Acute Care of the Victim of Multiple Trauma

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Chapter 66 Acute Care of the Victim of Multiple Trauma

Cindy Ganis Roskind, Peter S. Dayan, Bruce L. Klein

Epidemiology

Injury is a leading cause of death and disability in children throughout the world (Chapter 5.1). According to the World Health Organization report on child injury prevention, unintentional injuries are one of the leading causes of death in children younger than 20 yr and the leading cause of death in children between 10 and 20 yr in the world. Road traffic accidents, drowning, fire-related events, and falls rank among the top causes of death and disability in children. In Asia, injury accounts for more than 50% of deaths in children <18 yr, with drowning accounting for approximately half. In the USA, more than 12,000 children die each year secondary to unintentional injury, with motor vehicle related injuries being the leading cause.

Deaths represent only a small fraction of the total trauma burden. Approximately 9.2 million children are treated in U.S. emergency departments (EDs) each year for injury, most commonly for falls. Many survivors of trauma have permanent or temporary functional limitations. Motor vehicle–related injuries and falls rank among the top 15 causes of disability-adjusted life years in children worldwide.

Trauma is frequently classified according to the number of significantly injured body parts (1 or more), the severity of injury (mild, moderate, or severe), and the mechanism of injury (blunt or penetrating). In childhood, blunt trauma predominates, accounting for the majority of injuries. In adolescence, penetrating trauma increases in frequency, accounting for approximately 15% of injuries, and has a higher case fatality rate.

Regionalization and Trauma Teams

Mortality and morbidity rates have decreased in geographic regions with comprehensive, coordinated trauma systems. Treatment at designated trauma centers is associated with decreased mortality. At the scene of injury, paramedics should administer necessary advanced life support and perform triage (Fig. 66-1; Tables 66-1 and 66-2). It is usually preferable to bypass local hospitals and rapidly transport a seriously injured child directly to a pediatric trauma center (or a trauma center with pediatric commitment). Children have lower mortality rates after severe blunt trauma when they are treated in designated pediatric trauma centers or in hospitals with pediatric intensive care units.

Figure 66-1 Field triage decision scheme—United States, 2006.

(Adapted from American College of Surgeons: Resources for the optimal care of the injured patient, Chicago, 2006, American College of Surgeons.) Footnotes have been added to enhance understanding of field triage by persons outside the acute injury care field:

*The upper limit of respiratory rate in infants is >29 breaths/min to maintain a higher level of overtriage for infants.

^†Trauma centers are designated Level I-IV, with Level I representing the highest level of trauma care available.

^§Any injury noted in Steps 2 and 3 triggers a “yes” response.

^¶Age <15 yr.

**Intrusion refers to interior compartment intrusion, as opposed to deformation, which refers to exterior damage.

^††Includes pedestrians or bicyclists thrown or run over by a motor vehicle or those with estimated impact >20 mph with a motor vehicle.

^§§Local or regional protocols should be used to determine the most appropriate level of trauma center; appropriate center need not be Level I.

^¶¶Age >55 yr.

***Patients with both burns and concomitant trauma for whom the burn injury poses the greatest risk for morbidity and mortality should be transferred to a burn center. If the nonburn trauma presents a greater immediate risk, the patient may be stabilized in a trauma center and then transferred to a burn center.

^†††Injuries such as an open fracture or fracture with neurovascular compromise.

^§§§Emergency medical services.

^¶¶¶Patients who do not meet any of the triage criteria in Steps 1-4 should be transported to the most appropriate medical facility as outlined in local EMS protocols.

Table 66-1 CHANGES IN FIELD TRIAGE DECISION SCHEME CRITERIA FROM 1999 TO 2006 VERSION *

STEP ONE: PHYSIOLOGIC CRITERIA

• Add a lower limit threshold for respiratory rate in infants (aged <1 year) of <20 breaths per minute

• Remove Revised Trauma Score <11

STEP TWO: ANATOMIC CRITERIA

• Add crushed, degloved, or mangled extremity

• Change “open and depressed skull fractures” to “open or depressed skull fractures”

• Move combination trauma with burns and major burns to Step Four

STEP THREE: MECHANISM-OF-INJURY CRITERIA

• Add vehicular telemetry data consistent with high risk of injury

• Clarify criteria for falls to include:

— Adults: fall >20 ft (two stories)

— Children aged <15 years: fall >10 ft or two to three times the child’s height

• Change “high-speed auto crash” to “high-risk auto crash” and modify to include any of the following:

— Intrusion >12 inches at occupant site

— Intrusion >18 inches at any site

— Partial or complete ejection from the vehicle

— Death of another passenger in the same passenger compartment

— Vehicle telemetry data consistent with high risk for injury

• Revise “auto-pedestrian/auto-bicycle injury with significant (>5 mph) impact” and “pedestrian thrown or run over” to “Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact”

• Revise “motorcycle crash >20 mph with separation of rider from bike” to “motorcycle crash >20 mph”

• Remove “initial speed >40 mph, major auto deformity >20 inches, extrication time >20 min, and rollover”

STEP FOUR: SPECIAL CONSIDERATIONS

• Add “time-sensitive extremity injury, end-stage renal disease requiring dialysis, and Emergency Medical Service provider judgment”

• Add burns from Step Two

— Burns without other trauma mechanism: triage to burn facility

— Burns with trauma mechanism: triage to trauma center

• Clarify aged <5 years or >55 years to read:

— Older adults: risk of injury death increases after age 55 years

— Children: should be triaged preferentially to pediatric-capable trauma centers

• Change “patient with bleeding disorder or patient on anticoagulants” to “anticoagulation and bleeding disorders”

• Change “pregnancy” to “pregnancy >20 wks”

• Remove “cardiac disease, respiratory disease, insulin-dependent diabetes, cirrhosis, morbid obesity, and immunosuppressed patients”

* Scheme is shown in Fig. 66-1.

Modified from Sasser SM, Hunt RC, Sullivent EE, et al: Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, MMWR Recomm Rep 58(RR-1):1–35, 2009. http://www.cdc.gov/mmwr/PDF/rr/rr5801.pdf.

Table 66-2 CHILDREN REQUIRING PEDIATRIC TRAUMA CENTER CARE

Patients with serious injury to >1 organ or system

Patients with 1-system injury who require critical care or monitoring in an intensive care unit

Patients with signs of shock who require >1 transfusion

Patients with fracture complicated by suspected neurovascular or compartment injury

Patients with fracture of the axial skeleton

Patients with ≥2 long-bone fractures

Patients with potential replantation of an extremity

Patients with suspected or actual spinal cord or column injury

Patients with head injury with any 1 of the following:

Orbital or facial bone fracture

Cerebrospinal fluid leak

Altered state of consciousness

Changing neurologic signs

Open-head injury

Depressed skull fracture

Requiring intracranial pressure monitoring

Patients suspected of requiring ventilator support

Modified from Krug SE: The acutely ill or injured child. In Behrman RE, Kliegman RM, editors: Nelson essentials of pediatrics, ed 4, Philadelphia, 2002, WB Saunders, p 96.

When the receiving ED is notified before the child’s arrival, the trauma team should also be mobilized in advance. Each member has defined tasks. A senior surgeon (surgical coordinator) or, sometimes initially, an emergency physician leads the team. Team compositions vary somewhat from hospital to hospital; the model used at Children’s National Medical Center (Washington, DC) is shown in Figure 66-2. Consultants, especially neurosurgeons and orthopedic surgeons, must be promptly available; the operating room staff should be alerted.

Figure 66-2 Members of the inner core of the trauma team at Children’s National Medical Center (Washington, DC). Members of the outer core include a nursing administrator, a social worker, a radiology technician, a transport technician, and a security officer. ICU, intensive care unit.

Physiologic status, anatomic locations, and/or mechanism of injury are used for field triage as well as to determine whether to activate the trauma team (see Table 66-2). More importance should be placed on physiologic compromise and less on mechanism of injury. Scoring scales such as the Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), Pediatric Trauma Score, and Revised Trauma Score (Table 66-3) use these parameters to predict patient outcome. The AIS and ISS are used together. First, the AIS is used to numerically score injuries—as 1 minor, 2 moderate, 3 serious, 4 severe, 5 critical, or 6 probably lethal—in each of 6 ISS body regions: head/neck, face, thorax, abdomen, extremity, and external. The ISS is the sum of the squares of the highest 3 AIS region scores.

Table 66-3 REVISED TRAUMA SCORE*

Primary Survey

During the primary survey, the physician quickly assesses and treats any life-threatening injuries. The principal causes of death shortly after trauma are airway obstruction, respiratory insufficiency, shock from hemorrhage, and central nervous system injury. The primary survey addresses the ABCDEs: Airway, Breathing, Circulation, neurologic Deficit, and Exposure of the patient and control of the Environment.

Airway/Cervical Spine

Optimizing oxygenation and ventilation while protecting the cervical spine from potential further injury is of paramount importance. Initially, cervical spine injury should be suspected in any child sustaining multiple, blunt trauma. Children are at risk for such injuries because of their relatively large heads, which augment flexion-extension forces, and weak neck muscles, which predispose them to ligament injuries. To prevent additional spinal injury, the current standard is to immobilize the cervical (and thoracic and lumbar) spine in neutral position with a stiff collar, head blocks, tape or cloth placed across the forehead, torso, and thighs to restrain the child, and a rigid backboard.

Airway obstruction manifests as snoring, gurgling, hoarseness, stridor, and/or diminished breath sounds (even with apparently good respiratory effort). Children are more likely than adults to have airway obstruction because of their smaller oral and nasal cavities, proportionately larger tongues and greater amounts of tonsillar and adenoidal tissue, higher and more anterior glottic openings, and narrower larynxes and tracheas. Obstruction is common in patients with severe head injuries, owing in part to decreased muscle tone, which allows the tongue to fall posteriorly and occlude the airway. With trauma, obstruction can also result from fractures of the mandible or facial bones, secretions such as blood or vomitus, crush injuries of the larynx or trachea, or foreign body aspiration.

If it is necessary to open the airway, a jaw thrust without head tilt is recommended. This procedure minimizes cervical spine motion. In an unconscious child, an oropharyngeal airway can be inserted to prevent posterior displacement of the mandibular tissues. A semiconscious child will gag with an oropharyngeal airway but may tolerate a nasopharyngeal airway. A nasopharyngeal airway is contraindicated when there is a possibility of a cribriform plate fracture. If these maneuvers plus suctioning do not clear the airway, oral endotracheal intubation is indicated. When endotracheal intubation proves difficult, a laryngeal mask airway can be used as a temporary alternative. A laryngeal mask airway consists of a tube with an inflatable cuff that rests above the larynx and thus does not require placement of the tube into the trachea. Emergency cricothyrotomy is needed in <1% of trauma victims.

Breathing

The physician assesses breathing by counting the respiratory rate; visualizing chest wall motion for symmetry, depth, and accessory muscle use; and auscultating breath sounds in both axillae. In addition to looking for cyanosis, pulse oximetry is standard. If ventilation is inadequate, bag-valve-mask ventilation with 100% oxygen must be initiated immediately, followed by endotracheal intubation. End-expiratory carbon dioxide (CO₂) detectors help verify accurate tube placement.

Head trauma is the most common cause of respiratory insufficiency. An unconscious child with a severe head injury may have a variety of breathing abnormalities, including Cheyne-Stokes respirations, slow irregular breaths, and apnea.

Although less common than a pulmonary contusion, tension pneumothorax and massive hemothorax are immediately life-threatening (Tables 66-4 and 66-5). Tension pneumothorax occurs when air accumulates under pressure in the pleural space. The adjacent lung is compacted, the mediastinum is pushed toward the opposite hemithorax, and the heart, great vessels, and contralateral lung are compressed or kinked (Chapter 405). Both ventilation and cardiac output are impaired. Characteristic findings include cyanosis, tachypnea, retractions, asymmetric chest rise, contralateral tracheal deviation, diminished breath sounds on the ipsilateral (more than contralateral) side, and signs of shock. Needle thoracentesis, followed by thoracostomy tube insertion, is diagnostic and lifesaving. Hemothorax results from injury to the intercostal vessels, lungs, heart, or great vessels. When ventilation is adequate, fluid resuscitation should begin before evacuation, because a large amount of blood may drain through the chest tube, resulting in shock.

Table 66-4 LIFE-THREATENING CHEST INJURIES

TENSION PNEUMOTHORAX

One-way valve leak from the lung parenchyma or tracheobronchial tree

Collapse with mediastinal and tracheal shift to the side opposite the leak

Compromises venous return and decreases ventilation of the other lung

Clinically, manifests as respiratory distress, unilateral absence of breath sounds, tracheal deviation, distended neck veins, tympany to percussion of the involved side, and cyanosis

Relieve first with needle aspiration, then with chest tube drainage

OPEN PNEUMOTHORAX (SUCKING CHEST WOUND)

Effect on ventilation depends on size

MAJOR FLAIL CHEST

Usually caused by blunt injury resulting in multiple rib fractures

Loss of bone stability of the thoracic cage

Major disruption of synchronous chest wall motion

Mechanical ventilation and positive end-expiratory pressure required

MASSIVE HEMOTHORAX

Must be drained with a large-bore tube

Initiate drainage only with concurrent vascular volume replacement

CARDIAC TAMPONADE

Beck Triad:

1 Decreased or muffled heart sounds

2 Distended neck veins from increased venous pressure

3 Hypotension with pulsus paradoxus (decreased pulse pressure during inspiration)

Must be drained

Modified from Krug SE: The acutely ill or injured child. In Behrman RE, Kliegman RM, editors: Nelson essentials of pediatrics, ed 4, Philadelphia, 2002, WB Saunders, p 97.

Table 66-5 DIFFERENTIAL DIAGNOSIS OF IMMEDIATELY LIFE-THREATENING CARDIOPULMONARY INJURIES

Circulation

The most common type of shock in trauma is hypovolemic shock due to hemorrhage. Signs of shock include tachycardia; weak pulse; delayed capillary refill; cool, mottled, pale skin; and altered mental status (Chapter 64). Early in shock, blood pressure remains normal because of compensatory increases in heart rate and peripheral vascular resistance (Table 66-6). Some individuals can lose up to 30% of blood volume before blood pressure declines. It is important to note that 25% of blood volume equals 20 mL/kg, which is only 200 mL in a 10-kg child. Losses >40% of blood volume cause severe hypotension that, if prolonged, may become irreversible. Direct pressure should be applied to control external hemorrhage. Blind clamping of bleeding vessels, which risks damaging adjacent structures, is not advisable.

Table 66-6 SYSTEMIC RESPONSES TO BLOOD LOSS IN PEDIATRIC PATIENTS