25. Trauma and Burns
KeywordsPediatric traumaPediatric cervical spine injurySpinal cord injury without radiological abnormalityPediatric burn managementNon-accidental injuryPediatric burns resuscitation; Critical bleedingChildren
Trauma is the leading cause of morbidity and mortality in children aged over 1 year, accounting for 40% of all deaths. Children who survive serious injuries are often left with permanent disabilities which may be life-changing for the child and their family. Whilst the management of children after trauma follows the same principles as adults, there are unique features of pediatric trauma.
Children are at risk of injury because of their curiosity, risk taking behavior and lack of fear. Their small size means trauma is more likely to impact on multiple organs. Children have greater elasticity of their connective tissue, so shearing forces may cause tearing of major blood vessels and mediastinal structures. The flexible nature of a child’s skeletal system means that greenstick fractures are more common, and significant organ damage can occur with no overlying fractures. For example, blunt chest wall trauma may not result in rib fractures, but the force sustained during trauma may cause extensive injury to the thoracic organs. The abdominal wall of a child is less protected by fat and subcutaneous tissues so intra-abdominal organs are more prone to injury than in the adult population.
Normal values for physiological variables in children. Expected systolic blood pressure = 80 + (age in years × 2) mmHg
Heart rate (bpm)
Systolic blood pressure (mmHg)
The flexible skeleton of children allows them to withstand severe forces without incurring fractures. There may be few outward signs of injury when in fact there are severe internal injuries. Repeated reassessment of the child’s clinical condition is imperative.
Children possess robust compensatory mechanisms, so a high index of suspicion for serious injury should be maintained even when a child appears initially stable. Once clinical signs of injury become evident this is often at a late stage when cardiac arrest may be imminent.
25.1 Types of Injury
Injuries in children tend to follow set patterns according to age and gender. As children grow, they increase in size and their body proportions change. With age, muscle mass increases and the body is able to withstand the effects of blunt trauma better.
Causes of pediatric trauma
Causes of trauma
Transport related injuries
Pediatric trauma is different because:
Children have a smaller body size resulting in different patterns of injury.
Internal organs are less protected and more vulnerable to trauma.
There are anatomical differences e.g. airway, cervical spine.
They have a large body surface area and are more likely to lose heat and fluids.
Greater distribution of force is more likely to result in multi trauma than a single organ injury.
Increased metabolic rate and smaller functional residual capacity makes them more vulnerable to hypoxia.
Greater airway resistance and smaller airway diameter makes respiratory impairment more likely.
The large head in comparison to body makes head injuries more common.
Because they are able to increase systemic vascular resistance and heart rate to compensate for losses, children maintain their blood pressure until >30% blood volume is lost, causing sudden irreversible shock if not recognized early.
25.2 Initial Management
Advance preparation of drugs and equipment can be done if there is sufficient warning of an incoming trauma patient. Some centers use Broselow tapes to estimate the child’s weight and to determine drug doses and equipment sizes without any calculations (see Chap. 7, Sect. 7.1.4). The initial evaluation should identify life-threatening problems, using a primary survey followed by a secondary survey. The primary survey starts with assessment and control of the airway including cervical spine control followed by assessment of breathing and circulation. Appropriate life-saving interventions, such as endotracheal intubation, should be performed during the primary survey if indicated.
It is vital to uncover the child to ensure that a thorough secondary survey is performed and that no injuries are missed, but hypothermia from prolonged exposure must also be avoided. Infants have impaired thermoregulation and children have a larger surface area to body mass ratio so are more susceptible to heat loss than adults. Consider the use of warmed fluids, cling wrap, space blankets, forced air warmers and passive humidification of ventilator gases.
The important first steps during the initial management of the child with trauma are to establish a clear airway, give oxygen, immobilize the cervical spine, control any bleeding and immobilize any fractures to minimize blood loss.
Indications for intubation and ventilation in pediatric trauma
Indications for intubation and ventilation in pediatric trauma
Airway obstruction unrelieved by simple airway maneuvers
Risk of aspiration due to loss of airway reflexes
Inadequate ventilation (e.g. secondary to chest trauma)
Control of ETCO2 in head injuries
Transfer of patient (e.g. CT scan, inter-hospital transfer)
Anticipated airway obstruction (e.g. burns)
Chest trauma is usually caused by blunt trauma and there are usually associated injuries. Severe intra-thoracic injuries can occur without any obvious external signs on the chest. The main cause of cardiac arrest is respiratory failure. Children have a small respiratory reserve and may tire easily. Children who are tired will eventually have a decreased respiratory rate as a sign of an impending respiratory arrest. In children with chest trauma, respiratory compromise may be from direct injury to the chest wall or indirectly from shock or head injuries. Gastric distension may be caused by bag-mask ventilation and impedes ventilation, avoided by the insertion of gastric tubes to decompress the stomach early in resuscitation.
Hypotension is a late sign of hypovolemia in children due to their low resting sympathetic tone and excellent compensatory mechanisms
Signs of impending circulatory failure in children
Altered mentation (irritable, confused, combative, lethargic.)
Cool, clammy and mottled extremities
Prolonged capillary refill time >3 s
Poor urine output
Tachycardia or bradycardia
Poor pulse volume
Sunken fontanelle in children <1 year
Normal blood volumes in children of different ages
Blood volume (mL/kg)
Infants and children
Blood pressure measurements are an unreliable indicator of shock in the pediatric patient. Children can compensate for 25–40% loss of their blood volume. Hypotension indicates severe blood loss.
Intravenous access in the arms or legs may be difficult, and an intraosseous needle inserted in the tibia if not fractured, should be considered early. The saphenous vein at the ankle is a vein that can be cannulated by landmarks alone—it is found just in front of the medial malleolus (there is a groove in the malleolus where the vein runs). Central venous access should only be performed by those skilled and familiar with the technique, but the femoral vein is a possible site for the occasional operator as it has a low risk of complications at the time of insertion (see Chap. 28, Sect. 28.4).
Massive transfusion in children is defined as red cell transfusion of 50% of the total blood volume (TBV) in 3 h. Most hospitals now have a critical bleeding protocol to facilitate the supply of large amounts of blood products to a critically bleeding child. In time-critical situations, uncross matched O-negative blood or type-specific blood should be considered to avoid delay (see Chap. 5, Sect. 5.8.2). A fluid warmer is added to the IV fluid system as early as possible. As blood loss continues, coagulation is monitored with point of care devices such as ROTEM.