Airway

Initial evaluation of the airway is of utmost importance. A child who can phonate normally has a patent airway. In an unconscious patient, inspection for foreign body in the pharynx and for midface or mandibular injuries, which could compromise airway patency, should occur, as well as observation of obvious stridor or stertor with respiratory effort. Hoarseness or crepitus over the tracheal cartilage should raise concern for laryngeal fracture. After these areas have been examined, the physician should quickly move to secure an airway if necessary or move on to the assessment of ventilatory efficacy.

Readers are directed to Chapter 1 for complete information about airway evaluation and management. However, it is important to reiterate here the need for inline stabilization of the cervical spine (c-spine) during this assessment and treatment, especially if intubation is attempted. The collar should be opened or removed before direct laryngoscopy because it can impede successful visualization of the larynx. An assistant should hold the patient in the midclavicular line with the ears firmly between the lower arms to eliminate movement of the c-spine during intubation.

Breathing

Evaluation of effective ventilatory effort occurs after the airway evaluation. The chest wall excursion should be observed for symmetric chest rise. Visual inspection, including of the axillae and back, should identify open wounds. The clinicians should evaluate for symmetry and adequacy of breath sounds by auscultating the chest. Asymmetric chest rise or asymmetric breath sounds suggest the possibility of pneumothorax, hemothorax, flail chest, or an open chest wound.

Asymmetry in breath sounds may signify pneumothorax or hemothorax. This is important to note on the initial examination even when it appears clinically insignificant because a simple pneumothorax can be quickly converted to a tension pneumothorax when a patient is ventilated with positive pressure by bag–valve–mask (BVM) or endotracheal ventilation. Also, children are especially sensitive to the development of tension pneumothorax because of their relatively compliant and mobile mediastinum. Radiographs can be used to determine the presence and amount of air or blood in the pleural space. In a more clinically stable patient, a small simple pneumothorax may be treated noninvasively with inpatient monitoring, oxygen therapy, and serial chest radiography. Larger pneumothoraces or hemothoraces should be managed with chest tube drainage.

An absence of breath sounds, especially in conjunction with hypotension, should alert the clinician to possible tension pneumothorax. Tracheal deviation to the opposite side and hyperresonance of the chest to percussion may be less obvious in pediatric patients, and the more mobile mediastinum in this age group may produce vascular collapse in a more rapid fashion. Needle decompression can be immediately undertaken in such circumstances, with the introduction of a large-bore over-the-needle catheter (e.g., a 14-gauge intravenous [IV] catheter) into the second intercostal space in the midclavicular line. Needle decompression necessitates the subsequent placement of a chest tube. Massive hemothorax can present in a similar fashion, although the chest should be dull to percussion, and severe hypotension often predominates because of the significant blood loss (Figure 8-1).

Figure 8-1 Tension pneumothorax.

Open chest wounds create loss of the usual negative pressure upon inspiration that is needed to inflate the lung. If the chest wall defect is large compared with the airway, air will preferentially be brought into the defect as opposed to the airway, significantly impairing effective ventilation. An occlusive dressing should be placed over sucking chest wounds, closed on three sides, to allow for air to escape during exhalation but preventing air from entering during inspiration.

Circulation

After the respiratory assessment, hemodynamic status should be evaluated by auscultation of heart sounds; palpation of central pulses (femoral or brachial), paying attention to both the rate and quality; and rapid evaluation of skin color, capillary refill, and level of consciousness. Any obvious area of external hemorrhage should be identified and addressed with pressure dressings; whip stitching; or in the case of massive scalp wounds, stapling to control bleeding.

Complete details on hypoperfusion and shock may be found in Chapter 2. In patients who have sustained significant traumatic injuries, IV access should be secured as quickly as possible with two large-bore IV catheters placed in large peripheral veins. If peripheral access attempts are unsuccessful in a patient showing signs of shock, clinicians should proceed quickly to obtain interosseous (IO) access. IO lines should not be placed distal to any obvious fractures.

Shock in a trauma patient should be presumed to be attributable to hypovolemia secondary to hemorrhage. Because most pediatric trauma victims have sustained blunt trauma, hemorrhage may be attributable to internal injuries such as splenic or hepatic lacerations and not readily visualized. However, other causes of traumatic shock must be considered, especially in patients with shock unresponsive to fluid resuscitation or with hemodynamic collapse. Chief among these causes are tension pneumothorax, tension hemothorax, and cardiac tamponade.

Cardiac tamponade is more common with penetrating chest wounds but can be caused by rupture of the myocardium with blunt traumatic force. As with tension pneumothorax, patients with cardiac tamponade present with tachycardia, hypotension, and distended jugular veins. However, with tamponade, there is no tracheal deviation. Pulsus paradoxus, which is exaggeration of the normal decrease in blood pressure with spontaneous inspiration, may be present in association with tamponade. Rapid bedside ultrasonography can help make the diagnosis, but if unavailable or if the patient is hemodynamically unstable, pericardiocentesis can be used to diagnose and treat tamponade (Figure 8-2).

Figure 8-2 Cardiac tamponade and pericardiocentesis.

Finally, hypotension in the pediatric trauma patient can, rarely, be caused by spinal cord injury. This should be suspected in a patient with an appropriate injury mechanism who is observed to have bradycardia, or a lack of appropriate tachycardia, in the face of hypotension.

The rapid installation of IV fluids is standard first-line therapy for shock. Boluses of 20 mL/kg of 0.9% saline solution or lactated Ringer’s solution should be given rapidly. If there is no response after 40 mL/kg is administered, then blood products should be given. In a child with decompensated shock caused by trauma, O-negative packed red blood cells (PRBCs) should be pushed rapidly until type-specific or crossmatched blood is available. In patients who require massive transfusion, fresh whole blood or fresh-frozen plasma and platelets in addition to PRBCs should be considered. If shock is not rapidly reversed with transfusion therapy, identification of the source of hemorrhage must be achieved, and operative management to halt the hemorrhage must be immediately undertaken.

Disability

After the patient’s hemodynamic status has been stabilized, the neurologic status is evaluated. The symmetry, size, and briskness of pupillary response should be documented along with the level of responsiveness. Numerical scales, such as the Glasgow Coma Scale (GCS, see Figure 1-8), are used to generate structured assessments of the level of responsiveness. This allows for comparisons in mental status evaluations over time, comparisons of assessments performed by different clinicians, and improved communication among providers. The GCS has been adapted for use in preverbal patients as well. A more straightforward, although somewhat less nuanced, system for rapid neurologic evaluation is the AVPU (awake, verbal, pain, unresponsive) system. Abnormalities in the pupillary response or level of consciousness should increase concern for intracranial injuries and alert the team to prepare for possible interventions such as intubation for airway protection or to improve ventilation, mannitol, or hypertonic saline administration for increased intracranial pressure (ICP) or emergent neurosurgical intervention.

In patients who are alert and can cooperate with the examination, the patient’s strength and sensation should be assessed in all four extremities. Tenderness and deformities of the cervical, thoracic, and lumbar spine should also be assessed. In preverbal children, this assessment can be challenging. Observation of spontaneous movement, watching how the patient reaches for objects, and the patient’s response to touch or painful stimulus should be assessed. The spine should be palpated, but it is difficult to ascertain tenderness in these children.

Exposure and Environment

The final step in the primary survey is to ensure that all clothing has been removed from the patient so that all areas of the body can be visually inspected for injury. In this step, the patient’s core temperature should be evaluated with the understanding that trauma patients are often cold because of the environment and significant blood loss. Rewarming should be undertaken, as well as the prevention of heat loss now that the patient is fully exposed. Children, especially, lose a significant amount of heat through their skin because of their relatively large body surface area. The ambient temperature of the resuscitation area should be kept warm, and when inspection for injury is completed, warm blankets should be used to cover the patient to prevent heat loss.

Some sources have suggested adding “Family” as the final part of the primary survey in the care of injured children to prompt providers to remember to inform family members quickly about the child’s status and injuries as well as to consider allowing family members to be present for the resuscitation. Family presence at resuscitation has not been shown to hinder care and has been shown to increase family satisfaction. When family members are present for resuscitation efforts, a trained health care associate (nurse, social worker, or chaplain) must be assigned to be with and communicate to the family members to help them understand the efforts that are being undertaken.

Head

The initial evaluation of the head involves inspection for evidence of injury to the skull, as well as assessment of level of consciousness and neurologic status, which may indicate underlying brain injuries. Locations of all hematomas, lacerations, abrasions, depressions, and areas of tenderness should be documented. Because the middle meningeal artery runs through the temporal bone, hematomas or other signs of injury in the temporal region raise concerns for the possibility of an underlying epidural hematoma as a result of tearing of this artery. Epidural hematomas (Figure 8-3) are often described as presenting with a lucid interval followed by a rapid deterioration in mental status when the volume of blood filling the epidural space reaches the threshold to cause significant mass effect. On computed tomography (CT), epidural hematomas are seen as a convex fluid collection between the skull and brain. Significant epidural hematomas represent a neurosurgical emergency because evacuation of the growing hematoma before herniation can be lifesaving.

Figure 8-3 Epidural hematoma.