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PAEDIATRICS
Trauma is a leading cause of death for all children, with a
higher incidence in boys. The survival of children who sustain
major trauma depends on prehospital care and early resuscitation.
The initial assessment of the paediatric trauma patient is
identical to that for an adult. The first priorities are:
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Airway |
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Breathing |
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Circulation |
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Early
neurological assessment |
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Exposure
of the child, without losing heat. |
The
normal blood volume is proportionately greater in children
and is calculated at 80 ml/kg in a child and 85–90 ml/kg
in the neonate. Using a
height/weight chart is often the easiest method of finding the approximate weight
of a seriously-ill child.
Venous access in children who are hypovolaemic can be difficult. Useful
sites for cannulation include the long saphenous vein over the ankle, the
external jugular vein and femoral veins.
The intraosseous route can provide the quickest access to the circulation in
a shocked child in whom venous cannulation is impossible. Fluids, blood and
many drugs can be administered by this route. The intraosseous needle is normally
sited in the anterior tibial plateau, 2–3 cm below the tibial
tuberosity, thereby avoiding the epiphysial growth plate.
Once the needle has been located in the marrow cavity, fluids may need to be
administered under pressure or via a syringe when rapid replacement is required.
If purpose-designed intraosseous needles are unavailable, use a spinal, epidural
or bone marrow biopsy needle as an alternative. The intraosseous route has
been used in all age groups, but is generally most successful in children below
about six years of age.
Hypovolaemia
Recognition of hypovolaemia can be more difficult than in the adult. The increased
physiological reserves of the child may result in the vital signs being only
slightly abnormal, even when up to 25% of blood volume is lost (Class I and
II hypovolaemia).
Tachycardia is often the earliest response to hypovolaemia, but this can also be
caused by fear or pain.
Because the signs of hypovolaemia may only become apparent after 25% of
the blood volume is lost, the initial fluid challenge in a child should
represent this amount. Therefore, 20 ml/kg of crystalloid fluid should
be given initially to the child showing signs of Class II hypovolaemia
or greater. Depending on the response, this may need to be repeated up to
three times (up to 60 ml/kg).
Children who have a transient or no response to the initial fluid challenge
clearly require further crystalloid fluids and blood transfusion. 20 ml/kg
of whole blood or 10 ml/kg of packed red cells should be initially transfused
in these circumstances.
Due to the high surface-to-mass ratio in a child, heat loss occurs rapidly.
A child who is hypothermic may become refractory to treatment. It is therefore vital
to maintain the body temperature.
Acute gastric dilatation is commonly seen in the seriously ill or injured child.
Gastric decompression, usually via a nasogastric tube, is therefore an essential component
of their management.
After initial fluid resuscitation, and in the absence of a head injury, do
not withhold analgesia. A recommended regime is:
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50
microgm/kg intravenous bolus of morphine, followed by
10–20
microgm/kg increments at 10 minute intervals until an
adequate response is achieved. |
The principles in managing paediatric trauma patients are the same as for
the adult.
Specific resuscitation and intubation issues in the young
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Relatively
larger head and larger nasal airway and tongue |
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Nose
breathing in small babies |
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Angle
of the jaw is greater, larynx is higher and epiglottis
is proportionally bigger and more “U”-shaped |
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Cricoid
is the narrowest part of the larynx which limits the
size of the ETT; by adult life, the larynx has grown
and the narrowest part is at the cords |
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Trachea
in the full-term newborn is about 4 cm long and will
admit a 2.5 or 3.0 mm diameter ETT (the adult trachea
is about 12 cm long) |
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Gastric
distension is common following resuscitation, and a nasogastric tube
is useful to decompress the stomach. |
If tracheal intubation is required, avoid cuffed tubes in children less
than 10 years old so as to minimize subglottic swelling and ulceration.
Oral intubation is easier than nasal for infants and young children.
Shock in the paediatric patient
The femoral artery in the groin and the brachial artery in the antecubital fossa
are the best sites to palpate pulses in the child. If the child is pulseless,
cardiopulmonary resuscitation should be commenced.
Signs of shock in paediatric patients include:
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Tachycardia |
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Weak
or absent peripheral pulses |
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Capillary
refill >2 seconds |
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Tachypnoea |
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Agitation |
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Drowsiness |
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Poor
urine output. |
Hypotension may be a late sign, even in the presence of severe shock.
Vascular access should be obtained. Two large bore intravenous cannulae
should be inserted. Attempt peripheral veins first and avoid central
venous catheters. Good sites are the long saphenous vein at the ankle
and the femoral vein in the groin.
Hypothermia is a potentially major problem in a child.
Because of the child’s relatively large surface area
to volume ratio, they lose proportionally more heat through
the head. All fluids should be warmed. Exposure of the
child is
necessary for assessment, but consider covering as soon as possible.
The child should be kept warm and close to family, if at all possible.
Respiratory parameters and endotracheal tube size and placement
Age Weight Respiratory rate ETT ETT at ETT at
(kg) (breaths/min) size lip (cm) nose (cm)
Newborn 1.0–3.0 40–50 3.0 5.5–8.5 7–10.5
Newborn 3.5 40–50 3.5 9 11
3 months 6.0 30–50 3.5 10 12
1 year 10 20–30 4.0 11 14
2 years 12 20–30 4.5 12 15
3 years 14 20–30 4.5 13 16
4 years 16 15–25 5.0 14 17
6 years 20 15–25 5.5 15 19
8 years 24 10–20 6.0 16 20
10 years 30 10–20 6.5 17 21
12 years 38 10–20 7.0 18 22
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