Pediatric emergency medicine trisk 38

of treatment All patients with major trauma should receive supplemental oxygen therapy In both medically ill and traumatically injured patients, the airway is secured via endotracheal intubation as clinically necessary The chin-lift or jaw-thrust maneuver is the preferred method to open the airway while clearing secretions or preparing for intubation to minimize cervical spine movement It is imperative to anticipate a “difficult airway” prior to intubation If this is anticipated, the most experienced clinician in airway management should secure the airway If a difficult airway is suspected, management with bag-valve-mask ventilation or placement of a laryngeal mask may be preferred until a definitive airway can be established in a controlled environment TABLE 7.5 PRIMARY SURVEY COMPONENTS A Airway Cervical spine B Breathing C Circulation D Disability Dextrose Decontamination E Exposure Environment Determine if the airway is patent Note obstruction, complete or partial Reposition, suction, consider artificial airways, continuous positive pressure Assess need for C-spine immobilization Check for increased or poor respiratory effort Place on continuous CR monitor, pulse oximetry, ETCO2 Administer oxygen, assist ventilation with BVM Consider need for ETT, have LMA ready Decrease gastric distension Needle thoracostomy and chest tube as indicated Assess HR, BP, rhythm Peripheral pulses and capillary refill, pallor, cyanosis Assess mental status, pupils, motor activity, and symmetry Cardioversion, defibrillation, pericardiocentesis AVPU score, note lateralizing signs Treat hypoglycemia, seizures, increased ICP Drug overdoses, or electrolyte abnormalities Undress patient, log roll Check temperature, skin, and evidence of trauma Prevent hypothermia Breathing After the airway has been evaluated and secured as necessary, breathing is assessed to assure adequate air exchange Continuous oxygen saturation measurement and endtidal carbon dioxide (ETCO2 ) monitoring in both intubated and nonintubated patients allows for continued assessment of oxygenation and ventilation The most common causes of hypoxemia in children are ventilation/perfusion (VQ) mismatch and hypoventilation ETCO2 may help distinguish between these two entities; providers will note normal or low ETCO2 in cases of primary VQ mismatch, while in cases of hypoventilation, physicians will often see hypercarbia out of proportion to hypoxemia It is important to note that in trauma patients, compromise of ventilatory function most often occurs secondary to a depressed sensorium rather than a primary pathology of the respiratory system itself Circulation Circulation is assessed by examining the character of the pulse, skin color, and capillary refill time There is no single physical or laboratory finding that will identify shock, however, the physical signs exhibited by the patient in shock are ultimately due to insufficient oxygen and substrate delivery to the tissues The physical manifestations vary with type of shock but include tachycardia, decreased skin perfusion, and hypotension (cold shock) or tachycardia, bounding pulses and flushed skin with hypotension (warm shock) If cardiogenic shock is present, HR may be normal or only modestly elevated Remember that in children, hypotension is a late finding requiring a 50% decrease in the circulating volume to affect a decrease in systolic pressure In trauma, external hemorrhage visualized during the primary survey should be controlled by direct pressure or pneumatic splints Disability CNS failure is manifested by altered MS or by the presence of focal neurologic deficit(s) Recall that the CNS is composed of the brain and meninges, the blood vessels, and the cerebrospinal fluid Many diseases that cause CNS failure are caused by compartment physiology, as in the case of elevated intracranial pressure (ICP) Examples of primary CNS disease include intracranial hypertension secondary to mass or hemorrhage, and status epilepticus The CNS may also be secondarily affected by respiratory or circulatory disease as oxygen delivery to the tissues of the CNS is impaired The AVPU scale and GCS ( Table 7.2 ) are used to measure level of consciousness in a standardized way Interventions to treat CNS failure include modest hyperventilation and hypertonic therapy (in the case of elevated ICP), maintenance of MAP and oxygenation to ensure adequate CNS perfusion, and avoidance of hyperthermia Other therapies aimed at the underlying cause of CNS failure include anticonvulsants, antimicrobials, and surgical decompression Exposure/Environment A complete physical examination requires removal of all clothing, log rolling, and checking axillary and perineal areas of the patient Hypothermia is a particular risk in ill and injured children, due to their larger relative surface area Hypothermia can develop in the prehospital setting and can worsen in the ED, as proper assessment and treatment requires exposure of the patient The dangers of hypothermia include impaired hemodynamics and coagulation, increased peripheral vascular resistance, and increased metabolic demand Monitor and maintain body temperature using increased ambient temperature, warm blankets, and warmed fluids and oxygen While the use of therapeutic hypothermia in arrested pediatric patients remains understudied, hyperthermia should be treated aggressively IV Access Vascular access is an early but often challenging necessity in resuscitation Percutaneous cannulation of bilateral upper extremity veins with two large-bore intravenous (IV) cannulas is ideal For patients in pulseless arrest, for those with severe trauma, or for patients with known difficult access, intraossesous (IO) access provides a quick, reliable route to provide fluid resuscitation and medications ED clinicians should have an IV escalation plan in place with resources to assure timely IV access This has become a more important aspect of care due to the increasing numbers of children with difficult IV access due to success in treating chronic illnesses ( Table 7.6 ) Fluid Resuscitation Deliver isotonic fluids (normal saline or lactated Ringer’s) rapidly in 20 mL per kg aliquots up to 60 mL/kg and reassess VS, MS, and skin perfusion The push–pull technique using a 20-mL syringe with a macrodrip setup with a three-way stopcock and a T-connector is useful for rapid fluid resuscitation in children 50 kg, fluids can be infused using a pressure bag or a rapid infuser To date, evidence has not shown benefit for the use of albumin or synthetic colloids in pediatric septic shock, cardiopulmonary arrest, or trauma Dextrose-containing solutions should not be used for initial resuscitation due to risk for hyperglycemia and secondary osmotic diuresis and neurologic injury Nevertheless, bedside glucose testing is important; treat hypoglycemia with 10% dextrose solution, and follow with an infusion of dextrose-containing fluids in persistently hypoglycemic patients If volume resuscitation of 60 mL/kg has not been effective, consider initiating procontractility agents or vasopressors Treat hypoxemia, metabolic acidosis, and any other critical electrolyte abnormalities discovered during the resuscitation Among traumatically injured patients, failure to respond to crystalloid resuscitation is an indication for early transfusion Blood transfusion is preferentially performed with fully cross-matched, warmed blood In the face of a transient or absent response to a rapid crystalloid infusion, type-specific, or type O–negative blood can be given as a whole-blood transfusion Fluid and blood are given rapidly enough to maintain stable VS and adequate urine output Vasopressors, steroids, and sodium bicarbonate not play a role in the initial treatment of hemorrhagic shock Currently, there is no universally accepted massive transfusion protocol for pediatric trauma victims with most protocols institution-specific TABLE 7.6 IV ESCALATION PLAN • Establish large bore IVs and begin NS fluid resuscitation within the first 15 minutes • Implement IV escalation pathway considering individual patient • Ill patients require a second access at a peripheral site Minutes Access procedure 0–5 First peripheral IV with largest gauge possible Consider IO immediately in severely ill patients Second peripheral attempt Consider US-guided peripheral IV Consider EJ (US guided) Notify vascular access specialist (IV team) 5–10 10–15 If still no access EZ-IO EJ (consider US guided) Central line (consider US guided) or Call intensivist or surgeons to assist at bedside, if available SECONDARY SURVEY The goal of the secondary survey is to identify the definitive cause of the respiratory, circulatory, and/or neurologic abnormalities treated during the primary survey In the case of trauma patients, the secondary survey reveals any injuries not found and/or addressed in the primary survey During the secondary survey, a systematic head-to-toe examination is performed with special attention to specific organ systems associated with the patient’s chief complaint and personal risk factors Elements of the secondary survey may be skipped or deferred, depending on the clinical situation, and patient stability ( Table 7.7 )  ... warm blankets, and warmed fluids and oxygen While the use of therapeutic hypothermia in arrested pediatric patients remains understudied, hyperthermia should be treated aggressively IV Access Vascular... infuser To date, evidence has not shown benefit for the use of albumin or synthetic colloids in pediatric septic shock, cardiopulmonary arrest, or trauma Dextrose-containing solutions should not... hemorrhagic shock Currently, there is no universally accepted massive transfusion protocol for pediatric trauma victims with most protocols institution-specific TABLE 7.6 IV ESCALATION PLAN •