In this lecture, we’re going to review
the primary and secondary survey.
How we manage trauma patients
during the first few minutes
that they come into the emergency room.
What you should remember
is that children are
very different than
adults in a lot of ways.
But there are some similarities
between the way we manage adults
in the traumatic situation and
the way we manage children.
I’ll try to highlight some of those
for you during this lecture.
Remember about how we first
think about a trauma.
Typically, you’re standing with the doctors
and nurses and other therapists in the ER
and you get a call saying,
“Patient in a motor vehicle accident,
five-year-old, roll-over, is coming in.”
And that’s really all you know.
The first thing you
want to do is use the
mechanism of injury that’s
been reported to you
to assess the severity of trauma
and the likelihood of injury.
So in a rollover for
example, all hands on deck,
then we’re going to
consider also in children,
which is a little bit different than
adults the risk for child abuse.
Frequently children coming into
the trauma bay had been abused,
shaken, they may not have
outward signs of trauma,
but may have internal
signs of trauma.
And so sometimes we worry
that the severity of
the injury is sort of
worse than we expected,
than we got from the report.
So think about that as a
Consider the possibility of an acute
event precipitating the trauma.
In other words,
an adolescent who has a seizure while
driving, results in an accident,
is it possible this adolescent who’s
now down actually had a problem,
say drug use, resulting
in a seizure
and you’re dealing with more than
you think right off the bat.
So the way we describe patients with
trauma is using the Glasgow coma scale.
This is important because
the scale is going to help
us with certain decisions
such as when to intubate,
but is also very effective method of
communication between professionals
in terms of assessing quickly
how injured generally is this
patient in terms of their CNS.
So we do have the adult and children score,
which you’re probably familiar with.
But there’s also an infant score that’s
adapted from the children and adult score,
which we can use as well.
So generally, the eyes section
of the Glasgow coma scale,
which is a four-point scale, is the same.
We give four points if the patient
is spontaneously opening their eyes,
three points if they
open it to voice,
two points if they open it to pain,
and one point of they are
not opening their eyes.
Then we look at the verbal response.
Here obviously infants will be different,
they won’t express whether
So instead of oriented for five
points, we have coos and babbles.
If a patient is confused, it may be that
the infant is irritable and not consoling.
For an adult who’s inappropriate for three
points, for infants we say cries to pain.
For incomprehensible in children and
adults, we use in infants moans to pain.
And of course, if there’s no verbal
response, that’s only one point.
And lastly, the motor response,
in an infant, it’s unlikely they would
obey a command in the first place,
so we have to adapt
the scale again.
Six points for obeys commands correlates
with just spontaneous movements.
Localizing the pain correlates
to withdraws to touch.
Withdraws to pain is the same.
And then we still use the flexion
and extension motor score,
which indicates decorticate
and decerebrate activity
and of course, flaccid is only one point.
So this will give you
basically the GCS score
in both children and adults and infants.
It’s up to your discretion
looking at a child
as to what degree
they’re going to be.
And this is an approximation,
but it is important to be able to
rapidly assign a Glasgow coma scale.
Remember, 15 points is perfect and
three is the worse you can be.