Airway

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  Head: Children have a relatively large head in proportion to the body. When supine, the prominent occiput causes the neck to flex, which may lead to airway obstruction; always place a rolled towel or sheet under the scapulae to help align airway axes.²

  
  
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  Tongue: Usually large and may impede entrainment of air or laryngoscopy.²

  
  
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  Larynx: Located anterior and superior in position. The laryngoscopist can look from below up into the airway to aid visualization.²

  
  
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  Epiglottis: U-shaped, short, and stiff. As a result, a straight (Miller) blade helps to displace the anterior epiglottis for better visualization.² A curved (Macintosh) blade may be used in school-aged children and up.²

  
  
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  Vocal Cords: Unlike adult vocal cords, which have a horizontal slant, pediatric vocal cords slant vertically.²

  
  
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  Trachea: Tends to be short, leading to an increased likelihood of right mainstem intubation.²

  
  
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  Airway diameter: Funnel-shaped with the narrowest portion at the cricoid ring. Cricoid pressure can cause collapse of the delicate trachea, causing obstruction and poor visualization.²

  
  
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  Lung Capacity: Small lung capacity, leading to a short time to desaturation.²

Developing musculoskeletal system

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  Flexible cartilaginous skeleton and open growth plates cause children to suffer more avulsion injuries, rather than fractures (less calcified, less rigid skeleton).²

  
  
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  With less calcification and added flexibility, children have greater incidence of abdominal, chest, and spinal cord injuries without fracture.²

Age-Specific Vitals (Table 5.1)

Traumatic situations make vital sign interpretation difficult. Heart rate may be variably tachycardic in a frightened, screaming child in a traumatic situation, so a proper blood pressure cuff is essential to prevent an artificially low reading.³

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  Vasoconstriction is a compensatory mechanism to hypovolemia, specifically hemorrhagic shock in trauma. Children compensate for a loss of cardiac output by increasing their heart rate. Thus, tachycardia is the first sign of shock in children, while hypotension is an ominous, late finding.

  
  
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  Shock Index: Shock index is defined as HR/systolic BP. Though it has been around for some time, it is underutilized. It is most useful as a reference for physicians before the BP drops, especially in the occult shock patient.^4,5

  
  
  
  
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    Shock Index, Pediatric Adjusted (SIPA)^4,5

    
    
    
    
    1. 
       

       – 4–6 years = 1.2

       
       
    2. 
       

       – 6–12 years = 1

       
       
    3. 
       

       – >12 years = 0.9

    
    

  
  

Breathing

Pediatric patients are more prone to hypoxia for a variety of reasons.⁶

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  Extrathoracic Airway Differences:

  
  
  
  
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    Obligate nasal breathers

    
    
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    Smaller oral airway

    
    
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    Cephalic larynx

    
    
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    Epiglottis larger

    
    
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    Enlarged adenoid tissue

    
    
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    Congenital abnormalities

  
  
  
  
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  Intrathoracic Airway Differences:

  
  
  
  
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    Fewer, smaller alveoli

    
    
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    Poor collateral ventilation

    
    
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    Smaller intrathoracic airways collapse

    
    
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    Cartilaginous support lacking

    
    
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    Residual damage from birth leads to decreased pulmonary compliance

    
    
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    Chest wall musculature not fully developed

    
    
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    Lower functional residual capacity

  
  
  
  
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  Respiratory Drive Differences:

  
  
  
  
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    Immature respiratory center

    
    
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    Higher metabolic rates

  
  

Thermoregulation

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  Children readily lose heat through convection (high body surface area), conduction (wet diaper), and radiation (large, well perfused head).⁷

  
  
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  In addition, a high surface-area-to-mass ratio with thinner skin and less subcutaneous tissue to provide insulation predisposes children to hypothermia, which, in the setting of trauma, may lead to coagulopathy.⁷

Anatomy

The head is large relative to the body. The occiput is the biggest portion of the head. The open fontanelles (anterior and mastoid) should be evaluated, and clinicians should examine for subgaleal hematomas, which can be a major source of bleeding.

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  Caput succedaneum – Extra-periosteal collection. Crosses suture lines. Result of birth trauma usually.

  
  
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  Cephalohematoma – Between skull and periosteum. Does not cross suture lines.

  
  
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  Subgaleal hemorrhage/hematoma – Between skull periosteum and scalp galea aponeurosis. Crosses suture lines.

PECARN

The decision to obtain a CT head in a pediatric trauma should be completed with proper risk stratification using validated clinical predictors. The Pediatric Emergency Care Applied Research Network (PECARN) studies provide a set of guidelines to help guide physicians in cases of minor blunt head trauma (Figures 5.2 and 5.3). If a CT head non-contrast is not indicated, observation in the ED or at home is recommended with reassurance, education, and strict return precautions.

Figure 5.2 Blunt head trauma in children <2 years of age

(obtained from Cal ACEP, with permission)

Figure 5.3 Blunt head trauma in children ≥2 years of age

(obtained from Cal ACEP, with permission)

Airway Management

If the patient has any subtle changes in mental status, be proactive. Consider intubating early, as the respiratory center is underdeveloped, and hypoxia is associated with mortality in traumatic brain injury.