Introduction

Care of the Pediatric Trauma Victim in the Field

Care of the Traumatically Injured Child in the ER or Trauma Center

Care of the Traumaically Injured Child in the ICU

Ethnic, Cultural, and Religious

References

MONITORING THE CHILD

As soon as the traumatically injured child starts receiving assistance from the emergency medical system until he/she has been discharged from the acute care facility, technical monitoring will assist the nurses and physicians to know what is happening physiologically to the child.  The nurse must know what information the monitoring should provide, how to interpret the data in relationship to the observations made clinically of the patient and how to determine if the equipment is giving inaccurate data.  This section will discuss monitoring, support and measuring devices specific to the critically injured child.  Earlier in this course specific information relating to children was discussed.  That previous information needs to also be used when caring for the child who is being monitored.

One of the factors in designing equipment to be used on children is the issue of size.  As an example, electrodes need to be placed for cardiac monitoring.  The child has much smaller space available for placing the electrodes than the adult.  This may affect design and usage of the equipment.  The child’s respiratory system and cardiovascular system are both smaller than the adult.  Obviously small equipment and supplies need to be used, but there are also some physiological differences which need to be noted.

The size of the respiratory system is smaller.  Not only do endotracheal tubes and airways need to be smaller, ventilators need to be capable of providing smaller amounts of pressure and volume with short inspiratory times.  The equipment must be capable of measuring the very rapid breathing of the distressed child accurately.  Because the child has a very compliant chest wall and small lungs, it is easy to hyperventilate the child and cause a pneumothorax.  Manual ventilation may need to be done initially, but the child should be placed on an appropriate ventilator as soon as possible.  The child’s metabolic rate is higher than the adult.  Rapid heat loss may cause fluctuations in the child’s temperature which may cause extra labor to an already taxed respiratory system.  This can cause a child to use significantly more oxygen.  The child’s temperature needs to be frequently and carefully monitored.

Monitoring devices need to be accurate without recording artifact as clinical data.  Very small changers in such vital signs as blood pressure and pulse rate may signify critical differences in the condition of the child.  Arteries and veins are smaller in size.  Not only do catheters need to be smaller, additional consideration needs to be given in order to maintain patency of the catheters.

It is critical that the devices measuring intake, especially parenteral intake, measure accurately, in small volumes and in small veins and arteries.  The ventricles of a child’s heart function almost at maximum output when he/she is well.  When the child is injured, the cardiac output will depend more on heart rate than on stroke volume.  The cardiac monitor must be able to measure the heart rate accurately without artifact.  The monitors used to measure cardiac output and blood pressure must also be very accurate as small changes in blood pressure and cardiac rate may mean significant change in the patient’s condition.

During ventilation of the child, care must be taken not to hyperventilate the child with either too much volume or too much pressure.  Hyperventilation is easy to do in a child because the child’s chest wall is not very resistant.  A child also normally has small tidal volumes and short inspiratory times.  When the child is breathing rapidly, he/she has an increased heat and water loss through the respiratory system.  Therefore, an assisting device for the child must heat and humidify the air provided.  Changes in the child’s temperature will mean an increased need for oxygen to be provided because the child has increased oxygen consumption.  Temperature monitoring is important because of the changes in heat loss.  The nurse will want to involve the dietician to evaluate the child’s nutritional status because small changes in daily caloric intake may result in significant nutritional changes for the child.  The child normally has a high metabolic rate and this can increase when there are physiological changes such as an elevated temperature.  Invasive monitoring in the child greatly increases the possibility of the development of an infection.

EKG MONITORING

The most common type of monitor for the child to have is the EKG monitor.  It is with the standard of care for any patient in the Intensive Care Unit to have an EKG monitor.  The child may also be monitored in a step-down type of unit.  The nurse needs to know how to read the EKG reading and to be able to determine the appropriate actions to take based upon those readings.  As a reminder, the nurse needs to remember that the EKG is measuring the electrical activity of the child’s heart and not the mechanical activity of the heart.  The EKG furnishes not only the absolute heart rate, but also the sequence of intracardiac conduction.  The nurse needs to be careful to clean the skin with alcohol prior to placement of the leads so that the EKG can provide a stable reading without the interference of skin oil and/or dry skin cells.  Many of the monitoring systems in use today not only furnish an accurate EKG, but also provide arterial and venous pressure readings, temperature and respiratory rate.

Alarm limits (both high and low) must be set and verified for each parameter being monitored.  These limits must be checked each shift and before the nurse leaves the bedside for any reason.  Each Intensive Care Unit will have its own standards as to how often the readings need to be printed out and placed in the patient’s medical record.

When assessing the child, it is important to have an indirect measurement of the child’s blood pressure, but it is often quite difficult to obtain a dependable reading.  The most dependable method to indirectly measure blood pressure is the oscillometric method, but even this has not been proven to be accurate in critically ill children (Park and Menard, 1987).  The more reliable method of monitoring is direct intraarterial monitoring.

The insertion of arterial and venous lines also allow for the frequent blood sampling which must be done in the critically ill child.  The nurse assists with the insertion of the catheter, ensures accuracy of the transducer and maintains the sterility of the site of insertion.  Remember that critically ill children need to have their fluid requirements and administration monitored very carefully to prevent fluid overload.  It is better to use a monitoring device specifically designed for children, than to risk potential overload using a device designed for the adult patient.  Catheter patency needs to be maintained by the use of a heparinized solution.  Butt and others (1987) have established that a heparinized solution works better to positively affect catheter longevity than a specific fluid infusion rate.  Blood samples may be taken from heparinized lines if care is taken to withdraw enough to clear the catheter of heparin.  Each institution should establish their own policy for this practice, specific to the configuration of the lines used at that institution (Reinhardt and others, 1987).

When actually taking the measurements, the nurse must redefine the zero point of reference in order to have an accurate reading.  The reason to have a zero point of reference is to eliminate the atmospheric pressure so that one has an accurate isolated vascular pressure reading.  Readings can be taken with the patient in different positions if the relationship between the zero point of the system and the patient’s right atrium is kept consistent (Schroeder and Daily, 1989).  Once this point is established, all staff needs to use it when taking readings.  If the patient’s position is changed, the nurse will need to re-zero prior to taking the next reading.  The nurse also needs to calibrate both the monitor and the transducer.  These are two separate procedures and should be in the Procedure Manual of the specific Intensive Care Unit.

ARTERIAL PRESSURE MONITORING

Measures the systole, valve closure and the diastole.  Arterial lines should not be used to administer drugs, blood, etc.  They should be used only for fluids.  If the transducer is zeroed and the lines are properly prepared, this gives the most accurate blood pressure measurement.

VENOUS PRESSURE MONITORING

Used to measure right arterial pressure to assess blood volume and venuous return; to infuse fluids and drugs; and to provide a venous access for blood samples.  The line may need to be heparinized if blood samples are going to be drawn from it.

PULMONARY ARTERY PRESSURE MONITORING

Used to manage cardiopulmonary failure.  One can obtain measurements of right arterial pressure, pulmonary artery pressure and pulmonary artery wedge pressure.  The clinical indications for use of pulmonary artery pressure monitoring include evaluation of the amount of oxygen in a child who is receiving ventilator support; managing vasoactive drugs in the child with myocardial dysfunction; and management of shock (Hazinski, 1992).

CARDIAC OUTPUT

Used to determine myocardial function.  Cardiac output should be determined as a method of evaluating whether or not cardiac output is sufficient to meet the metabolic demands of the child which are higher in a traumatic injury situation.  Reading should always be placed within the context of the over-all clinical condition of the patient.

RESPIRATORY MONITORING

This is a critical parameter to be monitored in the child.  Respiratory distress needs to be identified as soon as possible and appropriate interventions need to be implemented to prevent the child from going into respiratory failure.  PULSE OXIMETRY:  This is the method of choice for non-invasive monitoring of the oxygen level in arterial blood.  This method works better than the transcutaneous method because it responds faster, does not require any calibration and does not add any risks to the patient.  (Hazinski, 1992).

OXYGEN ADMINISTRATION

Most traumatically injured children will have oxygen administered from the time treatment begins in the field and will continue to receive this treatment as they progress through the Emergency Department and in the Intensive Care Unit.  The Respiratory Therapist will be involved with the patient’s care, but the nurse needs to monitor both the system delivering the oxygen as well as the child and the child’s response to the oxygen.  The oxygen needs to be humidified and warmed and this may lead to the need for frequent linen and clothing changes.  Blood gas analysis will need to be done to determine the effectiveness of the oxygen being administered.

MECHANICAL VENTILATION

Assisted ventilation will need to be used for the patient who is in respiratory failure.  The traumatically injured child will need to be transported to a facility that has the proper equipment as well as the properly trained staff to provide such care.  Manual “bagging” of a child will be necessary until the transport team is present.  The child is most likely to be placed on a positive pressure ventilator.  The child’s size will help to determine the size of the ventilator to be used.  Chest wall stability in the traumatically injured child will also have a bearing on the ventilator chosen.  The nurse needs to monitor the child for proper ventilation.  Just because the child is on a mechanical ventilator does not mean he/she is receiving proper ventilation.

The child’s clinical condition needs to be monitored.  If ventilator effectiveness is in doubt, the Respiratory Therapist should be called and the child manually “bagged” until the problem is resolved.

INTRACRANIAL PRESSURE MONITORING

The traumatically injured child with a head injury will usually have invasive monitoring of the intracranial pressure (ICP).  This will enable a more detailed assessment of neurological functioning.  Increased intracranial pressure indicates an uncompensated increase in intracranial volume.  Cerebral perfusion may be compromised if this condition is not treated.  A continual non-treatment will result in death of the patient.

The patient who has an intracranial pressure monitor requires some definitive nursing care related to the ICP.  The technique of the ICP measurement needs to be standardized.  There should be a protocol for this standardization.  In addition, the patient is at risk for infection.

Other difficulties with ICP monitoring include catheter obstruction, excessive CSF drainage, obstruction to drainage, fluid and electrolyte imbalances and hemorrhage (Hazinski, 1992).  The nurse will need to monitor for each of these possible complications and intervene with appropriate actions.

TEMPERATURE MONITORING

The pediatric Intensive Care Unit patient will need to be monitored as well as his/her environmental temperature.  Children may lose heat very quickly.  The cold stress leads to increased oxygen consumption and may further distress an already compromised respiratory system.  The child’s temperature will have to be taken frequently and this may be a distressing procedure for the child.  The nurse needs to be prepared to provide a warming device for the hypothermic child.

The nurse caring for the critically ill child needs to focus on the patient, using all of the monitoring devices as adjunct to his/her own skills and observations.

Caring for the traumatically injured child is a special challenge which many nurses find very satisfying.  The nursing skills of assessment, planning the child’s care (involving parents in the process), implementing the plan of care and evaluating to see what worked and what needs to be adjusted make this process of nursing very worthwhile.  Watching the traumatically injured child’s condition improve to the point of rehabilitation makes the challenge worth the effort.

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