Management of Emergencies & Trauma in Children

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All sick children must be triaged upon arrival. This should be done using the ABCCCD approach. 

There are three triage categories:

  • Emergency: Children must be assessed and treated immediately. Emergency signs include obstructed breathing, central cyanosis, severe respiratory distress, weak or absent breathing, signs of shock (cold hands with capillary refill >3 seconds, weak, fast pulse), slow (<60 bpm) or absent pulse, coma, convulsions, severe dehydration.
  • Priority: Children not needing emergency treatment can be prioritized using 3TPRMOB. Tiny baby (<2 months old), temperature (very hot or cold), trauma, pallor, poisoning, pain (severe), respiratory distress (mild-moderate), restlessness, referral (urgent), malnutrition, oedema, burns.
  • Queue: Non-urgent cases who can wait to be seen.

EMERGENCY MANAGEMENT IN CHILDREN

AIRWAY:

  • Clearing and opening the airway:
    • Suctioning:
      • Only as far as you can see
    • Positioning:
      • If no trauma: use a chin lift and head tilt
        • <12 months neutral position
        • >12 months sniffing position
      • If trauma use a jaw thrust. Also remember C-spine immobilization.
      • NEVER use neck collars in children. 
  • Airway adjuncts:
    • Oropharyngeal airway
    • Nasopharyngeal airway
    • Laryngeal mask airway
    • Endotracheal intubation

ACUTE UPPER AIRWAY OBSTRUCTION:

Stridor: e.g., croup 

  • Keep the child calm
  • Minimize invasive procedures
  • Oxygen
  • Steroids
    • Prednisolone 2mg/kg PO (maximum 40mg) STAT OR
    • Dexamethasone 600 micrograms/kg PO (maximum 12 mg) STAT
  • Nebulized Adrenaline 1-2ml of 1:1000 in 2mls of 0.9% saline
  • May need intubation

ANAPHYLAXIS: 

Often caused by insect stings (bees), drugs and blood products

  • Oxygen
  • IM Adrenaline: is the PRIORITY; 0.01 ml/kg of 1:1000
  • Nebulized Adrenaline 1-2ml of 1:1000 in 2mls of 0.9% saline
  • IV Hydrocortisone 4mg/kg 6 hourly
  • Chlorpheniramine IV:
    • 6 months-6 years: 2.5 mg
    • 6-12 years: 5mg
    • 12-18 years: 10mg
  • Nebulized Salbutamol for wheeze:
    • <4 years: 2.5 mg
    • >4 years: 5mg
  • If also in shock: 10ml/kg 0.9% saline or ringer’s lactate over 20 minutes
  • May need PICU admission for respiratory and ionotropic support

CHOKING:

Encourage to cough. If ineffective cough and conscious

  • 5 back blows
  • Followed by 5 chest thrusts (infant), abdominal thrusts (>2 years) or Heimlich maneuver (older child)

If ineffective cough and unconscious 

  • Open airway, assess breathing, commence BLS

BREATHING:

  • Look, listen, and feel: Are they breathing?
  • If not breathing commence bag and mask ventilation
  • If breathing assess:
    • Effort
    • Respiratory rate
    • Evidence of increased work of breathing
    • Efficacy
    • Chest expansion
    • Auscultation

Effect

  • Evidence of cyanosis, oxygen saturations
  • Heart rate
  • Level of alertness

Detailed review of breathing

  • Inspection
  • Palpation
  • Percussion
  • Auscultation