Chapter 38. The injured child
Differences between children and adults
Children differ from adults in the following ways:
• Size – smaller size means that a child sustains more injuries than an adult would sustain from the same force
• Shape – the child’s relatively large head means that more forces may be applied through the neck during deceleration. A falling child tends to land head first
• Skeleton – the skeleton in children is very elastic, the child may sustain internal organ damage without overlying fracture; lung contusion may occur without overlying rib fracture because the ribs are more pliable
• Surface area – the larger surface area relative to body size in children means more rapid heat loss can occur.
Psychological problems
A careful and gentle approach is needed to the assessment and treatment of a frightened child who is in pain. Children almost invariably find the presence of a parent calming and although they may not understand what is said, continuous quiet speech is also reassuring. Under stressful circumstances, the child may regress to a younger age and may not behave as might be expected for the chronological age.
Equipment
Appropriately sized and designed equipment must be available in order to allow appropriate treatment.
Specific differences
Airway
• Relatively large tongue and easily damaged soft palate. This is why oropharyngeal airways are inserted the right way up instead of rotating them during insertion
• Relatively large epiglottis which should be picked up directly by the laryngoscope blade to allow better visualisation of the vocal cords
• Relatively short trachea. When inserted, the black vocal cord marker near the tip of the endotracheal tube should be placed at the level of the cords. After placement it is essential that intubation of the right main bronchus has been excluded
• The narrowest part of the upper airway is below the level of the cords at the level of the cricoid, cuffed ET tubes should be avoided to avoid necrosis of the wall of the trachea
• The larynx is more difficult to visualise
• Surgical cricothyroidotomy should not be performed in children; only needle cricothyroidotomy is appropriate.
Breathing
• Children have low oxygen reserves and their metabolism uses oxygen very quickly, so if ventilation is impaired, cyanosis rapidly ensues
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