Chapter 12: Emergencies & Injuries

Of the approximately 140 million annual emergency department (ED) visits in the United States, over 30 million (20%) are children 18 years and younger. Respiratory disorders are the leading cause of all pediatric ED visits (32%), with injuries and poisonings (27%) also accounting for a significant percentage. Though the vast majority (97%) of children presenting for ED evaluation are discharged home, nearly 1 million each year require hospital admission from the ED and, sadly, nearly 3000 children die every year in US EDs.

This chapter begins with the initial approach to the acutely ill pediatric patient, discusses the differentiation and initial management of shock, presents the general approach to the evaluation of pediatric trauma patients, summarizes commonly used emergency drugs, and concludes with the management of a number of common clinical scenarios in pediatric emergency medicine.

INITIAL APPROACH TO THE ACUTELY ILL INFANT OR CHILD

A pediatric patient in serious distress may present with a known diagnosis or in cardiorespiratory failure of unknown cause. The initial approach must be simple and consistent in order to rapidly identify physiologic derangements and injuries, prioritize management, and reverse life-threatening conditions immediately. Once stabilized following interventions, the provider must then carefully consider the underlying cause, focusing on those that are treatable or reversible. Specific diagnoses can then be made, and targeted therapy initiated.

Pediatric cardiac arrest most commonly results from progressive respiratory deterioration or shock as opposed to a primary cardiac etiology. Unrecognized deterioration may lead to bradycardia, agonal breathing, hypotension, and ultimately asystole. Resulting hypoxic and ischemic insult to the brain and other vital organs make neurologic recovery extremely unlikely, even in the doubtful event that the child survives the arrest. When cardiopulmonary arrest does occur, survival is rare and most often associated with significant neurological impairment. Current data reflect a 6% survival rate for out-of-hospital cardiac arrest, 8% for those who receive prehospital intervention, and 27% survival rate for in-hospital arrest. Children who respond to rapid intervention with ventilation and oxygenation alone or to less than 5 minutes of advanced life support are much more likely to survive neurologically intact. In fact, more than 70% of children with respiratory arrest who receive rapid and effective bystander resuscitation survive with good neurologic outcomes. Therefore, it is essential to recognize the child who is at risk for progressing to cardiopulmonary arrest and to provide aggressive intervention before asystole occurs.

Please see the selected references at the end of this section for more information on the specifics of the American Heart Association’s Pediatric Advanced Life Support (PALS) guidelines, most recently updated in 2018. The importance of quality Compressions is emphasized in both pediatric and adult cardiopulmonary resuscitation (CPR), with follow-up close attention paid to Airway and Breathing (acronym “C-A-B”). Please do not confuse this acronym with the “ABCs of resuscitation” approach described later as the following discussion details care of the critically ill pediatric patient who does not require CPR.

Of note, “compressions only” CPR has been touted as a way to encourage bystander CPR and increase survival rates of out-of-hospital cardiac arrests. In the pediatric population, however, conventional CPR (rescue breaths and chest compressions) is still emphasized and should be provided for infants and children in cardiac arrest. This is due to the asphyxial nature of most pediatric cardiac arrests which necessitates ventilation as part of effective CPR, whereas the majority of most adult cardiac arrest is due to a primary cardiac cause which may be more responsive to compressions-only CPR.

THE ABCS OF RESUSCITATION

A severely ill child should be rapidly evaluated in a deliberate sequence known as the ABCs: Airway patency, Breathing adequacy, and Circulation integrity. If a potentially life-threatening problem is detected during the evaluation, it must be corrected before proceeding to the next step. Age-appropriate equipment (including laryngoscope blade, endotracheal tubes, nasogastric or orogastric tubes, IV lines, and an indwelling urinary catheter) and monitors (cardiorespiratory monitor, pulse oximeter, and appropriate blood pressure cuff) should be assembled and readily available. Use a length-based emergency tape if available. See Table 12–1 for endotracheal tube and laryngeal mask airways (LMAs) sizes. Cuffed endotracheal tubes are acceptable for children and infants beyond the newborn period. Cuff inflation pressures must be carefully monitored and maintained below 20 cm H₂O. In certain circumstances, such as poor lung compliance or high airway resistance, the use of cuffed tubes may be preferable in controlled settings.

Airway

In all children, look for evidence of spontaneous breathing. Breath sounds such as stridor, stertor, or gurgling, or increased work of breathing without air movement are suggestive of airway obstruction. Significant airway obstruction often is associated with altered level of consciousness, including agitation or lethargy. During the airway assessment, if the patient is noted to be apneic or producing only gasping (agonal) breaths, chest compressions should be initiated immediately in accordance with PALS guidelines.

If concerned for obstruction, the airway is managed initially by noninvasive means such as oxygen administration, chin lift, jaw thrust, suctioning, or bag-valve mask ventilation (BMV). Invasive maneuvers, such as endotracheal intubation, laryngeal mask insertion, or rarely, cricothyroidotomy, are required if the aforementioned maneuvers are unsuccessful. The following discussion assumes that basic life support has been instituted.

Knowledge of pediatric anatomy is important for airway management. Children’s tongues are large relative to their oral cavities, and the larynx is high and anteriorly located. Infants are obligate nasal breathers; therefore, secretions, blood, or foreign bodies in the nasopharynx can cause significant distress.

1. Place the head in the sniffing position. In the patient without concern for cervical spine injury, the neck should be flexed slightly and the head extended. This position aligns the oral, pharyngeal, and tracheal planes. In infants and children younger than about 8 years, the relatively large occiput causes significant neck flexion and poor airway positioning. This is relieved by placing a towel roll under the shoulders, thus returning the child to a neutral position (Figure 12–1). In an older child, slightly more head extension is necessary. Avoid hyperextension of the neck, especially in infants.

2. Perform the head tilt/chin lift or jaw thrust maneuver (Figure 12–2). Lift the chin upward while avoiding pressure on the submental triangle, or lift the jaw by traction upward on the angle of the jaw. Important: head tilt/chin lift must not be done if cervical spine injury is possible. (See section Approach to the Pediatric Trauma Patient, later.)

3. Assess airway for foreign material. Suction the mouth; use Magill forceps to remove visible foreign bodies. If needed, visualize with a laryngoscope. Do not perform blind finger sweeps.

4. If airway obstruction persists, first attempt to reposition the head, then proceed with insertion of an airway adjunct, such as the oropharyngeal or nasopharyngeal airway (Figure 12–3). Such adjuncts relieve upper airway obstruction due to prolapse of the tongue into the posterior pharynx, the most common cause of airway obstruction in unconscious children. The correct size for an oropharyngeal airway is obtained by measuring from the upper central gumline to the angle of the jaw (Figure 12–4) and should be used only in the unconscious victim. Proper sizing is paramount, as an oropharyngeal airway that is too small will push the tongue further into the airway while one that is too large will obstruct the airway. Nasopharyngeal airways should fit snugly within the nares and should be equal in length to the distance from the nares to the tragus (Figure 12–5). This airway adjunct should be avoided in children with significant injuries to the midface due to the risk of intracranial perforation through a damaged cribriform plate.

Breathing

Assessment of respiratory status beings with inspection. Look for adequate and symmetric chest rise and fall, rate and work of breathing (eg, accessory muscle use, retractions, flaring, and grunting), skin color, and tracheal deviation. Pulse oximetry measurement and end-tidal CO₂ determination are highly desirable. Listen for adventitious breath sounds such as wheezing. Auscultate for air entry, symmetry of breath sounds, and rales. Feel for subcutaneous crepitus.

If spontaneous breathing is inadequate, initiate positive-pressure ventilation with BMV and 100% oxygen. Assisted ventilations should be coordinated with the patient’s efforts, if present. Effective BMV is a difficult skill that requires training and practice. To begin, ensure a proper seal by choosing a mask that encompasses the area from the bridge of the nose to the cleft of the chin. Form an E–C clamp around the mask to seal the mask tightly to the child’s face. The thumb and index finger form the “C” surrounding the mask, while the middle, ring, and small fingers lift the jaw into the mask (Figure 12–6). Use only enough force and volume to make the chest rise visibly. In the patient with a pulse, administer one breath every 3–5 seconds (12–20 breaths/min). This may be done using the timing mnemonic “squeeze-release-release” in a normal speaking voice. Two-person ventilation is optimal. When proper technique is used, BMV is effective in the vast majority of cases.

Adequacy of BMV is reflected with appropriate chest rise and auscultation of bilateral air entry. Avoid hyperventilation, as it may lead to barotrauma, increased risk of aspiration, and a decreased likelihood that return of spontaneous circulation will be achieved during cardiac arrest. If the chest does not rise and fall easily with bagging, reposition the airway and assess for foreign material as previously described. The presence of asymmetrical breath sounds in a child in shock or in severe distress suggests pneumothorax and is an indication for needle thoracostomy. In small children, the transmission of breath sounds throughout the chest may impair the ability to auscultate the presence of a pneumothorax. Note: Effective oxygenation and ventilation are the keys to successful resuscitation.

Cricoid pressure (Sellick maneuver) during positive-pressure ventilation may decrease gastric inflation; however, it has not been shown to reduce the risk of aspiration and is no longer recommended by the American Heart Association during CPR.

Circulation

The methodical assessment of blood circulation is critical to the diagnosis of shock, defined as the inadequate perfusion of vital organs. Circulation may be assessed in the following ways:

A. Pulses

Check adequacy of peripheral pulses and compare with central pulses. In the infant, central pulses should be checked at the brachial artery.

B. Heart Rate

Compare with age-specific norms. Tachycardia can be a nonspecific sign of distress; bradycardia for age is a sign of imminent arrest and necessitates aggressive resuscitation.

C. Blood Pressure

It is vital to understand that shock may be present even with a normal blood pressure. As intravascular volume falls, peripheral vascular resistance increases. Blood pressure is maintained until there is 35%–40% depletion of blood volume, followed by precipitous and often irreversible deterioration. Compensated shock occurs where there is normal blood pressure but signs of decreased organ perfusion. When blood pressure also falls, decompensated (hypotensive) shock is present. Blood pressure determination should be performed manually using an appropriately sized cuff, because automated machines can give erroneous readings in children.

D. Extremities

As shock progresses, extremities become cooler from distally to proximal. A child whose extremities are cool distal to the elbows and knees is in severe shock.

E. Capillary Refill Time

When fingertip pressure is applied to a patient’s distal extremity and released, blood should refill the area in less than 2 seconds. A prolonged capillary refill time in the setting of other signs of shock indicates a compensated shock state. It is important to recognize that capillary refill time is influenced by ambient temperature, limb position, site, age of the patient, and room lighting.

F. Mental Status

Assess the patient’s mental status, as hypoxia, hypercapnia, poor cerebral perfusion, or ischemia will result in altered mental status.

G. Skin Color

Skin that is pale, gray, sallow, mottled, or ashen may indicate compromised circulatory status.

MANAGEMENT OF SHOCK

Intravenous (IV) access is essential but can be difficult to establish in children with shock. Peripheral access, especially via the antecubital veins, should be attempted first. Use short, wide-bore catheters to allow maximal flow rates. Two IVs should be started in severely ill children. Intraosseous (IO) needle placement is an acceptable alternative in any severely ill child when venous access cannot be established rapidly (within 90 seconds) (Figure 12–7). Both manual and automated insertion devices are available for pediatric patients. Increasing evidence suggests that automated devices result in faster, more successful IO placement compared to manual devices. Decisions on more invasive access should be based on individual expertise as well as urgency of obtaining access. Options include percutaneous cannulation of femoral, subclavian, or internal or external jugular veins. Ultrasound guidance could make these attempts safer. In newborns, the umbilical veins may be cannulated. Consider arterial access if beat-to-beat monitoring or frequent laboratory tests will be needed.

Differentiation of Shock States & Initial Therapy

Therapy for inadequate circulation is determined by the cause of circulatory failure.

A. Hypovolemic Shock

The most common type of shock in the pediatric population is hypovolemia. Frequent causes include dehydration, diabetes, heat illness, and hemorrhage. Normal saline or lactated Ringer’s solution (isotonic crystalloid) is given as initial therapy in shock and should be initiated even in normotensive patients. There is no advantage to the early administration of colloid (albumin). Give 20 mL/kg body weight (maximum 1 L bolus) and repeat as necessary, until perfusion normalizes, being sure to appropriately monitor and reassess after each intervention. Packed red blood cell transfusion is indicated in trauma patients not responding to initial crystalloid bolus fluid replacement; however, there is insufficient evidence to determine the volume required. Pressors are not typically required in simple hypovolemic shock.

B. Distributive Shock

Distributive shock results from increased vascular capacitance with normal circulating volume. Examples are sepsis, anaphylaxis, and spinal cord injury. Initial therapy is isotonic volume replacement with crystalloid, but pressors may be required if perfusion does not normalize after delivery of two or three 20 mL/kg boluses of crystalloid (total of 40–60 mL/kg). Outcomes improve when threshold heart rates, normalized blood pressure, and a capillary refill in less than 2 seconds are achieved within the first hour of symptom onset. Early identification of septic shock and rapid delivery of goal-directed therapies as fluids, antibiotics, and inotropes within the first hour of presentation to the ED can reduce mortality and neurologic morbidity risks twofold. Recently updated recommendations from the American College of Critical Care Medicine (reference at end of section) stress the importance of aggressively managing hypotension in the pediatric population and recommend no patient be hypotensive for more than 1 hour without starting vasopressor medications. Depending on the clinical scenario, epinephrine, dopamine, norepinephrine, or dobutamine may be used safely in children, though it is important to note that central venous access is preferred for epinephrine and norepinephrine drips. Thus, dopamine may be a preferred agent to be given peripherally until central access can be established.

C. Cardiogenic Shock

Cardiogenic shock can occur as a complication of congenital heart disease, myocarditis, dysrhythmias, ingestions (eg, clonidine, cyclic antidepressants), or as a complication of prolonged shock due to any cause. The diagnosis is suggested by any of the following signs: abnormal cardiac rhythm, distended neck veins, rales, abnormal heart sounds such as an S₃ or S₄, friction rub, narrow pulse pressure, rales, or hepatomegaly. Chest radiographs may show cardiomegaly and pulmonary edema. An initial bolus of crystalloid may be given, but pressors, and possibly afterload reducers, are necessary to improve perfusion. Giving multiple boluses of fluid is deleterious, which is why frequent reassessment and comprehensive monitoring is essential. Bedside ultrasound is useful in rapidly determining if cardiac function is adequate and whether a pericardial effusion is present.

D. Obstructive Shock

Obstructive shock is rare in the pediatric population and involves extracardiac obstruction of blood flow and/or obstruction of adequate diastolic filling. Examples include cardiac tamponade, tension pneumothorax, massive pulmonary embolism, or a critical coarctation of the aorta after closure of the ductus arteriosus. Management is directed toward resolution of the obstruction. In the case of a critical coarctation, management should include emergent prostaglandin initiation to reopen the ductus arteriosus while awaiting surgical repair.

Observation & Further Management

Clinically reassess physiologic response to each fluid bolus to determine additional needs. Serial central venous pressure determinations or a chest radiograph may help determine volume status. Place an indwelling urinary catheter to monitor urine output.

Caution must be exercised with volume replacement if intracranial pressure (ICP) is potentially elevated, as in severe head injury, diabetic ketoacidosis, or meningitis. Even in such situations, however, normal intravascular volume must be restored in order to achieve adequate mean arterial pressure and thus cerebral perfusion pressure.

SUMMARY OF INITIAL APPROACH TO THE ACUTELY ILL INFANT OR CHILD

Assess the ABCs in sequential fashion and, before assessing the next system, immediately intervene if physiologic derangement is detected. It is essential that each system be reassessed after each intervention to ensure improvement and prevent failure to recognize clinical deterioration.

EMERGENCY PEDIATRIC DRUGS

Although careful attention to airway and breathing remains the mainstay of pediatric resuscitation, medications are often needed. Rapid delivery to the central circulation, which can be via peripheral IV catheter, is essential. Infuse medications close to the catheter’s hub and flush with saline to achieve the most rapid systemic effects. In the rare instance that no IV or IO access is achievable, important emergency resuscitation drugs such as epinephrine, atropine, and naloxone may be given endotracheally (see dosing in Table 12–2). However, the dose, absorption, and effectiveness of drugs given via this route are either unknown or controversial. The use of length-based emergency measuring tapes that contain preprinted drug dosages, equipment sizes, and IV fluid amounts (Broselow tapes) or preprinted resuscitation drug charts is much more accurate than estimation formulas and helps minimize dosing errors. Selected emergency drugs used in pediatrics are summarized in Table 12–2.

Traumatic injuries, including motor vehicle crashes, falls, burns, and immersions, account for the greatest number of deaths among children older than 1 year; injury exceeds all other causes of death combined with motor vehicle accidents accounting for the majority of deaths. Blunt trauma is most common, with penetrating trauma occurring in only 10% of cases. Head and abdominal injuries are particularly common and important.

A coordinated team approach to the severely injured child will optimize outcomes. A calm atmosphere in the receiving area will contribute to thoughtful care. Parents are often anxious, angry, or guilt-ridden, requiring ongoing support from staff, social workers, or child life workers (therapists knowledgeable about child development).

To provide optimal multidisciplinary care, regional pediatric trauma centers provide dedicated teams of pediatric specialists in emergency pediatrics, trauma surgery, orthopedics, neurosurgery, and critical care. However, most children with severe injuries are not seen in these centers. Community providers must often provide initial assessment and stabilization of the child with life-threatening injuries before transport to a verified pediatric trauma center.

MECHANISM OF INJURY

Document the time of occurrence, the type of energy transfer (eg, hit by a car, fall from playground), secondary impacts (if the child was thrown by the initial impact), appearance of the child at the scene, interventions performed, and clinical condition during transport. The report of emergency service personnel is invaluable. Forward all of this information with the patient to the referral facility if secondary transport occurs.

INITIAL ASSESSMENT & MANAGEMENT

The vast majority of children who reach a hospital alive survive to discharge. As most deaths from trauma in children are due to head injuries, cerebral resuscitation must be the foremost consideration when treating children with serious injuries. Strict attention to the ABCs (see the previous section) ensures optimal oxygenation, ventilation, and perfusion, and ultimately, cerebral perfusion.

The primary and secondary survey is a method for evaluating and treating injured patients in a systematic way that provides a rapid assessment and stabilization phase, followed by a head-to-toe examination and definitive care phase.

PRIMARY SURVEY

The primary survey is designed to immediately identify and treat all physiologic derangements resulting from trauma. The mnemonic, ABCDE, is a simple way to remember the general steps of the primary survey: Airway, with cervical spine control; Breathing; Circulation, with hemorrhage control; Disability (neurologic deficit); Exposure (maintain a warm Environment, undress the patient completely, and Examine)

If the patient is apneic or has agonal breaths, the sequence reverts to the CABs of PALS resuscitation (chest compressions, open the airway, provide two rescue breaths). Please refer to PALS guidelines for further information. Refer to preceding discussion regarding details of the ABC assessment. Modifications in the trauma setting are added as follows:

Airway

Failure to manage the airway appropriately is the most common cause of preventable morbidity and death. Administer 100% high-flow oxygen to all patients. Initially, provide cervical spine protection by manual inline immobilization, not traction. A hard cervical spine collar is applied after the primary survey.

Breathing

Most ventilation problems are resolved adequately by the airway maneuvers described earlier and by positive-pressure ventilation. Sources of traumatic pulmonary compromise include pneumothorax, hemothorax, pulmonary contusion, flail chest, and central nervous system (CNS) depression. Asymmetric breath sounds, particularly with concurrent tracheal deviation, cyanosis, or bradycardia, suggest pneumothorax, possibly under tension. To evacuate a tension pneumothorax, insert a large-bore catheter-over-needle assembly attached to a syringe through the second intercostal space in the midclavicular line into the pleural cavity and withdraw air. If a pneumothorax or hemothorax is present (evident by the sound of hissing as the air is evacuated), place a chest tube in the fourth or fifth intercostal space in the anterior axillary line. Connect to water seal. Insertion should be over the rib to avoid the neurovascular bundle that runs below the rib margin. Open pneumothoraces can be treated temporarily by taping petrolatum-impregnated gauze on three sides over the wound, creating a flap valve.

A child with a depressed level of consciousness (Glasgow Coma Scale [GCS] score < 9), a need for prolonged ventilation, severe head trauma, or an impending operative intervention requires endotracheal intubation after bag-mask preoxygenation. Orotracheal intubation is the route of choice and is possible without cervical spine manipulation. Nasotracheal intubation may be possible in children 12 years of age or older who have spontaneous respirations, if not contraindicated by midfacial injury.

Supraglottic devices, such as the LMA, are being used with increasing frequency, in both the prehospital and hospital settings. The device consists of a flexible tube attached to an inflatable rubber mask (Figure 12–8). The LMA is inserted blindly into the hypopharynx and is seated over the larynx, occluding the esophagus. Advantages to its use include ease of insertion, lower potential for airway trauma, and higher success rates. Patients remain at higher risk for aspiration with LMA use compared with orotracheal intubation; therefore, the LMA should not be used for prolonged, definitive airway management. Rarely, if tracheal intubation cannot be accomplished, particularly in the setting of massive facial trauma, cricothyroidotomy may be necessary. Needle cricothyroidotomy using a large-bore catheter through the cricothyroid membrane is the procedure of choice in patients younger than 12 years.

Circulation

Evaluation for ongoing external or internal hemorrhage is important in the trauma evaluation. Large-bore IV access should be obtained early during the assessment, preferably at two sites. If peripheral access is not readily available, an intraosseus line, central line, or cutdown, or IO line is established. Determine hematocrit and urinalysis in all patients. Blood type and cross-match should be obtained in the hypotensive child unresponsive to isotonic fluid boluses or with known hemorrhage. Consider coagulation studies, chemistry panel, liver transaminases, lipase, and toxicologic screening as clinically indicated.

External hemorrhage can be controlled by direct pressure. To avoid damage to adjacent neurovascular structures, avoid placing hemostats on vessels, except in the scalp. Determination of the site of internal hemorrhage can be challenging. Sites include the chest, abdomen, retroperitoneum, pelvis, and thighs. Bleeding into the intracranial vault rarely causes shock in children except in infants. Evaluation by an experienced clinician with adjunctive computed tomography (CT) or ultrasound will localize the site of internal bleeding.

Suspect cardiac tamponade after penetrating or blunt injuries to the chest if shock, pulseless electrical activity, narrowed pulse pressure, distended neck veins, hepatomegaly, or muffled heart sounds are present. Ultrasound may be diagnostic if readily available. Diagnose and treat with pericardiocentesis and rapid volume infusion.

Treat signs of poor perfusion vigorously: A tachycardic child with a capillary refill time of 3 seconds or more, or other evidence of diminished perfusion, is in shock and is sustaining vital organ insults. Recall that hypotension is a late finding. Volume replacement is accomplished initially by rapid infusion of normal saline or lactated Ringer solution at 20 mL/kg of body weight. If perfusion does not normalize after two crystalloid bolus infusions, 10 mL/kg of packed red blood cells is infused. Rapid reassessment must follow each bolus. If clinical signs of perfusion have not normalized, repeat the bolus. Lack of response or later or recurring signs of hypovolemia suggest the need for blood transfusion and possible surgical exploration.

A common problem is the brain-injured child who is at risk for intracranial hypertension and who is also hypovolemic. In such cases, circulating volume must be restored to ensure adequate cerebral perfusion; therefore, fluid replacement is required until perfusion normalizes. Thereafter provide maintenance fluids with careful serial reassessments.

Disability-Neurologic Deficit

Assess pupillary size and reaction to light and the level of consciousness. The level of consciousness can be reproducibly characterized by the AVPU (alert, voice, pain, unresponsive) system (Table 12–3). Pediatric GCS assessments can be done as part of the secondary survey (Table 12–4).

Exposure & Environment

Significant injuries can be missed unless the child is completely undressed and examined fully, front and back. Any patient transported on a backboard should be removed as soon as possible, as pressure sores may develop on the buttocks and heels of an immobilized patient within hours.

Because of their high ratio of surface area to body mass, infants and children cool rapidly. Hypothermia compromises outcome except with isolated head injuries; therefore, continuously monitor the body temperature and use warming techniques as necessary. Hyperthermia can adversely affect outcomes in children with acute brain injuries, so maintain normal body temperatures.

Monitoring

Cardiopulmonary monitors, pulse oximetry, and end-tidal CO₂ monitors should be put in place immediately. At the completion of the primary survey, additional “tubes” may be needed to be placed. See Table 12–1 for age/weight-appropriate equipment sizes.

A. Nasogastric or Orogastric Tube

Children’s stomachs should be assumed to be full so a nasogastric tube needs to be placed. Gastric distention from positive-pressure ventilation increases the chance of vomiting and aspiration. Of note, the nasogastric route should be avoided in patients with significant midface trauma.

B. Urinary Catheter

An indwelling urinary bladder catheter should be considered to monitor urine output. Contraindications are based on the risk of urethral transection; signs include blood at the meatus or in the scrotum or a displaced prostate detected on rectal examination. Urine should be tested for blood. After the initial flow of urine with catheter placement, the urine output should exceed 1 mL/kg/h.

SECONDARY SURVEY

After the Primary Survey and resuscitation phase, a focused history and a head-to-toe examination should be performed to reveal all injuries and determine priorities for definitive care.

History

Obtain a rapid, focused history from the patient (if possible), available family members or prehospital personnel. The AMPLE mnemonic is frequently used:

• A—Allergies

• M—Medications

• P—Past medical history/pregnancy

• L—Last meal

• E—Events/environment leading to the injury

Physical Examination

A. Skin

Search for lacerations, hematomas, burns, swelling, and abrasions. Remove superficial foreign material and cleanse as necessary. Cutaneous findings may indicate underlying pathology (eg, a flank hematoma overlying a renal contusion), although surface signs may be absent even with significant internal injury. Do not remove penetrating foreign objects because vital respiratory components, vascular structures, or organs may be involved and require removal in a controlled environment by a surgeon. Make certain that the child’s tetanus immunization status is current. Consider tetanus immune globulin for incompletely immunized children.

B. Head

Check for hemotympanum and for clear or bloody cerebrospinal fluid leak from the nares. The “battle sign” (hematoma over the mastoid) and periorbital hematomas (“raccoon eyes”) are late signs of basilar skull fracture. Explore wounds, evaluating for foreign bodies and defects in galea or skull. CT scan of the head is an integral part of evaluation for altered level of consciousness, posttraumatic seizure, or focal neurologic findings (see section Head Injury, later). Pneumococcal vaccine may be considered for basilar skull fractures as a preventive measure for meningitis.

C. Spine

Cervical spine injury must be excluded in all children. This can be done clinically in children older than 4 or 5 years with normal neurologic findings on examination who are able to deny midline neck pain or midline tenderness on palpation of the neck and who have no other painful distracting injuries that might obscure the pain of a cervical spine injury. If radiographs are indicated, a cross-table lateral neck view is obtained initially followed by anteroposterior, odontoid, and, in some cases, oblique views. Normal studies do not exclude significant injury, either bony or ligamentous, or involving the spinal cord itself. Therefore, an obtunded child should be maintained in cervical spine immobilization until the child has awakened and an appropriate neurologic examination can be performed. The entire thoracolumbar spine must be palpated and areas of pain or tenderness examined by radiography.

D. Chest

Children may sustain significant internal injury without outward signs of trauma. The most common type of injuries sustained from blunt chest trauma is pulmonary contusions which may lead to hypoxemia. Pneumothoraces are detected and decompressed during the primary survey. Hemothoraces can occur with rib fractures or with injury to intercostal vessels, large pulmonary vessels, or lung parenchyma. Tracheobronchial disruption is suggested by large continued air leak despite chest tube decompression. Myocardial contusions and aortic injuries are unusual in children.

E. Abdomen

Blunt abdominal injury is common in multisystem injuries. Significant injury may exist without cutaneous signs or instability of vital signs. Abdominal pain and tenderness coupled with a linear contusion across the abdomen (“seat belt sign”) increases the risk of intra-abdominal injury threefold. Tenderness, guarding, distention, diminished or absent bowel sounds, or poor perfusion mandate immediate evaluation by a pediatric trauma surgeon. Injury to solid viscera frequently can be managed nonoperatively in stable patients; however, intestinal perforation or hypotension necessitates operative treatment. Intra-abdominal injury is highly likely if the AST is greater than 200 U/L or the ALT greater than 125 U/L; however, elevated levels that are below these thresholds do not exclude significant injury if a significant mechanism has occurred. When measured serially, a hematocrit of less than 30% also may suggest intra-abdominal injury in blunt trauma patients. Coagulation studies are rarely beneficial if no concomitant head injury is present. There is no single test value that can reliably predict intraabdominal injury and therefore laboratory interpretation requires close clinical correlation. Laboratory studies are often most valuable in the nonverbal or obtunded patient, to increase the suspicion for injury and subsequent need for imaging.

Trauma ultrasonography, or the FAST (focused assessment with sonography for trauma), is routinely used in the adult trauma population. The purpose of the four-view examination (Morison pouch, splenorenal pouch, pelvic retrovesical space, and subcostal view of the heart) is to detect free fluid or blood in dependent spaces. In adults, such detection indicates clinically significant injury likely to require surgery. Accuracy and indications in children are much less clear. This examination has a high specificity rate to rule in free abdominal fluid, but low sensitivity to rule out significant intra-abdominal injury. Solid-organ injuries are more frequently missed. Additionally, much of the pediatric trauma management is nonoperative and therefore detection of free fluid by ultrasound in children is less likely to lead to surgery or result in a change in management. At least one recent study showed no change in the rate of pediatric patients eventually undergoing abdominal CT regardless of FAST findings.

F. Pelvis

Pelvic fractures are classically manifested by pain, crepitus, and abnormal motion. Significant blood loss into the pelvis may occur due to vascular injury, thus have a sign index of suspicion in the setting of unexplained tachycardia or hypotension. Pelvic fracture is a relative contraindication to urethral catheter insertion. Many providers perform a rectal examination, noting tone, tenderness, and in boys, prostate position. If this is done, stool should be tested for blood.

G. Genitourinary System

If urethral transection is suspected, perform a retrograde urethrogram before catheter placement. Diagnostic imaging of the child with hematuria less than 50 red blood cells per high-power (hpf) field often includes CT scan or occasionally, IV urograms. Management of kidney injury is largely nonoperative except for renal pedicle injuries.

H. Extremities

Long bone fractures are common but rarely life threatening. Test for pulses, perfusion, and sensation. Neurovascular compromise requires immediate orthopedic consultation. Treatment of open fractures includes antibiotics, tetanus prophylaxis, and orthopedic consultation.

I. Central Nervous System

Most deaths in children with multisystem trauma are from head injuries, so optimal neurointensive care is important. Significant injuries include diffuse axonal injury; cerebral edema; subdural, subarachnoid, and epidural hematomas; and parenchymal hemorrhages. Spinal cord injury occurs less commonly. Level of consciousness should be assessed serially. A full sensorimotor examination should be performed. Deficits require immediate neurosurgical consultation and should be considered for a patient with a GCS less than 12. Extensor or flexor posturing represents intracranial hypertension until proven otherwise. If accompanied by a fixed, dilated pupil, such posturing indicates that a herniation syndrome is present, and mannitol or 3% hypertonic saline should be given if perfusion is normal (see further discussion in next section). Treatment goals include aggressively treating hypotension to optimize cerebral perfusion, providing supplemental oxygen to keep saturations above 90%, achieving eucapnia (end-tidal CO₂ 35–40 mm Hg), avoiding hyperthermia, and minimizing painful stimuli. Early rapid sequence intubation, sedation, and paralysis should be considered. Mild prophylactic hyperventilation is no longer recommended, although brief periods of hyperventilation are still indicated in the setting of acute herniation. Seizure activity warrants exclusion of significant intracranial injury. In the trauma setting, seizures are frequently treated with fosphenytoin or levetiracetam. The use of high-dose corticosteroids for suspected spinal cord injury has not been prospectively evaluated in children and is not considered standard of care. Corticosteroids are not indicated for head trauma.

Closed-head injuries range in severity from minor asymptomatic trauma without sequelae to fatal injuries. Even after minor closed-head injury, long-term disability and neuropsychiatric sequelae can occur.

Prevention

Wearing helmets while riding wheeled recreational devices, playing contact sports, and participating in snow sports is a simple strategy in preventing head injuries. Over 50% of children fail to wear helmets when riding bicycles; rates are lower with other wheeled devices. Adolescents are less likely to use protective equipment and warrant special attention when discussing helmet use. More stringent helmet use while playing contact sports and return to play recommendations are now in place in child and high school sports programs. Toppled televisions, dressers and other unsecured furniture can also result in mild to severe head injuries in young children; anticipatory guidance regarding properly securing furniture should be provided to parents.

Clinical Findings

A. Signs and Symptoms

Head injury symptoms are nonspecific and may include headache, dizziness, nausea/vomiting, disorientation, amnesia, slowed thinking, and perseveration. Loss of consciousness is not necessary to diagnose a concussion (see Chapter 27 for more on concussion). Worsening symptoms in the first 24 hours may indicate more severe TBI. Obtain vital signs and assess the child’s level of consciousness by the AVPU system (see Table 12–3) or GCS (see Table 12–4), noting irritability or lethargy and pupillary equality, size, and light reaction. Perform a physical examination, including a detailed neurologic examination, being mindful of the mechanism of injury. Cerebrospinal fluid or blood from the ears or nose, hemotympanum, or the later appearance of periorbital hematomas (“raccoon eyes”) or “battle sign” (bruising over the mastoid process) imply a basilar skull fracture as discussed previously. Evaluate for associated injuries, paying special attention to the cervical spine. Consider child abuse; injuries observed should be consistent with the history, the child’s developmental stage, and the injury mechanism.

B. Imaging Studies

CT may be indicated. However, close observation for a period of time may be appropriate management and reduces the use of CT. A 2009 multicenter investigation of head-injured patients presenting to the ED derived and validated a decision rule for identifying those children at very low risk of clinically important traumatic brain injuries (Figure 12–9). Plain films are not generally indicated. In infants, a normal neurologic examination does not exclude significant intracranial hemorrhage. Consider imaging if large scalp hematomas or concerns of nonaccidental trauma are present in younger children.

Differential Diagnosis

CNS infection, toxicological ingestions, or other medical causes of altered mental status may present similarly to head injuries which often have no external signs of injury. In young infants when no history is available, one must also consider sepsis and inborn errors of metabolism.

Complications

A. Central Nervous System Infection

Open-head injuries (fractures with overlying lacerations) pose an infection risk due to direct contamination. Basilar skull fractures that involve the cribriform plate or middle ear cavity may allow a portal of entry for Streptococcus pneumoniae. Pneumococcal vaccination is considered for such cases.

B. Acute Intracranial Hypertension

Close observation will detect early signs and symptoms of elevated increased ICP. Early recognition is essential to avoid disastrous outcomes. Symptoms include altered mental status, headache, vision changes, vomiting, gait difficulties, and pupillary abnormalities. Papilledema is a cardinal sign of increased ICP. Other signs may include stiff neck, cranial nerve palsies, and hemiparesis. Cushing triad (bradycardia, hypertension, and irregular respirations) is a late and ominous finding. Consider CT scan before lumbar puncture if there is concern for elevated ICP because of the risk of herniation. Lumbar puncture should be deferred in the unstable patient.

Treatment—Therapy for elevated ICP must be swift and aggressive. Maintenance of adequate oxygenation, ventilation, and perfusion is paramount. Rapid sequence intubation is often necessary to protect the airway using a sedative and paralytic to decrease the ICP elevation accompanying intubation. Lidocaine is a controversial adjunct pretreatment medication (administered 2–3 minutes prior to attempt) during RSI and is thought to blunt increases in ICP during intubation by suppressing cough and gag reflexes and protect cerebral perfusion. Avoid hypoperfusion and hypoxemia, as both are associated with increased risk of morbidity and mortality. Hyperventilation (goal PCO₂ 30–35 mm Hg) is reserved for acute herniation; otherwise, maintain PCO₂ between 35 and 40 mm Hg. Mannitol (0.5–1 g/kg IV), an osmotic diuretic, will reduce brain water during acute herniation and hypertonic saline (3%; 4–6 mL/kg bolus doses or 1–2 mL/kg/h infusion) also may be used. Adjunctive measures to decreased ICP include elevating the head of the bed 30 degrees, maintaining the head in a midline position and treating hyperpyrexia (fever) and pain. Obtain immediate neurosurgical consultation. Further details about management of intracranial hypertension (cerebral edema) are presented in Chapter 14.

C. Prognosis

Children with concussion should be followed closely, return to sport only when symptom-free at rest and during exercise without medication use and then followed by a graduated return-to-play protocol. All states now have a concussion law and most require a physician’s note to return to play. In addition to sport limitations, patients may require a modified academic schedule and additional academic accommodations, including shorter days, longer testing periods, and decreased amounts of homework. Patients should only return to sports after a complete return to other school activities. Most children recover fully within 1–2 weeks. Acute symptoms seen in the ED do not correlate with long-term outcome, and therefore it is crucial for all patients to have follow-up management by their primary care physician. Persistent symptoms indicate the need for rehabilitation and/or neuropsychological referral. The CDC’s Heads Up program has accessible concussion and return to play information online and is a good resource for parents, coaches, and health care providers.

The prognosis for children with moderate to severe injuries depends on many factors including severity of initial injury, presence of hypoxia or ischemia, development and subsequent management of intracranial hypertension, and associated injuries.

THERMAL BURNS

Burns are a common cause of accidental death and disfigurement in children. Common causes include hot water or food, appliances, flames, grills, vehicle-related burns, and curling irons. Burns occur commonly in toddlers—in boys more frequently than in girls. The association with child abuse and the preventable nature of burns constitute an area of major concern in pediatrics.

Prevention

Hot liquids should be placed as far as possible from counter edges and parents/caregivers should take care when holding a child while drinking a hot beverage. While cooking, panhandles should be turned away from stove edge. Water heater thermostats should be turned to less than 120°F (49°C). Irons and electrical cords should be kept out of reach of children. Barriers around fireplaces are crucial. Infant and young children should wear protective clothing including hats when outdoors. Infant approved sunscreen should be applied, and reapplied frequently, to children 6 months and older, and also in younger infants in long periods of sun exposure outdoors.

Clinical Findings

A. Signs and Symptoms

Superficial-thickness burns are painful, dry, red, and hypersensitive. Sunburn is an example. Partial-thickness burns are sub-grouped as superficial or deep, depending on appearance. Superficial partial-thickness burns are red and often blister. Deep partial-thickness burns are pale, edematous, blanch with pressure, and they display decreased sensitivity to pain. Full-thickness burns affect all epidermal and dermal elements. A full-thickness wound is white or black, dry, depressed, leathery in appearance, and insensate. Deep full-thickness burns are the most severe, extending through all layers of skin as well as into the underlying fascia, muscle, and possibly bone. Singing of nasal or facial hair, carbonaceous material in the nose and mouth, and stridor indicate inhalational burns and may herald critical airway obstruction. Up to 25% of burns in children may be due to child physical abuse. Burn patterns can help distinguish inflicted from accidental causes. If the burn pattern does not fit the mechanism, consider child abuse.

B. Laboratory Findings

Laboratory evaluation is rarely indicated. With extensive partial- and full-thickness burns, baseline complete blood cell count (CBC), basic metabolic panel, and creatinine kinase are helpful for tracking infectious or renal complications. Consider carbon monoxide poisoning after inhalational injury: obtain an arterial blood gas and carboxyhemoglobin levels.

C. Imaging Studies

Imaging studies are rarely indicated. Neck x-rays should not delay intubation when inhalational injury is suspected.

Differential Diagnosis

The differential diagnosis of burns is limited when a history is provided. In the preverbal child when no history is available, the primary alternate consideration is cellulitis.

Complications

Superficial- and superficial partial-thickness burns typically heal well. Deep partial- and full-thickness burns are at risk of scarring. Loss of barrier function predisposes to infection. Damage to deeper tissues in full-thickness burns may result in loss of function, contractures, and in the case of circumferential burns, compartment syndrome. Renal failure secondary to myoglobinuria from rhabdomyolysis is also a concern with more severe burns.

Treatment

Burn extent can be classified as major or minor as determined by calculating the percent of body surface area (BSA) affected by partial- or full-thickness burns. Superficial thickness burns are not counted when assessing % BSA. Minor burns are less than 10% BSA for partial-thickness burns, or less than 2% for full-thickness burns. Partial- or full-thickness burns of the hands, feet, face, eyes, ears, and perineum are considered major.

A. Superficial- and Partial-Thickness Burns

These burns generally can be treated in the outpatient setting. Wounds with a potential to cause disfigurement or functional impairment—especially wounds of the face, hands, feet, digits, or perineum—should be referred promptly to a burn surgeon. Analgesia is paramount. After parenteral narcotic administration, initial treatment of partial-thickness burns with blisters consists of saline irrigation followed by application of clear antibiotic ointment and a non-adherent dressing (eg, petroleum gauze). Digits should be individually dressed to prevent adhesions. Because of the pain associated with aggressive debridement and the ability to provide an infectious barrier, smaller blisters may be left intact under the dressing. Larger bullae may either be drained or left in place. Protect the wound with a bulky dressing, reexamine within 48 hours and serially thereafter. Treatment at home with cool compresses and optimizing pain control with medications.

B. Full-Thickness, Deep or Extensive Partial-Thickness, and Subdermal Burns

Major burns require particular attention to the ABCs of trauma management. Early establishment of an artificial airway is critical with oral or nasal burns because of their association with inhalation injuries and critical airway obstruction. If singeing of the oro- or nasopharynx is noted on initial exam, immediate intubation is recommended.

Perform a primary survey (see earlier discussion). Consider toxicity from carbon monoxide, cyanide, or other combustion products. Place a nasogastric tube and bladder catheter. The secondary survey identifies associated injuries, including those suggestive of abuse.

Fluid losses can be substantial. Initial fluid resuscitation should restore adequate circulating volume. Subsequent fluid administration must account for increased losses. Fluid needs are based on weight and percentage of BSA with partial- and full-thickness burns. Figure 12–10 shows percentages of BSA by region in infants and children. The Parkland formula for fluid therapy is 4 mL/kg/% BSA burned for the first 24 hours, with half administered in the first 8 hours, in addition to maintenance rates. Use of burn tables improves calculation of appropriate fluids. Goal urine output is 1–2 mL/kg/h.

Children with burns greater than 10% BSA in a circumferential pattern, who are suspicious for abuse, or with burns associated with inhalational injury, explosions or fractures, should be admitted. Additionally, admission is warranted for adequate pain control in a patient requiring parenteral analgesia. Burns greater than 20% BSA or full-thickness burns greater than 2% BSA should be admitted to a children’s hospital or burn center. Children with subdermal burns require immediate hospitalization at a burn center under the care of a burn specialist.

Prognosis

Outcome depends on many factors. Healing occurs with minimal damage to epidermis in superficial burns. In contrast, full-thickness burns will be hard, uneven, and fibrotic unless skin grafting is provided. In general, the greater the surface area and depth of burn injury, the greater the risk of long-term morbidity and mortality.

ELECTRICAL BURNS

Electrical injuries vary from exposure to low-voltage, high-voltage, or lightning strike source. Children electrocuted with household current (low-voltage injury) who are awake and alert at the time of medical evaluation are unlikely to have significant injury. An electrocardiogram (ECG) is not necessary but urinalysis should be considered for severe electrical injury as rhabdomyolysis may result. Brief contact with a high-voltage source results in a contact burn and is treated accordingly. Infants and toddlers may bite electric cords, resulting in burns to the commissure of the lips. A late complication is labial artery hemorrhage. If current passes through the body, the pattern of the injury depends on the path of the current. Exposure to high-voltage current often induces a “locking-on” effect due to alternating current causing tetany. Extensive nerve and muscle injury, fractures, and cardiac arrhythmias in addition to dermal burns are possible. Lightning strikes are more likely to induce asystole and blast trauma. These patients often have no obvious physical injuries, but can present in cardiopulmonary arrest.

HEAT-RELATED ILLNESSES & HEAT STROKE

Prevention

Avoid exposure to extremes of temperature for extended periods. Plan athletic activities for early morning or late afternoon and evening. Acclimatization, adequate water, shade, and rest periods can prevent heat-related illness.

Clinical Findings

Heat cramps are brief, severe cramps of skeletal or abdominal muscles following exertion. Core body temperature is normal or slightly elevated. Electrolyte disturbance is rare and mild: laboratory evaluation is not indicated.

Heat exhaustion includes multiple, vague constitutional symptoms following heat exposure. Patients continue to sweat and have varying degrees of sodium and water depletion. Core temperature should be monitored frequently but is often normal or slightly increased. Symptoms and signs include weakness, fatigue, headache, disorientation, pallor, thirst, nausea with or without vomiting, and occasionally muscle cramps without CNS dysfunction. Shock may be present.

Heat stroke is a life-threatening failure of thermoregulation. Diagnosis is based on a rectal temperature above 40.6°C with associated neurologic dysfunction in a patient with an exposure history. Although typically present, lack of sweating is not a necessary criterion. Symptoms are similar to those of heat exhaustion, but severe CNS dysfunction is a hallmark. Patients may be incoherent or combative. In severe cases, vomiting, shivering, coma, seizures, nuchal rigidity, and posturing may be present. Cellular hypoxia, enzyme dysfunction, and disrupted cell membranes lead to global end-organ derangements and patients may develop rhabdomyolysis, myocardial necrosis, electrolyte abnormalities, acute tubular necrosis and renal failure, hepatic degeneration, acute respiratory distress syndrome (ARDS), and disseminated intravascular coagulation (DIC).

Differential Diagnosis

Viral gastroenteritis, sepsis and other infectious processes, neuroleptic malignant syndrome, malignant hyperthermia, and anticholinergic poisoning may present similarly.

Treatment

Removal from the offending environment and removal of clothing are the first steps in managing any heat-related illness. Heat cramps typically respond to rest and rehydration with electrolyte solutions. Severe cramping and heat exhaustion should prompt evaluation of electrolytes to guide IV fluid rehydration.

Heat Stroke Management

1. Address the ABCs and administer 100% oxygen.

2. Place monitors, rectal temperature probe, Foley catheter and nasogastric tube.

3. Administer IV fluids: isotonic crystalloid for hypotension; cooled fluids are acceptable. Consider central venous pressure monitoring. Consider providing diazepam for patient comfort.

4. Once resuscitative efforts have begun, initiate active cooling: fanning/misting with cool water; ice application at neck, groin, and axillae. Discontinue active cooling measures once core temperature reaches 38°C to prevent shivering.

5. Order laboratory tests: CBC; electrolytes; glucose; creatinine; prothrombin time and partial thromboplastin time; creatine kinase; liver function tests; arterial blood gases; urinalysis; and serum calcium, magnesium, and phosphate.

6. Admit to the pediatric intensive care unit.

Prognosis

Full recovery is the rule for heat cramps and heat exhaustion. Patients with heat stroke are at risk of end-organ damage. However, even in this critically ill population, most children recover fully with intensive management. Prognostic indicators include initial temperature, duration of elevated temperature, and number of systems involved.

HYPOTHERMIA

Prevention

Given the high association with submersion injuries, children should be carefully monitored around water. Proper use of life vests is critical.

Clinical Findings

A. Signs and Symptoms

Hypothermia is defined as a core temperature of less than 35°C. In an attempt to maintain core temperature, peripheral vasoconstriction leads to cool, mottled skin. Shivering increases heat production to two to four times basal levels. As temperature falls, heart rate slows and mental status declines. Severe cases (< 28°C) mimic death: patients are pale or cyanotic, pupils may be fixed and dilated, muscles are rigid, and there may be no palpable pulses. Heart rates as low as 4–6 beats/min may provide adequate perfusion due to lowered metabolic needs in severe hypothermia. Besides cold exposure, disorders that cause incidental hypothermia include sepsis, metabolic derangements, ingestions, CNS disorders, and endocrinopathies. Neonates, trauma victims, intoxicated patients, and the chronically disabled are particularly at risk. Because hypothermia may be confused with postmortem changes, death is not pronounced until the patient has been rewarmed and remains unresponsive to resuscitative efforts.

B. Laboratory Findings

Standard evaluation includes CBC, electrolytes, creatinine, coagulation studies, and glucose and blood gas studies. Coagulopathy, hypoglycemia, and acidosis are common. However, correction of derangements is accomplished by rewarming and resuscitating the patient. Also consider toxicology screen depending on the clinical scenario.

C. Imaging Studies

Submersion is the most common cause of hypothermia. Chest x-ray should be performed to assess for pulmonary edema and/or aspiration. Other radiographic studies should be performed according to the history with special attention to potential head or skeletal trauma.

Treatment

A. General Supportive Measures

Management of hypothermia is largely supportive. Administer warmed and humidified 100% oxygen. Continuously monitor core body temperature using a low-reading indwelling rectal thermometer. Handle patients gently as the hypothermic myocardium is exquisitely prone to arrhythmias. Ventricular fibrillation may occur spontaneously or as a result of minor handling or invasive procedures. If asystole or ventricular fibrillation is present on the cardiac monitor, perform chest compressions and use standard pediatric advanced life support techniques as indicated. Defibrillation and pharmacologic therapy (eg, epinephrine) are unlikely to be successful until core rewarming has occurred. Hypoglycemia should be corrected. Spontaneous reversion to sinus rhythm at 28–30°C may take place as rewarming proceeds.

B. Rewarming

Rewarming techniques are categorized as passive external, active external, or active core rewarming. Passive rewarming, such as removing wet clothing, covering with blankets, is appropriate only for mild cases (33–35°C). Active external rewarming methods include warming lights, thermal mattresses or electric warming blanket, and warm bath immersion. Be aware of potential core temperature depression after rewarming has begun when vasodilation allows cooler peripheral blood to be distributed to the core circulation. This phenomenon is called afterdrop.

Active core rewarming techniques supplement active external warming for moderate to severe hypothermia. The techniques include warmed, humidified oxygen, warmed (to 40°C) crystalloid IV fluids, and warm peritoneal and pleural lavage. If available, ECMO is the preferred method for rewarming a severely hypothermic patient, as it stabilizes volume, electrolyte disturbances while being safest for the heart. Bladder and bowel irrigation are not generally effective because of low surface areas for temperature exchange.

Prognosis

Recovery of the hypothermic victim is multifactorial. If associated with submersion injury (see next), CNS anoxic injuries and lung injury play a major role. Mortality rates are high and are related to the presence of underlying disorders and injuries. Children with a core temperature as low as 19°C have survived without neurologic compromise.

Prevention

The World Health Organization defines drowning as the process of experiencing respiratory impairment from submersion/immersion in liquid. The terms wet or dry drowning, near-drowning, and others are no longer used; nonfatal drowning describes survivors. Water hazards are ubiquitous; even toilets, buckets, and washing machines pose a threat. Risk factors include epilepsy, alcohol, and lack of supervision. Males predominate in submersion deaths. Prevention strategies include protective fencing around public and private pools, use of life vests, avoiding swimming alone, and adequate supervision. Swim lessons may have a role in a comprehensive prevention strategy, even for children 1–4 years of age.

Clinical Findings

A. Signs and Symptoms

Depending on the duration of submersion and any protective hypothermia effects, children may appear clinically dead or completely normal. Major morbidity stems from CNS and pulmonary insult. Cough, nasal flaring, grunting, retractions, wheezes or other lung sounds, and cyanosis are common. A child rewarmed to 33°C but who remains apneic and pulseless is unlikely to survive to discharge or will have severe neurologic deficits. Until a determination of brain death can be made, however, aggressive resuscitation should continue in a patient with return of circulation. Cardiovascular changes include myocardial depression and arrhythmias. Children may develop ARDS.

B. Laboratory Findings

Electrolyte alterations are generally negligible. Unless hemolysis occurs, hemoglobin concentrations change only slightly. Blood gas will show hypoxemia and acidosis.

C. Imaging Studies

Chest radiographs may be normal or may show signs of pulmonary edema. CT of the brain is warranted when the patient is comatose or believed to have suffered prolonged asphyxia or blunt head trauma. Consider cervical spine injury in teens where diving or intoxication may be involved.

Treatment

Care is supportive. Correct hypothermia and treat symptomatically. For children who appear well initially, observe for 12–24 hours for late pulmonary or neurologic compromise. Respiratory distress, an abnormal chest radiograph, abnormal arterial blood gases, or hypoxemia by pulse oximetry require maximal supplemental oxygen, cardiopulmonary monitoring, and frequent reassessment. There is little evidence for use of surfactant following drowning.

Prognosis

Anoxia from laryngospasm or aspiration leads to irreversible CNS damage after only 4–6 minutes. A child must fall through ice or directly into icy water for cerebral metabolism to be slowed sufficiently by hypothermia to provide protection from anoxia. Survival of the drowning victim depends on the duration of anoxia and the degree of lung injury. Children experiencing brief submersion with effective, high-quality resuscitation are likely to recover without sequelae. Children presenting asystolic are unlikely to survive.

Lacerations are a common reason to visit an ED. Lacerations can range from minor cuts that require no repair to complex lacerations that may require surgical consultation for adequate repair. The goals of laceration repair are to stop ongoing bleeding, prevent infection, and ensure wound healing that achieves optimal functional and cosmetic outcomes. Technical instruction of laceration repair is beyond the scope of this text as we present the basics of laceration wound care.

Clinical Findings

A. Signs and Symptoms

Lacerations present in a variety of shapes and sizes and occur over all parts of the body. Patients may present immediately after the injury or several days later. Wounds may contain foreign material, involve muscular, vascular, bony, tendon/ligamentous structures, or extend into joint spaces.

Options for wound repair include staples, suture material (both absorbable and nonabsorbable), and tissue adhesives. Tissue adhesives should never be used for highly contaminated wounds (eg, bites).

B. Imaging Studies

Imaging is usually not indicated for simple lacerations; however, plain x-rays may be indicated in certain situations. Lacerations caused by penetrating or crush injury may be associated with fractures. Lacerations across joints require specific evaluation for penetration of the joint space. Foreign bodies may be present in wounds and therefore careful attention must be made to assess complete removal when present.

Treatment

Obtain information regarding mechanism and age of the injury. Assess extent of the wound with identification of foreign bodies, neurovascular compromise, tendon/ligament damage, muscle, or joint involvement. Obtain appropriate surgical consultations as needed.

Provide adequate analgesia or anesthesia, using topical or injectable methods prior to wound care. Irrigate the wound using normal saline (tap water is an appropriate alternative) with high pressure (5–8 psi [pounds per square inch]). Debride devitalized tissue, remove foreign material, and then close wound using staples, sutures, or tissue adhesive. Antibiotic ointment may be applied after wound repair. Consider tetanus prophylaxis depending on immunization status. Patients should return as instructed to have suture material removed if needed (Table 12–5).

Prognosis

Functional and aesthetically pleasing cosmetics is generally achieved with initial repair. Complex lacerations may involve multiple visits with surgical service for wound reconstruction.

Bites account for a large number of visits to the ED. Most fatalities are due to dog bites. Human and cat bites cause the majority of infected bite wounds.

DOG BITES

Prevention

Boys are bitten more often than girls. The dog is known by the victim in most cases. Younger children have a higher incidence of head and neck wounds, whereas school-age children are bitten most often on the upper extremities. Children should be taught to not taunt dogs or approach dogs that are eating, sleeping, or are unknown to them.

Clinical Findings

A. Signs and Symptoms

Dogs may cause abrasions, lacerations, and puncture wounds. Larger dogs may tear skin, subcutaneous tissue, and muscle, or even cause fractures. Other signs and symptoms are related to the structures injured.

B. Imaging Studies

Bites caused by large dogs associated with significant crush injury may be associated with fractures. Dislodged teeth may also be present in the wound. Plain x-rays may be indicated.

Treatment

Provide appropriate analgesia or anesthesia before starting wound care. Debride any devitalized tissue and remove foreign matter. Irrigate using normal saline with high pressure (> 5 psi) and volume (> 1 L). Consider tetanus prophylaxis depending on immunization status. Rabies risk is low among dogs in developed countries; prophylaxis is rarely indicated. Suture wounds only if necessary for cosmesis as closure increases the risk of infection. Do not use tissue adhesives due to risk of infection. Prophylactic antibiotics do not decrease infection rates in low-risk dog bites, except those involving the hands and feet. Bites involving a tendon, joint, periosteum, or associated with fracture require prompt orthopedic surgery consultation.

Pasteurella canis and Pasteurella multocida, streptococci, staphylococci, and anaerobes may infect dog bites. Broad-spectrum coverage with amoxicillin and clavulanic acid is first-line therapy.

Complications

Complications of dog bites include scarring, skin infections, CNS infections, septic arthritis, osteomyelitis, endocarditis, sepsis, and posttraumatic stress.

CAT BITES

Prevention

Cat-inflicted wounds occur more frequently in girls. The principal complication is infection, and the risk is higher compared to dog bites as cat bites produce a puncture wound. Children should be observed closely when playing with kittens or cats.

Clinical Findings

A. Signs and Symptoms

Cat bites typically result in abrasions and puncture wounds. Within 12 hours, untreated bites may result in cellulitis or, when involving the hand, tenosynovitis and septic arthritis. Other signs and symptoms are related to the structures injured. Cat scratch disease (CSD) can occur after bites or scratches especially from kittens. Local findings include a papule, vesicle, or pustule at the site of inoculation. The hallmark of CSD is regional lymphadenitis. See Chapter 42 for a detailed discussion of CSD.

B. Laboratory Findings

Serologic tests for Bartonella henselae are available when cat scratch is suspected. C-reactive protein and erythrocyte sedimentation rate may be useful to monitor treatment response in infected cat bites.

Complications

Cellulitis, tenosynovitis, and septic arthritis are important potential complications of cat bites. Systemic illness is rare.

Treatment

Management is similar to that for dog bites. Provide appropriate analgesia or anesthesia before starting wound care. Debride any devitalized tissue and remove foreign matter. With isolated puncture wounds, high-pressure irrigation is contraindicated as it may force bacteria deeper into the tissue. Although controversial, soaking puncture wounds in an antiseptic solution (eg, dilute povidone-iodine) solution for 15 minutes is an accepted method to cleanse puncture wounds. Some experts recommend the practice to promote wound healing while others report delayed wound healing.

Alternatively, the wound may be soaked in dilute povidone-iodine solution for 15 minutes. Consider tetanus prophylaxis in the under- or unimmunized. As with dogs, rabies risk is low in developed countries and prophylaxis is rarely indicated. Cat bites should not be closed except when absolutely necessary for cosmesis.

P multocida is the most common pathogen. Prophylactic antibiotics are recommended. First-line treatment is amoxicillin and clavulanic acid. The dosage of the amoxicillin component should be 80 mg/kg/24 h in three divided doses. The maximum dosage is 2 g/24 h. Strongly consider admission and parenteral antibiotics for infected wounds on the hands and feet.

HUMAN BITES

Most infected human bites occur during fights when a clenched fist strikes bared teeth. Pathogens most commonly include streptococci, staphylococci, anaerobes, and Eikenella corrodens. Hand wounds and deep wounds should be treated with antibiotic prophylaxis against E corrodens and gram-positive pathogens with a penicillinase-resistant antibiotic (amoxicillin with clavulanic acid). Wound management is the same as for dog bites. Only severe lacerations involving the face should be sutured. Other wounds can be managed by delayed primary closure or healing by secondary intention. A major complication of human bite wounds is infection of the metacarpophalangeal joints. A hand surgeon should evaluate clenched-fist injuries from human bites if extensor tendon injury is identified or joint involvement is suspected.

Relief of pain and anxiety is paramount in providing care to pediatric patients and should be assessed and managed at all times. Parenteral agents are effective, safe, and produce few side effects if used judiciously. Intranasal administration of several sedative and narcotic medications is now an accepted route of administration and may omit the need for IV placement. Many agents also have amnestic properties. Refer to Chapter 32 for more information on typical analgesic medications used in pediatric emergency care.

Procedures such as fracture reduction, laceration repair, burn care, sexual assault examinations, abscess incision and drainage, lumbar puncture, and diagnostic procedures such as CT and magnetic resonance imaging may all be performed more effectively and compassionately if effective analgesia, anxiolysis or sedation is used. The clinician should decide whether procedures will require analgesia, anxiolysis, sedation, or a combination of methods.

Safe and effective sedation requires thorough knowledge of the selected agent and its side effects, as well as suitable monitoring devices, resuscitative medications, equipment, and personnel. The decision to perform procedural sedation and analgesia (PSA) must be patient-oriented and tailored to specific procedural needs, while ensuring the child’s safety throughout the procedure. In order to successfully complete this task, a thorough preprocedural assessment should be completed, including a directed history and physical examination. Risks, benefits, and limitations of the procedure should be discussed with the parent or guardian and informed; verbal consent must be obtained PSA goals in the ED setting usually involve minimal or moderate sedation. Minimal sedation is a state in which the patient’s sensorium is dulled, but he or she is still responsive to verbal stimuli. Moderate sedation is a depression of consciousness in which the child responds to tactile stimuli. In both cases, airway reflexes are preserved. It is important to remember that sedation is a continuum and the child may drift to deeper, unintended levels of sedation. Ensure appropriate resuscitative equipment and personnel are readily available when providing analgesia, anxiolysis, and sedation.