Paediatric month: trauma

Following on from the series of trauma articles published last month, we move into our next clinical focus on paediatrics and meningitis.

Whilst major trauma is a rare event within the region and paediatric major trauma is even rarer, this group of patients still exist and we need to remain prepared to provide high quality, safe care. In conjunction with the East of England (EoE) Trauma Network, we want to highlight key themes which have emerged with the care of paediatric trauma patients, including paediatric physiology; the importance of thorough assessment; analgesic options; preventing heat loss and disposition decisions when families are involved in trauma incidents.

Paediatric physiology:

With the EoE Trauma Triage Tool (TTT) identifying major trauma patients on a set of eight physiological and anatomical parameters it is important to take into account the physiological ‘norms’ for the age of the patient you are caring for. The reverse of the pocket TTT provides a simple memoir for staff to use, alternatively please utilise the age per page of the pocket JRCALC (Clinical Practice Guidelines). 

The importance of thorough assessment:

As highlighted in the article on immobilisation and packaging of trauma patients, it is imperative to adequately expose (generally fully while maintaining dignity) patients, including paediatrics, to enable a thorough and comprehensive assessment and appreciation of any overt or potentially hidden injuries. This also enables the ‘skin to scoop’ method of immobilisation minimising delays in ongoing assessment and care. As per TEMPO2 guidelines, paediatric patients should also have multi-modal monitoring applied to them with regular NIBPs taken. Staff should ensure that an appropriately fitting NIBP cuff is utilised and consider, if needed, modifying the site of NIBP cuff placement – placing it on the calf (but documenting this on the ePCR or PCR). Whilst the calf is an accepted alternate site, studies have shown variable correlations between arm and calf blood pressure measurements. It will however provide a consistent trend for analysis.

Analgesic options:

Pain management can always be a challenge, but more so in paediatric trauma patients. When compared to the adult population, pain management is not managed as effectively with paediatrics. Staff should actively seek to manage pain as best they can with appropriate use of entonox, IV paracetamol and IV morphine sulphate.

A request for help via critical care may offer additional analgesic options in the form of IV ketamine, IV/IN fentanyl and IN diamorphine. Whilst we normally think of pharmacological analgesic options it is also important to fully utilise non-pharmacological interventions. This can be achieved by alleviating anxiety through good communication strategies, distraction and the splinting of injuries fully.

Preventing heat loss:

Paediatric patients are more prone to heat loss following traumatic insult. Not only does this make the patient more uncomfortable, but it further exacerbates coagulopathy increasing mortality and morbidity risks. Whilst on one hand we need to fully expose the patient, we really need to pay attention to the potential of heat loss and actively keep patients covered with appropriate blanketing and active heat-loss prevention strategies if these are available. Do not give intravenous fluids unless clinically indicated.

Disposition decisions:

The application of the EoE TTT is simple, and some may say unambiguous. Major trauma for paediatrics, although a rare event, normally occurs in the form of RTCs where families are involved in traumatic insults together, so wherever possible crews should ensure that all family members are conveyed to the same receiving hospital. We should also give consideration to traumatic injuries that are non-accidental in nature.

The EoE Trauma Network, in collaboration with the major trauma centre(s), are keen to accept major trauma negative patients in a hospital bypass if one or more of the same family from the same incident are major trauma positive. If in doubt crews should call the network coordination centre (on the trauma pre-alert number 0300 330 3999), select option 1 and request to speak with the duty NCS consultant, who will be in a positon to advise and authorise bypass of patients outside of the EoE TTT.

When major trauma in paediatrics does happen, it can be particularly challenging both physically and mentally for our clinicians. The simple pointers above will help support you in providing high quality safe care. Remember – you are not alone, the clinical advice line and CCD clinician may be able to help you remotely with advice and guidance. There is also support available from your line manager, TRIM and the Employee Assistance Programme.

Published 25th June 2015