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Pediatric Terrorism and Disaster Preparedness

Public Health Emergency Preparedness

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Table 7.3. Principles of Advanced Trauma Life Support®

Principle Description
Primary Survey and Resuscitation
Airway/cervical spine Open: jaw thrust/spinal stabilization
Clear: suction/remove particulate matter
Support: oropharyngeal/nasopharyngeal airway
Establish: orotracheal/nasotracheal intubationa
Maintain: primary/secondary confirmationb
Bypass: needle/surgical cricothyroidotomy
Breathing/chest wall Ventilation: chest rise/air entry/effort/rate
Oxygenation: central color/pulse oximetry
Support: distress—NRB/failure—BVMc
Chest wall: ensure integrity/expand lungs
Tension pneumothorax: needle, chest tubed
Open pneumothorax: occlude, chest tube
Massive hemothorax: volume, chest tube
Circulation/external bleeding Stop bleeding: direct pressure, avoid clamps
Shock evaluation: pulse, skin CRT, LOCe
Blood pressure: avoid over/undercorrection
Infant/child: low normal = 70 + (age × 2) mmHg
Adolescent: low normal = 90 mmHg
Volume resuscitation: Ringer';s lactate → packed cells
Infant/child: 20 mL/kg RL, repeat x 1-2 → 10 mL/PRBC
Adolescent: 1-2l, repeat 1-2 × → 1-2 U PRBC
Disability/mental status Pupils: symmetry, reaction
LOC: GCS
Track and trend as a vital sign
Significant change = 2 points
Intubate for coma = GCS ≤8
Motor: strength, symmetry
Abnormality or deterioration: call neurosurgeon
Mild TBI (GCS 14-15): observe, consider CT for history of LOC
Moderate TBI (GCS 9-13): admit, obtain CT, repeat CT 12-24 hr
Severe TBI (GCS 3-8): intubate, ventilate, obtain CT, repeat CT 12-24 hr
Exposure and environment Remove clothing
Logroll: requires four people
Screening examination: front and back
Avoid hypothermia: keep patient warm
Adjuncts
  Foley catheter unless contraindicatedf
  Gastric tube unless contraindicatedg
Secondary Survey and Reevaluation
  History and physical: SAMPLE history, complete examination
  Imaging studies: plain radiographsh, special studiesi

a RSI technique: etomidate then succinylcholine.
b Primary: chest rise, air entry; secondary: exhaled CO2 detector, esophageal detector device; watch for DOPE: Dislodgement, Obstruction, Pneumothorax, Equipment failure.
c NRB = nonrebreather mask; BVM = bag valve mask.
d Do not wait for confirmatory chest x-ray.
e CRT = capillary refill time, LOC = level of consciousness; consider obstructive and neurogenic as well as hypovolemic shock: exclude tension pneumothorax, cardiac tamponade, spinal shock.
f Meatal blood, scrotal hematoma, high riding prostate.
g Cerebrospinal fluid (CSF) oto/rhinorrhea, basilar skull fracture, midface instability.
h Chest, pelvis, lateral cervical spine; others as indicated.
i FAST, computer tomography (CT) scan as indicated.

Source: Adapted with permission from the American College of Surgeons Committee on Trauma, Advanced Trauma Life Support® for Doctors Student Course Manual.

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