SUMMARY
THE STRUCTURED APPROACH TO THE SERIOUSLY INJURED CHILD
Primary survey A
B C D E Resuscitation
A B C
Secondary survey Head
Face Neck Chest Abdomen Pelvis Spine Extremities
Upper Lower
The structured approach to initial assessment and management, discussed here, allows the professional to care for the seriously injured child in a logical, efficacious fashion.
Assessment of vital functions (airway, breathing, and circulation) is carried out first;
resuscitation for any problems found is instituted immediately.
• Primary survey.
• Resuscitation.
A complete head-to-toe examination is then carried out, emergency treatment performed and finally referral to teams responsible for definitive care is made:
• Secondary survey.
• Emergency treatment.
• Definitive care.
15.5. Template for note-taking
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CHAPTER
I 16 I
The child with chest injury
Following the establishment of a secure airway, the next most important consideration in the resuscitation of a child is the assessment of breathing. The child who has suffered multiple injuries may well have significant intrathoracic trauma that severely compromises respiration, and requires immediate treatment.
Substantial amounts of kinetic energy may be transferred through a child’s chest wall with little or no external sign of injury. Furthermore, children have very elastic ribs which rarely fracture; thus a normal chest radiograph does not exclude major thoracic visceral disruption.
Thoracic injuries must be considered in all children who suffer major trauma. Some may be life threatening and require immediate resuscitative therapy during the primary survey and resuscitation, whereas others may be discovered during the secondary survey and be treated with appropriate emergency treatment at that stage. The vast majority can be managed in the first hour by any competent doctor. Practical procedures are described in detail in Chapter 24.
INJURIES POSING AN IMMEDIATE THREAT TO LIFE
Tension pneumothorax
This is a life-threatening emergency. Air accumulates under pressure in the pleural space; this, in turn, pushes the mediastinum across the chest and kinks the great vessels.
This then compromises venous return to the heart and therefore cardiac output is reduced. The diagnosis is a clinical one. A radiograph that shows a tension pneumothorax should never have been taken.
Signs
• The child will be hypoxic and may be shocked.
• There will be decreased air entry and hyperresonance to percussion on the side of the pneumothorax.
• Distended neck veins may be apparent in thin children.
• Later the trachea will be deviated away from the side of the pneumothorax.
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Resuscitation
• High-flow oxygen should be given through a reservoir mask.
• Immediate needle thoracocentesis should be performed to relieve the tension.
• A chest drain should be inserted urgently to prevent recurrence.
Air may be forced into the pneumothorax by positive pressure ventilation. Any patient with a pneumothorax will develop a tension pneumothorax if ventilated.
Massive haemothorax
Blood accumulates in the pleural space. This results from damage to the lung parenchyma with possible additional damage to pulmonary or chest wall blood vessels.
The hemithorax can contain a substantial proportion of a child’s blood volume.
Signs
• The child will be hypoxic and in shock.
• There will be decreased chest movement, decreased air entry, and decreased resonance to percussion on the side of the haemothorax.
Resuscitation
• High-flow oxygen should be given through a reservoir mask.
• Intravenous access should be established and volume replacement commenced.
• A relatively large chest drain should be inserted urgently.
Open pneumothorax
There is a penetrating wound in the chest wall with associated pneumothorax. The wound may be obvious, but it may be on the child’s back, and will not be seen unless actively looked for.
Signs
• Air may be heard sucking and blowing through the wound.
• The other signs of pneumothorax will be present.
Resuscitation
• High-flow oxygen should be given through a reservoir mask.
• The wound should be occluded (on three sides only in order to allow air to escape during expiration).
• A chest drain should be inserted urgently.
Flail chest
The elasticity of the child’s chest wall reduces the incidence of flail chest, on the one hand. On the other, the increased mobility means that children are badly affected by these injuries if they do occur, since the underlying lung injury tends to be worse.
Anteroposterior or posteroanterior chest radiographs do not demonstrate rib fractures reliably and should not be relied upon in making the diagnosis.
Signs
• The child will be hypoxic.
• Abnormal chest movement associated with rib crepitus may be seen.
• Flail segments may not be seen on initial examination because reflex splinting of the segment occurs.
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Tracheal intubation and ventilation should be considered.
Adequate pain relief must be given; this is difficult to achieve in children because intercostal nerve blockade is dangerous in the uncooperative patient, and anaesthetic consultation may be required.
Cardiac tamponade
Cardiac tamponade can occur after both penetrating and blunt injury. The blood that accumulates in the fibrous pericardial sac reduces the volume available for cardiac filling during diastole. As more blood accumulates cardiac output is progressively reduced.
Signs
The child will be in shock.
There may be muffled heart sounds.
There may be distended neck veins; this will not be apparent if significant hypovolaemia coexists.
Resuscitation
High-flow oxygen should be given through a reservoir mask.
Intravenous access should be established, and rapid volume replacement com-menced; this temporarily increases filling pressure.
Emergency needle pericardiocentesis should be performed; removal of a small volume of fluid from within the pericardium can dramatically increase cardiac output.