Volume I:
First Thirty Minutes
- Section 1
  Acute Care Algorithm/ Treatment Plans/ Acronyms
- Section 2
  Universal Approach
  - CALS Universal Approach To Emergency Advanced Life Support
- Section 3
  Steps 1-6
- Section 4
  Preliminary Impression/Focused Clinical Pathways
Volume II:
Resuscitation Procedures
Volume III:
Definitive Care

Pathway 9: Pediatric Trauma

(Secondary Survey for Trauma in Children)

The team continues the resuscitation along the pathway suggested by the initial clinical impression. Each pathway includes a complete, thorough, and rapid physical examination with additional history taking. The team leader is wary of conditions that may not be apparent. To obtain additional clinical data or to correct a missed or newly developed condition, the team leader repeats the initial survey if the patient is not responding satisfactorily.

PEDS: Because this entire pathway pertains only to pediatric patients, the convention of underlining has been omitted. For purposes of this survey, the pediatric age group ranges from infancy to the attainment of adult size.

Children are not small adults.

This obvious admonition needs to be stressed whenever discussing care of children. The ABCs are the most important aspects of any resuscitation, but certain aspects of the physiology and anatomy of children need to be considered. These differences are clarified in this pathway.

The team leader performs a head to toe, rapid but thorough, physical examination. Some possible abnormalities are:

Text Number	Diagnosis/Condition	Related Materials
1	Compromised Airway	Vol I—Airway Skills
2	Abnormal LOC	Vol I—Pathway 1 Altered Level of Consciousness
3	Facial and Skull Fracture/Scalp Laceration	Vol I—Acute Care Portals; Vol II—Disab Skills 2 Raney Scalp Clips; Vol III—NEU5 Increased Intracranial Pressure
4	Direct Eye Trauma
5	Soft Tissues of the Neck	Vol I—Airway Skills
6	Cervical Spine Injury	Vol I—Xray Skills 1 C-Spine Rules, Xray Skills 2 Cervical Spine Xray Interpretation
7	Chest Wall and Pulmonary Injury	Vol II—Breath Skills 1 Chest Tube Insertion, Breath Skills 2 Chest Suction/Autotransfusion, Breath Skills 5 Needle Thoracostomy
8	Cardiac Tamponade	Vol II—Circ Skills 6 Pericardiocentesis
9	Hypovolemic Shock	Vol I—Acute Care Portals; Vol II—Circ Skills 1 Arterial and Venous Catheter Insertion; Vol III—Trau Care 2 Shock
10	Abdominal Injury	Vol I—Acute Care Portals; Vol III—Trau Care 2 Shock
11	Pelvic Fracture	Vol II—Trau Skills 3 Pelvic Fracture Stabilization, Xray Skills 3 Interpretation of Pelvic Xray
12	Major Joints, Femurs, and Amputations	Vol I—Acute Care Portals; Vol II—Trau Skills 1 Compartment Pressure Measurement, Trau Skills 2 Femur Fracture Splinting; Vol III—Trau Care 2 Shock
13	Burns	Vol I—Acute Care Portals; Vol III—ENV3 Burns Management
14	Heat Stroke	Vol III—ENV2 Hyperthermia
15	Severe Hypothermia	Vol III—ENV1 Hypothermia
16	Near Drowning	Vol III—ENV4 Near Drowning
17	Caustic Substance Ingestion

For almost all patients, obtain the trauma series of x-rays. This includes a lateral c-spine, a supine chest x-ray, and an AP pelvis x-ray. Order these immediately and continue examining the patient as the x-rays are being obtained.

If the patient deteriorates during this survey, repeat the initial survey, checking airway, breathing, circulation, and so on.

Hidden back injury or wound

Carefully log roll the patient, while maintaining c-spine immobilization, just enough to expose the back. Palpate the entire length of the spine checking for deformity, hematoma, lacerations, and pain. Palpate the back of the head, posterior thorax, scapula, flanks, and buttocks. The log roll maneuver in the presence of an unstable pelvic fracture can stimulate more bleeding. The team should carefully lift the patient straight up instead. If spinal injury is suspected, securely immobilize the patient. If there is a question about the spine, order AP views of the thoracic and lumbar spine. Remove glass shards and any other harmful materials before laying the patient back down.

Compromised Airway

During the initial survey, the airway has been evaluated. Re-evaluate the airway, checking for patency, airway protection, correct ET tube placement, breath sounds, stridor, hypoxia, respiratory effort, soot, or burns. If possible, complete a mini-neuro exam before doing RSI.

The Mini-Neuro Exam

Level of Consciousness
AVPU and Glasgow Coma Scales
Pupils and Vision
Size, equality, and reactivity to light
Conjugate or disconjugate gaze
Count fingers
Tympanic Membranes
Hemotympanum
Neck
Posterior midline tenderness
Extremities
Movement and strength on command or to pain
Ankle, patellar, and brachial reflexes
Babinski reflexes and clonus
Sensation and position sense
Trunk and Perineum
Priapism, saddle sensation, anal sphincter tone
Sensory level

A child’s airway is significantly different from an adult’s.

The cartilages of a small child's larynx and trachea are soft and easily compressed by hyperextension and hyperflexion of the neck, resulting in airway obstruction. Because of the softness of the trachea, the esophageal intubation detector (EID) (Vol II—Air Skills 1 Aids to Intubation) is not useful. The operator cannot make a distinction between the trachea and the esophagus in children less than 1 year of age. End-tidal CO₂ is a reliable method in all but the smallest infants (< 2 kg).
A standard ET tube introducer (ETI) (Vol II—Air Skills 1 Aids to Intubation is 15 French in diameter. The smallest ET tube that fits over the ETI is size 5.5. A child able to receive a 5.5 ET tube is at least 5 to 6 years of age. For pediatric airway equipment sizes, see Vol II—Air Skills 1 Aids to Intubation. Though useful, the ETI is fortunately rarely needed in small children.
Relative to the position of the larynx in most adults, the larynx of a small child lies more superiorly and anteriorly. The cricoid pressure maneuver (Sellick's maneuver) is used to compress the esophagus during orotracheal intubation. To prevent air from entering the stomach during bagging, a separate maneuver, applying pressure backward, upward, and to the right (BURP) as described in Vol II—Air Skills 5 Cricoid Pressure and the BURP Technique, may help bring the glottic opening within view during intubation.
The cricoid cartilage forms the tightest ring of the airway in small children. An ET tube that can be inserted past the vocal cords may still be too large to be inserted past the cricoid cartilage. The cricoid cartilage forms an effective seal around the ET tube in children younger than about 6 to 8 years of age, negating the need for a balloon cuff. However, to prevent air leaks, low-pressure cuffed tubes are being increasingly used in children. Low-pressure cuffs are now being used in pediatric patients on ventilators in ICU settings. For ET tube sizes appropriate for children, see Vol II—Air Skils 1 Aids to Intubation.
The length of the trachea is not proportional to that of an adult: The trachea of a small child is surprisingly short. A ring on the pediatric ET tube indicates to the intubator when a tube is properly positioned. The intubator should insert the tube until the black ring is at the vocal cords. (Vol II—Air Skills 3 Orotracheal Intubation) Inadvertent right main stem intubation is a common problem in small children.
Infants can be easily extubated simply by head movement. Securing the ET tube after placement is of critical importance. (Vol II—Air Skills 1 Aids to Intubation.)
The upper airway is very reactive in small children, at times making intubation difficult. Stimulation of the hypopharynx may cause a vigorous gagging motion and laryngeal spasm. Rapid sequence intubation (RSI) negates these effects. (Vol II—Air Skills 4 Rapid Sequence Intubation)
Children under about 8 years of age are susceptible to vagal stimulation. Simply touching the pharynx can cause significant bradycardia. Pre-treatment with atropine 0.02 mg/kg with a minimum dose of 0.1 mg and a maximum single dose of 0.5 mg prevents this effect. (Vol II—Air Skills 4 Rapid Sequence Intubation)
The intercostal muscles are poorly developed in early childhood, the result being that a child relies heavily on diaphragmatic movement to breathe. For this reason, gastric and abdominal distension may severely interfere with respirations. Thus, insert an orogastric or nasogastric tube. Another effect is an inability to sustain increased effort when the work of breathing is increased for any reason.
The compliant chest wall retracts easily when there is airway obstruction. In small children with upper and lower airway obstruction, rib and supraclavicular retractions are early signs of an increase in the work of breathing. This is useful for identifying respiratory distress and obstruction.
In children, barotrauma is easily produced in the lungs by positive pressure ventilation (PPV). Tidal volume is small, and the respiratory rate is fast. Well-meaning team members may easily hyperinflate the lungs using mechanical devices or mouth-to-mouth breathing. Pneumothorax results.
Pneumothorax in children is especially likely to result in tension pneumothorax because the mediastinum may shift easily with resulting decreased filling of the heart and compression of the opposite lung. All those who care for children should be familiar with the technique of needle thoracostomy. (Vol II—Breath Skills 5 Needle Thoracostomy)
Due to the ribs being quite compliant, any rib fracture should raise suspicions of severe intrathoracic trauma.

Many different airway injuries and problems can develop in trauma situations. A variety of presentations in patient anatomy and size make absolute recommendations difficult. An algorithm quickly becomes confusing. A good way of approaching any clinical situation is to consider the tools best suited for a specific problem. A small number of tools are available:

Bag-Valve-Mask (BVM) Ventilation – This tool can be effective in many situations. Critical to success is skillful use of the BVM and oral and nasal airways. Additionally, pay careful attention to tidal volume, rate, and pressure. A BVM can keep a patient ventilated until other means of airway control are available. (Vol II—Air Skills 2 Bag-Valve-Mask Use)

Orotracheal intubation – This tool is still the preferred choice for airway management. Though orotracheal intubation can cause harmful reflexes as well be painful and difficult in an aware patient, the use of RSI removes these disadvantages. (Vol II—Air Skills 4 Rapid Sequence Intubation, Air Skills 1 Aids to Intubation)

Transtracheal needle ventilation (TTNV) – TTNV is an effective temporizing airway. TTNV increase the time available for more invasive procedures or even orotracheal intubation and is useful in all ages, especially below 8-10 years of age when the anatomy is too small for cricothyrotomy. (Vol II—Air Skills 16 Transtracheal Needle Ventilation)

Cricothyrotomy – Cricothyrotomy is fast and reliable and requires surgical skill. A tracheal hook and an ETI are helpful. A child must be at least 8 to 10 years of age. (Vol II—Air Skills 13 Cricothyrotomy)

Tracheotomy - The ultimate airway. More difficult than a cricothyrotomy but may be used in all ages. Transtracheal needle ventilation may be used as a temporizing technique while being performed. (Vol II—Air Skills 14 Tracheotomy, Air Skills 15 Tracheotomy in Infants)

Not every trauma patient needs to be intubated. Most seriously injured patients should be intubated, however, for safe ongoing care. Intubation allows control of the airway and of ventilations, affords the ability to administer pain medications and sedatives without fear of reducing ventilation, and makes transfer safe for many reasons. RSI has made performing orotracheal intubation possible without the former negative effects of tracheal intubation. On the negative side, neuromuscular blockade masks seizure activity and makes clinical neurological evaluation difficult. If head injury is suspected, consider seizure medications prophylactically.

If physical findings or a mechanism of injury suggest the possibility of a spinal injury, perform orotracheal intubation with in-line immobilization of the head and neck. Open the cervical collar because it can limit the ability to lift the chin. An assistant should kneel on the floor at the head of the table toward the left and hold the patient's head between his or her hands. The patient may be intubated over the right shoulder of this individual. This approach enables the application of cricoid pressure^a or BURP by another assistant. Another method is to lean across the child’s chest, rest your hands on the clavicles, and secure the head. See Vol II—Air Skills 5 Cricoid Pressure and the BURP Technique, Air Skills 3 Orotracheal Intubation for a description of the team approach to tracheal intubation and adjuncts, such as an ET tube introducer (ETI) and the EID.

If an already intubated patient is making cough attempts hindering ventilation, administer topical tracheal lidocaine 1 mg/kg through the ET tube or sedate and paralyze the patient.

Consider awake intubation instead of RSI when a patient is breathing but is tiring, when oxygen saturation is decreasing, when a patient must be sedated for transport or for a CT scan, or when there is difficulty intubating for whatever reason. (Vol II—Air Skills 12 Tracheal Foreign Body Removal)

Some rescue airways used in adults when orotracheal intubation is unsuccessful are not possible or available for use in children. The esophageal-tracheal Combitube™ may be used only in older children of adult stature (about 4 to 5 feet tall). (Vol II—Air Skills 6 Esophageal Tracheal Combitube, Air Skills 9 Nasotracheal Intubation) Pediatric-sized laryngeal mask airways (LMA) and pediatric-sized King airways are available and most commonly used. A pediatric intubating LMA (ILMA) is not available.

Nasotracheal intubation is rarely used in trauma resuscitation because it raises ICP and can cause bleeding. During infancy, adenoid tissue is prone to bleeding and the anteriorly placed larynx makes placement difficult, so this method is not used. In children, this should be done only be someone experienced.

A surgical airway may be the best option if anatomic problems are severe. In children younger than about 8 years of age, transtracheal needle ventilation (TTNV) is probably the best option. The tight cricoid ring of small children can make tracheal cannulation through the cricothyroid membrane difficult, for example, as in cricothyrotomy. If the larynx is easily palpable, the percutanous insertion of the needle is safe. However, if the larynx is very moveable in an infant or toddler, the best approach may be to use a small skin incision over the larynx to assure accurate placement of the needle. (Vol II—Air Skills 16 Transtracheal Needle Ventilation)

In children older than about 8 to 10 years, a cricothyrotomy can be quickly and reliably accomplished with the insertion of a cuffed 6.0 ET tube over an ETI as in adults. (Vol II—Air Skills 13 Cricothyrotomy)

When there is trauma to the larynx and airway obstruction occurs, tracheotomy is indicated. Tracheal stenosis may occur if the procedure is performed incorrectly in small children. In small children it is safest to keep the patient oxygenated using TTNV through the cricothyroid membrane while the tracheotomy is performed using meticulous technique. (Vol II—Air Skills 14 Tracheotomy, Air Skills 15 Tracheotomy in Infants)

Whichever method of airway management is used, carefully assess for correct tube placement and function. Monitor breath sounds, oxygen saturation, and blood gases. A post-intubation chest x-ray is also important.

Abnormal LOC

Continuing from the initial survey, parts of this evaluation and treatment have already been done. If the patient is unable to cooperate or is disoriented, use RSI to gain control of the airway, allowing the resuscitation to proceed. Again, be aware of the anatomic differences between children and adults. (Vol II—Air Skills 4 Rapid Sequence Intubation) However, before paralyzing the patient, obtain the SAMPLE history, determine LOC (using the AVPU scale or the Pediatric Glasgow Coma Scale), and document a mini neuro exam. During the initial survey, always check Dextrose, administer Oxygen as needed, and consider Narcan.

Level of Consciousness

AVPU	Scale	Corresponding GCS
A	Awake	14 to 15
V	Responds to voice	12 to 13
P	Responds to pain	8
U	Unresponsive to pain	3 to 4

Glasgow Coma Scale—Adult, Pediatric, Infant

Eye Opening
Infant (<1 year)	Pediatric (>1 year)	Adult
Spontaneous	Spontaneous	Spontaneous	4
Voice	Voice	Voice	3
Pain	Pain	Pain	2
None	None	None	1

Verbal Response
Infant (<2 years)	Pediatric (>2 years)	Adult
Coos, babbles	Appropriate word/ phrase	Oriented	5
Irritable but consolable	Disoriented/ converses	Confused	4
Persistent cries/ screams	Inappropriate word	Inappropriate	3
Moans/grunts to pain; restless	Incomprehensible sounds	Incomprehensible	2
None	None	None	1

Motor Response
Infant (<1 year)	Pediatric (>1 year)	Adult
Spontaneous	Obeys	Obeys	6
Localizes pain	Localizes pain	Localizes pain	5
Flexion-withdrawal	Flexion-withdrawal	Withdraws	4
Flexion/decorticate	Flexion/decorticate	Abnormal flexion (decorticate)	3
Extension/decerebrate	Extension/decerebrate	Abnormal extension (decerebrate)	2
None	None	None	1
			_________ 3 to 15

In infants younger than about 18 months, the fontanelle may be palpable. Bulging indicates increased ICP and signifies a severe injury. With decreasing or low level of consciousness, airway control is needed. Premedicate with lidocaine to prevent a rise in ICP (if there is time, takes 3 minutes to work) and with atropine to prevent bradycardia; then intubate using RSI.
If uncal herniation is occurring (dilated pupil and weak opposite extremity) or if the patient is posturing (extensor or flexor), carry out the following:

Hyperventilate to a CO₂ level of about 30 to 35 mm Hg. Ventilate at a rate of 16 to 20 breaths per minute; however, ventilate infants at a rate of 20 to 30 breaths per minute. Tidal volume should be about 10 to 15 mL/kg. To avoid producing a pneumothorax, limit the amount of pressure applied to the ventilating bag to less than about 30 cm of H₂O.⁶
Administer mannitol IV 1 g/kg. Administer a fosphenytoin load to 18 mg PE/kg IV at a rate of 2 mg PE/kg/min not to exceed 150 mg PE/min. If not available, administer a phenytoin load to 18 mg/kg IV at a rate of 0.5 to 1.0 mg/kg/min. Hypotension is the rate-limiting effect. Monitor pressure closely during the infusion. Infuse slowly if hypotension occurs.
Elevate the head of the bed.
If the patient had an initial lucid interval and continues to herniate despite these measures and transport to a trauma center has been delayed, obtain a head CT to identify epidural hematoma and location. A lucid interval followed by a herniation syndrome usually indicates the presence of an epidural. About 80% of the time, the epidural is located on the side of the dilated pupil. So, if a CT scan is unavailable, perform trephination on the side of the dilated pupil. (Vol II—Disab Skills 1 Skull Trephination)Consult with a neurosurgeon.

Epidural hematoma is less common in children than in teenagers or adults. The clinical picture of an epidural hematoma can be mimicked by a subdural hematoma. A subdural hematoma can possibly be decompressed through the trephination if the dura is opened. Unless the patient went through a lucid interval, trephination will probably not help. If on CT, the clot is all white, it means that it is clotted and probably will not extrude through a trephination hole, typically only 0.5 inch in diameter. If the hematoma is located in an unusual location, it is generally not feasible to perform a trephination in the ED. Skull thickness and the presence of venous sinuses in the skull can be problematic.

Cerebral edema is common in head-injured children; take care not to overdo volume resuscitation. On the other hand, hypovolemic shock is also detrimental. Do not use hypo-osmolar fluids.

Bilateral fixed and dilated pupils are ominous for brain death unless they are secondary to a reversible problem, such as hypothermia or anticholinergic poisoning. Disconjugate gaze and/or nystagmus may be associated with head injury or drug ingestion.

CNS and autonomic nervous system immaturity may mask seizure activity in small children. Any repetitive muscle motion, including eye and diaphragmatic motion, may represent seizure activity. Terminate seizure activity with diazepam (Valium) 0.3 mg/kg IV or IO or lorazepam (Ativan) 0.1 mg/kg IV. When administering these drugs rectally, do not dilute. Simply inject via the anal canal using a blunt cannula, such as a small syringe, feeding tube, or the plastic sheath of an IV needle.

A seizure in a head-injured patient is a severe complication. The injured but viable brain tissue may be permanently damaged. Avoid seizures in these patients at all costs.

Patients who are paralyzed and have a head injury are at risk for undetected seizure activity. If the patient has a probability of cerebral contusion, strongly consider seizure prophylaxis with fosphenytoin or phenytoin.

If the primary (initial) assessment is complete you can begin the secondary (focused) evaluation.

Skull Fracture/Scalp Laceration
Palpate the patient's face and jaw for abnormal step-offs and movement. It is not important to diagnose type of fracture, but Le Fort fractures are frequently mentioned in trauma manuals.

See right: 9_p_8_B

Examine the tympanic membranes for rupture or hemotympanum. Whenever basal skull fracture is possible, do not insert nasal tubes to avoid intubating the cranial vault. To avoid the cribriform plate, insert nasal tubes directly posterior over the top of the palate.

Check for loose or missing teeth that the patient may have aspirated. Look for them on the cervical spine and chest x-rays. Tongue injuries with swelling can endanger the airway. When facial trauma endangers the airway, cricothyrotomy or TTNV may be necessary. (Vol II—Air Skills 13 Cricothyrotomy, Air Skills 16 Transtracheal Needle Ventilation)

Palpate the skull. In small children, a subgaleal hematoma can result in hypovolemic shock. Battle's sign or discoloration referred to as raccoon eyes occurs after basal skull fracture, but usually after the immediate resuscitation phase. Check scalp wounds for excessive bleeding. If present, use pressure, staples, or Raney clips to stop the bleeding. These clips do not close the wound. (Vol II—Disab Skills 2 Raney Scalp Clips) Another technique is to use a large running suture along the wound edges to stop bleeding. Access to the scalp posteriorly is limited. When the patient is lifted or rolled for back inspection, there is an opportunity to address this. Of course, in-line immobilization of the head and neck is needed. Consider use of IV antibiotics.

With a gloved finger, gently explore scalp wounds to detect depressed skull fractures. If a depressed skull fracture is present, inform the trauma consultant.

Eye Trauma

Topical ophthalmologic anesthetic drops may be used in the initial evaluation and care of any painful eye injury except ruptured globe.

CNS injury, direct eye trauma, prior eye surgery or injury, as well as nasal decongestants such as phenylephrine may cause dilated or unequal pupils.

Remove contact lenses unless there is a possible globe rupture.

Globe rupture from blunt trauma is accompanied by peripheral scleral hemorrhage. If such is possible, avoid touching the eye. Cover it with a firm plastic or metal shield.

Blood in the anterior chamber of the eye is called hyphema. To prevent further bleeding into the chamber with subsequent severe corneal scarring, keep the patient still and calm. Keep the head elevated.

If the patient is awake at this time, ask him or her to count fingers as a vision check.

Lid lacerations involving the lid margins or the tear duct ultimately require repair by an ophthalmologic surgeon.

When there has been eye contamination with acidic or basic chemicals, use copious irrigation with sterile NS to prevent continuing injury. Check pH of the tears using a urine dipstick. The resulting pH should be 6 to 8. Children may tolerate a Morgan lens; if not, a nasal cannula over the bridge of the nose can drip fluid into both eyes.

Bilateral fixed and dilated pupils are ominous for brain death unless secondary to a reversible problem. Hypothermia is an example as well as anticholinergic poisoning. Disconjugate gaze and nystagmus may be associated with head injury or drug ingestion.

Retinal hemorrhage

Retinal hemorrhage is evidence of the shaken baby syndrome and should alert the team to the possibility of child abuse. Unfortunately, child abuse must be considered in almost all situations. Clues include unusual bruising, unexplained fractures, burns, and an unusual reaction to strangers and caregivers. If child abuse is suspected, remember to perform a thorough head-to-toe examination, as there may be other injuries. An ophthalmologist should be consulted to document the injuries for follow-up and for legal matters.

Soft Tissues of the Neck

Do not explore lacerations and penetrating wounds deeper than the platysma muscle in the ED. Massive hemorrhage can result. These may need to be explored in the operating room, with or without prior angiography. If the physical exam does not show evidence of severe injury, CT angiography may be sufficient. Deep lacerations of the neck can divide the trachea. The trachea can often be directly intubated in such cases.

Laryngeal fracture commonly results from a blow to the neck. A hematoma forms within the larynx, producing airway obstruction. Try gentle orotracheal intubation (if not already performed), but tracheotomy is probably needed. (Vol II—Air Skills 14 Tracheotomy)

The trachea can be displaced to the opposite side of a tension pneumothorax, or it can be displaced by a hematoma.

Carotid pulses can be absent secondary to hypotension, direct injury, and aortic injury.

If the external jugular veins can be seen, they provide valuable information regarding the volume status of the trauma patient. Jugular venous distension can indicate tension pneumothorax, cardiac tamponade, volume overload, pulmonary embolism, traumatic asphyxia (compression of the superior vena cava), and heart failure.

Cervical Spine Injury
If cervical spine injury is a possibility, take cervical spine fracture precautions with a hard collar, head blocks, and a spine board. In small children, place a pad behind the shoulders because the large posterior skull causes flexion of the neck. Clearing the c-spine involves, at a minimum, taking lateral, AP, and open mouth odontoid x-ray views of the neck. This is not practical in the typical multiple trauma case. Consequently, regardless of what the lateral c-spine x-ray shows, keep the patient immobilized in a hard collar and blocks. The reason for obtaining the lateral c-spine x-ray is that if a fracture is seen, the team is put on high alert that immobilization is a must.

Carefully review the lateral c-spine x-ray (Vol II—Xray Skills 2 Cervical Spine Xray Interpretation)for bony or ligamentous injury. Obtain a swimmer’s view if necessary to see the C7-T1 connection. Look for hematoma formation with airway displacement. Check the sphenoid sinus, if visible, for an air-fluid level signifying a basal skull fracture. In small children, the sinuses are poorly developed and very small.

When a patient who is breathing but obtunded needs intubation and the probability of cervical spine injury is high, be sure to maintain excellent c-spine control during intubation.

Spinal immobilization of children often requires a somewhat different approach than in the adult. Very young infants without evident critical injuries may be immobilized in an infant car seat with towel rolls and tape to immobilize the head. Seriously injured infants should be immobilized supine in the routine manner. Children under 8 or 9 have a prominent occiput that flexes the neck in the supine position. A pad or towel should be placed under the shoulders to maintain the head in neutral position. Color-coded cervical collars are available. When maintenance of spinal immobilization is critical in an uncooperative child, sedation with airway management may be necessary.

If not already performed, conduct a mini neuro exam. (See #2, this pathway, Abnormal LOC.)

Spinal cord injury syndromes follow:

Complete injury. Total loss of sensation and movement below the level of injury.

Level	Function	Sensory Level
C2	Breathing	Occiput
C3	Breathing	Neck
C4	Breathing	Top of shoulders
C5	Arm abduction	Anterior of arm
C6	Elbow flexion	Lateral arm and thumb
C7	Elbow extension	Posterior arm and index finger
C8	Finger flexion	Medial arm and small finger
T1	Finger abduction	Just below shoulders

9_p_8_D

Dermatomes corresponding to the levels of the spinal cord. From Emergency Management of Skeletal Injuries, Ruiz E, Cicero JJ, eds. Mosby-Yearbook, 1995. Reprinted with permission.¹⁰

Incomplete injury. This finding is extremely important because recovery may result from surgical intervention or aggressive reduction. Variable loss of sensation and movement below the level of injury indicates an incomplete injury. An example is sacral sparing with preserved anal sphincter tone. Another is the presence of an anterior cord syndrome in which there is muscle paralysis but preservation of position sense.
Brown-Sequard syndrome. Occurs with penetrating trauma with hemitransection of the cord. It results in loss of motor function below and on the same side as the lesion. This is coupled with loss of pain and temperature sensation on the opposite side of the lesion.
Cauda equina syndrome. Damage to the cauda equina as it descends through the sacrum or lumbar spine. This damage produces anesthesia in a saddle distribution of the perineum with loss of anal sphincter tone.
Central cord syndrome. Damage to the central area of the cord predominantly resulting in marked weakness of the arms relative to the legs. Test patient’s hand grip by shaking hands. Flexion-extension injuries result in ischemia and edema of the center of the spinal cord, producing this syndrome even without fracture.

Spinal cord injury without radiographic abnormality (SCIORWA) occurs in children because their soft vertebral column and lax ligaments allow considerable displacement without fracture. Spinal shock (hypotension with bradycardia) is a diagnosis of exclusion. Spinal shock responds to volume loading. Vasopressors may be added after volume loading is well under way.

Chest Wall and Pulmonary Injury
The sternum and ribs of a small child are soft and compliant. They are not easily broken, but the viscera of the chest are at risk for compression injury, even without rib fractures.

Palpate the clavicles and the chest wall again for crepitance and fracture. If there are wounds to the chest, do not explore them because a pneumothorax may result. Wounds that enter the chest should be covered with an occlusive dressing. Do not remove impaled objects because they may be providing tamponade to a pulmonary or cardiac wound. Observe for asymmetrical chest movement that may occur with pneumothorax, flail chest, and spinal cord injury with abdominal breathing.

If a needle thoracostomy has been performed during the initial survey for tension pneumothorax, insert a chest tube of appropriate size on that side now. (Vol II—Breath Skills 1 Chest Tube Insertion) Connect it to chest suction with preparations made to collect blood for possible autotransfusion. (Vol II—Breath Skills 2 Chest Suction and Autotransfusion)Chest wall crepitation means pneumothorax on that side. Insert a chest tube.

The immediate return of about 10 mL/kg of blood means that emergency surgery may be needed. The immediate return of blood that continues to come out is also ominous. If the BP falls precipitously with drainage of a large volume of blood from the chest, clamp the chest tube because the blood in the chest may have had a tamponade effect.

If a bronchus rupture has occurred, there may be a massive air leak from the chest tube with inability to inflate the lungs. If this occurs, intubate and insert the ET tube into the right or left main stem bronchus so that at least one lung can be ventilated.

Use a BVM to ventilate the patient. The ventilatory rate for a 1-year-old is about 25 breaths/min and about 15 breaths/min for an older child. The tidal volume should be 10 to 15 mL/kg. An orogastric tube also helps to prevent gastric distension and subsequent elevation of the diaphragm.

Palpate the ribs to detect rib fractures. Multiple rib fractures on the same side may result in paradoxical chest wall motion with breathing signifying a flail chest. Not all patients with flail chest need ET intubation. Monitor the patient carefully and intubate at the first sign of fatigue or hypoventilation.

Chest wall bruising or sternal tenderness—as with dashboard impact —may indicate that the aorta has been injured. Carefully review the chest x-ray for mediastinal widening or other clues such as tracheal deviation to the right and an apical cap. If thoracic aortic rupture is being considered, attempt to keep the BP at about 100 mm Hg.

If available, a helical CT scan of the chest with IV contrast is now considered to be adequate screening for this condition. However, this is technique dependent. Be certain your radiologist and CT technician understand the purpose of the scan.

Also examine chest x-ray for fractured ribs, pneumothorax, hemothorax, scapular fractures, elevated diaphragm, abnormal cardiac silhouette, lung contusion, position of ET and other tubes, and thoracic spine. With bronchial, tracheal, and esophageal injury, mediastinal air is visible. If pneumothorax is present, insert appropriate-sized chest tube; connect to chest suction.
If the patient has been tracheally intubated, listen for breath sounds carefully. If the tube is in too far, the left lung will be inadequately ventilated. Also check for this on the chest x-ray. When a patient is intubated, a follow-up x-ray is indicated to check for correct tube placement.

Pulmonary contusion worsens as the patient's hemodynamic status improves. Blood oxygen saturation decreases. Transtracheal pressures increase as the lungs become less compliant. Consider using 5 to 10 cm H₂O PEEP if pulmonary contusion is present and hypoxia develops. This may be problematic for a patient in a helicopter, so consider inserting a prophylactic chest tube so that if a pulmonary bleb ruptures, the lungs will still inflate.

Cardiac Tamponade
Muffled heart sounds associated with shock and distended neck veins (Beck's triad) may indicate cardiac tamponade. Cardiac tamponade with blunt trauma is uncommon, but does occur with atrial rupture. A majority of patients with this injury have suffered penetrating trauma.

Perform echocardiography from the subxiphoid window or along the left sternal border. (Vol II—UL2 Emergency Ultrasound Techniques)Hypovolemic shock and spinal shock are associated with a vigorously pumping heart; significant myocardial contusion is associated with a weakly pumping heart. Cardiac tamponade is associated with a ring of hypoechogenic fluid surrounding the heart. A compressed right ventricle with a weak beat may also be detected. Ultrasound is an invaluable tool in the management of trauma in many ways.

In such a case, insert a guidewire-assisted catheter device from the left subxiphoid position directed at the left scapula. (Vol II—Circ Skills 6 Pericardiocentesis) Use repeated aspirations to keep the patient stable pending surgical repair.

If this procedure is unsuccessful, consider an emergency thoracotomy if your facility has surgical backup. The blood in the pericardial sac may be clotted. Perform the thoracotomy as described in Vol II—Circ Skills 4 Emergency Thoracotomy. If the heart is beating, make a small incision into the sac creating a "window" through which the clot can extrude. A sterile suction catheter may be used to extract the clot. Use a finger to cover this window pending surgical repair.

If the heart is not beating, the sac will have to be widely opened to facilitate internal massage and staple repair of the wound. Open the sac widely by using two fingers to tear it horizontally. If possible, repair the cardiac wound using a skin stapler. Do this before restarting the heart. (Vol II—Circ Skills 4 Emergency Thoracotomy) The staples will be removed and replaced with suture in the operating room.

If myocardial contusion is possible, observe for ECG changes and evidence of heart failure. Lidocaine IV 1 mg/kg followed by an infusion at 2 mg/min may be indicated for significant ventricular arrhythmias. Amiodarone may also be used.

Because the chest wall is thin and soft in small children, penetration can occur with minimal force.

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Hypovolemic Shock
CPR is not as effective when there is hypovolemia. Volume replacement is the most important aspect of resuscitation from traumatic pulselessness. Conduct CPR while volume is restored.

If IVs have not been established and the child is younger than about 6 years, insert an intraosseous needle in the proximal tibia if other access cannot be obtained quickly. (Vol II—Circ Skills 5 Intraosseous Needle Placement) Do not use an intraosseous needle in a fractured extremity. Another choice would be the distal femur. A femoral venous line at the groin may also be used. If that is not successful, perform a saphenous vein cutdown at the ankle. (Vol II—Circ Skills 8 Saphenous Vein Cutdown) For accurate and quick administration, administer fluid boluses using a syringe and stopcock.
Small children are unable to maintain body temperature without support because of their large surface area compared to their body mass. Make every effort to keep the child warm. Hypothermia results in hypocoagulability and further bleeding.

Be aware of normal BP and pulse rate in children.

Infants have a systolic BP of 70 to 80 torr and a pulse rate of up to 160 bpm.
Toddlers have a systolic BP of 80 to 90 torr and a pulse rate of up to 140 bpm.
Older children have a systolic BP of 80 torr plus twice their age in years.

The vascular responsiveness of children potentially masks marked hypovolemia, so careful clinical monitoring is needed. By the time hypotension appears, more than 30% of blood volume has been lost, and the patient is in severe shock.

The blood volume of children is small in absolute terms, but their cardiac output is high relative to adults. This results in a small circulating blood volume reserve. The cardiac chambers are small and relatively stiff, with little reserve for increasing stroke volume. They respond to a need for increased cardiac output with an increase in heart rate. When bradycardia or extreme tachycardia (> 200 bpm) occurs, cardiac output falls dramatically.

Track vital signs and review physical examination for evidence of hypoperfusion, (prolonged capillary refill [> 3 seconds], pallor, coolness, tachycardia, depressed LOC, and decreased pulse pressure). Observe capillary refill centrally by applying pressure to the forehead or sternum. Observe the ECG monitor.

Head injuries do not cause hypotension except in infants with large subgaleal hematomas (cephalohematomas). A Broselow pediatric measuring tape can estimate weight as well as provide basic dosages of emergency drugs and abnormal vital sign guidelines. The Pediatric Emergency Drug Book, written and published by Hennepin County Medical Center in Minneapolis, MN is also an indispensable aid to drug dosing in children. This book lists drugs and dosages by body weight. Central venous access is not commonly used in children in emergency situations because volume overload is usually easier to detect and predict than in adults. Central venous access routes are similar to those used in adults. (Vol II—Circ Skills 2 Central Venous Access) However, steep Trendelenburg positioning at 30 degrees is advisable.

Warm NS is the preferred fluid during the initial resuscitation. Use a 10 to 20 mL/kg bolus administered with a 60 mL syringe and stopcock. If the patient's BP falls again or the pulse does not slow, the patient may be continuing to hemorrhage. Administer another 10 to 20 mL/kg bolus.

To avoid hemodilution, switch to blood transfusion after two 20 cc/kg boluses if patient remains in shock. Blood is usually administered as packed RBCs. While typed and crossmatched blood is preferred, type-specific blood may also be used. If blood is required immediately, type O blood is also acceptable. Use type O Rh-negative for any female with current or future childbearing potential; all others may get type O Rh-positive. Administer blood at 10 mL/kg.

Continuing hemorrhage is ominous; obtain surgical consultation as soon as possible. When blood is not available and large fluid infusions are necessary because of continuing bleeding, switch to Ringer’s lactate solution, after 40 mL/kg NS IV, to avoid hyperchloremic acidosis.

Maintenance fluids for children after normal volume is restored are as follows:

Infants < 1 year (< 10 kg)	4 mL/kg/h
Child 1 to 5 years (10 to 20 kg)	(40 mL plus 2 mL/kg)/h
Child 5 years or older (> 20 kg)	(60 mL plus 1 mL/kg)/h

Abdominal Injury
If the stomach is filled with air, blood, or food, insert a large orogastric tube and connect to suction. Children are prone to swallow air after trauma and should almost always have a gastric tube inserted and connected to low suction.

Abdominal tenderness may mean peritoneal irritation secondary to free blood from bowel injuries, splenic rupture, liver laceration or disruption, vena caval or aortic laceration, mesenteric laceration, penetrating wounds, and renal injuries. Examine for the linear bruising caused by seat belts.

Patients who are distracted by painful injuries such as pelvic or femur fractures may minimize symptoms when reporting abdominal tenderness.

Retroperitoneal organs may be injured without signs of peritoneal irritation. For example, duodenal rupture (or hematoma) and pancreatic laceration may be difficult to detect on physical examination.

Lower rib cage injuries can produce abdominal tenderness, but is a diagnosis of exclusion.

Flank wounds can involve the colon, kidneys, vena cava, and aorta. When you suspect intra-abdominal wounds, administer a broad-spectrum antibiotic such as cefotetan 25 mg/kg IV. Treat penicillin-allergic patients (those with anaphylactic reaction) with gentamicin 2.5 mg/kg IV and clindamycin 10 mg/kg IV. In most instances, CT scans (or ultrasound) have replaced peritoneal lavage in abdominal trauma. Peritoneal lavage should not be performed in the rural setting, unless immediate surgical intervention is available. The surgeon must choose between embolization of pelvic bleeding in the radiology suite and exploratory laparotomy in the operating room.

Rapid bedside ultrasound examination FAST (Focused Assessment Sonography in Trauma) performed by the clinician has become routine at many institutions. Sensitivity and specificity are variable, but identification of intraperitoneal fluid/blood greater than 700 cc and detection of pericardial tamponade are quite reliable and may guide subsequent management in selected cases. Morrison’s pouch view, subxiphoid view of the heart, and trans-vesical views are the easiest to perform.

Pelvic Fracture

As part of the initial survey, the pelvis was gently compressed in a horizontal and AP plane as part of the circulation evaluation. This is because a pelvic fracture can be a site of massive occult hemorrhage. Movement or pain with this test signifies pelvic fracture. Do not repeat this exam because it may stimulate further bleeding. Review the supine AP x-ray of the pelvis. (Vol II—Xray Skills 3 Interpretation of Pelvic X-ray) Pelvic fractures may be difficult to see, but some clue is almost always present. Any pelvic fracture must be considered dangerous. The major danger is occult hemorrhage, although children have less of a tendency for hemorrhage than adults.

Follow a protocol when evaluating pelvic trauma.

Examine for perineal lacerations, genital injury, and blood at the urinary meatus. Prepubertal children are at less risk for genital injuries.
Do not explore perineal lacerations because external hemorrhage may result.
Perform a rectal exam to detect frank blood in the rectum and to determine sphincter tone. In adolescent males, feel for the position and consistency of the prostate gland. Perform this exam before attempting to insert a Foley catheter because a boggy or high-riding prostate indicates urethral transection. Blood at the urinary meatus in males also indicates urethral injury. Blood in the rectum means rectal penetration or laceration. Begin antibiotics, such as cefotetan 25 mg/kg IV. Treat penicillin-allergic patients (those with anaphylactic reaction) with gentamicin 2.5 mg/kg IV and clindamycin 10 mg/kg IV.
Pelvic fractures, with or without instability, may be associated with massive internal hemorrhage. To provide external stabilization, you can fold a sheet to an appropriate size and wrap it tightly around the pelvis. This technique is called the Sheet Wrap Alternative. (Vol II—Trau Skills 3 Pelvic Fracture Stabilization) Commercially available pelvic stabilization devices are also available.
If the bladder is distended to palpation or ultrasound examination and a urethral disruption or injury has occurred (blood at the meatus), perform a percutaneous suprapubic cystostomy using guidewire technique. (Vol II—Trau Skills 4 Suprapubic Cystostomy) This is especially important in head-injured patients because bladder distension causes a rise in intracranial pressure (ICP). If mannitol is indicated because the patient's neuro status is deteriorating, providing bladder drainage is especially important.
Check for femoral pulses because some pelvic fractures are associated with iliac artery injury.
If there is blood at the introitus, perform a gentle digital vaginal examination feeling for laceration and bone spicules. If positive, begin antibiotics, such as cefotetan 25 mg/kg IV. Penicillin-allergic patients (those with anaphylactic reaction) may be treated with gentamicin IV 2.5 mg/kg and clindamycin IV 10 mg/kg.
Scrotal swelling and discoloration can indicate testicular injury. Obtain urologic consultation if such is found.
Hip dislocation is often associated with pelvic fracture. Look for this when reviewing the pelvis x-ray. Also, in children one often sees much of the abdomen on the pelvis film. Look for spine injury and evidence of intra-abdominal blood and air. (Vol II—Xray Skills 3 Interpretation of Pelvic Xray)

If the patient has an unstable pelvic fracture, take great care not to move the pelvis, causing more bleeding. Instead of log rolling the patient to view the back, lift the patient straight up. If the patient is large, simply slide one's hands under the patient to feel the back. Be careful of glass shards.

Major Joints, Femurs, and Amputations
Reduce major joint dislocations (such as hips, knees, and ankles) using sedation, relaxation, and traction with counter-traction. Short-acting sedatives such as ketamine or propofol work well for this purpose.

Add an opioid to propofol for pain relief. (Vol II—Air Skills 4 Rapid Sequence Intubation) Take airway precautions. Before the reduction, check for pulses and motion. Absent or decreased pulses can result from the deformity or direct trauma to arteries as well as systemic hypotension. Reduction often results in the return of pulses. Remove all jewelry from extremities prior to manipulation.

When a bone end or fragment is protruding from a wound, rinse off any gross contaminant (such as pebbles or dirt) with saline-soaked sponges; then, apply traction to reduce the fracture. Cover site with sterile dressing. Begin antibiotics, such as cefotetan 25 mg/kg IV. Treat penicillin-allergic patients (those with anaphylactic reaction) with gentamicin IV 2.5 mg/kg and clindamycin IV 10 mg/kg.

If there is a penetrating wound in proximity to a major vessel or nerve, special imaging and/or surgical exploration may be indicated, even in the presence of an apparently good pulse. Check the legs, thighs, and arms for tense swelling of the muscle compartments. Alert your surgeon about any area suspicious for a compartment syndrome. A decreased pulse is not a necessary component of the syndrome. Fasciotomy may be needed if the patient's transfer is delayed. (Vol II—Trau Skills 1 Compartment Pressure Measurement)

If life-threatening problems are ongoing, simply splint the limb in its current position, deferring reduction until the clinical situation permits. Reduce dislocated shoulders and elbows and splint when time permits. Avoid taking x-rays of the extremities for injuries that you will not have to definitively manage. If amputation has occurred and the body part is available, rinse in NS and place in a plastic bag (in case it can be implanted later or serve as a source for skin grafting). Place the bag on ice, but do not freeze.

Fractured femurs. Significant blood loss (with as much as 1500 mL) can occur into the soft tissues of the thighs. Traction splints can reduce this loss. Apply traction splints (Sager or Hare) to reduce femur fractures. The helicopter service may prefer one type of splint because of space issues. (Vol I—Trau Skills 2 Femur Fracture Splinting)

Burns

Continuing from the initial survey, perform orotracheal intubation with in-line immobilization, if not already done, for the following indications: stridor, soot in the pharynx, edema of the uvula, significant burns of the neck, and depressed LOC. If an explosion or closed space fire has occurred, be especially alert to the need to intubate. Ventilate with oxygen. Consider possible cyanide and carbon monoxide exposure if patient has been involved in closed space fire.

Completely undress the child. Be careful of smoldering clothing. Remove jewelry and contact lenses.

Using a pediatric burn chart, grossly estimate the percentage of body surface burned. In children older than 10 years, use the adult rule of nines chart.

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Immediately cool all burns with NS if <10% of TBSA is burned. (If NS is not available, use water.) If > 20% TBSA is burned, cover patient with dry gauze dressings. Patients with burns > 20% TBSA are at greater risk for developing hypothermia if wrapped in wet gauze. If < 20% TBSA is burned, keep burns moist, but cover patient with blankets to prevent hypothermia.

Start 2 IVs in unburned skin, but use burned skin sites if other sites are not available. Obtain pain relief with morphine IV. Do not administer IM. Titrate from 0.1 mg/kg to whatever dose provides relief. Ventilatory support may be needed.

Administer Ringer’s lactate (or normal saline) solution IV as a 20 mL/kg bolus to restore normal BP. Follow by another bolus if needed.

Insert a Foley catheter and monitor urine output to provide a guide to adequate fluid administration. A urine output of 1 mL/kg/h is the goal.

Monitor the child's core temperature with a rectal probe. Do not use cool saline soaks for pain relief. Use morphine instead. A dry occlusive dressing suffices. Do not apply antiseptic creams. Do not break blisters. Do not administer antibiotics. Consider tetanus status. A patient with a significant burn needs an NG tube.

The Parkland Formula for estimating fluid requirements for adults is not accurate for small burned children. The Parkland Formula for children is:

Lactated Ringer's 3 mL X weight in kg X percentage of body surface burned over the first 24 h plus maintenance.
Half is given over the first 8 hours; the second half over the following 16 hours.
Urine output is the most practical guide for ongoing fluid management.
Monitor small children closely for the development of hypoglycemia.
Circumferential third-degree burns of the extremities or the chest may produce a tough eschar that may compromise blood flow or chest wall movement. Escharotomies may be necessary. Contact a burn consultant regarding how and where to perform these escharotomies. Fortunately, these areas are anesthetic.

Send patients with the following indications to a burn center for treatment:
Burns > 10% of body surface for patients under 10 years
Burns > 20% of body surface in all age groups
Full thickness (third-degree) burns
Burns involving the hands, feet, eyes, perineum
Inhalation, electrical, or chemical burns
Burns associated with major trauma or preexisting disease

Electrical burns

The extent of damage from electrical burns may be difficult to ascertain immediately. The injury is typically to the deeper structures of the body, such as muscle and vascular (not superficial or cutaneous) tissue. Thus, the tissue is not easily observable to the naked eye on physical exam. For this reason, cardiac dysrhythmias may result from electrical burns. ECG monitoring is important. When dysrhythmias occur, see Vol I—Pathway 2 Cardiovascular Emergencies.

Another common finding is muscle necrosis resulting in myoglobinuria. Clinically, this is observed as a reddish hue to the urine. Increase the infusion of fluids to raise urine output to 1.5 mL/kg/h. If this does not rapidly clear the urine, give mannitol IV 0.25 g/kg and add 12.5 grams to each subsequent liter bag of Ringer’s solution. Many children with electrical injury have also suffered injuries from seizures and falls, including cervical spine injuries and head trauma. The whole child needs careful evaluation.

Lightning strike

Cardiac arrest with VF or asystole is the most serious effect of lightning strike. Treat any dysrhythmia as described in the Vol I—Pathway 2 Cardiovascular Emergencies. The term suspended animation has been ascribed to the recovery of lightning victims from cardiac standstill. Burns from lightning strike are often inconsequential. Wet clothing may protect the patient by causing the current to flow over the patient rather than through him or her. This is referred to as flashover phenomenon.¹¹ Under unusual conditions, an explosive or implosive effect from a lightning bolt can cause blunt injury. Initial management is as with all trauma patients.

Heat Stroke

Heat exhaustion is accompanied by weakness, faintness, and diaphoresis. Core body temperature does not reach dangerous levels. Cool liquids and rest usually suffice.

Heat stroke is accompanied by weakness, faintness, or coma and (classically) dry skin, with dangerous core temperatures of 40.5ºC (105ºF) or higher. In athletes and others well accommodated to heat, the skin may be diaphoretic.

The patient usually presents with prostration and a depressed LOC. Seizures may occur. You may need to perform orotracheal intubation to protect the airway. (Vol II—Air Skills 3 Orotracheal Intubation)

When vital signs reveal severe hyperthermia, immediately begin cooling the body to reduce core temperature before permanent CNS damage occurs. An effective method is to undress the patient and spray tepid water on the body while fans blow air over the body. The resulting evaporation lowers body temperature while not inducing shivering that is counter-productive. Ice packs may be placed in the axillae and groin. If the core temperature fails to respond, gastric and bladder irrigation with cool NS may also be used. Lower the body temperature to about 40ºC (104ºF) then remove the water and fans because the core temperature will continue to decrease.

Many complications may ensue including cerebral edema, heart failure, myonecrosis, and pulmonary edema. The patient may be severely dehydrated on arrival. Hydrate vigorously but monitor carefully so as not to overshoot the mark. Most patients will require monitoring in an intensive care unit post resuscitation.

Severe Hypothermia
Many children with hypothermia have also suffered trauma. Evaluate these patients as trauma patients.

Definition According to Core Temperature

Mild hypothermia	34ºC to 36ºC (93ºF to 96ºF)
Moderate hypothermia	30ºC to 34ºC (86ºF to 93ºF)
Severe hypothermia	< 30ºC

Mildly hypothermic patients may be rewarmed with the external application of warmth and warm fluids. Moderately hypothermic patients will require warm IV fluids and careful monitoring for possible dysrhythmias. Rectal temperature is the most practical method of measuring core temperature. Esophageal and urinary bladder probes are ineffective when gastric and bladder lavage are used as rewarming methods.

The severely hypothermic child may appear to be clinically dead. In the absence of other factors incompatible with life, aggressively attempt resuscitation until the core temperature is above 34ºC (93ºF). Asystole above this temperature should not be attributed to hypothermia and other causes should be considered. (Vol I—Acute Care Portals, Asystole)

Pronounce patient’s death if there is no response or if the history indicates a length of exposure incompatible with survival. Patients have survived total immersion in very cold water for 30 to 45 minutes and core temperatures of about 15ºC to 16ºC (60ºF). Use clinical judgment. The American Heart Association suggests that not every patient needs to be completely rewarmed before pronouncing death, but astounding cases of survival from apparent death have occurred.

Aggressive airway management is necessary to provide heated, humidified oxygenation. Cold bronchorhea occurs and demands good tracheal toilet.

Although gross movement of a hypothermic patient (such as going from an upright to a supine position) may precipitate VF, the benefit of ET intubation for oxygenation and airway protection far outweighs the risks of precipitating VF.

If the child is in VF, attempt defibrillation 1 time at 2 J/kg, but do not persist.
The natural history of VF arrest in hypothermia is as follows:
At a core temp of about 21ºC (75ºF), the rhythm spontaneously converts to atrial fibrillation with a slow ventricular response; At a core temp of about 27ºC (80ºF), the ventricular response will become faster; At a core temp of about 30ºC (86ºF), the rhythm will spontaneously convert to normal sinus rhythm.

Continue CPR until the pulse is palpable. If the child has not converted at a temp of about 32ºC (90ºF), administer appropriate cardiac medications to restore sinus rhythm. (Vol I—Pathway 2 Cardiovascular Emergencies) Cardiac medications are not effective in severely hypothermic patients and may accumulate with adverse effects when the child is warm. Hypothermic children may have abnormal electrolytes, acid/base components, and glucose. Measure these often. Hypothermic children are hypovolemic because of cold diuresis produced when the cold kidneys fail to concentrate urine. Establish large bore IVs for administering a bolus of warm NS. Cold causes a shift of the oxyhemoglobin dissociation curve to the left. Some degree of acidosis (which causes a shift to the right) is protective. A low PCO₂ can cause alkalosis; do not hyperventilate these patients.

Blood gases may be corrected for temperature or not. One line of reasoning is that the whole body is cold, not just the blood, so measuring blood gases at 37ºC (98.6ºF) is appropriate because the cold body temperature will change the body's enzyme systems and chemistries in the same way as it does the blood gases. Normal blood gases, under these circumstances, indicate that a physiologic balance of oxygen, hydrogen ions, and carbon dioxide are present in the hypothermic patient.

To rewarm severely hypothermic children, avoid using external methods before the body's central circulation is ready to supply the oxygen demands of the warmed periphery. Use internal methods if the patient's core temperature is less than 30ºC (86ºF). Expect a rate of rewarming of about 4ºC (7ºF) per hour.

Internal Rewarming Methods That May Be Used:

Heated, humidified oxygen ventilation at 40ºC (104ºF)
Warm IV fluids at 40ºC
Warm gastric lavage using tap water at 40ºC. Use a standard gastric lavage set up.
Warm urinary bladder lavage using sterile NS. Connect the Foley catheter to a standard gastric lavage set up that has been sterilized. Use a volume of about 10 to 15 mL/kg.
Closed peritoneal lavage if the patient does not have a surgical incision on the abdomen. Use NS or RL at 40ºC. (Vol II—Circ Skills 7 Rewarming Techniques)
Closed left chest lavage using a chest tube connected to chest suction (Vol II—Breath Skills 1 Chest Tube Insertion) and a large needle thoracostomy catheter inserted over the 3rd rib in the midclavicular line. (Vol II—Breath Skills 5 Needle Thoracostomy) Warm NS at 40ºC is infused into the chest through the needle thoracostomy catheter and allowed to bathe the heart and left lung before evacuation through the chest tube. You may not consider this method unless a chest tube is needed for other reasons.
Cardiopulmonary bypass is the most effective way of rewarming severely hypothermic patients. Trauma centers are prepared to do this. Patients that have solidly frozen extremities are most likely to benefit. Consult freely.

Near Drowning
Some near drowning patients are actually victims of diving accidents. Always keep the possibility of trauma in mind during the assessment of these patients.¹² Patients should be immobilized. Place C-collar if not already done. In the ED, patient evaluation and management follows the usual trauma patient protocol.

These children rarely inhale much fluid into the lungs because of laryngeal spasm and breath holding. The occurrence of hemolysis (in fresh water drowning)¹³ and hemoconcentration (in salt water drowning) is largely theoretical.

A significant admonition, however, is that these patients may develop acute pulmonary edema hours after the event. Observe near drowning patients for 24 hours.

Consider hypothermia as possibly being present. Measure rectal temperature.

If hypothermia, trauma, and significant aspiration are not present, hypoxic brain injury is probably the cause of continuing coma. (Vol I—Pathway 1 Altered Level of Consciousness)

Caustic Substance Ingestion

Caustic ingestions usually involve the intentional ingestion of drain cleaners containing concentrated alkaline powders or solutions. These strongly basic substances, usually sodium or potassium hydroxide, produce liquefaction necrosis. In powder form, they more likely result in more proximal tissue destruction and more airway compromise. In liquid form, they more likely produce most of their destruction in the distal esophagus and stomach.

The potential for airway compromise is great. If there is any question about swelling, edema or burning about the posterior pharynx, or stridor, orotracheally intubate the child. Perform RSI to ensure the gentlest intubation. (Vol I—Air Skills 4 Rapid Sequence Intubation)

If orotracheal intubation is not successful and the airway is compromised, perform emergency cricothyrotomy. In children younger than about 8 years, a tracheotomy will be necessary. (Vol II—Air Skills 13 Cricothyrotomy, Air Skills 14 Tracheotomy)Administer oxygen and establish IVs. Pain control may be needed. Support the patient’s vital signs.

Beyond airway control and general support, little can be done in the rural setting.

Gastric lavage and dilution may do more harm than good. Consult an otolaryngologist and prepare to transfer as quickly as possible. Your consultant may favor steroid therapy and antibiotics. Subsequent gastric and esophageal perforation may occur a week or two after the ingestion.

References

Miller RD, editor. Miller’s Anesthesia, 6th ed. Philadelphia, Pa: Churchill Livingstone, 2005.
Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis. Ann Emerg Med. 2007;50:653-665.
Shirley P. Cricoid pressure for emergency airway management. Emerg Med Australas. 2006;18:99.
Morris J, Cook TM. Rapid sequence intubation: a national survey of practice. Anaesthesia. 2001;56:1090-1097.
Hartsilver EL, Vanner RG. Airway obstruction with cricoid pressure. Anaesthesia. 2000;55:208-211.
Stocchetti N, Maas AIR, Chieregato A, van der Plas AA. Hyperventilation in head injury: a review. Chest. 2005;127:1812-1827.
Hurlbert RJ. Strategies of medical intervention in the management of acute spinal cord injury. Spine. 2006;31(11 suppl):S16-S21.
Sayer FT, Kronvall E, Nilsson OG. Methylprednisolone treatment in acute spinal cord injury: the myth challenged through a structured analysis of published literature. Spine J. 2006;6:335-343.
Bracken MB. Steroids for acute spinal cord injury. Cochrane Database of Systematic Reviews 2002. Issue 2. Art No: CD001046.DOI: 10.1002/14651858.CD001046.
Ruiz E, Cicero JJ, editors. Emergency Management of Skeletal Injuries. Mosby-Yearbook, 1995.
Cwinn AA, Cantrill SV. Lightning injuries. J Emerg Med. 1985; 2:379-388
Golden FS, Tipton MJ, Scott RC. Immersion, near-drowning and drowning. Br J Anaesth. 1997;79:214-225.
Noonan L, Howrey R, Ginsburg CM. Freshwater submersion injuries in children: a retrospective review of seventy-five hospitalized patients. Pediatrics. 1996;98(3 Pt1):368-371.

Pathway 9: Pediatric Trauma

(Secondary Survey for Trauma in Children)

References

Edition 13-October 2011