Advanced Trauma Life Support ATLS Student Course Manual 2018
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Advanced Trauma Life Support ATLS Student Course Manual 2018

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04.12.2017 Views

CIRCULATION AND SHOCK 197 table 10-5 normal vital functions by age group AGE GROUP WEIGHT RANGE (in kg) HEART RATE (beats/min) BLOOD PRESSURE (mm Hg) RESPIRATORY RATE (breaths/min) URINARY OUTPUT (mL/kg/hr) Infant 0–12 months 0–10 60

198 CHAPTER 10 n Pediatric Trauma the Seldinger technique. If these procedures fail, a physician with skill and expertise can perform direct venous cutdown, but this procedure should be used only as a last resort, since it can rarely be performed in less than 10 minutes, even in experienced hands, whereas even providers with limited skill and expertise can reliably place an intraosseous needle in the bonemarrow cavity in less than 1 minute. (See Appendix G: Circulation Skills.) The preferred sites for venous access in children are •• Percutaneous peripheral (two attempts)—Antecubital fossa(e) or saphenous vein(s) at the ankle •• Intraosseous placement—(1) Anteromedial tibia, (2) distal femur. Complications of this procedure include cellulitis, osteomyelitis, compartment syndrome, and iatrogenic fracture. The preferred site for intraosseous cannulation is the proximal tibia, below the level of the tibial tuberosity. An alternative site is the distal femur, although the contralateral proximal tibia is preferred. Intraosseous cannulation should not be performed in an extremity with a known or suspected fracture. •• Percutaneous placement—Femoral vein(s) •• Percutaneous placement—External or internal jugular or subclavian vein(s) (should be reserved for pediatric experts; do not use if there is airway compromise, or a cervical collar is applied) •• Venous cutdown—Saphenous vein(s) at the ankle Fluid Resuscitation and Blood Replacement Fluid resuscitation for injured children is weightbased, with the goal of replacing lost intravascular volume. Evidence of hemorrhage may be evident with the loss of 25% of a child’s circulating blood volume. The initial fluid resuscitation strategy for injured children recommended in previous editions of ATLS has consisted of the intravenous administration of warmed isotonic crystalloid solution as an initial 20 mL/kg bolus, followed by one or two additional 20 mL/kg isotonic crystalloid boluses pending the child’s physiologic response. If the child demonstrates evidence of ongoing bleeding after the second or third crystalloid bolus, 10 mL/kg of packed red blood cells may be given. Recent advances in trauma resuscitation in adults with hemorrhagic shock have resulted in a move away from crystalloid resuscitation in favor of “damage control resuscitation,” consisting of the restrictive use of crystalloid fluids and early administration of balanced ratios of packed red blood cells, fresh frozen plasma, and platelets. This approach appears to interrupt the lethal triad of hypothermia, acidosis, and trauma-induced coagulopathy, and has been associated with improved outcomes in severely injured adults. There has been movement in pediatric trauma centers in the United States toward crystalloid restrictive balanced blood product resuscitation strategies in children with evidence of hemorrhagic shock, although published studies supporting this approach are lacking at the time of this publication. The basic tenets of this strategy are an initial 20 mL/ kg bolus of isotonic crystalloid followed by weightbased blood product resuscitation with 10-20 mL/kg of packed red blood cells and 10-20 mL/kg of fresh frozen plasma and platelets, typically as part of a pediatric mass transfusion protocol. A limited number of studies have evaluated the use of blood-based massive transfusion protocols for injured children, but researchers have not been able to demonstrate a survival advantage. For facilities without ready access to blood products, crystalloid resuscitation remains an acceptable alternative until transfer to an appropriate facility. Carefully monitor injured children for response to fluid resuscitation and adequacy of organ perfusion. A return toward hemodynamic normality is indicated by •• Slowing of the heart rate (age appropriate with improvement of other physiologic signs) •• Clearing of the sensorium •• Return of peripheral pulses •• Return of normal skin color •• Increased warmth of extremities •• Increased systolic blood pressure with return to age-appropriate normal •• Increased pulse pressure (>20 mm Hg) •• Urinary output of 1 to 2 mL/kg/hour (age dependent) Children generally have one of three responses to fluid resuscitation: 1. The condition of most children will be stabilized by using crystalloid fluid only, and blood is not required; these children are considered “responders.” Some children respond to n BACK TO TABLE OF CONTENTS

CIRCULATION AND SHOCK 197<br />

table 10-5 normal vital functions by age group<br />

AGE GROUP<br />

WEIGHT<br />

RANGE<br />

(in kg)<br />

HEART RATE<br />

(beats/min)<br />

BLOOD<br />

PRESSURE<br />

(mm Hg)<br />

RESPIRATORY<br />

RATE<br />

(breaths/min)<br />

URINARY<br />

OUTPUT<br />

(mL/kg/hr)<br />

Infant<br />

0–12 months<br />

0–10 60

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