Appendix 8
Specialist Trauma Transfer Guidelines - 8.4 Paediatric Trauma

Primary Hospital Management

Prior to Reception

• Ensure adequately trained personnel with experience in paediatric resuscitation are present in the reception area.

• Ensure the necessary resuscitation equipment is available and easily accessible in a range of sizes.

• If possible, estimate the child's weight using the formula (Age +4) x 2 and calculate:
• The amount of fluid bolus at 20ml/kg
• The endotracheal tube size (Age /4) + 4.

• Make early contact with the Paediatric Major Trauma Service (tel: 03 9345 5211) for advice or dispatch of a retrieval team.

Airway and the Cervical Spine

• Assess the child's airway while protecting the cervical spine.

• Optimise the position of the upper airway, checking the cervical collar size and position carefully.

• If the airway is inadequate, apply a jaw thrust manoeuvre, clear any obstruction under direct vision and consider intubation.

Breathing

• Apply oxygen 10 litres/min by facemask.

• Assess the child's breathing by looking at:
  • The work of breathing (recession, respiratory rate, accessory muscle use)
  • Effectiveness of breathing (oxygen saturation, chest expansion, breath sounds)
  • Effects of inadequate respiration (heart rate, mental state).

• If breathing is inadequate, exclude a tension pneumothorax, use positive pressure ventilation with bag/valve/mask and consider intubation.

• Insert a large orogastric tube to treat and prevent gastric dilatation.

Circulation

• Assess the child's circulatory state by looking at:
  • Pulse rate, skin colour, capillary refill time, blood pressure.

• Effects of an inadequate circulation (respiratory rate, mental state).

• Establish intravenous access with two cannulae that are as large as practicable, ideally one situated in each cubital fossa.

• If an IV cannula is unable to be sited rapidly, consider the use of an intraosseous needle inserted into a non-traumatised leg.

• Give a fluid bolus of 20 mls/kg of normal saline.

• Tamponade any continuing external haemorrhage.

• If the circulation continues to be unstable, repeat the fluid bolus using normal saline or a colloid solution. If a third bolus is necessary, consider using whole blood and arranging immediate surgical intervention.

Mental State

• Assess mental state by determining the child's best response to pain and examining the pupillary reflexes.

• The response to pain is determined by squeezing one ear lobe hard and observing the best response to that stimulus (for example, flexion of one arm and extension of legs is recorded as flexion to pain).

• Note whether the child:
  • is alert
  • localises to pain
  • flexes to pain
  • extends limbs to pain
  • has no response to pain.

Monitor

• Response to pain, pupillary light response, respiratory rate, heart rate, non-invasive blood pressure, oxygen saturation.

Temperature

• Frequent rectal temperature monitoring.

• Limit exposure during assessment and resuscitation.

• All fluids and gases administered to the patient should be warmed.

Indications for Transfer to Paediatric Major Trauma Service

• Intubated or likely to need intubation.

• Head injury and does not localise to pain.

• Focal neurological signs.

• Multitrauma.

• Spinal trauma.

Possible Need for Transfer-Consult Paediatric Major Trauma Service

• Isolated fractures of femur, pelvis, facial bones.

• Possible need for abdominal, chest, plastic or neurosurgery.

Note:

Non-operative, 'observational' care is safe only in an environment that provides both close clinical observation by a surgeon experienced in the management of paediatric trauma and immediately available operative care.