Assessment

Management

< Circulation >

Control of exsanguinating external haemorrhage is the first priority

• Assess and expose all wounds
• Bandages controlling significant bleeding should not be removed until the child is stable and IV access is secured
• Assess for ongoing bleeding – including losses into bandages/gauze

• Apply direct pressure to the wound with a gauze pad
• Use a tourniquet to control life-threatening limb haemorrhage
• Do not use layers of gauze/bandages that may absorb and conceal blood loss
• Apply a pelvic binder if a pelvic fracture is suspected and there is haemodynamic compromise
• Activate the hospital massive transfusion protocol if appropriate

Airway and cervical spine

Assess for airway obstruction

• Typically role of airway doctor though may be shared by assessment doctor
• Assess airway, anterior neck and level of consciousness (using AVPU)
• Look for evidence of facial fractures, blood/vomit/loose teeth in airway
• If burns present, assess for:
  • Singeing of facial / nasal hair
  • Facial burns
  • Hoarseness of voice
  • Harsh cough
  • Head or neck swelling
  • Soot in mouth, nose or saliva
• Anterior neck should be assessed for blunt or penetrating trauma by looking/feeling for the following (TWELVE-C):
  • Tracheal deviation
  • Wounds
  • Emphysema (subcutaneous)
  • Laryngeal tenderness/crepitus
  • Venous distension
  • OEsophageal injury (unlikely if can swallow easily)
  • Carotid haematoma/bruits/swelling
• Causes of airway obstruction include:
  • Direct trauma to airway or laryngeal structures
  • Contamination of airway due to debris
  • Loss of pharyngeal tone (due to head injury or intoxication with drugs / alcohol)
  • Incorrect positioning (hyperflexion of infant due to large occiput)

• Use an age appropriate neutral head position
• Use a thoracic elevation device or towel under shoulder blades to achieve this if <8 years old
• Regardless of the need for airway support, all spontaneously breathing patients should have high-flow oxygen applied (typically 10-15 L via non-rebreather mask)
• Support the airway if needed using the following techniques:
  • Jaw thrust (avoiding head-tilt or chin lift)
  • Gentle suction of airway to remove blood/vomitus/secretions
  • Oropharyngeal airway if tolerated, or nasopharyngeal airway (if base of skull fracture unlikely)
  • Endotracheal intubation
• Cervical spine should be protected with manual in-line stabilisation until a soft foam collar is applied, see Cervical spine assessment

Breathing

• Assessment doctor: Look, Listen and Feel for:
  • Work of breathing
  • Effectiveness of breathing
  • Signs of inadequate respiration
  • Signs of injury (seatbelt marks, bruising, wounds)
  • Crepitus indicating Surgical emphysema
  • Chest wall tenderness
• The life threats to identify and manage with regards to breathing include:
  • Tension pneumothorax
  • Open pneumothorax
  • Massive haemothorax
  • Flail chest
  • Tracheo-bronchial injury
• If life threat has been identified, assessment doctor communicates to team leader
• Assessment doctor continues the primary survey. The procedure doctor should carry out any interventions

• Ensure all spontaneously breathing patients have high-flow oxygen applied
• If required:
  • Tension pneumothorax: chest decompression with a finger or instrument, thoracostomy or intercostal catheter insertion. Needle decompression may be used in emergencies but is unlikely to be effective
  • Open pneumothorax: immediate closure and chest drain insertion
  • Massive haemothorax: Chest drain insertion and blood transfusion  
  • Flail chest: analgesia, consider positive pressure ventilation
• Request a portable chest X-Ray
• In intubated children, insert an orogastric tube to prevent gastric dilatation which can impair effective ventilation

Circulation

Assess for shock and vascular injury

• Assessment doctor should assess circulation, and then continue with a focussed assessment looking for sites of potential bleeding such as:
  • External bleeding (expose wounds, do not remove penetrating foreign bodies)
  • Intra-thoracic bleeding (assess for massive haemothorax)
  • Intra-abdominal bleeding (inspect for distension, bruising. Palpate for tenderness)
  • Intra-pelvic bleeding – secondary to a pelvic fracture (assess by gentle palpation of pelvic structures)
  • Long bone fractures (particularly femoral)
  • Retroperitoneal bleeding (degree of suspicion should remain high if no other obvious source for bleeding)
  • Scalp or Intracranial bleeding in infants
  • eFAST has a limited role in paediatric trauma
• Care should also be taken to actively look for and exclude:
  • Obstructive cause for shock (eg tension pneumothorax or cardiac tamponade)
  • Neurogenic shock (associated with spinal injury above T6)

• In external haemorrhage, bleeding may be stopped with direct pressure
• Use a tourniquet to control life-threatening limb haemorrhage
• Establish IV access with two cannulae that are as large as practicable, ideally one in each cubital fossa. Take blood for cross-match, FBE, VBG, LFTs, UEC, lipase, coagulation screen
• If an IV cannula cannot be inserted rapidly, obtain IO access into a non-traumatised leg or humerus
• Inserting a chest drain into a massive haemothorax may improve ventilation but stopping ongoing bleeding can only be done in theatre
• Assessment doctor should, in consultation with the trauma team leader, consider the need for a pelvic X-Ray
• Life threatening bleeding into the abdomen, pelvis or retroperitoneal space may require surgery or interventional radiology. Early consultation with paediatric surgery +/- interventional radiology is required.
• Rapid transit to theatre, prior to completion of the secondary survey may be required for bleeding that cannot be controlled in the Emergency Department
• Consider application of a pelvic binder
• Bleeding from bone fractures may be reduced through traction
• If the circulation is inadequate, give 10 mL/kg bolus of sodium chloride 0.9%.
• If there is ongoing visible bleeding or suspicion of occult bleeding give packed red blood cells (10 mL/kg) if available.
• Give Tranexamic Acid 15 mg/kg if there is haemodynamic compromise from suspected haemorrhage
• Consider inserting urinary catheter

Disability (mental state)

Assess for traumatic brain injury

• Initial assessment of conscious state may be done using AVPU scale:
  • A = Alert
  • V = Responds to voice
  • P = Responds to pain
  • U = Unresponsive
• Any impairment on AVPU scale should prompt a formal assessment of GCS
• Check pupil response to light
• Check movement in all four limbs
• Measure blood glucose level on arrival
• Assess pain

• Provide analgesia
• Avoid secondary brain injury by:
  • maintaining adequate oxygenation
  • correcting hypotension
  • nursing head up to 30 degrees
  • correcting hypoglycaemia
• Consider need for urgent CT brain and discussion with neurosurgery