A Airway and cervical spine control

In the setting of trauma, ‘A’ refers to securing of the child’s airway with concurrent attention to the possibility of an unstable cervical injury. The cervical spine should be immobilised using an appropriate-sized hard collar, sandbags, tape and a spinal board where appropriate. It may be helpful in an infant to place a small towel under the space in the shoulder region caused by ‘the elevation off the bed’ by the prominent occiput at this age. As discussed in the ALS section in Chapter 2.3, the characteristics of the paediatric airway make it more vulnerable to obstruction. This can be exacerbated by the necessary supine positioning of the child on the resuscitation trolley. Due to comparatively higher oxygen demands and less reserve, a child manifests hypoxic decompensation earlier than adults. This reinforces the increased importance of airway management in achieving adequate ventilation. The initial airway-opening manoeuvre in trauma patients should be by the jaw thrust technique to maintain cervical spine immobilisation. Suctioning of any oropharyngeal soiling from blood, vomit, teeth or other foreign bodies may be necessary. Adjuncts such as the placement of an oropharyngeal airway may be required. In children, these should be placed into the oral cavity directly, using gentle depression of the tongue with a spatula to allow for atraumatic positioning. Nasopharyngeal airways are not recommended due to the potential presence of cribriform plate fractures, and trauma to the turbinates may cause bleeding that may further complicate airway patency.

The indications for intubation in children with major trauma are no different than those in adults. Thus, definitive airway intervention should occur in the child who is apnoeic (usually coma related), has persistent airway obstruction despite the above manoeuvres, is requiring bag–mask ventilation to achieve oxygenation, has respiratory insufficiency from major chest injury, has significant ongoing bleeding due to facial trauma compromising the airway or has high risk of subsequent compromise such as from an airway burn.

The technique of intubation should be rapid sequence with cricoid pressure. The control of the cervical spine during intubation should occur by manual immobilisation by a dedicated assistant. The patient should have continuous monitoring, pre-oxygenation and difficult airway adjuncts available, if required. The choice and dosage of the sedation agent (thiopentone, midazolam, propofol, or fentanyl, for example) may be individualised according to factors such as the level of coma, cardiovascular status of the child and the presence of other injuries. A rapidly and short acting muscle relaxant such as suxamethonium usually provides the most optimal intubation conditions, despite the potential for transient increase in intracranial and intraocular pressures with fasciculation. Children less than 2 years of age are prone to significant bradycardia on laryngoscopy, which may be blunted by the administration of atropine, prior to intubation. Confirmation of correct ETT placement should occur according to the methods described in Chapter 2.3. One needs to be prepared for the possibility of the difficult airway or failed intubation and have a planned algorithm to deal with this possibility. It is not the failed intubation that causes the problem, but the lack of a plan of action to alternatively oxygenate the patient in this situation, whilst summoning assistance.

B Breathing and high-flow oxygen

All children with severe trauma should receive high-flow oxygen (10–15 L min^–1) by a reservoir face mask, independent of the need determined by saturation monitoring. Inadequate spontaneous ventilation is supported by bag and mask assistance. If this need is ongoing, intubation is required. A rapid screen for life threats, such as a tension pneumothorax, should occur. This may require immediate decompression by needle aspiration for the child in extremis and a subsequent formal chest drain, as described in the section on chest trauma (see chapter 3.3). The possibility of developing tension due to a pneumothorax should be borne in mind as one of the potential precipitants of rapid deterioration following the initiation of positive pressure ventilation.

C Circulation and stop haemorrhage

It is important to be aware that a child may be profoundly shocked from blood loss resulting from trauma well before the occurrence of hypotension. A child responds to hypovolaemia with tachycardia and increasing peripheral vascular resistance. Therefore, the assessment of circulation status needs to be focused on the heart rate, pulse volume and the parameters of skin perfusion such as capillary refill time, colour and temperature. Perfusion inadequacy should be proactively corrected with volume resuscitation, rather than waiting for hypotension as an indicator. Hypotension occurs late due to cardiac decompensation and indicates that a child is nearing collapse. Likewise, bradycardia is often a prelude to imminent arrest. The persistence of tachycardia in the child with trauma should prompt concern and evaluation for occult ongoing blood loss.

The child with major trauma requires urgent intravenous access with the largest practical cannulae into visible or palpable peripheral veins. In the shocked child, cephalic, femoral or great saphenous veins are usually the most accessible. Where vascular cannulation is unsuccessful, after 60–90 seconds, the child who requires immediate fluids or drugs to facilitate intubation, should have a rapid intraosseous needle placed as described in Chapter 23.11. This is clearly the second line method that should be used in children without hesitation, rather than cutdown techniques that may be applicable in adults. In certain circumstances, such as the small child backed over by a motor vehicle with obvious major abdominal, pelvic or lower limb trauma, it may be prudent to use additional alternative access into a vein that drains into the SVC (e.g. external jugular or subclavian). In this rare situation, lower limb intraosseous infused volume may not access the circulation effectively due to disruption of the normal continuity of the intraosseous and intravascular spaces.

Fluid resuscitation should initially be with crystalloid or colloid titrated to clinical response. Boluses of 20 mL kg^–1 should be given using pressure infusion. In the hypotensive child who arrives in extremis the early use of uncross-matched O negative blood may be indicated. Otherwise, after two boluses of crystalloid or equivalent have been infused, ongoing hypovolaemia should be with crossmatched blood replacement. Whole blood or packed cells should be given in boluses of 20 and 10 mL kg^–1 respectively. Fluids should be warmed in order to reduce the incidence of hypothermic stress complicating the resuscitation. The child with ongoing cardiovascular instability needs urgent surgical intervention.

Part of the circulation phase of management includes therapy to limit ongoing blood losses from external or fracture sites by direct pressure or splinting. This is of vital importance as a child’s blood volume is only 80 mL kg^–1 and small ongoing losses contribute to haemodynamic instability.

Although in major trauma the most likely cause of shock is blood loss, one needs to consider other possible contributors such as myocardial injury, pericardial tamponade, spinal shock or tension pneumothorax.

D Disability

The most rapid way to assess a child’s conscious level in the primary survey is by using the AVPU scale (see Table 3.2.2).

A child who scores a non-purposeful P or U correlates with a GCS of 8 or less and requires intubation and ventilation. The brief neurological assessment during the primary survey is completed by checking equality of pupil size and reactivity to light.

E Exposure and environment

The child should be undressed fully to allow examination of the entire body in order to detect all external stigmata of injury. Once this is completed, the child should be covered by warm blankets. The potential for hypothermia can also be decreased by the use of radiant heaters and warm resuscitation fluids.

Early analgesia

Children who have significant pain or distress need to have prompt provision of analgesia as soon as intravenous access is obtained. This is usually best achieved by titrating intravenous morphine in doses of 0.1–0.2 mg kg^–1 to effect. Adequate analgesia allows a more rapid and reliable clinical assessment.

Continuous monitoring

This should include heart rate, blood pressure, respiratory rate, oxygen saturation and clinical assessment of perfusion.

Support of family members

It is important to provide early psychological support to other family members who arrive with the child with major injuries. This should occur via a senior member of the team assisted by a nurse or social worker who is dedicated to this role. Non-comatose children are often fearful and distressed and it is useful to have the parents available to provide comfort to them.

Definitive care and disposition

After the secondary survey and reassessment of the child’s physiological response to resuscitation, the next step is to prioritise injuries to determine the need and timing of further imaging or any surgical intervention. The general rule is if the child remains hypotensive despite a 1/2 blood volume resuscitation over the first 1 to 4 hours, the child needs surgery. Persistent fluid and blood resuscitation can quickly cause a coagulopathic state. It may be necessary to involve multiple surgical specialists depending on the child’s injuries and the approach varies according to local resources. The team leader needs to co-ordinate these inputs so that patient care is at all times expeditious and tailored to the specific and prioritised needs of the child. In the non-paediatric tertiary environment, early liaison with appropriate colleagues from a trauma centre with the capacity for definitive care of a child with major injuries, will help determine the most appropriate means for the individual child optimally to reach definitive care. Transfer of a child to definitive care is discussed in Section 27.

Care in paediatric hospitals can result in lower rates of non-therapeutic laparotomies. The skill of the paediatric surgical trauma team is often in deciding when not to operate. Repeated examinations identify the child who is continuing to bleed and highlight the child who may have a hollow viscus injury. Patterns of injury, such as with seat-belt bruises, are often recognised and are able to be put in the context of the child’s overall physiology. The optimal care of an injured child is in a paediatric institution where there is familiarity with children and a sufficient volume of work to maintain that. The care of the child throughout the hospital stay should include other important considerations such as early physiotherapy to stop limb contractures, early involvement of the rehabilitation team and schooling.