Pediatric emergency medicine trisk 38

of treatment. All patients with major trauma should receive supplemental oxygen
therapy. In both medically ill and traumatically injured patients, the airway is secured
via endotracheal intubation as clinically necessary. The chin-lift or jaw-thrust
maneuver is the preferred method to open the airway while clearing secretions or
preparing for intubation to minimize cervical spine movement. It is imperative to
anticipate a “difficult airway” prior to intubation. If this is anticipated, the most
experienced clinician in airway management should secure the airway. If a difficult
airway is suspected, management with bag-valve-mask ventilation or placement of a
laryngeal mask may be preferred until a definitive airway can be established in a
controlled environment.
TABLE 7.5
PRIMARY SURVEY COMPONENTS
A

Airway
Cervical spine

B

Breathing

C

Circulation

D

Disability
Dextrose
Decontamination

E

Exposure
Environment

Determine if the airway is patent
Note obstruction, complete or partial
Reposition, suction, consider artificial airways,
continuous positive pressure
Assess need for C-spine immobilization
Check for increased or poor respiratory effort
Place on continuous CR monitor, pulse oximetry,
ETCO2
Administer oxygen, assist ventilation with BVM
Consider need for ETT, have LMA ready
Decrease gastric distension
Needle thoracostomy and chest tube as indicated
Assess HR, BP, rhythm
Peripheral pulses and capillary refill, pallor,
cyanosis
Assess mental status, pupils, motor activity, and
symmetry
Cardioversion, defibrillation, pericardiocentesis
AVPU score, note lateralizing signs
Treat hypoglycemia, seizures, increased ICP
Drug overdoses, or electrolyte abnormalities
Undress patient, log roll
Check temperature, skin, and evidence of trauma
Prevent hypothermia

Breathing
After the airway has been evaluated and secured as necessary, breathing is assessed to
assure adequate air exchange. Continuous oxygen saturation measurement and endtidal carbon dioxide (ETCO2 ) monitoring in both intubated and nonintubated patients
allows for continued assessment of oxygenation and ventilation. The most common
causes of hypoxemia in children are ventilation/perfusion (VQ) mismatch and
hypoventilation. ETCO2 may help distinguish between these two entities; providers
will note normal or low ETCO2 in cases of primary VQ mismatch, while in cases of
hypoventilation, physicians will often see hypercarbia out of proportion to
hypoxemia. It is important to note that in trauma patients, compromise of ventilatory
function most often occurs secondary to a depressed sensorium rather than a primary
pathology of the respiratory system itself.

Circulation
Circulation is assessed by examining the character of the pulse, skin color, and
capillary refill time. There is no single physical or laboratory finding that will identify
shock, however, the physical signs exhibited by the patient in shock are ultimately
due to insufficient oxygen and substrate delivery to the tissues. The physical
manifestations vary with type of shock but include tachycardia, decreased skin
perfusion, and hypotension (cold shock) or tachycardia, bounding pulses and flushed
skin with hypotension (warm shock). If cardiogenic shock is present, HR may be
normal or only modestly elevated. Remember that in children, hypotension is a late
finding requiring a 50% decrease in the circulating volume to affect a decrease in
systolic pressure. In trauma, external hemorrhage visualized during the primary
survey should be controlled by direct pressure or pneumatic splints.

Disability
CNS failure is manifested by altered MS or by the presence of focal neurologic
deficit(s). Recall that the CNS is composed of the brain and meninges, the blood
vessels, and the cerebrospinal fluid. Many diseases that cause CNS failure are caused

by compartment physiology, as in the case of elevated intracranial pressure (ICP).
Examples of primary CNS disease include intracranial hypertension secondary to
mass or hemorrhage, and status epilepticus. The CNS may also be secondarily
affected by respiratory or circulatory disease as oxygen delivery to the tissues of the
CNS is impaired. The AVPU scale and GCS ( Table 7.2 ) are used to measure level of
consciousness in a standardized way. Interventions to treat CNS failure include
modest hyperventilation and hypertonic therapy (in the case of elevated ICP),
maintenance of MAP and oxygenation to ensure adequate CNS perfusion, and
avoidance of hyperthermia. Other therapies aimed at the underlying cause of CNS
failure include anticonvulsants, antimicrobials, and surgical decompression.


Exposure/Environment
A complete physical examination requires removal of all clothing, log rolling, and
checking axillary and perineal areas of the patient. Hypothermia is a particular risk in
ill and injured children, due to their larger relative surface area. Hypothermia can
develop in the prehospital setting and can worsen in the ED, as proper assessment and
treatment requires exposure of the patient. The dangers of hypothermia include
impaired hemodynamics and coagulation, increased peripheral vascular resistance,
and increased metabolic demand. Monitor and maintain body temperature using
increased ambient temperature, warm blankets, and warmed fluids and oxygen. While
the use of therapeutic hypothermia in arrested pediatric patients remains understudied,
hyperthermia should be treated aggressively.

IV Access
Vascular access is an early but often challenging necessity in resuscitation.
Percutaneous cannulation of bilateral upper extremity veins with two large-bore
intravenous (IV) cannulas is ideal. For patients in pulseless arrest, for those with
severe trauma, or for patients with known difficult access, intraossesous (IO) access
provides a quick, reliable route to provide fluid resuscitation and medications. ED

clinicians should have an IV escalation plan in place with resources to assure timely
IV access. This has become a more important aspect of care due to the increasing
numbers of children with difficult IV access due to success in treating chronic
illnesses ( Table 7.6 ).

Fluid Resuscitation
Deliver isotonic fluids (normal saline or lactated Ringer’s) rapidly in 20 mL per kg
aliquots up to 60 mL/kg and reassess VS, MS, and skin perfusion. The push–pull
technique using a 20-mL syringe with a macrodrip setup with a three-way stopcock
and a T-connector is useful for rapid fluid resuscitation in children <50 kg. For
children >50 kg, fluids can be infused using a pressure bag or a rapid infuser. To date,
evidence has not shown benefit for the use of albumin or synthetic colloids in
pediatric septic shock, cardiopulmonary arrest, or trauma. Dextrose-containing
solutions should not be used for initial resuscitation due to risk for hyperglycemia and
secondary osmotic diuresis and neurologic injury. Nevertheless, bedside glucose
testing is important; treat hypoglycemia with 10% dextrose solution, and follow with
an infusion of dextrose-containing fluids in persistently hypoglycemic patients. If
volume resuscitation of 60 mL/kg has not been effective, consider initiating
procontractility agents or vasopressors. Treat hypoxemia, metabolic acidosis, and any
other critical electrolyte abnormalities discovered during the resuscitation.
Among traumatically injured patients, failure to respond to crystalloid resuscitation
is an indication for early transfusion. Blood transfusion is preferentially performed


with fully cross-matched, warmed blood. In the face of a transient or absent response
to a rapid crystalloid infusion, type-specific, or type O–negative blood can be given as
a whole-blood transfusion. Fluid and blood are given rapidly enough to maintain
stable VS and adequate urine output. Vasopressors, steroids, and sodium bicarbonate
do not play a role in the initial treatment of hemorrhagic shock. Currently, there is no
universally accepted massive transfusion protocol for pediatric trauma victims with

most protocols institution-specific.
TABLE 7.6
IV ESCALATION PLAN
• Establish 2 large bore IVs and begin NS fluid resuscitation within the first 15
minutes
• Implement IV escalation pathway considering individual patient
• Ill patients require a second access at a peripheral site
Minutes

Access procedure

0–5

First peripheral IV with largest gauge possible
Consider IO immediately in severely ill patients
Second peripheral attempt
Consider US-guided peripheral IV
Consider EJ (US guided)
Notify vascular access specialist (IV team)

5–10

10–15

If still no access
EZ-IO
EJ (consider US guided)
Central line (consider US guided) or
Call intensivist or surgeons to assist at bedside, if available

SECONDARY SURVEY
The goal of the secondary survey is to identify the definitive cause of the respiratory,
circulatory, and/or neurologic abnormalities treated during the primary survey. In the
case of trauma patients, the secondary survey reveals any injuries not found and/or
addressed in the primary survey.
During the secondary survey, a systematic head-to-toe examination is performed
with special attention to specific organ systems associated with the patient’s chief
complaint and personal risk factors. Elements of the secondary survey may be
skipped or deferred, depending on the clinical situation, and patient stability ( Table
7.7 ).