Evaluation and Management of Pediatric Trauma


Algorithm: Pediatric trauma initial evaluation & resuscitation

Must-Know Essentials: Pediatric Trauma Evaluation and Management

Anatomical and Physiological Factors in Pediatric Trauma

  • 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.

Initial Evaluation and Resuscitation

  • 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.

Pediatric Vital Functions
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.

Airway: Special Considerations

  • 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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