IMMEDIATE MANAGEMENT OF SERIOUS & LIFE-THREATENING PROBLEMS
CERVICAL SPINE IMMOBILIZATION
Pediatric patients with blunt force trauma to the head should be assumed to have cervical spine injury until proven otherwise and thus should be managed with full immobilization during transport and initial evaluation. An important consideration is the use of an appropriately fitting cervical collar. Improper fitting can lead to poor immobilization of the cervical spine, and in some patients can obstruct the airway if it rides up over the chin and mouth. Additionally, the pediatric patient should be secured to a rigid backboard, with blocks for the head and towel rolls or other bulky buffers along the lateral aspect of the child to prevent side-to-side slippage.
Transient respiratory arrest and hypoxia may occur, which can lead to secondary brain injury. Hypoxia must be avoided at all costs and maintenance of an oxygen saturation of greater than 98% is preferred. Therefore, early endotracheal intubation should be performed for Glasgow coma scale (GCS) scores of 3-8 (see below and Figure 23-1), or for any patient with a decompensating level of consciousness and inability to protect the airway. On arrival to the emergency department, the patient should be provided 100% oxygen via a non-rebreather mask, and bag-valve-mask (BVM) with 100% oxygen can be used as well for apneic or bradypneic patients as a temporizing measure to a definitive airway.
Figure 23–1A, B.
A 15-year-old boy involved in MVC with signs of left facial trauma and altered mental status. (A) Noncontrast CT with brain windows. A small amount of pneumocephalus is noted in top-left image in the left frontal area. (B) Noncontrast CT with bone windows more clearly demonstrating a slightly displaced skull fracture through the left supraorbital area. Also noted is frontal scalp hematoma.
Once a definitive airway is established, or the patient is stable enough to maintain airway, blood gas measurements should be obtained. Gas measurements are important because, in addition to hypoxemia, hypo- and hypercarbia can lead to secondary brain injury. Hypocarbia leads to decreased cerebral perfusion and hypercarbia is associated with increased morbidity and mortality, so in general it is best to keep the pCO2 at about 35 mm Hg. In the rare case that there are incontrovertible signs of imminent or concurrent transtentorial herniation, such as a unilaterally blown pupil or acute neurological deterioration, hyperventilation with resultant permissive hypocarbia may be employed briefly until more definitive neurosurgical intervention is possible.
Hypotension in the setting of trauma is most likely a marker of severe blood loss, indicating Class III or IV shock. In pediatric patients, it is more ominous because children usually can compensate for hypovolemia farther into the disease process than adults. ...