Advanced Trauma Life Support ATLS Student Course Manual 2018

CIRCULATION AND SHOCK 195
breathing
A key factor in evaluating and managing breathing
and ventilation in injured pediatric trauma patients
is the recognition of impaired gas exchange. This
includes oxygenation and elimination of carbon
dioxide resulting from alterations of breathing caused
by mechanical issues such as pneumothorax and lung
injury from contusion or aspiration. In such cases,
apply appropriate countermeasures such as tube
thoracostomy and assisted ventilation.
Breathing and Ventilation
The respiratory rate in children decreases with age. An
infant breathes 30 to 40 times per minute, whereas an
older child breathes 15 to 20 times per minute. Normal,
spontaneous tidal volumes vary from 4 to 6 mL/kg
for infants and children, although slightly larger tidal
volumes of 6 to 8 mL/kg and occasionally as high as
10 mL/kg may be required during assisted ventilation.
Although most bag-mask devices used with pediatric
patients are designed to limit the pressure exerted
manually on the child’s airway, excessive volume
or pressure during assisted ventilation substantially
increases the potential for iatrogenic barotrauma due
to the fragile nature of the immature tracheobronchial
tree and alveoli. When an adult bag-mask device is used
to ventilate a pediatric patient, the risk of barotrauma
is significantly increased. Use of a pediatric bag-mask
is recommended for children under 30 kg.
Hypoxia is the most common cause of pediatric
cardiac arrest. However, before cardiac arrest occurs,
hypoventilation causes respiratory acidosis, which is
the most common acid-base abnormality encountered
during the resuscitation of injured children. With
adequate ventilation and perfusion, a child should be
able to maintain relatively normal pH. In the absence
of adequate ventilation and perfusion, attempting
to correct an acidosis with sodium bicarbonate can
result in further hypercarbia and worsened acidosis.
over-the-needle catheters in infants and small children,
as the longer needle length may cause rather than cure
a tension pneumothorax.
Chest tubes need to be proportionally smaller (see
n TABLE 10-3) and are placed into the thoracic cavity by
tunneling the tube over the rib above the skin incision
site and then directing it superiorly and posteriorly
along the inside of the chest wall. Tunneling is especially
important in children because of their thinner chest
wall. The site of chest tube insertion is the same in
children as in adults: the fifth intercostal space, just
anterior to the midaxillary line. (See Chapter 4: Thoracic
Trauma, and Appendix G: Breathing Skills.)
Circulation and Shock
Key factors in evaluating and managing circulation
in pediatric trauma patients include recognizing
circulatory compromise, accurately determining the
patient’s weight and circulatory volume, obtaining
venous access, administering resuscitation fluids
and/or blood replacement, assessing the adequacy of
resuscitation, and achieving thermoregulation.
Recognition of Circulatory
Compromise
Injuries in children can result in significant blood
loss. A child’s increased physiologic reserve allows for
maintenance of systolic blood pressure in the normal
range, even in the presence of shock (n FIGURE 10-4). Up
to a 30% decrease in circulating blood volume may be
required to manifest a decrease in the child’s systolic
Needle and Tube Thoracostomy
Injuries that disrupt pleural apposition—for example,
hemothorax, pneumothorax, and hemopneumothorax,
have similar physiologic consequences in children
and adults. These injuries are managed with pleural
decompression, preceded in the case of tension
pneumothorax by needle decompression just over
the top of the third rib in the midclavicular line. Take
care during this procedure when using 14- to 18-gauge
n FIGURE 10-4 Physiological Impact of Hemodynamic Changes on
Pediatric Patients.
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