Clinical Practice Guidelines

Major paediatric trauma - The primary survey

  • calculator Emergency Drug & Fluid Calculator

    See also the secondary survey

    Prior to Arrival

    • Ensure senior emergency medical and nursing staff are aware of all the available details.
    • Delegate specific tasks to appropriate individuals.
    • Notify the Intensive Care Unit registrar and the Surgical registrar on call
    • Notify other specialist registrars as appropriate (eg. neurosurgery, orthopaedics)
    • Notify other departments as appropriate (eg. radiology, blood bank)
    • Check the resuscitation equipment and prepare intravenous lines and fluids
    • If possible estimate the child's weight using the formula (Age + 4) x 2 and calculate:
      1. The amount of fluid bolus at 20 ml/kg
      2. The endotracheal tube size (age/ 4) + 4
      3. Any other drugs likely to be needed

    On Arrival

    • Immediately perform a primary survey by assessing and managing the child's airway, cervical spine, breathing and circulation.
    • Obtain a history from the parents or ambulance officers if possible eg. type of trauma, speed of the vehicle, height of the fall, restraints or safety equipment used, whether other people were injured.

    Airway and the Cervical Spine

    • Assess the child's airway whilst protecting the cervical spine. The cervical spine should be immobilized initially by in-line stabilisation, followed by the rapid (gentle) application of a properly fitted hard collar, sandbags and tape (see Cervical Spine guideline)
    • If the airway is inadequate, apply a jaw thrust manoeuvre, clear any obstruction using suction under direct vision and consider intubation.

    Breathing

    • Apply oxygen 10 l/min by face mask.
    • Assess the child's breathing by observing:
      1. the work of breathing (recession, respiratory rate, accessory muscle use)
      2. the effectiveness of breathing (oxygen saturation, chest expansion, breath sounds)
      3. the effects of inadequate respiration (heart rate, mental state)
    • If breathing is inadequate, exclude a tension pneumothorax, use positive pressure ventilation with bag/valve/mask and consider intubation.
    • Insert a large oro-gastric tube to treat and prevent gastric dilatation.

    Circulation

    • Assess the child's circulatory state by observing
      1. the pulse rate, skin colour, capillary refill time, blood pressure
      2. the effects of an inadequate circulation (respiratory rate, mental state)
    • Establish intravenous access with two cannulae that are as large as practicable - ideally one situated in each cubital fossa.
    • If an IV cannula is unable to be sited rapidly consider the use of an intraosseous needle inserted into a non-traumatised leg.
    • As the IV is inserted take blood for a blood sugar, FBE, cross match and lipase.
    • If circulation is inadequate give a fluid bolus of 20 ml/kg of normal saline.
    • Tamponade any continuing external haemorrhage.
    • If the circulation continues to be unstable, repeat the fluid bolus using normal saline or a colloid solution. If a third bolus is necessary consider using whole blood and arrange early surgical intervention

    Disability (Mental State)

    • Assess mental state by determining the child's best response to a painful stimulus, observing their posture and examining the pupillary reflexes
    • The response to pain is determined by squeezing one ear lobe hard and observing the best response to that stimulus (eg. flexion of one arm and extension of legs is recorded as flexion to pain)
    • Note whether the child:
      • A is alert, or
      • V responds to voice, or
      • P responds to pain by localizing appropriately, flexing limbs or extending limbs to pain, or
      • U is unresponsive.

    Monitor

    • Respiratory rate, heart rate, blood pressure, oxygen saturation and rectal temperature.
    • Response to pain and pupillary light reflexes

    Normal Physiological Values:

    Age Resp. rate
    (breaths per minute)
    Heart rate
    (beats per minute)
    Systolic blood pressure
    (mm Hg)
    <1 year 30 - 40 110 - 160 70 - 90
    2-5 years 25 - 30 95 - 140 80 - 100
    5-12 years 20 - 25 80 - 120 90 - 110
    >12 years 15 - 20 60 - 100 100 - 120

    Temperature

    • Minimize hypothermia by limiting exposure of the body during examination, and by warming all ongoing fluids.

    Radiology

    • Arrange for cervical spine, chest and pelvic X-rays.
    • If there is NO clinical suspicion of a pelvic injury AND the child has a normal conscious state the pelvic X-ray may be omitted.
    • Arrange additional radiology as indicated

    Secondary Survey

    Click here to read details of the secondary survey

    Analgesia