Advanced Trauma Life Support ATLS Student Course Manual 2018

CHEST TRAUMA 199
crystalloid and blood resuscitation; these
children are also considered responders.
2. Some children have an initial response
to crystalloid fluid and blood, but then
deterioration occurs; this group is termed
“transient responders.”
3. Other children do not respond at all to
crystalloid fluid and blood infusion; this group is
referred to as “nonresponders.”
Transient responders and nonresponders are candidates
for the prompt infusion of additional blood
products, activation of a mass transfusion protocol,
and consideration for early operation. Similar to adult
resuscitation practices, earlier administration of blood
products in refractory patients may be appropriate.
The resuscitation flow diagram is a useful aid in the
initial treatment of injured children (n FIGURE 10-6).
(Also see Resuscitation Flow Diagram for Pediatric
Patients with Normal and Abnormal Hemodynamics
on MyATLS mobile app.)
Urine Output
Urine output varies with age and size: The output goal
for infants is 1-2 mL/kg/hr; for children over age one
up to adolescence the goal is 1-1.5 mL/kg/hr; and 0.5
mL/kg/hr for teenagers.
Measurement of urine output and urine specific
gravity is a reliable method of determining the adequacy
of volume resuscitation. When the circulating blood
volume has been restored, urinary output should return
to normal. Insertion of a urinary catheter facilitates
accurate measurement of a child’s urinary output for
patients who receive substantial volume resuscitation.
Thermoregulation
The high ratio of body surface area to body mass in
children increases heat exchange with the environment
and directly affects the body’s ability to regulate core
temperature. A child’s increased metabolic rate, thin
skin, and lack of substantial subcutaneous tissue also
contribute to increased evaporative heat loss and
caloric expenditure. Hypothermia can significantly
compromise a child’s response ’to treatment, prolong
coagulation times, and adversely affect central nervous
system (CNS) function. While the child is exposed
during the initial survey and resuscitation phase,
overhead heat lamps, heaters, and/or thermal blankets
may be necessary to preserve body heat. Warm the
room as well as the intravenous fluids, blood products,
and inhaled gases. After examining the child during
the initial resuscitation phase, cover his or her body
with warm blankets to avoid unnecessary heat loss.
Cardiopulmonary
Resuscitation
Children who undergo cardiopulmonary resuscitation
(CPR) in the field with return of spontaneous
circulation before arriving in the trauma center have
approximately a 50% chance of neurologically intact
survival. Children who present to an emergency
department still in traumatic cardiopulmonary arrest
have a uniformly dismal prognosis. Children who
receive CPR for more than 15 minutes before arrival
to an ED or have fixed pupils on arrival uniformly are
nonsurvivors. For pediatric trauma patients who arrive
in the trauma bay with continued CPR of long duration,
prolonged resuscitative efforts are not beneficial.
Chest Trauma
n FIGURE 10-6 Resuscitation Flow Diagram for Pediatric Patients
with normal and abnormal hemodynamics.
Eight percent of all injuries in children involve
the chest. Chest injury also serves as a marker
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