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Trauma is the leading cause of death among children >1 years of age.
Small body size
Multiple injuries can result from a single impact due to the proximity of multiple organs and the wide transmission of energy.
Small blood volume
Hemorrhagic shock can result even from small blood loss.
Large surface-area-to-body-mass ratio
High risk of hypothermia due to larger heat loss
High risk of hypovolemia due to larger insensible fluid loss
Higher caloric requirement
Cartilaginous skeleton, less fat, and more elastic connective tissue
Severe pulmonary injury can result without any rib fracture.
Severe brain injury can result without skull fracture.
There is less risk of extremities fractures.
Larger solid organs with thin abdominal wall with less subcutaneous fat predisposes to the following:
Liver injury
Spleen injury
High risk of head injury is due to the proportionately larger size of the head.
Follows the same algorithm as in adults, which includes the following:
Airway
Cervical spine protection
Breathing
Circulation
Disability
Exposure
Leading causes of cardiopulmonary arrest in children
Lack of airway resulting in hypoxia and hypoventilation
Tension pneumothorax
Hypovolemia
Cardiac tamponade
Cardiac contusion
Severe head injury
Cervical spinal cord injury
Hypothermia
Hypotension is a sign of significant blood loss.
The Broselow Pediatric Emergency Tape is an essential adjunct in pediatric resuscitation. It provides weight- and length-based information on the following:
Medication dose
Fluid volume
Equipment size
Pediatric vital functions depend on age and weight, as shown in the illustration.
Vital Functions | Infant (0–12 months) | Toddler (1–2 years) | Preschool age (3–5 years) | School age (6–12 years) | Adolescent >13 years |
---|---|---|---|---|---|
Weight Range (kg) |
0–10 | 10–14 | 14–18 | 18–36 | 36–70 |
Heart Rate (beats/min) | >160 | <150 | <140 | <120 | <100 |
Blood pressure (mm Hg) |
>60 | >70 | >75 | >80 | >90 |
Respiratory rate (breaths/min) |
<60 | <40 | <35 | <30 | <30 |
Urine output (mL/kg/hour) |
2.0 | 1.5 | 1.0 | 1.0 | 0.5 |
Imaging in children
Potential risk of radiation-induced malignancy should be considered when evaluating with computerized tomography scan (CT).
Radiation must be kept as low as reasonably possible.
Selective CT is recommended to reduce radiation exposure.
Plain films are the initial imaging of choice.
High risk of airway obstruction
Smaller diameter of airway
Large occiput causing flexion of the neck
Larger tongue
Funnel-shaped larynx in children <8 years of age: High risk of aspiration as secretions accumulate in the retropharyngeal area.
Characteristics of respiratory distress
Tachypnea
Nasal flaring
Use of accessory muscles
Inspiratory retractions (suprasternal, substernal, and intercostal)
Oropharyngeal airway
Should be inserted only in unconscious children because the intact gag reflex can result in vomiting and aspiration.
Correct size of the tube
Flange at the level of incisors and distal end at the angle of the mandible
Insertion technique
Gently and directly into the oropharynx
A tongue blade to depress the tongue may be helpful.
Inserting the airway backward and rotating it to 180 degrees, as in adults, is not recommended due to risk of injury to soft-tissue structures.
Nasopharyngeal airway
Correct size
Diameter of the patient’s little finger
Insertion depth
Nose to the tragus of the ear
Indications for definitive airways
Respiratory failure or arrest
Airway obstruction
Potential of airway obstruction
Severe brain injury (Glasgow Coma Scale [GCS] 8 or less)
Intrathoracic injury
Severe or multiple injuries
Shock
Types of definitive airways
Endotracheal tube
Surgical airway
Needle cricothyroidotomy
Open cricothyroidotomy
Rescue airway
Laryngeal mask airway (LMA)
Intubating LMA
Endotracheal intubation
Considerations during intubation
Larger tongue and tonsils may occlude visibility of the airway during intubation.
There is risk of injury with bleeding to the prominent nasopharyngeal adenoids.
The larynx is placed anteriorly and higher at the level of C2-C3 in young children and at the level of C6-C7 in older children and adults.
A very narrow airway at the level of the cricoid ring may make intubation difficult.
The epiglottis is floppy, narrow, and angled posteriorly.
A straight-bladed laryngoscope should be used during intubation in smaller children.
A short trachea may result in intubation in the right mainstem bronchus causing the following:
Inadequate ventilation
Hypoxia
Barotrauma
Steps of drug-assisted/rapid sequence (orotracheal) intubation (RSI)
Evaluation for difficult intubation
Examination of the mouth
Examination of the neck for range of movement
Examination for any loose teeth
Selection of the endotracheal tube (ETT)
Cuffed ETTs
Diameter of the ETT
Approximate diameter of the ETT should correspond to the diameter of the child’s external nares or the tip of the little finger.
ETT diameter: Age/4 + 4 or Age + 16/4
Preoxygenation
100% oxygen using face mask for 3 minutes
Displaces nitrogen from the lungs and replaces it with oxygen
An increased amount of oxygen in the lung during intubation prevents apneic hypoxia during the procedure.
Medications
Atropine
0.1–0.5 mg in children <1 year
Infants have a pronounced vagal response to endotracheal intubation, more so than do children and adults.
Helps prevent bradycardia due to direct laryngeal stimulation
Not required for children >1 year of age
Sedation
Hypovolemic: etomidate 0.1 mg/kg or midazolam 0.1 mg/kg
Normovolemic: etomidate 0.3 mg/kg or midazolam 0.1 mg/kg
Paralytics
Succinylcholine: <10 kg weight: 2 mg/kg, >10 kg weight: 1 mg/kg or
Vecuronium: 0.1 mg/kg or
Rocuronium: 0.6 mg/kg
Intubation
May be performed using a video laryngoscope or a regular laryngoscope
Straight laryngoscope blade is preferred in smaller children.
In-line stabilization of the neck
Cricoid pressure (Sellick maneuver)
Compression of the esophagus between the cricoid cartilage and the vertebral body to prevent regurgitation of stomach content into the oropharynx
Also helps by moving the larynx during intubation
Position of the ETT
Depth (in cm) of the ETT from the level of the gum: approximately the size of the tube × 3. For example, a size 4.0 ETT should be positioned 12 cm from the gums.
Confirmation of the ETT position
Auscultation
Presence of bilateral breath sounds
Absence of breath sound over the epigastrium (stomach)
Capnography
Sensitive and specific to detect ETT placement
Colorimetric end-tidal carbon dioxide detector
Color change from purple to yellow
Chest x-ray
Secure the tube in position
Because of the short trachea, any movement of the head can result in displacement of the ETT leading to the following:
Inadvertent extubation
Right mainstem bronchial intubation
Surgical airways
Indications
Failed endotracheal intubation
Needle cricothyroidotomy
Steps
Cricothyroid membrane is punctured with a large IV catheter with needle.
Puncture is confirmed with aspiration of air in the syringe.
Needle is withdrawn and catheter is advanced in the trachea.
Cannula is connected to the high-pressure oxygen source (needle-jet insufflation).
It does not provide adequate ventilation and leads to progressive hypercarbia.
Open cricothyroidotomy
Rarely indicated for infants or small children
Can be performed in older children (>12 years of age) where cricothyroid membrane is easily palpable
Recue airway
Used for failed ETT
Performed with:
laryngeal mask airway LMA.
intubating LMA.
Selection of LMA sizeSize of LMA in Children
LMA Size | Patient’s Weight |
---|---|
1 | 0–5 kg |
1.5 | 5–10 kg |
2 | 10–20 kg |
2.5 | 20–30 kg |
3 | 30–50 kg |
4 | 50–70 kg |
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