Pediatric Trauma

Objectives of Learning
 Identify the unique characteristics of the
child as a trauma patient
 Types of injury
 Patterns of injury
 Anatomic and physiologic differences in
children as compared with adults.
 Long-term effects of injury.
Objectives of Learning
 Discuss the primary management of the
following critical injuries in children based on
the anatomic and physiologic differences as
compared with adults.
 Airway management.
 Shock and maintenance of body heat
 Fluid and electrolyte management
 Medications and dosages
 Central nervous system and cervical spine injuries
 Psychological support
Objectives of Learning -Skills
Demonstrate in a simulated situation
the following procedures for the
pediatric trauma victim.
 Endotracheal intubation.
 Intravenous / intraosseous access.
 Fluid and drug administration.
 Management of extremity trauma.
Introduction
 Injury continues to be the most common cause of death and
disability in childhood. Although falls are a very common cause of
injury, they infrequently result in death. Children with multisystem
injuies can deteriorate rapidly and develop serious complications.
Therefore, such patients should be transferred early to a facility
capable of managing the child with multisystem injuries.
 Unique anatomic characteristics of children require special
consideration in assessment and management.
 Size and shape
 Skeleton
 Surface Area
 Psychologic Status
 Long-term effects
 Equipment
Airway: Evaluation and management

 Anatomy
 The infant’s trachea is approximately 5 cm
long and grows to 7 cm by about 18
months. Failure to appreciate this short
length may result in intubation of the right
mainstem bronchus, inadequate
ventilation, and/ or mechanical barotrauma
to the delicate bronchial tree.
Airway: Evaluation and management

 Management
 Before attempts are made to mechanically establish an
airway, the child should be oxygenated.
 Oral airway
 The oral airway should only be inserted when a child is
unconscious. If placed when the child is awake, vomiting is
likely.
 Orotracheal intubation
 Child with significant head injury requiring hyperventilation.
 The child who cannot maintain an airway.
 The child suffering significant hypovolemia who requires
operative intervention.
Airway: Evaluation and Management
 Orotracheal intubation
 Uncuffed tubes of appropriate size should be used to avoid
subglottic edema, ulceration, and disruption of the infant’s
fragile airway.
 The smallest area of the child’s airway is at the cricoids ring,
which forms a natural seal with the endotracheal tube.
 Orotracheal intubation under direct vision with adequate
immobilization and protection of the cervical spine is the
preferred method of obtaining initial airway control.
 Auscultation of both hemithoraces in the qxillae should be
performed.
 A chest x-ray may be obtain to accurately identify the
position of the endotracheal tube.
Airway: Evaluation and Management

 Cricothyroidotomy
 Surgical cricothyroidotomy is rarely
indicated for the infant or small child, and if
absolutely necessary, it should be
performed by a surgeon.
 Needle cricothyroidotomy
Breathing Evaluation and management

 Breathing and Ventilation

 An infant requires 40 to 60 breaths per minute, whereas the
older child breathes 20 times per minute.
 Hypoventilation is the most common cause of cardiac arrest
in the child.
 In the absence of adequate ventilation and perfusion,
attempting to correct an acidosis with sodium bicaarbonate
results in further hypercarbia and worsened acidosis.
 Tube Thoracostomy
 Same as in adults except the size.
Circulation and Shock
 Recognition
 Early assessment of the child by a surgeon
is essential to the appropriate management
of the injured child.
 A 25% diminution in circulating blood
volume is required to manifest the minimal
signs of shock.
System <25% Blood Volume loss 25%-45% Blood >45% Blood
Volume Loss Volume Loss

Cardiac Weak, thready pulse, In creased heart Hypoten-sion,

incresed heart rate rate tachycar-dia to
bradycar-dia

CNS Lethargic, irritable confuse Change in level of Comato-s

consiousn-ess,
dulled
response to pain

Skin Cool, clammy Cyanotic, Pale, cold

decreased
capillary refill, cold
extremitie-s

Kidneys Minimal decrease in Minimal urine No urinary

urinary output; increased output output
specific gravity
Circulation and Shock: Evaluation
and management
 Fluid Resuscitation
 Goal in fluid resuscitation in the child is to
rapidly replace the circulating volume.
 When shock is suspected, a fluid bolus,
using warmed fluid, of 20 ml/ of crystalloid
solution is required.
 It may be necessary to give three boluses
of 20 ml/kg or a total of 60ml/kg to achieve
a replacement of the lost 25%.
Circulation and Shock: Evaluation
and management
 A return toward hemodynamic normality is
indicated by:
 Slowing of the heart rate (<130 beats/minute with
improvement of other physiologic signs)
 Increased pulse pressure (>20 mm Hg)
 Return of normal skin color
 Increased warmth of extremities
 Clearing of sensorium (improving GCS score)
 Increased systolic blood pressure (>80mm Hg)
 Urinary out put of 1 to 2ml/kg/hour (age-dependent)
Circulation and Shock: Evaluation
and management
 Blood Replacement
 When starting the third bolus of crystalloid
fluid or if the child’s condition deteriorates,
consideration must be given to the use of
10 ml/kg of type specific or O-negative
warmed PRBCs.
Circulation and Shock: Evaluation
and management
 Venous Access
 The sites for venous access in children are:
 Percutaneous peripheral (two attempts)
 Intraosseous (children <6 years of age)
 Venous cutdown-----Saphenous vein at the ankle
 Percutaneous placement -------Femoral vein
 Percutanceeous placement-----Subclavian vein
 Percutaneous placement-------- External jugular vein (do
not use if cervical collar applied
 Internal jugular vein

Intraosseous infusion, cannulating the marrow cavity of a

long bone in an uninjured extremity, is an emergent-
access procedure for the critically ill or injured child.
Circulation and Shock: Evaluation
and management
 Urinary Output
 Urinary output for the newborn and infant, up to 1
year, is 2ml/kg/hour.
 The toddler has a urinary output of 1.5 ml/kg/hour,
and the older child has urinary output of 1ml/kg/
hour through adolescence.
 Urinary output combined with urinary specific
gravity is an excellent method of determining the
adequacy of of volume resuscitation.
Circulation and Shock: Evaluation
and management
 Thermoregulation
 The high ration of body surface area to body mass
in children increases heat exchange with the
environment, and directly affects the child’s ability
to regulate core temperature.
 While the child is exposed during the initial survey
and resuscitation phase, overhead heat lamps or
heaters or thermal blankets may be necessary to
maintain body temperature to preserve body heat,
warm the room as well as the intravenous fluids,
blood products,and inhaled gases.
Chest Trauma
 Ten percent of all injuries involve the chest
 Chest injury also is a marker for other organ
system injury since more than two thirds of
children with chest injury have been shown to
have other organ system injuries.
 Mobility of mediastinal structures makes the
child more sensitive to tension pneumothorax
and flail segments.
Abdominal Trauma
 Assessment
 Talk quietly and calmly
 Palpate the abdomen gently
 Pass N/G tube before palpation

 Diagnostic Adjuncts
 Computed tomography (CT)
 Diagnostic peritoneal lavage (DPL)
 Ultrasound
Nonoperative Management
 The presence of intraperitoneal blood
on CT,DPL, or ultrasound does not
necessarily mandate a celiotomy.
 It has been well demonstrated that
bleeding from an injured spleen, liver,
and kidney generally is self-limiting.
Nonoperative Management
 If the child cannot be normalized
hemodynamically and if the diagnostic
procedure performed is positive for blood, a
prompt celiotomy to control hemorrhage is
indicated.
 Nonoperative management of confirmed
abdominal, visceral injuries is a surgical
decision made by surgeons, just as is the
decision to operative. Therefore, the surgeon
must provide the management of thepediatric
trauma patient
Head Trauma
 Outcome in children suffering severe head
injury is better than in adults. However, the
outcome in children less than 3 years of age
is worse than a similar injury in the older
child.
 Although an infrequent occurrence, infants
may become hypotensive from blood loss into
either the subgaleal or epidural space.
Head Trauma
 Vomiting and even amnesia are common after head
injury in children and do not necessarily imply
increased intracranial pressure.
 Seizures occurring shortly after head injury are more
common in children and are usually self-limited.
 Children tend to have fewer focal mass lesions than
do adults, but elevated intracranial pressure due to
cerebral edema is more common. In children, a lucid
interval may be prolonged, and the onset of
neurologic deterioration delayed
Head Trauma

Verbal Response V-score

Appropriate words or social 5

smile, fixes and follow
Cries, but consolable 4
Persistenly irritable 3
Restless, agitated 2
None 1
Head Trauma
 Drugs
 Phenobarbital 2 to 3 mg/kg
 Diazepam 0.25 mg/kg, slow IV bolus
 Phenytoin 15 to 20 mg/kg, administered at 0.5 to
1.5 ml/kg/minute as a loading dose, then 4 to 7
mg/kg/day for maintenance
 Mannitl 0.5 to 1.0 g/kg 9rarely required). Diuresis
with the use of mannitol or furosemide may
worsen hypovelemia and should be withheld early
in the resuscitation of the child with a head injury.
Head Trauma
 Management
 Rapid, early assessment and management of the
child’s ABCDEs.
 Appropriate neurosurgical involvement from the
beginning of treatment.
 Appropriate sequential assessment and
management of the brain injury with attention
director toward to prevention of secondarybrain
injury.
 Continuous reassessment of all parameters
Spine Cord Injury
 Anatomic difference
 Interspinous ligaments joints capsules are more
flexible.
 Vertebral bodies are wedged anteriorly and tend to
slide forward with flexion.
 The facet joints are flat.
 The child has a relatively large head compared to
the neck. Therefore, the force applied to the neck
is relatively grater than it is in the adult.
Spine Cord Injury
 Radiologic Consideration
 Pseudosubloxation----- About 40% of children
younger than 7 years of age show anterior
displacement of C-2 C-3 and 20% of children up to
16 years of age exhibit this phenomenon.
 Children may sustain spinal cord injury without
radiographic abnormality (SCIWORA) more
commonly than do adults.
 When in doubt about the integrity of the cervical
spine, assume that an unstable injury exists,
maintain immobilization of the child’s head and
neck, and obtain appropriate consultation.
Musculoskeletal Trauma
 History
 Blood loss
 Special considerations of the immature
skeleton
 Principles of immobilization
?
Summary
 Unique characteristics of children include
 airway anatomy & management
 Fluid requirements
 Recognition of CNS, as well as thoracic and
abdominal injuries
 Extremity #
 Resuscitate child appropriately to avoid
secondary brain damage from hypovolemia
 Non operative management of abdominal
visceral injuries only in facilities equipped to
handle any contigencies quickly