Pediatric Annals

The Crucial Hour

Burton H Harris, MD; Laurie Ahlgren Latchaw, MD; Richard E Murphy, PA; Steven D Schwaitzberg, MD

Abstract

At the time of a serious accident, it is no cliché that "children are not small adults." When the injured child is brought to the hospital, prior planning, equipment, and the experience of the medical and nursing staff become major determinants in successful treatment.

The concept of a crucial hour (often called the "golden hour") is the guiding principle of a pediatrie trauma receiving unit. Children who die soon after injury succumb to either irreparable central nervous system injury, airway compromise, or hemorrhagic shock.1 The task in the receiving unit is to reverse the pathophysiology of these injuries before the effects of hypoxia become irreversible.

Hypoxia is the final common pathway by which these three quick killers - airway obstruction, hypovolemia, and central nervous system injury - affect pediatrie trauma victims. Children are very sensitive to hypoxia. The cardinal sign of hypoxia in a child is bradycardia, which is also a late sign. The slowing of a child's pulse to rates approximating those of a normal adult is a danger signal which may lure the uninitiated to the false conclusion that the patient is actually responding to treatment. Bradycardia will usually be followed by cardiac arrest.

An experienced receiving unit team can stabilize a pediatrie trauma victim in 20 minutes. 2'3 Stabilization includes restraint of the neck, airway control, hyperventilation, and reconstitution of circulating volume.

IMMOBILIZE THE NECK

If a patient arrives in the receiving unit without a neck restraint, protection against the possibility of cervical spine fracture is the first priority. The "Philadelphia collar" is a firm, semi-adjustable device which comes in two sizes and works well in children above the age of 4 years. For a younger child a softer cervical collar, or sandbags beside the face and wide adhesive tape securing the patient's forehead to the stretcher, are reasonable alternatives.

If the history or physical findings suggest that a cervical spine fracture is a real possibility, axial traction should be applied. For this maneuver, the hands of one physician or nurse are placed on the patient's mandible and pulled gently upward, while another individual grasps the child's arms and pulls gently downward. This position can be maintained while a lateral cervical spine x-ray is taken, developed, and interpreted. Axial traction is the surest way to immobilize the neck.

AIRWAY

The "A" of the ABCs includes the upper airway (from lips to larynx) and the lower airway (from vocal cords to the carina). The frequency of head injury and the large size of a child's tongue relative to the oropharynx makes upper airway obstruction far more common. The first maneuver which should be attempted in a child with air hunger is the "chin lift." A chin lift is done by placing the examiner's thumb behind the mandible underneath the patient's chin, and the forefinger inside the mouth grasping the mandible from the buccal aspect. The mandible is then raised toward the ceiling (for a child in a supine posi' tion), bringing the tongue forward. When effective, the chin lift relieves air hunger almost instantaneously. If this fails, a quick look inside the child's mouth for foreign objects should be made; if none are found it is necessary to proceed to lower airway access.

Obstruction below the larynx requires insertion of a tubular device into the trachea. It may be placed via the nose or mouth through the vocal cords, or the larynx can be bypassed by making an opening directly into the trachea. Nasotracheal and orotracheal intubation are difficult in children, particularly in injured children, and are best left to those with skill and continuing experience. The same…

At the time of a serious accident, it is no cliché that "children are not small adults." When the injured child is brought to the hospital, prior planning, equipment, and the experience of the medical and nursing staff become major determinants in successful treatment.

The concept of a crucial hour (often called the "golden hour") is the guiding principle of a pediatrie trauma receiving unit. Children who die soon after injury succumb to either irreparable central nervous system injury, airway compromise, or hemorrhagic shock.1 The task in the receiving unit is to reverse the pathophysiology of these injuries before the effects of hypoxia become irreversible.

Hypoxia is the final common pathway by which these three quick killers - airway obstruction, hypovolemia, and central nervous system injury - affect pediatrie trauma victims. Children are very sensitive to hypoxia. The cardinal sign of hypoxia in a child is bradycardia, which is also a late sign. The slowing of a child's pulse to rates approximating those of a normal adult is a danger signal which may lure the uninitiated to the false conclusion that the patient is actually responding to treatment. Bradycardia will usually be followed by cardiac arrest.

An experienced receiving unit team can stabilize a pediatrie trauma victim in 20 minutes. 2'3 Stabilization includes restraint of the neck, airway control, hyperventilation, and reconstitution of circulating volume.

IMMOBILIZE THE NECK

If a patient arrives in the receiving unit without a neck restraint, protection against the possibility of cervical spine fracture is the first priority. The "Philadelphia collar" is a firm, semi-adjustable device which comes in two sizes and works well in children above the age of 4 years. For a younger child a softer cervical collar, or sandbags beside the face and wide adhesive tape securing the patient's forehead to the stretcher, are reasonable alternatives.

If the history or physical findings suggest that a cervical spine fracture is a real possibility, axial traction should be applied. For this maneuver, the hands of one physician or nurse are placed on the patient's mandible and pulled gently upward, while another individual grasps the child's arms and pulls gently downward. This position can be maintained while a lateral cervical spine x-ray is taken, developed, and interpreted. Axial traction is the surest way to immobilize the neck.

AIRWAY

The "A" of the ABCs includes the upper airway (from lips to larynx) and the lower airway (from vocal cords to the carina). The frequency of head injury and the large size of a child's tongue relative to the oropharynx makes upper airway obstruction far more common. The first maneuver which should be attempted in a child with air hunger is the "chin lift." A chin lift is done by placing the examiner's thumb behind the mandible underneath the patient's chin, and the forefinger inside the mouth grasping the mandible from the buccal aspect. The mandible is then raised toward the ceiling (for a child in a supine posi' tion), bringing the tongue forward. When effective, the chin lift relieves air hunger almost instantaneously. If this fails, a quick look inside the child's mouth for foreign objects should be made; if none are found it is necessary to proceed to lower airway access.

Obstruction below the larynx requires insertion of a tubular device into the trachea. It may be placed via the nose or mouth through the vocal cords, or the larynx can be bypassed by making an opening directly into the trachea. Nasotracheal and orotracheal intubation are difficult in children, particularly in injured children, and are best left to those with skill and continuing experience. The same is true of tracheotomy, a formidable surgical procedure in a child with an uncontrolled airway, particularly if proper surgical instruments, light, and assistance are unavailable. In such circumstances needle cricothyreotomy is the safest emergency procedure.

The first step in needle cricothyreotomy is the identification of the cricothyroid membrane. The landmark is the thyroid cartilage ("Adam's apple"); remaining in the midline and palpating 1 to 2 cm caudal from the thyroid cartilage a step-off is felt. This identifies the cricothyroid membrane, the thinnest and barest part of the anterior airway. A 12- or 14-gauge catheter-overneedle device (Angiocath) is inserted through the cricothyroid membrane. Correct position is assumed by the sensation of a single, distinct pop as the Angiocath enters the lumen of the trachea. The needle is removed, the plastic cannula left in place, the adapter from a size 3 endotracheal tube placed in the Luer lock of the catheter, and a breathing bag (or the rescuer's lips) are applied to the adapter and ventilation begun.

Needle cricothyreotomy is only a temporary solution. Alveolar hypoventilation will eventually occur, but in children below the age of 5 acceptable levels of arterial oxygen and carbon dioxide can be maintained for up to 15 minutes.4 The intervening time is used to summon expert help and assemble other equipment, and then the catheter can be replaced by a conventional endotracheal tube or tracheostomy.

BREATHING

Most trauma victims with difficulty breathing are successfully treated by rendering their airway patent. If the patient remains dyspneic, the etiology is usually central nervous system damage interfering with the drive to breathe or the bellows action of the chest, or direct injury to the lung or pleural space. The former situation is easily treated by adding positive pressure ventilation.

If hypoxemia continues, pneumothorax is the next most likely diagnosis. In the emergency situation it is apt to be a tension pneumothorax, which may have been made worse by previous therapeutic maneuvers. The quickest way to solve this problem is to connect a syringe to a 12-gauge Angiocath, and insert the Angiocath into the pleural space in the third or fourth interspace in the anterior chest wall, in both hemithoraces if necessary. The piston may be expelled from the syringe if the tension is high enough, or manual aspiration can be performed. If a pneumothorax is identified, the Angiocath may be connected temporarily to a Heimlich flutter valve and a tube thoracostomy done later.

CIRCULATION

Sudden, continuing hemorrhage is the phenomenon which makes trauma so different from the other emergency conditions of childhood. While the treatment of internal hemorrhage usually requires surgical hemostasis, control of external hemorrhage is an emergency procedure requiring prompt attention. Direct pressure stops almost all external hemorrhage. The temptation to use a hemostat should be resisted, particularly in large vessels in the proximal areas of the extremities. The tissue crushed by such instruments may be the critical length in subsequent surgical repair.

When external hemorrhage is controlled, access to the circulation becomes the next priority. The goal is to insert the shortest, largest diameter cannula as quickly as possible in an accessible peripheral vein. Hypovolemic, vasoconstricted patients in random motion are poor candidates for venipuncture. If the first venipuncture is unsuccessful, a venous cutdown to the saphenous vein just anterior to the medial malleolus is recommended, rather than the inevitable "one more try. " The infusion rate through this device will be appropriate for its intended purpose.

Hypovolemia can be treated once venous access is established. A child with signs of hypovoíemia has lost more than 20% of blood volume. The first step in fluid therapy is the calculation of normal blood volume for the patient; blood volume = 80 x body weight in kilograms (40 x body weight in pounds). Crystalloid solution is given in increments of 25% of calculated blood volume by hand with a syringe through a threeway stopcock. This method allows the most rapid administration with positive volume control.

Response to the bolus, particularly if sustained, suggests that there is no continuing blood loss and that an emergency operation to stop bleeding is not necessary. If there is an initial good response but then signs of hypovoíemia return, a second 25% bolus should be given. No response to replacement of 50% of calculated blood volume suggests a continuing source of hemorrhage, usually from the abdominal viscera but occasionally in the chest, rerroperitoneum or injured extremities.

CENTRAL NERVOUS SYSTEM INJURY

Cervical spinal cord injury is stabilized by immobilization of the neck. A patient with persistent hypotension in the absence of hypovoíemia or pericardial tamponade may have "spinal shock" from vasodilatation due to injuries of the spinal cord.

The most common serious problem in pediatrie trauma is closed head injury. Treatment of blunt trauma to the brain should begin during resuscitation in the receiving unit with control of intracranial pressure (ICP). The goal is to maintain cerebral perfusion pressure (CPP), which is mean arterial pressure (MAP) minus intracranial pressure. The ABCs of resuscitation are directed at maintenance of mean arterial pressure. Since blunt head injury often interferes with autoregulation of intracranial pressure, rising ICP must be artificially controlled. In the receiving unit this is most easily done by hypervemilation sufficient to lower the partial pressure of carbon dioxide in arterial blood (PaCO2) to 20 to 25 mmHg. Hyperventilation and relative hypocapnia is a benign treatment which is not harmful to injured children with normal ICP.

Immobilization of the neck, achievement of airway patency, control of respiration, repair of circulation, and attention to central nervous system injury treat the immediate threats to life following major trauma. In the rush to accomplish these essential tasks it is easy to forget priorities and to overlook many other details which later will become important. To establish a sequence which accomplishes all of these goals, a checklist has been developed which has proven quite useful in helping the trauma team members do their work in proper order (see Checklist). Improved outcome in pediatrie trauma always requires planning, both personal and institutional.

Management of the multiply injured child is among the most challenging problems in pediatrics and pediatrie surgery. The first 20 minutes are cnicial in determining outcome. A prepared receiving unit, the checklist approach, concentration on the ABCs, and individualized treatment for each patient are the surest ways to stay organized while accomplishing the essential steps in diagnosis and treatment.

REFERENCES

1. Hams BH: IVdátnc mukuySHH trauma management. Trama Q 1981; 1:79.

2. Hams BH: Managemeni of mufcple nanna- fekn Om Nonfi Am 1985; 32:175.

3 Etchdberger MR, Randolph JG: Ruberie trauma: An algorithm fat Ajp»m« and rfteiapf. ) Trauma 1963. 23:91.

4. Hams BH; Pnanoe of treatment - The 20 nunutt drill, in Hams BH (ed): Propositi fetamc Tnwma. Bastai. Not* HiU. 1985.

10.3928/0090-4481-19870401-05

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