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What's new in paediatric trauma resuscitation?

Paediatric cardiac arrest

The most recent modifications to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care were published in 2006. (1) In this publication the critical role that high-quality and continuous chest compressions play in successful resuscitation has been emphasised. Compressions should be done hard and fast, at a rate of about 100 compressions per minute, allowing time for the chest to fully recoil. Continuity while giving compressions is vital and every effort should be made to minimise interruptions. A compression to ventilation ratio of 30:2 should be used in all patients and each breath should be given over 1 second, producing a visible chest rise. In paediatric patients this ratio should be adjusted to 15:2 for 2-person CPR. Defibrillation should be followed by 5 cycles or 2 minutes of chest compressions before checking for a rhythm.

While a respiratory cause of cardiac arrest carries with it a better prognosis, arrest following blunt trauma has a particularly poor outcome, with survival rates of 1-6%, and survivors may have severe neurological deficits. (2) Despite sustaining significant injury, the long-term quality of life in patients with head injury who do not undergo cardiac arrest is high. (3) The use of hypothermic therapy following cardiac arrest in adult populations has shown improved neurological outcomes. Due to differences in the mechanisms of cardiac arrest between adult and paediatric patients therapeutic hypothermia has not been shown to be as effective, and further study in this field has been suggested. (4) In addition, the applicability of this modality of treatment to a trauma population where patients often present with severe hypothermia is uncertain.

Airway management and ventilation

Intubation remains the definitive method of airway management in the trauma patient but presents a greater challenge in the paediatric population than in adults. Prehospital intubation performed by health care providers with little paediatric airway experience has led to unacceptably high complication rates. (5) In these cases airway management should be achieved by means of bag-valve-mask-ventilation. When the practitioner has specific paediatric airway skills, prehospital intubation can be performed safely and successfully. (6)

Intubations should be performed using a rapid sequence induction technique and tracheal intubation confirmed with an exhaled [CO.sub.2] detector in both the pre- and intra-hospital setting. (7) The use of the mnemonic LEMON has been suggested as a tool for pre-intubation airway evaluation (Table I). (3) Although useful in drawing attention to the potential difficult airway, the utility of the (e)valuation and (m) allampati components of the mnemonic in the paediatric trauma patient is doubtful. When faced with a difficult airway the gum elastic bougie and the laryngeal mask airway (LMA) may be useful. The use of cuffed endotracheal tubes in the paediatric population is increasing. They provide additional airway protection together with reductions in air leaks and if appropriate sizes are used and cuff pressures are monitored (<20 cm [H.sub.2]O), are not associated with an increase in tracheal stenosis. (8)
Table I. LEMON mnemonic for the evaluation of a difficult airway

L-ook         For trauma, large incisors, large tongue
E-valuate     Mouth opening, inter-incisor distance
M-allampati   Perform a Mallampati score
O-bstruction  Identify obstructions in the airway
N-eck         Evaluate neck flexion, extension and thickness


Over-ventilation results in alkalosis, increased intrathoracic pressures with subsequent impairment of venous return and reduces the chance of a successful resuscitation. Once the patient is intubated, 8-12 breaths should be delivered per minute, which can be increased to between 12 and 20 per minute once a perfusing rhythm as been established.

Fluid and venous access

Hypovolaemic shock in paediatric patients may be difficult to appreciate. Together with a tachycardia the signs of peripheral vasoconstriction--cold, mottled extremities and delayed capillary refill time--assume greater importance than in adults. (9) Normal saline, Ringer's lactate or low substitution hydroxyethyl starches should be used as first-line agents in resuscitation and should be administered in boluses of 10-20 ml/kg of crystalloid or 7-10 ml/kg of colloids. (10) Care should be taken to avoid over-resuscitation with crystalloids as this may lead to the development of multiple systemic complications, including abdominal compartment syndrome. (11) The use of hypertonic saline may have a role to play in the management of the patient with head trauma but is currently not recommended except within the context of clinical trials. In the hospital setting paediatric patients are at significant risk of developing hyponatraemia due to their retention of water during physiological stress. The use of hypotonic fluids such as half Darrow's dextrose (DD), half normal saline or 5% dextrose in the paediatric trauma population is strongly discouraged. (12)

Fluid resuscitation should be targeted at the restoration of organ perfusion and to this end lactate, base deficit and central venous oxygenation may have clinical utility, particularly in the first 24 hours following injury. (13) When haemorrhage is ongoing fluid administration should be limited and a balance struck between maintaining organ perfusion and avoiding exsanguination, even if this means allowing a lower than normal blood pressure in the patient. Cognisance should be taken that the normal paediatric blood volume is 70-80 ml/kg and thus blood loss may often be underestimated. Care should be taken to avoid hypotension in patients who have sustained blunt trauma with associated head injury. (3)

Venous access remains a challenge in the paediatric population. After 3 unsuccessful attempts at percutaneous line placements an intraosseous tibial, femoral or central venous line should be placed immediately. These techniques have largely replaced the use of the saphenous cutdown, which should now be seen as a technique of last resort. (14)

Temperature management

Temperature management is often omitted during paediatric trauma management. (15) The relatively large body surface area of children, ineffective vasoconstriction and cold fluid infusion may combine to rapidly cause hypothermia. Care should be taken to avoid unnecessary exposure, to keep the patient dry and to provide a warm environment during resuscitation. Forced air warmers and in-line fluid warmers are essential in trauma patient management.

References

(1.) 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric advanced life support. Pediatrics 2006; 117: e1005-1028.

(2.) Crewdson K, Lockey D, Davies G. Outcome from paediatric cardiac arrest associated with trauma. Resuscitation 2007; 75: 29-34.

(3.) Kortbeek JB, Al Turki SA, Ali J, et al. Advanced trauma life support, 8th edition, the evidence for change. J Trauma 2008; 64: 1638-1650.

(4.) Doherty DR, Parshuram CS, Gaboury I. Hypothermia therapy after pediatric cardiac arrest. Circulation 2009; 119: 1492-1500.

(5.) Gausche-Hill M. Ensuring quality in prehospital airway management. Curr Opin Anaesthesiol 2003; 16: 173-181.

(6.) Gerritse BM, Draaisma JM, Schalkwijk A, van Grunsven PM, Scheffer GJ. Should EMS-paramedics perform paediatric tracheal intubation in the field? Resuscitation 2008; 79: 225-229.

(7.) Mace SE. Challenges and advances in intubation: rapid sequence intubation. Emerg Med Clin North Am 2008; 26: 1043-1068.

(8.) Clements RS, Steel AG, Bates AT, Mackenzie R. Cuffed endotracheal tube use in paediatric prehospital intubation: challenging the doctrine? Emerg Med J 2007; 24: 57-58.

(9.) Stallion A. Initial assessment and management of pediatric trauma patient. Respir Care Clin N Am 2001; 7: 1-11.

(10.) Boluyt N, Bollen CW, Bos AP, Kok JH, Offringa M. Fluid resuscitation in neonatal and pediatric hypovolemic shock: a Dutch Pediatric Society evidence-based clinical practice guideline. Intensive Care Med 2006; 32: 995-1003.

(11.) Cotton BA, Guy JS, Morris JA, Jr., Abumrad NN. The cellular, metabolic, and systemic consequences of aggressive fluid resuscitation strategies. Shock 2006; 26: 115-121.

(12.) Murat I, Dubois MC. Perioperative fluid therapy in pediatrics. Paediatr Anaesth 2008; 18: 363-370.

(13.) Randolph LC, Takacs M, Davis KA. Resuscitation in the pediatric trauma population: admission base deficit remains an important prognostic indicator. J Trauma 2002; 53: 838-842.

(14.) DeRoss AL, Vane DW. Early evaluation and resuscitation of the pediatric trauma patient. Semin Pediatr Surg 2004; 13: 74-79.

(15.) Hunt EA, Hohenhaus SM, Luo X, Frush KS. Simulation of pediatric trauma stabilization in 35 North Carolina emergency departments: identification of targets for performance improvement. Pediatrics 2006; 117: 641-648.

REITZE N RODSETH, MB ChB, DCH (SA), DA (SA), FCA (SA)

Department of Anaesthetics, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, and Inkosi Albert Luthuli Central Hospital, Durban

Correspondence to: Reitze Rodseth (ReitzeRodseth@gmail.com)
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Author:Rodseth, Reitze N.
Publication:CME: Your SA Journal of CPD
Article Type:Report
Geographic Code:6SOUT
Date:Mar 1, 2010
Words:1375
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