Pediatric triage

Rio, ASN, RN · Feb 19, 2006

I'm sorry but I can not get past :"breathing sonorous and slow","GCS is 9" and mechanism of injury. My next step would be an RSI (rapid sequence intubation) to protect the airway and effectively ventilate. Implicit to this is maintaing cervical spine integrity, two large bore IV's and shipping him to the nearest peds trauma center.

Again, I'm sorry this doesn't answer your question, just what needs to be done IMHO. And if the "breathing sonorous and slow" how are the "vss" ?

Pediatric Critical Care Columnist · Feb 19, 2006

Rio's concerns aside (which I agree with, BTW, although kids do have a much greater reserve than adults and could still have "stable" vitals in this scenario... at least for the time being) I think the questions your instructor is asking for would likely be things like: What's your name? How old are you? When's your birthday? What day is it today? Is it morning or night? Do you know where you are? Can you tell me what happened? Can you wiggle your toes for me? You're assessing orientation, short term memory, long term memory and ability to follow instructions, all important in an overall neurological assessment; a developmentally normal 8 year old should be able to answer all those. At any time during the process, if level of consciousness, ability to maintain the airway or alterations in vital signs occur, then you'd abandon your "game" and get on with your basic trauma life support.

BrightonRN · Feb 19, 2006

This really helps quite a bit. I am beginning to think that there are not 8 specific, maybe she just wants 8. I have chosen to do my focused assessment on the head, including airway. I think that my secondary assessment would be on the chest and abd because of the mechanism of injury. would this be appropriate based on the scenario presented? i feel like I am missing something, this just seems too easy.

Pediatric Critical Care Columnist · Feb 19, 2006

You're on the right track. Your primary survey looks at the ABCs. Airway... do they have one? If they don't, how can we get them one? Breathing... are they? If they aren't then we need to do it for them. Circulation... is their heart beating? If it isn't then we need to do that too. If it is, how fast is it beating? What is the blood pressure? What is their circulation like? What color is the skin? Is it warm or cold? (Centrally vs peripherally.) What kind of pulses do they have to their extremities? They'll need fluid regardless of the mechanism of injury, thus an IV or two, preferably the biggest ones that can be put in. A lot of the primary survey can be done without even touching the patient.

Once the primary survey's done you move on to the secondary survey. A more in-depth exam of the ABCs comes first. Are they maintaining their own airway? What do their air entry and breath sounds sound like? What are the sats like? How much oxygen do they need to get the sats in a good spot? Are they bleeding anywhere? Do they have any urine output? Then on to the less threatening. Disability... are they conscious? Can they move everything? Are there bones poking out where there shouldn't be? Do they feel the things being done to them? Exposure... Get their clothes off, but make sure the room is warm enough that they don't become hypothermic. How long were they laying on the road or outdoors on the stretcher before they were moved? What's their temperature? Do they have sunburn or frostbite? All the while you've got one eye on the things you assessed first... don't want to miss something.

Her'es a great website that gives an overview of trauma assessment and gives a scenario much like yours.

http://www.gpnotebook.co.uk/medwebpage.cfm?ID=393280

BrightonRN · Feb 21, 2006

Thank you so much. I think that I did well with this assignment. I will let you know how it turned out. I missed this post until today, and I turned my assignment in on Sunday. i think that I put most of this in.:) I really have to open that critical thinking box in my head. The hinges are a bit rusty, but I think that it won't be too much longer.

Pediatric Critical Care Columnist · Feb 21, 2006

I'm sure you did well. They can't expect a nursing student to function at the same level of critical thinking as someone with ten years of practice. In fact, even people who have been in the job for a long time can miss things. I proved that last night with two of my coworkers who have between them at least three times as much experience than I do. Too bad the one patient ended up getting a huge fluid bolus and inotropic meds she didn't need... It never occurred to me that this nurse wouldn't have done the simple things first. Oil up those hinges... it's never too late to think outside the box!

wincha · Feb 21, 2006

I am a nursing student working on my BSN. I currently work in a hospice as an RN. I am working on a pediatric case study and I have a couple of questions. The studey is about an eight year old boy that was hit by a car at 40mph. he has head and facial trauma. No obvious fractures. Awake and confused. GCS is 9 breathing sonorous and slow all vss. he is at an rural hospital not designated as a pediatric trauma center. I have completed the focused assessment. My instructor is asking for 8 specific questions to ask the patient. The patient is confused though, it seems as if I would ask parents and the EMS team questions. I cannot find 8 questions anywhere. Are there 8 specific questions for pediatric triage of a head injury?

not sure about all of them since i take call for peds and usually have my protocols.

1. did he lose consciousness and if yes for how long?

you would ask him question but you would also ask the parents or who witnessed the accident

2. how does your head feel? does it hurt?

3. ask questions to determine any blurred vision or visual changes

4. how confused is he? does he know his parents? does he remember what happened?

5. has he vomited and if so how many times?

6. what are his vital signs which you should be checking

7. what are his neuro checks per ems and what are they now that yo are taking him

8. is he getting worse, the same?

9. any neck pain?

10. any tingling in his arms or legs?

BrightonRN · Feb 22, 2006

Thank you!!

Kidrn911 · Feb 24, 2006

I work in a level 1 pediatric trauma facility and know from experience that we don't ask questions, GCS of 9 is intubated

Pediatric Critical Care Columnist · Feb 24, 2006

We have had kids whose GCS is less than 8 who aren't intubated. GCS isn't a very good tool for kids under about 6 years of age, or for kids who have developmental concerns. A toddler could easily have a GCS of 7 or 8 and not be in need of a tube. Eye opening to pain (2) could be behaviorally normal... I don't know you, I'm not going to look at you... OW! Withdraws to pain (4) ditto... Maybe if I lay really still and don't move she'll go away... OW! And no verbal response (1) or crying (2) also ditto... I've never laid eyes on you before, I'm scared and I'm just not going to talk to you... OW! It all has to be taken in context.

Kidrn911 · Feb 24, 2006

It all has to be taken in context.
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