EVALUATION AND ASSESSMENT
ATLS Sequence:2–3 Outlines a standard approach to trauma patients that reduces mortality and morbidity. The evaluation and assessment are critical for appropriate triage, diagnosis, and treatment of the trauma patient.
Primary survey and resuscitation: Serves to identify life-threatening conditions and should take only a few minutes.
Assess for a pulse: if no pulse is present, initiate cardiopulmonary resuscitation (CPR).
Assess the airway: determine if blood, stomach contents, edema, foreign bodies, or facial trauma is present; the presence of a closed head injury may lead to airway instability and be signified by the presence of stridor or inability to maintain a patent airway.
Assess breathing: breathing may be impaired by neurologic process, airway obstruction, chest wall, or respiratory pathology.
Major hemorrhage: all efforts should be made to control bleeding.
Assess disability and exposure: by evaluating neurologic status using the Glasgow Coma Scale (GCS) (Table 12-1)
Assess pupil size and reactivity to help ascertain underlying neurologic injury
Patient’s clothes should be fully removed to facilitate a full exam
Remove any hazardous material
Reduce risk of hypothermia from saturated clothing; avoid hyperthermia
Inline stabilization: should be used to avoid worsening of potential cervical cord injury; cervical spine injury should be assumed; even though the incidence is rare, the consequences are devastating.
Secondary survey: goal is to identify any other injury
More thorough history and examination; the practitioner can determine which laboratory and diagnostic tests are indicated to rule out underlying injury
“Pan-scanning” of pediatric trauma patients is not recommended, but further imaging is recommended when history and physical examination indicate suspicion for injury
Glasgow Coma Scale8
|Eye Opening Response||Spontaneously||4|
|Verbal Response||Oriented to time, place, and person||5|
|Best Motor Response||Obeys commands||6|
|Moves to localized pain||5|
|Flexion withdrawal from pain||4|
|Abnormal flexion (decorticate)||3|
|Abnormal extension (decerebrate)||2|
IMAGING STUDIES (SEE TABLE 12-2)
Imaging modalities in pediatric trauma with indications for use
|Plain X-Rays||C-spine||If clinical clearance of C-spine is unable to be determined, films can be done when patient is hemodynamically stable|
|Chest, pelvic, extremity||External signs of injury over the areas concerned or physiologic signs of injury on exam|
|CT||Head||Based on risk assessment determined by mechanism of injury and age* or|
|GCS <15 or|
|Symptoms concerning for neurologic process|
|Presence of altered mental status or|
|Palpable skull fracture|
|Abdomen||ALT >125 or AST >200|
|Gross hematuria or microhematuria (>5 RBC/HPF)|
|Clinical signs/symptoms of abdominal injury|
|C-spine||If clinical clearance or neck films not able to be obtained|
|CTA||Blunt cerebrovascular injury suspected|
Guided by the primary and secondary surveys
Undertaken with a direct indication in mind in order to reduce radiation exposure and guided by the primary and secondary surveys
UNIQUE CONSIDERATIONS FOR THE PEDIATRIC PATIENT
In general, children have less fat and more elastic tissues, which make them prone to multisystem injury.
The chest walls of children are more compliant and can absorb and distribute forces more evenly then adults, leading to fewer rib fractures; however, this can also mask serious underlying injury.
The relative large size of solid organs in relationship to total body combined with minimal subcutaneous fat and thinner muscular structure make pediatric patients more prone to abdominal injury.
Hypothermia and fluid losses:
Higher risk of hypothermia due to the larger body surface area to body mass index
Greater insensible fluid losses
Children can compensate with normal blood pressures even when they lose up to 30 percent of their blood volume from hemorrhage.
NONACCIDENTAL TRAUMA (NAT):
2 to 3.5/100,000 die each year from abuse and neglect
Greatest risk is from ages 0 to 3
4,500 hospitalized per year for physical abuse
Child risk factors: younger age (<2); history of prematurity or medical conditions; history of perinatal condition; no consensus on gender or race, although black children have higher mortality
Perpetrators: history of abuse as a child, young parent, female (although male perpetrators more likely to be responsible in lethal child abuse)
Family/situational risk factors: abuse is higher during economic recession and in high poverty counties, 66 percent of families live in inner cities, 76 percent received public assistance, parents with lack of community support, decreased self-esteem, mental health or substance abuse issues, parent in foster care, unwanted pregnancy, engagement in criminal activity, less prenatal care, history of problems with adults, shorter birth intervals between children, history of separation from child in the first year of life, familial history of corporal punishment
Bruising: look for bruising not on bony prominences such as cheeks, ears, neck, genitals, buttocks, and back (and consider further imaging if you suspect fracture underlying); consider patterned bruising such as from fingers, kitchen utensils, cords, shoes; exclude Mongolian spots and hemangiomas on your exam
Burns: up to 35 percent of burns are due to abuse, so have a high index of suspicion; hands, legs, feet, and buttocks more likely to be involved in abuse; scald burns due to hot liquids are often characterized by forced immersion patterns like sharp demarcations of the burn edge with sparing of flexed areas rather than splatter burns; thermal injuries can be seen due to forced contact with a hot object like an iron, cigarette, utensils
Fractures: ribs common with forced squeezing; long bones with spiral or oblique fractures from twisting, metaphyseal chip fractures more likely accidental, any femur fracture in nonambulating child, rarely spine injury (most are younger than 2 and have multilevel trauma)
Abusive head trauma (AHT): nonspecific presentation of vomiting, poor feedings, irritability or lethargy, seizures may lead to AHT being missed; primary injuries may include skull fractures, hemorrhage, cortical contusion, diffuse axonal injury; secondary injuries include cerebral edema, infarction, infection, herniation
Ocular manifestations: periorbital hematomas, lacerations, subconjunctival hemorrhage, subluxed lens, glaucoma, papilledema; retinal hemorrhage often occurs in multiple layers and occurs in 60 to 85 percent of nonaccidental head injuries (sensitivity is 75 percent and 93 percent specific for child abuse when severe retinal hemorrhages present, 100% specific for NAT)
Evaluation for NAT7:
History of bleeding disorders in patient or family
Labs: prothrombin time (PT), activated partial thromboplastin time (aPTT), factor VIII level, factor IX level, complete blood count (CBC), D-dimer, fibrinogen; urine and stool screens for blood, trauma labs as indicated, may require further testing for coagulopathy or osteogenesis imperfecta or causes of bone fragility such as calcium and vitamin D
Skeletal survey for any child <2 years of age with any evidence of abuse, and any child <5 or unable to communicate with suspicious fracture; may consider bone scan and repeat skeletal survey in 7 to 10 days if initial survey is negative but index of suspicion is high
Intracranial imaging – computerized tomography (CT), magnetic resonance imaging (MRI), or both
Ophthalmologic exam – dilated fundoscopic exam when clinical status allows, may also see retinal hemorrhages on MRI with an orbit Susceptibility weighted imaging (SWI) protocol
Early electroencephalogram (EEG) in AHT – risk for subclinical seizures
Treatment – treatment of found injuries, victims of AHT more likely to need neurosurgical intervention than accidental head injuries, consider antiepileptic treatment
Outcome – high morbidity in children <2 years who suffered head injury for neurologic deficit (50 percent) and mortality (15 to 38 percent), reduced rates of regaining independent ambulation and expressive language in child of abuse rather than accidental injury, high rates of seizures early after AHT; this remains an issue for patients with more severe AHT who survive