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Trauma - initial management in PICU

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General Points

  1. Trauma is the leading cause of mortality in children>6 months
  2. Ask about mechanism of injury including height of fall (>3m), GCS at scene, protective restraints and resuscitation required.
  3. Falls, MVA, pedestrian injury and drowning are most common
  4. Head injuries are likely due to weak neck control, relatively large head and increased risk of being thrown.
  5. Most abdominal trauma is treated conservatively
  6. A rapid, co-ordinated multidisciplinary approach is required.

Investigations

Bloods FBC / electrolytes / amylase/ liver function tests / urgent crossmatch
XR C Spine/ Chest / Pelvis
CT C Spine if unconscious, chest, abdo if indicated

Management

Primary survey

Airway
100% 02 in all cases
J
aw thrust (no head tilt) if obstructed upper airway
Suction to remove foreign bodies
Oropharyngeal airway
Intubate if GCS<8 or rapidly fluctuating LOC
upper airway obstruction/ major facial trauma
chest trauma, inhalational burn
need for prolonged/ controlled ventilation (head injury)
Intubation: preoxygenate, inline stabilisation, oral ETT, fluid anaesthetic gas induction if airway obstruction
Surgical Airway if unable to intubate
Breathing
Ventilate to normal pO2 and pCO2.
Circulation
Two large cannulae (intraosseous if necessary)
Saline/ colloid bolus 20/kg and repeat as necessary.

Transfuse if blood loss or high fluid requirement (O neg if urgent)
Titrate to heart rate, urine output
Drugs and Disability
Determine pupil size, reactivity and conscious state:GCS, AVPU
Morphine: titrate to pain: 0.05-0.1 mg/kg
Exposure
Maintain normothermia

Secondary survey

Expose patient, comprehensive regional review all body parts

Glasgow Coma Scale (GCS)

Glasgow Coma Scale  
Eye opening Motor response Verbal response
4 spontaneous 6 obeys commands  5 orientated 
3 to voice  5 localises to pain  4 confused 
2 to pain  4 flexion withdrawal  3 inappropriate 
1 no response  3 abnormal flexion  2 incomprehensible
  2 extension  1 no response
  1 no response   

AVPU

AVPU (for children under 2 years old) 
Alert   
Responds to Voice   
Responds to Pain  purposeful - localises 
non-purposeful - withdrawal, abnormal flexion or extension 
Unresponsive   

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Document Control

  • Date last published: 31 October 2005
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit
  • Owner: Brent McSharry
  • Editor: John Beca
  • Review frequency: 2 years