Page 723 - ACCCN's Critical Care Nursing

700 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

immuno dysfunction, increased risk of infections, mor- Immersions are another leading cause of death in chil-
bidity and death in children with organ dysfunction. 214 dren 0–4 years of age, with around 29% of near-drownings
in Australia in this age group, peaking in the summer
PAEDIATRIC TRAUMA months. Boys outnumber girls, with two-thirds being
boys. Infants are more likely to drown in the bath,
Trauma is the leading cause of death in children and 1–3-year-olds are most likely to drown in a backyard
young adults in all developed countries; in the develop- swimming pool and older children drown in open water-
ing world it is second only to deaths from infections. 4,225 ways such as dams and rivers. In Australia, in 2008–2009
The approach to management of trauma in children is there were a total of 302 deaths from drowning, including
the same as in adults. For further details on trauma 50 children. This figure has increased over the previous
systems and trauma management, see Chapter 23. While five years. 230
there has been some evidence from North America that
specialist paediatric trauma centres produce better out- Homicide and assault of children remains low in Australia
231
comes for children suffering traumatic injuries, the when compared with other developed economies,
23
largely spread-out and relatively small population distri- however it is listed as the third-leading cause of death
bution in Australia and New Zealand means that children from injury in children. 1,231,232 Spinal injury rates for chil-
will often need to be treated initially in adult settings. 4 dren are reportedly low at around 1% but are associated
with significant mortality and disability. Paediatric
233
INCIDENCE AND PATTERNS OF INJURY spinal injury statistics in Australia and New Zealand are
IN CHILDREN not currently reported, as current reporting only captures
3
Across Australia in 2007–2008 almost 68,000 children patients cared for in dedicated adult spinal units,
were hospitalised as the result of injury, accounting for however, the incidence is considered to be low, as it does
12% of all paediatric admissions, with 15% of all chil- not feature in the annual report of the Australian and New
4
dren’s deaths attributable to injury. 3,225 In 2008, injury Zealand Paediatric Intensive Care (ANZPIC) Registry.
accounted for around 7.1% of paediatric admissions to
Australian and New Zealand ICUs, with a 4.8% mortality RISK FACTORS
rate, accounting for 29% of all deaths in ICUs in the The kinetic forces involved in injury are associated with
1–15-years age group. 4 a more diffuse injury pattern and a greater incidence of
multiple trauma in children, as more of the child’s body
Injury patterns in children differ from adults, with 227
traumatic brain injury, blunt trauma and more diffuse is subjected to the traumatic forces. Children generally
injuries more common in children. There is a bimodal have less subcutaneous fat and musculature, providing
injury pattern associated with age, with peak incidence less protection to the liver, kidneys, and spleen, leading
occurring in children aged 1–4 years and a second peak to a higher incidence of lung contusions and abdominal
234
during adolescence and young adulthood, reflecting the trauma. In addition, the relatively large head size of the
different activities associated with each group. 1,226 Infants infant, particularly, and the child leads to a high inci-
227
and young children have a decreased sense of danger and dence of head injury.
reduced ability to protect themselves, while adolescents
have increased exposure to higher risk activities in con- Primary Survey and Resuscitation
junction with exposure to alcohol, drugs and motor vehi- Initial stabilisation of children who have experienced a
cles. 227,228 Children who live in regional and rural areas traumatic injury is likely to have occurred in the field.
have increased rates of traumatic injuries and deaths from Once at the hospital, the primary survey is conducted
trauma, as do children from lower socioeconomic back- to assess for, detect and stabilise the child with life-
grounds. The same pattern is reflected in Australian and threatening injuries. Undertaking a primary survey and
New Zealand statistics. 225,229 Time of day and seasonal resuscitation uses the same structured approach in chil-
factors play a role in childhood injury, with children dren and adults. Chapters 22 and 23 cover emergency
more likely to be injured between 3pm and 5pm, coincid- presentations and trauma management, however, specific
ing with the end of the school day, and during summer paediatric considerations are highlighted below.
months, where the incidence of submersion injuries Children sustaining trauma to the head, just as adults, are
increases. 5,226,230
managed with cervical spine precautions including a
Injury-related deaths in children are highest in the trans- collar, until the spine has been radiologically and clini-
port deaths category, followed by immersion and assault. cally cleared. 9,233 A selection of paediatric hard collars
1
Motor vehicle accidents involving children as passengers, should be available and the measuring guide used to
pedestrians or cyclists are the commonest cause of injury ensure good fit. As the collar can cause neck flexion in
in Australian children, with driveway injuries involving infants and small children, the child’s torso may need to
four-wheel drive or light commercial vehicles more likely be elevated with a folded blanket to maintain a neutral
19
to be fatal. 225 Trauma associated with the use of all terrain neck position. The head and neck are usually immobil-
vehicles such as quad bikes are becoming increasingly ised, with head blocks (e.g. rolled towels) placed either
common, particularly in rural areas. 228,229 For children side of the head to maintain in-line stabilisation and
under 14, falling from one level to another, such as falling tapes applied to the forehead and chin to prevent move-
from a window, was the most common form of falls- ment. The combative, uncooperative child will not toler-
related injury. 231 ate this, and the actions are likely to increase the child’s