Saturday, June 12, 1976. 4:10 p.m.
All is quiet in the Emergency Department.
Suddenly, the radio cracks:
Medical 3: "We are bringing in a six-year-old-boy struck by an automobile. He has possible fractures of the right femur and compound fracture of the left tibia and fibula. Profuse bleeding from laceration of the scalp. Comatose. Respirations are 50 and shallow. Blood pressure: 90/60. Pulse is weak and thready."
Hospital: "Medical 3, have you started an I.V.?"
Medical 3: "Negative."
Hospital: "Go ahead with the Ringer's lactate."
Medical 3: "QSL our ETA 5-6 minutes."
Hospital: "QSL - KCW 36 - Clear." *
As a physician, you will be dealing with a seriously injured child. How will you approach the problems?
The Emergency Department doors swing open, and the rescue unit brings in the injured child. Remember your ABCs!
The ABC sequence should always be started as quickly as possible. It should be performed in the order shown. There must be a maximum sense of urgency in starting basic life support. Only seconds should intervene between recognizing the need and starting the therapy.
The primary aim of emergency care is to save a life. This is accomplished by the support of ventilation and circulation in an orderly fashion. Remember, you have only a few precious minutes. The secondary aim is to restore the child to a normal life.
Management of ventilation requires bold and decisive action. When confronted with a child whose respirations have ceased, you must start mouth-to-mouth resuscitation while the ' emergency department personnel locate the appropria te -size mask-bag unit. The face is often bloody and covered with sour vomitus. If no suction is readily available, wrap a corner of the sheet around your finger to clean the mouth and clear the airway. Every minute counts. In the infant and young child, both the nose and mouth may be encompassed by the resuscitator's mouth. In older children, when using mouth-to-mouth resuscitation, be sure to pinch the nose. When the correct-fitting mask-bag unit has been located, breathing may be continued with the use of this unit.
1. Breathe for a school-age child 20 times per minute.
2. Breathe for a preschooler 30 times per minute.
3. Breathe for an infant 40 times per minute.
Oral airway. Evaluate the patient's breathing without an oral airway. Positioning of the head and jaw is all that may be required for breathing to resume spontaneously. The neck of the infant or child is so pliable that forceful backward tilting of the head may obstruct breathing passage: therefore the tilt position should not be exaggerated. If an oral airway is required, use one of appropriate size for the child. Remember that placing the airway into an unconscious or stuporous child may promote vomiting or laryngospasm. If the child is breathing spontaneously, oxygen may be administered by nasal cannula. Oxygen does not cure anything. If the child needs oxygen, find and treat the cause.
Intubation. Do not hurry to intubate. In most instances, the mask-bag unit is all that will be required. If the child requires intubation, a minute of hyperventilation with 100 per cent oxygen should precede the attempt at passing of the endotracheal tube. Have an assistant use a stopwatch to see how long it takes to pass the endotracheal tube. If it is longer than 30 seconds, stop and ventilate the child for a minute before resuming.
In intubation the most common error is improper positioning of the head. Often a well-meaning assistant will raise the child's shoulders off the table while the physician is on his knees looking up! Proper positioning of the head will avoid this (Figures 1 and 2). To position the head, the neck is flexed on the trunk and the head is extended on the neck - the "sniff" position. The occiput must be higher than the shoulders. I usually place a folded towel under the occiput and have an assistant hold the shoulders on the stretcher. This assures that the occiput will be higher than the shoulders.
Once the airway is visualized, you will need the proper-size endotracheal tube. Since every child carries with him, in plain view, an orifice that tells you what size endotracheal tube to use - the nose - you do not need to memorize a table. Any tube that will pass into the extemal nares will pass into the larynx. After you have selected the correct tube, place it through the mouth. In young infants, by palpating the trachea, you may feel the tube pass beneath your fingertips. Advance the tube another centimeter, and secure it to the upper lip and face. Do not secure the tube to the lower lip and jaw, because the motion of the tongue and jaw may easily displace the tube.
Figure 1. This demonstrates the correct position for intubation with the occiput higher than the shoulders - the "sniff" position.
Figure 2. This demonstrates the head lower than the shoulders, with the anterior convexity of the cervical spine making it difficult to intubate.
Auscultation of both lung fields should reveal equal aeration and movement of both chests; if not, you may have intubated the right mainstem bronchus. Back the endotracheal tube out. A chest x-ray will confirm the position of the tube above the carina. Once the patient is intubated, someone else can take over the task of ventilation, allowing the physician to continue his examination and treatment of the child. By this time the anesthesiologist or nurse-anesthetist will be on hand to help, or the inhalation therapist may be there to assist in placing the child on a mechanical ventilator if necessary.
To better assess the adequacy of respiration, arterial blood gases should be drawn. If you are unable to cannulate an artery, a capillary or venous sample will give you some indication of acid-base balance. Look for a respiratory or metabolic defect. Sodium bicarbonate is indicated for metabolic acidosis. Ventilation will reduce the pCOfe and correct the respiratory acidosis. A danger here is excessive use of sodium bicarbonate; with correction of the hypoxia and acidosis by ventilation, you may swing back too far to alkalinity. Go slowly. Inject 1 ml. of sodium bicarbonate per pound of body weight (1 mEq./ml.) as your initial dose. Repeat arterial blood gases, and reevaluate.
COMMONLY USED DRUGS FOR INFANTS AND CHILDREN
Gastric distention. In children, artificial ventilation frequently causes gastric distention. This is most likely to occur when excessive pressures are used for inflation or if the airways are obstructed. The overdistended stomach may be dangerous, because it promotes vomiting and aspiration and reduces the lung volume by elevating the diaphragm. To prevent this complication, a large nasogastric tube should be passed as soon as possible.
Stop external bleeding by direct pressure to open wounds with sterile dry pads everywhere except over a sucking wound of the chest, which you would first cover with a Vaseline gauze. If pressure does not control the bleeding, go to a pressure point. A tourniquet should not be necessary. If need be, extend the wound and clamp the bleeder. The wound can be tended to later. Unrecognized bleeding is the most common cause of preventable death in trauma. The obvious areas of blood loss, such as serious lacerations or fracture, are often assumed to be the only area of blood loss. Continue your evaluation, and consider the possibility of internal bleeding.
Shock. In a recently injured child, shock is almost always the result of blood loss. If the child is in shock, you can assume he has lost onequarter of his blood volume but no more than three-quarters of the total blood volume. We further know that blood pressure will not drop until approximately one-fourth of the blood volume is lost. To calculate the blood volume of anyone, you may use 40 ml. /Ib. (75 ml./kg.). Shock requires a Foley catheter to monitor urine flow. Start intravenous administration using the largest cannula possible.
The best solution for restoration of blood volume is Ringer's lactate. Do not use a hypotonic solution, such as Pediatric Maintenance, which is intended for use in the newborn.
Now give 10 ml./lb. (20 ml./kg.) of Ringer's lactate solution. Administer this as fast as possible. Push it in. This amount will not overload the child. Slow administration of blood or crystalline fluid may allow the patient to bleed as fast as it is put in; therefore, you might give unit after unit and never restore the blood volume. The most common treatable reason for continued shock is insufficient replacement. The other treatable reason is continued internal bleeding. Too little too late may lead to irreversible shock. The primary difference between reversible shock and irreversible shock is time. Work quickly. Check blood pressure and pulse. They may return to normal and stay there, or the blood pressure may gradually drop. This gives you an indication of continued bleeding and the rapidity with which it is occurring. If 10 ml./lb. (20 ml./kg.) or one-quarter blood volume does not restore vital signs, give another 10 ml./lb. (20 ml./kg.).
If the second bolus of crystalline solution has not restored the blood pressure, you can assume that there is massive bleeding, most probably within the abdomen. Paracentesis is indicated.
Paracentesis. Suspect intra-abdominal bleeding in (1) head injury, (2) pelvic fractures, (3) rib fractures, or (4) hematuria.
Use a plastic percutaneous intravenous catheter. Tap midway between the umbilicus and the midaxillary line, first on the right side and then on the left. If no blood is aspirated, leave the catheter in place. Infuse normal saline 10 ml./lb. Allow this solution to return in your syringe. This will increase the accuracy of the simple abdominal paracentesis to about 70 to 90 per cent; 50,000 RBCs/HPF indicates bleeding and need for abdominal exploration. If blood was aspirated on the first insertion of the catheter, let it stand in the syringe and check for clotting. The presence of a clot may indicate that a vessel was entered.
Blood. At some point, crystalline solution will not do. The child will need hemoglobin to carry oxygen. In an urgent situation, do not use O-negative blood. Contrary to popular opinion, this is not the universal donor. For a complete explanation of this, talk to your hematologist. Give type-specific blood; i.e., an Af child will receive Af blood. The initial type and cross-match should be 20 ml. of whole blood per pound. Typing takes a few seconds but will lessen future hematologic complications.
Cardiac arrest. In case of cardiac arrest, closed cardiac massage will usually give adequate circulation. Massage the heart 60 to 80 times per minute. Have someone check the femoral pulse. Be certain that with every compression a pulse is palpable. If closed chest massage does not provide circulation, open the chest. Obtain an ECG as soon as possible. When the child is ventilated and has a blood pressure, continue with emergency care. The crisis is over.
The more sophisticated technique of monitoring central venous pressure and arterial pressure and blood gases should not be reserved for adults but should be used on every seriously injured child in addition to the cardiac monitor. Where applicable, Swan-Ganz catheters should be used.
Approach every injured child as though he has more than one injury. Do not let obvious surface wounds and fractures distract you from a thorough search for internal injuries. The badly deformed or partial amputations of extremities are easily recognizable and are usually the first to be treated. There is no doubt that these injuries should be cared for; before proceeding with x-rays, however, let us turn our attention to the primary problems in the evaluation of the child:
1. Does an injury exist?
2. How severe is the injury?
3. Is surgery necessary?
Intra-abdominal bleeding is a major cause of death and may be obscured by associated neurologic trauma and lack of external findings. The fear and apprehension shown by the injured child may make it difficult to assess the injury. In the absence of central nervous system injury, you may use a short-acting barbiturate, such as pentobarbital (Nembutal®) or secobarbital (Seconal®), 1-1.5 mg. /Ib. administered intramuscularly. This will enable a tense and frightened child to relax in 20 or 30 minutes. It will not mask true abdominal tenderness.
History. Obtain a history of the injury. Unfortunately, the rescue unit is often the only historian you have. Try to determine the nature of the injury; estimate the force involved, and determine whether it was a crushing or a shearing force and what part of the body was injured.
Physical examination. Inspect for obvious signs of injury. Palpate. Assess for the evidence of a mass, crepitation of subcutaneous air, and presence or absence of localized or generalized tenderness rather than eliciting so-called rebound tenderness. Now is the time to insert the nasogastric tube, using a large tube. Connect to intermittent suction. Aspirate for stomach contents, and check for blood. To prevent the necessity of repeated irrigation of the nasogastric tube with normal saline, ventilate the tube with a #25 needle.
Measure and record abdominal girth. Do this at regular intervals. This may be an early indication of intra-abdominal bleeding if the size of the abdomen continues to expand.
A Foley catheter is now in order. Check for the presence of blood. If blood is present, proceed with an infusion pyelogram. Mix 1 ml./Ib. of body weight of sodium diatrizoate (Hypaque®) with an equal amount of saline and infuse rapidly - i.e., all within three to four minutes. Expose the first film just as the last of the contrast material is administered. With an infusion pyelogram, a single exposure may give you the answers you need. When possible, of course, you should follow it with the five-, 10-, 20-, and 30-minute films. If there is no visualization of one of the kidneys, go ahead with an arteriogram or a renal scan to see if there has been a tear of the renal artery. A cystogram is usually not necessary if an infusion pyelogram is performed.
Serum amylase. Do not let an elevated amylase deter you from exploring a tender abdomen. A serum amylase test is advisable in upper abdominal injuries, particularly those involving the epigastrium. Mild elevation is usually insignificant and returns to normal in three or four days. Elevation above four times the normal level may point to a pancreatic injury or to perforation of the duodenum or jejunum, with leakage of intestinal juices into the peritoneum. More than the pancreas may be injured. Explore.
CBC. Leukocytosis may indicate hemorrhage. Repeat hematocrit at one- to four-hour intervals. Reevaluate.
Now that the crisis situation is past and the child appears to be stable, do not be lulled into a sense of security. Repeated examinations will be necessary to uncover significant internal injuries, such as a subcapsular hematoma of the spleen or liver that gives rise to continuous slow bleeding and may not show signs or symptoms until several hours after the time of injury. The first chest film may be within normal limits. A film several hours later may show the characteristic infiltrates of pulmonary contusion. Arterial blood gases may change before demonstrating other physical signs or symptoms of metabolic or respiratory deficiencies.
The primary physician who cares for the multiply injured child must be familiar with the special needs of infants and children. They are not little adults. Dosages of medications differ; these children have special needs to meet for growth and development, and special psychologic needs.
In dealing with the very young, do not give up too soon, especially with central nervous system injury. Many of these children have the ability to make a "miraculous" recovery, with little or no residual damage.
I would like to make a special plea for the early use of hyperalimentation solution in the treatment of the multiple injury as a means of promoting optimum growth, development, and healing of the injured child.
Gertner, H. R.. Jr., et al. Evaluation of lhe management of vehicular fatalities secondary to abdominal injury. J. Trauma 12 (1972), 425.
Jackson, C. Obstructive Conditions of the Bronchial Tree. Philadelphia: W. B. Saunders Company. 1950, illustration p. 163.
Jackson. C. Oesophagoscopy. Philadelphia: W. B. Saunders Company. 1950. illustration p. 234.
Morse, T. S. Triage, technicians, and teaching in a children's emergency room. Postgraduate Course. Pediatric Surgery. Second Annual. March. 1976. Miami. Florida.
Morse, T. S. Pediatric abdominal injuries. Post-graduate Course, Pediatric Surgery Selected Innovatone, 58th Annual Clinical Congress. October. 1972, San Francisco.
Olsen, W. R., and Hildreth. D. H. Abdominal paracentesis and peritoneal lavage in blunt abdominal trauma. J. Trauma 11 (1971), 824.
Richardson. J. D.. Belin, R. P., and Griffen. W. O.. Jr. Blunt abdominal trauma in children, Ann. Surg. 176 (1972). 213.
Symposium on Nonpenetrating Thoracoabdominal Injuries. Surg Clin. North Am. 52 (1972). 529-792.
Standards for CPR & ECC. Part III: Advanced life support. J.A.M.A. 227 (Suppl.. 1974). 859.
COMMONLY USED DRUGS FOR INFANTS AND CHILDREN