Structured Approach To The Seriously Injured Child Flashcards

Question 1

Q

In what age group is injury the main cause of death?

Answer

A

5-14 year olds (25.41%)

Question 2

Q

How do the properties of children’s tissues affect the presentation of injury?

Answer

A

Children have more elastic tissues.

This allows energy to be transmitted away from the point of impact to other body parts during injury.

Question 3

Q

Describe a structured approach that team leaders in trauma cases can use to assimilate information after a trauma call is received.

Answer

A

ATMISTER

Age/ sex
Time of incident
Mechanism of injury
Injury suspected
Signs - vital signs, GCS
Treatment so far
Estimated time of arrival in ED
Requirements - blood, specialist services, tiered response, ambulance call sign

Question 4

Q

What preparations must be made prior to the arrival of a trauma call?

Answer

A

Allocate roles
- Leader
- Primary survey
- A
- B
- C
- Scribe
- Drug Management
- Family support
Make plan and back up plan according to age and mechanism
- rememeber management of catastrophic haemorrhage requires urgent blood products

Question 5

Q

When should a controlled ‘hands off’ handover NOT occur in trauma calls?

Answer

A

Traumatic cardiac arrest
Obstructed airway (A/B)
Catastrophic haemorrhage (C)

Question 6

Q

What should happen first upon arrival of trauma call?

Answer

A

Controlled hands off handover unless:
- traumatic cardiac arrest
- obstructed airway
- catastrophic haemorrhage
5 second review by team leader
Plan adapted as necessary

Question 7

Q

Describe the structured approach to the seriously injured child.

Answer

A

PREPARE for child’s arrival

get help / gather team
allocate roles
work out drug, fluid & equipment needs
make plan and back up plan

PRIMARY SURVEY (Immediate):

Responsive? (including AVPU)
NO: cardiac arrest Mx
YES: ABCDE looking for life threatening issues

RESUSCITATION
SECONDARY SURVEY looking for key features /clues to likeliest working diagnosis (Focused)

focused history (incl. immunisations, drug allergies, development, FHx)
clinical examination
specific Ix

EMERGENCY Tx
REASSESS focusing on system control (Detailed review)
STABILISATION
TRANSFER to definitive care environment

Question 8

Q

Describe the primary survey and resuscitation of the seriously injured child.

Answer

A

<<c>>ABCDE</c>

<<c>>= Catastrophic external haemorrhage</c>

obvious exsanguinating external haemorrhage = immediate priority
simple direct pressure
tourniquet
pelvic splint
specialised haemostatic dressings
tranexamic acid 15 mg/kg

A = Airway (with cervical spine control)

Airway patent? compromise?
GCS < 8 = unlikely to be protecting airway adequately
LOOK for
- LUMEN - material inside e.g blood, vomit, teeth, foreign body - NB commonest cause of occlusion is the tongue in an unconscious child w/ HI
- IN THE WALL - damage or loss of control of structures e.g. mouth, tongue, pharynx, larynx, trachea
- OUTSIDE THE WALL - external compression or distortion e.g. pre-vertebral haematoma in neck causing compression, displaced maxillary fracture causing distortion
RE-ASSESS
- problems can occur after the primary survey
- e.g. bleeding, progressive swelling in facial trauma/ burns
Airway Mx sequence
- Jaw thrust
  - NO head tilt/ chin lift
  - cervical spine injury may be present even if plain XR normal
  - e.g. ligamentous injury with no fracture
- Cervical Spine
  - Take off stretcher with 20 degree tilt method (P. 246) –> trauma board/ ED trolley
  - MILS = Manual In Line Stabilisation
  - Head block and strapping
    - do not immobilise too rigidly - increases leverage on neck if child struggling
    - minimise anxiety - avoid unnecessary interventions + parents at bedside
  - if paralysed/ sedated/ ventilated cannot clear C-spine until definitive imaging / neuro exam
- Suction/ removal of foreign body under direct vision
  - tilt head of trolley down to prevent aspiration of vomit
- Oro/ naso-pharyngeal airways
- Intubation
- Surgical airway

B = Breathing (with ventilatory support)

Vital signs - RR, O2 sats
Adequacy of breathing
- Effort
- Efficacy
- Effects on other organ systems
Inadequate –> BVM –> I+V
Indications for I+V:
- Airway obstruction
  - persistent
  - predicted e.g. inhalational burn
- Airway reflexes - loss of
- Ventilatory effort inadequate, or increasing fatigue
- Ventilatory mechanism disrupted e.g. severe flail chest
- Ventilation (controlled) needed to prevent secondary brain injury
- Hypoxia - persistent, despite O2 Tx
LOOK - asymmetry? FLAIL CHEST.
LISTEN - unequal BS? –> PTX x 2 + ABCDE
- PTX
- HaemoPTX
- Aspiration - of vomit or blood
- Blocked main bronchus/ pulmonary collapse
- Contusion (pulmonary)
- Diaphragmatic rupture
- ETT misplaced
FEEL
- Crepitus? SURGICAL EMPHYSEMA.
- Tracheal deviation
- Percuss. Tension PTX Vs. HAEMOTHORAX.
Conditions: ATOM FC
- Airway Obstruction
- Tension PTX
- Open PTX
- Massive haemothorax
- Flail Chest
- Cardiac Tamponade

C = Circulation (with haemorrhage control)

Assess
- HR
- rhythm
- Pulse
  - volume
  - peripheral pulses (trauma - limb injury)
- Peripheral perfusion
  - colour
  - temperature
  - CRT (prolonged in normal people if cold)
  - BP
- Haemorrhage
  - ?internal (Fem CH.A.P)
    - Femurs, Chest, Abdomen, Pelvis
    - ? multiple sites, progressive deterioration
    - Abdo –> CT + contrast
    - FAST (Focused Abdominal with Sonography for Trauma) - limited evidence in detecting abdo haemorrhage
  - ? external
    - see - apply pressure
Clinical signs indicating blood loss needing urgent Rx – SUMMON THE TEAM
- HR - increasing/ relative bradycardia
- BP - falling
- CRT - > 2 secs (increasing)
- RR - high, unrelated to resp problem
- Mental state - altered conscious level, unrelated to to isolated HI
IV access
- 2x large bore cannulae
  - peripheral veins
  - IO - tibia, femur, humerus
  - external jugular - if no C-spine injury suspected
  - femoral vein
  - cut down - elbow (cephalic vein), ankle (saphenous bein)
- Ix
  - gas - lactate + haemoglobin (circulatory compromise) + GLU
  - urgent cross match
  - FBC, U+E, amylase/ trypsinogen, Clotting (TEG/ ROTEM where available)
  - b-HCG
Fluids
- THE FIRST CLOT IS THE BEST CLOT
- NO fluid bolus if stable + no shock
- Consider bleeding in circulatory compromise
Major haemorrhage Mx - NB uncommon in children = MHP (Massive Haemorrhage Protocol)
NB reassess after every stage and consider surgical/ IR intervention
1. Adjuncts
  - simple direct pressure
  - tourniquet
  - pelvic splint
  - specialised haemostatic dressings
2. Tranexamic acid 15 mg/ kg
3. 1st BLOOD or BOLUS (10 ml/kg warmed normal saline) –> ongoing shock? –>
4. 2nd BLOOD or BOLUS –> ongoing shock?->
5. Clarify plan for haemorrhage control (with surgeons & interventional radiologists)
  - blood gases
  - Ca > 1 mmol/L (using 10% ca chloride 0.1 ml/kg)
  - K+ > 6 –> bolus INSULIN + DEXTROSE
    - 0.1 unit/ kg actrapid
    - 10 ml/kg 10% dextrose
  - Hb - aim not > 120
  - PLAT > 100
  - anaesthetic R/V
6. 5 ml/kg WARMED packed Red Cells OR FFP (1:1) –> Repeat up to 20 ml/kg blood products
7. Request major haemorrhage pack from blood bank - contains:
  - PRBCs
  - FFP
  - PLAT
8. 5 ml/kg WARMED packed Red Cells OR FFP (1:1) –> Repeat up to 20 ml/kg blood products
9. PLAT + CALCIUM CHLORIDE
  - PLAT 10-15 ml/kg (aim PLAT > 50)
  - 10% calcium chloride 0.1 ml/kg
10. CRYOPRECIPITATE + NOVOSEVEN + D/W HAEM
  - cryoprecipitate 10 ml/kg - aim fibrinogen =/> 1 g/l
  - novoseven (activated factor 7) - if still bleeding after 2 cycles
  - D/W haem consultant
11. Circle back to step 5

D = Disability (with prevention of secondary insult)

rapid - during the primary assessment
- AVPU –> GCS ASAP
- pupil size + reactivity
- agitation –> ? cerebral hypoxia
Decompensating HI + P/U OR GCS < 8 –> immediate neurological resuscitation (NB if deteriorating may need transfer to neuro centre PRIOR to CT)
- B
  - 15 L/ min O2
  - controlled ventilation aim PCO2 4.5-5.5
  - I+V (anaesthetise, paralyse, sedate) – reduces cerebral metabolism
- C
  - maintain normal BP to support cerebral perfusion
  - consider inotropes
- D
  - CT head + refer to neursurgeons
  - head tilt 30 degrees (helps cerebral venous drainage) Vs. 20 degrees up and head in line nursing in raised ICP
  - treat seizures
  - treat raised ICP
    - 3% hypertonic saline 3 ml/kg

–> 0.1 - 1 ml/kg/hr (keep osmolality < 360)

        * 20% Mannitol -- 250-500 mg/kg (1.25 - 2.5 ml) over 15 mins -----\> 2 hourly PRN if serum osmolality NOT \> 325 mOsml/L
        * Dexamethasone -- oedema around a SOL -- 0.5 mg/kg 6 hrly

* E
    * treat raised **temp** -- **analgesia** also reduces cerebral metabolism

E = Exposure (with temperature control)

avoid hypothermia
- airflow heating devices
- blankets
- warm ALL fluids and blood products
NGT / OGT
- acute gastric dilatation common in children - decompress
- major trauma often causes gastric stasis
- OGT if base of skull fracture suspected

G= DON’T EVER FORGET GLUCOSE

adolescents may become hypoglycaemic after drinking alcohol

A = DON’T EVER FORGET ANALGESIA

can be given just after primary survey and resuscitation

Question 9

Q

What history should be sought during the secondary survey and resuscitation of the seriously injured child?

Answer

A

HISTORY

Speak to LAS, relatives, witnesses
AMPLE
- Allergies
- Medications
- PMH + immunisations
- Last meal
- Environment and events –>
Mechanism of injury - increased likelihood of significant injury if DECE:
- Death / serious injury of an occupant of the vehicle
- Ejection from vehicle
- Collision - head-on, > 40 mph
- Extrication prolonged

Question 10

Q

Describe the secondary survey in seriously injured children.

Answer

A

SECONDARY SURVEY

Purpose = DIAGNOSIS
HOW?
- Systematic clinical examination to:
  - identify key anatomical features of injuries - thorough (head to toe, front to back)
  - diagnose conditions requiring emergency management
- Supplemented by:
  - history
  - obs
  - imaging
  - ECG – in chest trauma + unexplained collapse/ seizure
  - other Ix
WHEN?
- after the primary survey + resuscitation
- monitor vital signs + neurological status –> deterioration –> return to primary survey
- occasionally may be delayed if life-saving interventions required – DOCUMENT THIS DECISION CLEARLY
Secondary survey - looks for the SO(U)RCE of injury
- Surface
  - head to toe – including
    - full neuro exam + observe movement
    - SKIN: external evidence of injury (tyre marks, bruising, lacerations, swelling), ? NAI
  - front and back – don’t forget SPINE/ BACK
- ORifice
  - Upper: mouth, nose, ears, orbits
    - Mouth: inside and out, intraoral bruising = ? fracture
    - Teeth ? loose (palpate)
    - Nose: Nasal septal haematoma
    - Ears: otoscopy (haemotympanum), mastoid bruising (base of skull #)
    - Eyes: opthlamoscopy (retinal haemorrhage), panda eyes (base of skull #)
    - Face: Midface stability (assess)
    - Neck: neck veins + pulses (if neck injury)
  - Lower: rectum, genitals, perineum, external urethral meatus (blood)
- Cavity
  - chest
  - abdomen
  - pelvic cavity
  - retro-peritoneum
- Extremity
  - Upper limbs incl. shoulders
  - Lower limbs incl. pelvic girdle

Question 11

Q

What follows the secondary survey in the management of the seriously injured child?

Answer

A

EMERGENCY TREATMENT of

LIFE - and LIMB - THREATENING INJURIES (identified in secondary survey) AND
abnormal findings from adjunct Ix
may include definitive care of more minor injuries if this does not put the child at risk

If there is serious deterioration, return to the PRIMARY SURVEY.

Question 12

Q

Describe the process of continuing stabilisation in the seriously injured child.

Answer

A

CONTINUING STABILISATION

WHEN?
- After emergency management of problems identified in secondary survey
- Prior to or during transfer if definitive care is needed at a specialist centre
WHAT?
- Detailed review based on system control (Vs. Primary survey = crude physiological control)
- Systems (top to bottom)
  - NEURO
  - RESP
  - CVS (3 x HAEM’s)
    - Haemostasis
    - Haemoglobin
    - Haemodynamics
  - RENAL - including fluid balance and electrolytes
  - METABOLISM - including
    - GASTRO
    - FLUID BALANCE
    - ELECTROLYTES
    - HORMONES
  - HOST DEFENCE (4 x I’s)
    - INJURY
    - INFECTION
    - IMMUNITY
    - INTOXICATION

Systems Stabilisation

NEURO
- pupil size + reactivity - every 15 mins
- GCS - “
  - deterioration in either –> neurosurgeons +/- repeat CT scan
- ICP + CPP monitoring (theatres or PICU)
RESP
- A:
  - recheck
  - ETT - expected length at teeth for size of child?
- B:
  - BS - symmetrical? (could ETT have migrated into main stem bronchus?)
  - Sats monitoring - continuous
  - ETCO2
    - mandatory if ventilated
    - shows that breathing circuit is connected and ETT not dislodged
    - crude indicator of pulmonary perfusion but arterial PCO2 HIGHER than ETCO2 (due to ventilation-perfusion mismatch)
  - ABG – ART line needed if intubated. Venous Gas ok if not intubated.
CVS (3 x HAEM’s)
1. Haemodynamics
  - ECG - for HR and rhythm in children with serious injuries
  - NIBP/ invasive via arterial line for HI/ serious injury
  - CVP monitoring
2. Haemoglobin
  - ABG (hourly) for:
    - haematocrit/ Hb - to detect bleeding and decide on transfusion
    - Lactate - tissue perfusion (but also assess clinically)
3. Haemostasis
  - Clotting and PLAT count, consider TEG/ ROTEM
  - FFP/ PLAT to correct coagulopathy after major blood loss
  - Remember: hypothermia affects clotting
RENAL (including fluid balance and electrolytes)
- Urinary catheterisation - ONLY if:
  - unable to pass spontaneously OR
  - accurate input/ output to achieve stabilisation after a serious physiological insult
- Urethral or Suprapubic- depending on evidence of injury:
  - urethral e.g. blood at the external meatus
  - bladder
  - intra-abdominal
  - pelvic e.g. bruising in the scrotum/ perineum
- Consider:
  - Exclude urethral damage before catheterising a boy
  - If there is doubt about catheterisation let the surgeon decide
  - Use the smallest silastic catheter possible to avoid stricture formation
- Urine M/C/S
- Urine output
  - indicator of systemic perfusion - record hourly
  - aim 1-2 ml/kg/ hour
  - higher if high risk of myoglobinuria e.g. crush injury, electrical burn
  - LOW
    - usually hypovolaemia
  - HIGH
    - excessive fluid Tx
    - Diabetes insipidus (can occur w/i a few hrs of serious HI)
METABOLISM (biochemical processes) - including
- GASTRO - renal/ hepatic/ GI problems
- FLUID BALANCE
- ELECTROLYTES
- HORMONES - endocrine problems
- GLUCOSE - DEFG!! - consider alcohol and overdose in hypoglycaemia
HOST DEFENCE (4 x I’s) - the interaction b/w the body and external influences
- INJURY - incl.
  - thermal injury (NB hypothermia hinders blood clotting and predisposes to infection; avoid fever in HI)
  - injury from poor positioning e.g. avoid pressure injury from a badly fitting collar
- INFECTION - incl. wound care, ABx prophylaxis for open fractures
- IMMUNITY - what immunisations have been done? incl. tetanus prophylaxis (esp in heavily contaminated wound e.g. soil, faeces)
- INTOXICATION - alcohol/ drugs in circulation

Question 13

Q

What is the tertiary survey?

Answer

A

Re-examination of the child AND

Reviewing Ix esp. imaging

To find any missed injuries.

Done by:

Tranport escorts
Intensive care staff
Receiving unit medical staff

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Structured Approach To The Seriously Injured Child Flashcards

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