Pediatric Corner

What you might be doing wrong for pediatric trauma

If a major pediatric trauma came through the doors of your ED right now, would you get sidetracked by the obvious injuries without paying close attention to trends in vital signs? Would you lack specific crash cart equipment because no one replaced or these items during slow times? Would you forget to check a bedside glucose level or fail to give pain medication?

These are all common problems when a child involved in a major trauma, especially when an ED doesn’t see many of these cases, says Laura L. Kuensting, MSN(R), RN, CPNP, pediatric nurse practitioner and clinical nurse specialist for the ED at St. John’s Mercy Medical Center in St. Louis.

To improve care of pediatric trauma patients, do the following:

• Remember the basics.

Remember the "ABCs" of airway, breathing, and circulation for every patient, while maintaining cervical-spine immobilization, says Lanie St. Claire, RN, ED nurse and pre-hospital liaison at Children’s Medical Center Dallas.

"Although traumatic injuries are sometimes more obvious, nothing is more important than an airway," says St. Claire.

• Keep the child warm.

Hypothermia causes further decompensation in a patient already using compensatory mechanisms to normalize, which can deplete the pediatric patient’s glucose stores very quickly, warns St. Claire.

Immediately provide a source of warmth using a warming mattress, warming lights, warm blankets, or warm intravenous fluids; otherwise the child can become cold-stressed, says Kuensting. "If you use chemical warming pads, remember that these lay under the child, not on top of the child," she adds. "Chemical warming mattresses are heavy and may impede the child’s ability to ventilate. Also, it will obstruct the nurse’s view of chest rise and fall."

• Check equipment every day.

The only way to be sure items will be there when you need them is to check equipment levels daily, says Kuensting. "You must know where the equipment is and have all the appropriate sizes," she says.

She recommends having all sizes of airway equipment, including oxygen masks/nasal cannulas, oral airways, ambu masks/bags, endotracheal tubes, and laryngoscope blades, organized in a drawer, on the wall, or in a cart.

"They should be arranged so that it is easy to see when an item is missing," says Kuensting. "Color coding the background the equipment is up against will help in identifying an appropriate size for the weight of the victim." (See list of pediatric trauma equipment your ED should have.)

• Take a specific role.

Kuensting gives the example of one nurse clearly stating, "I am the procedure nurse," a second nurse stating, "I am the medication nurse," another stating, "I am the documentation nurse," and a fourth nurse assisting whoever needs helps at the time. "The point is that everyone is assigned a job," she says.

• Create a pediatric code/trauma form.

The goal is to prompt nurses to document important items that are often forgotten, such as an estimated weight, a documented bedside glucose, the heating source used, pediatric trauma score and/or pediatric Glasgow Coma Score (GCS), vital signs, medications, and the names of the caregivers at the bedside, says Kuensting.

• Take an Emergency Nursing Pediatric Course (ENPC).

"This is an internationally recognized gold standard’ for emergency departments and their care of children," says Teri Howick, RN, an ENPC instructor and nurse educator for the ED at McKay Dee Hospital in Ogden, UT.

She also recommends taking the American Heart Association’s Pediatric Advanced Life Support (PALS) class. "This is a one- or two-day course in teaching general resuscitation of pediatric patients," says Howick.

Although being certified in PALS and ENPC won’t give you the instant ability to handle all pediatric trauma that hits the door, it will educate you in the basics, says St. Claire. "Each time the nurse recertifies, they will more thoroughly understand the system’s approach."

Follow up after mistakes

• Don’t let the same mistakes occur twice.

What would you do if an inappropriate procedure was performed during a resuscitation, such as inserting a central line when you already have intravenous access with two large bore catheters, failure to maintain inline immobilization during intubation, or lack of end-tidal carbon dioxide monitoring while bagging a severe head injured child? What would you do if an appropriate-sized cervical collar or endotracheal tube was missing?

In many EDs, no follow-up is done after these mistakes occur, says Cook. "We as nurses need to take initiative to prevent recurrence in the future," she says. "This may be [meeting] with the physician team leader or ED performance improvement council. Or it may require review by the trauma performance improvement committee to investigate and identify solutions."

• Know differences in signs of adult and pediatric distress.

"Remember, there is no benign pediatric tachycardia," says St. Claire. This is a warning to the bedside nurse to reassess the ABCs and to reevaluate your pediatric GCS, she says. "If you ignore tachycardia and wait for a falling blood pressure, you have waited too long," St. Claire says.

• Take an active role when your patient is transported.

If the child requires a higher level of care after stabilization, make sure that transport occurs as quickly and safely as possible, says St. Claire. "Become acquainted with your hospital’s policies on transporting patients," she advises. "Ask yourself things like, Should an ambulance service that only offers basic life support be transporting my pediatric trauma patient?’"

Sources/Resource

For more information on pediatric trauma, contact:

  • Becky Cook, RN, MSN, CPNP, Trauma Nurse Practitioner, Children’s Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229. Telephone: (513) 636-7157. E-mail: BECKY.COOK@cchmc.org.
  • Teri Howick, RN, Nurse Educator, Emergency Department, McKay Dee Hospital, 4401 Harrison Blvd., Ogden, UT 84403. Telephone: (801) 387-2286. Fax: (801) 387-2244. E-mail: teri.howick@intermountainmail.org.
  • Laura L. Kuensting, MSN(R), RN, CPNP, Pediatric Nurse Practitioner, Pediatric Emergency Medicine, St. John’s Mercy Medical Center, 615 S. New Ballus Road, St. Louis, MO 63141. Fax: (314) 995-4450. E-mail: lknstng@charter.net.
  • Lanie St. Claire, RN, Emergency Center, Children’s Medical Center Dallas, 1935 Motor St., Dallas, TX 75235. Telephone: (214) 456-7308. E-mail: lanie.st.claire@childrens.com.

To find an Emergency Nursing Pediatrics Course near you, go to www.ena.org. Under the heading "CATN II/ENPC/TNCC," click on "ENPC" and then "U.S. courses."