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Updated: Feb 23 2022

Pediatric Trauma Evaluation & Management

Images ped cspine.jpg peds cspine.jpg spine board..jpg
  • 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
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