Airway/Cervical Spine

Optimizing oxygenation and ventilation while protecting the cervical spine from potential further injury is of paramount importance. Initially, cervical spine injury should be suspected in any child sustaining multiple, blunt trauma. Children are at risk for such injuries because of their relatively large heads, which augment flexion-extension forces, and weak neck muscles, which predispose them to ligament injuries. To prevent additional spinal injury, the current standard is to immobilize the cervical (and thoracic and lumbar) spine in neutral position with a stiff collar, head blocks, tape or cloth placed across the forehead, torso, and thighs to restrain the child, and a rigid backboard.

Airway obstruction manifests as snoring, gurgling, hoarseness, stridor, and/or diminished breath sounds (even with apparently good respiratory effort). Children are more likely than adults to have airway obstruction because of their smaller oral and nasal cavities, proportionately larger tongues and greater amounts of tonsillar and adenoidal tissue, higher and more anterior glottic openings, and narrower larynxes and tracheas. Obstruction is common in patients with severe head injuries, owing in part to decreased muscle tone, which allows the tongue to fall posteriorly and occlude the airway. With trauma, obstruction can also result from fractures of the mandible or facial bones, secretions such as blood or vomitus, crush injuries of the larynx or trachea, or foreign body aspiration.

If it is necessary to open the airway, a jaw thrust without head tilt is recommended. This procedure minimizes cervical spine motion. In an unconscious child, an oropharyngeal airway can be inserted to prevent posterior displacement of the mandibular tissues. A semiconscious child will gag with an oropharyngeal airway but may tolerate a nasopharyngeal airway. A nasopharyngeal airway is contraindicated when there is a possibility of a cribriform plate fracture. If these maneuvers plus suctioning do not clear the airway, oral endotracheal intubation is indicated. When endotracheal intubation proves difficult, a laryngeal mask airway can be used as a temporary alternative. A laryngeal mask airway consists of a tube with an inflatable cuff that rests above the larynx and thus does not require placement of the tube into the trachea. Emergency cricothyrotomy is needed in <1% of trauma victims.

Breathing

The physician assesses breathing by counting the respiratory rate; visualizing chest wall motion for symmetry, depth, and accessory muscle use; and auscultating breath sounds in both axillae. In addition to looking for cyanosis, pulse oximetry is standard. If ventilation is inadequate, bag-valve-mask ventilation with 100% oxygen must be initiated immediately, followed by endotracheal intubation. End-expiratory carbon dioxide (CO₂) detectors help verify accurate tube placement.

Head trauma is the most common cause of respiratory insufficiency. An unconscious child with a severe head injury may have a variety of breathing abnormalities, including Cheyne-Stokes respirations, slow irregular breaths, and apnea.

Although less common than a pulmonary contusion, tension pneumothorax and massive hemothorax are immediately life-threatening (Tables 66-4 and 66-5). Tension pneumothorax occurs when air accumulates under pressure in the pleural space. The adjacent lung is compacted, the mediastinum is pushed toward the opposite hemithorax, and the heart, great vessels, and contralateral lung are compressed or kinked (Chapter 405). Both ventilation and cardiac output are impaired. Characteristic findings include cyanosis, tachypnea, retractions, asymmetric chest rise, contralateral tracheal deviation, diminished breath sounds on the ipsilateral (more than contralateral) side, and signs of shock. Needle thoracentesis, followed by thoracostomy tube insertion, is diagnostic and lifesaving. Hemothorax results from injury to the intercostal vessels, lungs, heart, or great vessels. When ventilation is adequate, fluid resuscitation should begin before evacuation, because a large amount of blood may drain through the chest tube, resulting in shock.

Table 66-5 DIFFERENTIAL DIAGNOSIS OF IMMEDIATELY LIFE-THREATENING CARDIOPULMONARY INJURIES

Circulation

The most common type of shock in trauma is hypovolemic shock due to hemorrhage. Signs of shock include tachycardia; weak pulse; delayed capillary refill; cool, mottled, pale skin; and altered mental status (Chapter 64). Early in shock, blood pressure remains normal because of compensatory increases in heart rate and peripheral vascular resistance (Table 66-6). Some individuals can lose up to 30% of blood volume before blood pressure declines. It is important to note that 25% of blood volume equals 20 mL/kg, which is only 200 mL in a 10-kg child. Losses >40% of blood volume cause severe hypotension that, if prolonged, may become irreversible. Direct pressure should be applied to control external hemorrhage. Blind clamping of bleeding vessels, which risks damaging adjacent structures, is not advisable.

Table 66-6 SYSTEMIC RESPONSES TO BLOOD LOSS IN PEDIATRIC PATIENTS

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