1371CHAPTER 117 Evaluation, Stabilization, and Initial Management After Trauma history elements to obtain are those that most directly impact injured patients and the evaluation and treatments needed[.]
CHAPTER 117 Evaluation, Stabilization, and Initial Management After Trauma history elements to obtain are those that most directly impact injured patients and the evaluation and treatments needed for them The acronym AMPLE is useful for remembering these key elements (allergies, medications, past medical history, last meal, and the environment and events related to the injury) The physical examination contains elements similar to those performed in other settings but should be modified to include steps that identify common and important injuries Examination of the entire scalp should be performed to identify lacerations, contusions, or evidence of fractures Posterior scalp lacerations can easily be missed because of hair or the position of the cervical collar Massive facial injuries can produce significant facial edema, making the eye examination difficult Because facial swelling most often worsens with time, it is important to obtain an initial eye examination while the patient is in the emergency department Fractures to the maxillofacial bones—including nondisplaced fractures of the nasal bone, zygomatic arch, and orbital rim—can be difficult to detect on physical examination and often require radiographic imaging Examination of the chest in pediatric trauma can be misleading because severe intrathoracic injury may be present without evidence of obvious skeletal trauma Abdominal injuries should be aggressively sought in children who have sustained a significant blunt injury to the torso Repeated examinations are often needed to evaluate for the presence or absence of abdominal tenderness in the anxious child after injury.31 Examination of the perineum, rectum, and vagina should be focused on detecting direct trauma and evidence of a pelvic fracture Digital rectal examination may often be omitted in children with no other signs of injury but should be included if the child sustained significant blunt trauma, has other findings suggesting a pelvic fracture, or has neurologic findings suggesting a spinal cord injury Any evidence of pain, swelling, or limitation of movement may suggest an underlying fracture and usually warrants radiographic evaluation The secondary survey should include a more complete neurologic assessment than was performed in the primary survey, as well as a formal assessment of sensory and motor functions While the secondary survey can be performed in a free-form fashion, a systematic strategy is necessary to avoid missing key components of this evaluation In reviews of pediatric trauma resuscitations, components of the secondary survey that are often omitted include examination of the mouth, ears, back, and perineum As in the primary survey, findings in the secondary survey should be communicated to the team The trauma team leader should address the need for tetanus administration (depending on the child’s vaccine requirements) and antibiotic administration (e.g., for open fractures) during the secondary survey Missed injuries, although rare when ATLS protocols are followed, occur in trauma resuscitations and may lead to preventable morbidity during the patient’s hospital stay The risk of a missed injury is higher in children with more severe injuries, including those transported by air, those who undergo endotracheal intubation in the emergency department, those with a low admission GCS, and those with an injury severity score greater than 15.32 Missed injuries have been shown to be reduced with the implementation of a designated pediatric trauma response team, supporting a focused and stepwise approach to the initial evaluation of injured children.33 Critical care providers should be alert to the possibility of missed injuries in patients admitted to their unit and not rely on the emergency department evaluation for detecting all injuries 1371 Diagnostic Assessment The secondary survey is supplemented by diagnostic testing that focuses on identifying and treating injuries not found in the primary survey Performance of a standard set of tests is discouraged Injured children may be overtriaged to the resuscitation area and require no additional testing after the primary and secondary surveys have been completed Observation in the emergency department before discharge and close outpatient follow-up is an appropriate option for children identified as low risk for injury The most important laboratory study to obtain early in the evaluation of the injured patient is a complete arterial blood gas (ABG) analysis This test will identify metabolic acidosis and provide a baseline for hemoglobin and electrolytes The ABG should be obtained during or soon after the primary survey When available, a serum lactate can be obtained to evaluate the extent of the primary injury and guide the efficacy of resuscitation Laboratory Studies Routine laboratory evaluations in pediatric trauma have been shown to be of little value in the management of injured children.34,35 Among children injured from a significant blunt mechanism, a focused screening set of laboratory studies to identify occult intraabdominal or retroperitoneal injury and hemorrhage has been shown to be sufficient A complete blood cell count may be checked and trended The initial hemoglobin, however, will not be indicative of acute hemorrhage A screening panel that includes aspartate aminotransferase (AST) and alanine aminotransferase (ALT), urinalysis, and hemoglobin will effectively screen for most intraabdominal injuries.36 Patients with an AST less than 200, normal abdominal examination, normal chest radiograph, no abdominal pain, and normal pancreatic enzymes after blunt abdominal trauma may safely avoid CT of the abdomen, with a 100% negative predictive value for intraabdominal injury requiring intervention.37 Among children with major head injuries, penetrating trauma, multiple extremity fractures, and significant mechanisms of injury, this panel of laboratory studies may be expanded to include coagulation studies, electrolytes, and blood for crossmatching Coagulation studies in pediatric trauma are most often abnormal in the presence of severe TBI The use of viscoelastic monitoring, including thromboelastography (TEG) and rotational thromboelastometry (ROTEM), can allow for comprehensive characterization of the coagulation process with point-of-care availability In comparing the use of the international normalized ratio (INR) and TEG to identify a bleeding risk, patients with an elevated INR not necessarily have functional coagulopathy based on TEG values Using TEG can allow for goal-directed correction of coagulopathy and has been shown to improve outcomes in trauma patients If obtained early after injury, electrolyte studies are most often normal and serve only as a baseline for a patient who will require aggressive management of severe head injuries or aggressive resuscitation Blood should be obtained for crossmatching if significant fluid resuscitation has been required, the child has a preexisting condition causing a predisposition to bleeding, has a major head injury, or will undergo a surgical procedure with potential for blood loss Early after injury, pancreatic enzymes not need to be obtained as a screen for pancreatic injury because of the low diagnostic yield of these studies.38 Screening tests for alcohol or drug use may be appropriate in older children and adolescent patients 1372 S E C T I O N X I I Pediatric Critical Care: Environmental Injury and Trauma Radiographic Imaging Radiographs may be necessary to rule out specific injuries or to evaluate known injuries The three most common radiographs obtained are cervical spine, chest, and pelvic radiographs The need for each radiograph should be evaluated on the basis of the mechanism of injury and patient symptoms and examination.39 A cervical spine injury should be suspected in any child sustaining a significant head injury or injured by a major blunt mechanism Although cervical spine injuries are rare, these injuries can be devastating and can have worse outcomes when adequate spine precautions are not taken early after injury A systematic and efficient approach using both clinical and diagnostic modalities is necessary to ensure that a cervical spine injury is not present Implementation of standards for cervical spine assessment and clearance has been shown to decrease the time for cervical spine clearance.40 Each institution should develop an institution-specific protocol for managing the initial and subsequent imaging of the cervical spine to avoid either incomplete evaluations or excessive imaging If a patient meets the National Emergency X-Radiography Utilization Study criteria, then the cervical spine can be cleared clinically without radiographic imaging These criteria require that the patient is alert and oriented, there is no posterior midline cervical tenderness, no evidence of intoxication, no focal neurologic deficit, and no painful distracting injuries.41 A cervical spine series consists of a cross-table lateral, an anterior-posterior view, and an open-mouth view to assess the dens process of C1 With adequate films, a three-view series has a high sensitivity (89%) and a negative predictive value of 99.9%.42 Among these views, the lateral cervical spine film is most useful and has been adopted as the initial screening film at many institutions.43 A vertebral fracture at any level of the spine should prompt complete radiographic imaging of the entire spine, as the risk for additional injuries to the spine is high In a patient with neurologic symptoms suggesting a spinal cord injury but negative radiographs of the spine, the diagnosis of Spinal Cord Injury Without Radiographic Abnormality should be considered and prompt magnetic resonance imaging obtained The same is true for patients who cannot have their cervical spinal examination cleared clinically Chest radiographs can often be omitted for children without physical examination findings or symptoms suggesting a thoracic injury.39 This study, however, should be obtained for children who are injured by a major blunt mechanism, such as a high-speed motor vehicle crash or those who have sustained other significant torso injuries Pelvic radiographs can be safely omitted among children who are awake, alert, and have no physical examination findings or proximity injuries (e.g., a proximal femur fracture) to suggest a pelvic injury Radiographs of the extremities or other areas may also be necessary in the resuscitation area depending on the findings of the primary and secondary surveys While CT imaging is useful and has the advantages of being rapid and organ specific in defining injuries, there are potential hazards in its use, especially in pediatrics In 2007, a study from Los Angeles showed that pan-scanning—or doing a head, chest, and abdomen CT scan—often led to finding unsuspected injuries requiring treatment Of the patients in this study, 19% had an injury on CT scan that was not suspected on physical examination.44 After this study, it became common practice to pan-scan many blunt trauma patients Although rapid and specific, it was soon recognized that patients were being exposed to high doses of ionizing radiation without much proven clinical benefit, as many of the identified injuries did not require intervention A study from San Antonio in a level I trauma center attached dosimeters to the neck, chest, and groin of the injured children When a patient underwent CT imaging of more than two body regions, the dose of ionizing radiation exceeded the dose normally associated with thyroid cancer or leukemia.45 A recent study demonstrated that using a more restrictive protocol for obtaining CT imaging reduced the number of CT scans obtained in a cohort of trauma patients without increasing missed injuries or mortality.46 With regard to using CT scanning in children, the pendulum is swinging back to the more restrictive use of CT scans in order to avoid excessive amounts of radiation to younger patients, who have a higher lifetime risk of developing neoplasms after radiation CT is an accurate diagnostic tool and has become an integral component of the evaluation of injured patients Although CT scans can be essential in the evaluation of many children, excessive use is discouraged because of the higher radiation exposure associated with CT scans; rare but important complications, such as contrast reactions; and added costs CT scans are a growing source of medical radiation exposure in children and may contribute to the occurrence of radiation-related malignancy, particularly when performed among younger children.47 The two most common body regions imaged with a CT scan in pediatric trauma are the head and abdomen/pelvis A noncontrast head CT is performed to assess for closed-head injuries and fractures that may require additional treatment, such as a depressed skull fracture The most common indication for a head CT scan after pediatric injury is a history of loss of consciousness or altered mental status A head CT scan may also be necessary for preverbal children whose injury was not observed or those who have received endotracheal intubation or are sedated, as they cannot be reliably assessed for a potential head injury.48–50 The Pediatric Emergency Care Applied Research Network consortium conducted a large multicenter trial, developing predictive rules derived to identify children at very low risk of clinically important TBI after blunt trauma for which a head CT scan may be unnecessary CT of the head could be avoided in children under years who have a normal mental status, no scalp hematoma except frontal, loss of consciousness less than seconds, nonsevere mechanism, no palpable skull fracture, and normal behavior Children years and older must have a normal mental status, no loss of consciousness, no vomiting, nonsevere injury mechanism, no signs of basilar skull fracture, and no severe headache These prediction rules had a sensitivity of 100% in children years old and younger and 96.8% in children older than years; negative predictive value was 100% for all ages (Fig 117.5).51 Recent emphasis on developing approaches to reduce the need for screening abdominal/pelvic CT scans in pediatric trauma continues to evolve Imaging is indicated when an injury is suggested by physical examination findings such as major abdominal wall ecchymoses or abdominal tenderness Among children who sustain a significant blunt injury but not have physical examination findings suggesting an abdominal injury, the yield of screening abdominal CT scans is low While focused abdominal sonogram for trauma (FAST) has been widely adopted as a diagnostic tool for adult trauma patients, its value in pediatric trauma is less certain FAST is focused on identifying fluid in four areas, the presence of which is suggestive of hemopericardium or intraabdominal injury: the pericardial sac, hepatorenal fossa, splenorenal fossa, and pouch of Douglas Current evidence suggests that the role of FAST for evaluating CHAPTER 117 Evaluation, Stabilization, and Initial Management After Trauma ≥2 yrs