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2. Breathing.
3. Circulation and haemorrhage control.
4. Disability: brief neurological examination.
5. Exposure and environment: disrobe patient and prevent hypothermia.
B. Resuscitation
1. Oxygenation: 100 % O2.
2. Ventilation.
3. Hypovolemia correction.
4. Establish monitoring vital signs, ECG (Electrocardiogram), oximetry,
endtidal CO2, ICP (Intracranial pressure) as appropriate.
C. Secondary survey.
1. Systemic examination: head and skull, face, neck, chest, abdomen,
perineum and rectum, musculoskeletal, complete neurological
examination.
2. Diagnostic studies.
3. Treatment, temporary or definitive.
The primary survey is following the ABCDE sequence as mentioned
above. The airways are the first priority. Any obstruction of the airways
could cause death in 3-4 min. Any obstructing material like blood or
vomitus should be removed. In a child less than 8 years of age, the
oral airway should be inserted following the curve of the tongue to
avoid lacerating the soft palate and pharynx, that is small and soft.
Appropriate size airways should be used.
The resuscitation starts soon during transportation with proper
positioning of the injured and oxygen supply if needed. Any seriously
injured child must have intravenous access and infusion. In some cases
intravenous line could be difficult to be managed, especially in small
children.
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In such conditions alternatives are intraosseous infusion, venous cutdown and central venous line. Intraosseous infusion can be established
in the proximal tibia of a young child or just above the medial
malleolus of an older child. IV lines should not be made if proximal
fracture is present. If signs of hypovolemia or circulatory comprise are
present child should receive crystalloid infusion.
Blood could be given as a second bolus, if there is large blood loss.
Blood loss is possible in cases of severe trauma of the abdomen, the
chest, retroperitoneum and pelvic fractures. The rapid assessment and
diagnostic of the trauma case is very important and vital, especially in
unstable cases.
Diagnostic steps like ultrasonography of abdomen, x-rays of chest or
pelvic etc are quite helpful for rapid assessment and possible operative
intervention.
The secondary survey includes the complete systemic examination of
the patient from head to toe. The examining doctor should look for
wounds, deformities or other serious injuries on the face and back
including rectal examination. Sometimes chest tubes and nasogastric
and urinary catheters are needed and should be placed. Fractures must
be splinted and wounds covered with sterile gauzes. A proper medical
history should be obtained including past medical or surgical
treatments, allergies and previous transfusions.
The secondary survey includes the diagnostic procedure with plain
radiographs, special radiological studies and invasive procedures.
Plain x-rays are taken of any area exhibiting signs of injury. Computed
tomography (CT) scan of the head must be done in every unconscious
or obtunded child. Abdominal ultrasound should be requested in any
case of abdominal trauma. In severe abdominal injury a CT scan of the
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abdomen is highly useful for diagnosis of abdominal and retroperitoneal
injury with valuable information about the degree of solid organ
disruption, renal function and amount of intra- or retro-peritoneal
blood collection.
Diagnostic peritoneal lavage (DPL) is indicated in special rare cases
as a part of the primary survey in an unstable case or if the trauma
child is going directly to the operating room for another injury
(extradural haematoma or major arterial injury).
The value of DPL is nowadays less than before especially in the era of
increasing precision of ultasonography and CT scan.
The abdomen should be investigated in any case with suspicion of
intra- abdominal injury from the examination or mechanism of injury,
failure of resuscitation, or spinal cord injury.
Other diagnostic studies are rarely indicated e.g. angiography,
urethrography, cystosgraphy, duodenography esophagogastroduodenoscopy and bronchoscopy.
Multiple injuries are common, blunt with dissipated wounding force
and penetrating injuries with localized wounding force.
Injury may result from differential deceleration of soft tissue and bone
as well as from the direct blow (i.e. coup and contre-coup cerebral
injuries).
VI. ORGAN SYSTEM TRAUMAS.
1. THE HEAD.
As already mentioned before children are particularly susceptible to
reactive cerebral hyperaemia after head trauma. As in adults intracranial
haemorrhage will not cause hypovolaemia, but in very young children
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a scalp haematoma or cephalhaematoma could cause hypovolaemia
and lead to symptoms of hypovolaemic shock. The so-called shakenbaby syndrome with retinal haemorrhage should be excluded in
injured child with CHI.
A child with so-called shaken-baby syndrome needs intubation and
hyperventilation and rarely tabbing of a tight fontanelle, especially if
there is dilatation of pupils.
Severe CHIs have a high mortality rate of about 30%.
Head traumas are classified according the Glasgow Coma Scale (GCS).
Head trauma with
deep coma.
Skull fracture
left side.
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The pediatric modification of Glasgow Coma Scale (GCS):
Score Eye opening
4 Spontaneous
3 To speech
2 To pain
1 None
Score Best verbal response
Adult / adolescent Child Young child
5 Oriented Appropriate Smiles, fixes and follows
4 Confused Inappropriate Cries but consolable
3 Inappropriate Moaning Inconsolable, irritable
2 Incomprehensible Restless, agitated Restless, agitated
1 None None None
Score Best motor response
6 Follows commands or spontaneous appropriate movement
5 Localizes to pain
4 Withdraws to pain
3 Decorticate (flexor) posturing
2 Decerebrate (extensor) posturing
1 None
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2. THE FACE.
Lacerations in the face are common in children due to falls and play
injuries. Bony injuries and facial fractures are less common in
children than adults. This is because of the relatively large size of the
cranium, the undeveloped sinuses and thick soft tissues. Primary
hyphaemia is more common in children than adults. Concomitant
retinal injury should be carefully excluded. The eye should be covered
and the child kept quite for several days to avoid secondary hemorrhage.
Injuries of the face must be explored carefully. Lacerations and cut
wounds must be reapproximated meticulously to avoid significant
deformities as the child s face grows and develops.
Nasal and mandibular fractures are the most common fractures in
children. Fracture of the mandibular condyle can cause disturbances
of growth and deformity.
Nasal septum haematoma must be evacuated and properly packed to
prevent septal necrosis and saddle nose deformity.
3. THE NECK.
The neck in children is short and less susceptible to soft tissue injuries.
Neck traumas could be sustained as a result of falls onto bicycle Cervical
spine injuries in children tend to be high in the neck (C1, C2, C3)
rather than low in adults. Laxity of the ligaments and bony immaturity
cause spinal hypermobility which render the cords susceptible to
injury. Unless the injured child is alert and cooperative, with normal
neurological examination, the pediatric cervical spine can not be
considered normal and standard three radiological views (anteroposterior,
lateral, odontoid), should be done to exclude bony lesions. Spinal cord
injury symptoms may have a delayed onset. If the injured child is
obtunded or there is suspicion of spinal injury, work-up must go on
with CT scan or MRI or both.
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4. THE CHEST.
Chest wall trauma causes commonly more pulmonary contusion, and
the children have less rib fractures, because of the compliant chest
wall. Children are particularly susceptible to tension pneumothorax
which must be promptly managed. Other severe injuries like ruptured
diaphragm, flail chest, aortic transection, tracheobronchial rupture and
cardiac injury are rare.
Although severe chest injuries are not common in children, they
contribute significantly to the mortality rate in injured children with
thoracic component. Chest injury also increases the mortality rate for
pediatric patients with head injury. Children with thoracic trauma are
much more likely to have multisystem injuries, which increase the
mortality rate.
5. THE ABDOMEN.
The abdominal organs in children are more vulnerable, because of the
anatomical and structural condition and therefore susceptible to injury.
The majority of the injuries are well-tolerated and mostly do not require
operative treatment. Children with symptomatic abdominal traumas
should be admitted as in-patients and closely observed. Children with
renal trauma should be evaluated for hypertension and have urinanalysis
one year after trauma.
Pancreatic injuries are more common in children than adults. An
increase of serum amylase 24 h after admission heralds this and further
investigative steps e.g. endoscopic retrograde pancreatography (ERCP)
and / or laparotomy should be considered.
Hollow viscus injuries are much less common in children than in
adults and account about 10 % of laparotomies for blunt traumas. The
early diagnosis of bowel injury is usually not easy and only repeated
serial examinations and sometimes signs of peritonitis are reliable.
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Duodenal haematomas are rare but more common in children than in
adults and mostly treated conservatively with nasogastric suction and
parenteral feeding.
The urinary bladder in children is susceptible to injury without pelvic
fracture due to intra-abdominal location of the urinary bladder.
Young boys could sustain disruption of the anterior urethra. Genital
trauma is possible in boys and girls and could be due to child abuse.
6. EXTREMITIES.
Children have relatively flexible bones And therefore when fractures
found in children after trauma, soft tissue damage should be
considered. Complicated fractures with sometimes joint dislocation
could lead to neurovascular injury and this may lead to the
development of compartment syndrome. These severely injured cases
must be carefully assessed and properly. Early immobilization of
fractures with conservative cast application or operative fixation
reduces significantly pain and allows early mobilization.
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Abdominal Trauma
Abdominal trauma presents an important factor in the emergency
surgery nowadays. It makes about 20% of fatalities in traumatology.
Abdominal trauma could be as a result of blunt or penetrating injury.
Blunt and penetrating abdominal injuries may cause damage to solid
organs or hollow viscera in the peritoneal cavity or to their associated
blood vessels within the mesentery or retroperitoneal tissues.
Blunt abdominal trauma is often associated with multisystem injuries
which may include head, thoracic or injury to the limbs.
Penetrating abdominal trauma could lead to major intra- abdominal
vascular injury with hypovolemic shock.
Septic complications may follow disruption of solid organs and injury
to the bowel. These septic complications are a significant cause of late
mortality and morbidity.
ANATOMY OF THE ABDOMEN :
The abdominal cavity consists of 4 regions . These regions contain the
whole of the abdominal content.
1. Intrathoracic abdomen: which is the portion of the upper abdomen
that lies beneath the rib cage. Its content include the diaphragm, liver,
spleen, and stomach. The rib cage makes this area inaccessible for
palpation and complete examination.
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