Advanced Trauma Life Support ATLS Student Course Manual 2018

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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
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