Chapter 44 Pediatric Trauma
Traumatic injuries continue to be the leading cause of death and disability in pediatric patients (ages 1 to 18 years).1 Approximately one in every six pediatric patients in the United States is treated in emergency departments for injury each year, with an average of 12 pediatric patients under age 15 years injured every minute.2,3 This represents nearly 10 million pediatric patients, of which 10,000 die annually because of an injury-related event. For every pediatric patient who dies, four survive but are permanently disabled.2–4
Children have a smaller body mass, so there is more force per unit area, creating a propensity toward multiple injuries. Morbidity and mortality from trauma surpasses all major diseases in children and young adults.2
The most common mechanism of death and injury in this population is motor vehicle crashes, whether associated as an occupant, pedestrian, or cyclist. Other mechanisms for death and injury include falls, drownings, recreational injury, homicides, suicide, and burns.3–5 The vast majority of pediatric patients sustain blunt trauma (about 80%) as opposed to penetrating wounds (about 20%).6 Factors that influence the mechanism of injury include age and stage of development, gender, behavior, and environment.
Assessment and Treatment of the Pediatric Trauma Patient
The principles of trauma assessment and management are the same for pediatric and adult patients (see Chapter 35, Assessment and Stabilization of the Trauma Patient, for more information). Some aspects unique to the pediatric population are discussed below.
Primary Assessment
Airway7
Therapeutic Interventions
• Use jaw thrust to open the airway; the tongue is large compared to the oral cavity and can easily obstruct the airway.
• Maintain full spinal immobilization for any known mechanism of injury, symptoms, or physical findings that suggest a spinal injury or any unknown mechanism of injury in the unconscious pediatric patient (e.g., abusive head trauma).
• If the pediatric patient is unable to maintain a patent airway, place a nasopharyngeal airway (in the conscious patient) or an oropharyngeal airway (in the unconscious patient and those who may have a possible basilar skull fractures).
• As with adults, endotracheal intubation is recommended for any pediatric patient with respiratory distress, poor ventilation, or a Glasgow Coma Scale score less than or equal to 8. See also Chapter 8, Airway Management.
Breathing7
Assessment
• A pediatric patient’s chest wall is smaller and thinner so breath sounds can be transmitted easily from one location to another. Auscultate breath sounds for equality and the presence of adventitious sounds in the midaxillary region.
• Observe for respiratory fatigue. The pediatric patient’s intercostal muscles are more poorly developed.
Therapeutic Interventions
• Administer high-flow oxygen to all patients during the initial resuscitation phase.3
• Minimize metabolic stressors (e.g., pain, stimulation, hypothermia). An infant’s metabolic rate is about two times that of an adult.
• Prepare to perform optimal bag-mask ventilation. The pediatric patient has a small functional residual capacity and can desaturate rapidly despite preoxygenation.
• Hypoxemia, airway stimulation, and medications (especially succinylcholine for rapid sequence intubation) may result in a vagal response, such as bradycardia; therefore have atropine readily available to treat this potential reaction.
• Avoid overly aggressive ventilation. Pediatric patients are more prone to barotraumas so use the lowest possible tidal volume to achieve a gentle chest rise.
Circulation7
Assessment
• Check capillary refill time. Less than 2 seconds is considered normal; greater than 2 seconds is delayed.
• Palpate the quality and effectiveness of central and peripheral pulses. The pediatric patient’s circulating blood volume is 80 mL/kg and is proportionally greater than that of an adult. Hypovolemia can occur more quickly than in an adult.
• Observe skin color and feel for temperature; mottling and cool extremities are abnormal.
Therapeutic Interventions
• If the pediatric patient’s heart rate is less than 60 beats per minute and perfusion is ineffective, initiate cardiopulmonary resuscitation following the American Heart Association’s Pediatric Advanced Life Support (PALS) guidelines.9
• Administer crystalloid fluid resuscitation by the 3 : 1 rule (e.g., crystalloid resuscitation to blood loss). Therefore, for a 20 mL/kg blood loss, a replacement should be 60 mL/kg.11
• If a pulse is present but circulation is inadequate, obtain vascular access by inserting two large-bore intravenous catheters or intraosseous needles.
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