Advanced Paediatric Life Support - Case Study Example

Paediatric Trauma Case Study One of the most challenging careers in the professional world is the work of a paramedic as it deals with first line emergency cases that involve human life. This is a paediatric trauma case study involving a 9-year-old boy reported of accidental injury more likely associated with multiple traumas. Details of the case are presented in this paper as well as the proper medical management of this case base on the paramedical standard of paediatric trauma protocol and other reliable sources, utilising theories and related literatures significant in this study to convey a realistic and valid approach of management. Description of the Scene At 08:49, an accident was reported involving a 9-year-old boy, named Martin, who has been hit by a car travelling approximately 30 kilometres an hour whilst crossing the road on his bicycle. On the scene, the boy is conscious with some respiratory distress 10 minutes after the incident. His left leg appears to be deformed, more likely associated to fractured tibia, fibula, or both. A man holding the boy’s helmeted head, maintaining spinal alignment and who claimed that he is the driver of the car and a trained first aider, said that Martin complained about tightness in his chest and that he has asthma. Paediatric Trauma To start with, it is important to emphasize that the term “trauma” is being used in this study according to its medical definition as a serious or critical bodily injury, wound or shock (MedicineNet.com, 2011). Trauma is the leading cause of childhood mortality because after the age of 5 years, rapid neuromuscular development, frequent social interactions with other children, wider range of activities, and less parental supervision predisposes them to greater risk. Paediatric trauma is more difficult to handle than in adults as presented in Staheli’s (2003, pp. 105-107) ‘Pediatric Orthopaedic Secrets’ book of the contributions made by Dr. Cummings about child versus adult trauma management: Details about the child’s injury will be difficult to gather if the trauma was not witnessed by an adult; assessment is difficult to establish as children frequently resist examination. Trauma causes more death and injury in children than in adults and unintentional injury causing blunt trauma is more common to children. Between 30% to 70% of trauma deaths in children are due to head injury because anatomically, children’s head is larger in proportion to the body than in adults and their neck muscles are weaker, thus the cervical spine is more susceptible to injury; their skulls are thinner, and scalps are more vascular than those of adults. Children’s liver and spleen are larger relative to their size than in adults, making them prone to hemorrhage due to intra-abdominal injury. Children are more prone to hypothermia due to higher body surface-to-mass ratio, their skin is thinner and they have smaller stored fats compared to adults. Children cannot be relied on when it comes to immobilization required in fracture healing during recovery as they tend to resume normal activity (if unattended) once they do not feel pain anymore. Assessment of Paediatric Trauma At the moment the health care provider reaches the scene, it is a standard operating procedure that he/she will introduce himself/herself in the crowd while conducting the primary survey and clearing the site for potential harm. Assessment of paediatric trauma in pre-hospital setting should be done rapidly to make sure that the injured child will be transported right away to the nearest facility where in-depth assessment, management, and treatment shall be given. In the pre-hospital setting, the rapid assessment and preparation includes: (1) minimizing scene time, (2) controlling external bleeding and shock, (3) immobilization, (4) immediate transport to the closest appropriate facility, (5) obtaining information from the handover, (6) assessment for level of consciousness, respiratory rate, systolic blood pressure, revised trauma score, and paediatric trauma score, (7) examine flail chest, proximal long bone fractures, amputation proximal to wrist or ankle, penetrating trauma proximal to elbow or knee, limb paralysis, pelvic fracture, trauma with burns (Mitchell, 2007). A more detailed assessment includes four phases: (1) Primary Survey, (2) Resuscitation, (3) Secondary Survey, and (4) Definitive Treatment (Waterson, Helms, and Platt, 2006, p. 192). In the Primary Survey, ensure scene safety and assess environmental conditions and mechanism of illness or injury (Smith, O’Connor, & Markenson, n.d.). Listen carefully to the handover person and make sure that spinal board or scoop is removed using the “scoop to ski” technique to prevent occurrence of serious pressure sores (Naser, Stephens, & Das, n.d.). The mnemonic ABCDE (Airway, Breathing, Circulation/Hemorrhage, Disability, and Exposure/Environment) sequence of prioritization is then applied (Dries, 2011). Airway with cervical spine control is done by immobilising the cervical spine and talking to the patient to ask “How are you?” assessing the patency of airway (through voice quality) and level of consciousness, whilst doing the “trauma handshake” simultaneously (Waterson et al., 2006). Breathing assessment follows to identify any life-threatening injury such as tension pneumothorax, open chest wound, etc. Note for trachea position (central or displaced), neck vein distention, cyanosis, respiratory rate and pattern, breath sounds, oxygen saturation, visible wounds, flail chest, surgical emphysema, and chest symmetry (Naser et al., n.d.). Circulatory assessment, according to Crameri (2010) includes examination of pulse, noting for tachycardia (sign of shock, fear, and anxiety), bradycardia (sign of imminent death), and pulse volume (reduced in shock). Assess for capillary refill by pressing on the sternum for 5 seconds then releasing it and counting the time for reperfusion, where up to 2 seconds is normal. Assess for skin color (pallor, cyanosis) and temperature, blood pressure, and other signs of circulatory inadequacy (such as respiratory distress, agitation, confusion, decreased level of consciousness, etc.). Disability assessment is a rapid mini-neurological assessment of the papillary response and conscious level. Pupils are inspected for size, equality and responsiveness to light. The Glasgow Coma Scale is commonly used to check level of consciousness but the AVPU (Alert, Vocal stimuli response, Painful stimuli response, Unconscious) is used for rapid assessment in pre-hospital setting (Waterson et al., 2006, p. 192). Exposure assessment includes undressing the child completely to check for injuries, rashes, etc. (Waterson et al., 2006, p. 192). The child is rolled with C-spine precautions to examine presence of back injuries or wounds (Deaconess Trauma Services, 2004). Resuscitation follows after the primary survey by conducting a definitive airway assessment and the application of a hard collar for cervical spine immobilization. Patient should be given supplemental oxygen and IV fluid administration (Mitchell, 2007). Secondary survey begins after vital signs are normalised and resuscitation is underway. History taking is done identifying allergies, medications, past illness, and events related to injury. Thorough physical examination of head, cervical spine and neck, chest, abdomen, perineum, musculoskeletal, and neurological assessments is conducted. Definitive treatment is applied after in-depth assessment and initial management that may include surgical management or may require transfer to a more appropriate facility (Mitchell, 2007). In the case, Martin complained of tightness in his chest and mentioned that he has a history of asthma. Ask the patient (or folks) if when did he have the last asthma and what medicines does he usually use. According to Smith et al. (n.d.), management of patient showing signs of respiratory distress or a history of asthma and inadequate ventilation includes the administration of 2.5 mg albuterol via nebulizer over a 10 to 15-minute period and repeat administration at 15-minute intervals throughout transport if the symptoms persists. Also, a systemic agent for bronchodilation is administered via subcutaneous route using either epinephrine 1:1000 at 0.01 mg/kg (maximum individual dose 0.3 mg) or terbutaline at 0.01 mg/kg (maximum individual dose 0.4 mg) (Smith et al., n.d.). Paediatric Assessment Triangle The paediatric assessment triangle (PAT), according to Horeczko and Hill (2011), is an internationally accepted tool in paediatric life support for the initial emergency assessment of infants and children including the three components: (1) appearance, (2) work of breathing, and (3) circulation to skin. PAT employs a rapid assessment of the child without the use of the hands, yet answers the questions whether the child is sick or not, what is the most likely physiological abnormality, and if the child requires emergency treatment (Pante, 2010, p. 253). Note for signs of abnormalities: as to appearance, note for abnormal or absent cry or speech, decreased response to parents or environmental stimuli, floppy or rigid muscle tone or not moving; as to work of breathing, note for nasal flaring, retractions, or abdominal muscle use in increased or excessive breathing, or decreased/absent respiratory effort or noisy breathing; as to circulation to skin, note for cyanosis, mottling, paleness/pallor, or obvious significant bleeding (New York State’s Emergency Medical Services for Children, 2004). Description of Data GCS is 13 – abnormal; frequently associated with multiple traumas, abnormalities in CCT scan, require of neurosurgical procedure and Intensive Care Unit admission (Melo, Lemos-Junior, Reis, Araujo, C. Menezes, Santos, Barreto, T. Menezes, & Filho, 2010). Pulse rate is 114 beats per minute - indicates abnormality (tachycardia); normal pulse rate is 60-100 beats per minute in children (Willacy, 2011). SpO2 is 97% - considered normal; normal value ranges from 95% to 100% (Advanced Life Support Group, 2004). Respiratory rate is 24 cycles per minute - considered normal; normal rate for children aged 5-12 years old is 20 to 25 breaths per minute (Ambulance Technician Study, 2006). Systolic blood pressure (BP) is 94 mmHg - abnormal (hypotension); normal systolic BP for children aged 6 to 9 years old is 122 mmHg (highbloodpressureinfo.org, 2011). Identifying Potential for C-Spine Injury The X-ray diagnostic test determines C-spine injury due to blunt trauma. In emergency situation where x-ray test is still impossible to establish, assessment of mechanism of injury can be used to indicate possibility of C-spine injury. One indicator of potential C-spine injury, according to Browne, Cheng, McCaskill, Pheen, and Cree (2002), is when a pedestrian or cyclist is hit by vehicle travelling at a speed of at least 30km/hr. Other signs may include neck pain or neurological deficit at any time since injury, significant injury above the clavicle such as on the head, face or mandible. In the case, Martin was hit by a vehicle with a speed of 30 km/hr and GCS is 13 signifying neurological deficit, thus potentially significant for spine injury. Priority Level Identification Priority level of Martin shall be interpreted in this study base on UK HealthCare (2011) Protocol Manual for paediatric injury. Paediatric Trauma Score (PTS) < 13. Computation of PTS is hard to establish in this case because of the lack of information presented as to the child’s weight, but assuming that Martin’s weight is above 20 kg, PDS will be computed as: Weight = 2, Airway with oxygen=1, Systolic BP (94 mmHg)=2, Consciousness=1, Fracture (single, closed)=1, and Skin (intact)=2. This is base on Mitchell’s (2007) paediatric trauma score computation. Total PTS is 9, thus this is significant for Trauma Alert priority level base on UK HealthCare (2011) protocol manual criteria Respiratory rate (RR) 30. Martin’s RR of 24 is not significant for Trauma Alert. GCS < 10. Martin’s GCS of 13 is not significant for Trauma Alert. Since Martin exhibited one indicator, which is a PTS of 9, this case will be classified under Trauma Alert priority level that calls for emergency medicine attending discretion and paediatric surgery attending discretion (UK HealthCare Protocol Manual, 2011). Hence, it is necessary that the patient will be transported to the nearest hospital. Pain Assessment in Pre-hospital Paediatric Trauma In the article of Brooke (2009), he mentioned that though there were various types of pain assessment tools utilized in the hospital setting, it is quite unfortunate that in the pre-hospital setting, not much of the pain assessment tools are being utilize by the paramedics. However, he suggested that the Wong Baker Faces Pain Rating Scale could be employed. Wong Baker Scale has drawings of 6 facial expressions indicating severity of pain with the following descriptions: (1) no hurt, (2) hurts little bit, (3) hurts little more, (4) hurts even more, (5) hurts whole lot, and (6) hurts worst. The health care provider will show this to the child explaining each faces and asking the child to choose the face that best describes how he is feeling. Conclusion In spite of the lack of information presented in the case, the review of theories and related literatures have somehow gave clarity to the essential steps that health care providers should strictly follow in handling the challenging management of paediatric trauma. Rapid assessment and intervention are vital in the pre-hospital setting to avoid further delay of proper treatment in cases of severe injury and this calls for the competence of health care providers to provide necessary interventions at the quickest, yet correct approach of management. Limitations on pain management in pre-hospital setting of paediatric trauma shall be given attention by researchers to properly address this physiological need. References Advanced Life Support Group (2004). Advanced Paediatric Life Support: The Practical Approach, 4th Edition. Wiley-Blackwell Publishing; London, United Kingdom. Ambulance Technician Study (2006). Infants and children. Retrieved 10 May 2011 from . Brooke, M. (2009). The challenges of managing paediatric pain. Journal of Paramedic Practice, Continuing Professional Development. Retrieved 10 May 2011 from . Browne, G.J., Cheng, N.G., McCaskill, M.E., Pheen, S., & Cree, A. (2002). An approach to paediatric cervical spine injury. Retrieve 10 May 2011 from . Crameri, J. (2010). Trauma circulation management. Retrieved 10 May 2011 from . Deaconess Trauma Services (2004). Management of the pediatric trauma patient. Retrieved 10 May 2011 from . Dries, D.J. (2011). Initial evaluation of the trauma patient. Medscape Reference. Retrieved 09 May 2011 from . Highbloodpressureinfo.org (2011). Look after the whole family using this blood pressure reading chart. Retrieved 10 May 2011 from . Horeczko, T. & Hill, M.G. (2011). The paediatric assessment triangle: a powerful tool for the pre-hospital provider. Journal of Paramedic Practice, Vol. 3, Issue. 1 (pp. 20 – 25). MedicineNet.com (2011). Definition of trauma. Retrieved 07 May 2011 from . Melo, J.T., Lemos-Junior, L.P., Reis, R.C., Araujo, A.O., Menezes, C.W., Santos, G.P., Barreto, B.B., Menezes, T., & Filho, J.O. (2010). Do children with Glasgow 13/14 could be identified as mild traumatic brain injury? Retrieved 10 May 2011 from . Mitchell, J. (2007). Trauma initial assessment and management. Retrieved 10 May 2011 from . Naser, A., Stephens, R., & Das, R. (n.d.). How to initially manage acute trauma. Retrieved 09 May 2011 from . New York State’s Emergency Medical Services for Children (2004). Pediatric assessment. Retrieved 10 May 2011 from . Pante, M.D. (2010). Advanced Assessment and Treatment of Trauma (p. 253). Jones and Barlett Publishers International: London, United Kingdom. Smith, D.M., O’Connor, R.E., & Markenson, D. (n.d.). National Association of EMS Physicians model pediatric protocols. Retrieved 10 May 2011 from . Staheli, L.T. (2003). Pediatric Orthopaedic Secrets, 2nd Edition (pp. 105-107). Hanley & Belfus, Inc. (An Affiliate of Elsevier) Medical Publishers: Philadelphia, PA. UK HealthCare (2011). Protocol manual. Retrieved 10 May 2011 from . Waterson, T., Helms, P.J., & Platt, M.W. (2006). Paediatrics: A core Text on Child Health, 1st Edition, (p. 192). Radcliffe Publishing Ltd.: Oxon, United Kingdom. Willacy, H. (2011). Pulse examination. Retrieve 10 May 2011 from . Read More