Initial Assessment and Resuscitation of the Trauma Patient

Introduction The initial evaluation and treatment of the paediatric trauma patient require an organised, thorough approach. All patients must be assumed to have multiple injuries until proven otherwise. Resuscitation efforts should be early and aggressive to avoid the onset of irreversible shock;2,3 the ability to recognise and effectively treat shock is all that is required in the vast majority of injured patents in order to gain stability. Adequate assessment and management of the ABCs described in this chapter will provide adequate treatment of the patient’s other injuries, leading to an overall improvement in morbidity and mortality. Thus, the ABCs play an essential role in the initial evaluation and treatment of the paediatric trauma patient. Effective initial resuscitation can reduce mortality in most paediatric trauma patients. Guidelines have been developed to facilitate patient care in a systematic and productive manner. Advances have been made in both diagnostic and therapeutic methods. The evaluation and treatment of paediatric trauma patients will continue to engage paediatric surgeons as efforts in trauma prevention become more successful. The initial evaluation and care of a paediatric trauma patient uses the same protocols and procedures employed in adult trauma patients, the exception being that children should not be considered as little adults.4,5 In the same manner as in adults, the primary survey entails ABCDE: A is for Airway maintenance/access with control of the cervical spine (C-spine); B is for Breathing; C is for Circulation with external haemorrhage control; D is for Disability and neurological screening; and E is for Exposure/Environmental control with thorough examination.6 This is followed by a thorough secondary survey, which examines the injured child from head to toe. Guidelines in the Paediatric Advanced Life Support7 and the Advanced Trauma Life Support (ATLS)8 provide a consensus framework in which to manage the injured patient: 1. triage; 2. primary survey of the injured child; 3. resuscitation; 4. secondary survey of the injured child; 5. re-evaluation and monitoring the injured child after resuscitation; and 6. Definitive care. In the prehospital care of the injured child, emphasis is placed on airway maintenance, ventilation, control of external bleeding and shock, immobilisation of the patient, and immediate transport of the child to the closest appropriately functioning (and equipped to handle the injured) trauma centre.1,5,6 Every effort must be made to provide initial interventions for all life-threatening conditions to the extent possible at the scene of injury and to prevent delays in delivering the injured to such a facility.6 Management of trauma patients involves a team—it is teamwork, and most of the assessment and resuscitation of the injured is done simultaneously by members of the team, with one of them acting as the leader.9–10 Triage The most developed countries have designated centres where trauma patients, including children, are sent after being “sorted out” at the scene or field of injury. These centres are designated in levels.10 The following discussion is from the perspective of the West African subregion, Ghana being a good example; but is also true for many other African countries. Most hospitals have an Accident and Emergency (A&E) Department or Emergency Department (ED), where the injured are rushed by various means—ambulances (rare), private vehicles, or any other means available at the time. It is usually in this form that injured children are received in the emergency departments of hospitals, and it is here that the sorting of the injured starts. Triage is the sorting of patients based on the need for treatment and the available resources to provide that treatment.8 Children with injuries are usually admitted and sorted for treatment regardless of availability of resources, and then those who cannot be treated in that particular hospital are resuscitated and stabilised before being referred to another hospital that can handle the situation (which may be several kilometres away).