Section: ADC Trauma ADC ED/TRAUMA POLICY AND PROCEDURE Policy 270 Subject: Pediatric Trauma Resuscitation Protocol Trauma Coordinator UTMB respects the diverse culture needs, preferences, and expectations of the patients and families it serves to the extent reasonably possible while appropriately managing available resources and without compromising the quality of health care delivery. I. Title Trauma Resuscitation Protocol II. Definition To define the Pediatric Trauma Patient To provide triaged guidelines for the Pediatric Patient To provide guidelines for transfer of Pediatric Trauma Patients III. POLICY It is the policy of Angleton Danbury Campus that an organized multi-disciplinary team will manage and stabilize critical or seriously injured children. IV. PROCEDURE 1. All pediatric patients with spinal cord injuries should be transferred to a pediatric trauma center or children s hospital when stabilized. 2. Pediatric patients with major injury to any of the following should be transferred to a pediatric trauma hospital or children s hospital. Head Chest Abdomen Extremities Spine burns >5% BSA Patients with isolated major neurovascular extremity injuries Any patient under the age of 16 with suspected major injuries
NORMAL PEDIATRIC PHYSIOLOGICAL PARAMETERS Age Wt. (Kg) Blood Pressure Heart Rate Resp Rate (ml/h) Birth to 1 mo 4 60-90/20-60 120-160 30-60 17 3 mo 5 74-100/50-70 120-160 30-60 21 6 mo 7 74-100/50-70 120-160 30-60 29 9 mo 9 74-100/50-70 120-160 30-60 38 12 mo 10 80-112/50-80 90-140 24-40 42 15 mo 10.5 80-112/50-80 90-140 24-40 43 18 mo 11.5 80-112/50-80 90-140 24-40 45 21 mo 12 80-112/50-80 90-140 24-40 46 24 mo 12.5 80-112/50-80 90-140 24-40 47 30 mo 13.5 80-112/50-80 90-140 24-40 49 3 yr 14.5 82-110/50-78 80-100 23-34 51 4 yr 16.5 82-110/50-78 80-110 23-34 55 5 yr 18 82-110/50-78 80-110 23-34 58 6 yr 21 84-120/54-80 75-100 18-30 64 8yr 27 84-120/54-80 75-100 18-30 70 10yr 32 84-120/54-80 60-90 12-16 75 12yr 39 94-140/62-88 60-90 12-16 82 14yr 49 94-140/62-88 60-90 12-16 93 16yr 56 94-140/62-88 60-90 12-16 100 IV Maintenance 2
Pediatric Initial Assessment Primary Survey 1. Follow ED/Trauma Policy #300 Primary and Secondary Assessment Guidelines with the following pediatric considerations. Airway assessment 1. Primarily nose breathers first 4 weeks of life 2. Nasal obstruction may cause respiratory distress 3. Smaller oral cavities 4. Airway cartilage in infants is soft 5. Flexion or hyperextension of the neck may cause airway compression 6. Use neutral, mid-line sniffing position 7. Tongue is proportionally larger 8. May easily block airway 9. Use chin lift/jaw-thrust 10. Small Cricoid Cartilage 11. Use uncuffed endotracheal tubes in children less than 8 years of age 12. Patency Partial or complete obstruction Stridor Oral cavity with blood, emesis or FB No air exchange Airway management 1. Positioning (respect C-spine) 2. Head in a neutral, midline position 3. Open airway 4. Suction 5. Jaw thrust 6. Airway Adjuncts Oral/Nasal Airways Intubation - ET Tube Size = Age (yrs.) + 4 = ET size in mm 4 - Surgical Airway Cervical spine 1. Increased head size relative to body size 2. Cervical spine immobilization important due to weight of the head 3. Spine more mobile 4. Head larger, increased force of impact with deceleration Cervical Spine Management 1. Immobilization 2. Collar sizing 3. Alternate methods 4. Lateral stabilization 5. Parent stabilization 3
Breathing 1. Normal increase in rate in response to stress 2. Less tolerance to compromise 3. Smaller lung volumes 4. Smaller peripheral airways 5. Diaphragm principle muscle of respiration 6. Chest wall more pliable 7. Chest wall is soft due to sternum and ribs being cartilaginous 8. Assessment Spontaneous respirations Rate, depth & symmetry of respirations Chest wall integrity Breathing Management 1. Oxygen 100%, method most tolerable by child 2. Bag-Valve-Mast (BVM) 3. Intubation & Ventilation 4. Consider NGT/OGT placement to decompress stomach Circulation 1. Capillary refill is one of the best ways to access circulatory status 2. General color 3. JVD, tracheal deviation 4. Healthy, capable of intense vasoconstriction to compensate 5. BP poor indicator of shock state 6. Low BP is very late sign of shock, 25% of circulation volume lost Circulation Management 1. ACLS 2. Control obvious external bleeding 3. IV access Peripheral, large bore (3 attempts/90 seconds) Intraosseous infusion Femoral line or saphenous vein cut down 4. Fluid Resuscitation 20 ml/kg IV BOLUS, RAPID IV PUSH Consider blood replacement after administration of 3 IVF boluses and patient does not improve 5. Consider Etiology & Intervention if remaining hypotensive: Inadequate Ventilation Tension pneumothorax Pericardial tamponade Hypothermia Internal bleeding Disability 1. Assessment Developmental characteristics Communication abilities Level of activity 4
ADC ED/Trauma Policy 270 Orientation to Time/Place/Person Pupils response Extremity movements Infant: Fontanel/Tracking/Sucking - Bulging of firm fontanels may indicate presence of intracranial pressure Pediatric Coma Scale Large amount of body heat lost through head Hypoglycemia-Infants, small children will utilize glucose stores at accelerated rate in response to stress Check bedside glucose Consider Narcan LIFE THREATENING BREATHING CONDITIONS REQUIRING IMMEDIATE INTERVENTION Tension Pneumothorax 1. Air enters the pleural cavity during inspiration, but cannot escape during expiration. Accumulating pressure in the pleural cavity causes partial or total lung collapse, usually with mediastinal and impaired venous return. 2. Signs & Symptoms Acute respiratory distress Asymmetric chest movement JVD Cyanosis Decreased or absent breath sounds 3. Interventions Emergency needle thoracostomy Chest tube placement Open pneumothorax 1. Injury creates opening in chest wall, air under positive atmospheric pressure flows directly into pleural cavity. Increased intrapleural pressure leads to partial or total lunch collapse, with possible mediastinal shift and impaired venous return. 2. Signs & Symptoms Acute respiratory distress Sucking sound over open chest wound Cyanosis Subcutaneous emphysema Decreased or absent breath sounds on side of injury 3. Interventions Cover with 3 side s occlusive dressing Monitor for development of tension pneumothorax Hemothorax 1. Injury causes laceration of lung, heart, great vessels, intercostals artery or veins, vessels in the diaphragm or chest wall. Blood accumulates in the pleural cavity causing partial or total lung collapse with shift and impaired venous return. 2. Signs & Symptoms 5
ADC ED/Trauma Policy 270 Respiratory distress Mechanism of injury suggestive of hemothorax Decreased, absent breath sounds 3. Interventions Chest tube insertion, consider auto transfusion Volume or blood replacement Surgical intervention Pericardial tamponade 1. Injury to the heart causes blood or fluid to accumulate in the pericardial sac, which impairs ventricular filling and the pumping action of the heart, thus decreasing cardiac output. 2. Signs & Symptoms JVD Mechanism of injury suggestive of tamponade Chest Ecchymosis, rib or sternal fractures 3. Interventions Pericardiocentesis Emergency thoracotomy Surgical intervention V. SECONDARY SURVEY **BRIEF BUT THOROUGH** Expose 1. Remove all clothing in order to visualize all areas of the body 2. Protect against excess cooling of patient. Utilize warming measures such as warm blankets, fluids and overhead warming lights. Full set of vital signs 1. Obtain a complete set of vital signs, including a temperature (preferable rectal) 2. Serves as a baseline History 1. History of injury event 2. Use of restraints or mechanisms that should increase index of suspicion for certain injury patterns 3. EMS assessment and interventions 4. Child s personal medical history Head to toe assessment 1. General appearance Reaction to caregivers Unusual odors Alignment of head, neck and limbs Rigidity or flaccid extremities 2. Head/Face/Neck Scalp, check anterior fontanel in infants Ears, drainage & perauricular Ecchymosis Facial structures: bony deformities, soft tissue injury, petechial 6
ADC ED/Trauma Policy 270 Neck: open wounds, Ecchymosis, trachea position, sub-q-air 3. Chest Rate and effort of breathing Use of accessory muscles Paradoxical chest movement Auscultate breath sounds Rib cage integrity 4. Abdomen Inspect for open wounds, contusions, abrasions, Ecchymosis Inspect for obvious distention Palpate the abdomen for rigidity, tenderness, guarding, distention 5. Pelvis/Genital Assess stability of pelvis, symphysis pubis Inspect for blood at the urethra Rectal tone Swelling or hematoma 6. Extremities Angulation, swelling or open wounds Color, temperature of the extremity Distal pulses and symmetry of pulses Capillary refill Sensory & motor response Pain with movement Guarding of the limb 7. Inspect posterior surface Maintain cervical & spinal immobilization, logroll to visualize Inspect the back, flank areas, buttocks and posterior legs 8. Interventions Oxygen & airway management Spinal immobilization IV access Cardiac monitoring, pulse oximetry NGT/OGT Foley catheter connected to urimeter Baseline lab tests, type & cross match for blood products Radiology studies Pain management Wound care Fracture splinting, elevation and ice Immunization status Psychological support to the child & family 7
9. Reassessment Must have complete baseline to monitor from Frequent reassessments: - Vital signs & Oximetry - Neurological status - Neurovascular status to fractured extremities - Childs behavior and specific complaints - Urinary output VI. HEAD TRAUMA IN CHILDREN 1. Most common type of trauma in children 2. 4,000 children will die every year as a result of head trauma 3. Anatomical difference in children 4. Head proportionally larger than body 5. Cranium undergoing changes in thickness & elasticity, thus leaving the brain at risk for greater insult 6. Small changes in perfusion or increase in intracranial pressure, result in significant insults to the brain 7. Brain tissue less myelinated, therefore, more easily injured (shearing injuries) 8. Greater risk for secondary brain insults 9. Assessment Findings Indicating Head Trauma Loss of consciousness, duration & timing following injury insult Amnesia of injury event in the older child Lethargic, inability to recognize caregivers Nausea and emesis Bulging fontenelle Bradycardia Pupil dilation Posturing & seizures Irritability 10. General Head Trauma Management Principles Keep head midline, elevate HOB if possible Prepare for intubation & hyperventilation (if signs and symptoms are indicative of imminent herniation) Constant neurological checks Medications - Mannitol - Anti-conversant 8
11. Common Occurrences with Head Trauma Linear skull fractures Basilar skull fractures Depressed skull fractures Concussion/contusions Epidural hematoma Subdural hematoma Subarachnoid hemorrhage Intracranial hemorrhage Diffuse axonal injury VII. SPINAL CORD TRAUMA IN CHILDREN 1. Cervical spine less protected than that of an adult 2. Weaker muscles of the neck 3. Neck ligaments more lax, head larger 4. Bony differences that allow more forward motion with flexion 5. Common site of injury less than 8 years, is C-1 thru C-3 6. SCIWORA Spinal Cord Injury Without Radiographic Abnormality VIII. Lumber Spine Fractures 1. Common as result of lap belt restraints IX. CHEST TRAUMA CHILDREN 1. Significant chest trauma rarely occurs alone, usually concurrent with other significant multisystem trauma 2. Significant underlying injury can occur with rib fractures 3. If rib or sternal fractures present, tremendous forces exerted 4. Pulmonary contusions Very common underlying injury in children, who have sustained chest trauma. Sudden compression of thoracic cavity, followed by an equally sudden decompression, causes extravasation of blood into the lung parenchyma. This bruise decreases lung compliance and impairs transport of oxygen and carbon dioxide. 5. Assessment History and mechanism to suggest pulmonary contusion Respiratory distress and chest pain Localized races, wheezes or rubs Hemoptysis External bruises or abrasions across the chest Hypoxemia 6. Management Oxygen therapy, assisted ventilation if severe Fluids should be carefully monitored if not in shock Antibiotics Elevate head of bed 9
X. ABDOMINAL TRAUMA IN CHILDREN 1. Abdominal muscle thinner and weaker and less than developed 2. Chest wall more pliable, thus does not provide as much protection to abdominal organs 3. Liver and spleen less protected, more easily injured 4. Assessment Pain, tenderness & guarding Altered breathing pattern Expiratory grunt 5. Management CT Scan and Ultrasound Observation vs Surgical Intervention 6. Splenic Lacerations: Often seen to blunt impact associated with sports or falls from bicycles Associated with trauma to left upper quadrant of abdomen or left lower chest 7. Liver Lacerations: Major cause of morbidity and mortality in children who have abdominal trauma Associated with trauma to right upper quadrant of abdomen or right lower chest 8. Seat belt related injuries: Lap belt. Positioned over small frame of child improperly Jack-knifes over belt, compress internal organs Back pain with lumbar spine fractures Observe for small bowel injuries 9. Musculoskeletal Injuries Common in children of all ages is the greenstick fracture. This is the incomplete fracture through the bone, with the cortex and periosteum remaining intact. Problems with healing and future bone growth can occur if fracture extends through or involves the growth plate (epiphyseal) Amputations: - Rinse in sterile saline - Wrap part in gauze moistened with sterile saline, place in sealed bag - Place sealed bag on ice and label - X-ray part & stump 10. Consider Maltreatment Documentation Referral to CPS or Law Enforcement XI. PSYCHOLOGICAL SUPPORT OF CHILD AND FAMILY 10
XII. Additional References XIII. Dates Approved or Amended Include origination date, dates of major or minor revisions and dates reviewed without changes. Originated: Reviewed with Changes Reviewed without Changes 1/2016 XIV. Contact Information Andrea Anderson, RN Trauma Coordinator at Angleton Danbury Campus, ext.2524. 11