PEDIATRIC EMERGENCY MEDICINE
0031-3955/92 $0.00 + .20
TRIAGE, INITIAL ASSESSMENT, AND EARLY TREATMENT OF THE PEDIATRIC TRAUMA PATIENT Roger W. Yurt, MO, FACS
One of the greatest challenges in modem medicine has been to coalesce the advances of the past 20 years into regionalized systems of care for the victim of traumatic injury. That there is a need for such a systematic approach is now well documented by studies that indicate that outcome is improved when patients are cared for in an organized system. 1, 12, 13, 16 Furthermore, such an approach is supported by the fact that injuries account for more days of hospitalization in the United States than cardiac disease and cancer combined. 4 TRIAGE AND INITIAL ASSESSMENT
From the very first step in the care of the injured patient in the field to the conclusion of definitive care, appropriate triage of the patient is the cornerstone of management This is especially true of the injured pediatric patient who demands specific consideration, although the principles of care remain the same as those for the adult patient Just as it is important to identify the victim of traumatic injury in the field and transport him or her to a facility with appropriate resources, there is a need to identify immediately a "captain of the ship" who coordinates the care of the injured patient. In the initial phase of care this individual likely is an emergency room physician. Once the initial From the Department of Surgery, Cornell University Medical College; and Trauma Center, The New York Hospital, New York, New York
PEDIATRIC CLINICS OF NORTH AMERICA VOLUME 39 • NUMBER 5 • OCTOBER 1992
1083
1084
YURT
assessment is made, however, a physician with expertise in care of the injured pediatric patient should assume primary responsibility for the patient. This trauma specialist is most often a trauma surgeon who has expertise in care of the pediatric trauma patient but also may be a pediatric surgeon who has expertise in trauma. The importance of early identification of this captain of the ship cannot be overemphasized, particularly in the case of the patient with multiple injuries. These patients often require care by multiple specialists, each with his or her own desires to intervene and care for injuries related to his or her expertise. All of these individuals must be orchestrated by the trauma specialist and pediatrician working together to ensure that life-saving treatment is administered in an appropriate sequential or combined approach. Clearly, education and facilities for the care of the pediatric trauma patient should be a national priority in health care. Although some progress has been made in injury prevention, it is the pediatric age group that suffers the most from injuries. Based on the recognition that injuries are the leading cause of death of the young, we must all, whether in trauma centers or community hospitals, be prepared to provide a high standard of care directed particularly at this segment of our population. Such initial assessment and care is outlined and definitive care is summarized in this article. Assessment of the trauma patient is frequently done in the field and the patient is already triaged; however, on occasion this is performed in the emergency room. Quite simply, the trauma patient is anyone who has sustained either blunt or penetrating injury. In general, those who have sustained injury to one system may be cared for by a specialist in that area; however, anyone who has sustained injury to more than one system should be cared for by a trauma specialist. In addition to the identification of specific injuries that would define a trauma patient, the mechanism of injury also should be considered as one makes the triage determination. For example, a patient who has been in a high-speed motor vehicle accident, in particular, one in which a death has occurred, should be considered at high risk for multiple injuries. Other such situations in which multiple trauma may have occurred are cases in which someone has fallen from a height of two stories or more and someone was a pedestrian who has been hit by a motor vehicle. Beyond this there are several other types of patients who should be considered to be trauma patients, such as those who have sustained a fracture of the first rib. Experience has shown that these patients have sustained sufficient blow to the torso so as to have sustained multiple internal injuries. Several different injury severity scoring scales have been used to assist in determining the prognosis and the outcome of patients. During this early phase of care it is possible to perform such an estimate as the patient is being assessed either in the field or in the emergency room. The most useful scale for on-the-scene evaluation or in an urgent situation is the trauma score, which was initially developed for adult patients2 and since has been revised. 3 As seen in Table I, the revised
1085
TRIAGE, INITIAL ASSESSMENT, AND EARLY TREATMENT
Table 1. REVISED TRAUMA SCORE Coded Value Component
4
3
2
Glasgow Coma Score Systolic blood pressure Respiratory rate
13-15 >89 10-29
9-12 76-89 >29
6-8 50-75 6-9
o 4-5 1-49 1-5
3
o o
trauma score for adults has a possible total of 12 points for the patient who is least injured, and for the patient who has sustained major injuries the low end of the scale would be a total of 3 points. This scoring system is based on respiration, the Glascow Coma Scale, and the systolic blood pressure. Experience has shown that this trauma score is not valid for the pediatric age group, and therefore a pediatric trauma score has been developed by Tepas et al,14 as seen in Table 2. This scale takes into account the size of the child as well as the status of the airway, the central nervous system, and the systolic blood pressure, In addition, this scale includes whether the patient has an open wound and the extent of a skeletal injury. This scale, as is true in the adult scale, has a maximum of 12 points for the patient with minimal injury, but in contrast to the adult scale the child in fact may end up with a negative number for the overall trauma score. The trauma score can be determined as a part of the primary survey of the patient that is performed immediately on first evaluation of the patient. This survey can be summarized as the ABCs of initial trauma assessment and includes airway, breathing, circulation, brief analysis of disability, and finally, exposing the patient for complete evaluation of injuries, In this initial phase, the airway must be maintained with particular attention to cervical spine (C-spine) control. Many training programs in resuscitation do not emphasize adequately the importance of C-spine control, which is always of paramount importance in the trauma patient until it has been determined whether or not C-spine injury has occurred. The general respiratory status of the patient is evaluated, and a quick determination is made as to whether the patient needs respiratory support. Even if the airway is Table 2. THE PEDIATRIC TRAUMA SCORE Category Component
+2
+1
Size Airway Systolic blood pressure CNS
>20 kg (40#) Normal >90 mm Hg Awake
Skeletal Cutaneous
None None
10-20 kg Maintainable 50-90 mm Hg Obtund ed/loss of consciousness Closed fracture Minor
+2
-1
0031-3955/92 $0.00 + .20
TRIAGE, INITIAL ASSESSMENT, AND EARLY TREATMENT OF THE PEDIATRIC TRAUMA PATIENT Roger W. Yurt, MO, FACS
One of the greatest challenges in modem medicine has been to coalesce the advances of the past 20 years into regionalized systems of care for the victim of traumatic injury. That there is a need for such a systematic approach is now well documented by studies that indicate that outcome is improved when patients are cared for in an organized system. 1, 12, 13, 16 Furthermore, such an approach is supported by the fact that injuries account for more days of hospitalization in the United States than cardiac disease and cancer combined. 4 TRIAGE AND INITIAL ASSESSMENT
From the very first step in the care of the injured patient in the field to the conclusion of definitive care, appropriate triage of the patient is the cornerstone of management This is especially true of the injured pediatric patient who demands specific consideration, although the principles of care remain the same as those for the adult patient Just as it is important to identify the victim of traumatic injury in the field and transport him or her to a facility with appropriate resources, there is a need to identify immediately a "captain of the ship" who coordinates the care of the injured patient. In the initial phase of care this individual likely is an emergency room physician. Once the initial From the Department of Surgery, Cornell University Medical College; and Trauma Center, The New York Hospital, New York, New York
PEDIATRIC CLINICS OF NORTH AMERICA VOLUME 39 • NUMBER 5 • OCTOBER 1992
1083
1084
YURT
assessment is made, however, a physician with expertise in care of the injured pediatric patient should assume primary responsibility for the patient. This trauma specialist is most often a trauma surgeon who has expertise in care of the pediatric trauma patient but also may be a pediatric surgeon who has expertise in trauma. The importance of early identification of this captain of the ship cannot be overemphasized, particularly in the case of the patient with multiple injuries. These patients often require care by multiple specialists, each with his or her own desires to intervene and care for injuries related to his or her expertise. All of these individuals must be orchestrated by the trauma specialist and pediatrician working together to ensure that life-saving treatment is administered in an appropriate sequential or combined approach. Clearly, education and facilities for the care of the pediatric trauma patient should be a national priority in health care. Although some progress has been made in injury prevention, it is the pediatric age group that suffers the most from injuries. Based on the recognition that injuries are the leading cause of death of the young, we must all, whether in trauma centers or community hospitals, be prepared to provide a high standard of care directed particularly at this segment of our population. Such initial assessment and care is outlined and definitive care is summarized in this article. Assessment of the trauma patient is frequently done in the field and the patient is already triaged; however, on occasion this is performed in the emergency room. Quite simply, the trauma patient is anyone who has sustained either blunt or penetrating injury. In general, those who have sustained injury to one system may be cared for by a specialist in that area; however, anyone who has sustained injury to more than one system should be cared for by a trauma specialist. In addition to the identification of specific injuries that would define a trauma patient, the mechanism of injury also should be considered as one makes the triage determination. For example, a patient who has been in a high-speed motor vehicle accident, in particular, one in which a death has occurred, should be considered at high risk for multiple injuries. Other such situations in which multiple trauma may have occurred are cases in which someone has fallen from a height of two stories or more and someone was a pedestrian who has been hit by a motor vehicle. Beyond this there are several other types of patients who should be considered to be trauma patients, such as those who have sustained a fracture of the first rib. Experience has shown that these patients have sustained sufficient blow to the torso so as to have sustained multiple internal injuries. Several different injury severity scoring scales have been used to assist in determining the prognosis and the outcome of patients. During this early phase of care it is possible to perform such an estimate as the patient is being assessed either in the field or in the emergency room. The most useful scale for on-the-scene evaluation or in an urgent situation is the trauma score, which was initially developed for adult patients2 and since has been revised. 3 As seen in Table I, the revised
1085
TRIAGE, INITIAL ASSESSMENT, AND EARLY TREATMENT
Table 1. REVISED TRAUMA SCORE Coded Value Component
4
3
2
Glasgow Coma Score Systolic blood pressure Respiratory rate
13-15 >89 10-29
9-12 76-89 >29
6-8 50-75 6-9
o 4-5 1-49 1-5
3
o o
trauma score for adults has a possible total of 12 points for the patient who is least injured, and for the patient who has sustained major injuries the low end of the scale would be a total of 3 points. This scoring system is based on respiration, the Glascow Coma Scale, and the systolic blood pressure. Experience has shown that this trauma score is not valid for the pediatric age group, and therefore a pediatric trauma score has been developed by Tepas et al,14 as seen in Table 2. This scale takes into account the size of the child as well as the status of the airway, the central nervous system, and the systolic blood pressure, In addition, this scale includes whether the patient has an open wound and the extent of a skeletal injury. This scale, as is true in the adult scale, has a maximum of 12 points for the patient with minimal injury, but in contrast to the adult scale the child in fact may end up with a negative number for the overall trauma score. The trauma score can be determined as a part of the primary survey of the patient that is performed immediately on first evaluation of the patient. This survey can be summarized as the ABCs of initial trauma assessment and includes airway, breathing, circulation, brief analysis of disability, and finally, exposing the patient for complete evaluation of injuries, In this initial phase, the airway must be maintained with particular attention to cervical spine (C-spine) control. Many training programs in resuscitation do not emphasize adequately the importance of C-spine control, which is always of paramount importance in the trauma patient until it has been determined whether or not C-spine injury has occurred. The general respiratory status of the patient is evaluated, and a quick determination is made as to whether the patient needs respiratory support. Even if the airway is Table 2. THE PEDIATRIC TRAUMA SCORE Category Component
+2
+1
Size Airway Systolic blood pressure CNS
>20 kg (40#) Normal >90 mm Hg Awake
Skeletal Cutaneous
None None
10-20 kg Maintainable 50-90 mm Hg Obtund ed/loss of consciousness Closed fracture Minor
+2
-1
