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176 Initial Assessment and Resuscitation of the Trauma Patient

A good and focused history is necessary to be able to ascertain the are muffled. Absent or reduced breath sounds may indicate the presence
mechanism of injury. The mnemonic SAMPLE can be applied here. 1 of a pneumothorax or haemothorax; distant or muffled heart sounds
may be suggestive of cardiac tamponade.
S: Signs and symptoms as they relate to the chief complaint;
Thus, in examining the chest of an injured child, the physician tries
A: Allergies, including medications, food, and environmental factors; to exclude life-threatening injuries such as tension pneumothorax, open
M: Medications the patient currently takes—over-the-counter drugs, pneumothorax, cardiac tamponade, and massive haemothorax. In the
compliance with prescribed dosing regimen, time, date and amount management of children with chest trauma, a chest radiograph (supine
of last dose; or erect) will confirm the presence of a haemo- or pneumothorax. If a
child is hypoxic after chest trauma, then suspect lung contusion and put
P: Past pertinent medical history, including medical and surgical the child on supplementary oxygen with chest physiotherapy, and give
problems, preexisting diseases or chronic illnesses, previous adequate analgesics to control pain.
hospitalisations; for infants, a neonatal history of gestation,
prematurity, congenital anomalies, and so on; Abdomen
Abdominal trauma patients should be assessed to decide which need
L: Last oral intake of liquids, food, and—for adolescent females— further investigations and which will benefit from an immediate lapa-
sexual activity;
rotomy because of an unstable condition. The abdomen of the stable
1
E: Events related to the current injury, such as onset, duration, and patient is examined for tenderness, guarding, or distention. If any
precipitating factors, associated factors such as toxic inhalants, intraabdominal solid organ injury is suspected, an abdominal ultra-
drugs, and alcohol; injury scenario and mechanism of injury; and sound scan, in the form of focused abdominal sonography for trauma
treatment or first aid given at the site of injury or by caregivers. (FAST) in experienced hands, will be helpful. 5,6,12,17
When treating children with injuries, the clinician should bear in An abdominal ultrasound scan will visualise the presence or
mind the possibility of child abuse and examine the child appropriately. absence of fluid in the peritoneal cavity. Visualisation of fluid by using
A history not consistent with the injury or multiple injuries not ultrasonography, in the right upper quadrant, the left upper quadrant,
consistent with what had happened should cause the clinician to have a and the pelvis suggests solid organ injury or a mesenteric injury. FAST
1,6
high index of suspicion and try to exclude child abuse. is particularly useful in the hypotensive child and is the evaluation
After taking a good history, the patient is thoroughly examined of choice for the determination of significant amounts of fluid in the
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from head to toe, including an evaluation of the child’s vital signs, such paediatric abdominal cavity. It can also be used to diagnose pericardial
as temperature, blood pressure, pulse, and respiration as compared to tamponade. In a stable patient, however, the choice of investigation for
the normal for the child’s age group (see Table 27.1). The goal is to abdominal trauma evaluation is a computed tomography (CT) scan. 1,6,18
recognise and appropriately treat potential life- and limb-threatening It remains the gold standard for the accurate diagnostic evaluation
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pathology. The body is examined region by region to identify the of the child involved in trauma. The CT scan provides a structural
problem(s) and to assess the child for specific injuries to various organ evaluation of organs better than an ultrasound scan, and if combined
systems. A complete neurological examination is also performed, with intravenous contrast injection at the time of the scan, improves the
1
including the use of either the GCS or its modified version for children. clinician’s ability to determine the severity of organ injury. 18
The Paediatric Trauma Score (PTS) should be evaluated and recorded The stable child with a suspected blunt abdominal injury that
in the notes (see Chapter 26). does not demand immediate surgery should be closely observed and
The head is examined for bruises, lacerations, contusions, and re-evaluated several times, preferably by the same examiner. The
skull fractures. The eyes are examined for pupillary reaction to light, abdominal symptoms can change over time.
size, shape, equality, and the conjunctiva for haemorrhage. The face Where the vital signs of the injured child are still unstable after
is examined for facial symmetry, epistaxis, rhinorrhoea, raccoon eyes, proper and adequate resuscitation and after evaluation of the thoracic
and bony fractures. Look for trauma to the gums and tongue in the oral cavity, then it is in order to consider either an intraabdominal or
cavity, as well as missing or broken teeth. The neck is immobilised until pelvic injury and try to find out the cause and treat it appropriately.
a cervical spine injury (a rare occurrence in children) is completely In such cases, a diagnostic peritoneal lavage (DPL) can occasionally
excluded by evaluating the appropriate radiographs. If the radiographs be useful 12,19 in the absence of an ultrasound machine. DPL is a
4
are normal but the child still has neurological deficits or tenderness over method of rapidly determining whether free intraperitoneal blood
the cervical spine, immobilisation of the cervical spine should continue is present and is especially useful in the hypotensive child or the
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until the child is seen by a neurosurgeon. Where available, magnetic haemodynamically unstable trauma patient. In experienced hands,
resonance imaging (MRI) will aid the assessment of the spinal cord in DPL is fast and inexpensive, but more invasive than FAST, and it
children with suspected cervical spine injury. has a low complication rate. If DPL is to be performed in a child, the
Chest volume of fluid to be infused should be about 10 ml/kg of normal
1
The chest is re-inspected for changes from the initial primary survey to saline or Ringer’s lactate. The stomach and the urinary bladder should
assess thoracic trauma. Both posterior and anterior walls of the chest be decompressed by passing a nasogastric tube into the stomach and a
are inspected. The contour and integrity of the chest wall are noted. The urethral catheter into the bladder before the procedure is performed. A
chest is inspected for hyperinflated hemithorax, open wounds, and flail positive result is signified by microscopic findings of the presence of
chest. The ratio of inspiration to expiration is compared—a prolonged more than 100,000 red blood cells (RBCs)/ml, 500 white blood cells
expiration usually indicates distress. The chest is palpated to exclude (WBCs)/ml, bile, or urine from the sample of fluid infused into the
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rib, clavicular, scapular, and sternal fractures. The presence of rib peritoneal cavity. The presence of organic matter or elevated WBC
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fractures signifies that significant trauma has occurred. Where the rib count indicates a hollow viscus has been disrupted.
fractures are multiple and segmental, then a flail chest may occur and It is important to note that the presence of free blood in the
paradoxical respiratory motion may be noticed. 8 peritoneal cavity of a child does not always mean a laparotomy is the
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In the presence of contusions or haematomas on the thoracic wall, next logical thing to do. Such a child, if stable haemodynamically,
the examining physician should have in mind the possibility of occult can be managed nonoperatively provided there are no increasing signs
injury to the chest. The lungs should be auscultated for the presence or of peritonitis, abdominal distention, and hypotension, which would
absence of breath sounds and whether heart sounds are heard clearly or indicate continued bleeding into the peritoneal cavity.