Primary Survey, Secondary Survey, and Adjuncts
Priscilla Chiu MD, PhD, FRCSC
EPIDEMIOLOGY
Trauma is the leading cause of death in children age 16 and under.4
Blunt trauma is the most common mechanism of injury in children due to5:
Falls.
Motor vehicle accidents: passenger, pedestrian, bicycle.
Most common injuries: fractures, intracranial, internal.
Young children have better outcomes when treated at pediatric trauma centers.8
Children have better outcomes than adults following traumatic injuries.3
Traumatic injuries suspicious for abuse must be documented, investigated, and reported as per local practice patterns (such as Children’s Aid Society in Ontario).
Penetrating trauma incidence is increasing in some large urban centers.9
DEFINITIONS10
Primary Survey
Quick, initial patient assessment to identify life-threatening injuries.
Occurs simultaneously with active resuscitation (securing airway, establishing IV, fluid resuscitation, control of bleeding).
Happens in a systematic and logical sequence.
Secondary Survey
More detailed assessment of injuries.
Reevaluation of the interventions with the transition toward definitive care.
PRIMARY SURVEY
Pediatric Primary Survey: ABCDEs (Fig. 2-1)
Every trauma patient should arrive on a board with C-spine immobilization.
Collar on for school-age and adolescent children.
Rolls and tape for infants and toddlers.
Immediately check vital signs and temperature.
The initial management is always the ABCs, described next.
A: Airway with Cervical Spine Protection
Clear secretions, assess patency and need for intubation.
Look for foreign bodies.
Be cautious when small children have associated neurologic or craniofacial injuries— intubate early.
Significant airway burns or inhalation injury (based on mechanism, length of time of rescue, initial saturations) will require early intubation.
Ensure adequate C-spine protection, particularly when moving the patient.
See Chapter 9 on C-spine Management for details.
 FIGURE 2-1 • Algorithm for the hemodynamic resuscitation of the pediatric trauma patient. (From American College of Surgeons’ Committee on Trauma. Advanced Trauma Life Support for Doctors (ATLS) Student Manual. 7th ed. Chicago: American College of Surgeons; 2004, with permission.) |
B: Breathing
Assess adequacy of respirations (effort, efficacy, breath sounds, and oxygenation).
Apply oxygen in the tachypneic patient or if oxygen saturations <93% on room air or based on mechanism (smoke/carbon monoxide inhalation).
Via face mask in the older patient.
Via blow-by or hood in infants.
Low threshold to intubate if poor oxygenation and poor respiratory effort.
See Chapter 3 on Airway Management for details.
If intubated in the field, always reassess respirations bilaterally and confirm ETT position.
Common to find right mainstem intubations in children.
Monitor end-tidal CO2 continuously.
Obtain CXR.
C: Circulation with Control of External Hemorrhage
Most common cause of shock in pediatric trauma patients is hypovolemia.
Total blood volume in child = 80 mL/kg.
Start IVs and draw blood work while the ABCs are being assessed.
Order cross-match or type and screen.
Start IV: 20 mL/kg crystalloid bolus over 15-30 minutes.
Use warmed solutions if patient hypothermic.
Assess for and control obvious sources of bleeding.
Look for blood-soaked clothing or scalp laceration—apply direct pressure.
Internal bleeding (bulging abdomen, hemothorax) requires aggressive resuscitation toward definitive management and possible OR.
Wrap or splint unstable pelvic fracture to decrease bleeding in pelvic/retroperitoneal space.
Stable patients are apparent in the primary survey because a talking or crying child has a patent airway, is breathing spontaneously, and has sufficient blood pressure to maintain cerebral perfusion.
D: Disability
Brief musculoskeletal/neurologic examination for obvious limb deformities, check neurologic and pupillary responses:
Spontaneous movement.
Sensation or complaints of pain.
Responsiveness to voice.
Assess with modified GCS or Verbal Score (see below).
E: Expose Patient
Assess all surface areas (including diaper).
Prevent hypothermia.
Keep trauma room warm.
Cover patient with warm blankets after assessment.
Use overhead warmer for infants.
Burns should be calculated based on patient’s palmar surface = 1% BSA.
Quickly cover burns with moist, warm dressings.
See Chapter 14 on Thermal Injuries for details.
History
If patient can communicate, obtain details leading to injury and relevant medical history.
If patient cannot communicate, obtain history from EMS crew, witnesses at the scene, friends, family members, and authorities.
Important details of history requiring special attention:
Mechanism of injury (e.g., vehicle speed, distance thrown, fall from height, landing surface, farm accident).
Use of protective devices (e.g., child seat, seatbelt, helmet).
Patient’s initial exam at scene (e.g., initial responsiveness, any loss or changes in level of consciousness, any seizure activity, any evidence of bleeding and quantity at scene).
Initial vitals (Note: Not unusual to have tachycardia in frightened child, but important as a baseline).
Be sure to obtain pertinent AMPLE history:
A: Allergies.
M: Medications currently taking.
P: Past medical history/illnesses.
L: Last meal.
E: Events relating to injury.
Obtain immunization history from patient or family, especially last tetanus booster.
Specific Life-Threatening Injuries to Be Identified and Treated in the Primary Survey
Children are less likely to demonstrate changes in vital signs from hypovolemia until they can no longer compensate, at which point they may arrest.
The earliest sign of hypovolemia is tachycardia (Table 2-1).
Greatest risk is tension pneumothorax due to a mobile mediastinum.
Maintain a high index of suspicion!
Physical examination during primary survey must rule out presence of these life-threatening conditions that require immediate intervention:
Tension hemopneumothorax—more common in older children with rib fractures (Figure 2.2).
Hemodynamic instability, decreased breath sounds, uneven chest contours, tracheal deviation.
Difficult to check neck veins in small children with short necks.
Don’t wait for chest x-ray if patient unstable and clinical signs are present.
Needle decompression: 18-gauge angiocath at mid-clavicular line in 2nd intercostal space. Follow with chest tube insertion. See Chapter 21 on Procedures for details.
Cardiac tamponade—rare.
Low-amplitude QRS complex on ECG suggestive.
Continue to resuscitate with IV fluids.
Consider pericardiocentesis: 20-gauge needle through subxiphoid if emergent intervention required. See Chapter 21 on Procedures for details.
Early thoracotomy or pericardial window best treatment.
TABLE 2 – 1 Systemic Responses to Blood Loss in the Pediatric Patient | |||||||||||||||||||||||||||||||||
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Need for Reassessment
Reassess:
Patient’s vital signs.
Volume of fluids given and clinical response.
Determine whether antibiotic and tetanus prophylaxis are warranted.
If vital signs have normalized after initial bolus, one can leave IV fluids at maintenance rate and proceed with imaging studies.
If patient remains unstable, continue with resuscitation and reassess to determine if any injuries have been missed.
Give second or third bolus of 20 mL/kg warmed crystalloid IV if vitals unresponsive.
Increase venous access if current access not sufficient.
Administer warmed type-specific or O-negative PRBCs 10 mL/kg IV if third crystalloid bolus is required.
Assess for ongoing blood loss or restrictive cardiac output (tension pneumothorax, pericardial tamponade).
Involve surgical colleagues early.
Consider need to stabilize for early transfer.
NEVER transfer an unstable patient or send for lengthy radiologic imaging unaccompanied.
 FIGURE 2-2 • Right tension pneumothorax despite chest tube insertion. A right chest tube had been inserted for a right pneumothorax prior to patient transfer. The patient arrived at the trauma center hypotensive with high airway pressures. Breath sounds and chest movement were decreased on the right side. A second chest tube was subsequently inserted with complete decompression of the tension pneumothorax. |
