Risk of death from injury can occur during any of three critical times. The first occurs at the time of injury, the sec- ond is within the first few hours after trauma, and the third is some time later as a result of complications from the injuries sustained at the time of the traumatic event. Development of effective regional trauma systems and educational programs, such as the Advanced Trauma Life Support for Doctors course, has contributed significantly to the reduction in mortality during the second and third of these critical periods (Tuggle, 1998; Rogers et al., 1999). Unfortunately, however, over 70% of mortality from trauma occurs at the time of injury.
Injuries can be classified as either blunt or penetrating. Blunt injures far outnumber penetrating injuries (12:1), and whereas most are unintentional, up to 7% of injuries are a result of physical assault or abuse
The first priority is to save a life through identifying and treating all life-threatening illnesses and injuries. To understand and acquire the necessary clinical skills for the management of
The RSI for pediatric trauma patients can be accomplished with an induction agent that is immediately followed by a muscle relaxant. Standard induction agents for trauma patients include etomidate (0.2 to 0.3 mg/kg) and ketamine (2 to 4 mg/kg) or the combination of fentanyl (2 to 3 mcg/kg), midazolam (0.05 to 0.1 mg/kg) with lidocaine (1 mg/kg). Sodium thiopental (STP) and propofol should be reserved for patients who are not hemo- dynamically unstable. STP is an ideal induction agent for patients with head trauma, provided they are not hypovolemic. Ketamine is relatively contraindicated in patients with increased intracra- nial pressure (ICP). Although etomidate provides hemodynamic stability in trauma patients who are hypovolemic, it may decrease survival in patients with sepsis secondary to adrenal suppression (Annane et al., 2002). Muscle relaxation can be achieved with rocuronium (0.8 to 1.2 mg/kg) or succinylcholine (1 to 1.5 mg/kg). Succinylcholine is contraindicated in crush injuries, long-bone fractures, and patients susceptible to malignant hyperthermia. In patients who are hemodynamically stable, the combination of propofol (4 mg/kg) and remifentanil (3 mcg/kg) can be used for rapid-sequence intubation and has an onset and offset similar to propofol and succinylcholine (1 mg/kg) (Crawford et al., 2005).
Assuring adequate ventilation is the next task after securing the airway. Breathing is best assessed by auscultation and observa- tion of chest motion. During the primary assessment the patient should be assessed for the presence or absence of breathing, respiratory rate, and work of breathing. The chest should also be observed for symmetry of chest motion and breath sounds. The chest wall should also be observed for evidence of direct chest trauma resulting in abrasions, penetration, or chest-wall instability. The back needs to be assessed as well for posterior chest wall trauma. Although there are no concrete recommen- dations to guide intubation, pediatric patients with increased work of breathing or life-threatening injuries (head injuries) may require ETI. Immediately after ETT placement, the posi- tion should be confirmed with end-tidal CO2.
Children who sustain multiple injuries often arrive in hypo- volemic or hemorrhagic shock that must be promptly recog- nized and treated. Unlike adults, children maintain an almost normal blood pressure until 25% to 35% of their circulating blood volume is lost (Fig. 30-5). This is likely because of their high sympathetic tone that causes peripheral vasoconstric- tion in an effort to maintain blood pressure in the face of a diminished blood volume. Therefore, tachycardia is an earlier sign of impending shock than hypotension. Additionally, signs of poor peripheral perfusion such as delayed capillary refill (more than 2 seconds), weak or thready pulses, mottling or cyanosis of the skin, and impaired consciousness are earlier indicators of shock than low blood pressure. The presence of hypotension as a result of hypovolemia should be considered an ominous sign that usually heralds impending cardiovascu- lar collapse. Table 30-5 describes the stages of pediatric shock and clinical signs seen at these stages.
A brief rapid neurologic evaluation is performed as part of the primary survey. It should include assessment of the patient’s level of consciousness and pupillary function. The AVPU method or the more detailed GCS should be performed. If AVPU is selected, the GCS calculation is performed during the secondary survey with a detailed neurologic examination. Periodic reassessment of the level of consciousness is neces- sary to detect neurologic deterioration caused by progression of traumatic brain injury (TBI), hypoxemia, or hypovolemia. Changes in mental status require prompt reevaluation of the ABCs. If they are adequately managed, then deterioration in mental status should be considered to be a result of TBI, prompting further brain imaging and consultation with a neurosurgeon.
Exposure involves removing the trauma patient’s garments, usually with shears, to allow detailed physical examination and detect injuries. Rolling the patient, while maintaining cervical spine precautions, is necessary to identify injuries to the dorsal surface of the body that would otherwise be occult. Padding should be placed on the backboard at this time to pre- vent decubitus ulcer formation. This assessment should be rapid, and the patient should be covered in warmed blankets or with a warming device to prevent hypothermia. In addition, IV fluids should be warmed, and the room temperature should be raised. This is especially important in small children, who are more prone to hypothermia because of their larger surface area-to-volume ratio.
The diagnostic evaluation of the injured child involves clini- cal examination supplemented by radiologic examinations and laboratory testing. Imaging plays a major role in the evaluation of the injured child (Vane, 2002). Improvements in imaging techniques have allowed progress in the nonoperative manage- ment of abdominal and thoracic trauma, supplanting explor- atory laparotomy and diagnostic peritoneal lavage in many hemodynamically stable patients.
Trauma en pediatría
Abordaje inicial del paciente
Javier Esteban Toro López
Residente de Anestesiología
Trauma en pediatría
“Es la disrupción de la homeostasis que afecta la
función física, piscológica y familiar y permanece como
el problema número uno de salud pública pediátrica
en el mundo”
Jurkovich et al, 2004
Etomidato (0,2-0,3 mg/kg) y ketamina (2 a 4 mg/kg)
Fentanil (2 a 3 mcg/kg) midazolam (0,05 a 0,1 mg/kg) y
lidocaína (1 mg/kg)
Propofol y tiopental en pacientes estables
Rocuronio (0.8 a 1.2 mg/kg) o suxametonio (1 mg/kg)
Luego de asegurar la vía aérea se debe:
Inspeccionar, palpar, percutir y auscultar el tórax
Buscar causas reversibles
Se debe reconocer rápidamente los estados de
Evaluar estado mental, taquicardia, apariencia
de la piel, llenado capilar, pulsos periféricos
La hipovolemia es un signo ominoso
Se debe administrar un primer bolo de
cristaloides 20 ml/kg
Reevaluar, si no hay respuesta se puede
administrar un segundo bolo de 20 ml/kg y
hasta un tercer bolo de 10 ml/kg
Pensar en causas reversibles, sangrado oculto
D: evaluación neurológica
Escala de coma de glasgow
Reacción y tamaño pupilar
E: exposición con prevención de hipotermia
Buscar lesiones ocultas
Evitar úlceras por presión