Pediatric Trauma Primary Survey: C-ABCDE
C - Catastrophic Bleeding - Life-threatening hemorrhage
• Apply direct pressure/compression bandage
• Tourniquet for extremity bleeding (note time applied)
A - Airway Compromise - Position/patency, Need for protection
• Spinal motion restriction if indicated; expose neck to assess for neck injury/airway threat
• Jaw thrust to open; oral suction; oral airway (if obtunded)
• Early intubation with Manual In-Line Stabilization (MILS) if c-spine not cleared; plan for postintubation sedation needs
B - Respiratory Failure - Apnea/poor effort, Signs of tension pneumothorax (PTHX)
• Assist with BVM/prepare for drug-assisted intubation (See Drug Dosing Binder)
• Use POCUS to assess for PTX/HTX and/or pericardial tamponade
• Decompress chest: needle/finger thoracostomy, chest tube
• Consider chest tube insertion for any intubated patient with a pneumothorax
C - Hemorrhagic shock - Cool skin, ↑ HR, ↓ cap refill, ↓ BP is a late sign of shock
• Find bleeding source: Head/scalp, Chest/abdomen/pelvis, eFAST exam
• Bind pelvis if hemodynamically unstable/known or potential pelvic fracture
• NS/RL up to 40 mL/kq IV rapid bolus, then warmed PRBCs 10-20 mL/kg IV as rapidly as possible; repeat PRN. Move sooner to PRBCs if poor/no response to fluids.
• If active bleeding/hypotension, limit crystalloid and transfuse: uncrossmatched PRBCs (10-20 mL/kg, repeat PRN). IF ongoing need For blood, activate massive transfusion protocol if available, and transport STAT.
• Consider qivinq tranexamic acid (TXA) as a load 15-30 mq/kg/dose (MAX 1000-2000 mg) IV over 10-20 minutes, then 5-15 mg/kg/hr IV infusion (MAX 125 ma/hr) for the Tesser of 8 hours or until bleeding stops. Use higher end dosing range for more severe bleeds. Do NOT give TXA if greater than 3 hours since injury.
D - Severe head injury - GCS less than or equal to 8, Responds to pain only / Unresponsive (AVPU)
D - Impending herniation - Unilateral fixed and dilated pupil, Cushing's triad: ↓HR, ↑BP, irregular respirations
• ↑head of bed 30 degrees, head midline
• Drug assisted intubation with Manual In-Line Stabilization (MILS), maintain ETCO 35-40 mm Hg
• Analgesia/sedation plan (see ongoing care box below)
• Contact Neurosurgery; consider seizure prophylaxis
• If impending herniation:
- 3% NaCI 5 mL/kg/dose IV (MAX 250 mL/dose) over 10 minutes (repeat PRN) and/or mannitol I g/kg/dose (MAX 100g) over 15 min
- Initiate brief period of hyperventilation until responsive pupil, normalized vital signs
Neurogenic shock - ↓HR, ↓BP, Abnormal tone, ↓ power
• Vaspressor infusion IV/IO to maintain BP:
- NORepinephrine
- Phenylephrine
E - Exposure
• Maintain normothermia during assessment (warm blankets, forced-air warmer)
• Rectal examination only if concern for spinal cord injury
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