Remember that most (97%) paediatric trauma is simple and involves a single system of the body. These injuries are easily dealt with calmly with a careful, well documented history, a detailed documented examination, appropriate investigations and, if necessary, referral to the appropriate surgical registrar. There can be tricky penetrating injuries such as a fall on to knitting needles with an entry point on the flank resulting in a spinal cord injury, but these are usually identified with the routine medical process described above. In the case just noted, it was the lack of passing urine and a percussible bladder that alerted the clinician to a potential spinal cord injury. The most common error in these injuries is lack of history-taking, a cursory examination, with poor and illegible documentation and poor handover.
About 3% of paediatric trauma cases are potentially more serious and involve multisystem injuries. These patients need a different structure of care. The essential ingredients are to transport such a patient quickly to a facility that can provide definitive care of the injuries. If such a patient is brought by parents to your surgery or small hospital, then management of the airway, pressure on points of obvious bleeding and arranging of transfer is all that is possible.
Ideally, such patients have an emergency call that brings emergency services to the scene, and with modern communication there is often forewarning that the child is coming to your hospital.
Upon arrival in the emergency department (ED) there is a structured and pertinent handover from the prehospital team. The first examination (primary survey) identifies and corrects immediate life-threatening injuries. Then focused tests (such as a chest or spinal X-ray) can be done and quick adjuncts to care instituted (e.g. inserting a urinary catheter or nasogastric tube) followed by a comprehensive secondary survey, which is a head to toe examination in association with a detailed history. In children, the same process is followed as in adults, but with refinements that take into account paediatric anatomy, physiology and psychology. In the moment of immediate care, if in doubt, do not hesitate because the patient is an injured child: do the same as you would for an adult. If the conscious state is such that you would intubate in an adult, then do not try to get by with a bag and mask in a child because of uncertainty: intubate. If the child is screaming and agitated, do not become so anxious that you are feeling you must intubate. Be guided by the objective signs and symptoms, as you would in an adult.
However, in your training take every opportunity to understand the refinements of paediatric trauma care. In this way you will provide optimal care for the injured child. The fluids must be calculated on a milligram per kilogram (mL/kg) basis. The endotracheal tubes have to be the correct size.
It is increasingly realized that trauma patients do not need aggressive fluid resuscitation in many instances. In fact, this can be counterproductive. The aim is to support cellular function, not to return all physiological parameters to normal. It is best to insert an intravenous line and be poised to give fluids. If there is a palpable radial pulse and the child is speaking or crying appropriately, then the heart and brain are getting sufficient oxygen, and fluids can be given judiciously. The respiratory rate is a good indicator of cellular hypoxia and metabolic acidosis (see Chapter 5.2 for age-associated normal values). Brain function is an exquisite indicator of cellular function. Even when the child is pale and has tachycardia, if he or she can have a coherent conversation then hold off excessive fluids as this can restart bleeding. Where there is continuing severe blood loss the patient is confused and breathing rapidly, often leading to confusion that the patient has a head or chest injury. It is these patients who need rapid and aggressive fluid resuscitation.
In this early phase, making decisions is more important than defining the precise diagnosis. The child should go directly to theatre if there is uncontrolled bleeding. However, this is a rare event. With faster computed tomography (CT), especially if located in the ED, a head and chest and/or abdominal scan can be performed. In children we are reluctant to perform whole-body scans routinely because of the radiation doses. Every test should be done looking for an injury that may need early treatment. CT is especially indicated for neurosurgical injuries where the precise location and extent of the injuries assists surgery.
Handover in the acute trauma situation is paramount. There needs to be clear and concise communication, both spoken and written. For this reason, the trauma team leader should be the most senior person who can also offer continuity of care. A consultant may be able to offer more expert care for a few minutes of care but then have to hand over. Frequent handover in the acute, fast-moving situation will often fail to hand over small but potentially critical pieces of information. A registrar who can be with the patient for some hours is often a better team leader, because continuity of care up to the point of deciding on the need for definitive surgical care outweighs the transient expertise of a consultant. A key contribution to care is clear, legible notes.
