ATLS 9th for pediatric trauma

1. 10 Pediatric
Trauma
Paleerat Jariyakanjana, MD
Emergency physician
29/12/58

3. most injured children have no
hemodynamic abnormalities →
rapidly deteriorate, and serious
complications will develop

4. Unique
Characteristics of
Pediatric Patients

5. SIZE AND SHAPE
smaller body mass → greater force
applied per unit of body area
less fat, less connective tissue, and
closer proximity of multiple organs
high frequency of multiple injuries
seen
head is proportionately larger
 higher frequency of blunt brain injuries

6. SKELETON
incompletely calcified, contains
multiple active growth centers, and is
more pliable
internal organ damage is often noted
without overlying bony fracture
rib fractures in children are
uncommon, but pulmonary contusion
is not

7. SKELETON
skull or rib fractures
 massive amount of energy
 underlying organ injuries, such as traumatic
brain injury and pulmonary contusion, should
be suspected

8. SURFACE AREA
The ratio of a child’s body surface
area to body volume is highest at
birth and diminishes as the child
matures.
thermal energy loss is a significant
stress factor

9. LONG-TERM EFFECTS
long-term quality of life for children
who have sustained trauma is
surprisingly robust
aggressive resuscitation attempts

10. EQUIPMENT

11. EQUIPMENT

12. Airway:
Evaluation and
Management

13. ANATOMY
passive flexion of the cervical spine
caused by the large occiput
plane of the midface be maintained
parallel to the spine board in a
neutral position
Placement of a 1-inch-thick layer of
padding beneath the infant’s (<1
year of age) or toddler’s (1-3 years of
age) entire torso

15. ANATOMY

16. ANATOMY
soft tissues in an infant’s oropharynx
 relatively large
 visualization of the larynx difficult
A child’s larynx is funnel-shaped,
allowing secretions to accumulate in
the retropharyngeal area.
The larynx and vocal cords are more
cephalad and anterior in the neck.

17. ANATOMY
The vocal cords are frequently more
difficult to visualize when the child’s
head is in the normal, supine,
anatomical position during intubation
than when it is in the neutral position
required for optimal cervical spine
protection.
ETT: depth (cm) = 3 x size

18. MANAGEMENT
Oral Airway
practice of inserting the airway
backward and rotating it 180 degrees
is not recommended
 trauma with resultant hemorrhage into soft
tissue structures of the oropharynx

19. MANAGEMENT
Orotracheal Intubation
cuffed endotracheal tubes
Size
 child’s external nares
 tip of the child’s small finger
one size larger and one size smaller
than the predicted size

20. MANAGEMENT
Orotracheal Intubation
Nasotracheal intubation should not
be performed
 blind passage around a relatively acute angle
in the nasopharynx toward the
anterosuperiorly located glottis, making
intubation by this route difficult

21. MANAGEMENT
Cricothyroidotomy
bag-mask
ventilation or
orotracheal
intubation 
LMA, intubating
LMA, or needle
cricothyroidotom
y

22. MANAGEMENT
Cricothyroidotomy
Needle-jet insufflation via the
cricothyroid membrane is an
appropriate, temporizing technique
for oxygenation, but it does not
provide adequate ventilation, and
progressive hypercarbia will occur.

23. MANAGEMENT
Cricothyroidotomy
Surgical cricothyroidotomy is rarely
indicated for infants or small
children.
can be performed in older children in
whom the cricothyroid membrane is
easily palpable (usually by the age of
12 years)

24. Breathing:
Evaluation and
Management

25. BREATHING AND VENTILATION
excessive volume or pressure during
assisted ventilation substantially
increases the potential for iatrogenic
barotrauma
 fragile nature of the immature
tracheobronchial tree and alveoli
pediatric bag-mask: <30 kg

26. NEEDLE AND TUBE
THORACOSTOMY
needle decompression: using 14-18G
over-the-needle catheters
Chest tubes: tunneling
 thinner chest wall

27. Circulation and
Shock: Evaluation
and Management

28. RECOGNITION OF CIRCULATORY
COMPROMISE
A child’s increased physiologic
reserve allows for maintenance of
systolic blood pressure in the normal
range, even in the presence of shock.

29. RECOGNITION OF CIRCULATORY
COMPROMISE

30. RECOGNITION OF CIRCULATORY
COMPROMISE
Tachycardia and poor skin perfusion
often are the only keys to early
recognition of hypovolemia
early assessment by a surgeon

31. RECOGNITION OF CIRCULATORY
COMPROMISE

32. RECOGNITION OF CIRCULATORY
COMPROMISE
mean normal SBP = 90 + (2 x yr)
lower limit of normal SBP = 70 + (2 x
yr)
DBP = 2/3 x SBP

33. RECOGNITION OF CIRCULATORY
COMPROMISE

34. RECOGNITION OF CIRCULATORY
COMPROMISE
Hypotension
 decompensated shock
 severe blood loss >45%

35. DETERMINATION OF WEIGHT AND
CIRCULATING BLOOD VOLUME
EBW = (2 x age) + 10
Shock: bolus of 20 mL/kg

36. VENOUS ACCESS
percutaneous access x 2 attempts
 bone marrow needle (18G in infants, 15G in
young children)
 femoral venous line
 venous cutdown

37. FLUID RESUSCITATION

38. THERMOREGULATION
The high ratio of body surface area to
body mass in children increases heat
exchange with the environment
Increased metabolic rates, thin skin,
and the lack of substantial
subcutaneous tissue
overhead heat lamps, heaters, or
thermal blankets may be necessary

39. Cardiopulmonary
Resuscitation

40. Cardiopulmonary Resuscitation
Children receiving CPR for >15
minutes prior to arrival in an ED or
with fixed pupils on arrival uniformly
predict nonsurvival.
continued CPR of long duration,
prolonged resuscitative efforts are
typically not beneficial

41. Chest Trauma

42. Chest Trauma
Mobility of mediastinal structures

more susceptible to tension
pneumothorax

43. Abdominal
Trauma

44. ASSESSMENT
Orogastric tube decompression is
preferred in infants.

45. DIAGNOSTIC ADJUNCTS
Computed Tomography
Fatal cancers: 1/1,000 patients

46. DIAGNOSTIC ADJUNCTS
Focused Assessment Sonography in
Trauma
I/C operative management
 not by the amount of intraperitoneal blood
 by hemodynamic abnormality and its
response to treatment

47. DIAGNOSTIC ADJUNCTS
Diagnostic Peritoneal Lavage
10 mL/kg (up to 1000 mL)
Only the surgeon who will care for
the child should perform the DPL
 because DPL may interfere with subsequent
abdominal examinations or imaging upon
which the decision to operate may in part be
based

48. NONOPERATIVE MANAGEMENT
CT/FAST that is positive for blood
alone does not mandate a laparotomy
in a child who is hemodynamically
normal or who stabilizes rapidly with
fluid resuscitation

49. Head Trauma

50. lose significant amounts of blood in
the subgaleal, subdural, or
intraventricular spaces

51. ASSESSMENT
infant who is not in a coma but who
has bulging fontanelles or suture
diastases should be treated as having
a more severe injury

52. ASSESSMENT
Vomiting and even amnesia do not
necessarily imply increased
intracranial pressure
persistent vomiting or vomiting that
becomes more frequent is a concern
and mandates CT of the head
Impact seizures (seizures that occur
shortly after brain injury) are more
common in children and are usually
self-limited.

53. ASSESSMENT

54. ASSESSMENT
Medication
 Phenobarbital, 10-20 mg/kg/dose
 Diazepam, 0.1-0.2 mg/kg/dose; slow IV bolus
 Phenytoin or fosphenytoin, 15-20 mg/kg,
administered at 0.5-1.5 mL/kg/min as a
loading dose, then-7 mg/kg/day for
maintenance
 Hypertonic saline 3% (Brain Trauma
Foundation guidelines) 3-5 mL/kg
 Mannitol, 0.5-1.0 g/kg (rarely required)

55. Spinal Cord
Injury

56. ANATOMIC DIFFERENCES
Interspinous ligaments and joint
capsules are more flexible.
Vertebral bodies are wedged
anteriorly and tend to slide forward
with flexion.
The facet joints are flat.
The child has a relatively large head
compared with the neck.

57. ANATOMIC DIFFERENCES
the angular momentum is greater,
and the fulcrum exists higher in the
cervical spine, which accounts for
more injuries at the level of the
occiput-C3

58. RADIOLOGIC CONSIDERATIONS
Pseudosubluxation of the cervical
vertebrae
To correct this radiographic anomaly,
place the child’s head in a neutral
position by placing a 1-inch-thick
layer of padding beneath the entire
body from shoulders to hips, but not
the head, and repeat the x-ray.
True subluxation will not disappear
with this maneuver and mandates
further evaluation.

59. RADIOLOGIC CONSIDERATIONS
“spinal cord
injury without
radiographic
abnormalities”
(SCIWORA):
more commonly
than adults

60. Musculoskeletal
Trauma

61. BLOOD LOSS
Blood loss associated with long-bone
and pelvic fractures is proportionately
less in children than in adults.
Blood loss related to an isolated closed
femur fracture that is treated
appropriately is associated with an
average fall in hematocrit of 4
percentage points, which is not enough
to cause shock.
Hemodynamic instability in the presence
of an isolated femur fracture should
prompt evaluation for other sources of
blood loss

62. SPECIAL CONSIDERATIONS OF THE
IMMATURE SKELETON
The immature, pliable nature of
bones in children may lead to a so-
called greenstick fracture.
The torus, or “buckle,” fracture, seen
in small children, involves angulation
due to cortical impaction with a
radiolucent fracture line.

63. Child
Maltreatment

64. a history and careful evaluation of
the child in whom maltreatment is
suspected is critically important to
prevent eventual death, especially in
children who are <2 years of age

65. suspect
‒ A discrepancy exists between the history and
the degree of physical injury
‒ A prolonged interval has passed between the
time of the injury and presentation for medical
care.
‒ The history includes repeated trauma, treated
in the same or different EDs.
‒ The history of injury changes or is different
between parents or guardians.

66. suspect
‒ There is a history of hospital or doctor
“shopping.”
‒ Parents respond inappropriately to or do not
comply with medical advice
‒ The mechanism of injury is implausible based
on the child’s developmental stage.

68. findings
‒ Multicolored bruises (bruises in different
stages of healing)
‒ Evidence of frequent previous injuries,
typified by old scars or healed fractures on x-
ray examination
‒ Perioral injuries
‒ Injuries to the genital or perianal area
‒ Fractures of long bones in children <3 years
of age

69. findings
‒ Ruptured internal viscera without antecedent
major blunt trauma
‒ Multiple subdural hematomas, especially
without a fresh skull fracture
‒ Retinal hemorrhages
‒ Bizarre injuries, such as bites, cigarette
burns, or rope marks

70. findings
‒ Sharply demarcated 2nd & 3rd-degree burns
‒ Skull fractures or rib fractures seen in
children <24 months of age