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Initial management of pediatric trauma
INITIAL MANAGEMENT OF
PEDIATRIC TRAUMA By Carl R. Boyd, MD, FACS, Christopher Schroeder, MD, and Mary Ann Tolson, RN, MSN T r a u m a is the n u m b e r one k i l l e r of children a n d young a d u l t s in this country. Traumatic injuries are responsible for more young a d u l t deaths t h a n h e a r t disease and cancer combined; they kill more children t h a n all other causes of pediatric deaths combined, g r e a t e r t h a n 20,000 each year? 4 Despite t h e m a g n i t u d e of the problem, a d i s p r o p o r t i o n a t e l y small s u m of money is spent for research and prevention of this n a t i o n a l epidemic, which robs us of our richest resource--our children. Each y e a r 100,000 children are p e r m a n e n t l y disabled, and another two million are t e m p o r a r i l y incapacitated. In t e r m s of economic and societal significance, disabled children probably leave a g r e a t e r impact, considering the y e a r s of productive life lost. F r o m t h e first y e a r of life, males demonstrate a greater propensity for injury t h a n females. E i g h t y percent of t r a u m a t i c d e a t h s in the late t e e n a g e population are male.4 This a r t i c l e presents an organized app r o a c h to t h e i n i t i a l m a n a g e m e n t of elva Harvey (right), p e d i a t r i c t r a u m a , based on a n a t o m i c and physiologic principles, many of which are CRTT, and Sally King unique to t h e injured child. We have also (left), RN/EMT-P, attend included a discussion ofneurologic t r a u m a , to Michael Vopal in w h i c h a c c o u n t s for 75 p e r c e n t of a l l p e d i a t r i c h o s p i t a l i z a t i o n s due to t r a u m a ? transport aboard Teddy The m e c h a n i s m s a n d p a t t e r n s of injury Bear Air's fixed-wing seen in the p e d i a t r i c p a t i e n t differ m a r k aircraft. Teddy Bear Air edly from those encountered in the adult. Blunt t r a u m a is responsible for 80 percent of Fort Worth, Texas, to 90 percent of all serious pediatric inprovides intensive-care juries.~Unlike p e n e t r a t i n g t r a u m a , which transport for Cook-Fort u s u a l l y only involves one body system, the Worth Children's Mediblunt-injured child typically presents with m u l t i s y s t e m t r a u m a . Occult injuries comcal Center. m o n l y occur and m a y progress to irreparable organ d a m a g e if not d i a g n o s e d and treated early. (Unlike adults, children are more commonly victims of pedestrian accidents r a t h e r t h a n as p a s s e n g e r s in motor vehicle accidents.) 7 The classic t r i a d of injuries seen in this m e c h a n i s m consists of a long-bone fracture, a closed-head injury and a thoracic or a b d o m i n a l injury. The r i s k of death from a multiple-vehicle accident (MVA) increases tenfold for unrestrained pediatric passengers compared to those who are restrained.4 In children severely
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Trauma is the number one killer of children and is responsible for the deaths of more children than all other causes combined. Some 80 to 90 percent of serious injury in children are due to blunt trauma. injured from all forms of trauma, over 80 percent will have some form of head trauma, the leading cause of mortality in this age group? The head injury that appears benign during an initial examination may become lethal when complicated by the secondary effects of hypothermia, hypoxia or hypovolemia. It has been shown that children are often capable of surviving injuries of greater severity than the adult trauma victim? 1° The reason for their resilience has not been definitively documented, but a number of physiologic advantages may contribute. First, it has been demonstrated that their metabolic response to injury is superior to that of adults,9 by reversing a negative nitrogen balance more rapidly, therefore permitting greater healing capacity. While children are less likely to develop mass lesions than adults following severe head injuries, they are more likely to demonstrate diffuse cerebral edema. This is usually amenable to aggressive treatment and results in improved survival rates when compared to adultsP Children also have a more reactive vascular system and are, therefore, able to effectively compensate for at least a 25 percent blood loss by increasing their heart rate and peripherally vasoconstricting. This compensatory ability may be effective in up to a 50 percent bloodvolume loss, at which time a precipitous drop in blood pressure to near zero occurs?~ Children do possess some inherent anatomic and physiologic disadvantages as well. Severe fractures and crush injuries through the epiphyseal plate may result in an untreatable growth disturbance and significant disfigurement. The reactive vascular system that allows children to maintain a normal blood pressure in the face of blood loss may offer a false sense of security to the clinician evaluating the child. Finally, because of their large surface area relative to their weight, hypothermia can be a rapid and lethal development in children. The ABCs of pediatric trauma management are no different from 18 JANUARY/FEBRUARY1989 AMJ
those in adults. The sequence of primary survey, resuscitation, secondary survey and definitive treatment are followed with the same attention to potential development of lethal consequences33 In the primary survey, attention is focused on the following: • Airway with control of cervical spine • Breathing • Circulation with hemorrhage control • Disability with brief neurological exam • Expose the child P r i m a r y Survey Airway: Remember, control of the cervical spine is a part of airway management, although cervical-spine injury is relatively rare in the pediatric patient. In one survey of 2,133 injured children under 18 years of age, the incidence was only 1.2 percent.~4 As the child's cervical spine matures, however, it becomes more susceptible to injury, usually beginning at about 8 years old35 Any child with a history of trauma who presents with an injury above the clavicle, an alteration in level of consciousness, closed-head injury or complains of neck pain must be assumed to have a cervical-spine injury until proven otherwise by a lateral C-spine film that adequately visualizes all seven cervical vertebrae. There are certain notable anatomic differences in children that make their management unique, particularly when one is used to dealing with the adult patient. A child's oral cavity is much smaller, the tongue relatively large and the larynx more cephalad and anterior (Figures 1 and 2). During endotracheal intubation, these differences may cause the clinician to insert the blade of the laryngoscope too far, making it difficult or impossible to visualize the vocal cords. In addition, the cords are much more cartilaginous and, as such, more easily damaged. The relatively short trachea is responsible for probably the most common error in pediatric airway management: intubation of the
right main stem bronchus. Therefore, it is imperative to verify placement of the tube by listening carefully for bilaterally equal breath sounds in the regions of the axillae, chest and stomach. This may not be as easy as it appears, because breath sounds are readily transmitted in the small thorax. The quality, rather than the presence of breath sounds, may be the only clue to a pneumothorax, or area of atelectasis.
Breathing: In the unconscious child, the tongue is the most likely cause of airway obstruction. If the child is making some respiratory effort, the chin lift or jaw thrust maneuver may be all that is required to establish a patent airway to restore normal respirations. The mouth and airway should be suctioned of blood, secretions, vomitus or any obstructive debris. If the child is not breathing, he should first be hyperventilated and welloxygenated with a bag-valve mask. The resuscitation bag should be selfinflating (filling independently of gas inflow), accommodate a reservoir in order to maximize oxygen delivery (near 100 percent) and have no pressure-relief valve, or one that can be disabled. It may be necessary to use two rescuers to maintain an open airway, ensure a leak-proof seal and deliver adequate ventilatory volume. As simple as this sounds, never overestimate the ease, or underestimate the importance, of this type of airway management. In conjunction with the bag-valve mask set-up, an oropharyngeal airway may be helpful in maintaining separation of the tongue and the posterior pharyngeal wall in the unconscious child. The rotational insertion method used for the adult should not be used when placing the pediatric oral airway, as significant dental and soft-palate damage may result31,16 Instead, a straight-in approach will usually secure the airway. Use of a tongue blade to depress the tongue will avoid posterior displacement, with subsequent airway occlusion. Do not use this device in the conscious patient
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Figure 2
Figure 1
CHILD'S & UPPER FRACT
P
EPIGLOTTIS -THYROID CARTILAGE
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CRICOID CAR' TRACHEA
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who m a y vomit a n d a s p i r a t e or develop l a r y n g o s p a s m , t h e r e b y comp r o m i s i n g t h e airway. A welll u b r i c a t e d n a s a l a i r w a y m a y be beneficial, a l t h o u g h a t r a u m a t i c insertion m a y cause epistaxis and adenoid b l e e d i n g because of the v a s c u l a r i t y of t h e area. Choose t h e a p p r o p r i a t e size of both the n a s a l and oral a i r w a y by c o m p a r i n g t h e l e n g t h of t h e airway to the distance from t h e child's naris or m o u t h to t h e angle of the mandible. Definitive airway m a n a g e m e n t in the n o n - b r e a t h i n g child is achieved w i t h endotracheal intubation. Cuffed tubes, which are m a n u f a c t u r e d in sizes of 5 m m and larger, are not g e n e r a l l y used in children younger t h a n 7 or 8 years old. At t h e narrowest portion of t h e trachea, t h e cricoid c a r t i l a g e serves as a physiologic cuff. Cuffless t u b e s will help prevent subglottic stenosis and ulceration. Because of t h e a n t e r i o r and cephalad location of t h e larynx, the acute angle of the airway, which h a s to be n e g o t i a t e d by t h e n a s o t r a c h e a l tube, m a k e s this a difficult procedure in t h e p e d i a t r i c patient. Therefore, t h e preferred m e t h o d of a i r w a y control is orotracheal intubation. I m p r o p e r l y placed tubes, or hypoxia secondary to prolonged unsuccessful i n t u b a t i o n a t t e m p t s , can l e a d to significant morbidity. If int u b a t i o n t a k e s longer t h a n 30 seconds, or if b r a d y c a r d i a develops (pulse < 100 for a neonate, < 80 for an infant or < 60 for a child), the att e m p t should be aborted and the child v e n t i l a t e d a n d oxygenated for two to t h r e e m i n u t e s before the next a t t e m p t . I m m o b i l i z a t i o n of t h e h e a d and neck should be m a i n t a i n e d
t h r o u g h o u t airway m a n a g e m e n t , p a r t i c u l a r l y if cervical-spine stabilit y h a s not been r a d i o g r a p h i c a l l y proven. After proper p l a c e m e n t h a s been confirmed and the tube secured, m i n i m i z e h e a d and neck movement. F l e x i o n m a y cause the tube to m i g r a t e into a bronchus, while extension m a y facilitate extubation. Various methods have been suggested for d e t e r m i n i n g e n d o t r a c h e a l t u b e size needed for a child. Size can be e s t i m a t e d by m a t c h i n g t h e tube to the size of the child's little finger or the d i a m e t e r of t h e e x t e r n a l nares. P e r h a p s a more sophisticated method is to add 16 to t h e p a t i e n t ' s age and divide by four. This f o r m u l a is based on average weight for t h e age and should be adjusted accordingly. To be safe, it is best to have two a d d i t i o n a l e n d o t r a c h e a l t u b e s - one a h a l f m i l l i m e t e r s m a l l e r and another a half millimeter larger t h a n t h e t u b e size chosen, as well as a selection of laryngoscope b l a d e s available should t h e c a l c u l a t e d size be wrong. Tube sizes r a n g e from t h e newborn 2.5 mm, t h r o u g h t h e 6.5 m m s m a l l e s t " a d u l t " tube (useful in the 12 to 14 age group), up to a 9.0 mm, which m i g h t be used for a large male. Because of t h e a n a t o m y of an airway, a s t r a i g h t laryngoscope blade m a y p e r m i t e a s i e r cord visualization in t h e s m a l l child t h a n a curved blade. If, for any reason, i n t u b a t i o n cannot be done or is c o n t r a i n d i c a t e d because of severe facial or laryngot r a c h e a l t r a u m a , t h e preferred technique for t h e p e d i a t r i c p a t i e n t is needle cricothyroidotomy. Tracheostomies a n d surgical cricothyroidotomies are c o n t r a i n d i c a t e d in a
child in t h e emergency setting. Emergency tracheostomies in infants a n d young children are notorious for t h e i r difficulty and complications. The cricothyroid m e m b r a n e lies between t h e thyroid and cricothyroid c a r t i l a g e s a n d can be palpated as a n i n d e n t e d structure just below the l a r g y n g e a l prominence or Adam's apple. A t t a c h a 12 to 16 gauge intravenous c a t h e t e r to a 3 cc syringe c o n t a i n i n g a small amount of sterile saline. W h i l e immobilizing the t r a c h e a in t h e midline, i n s e r t the needle at a 45 degree angle, a i m i n g caudally. A p p l y gentle negative pressure as t h e needle is advanced. When the m e m b r a n e is punctured, a r u s h of bubbles into the saline will be noted signifying entrance into the trachea. Advance the catheter as you would a n IV, withdrawing the needle a n d syringe until t h e c a t h e t e r hub rests upon the skin. A 3 m m a d a p t o r from a pediatric endotracheal tube can now be a t t a c h e d for delivery of 100 percent oxygen by jet insufflation. If the c a t h e t e r size is adequate, and if there is no upper airway obstruction, e x h a l a t i o n m a y occur passively, either through t h e l u m e n or the upper airway passages. Oxygen is a d m i n i s t e r e d at a flow r a t e of 10 to 15 1/min. While t h i s m a y not facilitate the removal of carbon dioxide, studies show t h a t a p a t i e n t can be a d e q u a t e l y oxygena t e d for periods of up to 45 minutes. ~7,18This requires a t t a c h i n g a three-way stopcock or Y-connector t h a t will provide a port of exhalation or gas escape from the airway following i n c r e m e n t s of insufflation. Flow is allowed u n t i l t h e child's AMJ
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chest rises (usually about one second), followed by a three-to-four second resting period to allow decompression. But even under the best situations, it may be difficult or impossible to adequately ventilate or oxygenate the patient this way. Remember, this technique is only a temporizing field measure to secure an airway until more definitive management can be accomplished at a hospital where the trauma team is proficient in pediatric-injury care. Two devices contraindicated in the pediatric patient are the oxygenpowered breathing device (OPBD or demand valve) and the esophageal obturator airway (EOA), both designed for the adult patient. The OPBD does not permit the operator to feel the patient's compliance. It often creates severe gastric distention, which can significantly compromise ventilation in children. It relies on an airtight seal around the face mask to be effective, which is often difficult in the pediatric patient. Most importantly, the OPBD operates under high pressures that place the pediatric patient at serious risk for barotrauma. The EOA is manufactured in one size only and requires an adult esophagus for placement without tissue disruption. Among the hazards inherent in its design, and magnified in the pediatric setting, are inadvertent tracheal placement with airway occlusion or rupture, or both. The life-threatening pathology behind inadequate ventilation in the child with a thoracic injury includes tension pneumothorax, open pneumothorax, massive hemothorax and flail chest? 1,13,19Children may sustain a tension pneumothorax in the presence of a relatively small amount of air. Their mediastinum is mobile and shifts easily to compress the contralateral lung and the vena cava, which results in decreased venous return and circulatory collapse. The diagnosis is a clinical one; the clinician cannot wait for radiographic confirmation before rapidly correcting this situation by needle decompression through the second intercostal space, mid-clavicularly. The open pneumothorax, evidenced by a "sucking" chest wound, can be converted to a closed pneumothorax with the placement of an occlusive seal. Both types of pneumothoraces require definitive treatment with chest-tube drainage. A massive hemothorax results from laceration to the lung or great vessels. Before a chest tube is placed 20 JANUARY/FEBRUARY1989 ~tM$
Figure 3 LUNG
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for drainage, the child must have ongoing adequate volume resuscitation to counter the blood loss that accompanies thoracostomy. Without an adequate resuscitation effort, shock will be the inevitable result of chest-tube placement. A flail chest is poorly tolerated by a child. The pediatric rib cage is elastic and may absorb significant blows, incurring severe parenchymal damage while retaining the integrity of the ribs. Therefore, a blow sufficient enough to fracture several ribs in two or more places is certain to result in a potentially lethal pulmonary contusion, requiring intubation and mechanical ventilatory support. A prophylactic chest tube may be placed in these patients at risk for positive pressure-induced barotrauma. The following suggests several chest-tube sizes for use in the pediatric patient. Age Newborns Infants (1-2) Children
Tube Size 10-12 French 18-20 French 14-28 "French
The preferred placement of a chest tube in a child is lateral, whether the pathology is a simple pneumothorax or a large hemothorax. Anterior placement is not only difficult, but also hazardous because of the proximity of vital structures to the second intercostal space. The desired length of insertion should be marked on the chest tube prior to inserting it into the chest, since injuries to the mediastinum and apical structures can occur when placement is too deep. In a small child, it is sometimes easier to have a small guide or stylet inside the
tube to facilitate proper positioning. Tunneling beneath the skin will help prevent air from re-entering the pleural space following tube removal (Figure 3). A nasogastric tube should be placed in all children who have sustained significant trauma. The combination of aerophagia in a crying, anxious child with a reflex ileus can cause acute gastric distension. Not only does this place the child at risk for vomiting and aspiration, but it also elevates the diaphragm, compromising vital capacity. Additionally, distension may obscure the clinical picture if the examiner, in palpating the distended abdomen, incorrectly assumes an abdominal injury. Circulation: The initial step in managing shock is to recognize its presence, not an easy task in children. A child's first indicator of shock is tachycardia. Hypotension is considered a relatively late sign of shock and reflects at least a 25 percent to 30 percent loss of blood volume. Because a child's blood volume is approximately 80 cc/kg, hypotension in a 35 to 40 kg child signifies a loss of up to a liter of blood, a massive quantity for the pediatric patient. Shock is determined by inadequate tissue perfusion, not by low blood pressure. The child in shock will look pale and mottled. His extremities will be cool and capillary refill will be poor. Regardless of the blood pressure, a child with this clinical picture requires aggressive volume resuscitation to more normal physiologic parameters. Intravenous access should be by at
Remember,children are not small adults and cannot be treated in the same manner as the adult trauma patient. Children have their own unique qualities that require special skills and knowledge to be properly managed. least one large bore catheter, preferably two. The most common site for both p e r c u t a n e o u s sticks and cutdowns is t h e saphenous vein at the ankle. If a l a r g e r or an additional line is needed, t h e saphenofemoral j u n c t i o n a t the groin m a y also be used. Additional sites include the basilic vein at t h e elbow a n d the cephalic vein in the upper arm. It should be e m p h a s i z e d t h a t difficult IV access should never delay transport in the p r e h o s p i t a l setting. F l u i d r e p l a c e m e n t in c h i l d r e n is s i m i l a r to t h a t in t h e adult, w i t h Ringer's l a c t a t e the fluid of choice. R e p l a c e m e n t follows the three-toone rule: for every cc of blood loss, 3 cc of crystalloid should be replaced to m a i n t a i n t h e s a m e i n t r a v a s c u l a r volume. IVs cannot be infused indisc r i m i n a t e l y ; children are easily overloaded. Boluses of 20 c c / k g (or 25 percent of t h e blood volume) should be given and the child's response monitored. Most children respond w i t h improved skin color, p e r i p h e r a l perfusion, blood pressure and pulse. M i n i m a l or no response w a r r a n t s a r e p e a t bolus. If the child does not respond after second volume loading, packed red blood cells should be a d m i n i s t e r e d at 10 c c / k g or whole blood at 20 cc/kg. If the shock still r e m a i n s refractory to t r e a t m e n t , t h e child should be t a k e n i m m e d i a t e l y to the o p e r a t i n g room for control of intraa b d o m i n a l or i n t r a t h o r a c i c hemorrhage. D u r i n g t h i s phase, all p a t i e n t s should be placed on an E C G monitor. Anti-shock trousers designed to fit the p e d i a t r i c p a t i e n t m a y be a useful adjunct in t r e a t i n g shock. A Foley c a t h e t e r should be placed e a r l y in t h i s phase, and u r i n a r y outp u t should be carefully monitored d u r i n g r e s u s c i t a t i o n to indicate tissue perfusion. The desired r a n g e to m a i n t a i n is 0.5 to 1.0 c c / k g / h r , a s s u r i n g t h e clinician of sufficient blood flow to v i t a l organs a n d adequate resuscitation.
Disability: Designed to be brief, this p h a s e requires an a b b r e v i a t e d neurologic exam to d e t e r m i n e t h e level of consciousness, p u p i l size and reactivity.
A comprehensive neurologic evaluation can be conducted in t h e seconda r y survey. A useful mnemonic to r e m e m b e r for describing t h e level of consciousness is AVPU: Alert Responds to Verbal s t i m u l u s Responds to P a i n f u l s t i m u l u s Unresponsive
Expose: The child should be fully undressed at t h i s t i m e to p e r m i t a full visual exam and to prevent unnoticed injuries of unexposed areas. Infants younger t h a n six m o n t h s are u n a b l e to g e n e r a t e h e a t t h r o u g h s h i v e r i n g a n d m u s t resort to breaking down fat, a thermogenic process t h a t increases t h e infant's oxygen consumption. Because of t h e i r susceptibility to h y p o t h e r m i a , p e d i a t r i c p a t i e n t s should be placed u n d e r h e a t l a m p s and receive w a r m e d IV fluids d u r i n g t h e i r r e s u s c i t a t i o n in t h e emergency d e p a r t m e n t . Secondary Survey By now, all life-threatening problems should have been identified a n d t r e a t e d and t h e p a t i e n t stabilized. A t h o r o u g h head-to-toe exami n a t i o n is now in order. A complete neurologic e x a m i n a t i o n , including t h e calculation of a Glascow C o m a Score, as well as a n evaluation of motor a n d sensory function should be conducted. All p e r t i n e n t radiologic studies m a y be done at this time, in a d d i t i o n to diagnostic procedures such as p e r i t o n e a l lavage.
Definitive Treatment A n y n o n l i f e - t h r e a t e n i n g injuries identified t h u s far receive definitive t r e a t m e n t d u r i n g this phase. Several points to r e m e m b e r w h e n with a p e d i a t r i c t r a u m a p a t i e n t follow: • The large surface a r e a of the child r e l a t i v e to his or h e r weight is conducive to r a p i d h e a t loss. Children whose core t e m p e r a t u r e falls below 36 to 37 degrees centigrade are significantly more difficult to resuscit a t e t h a n t h e n o r m o t h e r m i c child 2°,21 The t h e r m a l r e g u l a t o r y m e c h a n i s m of a child often cannot respond to such situations. Care, then, m u s t be t a k e n to monitor and support t h e
t e m p e r a t u r e of all children. • Always calculate d r u g dosage based on weight or surface area. Do not " g u e s s t i m a t e " dosages. For example, if the resuscitation cart is not specifically set up for p e d i a t r i c resuscitation, don't i n d i s c r i m i n a t e l y order one-half an ampule simply because an a d u l t might receive a full a m p u l e of the drug. • W h e n o b t a i n i n g p a t i e n t history from a responsible adult, specifically inquire about any congenital a n o m a l i e s t h a t m a y affect your approach to t h e child's resuscitation. This is p a r t i c u l a r l y applicable to congenital h e a r t defects. • The m a r g i n for error in caring for a child is s m a l l e r t h a n in adults and m a y seem infinitesimal in the inj u r e d newborn. In the neonate, for example, a single blood-soaked sponge can r e p r e s e n t the difference between circulatory stability and shock. • Monitor the child's fluid and electrolyte b a l a n c e carefully, and correct any a b n o r m a l i t i e s quickly and precisely. F l u i d s m u s t be administered in a controlled m a n n e r and should be based on weight as previously stated. You cannot r u n fluids "wide open" in a child.
Neurologic Trauma C e n t r a l nervous system (CNS) t r a u m a is common in the pediatric population and occurs in 80 percent or more of severely injured children.8,11 It is t h e l e a d i n g cause of morbidity a n d m o r t a l i t y in childhood injury.8 As such, CNS t r a u m a will be addressed s e p a r a t e l y as a special p e d i a t r i c m a n a g e m e n t problem. If t h e child presents in shock and also has a head injury, look elsewhere for the source of the shock. A h e a d injury by itself will not cause the r a p i d pulse rate and low blood pressure typical of shock unless the cardiorespiratory centers in t h e m e d u l l a are failing, in which case d e a t h is u s u a l l y i m m i n e n t . Check the extremities for long-bone fractures and look for evidence of intrathoracic or i n t r a - a b d o m i n a l injuries. In neurologic injuries, Cushing's reflex is responsible for the t r i a d of AMJ
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hypertension w i t h increased pulse pressure, b r a d y c a r d i a a n d respiratory i r r e g u l a r i t y ? ~ These findings are u s u a l l y seen w i t h increased i n t r a c r a n i a l pressure (ICP). Note t h a t t h e presence of only one or two of t h e t h r e e signs does not preclude t h e presence of a significant h e a d injury w i t h elevated ICP. A l t h o u g h Cushing's reflex is frequently seen in a d u l t s w i t h ICP, it is r a r e l y seen in its complete form in children. Thus, isolated h y p e r t e n s i o n or b r a d y c a r d i a (often of r e s p i r a t o r y origin) in the child w i t h a h e a d inj u r y should a l e r t t h e physician t h a t the ICP m a y be elevated. For reasons t h a t r e m a i n unclear, children s e e m to develop i n t r a c r a n i a l h y p e r t e n s i o n e a r l i e r and more freq u e n t l y t h a n adults. If the PaO2 is allowed to drop below about 50 m m Hg, c e r e b r a l vessels dilate, increasing blood flow and volume t h a t leads to elevated ICP? a I n c r e a s i n g i n t r a c r a n i a l pressure p r e c i p i t a t e s a downhill neurological course t h a t , if left u n t r e a t e d , will lead to central or u n c a l h e r n i a t i o n and death. Therefore, it is i m p e r a t i v e to oxygenate t h e injured child well, m a i n t a i n i n g a PaO2 of at l e a s t 70 to 80 m m Hg. C e r e b r a l perfusion pressure (CPP) d e t e r m i n e s t h e degree of blood flow a n d n o u r i s h m e n t t h a t the b r a i n receives. It is d e t e r m i n e d by the m e a n a r t e r i a l pressure (MAP) and t h e ICP as expressed by the equation C P P = M A P - ICP. As can be seen from this equation, if t h e int r a c r a n i a l pressure increases, CPP will decrease unless the M A P increases proportionately. ICP is norm a l l y 12 to 15, a n d CPP should be at l e a s t 40 to 60. P r e s s u r e s less t h a n 40 r e s u l t in i s c h e m i a w i t h r e s u l t a n t infarction if allowed to r e m a i n low.3 In order to safely a n d a d e q u a t e l y control ICP, an invasive monitor m u s t be in place. A recipe of mannitol and steroids w i t h o u t monitoring is unscientific a n d p o t e n t i a l l y dangerous. At Children's H o s p i t a l of P h i l a d e l p h i a , the following c r i t e r i a for m o n i t o r i n g ICP are used: 24 • Glascow Coma Score of 3, 4 or 5 • Unconsciousness w i t h s y s t e m a t i c shock • D e t e r i o r a t i n g neurological s t a t u s • Significant cerebral pathology by CT, b u t no surgically correctable lesion • S t a t u s post-evacuation of an acute subdural h e m a t o m a ICP monitors are inserted as soon as possible, u s u a l l y in the ED, a n d monitoring is continued u n t i l t h e child improves sufficiently, or u n t i l his neurologic s t a t u s is stable. The two simplest methods to control ICP are h e a d evaluation, main22
JANUARY/FEBRUARY1989
2.MJ
Table 1: A Modification of the Glascow Coma Score used to Evaluate Function in the Pediatric Patient s Parameter
Response
Eye Opening
Spontaneous To speech To pal n None
4 3 2 1
Verbal Response
Coos, babbles Irritable cries Cries to pain Moans to pain None
5 4 3 2 1
Motor Response
Normal spontaneous movement Withdraws to touch Withdraws to pain Abnormal flexion Abnormal extension None
6 5 4 3 2 1
t a i n i n g a m i d l i n e position to avoid j u g u l a r compression, and hyperventilation, which decreases t h e PaCO2 c a u s i n g cerebral vasoconstriction. It is g e n e r a l l y agreed t h a t t h e PaCO2 should be m a i n t a i n e d between 25 to 30 m m Hg, a l t h o u g h some authors have shown t h e PaCO~ can be safely lowered to 20 m m H g w i t h o u t exa c e r b a t i n g cerebral ischemia? 5 No r e l i a b l e evidence suggests t h a t h y p e r v e n t i l a t i o n can induce significant b r a i n ischemia.2s In addition, an alkalosis-induced shift in the oxyhemoglobin-dissociation curve w i t h i m p a i r e d tissue oxygenation does not have practical i m p o r t a n c e for children. 2a M a n n i t o l is an osmotic a g e n t useful in decreasing ICP following i n t u b a t i o n and h y p e r v e n t i l a t i o n .
Score
The dosage for m a n n i t o l is 0.2 to 2.0 g m / k g . 22,25This d r u g should be used aggressively a n d u n d e r controlled circumstances. W h i l e barb i t u r a t e coma is occasionally used to control ICP, this method should be reserved for cases where simpler techniques have failed to a d e q u a t e l y control pressures. It should be adm i n i s t e r e d only by physicians experienced in its use and in the m a n a g e m e n t of associated complications.28 H y p o t h e r m i a m a y also be helpful in controlling i n t r a c r a n i a l pressure. There is no evidence to suggest steroids are of any immediate benefit to t h e head-injured child.~5 The h a l l m a r k of neurologic evaluation in the head-injured p a t i e n t is change in t h e level of consciousness.
Table 2: Pediatric Trauma Score (The assigned scores of each of the five components are summed to arrive at the total PTS.) s5 Component
Size Airway Systolic BP CNS Open wound Skeletal
+2
+1
>20 kg 10-20 kg Normal Maintainable >90 mm Hg 50-90 mm Hg Awake Obtunded/LOC None Minor None Closed fracture
- 1
__10 kg Unmaintainable <50 mm Hg Coma/decerebrate Major/penetrating Open/multiple fx
The simplest tool to m e a s u r e this change, w i t h proven reliability, is the Glascow Coma Scale (GCS)? s A score of seven or less defines coma, as do 50 percent of all scores totaling eight. 3° Of children s u s t a i n i n g h e a d injury, 99 percent have n o r m a l outcomes. At l e a s t 60 percent of all survivors of h e a d t r a u m a r e s u l t i n g in coma r e t u r n to t h e i r pre-injury status? 1 Pediatric h e a d t r a u m a is associated with a lower m o r t a l i t y r a t e and improved q u a l i t y of recovery over adults. 32 Studies show t h a t in the absence of decerebrate posturing a n d secondary complications of t r a u m a t i c shock, a GCS score of five to seven is associated w i t h m i n i m a l mortality? 5 But because t h e GCS was designed for adults, a modified version has b e e n s u g g e s t e d for use in t h e child who h a s not yet developed the cognitive functions e v a l u a t e d in t h e GCS (Table 1). 5
T r a u m a is the n u m b e r one k i l l e r of children. It is responsible for the d e a t h s of more children t h a n all other causes combined. Some 80 to 90 percent of serious injuries in children are due to b l u n t t r a u m a . Children have a l a r g e r surface a r e a relative to t h e i r weight and are more susceptible to h y p o t h e r m i a t h a n adults, often with l e t h a l consequences. They require an orderly system of fluid resuscitation t h a t t a k e s into account t h e i r unique physiologic needs. Children are
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MID YEAR CLINICAL CONFERENCE
Current Concepts in Trauma Management
Injury Severity Scoring Both t h e T r a u m a Score, a physiologic index of pathology, and t h e I n j u r y Severity Score (ISS), an anatomic index, are b a s e d on t h e a d u l t model? T M It is not surprising, then, that neither method adequately scores t h e severity of injuries sust a i n e d by children. This revelation led to t h e development of two corr e s p o n d i n g pediatric-injury scoring systems. The Pediatric T r a u m a Score (PTS), c u r r e n t l y used by major p e d i a t r i c t r a u m a centers, combines a n a t o m i c a n d physiologic bases to q u a n t i t a t e severity.~s The score uses t h e p a r a m eters of weight, airway, blood pressure, CNS, presence of open wounds a n d s k e l e t a l injury (Table 2). Values r a n g e from - 6 (fatal i n j u r y ) t o + 12 (best prognosis). The score addresses the specific m a n a g e m e n t problems of t h e p e d i a t r i c t r a u m a p a t i e n t , and studies show a good correlation with mortality? 5-87Accuracy, combined w i t h the simplicity of design, m a k e it useful as a field t r i a g e instrument. It h a s been suggested t h a t any child w i t h a score of e i g h t or less should be t r a n s p o r t e d to a p e d i a t r i c t r a u m a center? 2 All d e a t h s in t h e N a t i o n a l Pediatric T r a u m a Registry have occurred in children with a PTS less t h a n n i n e ; 2 The Modified Injury Severity Score (MISS), p u b l i s h e d in 1980 by Mayer et al, was designed to quant i t a t e m u l t i p l e injuries in the p e d i a t r i c age group.8 A l t h o u g h its calculation is identical to t h e ISS (the s u m of the square of t h e t h r e e most severely injured A b b r e v i a t e d Injury Scale [AIS] body systems), t h e r e are t h r e e modifications to t h e original scale:
Summary
• The " g e n e r a l " category has been deleted. • The GCS and specific clinical findings have been added to b e t t e r describe neurologic pathology. • " F a c e / n e c k " are grouped t o g e t h e r as a single category as they are in the AIS. In one survey of 288 pediatric t r a u m a patients, of those p a t i e n t s classified as severely injured by the MISS (score >20), 97.3 percent h a d a PTS of eight or less? 7 The GCS was also proven to correlate well w i t h the MISS and t h e PTS in t h e study.
The Terrace G a r d e n Inn A p r i l 7, 1989 - A t l a n t a , G e o r g i a Featured Topics: • The Multiple Trauma Victim Howard Champion, MD • Inhalation Injury and Carbon Monoxide Toxicity Robert Palmer, PA-C. NREMT-P • Resuscitation of the Hypothermic Patient Nicholas Benson, MD
• Volume M a n a g e m e n t in the Burn Victim James Rex Nelson, RN, NREMT-P • Pediatric Trauma Pauline Ignacio, RN • Shock M a n a g e m e n t Update Frank Thomas, MD
Continuing Education Credit has been applied for through the National Registry. Physician's Category I, AMA and Nursing CEU have also been applied for. For more conference information, call (817)-491-1358. For Hotel Reservations at The Terrace Garden Inn, Atlanta, Georgia Call 1-800-241-8260 in USA • 1-800-682-9600 in Georgia Identify Yourself as a Member of the NFPA Group
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AMJ JANUARY/FEBRUARY1989 23
typically walking or bicycling when injured, and t h u s demonstrate patterns of injury different from adults. The basic ABCs of t r a u m a care are the same for adults and children. The highest priority is to obtain a secure airway, with breathing and circulation the next priorities. CNS t r a u m a is common in children and the leading cause of mortality. Intracranial pressure monitoring is essential to control intracranial pressure and should be used early and whenever indicated. Although children have a r e m a r k a b l e capacity for recovery after head injury, remember t h a t you are dealing with a little person who is frightened and who doesn't understand what is happening to him--take time to care for his emotional needs as well. With a pediatric patient, you inherit a family of patients who need knowledge, comfort and assistance. Don't neglect t h e m in your t r e a t m e n t plan. Remember, children are not small adults and cannot be treated in the same manner as the adult t r a u m a patient. Although the basic principles are the same, children have their own unique qualities t h a t require special skills and knowledge
Trauma in Children. Rockville, MD: Aspen Pub., Inc 1986. 10. Mayer T, Walker ML, Johnson DG, et al: "Causes of Morbidity and Mortality in Severe Pediatric Trauma:' JAMA Marcus RE (ed) Rockvile, MD: Aspen Pub., Inc. 1986. 11. Joyce M: "Initial Management of Pediatric Trauma:' Trauma in Children. Rockville, MD: Aspen Pub., Inc. 1986. 12. Ramenofsky ML: "Initial Evaluation in Pediatric Trauma:' Common Problems in Trauma. Hurst JM (ed). Chicago, IL: Yearbook Med. Pub., Inc, 1987. 13. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support. Chicago, IL: American College of Surgeons. 1985. 14. Rachesky I, Boyce WT, Duncan B, et al: "Clinical Prediction of Cervical Spine Injuries in Children. Radiographic Abnormalities." Am J Dis Child. 141:199-201: 1987. 15. Frame SB, Hendrickson MF: "Problem: Pediatric Cervical Spine Injuries:' Emerg Med. 19:47-51: 1987. 16. Gervin AS: "Head, Chest and Abdominal Trauma:' Manual of Pediatric Emergencies Zanga JR (ed). New York, NY: Churchill Livingstone. 1987. 17. Neff CC, Pff~sterRC, VonSonnenberg E: "Percutaneous Transtracheal Ventilation: Experience and Practical Aspects." J Trauma. 23:84190: 1983. 18. Swatzmann S: "Percutaneous Transtracheal Jet Ventilation for Cardiopulmonary Resuscitation: Evaluation of a New Jet Ventilator:' Crit Care Med. 912:8-13: 1984. 19. Guyton SW. "Chest Injury in Children" Trauma in Children. Marcus RE (ed). Rockville, MD: Aspen Pub. Inc 1986. 20. Eichelberger MR, Randloph JG: "Pediatric
to be properly managed. Every physician who treats t r a u m a must be aware of these differences so t h a t more of our children can leave the hospital to continue happy and productive lives.
References 1. Ramenofsky M., Luteman A, Quindlen E, et al: "Maximum Survival in Pediatric Trauma: The Ideal System:' J Trauma. 24:818-823: 1984. 2. Marcus RE (ed): Trauma in Children. Rockville, MD: Aspen Pub., Inc. 1986. 3. Filston HC: "Pediatric Trauma Management:' Moylan JA (ed). Trauma Surgery. Philadelphia, PA: J.B. Lippincott Co. 1988. 4. Rudolph LA, Freed HA: "Childhood Accidents" Pediatrics, 18th Ed. Rudolph AM (ed). Norwalk, CT: Appleton & Lange. 1987. 5. James HE, Trauner AD: "The Glascow Coma ScaleY Brain Insults in Infants and Children: Pathophysiology and Management. James HE, Anas NG, Perkin RM (eds). Orlando, FL: Harcourt Brace Jovanovich. 1985. 6. Haller JA: "Pediatric Trauma, the No. 1 Killer of Children:' JAMA. 249:47: 1983. 7. Tanz RR, Christofel KK: "Pediatric Injury: The Next Motor Vehicle Injury Challenge" Am J Dis Child. 139:1187-1190: 1985. 8. Mayer T, Matlak ME, Johnson DG, et al: "The Modified Injury Severity Scale in Pediatric Multiple Trauma Patients:'J Pediatr Surg. 15:719-726: 1980. 9. Klein L, Marcus RE: "Trauma in Children: Management, Prognosis and Metabolism"
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Featured Guest Speaker. MARTIN
EICHELBERGER, M.D. Director of Pediatric Trauma Services Associate Professor of General Pediatric Surgery Children's Hospital National Medical Center Washington, D.C. Lander Haven Country Club Off 271 and Cedar Road 2101 Lander Road Mayfield Heights, Ohio
For more information call 216-459-3090 Introducing e Source Book of EMS Inf~
_Medical 91 • A n essential resource m a n u a l for every health-care professional w h o administers, p l a n s o r delivers E m e r g e n c y M e d i c a l Services For this fast-paced information age, keeping up with the changes and advances in EMS is a difficult and time-consuming task. That's why the Emergency Can Information Center, a national clearinghouse for EM.~ information, has published Medical 911 for the past 15 years. Here's just a sample of what you'll receive with a sub. scription to Medical 911 : • Timely, comprehensive news in the bimonth EMS Communicator. • Details on private and public EMS organizati • A comprehensive listing of books, films and programs, complete with ordering informat • Teaching programs and other instructional r • Synopses of key EMS reports, where to get 1
how much they cost. If you're tired of scrambling for information that should be, tips, then subscribe today. For a free brochure describing th, resource of EMS information, write or call us today!
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Trauma: An Algorithm for Diagonisis and Therapy." J Trauma. 23:91-97: 1983. 21. Ryckman FC, Noseworthy J: "Multisystem Trauma:' Surg Clin North Am. 65:1287-1302: 1985. 22. DeVivo DC, Dodge PR: "Head Injury:'
Smith's The Critically Ill Child: Diagnosis and Medical Management. Dickerman JD, Lucey JF (ed). Philadelphia, PA: WB. Saunders Co. 1985. 23. Bruce DA: "Cerebrovascular Dynamics:'
Brain Insults in Infants and Children: Pathophysiology and Management. James HR, Anas NG, Perkin RM (ed). Orlando, FL: Harcourt Brace Jovanovich, 1985. 24. Harris BH (ed). Progress in Pediatric Trauma. Proceedings of the First National Conference on Pediatric Trauma. Boston, MA: Sept 26-27, 1985. 25. Bruce DA: "Closed Head Injury." Common Problems in Trauma. Hurst JM (ed). Chicago, IL: Yearbook Med. Pub, 1987. 26. Manwaring KH, Spetzler RF: "Head and CNS Injury in the Child:' Trauma in Children. Marcus RE (ed). Rockvine, MD: Aspen Pub., Inc. 1986. 27. Grubb R., Raichle ME, Eichling JO, et al: "The Effects of Changes in PaCO= on Cerebral Blood Volume, Blood Flow, and Vascular Mean Transit Time:' Stroke. 5:630-639: 1974. 28. Colombani PM, Buck JE, Dudgeon DL, et al: "One Year Experience in a Regional Pediatric Trauma Center:' JPediatr Surg. 20:8-13. 1985. 29. Teasdaie G, Jennett B: "Assessment of Coma and Impaired Consciousness:' Lancet. 2:81-84: 1974. 30. Hammill JF: "Trauma to the Nervous System:' Pediatrics, 18th ed. Rudolph AM (ed). Norwalk, CT: Appleton & Lange 1987. 31. Strauss RH: "Nervous System:' Current Pediatric Therapy 12 Gellis SS, Kagan BM (eds). Philadelphia, PA: W.B. Saunders Co. 1986. 32. Wagstyl J, Sutcliffe AJ, Alpar EK: "Early Prediction of Outcome Following Head Injury in Children. J Pediatric Surg. 22: 127-129: 1987. 33. Champion HR, Sacci WF, Carnazzo AJ, et al: "Trauma Score:' Crit Care 9:672-676: 1981. 34. Baker SP, O'Neill B, Haddon W, et al: "The Injury Severity Score: A Method for Describing Patients with Multiple Injuries and Evaluation of Emergency Care:' J Trauma 14:187-196: 1974. 35. Tepas JJ, Mollitt DL, Talbert JL, et al: "The Pediatric Trauma Score as a Predictor of Injury Severity in the Injured Child:' J Pediatr Surg. 22:14-18: 1987. 36. Ramenofsky ML, Powell RW, Jurkovich GJ: "The Predictive Validity of the Pediatric Trauma Score (Abstract):' J Trauma. 27:830: 1987. 37. Ford EG, Jennings LM, Givson AE, et al: "The Pediatric Trauma Score: Accuracy of Prediction of Injury Severity in a Single Large Urban Pediatric Trauma Experience. Contemp Ortha 16:35-41: 1988.
Carl R. Boyd, MD, is the director of Trauma Service at Memorial Medical Center, Savannah, Georgia. Dr. Boyd is also medical director of L I F E S T A R Helicopter E M S in Savannah. Christopher Schroeder, MD, is the former chief resident of surgery at Memorial Medical Center, Savannah, Georgia. Mary A n n Tolson, RN, is the former trauma nurse coordinator of the Trauma Service at Memorial Medical Center, Savannah, Georgia.
PEDIATRIC TRAUMA By Carl R. Boyd, MD, FACS, Christopher Schroeder, MD, and Mary Ann Tolson, RN, MSN T r a u m a is the n u m b e r one k i l l e r of children a n d young a d u l t s in this country. Traumatic injuries are responsible for more young a d u l t deaths t h a n h e a r t disease and cancer combined; they kill more children t h a n all other causes of pediatric deaths combined, g r e a t e r t h a n 20,000 each year? 4 Despite t h e m a g n i t u d e of the problem, a d i s p r o p o r t i o n a t e l y small s u m of money is spent for research and prevention of this n a t i o n a l epidemic, which robs us of our richest resource--our children. Each y e a r 100,000 children are p e r m a n e n t l y disabled, and another two million are t e m p o r a r i l y incapacitated. In t e r m s of economic and societal significance, disabled children probably leave a g r e a t e r impact, considering the y e a r s of productive life lost. F r o m t h e first y e a r of life, males demonstrate a greater propensity for injury t h a n females. E i g h t y percent of t r a u m a t i c d e a t h s in the late t e e n a g e population are male.4 This a r t i c l e presents an organized app r o a c h to t h e i n i t i a l m a n a g e m e n t of elva Harvey (right), p e d i a t r i c t r a u m a , based on a n a t o m i c and physiologic principles, many of which are CRTT, and Sally King unique to t h e injured child. We have also (left), RN/EMT-P, attend included a discussion ofneurologic t r a u m a , to Michael Vopal in w h i c h a c c o u n t s for 75 p e r c e n t of a l l p e d i a t r i c h o s p i t a l i z a t i o n s due to t r a u m a ? transport aboard Teddy The m e c h a n i s m s a n d p a t t e r n s of injury Bear Air's fixed-wing seen in the p e d i a t r i c p a t i e n t differ m a r k aircraft. Teddy Bear Air edly from those encountered in the adult. Blunt t r a u m a is responsible for 80 percent of Fort Worth, Texas, to 90 percent of all serious pediatric inprovides intensive-care juries.~Unlike p e n e t r a t i n g t r a u m a , which transport for Cook-Fort u s u a l l y only involves one body system, the Worth Children's Mediblunt-injured child typically presents with m u l t i s y s t e m t r a u m a . Occult injuries comcal Center. m o n l y occur and m a y progress to irreparable organ d a m a g e if not d i a g n o s e d and treated early. (Unlike adults, children are more commonly victims of pedestrian accidents r a t h e r t h a n as p a s s e n g e r s in motor vehicle accidents.) 7 The classic t r i a d of injuries seen in this m e c h a n i s m consists of a long-bone fracture, a closed-head injury and a thoracic or a b d o m i n a l injury. The r i s k of death from a multiple-vehicle accident (MVA) increases tenfold for unrestrained pediatric passengers compared to those who are restrained.4 In children severely
B
16 JANUARY/FEBRUARY1989 AMJ
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J A N U A R Y / F E B R U A R Y 1989
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Trauma is the number one killer of children and is responsible for the deaths of more children than all other causes combined. Some 80 to 90 percent of serious injury in children are due to blunt trauma. injured from all forms of trauma, over 80 percent will have some form of head trauma, the leading cause of mortality in this age group? The head injury that appears benign during an initial examination may become lethal when complicated by the secondary effects of hypothermia, hypoxia or hypovolemia. It has been shown that children are often capable of surviving injuries of greater severity than the adult trauma victim? 1° The reason for their resilience has not been definitively documented, but a number of physiologic advantages may contribute. First, it has been demonstrated that their metabolic response to injury is superior to that of adults,9 by reversing a negative nitrogen balance more rapidly, therefore permitting greater healing capacity. While children are less likely to develop mass lesions than adults following severe head injuries, they are more likely to demonstrate diffuse cerebral edema. This is usually amenable to aggressive treatment and results in improved survival rates when compared to adultsP Children also have a more reactive vascular system and are, therefore, able to effectively compensate for at least a 25 percent blood loss by increasing their heart rate and peripherally vasoconstricting. This compensatory ability may be effective in up to a 50 percent bloodvolume loss, at which time a precipitous drop in blood pressure to near zero occurs?~ Children do possess some inherent anatomic and physiologic disadvantages as well. Severe fractures and crush injuries through the epiphyseal plate may result in an untreatable growth disturbance and significant disfigurement. The reactive vascular system that allows children to maintain a normal blood pressure in the face of blood loss may offer a false sense of security to the clinician evaluating the child. Finally, because of their large surface area relative to their weight, hypothermia can be a rapid and lethal development in children. The ABCs of pediatric trauma management are no different from 18 JANUARY/FEBRUARY1989 AMJ
those in adults. The sequence of primary survey, resuscitation, secondary survey and definitive treatment are followed with the same attention to potential development of lethal consequences33 In the primary survey, attention is focused on the following: • Airway with control of cervical spine • Breathing • Circulation with hemorrhage control • Disability with brief neurological exam • Expose the child P r i m a r y Survey Airway: Remember, control of the cervical spine is a part of airway management, although cervical-spine injury is relatively rare in the pediatric patient. In one survey of 2,133 injured children under 18 years of age, the incidence was only 1.2 percent.~4 As the child's cervical spine matures, however, it becomes more susceptible to injury, usually beginning at about 8 years old35 Any child with a history of trauma who presents with an injury above the clavicle, an alteration in level of consciousness, closed-head injury or complains of neck pain must be assumed to have a cervical-spine injury until proven otherwise by a lateral C-spine film that adequately visualizes all seven cervical vertebrae. There are certain notable anatomic differences in children that make their management unique, particularly when one is used to dealing with the adult patient. A child's oral cavity is much smaller, the tongue relatively large and the larynx more cephalad and anterior (Figures 1 and 2). During endotracheal intubation, these differences may cause the clinician to insert the blade of the laryngoscope too far, making it difficult or impossible to visualize the vocal cords. In addition, the cords are much more cartilaginous and, as such, more easily damaged. The relatively short trachea is responsible for probably the most common error in pediatric airway management: intubation of the
right main stem bronchus. Therefore, it is imperative to verify placement of the tube by listening carefully for bilaterally equal breath sounds in the regions of the axillae, chest and stomach. This may not be as easy as it appears, because breath sounds are readily transmitted in the small thorax. The quality, rather than the presence of breath sounds, may be the only clue to a pneumothorax, or area of atelectasis.
Breathing: In the unconscious child, the tongue is the most likely cause of airway obstruction. If the child is making some respiratory effort, the chin lift or jaw thrust maneuver may be all that is required to establish a patent airway to restore normal respirations. The mouth and airway should be suctioned of blood, secretions, vomitus or any obstructive debris. If the child is not breathing, he should first be hyperventilated and welloxygenated with a bag-valve mask. The resuscitation bag should be selfinflating (filling independently of gas inflow), accommodate a reservoir in order to maximize oxygen delivery (near 100 percent) and have no pressure-relief valve, or one that can be disabled. It may be necessary to use two rescuers to maintain an open airway, ensure a leak-proof seal and deliver adequate ventilatory volume. As simple as this sounds, never overestimate the ease, or underestimate the importance, of this type of airway management. In conjunction with the bag-valve mask set-up, an oropharyngeal airway may be helpful in maintaining separation of the tongue and the posterior pharyngeal wall in the unconscious child. The rotational insertion method used for the adult should not be used when placing the pediatric oral airway, as significant dental and soft-palate damage may result31,16 Instead, a straight-in approach will usually secure the airway. Use of a tongue blade to depress the tongue will avoid posterior displacement, with subsequent airway occlusion. Do not use this device in the conscious patient
l
Figure 2
Figure 1
CHILD'S & UPPER FRACT
P
EPIGLOTTIS -THYROID CARTILAGE
--
CRICOID CAR' TRACHEA
--
who m a y vomit a n d a s p i r a t e or develop l a r y n g o s p a s m , t h e r e b y comp r o m i s i n g t h e airway. A welll u b r i c a t e d n a s a l a i r w a y m a y be beneficial, a l t h o u g h a t r a u m a t i c insertion m a y cause epistaxis and adenoid b l e e d i n g because of the v a s c u l a r i t y of t h e area. Choose t h e a p p r o p r i a t e size of both the n a s a l and oral a i r w a y by c o m p a r i n g t h e l e n g t h of t h e airway to the distance from t h e child's naris or m o u t h to t h e angle of the mandible. Definitive airway m a n a g e m e n t in the n o n - b r e a t h i n g child is achieved w i t h endotracheal intubation. Cuffed tubes, which are m a n u f a c t u r e d in sizes of 5 m m and larger, are not g e n e r a l l y used in children younger t h a n 7 or 8 years old. At t h e narrowest portion of t h e trachea, t h e cricoid c a r t i l a g e serves as a physiologic cuff. Cuffless t u b e s will help prevent subglottic stenosis and ulceration. Because of t h e a n t e r i o r and cephalad location of t h e larynx, the acute angle of the airway, which h a s to be n e g o t i a t e d by t h e n a s o t r a c h e a l tube, m a k e s this a difficult procedure in t h e p e d i a t r i c patient. Therefore, t h e preferred m e t h o d of a i r w a y control is orotracheal intubation. I m p r o p e r l y placed tubes, or hypoxia secondary to prolonged unsuccessful i n t u b a t i o n a t t e m p t s , can l e a d to significant morbidity. If int u b a t i o n t a k e s longer t h a n 30 seconds, or if b r a d y c a r d i a develops (pulse < 100 for a neonate, < 80 for an infant or < 60 for a child), the att e m p t should be aborted and the child v e n t i l a t e d a n d oxygenated for two to t h r e e m i n u t e s before the next a t t e m p t . I m m o b i l i z a t i o n of t h e h e a d and neck should be m a i n t a i n e d
t h r o u g h o u t airway m a n a g e m e n t , p a r t i c u l a r l y if cervical-spine stabilit y h a s not been r a d i o g r a p h i c a l l y proven. After proper p l a c e m e n t h a s been confirmed and the tube secured, m i n i m i z e h e a d and neck movement. F l e x i o n m a y cause the tube to m i g r a t e into a bronchus, while extension m a y facilitate extubation. Various methods have been suggested for d e t e r m i n i n g e n d o t r a c h e a l t u b e size needed for a child. Size can be e s t i m a t e d by m a t c h i n g t h e tube to the size of the child's little finger or the d i a m e t e r of t h e e x t e r n a l nares. P e r h a p s a more sophisticated method is to add 16 to t h e p a t i e n t ' s age and divide by four. This f o r m u l a is based on average weight for t h e age and should be adjusted accordingly. To be safe, it is best to have two a d d i t i o n a l e n d o t r a c h e a l t u b e s - one a h a l f m i l l i m e t e r s m a l l e r and another a half millimeter larger t h a n t h e t u b e size chosen, as well as a selection of laryngoscope b l a d e s available should t h e c a l c u l a t e d size be wrong. Tube sizes r a n g e from t h e newborn 2.5 mm, t h r o u g h t h e 6.5 m m s m a l l e s t " a d u l t " tube (useful in the 12 to 14 age group), up to a 9.0 mm, which m i g h t be used for a large male. Because of t h e a n a t o m y of an airway, a s t r a i g h t laryngoscope blade m a y p e r m i t e a s i e r cord visualization in t h e s m a l l child t h a n a curved blade. If, for any reason, i n t u b a t i o n cannot be done or is c o n t r a i n d i c a t e d because of severe facial or laryngot r a c h e a l t r a u m a , t h e preferred technique for t h e p e d i a t r i c p a t i e n t is needle cricothyroidotomy. Tracheostomies a n d surgical cricothyroidotomies are c o n t r a i n d i c a t e d in a
child in t h e emergency setting. Emergency tracheostomies in infants a n d young children are notorious for t h e i r difficulty and complications. The cricothyroid m e m b r a n e lies between t h e thyroid and cricothyroid c a r t i l a g e s a n d can be palpated as a n i n d e n t e d structure just below the l a r g y n g e a l prominence or Adam's apple. A t t a c h a 12 to 16 gauge intravenous c a t h e t e r to a 3 cc syringe c o n t a i n i n g a small amount of sterile saline. W h i l e immobilizing the t r a c h e a in t h e midline, i n s e r t the needle at a 45 degree angle, a i m i n g caudally. A p p l y gentle negative pressure as t h e needle is advanced. When the m e m b r a n e is punctured, a r u s h of bubbles into the saline will be noted signifying entrance into the trachea. Advance the catheter as you would a n IV, withdrawing the needle a n d syringe until t h e c a t h e t e r hub rests upon the skin. A 3 m m a d a p t o r from a pediatric endotracheal tube can now be a t t a c h e d for delivery of 100 percent oxygen by jet insufflation. If the c a t h e t e r size is adequate, and if there is no upper airway obstruction, e x h a l a t i o n m a y occur passively, either through t h e l u m e n or the upper airway passages. Oxygen is a d m i n i s t e r e d at a flow r a t e of 10 to 15 1/min. While t h i s m a y not facilitate the removal of carbon dioxide, studies show t h a t a p a t i e n t can be a d e q u a t e l y oxygena t e d for periods of up to 45 minutes. ~7,18This requires a t t a c h i n g a three-way stopcock or Y-connector t h a t will provide a port of exhalation or gas escape from the airway following i n c r e m e n t s of insufflation. Flow is allowed u n t i l t h e child's AMJ
JANUARY/FEBRUARY1989
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chest rises (usually about one second), followed by a three-to-four second resting period to allow decompression. But even under the best situations, it may be difficult or impossible to adequately ventilate or oxygenate the patient this way. Remember, this technique is only a temporizing field measure to secure an airway until more definitive management can be accomplished at a hospital where the trauma team is proficient in pediatric-injury care. Two devices contraindicated in the pediatric patient are the oxygenpowered breathing device (OPBD or demand valve) and the esophageal obturator airway (EOA), both designed for the adult patient. The OPBD does not permit the operator to feel the patient's compliance. It often creates severe gastric distention, which can significantly compromise ventilation in children. It relies on an airtight seal around the face mask to be effective, which is often difficult in the pediatric patient. Most importantly, the OPBD operates under high pressures that place the pediatric patient at serious risk for barotrauma. The EOA is manufactured in one size only and requires an adult esophagus for placement without tissue disruption. Among the hazards inherent in its design, and magnified in the pediatric setting, are inadvertent tracheal placement with airway occlusion or rupture, or both. The life-threatening pathology behind inadequate ventilation in the child with a thoracic injury includes tension pneumothorax, open pneumothorax, massive hemothorax and flail chest? 1,13,19Children may sustain a tension pneumothorax in the presence of a relatively small amount of air. Their mediastinum is mobile and shifts easily to compress the contralateral lung and the vena cava, which results in decreased venous return and circulatory collapse. The diagnosis is a clinical one; the clinician cannot wait for radiographic confirmation before rapidly correcting this situation by needle decompression through the second intercostal space, mid-clavicularly. The open pneumothorax, evidenced by a "sucking" chest wound, can be converted to a closed pneumothorax with the placement of an occlusive seal. Both types of pneumothoraces require definitive treatment with chest-tube drainage. A massive hemothorax results from laceration to the lung or great vessels. Before a chest tube is placed 20 JANUARY/FEBRUARY1989 ~tM$
Figure 3 LUNG
~ ~.
for drainage, the child must have ongoing adequate volume resuscitation to counter the blood loss that accompanies thoracostomy. Without an adequate resuscitation effort, shock will be the inevitable result of chest-tube placement. A flail chest is poorly tolerated by a child. The pediatric rib cage is elastic and may absorb significant blows, incurring severe parenchymal damage while retaining the integrity of the ribs. Therefore, a blow sufficient enough to fracture several ribs in two or more places is certain to result in a potentially lethal pulmonary contusion, requiring intubation and mechanical ventilatory support. A prophylactic chest tube may be placed in these patients at risk for positive pressure-induced barotrauma. The following suggests several chest-tube sizes for use in the pediatric patient. Age Newborns Infants (1-2) Children
Tube Size 10-12 French 18-20 French 14-28 "French
The preferred placement of a chest tube in a child is lateral, whether the pathology is a simple pneumothorax or a large hemothorax. Anterior placement is not only difficult, but also hazardous because of the proximity of vital structures to the second intercostal space. The desired length of insertion should be marked on the chest tube prior to inserting it into the chest, since injuries to the mediastinum and apical structures can occur when placement is too deep. In a small child, it is sometimes easier to have a small guide or stylet inside the
tube to facilitate proper positioning. Tunneling beneath the skin will help prevent air from re-entering the pleural space following tube removal (Figure 3). A nasogastric tube should be placed in all children who have sustained significant trauma. The combination of aerophagia in a crying, anxious child with a reflex ileus can cause acute gastric distension. Not only does this place the child at risk for vomiting and aspiration, but it also elevates the diaphragm, compromising vital capacity. Additionally, distension may obscure the clinical picture if the examiner, in palpating the distended abdomen, incorrectly assumes an abdominal injury. Circulation: The initial step in managing shock is to recognize its presence, not an easy task in children. A child's first indicator of shock is tachycardia. Hypotension is considered a relatively late sign of shock and reflects at least a 25 percent to 30 percent loss of blood volume. Because a child's blood volume is approximately 80 cc/kg, hypotension in a 35 to 40 kg child signifies a loss of up to a liter of blood, a massive quantity for the pediatric patient. Shock is determined by inadequate tissue perfusion, not by low blood pressure. The child in shock will look pale and mottled. His extremities will be cool and capillary refill will be poor. Regardless of the blood pressure, a child with this clinical picture requires aggressive volume resuscitation to more normal physiologic parameters. Intravenous access should be by at
Remember,children are not small adults and cannot be treated in the same manner as the adult trauma patient. Children have their own unique qualities that require special skills and knowledge to be properly managed. least one large bore catheter, preferably two. The most common site for both p e r c u t a n e o u s sticks and cutdowns is t h e saphenous vein at the ankle. If a l a r g e r or an additional line is needed, t h e saphenofemoral j u n c t i o n a t the groin m a y also be used. Additional sites include the basilic vein at t h e elbow a n d the cephalic vein in the upper arm. It should be e m p h a s i z e d t h a t difficult IV access should never delay transport in the p r e h o s p i t a l setting. F l u i d r e p l a c e m e n t in c h i l d r e n is s i m i l a r to t h a t in t h e adult, w i t h Ringer's l a c t a t e the fluid of choice. R e p l a c e m e n t follows the three-toone rule: for every cc of blood loss, 3 cc of crystalloid should be replaced to m a i n t a i n t h e s a m e i n t r a v a s c u l a r volume. IVs cannot be infused indisc r i m i n a t e l y ; children are easily overloaded. Boluses of 20 c c / k g (or 25 percent of t h e blood volume) should be given and the child's response monitored. Most children respond w i t h improved skin color, p e r i p h e r a l perfusion, blood pressure and pulse. M i n i m a l or no response w a r r a n t s a r e p e a t bolus. If the child does not respond after second volume loading, packed red blood cells should be a d m i n i s t e r e d at 10 c c / k g or whole blood at 20 cc/kg. If the shock still r e m a i n s refractory to t r e a t m e n t , t h e child should be t a k e n i m m e d i a t e l y to the o p e r a t i n g room for control of intraa b d o m i n a l or i n t r a t h o r a c i c hemorrhage. D u r i n g t h i s phase, all p a t i e n t s should be placed on an E C G monitor. Anti-shock trousers designed to fit the p e d i a t r i c p a t i e n t m a y be a useful adjunct in t r e a t i n g shock. A Foley c a t h e t e r should be placed e a r l y in t h i s phase, and u r i n a r y outp u t should be carefully monitored d u r i n g r e s u s c i t a t i o n to indicate tissue perfusion. The desired r a n g e to m a i n t a i n is 0.5 to 1.0 c c / k g / h r , a s s u r i n g t h e clinician of sufficient blood flow to v i t a l organs a n d adequate resuscitation.
Disability: Designed to be brief, this p h a s e requires an a b b r e v i a t e d neurologic exam to d e t e r m i n e t h e level of consciousness, p u p i l size and reactivity.
A comprehensive neurologic evaluation can be conducted in t h e seconda r y survey. A useful mnemonic to r e m e m b e r for describing t h e level of consciousness is AVPU: Alert Responds to Verbal s t i m u l u s Responds to P a i n f u l s t i m u l u s Unresponsive
Expose: The child should be fully undressed at t h i s t i m e to p e r m i t a full visual exam and to prevent unnoticed injuries of unexposed areas. Infants younger t h a n six m o n t h s are u n a b l e to g e n e r a t e h e a t t h r o u g h s h i v e r i n g a n d m u s t resort to breaking down fat, a thermogenic process t h a t increases t h e infant's oxygen consumption. Because of t h e i r susceptibility to h y p o t h e r m i a , p e d i a t r i c p a t i e n t s should be placed u n d e r h e a t l a m p s and receive w a r m e d IV fluids d u r i n g t h e i r r e s u s c i t a t i o n in t h e emergency d e p a r t m e n t . Secondary Survey By now, all life-threatening problems should have been identified a n d t r e a t e d and t h e p a t i e n t stabilized. A t h o r o u g h head-to-toe exami n a t i o n is now in order. A complete neurologic e x a m i n a t i o n , including t h e calculation of a Glascow C o m a Score, as well as a n evaluation of motor a n d sensory function should be conducted. All p e r t i n e n t radiologic studies m a y be done at this time, in a d d i t i o n to diagnostic procedures such as p e r i t o n e a l lavage.
Definitive Treatment A n y n o n l i f e - t h r e a t e n i n g injuries identified t h u s far receive definitive t r e a t m e n t d u r i n g this phase. Several points to r e m e m b e r w h e n with a p e d i a t r i c t r a u m a p a t i e n t follow: • The large surface a r e a of the child r e l a t i v e to his or h e r weight is conducive to r a p i d h e a t loss. Children whose core t e m p e r a t u r e falls below 36 to 37 degrees centigrade are significantly more difficult to resuscit a t e t h a n t h e n o r m o t h e r m i c child 2°,21 The t h e r m a l r e g u l a t o r y m e c h a n i s m of a child often cannot respond to such situations. Care, then, m u s t be t a k e n to monitor and support t h e
t e m p e r a t u r e of all children. • Always calculate d r u g dosage based on weight or surface area. Do not " g u e s s t i m a t e " dosages. For example, if the resuscitation cart is not specifically set up for p e d i a t r i c resuscitation, don't i n d i s c r i m i n a t e l y order one-half an ampule simply because an a d u l t might receive a full a m p u l e of the drug. • W h e n o b t a i n i n g p a t i e n t history from a responsible adult, specifically inquire about any congenital a n o m a l i e s t h a t m a y affect your approach to t h e child's resuscitation. This is p a r t i c u l a r l y applicable to congenital h e a r t defects. • The m a r g i n for error in caring for a child is s m a l l e r t h a n in adults and m a y seem infinitesimal in the inj u r e d newborn. In the neonate, for example, a single blood-soaked sponge can r e p r e s e n t the difference between circulatory stability and shock. • Monitor the child's fluid and electrolyte b a l a n c e carefully, and correct any a b n o r m a l i t i e s quickly and precisely. F l u i d s m u s t be administered in a controlled m a n n e r and should be based on weight as previously stated. You cannot r u n fluids "wide open" in a child.
Neurologic Trauma C e n t r a l nervous system (CNS) t r a u m a is common in the pediatric population and occurs in 80 percent or more of severely injured children.8,11 It is t h e l e a d i n g cause of morbidity a n d m o r t a l i t y in childhood injury.8 As such, CNS t r a u m a will be addressed s e p a r a t e l y as a special p e d i a t r i c m a n a g e m e n t problem. If t h e child presents in shock and also has a head injury, look elsewhere for the source of the shock. A h e a d injury by itself will not cause the r a p i d pulse rate and low blood pressure typical of shock unless the cardiorespiratory centers in t h e m e d u l l a are failing, in which case d e a t h is u s u a l l y i m m i n e n t . Check the extremities for long-bone fractures and look for evidence of intrathoracic or i n t r a - a b d o m i n a l injuries. In neurologic injuries, Cushing's reflex is responsible for the t r i a d of AMJ
J A N U A R Y / F E B R U A R Y 1989
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hypertension w i t h increased pulse pressure, b r a d y c a r d i a a n d respiratory i r r e g u l a r i t y ? ~ These findings are u s u a l l y seen w i t h increased i n t r a c r a n i a l pressure (ICP). Note t h a t t h e presence of only one or two of t h e t h r e e signs does not preclude t h e presence of a significant h e a d injury w i t h elevated ICP. A l t h o u g h Cushing's reflex is frequently seen in a d u l t s w i t h ICP, it is r a r e l y seen in its complete form in children. Thus, isolated h y p e r t e n s i o n or b r a d y c a r d i a (often of r e s p i r a t o r y origin) in the child w i t h a h e a d inj u r y should a l e r t t h e physician t h a t the ICP m a y be elevated. For reasons t h a t r e m a i n unclear, children s e e m to develop i n t r a c r a n i a l h y p e r t e n s i o n e a r l i e r and more freq u e n t l y t h a n adults. If the PaO2 is allowed to drop below about 50 m m Hg, c e r e b r a l vessels dilate, increasing blood flow and volume t h a t leads to elevated ICP? a I n c r e a s i n g i n t r a c r a n i a l pressure p r e c i p i t a t e s a downhill neurological course t h a t , if left u n t r e a t e d , will lead to central or u n c a l h e r n i a t i o n and death. Therefore, it is i m p e r a t i v e to oxygenate t h e injured child well, m a i n t a i n i n g a PaO2 of at l e a s t 70 to 80 m m Hg. C e r e b r a l perfusion pressure (CPP) d e t e r m i n e s t h e degree of blood flow a n d n o u r i s h m e n t t h a t the b r a i n receives. It is d e t e r m i n e d by the m e a n a r t e r i a l pressure (MAP) and t h e ICP as expressed by the equation C P P = M A P - ICP. As can be seen from this equation, if t h e int r a c r a n i a l pressure increases, CPP will decrease unless the M A P increases proportionately. ICP is norm a l l y 12 to 15, a n d CPP should be at l e a s t 40 to 60. P r e s s u r e s less t h a n 40 r e s u l t in i s c h e m i a w i t h r e s u l t a n t infarction if allowed to r e m a i n low.3 In order to safely a n d a d e q u a t e l y control ICP, an invasive monitor m u s t be in place. A recipe of mannitol and steroids w i t h o u t monitoring is unscientific a n d p o t e n t i a l l y dangerous. At Children's H o s p i t a l of P h i l a d e l p h i a , the following c r i t e r i a for m o n i t o r i n g ICP are used: 24 • Glascow Coma Score of 3, 4 or 5 • Unconsciousness w i t h s y s t e m a t i c shock • D e t e r i o r a t i n g neurological s t a t u s • Significant cerebral pathology by CT, b u t no surgically correctable lesion • S t a t u s post-evacuation of an acute subdural h e m a t o m a ICP monitors are inserted as soon as possible, u s u a l l y in the ED, a n d monitoring is continued u n t i l t h e child improves sufficiently, or u n t i l his neurologic s t a t u s is stable. The two simplest methods to control ICP are h e a d evaluation, main22
JANUARY/FEBRUARY1989
2.MJ
Table 1: A Modification of the Glascow Coma Score used to Evaluate Function in the Pediatric Patient s Parameter
Response
Eye Opening
Spontaneous To speech To pal n None
4 3 2 1
Verbal Response
Coos, babbles Irritable cries Cries to pain Moans to pain None
5 4 3 2 1
Motor Response
Normal spontaneous movement Withdraws to touch Withdraws to pain Abnormal flexion Abnormal extension None
6 5 4 3 2 1
t a i n i n g a m i d l i n e position to avoid j u g u l a r compression, and hyperventilation, which decreases t h e PaCO2 c a u s i n g cerebral vasoconstriction. It is g e n e r a l l y agreed t h a t t h e PaCO2 should be m a i n t a i n e d between 25 to 30 m m Hg, a l t h o u g h some authors have shown t h e PaCO~ can be safely lowered to 20 m m H g w i t h o u t exa c e r b a t i n g cerebral ischemia? 5 No r e l i a b l e evidence suggests t h a t h y p e r v e n t i l a t i o n can induce significant b r a i n ischemia.2s In addition, an alkalosis-induced shift in the oxyhemoglobin-dissociation curve w i t h i m p a i r e d tissue oxygenation does not have practical i m p o r t a n c e for children. 2a M a n n i t o l is an osmotic a g e n t useful in decreasing ICP following i n t u b a t i o n and h y p e r v e n t i l a t i o n .
Score
The dosage for m a n n i t o l is 0.2 to 2.0 g m / k g . 22,25This d r u g should be used aggressively a n d u n d e r controlled circumstances. W h i l e barb i t u r a t e coma is occasionally used to control ICP, this method should be reserved for cases where simpler techniques have failed to a d e q u a t e l y control pressures. It should be adm i n i s t e r e d only by physicians experienced in its use and in the m a n a g e m e n t of associated complications.28 H y p o t h e r m i a m a y also be helpful in controlling i n t r a c r a n i a l pressure. There is no evidence to suggest steroids are of any immediate benefit to t h e head-injured child.~5 The h a l l m a r k of neurologic evaluation in the head-injured p a t i e n t is change in t h e level of consciousness.
Table 2: Pediatric Trauma Score (The assigned scores of each of the five components are summed to arrive at the total PTS.) s5 Component
Size Airway Systolic BP CNS Open wound Skeletal
+2
+1
>20 kg 10-20 kg Normal Maintainable >90 mm Hg 50-90 mm Hg Awake Obtunded/LOC None Minor None Closed fracture
- 1
__10 kg Unmaintainable <50 mm Hg Coma/decerebrate Major/penetrating Open/multiple fx
The simplest tool to m e a s u r e this change, w i t h proven reliability, is the Glascow Coma Scale (GCS)? s A score of seven or less defines coma, as do 50 percent of all scores totaling eight. 3° Of children s u s t a i n i n g h e a d injury, 99 percent have n o r m a l outcomes. At l e a s t 60 percent of all survivors of h e a d t r a u m a r e s u l t i n g in coma r e t u r n to t h e i r pre-injury status? 1 Pediatric h e a d t r a u m a is associated with a lower m o r t a l i t y r a t e and improved q u a l i t y of recovery over adults. 32 Studies show t h a t in the absence of decerebrate posturing a n d secondary complications of t r a u m a t i c shock, a GCS score of five to seven is associated w i t h m i n i m a l mortality? 5 But because t h e GCS was designed for adults, a modified version has b e e n s u g g e s t e d for use in t h e child who h a s not yet developed the cognitive functions e v a l u a t e d in t h e GCS (Table 1). 5
T r a u m a is the n u m b e r one k i l l e r of children. It is responsible for the d e a t h s of more children t h a n all other causes combined. Some 80 to 90 percent of serious injuries in children are due to b l u n t t r a u m a . Children have a l a r g e r surface a r e a relative to t h e i r weight and are more susceptible to h y p o t h e r m i a t h a n adults, often with l e t h a l consequences. They require an orderly system of fluid resuscitation t h a t t a k e s into account t h e i r unique physiologic needs. Children are
The National Flight Paramedics Association
Announces
MID YEAR CLINICAL CONFERENCE
Current Concepts in Trauma Management
Injury Severity Scoring Both t h e T r a u m a Score, a physiologic index of pathology, and t h e I n j u r y Severity Score (ISS), an anatomic index, are b a s e d on t h e a d u l t model? T M It is not surprising, then, that neither method adequately scores t h e severity of injuries sust a i n e d by children. This revelation led to t h e development of two corr e s p o n d i n g pediatric-injury scoring systems. The Pediatric T r a u m a Score (PTS), c u r r e n t l y used by major p e d i a t r i c t r a u m a centers, combines a n a t o m i c a n d physiologic bases to q u a n t i t a t e severity.~s The score uses t h e p a r a m eters of weight, airway, blood pressure, CNS, presence of open wounds a n d s k e l e t a l injury (Table 2). Values r a n g e from - 6 (fatal i n j u r y ) t o + 12 (best prognosis). The score addresses the specific m a n a g e m e n t problems of t h e p e d i a t r i c t r a u m a p a t i e n t , and studies show a good correlation with mortality? 5-87Accuracy, combined w i t h the simplicity of design, m a k e it useful as a field t r i a g e instrument. It h a s been suggested t h a t any child w i t h a score of e i g h t or less should be t r a n s p o r t e d to a p e d i a t r i c t r a u m a center? 2 All d e a t h s in t h e N a t i o n a l Pediatric T r a u m a Registry have occurred in children with a PTS less t h a n n i n e ; 2 The Modified Injury Severity Score (MISS), p u b l i s h e d in 1980 by Mayer et al, was designed to quant i t a t e m u l t i p l e injuries in the p e d i a t r i c age group.8 A l t h o u g h its calculation is identical to t h e ISS (the s u m of the square of t h e t h r e e most severely injured A b b r e v i a t e d Injury Scale [AIS] body systems), t h e r e are t h r e e modifications to t h e original scale:
Summary
• The " g e n e r a l " category has been deleted. • The GCS and specific clinical findings have been added to b e t t e r describe neurologic pathology. • " F a c e / n e c k " are grouped t o g e t h e r as a single category as they are in the AIS. In one survey of 288 pediatric t r a u m a patients, of those p a t i e n t s classified as severely injured by the MISS (score >20), 97.3 percent h a d a PTS of eight or less? 7 The GCS was also proven to correlate well w i t h the MISS and t h e PTS in t h e study.
The Terrace G a r d e n Inn A p r i l 7, 1989 - A t l a n t a , G e o r g i a Featured Topics: • The Multiple Trauma Victim Howard Champion, MD • Inhalation Injury and Carbon Monoxide Toxicity Robert Palmer, PA-C. NREMT-P • Resuscitation of the Hypothermic Patient Nicholas Benson, MD
• Volume M a n a g e m e n t in the Burn Victim James Rex Nelson, RN, NREMT-P • Pediatric Trauma Pauline Ignacio, RN • Shock M a n a g e m e n t Update Frank Thomas, MD
Continuing Education Credit has been applied for through the National Registry. Physician's Category I, AMA and Nursing CEU have also been applied for. For more conference information, call (817)-491-1358. For Hotel Reservations at The Terrace Garden Inn, Atlanta, Georgia Call 1-800-241-8260 in USA • 1-800-682-9600 in Georgia Identify Yourself as a Member of the NFPA Group
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AMJ JANUARY/FEBRUARY1989 23
typically walking or bicycling when injured, and t h u s demonstrate patterns of injury different from adults. The basic ABCs of t r a u m a care are the same for adults and children. The highest priority is to obtain a secure airway, with breathing and circulation the next priorities. CNS t r a u m a is common in children and the leading cause of mortality. Intracranial pressure monitoring is essential to control intracranial pressure and should be used early and whenever indicated. Although children have a r e m a r k a b l e capacity for recovery after head injury, remember t h a t you are dealing with a little person who is frightened and who doesn't understand what is happening to him--take time to care for his emotional needs as well. With a pediatric patient, you inherit a family of patients who need knowledge, comfort and assistance. Don't neglect t h e m in your t r e a t m e n t plan. Remember, children are not small adults and cannot be treated in the same manner as the adult t r a u m a patient. Although the basic principles are the same, children have their own unique qualities t h a t require special skills and knowledge
Trauma in Children. Rockville, MD: Aspen Pub., Inc 1986. 10. Mayer T, Walker ML, Johnson DG, et al: "Causes of Morbidity and Mortality in Severe Pediatric Trauma:' JAMA Marcus RE (ed) Rockvile, MD: Aspen Pub., Inc. 1986. 11. Joyce M: "Initial Management of Pediatric Trauma:' Trauma in Children. Rockville, MD: Aspen Pub., Inc. 1986. 12. Ramenofsky ML: "Initial Evaluation in Pediatric Trauma:' Common Problems in Trauma. Hurst JM (ed). Chicago, IL: Yearbook Med. Pub., Inc, 1987. 13. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support. Chicago, IL: American College of Surgeons. 1985. 14. Rachesky I, Boyce WT, Duncan B, et al: "Clinical Prediction of Cervical Spine Injuries in Children. Radiographic Abnormalities." Am J Dis Child. 141:199-201: 1987. 15. Frame SB, Hendrickson MF: "Problem: Pediatric Cervical Spine Injuries:' Emerg Med. 19:47-51: 1987. 16. Gervin AS: "Head, Chest and Abdominal Trauma:' Manual of Pediatric Emergencies Zanga JR (ed). New York, NY: Churchill Livingstone. 1987. 17. Neff CC, Pff~sterRC, VonSonnenberg E: "Percutaneous Transtracheal Ventilation: Experience and Practical Aspects." J Trauma. 23:84190: 1983. 18. Swatzmann S: "Percutaneous Transtracheal Jet Ventilation for Cardiopulmonary Resuscitation: Evaluation of a New Jet Ventilator:' Crit Care Med. 912:8-13: 1984. 19. Guyton SW. "Chest Injury in Children" Trauma in Children. Marcus RE (ed). Rockville, MD: Aspen Pub. Inc 1986. 20. Eichelberger MR, Randloph JG: "Pediatric
to be properly managed. Every physician who treats t r a u m a must be aware of these differences so t h a t more of our children can leave the hospital to continue happy and productive lives.
References 1. Ramenofsky M., Luteman A, Quindlen E, et al: "Maximum Survival in Pediatric Trauma: The Ideal System:' J Trauma. 24:818-823: 1984. 2. Marcus RE (ed): Trauma in Children. Rockville, MD: Aspen Pub., Inc. 1986. 3. Filston HC: "Pediatric Trauma Management:' Moylan JA (ed). Trauma Surgery. Philadelphia, PA: J.B. Lippincott Co. 1988. 4. Rudolph LA, Freed HA: "Childhood Accidents" Pediatrics, 18th Ed. Rudolph AM (ed). Norwalk, CT: Appleton & Lange. 1987. 5. James HE, Trauner AD: "The Glascow Coma ScaleY Brain Insults in Infants and Children: Pathophysiology and Management. James HE, Anas NG, Perkin RM (eds). Orlando, FL: Harcourt Brace Jovanovich. 1985. 6. Haller JA: "Pediatric Trauma, the No. 1 Killer of Children:' JAMA. 249:47: 1983. 7. Tanz RR, Christofel KK: "Pediatric Injury: The Next Motor Vehicle Injury Challenge" Am J Dis Child. 139:1187-1190: 1985. 8. Mayer T, Matlak ME, Johnson DG, et al: "The Modified Injury Severity Scale in Pediatric Multiple Trauma Patients:'J Pediatr Surg. 15:719-726: 1980. 9. Klein L, Marcus RE: "Trauma in Children: Management, Prognosis and Metabolism"
National Flight Nurses Association Getting Off the,
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Organization. Home Mailing Address City.
24
JANUARY/FEBRUARY1989
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LIFE FLIGHT 1
CLEVELAND METROPOLITAN GENERAL HOSPITAL SAVE
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CRITICAL CARE
TRANSPORT SYMPOSIUM
Featured Guest Speaker. MARTIN
EICHELBERGER, M.D. Director of Pediatric Trauma Services Associate Professor of General Pediatric Surgery Children's Hospital National Medical Center Washington, D.C. Lander Haven Country Club Off 271 and Cedar Road 2101 Lander Road Mayfield Heights, Ohio
For more information call 216-459-3090 Introducing e Source Book of EMS Inf~
_Medical 91 • A n essential resource m a n u a l for every health-care professional w h o administers, p l a n s o r delivers E m e r g e n c y M e d i c a l Services For this fast-paced information age, keeping up with the changes and advances in EMS is a difficult and time-consuming task. That's why the Emergency Can Information Center, a national clearinghouse for EM.~ information, has published Medical 911 for the past 15 years. Here's just a sample of what you'll receive with a sub. scription to Medical 911 : • Timely, comprehensive news in the bimonth EMS Communicator. • Details on private and public EMS organizati • A comprehensive listing of books, films and programs, complete with ordering informat • Teaching programs and other instructional r • Synopses of key EMS reports, where to get 1
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Trauma: An Algorithm for Diagonisis and Therapy." J Trauma. 23:91-97: 1983. 21. Ryckman FC, Noseworthy J: "Multisystem Trauma:' Surg Clin North Am. 65:1287-1302: 1985. 22. DeVivo DC, Dodge PR: "Head Injury:'
Smith's The Critically Ill Child: Diagnosis and Medical Management. Dickerman JD, Lucey JF (ed). Philadelphia, PA: WB. Saunders Co. 1985. 23. Bruce DA: "Cerebrovascular Dynamics:'
Brain Insults in Infants and Children: Pathophysiology and Management. James HR, Anas NG, Perkin RM (ed). Orlando, FL: Harcourt Brace Jovanovich, 1985. 24. Harris BH (ed). Progress in Pediatric Trauma. Proceedings of the First National Conference on Pediatric Trauma. Boston, MA: Sept 26-27, 1985. 25. Bruce DA: "Closed Head Injury." Common Problems in Trauma. Hurst JM (ed). Chicago, IL: Yearbook Med. Pub, 1987. 26. Manwaring KH, Spetzler RF: "Head and CNS Injury in the Child:' Trauma in Children. Marcus RE (ed). Rockvine, MD: Aspen Pub., Inc. 1986. 27. Grubb R., Raichle ME, Eichling JO, et al: "The Effects of Changes in PaCO= on Cerebral Blood Volume, Blood Flow, and Vascular Mean Transit Time:' Stroke. 5:630-639: 1974. 28. Colombani PM, Buck JE, Dudgeon DL, et al: "One Year Experience in a Regional Pediatric Trauma Center:' JPediatr Surg. 20:8-13. 1985. 29. Teasdaie G, Jennett B: "Assessment of Coma and Impaired Consciousness:' Lancet. 2:81-84: 1974. 30. Hammill JF: "Trauma to the Nervous System:' Pediatrics, 18th ed. Rudolph AM (ed). Norwalk, CT: Appleton & Lange 1987. 31. Strauss RH: "Nervous System:' Current Pediatric Therapy 12 Gellis SS, Kagan BM (eds). Philadelphia, PA: W.B. Saunders Co. 1986. 32. Wagstyl J, Sutcliffe AJ, Alpar EK: "Early Prediction of Outcome Following Head Injury in Children. J Pediatric Surg. 22: 127-129: 1987. 33. Champion HR, Sacci WF, Carnazzo AJ, et al: "Trauma Score:' Crit Care 9:672-676: 1981. 34. Baker SP, O'Neill B, Haddon W, et al: "The Injury Severity Score: A Method for Describing Patients with Multiple Injuries and Evaluation of Emergency Care:' J Trauma 14:187-196: 1974. 35. Tepas JJ, Mollitt DL, Talbert JL, et al: "The Pediatric Trauma Score as a Predictor of Injury Severity in the Injured Child:' J Pediatr Surg. 22:14-18: 1987. 36. Ramenofsky ML, Powell RW, Jurkovich GJ: "The Predictive Validity of the Pediatric Trauma Score (Abstract):' J Trauma. 27:830: 1987. 37. Ford EG, Jennings LM, Givson AE, et al: "The Pediatric Trauma Score: Accuracy of Prediction of Injury Severity in a Single Large Urban Pediatric Trauma Experience. Contemp Ortha 16:35-41: 1988.
Carl R. Boyd, MD, is the director of Trauma Service at Memorial Medical Center, Savannah, Georgia. Dr. Boyd is also medical director of L I F E S T A R Helicopter E M S in Savannah. Christopher Schroeder, MD, is the former chief resident of surgery at Memorial Medical Center, Savannah, Georgia. Mary A n n Tolson, RN, is the former trauma nurse coordinator of the Trauma Service at Memorial Medical Center, Savannah, Georgia.