Pediatric Trauma

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19 Pediatric Trauma

Alisha Armstrong, Purnima Unni, John B. Pietsch

Be sure to check out the supplementary content available at http://evolve.elsevier.com/Hazinski.

Pearls

• Differences between adult and pediatric trauma care relate directly to the differences in physiology, anatomy, and mechanism of injury. The care of victims of all ages requires the same fundamental sequences of assessment and care (primary and secondary ABCDE surveys), but slight differences in their application.

• The most common serious complications of pediatric trauma are problems with airway and breathing rather than bleeding and shock, because the most serious pediatric trauma is blunt trauma involving the head.

Introduction

Trauma is the leading cause of pediatric mortality and morbidity in the United States,⁷ and it is a common reason for admission to a pediatric critical care unit (PCCU). Managing the child with multisystem trauma requires specific knowledge, precise management, and keen attention to detail.^1,⁵⁹ This chapter reviews essential aspects of nursing care of the pediatric trauma victim. Chapters 2, 3, 6, 9 and 11 contain additional helpful information.

Epidemiology and incidence of pediatric trauma

Frequency of Injuries

Although often preventable, injury continues to be the leading cause of death and disability for children older than 1 year.^3,¹⁷ Nearly 3000 children 0 to 14 years old die every year as the result of injuries—more deaths than all diseases combined.^45,⁴⁷ Leading causes of injury death are falls, motor vehicle crashes, burn injuries, pedestrian injuries, and drowning.^45,⁴⁷ For additional information, see Epidemiology and Incidence of Pediatric Trauma in the Chapter 19 Supplement on the Evolve Website.

Intentional (Inflicted) Versus Unintentional Injuries

Injuries in the child can be categorized as either intentional or unintentional.¹⁹ Intentional injuries are inflicted injuries (i.e., child abuse) or injuries that result from neglect (see Intentional Injuries/Inflicted Trauma, later in the chapter). Unintentional injuries, such as many burns, drowning, and traffic-related injuries are often preventable.

Eighty to ninety percent of life-threatening pediatric trauma is blunt injury, resulting from motor vehicle-related causes and falls ^4,⁷; approximately half of motor vehicle-related injuries and fatalities are thought to be preventable with the use of age-appropriate safety restraints.^27,⁶⁰ Children can also sustain motor vehicle-related injuries as pedestrians or on bicycles. Although bicycle riding is a common childhood activity, it can be dangerous. The most severe head injuries are sustained when children who are not wearing bicycle helmets collide with motor vehicles.^48,^50,⁶⁸ When a child is in a bicycle crash, a helmet will likely decrease the severity of head injuries.²⁷

Role of Nurses and Healthcare Providers in Injury Prevention

Prevention of unintentional injuries requires an understanding of risk factors at each child’s developmental stage, and knowledge of risk-reducing actions.^15,^46,⁷⁰ Nurses should use every “teachable moment” with families to increase parental awareness⁴⁹ of the risk of unintentional injuries and to promote the use of appropriate safety equipment. A teachable moment can occur during encounters such as a well-child checkup or a parent visit to the school,^20,^35,⁶⁰ but is probably not present when the child is in the PCCU after an injury occurred. Nurses will need to select the best opportunities and methods to teach injury prevention strategies. See the Chapter 19 Supplement on the Evolve Website, for information about injury prevention.

Physiologic differences affecting manifestation and treatment of injuries

Airway and Ventilation

Larynx and Advanced Airways

The larynx in infants and children is smaller and is more anterior and cephalad than the larynx in adults. Intubation of children is difficult and should not be attempted by inexperienced practitioners (see Chapter 9). Unless the injured child has upper airway injury, edema, or obstruction, bag-mask ventilation usually provides adequate short-term oxygenation and ventilation. However, if the duration of transport is long, continued bag-mask ventilation is suboptimal, and skilled personnel should insert an advanced airway before transport.

The laryngeal mask airway (LMA) is an acceptable advanced airway when used by experienced providers for supporting a comatose patient.¹⁶ The LMA can be inserted blindly and, when properly positioned, isolates the trachea and produces less gastric distension than bag-mask ventilation. The LMA cannot be inserted in a patient with a cough or gag reflex.

The correct endotracheal tube size is determined by the size and configuration of the child’s larynx. The vocal cords are the narrowest portion of the adult larynx; in general the proper size of an adult endotracheal tube is the largest that can pass through the vocal cords.

In children younger than approximately 8 years, the narrowest portion of the larynx is in the subglottic area at the level of the cricoid cartilage, a circular cartilage with no membranous portion (C-shaped cartilages are present in the rest of the trachea, with the ends of the C-shaped cartilage connected by membrane). Endotracheal tube size for the child must be evaluated carefully, because a tube can readily pass through a child’s vocal cords but be too large in the subglottic area. If the tube is too large, then it can produce complications such as subglottic stenosis. The tube is likely the proper size if an air leak is present when a positive inflation pressure of 25 cm H₂O is provided.

Either cuffed or uncuffed endotracheal tubes may be used in children, and cuffed tubes may be more appropriate if the child’s lung compliance is low (e.g., as following a pulmonary contusion) or if the child has high airway resistance or a large glottic air leak. If a cuffed tube is used, the cuff inflation pressure must be monitored and maintained at the pressure recommended by the manufacturer (typically less than 20-25 cm H₂O).^9a,^38a

Providers can determine approximate airway equipment sizes (including endotracheal tubes) using a color-coded, length-based tape (e.g., a Broselow Pediatric Emergency Tape; Armstrong Medical Industries, Lincolnshire, IL).⁵⁴ A table containing these approximate sizes is included on the inside back cover of this book.

Chest Wall

The chest wall of infants and children is highly compliant, so rib fractures occur in only approximately one third of children with blunt thoracic trauma.¹³ The child may sustain significant intrathoracic injuries, yet may not have rib fractures.³ If a rib fracture is present, it suggests that major thoracic trauma has occurred involving substantial force and energy transfer,¹³ and the trauma team should suspect that underlying organs including the liver, spleen, and lungs may be injured. Upper rib injuries are associated most commonly with pulmonary and major vessel injuries, whereas lower rib fractures typically are associated with liver, spleen, lung, and kidney injury.⁴⁴

Because the ribs are relatively compliant in young children, the child’s chest should expand outward easily during positive-pressure ventilation. A unilateral reduction in chest expansion during positive pressure ventilation can result from endotracheal tube migration into a mainstem bronchus or from a unilateral pneumothorax, hemothorax, pleural effusion, or atelectasis.

The chest wall of the child is thin, and breath sounds are transmitted easily through the chest wall. When auscultation is performed over an area of atelectasis or fluid accumulation (e.g., a hemothorax), the nurse may note a change in pitch rather than a decrease in the intensity of breath sounds. For this reason, nurses must perform thorough auscultation and compare breath sounds heard over one side and one part of the chest to those heard over the other side and other parts of the chest.

Respiratory Muscles

During early childhood, the intercostal muscles are capable of only stabilizing the chest wall; they cannot elevate the chest wall to initiate inspiration. Therefore the infant or young child relies on diaphragm excursion for effective ventilation. Anything that impedes diaphragm movement can impair ventilation.

The child in respiratory distress frequently swallows air during spontaneous ventilation, and bag-mask ventilation can produce gastric distension. Gastric distension may compromise ventilation by restricting movement of the left hemidiaphragm; insertion of an orogastric or nasogastric tube may be required.

Cardiovascular Function and Circulating Blood Volume

Cardiac Output and Heart Rate

Children require a higher cardiac output per kilogram of body weight than do adults, because a child’s oxygen consumption and metabolic rate are higher than an adult’s. In infants and young children, cardiac output is primarily dependent on an adequate heart rate to maintain cardiac output; changes in stroke volume have less effect on cardiac output. Bradycardia is, therefore, often associated with a fall in cardiac output. Bradycardia is an ominous clinical finding in a pediatric trauma victim, usually indicating the presence of hypoxia or impending cardiopulmonary arrest. Tachycardia may be a nonspecific sign of distress, common in the frightened or injured child. However, tachycardia may also be a sign of significant volume loss, such as with hemorrhage. Hypotension is typically only a late sign of shock in children.

Circulating Blood Volume

Although a child’s circulating blood volume is large per kilogram body weight (80-85 mL/kg in newborns, 75-80 mL/kg in infants, 70-75 mL/kg in children, and 65-70 mL/kg in adolescents and adults), children have a smaller absolute circulating blood volume and cardiac output than adults. Consequently, small amounts of blood loss can produce significant reductions in the child’s circulating blood volume and can compromise systemic perfusion.

A useful way to determine the significance of blood loss in a child is to estimate the child’s total blood volume (TBV) and a 10% blood loss (an amount likely to require transfusion). For example, a 4-kg baby has a TBV of about 320 mL (4 kg × 80 mL/kg), so a 10% blood loss would be 32 mL. A 10-kg infant has a TBV of about 750 mL (10 kg × 75 mL/kg), so a 10% blood loss would be approximately 75 mL. A 30-kg child has a TBV of about 2,250 mL (30 kg × 75 mL/kg), so a 10% blood loss would be approximately 225 mL. A 10% blood loss is approximately 8 mL/kg for infants and 7.5 mL/kg for children. If the child’s weight is unknown, a color-coded Broselow tape will allow estimation of weight. A useful formula for estimating weight in children 1 to 10 years of age is:

Tachycardia is an early sign of hemorrhage in children. Significant hemorrhage (10%-15% of circulating blood volume) will produce signs of poor systemic perfusion (e.g., mottled color, cool extremities, delayed capillary refill, thready peripheral pulses). Because the child can initially compensate for blood loss by increasing the heart rate and systemic vascular resistance, hypotension often does not develop unless the child acutely loses 20% to 25% or more of circulating blood volume.⁵⁴

Neurologic Function

The morbidity and mortality of pediatric head injury is lower than the morbidity and mortality of similar head injury in adults. Many children who survive head injury recover completely; however, severe head injury can be fatal or produce long-term disability.

Neurologic Assessment

Although widely used, the Glasgow Coma Scale (GCS) may not be ideal for pediatric use for several reasons. It has not been validated in children, and it requires a cooperative child who is verbal and able to follow directions. If the child is preverbal or intubated, the verbal component of the GCS cannot be used.

The child’s level of consciousness and responsiveness will provide clues to the severity of the injuries. If the child is appropriately frightened and crying for parents and the child recognizes and responds to the parents, that child is presumed to be relatively alert and oriented. Irritability may be an early sign of neurologic deterioration or hypoxia, so an irritable child requires careful evaluation. Finally, if the child fails to respond to parents and is unresponsive to painful stimuli, neurologic compromise is present and urgent evaluation and support are needed.

Spinal Cord Injury

Many children with spinal cord injury have ligamentous injury with no evidence of vertebral fracture or other radiographic abnormalities on routine (anteroposterior and lateral) spine radiographs or CT scan.^42a These children have spinal cord injury without radiographic abnormality (SCIWORA), and many of these patients develop permanent neurologic injury.^3,²³

Nurses should carefully assess movement and sensation in all extremities on admission and at frequent intervals throughout the child’s hospitalization (see Chapter 11). The mechanism of injury should increase the index of suspicion of spinal cord injury. For example, a child wearing a lap belt without a shoulder strap who presents with abrasions or contusions on the lower abdomen may have an acute flexion injury of the lower spine (with or without a Chance fracture).

Data from the National Trauma Data Bank ⁵¹ indicates that 66% of cervical spine injuries in children younger than 3 years are caused by motor vehicle crashes, and only 15% are from falls. In the National Trauma Data Bank, cervical spine injuries were present in approximately 2.3% of all children less than 3 years of age injured in motor vehicle crashes.⁵¹ However, cervical spine injuries in children younger than 3 years were still relatively uncommon.⁵¹

Thermoregulation

Children have large surface area-to-volume ratios, so they lose more heat to the environment through evaporation, conduction, and convection than do adults. An injured child may experience a rapid fall in body temperature from exposure to a cold environment, submersion in cold water, or from evaporative losses when resuscitated in the out-of-hospital setting. Hypothermia, in turn, complicates resuscitation. Cold stress can be exacerbated by exposure in a cool emergency department (ED) or computed tomography (CT) scan room.

Every effort must be made to keep the injured child warm. Warm blankets and warming lights should be used if needed. In general, patient warming and rewarming should be performed with careful monitoring to prevent hyperthermia.

It may be necessary to warm intravenous (IV) fluids before they are administered to the child. Because microwave ovens warm fluids inconsistently, they should not be used to warm IV fluids.

Cold stress produces vasoconstriction that can mask the severity of blood loss; as the child is warmed, peripheral vasodilation may result in development or worsening of hypotension. Providers should anticipate the need for administration of additional fluid or blood during rewarming.

Fluid Administration

Rate

To control and accurately tally the total fluid administration rate, it is important to record all sources of fluid intake and output and administer all fluids by syringe or volume-controlled infusion pump. Adequate shock resuscitation is required for the trauma patient with hemorrhage, but excessive fluid administration should be avoided, particularly for the child with traumatic brain injury (it can be associated with free water retention in excess of sodium, a fall in serum sodium and cerebral edema) or the child with penetrating injury in the prehospital setting (it can increase blood pressure and increase hemorrhage). Fluid is not withheld from the hypovolemic patient; on the other hand, if the child is euvolemic (i.e., has adequate intravascular volume), excessive fluid administration may be harmful and should be avoided.

Vascular Access

It may be difficult to establish and maintain vascular access in the child with poor systemic perfusion. If vascular access can be achieved, providers should insert two large-bore venous catheters to enable effective volume administration.

If IV access cannot be achieved, intraosseous (IO) access is established; this route of access can be used for emergency fluid resuscitation and drug administration in patients of all ages.¹⁴ IO needles can be placed in the proximal or distal tibia or distal femur. Other placement options include the radius, ulna, pelvis, clavicle, and calcaneus. Medications and drugs can be given intraosseously until suitable venous access is achieved. Fluid may be delivered by infusion pump into an IO catheter, and bolus infusions can be provided through a syringe, an infusion pump, or a pressure bag (inflated up to 300 mm Hg). IO fluid boluses in children may be given as rapidly as 20 mL/kg over 5 min.

Initial stabilization of the pediatric trauma patient

Field Triage and Scoring

Scoring systems have been developed to quantify injury severity and predict patient outcome. These scoring systems also provide objective criteria to determine the need to transfer the trauma victim to a pediatric trauma center. As a result the transport team must select an accepted triage scoring system and use it consistently.

The trauma score (TS) is designed for scoring injury severity in the field; it uses the GCS score and the scoring of four additional physiologic parameters: systolic blood pressure, capillary refill, respiratory rate, and respiratory effort. Each category is scored and then totalled.¹⁰

The revised trauma score (RTS) was created to identify patients for triage to a trauma center.¹¹ It requires evaluation of fewer physiologic parameters than the TS. To calculate the RTS, the provider assigns a coded value to the GCS score, the systolic blood pressure, and the respiratory rate and then adds these three values together (Table 19-1). A weighted version of the RTS is a predictor of mortality; an RTS of less than four is correlated with a probability of survival of less than 60%, and should prompt consideration for transfer to a trauma center.²

Table 19-1 Revised Trauma Score^*

The pediatric trauma score (PTS) was developed to better identify the manifestations of injuries in children and better quantify their severity. The PTS evaluates the following six parameters: (1) patient size, (2) airway stability, (3) systolic blood pressure, (4) mental status, (5) wounds, and (6) skeletal injuries (Table 19-2).

Table 19-2 Pediatric Trauma Score

In the PTS, large size and optimum status result in a score of 2 for each parameter; extremely small size or systemic dysfunction results in a score of −1 for each parameter. The highest possible score is a 12 and the lowest possible score is a −6.⁶⁷ Children with a PTS totaling 8 or less have the highest potential for preventable mortality and morbidity, and they should be transported to a facility with the resources necessary to provide optimal pediatric care (e.g., a pediatric trauma center).⁶⁷

The PTS is a conservative scoring system and will result in the triage of some children who have only moderate injuries; however, conservative triage is generally thought to be appropriate for injured children. The PTS has not been shown to be consistently superior to the RTS, so many centers continue to use the RTS for the triage of children and with good results. Because vital signs (e.g., particularly blood pressures) are often not evaluated in the field,^22,³⁸ a simple scoring system that uses fewer vital signs (e.g., the RTS) can be used more consistently than one requiring evaluation of heart rate and respiratory rate in addition to blood pressure (i.e., the PTS).

In 2006, the National College of Surgeons Committee on Trauma convened a panel of national experts on trauma field triage to develop consensus trauma triage criteria for adults and children based on physiologic criteria (GCS score, systolic blood pressure, and respiratory rate), anatomy of the injury (e.g., penetrating trauma to the head, neck, or torso; flail chest; two or more long bone fractures; amputation; pelvic fractures; open or depressed skull fractures), the mechanism of injury (e.g., falls of 10 feet [3.048 m], or a distance of more than twice or threefold the child’s height, high risk auto crashes, motor vehicle vs. pedestrian crashes, motorcycle crashes), special patient or system considerations (e.g., children should be preferentially triaged to pediatric trauma centers; patients with associated anticoagulation or bleeding disorders; the EMS provider judges transport is indicated ⁵⁹), and protocols.

The criteria contained in the National College of Surgeons Committee on Trauma guidelines are included in Box 19-1. A detailed explanation of these guidelines was published by the Centers for Disease Control and Prevention in 2009.⁵⁶ A link to this publication is available in Triage of Injured Patients in the Chapter 19 Supplement on the Evolve Website.

Box 19-1 Indications for Transport of a Pediatric Trauma Victim To A Level I Trauma Center or a Pediatric Critical Care Unit

Modified from PCCC Transport Criteria, Harbor-UCLA Medical Center, Los Angeles, 1990; and Sasser SM, et al: Guidelines for field triage of injured patients: Recommendations of the National Expert Panel on Field Triage. Morbidity and Mortality Weekly Report 2009; 58 (RRO1):1-35.

^* These criteria are consistent with the 2006 National Expert Panel recommendations, detailed by Sasser, et al.

Management of the pediatric trauma victim in the emergency department

Team Approach to Management

Optimal trauma care requires organization of resources and personnel. The trauma team should have protocols in place that designate responsibilities for initial assessment and management of the injured child to specific members of the trauma team. Team composition can vary among institutions based on the number and skill level of personnel, but intervention priorities remain the same.

Emergency Department Stabilization and Transfer

The amount of care provided in the ED will be determined by the child’s clinical status and the distance between the ED and the definitive treatment center. Preferably, the child with major trauma will be transported from the ED directly to the PCCU in the same hospital. In this case, the time in the ED will be short. If the PCCU is located in a separate hospital, a more thorough evaluation should be performed in the ED to detect and stabilize major occult injuries before transfer. This evaluation requires a delicate balance between taking time to perform adequate evaluation and stabilization and the need to avoid excessive delay in transferring the child to the (definitive) trauma center. The child always should be stabilized before extensive diagnostic studies, such as CT scans, are performed. The radiology department is not the optimal location for the initiation of resuscitation.

General indications for transfer of the critically ill child to a trauma center with a PCCU include multisystem trauma, shock requiring multiple transfusions or vasoactive drug therapy, head injury accompanied by alteration in level of consciousness, multiple long bone fractures, rib fractures in the young child, penetrating injuries, traumatic amputations, significant burns, and anticipated need for prolonged mechanical ventilation (see Box 19-1).⁵⁶

Initial survey, resuscitation, and stabilization

The initial evaluation and stabilization (primary and secondary surveys) of the pediatric trauma victim are performed in the field and then repeated as needed in the ED. By the time the child arrives in the PCCU, the child should have a perfusing rhythm, an advanced airway (with confirmation of correct placement) and vascular access. However, if major trauma is present and the child is extremely unstable, resuscitation may continue in the PCCU.

The admitting critical care unit or the acute care unit admitting team should carefully assess the child to verify that cardiopulmonary function is adequate. In effect, they are performing a tertiary survey, repeating the primary and secondary surveys in a more thorough and methodical manner to ensure that the child is responding to therapy and that no injuries were missed. If the child is deteriorating, resuscitation is provided, and the primary and secondary surveys begin again.

The following information may apply to care in the ED, the acute care unit, or the PCCU. For further information regarding cardiopulmonary resuscitation in children, refer to Chapter 6.

Airway

Spine Stabilization

Spinal cord injuries are less common in children than in adults. When these injuries occur in children, they are generally associated with motor vehicle-related crashes, falls, and inflicted head trauma and can result in injuries of the upper or lower cervical spine (Fig. 19-1).⁴

Fig. 19-1 Cervical spine injury. Lateral cervical spine radiograph indicating cervical spine injury. A, Cervical spine radiograph of a toddler demonstrating wide separation between the first and second cervical vertebrae, consistent with complete cervical spine injury at the level of C1 to C2. Note the anterior displacement of the nasogastric tube (arrow) indicating anterior displacement of the esophagus (which should lie just anterior to the vertebrae) caused by edema at the site of the spinal cord injury. This child was intubated, but the endotracheal tube is not visible because it is not radiopaque. B, Normal anatomy of the cervical spine in a toddler. Note the horizontal articulation of the vertebrae, which increases the mobility of the upper cervical spine in this age group.

(A. Radiograph courtesy of John B. Pietsch, Nashville, TN. B. Illustration from Riviello JJ, et al: Delayed cervical central cord syndrome after trivial trauma. Pediatr Emerg Care 6:116, 1990. Williams and Wilkins.)

Spine stabilization and then immobilization is indicated after motor vehicle crashes, after pedestrian-related crashes, after crashes in which the child was unrestrained, for any unconscious trauma victim (because it is difficult to ascertain the extent of injury), and for any major trauma associated with head injury.² Manual stabilization is provided initially, and then a device is used to immobilize the cervical spine during transport and initial evaluation (Fig. 19-2).

Fig. 19-2 Cervical spine manual stabilization and immobilization. A, Preparation for intubation using a second person to stabilize cervical spine. This two-person technique may be necessary if a hard cervical collar of appropriate size is not available. No traction or force should be applied to the cervical spine, but movement is prevented. B, With a hard cervical collar in place, the patient’s torso is taped or strapped to the board, then the patient’s head and neck (with collar) are secured to the backboard. Linen rolls are used to prevent lateral movement of the head.

There are many acceptable methods for immobilizing the cervical spine. A semirigid collar (e.g., an extrication collar) immobilizes the cervical spine, but these collars are not recommended for use in children younger than 4 years.⁵ Foam collars can be applied easily and are available in small sizes, but they often provide no protection against head and neck movement. If an excessively large collar is applied, flexion of the neck may cause airway obstruction or hyperextension of the neck can result in the very movement and possible injury that the collar is designed to prevent.

Cervical spine immobilization in children requires a combination of a cervical collar (of the appropriate size) with a rigid spine board. The child’s head is supported in a neutral position on the board, using a board with head well or pads under the torso, and, foam blocks and straps. Towel rolls, and tape should be used to secure the torso and the head (see Fig. 19-2).^3,^25,²⁹

If the mechanism of injury suggests thoracic spine trauma, providers should avoid any flexion or torsion of the torso. If lap belt injuries are suspected (see Secondary Survey, Abdomen), providers should prevent movement of the lumbar spine until further examination.⁵⁵ The child should be log-rolled whenever turning is required until an injury to the spine is ruled out (i.e., the spine is cleared). If the child is sufficiently stable, the provider should evaluate and document movement and sensation of all extremities.

Airway Management

Oropharyngeal and nasopharyngeal airways can help to maintain a patent upper airway. Oral airways are reserved for the child with absent cough and gag reflex. Oral airways must be sized appropriately, because airways that are too small can push the tongue back into the oropharynx and those that are too long can obstruct the pharynx.⁵⁴ The length of the airway should equal the distance from the mouth to the angle of the mandible. Nasal airways can be inserted in the alert child or the unresponsive child who has no facial trauma; they may facilitate suctioning.

Intubation

Intubation may be necessary to maintain a patent airway and prevent anticipated deterioration. Indications for intubation of the pediatric trauma victim (Box 19-2) include: (1) inability to ventilate the child’s lungs adequately using a bag-mask device, (2) need for prolonged airway control and prevention of aspiration, (3) severe head injury (in anticipation of a need for controlled ventilation and oxygenation), (4) flail chest, (5) severe facial burns, and (6) shock unresponsive to volume infusion.^2,⁵⁴

When the child has inhalation injuries, trauma to the head and neck, or facial burns, elective intubation is performed in anticipation of the development of progressive airway obstruction. The trauma team should not wait for signs of severe respiratory distress to develop, because the intubation is then likely to be far more difficult.

The nurse must be able to select intubation equipment of appropriate size. Formulas, tables, or a length-based tape that indicates the equipment sizes (i.e., the Broselow tape—see inside back cover) may be used (Table 19-3).⁵⁴

Table 19-3 Endotracheal and Tracheostomy Tube Sizes

In the past, only uncuffed tubes were used for children younger than 8 years, because there was concern that cuffed tubes could produce subglottic tracheal injury.² However, for some children (e.g., those with noncompliant lungs, high airway resistance or large glottic air leak), the use of a cuffed tube may be preferable to an uncuffed tube, particularly if the child requires ventilation with high inspiratory pressure or maintenance of positive end-expiratory pressure.^9a,^38a Slightly different formulas are used to determine the internal diameter of a cuffed versus an uncuffed tube (see Table 19-3).

Gastric distension increases the risk of vomiting and aspiration, can stimulate a vasovagal reflex and bradycardia, compromises diaphragm movement, and can mimic or mask symptoms of abdominal injury. If gastric distension develops, providers should remove air through an orogastric tube. If the patient has craniofacial trauma with maxillofacial or basilar skull fracture, an orogastric tube is used for gastric decompression rather than a nasogastric tube. Case reports have documented intracranial migration of nasogastric tubes if they are inserted blindly.^4,¹⁸

Sedation and administration of neuromuscular blockers are advisable before intubation of a conscious trauma victim, particularly if the child is struggling or has a full stomach. Rapid sequence intubation (also known as drug assisted intubation) is designed to reduce stimulation of gag reflex (and the associated risk of vomiting and aspiration) when the child has a full stomach or when the time of the last meal cannot be determined (for further information about rapid sequence intubation, see Chapter 9 and Box 9-11).

Oral intubation is preferred over nasotracheal intubation. Nasotracheal intubation is not performed if cervical spine injury is suspected, because nasotracheal intubation will likely require excessive cervical spine manipulation. In addition, nasotracheal intubation is avoided if the child has maxillofacial injury and a dural tear, because the tracheal tube may be inserted intracranially and produces the added complication of introducing bacteria through the dura.

As soon as the endotracheal tube is inserted, providers should verify correct tube position using both clinical evaluation (including auscultation and visual assessment of chest expansion and monitoring of heart rate and oxyhemoglobin saturation) and a confirmation device (e.g., exhaled CO₂ detector, ideally with continuous capnography). If the tube is in the proper position, chest expansion should be visible and equal bilaterally during positive pressure ventilation, and bilateral breath sounds should be equal and adequate. In addition, the child’s oxyhemoglobin saturation (assessed via pulse oximetry) should improve.

Because breath sounds can be transmitted easily through the thin chest wall of the infant or child, as well as into the abdomen, use of a device to confirm tracheal tube placement is particularly important for children. If the child has a perfusing rhythm, an exhaled CO₂ detector (a colorimetric device or capnograph) can be used. If, after six positive-pressure breaths, CO₂ is detected in exhaled air using a colorimetric device or if a CO₂ waveform is documented via capnography, and the clinical exam documents breath sounds and chest expansion, tracheal tube placement is confirmed. If the child has a perfusing rhythm and CO₂ is not detected in exhaled air, the tube is not in the trachea; providers should remove it and provide bag-mask ventilation until another tube can be inserted.

Once the clinical and device confirmation have verified tube placement, a chest radiograph ultimately is performed to confirm depth of tube insertion. The chest x-ray cannot, however, confirm tube placement in the trachea.