Introduction

Pediatric trauma is a leading cause of morbidity and mortality in children. Although the principles of the initial evaluation and management are the same as in adult patients, it is important to take into account the anatomic and physiologic differences, which may affect the clinical presentation, investigations, and management of the pediatric trauma patient.

Special Considerations

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  Children can lose up to 20–30% of blood volume without having significant change in their blood pressure because of their excellent ability to vasoconstrict. Thus it is important to pay close attention to subtle changes in heart rate, respiratory rate, and peripheral perfusion.

  
  
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  Children have a larger head to body ratio, and a shorter and weaker neck, putting them at risk for traumatic head and neck injury.

  
  
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  Children have decreased abdominal musculature making crucial organs like the liver, spleen, and kidney more susceptible to injury.

  
  
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  Children have a larger body surface area relative to their weight, making them prone to increased heat loss, resulting in increased metabolic demand.

Vital Signs

Primary Survey

Similar to adults, ATLS guidelines should be followed when assessing a pediatric trauma patient. Some special considerations for children should be kept in mind during the primary survey:

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  Very young children may need total body immobilization using commercially available devices for spinal protection and radiologic investigations during transportation and the initial evaluation.

  
  
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  One key difference in the management of the pediatric patient is the use of weight-based medications and size-specific tubes and catheters. A Broselow tape and color-coded pediatric resuscitation cart should be available to provide assistance and prevent errors. If the Broselow tape is not available, the formula for estimating weight in children up to 10 years of age is: 2 × age (years) + 8 = weight in kg (Figure 13.1, Figure 13.2 A,B).

Figure 13.1 Total body immobilization of a pediatric trauma patient. Note the Broselow tape alongside the patient.

Figure 13.2 A,B Pediatric Broselow tape and color-coded packs containing age-appropriate airway and resuscitation instruments and catheters.

Airway

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  Infants are nose breathers. Keep nares clear; use an orogastric tube rather than a nasogastric tube.

  
  
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  Children have a larger tongue and larger adenoids relative to the size of their oropharynx. The use of an oropharyngeal airway device should be considered as needed.

  
  
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  The epiglottis in pediatric patients is a narrow, floppy, and curved structure; thus the use of a straight Miller blade as opposed to a Macintosh (i.e., MAC) blade is preferred to help lift the epiglottis and expose the glottic opening.

  
  
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  The vocal cords are higher and more anterior than in adults.

  
  
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  Traditionally, an uncuffed endotracheal tube was recommended for pediatric patients; however, with new technology tubes, this is a recommendation no longer deemed necessary.

  
  
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  The pediatric trachea is shorter in length relative to the adult, and therefore there is an increased risk of right mainstem intubation or inadvertent tube dislodgement. Inserting the tube to a length three times (in cm), the endotracheal tube size can help prevent this complication (Figure 13.3).

  
  
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  Cricothyroidotomy should be avoided in children <6 years of age because of the high incidence of tracheal stenosis. In situations of inability to oxygenate or ventilate, a needle cricothyrotomy with jet ventilation is performed as opposed to a surgical cricothyrotomy.

Figure 13.3 Right mainstem intubation, with no ventilation of the left lung.

Breathing

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  In pediatric patients, the respiratory rate is age-dependent. Children have less chest wall musculature and are more reliant on their diaphragm. This puts children at risk of becoming fatigued more quickly than adults, and a decreasing respiratory rate may be indicative of impending respiratory failure.

  
  
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  For children who are not maintaining adequate ventilation, bag mask ventilation can provide temporary respiratory support. It is important to ensure that proper size and methods are used to reduce the risk of barotrauma. Most pediatric bag valve mask systems are now equipped with a “pop-off” valve to limit maximal pressure to 35–40 cm H₂O; however, adequate chest rise should be assessed with each breath (Figure 13.4).

  
  
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  Children have a smaller functional residual capacity and can quickly desaturate during intubation. Maximizing preoxygenation and using apneic oxygenation can help mitigate the risk of hypoxia.

Figure 13.4 Pediatric bag valve mask with a pop-off valve, which limits the maximal pressure to 35–40 cm H₂O.

Circulation

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  Pediatric patients have a circulation blood volume of approximately 80 ml/kg, thus even a small amount of blood loss can have a significant impact on perfusion. Sources of external bleeding should be controlled with direct pressure.

  
  
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  Children vasoconstrict much more than adults and can maintain “normal” blood pressure, despite significant blood loss of up to 30% of blood volume. However, they can decompensate very quickly and go into severe hypotension.

  
  
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  In severe trauma, two large-bore IVs should be placed. If access is urgent and difficult, intraosseous access should be obtained (see Chapter 17, Intraosseous Access).

  
  
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  Initial bolus crystalloid 20 ml/kg or blood 10 ml/kg.