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Child Health Guideline Identifier

Trauma

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Starship trauma system

Trauma at Starship hospital is managed by a multidisciplinary team. This includes (but is not limited to) members of the following services; CED, Paediatric Surgery, PICU, Paediatric Orthopaedics and Paediatric Neurosurgery.

Starship Hospital has:

Paediatric trauma call

Injured children meeting any of the below criteria will have 777 Paediatric trauma call activated.

DIAL 777   H = Hospital 
   E = Extension No. of Receiving Room 
   L = Location - Children's Emergency Dept and Receiving Room No. 
   P = "PAEDIATRIC TRAUMA CALL" stat or in x minutes

Activation criteria

  • Airway or Respiratory compromise
  • Signs of shock
  • Penetrating injures to head, neck, chest, abdomen or pelvis
  • Facial or tracheal injury (including burns) with airway compromise (or potential for)
  • Altered level of consciousness (as per AVPU) or GCS ≤ 12 without sedation
  • Suspected spinal cord injury i.e. with flaccidity, areflexia or unexplained hypotension
  • Amputation proximal to the wrist or ankle
  • Any trauma transfer with respiratory and/or haemo-dynamic instability and/or GCS < 8 without sedation or paralytics
  • Multiple paediatric presentations from the same incident.


The Trauma call team consists of:

  • CED SMO or Fellow (to be contacted by Shift Co-ordinator if after hours)
  • Emergency Department Registrar
  • Surgical Registrar
  • PICU Registrar
  • Paediatric Registrar
  • Emergency Department Nurses x 3
  • Radiographer
  • PAR nurse
  • Paediatric Trauma Nurse Specialist
  • Paediatric Surgical Consultant on call - to be contacted by Surgical Registrar via cell-phone

Note: a trauma call can be activated at any time at the discretion of the CED Consultant, Fellow, Shift Co-ordinator or Registrar. This may be on the basis of significant mechanism of injury, co-morbidities, physiology or other pertinent factors.

Trauma transfers

  • Stable trauma transfers <24 hours post injury
  • Surgical Registrar to attend and take handover of patient and arrange disposition.
  • CED Registrar, Fellow or Consultant will attend patient and take handover if Surgical Registrar unavailable. If patient is considered unstable on initial assessment, a paediatric trauma call should be activated.

Initial trauma management 

Preparation

In general, trauma patients meeting "Trauma call" criteria should be managed in the Resus area of CED. Possible exceptions are patients assessed immediately by CED consultant and regarded as stable enough to be seen in main department and patients attending during a mass casualty event.

  • The paediatric surgical service should be involved early in the management of patients with chest or abdominal trauma.
  • Staff roles will alter according to the expected clinical situation but it is expected that all patients received into Resus will have:
    Clearly identified team leader
    Two additional doctors
    CED 'medical' nurse
    CED 'surgical' nurse
  • Complex trauma patients will require additional support through additional nursing and medical personnel.

For further information on Resus team roles see Cardiopulmonary Resuscitation Guideline

Handover

  • Brief (<1 minute) handover from one pre-hospital provider while trauma team listens.
  • Mechanism, time of injury, injuries noted, vitals at scene, interventions provided and response to interventions.

Catastrophic external haemorrhage

  • Direct pressure or tourniquet should be applied immediately to visible sources of active haemorrhage to prevent ongoing blood loss whilst primary survey is carried out. Tourniquets are stored in the Resus storeroom in CED.

A  -  Airway and Cervical Spine

  • Whilst airway management needs to occur in conjunction with cervical spine cares, airway management should take priority.
  • Some children may arrive to the Department in a semi-rigid collar. These should be removed at the earliest safe opportunity.
  • Unless the cervical spine is cleared, in-line stabilisation of the cervical spine should be provided by an assistant.
  • Airway management may involve suctioning, foreign body removal, jaw thrust, airway adjuncts, oro-tracheal intubation or surgical airway.
  • Suction and other airway clearance manoeuvres should be completed under direct vision where possible.
  • Indications for intubation in trauma patient
    Airway or breathing compromise (present or predicted)
    Unprotected airway
    GCS < 9
    Combative or uncooperative patients not able to be managed using analgesia and non-pharmacological techniques
  • Examine and investigate for possible cervical spine injury as indicated
  • Attempts to immobilise the head may increase leverage on the neck in an uncooperative patient and senior medical advice should be sought in this situation.
  • Red sandbags should be placed on either side of the head and a yellow lanyard placed around the neck in patients who have not had the cervical spine cleared.

B  -  Breathing 

  • Administer high flow oxygen
  • Assess:
    Effort of breathing
    Respiratory rate, recession, accessory muscle use, nasal flare, additional sounds.
    Efficacy of breathing - Chest expansion, abdominal excursion, breath sounds, percussion
    Effects of inadequate respiration - Heart rate, skin colour, mental status
  • If causing respiratory or cardiovascular compromise the following conditions should be managed as part of the primary survey:
    Tension pneumothorax
    Massive haemothorax
    Flail chest
    Sucking chest wound
    Pericardial tamponade

C  -  Circulation

  • Attach cardiac leads, oxygen saturation probe and appropriate sized BP cuff
  • Peripheral vs central pulses
  • Capillary refill times - peripheral vs central
  • HR and rhythm - compared to age appropriate normals
  • BP - compared to age appropriate normals
  • One IV line is usually sufficient
    Two IV lines are likely to be required for patients:
    Requiring intubation
    Requiring fluid resuscitation
    With injuries involving > 2 body regions
  • Trauma Bloods may be required:
    FBC, U and E, glucose, LFTs, amylase, coags
    Group and hold or cross match
  • Fluid resuscitation
    10-20ml/kg boluses are recommended (APLS) for initial resuscitation
     Blood should be considered early and used if patient remains unstable or actively haemorrhaging despite measures to control this
  • If patient is cardiovascularly unstable consider tranexamic acid use (see below) and consider activating the Massive Transfusion Protocol

    APLS Diagram

D  -  Disability

  • Assign GCS (assistance with this can be found on nursing documentation sheet)
  • Check pupils
  • Check ears for haemotympanum
  • See Head Injury guideline
  • Check blood sugar

E  -  Exposure

  • Remove clothing (except underwear) and briefly inspect abdomen and limbs
  • Maintain optimal body temperature
  • Formal assessment occurs during the secondary survey

Further trauma management

History

A         Allergies

M        Medications (especially anticoagulants, insulin and cardiac medications)

P         Previous medical/surgical history

L         Last meal (Time)

E         Events/Environment surrounding the injury (exactly what happened)

Analgesia

Analgesia is very important in paediatric trauma. Early use of appropriate analgesia will make assessment of the child more accurate and will reduce distress associated with cervical spine immobilisation and other procedures.

Non-pharmacologic measures are important; this includes caregiver presence, explanation and distraction.

The most appropriate analgesia in this setting is IV morphine (0.1mg/kg) (Morphine administration) and/or regional block (e.g. femoral nerve block) (Local Anaesthetic for Minor Procedures)

Radiology

  • Radiology is not 'routinely' required.
  • Chest X-ray if respiratory distress, chest contusions, history of impact to chest or other indicators of chest pathology.
  • Chest X-ray would also be indicated post-intubation to check ETT placement, chst drain placement and perhaps NG/OG position if concerns.
  • Pelvis X-ray only if clinically indicated by mechanism and examination findings.
  • Lateral cervical spine views in the Emergency Department are almost never indicated and not very helpful. If the trauma team suspects a cervical spine injury, maintain cervical spine protection and obtain imaging by a cervical spine series (Lateral cervical spine,AP and open mouth views +/- swimmers) in the Radiology department or a CT scan.

Tranexamic Acid

  • Anti-fibrinolytic drug which has been shown to reduce overall mortality in cardiovascularly unstable, bleeding adult trauma patients.  It's use in paediatric trauma is extrapolated from adult trauma experience and use in elective paediatric cardiac and spinal surgery (until further evidence is available from randomised controlled trials).
  • It should be given as early as possible and/or within 3 hours of the injury.
  • Indications for use:
    - Cardiovascular instability with ongoing active bleeding
    - Massive transfusion requirement
  • Dosage:
    - Loading dose :15mg/kg (max 1g) over 10 minutes - Dilute to 20mL of 0.9% NaCl or 5% Glucose
    - Maintenance infusion: 2mg/kg/hr for the next 8 hours. Dilute 500mg in 500ml of 0.9%NaCl or 5% Glucose (i.e. 1mg/ml)
  • Note:
    - Its use via an intraosseous route has not been studied, however the pragmatic approach would be to administer via this route if no other access is available.
    - It may cause hypotension if given rapidly

Abdominal trauma

  1. The organs within the abdomen in children are at increased risk of injury due to the large surface area and the decreased muscle mass of the abdominal wall.
  2. Mechanism of injury is a useful guide to the probability of abdominal injury. Abdominal examination is accurate 50% of the time but certain signs are very useful e.g. seat belt sign, handlebar sign, peritonism.
  3. Examination can be challenging but distraction, analgesia and reassurance along with caregiver proximity can assist with assessment. Repeated clinical examination is important
  4. Gross haematuria indicates renal trauma but associated injuries eg to liver or spleen are also likely.
  5. Microscopic haematuria is not an indication for CT scan, but may be associated with other injuries. Treat the patient on clinical grounds. If a CT scan is not indicated acutely on clinical grounds, microscopic haematuria following trauma is an indication for a renal ultrasound either completed before discharge from hospital or as an outpatient - this is to rule out a pre-existing renal anomaly that may have been unmasked by the traumatic event.
  6. CT scanning is currently the modality of choice for children with suspected abdominal trauma. Aim for ALARA principles - As Low As Reasonably Achievable. Request a CT scan only if clinically indicated. Scan only the regions indicated (no "pan-scans"). Avoid radiation to the thyroid, breast and pelvis if practical ("ALARA"). Radiology team to use the lowest dose achievable for an adequate scan.
  7. LFTs are often interpreted as abnormal if AST>200 U/L and/or ALT>125 U/L (Odds Ratio for liver injury 17.4). Abnormal LFTs alone are not an indication for CT scan.

eFAST

Most research regarding e FAST (Focused Assessment with Sonography for Trauma) pertains to adults. There are few randomized clinical trials involving children. The use of FAST in haemodynamically stable children following blunt abdominal trauma has a low sensitivity for detection of intraabdominal injury. Its use has not been shown to improve clinical care (use of resources, length of ED stay or missed abdominal injuries) when compared with standard care.

Secondary Survey

Head to toe examination

  • Head: check scalp, face, teeth, mandible, eyes 
  • Neck: use red sandbags (use in-line stabilisation of neck) and feel for tenderness and steps in the midline 
  • Upper limbs 
    - Inspect and feel clavicles, shoulders and arms for swelling and tenderness. 
    - Check joint movement. Check power.
  • Repeat examination of chest 
  • Examine abdomen 
  • Inspect urethral meatus for blood in male 
  • Check pelvis stability 
  • Lower limbs 
    - Inspect and feel thighs, lower limbs and feet for swelling and tenderness.
    - Check joint movement. Check power.
  • Log roll (whilst maintaining cervical spine immobilization if needed). A minimum of four people are required. 
  • PR exam is not routine in paediatric trauma patients. Asking a child to squeeze his/her buttocks should suffice. 
  • Be mindful of hypothermia and cover patient when secondary survey complete 
  • A urine sample should be collected if concerns about abdominal or pelvic trauma

Pelvic fractures

  • Are uncommon in paediatric trauma and have a much lower mortality and morbidity than adults 
  • If the patient is cardiovascularly 'unstable' (not normal haemodynamics), look for other sources of blood loss.
  • If the pelvis is mechanically unstable, consider placing a pelvic binder and seek an urgent orthopaedic review.

Disposition

  • The paediatric surgical team should always be involved in the care of major trauma patients. It is usual for multi-system trauma to be admitted under the paediatric surgical team with input from other subspecialties as required. It may be appropriate to admit a trauma patient to another service (e.g. neurosurgery or orthopaedics) if they do not have multi-system injuries (this decision should be made in conjunction with the paediatric surgical team). 
  • PICU should be consulted early in cases with airway difficulties, cardio-respiratory instability or severe head injury. 
  • Intubated patients requiring CT scan are usually transported by the PICU team. 

Tertiary survey

  • A tertiary survey should be performed on all patients admitted with an injury under the care of the Trauma service.
  • The survey should ideally be performed by a member of the Trauma service within 24-72 hours of admission
  • The survey can be performed whilst hte patient is in PICU as soon as patient status permits, or otherwise within 48 hours of transfer to the ward.

Injury prevention

Injury (intentional and unintentional) is the leading cause of paediatric mortality. The mortality and morbidity associated with injury is best avoided by preventing the injury.

From IPRU: Data Source: Mortality and Demographic Data 1994-2000, NZHIS, Ministry of Health.

  • Injury prevention should be a consideration when interacting with all caregivers and children in CED. Further information can be found in resources in CED. 
  • Proven injury prevention interventions that should be strongly advocated for include: 
    - Swimming pool fencing
    - Bicycle helmets
    - Reduced vehicle speed limits
    - Motor vehicle restraint systems (seatbelts and airbags)
    - Child car seats and booster seats
    - Child resistant packaging (reducing unintentional poisoning)
    - Smoke alarms
    - Motorbike helmets
    - Playground modification
  • Hospital staff involved in the management of trauma patients can be strong advocates for injury prevention. Injury prevention related research can be undertaken in conjunction with Starship's Children's Trauma service and Safekids New Zealand. 

Children's Trauma service:
Mr James Hamill jamesh@adhb.govt.nz
Dr K McCarthy karenmcc@adhb.govt.nz
Matt Sawyer msawyer@adhb.govt.nz
Safekids New Zealand www.safekids.org.nz

References

  1. Royal College of Paediatrics and Child Health. Evidence Statement: Major Trauma and the use of tranexamic acid in children. November 2012
  2. CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events and blood transfusion in trauma patients with significant haemorrhage(CRASH-2): a randomised, placebo controlled trial. The Lancet - 3 July 2010 (Vol 376, Issue 9734, pgs 23-32)
  3. CRASH-2 trial collaborators. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASG-2 randomised controlled trial. The Lancet - published online March 24, 2011
  4. Napolitano et al. Tranexamic Acid in Trauma: How should we use it? Journal of Trauma and Acute Care Surgery 2013; Vol 74, no 6 pp1575-1586
  5. Holmes James F et al. Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children With Blunt Torso Trauma A Randomized Clinical Trial JAMA. 2017;317(22):2290-2296
  6. Bennett W. Calder Bennett W et al. Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multiinstitutional analysis Journal of Trauma and Acute Care Surgery. 83(2):218-224,AUG 2017
  7. Rees MJ. Aickin R. Kolbe A. Teele RL. The screening pelvic radiograph in pediatric trauma. [Journal Article] Pediatric Radiology. 31(7):497-500, 2001 Jul.
  8. Holmes JF, Sokolove PE, Brant WE, et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med 2002;39(5):500-9.
  9. Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Ped Surg 2007;42:1588-94.
  10. Wisner DH, Kuppermann N et al. Management of children with solid organ injuries after blunt abdominal trauma. J Trauma Acute Care Surg 2015; 79: 206-214
  11. Shlamovitz GZ et al. Lack of evidence to support routine digital rectal examination in pediatric trauma patients. Pediatr Emerg Care 2007;23(8):537-43.
  12. American Academy of Pediatrics. Management of Pediatric Trauma. Pediatrics 2008;121:849-54.
  13. Advanced Paediatric Life Support manual (Sixth Edition). July 2016 Wiley Blackwell Publishing
  14. ATLS manual 10th edition.

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Document Control

  • Date last published: 27 November 2018
  • Document type: Clinical Guideline
  • Services responsible: Children’s Emergency Department
  • Author(s): Mike Shepherd, Karen McCarthy
  • Editor: Greg Williams
  • Review frequency: 2 years

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