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Initial Assessment and Resuscitation of the Trauma Patient 173

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of the airway being the cricoid ring), and a small oral cavity with a by complete cardiovascular collapse. It is not easy to diagnose the
relatively large tongue. 2,11,14 Knowledge of these facts will aid in the severity of shock in injured children. Tachycardia is usually the earliest
choice of equipment to maintain a patent airway (e.g., an oropharyngeal and most reliable measurable response to hypovolaemia in children,
airway; a nasopharyngeal airway, provided a basal skull fracture has but anxiety and pain can confound tachycardia as an indicator of
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been ruled out; or an endotracheal tube). hypovolaemic shock. Clues to immediately recognising early signs
Signs of impending or present respiratory failure include decreased of hypovolaemic shock in children include tachycardia; mental status
breath sounds, tachypnoea, intercostal space retractions, cyanosis, change (level of consciousness); decreased pulse pressure; respiratory
stridor, grunting, nasal flaring, abnormal chest wall motion, noisy compromise; skin perfusion (cold peripheries/cool extremities, mottled
breathing, and paradoxical breathing. If such signs are detected, skin); decreased urine output (minimum urine output for infants and
measures should be taken immediately to restore normal airway by children ranges from 1 to 2 ml/kg per hour); delayed capillary refill;
positioning the patient and using the jaw thrust method without head tilt hypothermia; and hypotension. 1,4,6 Hypotension is a late finding and
to create a patent airway, by suctioning or removing secretions, and by occurs in profound shock. Hypotension must be treated immediately
giving 100% oxygen via a paediatric mask. (Note that the head tilt/chin and aggressively if the child is to survive without any adverse
3,4
lift manoeuvre is not recommended because it may exacerbate a spinal consequences. Children have an amazing cardiovascular reserve, so
injury.) Nasal prongs should not be used because, with them, oxygen one should not be led into a sense of security with regard to the status
concentration cannot be controlled. of the child’s circulating blood volume if the initial vital signs of an
B: Breathing injured child are normal. Hypotension in a paediatric trauma patient is
Once the airway is patent or secured, it is necessary to check whether an indicator of uncompensated shock and occurs following the loss of
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the child is breathing adequately. The respirations must be spontane- more than 45% of the circulating blood volume, estimated to be 80 ml/
1
6,11,14
ous, unlaboured, and at a rate that is normal for the age of the child kg body weight (see Table 27.1).
(Table 27.1); chest expansion should be equal bilaterally; and if the Vascular Access and Venous Cannulation
child speaks, the speech should be normal. Look for the rise and fall of Once adequate ABCs have been established, the next priority is vas-
the chest and abdomen, listen at the child’s nose and mouth for exhaled cular access and venous cannulation. This can be difficult in the early
breath sounds, and feel for exhaled air flow from the child’s month. If stages of shock, and the largest bore cannula possible should be used.
respiration is inadequate, then provide ventilatory assistance, which If necessary, two percutaneous intravenous (IV) cannulae should be
4,6
3
may include supplemental oxygen, bag-mask ventilation, or even endo- placed in the upper extremities, preferably in the veins on the dorsum
tracheal intubation. If available, use pulse oximetry to monitor oxygen of the hands. Generally, two to three attempts are made at cannulating a
saturation. The indications for endotracheal intubation include the peripheral vein; if this fails in children younger than 6 years of age, an
inability to ventilate the child by bag-mask or the need for prolonged intraosseous (IO) access is established by using the anterior tibial pla-
airway management, respiratory failure, and shock unresponsive to teau about 3 cm below the tibial tuberosity 1,4-6 (Figure 27.1) or the infe-
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volume resuscitation. rior one-third of the femur about 3 cm above the external condyle; if
Table 27.1: Normal vital signs for infants and children. a percutaneous line is established later on, the intraosseous line should
be discontinued. There are special IO needles for this purpose; a 16 G or
Respiratory Blood volume
Heart rate Systolic BP 18 G needle should be used. The chosen site of the bone is entered per-
Age rate (breaths/ (ml/kg body
(beats/min) (mm Hg) pendicularly. Aspiration of marrow indicates that one is in the correct
min) weight)
11
15
position. An injured limb should never be used for IO cannulation.
Neonate 100–160 60–90 30–60 90
The potential complications of IO infusions include infection, cellulitis,
Infant 90–120 80–100 30–40 80 4,15
and osteomyelitis.
2–5 years 95–140 80–120 20–30 80 Other options are saphenous vein cutdown at the ankle (above the
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5–12 years 80–120 90–110 15–20 80 medial malleolus); median cephalic vein cutdown on the elbow (not to
> 12 years 60–100 100–120 12–15 70 be performed on the injured limb); or central venous cannulation using
the femoral, subclavian, or internal jugular veins. 1,12 Central venous
lines should be used in the postresuscitation stabilisation phase for
While ventilating the child, be sure the lungs are symmetrically monitoring and should not be attempted by an inexperienced doctor.
auscultated to ensure air exchange in them; the chest is also percussed Once venous access is established, blood samples are taken for the
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to exclude pneumo- or haemothorax; and finally, the chest is inspected determination of full blood count, grouping and cross-matching, urea,
and palpated to exclude injuries to the wall that may compromise
ventilation to some extent.
Note that adequate ventilation, combined with fluid resuscitation to
maintain perfusion, is the basis for resuscitation in the paediatric trauma
patient. Therefore, treat any life-threatening chest injuries immediately
to alleviate any respiratory distress. Potentially life-threatening injuries
include tension pneumothorax, open pneumothorax, flail chest, cardiac
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tamponade, airway obstruction, and massive haemothorax. These
injuries should be actively sought in an injured child and treated
appropriately and immediately.
C: Circulation
For a positive outcome in paediatric trauma patients, it is necessary
to recognise hypovolaemia. An attempt should be made to stop any
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external bleeding, if present, by direct manual compression over
the wound or proximal to the point of bleeding. It is known that
children have an increased physiological reserve and manifest signs
of hypovolaemic shock much later, with hypotension followed quickly Figure 27.1: Method of setting up an intraosseous infusion.