Dramatically improve care of pediatric trauma cases

Unless you work in a pediatric ED or trauma center, you probably treat only a handful of major pediatric trauma cases each month. For this reason, you must be aware of important differences between children and adults that will change the way you care for these patients, says Kaaren Fanta, RN, MSN, CPNP, trauma nurse practitioner at Cincinnati Children’s Hospital. "Unique anatomic and physiologic differences in children predispose them to different patterns of injury and resuscitative needs," she explains.

To dramatically improve care of pediatric trauma patients, incorporate the following into your practice:

Secure an adequate airway, and evaluate the patient’s breathing.

Almost all pediatric cardiopulmonary arrests are caused by a respiratory problem as opposed to a cardiac problem, notes Fanta. "Bag mask until appropriate medical personal are available to intubate," she advises.

You must address these questions, says Becky Cook, RN, MSN, CPNP, also a trauma nurse practitioner at Cincinnati Children’s:

  • Is the airway patent?
  • Is the child crying/talking?
  • Is the child’s breathing noisy?
  • Is the child able to maintain his or her airway?
  • What is the child’s level of consciousness?
  • Is there a potential for airway edema?
  • Is there extensive facial trauma?
  • Does the child have a large amount of secretions?

There are important anatomical differences between an adult’s and a child’s airway, stresses Cook. Children have proportionally larger heads and tongues, smaller nasal passages, more anterior larynx, and shorter tracheas, which can make intubation and ventilation more difficult, she says. Infants are obligate nasal breathers, so it is important to keep their nostrils patent, says Cook. "This can be done by simply suctioning blood or secretions from their nose," she says. Securing an adequate airway and providing oxygen does not ensure that adequate ventilation and gas exchange has occurred, so you also must evaluate breathing, says Fanta. (See evaluation questions, below.)

Ensure correct dosages are given.

For children, fluids and drugs are given per kilogram instead of unit doses as with adults, advises Fanta. To ensure correct dosages, use cheat sheets to approximate pediatric ages to weight, she suggests. The ED uses these for newborns and children ages 3 months, 1 year, 3 years, 6 years, 8 years, 10 years, 12 years, and 14 and older, she explains. "These are helpful, since we are usually not able to get an accurate weight but we do usually know the age," says Fanta.

Have necessary equipment easily accessible.

Your ED should have all of the pediatric equipment recommended by the Washington, DC-based National Emergency Medical Services for Children, says Laura L. Kuensting, MSN, RN, CPNP, pediatric nurse practitioner for the ED at St. John’s Mercy Medical Center in St. Louis.1

Your goals are twofold: To acquire the appropriate equipment, and to organize these items so they are easy to locate in an emergency. Designate a person, such as a pediatric clinical nurse specialist or a staff nurse, to handle this task, advises Cook. "Once you have done this, the staff function much less frantically in a traumatic situation," she says.

Address fluid resuscitation and intravenous access.

Look for early signs of shock, such as tachycardia, slowed capillary refill, and cool, pale skin, says Fanta. "Decreased blood pressure is a late sign!" she stresses. If you are unable to obtain peripheral access, use the interosseous route, she says. Interosseous needles need to be easily accessible, so remind physicians to use them, says Fanta. This is typically used in children younger than 6 years of age and can be used to infuse anything given intravenously, including medications, fluids, and blood products, she adds.

Look for these indicators of good interosseous placement, she says:

  • Fluid infuses easily with no swelling to surrounding tissues.
  • The interosseous is fixed in place.

"It is very difficult to move or manipulate an interosseous if it is properly placed," says Fanta. You may or may not see blood or marrow aspiration, she adds.

Ensure adequate oxygenation and circulation for children with head injuries.

Adequate oxygenation and circulation is key to preventing secondary brain injury, warns Fanta. If you are able to maintain the airway, provide supplemental oxygenation, says Fanta. "If you are unable to maintain an airway, consider endotracheal intubation," she says.

You must ensure adequate fluid resuscitation for good perfusion, says Cook. Consider inotropic support if fluid resuscitation does not provide adequate perfusion as demonstrated by heart rate, capillary refill, color, pulse, and blood pressure, she adds.

For rapid sequence intubation, use pre-made intubation kits containing the medications lidocaine, atropine, and etomidate, and use a standard intubation policy to minimize confusion, recommends Fanta. "Nurses can draw up medications in advance," she adds. "Doses are standardized based on weight so nurses can draw them up quickly, but remember these are short-acting medications, so the child may need stronger sedation or paralytic after proper intubation is confirmed," says Fanta.

Reference

1. Committee on Pediatric Equipment and Supplies for Emergency Departments, National Emergency Medical Services for Children Resource Alliance. Guidelines for pediatric equipment and supplies for emergency departments. Ann Emerg Med 1998; 31:54-57.

Sources

For more information on caring for pediatric trauma patients, contact:

Kaaren Fanta, RN, MSN, CPNP, Trauma Nurse Practitioner, Cincinnati Children’s Hospital, 3333 Burnet Ave., Cincinnati, OH 45229. Telephone: (513) 636-0575. Fax: (513) 636-3827. E-mail: kaaren.fanta@chmcc.org.

Becky Cook, RN, MSN, CPNP, Trauma Nurse Practitioner, Cincinnati Children’s Hospital, 3333 Burnet Ave., Cincinnati, OH 45229. Telephone: (513) 636-7157. Fax: (513) 636-3827. E-mail: becky.cook@cchmc.org.

Laura L. Kuensting, MSN, RN, CPNP, Pediatric Nurse Practitioner, Pediatric Emergency Medicine, St. John’s Mercy Medical Center, 615 S. New Ballas Road, St. Louis, MO 63141. Fax: (314) 995-4450. E-mail: lknstng@charter.net.