The main causes of serious injury in children are due to motor vehicle accidents and falls.
Injury prevention is the biggest factor in reducing trauma mortality but unfortunately children still continue to be injured.
Primary assessment and early ABC interventions will avoid some deaths and prevent late complications in children involved in major trauma.
At PMH, a trauma team consisting of staff from the Emergency Department, Paediatric Intensive Care Unit (PICU), surgical and anaesthetic teams manage major trauma as defined by mechanism of injury and physiological parameters.
This multidiscplinary trauma team will follow a structured approach to manage seriously injured patients.
This structured approach initially focuses on identifying and treating immediate threats to life – the primary survey.
Following this initial primary survey and resuscitation, the structured approach is again used as a secondary survey to identify other key injuries which require emergency treatment to stabilise the patient and prevent secondary insult.
It is recommended that all healthcare workers who work with injured children undertake an Advanced Paediatric Life Support (APLS), Emergency Management of Severe Trauma (EMST) course or similar to provide the skills needed to assess and manage seriously injured children.
A structured, systematic approach is essential when assessing seriously injured children.
Primary survey using an “ABCD” approach is a simple and highly effective method in major trauma.
Assume cervical spine injury in all trauma patients.
Treat problems immediately as thay are found during the primary survey, before moving on.
A detailed history of the incident should be sought including:
Mechanism of injury
Time of injury
The primary survey involves a rapid structured assessment of Airway, Breathing, Circulation, Disability and Exposure.
Treat life threatening issues immediately as they are discovered during the primary survey before moving on.
Airway and C Spine
Assume C-Spine injury in any major trauma patient
Immobilise C-Spine in a hard collar or manual in-line immobilisation
Assess airway patency and signs of obstruction
Bruising or swelling
Suction if necessary
Jaw thrust (head tilt is contraindicated if there is suspicion of C-Spine injury)
Oropharyngeal airway (nasopharyngeal airway containdicated if there is suspicion of a base of skull fracture)
Breathing & Ventilatory Support
Fully expose the neck and chest Look, listen and feel Provide oxygen via a non-rebreather mask with a reservoir
Symmetry of chest expansion
Effort – nasal flare, recession, accessory muscle use
Effects – heart rate, skin colour, mental state
Urgently exclude and treat:
Bag valve mask ventilation
Intubation and positive pressure ventilation
Consider an oro-gastric tube
!6 G needle into 2ICS if suspect pneumothorax
3 way occlusive dreesing for tension pneumothorax (while preparing for drain0)
Circulation & Haemorrhage Control
Control obvious external haemorrhage – apply pressure.
Obvious external haemorrhage
Distended neck veins
Muffled heart sounds
Signs of shock
Central capillary return
Two large bore cannulae (take blood for FBC and cross match)
Fluid resuscitation – 20ml/kg of 0.9% saline and repeat if necessary
Blood if further boluses required
Surgical intervention to stop internal bleeding (chest, abdomen, pelvis)
Disability and Prevention of Secondary Insult
Hypoxia and shock can cause a decrease in conscious level
Any ABC problem should be addressed before assuming a primary neurological problem
Assesslevel of consciousness, pupils, posture and blood glucose.
Conscious level – A V P U scale
Pupil size, symmetry and reactivity
Abnormal posturing (decorticate, decerebrate)
Bedside glucometer reading
Response to Pain or Unresponsive – consider intubation
Treat raised intracranial pressure – 20% mannitol or 3% saline
Correct hypoglycaemia – 2ml/kg of 10% glucose IV
Exposure and Temperature Control
Fully expose child and assess temperature and signs of injury.
Check core temperature
Don’t forget to log roll and check the back
Take blood for FBC, U&E, LFT, venous blood gas and Group & Hold or Cross Match
Trauma series X-rays – C-spine, chest
If concerns re abdomenor pelvis -need CT
Do CT neck rather than XR if doing CT head
Other adjuncts to the primary survey include FAST scan, orogastric tube and bladder catheterisation
A secondary survey is performed after treating any life threatening conditions detected during the primary survey.
The secondary survey should be abandoned to repeat a primary survey if there is any deterioration in the patient’s condition.
The secondary survey involves a head to toe and front to back examination to detect any non life threatening injuries which require further management.
Further investigations and management will be determined by injuries found on secondary survey, e.g. specific limb X-rays, CT scans etc.