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  • Trauma is most common cause of death in children > 1 years old
  • Epidemiology
    • mortality rate is approximately 20%
    • CNS injuries have highest overall morbiditya and mortality 
    • spine fractures have highest morbidity/mortality among musculoskeletal injuries 
      • cervical spine injuries more common in children <8-years-old 
        • due to fact that restraints do not fit young children 
  • Pathophysiology
    • falls and motor vehicle accidents most common
  • Occipital cut-out needed in spine board when transporting children <6 y.o. 
    • larger head size can flex unstable cervical spine leading to injury during transport
  • Help tips
    • Broselow tape = estimate medication doses, size of equipment, shock voltage for defibrillator
    • ETT = (age/4) + 4 or (age+16)/4 = uncuffed
    • BP = 80 + (age x 2)
    • Chest tube = 4 x ETT
    • Blood volume = 70 x wt (kg) or 75 - 80 mL/kg 
  • Intraosseous lines commonly needed due to difficulty obtaining venous access
    • Children may remain hemodynamically stable even after significant blood loss
      • hypovolemic shock may result from inadequate fluid resuscitation
    • "triad of death" reflects inadequate resusitation and is characterized by:
      • acidosis
      • hypothermia
      • coagulopathy
ATLS with Children
  • Overview
    • Should follow ATLS protocol  
      • Airway
      • Breathing
      • Circulation
      • Disability
      • Exposure
  • Smaller airway
    • greater risk of airway obstruction with foreign bodies
    • small amounts of swelling will result in a relatively greater reduction in airway diameter
  • Larger tongue, floppy epiglottis,
  • Larger occiput
    • flexes the head forward when placed supine on a flat surface.  
    • to achieve a neutral position, it may be necessary to lift the chin or place a pad under the torso of the infant (or head cut out)
  • Larynx is higher and more anterior
    • sits at the level of the C2-C3 vertebrae body in the young child, compared with C6-C7 in the adult.
      • positioning of the larynx makes its visualisation in the paediatric airway more difficult than in the adult.
  • Most common cause of cardiorespiratory arrest is hypoventilation
  • Ribs positioned more horizontally
    • with inspiration the ribs only move up, and not up-and-out, like the adult rib cage. 
    • limits the capacity to increase tidal volumes
  • Diaphragmatic breathing
  • Fewer Type 1 fibres in respiratory muscles
    • smaller number of fatigue-resistant, Type I fibres in their respiratory muscles
    • exhaust more quickly than adults
  • Respiratory rate varies with age
    • higher oxygen demand =  higher respiratory rates
  • Initial bolus = 20ml/kg NS
  • After two boluses = 10ml/kg of PRBC’s
  • Blood volume is relatively larger, but absolute volume is smaller
    • small volumes of blood will constitute significant blood loss in small children, 
      • example = 100ml haemorrhage experienced by a 5 kg child represents the loss of approximately 10% of their total blood volume.
  • Systemic vascular resistance is lower
    • increases from birth to adulthood
  • Hypotension is a late sign
    • remain normotensive until they are loosing large intravascular volumes
      • 25-30% of blood volume before signs of shock
  • Smaller vessels / more subcutaneous tissue
    • difficult to obtain vascular access due to small veins and increased subcutaneous tissue 
  • IV access more difficult – consider intraosseus
  • Open sutures, presence of fontanelle
  • Thinner cranial bones
    • thinner cranial bones of children do not afford as much protection to the brain tissue
  • Head relatively larger
    • higher centre of gravity =  higher incidence of head and neck trauma
  • Relatively small size
    • large head and organs
  • Higher BMR and surface area
    • greater consumption of oxygen and other metabolites
    • higher respiratory and heart rates
    • larger surface-area to body-mass ratio results in greater heat loss 
  • Increased glucose requirements but decreased glycogen stores
    • higher metabolic rate 
    • small glycogen stores
Pediatric Scoring Systems
  • Pediatric trauma score (PTS) 
    • PTS<0=100% mortality
    • PTS of 1-4=40% mortality
    • PTS of 5-8=7% mortality
      • PTS less than or equal to 8 should be sent to designated peds trauma center
  • Pediatric Galsgow Coma Scale 
    • GCS<8 correlates with a higher rate of mortality
  • O2 sat at presentation and GCS 72hrs post-injury are both prognostic of long-term neurologic recovery
  • Head and neck 
    • ICP can be elevated by pain
      • it is possible to decrease ICP by fracture fixation
    • heterotopic ossification is more common following traumatic brain injury
      • increase serum alkaline phosphatase heralds onset of HO
      • NSAID prophylaxis is indicated in these situations
  • Peripheral nerve injuries 
    • most common in closed fractures
      • obtain EMG if no return of function 2-3 months after injury

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