Page 725 - ACCCN's Critical Care Nursing

702 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

Treatment in children, with less musculature and a more compliant
Several of the therapies used in the treatment of the child ribcage, meaning that there can be injury to underlying
234
with severe head injury are controversial, as they have not organs with no apparent external injury. Blunt trauma
undergone rigorous scientific evaluation. Essentially is common, while penetrating injury is less common,
treatment of TBI in children is identical to adult manage- resulting from gunshot and stab wounds. These injuries
ment: minimising intracranial hypertension, maintaining are associated with older children and adolescents,
optimal CPP while preventing secondary injury from though a thinner body wall may result in greater
hypoxia, hypercarbia, and hypotension while reducing underlying organ damage, particularly if the flank is
234
the risk of iatrogenesis from treatment. Decompressive penetrated.
craniectomy is considered for intractable intracranial During the primary survey, the child’s abdomen should
hypertension to avoid herniation. 235,242 be exposed and may reveal signs such as bruising from
Hypothermia has not yet been shown to make a differ- bicycle handles, tyre marks, abrasions or contusions.
ence in outcome in children, as it has in newborns and Abdominal distension is a less reliable sign in children,
adults with hypoxic-ischaemic brain injury. Moderate as distension may be from air that is swallowed from pain
hypothermia (temperature maintained from 32–34°C) and crying. However, as in adults, the primary survey may
has been studied with disappointing results, 243 thought not include the abdomen if other immediately life-
to be associated with inadequate length of cooling (24 threatening injuries are present, such as thoracic and/or
hours). A multicentre study is planned to commence in head injuries. These injuries will take precedence, so it
the future to provide moderate hypothermia for 76 hours may not be until the secondary survey can be undertaken
with slow controlled rewarming. that abdominal injuries are considered. The monitoring
and management of children sustaining abdominal
Outcomes from traumatic brain injury in children are trauma is very similar to that of adults, 248 and is discussed
associated with the severity of the initial injury and the in Chapter 23.
presence and control of secondary brain injury, as in
adults. Hypotension and hypoxia prehospital admission A number of clinical indicators will determine the
are strongly linked to mortality and poor functional need for a CT scan of the abdomen. These include all
outcome, with some emerging evidence that hyperten- children with multiple injuries, children experiencing
sion in the first 24 hours may also predict poor outcomes pain and tenderness over the abdomen, gross haematuria
at one year post-injury. 244 with a minor injury, children with a haemoglobin
below 100 g/L and children who require fluid resuscita-
Chest Trauma tion with no obvious source of blood loss. Diagnostic
Thoracic injuries in children rarely occur in isolation with peritoneal lavage and FAST sonography are rarely used in
children because of the poor sensitivity of the test to
traumatic injuries and are often accompanied by head and detect the presence of intraabdominal injuries in chil-
neck injuries. There is some evidence that thoracic injuries dren. 249 However, when FAST sonography is combined
are indicative of a more severe injury; they have been with elevated liver transaminases, the sensitivity and
associated with higher mortality. 227 Injury to the heart and specificity of the screening increases to 88% and 98%,
great vessels in particular is associated with higher mortal- respectively. Monitoring of blood in urine is a simple,
250
ity. The combination of head injury and thoracic injury is useful technique to detect bladder and kidney injuries.
also known to have higher mortality. Most chest injuries Management of abdominal trauma generally requires
225
in children are sustained as a consequence of MVAs. The only haemodynamic and laboratory monitoring in con-
pattern of injury in children is predominantly one of junction with supportive therapies such as fluid replace-
blunt trauma. Lung contusions are the commonest tho- ment, monitoring of urine output, and pain management
racic injury seen in children. As the ribcage is much more with the aim of detecting signs of haemorrhage. 14,251
compliant in children, ribs are rarely broken, but they can
damage underlying structures such as the lungs, so pul-
monary contusions, pneumothorax and haemothorax are SUMMARY
often seen. The clinical manifestations, approach to Critically ill infants and children have several anatomical
assessment, monitoring and management of children sus- and physiological differences that predispose them to
taining thoracic trauma is similar to that in adults, and is different types of critical illness when compared to adults.
discussed in Chapter 23. Children with thoracic injuries Children’s relative physiological and psychological imma-
are generally managed in a specialist trauma centre turity means that their needs may be different from adults
equipped to manage children. 245 when critically ill. Family support is important and paren-
tal presence should be allowed at all times. Patterns of
Abdominal Trauma disease may be different from adults; for example, a high
Abdominal trauma in children is a leading cause of death incidence of respiratory illness and a predisposition to
when combined with head injury. 246 Blunt trauma from sustaining multiple trauma, but children have a lower
MVAs is the most common mechanism of injury, but incidence of sepsis, heart failure, liver failure and renal
bicycle handlebars may also inflict a significant injury. 247 failure than adults. The need for specialised nursing and
The liver and spleen are the most commonly injured medical care as well as adapted equipment means that
organs in abdominal trauma and can usually be managed many critically ill children will require transfer to a spe-
non-surgically. The abdominal organs are relatively large cialist paediatric centre.