A—Airway and Cervical Spine Stabilization

Table 38-1 describes anatomic considerations that have implications in the management of the pediatric airway. The physician assesses for possible airway obstruction or inability of the child to maintain his or her own airway. While the neck is being stabilized, the airway can be opened with a jaw-thrust maneuver. Maxillofacial trauma, loose teeth, blood, swelling, or vomitus may obstruct the airway, and efforts should be made toward clearing the oropharynx of debris. Gurgling or stridor may indicate upper airway obstruction. The physician must know normal pediatric oral anatomy and tooth development to recognize the possibility of missing primary or secondary teeth. Efforts to perform cricoid pressure, or ligatures such as ties on gowns, can easily occlude the infant’s or child’s airway with as little as 0.2 pounds of direct force.⁵ Table 38-2 describes priorities in the assessment of the pediatric airway.

Indications for endotracheal intubation of a pediatric trauma patient include (1) any inability to ventilate by bag-valve-mask (BMV) methods or the need for prolonged control of the airway, (2) Glasgow Coma Scale (GCS) score of less than 9 (to secure the airway and provide controlled hyperventilation if indicated), (3) respiratory failure from hypoxemia (e.g., flail chest and pulmonary contusions) or hypoventilation (e.g., injury to airway structures or spinal cord injury [SCI]), and (4) the presence of decompensated shock resistant to initial fluid administration.

Intubation of pediatric patients involves special considerations (see Table 38-1). In general, the orotracheal approach is recommended. In children, nasotracheal intubation can be complicated by the acute angle of the posterior pharynx, the potential for bleeding, and infection (sinusitis). Furthermore, nasotracheal intubation can cause increased intracranial pressure (ICP). In children younger than age 8, the cricoid ring is the narrowest portion of the airway. The cricoid ring may form a physiologic cuff on endotracheal tubes (ETT). However, the use of a cuffed tube allows for greater airway protection and may be considered in the injured child. Appropriate ETT size can be estimated through use of a length-based resuscitation tape or by the formulas in Box 38-2.

The clinician should consider the possibility of cervical cord injuries in all seriously traumatized children. Spinal column stabilization should be maintained until injury is ruled out. (Evaluation of the cervical spine in children is discussed later in this chapter.) A gentle, developmentally appropriate approach is used if reliable information is to be gained. Any complaint of past or current neurologic deficit, neck pain, or significant trauma to the head, chest, abdomen, or other spinal level injury should raise concern for spinal injury.

B—Breathing and Ventilation

The physician assesses for breath sounds and adequacy of chest rise. In a young child, this rise occurs in the lower chest and upper abdomen. Both the chest and the abdomen should move concordantly. Discordant motion with significant inward chest motion is referred to as paradoxical breathing and is a sign of impending respiratory failure. Respiratory rates that are too fast or too slow can also indicate impending respiratory failure. Treatment is assisted ventilation. If ventilation is necessary, a BMV device is recommended initially. Only the volume necessary to cause the chest to rise should be provided because excessive volume or rate of ventilation can increase the likelihood of gastric distention (increasing the risk of vomiting and aspiration) and impair ventilation further. Gentle cricoid pressure may help decrease the amount of air entering the esophagus during positive pressure ventilation. After intubation a nasogastric (NG) or orogastric (OG) tube should be placed within the first few minutes. Gastric distention often leads to respiratory embarrassment and potential hypotension caused by decreased venous return and impaired diaphragmatic function. Occasionally, BMV and air swallowing can lead to gastric distention, necessitating an NG tube. An NG tube should not be used if basilar skull fracture is possible. In conscious children, placement of an NG or OG tube should be preceded by local anesthesia with use of agents such as atomized or nebulized lidocaine plus lidocaine jelly. If a child with an NG or OG tube requires intubation, the gastric tube should be placed to suction to empty the stomach before rapid sequence intubation (RSI), because the gastric tube disrupts the gastroesophageal junction and can otherwise lead to aspiration.

Many factors may compromise ventilatory function in an injured child. These include depressed sensorium, occlusion of the airway, painful restriction of lung expansion, diaphragmatic fatigue, and direct pulmonary injury. Determination of adequate ventilation is possible only in the face of airway patency and adequate air exchange.

For assessment of “ventilation,” pulse oximetry is useful; however, pulse oximetry measures adequacy of oxygenation only. The measurement of exhaled carbon dioxide (CO₂) is useful to confirm ETT position. Historically, a colorimetric semiquantitative device has been used to detect the presence of exhaled CO₂ in patients with perfusion. Continuous end-tidal CO₂ capnography provides far more information and continues to be underused.⁶ In a patient with adequate perfusion, in addition to serving as an initial qualitative device to confirm successful intubation of the trachea, it may also provide an early warning of unintended extubation, tube kinking or partial occlusion, or ventilator malfunction. Continuous end-tidal CO₂ capnography also characterizes the response to therapeutic maneuvers instantaneously, provides a quantitative tool to manage the ventilatory aspects of respiration, and may provide prognostic information when used in patients with cardiac arrest. It can also be used to measure the effectiveness of cardiopulmonary resuscitation (CPR). The lack of appropriate CO₂ detection when the tube is in proper position often indicates poor perfusion. The use of end-tidal CO₂ capnography allows better ventilatory management during head injury resuscitation, and its values can be confirmed with a single venous or arterial blood gas measurement. This can assist greatly with continuing ventilatory management without the need for recurrent blood draws and the inherent delays and discomfort of acquiring blood gases (assuming stable pulmonary function). Table 38-3 describes priorities in the assessment of breathing in pediatric trauma patients.

C—Circulation and Hemorrhage Control

Shock is not defined by any specific blood pressure but is, instead, a state in which the body is unable to maintain adequate tissue perfusion. Maintenance of systolic blood pressure does not ensure that the patient is not in shock. The pediatric vasculature has the ability to constrict and increase systemic vascular resistance in an attempt to maintain perfusion. Signs of poor perfusion (cool distal extremities, decreases in peripheral versus central pulse quality, and delayed capillary refill time) are signs of pediatric shock, even when blood pressure is maintained at normal levels. Palpable pulses are detectable at a systolic blood pressure greater than 80 mm Hg in children over approximately 10 years of age; however, pulses may be felt at even lower pressures in infants and younger children. Normal capillary refill time is less than 2 seconds; however, many variables affect this clinical finding. Alteration in a child’s response to the environment or interaction with caregivers may indicate respiratory failure or shock. External hemorrhage should be sought and controlled with direct pressure. The assessment of circulation in pediatric trauma patients is described in Box 38-3.

D—Disability Assessment (Thorough Neurologic Examination)

For assessment of patient disability, a rapid neurologic and mental status evaluation is needed. The assessment of disability in pediatric trauma patients is described in Box 38-4. The AVPU system (Box 38-5) and the modified pediatric GCS (Table 38-4) can also be useful to the clinician.

E—Exposure and Thorough Examination

Fully undressing the patient to assess for hidden trauma is essential in injured children. Maintenance of normothermia is paramount in the undressed infant and toddler because metabolic needs are greatly increased by hypothermia. In addition to increased ambient temperature, additional warming methods such as warmed humidified oxygen, warmed fluids, warmed blood, head wraps, and convective warmers or radiant heat sources should be used as soon as possible. Preventing and treating hypothermia is not a matter of comfort for traumatized infants and children but, instead, one of survival. The exposure phase of the survey is often a good time to concurrently begin imaging and further diagnostic testing (Table 38-5).

F—FAST and Family

The focused assessment with sonography in trauma (FAST) can be a very useful examination in injured children.⁷ Bedside ultrasound evaluates for traumatic free fluid in the peritoneum (hepatorenal, perisplenic, and retrovesicular views) and pericardial space. In hemodynamically unstable children, a FAST may point to hemorrhage in the abdomen or the pericardial space and the need for intervention. In hemodynamically stable children, the FAST examination may indicate the need for computed tomography (CT) imaging, closer observation, repeat abdominal examinations, or repeat ultrasound examinations.

In the management of children, the family (caregivers) could be added to the primary survey. Rapidly informing the family of what has happened and of the evaluation and progress helps to lessen their stress. Allowing family members to be present during resuscitations is acceptable and often preferred by families. Some family members choose not to be present, but that choice should be given to them. If a family member is present, it is advisable to assign a staff member to be with him or her during the trauma resuscitation to explain the process.

Child life specialists and clergy are valuable members of the resuscitation team. They not only serve the patient directly through their provision of comfort and developmentally appropriate explanations of medical activities, but also serve as a single caring person for the child to focus on throughout the evaluation. They can also be instrumental in assisting the family to better understand what they may and may not do during and soon after the resuscitation. Families often wonder, but are sometimes afraid to ask, if they may touch the child and what the next step is. These specialists can play a role as the quintessential patient advocate, ensuring that the health care providers focus on the patient and not only on the individual medical issue at hand. Child life specialists should be viewed as part of the resuscitation team.

Physical Examination

After the primary survey, a head-to-toe examination is carefully performed. Specifics of the head examination include pupillary size and reactivity and palpation of the skull. A funduscopic examination may be considered in young children with possible nonaccidental trauma. A Wood’s lamp evaluation with fluorescein should be considered if there is possibility of occult injury to the eye.

Assessment of the cervical spine is done carefully, with the patient in full cervical spine immobilization. As soon as feasible, the patient should be removed from the backboard with cervical spine immobilization maintained. Backboards are uncomfortable and can cause rapid necrosis at pressure points. There are no common indications to justify leaving children on backboards after their initial evaluation. When the patient is rolled to remove the backboard, palpation of the rest of the spine can take place with an emphasis on evaluating for ecchymosis, tenderness, and step-offs. Obtunded patients and those with signs or symptoms of thoracic or lumbar spine injuries should be carefully moved and positioned to protect them from possible further injury until imaging or return of consciousness allows more definitive assessment.

Assessment of the chest and internal structures involves inspection for wounds and flail segments; palpation for tenderness, crepitus, and point of maximal cardiac impulse; and auscultation for asymmetry or poorly transmitted breath sounds. When air bags have deployed, occult trauma such as pulmonary contusions, myocardial injury, pneumothorax, and especially aortic injury should be specifically considered and ruled out.

The abdominal examination consists of inspection, palpation, and a FAST examination. A “lap belt sign” or “seat belt sign” across the abdomen is a significant harbinger of serious traumatic injury. Palpation is best done on a cooperative patient but is an insensitive screening test for the presence of an injury.

A rectal examination is not required in all cases of pediatric trauma and should be performed only when its result has a reasonable chance of meaningfully changing the patient’s treatment.9,10 A rectal examination may provide information on sphincter tone in possible spinal injury and the presence of blood in penetrating trauma. Unfortunately, the rectal examination lacks sensitivity. Its findings, when negative, are often misleading, and additional workup should be considered.

Although urethral injury is rare in children, all trauma patients should be assessed for a perineal, scrotal, penile, or lower abdominal hematoma and blood from the urethral meatus. If there is clinical concern for injury to the urethra, a retrograde urethrogram should be completed before the insertion of a urinary catheter.

Examination of the extremities is directed toward the evaluation of any deformities, penetrations, neurologic deficits, and interruptions of perfusion. Most fracture sites may be stabilized with splinting until surgical intervention can be carried out. Careful vascular and neurologic examinations should be performed in all cases of significant extremity injury and should be repeated frequently (especially after interventions such as splinting or reduction). Early orthopedic consultation is advisable.

Reexamination of trauma patients throughout their time in the emergency department is of utmost importance to ensure that their condition has not changed, that their pain is controlled, and that no injuries are overlooked. Up to 70% of injuries with delayed diagnosis in pediatric trauma are orthopedic in nature.¹¹

Pain Control

Pain control is an essential part of any trauma patient’s management. Yet when asked if they want pain medicine, many children in pain will say “No” because they are afraid of getting a shot or they interpret “pain medicine” as medicine that will cause pain. Therefore basing pain medication on pain scales and common sense seems to be most appropriate.

The mainstay of pain control is narcotic analgesics. Fentanyl has an advantage over morphine owing to its hemodynamic profile. It does not cause the release of histamine commonly seen with morphine and has a lower incidence of causing hypotension. Initial orders should generally be for both an initial dose and an as-needed (PRN) dose so that the nurse can continue to adequately control and assess the patient’s pain after the physician has left the bedside.

In head-injured patients, fentanyl has the additional advantage of a short duration of action. If the patient has a mental status change, fentanyl clears quickly, making it possible to differentiate worsening brain injury from side effects of the medication. This is generally a better option than reversing the pain medicine and pain control with a narcotic antagonist. It is not humane to withhold pain medication completely in a traumatized patient whose mental status is of concern; it is better to titrate with smaller doses of short-lived medications. If immediate concern arises, or there is respiratory depression, the narcotic can be reversed with very small doses of a narcotic antagonist.

In addition to use of narcotics for pain control, immobilization of fractures and extremities with significant soft tissue injury can help control pain. Visual imagery and distraction techniques can divert the patient’s attention away from noxious stimuli and toward more pleasant experiences. Child life specialists, patient representatives, chaplains, and most parents can assist in this endeavor. Assessment of pain control practice during pediatric trauma care should be part of each emergency department’s trauma protocols and quality improvement program.

Laboratory Studies

Blood sampling for a pediatric trauma patient is no different than that for an adult trauma patient; however, use of smaller blood collection tubes and microtechnique by laboratory staff may be necessary in infants and small children.

In patients with hypovolemic shock, the hemoglobin alone is unreliable because equilibration will not have occurred at the time of presentation to the emergency department.¹² Serial hemoglobin measurements may be useful to assess the possibility of ongoing bleeding.¹³

Bedside glucose testing should be performed on all patients with significant trauma. Children’s glucose utilization and metabolic rate per kilogram are much greater than those of an adult, and they have far less substrate reserve in the form of glycogen stores. Any child with a change in mental status after trauma should have a glucose level checked immediately. Any child requiring dextrose owing to hypoglycemia will likely need an ongoing dextrose supply to prevent recurrence of hypoglycemia. In patients who can eat, this may be a meal with starches, fats, and protein. In others, it may require intravenous dextrose.

All older pediatric trauma patients should be assessed for the possible use of drugs or alcohol and depression as contributing factors to the traumatic event. Female adolescents should also be tested for pregnancy.

Radiology

Chest and pelvic radiographs can assess for causes of respiratory failure, sites of blood loss, and causes of shock. In stable, alert children without distracting injuries, the pelvic film may be eliminated if no suggestion of sacral or pelvic fracture is found on thorough clinical examination. The following seven criteria are required to rule out any relevant pelvic fracture: patient age older than 3 years, no impairment of consciousness, no other major distracting injury, no complaint of pelvic pain, no signs of fracture on inspection, no pain on iliac or pubic symphysis compression, and no pain on hip rotation or flexion.14–16 In patients with remarkable sacral tenderness and negative plain radiographs, a CT scan should be strongly considered. Sacral fractures can be difficult to discern reliably on plain films.

Other imaging is obtained based on the physical examination. For patients sustaining minor trauma, no imaging may be needed. Children younger than 2 years with injuries consistent with child abuse should undergo a skeletal survey. In general, this survey should be completed on a nonemergent basis after admission to the hospital. In most cases, it can be scheduled in the inpatient radiology department with the pediatric radiologist or the most experienced radiologist available to interpret the films. Additional imaging for specific injuries is discussed later in the chapter.

Perspective

Each year, more than 500,000 children (ages 0 to 14 years) visit emergency departments in the United States after head injury.¹⁷ Falls account for 50.2% of pediatric head injuries. On an age-related basis, infants and toddlers are more prone to falls from their own height, school-age children are involved in sports injuries and MVCs, and children of all ages are subject to the sequelae of abuse. Although MVCs account for only 6.8% of pediatric head injuries, they represent more than 30% of fatal head injuries.¹⁷

Principles of Disease

Important anatomic variations lead to differences in pediatric and adult head trauma. The cranial vault of a child is larger and heavier in proportion to the total body mass. This predisposes children, specifically toddlers and infants, to high degrees of torque that are generated by any forces along the cervical spine axis. Sutures within the pediatric skull are both protective and detrimental to the outcome of head injury. Although the cranium may be more pliable relative to traumatic insult, forces are generated internally that predispose the pediatric patient to parenchymal injury in the absence of skull fractures. The pediatric brain is less myelinated, with a higher water content, predisposing it to shearing forces and further injury.

Clinical Features

The clinician obtains as many details regarding the traumatic event as possible. The height of the fall or injury is particularly important with regard to the development of associated injury. Most children fall from their own height. It is important to consider the quality of the surface at the point of impact, specifically the presence or absence of carpeting at the location where the injury occurred. Impact with an object increases the localized force, even after a short fall, and may lead to increased risk for fracture and intraparenchymal injury. Children involved in MVCs are best evaluated by the degree of restraint that was present during the time of the accident. Unrestrained and improperly restrained children involved in high-speed crashes are prone to serious injury.

It is also important to establish whether there was alteration of consciousness at the time of the injury event. With playground trauma, the history may be vague, and the interpretation of any change in consciousness of the child may be regarded as an actual loss of consciousness. The behavior of the child after the event should be assessed with questions related to the presence or absence of irritability, lethargy, personality change, abnormal gait, or other alterations in behavior. Any worsening of these symptoms after the injury should also be reported.

The prognostic significance of vomiting after pediatric head trauma is unclear. There is no adequate study defining an acceptable time frame in which vomiting after head injury is benign in nature. Vomiting appears to be more strongly correlated to personal or familial tendency to vomit than to intracranial injury; however, recurrent vomiting is commonly seen in patients with significant head injury and is often considered in the decision to obtain a CT study.¹⁸

The development of seizures after head trauma has been well studied.¹⁹ A brief seizure that occurs immediately after an insult (with rapid return to normal level of consciousness) is commonly called an impact seizure. This type of seizure is not usually associated with intracranial parenchymal injury. A CT scan is not necessary if the only concern is the impact seizure; the decision to scan should take into account the mechanism of injury and current neurologic status of the child. An isolated impact seizure does not require anticonvulsant therapy. Seizures that occur later (more than 20 minutes after the insult) portend the greater possibility of traumatic brain injury and the development of seizures at a later date. A CT scan is indicated for these later post-traumatic seizures. These patients may benefit from treatment with anticonvulsants, benzodiazepines for sedation if intubated, or both as the seizure threshold is generally lower in children. Having one later seizure (nonimpact) raises the risk of subsequent additional seizure, and seizure activity raises ICP while often decreasing oxygenation and ventilation. Children who experience later seizures often require neurosurgical evaluation.

The physical examination of a head-injured child includes strict attention to the ABCs (airway, breathing, and circulation) of emergency care. The maintenance of oxygenation and perfusion is paramount in eliminating further insult. Because the pediatric brain is sensitive to decreases in glucose, oxygen, and perfusion, their maintenance optimizes the chances of good recovery. Strict attention is paid to the maintenance of euvolemia because cerebral perfusion pressure (CPP) is adequate only in the face of a normal mean arterial pressure (MAP). Conceptually, CPP is equal to MAP minus ICP:

As MAP is reduced, so is CPP. Localized CPP at the site of injury and in the areas surrounding it may vary greatly from the approximations of this formula. Pediatric patients with any form of head injury should also be evaluated for and protected from cervical spine injury.

Several methods are available for evaluating the mental status of head-injured patients, including the AVPU system and the GCS. A commonly used modification of the GCS for children is shown in Table 38-4. Although the pediatric GCS is widely used, none of the pediatric modifications of the GCS has the inter-rater reliability or predictive validity of the adult GCS. Even children with low initial GCS scores can have favorable outcomes and neurologic status. The important message is that no matter what the patient’s neurologic presentation, all efforts should be initiated to ensure survival and maintain stable neurologic status in the emergency department.

Examining a brain-injured child involves mental status testing, cranial nerve testing, motor testing, sensory testing, and memory testing. The evaluation of cranial nerve function is essentially no different from that in an adult. The most important aspect of motor and cranial nerve evaluation involves ruling out the presence of increased ICP. Common symptoms and signs of increased ICP in infants and children should be sought (Boxes 38-8 and 38-9).

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