Life threatening problems should be treated as they are identified during the primary survey.
Assume a cervical spine injury is present until adequate investigation and examination exclude it.
Assess the effort and efficacy of breathing, and the effects of inadequate respiration on other organ systems as usual.
Estimate percentage blood loss:
| Sign | <25% | 25-40% | >40% |
| Heart Rate | + | ++ | ++/brady |
| BP | Normal | Normal, falling | Falling |
| Pulse volume | Normal/- | - | -- |
| Capillary refill time | Normal/+ | + | ++ |
| Skin | Cool,pale | Cold, mottled | Cold, pale |
| Resp rate | + | ++ | Sighing |
| Mental state | Agitated | Lethargic, uncooperative | Reacts only to pain |
Remember caveats on clinical signs.
As before.
A seriously injured child must have their clothes removed to assess fully. However the time taken for it should be minimised and a blanket provided at all other times to avoid cold exposure and embarrassment.
Airway management sequence:
Sandbags AND tape if high suspicion until normal X rays AND normal neurology. If combative, head collar only to reduce neck movements during struggling.
Ventilate if:
If breath sounds unequal consider:
All seriously injured children should have vascular access established urgently. 2 relatively large IV cannulae are mandatory. Percutaneous approach to peripheral veins is preferred, but if this fails, consider using external jugular or femoral veins, cut down on to the cepahlic vein at the elbow or long saphenous at the ankle. Intraosseous infusion will usually prove quicker and easier.
Central venous cannulation should not be attempted by the inexperienced, and its main use is for monitoring central venous pressure.
Fluids:
If urgent, type specific (cross match time 10-15 minutes) or O negative (unmatched) blood should be given.
From child, relatives, ambulance personnel and witnesses: accident site, pre-hospital care, past medical history, allergies, time of last meal.
RTA injury mechanism may be indicated by:
Also during resuscitation:
See specific injuries on next page.
Monitor pulse, BP, resp rate, O2 sats, pupil size and reactivity, coma score every 15 minutes or less. Urine output hourly. End tidal CO2 useful for ventilated children.
Good note taking and appropriate referral minimizes delays.