A 3 year old boy was hit by a car as he ran out into the street to chase his soccer ball. When the paramedics arrived at the scene he was unconscious and had sustained multiple abrasions to his face, chest, abdomen and extremities. His right thigh was noticeably deformed and swollen. Because he demonstrated very shallow respirations, he was immediately intubated with in-line cervical spine immobilization. Two large bore IV lines where placed and he was then rushed to the trauma center.
Exam: VS T 37.0, P160, RR ventilated via the tracheal tube at 20, BP 100/80, oxygen saturation 97%. He is still unresponsive and being ventilated via the tracheal tube. His pupils are briskly reactive to light. There is excellent chest wall rise and fall via ventilation through the tracheal tube. There are numerous abrasions over his face, chest, abdomen and lower extremities. The abdomen is distended with decreased bowel sounds. His pelvis is stable, but his right thigh is obviously swollen and tense. Distal perfusion to all four extremities seems adequate. The remainder of his physical examination is unremarkable.
A CT scan of his head reveals a small occipital lobe contusion but no cerebral edema or hemorrhage. The CT scan of his abdomen reveals a small splenic laceration and a mild contusion of the left kidney. Chest and extremity radiographs reveal a displaced midshaft right femur fracture and a small left pulmonary contusion. His cervical spine and pelvic radiographs are normal. After appropriate stabilization interventions, he is admitted to the pediatric intensive care unit. His intracranial, pulmonary and splenic injuries are managed with supportive care and his femur fracture is reduced with open reduction and internal fixation. He is eventually discharged from the hospital approximately three weeks later, neurologically intact, and he is back to playing soccer a year later.
Each year there are approximately 1.5 million injuries sustained by children (1). Although the majority of these children recover uneventfully, the overall mortality rate of pediatric trauma is estimated at 1.5% (1). Each year, 250,000-500,000 children are hospitalized with various trauma-related injuries. Of these children who are hospitalized, 50,000-100,000 are left with some degree of permanent disability (1).
Blunt trauma accounts for approximately 87% of all childhood injuries, with penetrating trauma accounting for only 10% (2). Motor vehicle-related accidents are responsible for 40% of blunt pediatric trauma and are the leading cause of trauma-related fatalities in children (1). Injuries due to falls are the second most common etiology of blunt trauma in children.
Although children are susceptible to the same mechanisms of injury as their adult counterparts, a child's physiologic and psychologic responses to trauma are very unique. Thus a thorough understanding of some of the unique anatomic and pathophysiologic differences of children will enhance the quality of care that is provided during the evaluation, stabilization and management of the pediatric trauma patient.
One of the first very obvious physiologic differences between children and adults is the variation of normal pediatric vital signs based on the age of the child. A thorough understanding of pediatric vital signs is imperative in being able to detect very subtle abnormalities in a child's heart rate and respiratory rate. For example a subtle tachycardia may be the only clue to the possibility of early hemorrhagic shock in a child who otherwise looks stable. A subtle tachypnea may be the earliest clue to possible intra-thoracic injuries in a child with a normal room air oxygen saturation. Thus, anyone involved in the emergency care of children must be aware of normal vital signs based on a child's age. A simplified method to easily and quickly recall pediatric vital signs is as follows (3):
A summary of some of the key anatomic differences in children are as follows (1):
. . . . . a) Smaller body size.
. . . . . b) Larger head-to-body ratio.
. . . . . c) Greater body surface ratio.
. . . . . d) Shorter trachea and relatively larger tongue size.
. . . . . e) Glottic opening more anterior and superior.
. . . . . f) Less protective muscle and body fat.
. . . . . g) Abdominal organs more anterior.
. . . . . h) Growth plates of long bones are more susceptible to injury.
Because of a child's smaller body size, traumatic forces can be distributed over a larger surface area, thus making multisystem trauma the rule rather than the exception with childhood injuries (1). Children often times sustain internal injuries with minimal to no evidence of trauma on the external surface of their bodies. The internal organs of a child are more susceptible to traumatic forces because of their decreased amount of protective muscle and surrounding subcutaneous tissue mass. The spleen is the most commonly injured organ associated with blunt abdominal trauma. The increased flexibility and resilience of the pediatric skeleton and surrounding soft tissues also permits traumatic forces to be transmitted deeper into the internal structures. Thus as a general rule, internal injury cannot be ruled-out in a child merely based on the absence of external signs of trauma.
The larger head-to-body ratio of infants and young children makes them more susceptible to head injuries during falls. The larger head size also affects the fulcrum forces along the neck, making upper cervical spine injuries more common in infants and younger children as opposed adults who more commonly sustain injuries to their lower cervical spine. The larger head size as well as the increased body surface area in children make them more susceptible to greater heat loss and hypothermia when they are exposed during the trauma resuscitation.
The unique anatomic differences of the pediatric airway are critical to keep in mind when assessing and managing airway, breathing and ventilation in children. The shorter tracheal length, larger tongue size and the more anterior/superior location of the glottic opening are key points to remember when attempting intubation in children. Because the pediatric epiglottis is less cartilaginous, use of a straight laryngoscope blade may facilitate intubation rather than the curved blades.
Pediatric head trauma is associated with the highest degree of morbidity and mortality. Injuries to the chest and abdomen also account for a fair amount of disability and death. Hypoxia and hemorrhagic shock are the final common pathways involved in pediatric trauma-related fatalities. Thus very strict attention to the assessment of a child's airway, breathing and circulation (ABCs of resuscitation) will reduce the morbidity and mortality of pediatric trauma.
The assessment and management of trauma patients is divided into the primary survey and secondary survey. The "ABCDE" of the primary survey involves the assessment of the following components:
A=Airway (cervical spine immobilization).
C=Circulation (with hemorrhage control).
D=Disability (a brief neurologic examination assessing the level of consciousness and pupillary size/reactivity).
E=Exposure (total exposure of the patient to be able to assess the entire body for possible injuries).
The major components of the primary survey therefore involve the assessment, stabilization and management of all acute, life-threatening conditions such as airway compromise, respiratory distress and hemorrhagic shock. This portion of the ABCs of trauma resuscitation are basically the same as in other resuscitation scenarios with two major caveats. These two caveats involve the possibility of cervical spine injury and hemorrhagic shock. The proper sequence that should always be adhered to in any resuscitation can be remembered by the mnemonic "A-I-R" (1):
R=Reassessment after each intervention
During the assessment and management the airway of any trauma patient, one must always consider the possibility of a neck injury and maintain cervical spine immobilization. This is extremely important if you are considering endotracheal intubation, during which time the airway should never be opened using the head-tilt maneuver. The jaw-thrust maneuver to open the airway with in-line cervical spine immobilization is the safest method to intubate any child with a potential cervical spine injury.
When assessing breathing and ventilation, always consider traumatic etiologies that could potentially compromise the child's ventilation and breathing such as open chest wounds, pneumothorax, hemothorax, rib fractures, flail chest and pulmonary contusions. Some of these traumatic etiologies may require immediate interventions such as needle thoracentesis and/or placement of a chest tube during the primary survey. Gastric distention which is also very common in pediatric trauma patients, can also compromise ventilatory efforts secondary to upward displacement of the diaphragm. Thus an orogastric tube may be helpful to decompress the stomach and thereby facilitate ventilatory efforts.
The most common etiology of shock in the pediatric trauma patient is hemorrhagic shock, although concomitant cardiogenic (e.g., cardiac tamponade), obstructive (e.g., tension pneumothorax) and neurogenic (e.g., spinal shock) may also exist. The increased reserve of a child's cardiovascular system allows children to compensate and maintain normal blood pressures despite even moderate degrees of hemorrhagic shock. Children will maintain a normal systolic blood pressure for age until they have lost up to 30% of their circulating blood volume (4). The circulating blood volume of a child is 70-80 ml/kg as compared to the typical adult circulating blood volume of 60 ml/kg. A normal systolic blood pressure for a child can be calculated via the formula: (Age X 2) + 90 mmHg. The corresponding expected diastolic blood pressure should be 2/3 X (SBP). The initial compensatory mechanism that one should look for during the early stages of hemorrhagic shock is tachycardia. The other compensatory mechanism that occurs to maintain normal perfusion and blood pressure is an increase in the systemic vascular resistance, which is manifested clinically by mottled/cool extremities, weak/thready distal pulses, delayed capillary refill time and a narrowed pulse pressure. If the early clinical signs of hemorrhagic shock are not identified and corrected, the child may progress to a preterminal stage of decompensated shock, which is defined as hypotension for age. Hypotension (systolic) in any aged child is defined via the formula: (Age X 2) + 70 mmHg. Thus a 5 year old child who presents with an initial systolic blood pressure less than or equal to 80 mmHg is already in the phase of decompensated shock and clinical has loss at least 30% of his circulating blood volume. The minimum systolic blood pressures for age are:
a) Newborns to 1 month old: >60 mmHg
b) 1 month old-1 year old: >70 mmHg
c) > 1 years old: (Age X 2) + 70 mmHg
The keys to the treatment of hemorrhagic shock in the pediatric trauma patient includes recognition of the early signs of shock, controlling any external sites/sources of hemorrhage, rapid fluid resuscitation to restore the circulating blood volume, early consideration of blood replacement therapy and an early involvement of the surgical team. Rapid fluid boluses are administered as 20 ml/kg of warmed crystalloid solutions (i.e., normal saline or lactated Ringer's solution are the only two acceptable solutions to use during fluid resuscitation). It is imperative to reassess the child's perfusion parameters after each fluid bolus in order to determine if additional fluid boluses will be required. If more than 40-60 ml/kg of crystalloid solution is required to restore adequate perfusion, blood replacement must then be considered. Blood replacement can be administered as either 10 ml/kg of warmed packed red blood cells (either crossmatched, type-specific or O-negative PRBCs, depending on how much time is available) or as 20 ml/kg of whole blood (not routinely available nowadays). Children who require blood replacement therapy may need surgical interventions to control the ongoing hemorrhage. Injuries that have the potential for extensive hemorrhaging include intra-abdominal and intra-thoracic injuries, pelvic fractures and femur fractures. As a general rule, it is taught that intracranial bleeds in themselves do not result in hypovolemic/hemorrhagic shock. The one exception to this rule involves head trauma in infants. Because the suture lines of an infant's skull are not yet fused, the skull has the capability to expand and accommodate large volumes of blood during acute intracranial hemorrhage.
If there is any difficulty in establishing intravenous access for fluid resuscitation and/or the administration of blood products, intraosseous (IO) lines should always be considered. IO line placement can be inserted just as quickly or even faster than venous cutdowns or central line placement. Although the previous Pediatric Advanced Life Support guidelines only allowed for IO line placement in children under 6 years of age, the current guidelines now have no age limitation for the use of IO lines in children. Although the ideal site for IO line placement in children is the proximal, medial aspect of the tibia (2-3 cm below the tibial tuberosity), an alternative site is the distal anterior aspect of the femur (2-3 cm proximal to the superior edge of the patella). Another alternative site in older children and adults is the distal tibia (2-3 cm proximal to the medial malleolus). The only clinical contraindications for placement of an IO line in a child's leg during trauma resuscitation would include: a) a suspected fracture of the underlying bone in which the IO line is placed, and/or b) a suspected traumatic disruption of the venous return proximal to the site of IO insertion.
The secondary survey begins with a reassessment of the life-threatening problems addressed during the primary survey and is then followed by a complete head-to-toe physical examination to assess and manage any non-life threatening injuries that were not identified during the primary survey. The assessment and management of specific head, neck, thoracic, abdominal, pelvic and extremity injuries is beyond the scope of this text. However a high clinical index of suspicion based on the mechanism of injury should always guide one's assessment and management. Although a more detailed assessment of child abuse is presented in another chapter of this textbook, the possibility of nonaccidental trauma (i.e., child abuse) should always be considered under certain circumstances (4): a) A discrepancy between the history that is presented by the caregivers and the actual physical examination findings. b) Injuries that are incompatible with a infant's neurodevelopmental capabilities. c) A delay in seeking medical advice/treatment for what appears to be a serious injury. d) Findings of multiple injuries at various chronological stages. e) Bites marks, cigarette burns or rope/cord marks. f) Burns with sharply demarcated margins. g) Genital or perianal trauma (including burns to these areas). h) Multiple subdural hematomas. i) Retinal hemorrhages. j) Rib fractures involving multiple ribs and/or at various chronological stages.
Successful resuscitation of the pediatric trauma victim involves more than just a systematic approach to the primary and secondary surveys. It also depends upon a thorough understanding of the unique anatomic and pathophysiologic differences in children. By keeping these unique differences in mind, trauma teams will be able to decrease the morbidity and mortality of pediatric trauma by providing more efficient and appropriate care for the injured child.
1. The first priority in the resuscitation phase of any pediatric trauma patient is:
. . . . . a. To immediately establish vascular access.
. . . . . b. To establish and maintain patency of the airway while maintaining cervical spine immobilization.
. . . . . c. To obtain immediate x-rays and laboratory studies in order to ascertain the patient's overall status.
. . . . . d. To alleviate any pain with intravenous analgesics in order to facilitate a more reliable physical examination.
2. The leading cause of death in children >1 year of age is:
. . . . . a. Sudden infant death syndrome.
. . . . . b. Lethal cardiac dysrhythmias.
. . . . . c. Meningitis.
. . . . . d. Trauma.
. . . . . e. Leukemia.
3. The most common etiology of shock in the pediatric trauma patient is:
. . . . . a. Neurogenic shock.
. . . . . b. Cardiogenic shock.
. . . . . c. Anaphylactic shock.
. . . . . d. Hypovolemic shock.
. . . . . e. Tension pneumothorax.
4. The main goal of the primary survey of trauma resuscitation includes:
. . . . . a. Obtaining STAT portable radiographs of the neck, chest and abdomen.
. . . . . b. Assessment and stabilization of the child's airway, breathing and circulation.
. . . . . c. Obtaining immediate vascular access with a central line.
. . . . . d. Performing immediate endotracheal intubation to prevent aspiration.
. . . . . e. A trauma surgeon must be present to perform the primary survey.
5. All of the following statements regarding pediatric trauma are true except:
. . . . . a. The majority of pediatric trauma-related fatalities are due to motor vehicle related accidents.
. . . . . b. The majority of trauma that occurs in children is due to blunt trauma rather than penetrating trauma.
. . . . . c. Cervical spine trauma is more common than abdominal trauma.
. . . . . d. Multisystem trauma is common in children who sustain motor vehicle related accidents.
6. The abdominal organ that is most commonly injured in children is the:
. . . . . a. Duodenum.
. . . . . b. Pancreas.
. . . . . c. Liver.
. . . . . d. Kidneys.
. . . . . e. Spleen.
7. What area of the body is associated with the greatest frequency of serious injuries in children?
. . . . . a. Head.
. . . . . b. Neck.
. . . . . c. Chest.
. . . . . d. Abdomen.
8. Which of the following scenarios would be most suspicious for possible child abuse?
. . . . . a. A 2 year old who presents with a tibial fracture after reportedly falling down a few steps.
. . . . . b. A 1 year old who presents with a forehead hematoma after reportedly falling out of a stroller.
. . . . . c. A 3 month old who presents with a nondisplaced femur fracture after reportedly rolling off the changing table.
. . . . . d. A 3 year old who presents with a spiral fracture of the tibia after reportedly getting his leg twisted while falling off a tricycle.
Yamamoto LG. Multiple Trauma in a 2-Year Old. In: Yamamoto LG, Inaba AS, DiMauro R (eds). Radiology Cases In Pediatric Emergency Medicine, 2002, volume 7, case 8. Available online at: www.hawaii.edu/medicine/pediatrics/pemxray/v7c08.html
1. Inaba AS, Seward PN. An approach to pediatric trauma: Unique anatomic and pathophysiologic aspects of the pediatric patient. Emerg Med Clin North Am 1991;9(3):523-548.
2. Pediatric Trauma. In: American College of Emergency Physicians and American Academy of Pediatrics. Advanced Pediatric Life Support Instructor Manual. 1998, Dallas: ACEP, pp. 75-87.
3. Inaba AS. A simple way to remember pediatric vital signs. Contemp Pediatr 2002;19(1):16.
4. American College of Surgeons. Chapter 10-Pediatric Trauma. In: Advanced Trauma Life Support Instructor Course Manual, Sixth Edition. 1997, Chicago: First Impression, pp. 353-375.
Answers to questions
1.b, 2.d, 3.d, 4.b, 5.c, 6.e, 7.a, 8.c