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Liverpool Hospital does not have paediatric ICU facilities, therefore seriously injured children are to be given definitive primary treatment here and then transferred to Westmead for further care. Transfer can be arranged by ringing the paediatric ICU registrar on (02) 9845 0000 The injured child differs from the injured adult in many respects 1. Size and shape - a child is a smaller target, hence the force is dissipated over a smaller area 2. Skeleton - the bones are incompletely ossified and are hence more elastic. Internal organs can therefore be damaged without overlying bony fracture. 3. Surface area - the surface area: volume ratio is higher, thus heat loss is greater and hypothermia develops more quickly PRIMARY SURVEY AIRWAY The cervical spine tends to passively flex in children due to the relatively large head, closing off the pharynx. This is best prevented by supporting the head in the 'sniffing' position whilst protecting the cervical spine. In the infant the larynx may be difficult to visualise because the tongue is relatively large, and in children the larynx has a more antero-caudal angle making intubation difficult. The trachea is 5cm long in an infant, growing to 7cm by the age of 18 months Guedel Airway - should not be inserted backwards then rotated - this can damage soft tissues. Insert directly using a tongue depresser as a guide. Intubation - use an uncuffed tube of appropriate size. The diameter of the nostril or little finger is a good guide. The tube should be positioned 2-3cm below the cords. Cricothyroidotomy - is rarely indicated. Needle cricothyroidotomy is the preferred method, but is a temporary measure. BREATHING Because of the elasticity of the ribs, there may be significant lung injury without overlying fractures. Smaller sized chest tubes are available for children, but the rule of inserting the largest size possible still applies. CIRCULATION Children have an increased physiological reserve and may therefore be shocked with only subde changes in vital signs. The primary response is tachycardia, but tachycardia is also caused by anxiety and pain. Vital signs vary with age:
For fluid resuscitation the initial fluid bolus is 20 ml / kg of crystloid, which can be repeated 3 times, ie up to 80 ml /kg. If blood transfusion is necessary, 10 ml / kg of blood should be given initially. If a child with a suspected liver or spleen injury requires blood in excess of this figure for haemodynamic stability, an immediate laparotomy should be considered. Venous access may be difficult in children, so consider an intraosseous infusion. It is indicated in a child of six years or younger in whom attempted cannulation has failed twice. The preferred site is the anterior tibial plateau, 2-3cm below the tibial
tuberosity. If the tibia is fractured, the inferior part of the femur, 3cm
above the external condyle is an alternative. An intraosseous needle (available
in Emergency and Theatre), is inserted at right angles to the bone, bevel
up. Aspiration of marrow confirms correct placement. Crystalloids, blood
products and all drugs except Bretylium can be administered. CHEST TRAUMA The child's chest wall is very compliant so energy may be transmitted to intrathoracic structures without causing rib fractures. Tension pneumothorax, haemopneumothorax and flail segments are not well tolerated, due to the mobility of the mediastinal structures. Bronchial injuries and diaphragmatic ruptures are more common than in adults, great vessel injuries are less common. ABDOMINAL TRAUMA Almost all children who are anxious will swallow air, so the stomach should be decompressed prior to examination The indications for DPL and interpretation of the results are the same as for adults. Ringers lactate should be infused at a rate of lO ml / kg up to a maximum of lOOOml. CT scanning may be preferable if the child is haemodynamically stable. Injuries to the liver and spleen can often be managed conservatively, but the decision rests with the surgical VMO. HEAD TRAUMA Children generally recover better than adults, but children <3yrs have worse outcomes than older children. Unlike adults, infants can become hypotensive from blood loss due to head injury. An open fontanelle will bulge when ICP rises. Most children vomit after a head injury. Persistent vomiting is an indication for CT scan The Glasgow Coma Scale was not developed for use in children. Paediatric modifications have been proposed, but none is ideal. SPINAL CORD INJURY Rare in children, but more commonly associated with absence of radiographic abnormality
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