Additional points for early management

Trauma imaging

Consider diagnostic imaging if indicated and available.
Three standard x-rays that should be considered routinely in major trauma:

• lateral C-spine
• chest
• pelvis

The desire to protect a child’s reproductive organs from radiation should not outweigh the risk of significant morbidity from a missed pelvic injury. Any abdominal/lower limb/spinal trauma, true multitrauma patients (i.e. MCA/MBA with suspected multi-system trauma etc.), all intubated patients or if the patient is difficult to assess must have a plain pelvic radiograph. Always safer to do the radiograph if unsure.

These x-rays are basic tests for major injuries. Full monitoring should be continued while obtaining the x-rays. X-rays are ideally done in the resuscitation room while the child is supervised by emergency staff.

FAST (Focused Assessment with Sonography for Trauma) scan: evidence suggests there is little value in paediatrics due to the risk of false reassurance, particularly when conducted by an inexperienced clinician. It may be useful only in structurally adult adolescents. The presence of free fluid in the abdomen on FAST does NOT mandate laparotomy. The absence of free fluid on FAST does NOT rule out significant intra-abdominal bleeding, therefore limiting its application.

eFAST (Extended FAST) scanning in children is helpful in diagnosing acute haemo/pneumothorax and haemopericardium when used by a skilled clinician.

Further imaging should only take place after discussion with PIPER.
The patient’s transfer to a definitive centre of care should not be delayed to await further imaging.

Analgesia

Injured children may require analgesia once their life-threatening problems have been rectified. Untreated or under-treated pain following trauma leads to multiple complications such as hypoventilation, reduced oxygenation, increased stress response, increased cardiac output and muscle tension and rigidity. In the emergency department, pain score documentation and management in children is suboptimal ¹⁸ and therefore requires additional focus.
Assessing pain in children can be difficult. An injury that is considered to be painful in an adult can reasonably be expected to be painful in a child. Children may respond by becoming quiet rather than crying. A developmentally acceptable pain assessment tool should be used. The tool should be explained to the child in a way that they can understand. If a child cannot utilize the provided scales the caregiver/clinician must attempt to assess the child’s pain in the context of their behaviour.
For patients aged one month up to seven years, a behavioural pain scale such as the FLACC Scale should be used. ¹⁹ 

FLACC SCALE – University of Michigan Health System
Face	0 No particular expression or smile	1 Occasional grimace or frown, withdrawn, disinterested	2 Frequent to consent quivering chin, clenched jaw
Legs	0 Normal position or released	1 Uneasy, restless, tense	2 Kicking or legs drawn up
Activity	0 Lying quietly, normal position, moves easily	1 Squirming, shifting back and forth, tense	2 Arched, rigid or jerking
Cry	0 No cry (awake or asleep)	1 Moans or whimpers, occasional complaint	2 Crying steadily, screams or sobs, frequent complaints
Consolability	0 Content, relaxed	1 Reassured by occasional touching or being talked to, distractible	2 Difficult to console or comfort

For verbal patients aged 4-5 up to 10–12 years, the Faces Pain Scale should be used.


For children aged over 7 years who are verbal and numerate, a numeric rating scale should be used.


Parents can also have useful input into the level of pain their child may be in. Take this into consideration when assessing pain.

Pain in children can be assisted by reducing fear and anxiety through having a parent or caregiver present, explaining what is happening in simple terms, reducing noise factors and managing injuries with splinting, traction, immobilisation, positioning and dressings.

Appropriate analgesics should be administered after determining the pain scale. The choice of which analgesia to use is directly related to this. It should be monitored for effectiveness and titrated accordingly.

Drug	Dose	Route	Pain severity	Comments	Adverse effects
Non-opioids
Paracetamol	15–20 mg/kg/dose 4–6 hourly (maximum dose 90 mg/kg/day or 4 g/day adult)	0/PR/IV	Mild to moderate	Opioid sparing effect. Review dose after 48 hours	Risk of hepatic impairment if prolonged use and/or high doses
Ibuprofen	10 mg/kg/dose 6–8-hourly (Maximum dose generally 600mg)	0	Mild to Moderate to severe	Caution if low BP or hypovolaemia. Opioid sparing effect. Least gastric irritating NSAID. Not for children under 3 months	Renal impairment, higher risk if hypotensive. Platelet dysfunction (not appropriate in haemorrhaging pt)
Ketamine	0.25-0.5mg/kg	IV	Severe	Dissociative anaesthetic. V effective analgesic where opiates are inadequate	Diplopia,nystagmus; emergence reaction (hallucination, delirium, confusion, irrational behaviour)
Opioids
Codeine (if oxycodone not available)	0.5–1 mg/kg/dose, 4–6-hourly (maximum dose 60 mg)	0 / PR	Mild to moderate	10 per cent of the population unable to metabolise. Do not give IV	Constipation and respiratory depression
Oxycodone (use 1st oral)	0.1–0.2 mg/kg/dose, 6-hourly	0 /PR	Moderate	Do not give administer with codeine	Respiratory depression
Morphine	0.05–0.2 mg/kg/dose, 2–4-hourly	IV	Moderate to severe	Give in increments, such as 20 mcg/kg, titrate to effect	Respiratory depression and hypotension
Fentanyl	0.5–1 mcg/kg/dose	IV	Moderate to severe	Give in increments, titrate to effect	Respiratory depression and bradycardia
	First dose: 1.5mcg/kg/dose 2nd dose 10 minutes post: 0.75 – 1.5 mcg/kg	IN *

Adapted from: Bevan C & Officer C, editors. Royal Children’s Hospital Paediatric Trauma Manual.2004. The Royal Children’s Hospital: Melbourne. Pg. 234.


Intramuscular injections are not recommended for analgesia in children with trauma. They are painful, feared by children, act slowly and have unreliable effects once administered.

Intranasal fentanyl is the preferred opiate prior to IV access being obtained.

Consider prophylactic antiemetic administration (recommend ondansetron or granisetron), especially if retrieval and transfer is likely. Metoclopramide should be used with caution especially in adolescent females. 

In-dwelling catheter

Placement of an in-dwelling catheter should be considered in severely injured patients/intubated patients/suspected pelvic injuries. Monitoring urine output is useful in managing a critically injured child as it is one of the best measures of core perfusion. Urine output can help guide appropriate fluid resuscitation. Intravascular volume and response to treatment can be measured using heart rate and urinary output.

Early consultation with paediatric surgeon if difficulty with insertion of the catheter.

A urinalysis should be performed to check for blood.

Once inserted, urine output should be measured hourly. The desired urine output is:

• infants: 2 mL/kg/hr.
• children: 1 mL/kg/hr.²⁰

Orogastric tube (OGT)

Insertion of an orogastric tube should be considered in all trauma patients. Even in relatively minor abdominal injuries, gastric dilatation can occur, complicating ventilation, and predisposing to vomiting or regurgitation.

After insertion, verify correct placement in the stomach.

All patients undergoing a CT scan should have consideration of an OGT in order to decrease the risk of vomiting. Not all patients will require an OGT, there is a need to balance co-operation in maintaining c-spine control with risk of aspiration.

All intubated patients must have an orogastric tube.

OGT should always be considered prior to transferring a child.

Patients should be kept nil orally in the initial post-resuscitation phase of injury.

Never insert a nasogastric tube in a child with a head injury without expert consultation. 

Antibiotics

Antibiotics should be administered for any injury with an open fracture.  Review allergies prior to administration.  Consider cephazolin 50mg/kg max 2g.

Tetanus immunisation

If an open wound is present, it should be cleaned and treated surgically if appropriate. If a wound is contaminated, tetanus immunoglobulin may be needed.

 

History of tetanus vaccination		Type of wound	Tetanus vaccine booster	Tetanus Immunoglobulin
3 or more doses	< 5 years since last dose	All wounds	No	No
	5–10 years since last dose	Clean minor wounds	No	No
	5–10 years since last dose	All other wounds	Yes	No
	> 10 years since last dose	All wounds	Yes	No
< 3 doses or uncertain		Clean minor wounds	Yes	No
< 3 doses or uncertain		All other wounds	Yes	Yes

A combination vaccine should be used in order to boost community protection against pertussis.
Please note that CDT and Tetanus Toxoid are no longer available.
 

<8 years old DTPa – IPV (Infanrix – IPV).
>8 years old dTPA (Boostrix).

Can use a diphtheria / tetanus toxoid vaccine (ADT) if pertussis vaccination is contraindicated.
 
Available from: http://www.rch.org.au/clinicalguide/guideline_index/Managament_of_tetanusprone_wounds/

Reassess

The importance of frequent reassessment cannot be overemphasised. A patient should be re-evaluated at regular intervals because deterioration can be rapid. This will be evident in vital signs and level of consciousness. If in doubt, repeat ABCDE.
 
The priorities for further investigation and treatment may now be considered and a plan for definitive care established.