- Email: [email protected]
Quick reference guides for pediatric trauma care
- ~2-
Quick Reference Guides for Pediatric Trauma Care
~
We d o n o t care f o r pediatric patients o n a regular basis. P l e a s e p r o v i d e c l i n i c a l g u i d e l i n e s that c a n b e u s e d to assist u s in p r o v i d i n g a p p r o p r i a t e care.
~
Pediatric trauma patients can be a challenge because they range in age and size - from infant to adult. Children differ anatomically and physiologically from adults, and they need appropriately sized equipment for physical assessment and interventions. The formulas and guidelines provided are intended to serve as a quick reference for assisting providers in adapting care to meet the needs of the children they are treating. These are intended to be only guidelines, a n d providers should check with their medical authority for approved interventions.
AIRWAY ASSESSMENT AND EQUIPMENT 1. Estimating size of artificial airway a. Nasopharyngeal 1 9 Measure from the tip of the nose to the tragus of the ear. The diameter should be the largest size that is easily inserted. (Caution: Children have fragile nasal mucosa that can lacerate and bleed during the insertion of a nasopharyngeal airway.) 9 Infants are obligate nose breathers. The airway will need to be kept as patent as possible. b. Oropharyngeal 1 9 Measure from the tip of the mandibular angle to the level of the central incisors. (Caution: The child's oral mucosa can be Kathy Nichols is a flight nurse with West Michigan AirCare, Kalamazoo,Michigan. For reprints write Kathy Nichols, RN, CFRN, CEN, EMT-P,West MichiganAirCare, 1535 Gull Road, Kalamazoo,M149001.
INT J TRAUMA NURS 1996;2:56-8. Copyright 9 1996 by the Emergency NursesAssociation. 1075-4210/96$5.00 + 0 65/1/72647
56
- 2 7 - - 2 E - -. . . .
~
easily injured; therefore avoid inserting the artificial airway upside d o w n and rotating it into place as is done with adults.) c. Endotracheal tubes 2 9 Size of tube (in millimeters) = 16 + Age (in years) + 4 9 Size of tube can be estimated by noting circumference of child's small finger. (Caution: Uncuffed tubes are r e c o m m e n d e d for a child less than 8 years old. Uncuffed tubes come in sizes 6.0 mm and smaller.) 9 To estimate placing the tip of endotracheal tube above carina, insert tube so that three times the tube size is equal to the centimeter mark on the tube at the tooth/gum line. Example: A 3.0 tube should be inserted so the 9 cm mark on the tube is at the tooth/ gum line. 2. Estimating the size of a suction catheter 9 Diameter = 2 x Size of endotracheal tube 9 Example: A 4Fr endotracheal tube would accept an 8Fr catheter.
CARDIOVASCULAR ASSESSMENTS AND INTERVENTIONS 1. Estimating blood pressure 9 Minimally acceptable systolic blood pressure 3 0-12 months = 60-70 mm Hg 1-2 years = 70-80 mm Hg >2 years = 80 mm Hg + (2 x Age [in years]) (Caution: Hypotension is a late sign of hypovolemia in the pediatric patient.) 2. Estimating body weight 9 >1 year: 2 x Age (in years) + 10 = Weight in kilograms) 9 0-12 months: 0.5 x Age (in months) + 3.5 = Weight (in kilograms) 3. Estimating urine output 9 Minimal acceptable urine output = 0.5 -1.0 ml/ kg/hr 4. Estimating intravenous fluid replacement 9 To estimate normal intravascular blood volume for child ~ Premature infants: 100 ml/kg Term infants: 80-85 ml/kg Children: 80 ml/kg Adults: 70-75 ml/kg
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Clinical Decisions
VOLUME 2, NUMBER 2
T a b l e 1. Pediatric trauma score Component
+2
1. Size 2. Airway
>20 kg Normal
3. Central nervous system 4. Systolic blood pressure 5. Open wounds 6. Skeletal
+1
-1
<20 kg Intubated, cricothyrotomy
Awake
10-20 kg Assisted with oxygen mask or cannula Lethargic, loss of consciousness
>90 mm Hg
90-50 mm Hg
<50 mm Hg
None None
Minor Closed fracture
Major, penetrating Open, multiple fractures
Unresponsive
Total possible score: 12-5; significant if <85.
9 To estimate volume to be replaced for maintenance fluid rates 2 4 ml/kg/hr for first 10 kg 2 ml/kg/hr for second 10 kg 1 m l / k g / h r for each kilogram of b o d y weight above 20 kg 9 To estimate volume to be replaced for acute, rapid loss Crystalloid, colloid, or blood fluid bolus: 10-20 ml/kg 9 To estimate volume to be replaced for a significant burn 4 1. Calculate percent of b o d y surface area burned with "rule of nines" Arm: 9% Head/neck: 18% Anterior trunk: 18% Posterior trunk: 18% Leg: 14% 2. Determine fluid replacement for the first 24 hours since burn 3-4 mi of lactated Ringer's solution x W e i g h t (in k i l o g r a m s ) x % B o d y surface area b u r n e d Give o n e half of c a l c u l a t e d v o l u m e within the first 8 hours Give the remaining one half volume over the next 16 hours (Caution: This formula is a guide for estimating fluid replacement. The patient's clinical response, especially urine output, should be used to monitor fluid needs rather than total reliance on estimated replacement needs.)
ASSESSING SEVERITY OF PEDIATRIC INJURY 1. Pediatric trauma score s See Table 1 for detailed information.
APRIL-JUNE 1996
Table 2. Glasgow Coma Score for infants and toddlers
Eye opening Opens spontaneously Opens to voice Opens to pain None Verbal response Coos, babbles Irritable but consolabte Cries to pain Moans to pain None Motor response Spontaneous movement Withdraws to touch Abnormal flexion Abnormal extension None
4 3 2 1 5 4 3 2 1 6 5 3 2 1'
Total possible score, 3-15; Significant if below < 14. s
2. Glasgow Coma Score for infants and toddlers See Table 2 for detailed information.
EMERGENCY MEDICATIONS Bolus medications ("IV push") 1. Resuscitation medications 2 9 Adenosine: 0.1-0.2 m g / k g (maximum single dose 12 mg) 9 Atropine: 0.02 mg/kg (minimum dose 0.15 mg) 9 Bretylium: 5 mg/kg; repeat with 10 m g / k g 9 Calcium chloride: 20 m g / k g 9 Dextrose: 0.5-1.0 g m / k g ~ (Caution.. Because of hypertonicity of dextrose solution, it must be diluted.) Neonate: 10%-20% solution (Dilute 50% dextrose 1:5 with sterile water to make a 10% solution.)
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Clinical Decisions 57
Child: 25% solution (Dilute 50% dextrose 1:1 with sterile w a t e r to m a k e 25% solution.) Adolescent: 50% solution 9 Epinephrine 0.1 ml/kg of 1:10,000 solution (first dose) 0.1 ml/kg of 1:1000 solution (subsequent doses) 9 Lidocaine: 1.0 mg/kg (infusion 20-50 lag/kg/min) 9 Naloxone <20 kg: 0.1 mg/kg >20 kg: 2.0 mg/kg 9 Sodium bicarbonate: 1 mEq/kg in documented metabolic acidosis or 0.3 mEq x Weight (in kilograms) x Base deficit (Note.. Atropine, epinephrine, lidocaine, and n a l o x o n e h y d r o c h l o r i d e (Narcan) may be given by endotracheal tube. Increase dose two to three times and dilute with saline solution for a total of 3 to 5 ml. Follow with positive pressure ventilations.) 2. Sedation/analgesia 9 Diazepam (Valium): 0.1 mg/kg 9 Fentanyl (Sublimaze): 1.0-3.0 pg/kg 9 Midazolam (Versed): 0.5-0.1 mg/kg 9 Morphine sulfate: 0.1 mg/kg 3. Neuromuscular blocking agents 9 Mivacurium chloride (Mivacron): 0.09-0.11 mg/kg 9 Pancuronium bromide (Pavulon): 0.1 mg/kg 9 Succinylcholine: 1-2 mg/kg 9 Vecuronium: 0.1 mg/kg
Infusion Medications ("IV Drip"): The Rule of 6s 9 Dobutamine 9 Dopamine 1. Calculate dose of drug (in milligrams) to be added to diluent by the following formula: 6.0 x Weight (in kilograms) = Dose dose 2. Note volume of drug dose in milliliters. 3. Select diluent that does not exceed 100 ml. 4. Remove a comparable number of milliliters of diluent equal to that calculated in step 12. 5. Add milliliters of medication so that total volume of infusion is 100 ml. 6. Infuse at 1 ml/hr to deliver 1 lag/kg/min. 9 Epinephrine 1. Calculate dose of drug (in milligrams) to be added to diluent by the following formula: 0.6 x Weight (in kilograms) = Drug dose 2. Add to 100 ml of diluent. 3. Infuse at 1 ml/hr to deliver 1 1.1g/kg/min.
58
SPECIAL CONSIDERATIONS FOR THE PEDIATRIC PATIENT Caring for an injured child requires specialized skills, experience, and attention to details. The following special considerations may be helpful w h e n caring for the pediatric trauma patient. 1. Temperature control. The pediatric trauma patient has a high potential for loss of body heat. Special a t t e n t i o n s h o u l d b e p a i d to p r e v e n t i n g h y p o t h e r m i a ( b y m i n i m i z i n g e x p o s u r e to ambient air and moisture) and to monitoring core b o d y temperature. 2. E m o t i o n a l care. D e p e n d i n g o n a g e a n d developmental stage, children may not be able to comprehend the pain and helplessness they are feeling. They may have a variety of common c h i l d h o o d fears or be o v e r w h e l m e d by the hospital environment. A soothing voice, comforting touch, and the use of family-centered care w h e n e v e r possible will help to reduce a child's anxiety. Parents and other relatives of the injured child are usually anxious and may have feelings of guilt or anger. T h e y s h o u l d be communicated with frequently and allowed to be with the child as much as possible. 3. Patient comfort. Children do have pain and anxiety, and they need medication. Procedures should be explained. This is especially true for the chemically relaxed, intubated patient. 4. Rapid changes. The pediatric trauma patient has strong homeostatic protective mechanisms that can hide distress until the body loses its ability to compensate. Once that occurs, the child may undergo rapid physiologic deterioration. Subtle changes may be indicative of a changing status. An acutely injured child's vital signs, including level of consciousness should be m o n i t o r e d frequently for changes. REFERENCES 1. Stillwell SB. Mosby's critical care nursing reference. St. Louis: Mosby-Year Book, 1992. 2. American Academy of Pediatrics. Textbook of pediatric life support. Dallas: American HeartAssociation, 1994. 3. Aoki B, Mckloskey K. Evaluation, stabilization, and transport of the critically ill child. St. Louis: Mosby-Year Book, 1992. 4. National Burn Institute. Advanced burn life support. Lincoln, NE: National Burn Institute, 1992. 5. Committee on Trauma, American College of Surgeons. Advanced trauma life support. Chicago: American College of Surgeons, 1993. 6. Rogers M. Textbook of pediatric intensive care. 2nd edition. Baltimore: Williams & Wilkins, 1992.
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Clinical Decisions
VOLUME 2, NUMBER 2
Quick Reference Guides for Pediatric Trauma Care
~
We d o n o t care f o r pediatric patients o n a regular basis. P l e a s e p r o v i d e c l i n i c a l g u i d e l i n e s that c a n b e u s e d to assist u s in p r o v i d i n g a p p r o p r i a t e care.
~
Pediatric trauma patients can be a challenge because they range in age and size - from infant to adult. Children differ anatomically and physiologically from adults, and they need appropriately sized equipment for physical assessment and interventions. The formulas and guidelines provided are intended to serve as a quick reference for assisting providers in adapting care to meet the needs of the children they are treating. These are intended to be only guidelines, a n d providers should check with their medical authority for approved interventions.
AIRWAY ASSESSMENT AND EQUIPMENT 1. Estimating size of artificial airway a. Nasopharyngeal 1 9 Measure from the tip of the nose to the tragus of the ear. The diameter should be the largest size that is easily inserted. (Caution: Children have fragile nasal mucosa that can lacerate and bleed during the insertion of a nasopharyngeal airway.) 9 Infants are obligate nose breathers. The airway will need to be kept as patent as possible. b. Oropharyngeal 1 9 Measure from the tip of the mandibular angle to the level of the central incisors. (Caution: The child's oral mucosa can be Kathy Nichols is a flight nurse with West Michigan AirCare, Kalamazoo,Michigan. For reprints write Kathy Nichols, RN, CFRN, CEN, EMT-P,West MichiganAirCare, 1535 Gull Road, Kalamazoo,M149001.
INT J TRAUMA NURS 1996;2:56-8. Copyright 9 1996 by the Emergency NursesAssociation. 1075-4210/96$5.00 + 0 65/1/72647
56
- 2 7 - - 2 E - -. . . .
~
easily injured; therefore avoid inserting the artificial airway upside d o w n and rotating it into place as is done with adults.) c. Endotracheal tubes 2 9 Size of tube (in millimeters) = 16 + Age (in years) + 4 9 Size of tube can be estimated by noting circumference of child's small finger. (Caution: Uncuffed tubes are r e c o m m e n d e d for a child less than 8 years old. Uncuffed tubes come in sizes 6.0 mm and smaller.) 9 To estimate placing the tip of endotracheal tube above carina, insert tube so that three times the tube size is equal to the centimeter mark on the tube at the tooth/gum line. Example: A 3.0 tube should be inserted so the 9 cm mark on the tube is at the tooth/ gum line. 2. Estimating the size of a suction catheter 9 Diameter = 2 x Size of endotracheal tube 9 Example: A 4Fr endotracheal tube would accept an 8Fr catheter.
CARDIOVASCULAR ASSESSMENTS AND INTERVENTIONS 1. Estimating blood pressure 9 Minimally acceptable systolic blood pressure 3 0-12 months = 60-70 mm Hg 1-2 years = 70-80 mm Hg >2 years = 80 mm Hg + (2 x Age [in years]) (Caution: Hypotension is a late sign of hypovolemia in the pediatric patient.) 2. Estimating body weight 9 >1 year: 2 x Age (in years) + 10 = Weight in kilograms) 9 0-12 months: 0.5 x Age (in months) + 3.5 = Weight (in kilograms) 3. Estimating urine output 9 Minimal acceptable urine output = 0.5 -1.0 ml/ kg/hr 4. Estimating intravenous fluid replacement 9 To estimate normal intravascular blood volume for child ~ Premature infants: 100 ml/kg Term infants: 80-85 ml/kg Children: 80 ml/kg Adults: 70-75 ml/kg
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Clinical Decisions
VOLUME 2, NUMBER 2
T a b l e 1. Pediatric trauma score Component
+2
1. Size 2. Airway
>20 kg Normal
3. Central nervous system 4. Systolic blood pressure 5. Open wounds 6. Skeletal
+1
-1
<20 kg Intubated, cricothyrotomy
Awake
10-20 kg Assisted with oxygen mask or cannula Lethargic, loss of consciousness
>90 mm Hg
90-50 mm Hg
<50 mm Hg
None None
Minor Closed fracture
Major, penetrating Open, multiple fractures
Unresponsive
Total possible score: 12-5; significant if <85.
9 To estimate volume to be replaced for maintenance fluid rates 2 4 ml/kg/hr for first 10 kg 2 ml/kg/hr for second 10 kg 1 m l / k g / h r for each kilogram of b o d y weight above 20 kg 9 To estimate volume to be replaced for acute, rapid loss Crystalloid, colloid, or blood fluid bolus: 10-20 ml/kg 9 To estimate volume to be replaced for a significant burn 4 1. Calculate percent of b o d y surface area burned with "rule of nines" Arm: 9% Head/neck: 18% Anterior trunk: 18% Posterior trunk: 18% Leg: 14% 2. Determine fluid replacement for the first 24 hours since burn 3-4 mi of lactated Ringer's solution x W e i g h t (in k i l o g r a m s ) x % B o d y surface area b u r n e d Give o n e half of c a l c u l a t e d v o l u m e within the first 8 hours Give the remaining one half volume over the next 16 hours (Caution: This formula is a guide for estimating fluid replacement. The patient's clinical response, especially urine output, should be used to monitor fluid needs rather than total reliance on estimated replacement needs.)
ASSESSING SEVERITY OF PEDIATRIC INJURY 1. Pediatric trauma score s See Table 1 for detailed information.
APRIL-JUNE 1996
Table 2. Glasgow Coma Score for infants and toddlers
Eye opening Opens spontaneously Opens to voice Opens to pain None Verbal response Coos, babbles Irritable but consolabte Cries to pain Moans to pain None Motor response Spontaneous movement Withdraws to touch Abnormal flexion Abnormal extension None
4 3 2 1 5 4 3 2 1 6 5 3 2 1'
Total possible score, 3-15; Significant if below < 14. s
2. Glasgow Coma Score for infants and toddlers See Table 2 for detailed information.
EMERGENCY MEDICATIONS Bolus medications ("IV push") 1. Resuscitation medications 2 9 Adenosine: 0.1-0.2 m g / k g (maximum single dose 12 mg) 9 Atropine: 0.02 mg/kg (minimum dose 0.15 mg) 9 Bretylium: 5 mg/kg; repeat with 10 m g / k g 9 Calcium chloride: 20 m g / k g 9 Dextrose: 0.5-1.0 g m / k g ~ (Caution.. Because of hypertonicity of dextrose solution, it must be diluted.) Neonate: 10%-20% solution (Dilute 50% dextrose 1:5 with sterile water to make a 10% solution.)
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Clinical Decisions 57
Child: 25% solution (Dilute 50% dextrose 1:1 with sterile w a t e r to m a k e 25% solution.) Adolescent: 50% solution 9 Epinephrine 0.1 ml/kg of 1:10,000 solution (first dose) 0.1 ml/kg of 1:1000 solution (subsequent doses) 9 Lidocaine: 1.0 mg/kg (infusion 20-50 lag/kg/min) 9 Naloxone <20 kg: 0.1 mg/kg >20 kg: 2.0 mg/kg 9 Sodium bicarbonate: 1 mEq/kg in documented metabolic acidosis or 0.3 mEq x Weight (in kilograms) x Base deficit (Note.. Atropine, epinephrine, lidocaine, and n a l o x o n e h y d r o c h l o r i d e (Narcan) may be given by endotracheal tube. Increase dose two to three times and dilute with saline solution for a total of 3 to 5 ml. Follow with positive pressure ventilations.) 2. Sedation/analgesia 9 Diazepam (Valium): 0.1 mg/kg 9 Fentanyl (Sublimaze): 1.0-3.0 pg/kg 9 Midazolam (Versed): 0.5-0.1 mg/kg 9 Morphine sulfate: 0.1 mg/kg 3. Neuromuscular blocking agents 9 Mivacurium chloride (Mivacron): 0.09-0.11 mg/kg 9 Pancuronium bromide (Pavulon): 0.1 mg/kg 9 Succinylcholine: 1-2 mg/kg 9 Vecuronium: 0.1 mg/kg
Infusion Medications ("IV Drip"): The Rule of 6s 9 Dobutamine 9 Dopamine 1. Calculate dose of drug (in milligrams) to be added to diluent by the following formula: 6.0 x Weight (in kilograms) = Dose dose 2. Note volume of drug dose in milliliters. 3. Select diluent that does not exceed 100 ml. 4. Remove a comparable number of milliliters of diluent equal to that calculated in step 12. 5. Add milliliters of medication so that total volume of infusion is 100 ml. 6. Infuse at 1 ml/hr to deliver 1 lag/kg/min. 9 Epinephrine 1. Calculate dose of drug (in milligrams) to be added to diluent by the following formula: 0.6 x Weight (in kilograms) = Drug dose 2. Add to 100 ml of diluent. 3. Infuse at 1 ml/hr to deliver 1 1.1g/kg/min.
58
SPECIAL CONSIDERATIONS FOR THE PEDIATRIC PATIENT Caring for an injured child requires specialized skills, experience, and attention to details. The following special considerations may be helpful w h e n caring for the pediatric trauma patient. 1. Temperature control. The pediatric trauma patient has a high potential for loss of body heat. Special a t t e n t i o n s h o u l d b e p a i d to p r e v e n t i n g h y p o t h e r m i a ( b y m i n i m i z i n g e x p o s u r e to ambient air and moisture) and to monitoring core b o d y temperature. 2. E m o t i o n a l care. D e p e n d i n g o n a g e a n d developmental stage, children may not be able to comprehend the pain and helplessness they are feeling. They may have a variety of common c h i l d h o o d fears or be o v e r w h e l m e d by the hospital environment. A soothing voice, comforting touch, and the use of family-centered care w h e n e v e r possible will help to reduce a child's anxiety. Parents and other relatives of the injured child are usually anxious and may have feelings of guilt or anger. T h e y s h o u l d be communicated with frequently and allowed to be with the child as much as possible. 3. Patient comfort. Children do have pain and anxiety, and they need medication. Procedures should be explained. This is especially true for the chemically relaxed, intubated patient. 4. Rapid changes. The pediatric trauma patient has strong homeostatic protective mechanisms that can hide distress until the body loses its ability to compensate. Once that occurs, the child may undergo rapid physiologic deterioration. Subtle changes may be indicative of a changing status. An acutely injured child's vital signs, including level of consciousness should be m o n i t o r e d frequently for changes. REFERENCES 1. Stillwell SB. Mosby's critical care nursing reference. St. Louis: Mosby-Year Book, 1992. 2. American Academy of Pediatrics. Textbook of pediatric life support. Dallas: American HeartAssociation, 1994. 3. Aoki B, Mckloskey K. Evaluation, stabilization, and transport of the critically ill child. St. Louis: Mosby-Year Book, 1992. 4. National Burn Institute. Advanced burn life support. Lincoln, NE: National Burn Institute, 1992. 5. Committee on Trauma, American College of Surgeons. Advanced trauma life support. Chicago: American College of Surgeons, 1993. 6. Rogers M. Textbook of pediatric intensive care. 2nd edition. Baltimore: Williams & Wilkins, 1992.
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Clinical Decisions
VOLUME 2, NUMBER 2