e6 252 Tapking C, Popp D, Herndon DN, et al Cardiovascular effect of varying interval training frequency in rehabilitation of severely burned children J Burn Care Res 2018;40(1) 34 38 253 Bombaro KM,[.]
e6 expenditure and lean mass during pediatric burn rehabilitation J Burn Care Res 2010;31:400-408 240 Hundeshagen G, Suman OE, Branski LK Rehabilitation in the Acute vs Outpatient Setting Clin Plast Surg 2017;44(4):729-735 241 Finnerty CC, Jeschke MG, Branski LK, Barret JP, Dziewulski P, Herndon DN Hypertrophic scarring: the greatest unmet challenge following burn injury Lancet 2016;388(10052):1427-1436 242 Duke JM, Randall SM, Fear MW, Boyd JH, Rea S, Wood FM Long-term Effects of Pediatric Burns on the Circulatory System Pediatrics 2015;136(5):e1323-e1330 243 Ward RS, Hayes-Lundy C, Schnebly WA, Reddy R, Saffle JR Rehabilitation of burned patients with concomitant limb amputation: case reports Burns 1990;16(5):390-392 244 Blakeney P, Herndon DN, Desai MH, Beard S, Wales-Seale P Long-term psychosocial adjustment following burn injury J Burn Care Rehabil 1988;9(6):661-665 245 Cambiaso-Daniel J, Rivas E, Carson JS, et al Cardiorespiratory capacity and strength remain attenuated in children with severe burn injuries at over years postburn J Pediatr 2018;192: 152-158 246 Edgar DW, Brereton M Rehabilitation after burn injury BMJ 2004;329(7461):343-345 247 Richard RL, Hedman TL, Quick CD, et al A clarion to recommit and reaffirm burn rehabilitation J Burn Care Res 2008;29(3):425-432 248 Serghiou M, Cowan A, Whitehead C Rehabilitation after a burn injury Clin Plast Surg 2009;36(4):675-686 249 Clayton RP, Wurzer P, Andersen CR, Mlcak RP, Herndon DN, Suman OE Effects of different duration exercise programs in children with severe burns Burns 2017;43(4):796-803 250 Porter C, Hardee JP, Herndon DN, Suman OE The role of exercise in the rehabilitation of patients with severe burns Exerc Sport Sci Rev 2015;43(1):34-40 251 Tapking C, Armenta AM, Popp D, et al Relationship between lean body mass and isokinetic peak torque of knee extensors and flexors in severely burned children Burns 2018;45(1):114-119 252 Tapking C, Popp D, Herndon DN, et al Cardiovascular effect of varying interval training frequency in rehabilitation of severely burned children J Burn Care Res 2018;40(1):34-38 253 Bombaro KM, Engrav LH, Carrougher GJ, et al What is the prevalence of hypertrophic scarring following burns? Burns 2003;29(4):229-302 254 Frantz CH, Delgado S Limb-length discrepancy after third-degree burns about foot and ankle: a report of cases J Bone Joint Surg Am 1966;48(3):443-450 255 Friedstat JS, Hultman CS Hypertrophic burn scar management: what does the evidence show? A systematic review of randomized controlled trials Ann Plast Surg 2014;72(6):198-201 256 Barret JP Burns reconstruction BMJ 2004;329(7460):274-276 257 Hundeshagen G, Zapata-Sirvent R, Goverman J, Branski LK Tissue rearrangements: the power of the Z-Plasty Clin Plast Surg 2017;44(4):805-812 258 Grant EJ Burn Injuries: Prevention, Advocacy, and Legislation Clin Plast Surg 2017;44(3):451-466 259 Liao CC, Rossignol AM Landmarks in burn prevention Burns 2000;26(5):422-434 260 Lehna C, Janes EG, Rengers S, et al Community partnership to promote home fire safety in children with special needs Burns 2014;40(6):1179-1184 261 Lehna C, Ramos P, Myers J, Coffey R, Kirk E A web-based educational module increases burn prevention knowledge over time Burns 2011;37(7):1255-1258 262 Hammond J The status of statewide burn prevention legislation J Burn Care Rehabil 1993;14(4):473-475 263 Atiyeh BS, Costagliola M, Hayek SN Burn prevention mechanisms and outcomes: pitfalls, failures and successes Burns 2009;35(2):181-193 e7 Abstract: Burns are among the most traumatic injuries that can vary from minor skin involvement that does not require specific treatment to a major multiorgan and potentially life-threatening injury Approximately million people per year experience burns in the United States alone with half of them being admitted to a specialized burn center Inhalation injury due to inhalation of hot smoke or steam is present in up to one-third of all burn patients and contributes significantly to burn-related mortality The diagnosis of inhalation injury is based on the circumstances of the burning event, observation, and bronchoscopic findings Key words: Burns, inhalation injury, diagnosis, treatment, rehabilitation, pediatric 117 Evaluation, Stabilization, and Initial Management After Trauma JESSICA A NAIDITCH, MICHAEL DINGELDEIN, AND DAVID TUGGLE PEARLS • • The primary survey, as defined by Advanced Trauma Life Support, is a prioritized evaluation and management protocol focused on identifying and treating the most life-threatening injuries first This framework is unique to trauma care Pediatric trauma patients with respiratory failure can be considered the most seriously injured One should expect them to behave as such despite potentially having “normal” heart rate or blood pressure Having awareness of basic pediatric airways skills, including bag-mask, is crucial The most effective, objective, and rapid steps in evaluating breathing and adequate ventilation Trauma is the leading cause of death and acquired disability in children and adolescents, resulting in more deaths in children than all other causes combined.1,2 Because children with severe injuries can rapidly deteriorate, resources for rapidly identifying and treating injuries are needed immediately on arrival at the receiving hospital The initial evaluation of injured children in the emergency department (trauma resuscitation) has two main goals: (1) identify and immediately treat potentially life-threatening injuries and (2) determine disposition after the trauma resuscitation on the basis of known or suspected injuries The trauma team must stabilize the child, determine the extent of the injury, and develop an initial treatment plan for the child’s hospitalization Advanced Trauma Life Support (ATLS) is a framework and series of protocols developed to standardize the initial evaluation and management of injured patients and avoid omission of potentially lifesaving interventions After decades of refinement, ATLS serves as the standard for the initial management of injured patients and is now taught to providers around the world.2 The impact of ATLS on reducing morbidity and mortality after injury has been affirmed in several studies.3,4 ATLS training is mainly focused on treating the injured adult but includes modules that emphasize the anatomic, physiologic, and psychologic features that make management of the injured child unique The basic algorithms of assessing and addressing life-threatening injuries first are the same for children as they are for adults • • • are auscultation of the chest, application of a pulse oximeter for measurement of oxygen saturation, and assessment of respiratory rate The greater physiologic reserve of children makes early identification of cardiovascular compromise more challenging than in adults Of the three main components of the Glasgow Coma Scale, the motor score has been shown to be the best predictor of outcome after injury When intravenous access is challenging, moving quickly to placing intraosseous access can be lifesaving The first phase of ATLS is the primary survey, a rapid evaluation focused on identifying life-threatening injuries The steps include evaluation and treatment of the airway (A, airway) followed by evaluation of respiratory dynamics (B, breathing), evaluation of the patient’s hemodynamic status (C, circulation), followed by a neurologic assessment (D, disability) The final phase of the primary survey (E, exposure/environment) includes removing the patient’s clothing to identify concealed injuries and ensuring that the patient is protected from environmental heat loss The primary survey is then followed by the secondary survey, a detailed head-to-toe evaluation that identifies other injuries The steps within the primary survey are repeated as needed if the patient’s status changes and to monitor the response to therapeutic interventions The initial management of injured adults has been the domain of trauma surgeons; the jurisdiction of care for the injured child is not as well defined at many centers Frequently, pediatricians, anesthesiologists, and emergency department physicians have an active role in the initial management and treatment of injured children.5 Although formal ATLS training is not needed for most pediatric providers, this training should be mandatory for those actively involved in the initial evaluation of injured children The goal of this chapter is to provide a focused introduction to the initial resuscitation of injured children This chapter does not serve as a replacement for ATLS training but will instead highlight aspects of the resuscitation that are unique to injured children or may not be emphasized in the ATLS curriculum 1363 1364 S E C T I O N X I I Pediatric Critical Care: Environmental Injury and Trauma Prehospital Care and Trauma Team Activation Initial field care, appropriate triage, and rapid transport are all aspects of prehospital care that can have an important impact on the outcome in pediatric trauma Cities and regions have developed trauma systems that coordinate these aspects of care by creating networks of prehospital and hospital providers The most severely injured children are triaged to the centers within each trauma system that have the personnel, facilities, and equipment to manage these patients Equally important, minimally injured patients can be directed to nontrauma hospitals to avoid burdening pediatric trauma centers with these patients Field triage is based on several components, including physiologic criteria, anatomic injury, mechanism of injury, and underlying medical conditions Triage criteria are designed to minimize inappropriate transport of severely injured patients to nontrauma hospitals (undertriage) but achieve this goal at the cost of directing some patients to trauma centers who are only minimally injured (overtriage) Due to the limited time and resources available for evaluation in the prehospital setting, overtriage is an unavoidable aspect of current trauma systems Injured children who have met criteria for transport to high-level trauma centers by current criteria may be minimally injured and require no specific interventions before discharge from the emergency department A key aspect of the initial management of the injured child in the emergency department is effectively continuing the care started in the field while avoiding unneeded care for those with minimal injuries One approach that has been used in many centers to address the problem of overtriage is the use of a tiered team response in the emergency department.6 On the basis of prehospital criteria, patients who are identified as being most at risk for severe injury are met by a full team upon arrival, including a trauma surgeon, emergency department physicians, critical care physicians, anesthesiologists, nurses, and radiology technicians Patients with a lower likelihood of severe injury are initially met by a smaller team with the option of summoning a larger team if the initial evaluation suggests a severe injury Centers that have used this approach for team activation have significantly reduced the expenditure of resources on minimally injured patients without any impact on the care received for more severely injured patients.7 Trauma Resuscitation Trauma resuscitations are among the most resource-intensive and time-pressured events in any hospital The severity of the patient’s injuries, number of team members required, and number of simultaneous evaluation and management steps needed contribute to the complexity of the environment To manage the complexity of trauma resuscitation, a systematic team-based and processfocused approach is needed to rapidly identify and treat lifethreatening injuries and minimize team errors Designating a specific room and team for trauma resuscitations helps ensure that the needed resources are immediately available A single location ensures that supplies (i.e., emergency airway kits, chest tube and thoracotomy trays, cervical collars, and central or intraosseous vascular access kits) are available and that team members know to gather at a specific site Physicians, nurses, radiography technicians, respiratory therapists, and other hospital personnel needed for trauma resuscitation are identified in advance as trauma team members assemble and assume their roles in the resuscitation area upon arrival of the injured child These seemingly simple preparations ensure that the arriving patient has the maximal resources available at the receiving hospital It is especially helpful to have a resuscitation room equipped with pediatric age- and sizespecific equipment Special carts, with color-coded drawers matching the Broselow measuring device, are helpful to organize size-specific equipment The trauma resuscitation room should be warmed in preparation for patient arrival as an effort to prevent hypothermia Before arrival at the hospital, prehospital providers transmit information to hospital providers regarding the mechanism of injury, status of the patient, and initial treatments or interventions that have been provided This information can alert the team to prepare specific equipment or resources or to summon other essential personnel Before the patient arrives, it is good practice for the team to review prehospital information to ensure that all team members are aware of the patient’s status and anticipated needs On arrival at the emergency department, an additional and final exchange of information between the prehospital providers and trauma team occurs A “time out,” or quiet period, facilitates this information transfer Essential elements that should be obtained in this report include details about the injury event, vital signs obtained at the scene and during transport, pertinent physical findings, and the initial treatments administered and response to these treatments.8 Allowing the prehospital providers to give their report before starting the patient evaluation or even transferring the patient to the emergency department gurney improves information exchange and prevents repetitive questions later in the resuscitation Primary Survey Overview The primary survey, as defined by ATLS, is a prioritized evaluation and management protocol focused on identifying and treating the most life-threatening injuries first This approach is different from the traditional initial evaluation in a patient in which an extensive history and physical examination are performed before diagnosis and treatment The classic steps of the primary survey are taught in the ATLS course as a sequence, with evaluation and treatment by one provider of “A” followed by “B,” and so forth In actual practice, most centers have a team of providers allowing the evaluation and management steps to proceed forward in parallel A designated team leader stands at the foot of the bed, receives information reported by the team, and provides higher-level direction of the conduct of the resuscitation While the steps of the primary survey provide the framework for the initial assessment, new information may be obtained in later phases or a patient’s status may change, requiring iterative performance of each step It is often a challenge to ensure that the team retains its focus on the underlying prioritization scheme of the primary survey and does not omit or minimize steps in this process (Fig 117.1).2 When resuscitations are evaluated, compliance with ATLS protocols is often low, mandating continued training and retraining to ensure that the well-established benefits of this protocol are realized.9 The use of a checklist by the trauma team leader has been associated with greater ATLS task performance and with increased frequency and speed of primary and secondary survey task completion.10,11 CHAPTER 117 Evaluation, Stabilization, and Initial Management After Trauma Primary survey Secondary survey 1365 Missed Components of the Primary and TABLE Secondary Survey in Pediatric Trauma 117.1 Resuscitation: Management Errors Among Airway All Patients (N 90) Errors Identified N (%) Airway and Breathing Breathing Circulation Delay in oxygen therapy 60 (67) Chest not auscultated 40 (44) Oxygen saturation not measured 33 (37) Neck not adequately examined 71 (79) Cervical Spine No head stabilization on transfer 18 (20) Circulation Disability Exposure Inappropriate intravenous access 18 (20) Pulse not assessed 37 (41) Central capillary refill not assessed 59 (66) Blood pressure not measured 28 (31) Fluid bolus not warmed 33 (89) Disability Head-to-toe examination focused history (AMPLE) adjunctive procedures/tests • Fig 117.1 Schematic of initial trauma resuscitation AMPLE, Allergies, medications, past medical history, last meal, and the environment Pupils 22 (25) Posture 22 (25) Secondary Survey Perineum not examined 41 (45) Head not examined 13 (15) Establish an Airway With Cervical Spine Stabilization (A) Ears not examined 16 (18) Mouth not examined 41 (45) Establishment of a patent airway with cervical spine stabilization is the first step of the primary survey All patients should immediately receive oxygen as the evaluation is begun After oxygen is placed, evaluation of the airway can proceed Injured children who present to the emergency department can be placed into three categories with respect to initial airway management: (1) those with a patent airway requiring no manipulation, (2) those who have undergone intervention in the field or at another hospital to establish a patent airway, and (3) those who will need an intervention to establish a patent airway Most children evaluated by the trauma team are in the first group For these patients, evaluation should consist of several simple steps, including asking the patient’s name, inspection for craniofacial injuries, assessment for voice changes, and listening for obvious stridor These steps can be performed easily and rapidly in most children A simple statement that “the airway is patent” will communicate to the team that these confirmatory steps have been accomplished Because most injured children will not require any specific airway management, omission of elements of the airway assessment is common in pediatric trauma resuscitation Although the patency of the airway may seem “obvious” in many patients, subtle and early signs of pending airway compromise will be missed if a formal airway evaluation is not completed (Table 117.1) The second category is children with an airway already established in the field or other hospital, usually by endotracheal intubation Airway interventions performed before a patient’s arrival should not be interpreted as an adequate airway; additional steps Back not examined 13 (15) Chest not examined (3) Abdomen not examined (2) Modified from Oakley E, Stocker S, Staubli G, et al Using video recording to identify management errors in pediatric trauma resuscitation Pediatrics 2006;117:658-664 should be performed to assess airway patency, especially in light of the relative tenuous nature of pediatric airways placed under emergency situations.12 The key steps to evaluating an endotracheal tube placed outside the emergency department are assessing the appropriateness of tube size, evaluating tube depth, assessing adequacy of ventilation by auscultation and inspection of the chest, measurement of end-tidal carbon dioxide (CO2), and confirmation of tube position with a chest radiograph The appropriate tube size can be evaluated using age-specific formulas and charts or by comparing the tube with the child’s fifth (little) finger Inadvertent deep placement of an endotracheal tube in a prehospital setting is common, especially among younger children The short airway in pediatric patients increases the likelihood that an endotracheal tube will migrate from the proper position during transport An easy rule for rapidly assessing tube depth is that the length of the tube at the teeth should be three times the tube size (internal diameter measured in millimeters) Age-specific formulas for evaluating endotracheal tube depth are ... needed for most pediatric providers, this training should be mandatory for those actively involved in the initial evaluation of injured children The goal of this chapter is to provide a focused... trauma team occurs A “time out,” or quiet period, facilitates this information transfer Essential elements that should be obtained in this report include details about the injury event, vital signs... Management Errors Among Airway All Patients (N 90) Errors Identified N (%) Airway and Breathing Breathing Circulation Delay in oxygen therapy 60 (67) Chest not auscultated 40 (44) Oxygen saturation