RESUMEN
Both blunt and penetrating chest trauma in children are less common than in adults but cause severe acute morbidity and mortality. As the literature suggests, pulmonary contusion is the most common chest injury in children, occurring in more than half of all blunt chest trauma cases. Even patients with blunt injuries are likely to have a longer hospital stay. The difference in physiological and anatomical variations in children compared to adults makes it more difficult from the diagnosis, management, and monitoring perspectives. A thorough physical examination is needed with close clinical monitoring, and additional vigilance is important during the management of a child. The physiologic consequences, such as the dreaded complication of alveolar hemorrhage and pulmonary parenchymal destruction, usually manifest within a few hours of the trauma and can take up to seven days to recover. Hence, timely diagnosis is crucial during the emergency evaluation. The clinical diagnosis can be supported by a special imaging modality in the form of chest computed tomography (CT), which confirms the radiological parenchymal destruction with high sensitivity. Management is mostly supportive to start with and includes high-flow oxygen, ventilatory pressure support as needed for the severity of acute lung injury (ALI) or acute respiratory distress syndrome (ARDS), judicious fluid administration, control of the pain associated with bony and thoracic soft tissue injuries, and careful hemodynamic monitoring for other complications and sequelae likely to develop. Here, we report an interesting case of a 10-year-old male child presenting to the Pediatric Emergency Department with acute moderate-to-severe respiratory distress that developed after two days of a few vomiting episodes along with non-specific lower chest and substernal pain following blunt trauma to the chest. The injury was trivial in nature as described by the father caused by an accidental fall on a small pile of bricks while playing near his home. After triaging under the red category, the child was managed in line with acute respiratory distress. We ruled out pneumothorax, hemorrhagic pleural effusion or pericardial effusion, and other evidence of invasive chest as well as gross abdominal injuries by comprehensive but focused history and clinical examinations, including adjuncts such as point-of-care ultrasound) and chest X-ray (CXR). Although the initial arterial blood gas analyses were suggestive of a mild form of ARDS or ALI by the criteria based on the P:F ratio (PaO2 to FiO2 ratio, which was between 200 and 300 for the case), the CXR and the chest CT revealed that the child had significant lung parenchymal injury in the form of bilateral fluffy pulmonary infiltrates. This case indicates that even a trivial blunt trauma can induce certain mechanisms of lung injury, leading to severe manifestations and sometimes fatal complications such as pulmonary contusion, hemorrhage, and ARDS.
RESUMEN
INTRODUCTION: Triage is crucial in patient screening within emergency departments (EDs) worldwide. It is one of the essential and standard medical practices in many developed countries. However, in India, there is a need for improvement in triage utilization, as it is predominantly performed by resident doctors or medical officers, leading to an uneven distribution of clinical skills among healthcare providers (HCPs). A comprehensive analysis incorporating literature review and data collection revealed that while mandatory screening is conducted in most Indian EDs, the formal implementation of standardized triage protocols remains limited. Like in developed countries, registered nurses or nursing officers (NOs) can be effectively trained and directed to play the role of dedicated triage personnel in EDs of most of the healthcare facilities in India. METHOD AND MATERIALS: This study aimed to examine the current state of triage utilization and its impact on the distribution of responsibilities among HCPs in Indian EDs. Through this online survey, the investigators assessed the knowledge and practical understanding of clinical triaging among NOs, working at various hospitals nationwide. RESULTS: The participants included 5,029 NOs working in various parts of India, predominantly nursing graduates (82.52%), the majority being employed in government healthcare settings (84.01%) and most having over five years of cumulative working experience in the ED (70.77%). Nurses showed inadequate knowledge and awareness about the Pediatric Assessment Triangle (PAT) used for quick initial evaluation (62.18% among all participants). Concerning the complete triage process applicable, especially in pediatric ED settings, they had even less satisfactory knowledge and understanding, e.g., identifying primary (28.27%) and secondary (22.69%) survey components via focused history and examination, properly using temperature assessment (23.32%) and instant blood glucose level assessment (22.95%) in triage, and knowing various types of internationally accepted triage systems for ED-based health facilities such as the Emergency Severity Index (ESI), Canadian Triage and Acuity Scale (CTAS), and Australasian Triage Scale (ATS) (15.87%). ANOVA and post hoc analysis revealed that the intergroup performance of the study participants with maximum correct responses to the knowledge-determining specified subset of the questionnaire depicts the significantly higher role of graduate nursing degree over diploma such as General Nursing and Midwifery (GNM)/Auxiliary Nursing and Midwifery (ANM) qualification, working in government hospital versus private setup, and ED working experience of >5 years over that of <5 years. CONCLUSIONS: Of the participants in the study, 50% were not evaluated for cognitive or psychomotor domains during their assessment examinations. The research illuminated a significant disparity in knowledge and proficiency levels among Indian nurses concerning pediatric triage, especially with the ability to effectively apply the PAT for initial patient evaluations, discern components of primary and secondary surveys, and comprehend various triage systems. This study underscores the importance of comprehensive reform in the Indian healthcare system and teaching curriculum by emphasizing clinical triage training and interprofessional collaboration, and establishing guidelines and regulations to ensure consistent and standardized triage practices across all EDs.