Paediatric trauma patients have unique anatomical and physiological characteristics compared to adults. These include a larger head size, more flexible bones, higher metabolic rate and greater risk of hypothermia. The ABCD approach is used to assess and manage the airway, breathing, circulation and disability of paediatric trauma patients. Special considerations include low tidal volumes during ventilation, weight-based fluid resuscitation, and assessing mental status using the Glasgow Coma Scale or AVPU score. Maintaining normothermia through warming measures is also important due to their increased risk of heat loss. Head injuries require rapid evaluation and treatment to prevent secondary brain injury.

1. Paediatric trauma
2170356 Che Hafiqrie Idham Bin Che
Hafsham
2170339 Ahmad Faiz Bin As’ari

2. Definition of Paediatic trauma
Paediatrcs trauma is life-threatening injury to children and it’s the
number one killer of children in world, more than all other causes
combined. These injuries require hospitalization, and usually
emergency surgery.

3. Unique Characteristics of
Pediatric Patients

4. according to system
System / anatomy Unique characteristic Relation to trauma How to overcome (if any)
Head • larger surface • is prone to injury from bleeding, fractures
or polytrauma
Laryngeal cartilages • more flexible (less
prone to fracture) and
protected
• can compromise airway due to soft tissue
swelling or expanding hematoma.
• Low threshold for
intubation
Chest wall • compliant and
vulnerable
tracheobronchial
structures and heart
lie anteriorly with
mobile mediastinal
structures
• predispose to intrathoracic injury
• less risk of rib fracture
Respiratory
structure
• smaller diameter
compared to adult
• predispose to airway obstruction when
change in inner diameter from aspirated
fluids or secretions.
• insert orotracheal tube to
secure the airway

5. System / anatomy Unique characteristic Relation to trauma How to overcome
(if any)
Abdomen • larger in size, has
underdeveloped musculature,
and has relatively larger intra-
abdominal organs
• thick capsule
• lower intra-abdominal fat
content and elastic ligamentous
ligamentous
• predispose to solid organ
injuries in blunt abdominal
trauma
• limits hemoperitoneum in solid
organ injury in children
• increased vulnerability to injury
from acceleration-deceleration
or abdominal
Bladder boundaries • cephalically extend just below
umbilicus
• vulnerable to direct blows to the
lower abdomen

6. System / anatomy Unique characteristic Relation to trauma How to overcome (if any)
Skeleton • incompletely calcified ,
contains multiple active
growth centers, weaker
epiphysis and is more pliable
• internal organ damage is often
damage noted without bony
fractures
• pulmonary contusion is common
but rib fractures is not
The presence of skull and/or rib
fractures in a child
- suggests the transfer of a massive
amount of energy
- in this case, underlying organ
injuries, such as traumatic brain
injury and pulmonary
• High index of intrathoracic
injury without rib fractures
Surface area • ratio of a child’s body
surface area to body
volume is highest at birth
and diminishes as the child
child mature.
• Themal energy loss is a significant
stress factor such as hypothermia
in cold environments. (trauma
bay)
• - complicate the treatment of
pediatric patients with
hypotension
• Use warm IVD / blood
product
• Use warm blanket / body
warmer

8. Metabolic activity
• Metabolic demands in children are higher than in adults.
• Energy expenditure and caloric requirement is higher in
children at baseline.
• Hyperglycemia – stress-induced hyperglycemia is
common in polytrauma
• Hypoglycemia – can occur in younger children

9. ABCD APPROACH IN PEADIATRICS
TRAUMA
AIRWAY (3 P’s)
 Inability to establish and/or maintain a patent airway associated with
lack of oxygenation and ventilation
 Patency – use an oral airway to prevent obstruction by the tongue,
suction any blood, secretions, foreign bodies
 Position – towel under torso, occiput on bed
 Protection – cuffed ETT / uncuffed ETT

10. Airway: Evaluation and Management
• passive flexion of cervical spine caused by the large occiput.
• plane of the midface be maintained parallel to the spine board in a
neutral position (as shown in the next slide)
• placement of a 1- 2.5 inch-thick layer of padding beneath the infant’s
(<1 years of age) or toddler’s (1-3 years of age) entire torso (as
shown in the next slide)

12. Airway: Evaluation and Management
• Spontaneous breathing– jaw thrust maneuver combined with bimanual inline
spinal motion restriction to open the airway.
• unconscious – fully pre oxygenate the child before doing mechanical
methods of maintaining the airway.
Oral Airway
• should be inserted only if a child is unconscious, because vomiting is likely to occur if the gag reflex is
intact.
• Insert the oral airway gently and directly into the oropharynx. Using a tongue blade to depress the
tongue may be helpful
• practice of inserting the airway backward and rotating it 180 degrees is not recommended
• Complication: trauma with resultant hemorrhage into soft tissue structures of the oropharynx
Orotracheal intubation
Indication:
• severe brain injury who requires controlled ventilation
• airway cannot be maintained
• signs of ventilatory failure
• suffered significant hypovolemia and has a depressed sensorium or requires operative
intervention

13. Airway: Evaluation and Management
• 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.
• The head and occiput is relatively
large
• A disproportionately large tongue and
small mandible

14. Airway: Evaluation and Management
• 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.

15. Orotracheal Intubation
• Cuffed endotracheal tubes
• Uncuff endotracheal tube
• Size
• ETT depth (cm) = 3 x size
• one size larger and one size smaller than
the predicted size

16. • 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
Nasotracheal intubation

17. Cricothyrotomy
• A needle cricothyrotomy may be required
if orotracheal intubation is not possible due
to severe maxillofacial injuries and the
patient cannot be adequately ventilated and
oxygenated.
• Open surgical cricothyrotomy is not an
option in children <10 years old due to the
small cricothyroid membrane. Needle
cricothyrotomy is therefore recommended
in children <10 years old
• 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.

18. • An infant’s trachea is approximately 5 cm long and grows to 7 cm by about
18 months.
- Failure to appreciate this short length can result in
- malposition of ETT
- inadequate ventilation
- accidental tube dislodgment
- and/or mechanical barotrauma

19. Breathing: Evaluation and
Management
• 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
• volume of O2 in reservoir (self inflating bag size) : 250 ml for newborn or
small neonates, 500 ml for neonates – infants, 1500ml adults
• tension pneumothorax - needle decompression 14- to 18-gauge IV catheter
in the midclavicular line just above the third rib.
• orogastric tube can significantly improve their work of breathing for
increased intra-abdominal pressure

20. BREATHING- recognition of impaired gas exchange
• infant breathe rate: 30-40/minute, older child breathe rate:15-20/minute.
• Normal spontaneous tidal volumes 5-8ml/kg for infants and children.
Manage patient’s breathing by:
1. Positive pressure ventilation
2. Variable mask
3. Fixed mask
• Fixed pulmonary tidal volume - minute ventilation is maintained primarily by respiratory rate
(tachypnea) rather than depth (hyperpnea).
• Low residual volumes and low functional residual capacity contribute to atelectasis and rapid
desaturation during apnea respectively.

21. Venturi mask
Manual resuscitator Rebreathing mask

22. Cont.
NEVER ATTEMPT to correct acidosis with sodium bicarbonate
- can result in hypercarbia (CO2 retention) & worsened the acidosis Adequate
perfusion and ventilation is required
excessive volume or pressure during assisted ventilation
-results in iatrogenic barotrauma
- because of the fragile nature of the immature tracheobronchial tree and alveoli.
- pediatric bag-mask - for children under 30 kg. (volume of O2 in paediatric bag-valve-mask
reservoir is 500ml-1000ml (compare to adult size 1500ml – 2000ml)
Hypoventilation
Respiratory
acidosis
Hypoxia Cardiac
arrest

23. PLEURAL DECOMPRESSION
 INDICATION - Injuries that disrupt pleural apposition (hemothorax,
pneumothorax, and hemopneumothorax)
 NEEDLE DECOMPRESSION
- over the top of the third rib in the midclavicular line.
- using 14-18 gauge over- the- needle catheters

24. Circulation and Shock: Evaluation and
Management
• Catastrophic bleeding – addressed and control by applying direct pressure,
tourniquets, and pelvic binding are essential prehospital interventions
• Signs of circulatory compromise
-tachycardia and narrowing of the pulse pressure to <20 mm Hg
-poor skin perfusion, cool extremities relative to the torso, mottled skin
-weakening of peripheral pulses,
-altered sensorium including dulled response to pain,
-low BP and urinary output indicate inadequate organ perfusion
• children prone to get internal injury rather than rib fracture because the skeletal
incompletely calcified , contains multiple active growth centers, weaker epiphysis
and is more pliable

25. Circulation and Shock: Evaluation and
Management
• Vascular access – can be difficult especially in hypovolemic shock
• Place proximal large-bore IV branula intraosseous if fail in 90
sec
• pressure bag or multiple handheld syringes - used for rapid fluid resuscitation
• children tolerate initial boluses of 10 to 40 mL/kg.
• shock : bolus of 20 ml/kg of warmed crystalloids
• weight-based blood product resuscitation ( 10 to 20 mL/kg of packed red
blood cells for children <40 kg)
• tranexamic acid should be strongly considered within 3 hours of injury in
adolescents as well as children of all ages requiring a blood transfusion.
Dosage 15mg/kg bolus max 1g, followed by 2mg/kg/hr infusion for 8
hours for children <12 years old. >12 years to follow adult dose

26. Con’t
Evaluate and manage circulation in patient by:
1)accurately determining the patient’s weight and
circulatory volume
2)recognize circulatory compromise
3)obtaining venous access
4)administering resuscitation fluids and blood replacement
5)assessing the adequacy of resuscitation

27. These physiologic changes must be treated by a rapid infusion of both
isotonic crystalloid and blood.

29. BLOOD PRESSURE FORMULA
• mean normal SBP = 90 + (2 x yr)
• lower limit of normal SBP = 70 + (2 x yr)
• DBP = 2/3 x SBP

30. WEIGHT AND CIRCULATORY VOLUME
NORMAL BLOOD VOLUME
 Infant :80 mL/kg,
 1-3 years :75 mL/kg,
 over age 3 years: 70 mL/kg.
• Cardiovascular differences – CO is mediated primarily by heart rate, in adults by stroke
volume.
• Therefore, Children with significant blood loss develop tachycardia, which can be sustained
for a variable period of time before cardiac output is compromised

31. Venous access
• A peripheral percutaneous route is
preferable to establish venous access.
• If percutaneous access is unsuccessful
after two attempts, consider
intraosseous route:
- intraosseous: 18-gauge in infants, 15-gauge in
young children
• femoral venous line
• venous cutdown

32. PREVENTION OF SHOCK IN PEADS
PATIENTS
 Recognize that tachycardia may be the only
physiologic abnormality
 Recognize that the children have increased physiologic
reserve
 Recognize that normal vital sign vary with the age of child
 Reassess for mottled skin

33. FLUID RESUSCITATION AND BLOOD
REPLACEMENT
• Weight based
• Goal – to replace lost intravascular volume loss of 25% of a child’s circulating
blood volume indicates haemorrhage
i) initial 20 mL/ kg bolus of isotonic crystalloid
ii) blood product resuscitation with 10-20 mL/kg of packed red blood cells
iii) 10-20 mL/kg of fresh frozen plasma and platelets.
• For facilities without ready access to blood products, crystalloid resuscitation can
be used until blood product is available

34. MONITOR :
• Slowing of the heart rate (age appropriate with improvement of other physiologic
signs)
• Clearing of the sensorium
• Return of peripheral pulses
• Return of normal skin color
• Increased warmth of extremities
• Increased systolic blood pressure with return to age-appropriate normal
• Increased pulse pressure (>20 mm Hg)
ASSESS THE ADEQUACY OF
RESUSCITATION

35. URINE OUTPUT
• To determine the adequacy of volume resuscitation
• When the circulating blood volume has been restored
Infants Adolescence Teenagers
1-2 mL/kg/hr 1-1.5 mL/kg/hr 0.5 mL/kg/hr
urinary
output
use urinary catheter

36. Children generally have one of three responses to fluid
resuscitation:
Responders Transient responders Non- responders
The condition of most
children will be stabilized
- by using crystalloid
fluid only,
- blood is not required.
Some children respond to
crystalloid and blood
resuscitation
Some children have an initial
response to crystalloid fluid
and blood, but then
deterioration occurs.
do not respond at all to
crystalloid fluid and blood
infusion
prompt infusion of - additional blood products,
- activation of a mass transfusion protocol,
- and consideration for early operation

37. DISABILITY
• Assessment of mental status in preverbal children using
modified pediatric Glasgow Coma Scale (GCS).
• A simpler and validated method to assess mental status in
children is by using the AVPU score

40. DISABILITY

41. EXPOSURE AND ENVIRONMENTAL
CONTROL
• Maintain a warm resuscitation environment, remove wet
clothing, and cover the child with warm blankets or an
external warming device as soon as the assessment is
complete to keep the child warm
• Give warmed crystalloids and blood products if remains
hypothermic
• Examine the back of the scalp for ongoing bleeding.
• The digital rectal exam is performed in serious spinal injury.

42. 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
• How to overcome issue: Usage of overhead heat lamps,
heaters, or thermal blankets

43. ASSESSMENT OF HEAD INJURY - PECARN

45. Management of head injury on paeditaric trauma
Rapid, early assessment and management of the ABCDEs :
 Appropriate neurosurgical involvement from the beginning of treatment.
 Appropriate sequential assessment and management of the brain injury focused on
preventing secondary brain injury—that is, hypoxia and hypoperfusion—is also critical.
 Early endotracheal intubation with adequate oxygenation and ventilation
 Orally intubating the trachea in an uncooperative child with a brain injury may be difficult
 Experienced clinician intubating such children, pharmacologic sedation and neuromuscular
blockade may be used to facilitate intubation.
 Hypertonic saline and mannitol
( create hyperosmolality and increased sodium levels in the brain, decreasing edema and pressure
within the injured cranial vault, rheostatic agents that improve blood flow and downregulate the
inflammatory response. )
 Continuously reassess all parameters

46. RESUSCITATION TAPE

47. • A length based resuscitation tape for rapidly determining weight based on length for appropriate
fluid volume, drug doses and equipment size
• Clinician can estimate the weight by measuring the child height
• One of the side provides name of drug and their recommended doses for peadiatrics patients
• Other side provide suitable equipment needs for peads patient based on height
BROSELAW TAPE

48. PITFALL PREVENTION
Incorrect volume of fluid and doses of
drug
Use a resuscitation tape to estimate
weight from length then recognize
suitable dosage
The Broselow Tape help to estimate the weight of the child from his/her length the
provide:
1. The medication dosage
2. Suitable size of equipment
3. Defibrillator shock voltage level

49. SECONDARY SURVEY: AMPLE HISTORY
COMMON MECHANISM OF INJURY
MECHANISM OF INJURY COMMON PATTERNS OF INJURY
Struck by motor vehicle At low speed may cause lower extremity fractures while at high speed may
cause multiple trauma, head and neck injury plus lower-extremity fractures
Motor vehicle collision With safety seat belt ; multiple trauma, head and neck injuries, scalp and facial
lacerations
Without seat belt, chest and abdominal injuries, lower spine fractures
Fall from height • Low: Upper-extremity fractures
• Medium: Head and neck injuries, upper- and lower-extremity fractures
• High: Multiple trauma, head and neck injuries, upper- and lower extremity
fractures
Fall from bicycle Without safety helmet, knee and elbow pad: head, neck, scalp, facial, upper
and lower extremity laceration, upper and lower extremity fractures
With safety: upper extremity fractures Hit
handlebar: internal abdominal injuries

50. RECOGNITION OF NON-
ACCIDENTAL INJURY
• Child Maltreatment
- history and careful evaluation of the child in whom maltreatment is
suspected is critically important to prevent eventual death

51. 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.

52. 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.
 Pattern of bone fracture :
- Rib fractures are rare in infants and young children and are generally seen
only in cases of severe trauma such as motor vehicle collisions
- Classic metaphyseal fractures are shear injuries to the immature ends of
growing bones in infants caused by the rapid acceleration and deceleration
associated with yanking or shaking

54. 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

55. Findings
Ruptured internal viscera without
antecedent major blunt trauma
Multiple subdural hematomas,
especially without a fresh skull
fracture (suspect shaken baby
syndrome)
Retinal hemorrhages
Bizarre injuries, such as bites,
cigarette burns, or rope marks

56. Findings
Sharply demarcated 2nd & 3rd-degree burns
Skull fractures or rib fractures seen in children <24 months
of age

57. Fine, parallel linear
bruises that trace the
outline of fingers
‘Punched out’, circular and
deep burns are typical
Injuries to the neck and
bruises on the upper half of
the ear
Severe bruises
causes by a ruler
Human
bite

58. Multiple small
scars on the
dorsal part of the
hand and swelling
of the middle
finger
Burns from a hot
light bulb
against the sole
of the feet
Bruises in babies
before they able
to move on their
own are rare.
The bruises was
noted on the
cheek.
Spanking
that causes
bruising
definitively
abuse

59. References
1) Judith E. Tintinalli (ed), O. John Ma, Donald M. Yealy, Garth D. Meckler, J. Stephan
Stapczynski, David M. Cline, Stephen H. Thomas Tintinalli's Emergency Medicine:
A Comprehensive Study Guide, 9e
2) Advanced Trauma Life Support (ATLS) 10th edition
3) https://bda.org/childprotection/Recognising/Pages/Physical.aspx