pediatric trauma

1. Initial Assessment and Management
Pediatric Trauma
Dr Tariq Chundrigar
FRCS Ed, MHPE

2. Case Scenario
● A 7-year-old boy is struck by a moving car
while riding his bicycle.
● He was not wearing a helmet.
● He is unresponsive on arrival, breathing
rapidly, and pale with dusky extremities.
● Vital signs on admission: HR 144, RR 38,
BP 84/60, GCS score 5 (E = 1, V = 2, M = 2)
What are your priorities for initial resuscitation?
What is your initial assessment?

3. Objectives
● Identify unique anatomic and physiologic
characteristics that affect injured children.
● Describe common patterns and responses to
both unintentional and intentional injury.
● Explain the application of Trauma
management principles to pediatric trauma
patients.
● State the importance of injury prevention in
reducing the impact of childhood trauma.

4. Injury in Children
● Injury mortality surpasses deaths from all
other childhood illnesses combined.
● Anatomy, physiology, and mechanisms
produce distinct patterns of injury.
● Mechanisms of injury are related both to
age and stage of development.
● Neurologic and respiratory derangements
far exceed hemodynamic derangements.

5. Anatomic Considerations
Larger head,
smaller jaw
Shorter,
narrower, funnel-
shaped airway
What aspects of childhood anatomy do I need to
consider?

6. Anatomic Considerations
Softer cranium,
open fontanelles
More cognitive
development
What aspects of childhood anatomy do I need to
consider?

7. Anatomic Considerations
Prominent
occiput in
younger child
1” pad under
torso for neutral
position
What aspects of childhood anatomy
do I need to consider?

8. Anatomic Considerations
● Flexible spinal ligaments
● Anteriorly wedged
vertebrae
● Flat facet joints
● Angular momentum forces
● Pseudosubluxation
● SCIWORA
Cervical Spine

9. Anatomic Considerations
● Soft, pliable, soft wall –
pulmonary contusion
● Horizontally aligned ribs,
weak intercostal muscles
● Rib fractures indicate
significant force
● Tension pneumothorax
poorly tolerated
Chest

10. Anatomic Considerations
● Softer, thinner, muscular wall
● Lower-riding liver, spleen
● Higher-riding bladder
● Multiple injuries are common
Abdomen

11. Physiologic Impact
● Age-specific vital signs
● Smaller blood volume
● Decreased functional residual
capacity
● Vigorous compensatory response
● Limited cardiorespiratory reserve
● Sudden deterioration

12. Management Issues
Vital Signs
Sign
0 – 2
years
3 – 5
years
6 – 12
years
Heart Rate < 150 - 160 < 140 < 100 - 120
Blood Pressure > 60 - 70 > 75 > 80 - 90
Respiratory
Rate
< 40 - 60 < 35 < 30

13. Management Issues
Urine Output
1.5 – 2
mL / kg
0 – 2 years
1 mL / kg
3 – 5 years
0.5 – 1 mL / kg
6 – 12 years

14. Physiologic Impact

15. Physiologic Impact
Thermoregulation
● Higher body surface area to mass ratio
● Thinner skin
● Less insulation by subcutaneous tissue
What physiologic differences will impact on
my management of pediatric trauma patients?
Prevent hypothermia!

16. Key Differences from Adults
Physical Difference Clinical Implication
Larger tongue More airway obstruction
High anterior larynx Straight blade for ETI
Much larger occiput Padding under torso
Head > torso injuries CNS, respiratory > shock
Much smaller torso Fewer truncal injuries

17. Key Differences From Adults
Physical Difference Clinical Implication
Much larger head More brain injuries
Body more compact Multiple injuries typical
Medications / fluids Broselow® Tape
Softer outer shell Underlying organ injury
Thin skin, less fat Keep the child warm!

18. Types of Injuries
Mechanism Pattern
Pedestrian
Slow
Soft tissue contusions, lower extremity
fractures
Fast
Head, torso, lower extremity fracture
Automobile
Occupant
Unrestrained
Head, face, spine
Restrained
Lap belt complex

19. Types of Injuries
Mechanism Pattern
Bicycle
No helmet
Head, face, spine, upper extremity
fractures
Handle bar
Liver, spleen, pancreas, duodenum
Fall
Low
Soft tissue contusions, upper extremity
fracture
High
Head, face, spine, abdomen, long-bone
fracture

20. Management
How do I apply Trauma
principles to the treatment of
children?
A
B
C D E
ABCDE priorities
are the same!

21. Management Issues: ABCDEs
E
A
B
C
D
Obstructs easily; uncuffed ET tube
Tension pneumothorax; avoid barotrauma
Vascular access; fluid and blood
Pediatric GCS score; diffuse swelling
Gastric dilation; avoid heat loss

22. Pitfalls
● Short trachea: main stem bronchial
intubation
● Endotracheal tube easily obstructed
● Deceptive presentation of
hypovolemic shock
Pitfalls

23. Pitfalls
● Difficult intravenous access in
children < 6 years
● Missed hollow viscus injury
● Subtle musculoskeletal injury findings
Pitfalls

24. Management Issues: Adjuncts
● CT
● DPL
● FAST
● Tubes

25. Abuse Injuries
History
● Discrepancies
● Delay in care
● Repetitive injuries
● Inappropriate
responses
● Medical neglect
How do I recognize abuse injuries?
Physical
● Multicolored bruises
● Bilateral subdurals
● Retinal hemorrhages
● Femur fracture(s)
● Unusual scald /
contact burns

26. Injury Prevention
Case Scenario
• Bicycle crashes are the
second leading cause of TBI
death in children.
• Severe TBI might have been
avoided if the child had been
wearing a helmet.

27. Injury Prevention
• Prevention ABCDEs
• Analyze injury data
• Build local coalitions
• Communicate the problem
• Develop prevention activities
• Evaluate program interventions

29. Summary
● Management principles are always the
same.
● Unique anatomic, physiologic, and
mechanistic Trauma principles.
● Involve appropriate surgeon early!
● Have a high index of suspicion for child
abuse.
● Injury prevention