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CHAPTER 27

Initial Assessment and Resuscitation

of the Trauma Patient

Francis A. Abantanga
Sha-Ron Jackson
Jeffrey S. Upperman

Introduction Triage
The initial evaluation and treatment of the paediatric trauma patient The most developed countries have designated centres where trauma
require an organised, thorough approach. All patients must be assumed patients, including children, are sent after being “sorted out” at the
to have multiple injuries until proven otherwise. Resuscitation efforts scene or field of injury. These centres are designated in levels. The
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should be early and aggressive to avoid the onset of irreversible following discussion is from the perspective of the West African sub-
2,3
shock; the ability to recognise and effectively treat shock is all that region, Ghana being a good example; but is also true for many other
is required in the vast majority of injured patents in order to gain sta- African countries. Most hospitals have an Accident and Emergency
bility. Adequate assessment and management of the ABCs described (A&E) Department or Emergency Department (ED), where the injured
in this chapter will provide adequate treatment of the patient’s other are rushed by various means—ambulances (rare), private vehicles, or
injuries, leading to an overall improvement in morbidity and mortal- any other means available at the time. It is usually in this form that
ity. Thus, the ABCs play an essential role in the initial evaluation and injured children are received in the emergency departments of hospi-
treatment of the paediatric trauma patient. tals, and it is here that the sorting of the injured starts.
Effective initial resuscitation can reduce mortality in most paediatric Triage is the sorting of patients based on the need for treatment
trauma patients. Guidelines have been developed to facilitate patient care and the available resources to provide that treatment. Children with
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in a systematic and productive manner. Advances have been made in injuries are usually admitted and sorted for treatment regardless of
both diagnostic and therapeutic methods. The evaluation and treatment availability of resources, and then those who cannot be treated in that
of paediatric trauma patients will continue to engage paediatric surgeons particular hospital are resuscitated and stabilised before being referred
as efforts in trauma prevention become more successful. to another hospital that can handle the situation (which may be several
The initial evaluation and care of a paediatric trauma patient uses kilometres away).
the same protocols and procedures employed in adult trauma patients, Primary Survey
the exception being that children should not be considered as little
adults. In the same manner as in adults, the primary survey entails The primary survey identifies life-threatening injuries that compromise
4,5
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ABCDE: A is for Airway maintenance/access with control of the oxygenation and circulation. The vital functions of the patient are
cervical spine (C-spine); B is for Breathing; C is for Circulation with assessed quickly and efficiently; this entails a rapid primary evaluation,
external haemorrhage control; D is for Disability and neurological resuscitation of the vital functions, and later a more detailed re-evalua-
screening; and E is for Exposure/Environmental control with thorough tion of the injured child. The evaluation of the child’s ABCDEs is made
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examination. This is followed by a thorough secondary survey, which the priority of the primary survey or initial phase. F is sometimes
examines the injured child from head to toe. added to ABCDE to signify Further interventions necessary to help
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Guidelines in the Paediatric Advanced Life Support and the manage the patient. It is during the primary survey that life-threatening
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Advanced Trauma Life Support (ATLS) provide a consensus conditions are identified and effectively managed simultaneously.
framework in which to manage the injured patient: This initial assessment should not take long and should detect and man-
age all clinically evident, immediate threats to life. We expand on the
1. triage; ABCDEFs in the next subsections.
2. primary survey of the injured child; A: Airway Access/Maintenance and C-Spine Control
3. resuscitation; Management of the airway begins by assessing its patency, or assess-
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4. secondary survey of the injured child; ing for potential obstruction. Any impaired or obstructed airway is
optimised by using the jaw thrust manoeuvre 1,11,13 or by looking for and
5. re-evaluation and monitoring the injured child after resuscitation;
and removing foreign bodies and/or clearing the oropharynx of debris, as
well as administering supplemental oxygen if required. 1,14 Visible gross
6. Definitive care. debris is manually removed and the airway suctioned to maintain paten-
In the prehospital care of the injured child, emphasis is placed cy, if necessary. In the attempt to assess and manage the child’s airway,
on airway maintenance, ventilation, control of external bleeding and it is necessary to control the C-spine to prevent its excessive movement.
shock, immobilisation of the patient, and immediate transport of the It is wise to always assume C-spine injury until proven otherwise by
child to the closest appropriately functioning (and equipped to handle the necessary follow up investigations. As such, the head and C-spine
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the injured) trauma centre. 1,5,6 Every effort must be made to provide should always be appropriately immobilised with appropriate devices.
initial interventions for all life-threatening conditions to the extent The child’s breathing is carefully assessed again once a patent
possible at the scene of injury and to prevent delays in delivering the airway is established, and if there is the need to provide ventilatory
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injured to such a facility. Management of trauma patients involves a support, this must be done immediately. A child has a large head
team—it is teamwork, and most of the assessment and resuscitation of relative to body size, a short neck and therefore a short trachea, a small
the injured is done simultaneously by members of the team, with one and anterior larynx, a floppy U-shaped epiglottis (the narrowest part
of them acting as the leader. 9–10