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Pediatric Trauma


Key Concepts

  • Trauma is the leading cause of death in children in the United States.

  • Avoid hypoxia and hypotension by early administration of oxygen and assisted ventilation, and fluid resuscitation with crystalloid at 20 mL/kg increments. Initiate transfusion of 10 mL/kg of packed red blood cells (pRBCs) if hypotensive or signs of hypovolemic shock after 40 mL/kg of crystalloid is infused.

  • Key pediatric anatomic and physiologic differences include:

    • Children are smaller, so bodily force is more widely distributed, making multi-system injuries more likely.

    • The infant’s head-to-body ratio is greater, creating a relatively higher center of gravity. This, combined with a less myelinated brain and thinner cranial bones, predisposes infants to more serious head injury.

    • Children have a higher anatomic fulcrum in the cervical spine (C2 to C3 in children <8 years old), resulting in higher cervical spine injuries.

    • Children have greater laxity of the cervical column ligaments, leading to a greater risk of spinal cord injury without radiographic abnormalities (SCIWORA).

    • Children have more horizontally positioned ribs, resulting in a more upward movement during inspiration; this leads to a limited ability to increase tidal volume and risk for respiratory failure with chest or diaphragmatic injury.

    • Children have more elastic ribs, allowing for pulmonary injury without skeletal injury.

    • Children have thinner abdominal walls and a more anterior location of the liver and spleen; this results in a greater chance of injury to those organs.

    • Despite large intravascular volume loss, children are able to substantially increase their systemic vascular resistance to remain normotensive; hypotension is a very late sign.

  • Most minor head trauma may be managed with observation and without computed tomography (CT) imaging. When applied, clinical decision rules may reduce imaging and radiation exposure.

  • In major trauma patients, indications for intubation include respiratory failure or a Glasgow Coma Scale ≤8.

  • The diagnostic test of choice for the evaluation of intra-abdominal injury in a stable patient with high suspicion for injury is abdominal CT.

  • Solid organ injuries are generally treated nonoperatively in children.

Foundations

Injury is the leading cause of death among children 1 to 18 years of age in the United States, accounting for over 10,000 deaths and 9 million annual emergency department (ED) visits. Motor vehicle collisions (MVCs) account for more than half of all pediatric trauma deaths, whereas nonfatal injuries are primarily due to unintentional falls. Mechanisms of injury vary by patient age, and certain mechanisms result in specific injury patterns (e.g., sports and concussions). Blunt mechanisms account for over 95% of childhood injuries. The trauma history, as well as the initial response, determine injury risk and response required. Criteria for trauma center transport (primary triage) and trauma team activation (secondary triage) are primarily based on expert consensus and an area ripe for further research. Although the examination of the injured patient is standardized, diagnostic testing should be tailored to avoid unnecessary testing while assessing for important injuries.

Anatomy and Physiology

Children have distinct anatomy and unique physiology that impact their evaluation and management ( Box 160.1 ). Force is more widely distributed throughout the child’s body, making multi-system injuries more likely in children. The younger a patient is, the higher their surface area to weight ratio, resulting in a greater potential for heat loss. As injured patients are at increased risk of hypothermia, this is especially true in children.

BOX 160.1
Important Anatomic Differences in Adults and Children: Implications for Pediatric Trauma Management
SCIWORA , Spinal cord injury without obvious radiographic abnormality.

  • The child’s head-to-body ratio is greater, the brain is less myelinated, and cranial bones are thinner, resulting in more serious head injuries.

  • The child’s internal organs are more susceptible to injury based on more anterior placement of the liver and spleen, and less protective musculature and subcutaneous tissue mass.

  • The child’s kidney is less well protected and more mobile, making it susceptible to deceleration injury.

  • The elasticity of the child’s chest wall allows for pulmonary injury without rib fracture.

  • Children have a more tenuous spinal cord blood supply and a greater elasticity of the vertebral column, predisposing them to unique spinal cord injuries including SCIWORA.

Normal ranges for pediatric vital signs vary greatly and should be readily available in the ED ( Chapter 155 ). A child’s physiologic response to injury is different from the adult’s, depending on the age and maturation of the child and severity of the injury. Children have a high capacity to maintain blood pressure despite significant hemorrhage; hypotension is a late finding with blood loss exceeding 30% of total blood volume. The younger the child is, the less their ability to increase cardiac contractility. Thus, a young child’s cardiac output is primarily determined by heart rate and systematic vascular resistance. Compensated shock should be considered and promptly addressed when a child is tachycardic, especially if capillary refill is delayed. Changes in heart rate, blood pressure and extremity perfusion commonly precede cardiorespiratory failure and should prompt resuscitation.

Clinical Features

Initial Assessment and Primary Survey

Most children evaluated in the ED are minimally injured and require limited diagnostic evaluation after the standard history and physical evaluation. In those with major trauma, cardiac and pulse oximetry monitoring, supplemental oxygen, frequent vital sign measurements, intravenous (IV) access, and laboratory testing are often needed. Immediately after prehospital notification, preparation should include assigning team member functions, preparing necessary equipment, and donning protective clothing. Color-coded length-based tape measures are often used to provide initial estimates of patient weight, equipment size and medication dosages, but important equipment sizes are in Box 160.2 .

BOX 160.2
Specific Equipment Size Estimates for Pediatric Trauma

Endotracheal Tube (ETT) Size Estimates (Sizing in Millimeters Internal Diameter) and Depth

  • Endotracheal (cuffed) tube size (mm) = (Age in years/4) + 3.5

  • An ETT 0.5 mm larger and 0.5 mm smaller than the calculated size should also be ready at the bedside

  • ETT tube depth = tube size × 3

Chest Tube Size (Diameter) = 4 × the ETT Size

Orogastric, Nasogastric, or Foley Size (Diameter) = 2 × ETT Size

The initial trauma assessment is designed to rapidly identify and treat life- or limb-threatening injuries. Treatment of these injuries precedes the continuation of the evaluation. The initial assessment and resuscitation occur simultaneously over the initial 5 to 10 minutes of care. Similar to adults, the elements of the primary survey for children are remembered as A, B, C, D, E, and F. Patient deterioration warrants repeat of the primary survey to identify the cause and institute treatment.

A—Airway and Cervical Spine Stabilization

Children have important anatomic considerations that impact the management of the pediatric airway ( Chapter 156 ). The patient is initially evaluated for possible airway obstruction or inability to maintain their airway. Gurgling or stridor may indicate upper airway obstruction. Maxillofacial trauma, blood, swelling, or vomitus may also obstruct the airway, and efforts are made toward clearing the oropharynx of debris. Initial attempts to open the airway include a jaw-thrust maneuver. If an open airway cannot be established and maintained by noninvasive means, endotracheal intubation (ETI) should be performed. Unless the neck has been cleared of injury, cervical spine immobilization should be maintained with in-line immobilization when airway maneuvers are performed.

Indications for ETI in a pediatric trauma patient include (1) inability to ventilate with bag-mask ventilation (BMV) or the need for prolonged airway control, (2) Glasgow Coma Scale (GCS) score ≤8, (3) respiratory failure from hypoxemia or hypoventilation, and (4) worsening decompensated shock resistant to initial fluid resuscitation. Rapid sequence intubation is the preferred method for ETI in severely injured children, and includes both sedative medications (e.g., ketamine or etomidate) and paralytic medications (e.g., succinylcholine or rocuronium), see Chapter 156 . Although unlikely to do harm, premedication with fentanyl or lidocaine to blunt the rise of intracranial pressure (ICP) is not evidence-based, and we do not recommend its use for this purpose.

B—Breathing and Ventilation

Breath sounds and adequacy of chest rise should be assessed. Adequate ventilation is dependent upon airway patency and sufficient air exchange. Pulse oximetry measures the adequacy of oxygenation, but not ventilation. Continuous end-tidal carbon dioxide capnography better informs ventilatory status but should be interpreted in conjunction with the respiratory wave form. For example, a child with a low capnography reading could either be taking slow shallow breaths (e.g., hypoventilation), or may be breathing deeply and rapidly (e.g., hyperventilation). Many factors may compromise ventilatory function in an injured child, including depressed sensorium, airway obstruction, painful respirations, diaphragmatic fatigue, and direct pulmonary injury.

In a young child, chest rise occurs in the lower chest and upper abdomen, and both should move concordantly. Discordant motion or paradoxical breathing is a sign of impending respiratory failure. Respiratory rates that are very fast or very slow may indicate impending respiratory failure; tachypnea may also be due to shock or inadequate pain control. If assisted ventilation is necessary, BMV should be initiated with only the volume necessary to cause the chest to rise. In addition to a potential increased risk of vomiting and aspiration, excessive bagging volumes (i.e., hyperventilation) can lead to gastric distension ( Fig. 160.1 ). As the stomach distends, the diaphragm can push into the thoracic cavity, causing increased intrathoracic pressures, decreased venous return, and hypotension. Gastric decompression may be performed with either an orogastric tube or nasogastric tube (if no evidence of facial trauma).

Fig. 160.1, CT (Scout) Demonstrating Gastric Distention in a Child Having Swallowed Large Amounts of Air from Crying. Severe Gastric Distention Can Harm Diaphragmatic Excursion and Impact Ventilation.

C—Circulation and Hemorrhage Control

Shock occurs when the body is unable to maintain adequate tissue perfusion. Normal systolic blood pressure does not exclude shock. The pediatric vasculature maintains normal blood pressure by constricting peripheral arteries and progressively increasing systemic vascular resistance. Signs of poor perfusion (cool distal extremities, decreased peripheral pulse quality, and delayed capillary refill) are signs of pediatric shock, even when blood pressure is normal ( Box 160.3 ). External hemorrhage should be sought and controlled with direct pressure. IV access should be established and blood collected for laboratory testing (see following).

BOX 160.3
Circulation Assessment and Treatment in Critical Pediatric Trauma Patients
IV, Intravenous; pRBC, packed red blood cells.

Assessment

  • Tachycardia, delayed capillary refill, decreased peripheral pulses, tachypnea or bradypnea, and altered sensorium may indicate volume loss prior to hypotension.

  • Vital signs, monitored every 5 min during the initial assessment.

  • Continuous oximeter and cardiac monitor.

Treatment and Interventions for Hypovolemic Shock from Trauma

  • Place two large-bore IV lines (above and below diaphragm if indicated).

  • Intraosseous line placement if peripheral venous access is difficult.

  • Bolus with 20 mL/kg of warm normal saline/lactated Ringers and repeat if necessary.

  • Consider intubation and ventilation to decrease work of breathing.

  • Transfuse 10 mL/kg pRBC for hemorrhagic shock secondary refractory to crystalloid.

Vascular access is best obtained by placing two large-bore IV lines, ideally in the upper extremities (lower extremity sites may be used if needed). If obtaining vascular access is unsuccessful or delayed in the critically injured patient, intraosseous (IO) access is a safe, quick, and reliable procedure to access the vascular space and is recommended prior to attempting a central line. The preferred site for IO placement is the proximal medial tibia, just below (and directed slightly away from) the growth plate; other potential locations include the proximal humerus, the flat area of the anterior distal femur, or the distal tibia. Once IO access is obtained, it should be stabilized and secured. More than one IO needle may need to be placed (in separate bones); IV access may be easier after initial fluid resuscitation and vascular volume expansion. IO placement in a fractured extremity is contraindicated. Medications and blood products can be administered through an IO line similar to an IV. Central line placement in young children is difficult, with frequent complications, and should be avoided if possible. If absolutely necessary, ultrasound-guided femoral line placement is our preferred initial option. Much less commonly used vascular access techniques include a venous cut-down, or a central line into the intrajugular, supraclavicular, or subclavian vein. Venous cutdown is a skill not often performed and is rarely needed to obtain vascular access in the pediatric trauma patient. If performed, the greater saphenous vein at the ankle is the preferred site. In the rare occasion that a neonate presents after trauma, an umbilical vein cannulation can be attempted in infants up to 10 days old if there is enough of an umbilical stump to perform the procedure.

Fluid resuscitation in pediatric trauma patients begins with a 20 mL/kg bolus of warm isotonic crystalloid solution over 10 minutes. A second bolus of 20 mL/kg of warm isotonic crystalloid is given for those who do not initially improve or stabilize. If the patient continues to require fluid resuscitation after two boluses, warmed, packed red blood cells (pRBCs) at 10 mL/kg should be transfused, while identifying and treating any sources of hemorrhage. In cases of massive transfusion (blood products >40 mL/kg in an adolescent or >50 mL/kg in a child/infant), it is important to add plasma and platelets to correct coagulopathy. Adult patients undergoing massive transfusion are resuscitated with plasma, platelets, and pRBCs in a 1:1:1 ratio. Less data exists for this strategy in the pediatric trauma population as data is conflicting, , although many centers now resuscitate children with a 1:1 plasma: pRBC ratio. In adult patients with significant traumatic hemorrhage, tranexamic acid is now routinely used to stabilize clot and limit blood loss. Although frequently used in non-traumatic pediatric surgery, use of tranexamic acid in injured children is rare. The dosage in injured children (15 mg/kg over 20 minutes, then 2 mg/kg/h for 8 hours or 30 mg/kg over 20 minutes, then 4 mg/kg/h for 8 hours) is currently under study.

D—Disability Assessment

A rapid neurologic and mental status evaluation is performed to assess neurologic status. The assessment of disability in pediatric trauma patients is described in Box 160.4 . The alert, verbal, painful, unresponsive (AVPU) system and the GCS ( Table 160.1 ) are utilized to assess neurologic status. The modified pediatrics GCS (used in pre-verbal children) performs similarly to the standard GCS in older children (see Table 160.1 ). Children’s higher metabolic demands result in higher oxygen consumption and glucose utilization; a rapid bedside glucose level should be checked in any child with altered mental status after trauma.

BOX 160.4
Disability: Neurologic Assessment and Treatment
AVPU, Alert, verbal, painful, unresponsive; CPP, cerebral perfusion pressure; CT, computed tomography; ETI , endotracheal intubation; GCS, Glasgow Coma Scale; IV , intravenous; Pco 2 , partial pressure of carbon dioxide, RSI, rapid sequence induction.

Assessment

  • Level of consciousness: Use AVPU scale and age-appropriate GCS

  • Pupil size and reactivity

  • Movement in all extremities and tone

  • Posturing and reflexes

Treatment and Interventions

  • Stabilize spinal column with spinal immobilization techniques.

  • Rapid Sequence intubation for GCS scores ≤8

  • Cranial CT scan all with GCS scores less than 15 and neurosurgical consultation as needed.

  • With signs of herniation, elevate head of the bed and 3% hypertonic saline 2–5 mL/kg IV (or mannitol 0.5–1.0 g/kg IV).

  • Maintain CPP of at least 40 mm Hg in children.

TABLE 160.1
Glasgow Coma Scale Score and Modified Pediatric Glasgow Coma Scale (For Those <2 Years)
Best Eye Opening Response
Score >2 Years Old <2 Years Old
4 Spontaneous Spontaneous
3 To verbal command To voice
2 To pain To pain
1 None None

Best Motor Response
Score >2 Years Old <2 Years Old
6 Follows commands Spontaneous movement
5 Localizes pain Withdraws to touch
4 Withdraws to pain Withdraws to pain
3 Abnormal flexion to pain (decorticate) Abnormal flexion to pain (decorticate)
2 Abnormal extension to pain (decerebrate) Abnormal extension to pain (decerebrate)
1 None None

Best Verbal Response
Score >2 Years Old <2 Years Old
5 Oriented and converses Coos/babbles
4 Confused conversation Irritable/cries
3 Inappropriate words Cries to pain
2 Incomprehensible sounds Moans
1 None None

a Total score key for traumatic brain injury: severe, ≤8; moderate, 9 to 12; mild, 13 to 15.

E—Exposure and Environment

Trauma patients should have each body area fully exposed for evaluation; preverbal children are particularly high risk for missed injuries. However, children are often embarrassed or shy about physical exposure. In the stable patient, body areas can be examined in sections, keeping other parts covered from view. Compared to adults, children are also more susceptible to insensible heat and fluid loss due to their greater surface to mass ratios and should be kept normothermic, as hypothermia increases morbidity and mortality. Hypothermia contributes to metabolic acidemia and has direct adverse effects on cardiac inotropy, chronotropy, catecholamine responsiveness, platelet function, and both renal and hepatic drug clearance.

Interventions to maintain normothermia include increasing ambient temperature, administering warmed humidified oxygen, and warming all infused fluids, especially all blood products. Head wraps and convective warmers or radiant heat sources are adjuncts in newborns and infants, as well as older children with mild hypothermia (temperature <36°C). The exposure phase of the survey is often the appropriate time to concurrently begin initial imaging and further diagnostic testing (see following).

F—Family

We recommend the option of family members present during the initial resuscitations, a practice often preferred by families in both traumatic and non-traumatic pediatric resuscitations. A social worker or other qualified staff member dedicated to the family should be available to help explain treatments, answer questions, and provide emotional support.

Secondary Survey

A systematic secondary survey should follow the primary survey and necessary interventions, and should consist of an organized, complete head to toe assessment to detect additional injuries. Significant historical findings are collected at this time and can be remembered by the mnemonic AMPLE ( Box 160.5 ). Key points of the ongoing assessment of the patient, after the secondary assessment, are summarized in Box 160.6 . If patient instability prohibits completion of the secondary survey, this should be communicated to the next caregivers. Tertiary surveys are now completed on all trauma patients within 24 hours of admission.

BOX 160.5
Ample History

  • A—A llergies

  • M—M edications

  • P—P ast medical history

  • L—L ast meal

  • E—E vents and E nvironment

BOX 160.6
Tasks to Be Completed After the Secondary Survey

  • Continuous monitoring of vital signs

  • Provision of analgesia, and continuous reassessment of pain

  • Antibiotics and tetanus as appropriate

  • Ensure urine output of 1 mL/kg/h

  • Begin transport process if the patient will obviously need transport

Physical Examination

During the secondary survey, a head-to-toe examination should be carefully performed. Specifics of the head examination include inspection and palpation of the skull (fontanelle) and facial bones, assessing pupillary size and reactivity, and evaluation of extraocular movements. In possible nonaccidental trauma, funduscopic examination may reveal retinal hemorrhages. A fluorescein examination may reveal occult eye injury in the crying child.

Cervical spine immobilization should be maintained until the patient’s neck is cleared of injury. Patients in spinal immobilization should be removed from the backboard with spinal motion restriction maintained. When the patient is log-rolled for backboard removal, the thoracic and lumbar spinous processes are individually palpated, evaluating for tenderness or step-offs. To protect them from further injury, obtunded patients and those with signs or symptoms of thoracic or lumbar spine injuries should be carefully moved and positioned until imaging or clinical assessment provides a more definitive assessment.

Chest assessment involves visual inspection for wounds and flail segments, palpation for tenderness or crepitus, and auscultation for breath sounds. The abdominal examination consists of inspection for evidence of abdominal wall trauma and palpation for the presence of tenderness. A “seat belt sign,” consists of erythema, abrasions, or ecchymosis extending across the chest or abdomen from the seat belt (see below). Abdominal tenderness is present in approximately 75% of alert children with an intra-abdominal injury; however, the reliability of the abdominal examination decreases drastically in patients with GCS scores less than 14. Digital rectal examination should only be performed to evaluate rectal tone in suspected spinal cord injury, or if the integrity of the rectum is in question. Testing the injured child’s stool for occult blood is not useful and we do not recommend this. All pelvic bones should be assessed for stability and tenderness. Although rare in children, urethral injuries may result in perineal, scrotal, penile, or lower abdominal hematomas, or blood at the urethral meatus. If there is a concern for urethral injury, a retrograde urethrogram should be completed prior to insertion of a urinary catheter to avoid further injury.

Extremity examination evaluates for deformities, skin disruptions, neurologic deficits, and abnormal perfusion. Fractures may be stabilized with splinting before definitive management. Careful and recurrent vascular and neurologic examinations should be performed and documented, especially after interventions such as splinting or reduction.

Trauma patients should be reexamined throughout their time in the ED to ensure their condition is stable, their pain is controlled, and no injuries are missed. When possible, ambulation can expose additional injuries not identified with previous examinations. Up to 70% of injuries with delayed diagnosis in pediatric trauma are orthopedic.

Pain Assessment

Pain assessment and control is an essential part of any trauma patient’s management. Analgesic medications, immobilization of injured extremities, and non-pharmacologic techniques should all be considered. Please refer to Chapter 157 for further discussion of pain control in children.

Diagnostic Testing

Laboratory Testing

Laboratory testing is used to guide resuscitation, monitor blood loss, and screen for particular injuries, but should be tailored to avoid unnecessary testing. Patients at risk for hemorrhage should have a type and screen in addition to hemoglobin measurements. In acute hemorrhage, hemoglobin requires time to equilibrate and does not initially correlate with severity of blood loss. Serial hemoglobin measurements are not useful to screen for occult injuries; however, serial measurements may identify ongoing blood loss in patients with undifferentiated hypotension. In children with solid organ injuries, serial hemoglobin measurements are routinely performed, but the exact timing and utility is unclear. , Liver transaminases are useful to screen for hepatic injury, as they immediately elevate following liver injury. Children with GCS scores ≤13, hypotension, open or multiple bony fractures, or major tissue wounds are at risk for coagulopathy and should be screened with coagulation studies (INR and aPTT). Urinalysis is used to assess for blood (see below). Older pediatric trauma patients should be assessed for substance abuse and depression as contributing factors to the traumatic event. Post-pubertal females or those Tanner stage greater than 3 should be tested for pregnancy. Other than glucose testing in patients with altered mental status, serum electrolytes are routinely measured, but of limited initial use.

Radiologic Imaging

In the severely injured patient, we recommend performing an anteroposterior chest radiograph and a focused assessment with sonography for trauma (FAST), particularly if hypotensive. Plain films should be performed following the primary survey (routinely after the patient is rolled to their side, backboard removal and radiograph plates placed under the patient). An initial chest radiograph screens for immediate life-threatening thoracic injuries, but misses more subtle thoracic injuries. The FAST can be performed after the primary survey (or in conjunction if multiple providers), and evaluates for the presence of intraperitoneal and pericardial fluid. In hemodynamically unstable children, the FAST has good test characteristics for detecting intra-abdominal hemorrhage and can guide further management. The extended FAST (eFAST) examination incorporates the addition of lung views to evaluate for pneumothorax or hemothorax, but has yet to be proven useful in children. A plain pelvis radiograph may identify major pelvic disruptions, but should only be performed in patients who are hypotensive or have unstable pelvic bone examinations. In these patients, the pelvic radiograph may guide the use of a pelvic binder to limit further hemorrhage.

Further imaging should be obtained based on findings from the history and physical examination. Computed tomography (CT) has substantially changed the trauma patient evaluation, as it provides rapid injury identification and details to guide treatment. However, CT carries the risk of radiation-induced malignancy, which is greater in children than adults due to their higher organ sensitivity and longer life expectancy. Data suggests the risk of radiation-induced malignancy is 1 per 5000 to 10,000 cranial CT scans and 1 per 300 to 600 abdominal CT scans. Girls are more sensitive to CT radiation than boys. CT use has rapidly increased in injured children and is highly variable, and CT scans are more commonly obtained in children treated at adult or mixed trauma centers than pediatric trauma centers. In an effort to improve and provide evidence-based care, investigators have developed clinical decision instruments that align CT use in injured children with need (see following).

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