CARE OF THE TRAUMATICALLY INJURED CHILD IN THE INTENSIVE CARE UNIT CONTINUEDCARE OF THE CHILD WITH A HEAD OR NEUROLOGICAL INJURYApproximately 500,000 head injuries occur in children annually. About 25,000 of these children will die or be permanently disabled (Eichelberger and Pratsch, 1988). All children with a moderate to severe head injury should be admitted to the Intensive Care Unit after leaving the Trauma Unit. It needs to be assumed that these children also have spinal cord injuries until these are ruled out. A CAT scan should be performed as soon as possible after admission to the Trauma Unit. Definitive treatment will be based upon the CAT scan as well as the child’s other injuries (Hennes, 1988). The newly admitted child with a head injury should be immediately assessed for the establishment and maintenance of an adequate airway, ventilation and systemic perfusion. Increased intracranial pressure can cause apnea. Hypoventilation and hypercapnia can cause increased intracranial pressure, therefore, adequate ventilation must be maintained (Hazinski, 1992). A nasogastric tube should have been placed in the patient during the time in the Trauma Unit. This will allow for decompression of the stomach and prevent vomiting. The child needs to be carefully assessed for adequate systemic perfusion. The nurse should check for capillary refill. It should be brisk and the nail beds should be pink. Peripheral pulses should be checked for rate, but particularly for strength of the pulse. The blood pressure should be checked and should be age appropriate. Urinary output should be 1-2ml/kg/hr (Hazinski, 1992). Once it has been established that the cardiopulmonary function is being maintained, the nurse needs to do a complete neurological assessment. The neurological assessment will include a determination of the level of consciousness, pupil size and response to light, and assessment of motor reflexes and activities, including the child’s ability to follow commands. The Glascow Coma Scale can be used in the Intensive Care Unit as well as in the Emergency Department. It is good follow up to use the same scale so that any changes can be more readily ascertained. Pupil size and responsiveness should be checked frequently (usually there is a protocol for the frequency). The pupils should be quail in size and respond equally to light. The nurse needs to be observant for any seizure activity. This should be immediately reported and appropriate safety precautions should be taken to prevent injury. Status epilepticus must be treated because it will compromise blood flow. Any abnormal signs of posturing must be reported to the physician immediately. Intracranial pressure monitoring may be established prior to the patient’s admission to the Intensive Care Unit and must be closely monitored. The nurse and physician should have an established plan of action for responding to rises in intracranial pressure monitoring readings. There will be orders for additional hyperventilation to be performed, diuretics and/or anesthetic agents to be administered. There may be a ventriculostomy catheter and closed drainage system in place. Adjustments may need to be made in this, but will require either a protocol or a specific physician order. A sudden change in the patient’s level of irritability, confusion, lethargy or pupil dilation needs to be immediately reported. As the nurse is giving ongoing care, he/she needs to further assess the patient for any additional injuries which may be present and were not attended to earlier, during the resuscitative phase. The nurse should look for lacerations, hematomas, edema and any depressed areas on the scalp. The child needs to be kept warm because cold stress can cause additional oxygen consumption and peripheral vasoconstriction. Skin and rectal temperature readings should be taken frequently. Poor systemic perfusion would be indicated if the rectal temperature was elevated and the skin temperature low. Once the child has stabilized, the specific injury will be treated. The following are the most common forms of pediatric head injury:
SPINAL CORD INJURYThe child with a spinal cord injury will have the spinal cord immobilized until the child is stable, then the appropriate therapy is started. Steroid therapy is suggested in order to prevent secondary spinal cord edema and inflammation. Surgical intervention is rarely a treatment modality. CHEST TRAUMAChildren most frequently have non penetrating chest injuries, usually from automobile accidents. These injuries are quite serious because there may be fatal internal injuries. When a child sustains a chest injury, it is uncommon for the child to have fractured ribs because the rib cage is more compliant and resilient than in the adult. However, the absence of fractured ribs does not eliminate the possibility of serious injuries. If there are rib fractures, there is likely to be a pneumothorax, hemothorax or a pulmonary contusion. There may also be fracture of the sternum and lacerations of the trachea, bronchi and heart. Rupture of the larynx and pericardial tamponade may also be present. The penetrating injuries are most likely caused by knives, bullets or ice picks. If a tension pneumothorax is present, there will be severe hypoxemia and decreased cardiac output. Extreme respiratory distress and extreme compromise of the systemic perfusion should suggest cardiac tamponade. Traumatic rupture of the trachea or bronchi will be indicated by severe respiratory distress and a large pheumothorax. There will be hemoptysis and a large air leak on both inspiration and expiration after a chest tube is inserted. Cardiac contusion should be considered any time there is blunt chest trauma (Hazinski, 1992). The rapid assessment of the child with chest trauma will have been accomplished in the Trauma Center. When the child arrives in the Intensive Care Unit, the nurse will monitor the chest tubes, noting the amount of air being evacuated from the chest. The area around the chest tube will need to be observed when the dressing is changed for any drainage, erythema or subcutaneous emphysema. Cardiac tamponade is life-threatening. A pericardial aspiration is done, under EKG monitoring. The nurse needs to monitor the EKG and systemic perfusion, bringing any cardiac arrhythmias or S-T segment changes to the attention of the physician doing the cardiac aspiration. The first priority of the nurse when caring for the child with a chest injury is to maintain adequate cardiopulmonary functioning and identify low cardiac output or respiratory distress (Hazinski, 1992). ABDOMINAL INJURIESTwo of the most important indications of abdominal trauma are rapid, shallow breathing and abdominal tenderness. Progressive abdominal distention is one of the first signs of abdominal injury (Tepas, 1988). If there is unilateral splinting of the respirations, spleen/liver damage should be suspected (Seidel and Henderson, 1987). The pediatric patient with blunt trauma needs to be closely monitored. Vital signs should be taken frequently and the nurse should be aware of any signs of hemorrhage or abdominal pain. Rapid surgical intervention may be needed if deterioration occurs quickly. Use of the peritoneal lavage is currently undergoing re-evaluation (Tepas, 1988). Information received from the lavage is not now as critical to the care of the patient since more physicians are accepting a non-operative approach to treating splenic lacerations. Additionally, the insertion of a lavage catheter causes abdominal tenderness which may confuse further abdominal evaluation. The peritoneal lavage will not reveal the presence of retroperitoneal bleeding (Tepas, 1988). Neff and Kitt (1993) list the following as indications for the use of the peritoneal lavage:
The CT scan has been a major factor in accurately diagnosing abdominal trauma in a non-invasive manner. If the conservative approach is used, the patient may have stopped any bleeding prior to arrival at the hospital. This patient still must be closely monitored for any change in condition which might necessitate surgical intervention (Zeigler, 1988). Sepsis from peritoneal contamination, ongoing hemorrhage and organ dysfunction are all complications which can be experienced later (Ramenofsky, 1987). MUSCULOSKELETAL INJURIESMusculoskeletal injuries are noted during initial assessment, but they are managed after other injuries are stabilized. Fractures in the long bones can constitute an emergency because they are highly vascular and blood volume can be depleted in the child (Neff and Kidd, 1993). The history should include the possible mechanism of injury and the physical examination should include observations for color, coolness, tenderness, deformity, swelling, pallor, peripheral pulses (especially noting any diminishment in pulses) and any wounds. If a wound is present, it should be cultured, cleaned and dressed with a moist, sterile dressing. Antibiotic therapy needs to be instituted and an orthopedic consult ordered (Hazinski, 1992), Neff and Kidd, 1993). One of the complications of orthopedic injuries for which nurses need to observe is compartment syndrome. The extremities most likely to be affected by this are the lower leg and the forearm. This is brought about because of constricted edernatous tissue within a muscle compartment. Sheaths of fascia surround muscle fibers, creating compartments. When these compartments are constricted (whether due to bleeding, a pneumatic shock garment, or edema), vascular supply to both muscle and tissue is compromised. Both ischemia and nerve damage can be the result (Mourad, 1991), (Hazinski, 1992). Signs which may indicate compartment syndrome are:
If these signs are present, a physician needs to be notified so that the pressure can be relieved before any permanent damage occurs. Pressures equaling or exceeding 30 to 60 mm Hg require treatment to relieve the pressure (Hazinski, 1992). Ischemia for a period of longer than six (6) hours can result in permanent damage (Mourad, 1991). CARE OF THE PATIENT IN A CASTA cast may not be placed on a child for up to 48 hours after the injury to allow for swelling to decrease, unless vascular compromise exists (Neff and Kidd, 1993). During the time a case is drying (may be 2-3 days), the cast must be well supported on a firm surface. Soft surfaces may lead to molding of the cast into the soft surfaces. When the casted extremity is being moved, the palms of the hands should be used. This will keep the fingers from indenting the soft cast. The cast should always be lifted by supporting the extremity under two joints. This prevents stress at the site of injury as well as stress on the cast. The patient should be turned every two (2) to four (4) hours to allow all surfaces to dry and the cast should be left uncovered to aid in the drying process (Mourad, 1991). CARE OF THE PATIENT IN TRACTIONTraction is used to restore alignment following a fracture, maintain alignment while a fracture heals, to overcome a deformity and to relieve muscle spasms and/or pain. For the greatest effectiveness, the pull of the traction needs to be constant, both in amount and direction (Mourad, 1991). There are two methods for applying traction: SKIN TRACTION is applied indirectly to the bone by applying the pressure to the skin and the subcutaneous tissue around the fractured bone. It is usually applied for up to one week. Can be applied intermittently, removed for skin care and rest. Usually used for less severe injuries. SKELETAL TRACTION is applied directly to the bone by using a pin or wire and attaching pulleys and weights. Skeletal traction is used for longer periods of time and cannot be discontinued until the time it is removed. It is used for the more severe injuries. NURSING CARE includes assessing the patient’s extremity for color, temperature, edema, any signs of pressure, capillary refill, numbness, burning, itching, tingling, pain, rash and muscle spasms. In addition to assessing the extremity, the traction should be checked. The intent is to verify that the traction is still in alignment so that it is correctly pulling on the extremity (Mourad, 1991). Other areas of care the nurse needs to focus on with the child are nutritional needs, adequate bowel and urinary elimination and level of contentment being so confined. Meeting the needs of a confined, usually active child may be a significant challenge for the nursing staff even while the patient is still in the Intensive Care Unit. Early involvement of the dietician and the play therapist or occupational therapist will be very helpful. The physical therapist will usually be involved early to begin making plans for the rehabilitation phase and to advise regarding any exercises which should be started while still in traction. CARE OF THE PATIENT WITH BURNSFluid replacement is a crucial issue with burned children. Within the first 12 to 36 hours fluid shifts from the intravascular space to the interstitial space because of the increased capillary permeability. This shift is called “third-spacing” because the fluid is not in either the intravascular or intercellular spaces, but is in a third space (interstitial space). If the intravascular fluid is not replaced, cardiac output will decrease, hypovolemia will occur and systemic perfusion will decrease. The seriousness of this issue is largely dependent upon the severity of the burn. Electrolyte balance needs to be carefully monitored. Intravascular proteins, plasma, potassium and other electrolytes are being lost into the interstitial space. As capillaries heal (approximately 24-36 hours after a burn), intravascular fluid loss stops and fluid begins to shift back into the intravascular space. As this occurs, fluid volume replacement needs to be decreased. Urine output increases and edema decreases. Body weight returns to normal. The nurse should be alert for the diuresis which should occur as well as observing for hyponatremia and hypokalema. The hyponatremia will occur 80-because sodium excretion is greater during diuresis. The hypokalemia will occur because of the potassium returning to the intracellular space (Hazinski, 1992). A major cause of morbidity and mortality in burned children is respiratory insufficiency due to inhalation of smoke, fumes, steam or super-heated air (Herdon, 1985). Inhalation of any of these irritants will cause edema, erythema and blistering in the upper airway. The increasing edema may cause upper airway obstruction. Sloughing of these damaged tissues may begin with 48 to 72 hours and may also cause upper airway obstruction (Charnock and Meehan, 1980). The nurse must remain alert for respiratory system compromise. When the cardiac output decreases, the brain shifts circulation away from less vital systems to the brain and heart, in order to maintain their functioning. When this occurs, blood flow decreases to the gastrointestinal system. Decreased gastrointestinal perfusion can result in impaired motility. Severe impairment in motility results in further reduction in perfusion, causing intestinal ischemia to develop. This may increase the permeability of the mucosa of the gastrointestinal system to gram-negative bacteria and endotoxin, paving the way for gram-negative shock to develop. Severe abdominal distention can also occur. The gastrointestinal perfusion and motility will improve when hypovolemia and cardiac output are corrected (Hazinski, 1992). A burn is a major body stress. The burned patient has a high oxygen consumption and high caloric requirements. Increased dietary requirements are high, especially for additional protein. The burned patient is at a high risk for infection. The burn has removed the first line of defense against infection…the skin. NURSING CARE OF THE BURNED PATIENT will include the following:
REHABILITATIONRehabilitation for the child who is a trauma victim is an area which needs additional attention. Many trauma victims who would improve with rehabilitation are never referred for rehabilitation by their physicians (Brogan, 1981). The child who is injured has not completed the growing cycle. As he/she develops, especially the brain, additional problems affecting learning, perception, etc may develop which were not even considered at the time of his/her acute care. The child who is referred for rehabilitation will have these issues addressed more easily than the child who is not into that system. The child’s needs may be able to be met by a home health service or by the family, depending upon the support systems available. Rehabilitation, for some children, will present difficulties for the family because the facility is located some distance from their home. In order for the child to go to the facility and receive adequate family support may require extensive planning upon the part of the family. For this reason (plus others), families need to be included early in the process of planning for rehabilitation. Another reason for early inclusion in the process is the issue of funding for rehabilitation. Rehabilitation facilities are usually for profit institutions, and as such, do not take patients without adequate funding sources. Families (working with Social Services) will need time to make appropriate arrangements. If these processes are started early, the child’s transfer to a rehabilitation facility in a timely manner should not be interrupted. If the child is to be discharged home, plans must be carefully made with the caretakers to make sure that the home care is planned and that the family knows what to expect and what to do in case of an emergency situation. A home visit by the home health nurse prior to discharge is often helpful in planning for the child’s homecoming. Next: CARE OF THE TRAUMATICALLY INJURED CHILD IN THE INTENSIVE CARE UNIT, CONTINUED |