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174 Initial Assessment and Resuscitation of the Trauma Patient

creatinine and electrolytes, prothrombin time (PT), and amylase, after weight) or phenobarbital (2–3 mg/kg body weight) may be given if
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which volume replacement begins. traumatic brain injury is suspected. Mannitol (0.5–1 gm/kg body
Initial fluid replacement will depend on the child’s weight and weight) and furosemide (1 mg/kg body weight) should be used with
should consist of warm isotonic crystalloids. Warm intravenous fluids care because they can exacerbate hypovolaemia in haemodynamically
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will prevent hypothermia during the initial phase of resuscitation. unstable patients.
As we know, hypothermia results in vasoconstriction, acidosis, and It is prudent to perform neurological assessment of the injured
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consumptive coagulopathy —all deleterious to the injured child. The child frequently to detect any changes that might occur during the
weight of a child (in kilograms), if unknown, can easily be estimated resuscitation period.
by using the following formula: E: Exposure
Weight = 2 × (age in years + 4) or Weight = [5 × (age in years + 3)]/2 Expose the child by completely cutting away clothing where neces-
sary; it is also wise, however, to preserve evidence of torn clothing as
Systolic blood pressure (SBP) and diastolic blood pressure (DBP) in well as to address patient modesty. The patient must be well exposed
children can be estimated by using the appropriate formula: to aid thorough physical examination and to facilitate practical pro-
cedures. 1,4,15 Expose both front and back to ensure that no injuries are
SBP = 80 + (2 × age in years)
missed—for this, the child should be log rolled while maintaining
DBP = 2/3 × SBP C-spine immobilisation. The child is also assessed for signs of heat or
Resuscitation chemical exposure to determine whether there is a need for irrigation
The solutions to use for resuscitation include isotonic normal saline of the affected area. Measures should be taken to prevent the child
(NS) (0.9%) or Ringer’s lactate (RL) at an initial bolus of 20 ml/kg from losing heat and becoming hypothermic during exposure and
body weight with a goal to achieving haemodynamic stability and examination in the A&E department. 13,15 The child is kept warm and
improvement and restoring tissue perfusion as quickly as possible. 6,12 intravenous fluids warmed before being administered. This may not
If there is no improvement in the haemodynamic status within 30–60 be a requirement in our subregion where intravenous fluids are usually
minutes, then another bolus of 20 ml/kg body weight of the same warm warm, except for blood and blood products. Lastly, signs of child abuse
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crystalloid solution should be given, for a total of 40–60 ml/kg; in are assessed and carefully documented. Nothing should be left out as
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the case of children with evidence of haemorrhagic shock who fail being unimportant.
to respond to fluid resuscitation, they should receive a transfusion of F: Further Interventions
grouped and cross-matched packed red blood cells at a dose of 10 ml/ Further interventions include: 13
kg body weight, or whole blood at a dose of 20 ml/kg body weight. 4,6,13 • the passage of a nasogastric tube to decompress the stomach since
Of course, the source of bleeding should be identified and appropriately acute gastric dilatation may precipitate vomiting and aspiration;
managed. compress the inferior vena cava leading to diminished venous
The algorithm in Figure 27.2 can be used for the initial assessment return to the heart and result in hypotension; splint the diaphragm
and resuscitation of a child admitted with trauma. leading to respiratory embarrassment.
During resuscitation, it is prudent to have a urinary catheter in situ
because urine output is an excellent indicator of volume status and can • insertion of a urinary catheter in the urinary bladder; and
be used to guide resuscitation. Aim to get about 2 ml/kg or more per • managing pain relief by using the appropriate analgesics, such as
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hour of urine for children up to 1 year of age and about 1 ml/kg per morphine (0.1 mg/kg), once the primary survey is completed.
hour for older children. If there is suspicion of a pelvic fracture with Other necessary confirmatory investigations can be done at this
the possibility of injury to the urethra, then passage of a catheter is stage when the child is considered stable enough to be moved.
contraindicated (this is a relative contraindication).
Fluid resuscitation for children with isolated head injury should be Secondary Survey
considered carefully so as not to cause a rise in the intracranial pressure Once tachycardia, hypotension, hypoxia, and hypothermia have been
with too much fluid. 4 managed, then a secondary survey with definitive treatment can be
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D: Disability safely started. The secondary survey begins when the primary survey
is completed, resuscitation has been started, and the child is responsive
A rapid neurological survey is performed to assess the level of
or haemodynamically stable.
consciousness, pupillary response, symmetry and size. The mne-
The secondary survey involves a more detailed systemic assessment
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monic AVPU is used to quickly assess the child’s conscious level:
of the patient than the initial evaluation (from head to toe, front and
Alert, response to Verbal stimulus, response to Painful stimulus,
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back) and initiation of relevant diagnostic investigations (all the
Unresponsive.
necessary radiographs and laboratory tests). It should never be started
In using this rapid method of assessment, it is necessary to observe
in a haemodynamically unstable patient. Attention should be paid to
the ability of the child to follow simple commands and the quality and
the history and signs and symptoms of the present injury. The history
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rapidity of the responses. The pupils are briefly tested for size, equality,
should be taken directly from the child (if the child is old enough
and bilateral reactivity. Both pupils should react briskly and positively.
and cooperative to do so), from family, and from bystanders, or other
The Glasgow Coma Scale (GCS) (see Chapter 26) can be used
relevant persons. It should include the name, age, and what happened. It
either during the primary survey or during the secondary survey for a
may sometimes be necessary to interview older children in the absence
more detailed neurological assessment of an injured child, especially
of caregivers if accurate information is to be obtained in areas such as
after resuscitative efforts. There is evidence available to indicate that
child abuse, drug and alcohol use, and sexual abuse.
children who present with an initial GCS score of 6–8 in the presence of
It is in the interest of both the child and the doctor to allow a parent
hypotension (SBP <90 mm Hg) have a significantly increased mortality
to be by the child. This will calm anxiety from both parent and patient
4
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rate; therefore, it is important to prevent systemic hypotension
and allow the physician to completely examine the child. Again, pain
during the initial efforts at resuscitation of the paediatric trauma
must be treated adequately, and all critically injured children must be
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patient, especially children with head injury. A GCS score ≤ 8 is an
admitted to an intensive care unit (preferably, a paediatric intensive
indication for intubation of the child with head injury. Administration
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care unit).
of phenytoin (10–20 mg/kg body weight), diazepam (0.25 mg/kg body