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Initial Assessment and Resuscitation of the Trauma Patient 177

The abdominal examination is not complete if the perineum Re-evaluation
is not inspected and a digital rectal examination is not done. The Ongoing assessment or re-evaluation of the injured child is very
perineum should be examined for bruises, haematoma, contusions, critical to successful care and rehabilitation. Re-evaluation is usually
and lacerations. The rectum should be assessed for blood in the performed following the detailed physical examination in the second-
gastrointestinal tract, and the urethral meatus also should be inspected ary survey. Repeated assessments are essential for the clinician to
for blood. This will inform the physician as to the next line of action. effectively maintain awareness of changes in the condition of the child.
For example, in the case of blood in the urethral meatus, the physician Repeated assessments should be performed every 5 minutes for the
will think of a possible urethral tear and try to avoid unnecessary unstable child and every 15 or so minutes for the stable injured child.
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manipulations in passing a urethral catheter or, better still, inform the Re-evaluation includes:
urologist to do that if there is the need for passing a bladder catheter. • standard respiratory monitoring (ventilatory rate, signs of impaired
Musculoskeletal Examination airway, breath sounds, etc.);
The musculoskeletal system should be inspected. Here the four • standard cardiovascular monitoring (pulses, BP, heart sounds, etc.);
extremities (upper and lower) should be evaluated for pain, pallor,
paresthesia, paralysis, and pulselessness. It is important to inspect the • standard neurological monitoring (GCS, pupils, motor and sensory
limbs for skin colour, ecchymoses, pallor or cyanosis, for symmetry changes, etc.);
and for length and position. Where there is suspicion of a fracture, the • monitoring of temperature; and
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limb must be straightened and splinted or immobilised. It is impor-
tant to bear in mind the possibility of compartment syndrome when • response to pain management.
manipulating and splinting limb fractures. Remember to examine the Definitive care is carried out after the secondary survey. All
child’s pelvis for fractures. problems found during the secondary survey are managed at this
Skin and Soft Tissues stage. All the essential investigations are also carried out during this
stage of the child’s care. The decision to manage the child’s problems
Skin and soft tissues should be carefully examined, especially in the
nonoperatively or surgically (with reference to the haemodynamically
case of burns. Airway management is paramount in children with burns,
stable patient) is also made at this stage.
especially if they involve the face, with the possibility of inhalation
injury. The percentage of body surface area (BSA) burned should be Conclusion
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assessed by using the Lund and Browder chart and fluid resuscita- In conclusion, paediatric trauma patients undergo the same principles of
tion started using either RL or NS at 3–4 ml/kg body weight × % BSA management as for adult patients. Children should never be considered
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burned, in addition to the maintenance fluid. The calculated amount as little adults—their physiology, anatomy, and psychological needs
should be given over the next 24 hours, with half of it being given differ from those of adults. The primary survey and initial phase of
in the first 8 hours. Burns should be cleaned with normal saline and resuscitation of a paediatric trauma patient should address life-threat-
a nonocclusive dressing applied. The child should be transferred to a ening injuries that compromise oxygenation and circulation. Control
burn centre for further management. All the following burns in children of the airway is the most important and first priority. The evaluation
should be managed in a burn centre or in a hospital if a centre does not of the paediatric trauma patient’s ABCs, disability, and exposure are
exist: partial thickness burns of over 10% of the BSA; full thickness made the priority of the initial phase. The aim is to stabilise the injured
burns of over 5% of the BSA; burns on the face, neck, hands, genitalia, patient by thoroughly assessing for injuries and treating those injuries
perineum, feet and over major joints; circumferential burns of any part appropriately before transferring the patient to a trauma centre or to a
of the body; electrical or chemical burns; and burns due to inhalation. facility or hospital where the injuries can be managed better.
All children with burns must have appropriate pharmacologic pain After the primary survey, during which resuscitation of the patient
management, such as injection pethidine or oral morphine. is carried out at the same time, the patient then undergoes a secondary
Neurological Examination survey, in which a detailed history is taken and examination is
The neurological examination determines the mental status of the child, performed; diagnostic investigations are carried out, and the appropriate
or the level of consciousness. The level of consciousness can be deter- treatment is instituted. At this stage, a decision should be made as to
mined by using either the GCS or the modified GCS for infants. The whether the injured child is to be managed in the present facility or be
size and reaction of the pupils to light are determined. Both pupils are transferred to a more appropriate centre, provided, of course, that the
examined for size, shape, equality, deviation, and reactivity to light— patient’s condition is stable.
direct or consensual. Finally, all the limbs must be examined for spon- Evidence-Based Research
taneous and purposeful movements, response to verbal commands, and Table 27.2 presents an example of holistic management of a case
sensory deficits or abnormalities. Where there is paralysis or paresis of involving a 5-year-old child who sustained an injury in a traffic acci-
a limb, injury to the spinal cord or peripheral nervous system should be dent. Table 27.3 presents a study addressing the use of a CT scan to
suspected and the child immobilised with appropriate immobilisation noninvasively evaluate and treat paediatric patients with head and
devices until a spinal injury is ruled out.
abdominal injuries.