During the primary survey life-threatening conditions are identified. Assessment follows the familiar ABC pattern with significant additions:
CHAP TITLE
Structured approach Primary survey
Resuscitation Secondary survey Emergency treatment
Definitive care
A Airway and cervical spine control B Breathing
C Circulation and haemorrhage control D Disability
E Exposure
Airway and cervical spine
Airway assessment following trauma should follow the LOOK
LISTEN FEEL technique discussed in Chapters 4 and 5.
A cervical spine injury should be assumed to be present until adequate investigation and examination exclude it.
Breathing
Once the airway has been secured and the cervical spine controlled, breathing should be assessed. As discussed in earlier chapters the adequacy of breathing is gained from three sets of observations – the effort of breathing, the efficacy of breathing, and the effects of inadequate respiration on other organ systems. These are summarised in the box.
The normal resting respiratory rate changes with age. These changes are summarised in Table 15.2.
Circulation
Circulatory assessment in the primary survey consists of the rapid assessment of heart rate, systolic blood pressure, capillary refill time, skin colour and temperature, respiratory rate, and mental status. Using these measures an approximate estimate of the percentage of blood loss can be made as shown in Table 15.1. Remember the caveats on the clinical signs of differential pulse volume and capillary refill time in Chapter 3.
THE STRUCTURED APPROACH TO THE SERIOUSLY INJURED CHILD
Assessment of the adequacy of breathing Effort of breathing
Recession Respiratory rate
Inspiratory or expiratory noises Grunting
Accessory muscle use Flare of the alae nasi Efficacy of breathing
Breath sounds Chest expansion Abdominal excursion
Effects of inadequate respiration Heart rate
Skin colour Mental status
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Table 15.1. Recognition of stages of shock
Resting heart rate, blood pressure, and respiratory rate vary with age, and circulatory assessment of a child must take this variation into account. The normal values are shown in Table 15.2. A recent study has shown that injured children have a relative systolic hypertension unrelated to age or trauma severity.The clinician should therefore view with suspicion a systolic pressure in the lower part of the normal range in an injured child.
Table 15.2. Vital signs: approximate range of normal
Disability
The assessment of disability during the primary survey consists of a brief neurological examination to determine conscious level, and assessment of pupil size and reactivity.
Conscious level determination is kept as simple as possible – and requires only that the child is put into one of the four following categories:
A Alert
V Responds to Voice P Responds to Pain U Unresponsive
Exposure
In order to assess a seriously injured child fully, it is necessary to take his or her clothes off. Children become cold very quickly, and may be acutely embarrassed when undressed in front of strangers. Although exposure is necessary the time taken for it should be minimised, and a blanket provided at all other times.
THE STRUCTURED APPROACH TO THE SERIOUSLY INJURED CHILD
Assessment of percentage blood loss
Sign <25 25–40 >40
Heart rate Tachycardia+ Tachycardia++ Tachycardia/
bradycardia
Systolic BP Normal Normal or falling Falling
Pulse volume Normal/reduced Reduced+ Reduced++
Capillary refill time Normal/increased Increased+ Increased++
(Normal <2s)
Skin Cool, pale Cold, mottled Cold
Pale
Respiratory rate Tachypnoea+ Tachypnoea++ Sighing respiration
Mental state Mild agitation Lethargic Reacts only to pain
Uncooperative
Age (years) Respiratory rate Systolic BP (mmHg) Pulse (beats/min) (breaths/min)
<1 30–40 70–90 110–160
1–2 25–35 80–95 100–150
2–5 25–30 80–100 95–140
5–12 20–25 90–110 80–120
>12 15–20 100–120 60–100
RESUSCITATION
Life-threatening problems should be treated as they are identified during the primary survey.
Airway and cervical spine Airway
The airway may be compromised by extrinsic material (blood, vomit, or a foreign body), by the tongue, or by injury to the face, mouth, or upper airway. Whatever the cause, airway management should follow the sequence described in Chapters 4 and 5.
This is summarised in the box.
Head tilt/chin lift is not recommended following trauma, because cervical spine injuries may be made worse.
Cervical spine
The cervical spine should be presumed to be damaged until proved intact, especially if there is obvious injury above the clavicle. Children can have significant spinal cord injury without radiographic abnormality (with devastating consequences if ignored). Even if normal radiographs are obtained the cervical spine must be protected in any patient where there is a high index of suspicion. If the child is unconscious or cooperative, his or her head and neck should be immobilised initially by in-line manual stabilisation, and then using a semi-rigid collar, sandbags, and tape. Uncooperative or combative patients should simply have a hard collar applied, because too rigid immobilisation of the head in such cases may increase neck movement as struggling occurs. Only when radiographs are normal, and the neurological examination has been demonstrated to be completely normal, should immobilising manoeuvres be discontinued. A full neurological assessment cannot be carried out if the child is paralysed and ventilated. Spinal immobilisation may need to be maintained for prolonged periods in such cases.
Breathing
If breathing is inadequate, ventilation must be commenced. Initially bag-mask ventilation should be performed. Generally speaking, a child who requires bag-mask ventilation initially following trauma will subsequently require intubation to control the airway. Following intubation, mechanical ventilation can be commenced.
The indications for intubation and mechanical ventilation are summarised in the box.
THE STRUCTURED APPROACH TO THE SERIOUSLY INJURED CHILD
Airway management sequence
Jaw thrust
Suction/removal of foreign body
Oral/pharyngeal airways
Tracheal intubation
Surgical airway
If breath sounds are unequal then pneumothorax, misplaced tracheal tube, or blocked main bronchus should be considered, and appropriate measures should be taken.
Circulation
All seriously injured children require vascular access to be established urgently. Two relatively large intravenous cannulae are mandatory. The percutaneous approach to peripheral veins is the preferred route, but, if this fails, other routes should be used. The external jugular veins and femoral veins can be cannulated, and a cut-down onto the cephalic vein at the elbow or long saphenous at the ankle should be considered.
Intraosseous infusion may be used, and will usually prove quicker and easier than the more specialised techniques mentioned above. Vascular access techniques are discussed in detail in Chapter 23.
Central venous cannulation is particularly hazardous in children, and should not be attempted by the inexperienced. If a central venous line is inserted, its main use is for monitoring central venous pressure.
Fluid therapy should be commenced as a bolus using 20 ml/kg of crystalloid (e.g.
normal (physiological) saline) or colloid (e.g. gelatin or starch compounds). The response should be assessed. If there is no change, a further bolus of fluid is given. If there is still no improvement, the next bolus should be of whole blood or packed cells, and a surgical opinion should be sought urgently – this is summarised in Figure 15.1.
Inadequate oxygenation via bag-and-mask technique
Prolonged ventilation required
Controlled hyperventilation required
Flail chest
Inhalation burn injury