12. Emergencies & Injuries
Maria J. Mandt, MD
Joseph A. Grubenhoff, MD
ASSESSMENT & MANAGEMENT OF THE ACUTELY ILL INFANT OR CHILD
When faced with a seriously ill or injured child, a systematic approach and rapid determination of the child’s physiologic status with concurrent initiation of resuscitative measures is imperative. Initial management must be directed at correcting any physiologic derangement. Specifically, one must evaluate the airway for any obstruction, assess ventilatory status, and evaluate for shock. Intervention to correct any abnormalities in these three parameters must be undertaken immediately. Following this initial intervention, the provider must then carefully consider the underlying cause, focusing on those that are treatable or reversible. Specific diagnoses can then be made, and targeted therapy (eg, intravenous [IV] glucose for hypoglycemia) can be initiated.
Pediatric cardiac arrest more frequently represents progressive respiratory deterioration or shock, also called asphyxial arrest, rather than primary cardiac etiologies. Unrecognized deterioration may lead to bradycardia, agonal breathing, hypotension, and ultimately asystole. Resulting hypoxic and ischemic insult to the brain and other vital organs make neurologic recovery extremely unlikely, even in the doubtful event that the child survives the arrest. Children who respond to rapid intervention with ventilation and oxygenation alone or to less than 5 minutes of advanced life support are much more likely to survive neurologically intact. In fact, more than 70% of children with respiratory arrest who receive rapid and effective bystander resuscitation survive with good neurologic outcomes. Therefore, it is essential to recognize the child who is at risk for progressing to cardiopulmonary arrest and to provide aggressive intervention before asystole occurs.
When cardiopulmonary arrest does occur, survival is rare and most often associated with significant neurological impairment. Current data reflect a 6% survival rate for out-of-hospital cardiac arrest, 8% for those who receive prehospital intervention, and 27% survival rate for in-hospital arrest.
The following discussion details care of the critically ill pediatric patient who does not require cardiopulmonary resuscitation (CPR). Detailed information regarding the 2010 Guidelines for Pediatric Basic (BLS) and Advanced Life Support (PALS) can be found under Statements & Guidelines at http://myamericanheart.org/professional. Note: Standard precautions (personal protective equipment) must be maintained during resuscitation efforts.
THE ABCs OF RESUSCITATION
Any severely ill child should be rapidly evaluated in a deliberate sequence of airway patency, breathing adequacy, and circulation integrity. Derangement at each point must be corrected before proceeding. Thus, if a child’s airway is obstructed, the airway must be opened (eg, by head positioning and the chin lift maneuver) before breathing and circulation are assessed.
Look for evidence of spontaneous breathing effort. Adventitious breath sounds such as stridor, stertor, or gurgling, or increased work of breathing without air movement is suggestive of airway obstruction. Significant airway obstruction often is associated with altered level of consciousness, including agitation or lethargy. During this rapid assessment, if the patient is noted to be apneic or producing only gasping (agonal) breaths, chest compressions should be initiated immediately in accordance with pediatric advanced life support guidelines.
The airway is managed initially by noninvasive means such as oxygen administration, chin lift, jaw thrust, suctioning, or bag-valve-mask ventilation. Invasive maneuvers such as endotracheal intubation, laryngeal mask insertion, or rarely, cricothyroidotomy are required if the aforementioned maneuvers are unsuccessful. The following discussion assumes that basic life support has been instituted.
Knowledge of pediatric anatomy is important for airway management. Children’s tongues are large relative to their oral cavities, and the larynx is high and anteriorly located. Infants are obligate nasal breathers; therefore, secretions, blood, or foreign bodies in the nasopharynx can cause significant distress.
1. Place the head in the sniffing position. In the patient without concern for cervical spine injury, the neck should be flexed slightly and the head extended. This position aligns the oral, pharyngeal, and tracheal planes. In infants and children younger than about 8 years, the relatively large occiput causes significant neck flexion and poor airway positioning. This is relieved by placing a towel roll under the shoulders, thus returning the child to a neutral position (Figure 12–1). In an older child, slightly more head extension is necessary. Avoid hyperextension of the neck, especially in infants.
Figure 12–1. Correct positioning of the child younger than 8 years for optimal airway alignment: a folded sheet or towel is placed beneath the shoulders to accommodate the occiput and align the oral, pharyngeal, and tracheal airways.
2. Perform the head tilt/chin lift or jaw thrust maneuver (Figure 12–2). Lift the chin upward while avoiding pressure on the submental triangle, or lift the jaw by traction upward on the angle of the jaw. Head tilt/chin lift must not be done if cervical spine injury is possible. (See section Approach to the Pediatric Trauma Patient, later.)
Figure 12–2. A: Opening the airway with the head tilt and chin lift in patients without concern for spinal trauma: gently lift the chin with one hand and push down on the forehead with the other hand. B: Opening the airway with jaw thrust in patients with concern for spinal trauma: lift the angles of the mandible; this moves the jaw and tongue forward and opens the airway without bending the neck.
3. Assess airway for foreign material. Suction the mouth; use Magill forceps to remove visible foreign bodies. Visualize by means of a laryngoscope if necessary. Blind finger sweeps should not be done.
4. If airway obstruction persists, first attempt to reposition the head, then proceed with insertion of an airway adjunct, such as the oropharyngeal or nasopharyngeal airway (Figure 12–3). Such adjuncts relieve upper airway obstruction due to prolapse of the tongue into the posterior pharynx, the most common cause of airway obstruction in unconscious children. The correct size for an oropharyngeal airway is obtained by measuring from the upper central gumline to the angle of the jaw (Figure 12–4) and should be used only in the unconscious victim. Proper sizing is paramount, as an oropharyngeal airway that is too small will push the tongue further into the airway while one that is too large will mechanically obstruct the airway. Nasopharyngeal airways should fit snugly within the nares and should be equal in length to the distance from the nares to the tragus (Figure 12–5). This airway adjunct should be avoided in children with significant injuries to the midface due to the risk of intracranial perforation through a damaged cribriform plate.
Figure 12–3. A: Oropharyngeal airways of various sizes. B: Nasopharyngeal airways of different sizes.
Figure 12–4. Size selection for the oropharyngeal airway: hold the airway next to the child’s face and estimate proper size by measuring from the upper central gumline to the angle of the jaw.
Figure 12–5. Size selection for the nasopharyngeal airway: hold the airway next to the child’s face and estimate proper size by measuring from the nares to the tragus.
Assessment of respiratory status is largely accomplished by inspection. Look for adequate and symmetrical chest rise and fall, rate and work of breathing (eg, retractions, flaring, and grunting), accessory muscle use, skin color, and tracheal deviation. Note the mental status. Pulse oximetry measurement and end-tidal CO2 determination, if available, are highly desirable. Listen for adventitious breath sounds such as wheezing. Auscultate for air entry, symmetry of breath sounds, and rales. Feel for subcutaneous crepitus.
If spontaneous breathing is inadequate, initiate positive-pressure ventilation with bag-valve mask ventilation (BMV) and 100% oxygen. Assisted ventilations should be coordinated with the patient’s efforts, if present. Effective BMV is a difficult skill that requires training and practice. To begin, ensure a proper seal by choosing a mask that encompasses the area from the bridge of the nose to the cleft of the chin. Form an E–C clamp around the mask to seal the mask tightly to the child’s face. The thumb and index finger form the “C” surrounding the mask, while the middle, ring, and small fingers lift the jaw into the mask (Figure 12–6). Use only enough force and volume to make the chest rise visibly. In the patient with a perfusing rhythm, administer one breath every 3–5 seconds (12–20 breaths/min). To more easily achieve this rate, recite the pneumonic “squeeze-release-release” in a normal speaking voice. Two-person ventilation using this technique is optimal. When proper technique is used, BMV is effective in the vast majority of cases.
Figure 12–6. A: Bag-valve-mask ventilation, one-person technique: the thumb and index finger form the “C” surrounding the mask, while the middle, ring, and little fingers lift the jaw into the mask. B: Bag-valve-mask ventilation, two-person technique: the first rescuer forms the “C” and “E” clamps with both hands; the second rescuer provides ventilation.
Adequacy of ventilation is reflected in adequate chest movement and auscultation of good air entry bilaterally. Take care to avoid hyperventilation. Excessive ventilation leads to barotrauma, increased risk of aspiration, and a decreased likelihood that return of spontaneous circulation will be achieved during cardiac arrest. If the chest does not rise and fall easily with bagging, reposition the airway and assess for foreign material as previously described. The presence of asymmetrical breath sounds in a child in shock or in severe distress suggests pneumothorax and is an indication for needle thoracostomy. In small children, the transmission of breath sounds throughout the chest may impair the ability to auscultate the presence of a pneumothorax. Note: Effective oxygenation and ventilation are the keys to successful resuscitation.
Cricoid pressure (Sellick maneuver) during positive-pressure ventilation may decrease gastric inflation; however, it has not been shown to reduce the risk of aspiration and should only be used if it does not interfere with ventilation or the speed and ease of intubation. Advanced airway management techniques are described in the references accompanying this section. (See also section Approach to the Pediatric Trauma Patient.)
The methodical assessment of perfusion is critical to the diagnosis of shock, which results from inadequate perfusion of vital organs. This diagnosis should be made rapidly by clinical examination detailed as follows.
Check adequacy of peripheral pulses. Pulses become weak and thready only with severe hypovolemia. Compare peripheral pulses with central pulses. In the infant, central pulses should be checked at the brachial artery.
B. Heart Rate
Compare with age-specific norms. Tachycardia can be a nonspecific sign of distress; bradycardia for age is a sign of imminent arrest and necessitates aggressive resuscitation.
Extremities become cooler from distal to proximal, as shock progresses. A child whose extremities are cool distal to the elbows and knees is in severe shock.
D. Capillary Refill Time
When fingertip pressure is applied to a patient’s distal extremity and then released, blood should refill the area in less than 2 seconds. A prolonged capillary refill time in the setting of other signs of shock indicates a compensated shock state. It is important to recognize that capillary refill time is influenced by ambient temperature, limp position, site, age of the patient, and room lighting.
E. Mental Status
Hypoxia, hypercapnia, or ischemia will result in altered mental status. Other important treatable conditions may also result in altered mental status, such as intracranial hemorrhage, meningitis, and hypoglycemia.
F. Skin Color
Pallor, gray, mottled, or ashen skin colors all indicate compromised circulatory status.
G. Blood Pressure
It is important to remember that shock may be present before the blood pressure falls below the normal limits for age. As intravascular volume falls, peripheral vascular resistance increases. Blood pressure is maintained until there is 35%–40% depletion of blood volume, followed by precipitous and often irreversible deterioration. Shock represents a continuum that progresses if left untreated. Shock that occurs with any signs of decreased perfusion but normal blood pressure is compensated shock. When blood pressure also falls, decompensated (hypotensive) shock is present. Blood pressure determination should be done manually, using an appropriately sized cuff, because automated machines can give erroneous readings in children.
MANAGEMENT OF SHOCK
IV access is essential but can be difficult to establish in children with shock. Peripheral access, especially via the antecubital veins, should be attempted first, but central cannulation should follow quickly if peripheral access is unsuccessful. Alternatives are percutaneous cannulation of femoral, subclavian, or internal or external jugular veins; cutdown at antecubital, femoral, or saphenous sites; or intraosseous (IO) lines (Figure 12–7). IO needle placement is an acceptable alternative in any severely ill child when venous access cannot be established rapidly (within 10 seconds). Both manual and automated insertion devices are available for pediatric patients. Increasing evidence suggests that automated devices result in faster, more successful IO placement compared to manual devices. Decisions on more invasive access should be based on individual expertise as well as urgency of obtaining access. Use short, wide-bore catheters to allow maximal flow rates. Two IV lines should be started in severely ill children. In newborns, the umbilical veins may be cannulated. Consider arterial access if beat-to-beat monitoring or frequent laboratory tests will be needed.
Figure 12–7. Interosseous (IO) cannulation technique. The IO line is inserted by grasping the needle hub firmly with the palm of the hand and angling the needle tip perpendicular to the anterior tibial surface approximately two fingerbreadths distal to the tibial plateau. With a firm, twisting motion, advance the needle until a sudden lessening of resistance is felt as the needle enters the marrow space. Aspiration of blood and marrow confirms IO placement.
Differentiation of Shock States & Initial Therapy
Therapy for inadequate circulation is determined by the cause of circulatory failure.
A. Hypovolemic Shock
The most common type of shock in the pediatric population is hypovolemia. Frequent causes include dehydration, diabetes, heat illness, hemorrhage, and burns. Normal saline or lactated Ringer solution (isotonic crystalloid) is given as initial therapy in shock and should be initiated even in normotensive patients. There is no advantage to the early administration of colloid (albumin). Give 20 mL/kg body weight and repeat as necessary, until perfusion normalizes. Children tolerate large volumes of fluid replacement and frequent reassessment is necessary. Typically, in hypovolemic shock, no more than 60 mL/kg is needed, but more may be required if ongoing losses are severe. Appropriate monitoring and reassessment will guide your therapy. Packed red blood cell transfusion is indicated in trauma patients not responding to initial crystalloid bolus fluid replacement; however, there is insufficient evidence to determine the volume required. Pressors are not required in simple hypovolemic states.
B. Distributive Shock
Distributive shock results from increased vascular capacitance with normal circulating volume. Examples are sepsis, anaphylaxis, and spinal cord injury. Initial therapy is again isotonic volume replacement with crystalloid, but pressors may be required if perfusion does not normalize after delivery of two or three 20-mL/kg boluses of crystalloid. If necessary, pressors may be initiated through a peripheral line until central access is obtained. Outcomes improve when threshold heart rates, normalized blood pressure, and a capillary refill in less than 2 seconds are achieved within the first hour of symptom onset. Children in distributive shock must be admitted to a pediatric intensive care unit.
The most recent clinical practice parameters from the American College of Critical Care Medicine emphasized four key concepts when faced with the pediatric or neonatal patient in septic shock. When compared to adults, infants and children are more likely to require (1) proportionally more fluid; (2) early inotrope or vasodilator therapy; (3) hydrocortisone for absolute adrenal insufficiency (caused by severe illness); (4) ECMO (extracorporeal membrane oxygenation) for refractory shock.
C. Cardiogenic Shock
Cardiogenic shock can occur as a complication of congenital heart disease, myocarditis, dysrhythmias, ingestions (eg, clonidine, cyclic antidepressants), or as a complication of prolonged shock due to any cause. The diagnosis is suggested by any of the following signs: abnormal cardiac rhythm, distended neck veins, rales, abnormal heart sounds such as an S3 or S4, friction rub, narrow pulse pressure, rales, or hepatomegaly. Chest radiographs may show cardiomegaly and pulmonary edema. An initial bolus of crystalloid may be given, but pressors, and possibly afterload reducers, are necessary to improve perfusion. Giving multiple boluses of fluid is deleterious. Comprehensive cardiopulmonary monitoring is essential. Children in cardiogenic shock must be admitted to a pediatric intensive care unit.
D. Obstructive Shock
Obstructive shock is rare in the pediatric population and involves extracardiac obstruction of blood flow and/or obstruction of adequate diastolic filling. Examples include cardiac tamponade, tension pneumothorax, massive pulmonary embolism, or a critical coarctation of the aorta after closure of the ductus arteriosus. Management is directed toward resolution of the obstruction. In the case of a critical coarctation, management should include prostaglandin initiation to reopen the ductus arteriosus while awaiting surgical repair.
Observation & Further Management
Clinically reassess physiologic response to each fluid bolus to determine additional needs. Serial central venous pressure determinations or a chest radiograph may help determine volume status. Place an indwelling urinary catheter to monitor urine output.
Caution must be exercised with volume replacement if intracranial pressure (ICP) is potentially elevated, as in severe head injury, diabetic ketoacidosis, or meningitis. Even in such situations, however, normal intravascular volume must be restored in order to achieve adequate mean arterial pressure and thus cerebral perfusion pressure.
SUMMARY OF RESUSCITATING THE ACUTELY ILL INFANT OR CHILD
Assess the ABCs in sequential fashion and, before assessing the next system, immediately intervene if physiologic derangement is detected. It is essential that each system be reassessed after each intervention to ensure improvement and prevent failure to recognize clinical deterioration.
APLS (the pediatric emergency medicine resource): http://www.aplsonline.com.
Brierley J, Carcillo JA, Choong K et al: Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37(2):666–688 [PMID: 19325359].
Chameides L et al (eds): PALS Provider Manual. American Heart Association; 2011.
ECC Committee, Subcommittees and Task Forces of the American Heart Association: Part 13: pediatric basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S862–S875 [PMID: 20956229].
ECC Committee, Subcommittees and Task Forces of the American Heart Association: Part 14: pediatric advanced life support: 2010 American Heart Association guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122;S876–S908 [PMID: 20956230].
Tobias JD, Ross AK: Intraosseous infusions: a review for the anesthesiologist with a focus on pediatric use. Anesth Analg 2010;110(2):391–401 [PMID: 19897801].
EMERGENCY PEDIATRIC DRUGS
Although careful attention to airway and breathing remains the mainstay of pediatric resuscitation, medications are often needed. Rapid delivery to the central circulation, which can be via peripheral IV catheter, is essential. Infuse medications close to the catheter’s hub and flush with saline to achieve the most rapid systemic effects. In the rare instance that no IV or IO access is achievable, some drugs may be given by endotracheal tube (Table 12–1). However, the dose, absorption, and effectiveness of drugs given via this route are either unknown or controversial. The use of length-based emergency measuring tapes that contain preprinted drug dosages, equipment sizes, and IV fluid amounts (Broselow tapes) or preprinted resuscitation drug charts is much more accurate than estimation formulas and helps minimize dosing errors. Selected emergency drugs used in pediatrics are summarized in Table 12–2.
Table 12–1. Emergency drugs that may be given by endotracheal tube.
Table 12–2. Emergency pediatric drugs.
APPROACH TO THE ACUTELY ILL INFANT OR CHILD
An unstable patient may present with a known diagnosis or in cardiorespiratory failure of unknown cause. The initial approach must rapidly identify the injuries, prioritize management, and reverse life-threatening conditions.
PREPARATION FOR EMERGENCY MANAGEMENT
Resuscitation occurs simultaneously at two levels: rapid cardiopulmonary assessment, with indicated stabilizing measures, while venous access is gained, and cardiopulmonary monitoring initiated. The technique of accomplishing these concurrent goals is outlined as follows:
1. If advance notice of the patient’s arrival has been received, prepare a resuscitation room and summon appropriate personnel and subspecialty expertise as needed.
2. Assign team responsibilities, including a team leader plus others designated to manage the airway, perform chest compressions, achieve access, draw blood for laboratory studies, place monitors, gather additional historical data, and provide family support.
3. Age-appropriate equipment (including laryngoscope blade, endotracheal tubes, nasogastric or orogastric tubes, IV lines, and an indwelling urinary catheter) and monitors (cardiorespiratory monitor, pulse oximeter, and appropriate blood pressure cuff) should be assembled and readily available. Use a length-based emergency tape if available. See Table 12–3 for endotracheal tube sizes. Cuffed endotracheal tubes are acceptable during the inpatient setting for children and infants beyond the newborn period. Cuff inflation pressures must be carefully monitored and maintained below 20 cm H2O. In certain circumstances, such as poor lung compliance or high airway resistance, the use of cuffed tubes may be preferable in controlled settings.
Table 12–3. Equipment sizes and estimated weight by age.
RECEPTION & ASSESSMENT
Upon patient arrival, the team leader begins a rapid assessment as team members perform their assigned tasks. If the patient is received from prehospital care providers, careful attention must be paid to their report, which contains information that they alone have observed. Interventions and medications should be ordered only by the team leader to avoid confusion. The leader should refrain from personally performing procedures. A complete timed record should be kept of events, including medications, interventions, and response to intervention.
In addition to cardiac compressions and ventilation, ensure that the following are instituted:
1. Hundred percent high-flow oxygen.
2. Cardiorespiratory monitoring, pulse oximetry, and end-tidal CO2 if the patient is intubated.
3. Vascular (peripheral, IO, or central) access; two lines preferred.
4. Blood drawn and sent. Bedside blood glucose determination is essential.
5. Full vital signs.
6. Clothes removed.
7. Foley catheter and nasogastric or orogastric tube inserted.
8. Complete history.
9. Notification of needed consultants.
10. Family support.
11. Law enforcement or security activation and emergency unit lockdown for cases involving potential terrorism, gang violence, or threats to staff or family.
1. Immobilize neck.
2. Obtain chest radiograph (line and tube placement).
3. Insert central venous pressure and arterial line.
Kleinman ME et al: Pediatric basic and advanced life support: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Pediatrics 2010;126(5):e1261–e1318 [PMID: 20956433].
Mandt MJ, Rappaport LD: Update in pediatric resuscitation. Adv Pediatr 2009;56:359–385 [PMID: 19968956].
Waltzman ML, Mooney DP: Chapter 105: Major trauma. In: Fleisher GR et al (eds): Textbook of Pediatric Emergency Medicine, 6th ed. Lippincott Williams & Wilkins; 2010:1244–1255.
APPROACH TO THE PEDIATRIC TRAUMA PATIENT
Traumatic injuries, including motor vehicle crashes, falls, burns, and immersions, account for the greatest number of deaths among children older than 1 year; injury exceeds all other causes of death combined. A team approach to the severely injured child, using assigned roles as outlined in the preceding section, will optimize outcomes. A calm atmosphere in the receiving area will contribute to thoughtful care. Analgesia and sedation must be given to stable patients. Parents are often anxious, angry, or guilty, requiring ongoing support from staff, social workers, or child life workers (therapists knowledgeable about child development).
To provide optimal multidisciplinary care, regional pediatric trauma centers provide dedicated teams of pediatric specialists in emergency pediatrics, trauma surgery, orthopedics, neurosurgery, and critical care. However, most children with severe injuries are not seen in these centers. Primary care providers must be able to provide initial assessment and stabilization of the child with life-threatening injuries before transport to a verified pediatric trauma center.
MECHANISM OF INJURY
Document the time of occurrence, the type of energy transfer (eg, hit by a car, rapid deceleration), secondary impacts (if the child was thrown by the initial impact), appearance of the child at the scene, interventions performed, and clinical condition during transport. The report of emergency service personnel is invaluable. Forward all of this information with the patient to the referral facility if secondary transport occurs.
Trauma in children is predominantly blunt, with penetrating trauma occurring in 10% of cases. Head and abdominal injuries are particularly common and important.
INITIAL ASSESSMENT & MANAGEMENT
The vast majority of children who reach a hospital alive survive to discharge. As most deaths from trauma in children are due to head injuries, cerebral resuscitation must be the foremost consideration when treating children with serious injuries. Strict attention to the ABCs (airway, breathing, circulation) ensures optimal oxygenation, ventilation, and perfusion, and ultimately, cerebral perfusion.
The primary and secondary survey is a method for evaluating and treating injured patients in a systematic way that provides a rapid assessment and stabilization phase, followed by a head-to-toe examination and definitive care phase.
The primary survey is designed to immediately identify and treat all physiologic derangements resulting from trauma.
Airway, with cervical spine control
Circulation, with hemorrhage control
Disability (neurologic deficit)
Exposure (maintain a warm Environment, undress the patient completely, and Examine)
If the patient is apneic or has agonal breaths, the sequence becomes the CABs (chest compressions, open the airway, provide two rescue breaths). Please refer to pediatric advanced life support guidelines for further information. Refer to preceding discussion regarding details of the ABC assessment. Modifications in the trauma setting are added as follows.
Failure to manage the airway appropriately is the most common cause of preventable morbidity and death. Administer 100% high-flow oxygen to all patients. Initially, provide cervical spine protection by manual inline immobilization, not traction. A hard cervical spine collar is applied after the primary survey.
Most ventilation problems are resolved adequately by the airway maneuvers described earlier and by positive-pressure ventilation. Sources of traumatic pulmonary compromise include pneumothorax, hemothorax, pulmonary contusion, flail chest, and central nervous system (CNS) depression. Asymmetrical breath sounds, particularly with concurrent tracheal deviation, cyanosis, or bradycardia, suggest pneumothorax, possibly under tension. To evacuate a tension pneumothorax, insert a large-bore catheter-over-needle assembly attached to a syringe through the second intercostal space in the midclavicular line into the pleural cavity and withdraw air. If a pneumothorax or hemothorax is present, place a chest tube in the fourth or fifth intercostal space in the anterior axillary line. Connect to water seal. Insertion should be over the rib to avoid the neurovascular bundle that runs below the rib margin. Open pneumothoraces can be treated temporarily by taping petrolatum-impregnated gauze on three sides over the wound, creating a flap valve.
A child with a depressed level of consciousness (Glasgow Coma Scale [GCS] score < 9), a need for prolonged ventilation, severe head trauma, or an impending operative intervention requires endotracheal intubation after bag-mask preoxygenation. Orotracheal intubation is the route of choice and is possible without cervical spine manipulation. Nasotracheal intubation may be possible in children 12 years of age or older who have spontaneous respirations, if not contraindicated by midfacial injury.
Supraglottic devices, such as the laryngeal mask airway (LMA), are being used with increasing frequency, in both the prehospital and hospital settings. The device consists of a flexible tube attached to an inflatable rubber mask (Figure 12–8). The LMA is inserted blindly into the hypopharynx and is seated over the larynx, occluding the esophagus. Advantages to its use include ease of insertion, lower potential for airway trauma, and higher success rates. Patients remain at higher risk for aspiration with LMA use compared with orotracheal intubation; therefore, the LMA should not be used for prolonged, definitive airway management. Rarely, if tracheal intubation cannot be accomplished, particularly in the setting of massive facial trauma, cricothyroidotomy may be necessary. Needle cricothyroidotomy using a large-bore catheter through the cricothyroid membrane is the procedure of choice in patients younger than 12 years. Operative revision to a tracheostomy is necessary.
Figure 12–8. Laryngeal mask airways of various sizes.
Evaluation for ongoing external or internal hemorrhage is important in the trauma evaluation. Large-bore IV access should be obtained early during the assessment, preferably at two sites. If peripheral access is not readily available, a central line, cutdown, or IO line is established. Determine hematocrit and urinalysis in all patients. Blood type and cross-match should be obtained in the hypotensive child unresponsive to isotonic fluid boluses or with known hemorrhage. Consider coagulation studies, chemistry panel, liver transaminases, amylase, and toxicologic screening as clinically indicated.
External hemorrhage can be controlled by direct pressure. To avoid damage to adjacent neurovascular structures, avoid placing hemostats on vessels, except in the scalp. Determination of the site of internal hemorrhage can be challenging. Sites include the chest, abdomen, retroperitoneum, pelvis, and thighs. Bleeding into the intracranial vault rarely causes shock in children except in infants. Evaluation by an experienced clinician with adjunctive computed tomography (CT) or ultrasound will localize the site of internal bleeding.
Suspect cardiac tamponade after penetrating or blunt injuries to the chest if shock, pulseless electrical activity, narrowed pulse pressure, distended neck veins, hepatomegaly, or muffled heart sounds are present. Ultrasound may be diagnostic if readily available. Diagnose and treat with pericardiocentesis and rapid volume infusion.
Trauma ultrasonography, or the focused assessment with sonography for trauma (FAST), is routinely used in the adult trauma population. The purpose of the four-view examination (Morison pouch, splenorenal pouch, pelvic retrovesical space, and subcostal view of the heart) is to detect free fluid or blood in dependent spaces. In adults, such detection indicates clinically significant injury likely to require surgery. Accuracy and indications in children are much less clear. Solid-organ injuries are more frequently missed and much of the pediatric trauma management is nonoperative. As a result, detection of free fluid by ultrasound in children is less likely to lead to surgery or result in a change in management.
Treat signs of poor perfusion vigorously: A tachycardic child with a capillary refill time of 3 seconds, or other evidence of diminished perfusion, is in shock and is sustaining vital organ insults. Recall that hypotension is a late finding. Volume replacement is accomplished initially by rapid infusion of normal saline or lactated Ringer solution at 20 mL/kg of body weight. If perfusion does not normalize after two crystalloid bolus infusions, 10 mL/kg of packed red blood cells is infused.
Rapid reassessment must follow each bolus. If clinical signs of perfusion have not normalized, repeat the bolus. Lack of response or later or recurring signs of hypovolemia suggest the need for blood transfusion and possible surgical exploration. For every milliliter of external blood loss, 3 mL of crystalloid solution should be administered.
A common problem is the brain-injured child who is at risk for intracranial hypertension and who is also hypovolemic. In such cases, circulating volume must be restored to ensure adequate cerebral perfusion; therefore, fluid replacement is required until perfusion normalizes. Thereafter provide maintenance fluids with careful serial reassessments. Do not restrict fluids for children with head injuries.
Assess pupillary size and reaction to light and the level of consciousness. The level of consciousness can be reproducibly characterized by the AVPU (alert, voice, pain, unresponsive) system (Table 12–4). Pediatric GCS assessments can be done as part of the secondary survey (Table 12–5).
Table 12–4. AVPU system for evaluation of level of consciousness.
Table 12–5. Glasgow Coma Scale.a
Exposure & Environment
Significant injuries can be missed unless the child is completely undressed and examined fully, front and back. Any patient transported on a backboard should be removed as soon as possible, as pressure sores may develop on the buttocks and heels of an immobilized patient within hours.
Because of their high ratio of surface area to body mass, infants and children cool rapidly. Hypothermia compromises outcome except with isolated head injuries; therefore, continuously monitor the body temperature and use warming techniques as necessary. Hyperthermia can adversely affect outcomes in children with acute brain injuries, so maintain normal body temperatures.
Cardiopulmonary monitors, pulse oximetry, and end-tidal CO2 monitors should be put in place immediately. At the completion of the primary survey, additional “tubes” should be placed.
A. Nasogastric or Orogastric Tube
Children’s stomachs should be assumed to be full. Gastric distention from positive-pressure ventilation increases the chance of vomiting and aspiration. The nasogastric route should be avoided in patients with significant midface.
B. Urinary Catheter
An indwelling urinary bladder catheter should be placed to monitor urine output. Contraindications are based on the risk of urethral transection; signs include blood at the meatus or in the scrotum or a displaced prostate detected on rectal examination. Urine should be tested for blood. After the initial flow of urine with catheter placement, the urine output should exceed 1 mL/kg/h.
After the resuscitation phase, a focused history and a head-to-toe examination should be performed to reveal all injuries and determine priorities for definitive care.
Obtain a rapid, focused history from the patient (if possible), available family members or prehospital personnel. The AMPLE mnemonic is frequently used:
• P—Past medical history/pregnancy
• L—Last meal
• E—Events/environment leading to the injury
Search for lacerations, hematomas, burns, swelling, and abrasions. Remove foreign material and cleanse as necessary. Cutaneous findings may indicate underlying pathology (eg, a flank hematoma overlying a renal contusion), although surface signs may be absent even with significant internal injury. Make certain that the child’s tetanus immunization status is current. Consider tetanus immune globulin for incompletely immunized children.
Check for hemotympanum and for clear or bloody cerebrospinal fluid leak from the nares. Battle sign (hematoma over the mastoid) and raccoon eyes are late signs of basilar skull fracture. Explore wounds, evaluating for foreign bodies and defects in galea or skull. CT scan of the head is an integral part of evaluation for altered level of consciousness, posttraumatic seizure, or focal neurologic findings (see section Head Injury, later). Pneumococcal vaccine may be considered for basilar skull fractures.
Cervical spine injury must be excluded in all children. This can be done clinically in children older than 4 or 5 years with normal neurologic findings on examination who are able to deny midline neck pain or midline tenderness on palpation of the neck and who have no other painful distracting injuries that might obscure the pain of a cervical spine injury. If radiographs are indicated, a cross-table lateral neck view is obtained initially followed by anteroposterior, odontoid, and, in some cases, oblique views. Normal studies do not exclude significant injury, either bony or ligamentous, or involving the spinal cord itself. Therefore, an obtunded child should be maintained in cervical spine immobilization until the child has awakened and an appropriate neurologic examination can be performed. The entire thoracolumbar spine must be palpated and areas of pain or tenderness examined by radiography.
Children may sustain significant internal injury without outward signs of trauma. Pneumothoraces are detected and decompressed during the primary survey. Hemothoraces can occur with rib fractures or with injury to intercostal vessels, large pulmonary vessels, or lung parenchyma. Tracheobronchial disruption is suggested by large continued air leak despite chest tube decompression. Pulmonary contusions may require ventilatory support. Myocardial contusions and aortic injuries are unusual in children.
Blunt abdominal injury is common in multisystem injuries. Significant injury may exist without cutaneous signs or instability of vital signs. Abdominal pain and tenderness coupled with a linear contusion across the abdomen (“seat belt sign”) increases the risk of intra-abdominal injury threefold. Tenderness, guarding, distention, diminished or absent bowel sounds, or poor perfusion mandate immediate evaluation by a pediatric trauma surgeon. Injury to solid viscera frequently can be managed nonoperatively in stable patients; however, intestinal perforation or hypotension necessitates operative treatment. Serial examinations, ultrasound, and CT scan provide diagnostic help. Intra-abdominal injury is highly likely if the AST is less than 200 U/L or the ALT greater than 125 U/L; however, elevated levels that are below these thresholds do not exclude significant injury if a significant mechanism has occurred. When measured serially, a hematocrit of less than 30% also may suggest intra-abdominal injury in blunt trauma patients. Coagulation studies are rarely beneficial if no concomitant closed-head injury is present. Obtaining a serum amylase immediately postinjury is controversial, as recent studies have shown variable correlation between elevated levels and pancreatic injury.
Pelvic fractures are classically manifested by pain, crepitus, and abnormal motion. Pelvic fracture is a relative contraindication to urethral catheter insertion. Many providers perform a rectal examination, noting tone, tenderness, and in boys, prostate position. If this is done, stool should be tested for blood.
If urethral transection is suspected (see earlier discussion), perform a retrograde urethrogram before catheter placement. Diagnostic imaging of the child with hematuria less than 50 red blood cells per high-powered field often includes CT scan or occasionally, IV urograms. Management of kidney injury is largely nonoperative except for renal pedicle injuries.
Long bone fractures are common but rarely life threatening. Test for pulses, perfusion, and sensation. Neurovascular compromise requires immediate orthopedic consultation. Treatment of open fractures includes antibiotics, tetanus prophylaxis, and orthopedic consultation.
Central Nervous System
Most deaths in children with multisystem trauma are from head injuries, so optimal neurointensive care is important. Significant injuries include diffuse axonal injury; cerebral edema; subdural, subarachnoid, and epidural hematomas; and parenchymal hemorrhages. Spinal cord injury occurs less commonly. Level of consciousness by the AVPU system (see Table 12–4) or GCS (see Table 12–5) should be assessed serially. A full sensorimotor examination should be performed. Deficits require immediate neurosurgical consultation and should be considered for a patient with a GCS less than 12. Extensor or flexor posturing represents intracranial hypertension until proven otherwise. If accompanied by a fixed, dilated pupil, such posturing indicates that a herniation syndrome is present, and mannitol or 3% hypertonic saline should be given if perfusion is normal. Treatment goals include aggressively treating hypotension to optimize cerebral perfusion, providing supplemental oxygen to keep saturations above 90%, achieving eucapnia (end-tidal CO2 35–40 mm Hg), avoiding hyperthermia, and minimizing painful stimuli. Early rapid sequence intubation, sedation, and paralysis should be considered. Mild prophylactic hyperventilation is no longer recommended, although brief periods of hyperventilation are still indicated in the setting of acute herniation. Seizure activity warrants exclusion of significant intracranial injury. In the trauma setting, seizures are frequently treated with fosphenytoin or levetiracetam. The use of high-dose corticosteroids for suspected spinal cord injury has not been prospectively evaluated in children and is not considered standard of care. Corticosteroids are not indicated for head trauma.
Advanced Trauma Life Support: http://www.facs.org/trauma/atls/information.html.
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Orenstein JB: Pre-hospital pediatric airway management. Clin Ped Emerg Med 2006;7:31.
Sayer FT et al: Methylprednisolone treatment in acute spinal cord injury: the myth challenged through a structured analysis of published literature. Spine J 2006;6:335 [PMID: 16651231].
Closed-head injuries range in severity from minor asymptomatic trauma without sequelae to fatal injuries. Even after minor closed-head injury, long-term disability and neuropsychiatric sequelae can occur.
ESSENTIALS OF DIAGNOSIS
Traumatic brain injury (TBI) is the most common injury in children.
Rapid acceleration-deceleration forces (eg, the shaken infant) as well as direct trauma to the head can result in brain injury.
Rapid assessment can be made by evaluating mental status with the GCS score and assessing pupillary light response.
Minor head injuries require a screening evaluation with symptom inventory and complete neurologic examination.
Wearing helmets during snowsports or while riding wheeled recreational devices is a simple preventative strategy. Over 50% of children fail to wear helmets when riding bicycles; rates are lower with other wheeled devices. Adolescents are less likely to use protective equipment and warrant special attention when discussing helmet use. All-terrain vehicle (ATV)–related hospitalizations increased 150% among children from 1997 to 2006. Forty percent of children ride without helmets and 60% without adult supervision; fewer than 5% receive safety instruction. Their body size and weight likely contribute to an inability to control these vehicles safely. Toppled televisions result in mild to severe head injuries in young children; anticipatory guidance regarding properly securing furniture should be provided to parents.
A. Signs and Symptoms
Head injury symptoms are nonspecific; frequently they include headache, dizziness, nausea/vomiting, disorientation, amnesia, slowed thinking, and perseveration. Loss of consciousness is not necessary to diagnose a concussion (see Chapter 27 for more on concussion). Worsening symptoms in the first 24 hours may indicate more severe TBI. Obtain vital signs and assess the child’s level of consciousness by the AVPU system (see Table 12–4) or GCS (see Table 12–5), noting irritability or lethargy and pupillary equality, size, and light reaction. Perform a physical examination, including a detailed neurologic examination, being mindful of the mechanism of injury. Cerebrospinal fluid or blood from the ears or nose, hemotympanum, or the later appearance of periorbital hematomas (raccoon eyes) or Battle sign imply a basilar skull fracture. Evaluate for associated injuries, paying special attention to the cervical spine. Consider child abuse; injuries observed should be consistent with the history, the child’s developmental, and the injury mechanism.
B. Imaging Studies
CT may be indicated. A 2009 multicenter investigation of head-injured patients presenting to the ED derived and validated a decision rule for identifying those children at very low risk of clinically important traumatic brain injuries (Figure 12–9). Observation may be appropriate and reduces the use of CT. Plain films are not generally indicated. In infants, a normal neurologic examination does not exclude significant intracranial hemorrhage. Consider imaging if large scalp hematomas or concerns of nonaccidental trauma are present.
Figure 12–9. Suggested CT algorithm for children younger than 2 years (A) and for those aged 2 years and older (B) with GCS scores 14–15 after head trauma.
In young infants when no history is available, consider sepsis and inborn errors of metabolism. CNS infection, intoxication, or other medical causes of altered mental status may present similarly to head injuries which often have no external signs of injury.
Central Nervous System Infection
Open-head injuries (fractures with overlying lacerations) pose an infection risk due to direct contamination. Basilar skull fractures that involve the cribriform plate or middle ear cavity may allow a portal of entry for Streptococcus pneumoniae. Pneumococcal vaccination is sometimes considered for such cases.
Acute Intracranial Hypertension
Close observation will detect early signs and symptoms of elevated ICP. Early recognition is essential to avoid disastrous outcomes. Symptoms include headache, vision changes, vomiting, gait difficulties, and declining level of consciousness. Papilledema is a cardinal sign of increased ICP. Other signs may include stiff neck, cranial nerve palsies, and hemiparesis. Cushing triad (bradycardia, hypertension, and irregular respirations) is a late and ominous finding. Consider CT scan before lumbar puncture if there is concern about elevated ICP because of the risk of herniation. Lumbar puncture should be deferred in the unstable patient.
Treatment—Therapy for elevated ICP must be swift and aggressive. Maintenance of adequate oxygenation, ventilation, and perfusion is paramount. Rapid sequence intubation is often necessary to protect the airway. A sedative, paralytic, and lidocaine (administered 2–3 minutes prior to attempt) decrease the ICP elevation accompanying intubation. Avoid hypoperfusion and hypoxemia, as both are associated with increased risk of morbidity and mortality. Hyperventilation (goal Pco2 30–35 mm Hg) is reserved for acute herniation; otherwise, maintain Pco2 between 35 and 40 mm Hg. Mannitol (0.5–1 g/kg IV), an osmotic diuretic, will reduce brain water. Hypertonic saline (3%; 4–6 mL/kg bolus doses or 1–2 mL/kg/h infusion) also may be used. Adjunctive measures include elevating the head of the bed 30 degrees, maintaining the head in a midline position and treating hyperpyrexia and pain. Obtain immediate neurosurgical consultation. Further details about management of intracranial hypertension (cerebral edema) are presented in Chapter 14.
Children with concussion should not return to sports on the day of injury. Return to sport usually begins when symptom-free at rest, followed by a graduated return-to-play protocol. Most children recover fully. Persistent symptoms indicate the need for rehabilitation and/or neuropsychological referral.
The prognosis for children with moderate to severe injuries depends on many factors including severity of initial injury, presence of hypoxia or ischemia, development and subsequent management of intracranial hypertension, and associated injuries.
Dellinger AM, Kresnow MJ: Bicycle helmet use among children in the United States: the effects of legislation, personal and household factors. J Safety Res 2010;41(4):375–380. [PMID: 20846554].
Kuppermann N et al: Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009;374(9696):1160–1170 [PMID: 19758692].
Mattei TA et al: Definition and measurement of rider-intrinsic physical attributes influencing all-terrain vehicle safety. Neurosurg Focus 2011;31(5):E6 [PMID: 22044105].
Nigrovic LE et al: The effect of observation on cranial computed tomography utilization for children after blunt head trauma. Pediatrics 2011;127(6):1067–1073. [PMID: 21555498].
Page JL, Macpherson AK, Middaugh-Bonney T, Tator CH: Prevalence of helmet use by users of bicycles, push scooters, inline skates and skateboards in Toronto and the surrounding area in the absence of comprehensive legislation: an observational study. Inj Prev 2012;18(2)94–97 [PMID: 21873306].
Pardes Berger R, Adelson PD: Evaluation and management of pediatric head trauma in the emergency department: current concepts and state-of-the-art research. Clin Ped Emerg Med 2005;6:8.
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Burn patterns can distinguish accidental burns from inflicted burns.
Burns of the hands, feet, face, eyes, ears, and perineum are always considered to be major burns.
Burns are a common cause of accidental death and disfigurement in children. The association with child abuse and the preventable nature of burns constitute an area of major concern in pediatrics. Common causes include hot water or food, appliances, flames, grills, vehicle-related burns, and curling irons. Burns occur commonly in toddlers—in boys more frequently than in girls.
Hot liquids should be placed as far as possible from counter edges. Water heater thermostats should be turned to less than 120°F (49°C). Irons and electrical cords should be kept out of reach. Barriers around fireplaces are crucial. Children older than 6 months should wear sunscreen and hats when outdoors.
A. Signs and Symptoms
Superficial thickness burns are painful, dry, red, and hypersensitive. Sunburn is an example. Partial-thickness burns are subgrouped as superficial or deep, depending on appearance. Superficial partial-thickness burns are red and often blister. Deep partial-thickness burns are pale, edematous, blanch with pressure, and they display decreased sensitivity to pain. Full-thickness burns affect all epidermal and dermal elements. The wound is white or black, dry, depressed, leathery in appearance, and insensate. Deep full-thickness burns are the most severe, extending through all layers of skin as well as into the underlying fascia, muscle, and possibly bone. Singing of nasal or facial hair, carbonaceous material in the nose and mouth, and stridor indicate inhalational burns and may herald critical airway obstruction. Up to 25% of burns in children may be due to child physical abuse. Burn patterns help distinguish inflicted from accidental causes.
B. Laboratory Findings
Laboratory evaluation is rarely indicated. With extensive partial- and full-thickness burns, baseline complete blood cell count (CBC), basic metabolic panel, and creatine kinase are helpful for tracking infectious or renal complications. Consider carbon monoxide poisoning after inhalational injury: obtain an arterial blood gas and carboxyhemoglobin levels.
C. Imaging Studies
Imaging studies are rarely indicated. Neck x-rays should not delay intubation when inhalational injury is suspected.
The differential diagnosis of burns is limited when a history is provided. In the preverbal child when no history is available, the primary alternate consideration is cellulitis.
Superficial and superficial partial-thickness burns typically heal well. Deep partial- and full-thickness burns are at risk of scarring. Loss of barrier function predisposes to infection. Damage to deeper tissues in full-thickness burns may result in loss of function, contractures, and in the case of circumferential burns, compartment syndrome. Renal failure secondary to myoglobinuria from rhabdomyolysis is a concern.
Burn extent can be classified as major or minor. Minor burns are less than 10% of the body surface area (BSA) for partial-thickness burns, or less than 2% for full-thickness burns. Superficial thickness burns are not counted when assessing % BSA. Partial- or full-thickness burns of the hands, feet, face, eyes, ears, and perineum are considered major.
A. Superficial and Partial-Thickness Burns
These burns generally can be treated in the outpatient setting. Wounds with a potential to cause disfigurement or functional impairment—especially wounds of the face, hands, feet, digits, or perineum—should be referred promptly to a burn surgeon. Analgesia is paramount. After parenteral narcotic administration, initial treatment of partial-thickness burns with blisters consists of saline irrigation followed by application of antibiotic ointment and a nonadherent dressing (eg, petroleum gauze). Digits should be individually dressed to prevent adhesions. Due to the pain associated with aggressive debridement and the ability to provide an infectious barrier, smaller blisters may be left intact under the dressing. Larger bullae may either be drained or left in place. Protect the wound with a bulky dressing, reexamine within 48 hours and serially thereafter. Treatment at home with cool compresses and hydrocodone or oxycodone is preferred.
B. Full-Thickness, Deep or ExtensivePartial-Thickness, and Subdermal Burns
Major burns require particular attention to the ABCs of trauma management. Early establishment of an artificial airway is critical with oral or nasal burns because of their association with inhalation injuries and critical airway obstruction.
Perform a primary survey (see earlier discussion). Consider toxicity from carbon monoxide, cyanide, or other combustion products. Place a nasogastric tube and bladder catheter. The secondary survey identifies associated injuries, including those suggestive of abuse.
Fluid losses can be substantial. Initial fluid resuscitation should restore adequate circulating volume. Subsequent fluid administration must account for increased losses. Fluid needs are based on weight and percentage of BSA with partial- and full-thickness burns. Figure 12–10 shows percentages of BSA by region in infants and children. The Parkland formula for fluid therapy is 4 mL/kg/% BSA burned for the first 24 hours, with half administered in the first 8 hours, in addition to maintenance rates. Use of burn tables improves calculation of appropriate fluids. Goal urine output is 1–2 mL/kg/h.
Figure 12–10. Lund and Browder modification of Berkow scale for estimating extent of burns. (The table under the illustration is after Berkow.)
Children with burns greater than 10% BSA, suspicion for abuse, associated with inhalational injury, explosion, or fractures, or requiring parenteral analgesia should be admitted. Burns greater than 20% BSA or full-thickness burns greater than 2% BSA should be admitted to a children’s hospital or burn center. Children with subdermal burns require immediate hospitalization at a burn center under the care of a burn specialist.
Outcome depends on many factors. Healing occurs with minimal damage to epidermis in superficial burns. In contrast, full-thickness burns will be hard, uneven, and fibrotic unless skin grafting is provided. In general, the greater the surface area and depth of burn injury, the greater the risk of long-term morbidity and mortality.
Brief contact with a high-voltage source results in a contact burn and is treated accordingly. Infants and toddlers may bite electric cords, resulting in burns to the commissure of the lips. A late complication is labial artery hemorrhage. Children electrocuted with household current who are awake and alert at the time of medical evaluation are unlikely to have significant injury. An electrocardiogram (ECG) is not necessary. If current passes through the body, the pattern of the injury depends on the path of the current. Exposure to high-voltage current often induces a “locking-on” effect due to alternating current causing tetany. Extensive nerve and muscle injury, fractures, and ventricular fibrillation in addition to dermal burns are possible. Lightning strikes are more likely to induce asystole and blast trauma. The brevity of exposure is unlikely to cause significant burns.
Lindford AJ, Lim P, Klass B, Mackey S, Dheansa BS, Gilbert PM: Resuscitation tables: a useful tool in calculating pre-burns unit fluid requirements. Emerg Med J 2009;26(4):245–249 [PMID: 19307382].
DISORDERS DUE TO EXTREMES OF ENVIRONMENT
HEAT-RELATED ILLNESSES & HEAT STROKE
ESSENTIALS OF DIAGNOSIS
Heat illness is a spectrum ranging from heat cramps to life-threatening heat stroke.
A high index of suspicion is required to make the diagnosis given the lack of specific symptoms and a usually normal or only slightly elevated temperature.
Avoid exposure to extremes of temperature for extended periods. Plan athletic activities for early morning or late afternoon and evening. Acclimatization, adequate water, shade, and rest periods can prevent heat-related illness.
Heat cramps are brief, severe cramps of skeletal or abdominal muscles following exertion. Core body temperature is normal or slightly elevated. Electrolyte disturbance is rare and mild: laboratory evaluation is not indicated.
Heat exhaustion includes multiple, vague constitutional symptoms following heat exposure. Patients continue to sweat and have varying degrees of sodium and water depletion. Core temperature should be monitored frequently but is often normal or slightly increased. Symptoms and signs include weakness, fatigue, headache, disorientation, pallor, thirst, nausea and vomiting, and occasionally muscle cramps without CNS dysfunction. Shock may be present.
Heat stroke is a life-threatening failure of thermoregulation. Diagnosis is based on a rectal temperature above 40.6°C with associated neurologic dysfunction in a patient with an exposure history. Lack of sweating is not a necessary criterion. Symptoms are similar to those of heat exhaustion, but severe CNS dysfunction is a hallmark. Patients may be incoherent or combative. In severe cases, vomiting, shivering, coma, seizures, nuchal rigidity, and posturing may be present. Cardiac output may be high, low, or normal. Cellular hypoxia, enzyme dysfunction, and disrupted cell membranes lead to global end-organ derangements: rhabdomyolysis, myocardial necrosis, electrolyte abnormalities, acute tubular necrosis and renal failure, hepatic degeneration, acute respiratory distress syndrome (ARDS), and disseminated intravascular coagulation (DIC).
Viral gastroenteritis, sepsis and other infectious processes, neuroleptic malignant syndrome, malignant hyperthermia, and anticholinergic poisoning may present similarly.
Removal from the offending environment and removal of clothing are the first steps in managing any heat-related illness. Heat cramps typically respond to rest and rehydration with electrolyte solutions. Severe cramping and heat exhaustion should prompt evaluation of electrolytes to guide IV fluid rehydration.
Heat Stroke Management
1. Address the ABCs and administer 100% oxygen.
2. Administer IV fluids: isotonic crystalloid for hypotension; cooled fluids are acceptable. Consider central venous pressure monitoring. Consider providing diazepam for patient comfort.
3. Once resuscitative efforts have begun, initiate active cooling: fanning/misting with cool water; ice application at neck, groin, and axillae. Discontinue active cooling measures once core temperature reaches 39°C to prevent shivering.
4. Place monitors, rectal temperature probe, Foley catheter, and nasogastric tube.
5. Order laboratory tests: CBC; electrolytes; glucose; creatinine; prothrombin time and partial thromboplastin time; creatine kinase; liver function tests; arterial blood gases; urinalysis; and serum calcium, magnesium, and phosphate.
6. Admit to the pediatric intensive care unit.
Full recovery is the rule for heat cramps and heat exhaustion. Patients with heat stroke are at risk of end-organ damage due to volume depletion, rhabdomyolysis, direct renal injury, hepatocellular injury, and DIC; however, even in this critically ill population, some children recover fully with intensive management.
ESSENTIALS OF DIAGNOSIS
Hypothermia is defined as a core temperature of less than 35°C.
Children are at increased risk due to a greater body surface area-weight ratio.
In children, hypothermia is most commonly associated with water submersion.
Given the high association with submersion injuries, children should be carefully monitored around water. Proper use of life vests is critical.
A. Signs and Symptoms
Hypothermia is defined as a core temperature of less than 35°C. In an attempt to maintain core temperature, peripheral vasoconstriction leads to cool mottled skin. Shivering increases heat production to two to four times the basal levels. As temperature falls, heart rate slows and mental status declines. Severe cases (< 28°C) mimic death: patients are pale or cyanotic, pupils may be fixed and dilated, muscles are rigid, and there may be no palpable pulses. Heart rates as low as 4–6 beats/min may provide adequate perfusion, because of lowered metabolic needs in severe hypothermia. Besides cold exposure, disorders that cause incidental hypothermia include sepsis, metabolic derangements, ingestions, CNS disorders, and endocrinopathies. Neonates, trauma victims, intoxicated patients, and the chronically disabled are particularly at risk. Because hypothermia may be confused with postmortem changes, death is not pronounced until the patient has been rewarmed and remains unresponsive to resuscitative efforts.
B. Laboratory Findings
Standard evaluation includes CBC, electrolytes, coagulation studies, and glucose and blood gas studies. Coagulopathy, hypoglycemia, and acidosis are common. However, correction of derangements is accomplished by rewarming and resuscitating the patient.
C. Imaging Studies
Submersion is the most common cause of hypothermia. Chest x-ray should be performed. Other radiographic studies should be performed according to the history with special attention to potential head or skeletal trauma.
A. General Supportive Measures
Management of hypothermia is largely supportive. Continuously monitor core body temperature using a low-reading indwelling rectal thermometer. Handle patients gently as the hypothermic myocardium is exquisitely prone to arrhythmias. Ventricular fibrillation may occur spontaneously or as a result of minor handling or invasive procedures. If asystole or ventricular fibrillation is present on the cardiac monitor, perform chest compressions and use standard pediatric advanced life support techniques as indicated. Defibrillation and pharmacologic therapy (eg, epinephrine) are unlikely to be successful until core rewarming has occurred. Hypoglycemia should be corrected. Spontaneous reversion to sinus rhythm at 28–30°C may take place as rewarming proceeds.
Remove wet clothing. Rewarming techniques are categorized as passive external, active external, or active core rewarming. Passive rewarming, such as covering with blankets, is appropriate only for mild cases (33–35°C). Active external rewarming methods include warming lights, thermal mattresses or electric warming blanket, and warm bath immersion. Be aware of potential core temperature depression after rewarming has begun when vasodilation allows cooler peripheral blood to be distributed to the core circulation. This phenomenon is called afterdrop.
Active core rewarming techniques supplement active external warming for moderate to severe hypothermia. The techniques include warmed, humidified oxygen, warmed (to 40°C) IV fluids, and warm peritoneal and pleural lavage. Bladder and bowel irrigation are not generally effective because of low surface areas for temperature exchange. Extracorporeal membrane oxygenation achieves controlled core rewarming, can stabilize volume and electrolyte disturbances, and is maximally effective (Table 12–6).
Table 12–6. Management of hypothermia.
As with all trauma, recovery of the hypothermia victim is multifactorial. If associated with submersion injury (see next), the CNS anoxic injuries and lung injury play a major role. Mortality rates are high and are related to the presence of underlying disorders and injuries. Children with a core temperature as low as 19°C have survived neurologically intact.
Hostler D, Northington WE, Callaway CW: High-dose diazepam facilitates core cooling during cold saline infusion in healthy volunteers. Appl Physiol Nutr Metab 2009;34(4):582–586 [PMID: 19767791].
ESSENTIALS OF DIAGNOSIS
CNS and pulmonary injuries account for major morbidity.
Child may appear well at presentation, but late CNS and pulmonary changes can occur hours later.
Minimum observation period is 12–24 hours.
The World Health Organization defines drowning as the process of experiencing respiratory impairment from submersion/immersion in liquid. The terms wet or dry drowning, near-drowning, and others are no longer used; nonfatal drowning describes survivors. Water hazards are ubiquitous; even toilets, buckets, and washing machines pose a threat. Risk factors include epilepsy, alcohol, and lack of supervision. Males predominate in submersion deaths. Prevention strategies include fencing around public pools, use of life vests, avoiding swimming alone, and adequate supervision. Swim lessons may have a role in a comprehensive prevention strategy, even for children 1–4 years of age.
A. Signs and Symptoms
Depending on the duration of submersion and any protective hypothermia effects, children may appear clinically dead or completely normal. Major morbidity stems from CNS and pulmonary insult. Cough, nasal flaring, grunting, retractions, wheezes and/or rales, and cyanosis are common. A child rewarmed to 33°C but who remains apneic and pulse- less is unlikely to survive to discharge or will have severe neurologic deficits. Until a determination of brain death can be made, however, aggressive resuscitation should continue in a patient with return of circulation. Cardiovascular changes include myocardial depression and arrhythmias. Children may develop ARDS.
B. Laboratory Findings
Electrolyte alterations are generally negligible. Unless hemolysis occurs, hemoglobin concentrations change only slightly. Blood gas will show hypoxemia and acidosis.
C. Imaging Studies
Chest radiographs may be normal or may show signs of pulmonary edema. Brain CT is warranted when the patient is comatose or believed to have suffered prolonged asphyxia or blunt head trauma. Consider cervical spine injury in teens where diving or intoxication may be involved.
Care is generally supportive. Correct hypothermia. For children who appear well initially, observe for 12–24 hours for late pulmonary or neurologic compromise. Respiratory distress, an abnormal chest radiograph, abnormal arterial blood gases, or hypoxemia by pulse oximetry require maximal supplemental oxygen, cardiopulmonary monitoring, and frequent reassessment. There is little evidence for use of surfactant following drowning.
Anoxia from laryngospasm or aspiration leads to irreversible CNS damage after only 4–6 minutes. A child must fall through ice or directly into icy water for cerebral metabolism to be slowed sufficiently by hypothermia to provide protection from anoxia. Survival of the drowning victim depends on the duration of anoxia and the degree of lung injury. Children experiencing brief submersion with effective, high-quality resuscitation are likely to recover without sequelae. Children presenting asystolic are unlikely to survive.
Brenner RA et al: Association between swimming lessons and drowning in childhood: a case-control study. Arch Pediatr Adolesc Med 2009;163(3):203–210 [PMID: 19255386].
Weiss J; American Academy of Pediatrics Committee on Injury, Violence, and Poison prevention: Technical report—prevention of drowning. Pediatrics 2010;126(1):e253–e262 [PMID: 20498167].
ANIMAL & HUMAN BITES
Bites account for a large number of visits to the emergency department. Most fatalities are due to dog bites. Human and cat bites cause the majority of infected bite wounds.
Boys are bitten more often than girls. The dog is known by the victim in most cases. Younger children have a higher incidence of head and neck wounds, whereas school-age children are bitten most often on the upper extremities. Children should be taught not to taunt dogs or approach dogs that are eating, sleeping or are unknown to them.
A. Signs and Symptoms
Dogs may cause abrasions, lacerations, and puncture wounds. Larger dogs may tear skin, subcutaneous tissue, and muscle, or even cause fractures. Other signs and symptoms are related to the structures injured.
B. Imaging Studies
Bites caused by large dogs associated with significant crush injury may be associated with fractures. Dislodged teeth may also be present in the wound. Plain x-rays may be indicated.
Provide appropriate analgesia or anesthesia before starting wound care. Debride any devitalized tissue and remove foreign matter. Irrigate using normal saline with high pressure (>5 psi [pounds per square inch]) and volume (> 1 L). Consider tetanus prophylaxis depending on immunization status. Rabies risk is low among dogs in developed countries; prophylaxis is rarely indicated. Suture wounds only if necessary for cosmesis as closure increases the risk of infection. Do not use tissue adhesives. Prophylactic antibiotics do not decrease infection rates in low-risk dog bites, except those involving the hands and feet. Bites involving a joint, periosteum, or associated with fracture require prompt orthopedic surgery consultation.
Pasteurella canis and Pasteurella multocida, streptococci, staphylococci, and anaerobes may infect dog bites. Broad-spectrum coverage with amoxicillin and clavulanic acid is first-line therapy.
Complications of dog bites include scarring, CNS infections, septic arthritis, osteomyelitis, endocarditis, sepsis, and posttraumatic stress.
Cat-inflicted wounds occur more frequently in girls. The principal complication is infection, and the risk is higher compared to dog bites because cat bites produce a puncture wound. Children should be observed closely when playing with kittens or cats.
A. Signs and Symptoms
Cat bites typically result in abrasions and puncture wounds. Within 12 hours, untreated bites may result in cellulitis or, when involving the hand, tenosynovitis and septic arthritis. Other signs and symptoms are related to the structures injured. Cat scratch disease (CSD) can occur after bites or scratches especially from kittens. Local findings include a papule, vesicle, or pustule at the site of inoculation. The hallmark of CSD is regional lymphadenitis. See Chapter 42 for a detailed discussion of CSD.
B. Laboratory Findings
Serologic tests for Bartonella henselae are available when cat scratch is suspected. C-reactive protein and sedimentation rate may be useful to monitor treatment response in infected cat bites.
Cellulitis, tenosynovitis, and septic arthritis are important potential complications of cat bites. Systemic illness is rare.
Management is similar to that for dog bites. Provide appropriate analgesia or anesthesia before starting wound care. Debride any devitalized tissue and remove foreign matter. With isolated puncture wounds, high-pressure irrigation is contraindicated as it may force bacteria deeper into tissue. Alternatively, the wound may be soaked in dilute povidone-iodine solution for 15 minutes. Consider tetanus prophylaxis in the under- or unimmunized. As with dogs, rabies risk is low in developed countries and prophylaxis is rarely indicated. Cat bites should not be closed except when absolutely necessary for cosmesis.
P multocida is the most common pathogen. Prophylactic antibiotics are recommended. First-line treatment is amoxicillin and clavulanic acid. The dosage of the amoxicillin component should be 80 mg/kg/24 h in three divided doses. The maximum dosage is 2 g/24 h. Strongly consider admission and parenteral antibiotics for infected wounds on the hands and feet.
Most infected human bites occur during fights when a clenched fist strikes bared teeth. Pathogens most commonly include streptococci, staphylococci, anaerobes, and Eikenella corrodens. Hand wounds and deep wounds should be treated with antibiotic prophylaxis against E corrodens and gram-positive pathogens with a penicillinase-resistant antibiotic (amoxicillin with clavulanic acid). Wound management is the same as for dog bites. Only severe lacerations involving the face should be sutured. Other wounds can be managed by delayed primary closure or healing by secondary intention. A major complication of human bite wounds is infection of the metacarpophalangeal joints. A hand surgeon should evaluate clenched-fist injuries from human bites if extensor tendon injury is identified or joint involvement is suspected.
PROCEDURAL SEDATION & ANALGESIA
Relief of pain and anxiety is a paramount concept in the provision of acute care pediatrics, and should be considered at all times. Many agents also have amnestic properties. Parenteral agents can be effective and safe and produce few side effects if used judiciously.
Conditions such as fracture reduction, laceration repair, burn care, sexual assault examinations, lumbar puncture, and diagnostic procedures such as CT and magnetic resonance imaging may all be performed more effectively and compassionately if effective sedation or analgesia is used. The clinician should decide whether procedures will require sedation, analgesia, or both, and then choose agents accordingly.
Safe and effective sedation requires thorough knowledge of the selected agent and its side effects, as well as suitable monitoring devices, resuscitative medications, equipment, and personnel. The decision to perform procedural sedation and analgesia (PSA) must be patient-oriented and tailored to specific procedural needs, while ensuring the child’s safety throughout the procedure. In order to successfully complete this task, a thorough preprocedural assessment should be completed, including a directed history and physical examination. Risks, benefits, and limitations of the procedure should be discussed with the parent or guardian and informed; verbal consent must be obtained. PSA then proceeds as follows:
1. Choose the appropriate medication(s) and route. Commonly used medication classes include benzodiazepines (such as midazolam), opiates (fentanyl), barbiturates (pentobarbital), dissociative anesthetics (ketamine), and sedative-hypnotics (propofol).
2. Ensure appropriate NPO (nothing-by-mouth) status for 2–6 hours, depending on age and type of intake. For certain emergency procedures, suboptimal NPO status may be allowed, with attendant risks identified.
3. Establish vascular access as required.
4. Ensure that resuscitative equipment and personnel are readily available. Attach appropriate monitoring devices, as indicated.
5. Give the agent selected, with continuous monitoring for side effects. A dedicated observer, usually a nurse, should monitor the patient at all times. Respiratory effort, perfusion, and mental status should be assessed and documented serially.
6. Titrate the medication to achieve the desired sedation level. The ideal level depends on sedation goals and procedure type. PSA goals in the emergency department setting usually involve minimal or moderate sedation. Minimal sedation is a state in which the patient’s sensorium is dulled, but he or she is still responsive to verbal stimuli. Moderate sedation is a depression of consciousness in which the child responds to tactile stimuli. In both cases, airway reflexes are preserved. It is important to remember that sedation is a continuum and the child may drift to deeper, unintended levels of sedation.
7. Continue monitoring the patient after the procedure has finished and the child has returned to baseline mental status. Once a painful stimulus has been corrected, mental status and respiratory drive can decrease.
8. Criteria for discharge include the child’s ability to sit unassisted, take oral fluids, and answer verbal commands. A PSA discharge handout should be given, with precautions for close observation and avoidance of potentially dangerous activities.
American Academy of Pediatrics; American Academy of Pediatric Dentistry; Coté CJ et al: Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics 2006;18:2587 [PMID: 17142550].
Couloures KG et al: Impact of provider specialty on pediatric procedural sedation complication rates. Pediatrics 2011;127(5):e1154–e1160 [PMID: 21518718].
Gozal D, Gozal Y: Pediatric sedation/anesthesia outside the operating room. Curr Opin Anaesthesiol 2008;21(4):494–498 [PMID: 18660660].
Krauss B, Green SM: Procedural sedation and analgesia in children. Lancet 2006;367:766 [PMID: 16517277].