You are on page 1of 5

1 of 5 Page

Basic Principles in Trauma


Objectives
1. To lay ground work for the establishment of standards of care in
trauma management
2. Provide of correct sequence in assessing the multiply injured
patient
3. To provide guidelines and techniques in treating the multiply
injured patient

TRAUMA
An injury or wound characterized by a structural alteration or
physiologic imbalance that results when energy is imparted
during the interaction with physical or chemical agents.
a bodily lesion which results from transfer of energy, force is
beyond the physiologic tolerance of the individual

When a trauma patient enters the emergency room, you have to
do an initial assessment. The first priority is to recognize is life-
threatening conditions and then be able to resuscitate the patient.

TYPES OF INJURY
1. Mechanical
2. Thermal
3. Electrical
4. Chemical
*most cases seen are vehicular crashes or projectile trauma

TRIMODAL PATTERN OF DEATH
1. Immediate post-injury period
where most of the mortality occurs,
associated with overwhelming injuries (e.g. cord dissection,
aortic destruction);
you cannot do anything to treat it, but you can prevent it
2. Death which occurs hours after injury
occurs in 1/3 of patients
proper management can decrease mortality rate
3. Patients who stay in the hospital for long periods with 1 mo. old
injury
mostly die due to pulmonary complications
can prevent death, however rehabilitation would be important

TRIAGE
when you have a lot of victims in one area
Prioritizing
identify patients who are most in need of care and send
patients to institutions capable of giving them adequate care
sort out patients based on their need for treatment, taking into
consideration resources available
decide where to send these patients (send them to a trauma
center)
achieve the greatest good for the greatest number of casualties
differentiate patients whom you can help from those whom you
cannot help

CRITERIA FOR CLASSIFYING PATIENTS
Physiologic Glasgow Coma Scale



Anatomical Criteria head, neck, torso or extremities, flail chest,
burns and concomitant traumatic, fractures to two or more
proximal long bones, pelvic fracture, spinal cord injury,
amputation proximal to wrists or ankles = immediate attention

Mechanism of Injury



Adult Triage See Appendix A
Expectant (black tag) victim unlikely to survive given severity of
injuries, level of care, or both. Palliative care and pain relief
should be provided
Immediate (red tag) victim can be helped. Immediate
intervention and transport. Require medical attention within
minutes (up to 60). Include compromises to patients airway,
breathing, circulation
Delayed (yellow tag) victims transport can be delayed. Includes
serious and life threatening injuries but status not expected to
deteriorate significantly over several hours
Minor (green tag) victim with relatively with minor injuries. Status
unlikely to deteriorate. May be able to assist in own care.
Walking wounded

IMPORTANT NOTES
Life-threatening conditions are things that may kill the person
(aka ABCs of trauma)
Blocked airway - no oxygen then the patient dies
Poor breathing or ventilation - you need the lungs for
exchange of gases
Pneumothorax (air in thoracic cavity) and hemothorax (blood
in thoracic cavity) may compromise lung function
Compromised circulation - if the patient bleeds you will have
hypovolemia thus delivery of blood to all organ systems is
diminished.
Lack of definitive diagnosis should not hinder the application of
an indicated treatment; detailed history is not important

PRIORITIES (done almost simultaneously)
1. Primary Survey
2. Resuscitation
3. Secondary Survey
4. Tertiary Survey
Importance of REASSESSMENT

INITIAL ASSESSMENT
The management of severe multiple injuries require clear
recognition of management priorities and the 1st priority are life
threatening conditions!!!
Primary survey checks: airway, breathing, circulation, disabilities
and exposure of patients from head to foot.
Resuscitation of patient
History and PE must be brief and concise; usually 2-5 minutes
from head-to-foot

PRIMARY SURVEY (ABCDE)
Airway
Breathing
Circulation
Disability
Exposure

This primary survey if done correctly identify such life threatening
conditions:
Airway obstruction
Chest injuries with breathing difficulties
Severe external or internal hemorrhage
Abdominal injuries

Primary survey must be performed in no more than 2-5 mins.
Simultaneous treatment of injuries can occur when more than
one life-threatening condition exist. While youre doing
resuscitation, do complete work-up all at the same time. Do not
wait.

AIRWAY
Assess by talking to the patient, if patient can communicate
perfectly then airways are intact
Loss of airway patency is the most immediate life-threatening
complication in trauma
Importance of cervical spine control- assume that patients have
surgical spine injuries until you prove that the patient does not
Transport patient by immobilizing the cervical spine or put
cervical collar
Assume that patient has a full stomach and is at risk for
aspiration (airways will be blocked= lead to hypoxia)

If obstructed the steps to be considered are:
Chin lift/jaw thrust (tongue is attached to the jaw)
Suction (if available)
Nasopharyngeal airway
Intubation at the area of the trachea. Keep the neck
immobilized in neutral position.
Airway Management
1. Talk to the patient
A patient who can talk must have a clear airway.
2 of 5 |Page
The unconscious patient may require airway and ventilatory
assistance.
The cervical spine must be protected during endotracheal
intubation if a head, neck or chest injury is suspected.
Airway obstruction is most commonly due to obstruction by the
tongue in the unconscious patient

2. Give oxygen
ALL INJURED PATIENTS SHOULD BE GIVEN SUPPLEMENTAL
OXYGEN should be given once patient arrives at emergency
room
Snoring or gurgling
Stridor or abnormal breath sounds
Agitation (hypoxia e.g. putting a pillow on your face while
sleeping)
Using the accessory muscles (e.g. pectoralis) of ventilation or
paradoxical chest movements (e.g. when the whole thoracic
cage expands seen in patients with segmental fracture of the
ribs)
Cyanosis
Be alert for foreign bodies. Intravenous sedation is absolutely
contraindicated in this situation because it will further depress
the respiratory muscle.

3. Consider need for advanced airway management eg.
endotracheal intubation (airway obstruction requires URGENT
treatment)
better control of respiration, more permanent airway, prevents
aspiration

Indications for advance airway management techniques for
securing the airway include:
Persisting airway obstruction
Penetrating neck trauma with hematoma
Apnea
Hypoxia
Severe head injury
Chest trauma
Maxillofacial injury
Hemodynamic instability (concomitant chest/pulmonary
airway)
Unresponsive patient (problem is position of tongue, may
obstruct airway)
Shock
Depressed mental status
Flail chest (unable to breathe efficiently)
Fracture in the ribs (3 adjacent ribs)
Combative patients possibility that these patients are hypoxic

BREATHING
Breathing is assessed as airway patency and breathing adequacy
are re-checked. If inadequate, the steps to be considered are:
Decompression (by putting a tube) and drainage of tension
pneumothorax/hemothorax
Closure of open chest injury
Artificial ventilation by placing an endo-tracheal tube.
Give oxygen if available
Reassessment of ABCs must be undertaken if patient is unstable

Problems in Adequate Lung Function or Chest Wall
tension pneumothorax (air outside lungs, inside pleural cavity,
pressure that is enough to cause compression of mediastinal
structures)
open pneumothorax (atmospheric air is able to enter the cavity
because of a negative pressure, as in penetrating chest
traumacover the opening using gauze with petroleum, tape
the gauze on three sides to allow for air inside to go outside
massive hemothorax- bleeding in pleural cavity
flail chest
cardiac tamponade
Locate problem through physical examination

CIRCULATION
Assess circulation, as oxygen supply, airway patency and
breathing adequacy are re-checked. If inadequate, the steps to
be considered are:
Stop external hemorrhage (stop the bleeding by pressure)
Establish 2 large-bore IV lines (14-16 G) if possible to replace the
blood loss
Administer fluid if available

How to Recognize Shock
Assessment of vital signs of patient: HR, RR, pulse pressure, urine
output, sensorium of patient (will give you an idea as to how
much blood was lost)
Decreased RR,HR and some sensorium changes= blood loss of
about 750 cc
2 L of blood loss drastic manifestations such as tachycardia,
hypotension, tachypnea, little urine output, sensorium changes
may need surgery in immediate period and needs to be
prioritized
>2 L blood loss classic signs of late shock

Circulatory management (the third priority is establishment of
adequate circulation)
Shock is defined as inadequate organ perfusion and tissue
oxygenation. In the trauma patient, it is most often due to
hypovolemia (blood loss).
The diagnosis of shock is based on clinical findings:
hypovolemia, tachycardia, tachypnea, as well as hypothermia,
pallor, cool extremities, decreased capillary refill (press nail beds
then release, color must return within 2 seconds), and
decreased urine production (normal is 50mL per hour).

There are different types of shock
Hemorrhagic (hypovolemic) shock
Cardiogenic shock
Neurogenic shock
Septic shock

Hemorrhagic (hypovolemic) shock
Due to acute loss of blood or fluids. The amount of blood loss
after trauma is often poorly assessed and in blunt trauma is
usually underestimated.

Cardiogenic shock
Due to inadequate function of the heart. This may be from:
Myocardial contusion
Cardiac tamponade
Tension pneumothorax (preventing blood returning to heart)
Penetrating wound of the heart
Myocardial infarction
Assessment of the jugular venous pressure is essential in these
circumstances and an ECG should be recorded when
available.

Neurogenic shock
Due to the loss of sympathetic tone, usually resulting from spinal
cord injury, with the classical presentation of hypotension
without reflex tachycardia or skin vasoconstriction. The
autonomic function is lost.

Septic shock
Rare in early phase of trauma but common cause of late death
(via multi-organ failure) in the weeks following injury.
It is commonly seen in penetrating abdominal injury and burn
patients

Circulatory Resuscitation Measures
The goal is to restore oxygen delivery to the tissues.
As the usual problem is loss of blood, fluid resuscitation must be
a priority.
Hypovolemia is a life-threatening emergency and must be
recognized and treated aggressively.

Adequate vascular access must be obtained.
Infusion fluids (crystalloids e.g. normal saline as first line) should
be warmed to body temperature. Hypothermia can lead to
abnormal blood clotting.
Avoid solution containing glucose.
Take any specimen you need for lab and cross matching.

Blood Transfusion
Consider fluid infusion instead of blood transfusion because of:
difficulty of getting blood
possibility of incompatibility
hep B and HIV risks

Blood transfusion must be considered when patient has persistent
hemodynamic instability despite fluid colloid/crystalloid infusion.
If specific blood type is unavailable, packed type O rh negative
red blood cells should be used.
Consider blood transfusion when hemoglobin is less than 7 or if
patient is still bleeding.
1 ml of blood loss= 3 ml of crystalloids should be infused
Packed RBC- blood loss greater than 1L

DISABILITY
Rapid neurological assessment (is patient awake, vocally
responsive to pain or unconscious). There is no time to do the
Glasgow Coma Scale so a system at this stage is clear and quick:
Awake
Verbal response
Painful response
Unresponsive (intracranial lesions, spinal cord injuries)

EXPOSURE
vital signs, what you see
Undress patient (by cutting using scissors) and look for injury.
If patient is suspected of having a neck or spinal injury, in-line
immobilization is important.
During the exposure, bruises, contusions, penetrating wound,
swelling from head to foot are noted especially of the
abdomen, extremities.
If there is fracture, you have to splint while doing resuscitation.
3 of 5 |Page

SECONDARY SURVEY
This is undertaken only when the patients ABCs are stable
If any deterioration occurs during this phase then this must be
interrupted by another PRIMARY SURVEY
Head-to-toe examination is now undertaken (finger to every
orifice) CRASHPLAN

C erebration
R espiration
A bdomen
S pine
H ip
P elvis
L imbs
A rteries
N erves


Allergies
Medications
Past history
Last meal
Events leading to injury

*those that are italicized were taken from the voice recording


OTHER INFO FROM OLD TRANS THAT WERE NOT EXACTLY DISCUSSED IN THE
LECTURE
CHEST TRAUMA
A quarter of deaths due to trauma are attributed to thoracic injury.
Immediate deaths are essentially due to major disruption of the heart or
great vessels
Early deaths due to thoracic trauma include airway obstruction, cardiac
tamponade or aspiration
Majority of patients with thoracic trauma can be managed by simple
maneuvers and do not require surgical treatment.
The extent of internal injuries cannot be judged by the appearance of a
skin wound (*a blunt injury is more deceptive and more difficult to
manage than a penetrating injury)

Respiratory Distress may be caused by
1. Rib fractures
2. Flail chest
3. Pneumothorax
4. Tension pneumothorax
5. Hemothorax
6. Pulmonary contusion (bruising)
7. Open pneumothorax
8. Aspiration
9. Hemomediastinum

Rib Fracture
Rib fracture may occur at the point of impact and damage to the
underlying lung may produce lung bruising or puncture.
In the elderly fractured rib may result from simple trauma.
Ribs usually become fairly stable within 10 days to two weeks. Firm healing
with callus formation (you dont develop a scar) is seen after about six
weeks.

Flail Chest
The unstable segment moves separately and in an opposite direction
from the rest of the thoracic cage during the respiration cycle. Severe
respiratory distress may ensue.

Tension Pneumothorax
Develops when air enters the pleural space but cannot leave. The
consequence is progressively increasing intrathoracic pressure in the
affected side resulting in mediastinal shift. The patient will become short
of breath and hypoxic. Urgent needle decompression is required prior to
the insertion of an intercostal drain. The trachea may be displaced (late
sign) and is pushed away from the midline by the air under tension.

Hemothorax
More common in penetrating than in non-penetrating injuries to the
chest. If the hemorrhage is severe, hypovolemic shock will occur and also
respiratory distress due to compression of the lung on the involved side.
Optimal therapy consists of the placement of a large chest tube.
Hemothorax of 500 -1500 ml that stops bleeding after insertion of an
intercostal catheter can generally be treated by closed drainage alone.
Hemothorax of greater than 1500-2000 ml or with continued bleeding of
more than 200-300 ml per hour is an indication for further investigation by
opening the patient e.g. thoracotomy

Pulmonary Contusion
Common after chest trauma that appears like bruising. It is potentially life-
threatening condition. The onset of symptoms may be slow and progress
over 24 hrs post injury. It is likely to occur in cases of high-speed accidents,
falls from great heights and injuries by high-velocity bullets. Symptoms and
signs include:
Dyspnea
Hypoxemia
Tachycardia
Rare or absent breath sounds
Rib fractures
Cyanosis

Myocardial Contusion
Associated with fractures of the sternum or ribs
Associated with ECG abnormalities and elevation of cardiac enzymes.
Cardiac contusion can simulate myocardial infarction
Placed under observation and monitoring
May cause sudden death well after the accident

Pericardial Tamponade
Pericardial cardiac injuries are a leading cause of death in urban areas
It is rare to have pericardial tamponade with blunt trauma.
Pericardiocentesis must be undertaken early if this injury is considered
likely. Look for it in patients with:
shock
distended neck veins
cool extremities and no pneumothorax
muffled heart sounds

Thoracic great vessels injuries
Injury to pulmonary veins and arteries is often fatal
One of the major causes of on-site death

Rupture of trachea or major bronchi
Rupture of the trachea or major bronchi is a serious injury with an overall
estimated mortality of at least 50%
The majority (80%) of ruptures of bronchi are within 2.5 cm of the carina.
The usual signs of tracheobronchial disruption are the followings:
hemoptysis
dyspnea
subcutaneous and mediastinal emphysema
occasionally cyanosis

Trauma to esophagus
In patients with blunt trauma this is rare. More frequent is the perforation
of the esophagus by penetrating injury.
It is lethal if unrecognized because of mediastinitis. Patients often
complain of sudden sharp pain in the epigastrium and chest with
radiation to the back. Dyspnea, cyanosis and shock occur but these may
be late symptoms.

Diaphragmatic injuries
Occur more frequently in blunt chest trauma, paralleling the rise in
frequency of car accidents.
The diagnosis is often missed.
Diaphragmatic injuries should be suspected in any penetrating thoracic
wound:
below 4
th
intercostal space anteriorly
6
th
interspace laterally
8
th
interspace posteriorly
usually the left side

Thoracic Aorta Rupture
Occurs in patients with severe decelerating forces such as high speed car
accidents or a fall from a great height.
They have high mortality as cardiac output is 5 l/min and the total blood
volume in an adult is 5 liters

ABDOMINAL TRAUMA
The abdomen is commonly injured in multiple trauma.
The most commonly injured in penetrating trauma is liver, and in blunt
trauma the spleen
The initial evaluation of the abdominal trauma patient must include the A
(airway and C-spine), B (breathing), C (circulation), and D (disability and
neurological assessment) and E (exposure)
Until proven otherwise, any patient involved in any serious accident
should be considered to have an abdominal injury.
Unrecognized abdominal injury remains a frequent cause of preventable
death after trauma.

2 Basic Categories of Abdominal Trauma
1. Penetrating trauma
Gunshot
Stabbing

2. Non-penetrating trauma (blunt trauma)
Compression
Crush
Seat belt
Acceleration/deceleration injuries

Indications for peritoneal lavage include
Unexplained abdominal pain
Trauma of the lower part of the chest
Hypotension, hematocrit fall with no obvious explanation.
Any patient suffering abdominal trauma and who has an altered mental
state (drugs, alcohol, brain injury)
Patient with abdominal trauma and spinal cord injuries.
Pelvic fractures

Relative contraindications for DPL (diagnostic peritoneal lavage):
Pregnancy
Previous abdominal injury
Operator inexperience
If the result does not change your management

Other issues with abdominal trauma
Pelvic fractures are complicated by massive hemorrhage (as much as 2L
of blood) and urology injury
Management of pelvic fracture
Resuscitation
Transfusion
Immobilization (place patient in a pelvic hammock) and assessment for
surgery
Analgesia

Complete physical examination of abdomen includes rectal examination,
assessing:
Sphincter tone
Integrity of rectal wall
Blood in the rectum
Prostate position
Check blood at the external urethral meatus

Women should be considered pregnant until proven otherwise
Fetus may be salvageable and the best treatment of the fetus is
resuscitation of the mother
A pregnant mother at term can usually only be resuscitated properly
after delivery of child

HEAD TRAUMA
Delay in the early assessment of head-injured patients can have
devastating consequence in terms of survival and patient outcome
Hypoxia and hypotension double the mortality of head injured patients
There are difficult to treat cases in district hospital but immediate
recognition and early management must be made: e.g. acute extradural
(epidural hematoma)
Alteration of consciousness is the hallmark of brain injury!
The most common error in head injury evaluation and resuscitation are
Failure to perform ABC and prioritise management (TRIAGE to treat what
you can with your expertise and resources)
4 of 5 |Page
Failure to look beyond the obvious head injury
Failure to assess the baseline neurological examination
Failure to re-evaluate patient who deteriorates

Acute extradural (epidural hematoma) classically the signs consist of
Loss of consciousness following a lucid interval, with rapid deterioration
Middle meningeal artery bleeding (due to fracture at the temporal area)
with rapid raising of intracranial pressure
The development of hemiparesis on the opposite side with a fixed pupil
on the same side as the impact area

Acute subdural hematoma: clotted blood in the subdural space,
accompanied by severe contusion of the underlying brain. It occurs from
tearing of bridging vein between the cortex and the dura.

***the management of the above 2 is surgical and every effort should be
made to do burr-hole decompressions

The conditions below should be treated with more conservative medical
management, as neurosurgery does not improve outcome:
Base-of-skull fractures: you see bruising of eyelids (Racoon eyes) or over
the mastoid process (battles sign), cerebrospinal fluid (CSF) leak from
ears and/or nose
Depressed skull fracture: an impaction of fragmented skull that may result
in penetration of underlying dura and brain.
Intracerebral hematoma may result from acute injury or progressive
damage to contusion.
Cerebral concussion with temporary altered consciousness. (Concuss:
bruising, contuse: parang sabaw, nalulusaw)

Management of Head Trauma
ABCS are stabilized (and the cervical spine immobilized, if possible)
Neuro-vital signs are monitored and recorded
Glasgow Coma Score GCS evaluation is undertaken

Remember:
severe head injury is when GCS is 8 or less
moderate head injury is when GCS between 9 and 12
minor head injury is when GCS between 13 and 15
never assume that alcohol is the cause of drowsiness in a confused
patient

Deterioration may occur due to bleeding
Unequal or dilated pupils may indicate an increase in intracranial
pressure
Head or brain injury is never the cause of hypotension in the adult trauma
patient
Sedation should be avoided as it interferes with the status of
consciousness but will promote hypercarbia (slow breathing with
retention of CO2)
The cushing response is a specific response to a lethal rise in intracranial
pressure. This is a late and poor prognostic sign. The hall marks are:
bradycardia
hypertension
decreased respiratory rate

Basic medical management for severe head injuries includes:
Intubation and hyperventilation, producing hypocapnia (PCO2 to 4.55).
This will reduce both intracranial blood volume and intracranial pressure
temporarily
Sedation with possible paralysis
Moderate IV fluid input with diuresis i.e. do not overload
Nurse head up 20%
Prevent hyperthermia

SPINAL TRAUMA
The most common injuries include damaged nerves to fingers, brachial
plexus and central spinal cord
The first priority is to undertake primary survey ABCDE, D (means
observation of neurological damage and status of consciousness), E
(exposure of the patient to assess skin injuries and peripheral limb
damage)
Examination carried out with patient in the neutral position (i.e. without
flexion, extension, or rotation) Patient should be:
Log rolled
Properly immobilized
Transported in a neutral position
Never transport a patient with a suspected injury of cervical spine in the
sitting or prone position. Always make sure patient is stabilized before
transferring

C-spine: if available in addition to the initial X-rays, all patients with suspicion
of cervical injury should include an AP and a lateral X-ray with a view of the
atlas-axis joint. All seven cervical vertebrae must be seen on the AP and
lateral view.

With vertebral injury (which may overlie spinal cord injury) look for
Local tenderness along the spine
Deformities as well as posterior step off injury
Edema

Clinical findings indicating injury of the cervical spine include
Difficulties in respiration (diaphragmatic breathing; check for paradoxical
breathing)
Flaccid and no reflexes
Hypotension with bradycardia (without hypovolemia)



Neurological assessment: assessment of the level of neurological injury must
be undertaken

Motor response (intact level) Sensory response
Diaphragm C3,C4,C5
Shrug shoulder C4
Biceps (flex elbow) C5
Extension of wrist C6
Extension of elbow C7
Flexion of wrist C7
Abduction of fingers C8
Active chest expansion T1 T2
Hip flexion L2
Knee extension L3 L4
Ankle dorsiflexion L5 S1
Ankle plantarflexion S1 S2
Anterior thigh L2
Anterior knee L3
Anterolateral ankle L4
Dorsum great and 2nd toe L5
Lateral side of foot S1
Posterior calf S2
Peri-anal sensation (perineum) S2
S5

Special issues relating to limb trauma
Stop active bleeding by direct pressure, rather than by tourniquet as it
can be left on by mistake, and this can result in ischemic change.
Open fractures: any wound situated in the neighbourhood of a fracture
must be considered as a communicating one. Principles of treatment:
Stop external bleeding
Immobilize and relieve pain
Compartment syndrome is caused by an increase in the internal pressure
of fascial compartment resulting to compression of peripheral nerves and
vessels. E.g. Volkmanns ischemia.
Amputated parts of extremities should be covered with sterile gauze
towels which are moistened with saline and put into sterile plastic bag. A
non-cooled amputated part may still be implanted within 6 hrs after
injury, a cooled one as late as 18-20 hrs.

Limb support: Early fasciotomy
The problem with compartment syndrome is often underestimated.
Tissue damage due to hypoxemia: compartment syndromes with
increased intramuscular (IM) pressures and local circulatory collapse are
common in injuries intramuscular hematomas, crush injuries, fractures or
amputations. If the perfusion pressure (systolic BP) is low, even a slight rise
in IM pressure causes local hypoperfusion. With normal body temperature
peripheral limb circulation starts to decrease at systolic BP around 80
mmHg
The damage on reperfusion is often serious: If there is local hypoxemia
(high IM pressure, low BP) for more 2 hours, the reperfusion can cause
extensive vascular damage. That is why decompression should be done
early. In particular the forearm and lower leg compartments are at risk.
When bleeding source is controlled, in-field fasciotomy and lower leg and
forearm compartment is recommended if the evacuation time is 4 hrs or
more. Fasciotomy should be done by any trained doctor or nurse under
ketamine anesthesia at the district location
Deep penetrating foreign bodies should remain in situ until operating
room exploration.

Special trauma cases
Pediatrics
Pregnancy
Burns

PEDIATRIC TRAUMA
Trauma is a leading cause of death for all children
Initial assessment is identical to that of an adult: ABCDE, early
neurological assessment, and exposing the child without losing heat.
Principles in managing pediatric trauma patients are the same as adults
Specific intubation issues: larger head nasal airway and tongue, nose
breathing in infants, cricoid is narrowest part of larynx, gastric distention is
common following resuscitation. Oral intubation is easier than nasal for
infants and children, avoid cuffed tubes to minimize subglottic swelling
and ulceration especially in less than 10 years old

Shock in Children
Femoral artery in the groin and brachial artery in the antecubital fossa
are the best sites to palpate pulses in children
Child that is pulseless warrants immediate CPR!
Signs of shock: tachycardia, weak or absent peripheral pulses, capillary
refill > 2 seconds, tachypnea, agitation, drowsiness, poor urine output
Hypotension may be a late sign, even in the presence of severe shock

The principles in managing pediatric trauma patients are the same as for the
adult
Vascular access should be obtained; good sites saphenous vein at ankle,
femoral vein in groin
Intraosseous access safe and effective; best site on anteromedial aspect
of the tibia below tibial tuberosity
Fluid replacement should be aimed to produce 12ml/kg/hr for infant, and
0.51 ml/kg/hr in the adolescent. A bolus of 20 ml/kg body weight of
normal saline. If no response after 2nd bolus, then 20ml/kg specific type
of blood or O Rh negative packed red blood cells(10ml/kg) should be
administered
Hypothermia is a major problem; lose heat through the head. Child has a
relatively large surface area. All fluids should be warmed.
Child should be kept warm and close to family if at all possible













APPENDIX A: ADULT TRIAGE

5 of 5 |Page

You might also like