Primary Survey (Emerg Med Clin N Am 2007;25:803)
• Airway and C-spine control: Protect C-spine. Need for patency, chin lift/jaw thrust/oral airways/LMA/ETT as needed. Surgical cricothyroidotomy rare in pediatrics,↑ risk tracheal stenosis in pts < 9–12 yo as cricothryoid membrane immature
• Intubate if (1) unable to ventilate w/ bag-mask, (2) GCS ≤ 8, (3) respiratory failure from hypoxemia or hypoventilation, (4) decompensated shock resistant to fluid (5) loss of laryngeal protective reflexes. See PICU section for ETT size chart
• Breathing: Seriously injured patients receive 100% NRB mask. Early monitoring w/ pulse oximetry. Assess inspiratory effort/mechanical fxn. Assess for tension/hemo/pneumothorax, flail chest. Pulmonary contusions common, particularly in younger pts
• Circulation: Eval extremities/cap refill/central pulses; HoTN usually late finding; volume resusc as need; bolus LR or NS 20 cc/kg × 3 (warm fluids for significant trauma) followed by pRBC xfusion 10 mL/kg. Control external bleeding. Pressors as needed. Consider internal bleeding, if not stable → FAST exam → potentially w/ evaluation w/ ex lap
• Disability: Evaluate GCS (See Head Trauma) or AVPU:
A = Alert, V = Responds to Verbal stim, P = Responds to Painful stim, U = Unresponsive
• Rule out hypoglycemia in any patient with altered mental status
• Exposure: Fully undress patient to assess for hidden injury. Maintain temperature with warm lights, warm blankets, warm fluids and warm inspired air
Secondary Survey (Emerg Med Clin N Am 2007;25:803)
• 2° survey performed after initial resuscitation to include:
• AMPLE history – Allergies, Meds, PMH, Last meal, Events related to injury
• Age-appropriate motor and sensory examination
• Detailed head-to-toe inspection for unsuspected injury
• Head exam includes pupillary size/reactivity, fundoscopic exam, palpation of skull
• Assess chest for wounds and crepitus, auscultation
• Back and buttocks exposed by rolling pt while maintaining cervical spine alignment. Rectal exam to assess sphincter tone, and bleeding (guaiac)
• Lacerations, abrasions, ecchymosis, deformities, or tenderness should be noted
• Labs: CBC, CMP, coags, type and cross ± serum/urine tox, urine β-HCG
• Diagnostic testing
• Plain films: AP chest, lateral C-spine, pelvis, & selected extremities of blunt trauma (consider trauma series during primary survey)
• Can obtain cross-table lat views for free air, AP/odontoid views to eval C-spine
• FAST scan: Consists of U/S scanning of 4 areas: (Am J Emerg Med 2000;18:244)
• Subxiphoid: To visualize the heart (assess for pericardial effusion)
• RUQ: To visualize Morison pouch and paracolic gutter; can see lung base (PTX)
• LUQ: To visualize the splenorenal recess and paracolic gutter; can see lung base
• Suprapubic: To visualize Douglas pouch
• Limited data in peds: Sens 75%; spec 97%; PPV 90%; NPV 92% in a small study
• Cannot detect injury to bowel, diaphragm, or retroperitoneal organs
• Head CT: To evaluate for acute intracranial bleed
• Abd/Pelv CT: Test of choice to assess intra-abdominal injury. Only for hemodynamically stable patients. Does not rule out duodenal hematoma