and Burns

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© Springer Nature Switzerland AG 2020
Craig Sims, Dana Weber and Chris Johnson (eds.) A Guide to Pediatric Anesthesia

25. Trauma and Burns

Mary Hegarty1  

Department of Anaesthesia and Pain Management, Perth Children’s Hospital, Nedlands, WA, Australia



Mary Hegarty


Pediatric traumaPediatric cervical spine injurySpinal cord injury without radiological abnormalityPediatric burn managementNon-accidental injuryPediatric burns resuscitation; Critical bleedingChildren

Trauma is the leading cause of morbidity and mortality in children aged over 1 year, accounting for 40% of all deaths. Children who survive serious injuries are often left with permanent disabilities which may be life-changing for the child and their family. Whilst the management of children after trauma follows the same principles as adults, there are unique features of pediatric trauma.

Children are at risk of injury because of their curiosity, risk taking behavior and lack of fear. Their small size means trauma is more likely to impact on multiple organs. Children have greater elasticity of their connective tissue, so shearing forces may cause tearing of major blood vessels and mediastinal structures. The flexible nature of a child’s skeletal system means that greenstick fractures are more common, and significant organ damage can occur with no overlying fractures. For example, blunt chest wall trauma may not result in rib fractures, but the force sustained during trauma may cause extensive injury to the thoracic organs. The abdominal wall of a child is less protected by fat and subcutaneous tissues so intra-abdominal organs are more prone to injury than in the adult population.

Physiological compensation may mask clinical signs of deterioration. This can lead to a delay in the recognition of injury and failure to respond appropriately to subtle clinical signs, particularly when there may be little external evidence of injury. Children may rapidly decompensate if these subtle signs are missed, so continual reassessment is required (Table 25.1). Caution is therefore advisable when administering opioids and anesthetic drugs, which have the potential to cause cardiovascular instability in the injured child with unrecognized and untreated shock.

Table 25.1

Normal values for physiological variables in children. Expected systolic blood pressure = 80 + (age in years × 2) mmHg

Age (years)

Heart rate (bpm)

Systolic blood pressure (mmHg)














The flexible skeleton of children allows them to withstand severe forces without incurring fractures. There may be few outward signs of injury when in fact there are severe internal injuries. Repeated reassessment of the child’s clinical condition is imperative.


Children possess robust compensatory mechanisms, so a high index of suspicion for serious injury should be maintained even when a child appears initially stable. Once clinical signs of injury become evident this is often at a late stage when cardiac arrest may be imminent.

25.1 Types of Injury

Injuries in children tend to follow set patterns according to age and gender. As children grow, they increase in size and their body proportions change. With age, muscle mass increases and the body is able to withstand the effects of blunt trauma better.

Falls and transport-related incidents are the leading overall causes of injury, followed by accidental poisoning and burns. In children under 5 years, suffocation, drowning and burn injuries are more prevalent, whilst intentional self-harm, suicide and assaults are an increasing problem in adolescents. The commonest traumatic injuries in children are falls and transport-related incidents, and children have the highest death rates of occupants in motor vehicles (Table 25.2). In pedestrian incidents, younger children hit by a car are more susceptible to thoracic and abdominal trauma than adolescents because of their low center of gravity, whilst older children are more likely to incur to limb injuries as their center of gravity is higher. Children are less visible to drivers, and driveway-reversing accidents are relatively common in pre-school age children. Head injuries cause the greatest mortality in children. Infants are particularly vulnerable as they have large heads with thin cranial bones, less head and neck control and incomplete myelination of brain tissue. Falls from a height, suffocation, drowning and burns are more likely to occur in children younger than 5 years. Two thirds of trauma related injuries occur in males, which may be related to a higher incidence of risk taking behavior.

Table 25.2

Causes of pediatric trauma

Causes of trauma

Transport related injuries




Accidental poisoning

Non-accidental injury




Pediatric trauma is different because:

Children have a smaller body size resulting in different patterns of injury.

Internal organs are less protected and more vulnerable to trauma.

There are anatomical differences e.g. airway, cervical spine.

They have a large body surface area and are more likely to lose heat and fluids.

Greater distribution of force is more likely to result in multi trauma than a single organ injury.

Increased metabolic rate and smaller functional residual capacity makes them more vulnerable to hypoxia.

Greater airway resistance and smaller airway diameter makes respiratory impairment more likely.

The large head in comparison to body makes head injuries more common.

Because they are able to increase systemic vascular resistance and heart rate to compensate for losses, children maintain their blood pressure until >30% blood volume is lost, causing sudden irreversible shock if not recognized early.

25.2 Initial Management

Advance preparation of drugs and equipment can be done if there is sufficient warning of an incoming trauma patient. Some centers use Broselow tapes to estimate the child’s weight and to determine drug doses and equipment sizes without any calculations (see Chap. 7, Sect. 7.​1.​4). The initial evaluation should identify life-threatening problems, using a primary survey followed by a secondary survey. The primary survey starts with assessment and control of the airway including cervical spine control followed by assessment of breathing and circulation. Appropriate life-saving interventions, such as endotracheal intubation, should be performed during the primary survey if indicated.

It is vital to uncover the child to ensure that a thorough secondary survey is performed and that no injuries are missed, but hypothermia from prolonged exposure must also be avoided. Infants have impaired thermoregulation and children have a larger surface area to body mass ratio so are more susceptible to heat loss than adults. Consider the use of warmed fluids, cling wrap, space blankets, forced air warmers and passive humidification of ventilator gases.


The important first steps during the initial management of the child with trauma are to establish a clear airway, give oxygen, immobilize the cervical spine, control any bleeding and immobilize any fractures to minimize blood loss.

25.2.1 Airway

Intubation is needed if there is airway obstruction, depressed conscious state or if the child is combative and unmanageable (Table 25.3). Children are more at risk than adults from edema of the upper airway caused by burns for example. A common problem is the use of an uncuffed endotracheal tube (ETT) that is too small and has an excessive leak preventing effective ventilation. Cuffed tubes are now more commonly used. When planning to intubate, it is important to prepare the appropriately sized equipment and to consider the choice of anesthetic agent that will be used to induce anesthesia. In the child with shock, ketamine may be preferable to propofol, or otherwise propofol in reduced doses. Suxamethonium is safe to use in children with head injuries and children with burns less than 24–48 h old.

Table 25.3

Indications for intubation and ventilation in pediatric trauma

Indications for intubation and ventilation in pediatric trauma

Airway obstruction unrelieved by simple airway maneuvers

Risk of aspiration due to loss of airway reflexes

Inadequate ventilation (e.g. secondary to chest trauma)


Control of ETCO2 in head injuries

Transfer of patient (e.g. CT scan, inter-hospital transfer)

Anticipated airway obstruction (e.g. burns)

25.2.2 Breathing

Chest trauma is usually caused by blunt trauma and there are usually associated injuries. Severe intra-thoracic injuries can occur without any obvious external signs on the chest. The main cause of cardiac arrest is respiratory failure. Children have a small respiratory reserve and may tire easily. Children who are tired will eventually have a decreased respiratory rate as a sign of an impending respiratory arrest. In children with chest trauma, respiratory compromise may be from direct injury to the chest wall or indirectly from shock or head injuries. Gastric distension may be caused by bag-mask ventilation and impedes ventilation, avoided by the insertion of gastric tubes to decompress the stomach early in resuscitation.

25.2.3 Circulation

Children have excellent compensatory mechanisms and will remain normotensive until they have lost 25–40% of their blood volume. Consequently, hypotension indicates severe blood loss. Tachycardia and peripheral vasoconstriction are earlier signs of hypovolemia—an important early sign is cool, clammy and mottled extremities (Table 25.4). The blood volume should be calculated early in resuscitation (Table 25.5). An algorithm for the initial management of hypovolemia is shown in Fig. 25.1.

Table 25.4

Hypotension is a late sign of hypovolemia in children due to their low resting sympathetic tone and excellent compensatory mechanisms

Signs of impending circulatory failure in children

Altered mentation (irritable, confused, combative, lethargic.)

Cool, clammy and mottled extremities

Prolonged capillary refill time >3 s

Poor urine output

Tachycardia or bradycardia

Poor pulse volume

Sunken fontanelle in children <1 year

Earlier signs of hypovolemia should be sought

Table 25.5

Normal blood volumes in children of different ages

Age group

Blood volume (mL/kg)

Preterm babies




Infants and children



Fig. 25.1

An algorithm for the initial management of hypovolemia in children


Blood pressure measurements are an unreliable indicator of shock in the pediatric patient. Children can compensate for 25–40% loss of their blood volume. Hypotension indicates severe blood loss.

Intravenous access in the arms or legs may be difficult, and an intraosseous needle inserted in the tibia if not fractured, should be considered early. The saphenous vein at the ankle is a vein that can be cannulated by landmarks alone—it is found just in front of the medial malleolus (there is a groove in the malleolus where the vein runs). Central venous access should only be performed by those skilled and familiar with the technique, but the femoral vein is a possible site for the occasional operator as it has a low risk of complications at the time of insertion (see Chap. 28, Sect. 28.​4).

Massive transfusion in children is defined as red cell transfusion of 50% of the total blood volume (TBV) in 3 h. Most hospitals now have a critical bleeding protocol to facilitate the supply of large amounts of blood products to a critically bleeding child. In time-critical situations, uncross matched O-negative blood or type-specific blood should be considered to avoid delay (see Chap. 5, Sect. 5.​8.​2). A fluid warmer is added to the IV fluid system as early as possible. As blood loss continues, coagulation is monitored with point of care devices such as ROTEM.

In a critical bleeding situation, tranexamic acid (TXA) should be administered early, with a loading dose of 15 mg/kg followed by an infusion of 2 mg/kg/h. Packed red blood cells are given at a dose of 10–20 mL/kg with cryoprecipitate at 5 mL/kg or human fibrinogen concentrate 70 mg/kg. Guided by laboratory tests, the patient may then require further packed red blood cells at a dose of 20 mL/kg with platelets at 10 mL/kg with or without fresh frozen plasma (FFP) 15 mL/kg (Table 25.6). It is important to consider the critical triad of massive blood loss—hypothermia, acidosis and coagulopathy. In addition, calcium gluconate 30 mg/kg may be required to treat hypocalcemia.
Nov 27, 2021 | Posted by in ANESTHESIA | Comments Off on and Burns

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