CARE OF THE TRAUMATICALLY INJURED CHILD IN THEEMERGENCY DEPARTMENT OR TRAUMA CENTEROne of the benefits in participating as part of a trauma system is the organization of the care that is delivered to the patient. When the patient enters the Trauma Room (whether it is located in the Emergency Department or elsewhere), the Trauma Team begins to function as a team to provide care. Each team member is assigned to a list of duties which he/she initiates as soon as the patient arrives. There is no waiting until someone tells a team member what to do. The assignment to the specific role delineates their priorities. The team functions as one unit in providing care. The confusion in the room is minimized and patient care happens in a much smoother manner than when one person is assessing and identifying all of the needs for treatment. Delineation of role responsibilities will differ by institution and make-up of the Trauma Team. The members of the Trauma Team include: The physician team leader (often a Trauma Surgeon), an Emergency Physician and/or Anesthesiologist (these may be interns and/or residents in a teaching facility), one or two nurses, respiratory therapist and a person to document. Either the Anesthesiologist or the Emergency Physician will assume responsibility to assess and manage the patient’s airway and respiratory status. This role will assess what procedures have already been implemented and will institute any additional ones necessary. These procedures may include intubation, applying dressings to head wounds, inserting a nasogastric tube and determining the need for ventilator use (including helping to set up the ventilator). This role also assesses neuro status of the head and cervical spine. The respiratory therapist and one of the nurses (as necessary) will assist this person. The Physician Team Leader will do the over-all assessment of the patient, evaluating procedures already implemented and will perform any needed critical procedures (insert chest tubes, put in a central line, etc.). The nurse role will usually be assigned such procedures as putting on the cardiac monitor, obtaining vital signs, inserting an indwelling catheter, setting up a heat source as needed, applying pressure dressings, additional assessment for injuries, the administration of fluids/blood products, etc. Other professionals who will usually be designated to respond to the Trauma Resuscitation area are a Laboratory Technician, a Radiology Technician, and in some facilities, a Pharmacist. Systematizing is implemented more easily if protocols are predetermined for X-rays and for Laboratory Tests that will be ordered. Time should not be used during the resuscitation to determine anything that could be determined ahead of time. Of course, there will always be individual patient care decisions which will need to be made by the Physician Team Leader, but the more that can be systematized, the better. The less the Team has to think about routine issues, the better able they are to deal effectively with the individual needs of the patient. The other essential member of the Team is an individual who is assigned to document all that transpires in the resuscitation of the patient. This individual does not need to be a nurse, but does need to have some specific training for the role of “scribe”. Some Trauma Centers have very effectively used unit secretaries or nurse assistants to fulfill this role. When a child is the trauma victim it is of upmost importance that the child be transported to the Trauma Center designated, equipped and staffed for children. A multidisciplinary group was formed under the auspices of the American Academy of Pediatrics and has published recommendations relating to pediatric transport systems (Day, et al., 1991). Hart and others (1987) have outlined recommendations for transport of the pediatric trauma patient which speak to specific patient conditions. These recommendations include:
The physician makes the final determination regarding transfer and guidelines will be specific to a particular emergency medical response system. The injured child must be stabilized prior to transport. Family members need to be told about the transport and should be allowed to see the child before transport (Neff and Kidd, 1992). The Social Worker who is part of many Trauma Teams will usually handle these details, but if the system in which the nurse is working does not provide a Social Worker, this responsibility will often become the nurse’s role. The Social Worker will also be a key factor in assisting the family to cope with the crisis involved with the traumatic situation. In a child abuse situation, the Social worker adds an important role as an assessor of the individual and family interactions. Evaluating family dynamics is an art of this professional role. As the patient arrives in the Trauma Room and the trauma team begins working, the first priority of one of the team members is to assess the airway and make certain that provision has been made for adequate ventilation. This has to be accomplished while cervical immobility is maintained. The usual way of opening the airway is to do a chin lift or jaw thrust to avoid any manipulation of the head until cervical spine injuries have been ruled out. Spine immobilization should be done in the field and not removed until the spinal x-ray films are judged to be negative. If a lap belt injury is suspected, then the lumbar area should also be immobilized. The airway needs to be checked to make sure that no obstructive items such as food, blood, mucous, etc. are present. Suctioning can easily remove such obstructions. A crushing airway obstruction will usually require intubation and surgical intervention. Stabilization needs to be completed before the patient has t undergo diagnostic studies such as a CAT scan. If an airway is not sufficient, then intubation is necessary and should be performed by someone skilled in pediatric intubation. The tube placement must be verified by X-ray and then need to be securely taped. Throughout the stages of resuscitation, proper airway management must be provided. Oxygen should be administered by face mask at 10 L/min or by nasal cannula at 6 L/min. Be sure that the face mask chosen is of the appropriate size for the patient. In the alert child, oxygen administration by mask may be very upsetting. Most children do not like having something placed on their face. It may be helpful for the nurse to hold the mask up to the face so that oxygen is still delivered, but the child does not feel as if it is covering his/her face. This may also be a good task for a parent to do. Because the child uses the abdominal muscles for breathing and because children swallow air more so than adults, a nasogastric tube is often inserted to decompress the abdomen as an aid to easier breathing and as a way to prevent aspiration. The nurse must observe the child for any signs of airway obstruction. The signs of airway obstruction are:
LATE SIGNS ARE:
If respiratory efforts are not adequate, then positive pressure ventilation must be considered and initiated before deterioration occurs. There are some traumatic thoracic injuries which will result in respiratory failure if not treated in a timely manner. They are:
Fortunately, penetrating trauma in children is not very common (O’Neill, 1989). Once the airway and circulation are properly evaluated and appropriate interventions are in place, a secondary assessment must be done on the patient. Two goals are to be accomplished by the secondary assessment. One is to evaluate the trauma victim’s response to the initial resuscitation efforts. The second is to identify any other injuries, systemically examining all systems and parts of the body. It is best to do a head-to-toe assessment to ensure that no injuries are overlooked and to prevent any deterioration in the patient’s condition. HEADThe most common head injury in children is closed head injury (Seidel and Henderson, 1987). Head trauma is the most common pediatric trauma seen in the Emergency Department. There are about 500,000 head injuries in children each year. It is estimated that about 25,000 of these children will either die or be permanently disabled due to the head injury. About 15% of pediatric patients with a head injury will require surgical intervention (Eichelberger and Pratsch, 1988). The head should be carefully examined for any lacerations. The nose and ears should be checked for any drainage. If clear drainage is present, it should be tested for glucose. If it is positive for glucose, it may indicate that the fluid is cerebrospinal fluid. The nurse should assess the patient’s mental status, sensation, response to pain, and movement on a regular basis. The patient should be asked to follow simple commands. Any deterioration in the patient’s neurological status should be reported immediately. Head injuries in children are classified into three categories: minor, moderate, and severe. Minor head injuries include scalp lacerations and concussions with a transient loss of consciousness. The Modified Glascow Coma Scale allows for this category to include the young child who is crying and cannot be soothed enough to stop crying as well as the older child who is combative. These children will usually be admitted and have a CAT scan done to determine specific injuries. Severe head injury is said to be present when the Modified Glascow Coma Score is less than 8. The primary objective then is to obtain a rapid evaluation using the CAT scan and to prevent increased intracranial pressure (Neff and Kidd, 1993). NECK AND SPINEThe incidence of cervical spinal injury is about 2 to 3%, but the child’s cervical area should always be protected until a cervical injury has been ruled out (Marcus, 1986). In order to fully evaluate the cervical and thoracic spine areas, a complete spine series will usually be done. A CAT scan may be utilized in the more unstable patient. The unstable patient will usually not undergo a MRI because of the difficulty in providing resuscitative measures should they be needed. If the mechanism of injury (i.e., lap belt) indicates the need, lumbar and sacral spine series will also be completed. THORACICRib fractures are not common in children because their rib cage is more pliable than the adult. Observations need to be made regarding breath sounds, chest asymmetry, difficult breathing and indications of pulmonary edema. Chest x-rays and CAT scan should be done if the child has an injury to the chest. If the child has suffered blunt trauma to the chest, there is an increased possibility of cardiac contusions so a 12 lead EKG and cardiac monitoring are usually ordered. ABDOMINALThe pediatric trauma victim with an abdominal injury usually has a blunt injury. The nurse must monitor the child frequently and be skilled at detecting subtle changes in vital signs and pain which may indicate hemorrhage and impending shock. If it is suspected that there is splenic, hepatic, or renal injuries, a CT scan with double contrast will be needed for proper visualization of the organs. Conservative management includes monitoring and caring for the child in an intensive care unit. Surgical intervention is also a possibility if the patient continues to bleed. When surgery is necessary, the attempt is to try to repair the injured organ instead of removing it. GENITOURINARYThese injuries are not likely to be life-threatening, but trauma team members need to remember that children are more susceptible to renal injury because the kidneys are less protected in the child than in the adult. Hematuria, flank hematomas and abdominal pain, are signs of renal injury (West, et al, 1985). In addition, the nurse needs to be especially aware to look for any sign of blood in the urinary meatus before inserting the foley catheter. Blood being present is a contraindication to the insertion of the foley catheter. In the stable pediatric trauma patient, it may be advisable to wait until the child voids before determining to catheterize. The presence of any meatal blood is an indication for radiological procedures such as an IVP and/or CAT scan. A pediatric urological consultant may also be called in to evaluate the patient. MUSCULOSKELETALManagement of injuries to the musculoskeletal system is usually started after the initial management of the critical traumatic period unless there is significant blood loss from the injured portion. The vascular long bones such as the femur can be of major significance in the child because of the potential for blood loss. Pelvic fractures can also cause significant blood loss. The trauma nurse needs to do the evaluation for musculoskeletal injuries keeping in mind the developmental level of the child and the injuries that most frequently go with that specific age child. The nurse and physician always need to keep in mind the possibility of child abuse. A careful history about the mechanism of injury needs to be taken, from parents as well as the child. In evaluating the musculoskeletal injury, the nurse needs to observe the following: The presence and quality of pulses, loss of motion, absent or diminished capillary refill, swelling, color changes, pallor, coolness, any open wounds, protrusion of bones, deformities, pain/tenderness, bleeding and decreased sensation. Any deviations from normal need to be documented and brought to the attention of the physician team leader. If a pelvic fracture is suspected, the Trauma Team will want to take steps to ensure that pelvic structures are intact and will want to evaluate closely for blood loss and replace as needed. There are six types of musculoskeletal trauma. They are:
BURNSBurns are a leading cause of accidental death in children between ages one and fourteen (East, et al, 1988). Approximately 745,000 children are burned yearly, with about 40% requiring hospitalization (Herdon, et al). The number of serious disabilities out-numbers the number of deaths. Many burns are preventable. One of the key factors the Trauma Nurse should remember is that the child with a significant burn loses a large amount of fluid from the burn area itself. Fluid volume replacement in these children is crucial. Venous assessment is vital in order to adequately meet the fluid resuscitation requirements. These children also may lose heat rapidly so a warming source needs to be available. Pain relief may be an issue depending upon the severity and depth of the burn. It is highly likely that the Trauma Nurse may only see these children for a short period of time since they will likely be transferred to the Burn Center as soon as possible. The skin is the largest organ in the body, comprised of three layers. The layers are (1) the epidermis, (2) the dermis and (3) the subcutaneous tissue. The epidermis regenerates continually and after a superficial burn, it will re-grow naturally. The dermis is thicker than the epidermis and actually makes up the major portion of the skin. It is this portion that contains the blood vessels, nerve endings, sweat and sebaceous glands, hair follicles and lymph spaces. When the dermis is burned, the skin cannot re-grow because all of the epithelial elements have been destroyed. The subcutaneous tissue contains adipose tissue and collagen. When this layer is burned, bones, tendons, and muscles may be exposed. The functions of the skin have significant importance to the nurse caring for the burn patient. The functions include: thermoregulation, fluid and electrolyte balance, a protective barrier (the first line of defense against infection). These functions are all compromised when a child is burned. The severity of the burn injury is determined by the amount of skin burned and by the depth of the burn. Since the skin has different thicknesses in different parts of the body and the agent causing the burn may be in contact for varying amounts of time, the severity of the burns will differ in different locations. A superficial burn (called a first degree burn) involves only the epidermis. When the burn involves the epidermis and extends into the dermis, it is called a partial thickness injury or a second degree burn. A full thickness or third degree burn includes the entire epidermis and dermis layers. The wound surface will be dry, leathery and with a waxy-white or black color produced by the destroyed dermis tissue. The patient with third degree burns experiences little or no pain because nerve endings have been destroyed. Fourth degree burns extend beyond the subcutaneous tissue into muscle and bone. In children, the majority of deaths related to fires are due to smoke inhalation, so a major factor for the Trauma Nurse to focus on during the resuscitation phase is the child’s respiratory condition. As soon as the seriously burned child is stable, he/she will be transferred to either a burn center or to a Pediatric Intensive Care Unit. CHILD ABUSEChild abuse is a term that is used to describe any mistreatment of children. It can include physical, emotional or sexual abuse. The definition has been broadened to include neglect of children as well as sexual exploitation. Unfortunately, the persons most likely to commit child abuse are the parents of a child. Child abuse is not just a one-time incident, but actually is a pattern of maladjusted behavior. Steele (1987) has identified a three component syndrome that includes the maladjusted adult, the vulnerable child and the presence of situational stressors. It has been well documented that the usual adult abuser was abused as a child, both physically and emotionally. This child grows into a maladjusted adult, usually with feelings of inferiority, depression and problems with his/her own identity. Because of the abuse during childhood, the child will not learn loving, supportive behavior during childhood, so will not be able to demonstrate such as an adult. Because the adult did not experience affectionate behavior and empathy as a child, he/she cannot even realize that the child with whom he/she is interacting needs affection and empathy. Additionally, the adult often has unrealistically high expectations and may punish the child if the child does not live up to the expectations (Steele, 1987). The nurse has some unique opportunities to observe and be alerted to the potential for an abusive situation to develop. As a newborn, the nurse can observe the bonding or lack of bonding between the child and parents. This observation can be made in either the Birthing Center or in the Out-Patient setting if the newborn needs to return for care (often additional blood tests are needed). The nurse needs to observe for interaction between the parent(s) and the newborn. Parent(s) may carry out parenting tasks without any interaction with the child. Premature and/or chronically ill children may be abused because the parents become frustrated and angry with a situation where the child is not responding to them as they think the child should respond. It is possible for physical child abuse to occur all of a child’s life, but it is more likely to occur on a periodic, episodic basis. The abuse happens as a result of stressors in the life of the adult. The adult expects the child to meet his/her needs and when the child doesn’t, the abuse occurs. The child feels it is he/her fault and will often tell the inquirer that he/she was bad and that is why the beating occurred. About ten percent of all the children less than five years of age seen in the Emergency Department with a traumatic injury are the victim of physical child abuse (Schmitt, 1987). Health care workers are required to report suspected cases of child abuse to the child protective agency in their area (Carroll and Haase, 1987). There are several flags which should alert the health care worker to the possibility of child abuse. They are:
As a further explanation, if there are multiple bruises from a fall down the stairs, the bruises should all be of the same age. There should not be bruises in various stages of healing or fading. Bruises can be dated as to recency by the color of the bruise. The presence of a skull fracture or of multiple bruises is not consistent with a single fall out of bed (Schmitt, 1987). The Trauma Nurse will have the usual duties of resuscitation and stabilization of the child, the details of which will depend largely upon the injuries inflicted. Once the child has been stabilized, very careful documentation of the injuries will need to be done and a complete “child abuse work-up” completed. Throughout all of this, the nurse needs to keep the parents informed and should not pass judgment or place blame on the parents. The medical record will be needed to substantiate child abuse and in addition, the physicians and nurses caring for the child at the time of admission will probably have to testify as to the record and what they observed and recorded. Colored photographs may be taken as an assistance to the documentation procedure. The Social Worker will be involved in the care of the patient and in relating with the parents. Any court related issues will usually be handled through the Social Worker and he/she will keep the nursing staff informed. The child admitted to the Emergency Department for suspected sexual abuse needs to be cared for by individuals with additional special training in this field. Often, hospitals will have a special “team” of individuals who need to be called in for assistance and/or consultation. Physical examination of the child needs to be done carefully in accordance with the collection of evidence which will likely be used in the court system. Additionally, interviews with parents (separately) and with the child will need to be done. Physical examination of the child should carefully be done, noting any signs of tenderness or other evidence of additional trauma. Usually a bone scan is ordered to ascertain whether or not there has been other abuse. A special lamp is used throughout the examination, because it will more easily illuminate pubic hairs and semen. Rectal penetration will be evidenced by tenderness, lacerations and a decreased in rectal sphincter tone. Labial adhesions, tenderness and the presence of a vaginal opening larger than normal are all suggestive of sexual abuse. The child cannot be discharged home unless it can be assured that the home is a safe place for the child. Next: CARE OF THE TRAUMATICALLY INJURED CHILD IN |