Electronic Textbook Injuries Chapter 43 Child-resuscitation

Electronic Textbook Injuries Chapter 43 Child-resuscitation

  • Introduction
  • Epidemiology
  • Aim of trauma care
  • Classification
  • Definitions and scoring of trauma
  • Trauma team
  • Before arrival
  • Primary survey and resuscitation
  • Secondary survey
  • Definitive care
  • Trauma arrest
  • Management issues
  • Transfer
  • Conclusion

Perhaps no other emergency creates as much anxiety as that of a critically injured child because the margin for error is so narrow. Children are not small adults and although the approach to the injured child follows a similar framework to that of adults there are many differences.

An area of similarity between children and adults is the trimodal distribution of death.
At the scene of the accident death usually occurs as a result of unsalvageable injuries such as massive head injury, high cervical spinal injury, major thoracic injury or major vessel disruption.

During the first few hours (the “Golden Hour” concept popularized by Trunkey) death and morbidity during this period are potentially preventable if attention is directed to restoring airway, breathing and circulation.

Death in the days and weeks following the accident is usually secondary to sepsis and multisystem organ failure. These late deaths may be preventable if adequate resuscitation occurs in the first few hours.

Trauma is the leading cause of death in children over one year of age. Non-penetrating or blunt trauma is seen in over 90% of cases, of which motor vehicle accidents and pedestrian injury account for 70% in western countries . Head injury accounts for 60-70% of total trauma cases and is the single most important cause of death and morbidity in children. Countries such as Australia and the United Kingdom are now experiencing an increase in penetrating injury from gun shot and stabbing, most cases relating to suicide or violence in the adolescent (not dissimilar to the experience in the United States).

Aim of trauma care
An important principle in early trauma management is to get those most skilled in treating severely injured children in attendance as soon as possible.
The keys to good trauma care are:
Focus on the priorities of Airway, Breathing, Circulation and Disability.
Pay attention to details.
Re-evaluate the child frequently.
Assume that serious injuries do exist and then work systematically to exclude these injuries.

Important points include:
1. A systematic, integrated and coordinated team approach. A senior medical officer acts as team leader to oversee assessment, resuscitation and subsequent management. Each team member has a defined role, eg airway management, IV cannulation.
2. Appreciating the anatomic and physiologic aspects of the paediatric patient (Appendix L). These have implications for:
• Specific patterns of injury seen in children (frequently different from those in adults).
• IV infusion rates and drug dosages (more often weight-related in children).
• Special equipment requirements for children.
• Because of their small size and elastic skeleton children often sustain injuries to their internal organs with minimal or no external trauma.
3. Consider the mechanism of injury. Details of the accident frequently give important clues to the types and pattern of injury.
4. Recognize that the response to trauma is a dynamic process. Regular monitoring of vital signs and repeated examinations are necessary if occult injuries are not to be missed.
5. Consider the psychological impact. Trauma frequently places the child and his/her family under enormous psychological strain with possible long-term consequences. Clear communication and allowing parents to see their child early and frequently help to alleviate stress.
6. Consider the possibility of child abuse. Important clues may be found in the history or the pattern of injury seen.

The majority of blunt injuries involve a localized area or single system. Children suffering from multiple injuries often have been exposed to critical forces distributed throughout all body regions resulting in a high mortality rate.

The key to understanding traumatic injury, and therefore not missing injuries such as splenic trauma, is to understand the mechanisms of injury. Minimal forces will nearly always be associated with minor trauma that is often localized or single system in nature, while severe injury or multiple trauma must be considered when critical forces are involved. This is summarized in Fig 26.1.

There are, however, circumstances that can lead to more serious injury although the forces involved may have been considered minimal. A child who falls from a low height such as a bed and hits a very hard surface such as a concrete or tiled floor may suffer a disproportionate injury. A skull fracture leading to an extradural haematoma may go unnoticed, the child being discharged before the injury has evolved, with serious consequences. Additionally, if injuries are multiple and force is historically minimal, or explanation is unsatisfactory then non-accidental injury must be considered.

The mechanism of injury is therefore just as important in children as it is in adults. For example, in the 9 year old boy in Fig. 26.2, only critical force could cause such extensive multiple injuries. This child was hit by a bus at 60 km/hr and thrown 5 metres across the road. A good history of the mechanism of injury allowed the treating clinicians to predict the potential problems that might arise before and during the initial resuscitation and stabilization of this child.

Definitions and scoring of trauma
Multiple trauma has been defined as substantial injury to more than one organ system or life-threatening injury to a single system. The recognized standards for describing injuries are the Abbreviated Injury Score and its derivative the Injury Severity Score, which classify injuries according to anatomical site and severity. Children with an ISS >15 are considered to have major trauma with a high mortality and morbidity rate. Trauma scores were originally designed for rapid assessment and triage, for measuring progress of injury, for predicting outcome and for assisting in quality assessment. It has proved to be useful in the overall management of the trauma patient, but less sensitive for severe injury to a single organ system.

Neither of these scores is used in the field by pre-hospital staff or in the emergency department. More useful tools for assessing the severity of injury are the Paediatric Trauma Score (Table 26.1) and the revised Trauma Score (Table 26.2). The PTS was developed to reflect the unique nature of injury patterns in children and to incorporate age. It is useful in triage and in predicting outcome in children. Children with a Paediatric Trauma Score 8 or a revised Trauma Score 11 should be treated in a designated trauma centre. Although these scores have a tendency to over triage children with injury, there is no doubt that children with major trauma have a better outcome if managed in a designated trauma center.

Regardless of their trauma score children who have sustained a high-energy impact should always be assessed carefully for possible life threatening injuries.

Key points
Children with an ISS >15 are considered to have major trauma with a high mortality and morbidity rate
More useful tools for assessing the severity of injury are the Paediatric Trauma Score (Table 26.1) and the revised Trauma Score (Table 26.2).

Trauma team
Trauma management is a team activity that requires a coordinated approach, and much expertise channelled in a productive way for the optimal management of the patient. Most paediatric trauma centres have a team responsible for the initial care of children with a potential for major injury. Specialists in general surgery (often the team leader) and emergency medicine, intensive care, anesthesiology and radiology and specialist trauma nurses are all involved. At our institution the emergency physician is often the first to respond, and leads the trauma team. The make-up of the trauma team in our institution the New Children’s Hospital is seen in Fig. 26.3.

It is important for smaller hospitals without a caseload large enough to warrant a trauma team to have protocols to define major trauma and for initial management, and criteria for transfer to a trauma centre.

Before arrival
Communication with the transporting pre-hospital service is vital in order to determine the extent of the child’s injuries and the level of haemodynamic stability and the current treatment of the child. The team can be prepare for the resuscitation by estimating the child’s weight, and assembling age appropriate equipment – laryngoscopes, endotracheal tubes, suction catheters, intravenous cannula and appropriate fluid delivering devices. Various support services such as Blood Bank and operating theatres should be notified. If the child has suffered multiple injuries ensure O-negative blood is on stand-by for use immediately if necessary.

Primary survey and resuscitation
The key to successful resuscitation is to prioritize management according to injury severity. Attention should be paid first to life-threatening injuries; then limb-threatening injuries or high morbidity injuries; then minor injuries. Prioritization takes these steps:
Primary survey and resuscitation
Secondary survey
Definitive care

The initial 5-10 minutes are spent evaluating and rapidly resuscitating vital signs with immediate attention to life threatening conditions. Resuscitation and monitoring continue throughout this process and through the child’s stay in the emergency department. The secondary survey occurs during the next 20 minutes.

These priorities are summarized in the following Fig. 26.4

Primary survey and resuscitation.
Rapidly assess vital functions to identify life-threatening conditions and correct them. The priorities in order are:
A Airway with cervical spine control
B Breathing
C Circulation with control of bleeding
D Disability (brief neurological assessment)
E Exposure; completely undress the child

Details regarding the accident, vital signs, neurological status and injuries can usually be obtained from the ambulance personnel while transferring the patient to a hospital bed.

Ask the older child: ‘What is your name?’ ‘How old are you?’, ‘What happened?’. The child who answers has a patent airway, is breathing and has adequate cerebral perfusion. Check for cyanosis, stridor, hoarseness and the free passage of air with each breath.

Assume that there is cervical spine injury until proven otherwise by physical examination and radiology. During airway control, protect the cervical spine by one or a combination of the following:
In-line bimanual axial immobilization
A hard cervical collar (of appropriate size)
Sandbags and adhesive tape (strapping the head and trunk to a spinal board will further assist to immobilize the cervical spine)

The principles of splinting involve immobilization of a body region above and below the injury. The neck should be kept in the neutral position.

Measures to establish an open airway
Chin lift (but beware of excessive extension if risk of cervical spine injury) or jaw thrust (in spontaneously breathing, obstructed child). Avoid applying undue force on the soft tissues under the chin, which may cause upper airway obstruction
Suction (or manual removal of foreign material)
Oropharyngeal airway
Orotracheal intubation

If there is any difficulty, or problems are anticipated, call for senior help. Do not delay establishing a patent airway while awaiting assistance. Intubation is not immediately necessary if a patent airway and adequate ventilation are achieved. Remember that infants (<6 months old) are obligate nasal breathers. The initial hour of resuscitation for the injured child frequently involves attention to respiratory rather than circulatory problems. Injured children, particularly with head injury may have altered consciousness or seizures, or may hypoventilate. Prompt assessment and rapid intervention are required to prevent hypoxia, secondary insult and progression to cardiopulmonary arrest. The important anatomic (Fig. 26.5) and physiologic aspects of the paediatric airway should be reviewed (see also Table 2.3). Key points The initial hour of resuscitation for the injured child frequently involves attention to respiratory rather than circulatory problems Equipment and assistance All hospitals dealing with seriously injured children should have readily available basic monitoring equipment. This includes pulse oximetry, end-tidal carbon dioxide (ETCO2), ECG and non-invasive blood pressure (NIBP). It is essential that all equipment be checked on a daily basis and also immediately prior to use. Minimum requirements for intubation are: 1. Oxygen (either cylinder or wall outlet) plus backup supply 2. Suction tubing, Yankauer sucker, Y-suction catheters 3. Paediatric breathing circuit: Either Bag-valve-mask of appropriate size Or T-piece circuit (Ayre’s or Jackson-Rees) 4. Face masks of various sizes according to age 5. Guedel oropharyngeal airways 6. Nasopharyngeal airways, laryngeal masks (optional) 7. Full range of endotracheal tubes and tape for fixation 8. Laryngoscopes Standard Macintosh (curved) blade Infant blade (many variations of straight blade) 9. Magill intubating forceps 10. Flexible introducers and stylets Many procedures performed on the injured child in emergency situations involve uncooperative patients who may be distressed by their injury, and by pain or anxiety related to the impending intervention, and by parental anxiety. When any airway intervention is required skilled assistance must be available and dedicated to the operator attempting to secure the airway. There should be ready access to equipment without leaving the patient. Other staff may be required to restrain the child or assist with other procedures. In the event of suspected cervical spine injury an additional person must assist by immobilising the neck. If there are any anticipated deviations from the usual procedure, then these should be outlined beforehand. In particular the assistant needs to be familiar with the technique of rapid sequence induction, endotracheal intubation and the use of cricoid pressure to minimize the risk of pulmonary aspiration of regurgitated stomach contents. Key points Many procedures performed on the injured child in emergency situations involve uncooperative patients who may be distressed by the injury Oropharyngeal (Guedel) airway Size determined by placing flange adjacent to incisors; tip of airway should reach angle of mandible. Insert an oropharyngeal airway directly in a child less than 1 year of age using a tongue depressor, rather than upside down and rotating 180° as in adults so that it follows the contour of the tongue. If too large, may push epiglottis over larynx; if too small may obstruct against back of tongue. Only tolerated if consciousness and protective reflexes are impaired, otherwise gagging, coughing or laryngeal spasm may occur. Nasopharyngeal airway This is a soft rubber or plastic, flanged tube that is gently inserted (well lubricated) via a nostril so that tip lies above laryngeal inlet. Great care is needed during insertion to prevent mucosal damage or adenoidal bleeding. A shortened endotracheal tube, suitably fixed, can be used as a substitute but must be clearly labelled as being nasopharyngeal rather than tracheal. Bag-valve-mask ventilation The self-inflating bag with valve attaches to an endotracheal tube or facemask. Remember to turn on the oxygen supply so that the reservoir bag is inflated (provides up to 80% FiO2). Use an adult bag (1600 ml capacity) for children over 5 years old and the paediatric bag (500 ml) for younger children and infants. Self-inflating bags should be fitted with a pressure release valve (30-40 cm H2O pressure) that can be overridden if necessary. Only use an anaesthetic breathing circuit (eg the Ayre’s T-piece, Jackson Rees circuit) if you are experienced with it. In certain difficult airway situations, in particular the obstructed airway, the T-piece circuit affords better airway control than the bag-valve-mask. First establish a clear airway, using head position, chin lift or jaw thrust as necessary depending on the size and age of the child. Suction the airway if blood or secretions are present. Infants will generally maintain a better airway with the head in a neutral position, whereas the older child will require some extension of the atlanto-occipital joint. Gentle chin lift will usually clear the airway in a small child, providing the mouth is held open. In an older child more vigorous jaw thrust may be required, using support at the angle of the mandible. Choose a face mask, either a low dead-space Rendell Baker or the softer cushioned type mask (easier if inexperienced), that fits over the bridge of the nose and extends to the cleft between chin and lower lip. It is important that the fingers (thumb and index) used to hold the mask remain at the top (where the mask connects to the bag-valve) so that pressure is distributed evenly around the base of the mask, maintaining a seal. The remaining three fingers are used to support the jaw or chin, taking care not to place any force on the soft tissues under the chin as this will tend to force the tongue up against the palate, obstructing the airway. Commence ventilation at a rate appropriate to the age of the child, achieving adequate chest movement. Laryngeal mask airway Widely used during anaesthesia, this is useful for maintaining airway especially where intubation is difficult or personnel are unskilled in intubation. Consists of large bore tube with elliptical cuffed ‘mask’ on distal end which, following insertion, rests over larynx. Cuff may be gently inflated to seal off larynx, although this does not reliably prevent aspiration. Gentle ventilation may be performed, but care must be taken to prevent gastric distension. Requires care in insertion and fixation, as torsion will cause obstruction to airflow. It is not recommended if the operator is unfamiliar with its use. Use size 1 in infants under 12 months, size 2 in 6 months to 6 years, size 2½ in 6-10 years and size 3 in >10 years.

Endotracheal tube
This is the most practical way of establishing an artificial airway for ventilation or managing obstruction. However in the injured child there may be other reasons why endotracheal intubation may be required as outlines in Table 26.3.
The standard tube is soft, gently curved and has an opening (Murphy eye) at one end to reduce the risk of lung collapse if inadvertent endobronchial placement occurs. The proximal end has a standard 15 mm adaptor, which will fit on to a breathing circuit or self-inflating bag. Most tubes have markings to indicate the length from the tip of the tube, which is bevelled to facilitate placement. In most cases there is a glottic marking. Shouldered tubes cause laryngeal trauma and are best avoided.
Use tube size 2.5 mm internal diameter in pre-term infants <1.5 kg, 3.0 mm in term infants, 3.5 mm in 3-9 months old, 4.0 mm in 9-24 months old. From age 2 years, use the formula: Internal diameter (mm) = Age/4 + 4 Have tubes one size smaller and larger. Under the age of 8-10 years uncuffed tubes are used and there must be an audible leak around the tube to ensure there is not too much pressure on the subglottis. The optimal position for the tip of the tube is mid-trachea, as there is less likelihood of spontaneous extubation or endobronchial migration. This position is approximated using the formula: Length (cm at incisor teeth) = Age/2 + 12 for an oral tube (age + 10 for age 1-5) or: Length (cm at nostril) = Age/2 + 16 for a nasal tube (age + 13 for age 1-5) Confirm position by CXR as soon as possible. The tip should be level with the body of T2, or between the clavicular heads. At least two assistants are required. Always assume the child has a full stomach. Rapid sequence induction (using an anaesthetic induction agent and rapidly acting muscle relaxant, eg suxamethonium, rocuronium or vecuronium) together with cricoid pressure is performed to minimize the risks of vomiting and aspiration. Thiopentone (3-5 mg/kg) is the anaesthetic of choice but caution should be taken in hypotensive patients when lower doses (0.5-1.0 mg/kg) should be used. Alternatively, midazolam (0.1-0.2 mg/kg) or the dissociative anaesthetic ketamine (1-2 mg/kg) may be preferred if the patient is hypotensive. Intubation Endotracheal intubation provides the following advantages: 1. Ensures lungs are ventilated while minimising gastric distension 2. Permits higher ventilatory pressures, hyperventilation and use of PEEP 3. Protects airway from aspiration of gastric contents, blood or secretions 4. Allows endotracheal administration of drugs (adrenaline, atropine) if no IV access 5. Allows suction of airway to remove secretions 6. Frees up operator (less skill required to squeeze bag) 7. Allows access to head and neck, eg assessment, venous access 8. Humidification can be provided 9. Easy to induce anaesthesia Visualization of the larynx requires alignment of three axes: oral cavity, pharynx and trachea, achieved by correct head positioning and then using a laryngoscope to displace the tongue and soft tissues while elevating the epiglottis to reveal the laryngeal inlet. For correct head position when a cervical spine injury is not a problem, extend the atlanto-occipital joint while flexing the lower cervical spine (‘sniffing the morning air’), by placing a small pillow or folded towel under the head but not the shoulders. In infants who have a larger occiput this position is achieved without a pillow, providing the head remains in the neutral position. Older children will require manual extension of the head by placing a hand on the occiput and as the head is extended the mouth opens allowing the laryngoscope to be inserted. Infants require the palm of the right hand to rest on the forehead, preventing excessive mobility, and thumb/index fingers to open the mouth. The technique for oral intubation in a trauma patient is somewhat different. The child is supine on a spinal board with a semi-rigid collar in place. Drugs are given as needed. Before paralysing the patient the anterior half of the collar is removed, and one assistant applies cricoid pressure as another holds the head in neutral position. Positive pressure ventilation may be applied with bag, mask and oxygen to pre-oxygenate in the unconscious child with cricoid pressure applied to ensure ability to ventilate. Cricoid pressure will keep gas out of the stomach. The pressure required is quite firm, such that, if applied to the bridge of the nose, would cause some discomfort in an awake person. It is best applied using index finger and thumb (or one finger alone in an infant), pressed firmly backwards against the cricoid cartilage, but not so firm that laryngeal anatomy is distorted. When muscle relaxation is achieved, oral intubation is performed, while in-line immobilization and cricoid pressure are maintained. Auscultation of both the axilla and over the epigastrium confirms correct endotracheal tube position. The cervical collar is reapplied, the tube taped, an oral airway can be inserted and positive pressure ventilation continued. Key points The technique for oral intubation in a trauma patient is somewhat different Rapid sequence intubation Rapid sequence induction is where anaesthetic and muscle relaxant are given and then airway is secured as rapidly as possible to minimize the risk of regurgitation and aspiration. It relies on the use of cricoid pressure to compress the oesophagus against the vertebral column. Cricoid pressure may also be used in unconscious patients during bag and mask ventilation to reduce gastric distension. Cricoid pressure should not be confused with the use of laryngeal pressure to bring the vocal cords into view during a difficult intubation. The correct method for rapid sequence intubation is: 1. Pre-oxygenate for 3 minutes. Have sucker working and next to patient’s head. 2. Give atropine 20 µg/kg (minimum 100 µg) in children <8 years old. 3. Give thiopentone / suxamethonium rapidly using pre-calculated dose, preferably into a running IV infusion to speed up onset. 4. Assistant applies cricoid pressure as consciousness is lost. 5. Intubation performed after suxamethonium fasciculation seen (noting that some infants may not fasciculate with suxamethonium) while cricoid pressure maintained. 6. Once intubation accomplished and confirmed, release cricoid pressure and fix tube. 7. If intubation is unsuccessful maintain cricoid pressure, oxygenate with bag and mask while allowing patient to wake up. Release cricoid only on return of reflexes or consciousness. 8. Seek further expertise before attempting intubation again. 9. Place gastric tube as soon as ETT in place and secured. Nasotracheal intubation Nasotracheal intubation is not routinely recommended for the injured child although there may be an occasion where this technique is preferred to secure the airway. Nasotracheal intubation requires considerable practice and experience particularly when performed in smaller children. In the injured child with an undifferentiated head injury in whom a base of skull fracture with disruption of the cribriform plate has occurred but not identified, there is a small risk of passing the endotracheal tube into the cranial cavity. The reasons for changing the tube are as follows: Long term fixation of a nasal tube is easier and more secure, especially when an intubated child requires transfer by air or road. Suction is easier via a nasotracheal tube, and the patient cannot bite on the tube. An awake patient, eg weaning prior to extubation, tolerates a nasal tube better. In addition to equipment for oral intubation, have a Magill forceps and tape pre-cut for fixation. Fixation is best achieved using two 5-10 cm long × 2.5 cm wide tapes prepared as ‘trouser legs’, ie split longitudinally for half their length. Intubation is accomplished in much the same manner as before, with the following differences: Ensure the patient is well sedated and muscle relaxed and pre-oxygenate for a few minutes via the OTT. A nasogastric tube should be in place. Use cricoid pressure if there is any likelihood of a full stomach. The tube (well lubricated) is gently inserted via the nostril (right side preferred) backwards not upwards until it lies in the nasopharynx before laryngoscopy. A nasal vasoconstrictor may be applied beforehand to reduce the risk of bleeding. Consider softening a PVC tube in warm water to minimize nasopharyngeal trauma. Visualize the larynx and advance the tube to the larynx. Withdraw the OTT. Gentle manipulation of the laryngoscope can then be used to align the larynx with the advancing tube. It is important to maintain the head in a neutral, even slightly flexed, position at this stage. Excessive extension displaces the laryngeal axis upward, making alignment with the tube difficult. If necessary use the Magill forceps to grasp the distal end of the tube and assist its passage into the larynx. At this point the tube tip sometimes gets caught on the anterior commissure of the larynx, and slight flexion may assist in re-aligning the tube. Once correct position is established using the criteria previously mentioned secure the tube using interlocking adhesive ‘trouser leg’ tapes following application of tincture of benzoin. As with oral intubation it is important to avoid hypoxia. Re-oxygenate with 100% oxygen and bag-valve-mask in the event that intubation is not successful. Cricothyroidotomy Cricothyroidotomy is the next option if intubation is not possible, eg due to massive facial fractures. Surgical cricothyroidotomy is restricted to children older than 12 years. Needle cricothyroidotomy, using a 14-18 gauge cannula, is indicated in younger children. Both procedures are temporising measures. All children requiring a cricothyroidotomy should have a surgical tracheostomy within two hours. Disadvantages of this technique include difficulty in ensuring correct entry to trachea, damage to larynx or trachea, and insufficient exhalation in an obstructed patient. It may however be life saving while a tracheostomy is performed. It is of no use if the obstruction is below the cricoid level, eg tracheal foreign body. As the cricoid is the narrowest part of the paediatric airway it is quite possible that cricothyroidotomy will not provide access to the trachea if a foreign body is impacted at this level. If this occurs it is recommended that the patient be intubated and the endotracheal tube used to force the foreign body into a main bronchus. The tube can then be withdrawn to mid-trachea and ventilation can proceed on one lung pending urgent bronchoscopy. With neck extended stabilize trachea using thyroid cartilage. Locate cricothyroid space below lower border of thyroid cartilage. Puncture cricothyroid membrane using large bore (14 or 16 G) IV cannula connected to 2 ml syringe and inserted at 45 inferiorly and caudally. Aspirate air to confirm correct placement; withdraw trocar from cannula. Connect a T-piece circuit with O2 (15 l/min) via a 3 mm endotracheal tube fitted directly into the IV cannula. Alternatively, cut off the end of an IV giving set, insert into the cannula, attach oxygen tube to the cut end and use the side injection port (also cut off) to administer intermittent positive pressure with your thumb on the cut end, one second on and four seconds off. Note that you still cannot ventilate adequately for long periods using such a small calibre airway. The technique is difficult to perform in a child <2 years old because of the shorter neck, and ventilation through small bore cannulas may be inadequate. Techniques using high flow jet ventilators are unsuitable in this setting and generate very high pressures in the young child, with risk of barotrauma. After age 12 years it may be easier and quicker to use a surgical approach: use a scalpel to cut transversely through to the cricothyroid membrane, open up the space with the handle and insert an endotracheal tube of appropriate size, although there may be small risk to deeper structures. This will also provide better gas exchange. Key points The technique is difficult to perform in a child <2 years old Airway problems in trauma management Head injury is a leading condition requiring airway intervention in our institution (Hahn et al. 1988). Proper initial management of the airway is fundamental to improving outcome, in particular the early correction of hypoxia and hypercapnia and the ability to induce hypocapnia as method of reducing ICP. This almost always requires endotracheal intubation using a rapid sequence technique and then commencing ventilation to improve oxygenation and normalize carbon dioxide levels. Adequate anaesthesia must be provided to cover intubation in order to prevent a sudden increase in ICP. Muscle relaxation alone is inadequate. At all times consider the possibility of cervical spine injury and an assistant should maintain in-line cervical immobilization (in a neutral position) during intubation to avoid exacerbating spinal cord injury. Cervical spine injury in children and has a high mortality and morbidity. In general, children requiring intubation can be safely managed using the standard technique for rapid sequence induction, using in-line immobilization in the neutral position without traction. While it may be preferable to intubate using an awake blind nasal or fibre-optic technique this is rarely possible (or desirable) in the injured child. It would seem prudent to allow the most accomplished operator available perform the procedure, and to avoid excessive movement or pressure on neck structures. Faciomaxillary injury may require urgent intervention to secure the airway, as swelling may worsen if intubation is delayed. Blood in the airway may make visualization difficult, and the mobility of tissues and anatomical disruption contribute to problems with ventilation using a bag and mask prior to intubation. In severe injury, eg LeFort III and bilateral mandibular fractures airway obstruction may be improved by positioning the child on their side or semi-prone with traction on mobile structures. Once anaesthesia is induced it is usually possible to displace free-floating structures using the blade of the laryngoscope. There is usually the added problem of a stomach full of swallowed blood and the risks of cervical spine injury. If obstruction is severe it may be necessary to perform an urgent tracheostomy under local anaesthesia unless expertise exists for other means of securing the airway. Airway burns may contribute to respiratory problems in several ways: carbon monoxide poisoning, oedema of the upper airway and direct thermal injury to the tracheobronchial tree from inhalation of hot gases. As a late development eschar may cause chest wall contraction and impede ventilation. 100% oxygen should be administered in the presence of suspected carbon monoxide poisoning. Close observation is essential and if there is evidence of severe airway burns early intubation and assessment with fibre-optic bronchoscopy is mandatory, as swelling may preclude later intubation if obstruction becomes severe. Key points Proper initial management of the airway is fundamental to improving outcome Breathing Assessment Expose the chest and neck. LOOK for signs of respiratory distress such as cyanosis, tachypnoea, flaring of the alae nasi, use of accessory muscles. Observe the degree and symmetry of chest wall excursion. Look for external signs of trauma such as contusions, abrasions or the paradoxical movement of a flail segment. Check the neck veins for distension. FEEL for the trachea for its relationship to the mid-line. Palpate the chest for subcutaneous emphysema and areas of tenderness. LISTEN for breath sounds. Are they normal and symmetrical? Are the heart sounds normal? Listen for grunting, stridor or wheeze. Life-saving procedures Administer high flow oxygen (12 litres/min) via a reservoir facemask, or assist ventilation with a bag-valve-mask if required. Nasal prongs do not deliver sufficient oxygen but may be a compromise in a distressed, combative child who does not allow a mask to be used. Tension pneumothorax (Fig. 26.8) is a clinical diagnosis and should immediately be relieved by inserting a 14-18 gauge over-the-needle catheter into the second intercostal space in the mid-clavicular line. Subsequently, insert a chest tube in the 4th or 5th intercostal space in the anterior axillary line. It must be remembered that once the chest has been needled to drain a pneumothorax that a chest drain is mandatory. Relieve a massive haemothorax by inserting a chest tube and administering IV fluids for resuscitation. Treat a flail segment by inserting a chest tube, even if a pneumothorax is not initially seen on CXR. Intubation may be required for associated pulmonary contusion. Cover an open pneumothorax with an occlusive dressing that is taped on three sides; this produces a ‘flutter-valve’ effect which allows air to escape from the pleural cavity on exhalation, but prevents air from entering on inspiration. Insert a chest tube at a site remote from the open wound. Appropriate sizes for chest tubes in children are: • Size 12 in infants • Sizes 16-20 in 2-10 year olds • Sizes 24-28 in 11-16 year olds Use the larger diameter tube that will pass through the intercostal space when draining a haemothorax. Assisted ventilation If breathing is inadequate, assist ventilation with a T-piece bagging circuit or self-inflating bag-valve device. For the experienced practitioner, a compressed gas driven ventilator, eg Dräger Oxylog may be used to ventilate children over 1 year of age (pressure limiting valve is used when ventilating infants). Guidelines (Rubin and Sadonohoff 1996): 1. Start with tidal volume = 10 ml/kg 2. Rate = 20/min (30/min for infants) 3. Peak airway pressure = 20 cm H20 4. Check arterial blood gases 5. Maintain paCO2 = 35-40 mmHg (30-35 mmHg if head injury) Always exclude hypoxaemia or hypovolaemia if the child is agitated and/or confused. Ventilation difficulties may be due to: • Struggling child • Gastric distension • Airway obstruction • Massive aspiration • Direct laryngeal injury • Pneumothorax with increased airway pressure • Laryngospasm • Massive pulmonary artery obstruction Key points Always exclude hypoxaemia or hypovolaemia if the child is agitated and/or confused. Circulation Life-threatening injuries Immediate life-threatening injuries are massive internal and/or external haemorrhage, cardiac tamponade and tension pneumothorax. Cardiac output is the volume of blood pumped by the heart each minute (heart rate x stroke volume), while stroke volume is the volume pumped with each contraction. In younger children the stroke volume is relatively fixed with cardiac output primarily reliant on heart rate. Blood pressure is determined by cardiac output and peripheral vascular resistance. Normal blood pressure can be maintained (Fig. 26.9) as long as the circulation compensates adequately with vasoconstriction, tachycardia, and increased cardiac contractility. When compensation fails hypotension occurs. Tachycardia persists until pre-arrest. Key points Immediate life-threatening injuries are: • massive internal and/or external haemorrhage, • cardiac tamponade and • tension pneumothorax If tachycardia in children is overlooked then shock may go unrecognized. Although cardiac output falls in an almost linear fashion as blood volume is depleted, blood pressure remains initially unchanged because of increased vascular resistance. Hypotension is often a late and sudden sign of cardiovascular decompensation in seriously injured children and young adults. Even mild hypotension must be taken seriously and treated quickly and aggressively since cardiopulmonary arrest is often imminent. A further consequence of this robust cardiac response to haemorrhage in children is the degree of peripheral vasoconstriction that may occur. Many injured children in a compensated shocked state will be pale and shut down due to vasoconstriction. Capillary refill is often prolonged early on in seriously injured children who have compensated shock, provided ambient temperature is accounted for when assessed. This increase in peripheral vascular resistance and associated vasoconstriction makes intravenous access extremely difficult in seriously injured children. Key points If tachycardia in children is overlooked then shock may go unrecognized Intravascular access (Fig. 26.10) Drug administration requires access to the circulation. If no access is present or the cannula has extravasated or become blocked, then peripheral venous cannulation should be performed. If peripheral venous cannulation attempts are unsuccessful within 90 seconds, then alternative vascular access is obtained via the intraosseous route. The antero-medial surfaces of the proximal or distal tibia are suitable sites. The needle is inserted perpendicularly to the bone surface and a screwing action is used to traverse the cortex. A loss of resistance is felt once the marrow is entered. Correct positioning of the needle, confirmed by aspiration of bone marrow or injection of saline without extravasation, is necessary to avoid compartment syndrome. When resuscitating through the intraosseous route it must be remembered that in order for fluids to be infused they will need to be pump through. Contraindications to the intraosseous route are few, however it should be avoided in the case of a significant or open fracture of the extremity (Rupert et al. 1994). The 18-gauge needle is for use in infants and small children. The 16-gauge needle is designed for older children. All drugs and resuscitative fluids may be given via the intraosseous route but only adrenaline, atropine, lignocaine and naloxone may be given via the endotracheal tube. Central venous cannulation via the subclavian or internal jugular veins should be reserved for the post-resuscitation phase. However cannulation of the external jugular or femoral veins may be attempted during resuscitation. Surgical cutdown on to a vein remains an alternative but is also time consuming. Assessment Shock (Fig. 26.11) is a clinical syndrome that results from tissue perfusion that is inadequate to meet metabolic needs. Clinically, it is manifest by changes in haemodynamic measurements, tachypnoea and poor perfusion of the skin, brain and kidneys. Shock can exist with a normotension, hypotension or hypertension. Blood pressure, pulse rate and respiratory rate are age dependent (Appendix M). Systolic BP = 80 + (2  age in years). Diastolic pressure is usually two-thirds of the systolic measurement. Children compensate extremely well for hypovolaemia. The first sign of hypovolaemia is narrowing of the blood pressure (rising diastolic pressure). Systolic hypotension occurs very late and indicates severe hypovolaemia (up to 40% of blood volume loss). Tachycardia is a very sensitive, but not specific, marker of shock. Assess pulse rate, pulse volume and the presence of distal pulses. Bradycardia is a preterminal event. Assess skin for colour, temperature, clamminess and capillary refill time (normal <2 seconds but varies according to the ambient temperature and is very observer dependent). Tachypnoea is frequently associated with hypovolaemia. Assess for ‘air hunger’ (hyperpnoea and tachypnoea). Cerebral hypoperfusion may present as depressed consciousness, lethargy, agitation or hypotonia. There may be thirst and poor urine output (<1 ml/kg/hr for infants, <0.5 ml/kg/hr for older children). Cardiac tamponade classically presents with Beck’s triad, ie systolic hypotension, jugular venous distension and muffled heart sounds. Symmetrical breath sounds and a midline trachea excludes tension pneumothorax. Life-saving interventions (Table 26.5) 1. Give high flow oxygen, monitor continuous ECG, pulse oximetry and continuous to 3 minutely non-invasive blood pressure monitoring. 2. Control haemorrhage by: •Applying direct pressure to external bleeding sites. Tourniquets should be removed as soon as possible. •Reducing fractures as soon as possible. •Recognising haemorrhage that is uncontrolled or uncontrollable and arrange urgent intravascular access and surgery. 3. Restore circulating volume. Insert two short-length, large bore IV cannulas into a large proximal vein eg cubital fossa. Collect blood for laboratory tests and cross-match. Administer warmed fluids immediately (colloid, eg Haemaccel 20 ml/kg or crystalloid, eg Hartmann’s solution 20 ml/kg). If a patient fails to respond to a second bolus, then blood (whole blood 20 ml/kg or packed cells 10 ml/kg) is required (Table 26.4). In small infants/children with refractory shock a blood glucose level should be performed early on in the resuscitation. 4. If packed cells are used, volume is made up using saline, plasma or 5% albumin. If the child is stable and blood will be available within 10-15 minutes, wait for fully cross-matched blood. If unstable, type specific blood may have to be used. If a delay of even a few minutes is critical, group O-negative blood is given. 5.Cardiac tamponade unresponsive to fluid loading is treated with urgent pericardiocentesis. Arrange rapid transfer to the operating theatre for urgent thoracotomy. Technique for pericardiocentesis: Place child supine and upright at 30-45. Ensure airway and ventilation are optimized. Continue volume loading. Prepare with antiseptic solution and infiltrate the area just below the xiphoid process with 1% lignocaine. Attach a 16-21 gauge cardiac or spinal needle to a stopcock and a 20-50 ml syringe. Attach an alligator clip leading to a precordial lead of the ECG monitor to the needle’s hub. Insert the needle just below the xiphoid process at 60-70 to the horizontal, aiming at the left shoulder, advancing slowly while maintaining gentle suction to the syringe. Advance until pericardial fluid is aspirated or epicardial contact is made as indicated by an injury pattern (ST or PR elevation or T-wave inversion). Withdraw the needle until the ECG pattern normalizes and re-advance at a more medial angle. Aspirate fluid to relieve tamponade and then insert a soft catheter via a guide-wire to allow for continued drainage. Complications of pericardiocentesis include myocardial penetration, coronary artery laceration, arrhythmias, pneumothorax and infection. 6. Military anti-shock trousers (MAST suits) are no longer recommended for use in the haemodynamically unstable patient. Their main use is pre-hospital splinting of pelvic and long-bone fractures. Occasionally, children arrive with a MAST suit on. The management of this situation is: If the suit is deflated remove it. If one leg compartment is inflated to splint a fracture, leave it inflated until the limb is examined. The suit should not be inflated for more than 90-120 minutes. If the suit is inflated for hypovolaemic shock: Insert two large bore IV cannulas and give volume replacement rapidly. Slowly deflate the abdominal compartment followed by lower limb compartments. Deflate about 1/3 of volume at a time, then recheck blood pressure. Stop deflating if systolic blood pressure drops by >10 mmHg and give more volume replacement.

Key points
Military anti-shock trousers (MAST suits) are no longer recommended for use in the haemodynamically unstable patient

Assess level of consciousness with the AVPU mnemonic:
A Alert and oriented
V responds to Verbal stimuli
P responds only to Painful stimuli
U Unresponsive

Note pupillary size and reaction to light. A unilateral, fixed dilated pupil may indicate the presence of an acute extradural or subdural haematoma. Bilateral, fixed dilated pupils indicate more serious traumatic or hypoxic brain injury.
Note any gross asymmetry in movement. A more detailed neurological examination is performed in the secondary survey. Mentally alert or aware, Pupillary activity and size should be noted.

Undress the child fully to allow examination of the entire body. Monitor core temperature via a rectal probe.
Expose the child only as long as it takes to complete the physical examination. Maintain normothermia by using warmed IV fluids, blood warmers, warm blankets and overhead heating lamps.

By the completion of the Primary Survey and Resuscitation the patient should be connected to the following ‘lines’ for monitoring and treatment:
Oxygen via mask or endotracheal tube
End-tidal CO2 monitor if ventilated
Nasogastric or orogastric tube
Large bore IV cannula ×2
Pulse oximeter
ECG monitor
Chest tube
Rectal temperature probe
Urinary catheter. Examine the perineum and rectum for urethral trauma prior to insertion. Perineal haematoma, urethral meatal blood or a high-riding prostate on rectal examination indicate likely urethral trauma and contraindicate urethral catheterization. Suprapubic catheterization would be required.

Secondary survey
The important aspects of the secondary survey are:
Continuing resuscitation and monitoring. Any deterioration mandates immediate return to the airway, breathing and circulation (ABCs).
History. An AMPLE history should be obtained from the child (if possible), family, ambulance personnel, friends and bystanders:
A Allergies
M Medications, including tetanus immunization status
P Past medical history
L Last ate or drank (time)
E Events/environment related to the injury
Head to toe examination. Perform a systematic head-to-toe, front-and-back examination to detect any injuries not noted in the Primary Survey. Assess each region of the body including the ears, nose, mouth, rectum and pelvis using the ‘look, feel, listen’ and ‘tubes and fingers in every orifice’ approach. In young children, if rectal or internal vaginal examination is required, then it may be prudent to have it performed once by the most senior clinician or while the child is under general anaesthesia. The sequence of examination is:
Chest and shoulder
Lower limbs
Upper limbs
Central nervous system (include Glasgow coma scale, GCS)
Perineum and rectum

Secondary survey
Reassess the ABCDE of the primary survey regularly or as indicated
Head: Check pupillary size, conjunctiva, reaction of pupils, fundal appearance and vision. Examine face for maxillofacial trauma. Check dentition. Examine scalp for laceration of soft tissue injury. Look for signs of basilar skull fracture. Check for symmetry of voluntary movement and neurological function of facial muscles.
Neck: Palpate cervical spine. Check for subcutaneous emphysema, abnormal tracheal position, haematoma, and localized pain. Evaluate neck veins for distension.
Chest: Check for bilateral chest excursion, asymmetry of wall motion, and flail segment. Palpate trachea midline. Palpate chest. Auscultate lung fields and cardiovascular system.
Abdomen: Repeated measurement of girth may help diagnosis of unsuspected bleeding. Inspect for ease of movement with respiration, bruises, lacerations, and bowel sounds. Palpate for localized findings. Observe and palpate flanks.
Pelvis: Palpate bony prominences for tenderness or instability. Check for laceration, haematoma, and active bleeding. Check urethral meatus for blood.
Rectum: Should be examined by a surgeon or a person responsible for the child’s care only once, checking for sphincter tone. If urethral damage is considered then the level of the prostate should be noted.
Extremities: Check for signs of fracture, dislocation, abrasion, contusion, and haematoma. Note bony instability.
Back: Examine only if spinal cord injury is not suspected.
Skin: Look for petechiae, burns, and contusions.
Neurological: In depth neurological examination including a Glasgow Coma score.

Explanatory notes for paediatric coma scale
In clinical practice because the GCS is universally used and understood in adult emergency practice in many cases extrapolate of this 3-15 score occurs to children. The concern here is that such extrapolation is at best an approximation of the child’s level of consciousness rather than an objective representation of the child’s clinical state. Although this score has not been validated we have found the modification for children of the GCS useful and highly accurate for use early on during resuscitation and stabilization.

a) Laboratory tests: most of these specimens should already have been collected during the resuscitation phase.
Full Blood Count
Coagulation studies
Electrolytes, urea, creatinine
Liver function tests. Sensitive and specific for hepatic trauma
Amylase. Not sensitive, not specific for pancreatic injury
Creatinine Kinase. Relevant for myocardial contusion, crush injury
Arterial Blood Gases
Urinalysis for blood and myoglobin.
b) Radiology: trauma series. Most injured patients require three X-rays in the resuscitation room.
Chest X-ray
Lateral cervical spine X-ray. A normal lateral X-ray does not exclude cervical spine injury. Other views are Antero-posterior and Odontoid. Immobilization of the spine must still be maintained until more definitive assessment.
Other radiological investigations that may be required in the trauma patient include:
CT scan, eg head, abdomen, chest, spine (Table 26.7)
Full cervical spine series
X-rays of the extremities, thoracic spine, lumbo-sacral spine
Skull X-ray
Sternum X-ray
Urethrogram (for suspected urethral injury)
Cystogram (for suspected bladder injury)
Angiogram for suspected arterial injury; rarely, arch aortogram for suspected injury to the thoracic aorta.

Special exams
Liver/spleen scan
Compartment pressure measurement
ECG in cases of chest trauma with suspected myocardial contusion.

Definitive care
After completion of the secondary survey the following issues need to be addressed:
1. Response to resuscitation
2. Prioritize injuries according to, immediate threats to life and, possible morbidity (in descending order of importance):
Airway/breathing derangement
Haemorrhage with shock
Intracranial space-occupying haemorrhage
Contained aortic disruption
Spinal cord compression
Vascular injury with distal ischaemia
Ruptured hollow viscus
Ocular injuries
Open or displaced fractures
Contaminated wounds
3. Analgesia:
• Treat the cause of pain if possible, eg finding a position of comfort for a fractured limb.
• Intravenous morphine titrated carefully will relieve severe pain. The intramuscular route should be avoided if possible as the absorption may be somewhat unpredictable and erratic in the seriously injured child. Commence with a dose of 0.1-0.2 mg/kg. It does not usually mask clinical signs. Be cautious in hypotensive or lethargic children with head injury.
• Regional blocks can be very effective, eg femoral nerve block for femoral fracture.
• Nitrous oxide may be a useful adjunct, especially in orthopaedic injuries. It has been used in children as young as 16 months in the emergency department. Avoid use in head injury, pneumothorax or eye injuries.
4. Tetanus status (Table 26.8): if the child has received three doses of DTP and the last dose was administered within five years, no further action is required. Otherwise, a tetanus toxoid booster is required. If the child has not been fully immunized, or there is a doubt about immunization status, then a tetanus immunoglobulin should be administered in addition to a tetanus toxoid (use separate syringes and inject at different sites).
5. Antibiotics: give a first generation cephalosporin or penicillinase-resistant penicillin for open fractures, penetrating joint injuries, large contaminated soft tissue injuries and penetrating eye injuries. If severe penicillin allergy exists, consider clindamycin or erythromycin. Penetrating abdominal injuries and perforated hollow viscera require broad spectrum antibiotics, eg gentamicin, amoxycillin and metronidazole.
6. Fractures and dislocations: splint and, if necessary, reduce orthopaedic injuries in the Emergency Department. Early reduction will be required especially if there is neurovascular compromise.
7. Wound management: clean, dress and cover open wounds to reduce the likelihood of infection. Suture lacerations as indicated.

Trauma arrest
The outcome from children with an out-of-hospital cardiopulmonary arrest remain poor (Basket 1989, Hazibnski et al. 1994). This is also true of children who have suffered blunt trauma and are in cardiopulmonary arrest from the time of the injury. Underlying conditions to exclude if an “on the scene” arrest has occurred with a response to treatment in the pre-hospital setting include children with serious neurological injury from a major head injury or those having juvenile cervical spine injury or SCIWORA. These injuries are mostly associated with an extremely poor prognosis and this issue should be addressed. In general, trauma patients who deteriorate to the point of cardiopulmonary arrest have a poor outcome (Schoenfield and Baker 1993).

The only exception are young patients who have suffered penetrating trauma such as a stab wound to the chest who lose their vital signs in the emergency department or immediately prior to arrival.

Managing a trauma arrest follows the principles of advanced life support with a focus on volume replacement and controlling haemorrhage. Commence CPR, intubate, ventilate with 100% oxygen and insert two large bore cannula or intraosseous needles and rapidly infuse volume at 20 ml/kg aliquots. Decompress both hemithoraces either by needle thoracocentesis followed by intercostal tubes or by intercostal tubes alone. Assess the rhythm on the ECG and treat appropriately in children (Goetting 1995). The most common underlying rhythm disturbances leading to cardiopulmonary arrest in children are asystole/bradycardia and electromechanical dissociation or pulseless electrical activity (APLS 1996, Colucci and Somberg 1994). The underlying cause in almost all cases is profound hypovolaemia due to multiple injury. Unexpected hypoxia due to poor airway control should never be a cause for cardiopulmonary arrest in children in this day and age. The treatment of these rhythm disturbances uses standard protocols (Fig. 26.12). If no response then give volume to a total of 20 ml/kg. If the neck veins are distended or there is a strong suspicion of tamponade, perform a needle pericardiocentesis or go straight to thoracotomy or sub-xiphoid window. If the pericardiocentesis is successful arrange immediate transfer to surgery. It is important to remember that fluid volume resuscitation throughout the management of the cardiopulmonary arrest with crystalloid or preferably whole blood must be aggressively pursued using two large bore intravenous cannulas.

Key points
The outcome from children with an out-of-hospital cardiopulmonary arrest remain poor

Post-resuscitation stabilization
In the case of the injured child post-resuscitation stabilization will entail continued supportive therapy together with urgent transfer to the emergency operating suite. This care will need to be continued in the operating theatre, which should be prepared at the time the trauma call is put out. In most cases the cardiopulmonary arrest has occurred due to hypovolaemia as a result of near fatal injuries and every member of the trauma team will need to be involved.

Once in the intensive care unit post-resuscitation stabilization will usually entail continued supportive therapy. Continuing support will usually include mechanical ventilation with supplemental oxygen, insertion of central and arterial lines, inotrope infusion, antiarrhythmic agents, fluid therapy and possibly renal support (continuous veno-venous haemofiltration, peritoneal dialysis).

The cause of the cardiopulmonary arrest should be corrected if possible. Complications of resuscitation should also be sought, particularly if secondary deterioration occurs. A chest X-ray should be performed to check the ETT position and central venous catheter position, to exclude pneumothorax, lung collapse or aspiration and to check the cardiac outline. Investigations should include full blood count, arterial blood gas and serum biochemistry.

As earliest as possible, assessment of any neurological damage should be sought.

Emergency department thoracotomy
Emergency department thoracotomy as a technique for resuscitation of moribund thoracic trauma patients became popular in the 1960’s. Emergency department thoracotomy is a controversial procedure in children and is not practiced at our institution. Enthusiasm for this procedure has waned as evidence has accumulated that these patients do not benefit from the procedure. In blunt trauma the evidence for any benefit is very scant indeed with dismal survival rates of less than 1% in better studies (Balazs 1983). We believe that resources are best placed into areas where returns will be higher such as better pre-hospital trauma care and improving trauma systems. The resources and organisation that needs to be available to preform this technique 24 hours a day are often beyond even the financial scope of major trauma centers. It must be left up to the particular institution to weigh up the benefits of such an approach. If penetrating trauma makes up a large component of the daily trauma workload, benefits may occasionally be seen from emergency department thoracotomy.

Children with blunt trauma who sustain cardiopulmonary arrest at the scene of the injury and in whom CPR does not result in return of cardiac function are almost uniformly unsalvageable, and do not benefit from ED thoracotomy (Sheikh and Culbertson 1993). Children with penetrating trauma who suffer loss of vital signs at the scene and have no electrical cardiac activity in the ED after standard CPR in the ambulance, do not benefit from ED thoracotomy, especially if the prehospital time is longer than 20 minutes (Millham and Gringlinger 1993). Paediatric trauma resources are better placed in other more productive areas such as injury prevention.

Cessation of resuscitation
Cardiac arrest in children has a poor outcome. The decision to stop resuscitation is based on a number of variables including the pre-arrest state, response to resuscitation, reversible factors, patient and parental wishes, likely outcome and opinions of experienced staff. Senior medical staff are responsible for the decision to terminate resuscitation and should almost always be consulted.

Transfer of the injured child
Adequate attention at the referring hospital to the ABCs of resuscitation by those most experienced in paediatric care is more likely to reduce morbidity & mortality than rapid transfer to a tertiary centre.

Reasons for transfer of children:
need for expert centralized care
need for specialist services only available in a children’s hospital
the remoteness of the referring hospital
resources available in referral hospital
type of service available in the referring hospital
designated transfer criteria.

Some considerations in the transport of critically ill children (McNab 1991):
patience and attention to detail will win the day
transport methods
types of transport teams, paramedic based, specialized, pressure to ‘scoop and run’
the ‘golden hour’ concepts does not apply to the transport of critically ill children
airway problems & respiratory compromise are the most common reasons for transport
50% of critically ill children require some form of airway intervention
airway either needs: protected or stabilized
accidental extubation should never occur.

Procedures performed prior to transport:
intubation 60%
reintubation 30%
repositioning ETT 50%
ventilation 50%
chest drain insertion 0.9%.

Optimal mode of ventilation of the transported patient:
hand ventilation had 75% incidence in changes in haemodynamic status and blood gases
hand ventilation may prove a problem in trying to duplicate the mechanical ventilator settings in children
for intrahospital transport, hand ventilation is acceptable. Use a ventilator for all others: eg Oxylog.

Mode of transport:
Ground transport: short to middle distance

Helicopter: medium to long distances, limited room, ensure child stable, hypovolemia corrected, air collections drained

Fixed wing aircraft: long journeys, ensure connectors are compatible, gas supplies adequate, and child stable. Factors to consider, space, speed of transport, cost, distance, severity of illness, safety to staff and patient.

Adverse events during transport:
respiratory events: 64%, accidental tracheal extubation, occlusion of the ET tube with secretions, secondary hypoxia from hypoventilation, acute airway obstruction other than secretions, acute gastric dilatation events during transport
cardiovascular events: 24%, hypertension, hypotension, cardiac arrest, hypothermia and related events
central nervous system events: 40%
24%, secondary brain insult, seizures.

Intrahospital transport can be the greatest threat to the trauma patient (Wallen et al. 1994). Intrahospital transport even in the best hands can result in adverse events for the trauma patient mostly being changes in vital signs, alteration in ventilation or oxygenation, equipment failure and most important the sequelae of unrecognized shock during a radiology procedure. The radiology suite is notorious in being the main area where an unstable or poorly differentiated trauma patient can come to grief, particularly if shock has not been anticipated or aggressively anticipated. The following rules may help:
pretransport coordination/communication, ie have a plan, prethink what may go wrong and formulate solutions
ensure personnel who accompany the patient are aware of potential problems and their solutions
ensure equipment to accompany the patient is in working order, fully charged and that adequate oxygen & air is available. Always be a “parasite” as far as electrical power and oxygen is concerned. Only use your own battery power or gases when absolutely necessary
monitoring during transport interhospital transport, pretransport coordination, communication, accompanying personnel, equipment
constantly monitor the ABC’s

Interhospital transport checklist:
copy all patient records and radiographs
obtain transport consent
secure vascular access and ETT
stabilize cervical spine and any fractures
prepare blood products
if indicated, provide laboratory telephone number for pending laboratory results
be aware of the capabilities of the transferring hospital
be aware of the support services available
ensure appropriate monitoring during transport
constant clinical evaluation

Key points
Intrahospital transport can be the greatest threat to the trauma patient

Trauma is the epidemic of the late 20th century. Although it still accounts for a large number of paediatric deaths these have reduced in many western countries over the last decade. This has come about through a number of factors including improved trauma care, trauma systems and better pre-hospital care for injured children. However one area that continues to be important in reducing morbidity and mortality from trauma in children is injury prevention. Various prevention strategies such as wearing of helmets, seat belts to name just a few have in many countries made a significant impact on reducing death rates and morbidity related to trauma.

However, despite the best prevention strategies, children will continue to be injured and therefore the knowledge, skills and resources will always be needed to resuscitate and stabilize seriously injured children.

Key points
Trauma is the leading cause of death in children over one year of age
AIS, ISS, PTS and revised Trauma Score are classifications for describing site and severity of multiple trauma
Management of trauma is prioritized: primary survey (ABCDE) and resuscitation, secondary survey then definitive care



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