Helping severely injured children make a full recovery

Shock is the most reversible cause of death in children, but recognizing and treating it in the early stages can be uniquely challenging. Presenting symptoms differ from those in adults, and a child's anatomy and physiology make management more difficult, according to Brenda M. Schiltz, M.D., of Mayo Clinic in Rochester, Minn. And, she points out, children pose investigational challenges, too.

"The hardest thing with children and shock is that they can't always tell you what's wrong. An infant or young child brought in from a trauma scene is probably crying, but whether from fear or because they're hurt often isn't clear. They may be seriously injured, so you have to quickly differentiate between pain, anxiety and serious injury," she says.

For instance, although tachycardia is the first sign of shock in children and infants, it can result from other causes, including emotional upset. Dr. Schiltz explains, "Is there tachycardia because the child is struggling to breathe or because circulation is compromised, or is it simply stranger anxiety? It's certainly possible for a child to have tachycardia not caused by shock, but if tachycardia is there, you have to find to find out why."

First, address the ABCs — airway, breathing, circulation — she advises. "In children, you can rely on capillary refill to tell if perfusion is impaired. Are the legs mottled and skin cool to the touch? These are all abnormal signs in children, who have really healthy cardiovascular systems."

But a strong cardiovascular system can also mask serious problems, keeping blood pressure normal until shock is nearly irreversible. Even profoundly hypotensive children can be resuscitated and make a full recovery, Dr. Schiltz says, "but you absolutely want to recognize and treat shock long before they get to that point."

Oxygen, airway, fluids

For children in shock, Dr. Schiltz recommends starting oxygen immediately, even if oximeter readings are normal. In addition, the airway needs to be secured if a child is unable to maintain patency or is very hypoxic, has compromised perfusion or the Glasgow Coma Scale is less than 8.

Intubation in children presents special difficulties, though. A child's airway is anatomically different from an adult's, and children have small mouths, so there is less space for equipment. Infants, especially, may become profoundly bradycardic during intubation.

Dr. Schiltz says alternatives exist for providers who aren't comfortable with pediatric intubation. "They can hand ventilate the patient until a pediatric specialist is available," she suggests. "Or they can put in an artificial airway such as an LMA or call an anesthesiologist for help."

Rapid restoration of blood volume is also essential, but children's subcutaneous fat and small veins make obtaining intravenous (IV) access challenging. Dr. Schiltz says options exist there, too, particularly intraosseous infusion, a temporary measure that can be used when intravenous access fails.

"You should try to get IV access right away, but if you're struggling, insert an intraosseous needle into a long bone, such as the tibia or femur," she says. "It's more important to get vascular access early than spend a lot of time struggling to put in an IV."

Intraosseous infusion, first described in the 1930s, has experienced something of a resurgence, especially in pediatric resuscitation. The venous circulation around and within the marrow makes bone an effective site for the rapid infusion of fluids and drugs. In experienced hands, intraosseous access can be established in about one minute or less.

What's really important, Dr. Schiltz stresses, is constant reassessment. "The hemodynamics will tell you quickly what's happening. In the majority of pediatric trauma patients who are tachycardic, the heart rate will come down quickly with good fluid resuscitation. If it doesn't, you have to think about ongoing blood loss," she says.

Outcomes

Dr. Schiltz says that despite the challenges for providers, children usually recover quickly when traumatic shock is well managed. "When bleeding is controlled and blood volume restored, tachycardia will normalize, perfusion will get better, skin color will improve and capillary refill will be brisk. We can reverse everything that's going on assuming we have control of the injuries, and we often can restore children to their previous state of health."