After reading this chapter you should be able to assess, diagnose and manage:
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unintentional injuries including trauma and drowning
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life-threatening haemorrhage
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head and spinal injuries
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burns and scalds
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life- or limb-threatening injuries
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injuries that can be managed less urgently and their x-ray appearances
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poisoning
Unintentional injuries
Children and young people can present to the emergency department with significant and life-threatening injuries. Their emergency care and management require prompt assessment and urgent action applying a structured approach by a well-rehearsed team of experienced clinicians.
The management of all those with significant injuries begins with a primary survey of the patient and their presenting problem with resuscitation using an ABCDE approach. Obvious life-threatening injuries will need immediate action whilst airway management and circulatory compromise may need special consideration in light of any injuries. Once stabilised, the injured children must then have a secondary survey to determine less urgent consequences of the insult.
Trauma
Trauma in the form of road traffic accidents, falls and nonaccidental injury (NAI) remains the biggest cause of death in children worldwide.
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Primary survey of patient and resuscitation
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follow Airway, Breathing, Circulation, Disability, Environment steps
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address bleeding, hypovolaemia, pain control
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Secondary survey of patient
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detailed head-to-toe assessment to identify any other injuries or issues
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Primary survey
Addressing an exsanguinating haemorrhage in a child must be the first priority in trauma and early use of pressure and tranexamic acid will improve outcomes. Endotracheal intubation is required if there are signs of airway compromise but a nasopharyngeal airway should be avoided if there is basal skull trauma or facial injuries. Any assessment must assume that there is a cervical spine injury and so immobilisation is crucial until the cervical spine is assessed and known to be without injury.
Those patients who present with rib fractures, especially flail chest, have been exposed to large forces and consequently serious internal damage is likely. Some chest injuries require immediate treatment including a tension pneumothorax ( Figure 9.1 ), massive haemothorax, flail chest and cardiac tamponade.
Falling blood pressure in children indicates a decompensating shock and is a preterminal event. Consequently, obtaining venous access with high flow intravenous cannulae or intraosseous needles is a priority.
The initial assessment must consider the distress and pain evident in the patient and administer appropriate levels of analgesia. The type, dose and route of administration of any analgesia should be carefully monitored and titrated to the child’s response particularly for those with a decreased level of consciousness. Intravenous morphine, intranasal diamorphine or intranasal fentanyl are the commonly used agents.
Drowning
Drowning is the commonest cause of traumatic death in children aged between 1–4 years and survival is dependent on immersion time, on-scene resuscitation and subsequent intensive care management. In those children who are competent swimmers, a medical cause such as seizures, arrhythmias, long QT syndrome and intoxication should be suspected as a cause for the drowning. In young children it is important to consider that the episode may be caused intentionally and that actions to safeguard the child may be necessary.
Treatment and management
Active management requires the maintenance of adequate oxygenation, prevention of aspiration and the stabilisation of body temperature. Hypothermia is common and wet clothes should be removed, the child dried and, if there is no cardiovascular instability, they should be rewarmed at a rate of at 0.5°C per hour to 34°C. The administration of warmed intravenous fluids will help in raising the core temperature particularly if it is less than 35°C. Active management should also aim to maintain cerebral perfusion and oxygenation with the administration of osmotic agents (hypertonic saline or mannitol) if there are signs of raised intracranial pressure.
Investigations
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electrolytes to aid fluid assessment and management
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ECG for prolonged QT syndrome
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consider drug and alcohol screen
A two-year-old girl was unsupervised at a family party and was found floating face down in the outdoor swimming pool. The lifeguard pulled her out of the pool, called for help and started immediate basic life support. It was felt she had been missing for a maximum of three minutes. The emergency services team continued the cardiac massage, maintained adequate oxygenation and prevented aspiration. Her core temperature was 35.5 o C but had she been hypothermic she needed rewarming at a rate of at 0.5 o C per hour to 35 o C. When she arrived at the emergency department, she was spontaneously breathing with high flow oxygen attached and her cardiovascular assessment was appropriate for her age. High flow oxygen was continued and she was given warmed intravenous fluids.
This child had a short immersion time, immediate resuscitation and basic life support and was then quickly taken to an emergency department. The most important indicator of a good outcome is the response to the initial resuscitation. Drowning can occur quickly even in a few inches of water and children should therefore always be supervised by a responsible adult.
Life-threatening haemorrhage
Severe hypovolemic shock is typically caused by the disruption of intrathoracic or intraabdominal organs or vessels although significant blood loss may result from long bone or pelvic fractures.
The clinical response to volume loss includes tachycardia, weak peripheral pulse, cool mottled peripheries and prolonged capillary refill time. A further clinical deterioration will lead to lethargy and poor urine output. A fall in systolic BP may not occur until there is a 30% decrease in circulating blood volume and consequently hypotension is a late sign of hypovolaemia.
Treatment and management
The initial control of haemorrhage is crucial and any obvious external sites of haemorrhage will require direct manual pressure to control the bleeding. If internal haemorrhage is suspected, tranexamic acid (antifibrinolytic) may be used to reduce the bleeding whilst urgent surgical assessment is obtained. Those with long bone fractures may require reduction and splinting to produce haemostasis whilst those with suspected pelvic fractures will benefit from a pelvic stabilisation device. Large scalp lacerations usually respond to surgical closure using sutures, surgical staples or scalp clips.
The need for fluid resuscitation will also be identified during the primary survey and the aim will be to rapidly replace the circulating volume to the level appropriate for the age of the patient. In an acute situation, calculations of the weight of the child can either come from the carers or from a length-based resuscitation tape available in all resuscitation rooms.
Blood products including packed red blood cells, fresh frozen plasma and platelets are preferred over crystalloids although an initial use 20 ml/kg of isotonic saline followed by 10–20 ml/kg of packed red cells, 10–20 ml/kg of fresh frozen plasma and platelets ( Table 9.1 ).
| Infant | 80 ml/kg |
|---|---|
| 1–3 yrs of age | 75 ml/kg |
| over 3 yrs | 70 ml/kg |
Head and spinal injuries
Head injury
Trauma to the head is common in the paediatric population and although the majority are minor, about 5% have intracranial complications. The most common causes of severe head injury are road traffic collisions, falls from a height and, in the under 2-year age group, nonaccidental injury. Intracranial bleeds can occur at different anatomical sites leading to differences in management.
Extradural
This is usually the result of a significant blow to the head with a loss of consciousness resulting in the laceration of the middle meningeal artery. The classical history sees the patient regaining consciousness (lucid period) before deteriorating over the next few hours as arterial blood accumulates under pressure in the extradural space ( Figure 9.2 ). If left unchecked, there is coning and death, but if surgically decompressed in time, the prognosis is good.
Subdural haemorrhage
Shearing forces during trauma cause disruption of bridging veins over the sulci which then empty into the dural venous sinuses. In under 2-year-olds, the presence of subdural haemorrhage is highly suspicious of abusive head trauma.
Classification of head injury
The main measurements of severity used to classify head injury are the Glasgow Coma Score (GCS), duration of loss of consciousness (LOC) and posttraumatic amnesia (PTA) ( Table 9.2 ).
| GCS | LOC | PTA | |
|---|---|---|---|
| Mild | 13–15 | < 30 mins | < 1 hour |
| Moderate | 9–12 | 30 mins–24 hrs | 1–24 hrs |
| Severe | 3–8 | >24 hrs | >24 hrs |
Investigations
Skull x-rays are not useful in the investigation of acute trauma and they should not be requested. CT scanning is used for the assessment of the head injury, and the NICE guidelines indicate a need for such a scan within an hour of the injury in the following circumstances:
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suspicion of nonaccidental injury
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posttraumatic seizure but no history of epilepsy
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GCS less than 14
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suspected open or depressed skull fracture or tense fontanelle
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any sign of basal skull fracture
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focal neurological deficit
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laceration of more than 5 cm or bruising on the head of a child under 1 year
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further clinical deterioration
Treatment and management
A primary and secondary survey with an ABCDE approach is required although the special consideration for those with a head injury require a full assessment of the cervical spine in case of the need for intubation. Whilst such an assessment is being undertaken, the airway is maintained using a jaw thrust manoeuvre where the mandible is pushed anteriorly and the mouth opened manually. This draws the tongue forward and away from the pharynx. Nasopharyngeal airways or nasogastric tubes must be avoided if there are signs of a base of skull fracture.
The monitoring of the level of consciousness using the GCS scale and pupillary response will continue throughout the survey periods ( Table 9.3 ).
| Eye opening | Best verbal response | Best motor response | |||
|---|---|---|---|---|---|
| spontaneous | 4 | Oriented | 5 | follows commands | 6 |
| to verbal stimuli | 3 | Confused | 4 | localized pain | 5 |
| to pain | 2 | inappropriate words | 3 | withdraws to pain | 4 |
| None | 1 | incomprehensible sounds | 2 | flexion to pain | 3 |
| None | 1 | extension to pain | 2 | ||
| none | 1 |
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