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Management of Multiple Trauma
4
Symposium on Injuries and Injury Prevention
Management of Multiple Trauma Burton H. Harris, M.D.*
Any pediatrician may suddenly find himself attending a multiple trauma victim. At such moments, those present will look to the most senior physician for leadership; a tenative response invites a sudden change from leader to spectator and may deprive the injured child of the special skills of those who know most about pediatric care. Personal preparation is the proper prophylaxis. The first 20 minutes of medical treatment are crucial in determining the outcome for the multiply injured child. The duty of the physician in this critical period is to preserve life, to protect the patient from further injury, to begin to reverse the disordered pathophysiology of trauma, and to find all of the injuries and decide the priority of treatment. There is a definite sequence in which these tasks are best accomplished, 1 and our experience in the Trauma Receiving Unit (TRU) of the Kiwanis Pediatric Trauma Institute prompts the following recommendations for the management of acutely injured children at the time of emergency admission. Immobilize Neck The patient with an unrestrained neck needs a firm Philadelphia collar. If a Philadelphia collar is unavailable, a softer cervical collar, the type used for whiplash injuries, may be sustituted. An alternate method is to place sandbags against both sides of the face and apply wide adhesive tape to the forehead, securing the patient's head to the stretcher. Remove Clothing It is impossible to properly evaluate a clothed victim. Moving the patient as little as possible, clothing should be sacrificed without regard to cost or modesty, cutting it off qUickly (including shoes) with a large bandage scissors.
*Professor of Surgery, Tufts University School of Medicine; Chief, Division of Pediatric Trauma and Director of the Kiwanis Pediatric Trauma Institute, New England Medical Center, Boston, Massachusetts
Pediatric Clinics of North America-Vol. 32, No.1, February 1985
175
176
BURTON H. HARRIS
60-Second Physical Airway, breathing, and circulation ("the ABCs") must be evaluated at once, because instantaneous treatment must be given if there is any compromise of these vital functions. The cardinal sign of airway obstruction is air hunger-gulping, gasping respiratory effort that usually includes use of the accessory muscles of respiration and the shoulder girdle. Most cases of pediatric airway obstruction result from obstruction of the oropharynx, which is relatively smaller in children than in adults. Upper airway obstruction is promptly relieved by the chin lift, a maneuver that delivers the mandible-tongue unit anteriorly, and that should be attempted in all trauma patients in respiratory distress without facial fractures. If the situation does not improve rapidly, then the obstruction is likely to be in the lower airway beyond the larynx. Relief of lower airway obstruction requires the insertion of a device to bypass the obstruction. Endotracheal intubation, the traditional solution to this dilemma, involves manipulation of the head and neck and may be illadvised before the possibility of cervical vertebral fracture has been assessed. Tracheostomy in the absence of airway control is a difficult task for the occasional surgeon. Needle cricothyrotomy (Fig. 1) is recommended as the most safe and rapid method of airway access in such circumstances. The anatomic landmarks of the neck are first identified. Starting from the thyroid cartilage (the "Adam's apple") and taking great care to stay in the midline, the structures are palpated inferiorly until a distinct edge is felt, below which the palpating finger comes to rest closer to the trachea;
Figure 1. Percutaneous cricothyrotomy for relief of lower airway obstruction. A largebore needle is inserted into the tracheal lumen through the cricothyroid membrane.
, MANAGEMENT OF MULTIPLE TRAUMA
~
I
I 1
\
I
177
this is the cricothyroid membrane. With the thumb and forefinger of the nondominant hand holding the trachea, a 14-gauge Angiocath is placed through the cricothyroid membrane into the lumen of the trachea. There is a single, distinct "pop" as the needle enters this space, and the position in the lumen may be confirmed by the resistance-free passage of air in and out. A jet insufflator, bag-and-mask, or mouth-to-needle-hub system is used to deliver an inspiratory-expiratory cycle of air supply. Ventilation, the movement of air through the lungs, is determined by listening to breath sounds or watching the movement of the hemithoraces. Inequality suggests a pneumothorax in the quieter or nonmoving side. This should be noted, but is not a priority for treatment if ventilation on the other side is reasonable. Rapid insertion of a needle and syringe to relieve a possible tension pneumothorax might be a tolerable delay. The adequacy of circulation is judged by observation of skin color, or the time required for capillary refill of the nailbeds. Injuries known to be associated with blood loss are noted but not treated, except for major external hemorrhage, which should be stopped. Direct pressure is preferable to blind clamping with hemostats. Application of crushing instruments to bleeding vessels may cause loss of usable length and prevent later reconstruction. Heart rate and blood pressure are noted. Apply Leads Monitoring cardiac rate and rhythm is essential, but a monitor should not be confused with an electrocardiogram. The shape of the complex has little meaning during resuscitation. Place the electrodes wherever they produce a readable tracing. A standard 12-lead cardiogram can be obtained later. Venipuncture
\ \
The temptation to draw blood for a complete battery of tests should be resisted. Assume all values were normal at the moment of injury. The essential studies are a hematocrit and a sample for type and crossmatch. Because an elevated serum amylase may be the only way to make an early diagnosis of pancreatic injury, this test should be included. The task of obtaining blood may be a real challenge in a limb-injured, hypovolemic, vasoconstricted, agitated patient. A femoral vein venipuncture at the groin usually allows sampling of a sufficient quantity of blood on the first try. General or repeated use of this procedure cannot be recommended, but the one-time risk is acceptable when managing the care of a severely injured patient. Nasal Oxygen
If the patient whose mechanics of breathing, blood volume, and heart and lung function are normal, the partial pressure of oxygen in the blood (Pa02) varies directly with the fraction of oxygen (Fi0 2) in the inspired air. Transient elevations of Pa02 are not harmful. Until the cardiorespiratory dynamics are known, oxygen at 2Umin should be given. Children dislike face masks but will usually tolerate nasal prongs.
178
BURTON H. HARRIS
Venous Access Rapid repair of hypovolemia is a priority of initial trauma treatment. During this early phase no attempt should be made to place central venous lines for either fluid replacement or hemodynamic measurements, because precious time will be lost in nonessential effort. The trauma patient's first venous line should be the shortest, largest-diameter cannula capable of rapid insertion in the peripheral vein of an uninjured extremity. Venipuncture with a catheter-over-needle device should be attempted one time. If unsuccessful, the equipment for peripheral venous cutdown should be brought to the patient's side with no further hesitation or the inevitable "one more try." The greater saphenous vein just anterior to the medial malleolus is the preferred cutdown site. This superficial vein is the easiest to find and cannulate. The external jugular vein or the saphenous vein at the saphenofemoral junction in the groin are other reliable vessels.
Fluid Resuscitation In acute phase resuscitation, organ perfusion is more important than oxygen transfer, and crystalloids work as well as blood. Lactated Ringer's solution, an extracellular fluid mimic, has theoretic advantages over other solutions. Acute loss of the first 10 to 15 per cent of blood volume is replenished by autotransfusion from the extracellular fluid space. Hypovolemia is the loss of more than 20 per cent of blood volume. Therefore the first step in fluid therapy is calculation of blood volume; blood volume in ml = 40 X estimated weight in pounds. Intravenous fluid is given in increments of 25 per cent of calculated blood volume, preferably by hand with a syringe through a three-way stopcock. This method allows the most rapid administration with positive control of the volume infused. The response to this bolus has great prognostic value. Cervical Spine X-Rays The integrity of the cervical spines must be assured prior to movement of the neck. A portable, cross-table lateral x-ray of the neck is taken. For this film to show all seven cervical vertebrae, one person must pull the patient's arms toward the feet while another person holds the head in axial countertraction as the x-ray is taken. These maneuvers clear the structures of the shoulder girdle from the field while protecting the spinal cord. If the film is normal, traction can be released and there is no need to replace the collar. Insert Foley Catheter Measurement of urine output is the best formula to assess organ perfusion (>0.5 mllkglhour), and every hypovolemic patient should have a urinary drainage catheter. An umbilical artery catheter or plastic feeding tube is a very satisfactory catheter in small patients. The only contraindications to catheterization are gross blood at the meatus or resistance to passage of the catheter, either of which may be a sign of urethral disruption.
MANAGEMENT OF MULTIPLE TRAUMA
179
Endotracheal Intubation Airway obstruction or an absence of effective respiratory effort requires endotracheal intubation. Respiratory insufficiency is a relative indication. After the integrity of the cervical vertebrae is ensured, the head is extended on the neck in the "sniffing position." Hyperextension may obscure the larynx. Using an appropriate laryngoscope blade, the uvula is first visualized, then the epiglottis and then the vocal cords, and an uncuffed endotracheal tube is passed. A snug fit usually will be achieved with a tube equal in diameter to the patient's nostril or fifth finger. The position of the tube above the carina, later to be confirmed by chest x-ray, can be estimated by the observation of equal expansion of both hemithoraces. Insert N asogastric Tube Virtually every pediatric trauma patient has gastric dilatation. A substantial nasogastric tube, preferably the newer soft type with multiple holes and a supplemental air channel ("sump tube") should be placed. Midfacial fractures or cerebrospinal fluid rhinorrhea are relative contraindications to this procedure. Peritoneal Lavage Peritoneal lavage is a diagnostic test for abdominal bleeding and perforation of the intestine. Following satisfactory bladder decompression, suitable skin preparation, and local xylocaine anesthesia if necessary, a short transverse infraumbilical incision is made. The incision is carried through the subcutaneous tissue, exposing the middle of the abdominal wall. Traction sutures of 000 silk are placed to the left and right of the midline. The midline is incised vertically and a pediatric peritoneal dialysis catheter inserted and directed caudal and lateral. Normal saline solution, which may be prewarmed, is instilled by gravity (bottle on an IV pole) in an amount equal to 15 mllkg of estimated body weight (or 600 mllm 2 body surface area). After a few minutes to allow admixture with the abdominal contents, an aliquot of the fluid is drained by gravity (bottle on the floor) and sent for laboratory analysis. A "positive" test is the presence of more than 100,000 rbclml, or 500 wbclml, or amylase in excess of serum amylase, or visualization of material consistent with stool. Children with a positive lavage become candidates for exploratory celiotomy even if they have no other evidence of abdominal injury. Peritoneal lavage should be performed in all trauma patients with uncertain abdominal signs who otherwise would not be explored. The most frequent application of this test is in patients with a head injury and an altered sensorium, in whom it is almost mandatory. Patients who are scheduled for a general anesthetic to repair a nonabdominal injury should undergo lavage prior to the induction of anesthesia. The test should be used in any patient where doubt about abdominal injury exists. Over the years it has been extremely accurate and useful. 2 Adhesions from prior abdominal surgery may result in false-negative tests. A computed tomographic (CT) scan of the abdomen cannot be done in patients who have had a recent lavage, and pneumoperitoneum may be present on upright films of the abdomen in such patients.
180
BURTON H. HARRIS
Insert Arterial Line
If a need for frequent determinations of arterial blood gases is anticipated, a plastic catheter can be inserted percutaneously or by cutdown into the radial artery at the wrist after the existence of an ulnar collateral circulation has been confirmed by Doppler examination or palpation. Physical Examination The multiple trauma patient needs a head-to-toe physical examination. In addition to the usual comprehensive pediatric assessment, this examination should include a specific search for those physical signs associated with injuries; the absence of such signs is worth recording as a pertinent negative in the written record of the examination. Blood or cerebrospinal fluid behind the eardrum, around the orbit, or in the nose ("Battle's sign") is presumptive evidence of basilar skull fractures. Palpation of the orbits, the nasal bones, the teeth, and the facial and buccal aspects of the maxilla may disclose important fractures. The location of the trachea with respect to the midline should be noted. Integrity of the ribs is tested by placing an examining hand on the lateral aspects of the left and right chest and exerting pressure toward the sternum to elicit tenderness. Heart sounds should be clear and distinct. Distention of the abdomen suggests gastric dilatation but also may be a sign of abdominal bleeding. Simultaneous compression of the wings of the ileum is painful if there is a pelvic fracture, which may also produce a hematoma of the scrotum or perineum. A digital rectal examination completes the evaluation of the bony pelvis. Modem neurosurgical diagnosis depends so much on computed tomography that observation of the state of consciouness, movement of the extremities, and size and reaction of the pupils constitutes an adequate first neurologic examination. If no gross deformity or shortening is apparent, each bone in each extremity should be randomly but gently moved in a search for the tenderness that invariably accompanies fractures. The tape around any intravenous cannula placed prior to arrival should be removed and the device inspected and re-taped. Lacerations should be undressed, evaluated, and redressed. Errors of omission will be avoided if the patient is placed in a sitting position long enough to inspect the posterior scalp and the back. History A historian is not always available. The paramedic or police officer accompanying the child to the hospital usually is aware of the basic details, having mentally organized these data for the accident report. Sooner or later a parent or relative will arrive and be able to provide more information. In addition to the usual pediatric history, details of immunizations, drug allergies, and current medication have immediate importance. Specific questions also should be asked about the child's family situation and whether parents or siblings also have been injured. An adequate history can usually be assembled from various sources, but it should be reviewed with a family member later in more calm circumstances.
MANAGEMENT OF MULTIPLE TRAUMA
181
X-rays After the film of the cervical spines, the only other essential study is the chest x-ray. Many trauma patients get so many portable x-rays that more important things are delayed by the presence of the x-ray machine. An x-ray of the pelvis may be helpful, but fractured long bones can be splinted and examinated later. Skeletal surveys should be avoided. Most patients for whom skull x-rays are ordered would be better served by CT. The importance of these and other films is undeniable, 3 but the low-yield and non-emergent studies should be deferred until the patient is completely stable and can be moved to the x-ray department. Make a Diagnosis! After the history is taken, the physical examination done, the x-rays taken, and the laboratory data obtained, the final step is to establish the order of treatment. The most helpful aid to figuring out what to do next is to take a few minutes and actually write down all the known injuries. This is not a time for "rule-outs," but rather a recording of results of the extensive evaluation which already has been completed. The self-discipline to pause, calm down, organize one's thoughts, and commit diagnoses to writing is a most useful step in trauma treatment. Once the injuries have been listed, the priorities for treatment usually become clear. Conclusion The individual clinical procedures are standard techniques that can be practiced, but the rush to care for the patient can evoke inappropriate responses. The most important aspect of these recommendations is the sequence. An easy way to keep things in order is to reduce these suggestions to a checklist available in the receiving unit for use by the senior physician. Such a simple outline of treatment can help preserve the calm ambience that contributes to thoughtful care. Management of the multiply injured child is among the most challenging problems in pediatrics. With little pertinent training or experience to draw upon, a proven and systematic approach to the trauma patient is very helpful. The best self-preparation is mental. The system aspect involves facilities and equipment, and is a hospital responsibility. Commitment at all levels-personal and institutional-is the essential ingredient in improving pediatric trauma care. REFERENCES 1. Eichelberger, M. R., and Randolph, J. G.: Pediatric trauma: An algorithm for diagnosis and therapy. J. Trauma, 23:91-97, 1983. 2. Powell, R. W., Smith, D. E., Zarins, C. K., et al.: Peritoneal lavage in children with blunt abdominal trauma. J. Pediatr. Surg., 11:973 77, 1975. 3. Harris, B. H., Morse, T. S., Weidenmier, C. H., et al.: Radioisotope diagnosis of splenic trauma. J. Pediatr. Surg., 12:385-388, 1977.
New England Medical Center 171 Harrison Avenue Boston, Massachusetts 02111
Symposium on Injuries and Injury Prevention
Management of Multiple Trauma Burton H. Harris, M.D.*
Any pediatrician may suddenly find himself attending a multiple trauma victim. At such moments, those present will look to the most senior physician for leadership; a tenative response invites a sudden change from leader to spectator and may deprive the injured child of the special skills of those who know most about pediatric care. Personal preparation is the proper prophylaxis. The first 20 minutes of medical treatment are crucial in determining the outcome for the multiply injured child. The duty of the physician in this critical period is to preserve life, to protect the patient from further injury, to begin to reverse the disordered pathophysiology of trauma, and to find all of the injuries and decide the priority of treatment. There is a definite sequence in which these tasks are best accomplished, 1 and our experience in the Trauma Receiving Unit (TRU) of the Kiwanis Pediatric Trauma Institute prompts the following recommendations for the management of acutely injured children at the time of emergency admission. Immobilize Neck The patient with an unrestrained neck needs a firm Philadelphia collar. If a Philadelphia collar is unavailable, a softer cervical collar, the type used for whiplash injuries, may be sustituted. An alternate method is to place sandbags against both sides of the face and apply wide adhesive tape to the forehead, securing the patient's head to the stretcher. Remove Clothing It is impossible to properly evaluate a clothed victim. Moving the patient as little as possible, clothing should be sacrificed without regard to cost or modesty, cutting it off qUickly (including shoes) with a large bandage scissors.
*Professor of Surgery, Tufts University School of Medicine; Chief, Division of Pediatric Trauma and Director of the Kiwanis Pediatric Trauma Institute, New England Medical Center, Boston, Massachusetts
Pediatric Clinics of North America-Vol. 32, No.1, February 1985
175
176
BURTON H. HARRIS
60-Second Physical Airway, breathing, and circulation ("the ABCs") must be evaluated at once, because instantaneous treatment must be given if there is any compromise of these vital functions. The cardinal sign of airway obstruction is air hunger-gulping, gasping respiratory effort that usually includes use of the accessory muscles of respiration and the shoulder girdle. Most cases of pediatric airway obstruction result from obstruction of the oropharynx, which is relatively smaller in children than in adults. Upper airway obstruction is promptly relieved by the chin lift, a maneuver that delivers the mandible-tongue unit anteriorly, and that should be attempted in all trauma patients in respiratory distress without facial fractures. If the situation does not improve rapidly, then the obstruction is likely to be in the lower airway beyond the larynx. Relief of lower airway obstruction requires the insertion of a device to bypass the obstruction. Endotracheal intubation, the traditional solution to this dilemma, involves manipulation of the head and neck and may be illadvised before the possibility of cervical vertebral fracture has been assessed. Tracheostomy in the absence of airway control is a difficult task for the occasional surgeon. Needle cricothyrotomy (Fig. 1) is recommended as the most safe and rapid method of airway access in such circumstances. The anatomic landmarks of the neck are first identified. Starting from the thyroid cartilage (the "Adam's apple") and taking great care to stay in the midline, the structures are palpated inferiorly until a distinct edge is felt, below which the palpating finger comes to rest closer to the trachea;
Figure 1. Percutaneous cricothyrotomy for relief of lower airway obstruction. A largebore needle is inserted into the tracheal lumen through the cricothyroid membrane.
, MANAGEMENT OF MULTIPLE TRAUMA
~
I
I 1
\
I
177
this is the cricothyroid membrane. With the thumb and forefinger of the nondominant hand holding the trachea, a 14-gauge Angiocath is placed through the cricothyroid membrane into the lumen of the trachea. There is a single, distinct "pop" as the needle enters this space, and the position in the lumen may be confirmed by the resistance-free passage of air in and out. A jet insufflator, bag-and-mask, or mouth-to-needle-hub system is used to deliver an inspiratory-expiratory cycle of air supply. Ventilation, the movement of air through the lungs, is determined by listening to breath sounds or watching the movement of the hemithoraces. Inequality suggests a pneumothorax in the quieter or nonmoving side. This should be noted, but is not a priority for treatment if ventilation on the other side is reasonable. Rapid insertion of a needle and syringe to relieve a possible tension pneumothorax might be a tolerable delay. The adequacy of circulation is judged by observation of skin color, or the time required for capillary refill of the nailbeds. Injuries known to be associated with blood loss are noted but not treated, except for major external hemorrhage, which should be stopped. Direct pressure is preferable to blind clamping with hemostats. Application of crushing instruments to bleeding vessels may cause loss of usable length and prevent later reconstruction. Heart rate and blood pressure are noted. Apply Leads Monitoring cardiac rate and rhythm is essential, but a monitor should not be confused with an electrocardiogram. The shape of the complex has little meaning during resuscitation. Place the electrodes wherever they produce a readable tracing. A standard 12-lead cardiogram can be obtained later. Venipuncture
\ \
The temptation to draw blood for a complete battery of tests should be resisted. Assume all values were normal at the moment of injury. The essential studies are a hematocrit and a sample for type and crossmatch. Because an elevated serum amylase may be the only way to make an early diagnosis of pancreatic injury, this test should be included. The task of obtaining blood may be a real challenge in a limb-injured, hypovolemic, vasoconstricted, agitated patient. A femoral vein venipuncture at the groin usually allows sampling of a sufficient quantity of blood on the first try. General or repeated use of this procedure cannot be recommended, but the one-time risk is acceptable when managing the care of a severely injured patient. Nasal Oxygen
If the patient whose mechanics of breathing, blood volume, and heart and lung function are normal, the partial pressure of oxygen in the blood (Pa02) varies directly with the fraction of oxygen (Fi0 2) in the inspired air. Transient elevations of Pa02 are not harmful. Until the cardiorespiratory dynamics are known, oxygen at 2Umin should be given. Children dislike face masks but will usually tolerate nasal prongs.
178
BURTON H. HARRIS
Venous Access Rapid repair of hypovolemia is a priority of initial trauma treatment. During this early phase no attempt should be made to place central venous lines for either fluid replacement or hemodynamic measurements, because precious time will be lost in nonessential effort. The trauma patient's first venous line should be the shortest, largest-diameter cannula capable of rapid insertion in the peripheral vein of an uninjured extremity. Venipuncture with a catheter-over-needle device should be attempted one time. If unsuccessful, the equipment for peripheral venous cutdown should be brought to the patient's side with no further hesitation or the inevitable "one more try." The greater saphenous vein just anterior to the medial malleolus is the preferred cutdown site. This superficial vein is the easiest to find and cannulate. The external jugular vein or the saphenous vein at the saphenofemoral junction in the groin are other reliable vessels.
Fluid Resuscitation In acute phase resuscitation, organ perfusion is more important than oxygen transfer, and crystalloids work as well as blood. Lactated Ringer's solution, an extracellular fluid mimic, has theoretic advantages over other solutions. Acute loss of the first 10 to 15 per cent of blood volume is replenished by autotransfusion from the extracellular fluid space. Hypovolemia is the loss of more than 20 per cent of blood volume. Therefore the first step in fluid therapy is calculation of blood volume; blood volume in ml = 40 X estimated weight in pounds. Intravenous fluid is given in increments of 25 per cent of calculated blood volume, preferably by hand with a syringe through a three-way stopcock. This method allows the most rapid administration with positive control of the volume infused. The response to this bolus has great prognostic value. Cervical Spine X-Rays The integrity of the cervical spines must be assured prior to movement of the neck. A portable, cross-table lateral x-ray of the neck is taken. For this film to show all seven cervical vertebrae, one person must pull the patient's arms toward the feet while another person holds the head in axial countertraction as the x-ray is taken. These maneuvers clear the structures of the shoulder girdle from the field while protecting the spinal cord. If the film is normal, traction can be released and there is no need to replace the collar. Insert Foley Catheter Measurement of urine output is the best formula to assess organ perfusion (>0.5 mllkglhour), and every hypovolemic patient should have a urinary drainage catheter. An umbilical artery catheter or plastic feeding tube is a very satisfactory catheter in small patients. The only contraindications to catheterization are gross blood at the meatus or resistance to passage of the catheter, either of which may be a sign of urethral disruption.
MANAGEMENT OF MULTIPLE TRAUMA
179
Endotracheal Intubation Airway obstruction or an absence of effective respiratory effort requires endotracheal intubation. Respiratory insufficiency is a relative indication. After the integrity of the cervical vertebrae is ensured, the head is extended on the neck in the "sniffing position." Hyperextension may obscure the larynx. Using an appropriate laryngoscope blade, the uvula is first visualized, then the epiglottis and then the vocal cords, and an uncuffed endotracheal tube is passed. A snug fit usually will be achieved with a tube equal in diameter to the patient's nostril or fifth finger. The position of the tube above the carina, later to be confirmed by chest x-ray, can be estimated by the observation of equal expansion of both hemithoraces. Insert N asogastric Tube Virtually every pediatric trauma patient has gastric dilatation. A substantial nasogastric tube, preferably the newer soft type with multiple holes and a supplemental air channel ("sump tube") should be placed. Midfacial fractures or cerebrospinal fluid rhinorrhea are relative contraindications to this procedure. Peritoneal Lavage Peritoneal lavage is a diagnostic test for abdominal bleeding and perforation of the intestine. Following satisfactory bladder decompression, suitable skin preparation, and local xylocaine anesthesia if necessary, a short transverse infraumbilical incision is made. The incision is carried through the subcutaneous tissue, exposing the middle of the abdominal wall. Traction sutures of 000 silk are placed to the left and right of the midline. The midline is incised vertically and a pediatric peritoneal dialysis catheter inserted and directed caudal and lateral. Normal saline solution, which may be prewarmed, is instilled by gravity (bottle on an IV pole) in an amount equal to 15 mllkg of estimated body weight (or 600 mllm 2 body surface area). After a few minutes to allow admixture with the abdominal contents, an aliquot of the fluid is drained by gravity (bottle on the floor) and sent for laboratory analysis. A "positive" test is the presence of more than 100,000 rbclml, or 500 wbclml, or amylase in excess of serum amylase, or visualization of material consistent with stool. Children with a positive lavage become candidates for exploratory celiotomy even if they have no other evidence of abdominal injury. Peritoneal lavage should be performed in all trauma patients with uncertain abdominal signs who otherwise would not be explored. The most frequent application of this test is in patients with a head injury and an altered sensorium, in whom it is almost mandatory. Patients who are scheduled for a general anesthetic to repair a nonabdominal injury should undergo lavage prior to the induction of anesthesia. The test should be used in any patient where doubt about abdominal injury exists. Over the years it has been extremely accurate and useful. 2 Adhesions from prior abdominal surgery may result in false-negative tests. A computed tomographic (CT) scan of the abdomen cannot be done in patients who have had a recent lavage, and pneumoperitoneum may be present on upright films of the abdomen in such patients.
180
BURTON H. HARRIS
Insert Arterial Line
If a need for frequent determinations of arterial blood gases is anticipated, a plastic catheter can be inserted percutaneously or by cutdown into the radial artery at the wrist after the existence of an ulnar collateral circulation has been confirmed by Doppler examination or palpation. Physical Examination The multiple trauma patient needs a head-to-toe physical examination. In addition to the usual comprehensive pediatric assessment, this examination should include a specific search for those physical signs associated with injuries; the absence of such signs is worth recording as a pertinent negative in the written record of the examination. Blood or cerebrospinal fluid behind the eardrum, around the orbit, or in the nose ("Battle's sign") is presumptive evidence of basilar skull fractures. Palpation of the orbits, the nasal bones, the teeth, and the facial and buccal aspects of the maxilla may disclose important fractures. The location of the trachea with respect to the midline should be noted. Integrity of the ribs is tested by placing an examining hand on the lateral aspects of the left and right chest and exerting pressure toward the sternum to elicit tenderness. Heart sounds should be clear and distinct. Distention of the abdomen suggests gastric dilatation but also may be a sign of abdominal bleeding. Simultaneous compression of the wings of the ileum is painful if there is a pelvic fracture, which may also produce a hematoma of the scrotum or perineum. A digital rectal examination completes the evaluation of the bony pelvis. Modem neurosurgical diagnosis depends so much on computed tomography that observation of the state of consciouness, movement of the extremities, and size and reaction of the pupils constitutes an adequate first neurologic examination. If no gross deformity or shortening is apparent, each bone in each extremity should be randomly but gently moved in a search for the tenderness that invariably accompanies fractures. The tape around any intravenous cannula placed prior to arrival should be removed and the device inspected and re-taped. Lacerations should be undressed, evaluated, and redressed. Errors of omission will be avoided if the patient is placed in a sitting position long enough to inspect the posterior scalp and the back. History A historian is not always available. The paramedic or police officer accompanying the child to the hospital usually is aware of the basic details, having mentally organized these data for the accident report. Sooner or later a parent or relative will arrive and be able to provide more information. In addition to the usual pediatric history, details of immunizations, drug allergies, and current medication have immediate importance. Specific questions also should be asked about the child's family situation and whether parents or siblings also have been injured. An adequate history can usually be assembled from various sources, but it should be reviewed with a family member later in more calm circumstances.
MANAGEMENT OF MULTIPLE TRAUMA
181
X-rays After the film of the cervical spines, the only other essential study is the chest x-ray. Many trauma patients get so many portable x-rays that more important things are delayed by the presence of the x-ray machine. An x-ray of the pelvis may be helpful, but fractured long bones can be splinted and examinated later. Skeletal surveys should be avoided. Most patients for whom skull x-rays are ordered would be better served by CT. The importance of these and other films is undeniable, 3 but the low-yield and non-emergent studies should be deferred until the patient is completely stable and can be moved to the x-ray department. Make a Diagnosis! After the history is taken, the physical examination done, the x-rays taken, and the laboratory data obtained, the final step is to establish the order of treatment. The most helpful aid to figuring out what to do next is to take a few minutes and actually write down all the known injuries. This is not a time for "rule-outs," but rather a recording of results of the extensive evaluation which already has been completed. The self-discipline to pause, calm down, organize one's thoughts, and commit diagnoses to writing is a most useful step in trauma treatment. Once the injuries have been listed, the priorities for treatment usually become clear. Conclusion The individual clinical procedures are standard techniques that can be practiced, but the rush to care for the patient can evoke inappropriate responses. The most important aspect of these recommendations is the sequence. An easy way to keep things in order is to reduce these suggestions to a checklist available in the receiving unit for use by the senior physician. Such a simple outline of treatment can help preserve the calm ambience that contributes to thoughtful care. Management of the multiply injured child is among the most challenging problems in pediatrics. With little pertinent training or experience to draw upon, a proven and systematic approach to the trauma patient is very helpful. The best self-preparation is mental. The system aspect involves facilities and equipment, and is a hospital responsibility. Commitment at all levels-personal and institutional-is the essential ingredient in improving pediatric trauma care. REFERENCES 1. Eichelberger, M. R., and Randolph, J. G.: Pediatric trauma: An algorithm for diagnosis and therapy. J. Trauma, 23:91-97, 1983. 2. Powell, R. W., Smith, D. E., Zarins, C. K., et al.: Peritoneal lavage in children with blunt abdominal trauma. J. Pediatr. Surg., 11:973 77, 1975. 3. Harris, B. H., Morse, T. S., Weidenmier, C. H., et al.: Radioisotope diagnosis of splenic trauma. J. Pediatr. Surg., 12:385-388, 1977.
New England Medical Center 171 Harrison Avenue Boston, Massachusetts 02111