Begin the secondary survey after the primary survey is complete and resuscitative measures have been initiated. For the secondary survey, perform a complete head-to-toe physical examination, cervical spine evaluation, and clearance. Ancillary tools such as pulse oximetry, blood gas measurement, and quantitative end-tidal carbon dioxide (CO2) monitoring help guide therapy. Initiate laboratory evaluation, bedside ultrasonography, and radiographic imaging. During the secondary survey, perform nonemergent procedures such as placing a nasogastric or orogastric tube and Foley catheter (minimum urine output should be 0.5 mL/kg/h). A nasogastric tube will decompress the stomach, as a full stomach can restrict functional residual capacity.
In this phase, stabilize the child's condition sufficiently to allow transfer to the radiology suite or inpatient unit or a facility that can provide a higher level of care. Reassess the airway, breathing, circulation, and neurologic status continually because some injuries may manifest over time and complications from therapeutic interventions can occur. Consider endotracheal tube dislodgment, equipment failure, pneumothorax, regurgitation and aspiration of stomach contents, occult hemorrhage, and progression of intracranial hypertension as causes for deterioration. Carefully monitor fluid administration to prevent inadvertent overhydration. Provide appropriate analgesics and sedatives because pain treatment is often neglected in children.
REFERRAL TO A PEDIATRIC CENTER
Pediatric trauma center designation in the United States is conferred by governmental authority, and requirements vary from state to state. Guidelines have been created by American College of Emergency Physicians and American College of Surgeons to delineate the capabilities of a pediatric trauma center.18 The receiving institution should have a dedicated pediatric trauma service; comprehensive pediatric services should be available from scene care to rehabilitation and reintegration into the family and society. The trauma team should be immediately available at all times and capable of treating at least two patients simultaneously. Additional pediatric specialists should be on site or immediately available, including specialists in pediatric emergency medicine, anesthesiology, neurosurgery, radiology, orthopedics, critical care, and nursing. A pediatric intensive care unit is an essential component of a designated pediatric trauma center.
Use of trauma triage scores can help identify a child with more severe injuries, increase awareness of the need for higher level of care and monitoring, and predict outcomes. Two of the most commonly used systems are the Pediatric Trauma Score (Table 110-4) and the Revised Trauma Score (Table 110-5). Their advantages over other systems include use of physiologic variables instead of reliance solely on anatomic factors. Lower scores are associated with greater mortality and thus a need for pediatric trauma center care: a Revised Trauma Score of <12 or a Pediatric Trauma Score of <8 should prompt transfer to a pediatric trauma center.31
TABLE 110-4Pediatric Trauma Score* ||Download (.pdf) TABLE 110-4 Pediatric Trauma Score*
| ||–1 ||+1 ||+2 |
|Size (kg) ||<10 ||10–20 ||>20 |
|Airway ||Unmaintained ||Maintained ||Normal |
|Systolic blood pressure (mm Hg) ||<50 ||50–90 ||>90 |
|Level of consciousness ||Comatose ||Altered ||Awake |
|Wounds ||Major open ||Minor open ||None |
|Skeletal trauma ||Open/multiple ||Closed ||None |
TABLE 110-5Revised Trauma Score* ||Download (.pdf) TABLE 110-5 Revised Trauma Score*
|Number ||Glasgow Coma Scale Score ||Systolic Blood Pressure (mm Hg) ||Respiratory Rate (breaths/min) |
|4 ||13–15 ||>89 ||10–29 |
|3 ||9–12 ||76–89 ||>29 |
|2 ||6–8 ||50–75 ||6–9 |
|1 ||4–5 ||1–49 ||1–5 |
|0 ||3 ||0 ||0 |
Additional indications for transfer to a pediatric trauma center are listed in Table 110-6.32 Anatomic and physiologic parameters are most useful in determining which children should be transported to a trauma center.
TABLE 110-6Indications for Transfer to a Pediatric Trauma Center ||Download (.pdf) TABLE 110-6 Indications for Transfer to a Pediatric Trauma Center
|Mechanism of injury || |
Ejection from motor vehicle
Fall from a significant height
Motor vehicle collision with prolonged extrication
Motor vehicle collision with death of another vehicle occupant
|Anatomic injury || |
Multiple severe trauma
More than three long-bone fractures
Spinal fractures or spinal cord injury
Severe head or facial trauma
Penetrating head, chest, or abdominal trauma
Care of seriously injured children at a pediatric trauma center is associated with improved survival. In a study of 53,702 pediatric traumas comparing children treated at adult or pediatric trauma centers, the adjusted odds of mortality was 20% lower for children seen at trauma centers with pediatric qualifications.33 If not available, transport to a designated trauma center, adult or pediatric, is still associated with improved outcomes.34,35 Interfacility transfer of critically injured children is best done by a specialized pediatric transport team or a critical care transport team with pediatric experience when available (see chapter 107, "Neonatal and Pediatric Transport").
The goals of evaluation in a trauma victim are to determine the extent and severity of injury, what interventions, if any, are needed, and the level of monitoring required if admission is indicated. The mechanism of injury, history, and initial physical examination influence the degree of suspicion for intra-abdominal injury and guide subsequent radiographic and laboratory evaluation. Persistent emesis (especially bilious or bloody), abdominal distention, abdominal pain or any signs of peritoneal irritation, gross hematuria, and blood on rectal examination are indications for further investigation.
Carefully inspect the abdomen for signs of trauma including distention, abrasions, seat belt marks, or ecchymosis. Palpate for abdominal tenderness, which has a has a high positive predictive value for intra-abdominal injury. In high-mechanism injuries, maintain a high index of suspicion because pancreatic and hollow viscus injuries can present with delayed symptoms such as pain or emesis. Clinical evaluation of patients with altered mental status or distracting or associated injuries is difficult, and in this setting, a normal abdominal examination does not rule out the possibility of injury.
Routine laboratory "trauma panels" are frequently obtained in the evaluation of injured children, but individual laboratory abnormalities, while common, are seldom useful to dictate therapy, and no single laboratory test has acceptable sensitivity or negative predictive value to safely and effectively screen patients with abdominal trauma when used alone.36 Even organ-specific chemistries predicted injury poorly in children, are of little value, and alter acute management in only 5% to 6% of trauma patients.37 Although elevated liver function tests, particularly alanine aminotransferase, are suggestive of liver injury, no consensus exists as to the cut point for determining risk. Alanine aminotransferase levels >80 to 125 units/L have a sensitivity of 77%, specificity of 82%, but a positive predictive value of only 16%.38,39 An exception to the generally poor utility of liver function tests is in the setting of suspected inflicted injury in infants and young children, for whom liver function tests are recommended as a screening tool to detect occult blunt intra-abdominal injury.40
Amylase is not sensitive for acute pancreatic or other intra-abdominal organ injury, but lipase levels are fairly specific for pancreatic injury and can be used to serially monitor children for the development of complications such as pseudocyst formation or small bowel injury.41 In the seriously injured child, a base deficit >8 on blood gas analysis and lactate >4.0 mg/dL correlate with severe intra-abdominal injury and prognosis.42,43,44
Urinalysis is frequently obtained in trauma patients, but microhematuria alone is poorly predictive of either genitourinary or intra-abdominal injury across a range of cut points for number of red blood cells per high-power field; gross hematuria and mechanism of injury, rather than microhematuria, should guide imaging studies.45
Plain Radiography Plain radiography is still advocated as part of the trauma series in which the cervical spine, chest, and pelvis are imaged. Plain radiography has a low sensitivity for detecting intra-abdominal injury.
US Bedside ultrasonography is an extension of the physical examination of adult trauma patients. The FAST and extended FAST are used to evaluate for fluid in the peritoneal, pericardial, or pleural spaces. The utility of FAST is predicated upon its ability to identify free fluid (hemoperitoneum) and the assumption that the presence of free fluid is an indication of serious intra-abdominal injury requiring further evaluation. FAST is an appealing test due to its rapid bedside acquisition, relatively low cost, and lack of radiation, but there are a number of limitations in pediatric use. Due to anatomic and physiologic differences between children and adults, up to 30% of children with solid organ injury have no demonstrable free fluid on FAST, decreasing the sensitivity of this exam for solid organ injuries and limiting its negative predictive value, particularly in hemodynamically stable patients. Moreover, unlike adults in whom free fluid (hemoperitoneum) usually requires laparotomy, the vast majority of children with hemoperitoneum are successfully managed nonoperatively, so a positive FAST does not always change management. On the other hand, in the hemodynamically unstable patient with multiple trauma, FAST can provide valuable information as to the source of instability and help to focus resuscitative and surgical efforts when positive.46,47,48 As in adults, FAST poorly detects retroperitoneal and hollow viscus injury.
CT CT scan is the study of choice for the evaluation of blunt pediatric abdominal trauma. Advantages of CT include its speed, excellent depiction of solid organs, and widespread availability. Reformatted images in the coronal and sagittal planes allow good depiction of anatomy, and CT angiography can provide additional detail. Disadvantages include the need to remove the patient from the controlled and monitored setting of the trauma bay, radiation exposure, and potential complications related to the use of contrast materials. The main limitation to CT use is persistent hemodynamic instability despite adequate fluid resuscitation.
Common indications for CT include intubated children with multisystem trauma; altered mental status in the setting of trauma; spinal cord injuries resulting in loss of abdominal sensation; gross hematuria; abdominal pain and tenderness on examination; free fluid on FAST examination; abdominal or flank bruising or seat belt mark above the iliac crests; suspected inflicted trauma to the abdomen with elevated liver function tests; and direct blow to the abdomen from bicycle handlebars.49,50