate of 20 ml./kg. If TBI present, use fluids to avoid hypotension. For smaller quantities utilize a Buretrol if accessible.
v. Tachycardia is usually present with hypovolemia or significant bleeding. Bradycardia is a worrisome late finding of hypovolemia and shock or indicates head or spinal trauma.
d. MENTAL STATUS
i. Assess mental status for lethargy, diminished level of consciousness, restlessness, agitation all of which could indicate hypoxia and poor cerebral perfusion
ii. Unresponsiveness and coma are troubling findings and late in hypoxia, hypotension, shock, and head trauma.
e. BURNS
i. Use crystalloid (LR) to maintain blood pressure.
ii. If > 20% BSA affected or patient is hypotensive administer fluids: 5 or younger: 125 ml./hr., 6-13: 250 ml./hr., and 14 or older: 500 ml./hr.
f. SECONDARY SURVEY
i. Perform a thorough head-to-toe assessment.
ii. Obtain as much history as is possible
g. PAIN MANAGEMENT
i. It is easy to underestimate the degree of pain a pediatric patient is experiencing. Pain scales are poor indicators. Tourniquets are painful within minutes of application, for example. Follow the PAIN MANAGEMENT GUIDELINES for interventions.
h. TRAUMATIC ARREST
i. Follow the TRAUMA ARREST guidelines.
ii. Transport patient
INTRODUCTION
Pediatric trauma patients are stressful. Trauma is a leading cause of death among certain age groups. Like most trauma patients the scene time should be limited to those procedures that are clearly beneficial to the patient.
GENERAL GUIDELINES
1. Quickly determine if a life threat exists following the XABC paradigm.
a. Identify and manage any significant bleeding.
b. Airways are readily compromised in younger children and need to be carefully assessed and managed.
c. Circulation and perfusion should be assessed and managed where there are signs of inadequate perfusion like poor pulses, tachycardia, bradycardia, hypotension (see VITALS TABLES PEDIATRIC at end of PEDIATRIC section. Pediatric patients can maintain stable or normal vitals until late decompensation.
d. Evaluate for altered mental status or depressed level of consciousness.
e. Expose the patient to look for hidden injuries and to thoroughly evaluate.
f. Assess the integrity of the cervical spine and stabilize as needed.
g. Air transport to advanced trauma center should be considered for severe traumatic injuries. Local hospitals offer ER stabilization, blood products, and advanced airway management in smaller children. Limited in pediatric trauma care otherwise.
2. Interventions to consider
a. AIRWAY
i. Position head to optimize airway.
ii. Suction may be necessary
iii. Consider airway adjuncts including NPA, OPA, and LMA.
iv. Intubation is limited to children older than 12.
1. Consider post intubation pain management and sedation.
b. BREATHING
i. Assess the chest and obtain breath sounds
ii. In cases of inadequate ventilation assist with BVM.
iii. Oxygen should be considered by mask if tolerated to maintain pulse oximetry to approximately 94%.
1. If Traumatic Brain Injury (TBI) present push 100% oxygen to avoid any hypoxia.
2. Avoid hyperventilation keeping end tidal in the 35-45 range.
iv. In extreme cases where tension pneumothorax is suspected consider needle decompression of the chest in the 2nd anterior intercostal space or the 4th intercostal space in the anterior axillary line.
v. Obtain pulse oximetry and end tidal CO2 readings.
c. CIRCULATION
i. Control external bleeding with pressure, dressings, or hemostatic fabric.
ii. Tourniquets are sometimes indicated.
iii. TXA approved over 15 years old. 2 grams IV/IO over ten minutes.
iv. IV/IO access should be considered. Below or equal to 7 years old proximal tibia or distal femur only. In cases of decreased perfusion bolus crystalloid fluids at rate of 20 ml./kg. If TBI present, use fluids to avoid hypotension. For smaller quantities utilize a Buretrol if accessible.
v. Tachycardia is usually present with hypovolemia or significant bleeding. Bradycardia is a worrisome late finding of hypovolemia and shock or indicates head or spinal trauma.
d. MENTAL STATUS
i. Assess mental status for lethargy, diminished level of consciousness, restlessness, agitation all of which could indicate hypoxia and poor cerebral perfusion
ii. Unresponsiveness and coma are troubling findings and late in hypoxia, hypotension, shock, and head trauma.
e. BURNS
i. Use crystalloid (LR) to maintain blood pressure.
ii. If > 20% BSA affected or patient is hypotensive administer fluids: 5 or younger: 125 ml./hr., 6-13: 250 ml./hr., and 14 or older: 500 ml./hr.
f. SECONDARY SURVEY
i. Perform a thorough head-to-toe assessment.
ii. Obtain as much history as is possible
g. PAIN MANAGEMENT
i. It is easy to underestimate the degree of pain a pediatric patient is experiencing. Pain scales are poor indicators. Tourniquets are painful within minutes of application, for example. Follow the PAIN MANAGEMENT GUIDELINES for interventions.
h. TRAUMATIC ARREST
i. Follow the TRAUMA ARREST guidelines.
ii. Transport patient