Pediatric Corner: Which trauma patients need fluid resuscitation?
Which trauma patients need fluid resuscitation?
Fluid bolusing not as critical in pediatric patients
The rules for which trauma patients require fluid resuscitation are different for children than adults, says a new study. Due to the differences in the epidemiology of pediatric trauma patients, they may not require aggressive fluid resuscitation, say researchers. Of 152 cases reviewed, nearly 50% had no second intravenous (IV) catheters, which suggests that the Advanced Trauma Life Support guidelines may not always be appropriate for the management of pediatric trauma.1
"This research reveals the reason that fluid bolusing is not as critical in the pediatric patient as it is in the adult patient," says Barbara Weintraub, RN, MSN, MPH, APN, CEN, manager of pediatric emergency services at Northwest Community Hospital in Arlington Heights, IL.
Pediatric trauma patients respond to hypovolemia differently than adults, explains Lori Vinson, RN, an ED nurse at Children's Medical Center Dallas. Hypotension in a pediatric patient would be a late sign of hypovolemia and could indicate a fluid loss of 20%-25% of circulating blood volume, she says. Children have a higher extracellular to intracellular fluid volume ratio and may require more fluids than an adult during resuscitation, she says. "Children also require maintenance fluids, and rates would be based on their weight in kilograms."
There is a mistaken belief that because children in general have healthy hearts, you can give them unlimited amounts of fluid without worrying about fluid overload, says Weintraub. Although most children do have healthy hearts, they also have immature kidneys and hormonal regulation of fluid balance, and it is possible to induce congestive heart failure in a child by giving too much fluid, she explains. "That is why it is critical to have a weight on the child, to control fluid infusion via IV pump, to calculate the correct fluid amount per kilo, monitor urine output, and deliver fluid in 20 ml/kg aliquots," Weintraub says.
If a patient is extremely ill, the intraosseous route is very useful for resuscitation of pediatric patients and is preferred over central access because of the ability to insert it very rapidly, says Pamela Smith, MSN, MBA, RN, clinical operations coordinator for the children's ED at Medical University of South Carolina in Charleston. The study shows that it is more important to have one solidly working line than to struggle to obtain two lines in the pediatric trauma patient, she says. "A 24-gauge IV is perfectly acceptable in the very young patient as long as it flows well and allows for fluid replacement."
Hypotension = unstable
Shock should be evaluated in children by perfusion and pulses, rather than by blood pressure, says Weintraub. "Hypotension is a very late sign in the pediatric patient and is generally acknowledged as a pre-arrest sign," she says.
Pediatric patients cannot increase stroke volume to compensate for a decreased cardiac output, says Smith. "Their initial response to hypovolemia will be an increased heart rate, with hypotension as a late sign."
Pediatric patients will not exhibit hypotension until 20%-25% of their blood volume is lost, says Smith. "Any patient with hypotension should be considered very unstable and critical," she says.
The American Heart Association defines a normal systolic blood pressure for children between 1 and 10 years as 70 plus two times the age in years. The Emergency Nurses Association's Emergency Nursing Pediatric Course (ENPC) teaches nurses to give an initial bolus of 20 cc/kg.2 Here are other recommendations from the ENPC course:
- The bolus can be repeated, and if signs and symptoms of shock persist after three boluses of warm fluids, then 10 cc/kg of packed red blood cells should be given.
- In the unstable child, the bolus should be given rapidly with the use of a syringe and stopcock.
- Rapid infusers such as the Level One should not be used on children who weigh less than 20 kg or who have an IV smaller than a 20 g.
- Urine output provides the best gauge of fluid resuscitation in the child and should be maintained at 0.5-2 cc/kg/hr.2
Remember to provide maintenance fluids during the post-resuscitative phase, says Smith. "Children have increased insensible losses due to the higher metabolic rate and exposed skin surfaces," she says. "We need to ensure maintenance fluids are adequate based on a fluid replacement formula, such as the 4-2-1 replacement formula."
References
- Vella AE, Wang VJ, McElderry. Predictors of fluid resuscitation in pediatric trauma patients. J Emerg Med 2006; 31:151-155.
- Cooper MC, Walz K. Emergency Nursing Pediatric Course, 3rd edition. J Emerg Nurs 2005; 31:203-205.
Sources
For more information about fluid resuscitation in pediatric trauma patients, contact:
- Pamela Smith, MSN, MBA, RN, Clinical Operations Coordinator, Children's Emergency Department, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC 29425. Telephone: (843) 792-1299. E-mail: [email protected].
- Barbara Weintraub, RN, MSN, MPH, APN, CEN, Manager, Pediatric Emergency Services, Northwest Community Hospital, 800 W. Central Road, Arlington Heights, IL 60005. Telephone: (847) 618-5432. Fax: (847) 618-4169. E-mail: [email protected].
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