Serious injury

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full PCH Emergency Department disclaimer.

Aim 

To guide PCH ED staff with the assessment and management of serious injury.

This guideline gives an overview of the approach to the seriously injured child including the primary and secondary survey. 

Background

• Trauma/serious injury is a leading cause of death in children in Australia
• Early ABC interventions improve morbidity and mortality secondary to major trauma
• A trauma team approach should be used to manage seriously injured children
• Activate a ‘Trauma Call’ for all major trauma patients – see Major trauma management pathway.

Key points

• The main causes of serious injury in children are due to motor vehicle accidents and falls
• Injury prevention is the biggest factor in reducing trauma mortality but unfortunately children still continue to be injured
• Primary assessment and early ABC interventions will avoid some deaths and prevent late complications in children involved in major trauma
• At PCH, a trauma team consisting of staff from the Emergency Department, Paediatric Intensive Care Unit (PICU), surgical and anaesthetic teams manage major trauma as defined by mechanism of injury and physiological parameters
• This multidiscplinary trauma team will follow a structured approach to manage seriously injured patients
• This structured approach initially focuses on identifying and treating immediate threats to life – the primary survey
• Following this initial primary survey and resuscitation, the structured approach is again used as a secondary survey to identify other key injuries which require emergency treatment to stabilise the patient and prevent secondary insult
• It is recommended that all healthcare workers who work with injured children undertake an Advanced Paediatric Life Support (APLS), Emergency Management of Severe Trauma (EMST) course or similar to provide the skills needed to assess and manage seriously injured children.

Assessment

• A structured, systematic approach is essential when assessing seriously injured children
• Primary survey using an 'ABCD' approach is a simple and highly effective method in major trauma.
• Assume cervical spine injury in all trauma patients
• Treat problems immediately as thay are found during the primary survey, before moving on.

History

• A detailed history of the incident should be sought including:
  • Mechanism of injury
  • Time of injury
  • Other fatalities
  • Obvious injuries
  • Pre-hospital treatment

Primary survey

• The primary survey involves a rapid structured assessment of Airway, Breathing,Circulation, Disability and Exposure.
• Treat life threatening issues immediately as they are discovered during the primary survey before moving on.

Airway and C-spine
Assume C-spine injury in any major trauma patient  Immobilise C-spine in a hard collar or manual in-line immobilisation
Assess airway patency and signs of obstruction: Stridor Stertor Hoarse voice Bruising and swelling	Resuscitation Suction if necessary Jaw thrust (head tilt is contraindicated if there is suspicion of c-spine injury) Oropharyngeal airway (nasopharyngeal airway contraindicated if there is suspicion of a base of skull fracture) Endotrachael intubation Surgical airway

Breathing and Ventilatory Support
Fully expose the neck and chest Look, listen and feel Provide oxygen via a non-rebreather mask with a reservoir
Assess Bruising, wounds Symmetry of chest expansion Trachea midline? Rate effort - nasal flare, recession, accessory muscle use Air entry Oxygen saturation Percussion note Effects - heart rate, skin colour, mental state	Urgently exclude and treat: Airway obstruction Tension pneumothorax 16 gauge needle into second intercostal space if suspected tension pneumothorax Open pneumothorax 3 way occlusive dressing (while preparing for drain) Massive haemothorax Flail chest Support Ventilation  Bag valve mask ventilation  Intubation and positive pressure ventilation  Consider an orogastric tube 16 gauge needle into second intercostal space if suspected pneumothorax 3 way occlusive dressing for tension pneumothorax (while preparing for drain)

Circulatory And Haemorrhage Control
Control obvious external haemorrhage - apply pressure
Assess Obvious external haemorrhage Distended neck veins Muffled heart sounds Signs of shock Heart rate Pulse pressure Skin colour Mental state	Exclude and treat Cardiac tamponade Shock Resuscitation  Two large bore cannulae (take blood for FBC and cross match) Fluid resuscitation - 10mL/kg of 0.9% saline and repeat if necessary Blood if haemodynamically unstable Massive transfusion protocol if ongoing blood loss Surgical intervention to stop internal bleeding (chest, abdomen, pelvis)

Disability and Prevention of secondary insult
Hypoxia and shock can cause a decrease in conscious level Any ABC problem is to be addressed before assuming a primary neurological problem
Assess level of consciousness, pupils, posture and blood glucose.  Conscious level - AVPU scale Pupil size, symmetry and reactivity Abnormal posturing (decorticate, decerebrate) Seizure activity Bedside glucometer reading	Resuscitaion  Response to Pain or Unresponsive - consider intubation  Treat raised intracranial pressure - 20% mannitol 2.5-5mls/kg IV over 20 mins or 3% saline 3 ml/kg slow IV push Correct hypoglycaemia - 2mL/kg of 10% glucose intravenous Treat seizures

Exposue and Temperature control
Fully expose child and assess temperature and signs of injury Check core temperature Don't forget to log roll and check back for injuries	Prevent hypothermia

Investigations

• Take blood for FBC, UEC, LFT, lipase,venous blood gas and Group & Hold or Cross Match
• Trauma series X-rays – c-spine, chest, pelvis
• If concerns re abdomenor pelvis - need CT 
• Do CT neck rather than XR if doing a CT head
• Other adjuncts to the primary survey include FAST scan, orogastric tube and bladder catheterisation.

Management

Further management

Secondary survey

• A secondary survey is performed after treating any life threatening conditions detected during the primary survey
• The secondary survey should be abandoned to repeat a primary survey if there is any deterioration in the patient’s condition
• The secondary survey involves a head to toe and front to back examination to detect any non-life threatening injuries which require further management
• Further investigations and management will be determined by injuries found on secondary survey, e.g. specific limb X-rays, CT scans etc.

Medications

• Analgesia
• Tetanus prone wounds
• Consider antibiotics. 

Admission criteria

• All major trauma should be admitted under the general surgical team (which at PCH is the Trauma Team)
• Other surgical subspecialty involvement will be determined by the injuries sustained.

Management paperwork

• All major trauma patients should have documentation done on an ED Trauma Sheet. These are A3 folded forms, located in the Resuscitation Bay and Doctor’s offices.

Bibliography

1. Advanced Paediatric Life Support: The Practical Approach. 5th ed Australia and New Zealand Version. Wiley-Blackwell, 2011.
2. Textbook of Pediatric Emergency Medicine. 6th ed. Fleisher GR, Ludwig S. Philadelphia: Lippincott Williams & Wilkins, 2010.
3. Teppas JJ Paediatric Trauma TRAUMA 5th edition 2004 McGraw Hill Companie
4. Textbook of Paediatric Emergency Medicine 2nd Edition Cameron Elesevier 2012

Endorsed by:	Director, Emergency Department	Date:	Feb 2018
		Review date:	Feb 2021

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