Updated: 2/23/2022

Pediatric Trauma Evaluation & Management

Review Topic
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  • Epidemiology
    • Trauma is most common cause of death in children > 1 years old
    • Epidemiology
      • mortality rate is approximately 20%
      • CNS injuries have highest overall morbidity 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
  • Etiology
    • Pathophysiology
      • falls and motor vehicle accidents most common
  • Transport
    • Occipital cut-out needed in spine board when transporting children <8 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 = 75 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
  • Airway
    • 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.
  • Breathing
    • 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
  • Circulation
    • 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 hemorrhage experienced by a 5 kg child represents the loss of approximately 26.7% of their total blood volume assuming a blood volume of 75ml/kg
    • Systemic vascular resistance is lower
      • increases from birth to adulthood
    • Hypotension is a late sign
      • remain normotensive until they are losing 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
  • Disability
    • Risk factors for head injury
      • 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 center of gravity = higher incidence of head and neck trauma
  • Exposure
    • 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
  • Injuries
    • Head and neck
      • Most common injury associated with all-terrain vehicle injuries is traumatic brain injury
        • ICP can be elevated by pain
          • it is possible to decrease ICP by fracture fixation
        • heterotopic ossification is more common following traumatic brain injury
          • increased 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
    • Multiorgan failure
      • occurs early after admission and affects all organ systems
Flashcards (3)
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Questions (8)
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(OBQ18.15) Which of the following correctly describes multiorgan failure in pediatric trauma patients?

QID: 212911

Occurs early after admission; all organ systems affected simultaneously



Occurs early after admission; cardiovascular system affected first



Occurs within 12-24 hours after admission; cardiovascular system affected first



Occurs around 48 hours after admission; all organ systems affected simultaneously



Occurs around 48 hours after admission; cardiovascular system affected first



L 1 A

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(OBQ13.29) A 4-year-old girl is involved in a tobogganing accident. She has a fluctuating level of consciousness and requires urgent transport to the local pediatric trauma center. When transporting a pediatric trauma patients, which of the following factors should be considered?

QID: 4664

A pelvic binder is required in all pediatric trauma patients



Intraosseous cannulation is the first choice for access in patients with hypovolemia



Modified spinal boards are required for pediatric trauma patients with a suspected spine injury



Intubation is required in pediatric patients when Glosgow Coma Score <12



Nasal cannula airways are required in pediatric patients with head injuries



L 2 B

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(OBQ11.62) A 5-year-old female presents after being struck by a vehicle in her driveway. She has multiple injuries, including a right femur fracture, and open book pelvis injury, and bilateral clavicle fractures. Peripheral IV access is not able to be obtained in the trauma bay after multiple attempts, and the patients blood pressure is 110/70. Which of the following is the most appropriate method to obtain vascular access in this patient?

QID: 3485

Placement of an intraosseous infusion device



Peripherally inserted central catheter (PICC) placement in the upper extremity



Femoral venous cutdown



Subclavian central line placement



Continued attempts at obtaining peripheral IV access



L 2 C

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(OBQ10.34) A 4-year-old child involved in a motor vehicle collision sustains multiple injuries including splenic rupture, bilateral open femur fractures, lumbar burst fracture with compression of the neural elements, and a closed head injury requiring a ventriculostomy. Of these injuries, which is likely to cause the greatest long-term morbidity?

QID: 3122

Traumatic brain injury



Peripheral nerve injury



Vertebral column injury



Intra-abdominal injury



Open fractures



L 1 C

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(OBQ10.192) How many milliliters(mL) of intravascular blood volume are present per kilogram of body weight in a healthy 5-year-old child?

QID: 3284

40-50 mL



75-80 mL



90-95 mL



110-120 mL



140-150 mL



L 4 B

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(SAE07PE.75) A 9-year-old boy sustained a traumatic brain injury and right lower extremity trauma in an accident involving a motor vehicle and a pedestrian. Initial evaluation in the emergency department reveals an obtunded patient who is breathing spontaneously and withdraws appropriately to painful stimuli. After initial resuscitation and stabilization, a CT scan reveals a right parietal intracranial hemorrhage. Radiographs of the swollen right thigh are shown in Figures 32a and 32b. Management of the fractured femur should ultimately consist of

QID: 6135

immediate hip spica casting.



closed reduction and percutaneous pin fixation supplemented by a hip spica cast.



placement in 90-90 traction after insertion of a distal femoral traction pin.



insertion of a reamed antegrade intramedullary nail starting at the piriformis fossa, stopping the nail short of the distal femoral growth plate.



closed reduction and stabilization using retrograde flexible intramedullary nails.



L 2 E

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Evidence (10)
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