Multisystem Issues







6679


MULTISYSTEM ISSUES






 


SECTION I. MULTIPLE TRAUMA


Frances Blayney and Colleene Young


Critically injured children and their families require the expertise of a multiprofessional team consisting of pediatric nurses, intensivists, and other healthcare professionals to provide optimal trauma care. Children are different from adults and they exhibit unique physiological response to polytrauma/multiple trauma compared to adults (Table 9.1). This section on multiple trauma covers knowledge of developmental considerations, mechanisms of injury, specific injuries, treatment of injuries, and prevention strategies to assist the pediatric intensive care unit (PICU) nurse in the provision of safe, effective, quality care for the injured child and family. Pediatric trauma patients may suffer severe disabilities as a result of their injuries, which may require long-term care and pose a financial burden on society.


Children are unique and require special resources. Trauma centers or healthcare systems need to be able to provide care according to their needs and develop plans to ensure those needs are met and specialized care is provided. Such care is optimally provided at pediatric hospitals that are dedicated to children and have demonstrated expertise and commitment in caring for pediatric trauma patients. It is vital that the trauma team and trauma surgeon be properly trained and specifically credentialed by the hospital to provide pediatric trauma care (American College of Surgeons [ACS], 2014). Healthcare professionals must advocate for the needs of the injured pediatric patient within the community by establishing close working relationships with other hospitals. There are different levels of pediatric trauma centers based on annual admissions with Level I centers admitting at minimum more than 200 injured children under the age of 15 each year and Level II centers admitting more than 100 injured children younger than the age of 15 each year. All Level I and II pediatric trauma centers must have systems in place to screen and identify for child maltreatment and nonaccidental trauma (NAT). Pediatric patients sustaining major trauma must be fully evaluated by the trauma team (with specialists in pediatric surgery, anesthesiology, neurosurgery, orthopedic surgery, emergency medicine, radiology, and rehabilitation) and be able to respond when needed to deliver the appropriate care as expeditiously as possible to limit the extent of the injury.


Minimum criteria for activation of pediatric trauma teams include (ACS, 2014):



  Hypotension by age criteria



  Gunshot wounds (GSWs) to the neck, chest, abdomen, or extremities proximal to the elbow or knee



  Glasgow Coma Score (GCS) of less than 9 or deteriorating by 2, with a mechanism due to the trauma



  Patients transferred from other hospitals requiring blood transfusions to maintain vital signs



  Intubated patients transferred from the scene, patients in respiratory compromise or requiring an emergent airway, or intubated patients with respiratory compromise transferred from another hospital



  Per emergency department physician’s discretion


There must be collaboration among all critical care providers and the trauma service caring for a pediatric trauma patient. All Level I and II pediatric trauma centers need to have surgeons certified or eligible for certification by the American Board of Surgery. All Level I and II pediatric trauma centers must submit data to the National Trauma Data Bank (NTDB) and all data should be benchmarked with national pediatric trauma data from such registries as the NTDB or Pediatric Trauma Quality Improvement Program (TQIP). In addition, pediatric trauma surgeons and other healthcare providers should have structured education specific to care for pediatric trauma patients. The education available includes, but is not limited to, Pediatric Advanced Life Support (PALS) from the American Heart Association (AHA); courses such as Pediatric Care After Resuscitation (PCAR) from TCAR Education Programs; Emergency Nursing Pediatric Course (ENPC) and Trauma Nursing Core Course (TNCC) from Emergency Nurses Association; courses from the American Academy of Pediatrics (AAP), the American College of Emergency Physicians, and the Advanced Trauma Life Support (ATLS) from the ACS. Pediatric trauma mortality is significantly improved in pediatric trauma centers or adult centers with pediatric trauma certification, compared to just Level I or II adult trauma centers (Daley, 2015).


668TABLE 9.1    Comparison of Adult and Pediatric Physiologic Response to Polytrauma








































Factor


Adults


Children


Timing of organ failure


48–72 hours after injury


Immediately after injury


Organ failure sequence


Sequential


Simultaneous


Acute lung injury


High risk


Low risk


Systemic inflammatory response


Robust


Dampened


Local inflammatory response


Dampened


Robust


Death due to pelvic fracture


High risk


Low risk


Morbidity


Associated with pelvic fracture


Associated with organ injuries


Neurologic injury


Low recovery rate


High recovery rate


Source: From Pandya, N. K., Upasani, V. V., & Kulkarni, V. A. (2013). The pediatric polytrauma patient: Current concepts. Journal of the American Academy of Orthopaedic Surgeons, 21(3), 170–179. doi:10.5435/JAAOS-21-03-170


EPIDEMIOLOGY AND INCIDENCE



A.    Epidemiology



1.    For all children aged 1 to 19 years, accidental injury (unintentional injury) is the leading cause of death, with motor vehicle traffic-related deaths the number one cause in that category. Other fatal childhood injuries, in order, are suffocation, firearms, and drowning/submersion (Nance, 2015). The data also indicate that firearm incidents occur 38 to 81 times more frequently than suffocation and drowning/submersion incidents, respectively. According to the Centers for Disease Control and Prevention’s (CDC) National Vital Statistics System, in 2014 suicide became the second leading cause of death in the 10 to 14 and the 15 to 24 age groups. Homicide is the third leading cause of death in the 1 to 4 and 15 to 24 age groups (CDC & National Center for Injury Prevention and Control, 2014).



2.    In the Traffic Safety Facts annual report for 2015 from the National Highway Traffic Safety Administration (2017), fatal crashes increased by 7.2% in 2015 compared with 2014, which is the largest increase in one year since 1965 to 1966. Although the percentage of alcohol-impaired driving fatalities declined over the past two decades, the rate increased in 2015. Several factors influence childhood injuries:



a.    Age and stage of development



b.    Gender



c.    Behavior



d.    Environment



3.    Developmental milestones also correlate with the mechanism of pediatric injuries.


B.    Age and Stage of Development, Gender



Children’s abilities to react and respond to others, to coordinate, anticipate, and judge the consequences of their actions are factors that change predictably as children’s physical, communicative, social, and intellectual abilities develop. The mechanism and outcomes of injury varies by age. There are very interesting statistics in the Pediatric Annual Report 2015 regarding gender. For example, females showed a higher incident rate than males in falls and motor vehicle accidents (MVAs), but lower fatality rates. Females had a higher incident of hot object/substance injuries than males and a higher fatality rate for this injury type. With firearms as the mechanism of injury, males had a fourfold incident rate, yet females had a higher firearms fatality rate (Nance, 2015).


669C.    Mechanisms of Injury



Falls are the leading cause of nonfatal injury and are most common from infancy through age 14. Children tend to fall from objects, balconies, windows, and trees. Falls occur most often in homes, followed by schoolyards and playgrounds. The next major mechanism of injury is MVAs, followed by pedestrian injury (i.e., when children are struck by motor vehicles; Table 9.2). Most pediatric injuries occur as a result of blunt trauma with penetrating trauma accounting for only a small portion. Head injuries are the most severe type of blunt trauma and are responsible for the most deaths (Nance, 2015).


D.    Environment



1.    Although they constitute a smaller percentage of injuries than does blunt force, penetrating injuries in children have increased in recent years, attributable in large part to the proliferation of handguns, increased gang violence, drug use, and the trafficking of drugs. Rgardless of age, poverty is the major factor influencing the rate of penetrating injury (Schecter, Betts, Schecter, & Victorino, 2012).



2.    In 2014, state and local child protective services received approximately 3.2 million referrals for child abuse or neglect, of which 702,000 children were determined to be victims and resulted in 1,580 pediatric deaths. Most of the deaths were children younger than 3 years of age, with the highest rates of child abuse occurring in children younger than age 1 (U.S. Department of Health & Human Services [HHS], 2016). As demonstrated in earlier reports, neglect comprised the greatest percentage of maltreatment incidents at 75%. Physical abuse was second at 17%. Important to note is that children may have suffered multiple types of maltreatment at the same time or repeatedly, but it was counted as one type.



3.    Child maltreatment resulting from blunt trauma to the head or from shaking is the leading cause of head injury among infants and young children. Boys have a higher incidence of child fatalities from maltreatment than girls (2.48 per 100,000 population of male children compared to 1.82 per 100,000 population of female children). Child sexual abuse is four times higher among females than among males with one in five girls suffering from child sexual abuse (National Center for Victims of Crime, n.d.). The victimization rate of children younger than 1 year has had the largest increase in all age groups for the past 5 years (HHS, Administration for Children & Families [ACF], Administration on Children, Youth and Families, & Children’s Bureau, 2016).



4.    For every child who dies of an injury caused by abuse, 40 others are hospitalized and 1,120 are treated in emergency departments. An estimated 50,000 children acquire permanent disabilities each year from abuse. The American Society for Positive Care of Children, State of America’s Children 2014 report, states that child abuse and neglect costs the U.S. $80 billion each year.


image



6705.    As has been shown, the statistics on unintentional injury leading to death, injuries, and disability in the pediatric population are alarming and push us to find solutions and educate our communities.


INJURY PREVENTION AND FAMILY EDUCATION



In all age groups, prevention is paramount to safety and health. When children are admitted to the ICU, nurses are primary advocates for preventive care and guidance. Using knowledge of child development as a foundation, safety education and anticipatory guidance for both parents and children can be incorporated into many nursing interventions and parent teaching (Table 9.3). Although it is difficult to approach the subject of prevention in a critical setting, the opportunity to teach families about how to prevent recurring injuries should not be lost.


MECHANISMS OF INJURY



Mechanism of injury can be described as the effect of energy on human tissue. Several mechanisms of injury are responsible for pediatric trauma, including kinetic, thermal, electrical, chemical, and radiant energy. It follows that specific injuries are classified according to the responsible mechanism. Other mechanisms include water submersion, cold exposure, asphyxia, and intentional injury (see “Child Maltreatment” section).


TABLE 9.3    Developmental Risk Factors and Education
























































































Developmental Risk Factors


Mechanisms/Types of Injury


Prevention Strategies and Parent Teaching


Infant


Learns to roll, sit, crawl, and walk


Falls (most frequent)


         Walker related


         Rolling from high surfaces


         Fall from adults’ arms


Use safety straps in


         High chair


         Stroller


         Changing table


         Swing


         Infant seat


Keep doors closed to stairs and laundry chutes


Do not open windows more than 4 inches


Cries to communicate until language develops


Homicide


Promote parenting skills and coping interventions


         Support networks


         Health promotion (balanced diet, adequate sleep)


Depends on others for needs and safety


Drowning


Burns/scalding


MVAs


Never leave child unattended in


         Bathtub, pool, water sources


         Walker


Test temperature of water before bathing


Use safety locks/gates on stairs, doors, and windows


Use ACT mnemonic: Avoid heat stroke by never leaving child in car; Create a reminder in back seat; Take action—call 911 if you see a baby left in a car


Restrain infant in an approved rear-facing infant seat in rear seat


Explores through touch, taste, feelings, and motion


Suffocation


Choking


Aspiration


Poisoning


Burns/scalding


Avoid drinking hot liquids, cooking, smoking while holding infant


Test temperature of food before feeding and water before bathing


Use flame-retardant nightwear


Crib should not have moveable side rails; lower mattress when infant can sit


Keep crib free of toys, blankets; crib should only have a firm mattress covered with a tight-fitting crib sheet


Crib corner posts should not stick up more than 1/16 of an inch


Keep small objects, inappropriate toys, and household items out of reach


Avoid latex balloons


671Position infant on back for sleep


Toddler


Explores his or her body and the world


Fall from greater heights than infants


         Windows


         Porches


         Playground equipment


Riding toys


Use safety locks/gates on stairs, doors, and windows


Lower mattress when infant can sit


Supervise playground activity


Keep doors closed and use child protective devices on doorknobs


Have child wear a helmet


Desires increased independence


Choking


Cut food into small pieces


Avoid foods such as peanuts, hard candy, and popcorn


Remind toddlers not to run with food/toys in their mouths


Lacks concept of danger


Lacks comprehension of cause–effect


Heat injuries, burns/scalds


Chemical burn injuries


Drowning


Avoid drinking hot liquids, cooking, or smoking while holding child


Test temperature of food before feeding and water before bathing


Use flame-retardant nightwear.


Never leave child unattended in bathtub, pool, water sources


Avoid latex balloons


Use electrical outlet covers


Keep appliances and cords out of reach


Avoid tablecloths


Help child avoid dangerous situations by teaching and reinforcing associated risks


Restrain toddler in an approved car seat in rear seat


Preschool Age


Desires increased independence


Learns skills by imitating others


Develops increased motor skills


Lacks well-developed sense of direction


Lacks well-developed peripheral vision


Experiences the world through egocentrism, imagination, and fantasy


Bike vs. pedestrian accidents


Falls


Provide safe riding toys


Avoid permitting child to ride on inappropriate equipment such as tractor, lawn mower, ATV


Teach street safety by informing child of stop/look/listen and the buddy system when crossing the street


Teach helmet safety


Use safety locks/gates on stairs, doors, and windows


Supervise playground activity


Keep doors closed and use child protective devices on doorknobs


Use electrical outlet covers


Keep appliances and cords out of reach


Help children avoid dangerous situations by teaching and reinforcing associated risks


General age-specific safety


Burns (fire related burns are most common; overall rare in this age)


Keep pot handles turned inward or toward back of stove


Keep matches and lighters out of reach


Teach child to stop, drop, and roll


Use three-point restraints or approved car seat in motor vehicle


672School Age


Well-developed motor skills


May lack the cognitive skills to analyze and judge situations accurately


Increasingly advanced motor skills


Learning to ride bicycle


MVAs


Falls


         Balconies


         Windows


         Playground equipment


         Trees


Head injuries


Avoid riding inappropriate equipment/toys such as lawn mower or ATV


Teach street safety by looking both ways, holding hands, and not crossing the street alone


Teach helmet safety


Supervise playground activity


Teach swimming skills and water safety


Increasing independence


Developing relationship with peers


General age-specific safety


Burns (fire-related burns are most common; overall are rare in this age)


Help children avoid dangerous situations and remind them of potential dangers


Keep pot handles turned inward


Keep matches and lighters out of reach


Teach child to stop, drop, and roll


Use three-point restraints in rear seat of motor vehicle.


Adolescent


Increased activity in sports


Able to drive motor vehicles


MVAs


Spinal cord injuries, head injuries, and long-bone fractures


Use three-point restraints in motor vehicle


Encourage adolescents not to use drugs and alcohol and never before driving a motor vehicle or getting into a car with someone who has


Encourage use of helmets with motorcycles, bicycles, skateboards, and sports activities


Desires increased independence


Drowning


Firearm injuries


Homicide/suicide


Validate peer pressure while helping adolescent live within the limits set by his or her parents


Teach swimming skills and water/boat safety


Developing relationship with peers


Participates in risk-taking behavior and succumbs easily to peer pressure


Believes injury will not happen to him or her; judgment may not be well defined

 

Teach firearm safety


         Treat firearms with respect


         Do not play with firearms


         Treat all firearms as if they are loaded


         Use gun locks if gun is in home and store ammunition in a separate place from firearm


All Age Groups


General safety

 

Teach parents and children that restraint devices are the most effective safety devices in preventing serious injury and death in MVAs (American College of Surgeons, 2003)


Use age-appropriate restraint device and position while in motor vehicle


Teach child to treat driveways and parking lots the same as streets


Firearm safety


         Keep firearms in areas secure from children


         Utilize gun locks if firearms are in home and store ammunition in a separate place from firearm


         Reinforce gun safety and not to play with guns


Teach swimming skills and water safety


Restrict exposure/teach safety related to environmental elements such as sun/cold


673Encourage use of helmet and protective gear for bike riding and appropriate sports


Maintain a safe environment

 

Increase knowledge related to age-appropriate toys/activities and playground equipment


Have smoke detectors/fire ladders and fire extinguishers in home


Practice fire and emergency evacuation plans at home at least every 6 months


Safety around animals


Animal bites


Introduce infants to pets slowly and cautiously


Teach children pet safety


Teach not to tease animals


Teach not to approach unfamiliar animals


Teach injury prevention as part of a healthy lifestyle


Healthcare professionals should help increase parents’ awareness of the community programs that can help them with injury prevention and the challenges they may face in keeping their children safe


ATV, all-terrain vehicle; MVAs, motor vehicle accidents.


A.    Kinetic Energy



Kinetic energy is the energy of motion. The equation for kinetic energy is KE = mass × velocity2/2. This means, for example, in a frontal collision, an increase in 40% of speed produces almost a 100% increase in force (Criddle, 2013; Hodnick, 2012). Kinetic energy is the force that is responsible for most traumatic injuries. Kinetic forces cause blunt, crush, shear, acceleration–deceleration, and penetrating injuries.



1.    Blunt-Force Trauma. Most pediatric injuries are due to blunt-force trauma, which results in injuries to the solid and hollow organs as well as to the long bones. It also produces crushing, shearing, or tearing of tissue both externally and internally. Some examples of blunt-force trauma are falls, MVAs, seat belt injuries, and pedestrian versus motor vehicle. Children who are hit by moving vehicles will often have multiple injuries. The patterns of injuries that occur when a child is struck by a vehicle depend primarily on two factors: the size of the child and type of vehicle involved.



2.    Crush Injury. A crush injury occurs when compressive strain (energy) is concentrated in one body area. Crush injuries include animal bites, being caught in machinery or equipment (e.g., finger caught in a car door).



a.    Patients who experience crush injuries from extreme forces (e.g., high-speed MVAs, earthquakes) are at particular risk for the development of rhabdomyolysis and myoglobinuria. Volume depletion from fluid sequestration in damaged tissues and poor fluid intake can lead to acute kidney injury (AKI).



b.    Myoglobinuria is usually associated with rhabdomyolysis or muscle destruction. The cellular release of myoglobin is often accompanied by an increase in creatinine kinase (CK). When excreted into the urine, myoglobin can precipitate tubular obstruction and AKI. Myoglobinuria causes little or no morbidity or mortality except when it is associated with the secondary complications of rhabdomyolysis, including hyperkalemia, hypocalcemia, acidosis, and AKI. In 674patients experiencing myoglobinuria, physical examination reveals generalized muscle weakness (often with painful muscle groups), trauma, or areas of ischemic pressure necrosis where the patient has lain for extended periods. Expect any patient with extensive trauma to have some degree of myoglobinuria (Devarajan, 2015).



i.    Animal bites can lead to a localized infection, cellulitis, and, in some instances, to surgical intervention. Bites vary from a small puncture wound or laceration to crushing of major arteries, veins, and nerves. Children are most likely to be involved in animal bites from cats, dogs, ferrets, and other small animals. Most bites occur at home by the family dog (Ginsburg & Hunstad, 2016).



ii.    Dog bites may result in a child being admitted to the ICU, depending on the location and severity of the bite. Dog bites are associated with a lower incidence of infection than human bites. However, cat bites or scratches have a higher risk for infection (>50%; Babovic, Cayci, & Carlsen, 2014; Ginsburg & Hunstad, 2016). Bites to the airway region may be severe and require mechanical ventilation and surgery. Underlying injuries, such as fractures, may also be present. Potential complications include infection (most common) and rabies (most serious).



iii.    Parental concerns are often focused on cosmetic implications for the future and on bleeding. The discrepancy between the potential complications and common parental concerns presents teaching opportunities for critical care nurses.



iv.    Wound care should include irrigation under pressure and cleansing of the site with benzalkonium chloride to kill rabies. A wound culture should be obtained. The nurse should anticipate radiographic studies and administration of tetanus toxoid and antibiotics (Ginsburg & Hunstad, 2016).



v.    Providing education to the family regarding prevention strategies for the future is crucial. Education should include information about how to approach dogs and other animals, when to avoid approaching them, as well as available community resources for dog-bite education (AAP, 2015).



3.    Shear Injury. Shear injury occurs when forces are applied in opposite directions (as when the brain moves within the cranium). When a shear injury is present in the absence of a significant trauma history and in combination with retinal hemorrhages, inflicted trauma, such as shaken baby syndrome (SBS), must be ruled out (see “Child Maltreatment” section).



4.    Acceleration–Deceleration Injury. Acceleration–deceleration injuries occur when a body stops suddenly and the internal organs keep moving inside the body, for example, in a high-speed MVA. The internal organs and vessels (e.g., spinal cord, hepatic artery and vein, descending thoracic aorta) rupture or tear. This type of injury can occur in a high-speed MVA when the child is thrust against the seat belt. This also applies to the brain moving within the cranial vault. This injury is historically referred to as “coup contra coup.” The brain hits an object when the forward thrust is stopped and hits the back of the skull when the backward motion is stopped.



5.    Penetrating Injury



a.    Penetrating injuries occur from firearms (the most deadly), knives, or other sharp objects.



b.    The severity of knife wounds is related to the anatomic area inflicted with the knife, the length of the blade, and the angle of penetration. An exit wound may or may not be present and the blade may be impaled. Objects and toys can become missiles that can penetrate a child’s body. A young child running with a toy in his or her mouth who subsequently falls can sustain a penetrating injury to the oropharynx. Damage to the internal organs results from kinetic force along the path of the penetrating object (Hodnick, 2012).



c.    Firearm injuries are one of the leading causes of injury deaths in the United States. The case fatality rate for children is 15.4% compared to suffocation at 27.7% and drowning/submersion at 14.6% (Nance, 2015). Injuries from low-velocity weapons are generally less destructive than from high-velocity weapons (e.g., semiautomatic weapons) because velocity plays a more important part in the kinetic energy equation (see previous discussion on kinetic energy). Injuries from firearms are related to the type of weapon, size, caliber of bullet, muzzle velocity of the projectile, number of bullets that penetrate the body, bullet trajectory, and the distance from which the firearm was discharged. Dense organs, such as the liver and muscles, or fluid-filled organs, such as the heart or gastrointestinal (GI) system, sustain greater damage than less dense organs, such as the air-filled lungs. The damage to body tissues from a bullet or missile is related 675to three processes: tearing and crushing of the tissues, cavitation, and shock waves. Cavitation is the development of a cavity along the track of the projectile as the projectile comes into contact with the relatively liquid human body. The “temporary” cavity closes as the energy dissipates, but there may be enough tissue injury from the projectile that a permanent cavity is created along the central core of the projectile tract. As the energy of the projectile increases, the size of the temporary cavity increases, causing considerable damage. This is one of the reasons that high-velocity, high-energy weapons cause so much damage. Another reason is the shock waves generated by high-velocity, high-energy weapons. In the human body, shock waves refer to a rapid change in temperature, pressure, or density secondary to the projectile (Hodnick, 2012).



6.    GSW Characteristics. GSWs to the head are less common than are GSW to the extremities and are understandably more fatal. The bullet may course through multiple routes once it is in the body. It may ricochet off bone, resulting in bony fragments. Moreover, the bullet itself may fragment. Fragments of any type will increase the size and severity of the wound. A bullet may tumble or somersault within the body, causing increased damage and greater wound severity. Penetrating forces produce entrance and often exit wounds. This is important to keep in mind when performing a primary survey.



7.    Bullet Wounding Mechanisms. Tearing and crushing of tissues occurs when the missile initially strikes. Yaw is the deviation of a bullet from a straight path. If the bullet strikes the body at an angle, the angle of yaw is increased and more damage occurs (Hodnick, 2012). Temporary cavitation occurs as a result of the bullet losing energy to the surrounding tissues as it enters the body. This cavity can exceed the size of the bullet and it is achieved within milliseconds of penetration. Cavitation is defined by bullet velocity. It is produced from the effects of combustion (muzzle blast) and is commonly seen with shotgun wounds. Internal explosion of gas and powder results in burns to the surrounding tissue.



8.    Risk for Injury. Bone, brain, liver, spleen, and fluid-filled organs (e.g., heart, GI tract) can be damaged severely by the formation of a temporary cavity because of the greater amount of energy imparted to this dense and relatively inelastic tissue. Lower density, elastic tissues (e.g., the lung) are less affected by cavitation because less energy is transferred to the tissue. Nursing implications and treatment for GSW patients and basic principles (airway, breathing, circulation [ABCs]) of trauma apply to victims of GSW.



9.    The primary survey should also include rapid assessment for the location of entry and exit wounds. The nurse should be aware that GSW to the neck could cause significant airway complications (e.g., hematoma, direct injury to the larynx). Anticipation of endotracheal intubation or emergent cricothyrotomy for GSW to the neck is prudent.



a.    It is understandable that if multiple body regions are affected, this will increase the likelihood of death. Most children who arrive at trauma centers alive but subsequently die of nonintracranial fatal firearm injuries, die quickly as the result of major vascular and thoracic injuries (Hodnick, 2012).



b.    “Damage control” for abdominal injuries is intended for severe hemorrhage uncontrolled with aggressive fluid and blood product administration. The cascade of physiologic derangements that often accompany severe hemorrhage refractory to fluid administration plays a large part in patient demise. The cascade includes a triad of acidosis, hypothermia, and coagulopathy. Damage control entails initial laparotomy with control of hemorrhage and contamination followed by an ICU course of aggressive resuscitation aimed at restoring metabolic homeostasis. After this, definitive repair of injuries and abdominal closure 12 to 48 hours after the initial laparotomy are recommended (Hughes, Burd, & Teach, 2014).



c.    Following the primary survey, intravascular access should be established and fluids administered (20 mL/kg). Accurate, precise description of the wound and surrounding landmarks should follow. If the GSW is to the child’s head, the nurse should anticipate CT scan, surgical debridement, and antibiotic therapy postoperatively if complications of infection develop. GSW to the abdomen can result in immediate peritonitis (e.g., major vascular injuries, hollow organ injuries).



d.    Several wound outcome measures should be assessed throughout the child’s ICU course, including the incision color, the surrounding tissue (degree, color, and pain intensity), and progression of exudate (type, color, and amount). The nurse should also asses the type of closure materials present: sutures (most common), staples, tissue adhesive, adhesive tapes, and laser tissue bonding (Al-Mubarak & Al-Haddab, 2013).



676e.    Vigilant pulmonary, neurologic, and peripheral vascular assessment is necessary to detect complications such as bullet embolization. If bullet embolization is suspected or confirmed, anticipate surgical debridement and anastomosis of the involved injured major vessels. Wounds that are close to major vessels warrant astute observation for hematoma formation. GSW to bones are treated as compound fractures that require surgical exploration and debridement.



f.    It is advisable to start teaching the family as close to the ICU admission as possible. Teaching should include prevention and signs and symptoms of posttraumatic stress disorder (PTSD).


B.    Exposure Injuries



1.    Thermal Injury. Thermal injury occurs when the rate of heat absorption is greater than the rate of heat dissipation and results in scalds and flame burns (see “Section IV. Burns” later in the chapter).



2.    Electrical Injury. When electricity—either through current or lightning—comes into contact with the body, its electrical energy is converted to heat. The heat causes injury. Most electrical injuries are due to low-voltage alternating current in the home setting (see “Section IV. Burns”).



3.    Chemical Injury. When a chemical is applied to the body, it causes injury by either producing heat or denaturing protein (see “Section II. Toxicology” and “Section IV. Burns”). An example of chemical injury is an abusive parent who pours bleach on a child’s skin.



4.    Radiant Burns. Exposure to the sun or to nuclear or therapeutic radiation can cause radiant burns (see “Section IV. Burns”).



5.    Heat and Cold Exposure Injuries



a.    Environmental exposure during extreme cold results in hypothermia and frostbite. Hypothermia begins when a child’s temperature is 35°C. Children are at risk for hypothermia because of their large body surface area (BSA)-to-mass ratio and because they have less subcutaneous fat for heat production. Blood loss, alcohol use, and the injuries themselves may be hypothermia-related conditions.



b.    Frostbite may accompany hypothermia and multiple trauma injuries and occurs when ice crystallizes in the body’s extracellular and intracellular fluid. Frostbite usually affects the areas most exposed (e.g., fingers, hands, feet, toes, ears, nose; Zonnoor, 2017). The severity of frostbite and resultant tissue injury depends on the absolute temperature and the duration of exposure. The wind-chill factor will also greatly affect the severity of frostbite. A review of the literature has shown novel, eccentric causes of frostbite, such as inhalant abuse (Koehler, 2014), recreational use of nitrous oxide and toluene (Koehler, 2014; Van Amsterdam, Nabben, & Van den Brink, 2015). Frostbite from these causes is related to the coldness of pressurized gas. Although a number of frostbite classifications exist, the grades for the severity of frostbite injury presented by Cauchy, Chetaille, Marchand, and Marsigny (2001) are useful in that they are descriptive and also predictive of the extent of injury and probable outcome. The grades are assigned after rewarming.



i.    Grade 1. Absence of initial lesion; no blisters. On day 2: no need for bone scanning; prognosis: no amputation, no sequelae.



ii.    Grade 2. Initial lesion on distal phalanx; clear blisters. On day 2: bone scan shows hypofixation of radiotracer uptake area; prognosis: tissue amputation; fingernail sequelae.



iii.    Grade 3. Initial lesion on intermediary and proximal phalanx; hemorrhagic blisters on digit. On day 2: bone scan shows absence of radiotracer uptake on digit; functional sequelae.



iv.    Grade 4. Initial lesion on carpal/tarsal; hemorrhagic blisters over carpal/tarsal region. Day 2: bone scan shows absence of radiotracer uptake area on the carpal/tarsal region; prognosis: bone amputation of limb with possible systemic involvement, sepsis, functional sequelae (Cauchy et al., 2001).



c.    The goal of frostbite treatment is to save as much tissue as possible to regain maximal function and to prevent complications. The focus of frostbite treatment is rapid rewarming when it is permanent (as refreezing causes more tissue injury), pain control, reperfusion, infection prevention, safe manipulation of the affected region, prevention of future reperfusion, and manipulation of body part. Combination therapy (pharmacologic and nonpharmacologic interventions) can be useful (see Chapter 1).



d.    Wash wounds with mild soap and water if they appear clean. Consider chlorhexidine gluconate if wounds appear or are suspected of being soiled. If a dressing is required, use a nonadherent dressing to provide a pain-free, nonocclusive barrier. Anticipate administering prophylactic antibiotics and tetanus toxoid. The 677draining or aspiration of clear blisters is controversial and should be a multidiscipline decision. Hemorrhagic blisters should not be drained. This type of blister implies a deeper injury and should be left intact to prevent infection and desiccation (Zonnoor, 2017).



e.    Rapid rewarming in circulating water is the definitive treatment for frostbite. The circulating water allows for a constant temperature of 37°C to 39°C to be applied to the affected areas. The temperature of the water should be closely monitored to avoid slow rewarming or overheating. Antiseptic solutions, such as povidone–iodine or chlorhexidine, may be helpful when added to the bath. Thawing of the injured area can take from 20 to 40 minutes for superficial injuries and up to an hour for deep injuries. “The most common error in this stage of treatment is premature termination of the rewarming process because of reperfusion pain” (Zonnoor, 2017). Avoid applying dry heat as the loss of temperature sensitivity in the injured area may lead to burns. Prevent mechanical friction by avoiding tissue-to-tissue contact and touching the extremity to the sides during a rewarming bath. Elevate and splint the affected extremity and apply sterile nonadherent dressings. Local wound care should be followed diligently with frequent assessment for signs of infection. Daily hydrotherapy is recommended for 30 to 40 minutes at 40°C (Zonnoor, 2017).



f.    Prolonged environmental exposure to heat may result in heat-related illnesses spanning from heat cramps, heat exhaustion/heat syncope to heat stroke. Of these, heat stroke is a true medical emergency. It is crucial to detect and treat the less dangerous heat-related illnesses before they progress to heat exhaustion and finally heat stroke. Children are at risk for heat-related emergencies because they acclimate more slowly to exercise in the heat compared with adults (exertional heat stroke; Laskowski-Jones, 2010). Other predisposing risk factors for heat stroke that may be considered unique for the pediatric population include, but are not limited to, dehydration, fatigue, sleep deprivation, fever, muscular exertion, history of seizures, sunburn, and the use of certain drugs (e.g., alcohol, amphetamines, cocaine; Bakar & Schleien, 2016). Heat illness is caused by the body’s inability to manage heat. Heat exhaustion and heat stroke occur when the body’s thermoregulatory mechanisms are no longer able to maintain a body temperature around 37°C/98.6°F. Factors that may contribute are high temperature, high humidity, and physical exertion in high temperatures making evaporative cooling less effective. Children and the elderly have physiologic limitations, especially if combined with chronic illness (Glazer, 2005).



g.    Heat exhaustion is a milder illness than heat stroke. Exercise-related heat exhaustion may occur as exercising muscles create 10 to 20 times more heat than muscles at rest. Core body temperatures with heat exhaustion are between 37°C/98.6°F and 40°C/104°F. Symptoms include nausea, vomiting, dizziness, fatigue, weakness, and headache. Treatment consists of vigorous rehydration with intravenous (IV) fluids if mental status or GI problems preclude oral intake. Children experiencing heat exhaustion should be moved to a cooler environment and measures to cool the body (e.g., ice packs to the neck or axilla, cool towels, fanning) should be used (Glazer, 2005; Laskowski-Jones, 2010).



h.    Heat stroke is an acute medical emergency caused by an extreme buildup in body heat with core body temperatures usually between 40°C/104°F and 44°C/111.2°F (Bakar & Schleien, 2016). It is life threatening with a mortality rate of around 10% despite good medical management. Shock, circulatory abnormalities, disseminated intravascular coagulation (DIC), rhabdomyolysis, arrhythmias, and seizures are prominent features. Treatment involves immediate transport to an emergency medical facility. Rapid reversal of hyperthermia is the main goal, starting before transport utilizing whatever means available (most likely evaporative cooling). After arrival at a medical facility, rapid cooling may be accomplished by immersion cooling and internal cooling procedures such as gastric, bladder, and rectal cold-water lavage. More extreme rapid cooling methods include peritoneal and/or thoracic lavage and cardiopulmonary bypass (Bakar & Schleien, 2016; Glazer, 2005). The pediatric patient with heat stroke will require close management of circulation, hydration, and intensive multisystem monitoring and support.


C.    Drowning, Submersion, and Anoxic Injury



1.    Drowning is a common and highly preventable cause of death in childhood. Children aged 1 to 4 years have the highest rate of morbidity and mortality from drowning; about one in five people 678who die from drowning are children aged 14 and younger (CDC, 2017). The definition of drowning is a process resulting in primary respiratory impairment from submersion or immersion in a liquid medium (ILCOR Advisory Statement on Drowning, 2003). The child may survive the event or not. Drowning is a type of asphyxial injury. Other examples of asphyxial injuries include inhalation, traumatic asphyxia, apnea, strangulation, suffocation, foreign-body aspiration, and adolescents playing the “choking game” or committing suicide by hanging (Byard, Austin, & Van den Heuvel, 2011; Toblin, Paulozzi, Gilchrist, & Russell, 2008). The “choking game” is either self-strangulation or strangulation by another person using his or her hands or a noose to achieve a state of euphoria, which is brief and attributed to cerebral hypoxia (Toblin et al., 2008).



2.    The three most important risk factors that contribute to drowning and near drowning are the following:



a.    Inability to swim or the overestimation of swimming capabilities



b.    Risk-taking behavior



c.    Inadequate adult supervision. Sites where childhood drownings occur may be distinguished as domestic (e.g., bathtubs, buckets), artificial pools (e.g., swimming pools, hot tubs), natural freshwater (e.g., ponds, pits), and salt water (Semple-Hess & Campwala, 2014). Most drownings occur in June, July, and August in backyard pools (Laskowski-Jones, 2010).



3.    Pathophysiology



a.    The actual process of drowning occurs when the victim’s airway is beneath the surface of the water. Voluntary breath holding occurs, which may only last for 20 seconds to maximum of around 60 seconds, at which time small amounts of water are aspirated into the airways. The presence of water in the airways triggers coughing and laryngospasm. The victim is unable to breathe, which leads to hypoxia, hypercarbia, and acidosis. The hypoxia to the brain leads to loss of consciousness (LOC) and apnea. The laryngospasm stops and the victim may aspirate larger volumes of water. The sustained hypoxia leads to cardiac deterioration and multiple organ failure (Semple-Hess & Campwala, 2014).



b.    Cardiac pathophysiologic changes associated with submersion injury are the consequence of the hypoxia and acidosis. Hypothermia may play a role depending on the temperature of the water. Dysrhythmias associated with cardiac dysfunction due to drowning generally progress from tachycardia to bradycardia to pulseless electrical activity (PEA) to asystole (Semple-Hess & Campwala, 2014). Pulmonary pathophysiologic changes are related primarily to intrapulmonary shunting from a variety of factors: bronchospasm, impaired gas exchange due to aspiration of fluids into the lungs, washout of surfactant, alveolar injury, and atelectasis (Semple-Hess & Campwala, 2014). Research has now shown that there are no clinical differences in pulmonary injury whether fresh water or salt water is aspirated. The type of fluid aspirated should also be kept in mind. Dirty stagnant water may breed infectious injury and chemical aspiration from gastric contents or cleaning solutions may lead to chemical pneumonitis (Semple-Hess & Campwala, 2014). In addition, submersion injury victims intubated and on mechanical ventilation will be at increased risk for ventilator-associated pneumonia (VAP).



4.    Hypothermia Hypothermia is often associated with submersion injuries and the severity of the hypothermia is dependent on the temperature of the water. It has been hypothesized that cold water is protective as it elicits the “dive reflex” and causes hypothermia. Both the diving reflex and the hypothermia provide protection of vital organ function by decreasing metabolic demand and reducing the damaging effects of hypoxia (Quan, Mack, & Schiff, 2014). The mammalian “dive reflex” is elicited by the face coming in contact with cold water and consists of breath holding, intense peripheral vasoconstriction with bradycardia, decreased cardiac output, and increased mean arterial pressure (MAP). However, physiologic studies have found the diving reflex to be transient and ultimately not a protection or a predictor of survival in drowning victims (Quan et al., 2014, 2016).



5.    Recovery and Outcome



a.    In a recent study performed by Quan et al. (2016), the strongest outcome predictor was submersion duration. They found that less than 5-minute submersion durations were associated with favorable outcomes. The worst outcomes were at submersion durations longer than 25 minutes. A longer than 25-minute submersion duration was statistically found to be invariably fatal. Their conclusion is that submersion duration greater than 10 minutes has a very low 679likelihood of a good outcome (Quan et al., 2016). There is no question regarding the critical role of bystander CPR in the survival of the drowning victim. Immediate CPR, as soon as it is possible and safe, will help to restore oxygenation and ventilation (AHA, 2015; Venema, Groothoff, & Bierens, 2010).



b.    Prediction of functional neurologic outcome versus death or severe disability becomes more reliable with time as the child is treated and recovery or response to therapy is observed. Neurologic examination within the first 24 to 72 hours of therapy (combined with other imaging and testing procedures) is the best indicator of neurologic outcome (Ibsen & Koch, 2002). Magnetic resonance spectroscopy rather than CT scan may be useful in the early evaluation of hypoxic–ischemic injury (Ibsen & Koch, 2002). Early EEG is complicated by the use of sedatives, analgesics, and muscle relaxants consistent with resuscitation and initial treatment. A flat or severely attenuated EEG or burst suppression record is often a poor prognostic indicator, but it is most likely reflective of the initial insult and resuscitation. Similar findings that persist in the absence of such medications are more predictive of a poor neurologic prognosis (Isben & Koch, 2002).



6.    Treatment in the ICU



a.    An important focus of treatment for a drowning victim is core rewarming. Passive and active rewarming procedures are used based on the degree of hypothermia. Passive methods would involve removing all wet garments and covering the victim with warm blankets. Active rewarming includes external and internal measures. External measures are the use of hot packs, heating lamps, or forced-air external warmers. Internal active rewarming would include warming IV fluids, warm humidified oxygen (either through face mask or endotracheal tube [ETT]), warm saline lavage of stomach, peritoneum, rectal, and even mediastinal spaces. Most aggressive and most efficient would be the use of extracorporeal circulation (ECC) or extracorporeal membrane oxygenation (ECMO) rewarming technique (Biagas & Aponte-Patel, 2016).



b.    The goal of mechanical ventilation after hypoxic-ischemic injury is to optimize ventilation and oxygenation and to maintain normocarbia (Hazinski, 2013).



c.    Fluid resuscitation and inotropic agents may be required to restore adequate tissue perfusion as a result of impaired myocardial contractility, persistent hypoxemia, hypothermia, acidosis, suboptimal intravascular volume, and electrolyte abnormalities (Caglar & Quan, 2016). Long-term morbidity and mortality after near drowning are due to hypoxic–ischemic brain injury. However, reduction of increased intracranial pressure (ICP) has not been proved an effective cerebroprotective strategy in drowning victims (Biagas & Aponte-Patel, 2016; Caglar & Quan, 2016).


HISTORY



A.    Trauma Resuscitation



Trauma resuscitation begins immediately after the injury, with first aid initiated by family or bystanders, and continues with the prehospital care providers and emergency department staff. The initial assessment and treatment must be organized and methodical to decrease trauma-related morbidity and mortality.


B.    Injury History



1.    The history surrounding the injury is obtained from family, bystanders, prehospital providers, and the patient (if possible). Pertinent historical information is obtained and relates to three important areas: mechanism of injury, patient history, and the plausibility of the mechanism of injury and patient history. The critical care nurse plays a pivotal role in assimilating details specific to the mechanism of injury and the presenting injury and complications. The following serves as a guide for the nurse and lists basic information that should be obtained relative to each mechanism of injury.



a.    Motor vehicle occupant. Scene fatalities, use of restraining devices (e.g., car seat, three-point restraints, booster seat, lap belt), front or backseat passenger, ejection from the vehicle, site of impact (e.g., side, rear end, head on), motor vehicle speed, object of collision (e.g., oncoming vehicle, stationary vehicle, or object), passenger compartment intrusion, entrapment



b.    Pedestrian versus motor vehicle crash. Speed of the vehicle, travel of the patient after the impact, being run over by or pinned under the vehicle, the type of surface on which the 680patient landed, the point of impact on the patient’s body



c.    Bicycle versus motor vehicle crash. Speed of the bicycle, speed of the vehicle (if moving), use of a bicycle helmet



d.    Fall. The height from which the patient fell, the number of steps, the surface onto which the patient landed, and the area of body that hit the ground first



e.    Penetrating injury. The type of weapon used, number of bullets fired, caliber of bullets, firing range, number, and location of stab wounds



2.    The following questions related to the injury history help elicit valuable information to anticipate ICU course and outcome.



a.    Airway. Did the child have a choking or vomiting episode? Was assistance needed to maintain the child’s airway?



b.    Breathing. Did the child stop breathing or have difficulty breathing? If so, for how long did this occur? Was rescue breathing initiated?



c.    Circulation. Was blood lost? About how much? Was cardiopulmonary resuscitation (CPR) initiated? How long was it in progress?



d.    Disability. Did the child sustain an LOC? If so, for how long? Was the child easily arousable? Does the child have antegrade (loss of memory after the injury) or retrograde (loss of memory before the injury) amnesia? Does the child recognize family members and familiar objects? Was the child able to wiggle his or her fingers and toes? Did the child appear flaccid? Did the child appear frightened, apprehensive, or anxious?



e.    Other. Was any first aid administered? Were any splints or bandages applied? Did the child get up and walk around after the injury or was the child found in the same position as immediately following the injury?



3.    Additional information may integrate the mechanisms of injury with the patient’s social history. Family and developmental history may be elicited from the following questions:



a.    Developmental plausibility. Is the mechanism of injury consistent with the injuries seen and the history related to these injuries? Does the mechanism of injury match the patient’s history? That is, if the mechanism of injury in an infant was a fall from a couch (approximately 1 foot high) onto a carpeted floor and the infant is in cardiopulmonary arrest, intentional injury must be suspected (see “Child Maltreatment” section).



b.    Credibility of witnesses. Are family members or bystanders changing their stories to match the child’s injuries? Are witnesses reluctant to divulge information? For example, the mechanism of injury in a 13-year-old child is a GSW to the chest from a drive-by shooting. It is a warm evening; all the neighbors are outside, and yet no one sees the car or driver. Such witnesses may be afraid to come forward for fear of gang retaliation.



c.    Patient’s overall appearance. How does the child appear overall? Does the child appear well nourished and clean? Is the child’s appearance developmentally appropriate? Does the child appear to be the correct size and weight for his or her age? Does the child have any bruises, scars, or other signs of child maltreatment? How is the parent–child relationship? Does the parent or caregiver comfort or scold the child for the injury? Does the parent label the child as “clumsy” or “accident prone”? Does the child go willingly to strangers or shrink from human touch? (see “Child Maltreatment” section).


C.    Patient Health History



1.    Parents may have been involved in the injury and may be receiving treatment elsewhere (e.g., for an MVA). Family members called to the hospital might not be able to provide information about the patient’s health history. Parents or legal guardians must be notified when an injury occurs; however, emergency treatment is not withheld until parental consent is obtained.



2.    The critical care nurse can use the acronym SAMPLE to guide the assessment of the basic past health history (AAP & AHA, 2016, p. 38):



a.    Signs/symptoms



b.    Allergies to medications, food, latex, and so on



c.    Medications the patient regularly receives (both over-the-counter and prescription); last dose and time of recent medications



d.    Past medical history or illness as well as special needs (e.g., hearing impairment, use of special devices)



e.    Last meal eaten



f.    Events or environment that led to the injury (obtained in injury history)


681INITIAL ASSESSMENT



The initial assessment of the multiply injured child includes the primary and secondary assessments. Children have unique anatomic and physiologic features that make them different from adults. These features should be taken into consideration when conducting the primary and secondary assessments.


A.    Primary Assessment



1.    In the primary assessment, life-threatening injuries are detected and treated. Life-threatening injuries include airway obstruction; open, tension, and bilateral hemopneumothoraces; traumatic arrest; flail chest; cardiac tamponade; and hemorrhagic shock.



2.    Life-saving interventions are initiated simultaneously with the detection of these injuries and include airway stabilization and restoration of breathing and circulation.



3.    Airway and Cervical Spine Assessment



a.    Pediatric developmental considerations (Table 9.4; see “Respiratory System” and “Neurological System” within the table)



b.    Assessment and interventions



i.    The airway is assessed for patency. The presence of loose teeth, vomit, and blood is determined and cleared if possible and safe to do so. Cervical spine injury is assessed very carefully and prehospital protocols have been developed to guide emergency medical services (EMS) in recognizing clinical evidence for a cervical spine injury or a high suspicion of injury. The automatic use of cervical spine immobilization with rigid cervical collars and straight backboard for any or all trauma patients has been a topic of much debate in the research. Studies have shown that cervical immobilization is not effective and can have harmful effects when improperly applied (Bledsoe & Carrison, 2015; E. Kim et al., 2013; Morrissey, Kusel, & Sporer, 2014; Sundstrøm, Asbjørnsen, Habiba, Sunde, & Wester, 2014). If cervical spine injury is clinically assessed or a high suspicion remains, recommendations are to secure the child to the backboard and stabilize the neck to prevent movement. Various cervical stabilization techniques are used, including leaving the infant in the car seat and the use of properly fitting collars either rigid or soft and placing on a firm/rigid backboard. Proper alignment is a challenge for the young infant and child trauma patients due to their large occiput causing flexion of the cervical spine, which can cause airway compromise or aggravation of an existing spinal cord injury. The guideline is to assess the infant or child’s occiput in relation to the board and pad the upper back to align the external auditory meatus to the shoulders (M. Crowley, 2014).



ii.    Signs and symptoms of spinal cord injury are quickly ascertained, such as numbness, tingling, and inability to wiggle the toes and fingers. If initiated, full spinal immobilization is maintained throughout the initial treatment until discontinued by a physician.


TABLE 9.4    Pediatric Developmental Considerations






















































































































































































Anatomy and Physiology


Significance


Age Anatomy Matures


RESPIRATORY SYSTEM


Oxygen consumption higher compared with adults


Lower FRC


Hypoxemia occurs more rapidly when distressed


Shorter safe apnea time


Results in ↑ respiratory rates


Smaller intrapulmonary oxygen stores


Increases with age


Small length and diameter of airways


Predisposition to obstruction, infection, and atelectasis


Resolves with age and growth


Shorter trachea


Predisposition to inadvertent extubation


Unintentional head movement may displace ETT


Resolves with age


Large head with prominent occiput, short neck, weak shoulder girdle


Cartilages of infant’s larynx and trachea are soft


Predisposition to upper airway obstruction by position alone


Makes visualization of cords difficult on laryngoscopy


Easily compressed by hyperextension or hyperflexion of the neck—obstructing airway


6822–6 years


Narrow nasal bridge; obligate nose breathers


Predisposition to nasal obstruction by foreign body, trauma, secretions, edema, or surgery


3–6 months


Large tongue


Large, floppy, U-shaped epiglottis


↑ Likelihood of airway occlusion


↑ Sensitivity to edema, trauma, and infection


↑ End expiratory pressure during respiratory failure


Up to 10 years


2 years


Weaker hyoepiglottic ligament (at base of vallecula attaches the epiglottis to base of the tongue)


Curved blades aimed at the vallecula to lift epiglottis from the airway may not work in infants and young children

 

Cricoid cartilage most narrow aspect of trachea causing funnel shape


↑ Susceptibility to trauma, edema, and infection


1 mm of edema ↑ resistance to airflow by factor of 16a, which ↑ work of breathing in infants and young children


Foreign bodies may become lodged below the cords


May provide an effective seal around ETT (uncuffed)


Varies with age and growth


Generally <10 years


About 6–8 years


Diaphragm is primary muscle of respiration


Diaphragm sits horizontally in infants


Generates large negative pressure in thorax


↑ In abdominal contents can compromise diaphragmatic movement (bleeding in trauma; swallowing air when crying)


Contraction of diaphragm draws lower ribs inward


↓ Efficiency of diaphragmatic effort in breathing


4–5 years


Varies with age and growth


Immature development of intercostal and abdominal muscles


These muscles cannot be relied upon for respiratory effort, they fatigue more easily and predispose infants and young children to atelectasis and respiratory failure


Infant compensates by ↑ respiratory rate


Transition from abdominal to costal breathing at 2–3 years, completed by 7 years


Right and left mainstem bronchi at 55 degree angles


Intubation of either mainstem bronchi equally possible


High risk of bilateral aspiration


1–2 years


Immature alveolar system causing ↓ number of alveoli and ↓ surface area for gas exchange


↓ Diffusion


↑ Shunting


8 years


Chest wall in younger children is cartilaginous


Thin chest wall


Blunt and penetrating energy forces easily transmit to underlying lung and cardiac tissue


Breath sounds easily transmitted allowing false assumption that breath sounds are equal


683About 10 years


Ribs: flexible, attach horizontally instead of bucket-handle attachment in mature rib cage


Soft, thin, more compliant chest wall


Limits ability to ↑ tidal volume with chest excursion


Less effective at protecting upper abdominal structures and lungs


About 10 years


Infant’s upper airway very reactive


Makes ETT intubation difficult


Stimulation of hypopharynx may cause vigorous gagging and laryngeal spasm

 

Faster respiratory rate and smaller tidal volumes


Greater insensible pulmonary fluid loss


If trauma in closed space ↑ RR may lead to ↑ uptake of smoke and toxic gases


More prone to fatigue and respiratory failure

 

Cardiovascular System


Low cardiac stroke volume


High cardiac rate


↑ Rate doubles cardiac output (twice that of an adult) to meet needs for ↑ metabolic rate


Little/limited ability to ↑ their stroke volume


After 6–8 years


Higher oxygen requirement and faster metabolic rate


Requires higher cardiac output per kilogram of body weight


Varies with age and growth


Circulating blood volume small (80 mL/kg) but larger mL/kg basis than adults


Children may have a blood loss of up to 25%–30% before BP changes


Small amounts of blood loss can ↓ circulating volume and ↓ perfusion


Hypotension is a late sign of circulatory compromise


Assessment of perfusion parameters is best indication of worsening perfusion

 

Cardiac output rate dependent in infants and young children


Tachycardia is initial response to hypovolemia and ↓ oxygen delivery


Tachycardia may be first and only sign of impending shock

 

Proportionately, larger volume of blood in the head


Rapid onset of cerebral edema and ↑ ICP


2–6 years


Immature adrenergic receptors


Limited response to sympathetic innervation in stress due to trauma, blood loss, surgery


About 2 years


Parasympathetic nervous system more mature at birth


↑ Sensitivity to vagal stimulation causing bradycardia


About 1 year


Greater BSA in proportion to their body weight


Higher extracellular-to-intracellular fluid volume ratio


Requires proportionally more fluid during resuscitation


Will require maintenance fluid

684 

Neurological System


Large head-to-body ratio


Weak neck muscles


Spinal facet joints horizontally oriented


Lax ligaments


With falls or ejection or struck then flown—the head will land or hit first


Predisposes children to head trauma


More head and neck movement in children—maximal movement at C1–C3 in young children; maximal movement at C5–C6b in older children


Predisposes children to neck trauma; younger children have more high-level cervical injuries, fewer fractures, more dislocations, more spinal cord injuriesc


Up to 6–8 years


Young child <12 years


Older child >12 years


Skull is soft and compliant


Less protection for brain tissue; more susceptible to injury


Bone growth in childhood


Complete ossification by early 20s


Fontanelles open


Open fontanelles and sutures may allow for ↑ ICP delaying herniation but hiding signs of tissue injury


Anterior fontanelle closes at 12–18 months


Sutures not fused (children <2 years)


Predisposes to diastatic fractures

 

Nerve myelination not complete at birth


Unmyelinated brain tissue is particularly vulnerable to injury, especially shearing forces


Visible growth up to 2 years, maturation in adolescence, adult


Physical and psychological age-related milestones


Important to know whether milestones have been reached as initial neuro assessment is performed

 

Exposure


Immature thermostatic control


Less adaptive behavioral reaction to cold stressb


Large body surface to body mass (BSA to weight)


Decreased subcutaneous fat


Inability to shunt blood away from skin when cold


↓ Ability to adjust to temperature changes


More prone to hypothermia (which can slow resuscitative measures) and frostbite


Susceptible to convective and conductive heat loss


↓ Ability to maintain temperature; T ↓36.5°C causing ↑ metabolic rate, ↑ oxygen consumption and metabolic acidosis


6 months to 1 year


Develops with maturation


Nonshivering thermogenesis


Brown fat broken down to provide warmth; ↑ oxygen consumption and leads to decompensation


After 6 months


Thinner skin


Inefficient sweating


Higher metabolic rate


Unable to care for themselves or to control their environment


Susceptible to significant burn injuries from exposure to less heat compared to adults


Easily internally bruised


Higher incidence of heatstroke—most severe form of heat-related illnesses

 

685Abdomen


Round protuberant abdomen


Immature abdominal muscles


Rib cage higher and pelvis smalld


Little protection for underlying solid and hollow abdominal organs


Solid organs in abdomen proportionately larger


Abdominal organs prone to injury


Trauma forces readily commuted to internal organs without bruising

 

Sigmoid colon and ascending colon not completely attached to peritoneal cavity


More prone to deceleration injuriese

 

Glucose


Children more prone to hypoglycemia


Monitor blood glucose frequently in burns or trauma

 

Coagulopathy


Early trauma induced coagulopathyf


Local activation of the coagulation system after trauma


Most commonly encountered complication of trauma


Independent predictor of mortality

 

Eustachian Tube


Eustachian tube is short and horizontal


More prone to infection


Begins slanting downward between 6 and 8 years


Behavior/Ability to Cooperate


Infants and young children are scared and anxious


Performing a physical exam on infants and young children is challenging due to their anxiety and fear


Important to approach with calmness, confidence, and compassion

 

BP, blood pressure; BSA, body surface area; ETT, endotracheal tube; FRC, functional residual capacity; ICP, increased intracranial pressure; RR, respiratory rate.


Sources: Adapted, modified, and updated from Crowley, C. M., & Morrow, A. I. (1980). A comprehensive approach to the child in respiratory failure. Critical Care Nursing Quarterly, 3(1), 27–44.


aKline-Tilford, A. M., Sorce, L. R., Levin, D. L., & Anas, N. G. (2013). Pulmonary disorders in nursing. In M. F. Hazinski (Ed.), Nursing care of the critically ill child (3rd ed., pp. 483–561). St. Louis, MO: Elsevier.


bHardcastle, N., Benzon, H. A., & Vavilala, M. S. (2014). Update on the 2012 guidelines for the management of pediatric traumatic brain injury—Information for the anesthesiologist. Pediatric Anesthesia, 24(7), 703–710.


cSundstrøm, T., Asbjørnsen, H., Habiba, S., Sunde, G. A., & Wester, K. (2014). Prehospital use of cervical collars in trauma patients: A critical review. Journal of Neurotrauma, 31(6), 531–540.


dEmergency Nurses Association. (2013). ENPC provider manual (4th ed.). Des Plaines, IL: Author.


eZonnoor, B. (2017). Frostbite. In D. M. Elston (Ed.), Medscape. Retrieved from emedicine.medscape.com/article/926249-overview


fMacLeod, J. B., Winkler, A. M., McCoy, C. C., Hillyer, C. D., & Shaz, B. H. (2014). Early trauma induced coagulopathy (ETIC): Prevalence across the injury spectrum. Injury, 45(5), 910–915.



6864.    Respiratory Assessment



a.    Developmental considerations (Table 9.4; see “Respiratory System” section within the table)



b.    Assessment and interventions



i.    Respirations are assessed by observation and inspection. The qualities of respirations are determined by assessing the presence of breath sounds high in the axillae and anterior chest. Unequal bilateral breath sounds may indicate a pneumothorax on the diminished side. Signs of respiratory distress include retractions of the intercostal muscles, nasal flaring, grunting (in infants), adventitious breath sounds, diminished, or absent breath sounds. Rescue breathing with 100% oxygen via bag-valve mask (BVM) is initiated in the apneic or bradypneic child.



ii.    The chest is exposed and inspected for any surface trauma, penetrating wounds, paradoxical movements, and flail segments. The rib cage is gently palpated for tenderness, crepitus, and flail segments. The sternum is palpated for tenderness as well.



5.    Circulatory Assessment



a.    Developmental considerations (Table 9.4; see “Cardiovascular System” section within the table)



b.    Assessment and interventions



i.    Circulation is assessed by auscultation of heart sounds for their rate, rhythm, and quality. If the pulse is absent or if peripheral pulses or blood pressure (BP) are nonpalpable in the presence of an electrical rhythm (PEA), chest compressions are immediately initiated. Muffled heart tones, distended neck veins (if visible), and shock may indicate cardiac tamponade, which may necessitate pericardiocentesis or open pericardiotomy. Major external hemorrhage is controlled by applying direct pressure.



ii.    Peripheral circulation is assessed by palpating the radial or brachial pulse, measuring capillary refill time (should be ≤2 seconds), assessing skin color (pink), and temperature (warm). Deviations in peripheral circulation may indicate decreased blood flow to the periphery, which can result in decreased oxygen and substrate delivery to the tissues.



6.    Neurologic Assessment



a.    Developmental considerations (Table 9.4; see “Neurologic System” section within the table)



b.    Assessment and interventions



i.    A brief neurologic evaluation establishes the patient’s LOC and pupillary size and reactivity. Responsiveness may be more difficult to evaluate in the preverbal child. Alterations in developmentally expected behaviors (e.g., lack of stranger anxiety in an 8-month-old infant, decreased muscle tone in a 2-month-old infant or inability to focus and follow objects in a 6-month-old infant), may indicate changes in neurologic functioning. Changes in the child’s LOC may indicate decreased oxygenation (pulmonary exchange) or perfusion (hypovolemia), not necessarily brain injury.



ii.    Throughout the primary assessment, the nurse talks to the child to determine his or her LOC and to provide emotional support. The AVPU method of evaluation determines the child’s response to stimulation (Emergency Nurses Association, 2013):



  Awake



  Responsive to verbal stimuli



  Responsive to painful stimuli



  Unresponsive



iii.    The infant should respond by looking around and being wary of strangers. The verbal child should be able to state his or her name and perhaps other information. The child who changes from awake to sleepy to disoriented should be watched closely. The Pediatric Glasgow Coma Score (PGCS) should be obtained to record the best eye, motor, and verbal responses (see “Clinical Assessment of Neurologic Function” in Chapter 4 for information on the GCS).



7.    Exposure



a.    Developmental considerations (Table 9.4; see “Exposure” section within the table)



b.    Assessment and interventions. The child is completely undressed to allow inspection of all injuries. Overhead warming lights and warm ambient temperature should help maintain body temperature within a normal range. Warm blankets should be applied to respect modesty, prevent convective heat loss, and promote comfort.


B.    Secondary Assessment



A complete head-to-toe assessment is conducted to detect and treat all non–life-threatening injuries.



1.    The head is examined for depressions, lacerations, hematomas, and impaled objects. The anterior and 687posterior fontanelles in infants are palpated. A tense and bulging fontanelle may indicate increased ICP. The scalp is palpated for lacerations and observed for dirt, glass, and other debris.



2.    The face is inspected for deformities, lacerations, foreign bodies, and impaled objects. The orbits, facial bones, and mandible are palpated for pain and crepitus. Asymmetric facial movement is observed, which may indicate facial nerve paralysis. Classic LeFort (facial) fractures, although rare in children, should be suspected in any blunt force or penetrating facial trauma. Malocclusion is indicative of a fractured mandible. An example of a combined traumatic finding to the head or face would be a child with a self-inflicted GSW to the mandible who has a palate impaled with a tongue piercing.



3.    The eyes are assessed for pupillary reactivity, symmetry, and extraocular movements. Blood in the anterior chamber of the eye (hyphemia) should be reported immediately because this finding indicates a serious injury. Foreign bodies should be noted, and penetrating objects should be stabilized in place with gauze and tape. A ruptured globe is possible if the eye is swollen shut and bruised and a penetrating or direct blunt force was applied during the injury. The presence of tearing should be noted as well. Visual acuity may be easily assessed by asking the young child to point to an object or by having an older child verbalize his or her ability to see. The presence of contact lenses should be ascertained, and the contact lenses removed. Periorbital bruising or “raccoon’s sign” is indicative of a basilar skull fracture. Scleral hemorrhage may be observed if compression forces were applied at the time of injury.



4.    The ears are examined for cerebrospinal fluid or bloody drainage. Such drainage can be collected onto a gauze pad; however, the ear is never packed with gauze. Hematotympanum should be noted. Ecchymosis over the mastoid process or “Battle’s sign” is indicative of a basilar skull fracture. When ecchymosis over the mastoid process is noted, the skull fracture is more than 12 hours old. Ear lacerations should be covered with gauze soaked in normal saline (NS) until definitive repair is scheduled.



5.    The nose is examined for cerebrospinal fluid or bloody drainage, deformities, lacerations, or bruising. Drainage can be collected onto a gauze pad, but the nares are not packed with gauze.



6.    The oral cavity, including the tongue, mucous membranes, and teeth, is examined for injury. Displaced permanent teeth can be placed in milk or NS and dated. Debris should not be removed from the tooth because this material aids in reimplantation. Dental apparatus, such as braces, may have been damaged during the injury and should be assessed by a pediatric dentist or orthodontist.



7.    The neck examination involves opening the front piece of the cervical collar for inspection of the anterior neck. The neck is assessed for lacerations, swelling, deformities, jugular vein distention, and impaled objects. The neck is palpated for pain, tenderness, and subcutaneous emphysema. Tracheal positioning is noted. Normal position is midline. The larynx is palpated for integrity. A fractured larynx is easier to palpate than visualize. The awake child’s voice is assessed for hoarseness or changes. A hoarse or “gravelly” voice may also indicate tracheal trauma and the possible need for airway intervention. After the neck is assessed, the collar is secured.



8.    The chest is reinspected for symmetry, flail segments, open wounds, and impaled objects. The anterior chest is examined for cutaneous lesions that might indicate underlying pulmonary or cardiac injury. The chest is auscultated for the presence of normal and adventitious breath sounds. The anterior rib cage and both clavicles are palpated for pain and tenderness. Pain with inspiration should be noted. The heart sounds are auscultated and should be clear and distinct. The point of maximal impulse (PMI) should be noted.



9.    The abdomen is observed for distention, bruising, penetrating wounds, and impaled objects. Bowel sounds should be auscultated. The abdomen is then palpated for pain, rigidity, and tenderness. The lower abdomen is palpated for bladder tenderness and distention.



10.  The pelvis is palpated for tenderness and intactness. Any pain or displacement on palpation is indicative of a pelvic fracture. Femoral pulses are assessed for equality and strength. The bladder is palpated for distention. The genitalia, urinary meatus, perineum, and rectum are inspected for signs of trauma, bleeding, and impaled objects. Blood at the urinary meatus may indicate a urethral tear. The prostate gland is difficult to palpate in the preadolescent boy. A flaccid rectal sphincter is indicative of spinal cord injury. The rectal examination may be deferred in cases of severe rectal trauma when an examination under anesthesia (EUA) or surgical intervention is needed or when a foreign body is lodged in the rectal vault. Priapism may be noted. Anal examinations specific to abuse are difficult to interpret due to a number of variables: (a) the size of the object introduced, (b) the presence of force, (c) use of lubricants, (d) degree of cooperation 688from the victim, (e) the number of episodes of penetration, (f) the time since the last contact (Herrmann, Banaschak, Csorba, Navratil, & Dettmeyer, 2014).



11.  The extremities are inspected for any deformities, open wounds or fractures, contusions, and impaled objects. Each extremity is palpated for pain and peripheral pulses are assessed for equality and amplitude. Skin color and temperature are reassessed as well as is capillary refill time. The responses given when asking the child to wiggle his or her toes and fingers and asking whether he or she can feel the nurse touching the toes and fingers indicate neurovascular and neuromotor integrity. Hand grasps and foot flexion and extension determine strength and motor nerve functioning.



12.  The back examination involves carefully log rolling the child to inspect the back. To log roll the child, one person is assigned to keep the child’s head midline and to execute the move. Additional staff members are needed to roll the child onto his or her side at the surgeon’s command. Another person examines the back for any deformities, lacerations, hematomas, impaled objects, or abrasions on the posterior surface and flank. Each vertebra is palpated for stability and the presence of pain. After this examination, the surgeon gives the command to roll the child to the supine position, maintaining in-line cervical stabilization the entire time. The child’s motor and neurovascular statuses are assessed immediately before and after the log rolling to assess the presence of spinal cord injury.



13.  Vital signs and pulse oximetry readings are measured continuously and recorded every 5 minutes until the child is stable and then every 15 minutes for the first hour of treatment. Temperature is measured frequently to evaluate the effectiveness of warming measures and to detect and treat hypothermia. The child’s vital signs should be compared with age-appropriate norms for heart rate, respiratory rate, and BP. Immediately after the injury, however, the child’s physiologic requirements may not fall within age-appropriate ranges. Therefore, these parameters should serve as a guide only.


C.    Trauma Scoring



1.    After the primary and secondary assessments are completed in the field or emergency department (ED), a trauma score (TS) and a PGCS score are assigned. TS determinations are integral to the appropriate triage to pediatric trauma centers. TS systems are intended to be simple and based on rapidly obtainable clinical findings. TSs utilized are easy to calculate as well as sensitive enough to include pediatric patients who require a higher level of expertise and care (Brazelton & Gosain, 2016).



2.    Validated triage scoring systems for pediatric trauma include the PGCS, TS, Revised Trauma Score (RTS), and the Pediatric Trauma Score (PTS). The PTS, utilized at many pediatric emergency departments, assesses six parameters important in the outcome of pediatric trauma: size, airway, blood pressure, central nervous system (CNS), fractures, and wounds (Denke, 2013). This scoring system has been validated as a reliable predictor of injury severity as well as an indicator for triage to an appropriate pediatric trauma center. The TS assesses respiratory rate and effort, BP, and capillary refill. It also includes the GCS score. The RTS comprises the GCS score (see Chapter 4), BP, and respiratory rate. Ideally, TSs are calculated during three phases: in the prehospital setting, on arrival to the ED, and 1 hour later.


INITIAL TREATMENT



A.    Airway and Cervical Spine



1.    In the unconscious child, the airway initially is opened and maintained using the jaw-thrust maneuver. This maneuver is the safest technique for opening the airway in the child with a suspected cervical spine injury (AAP & AHA, 2016). The head-tilt/chin-lift method is not used in pediatric trauma patients because this method may convert a cervical spine fracture without neurologic injury into a cervical spine fracture with neurologic injury. Because the child’s oral cavity is relatively small, the upper airway is easily obstructed by the lax oropharyngeal musculature in the unconscious child.



2.    Foreign material (e.g., teeth, vomit, or blood), is cleared from the oral cavity with a tonsillar tip (Yankauer) suction tube. Stimulation of an intact gag reflex must be avoided as gagging, vomiting, and aspiration may result. Blind finger sweeps are not recommended for foreign-body removal in infants and young children because foreign material may be displaced distally and injury to the friable oral mucosa may result.



3.    An oropharyngeal airway may be placed in unconscious children to maintain airway patency. Oral airway size must be appropriate because an artificial airway that is too small may push the tongue backward. One that is too large may damage 689the delicate, soft intraoral tissues causing bleeding and swelling and further complicating airway management. The oropharyngeal airway is measured from the corner of the mouth to the angle of the jaw (AAP & AHA, 2016). This type of airway is inserted directly using a tongue blade to pull the tongue forward. This airway is not rotated 90 degrees as in the adult because damage may occur to the oral tissues. Furthermore, the tongue may be displaced posteriorly into the pharynx, causing an airway obstruction.



4.    Nasopharyngeal airways are not recommended in pediatric trauma patients. In the child with a head injury, a basilar or cribriform plate fracture may be present. During insertion of a nasopharyngeal airway, entry into the cranial vault may occur.



5.    These basic airway maneuvers are acceptable for short-term airway control. Endotracheal intubation is preferred for extended periods. The equipment is prepared and cardiorespiratory and pulse oximetry monitors are used. The child’s vital signs are closely monitored for cardiac dysrhythmias, lower oxygen saturation, or bradycardia. During endotracheal intubation, neutral cervical spine alignment is maintained by the surgeon or another skilled practitioner to avoid hyperextension. Endotracheal intubation is best accomplished by rapid sequence technique by a skilled practitioner.



6.    A combination of medications is often used during rapid sequence intubation to prevent increased ICP and to produce adequate states of sedation, analgesia, and paralysis (Stewart, Bhananker, & Ramaiah, 2014). Succinylcholine and rocuronium both have a short onset of action. Succinylcholine is used when a fast-acting and short duration paralytic agent is required. For example, in head trauma patients for whom the neurological exam is essential or in a trauma patient who has recently eaten and has a full stomach. Due to its nondepolarizing effects, succinylcholine must be used cautiously in trauma patients with long-bone fractures as fasciculation may occur and in patients with known or suspected hyperkalemia. Routine use of atropine as a premedication for intubation in nonneonates is controversial, especially if used to prevent dysrhythmias. There are also no studies that validate the use of a minimum dose of atropine (AAP & AHA, 2016). The sedatives, anesthetic, and neuromuscular blocking agents (NMBA) used are based on the condition and stability of the patient and the treating physician’s discretion. For a normotensive patient, midazolam, etomidate, propofol, or thiopental may be used. Propofol has been reported to have a high potential for morbidity when used as an infusion in children, causing the “propofol infusion syndrome” (PIS; Loh & Nair, 2013). Etomidate is a short-acting sedative-hypnotic that is commonly used in rapid sequence intubation. Etomidate is known to blunt the normal stress-induced increase in adrenal cortisol production. It is for this reason that the cautious use of etomidate in septic or debilitated patients is warranted (see Chapter 2).



7.    An uncuffed ETT is used in children 8 years of age and younger because the cricoid cartilage serves as an effective seal. The orotracheal route is preferred. The ETT is secured with tape and benzoin or with commercially prepared devices. An orogastric tube may be inserted after intubation to decompress the stomach. The gastric tube is measured from the corner of the mouth, over the ear to the xiphoid process, and marked with tape. Once the tube is properly placed, it is secured with tape. A chest radiograph is taken to confirm the ETT placement and depth, as well as the presence of the orogastric tube in the stomach. Indicators of correct airway placement include symmetric chest movement, equal bilateral breath sounds auscultated in all fields and absent over stomach, end-tidal carbon dioxide (EtCO2) detection and condensation in the ETT. Endotracheal suctioning may be required if copious secretions or oral trauma are present.



8.    The most common complication of endotracheal intubation is inadvertent intubation of the right mainstem bronchus or dislodgment of the ETT into the right mainstem bronchus if the patient is positioned for procedures or transported within the facility. When this situation arises, chest expansion may not be equal and breath sounds are absent or diminished in the left side of the chest. Pulse oximetry readings may be low and ventilation may be difficult. Prompt recognition of this complication is essential. It is corrected by withdrawing the ETT until equal breath sounds and equal chest movement are observed. Documentation of ETT placement measurement at the nose or lip is valuable.



9.    In children in whom airway patency and control are not possible because of extensive craniofacial injuries, an emergency tracheostomy or cricothyrotomy may be required.



10.  Spinal precautions are maintained during emergency treatment. Spinal precautions include the application of a rigid cervical collar, cervical immobilization device (CID) and an immobilization board. If the child vomits, the child is log rolled as a unit with the equipment remaining intact after which 690suctioning is performed. Anteroposterior, lateral, oblique, and odontoid cervical spine radiographs from C1 through T1 may be obtained to determine the presence of spinal fractures. When obtaining the lateral views, the child’s arms are pulled downward by a surgeon or a nurse to allow for radiographic visualization of T1. The radiographs are assessed for vertebral symmetry, alignment, and spacing. If the child does not have radiographic evidence of bony spinal abnormalities and the child has normal neurologic findings and no pain on palpation, the spinal immobilization devices may be removed. Normal neurologic findings include absence of pain with full range of cervical motion. This is often difficult to assess in the presence of distracting injuries or head trauma. An MRI may be needed to evaluate the spine further.


B.    Breathing



1.    High-flow oxygen through a nonrebreather face mask at a flow rate of 10 to 15 L/min is administered. The face mask fits properly if it is snug and covers the nose and mouth. If the child will not tolerate a face mask and oxygen saturation levels are maintained at 98% to 99%, the oxygen can be administered in a blow-by fashion.



2.    If apnea or shallow breathing occurs, ineffective respirations are present. In such cases, artificial ventilation is initiated with a BVM and 100% high-flow oxygen. If breathing is spontaneous, but effective respirations are not achieved, endotracheal intubation is performed. The chest should rise and fall symmetrically when the bag is squeezed. If the chest does not rise, the face mask and head should be carefully repositioned while maintaining spinal precautions. The BVM device should have a bag capacity of at least 450 mL, be self-refilling, and come in pediatric and adult sizes. The pop-off valve should be occluded to allow for the need for higher ventilation pressures.



3.    A pulse oximeter detects the percentage of oxygen saturation in the blood and is a useful adjunct for determining adequacy of oxygenation.



4.    Mechanical ventilation is initiated once proper endotracheal placement and adequate ventilation are achieved. The initial settings include an age-appropriate rate, 100% oxygen and a low positive end-expiratory pressure (PEEP). The ventilator settings are adjusted according to the child’s response to treatment.



5.    Life-threatening thoracic injuries include tension hemothoraces, pneumothoraces, and pericardial tamponade. All these conditions are rare but must be anticipated. Pneumothoraces are initially treated with rapid needle decompression followed by chest tube placement. Pericardial tamponade is treated with a pericardiocentesis or a pericardial window in the operating room.


C.    Circulation



1.    Cardiorespiratory and blood pressure monitors are employed immediately after the child’s arrival at the hospital. The appropriate cuff size should be two thirds the size of the child’s upper arm or thigh.



2.    IV cannulation with the largest catheter diameter possible is attempted in the upper, preferably uninjured extremity. Intraosseous (IO) access should be considered if IV access cannot be achieved in a reasonable amount of time. If IO access is unsuccessful, central venous cannulation or cut down should be attempted by an experienced physician or surgeon in the antecubital space or via the saphenous system. During IV cannulation, blood is obtained and sent for the following tests, depending on the location of injury. In suspected abdominal trauma, the following are assessed: hemoglobin, hematocrit, and platelet count; electrolytes and glucose; blood urea nitrogen (BUN) and creatinine; amylase, lipase, aspartate aminotransferase (AST), and alanine aminotransferase (ALT). Creatinine phosphokinase (CPK) is assessed for a child with suspected cardiac trauma. Type and crossmatch or type and screen are required if operative management is anticipated or blood will be administered. Blood toxicology screening is done for patients with suspected drug or alcohol use. The IV crystalloid fluid of choice is lactated Ringers (LR) solution, which is administered at a maintenance rate in the absence of hypovolemic shock. The fluid is warmed if rapid infusion is administered. A stopcock can be connected to the tubing if fluid boluses are anticipated. Overhydrating is avoided in children with significant head injury to prevent cerebral edema.



3.    In the tachycardic or hypotensive child, a 20 mL/kg fluid bolus of crystalloid is administered. If no improvement in heart rate or blood pressure is observed, a second bolus is administered. More than two boluses of fluid may be required. If no response is apparent, a 10-mL/kg bolus of warm, O-negative blood may be administered rapidly.



4.    External hemorrhaging is controlled with direct pressure to the wound. Elevation of a bleeding extremity in conjunction with direct pressure may help to slow the bleeding process. Tourniquet and hemostat applications are controversial and are not used.



6915.    The application of a pneumatic antishock garment (PASG) has limited value in the pediatric population. Its use in children is generally limited to inflation of a leg compartment for splinting of a femur fracture.



6.    Traumatic arrest (empty heart syndrome) is treated with CPR and rapid infusion of warmed crystalloid and blood products. Thoracotomy and open cardiac massage are rarely performed for blunt trauma and are usually a last-chance effort to resuscitate the child. Prognosis is poor.


D.    Disability and Neurologic Checks



1.    Frequent neurologic checks are performed to observe for changes in LOC, motor, and sensory function. The PGCS score is helpful to document serial neurologic assessments. Changes in the child’s LOC may indicate hypovolemia or increased ICP. Vomiting and irritability are early signs of increased ICP. In infants, a bulging fontanelle or an increased head circumference is a late sign of increased ICP.



2.    Normoventilation with 100% oxygen is initiated in the child with a severe head injury to keep the PaCO2 between 35 and 45 mmHg. Hyperventilation is initiated to achieve a PaCO2 of approximately 30 mmHg if signs of a lesion (e.g., epidural) or rapid decompensation are present. A PaCO2 less than 28 mmHg may contribute to brain ischemia.



3.    Procedures and treatments are explained to the child at a level he or she can understand. Words of praise and comfort go far to help reassure the frightened, injured child.


E.    Exposure



1.    Passive and active warming measures are initiated to prevent conductive and convective heat loss. Passive warming measures include warm blankets and increased ambient room temperature. Active warming measures include the administration of normothermic IV fluids and blood products to help with core warming.



2.    Temperature measurements are obtained via the oral, rectal, or tympanic routes. Temperature probes on ETTs, esophageal probes, or urinary bladder thermistors are other options for temperature measurement.


F.    Gastrointestinal and Genitourinary Systems



1.    An orogastric or nasogastric tube (NGT; if no facial or cranial injury suspected) should be inserted to prevent gastric distention, vomiting, and aspiration. Initial drainage can be tested for the presence of blood. Gastric contrast can be administered through the gastric tube before CT testing.



2.    In the absence of trauma or blood at the urinary meatus or suspected urethral trauma, an indwelling bladder catheter may be inserted and connected to a urinary drainage bag. If urethral trauma is suspected, a retrograde urethrogram must be performed before insertion of an indwelling bladder catheter. When drug or alcohol use is suspected, urinalysis and toxicology and blood toxicology screen are indicated. In postmenarchal females, urinary chorionic gonadotropin (UCG) testing should be done to rule out pregnancy.



3.    A stool smear should be tested for occult blood.


G.    Musculoskeletal System



1.    All long-bone fractures are immobilized. The child’s neurovascular status is assessed immediately before and after splinting to ensure that an injury has not occurred or been aggravated. Open fractures, lacerations, or wounds require careful evaluation and cleaning.



2.    Amputated body parts are wrapped in dry or moistened gauze, sealed in a plastic bag, and then placed in an ice-water bath. At no time should the amputated part touch the ice directly, as tissue necrosis may occur. Subspecialists (e.g., plastic surgery, reimplantation specialists) will determine whether reattachment is possible after evaluating the child’s amputated parts. Whether the child and family view the amputated part or injured limb is decided on an individual case basis. Younger children may become frightened of the wound, whereas older children may be curious, and their imagined injury may be worse than the reality (see Chapter 1). Tetanus prophylaxis, antibiotics, and analgesic administration are necessary.


SECONDARY INTERVENTIONS



A.    Diagnostic Testing



1.    During any intrahospital transport, an experienced nurse and physician should always accompany the child and be prepared to intervene should the child have any changes or he or she deteriorates. Appropriately sized resuscitation equipment consisting of an Ambu bag, mask, oral airway, oxygen tank, and intubation equipment (e.g., appropriate-sized ETT, blade, handle, and stylet) if needed. If the patient is already intubated, confirm 692that the ETT is secure prior to transport. The child should be monitored with at least the minimum of ECG, oximetry, and blood pressure capabilities. Additional considerations for safe transport are to have suction available and medications for sedation and/or intubation.



2.    Chest radiographs are obtained to determine the placement of ETTs, gastric tubes, and chest tubes. They can be done at the bedside in the trauma room, and technology today allows immediate interpretation of the radiographs at the bedside. These films also confirm the presence of pneumothoraces or hemopneumothoraces, rib and clavicle fractures, and diaphragm integrity. Abdominal radiographs confirm the placement of gastric tubes and bladder catheters; stomach and intestine intactness can be observed as well. Free air is noted, and the pelvis is examined for fracture. Radiographs of the spine and extremities remain the standard diagnostic test for rapid evaluation screening for injuries to those areas. Skeletal radiographs are obtained according to the suspected injury and skeletal survey should be performed when there is a suspicion of NAT. If the child needs to be transported to the radiology department for additional radiographs, the nurse should remain with the patient to monitor his or her condition and explain procedures to help alleviate any anxiety the child may have or to administer sedation or pain medications if needed.



3.    CT scanning is undertaken in children with significant head, face, chest, or hemodynamically stable abdominal trauma. CT scanning is the diagnostic modality of choice for blunt abdominal trauma. The use of oral contrast or IV contrast can improve the diagnostic capabilities of the CT scan. Contrast can be used in stable patients who are able to tolerate the time it takes to administer it. However, CT scans should not be delayed in more urgent cases. Angiography may be obtained for suspected severe vessel injury from blunt or penetrating trauma.



4.    Diagnostic peritoneal lavage (DPL) use is decreasing with the emergence of focused assessment by sonography in trauma FAST). It is useful in detecting intra-abdominal blood (Bacade & Bowlling 2016). A FAST study can be done quickly at the bedside, is noninvasive, and can be repeated as serial diagnostic exams. Some of its limitations are inexperience of the operator and the fact that the FAST exam is insufficient in excluding injuries or in grading the injuries to solid organs. DPL has its limitations as it does not identify which organ may be injured or the grade of the injury. There is also risk of perforation of the bowel with clinicians less experienced in performing DPL in the pediatric patient. Therefore, DPL is rarely performed to diagnose hemorrhage or visceral perforation in the pediatric population. CT scanning is still the procedure of choice to identify intra-abdominal injuries. DPL or FAST may be indicated when a CT scanner is unavailable, or when CT scan findings are normal but a hollow viscus injury is suspected (Simone, 2003).



5.    Echocardiography (echo) can be useful in evaluating thoracic injuries because it can reveal functional or anatomic cardiovascular injuries or injuries adjacent to cardiovascular structures. An electrocardiogram may show rhythm disturbances, premature beats, or S–T segment changes, which may occur as a result of blunt-force trauma to the chest and can result in cardiac contusions.


B.    Pain Assessment



1.    There are many factors that can affect pain assessment in the pediatric patient. These can include developmental stage of the child, anxiety, past experiences, family perceptions, and medications, as well as the child’s past experiences with medications. Pain can involve physical, social, and emotional factors. Pain can also be subjective and multidimensional (Joestlein, 2015). AAP states, “suffering occurs when the pain leads the person to feel out of control, when the pain is overwhelming, when the source of pain is unknown, when the meaning of pain is perceived to be dire, and when the pain is chronic” (AAP and American Pain Society, 2001, p. 793).



2.    Inadequate pain management can have long- and short-term effects. This can lead to increased length of stay (LOS), as well as slower recovery and healing. It can cause emotional trauma and may cause analgesia to be less effective in future procedures (Joestlein, 2015). Fear and anxiety as well as separation from the parent(s) can increase the child’s perception or experience of pain. The parent(s) or family member’s beliefs or attitudes can alter or influence the child’s perception of pain or the child’s ability to admit whether he or she is experiencing pain. Some of these beliefs or attitudes include the parent’s fear that their child could become addicted to pain medications, overdose, or experience negative side effects. It is imperative for the nurse to educate the patient and the family regarding pain management, which may lead to a better understanding of the rationale behind the use of pain medication, thus allowing for better pain control with less emotional 693or psychological trauma or fear of pain. The nurse needs to be able to identify both emotional and physical components of pain and know how to distinguish between the two.



3.    The American Society of Pain Management Nursing (ASPMN) recommends using a modified Hierarchy of Pain Assessment Technique, which consists of self-reporting pain (if applicable) or reporting by proxy such as a parent or family member. It also should include looking for and identifying potential causes of pain, and observing patient behaviors while assessing pain (Herr, Coyne, McCaffery, Manworren, & Merkel, 2011). Self-reporting remains the recommended method to assess pain intensity and is used primarily for older children and adolescents. It is the most accurate measurement tool for pain assessment. Most self-reporting tools measure the sensory component of pain, not the behavioral component. However, factors, such as developmental age, behavioral conditions (e.g., autism), intubation, sedation, and/or chemically paralyzed patients, can limit the child’s ability to convey whether he or she is experiencing pain. The nurse should document why the patient is unable to self-report pain, which pain assessment tool is being utilized, what the plan is for managing pain, as well as the patient’s response to pain management interventions.



4.    The Faces, Legs, Activity, Cry, and Consolability (FLACC) scale can be used with children as young as infants. There is also a modified version of the FLACC scale for cognitively impaired children. The FLACC scale lends itself well to children who have an artificial airway, who have significant cognitive delay, and who are unable to self-report pain because of conditions associated with multiple trauma (e.g., multiple surgical procedures; Willis, Merkel, Voepel-Lewis, & Malviyas, 2003). The acronym FLACC denotes the following assessment categories: face (expression, muscle movement), legs (position, movement), activity (body position, movement), cry (degree, quality), and consolability (degree, effective interventions; Merkel, Voepel-Lewis, Shayevitz, & Malviya, 1997).



5.    The Behavioral Pain Assessment Scale is a valid, reliable, and clinically useful tool (Manworren & Hynan, 2003). Behavioral assessment tools are typically used in preverbal children, but can be used in the school-age child as well. It includes observing and assessing defined behaviors (e.g., crying, grimacing, or posturing), which may be associated with pain.



6.    Pain rating scores, which may be numeric usually (i.e., on a scale of 1–10) or picture based, are commonly used for school-aged children to adolescents, but may be applicable for the younger child, especially the picture-based scale. Most of these pain assessment tools measure the intensity of the pain, but not the location of the pain or quality of the pain. Also, children may sleep or be withdrawn as a way to control pain. So it cannot be assumed that a sleeping child does not have pain.



7.    Newborns experiencing trauma present unique challenges. The following are general principles for the prevention and management of newborn pain. Pain in newborns may be of a diagnostic (e.g., arterial puncture), therapeutic (e.g., chest tube insertion), or surgical nature. If a procedure is painful for adults, it should be considered painful in newborns. Newborns may experience a greater sensitivity to pain and are more susceptible to the long-term effects of painful stimulation (Anand, 2001). Hyperalgesia may be a problem for babies who have experienced previous tissue injury, postoperative pain, localized infection, or inflammation (Anand, 2001). Adequate pain management may be associated with decreased clinical complications and even decreased mortality. Sedatives do not relieve pain and may mask the newborn’s pain response (Anand, 2001).



8.    A combination of environmental, behavioral, and pharmacological interventions can prevent, reduce, and sometimes even eliminate newborn pain (Anand, 2001). An example would be the use of a sucrose pacifier and swaddling (behavioral and environmental management) together with fentanyl citrate (pharmacologic management) for a chest tube insertion procedure.


C.    Emotional Support



1.    The injured child experiences many painful and frightening events before, during, and after the injury. Children have fears of parental separation, pain, disfigurement, and mutilation. Nurses need to provide comfort and emotional support to the child and family during this time of crisis. There are several resources available to the critical care nurse to provide this support such as social work, support groups, and spiritual care. There has been a great deal of research and study dedicated to PTSD recently and its symptoms, which will be discussed later in this chapter.



2.    The assignment of a primary nurse to the patient helps the child focus on one person and provide consistency for the child and family. Speaking in a calm, reassuring voice may help the child to relax or to be less fearful and allow trust to develop with the child. 694For example, consider the child who receives spinal immobilization, standing at the child’s side near chest level allows the child to see the nurse without attempting to move his or her head sideways; standing over the child’s head may be frightening and intimidating. Holding the child’s hand, stroking the child’s hair, and talking calmly and confidently can help the child to gain trust.



3.    Explanations for procedures should be age appropriate for the child and also given to the parents so that they can comprehend what is being done. This may involve the use of interpreters, child life specialists, and social workers to provide support. The truth should be told about any pain or discomfort that may occur as well as the healthcare team’s interventions to prevent or limit any pain or discomfort the child may endure. Coping measures for painful procedures include deep breathing, guided imagery, counting, singing, or other activities that allow for distraction (e.g., such as videos, music). Allowing the child to wiggle a hand or foot gives the child some sense of control. Child life specialists can be of special assistance in identifying and implementing helpful coping skills that the child or parent(s) can apply to get through potentially scary and painful procedures. Use of pet therapy is now widely accepted to calm and distract children when it is deemed appropriate for the pet to be present at the bedside.



4.    Parents or family members should be permitted to see the child as soon as possible. The nurse should explain to the family what they will see, hear, and smell upon entering the child’s room as well as orienting the family that they may hear many different sounds or alarms. To alleviate fears that may be associated with the various alarms frequently heard within an ICU setting, the nurse should ensure family members that skilled staff are specially trained and knowledgeable in regard to what each alarm represents and that their child will be continually monitored to alert staff to any vital changes. Having child life specialists available to prepare siblings of a critically injured pediatric patient, especially prior to their first visit, on what they may experience or feel is helpful to prevent or limit the effects of a potentially traumatic experience. This is especially helpful if the sibling(s) was involved or witnessed the injuries incurred by the patient. Child life specialist and/or social work may be of assistance to family members in their decision making to allow siblings to visit, depending upon the severity of the injuries suffered. Sibling’s age and developmental status may also be taken into account. Explain the current plans for the child’s treatment to the family in language that they can comprehend. Encourage them to ask questions and allow them to be present and/or participate in medical rounds. The family is encouraged to touch and talk to the child and participate in his or her care whenever it is appropriate or safe to do so (e.g., changing a diaper, bathing, or turning the patient). However, the family should be educated on the effects of overstimulation of the patient and when physical or verbal interaction is appropriate or may be harmful. The family may welcome having a social worker, religious counselor, or other support person present. Parental presence during resuscitation is not only advocated, but encouraged. Family presence during their child’s CPR provides the family with an awareness that every effort is being made to care and support their child. It also allows them to be with the child in the event the resuscitation efforts are not successful (Gilmer, 2016).



5.    PTSD is becoming more recognized and studied in the pediatric population, especially in children who are victims of trauma, child maltreatment (which is also referred to as NAT), or who have experienced inadequate pain management. It is estimated that one in six children and/or parent(s) will develop PTSD after a traumatic event, which can lead to poorer physical and functional recovery (Kassam-Adams, Marsac, Hildenbrand, & Winston, 2013). PTSD symptoms that go unrecognized may inhibit full recovery, lead to inadequate coping skills, and an increased use of healthcare services. The Medical Trauma Working Group of the National Child Traumatic Stress Network defined pediatric medical stress as “a set of psychological responses of children and their families to pain, injury, serious illness, medical procedures, and invasive or frightening treatment experiences” (para. 1). Injuries that can cause PTSD include various forms of violence, burns, animal bites, accidents, and NAT. Persistent PTSD symptoms can impair daily functioning. The healthcare team should optimize pain management, minimize traumatic procedures and encourage the child and parent(s) or family members to verbalize their fears, and provide reassurance and realistic hope. Parent(s) have a key role in the child’s recovery; however, the parent(s) may also experience PTSD. Their responses can affect how the child copes with the event or situation. This can lead to the parent’s inability to assist the child in coping with the traumatic event.



6.    Seeking professional social support has shown to decrease PTSD symptoms after traumatic events, injuries, or experiences. Professional social support may include the services of a child life specialist and social worker as well as pet therapy, music therapy, art therapy, imagery, and psychological support. Social withdrawal is associated with an increased risk of PTSD. Follow-up therapy should include identifying the child’s coping mechanism as well as the child’s interpretation of the injury or event to identify issues that could prevent the child’s recovery. The natural psychological process for recovery includes thinking about the event balanced with distracting oneself or avoiding distressing reminders. Recovery may also be facilitated by reexperiencing and avoiding the distressing event or experience in doses so that the child does not get overwhelmed and allows him or her to process the event or experience (Table 9.5). PTSD symptoms may continue with the use of avoidance coping, blaming others, and other maladaptive behaviors such as suppression of the event.


695TABLE 9.5    Posttraumatic Stress Disorder Syndrome Risk Factors and Symptoms










Risk Factors For PTSD


Symptoms Indicating PTSD


Peritrauma subjective life threat: child believes he or she could have died or injury was life threatening


Peritrauma fear: psychological reactions of PTSD, depression, or anxiety


Little or no past trauma support from parents, friends, or teachers


Past trauma experience with poor family functioning


Posttrauma coping strategies (e.g., withdrawal, distraction, or suppression of thoughts)


Invasion or intrusion of distressing memories, dreams with trauma reminders


Avoids thoughts, feelings, people, activities that remind the individual of the traumatic event


Dissociated feelings of reality or altered sense of oneself or surroundings


Changes in mood or cognition


Persistent negative expectations of self, others, or of the world


Negative emotions and feelings of detachment


Changes in arousal that include hypervigilance, sleep disturbance, exaggerated startle response, and/or difficulty concentrating


PTSD, posttraumatic stress disorder.


SPECIFIC INJURIES



Critical care nurses need to have a strong understanding of the body’s organ systems. This should include physiologic as well as anatomic organ system understanding as many trauma patients may have sustained injuries to more than one organ system, presenting as a multitrauma patient. The critical care nurse must be able to prioritize those injuries or complications, which may be life-threatening and intervene quickly, whereas other injuries that are non–life-threatening can be treated once the patient has been stabilized. Many times these complications may be masked in the multitrauma patient. The pediatric patient can decompensate quickly if the injuries or complications are not treated in a timely manner. For the purpose of discussion, specific body system injuries are briefly addressed in this section with the understanding that these injuries will not be isolated in the multiple trauma patient (Figure 9.1).


A.    Head Injuries



1.    According to the CDC, head injuries are the leading cause of injury-related deaths in children and adolescents. In 2015, the CDC reported an estimated 2.5 million ED visits, 280,000 hospitalizations, and 50,000 deaths among all age groups with an increase seen in those younger than 1 to 4 years and 15 to 24 years. Of those deaths, the most common mechanism of injury was due 696to MVA. The medical system spends over $1 billion annually on pediatric traumatic brain injury (TBI; Schaller, Lakhani, Hsu, 2015). Other common causes of TBI in pediatrics include NAT, falls, auto versus pedestrian collisions, assault, violence, and sports. The majority of these injuries are due to blunt-force trauma. Children have proportionately larger heads with weaker cervical ligaments and muscles, leading to an increased incidence(s) of head trauma as well as an increase in severity of injuries. There is also a proportionately larger volume of blood in the pediatric head, which can cause a rapid onset of cerebral edema and increased ICP. Children’s (<2 years of age) skulls tend to be softer and the cranial suture lines are not completely fused, which can predispose them to diastatic fractures or separation of the bones at the suture line. The thin pliable skull provides less protection for the brain, making children more vulnerable to shearing from linear and rotational forces. Traumatic injuries to the head may impact the skull, neural tissue, and/or the cerebral vasculature. Head trauma can be either from primary or secondary causes. Primary TBI is a direct result of an injury when it occurs. Secondary TBI occurs as a result of the initial injury that can lead to cerebral edema, hypoxic–anoxic brain injury, bony fragments impinging on the brain, and/or delayed vascular injuries. Care of the TBI patient is aimed at preventing or controlling secondary injuries. TBI is divided into mild (GCS 13–15), moderate (GCS 9–12), and severe (GCS ≤8). CT scans can be performed quickly to assess for hemorrhages, hematomas, midline shifts, skull fractures, excess cerebrospinal fluid (CSF), edema, or herniation. MRI scans can be performed if the patient is stable, due in part to the length of time required to complete the scan. MRI can be useful to assess for extra-axial hemorrhage and ischemia.





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Feb 19, 2020 | Posted by in NURSING | Comments Off on Multisystem Issues
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