Pediatric patients with trauma pose unique challenges, both practical and cognitive, to front-line care providers. The combination of anatomic, physiologic, and metabolic factors leads to unique injury patterns with different approaches and responses to treatment compared with adults. A similar traumatic mechanism can lead to slightly different internal injuries with unique management and treatment strategies between the two groups. This article is intended for community, nonpediatric trauma centers, and emergency physicians who are frequently required to assess, resuscitate, and stabilize injured children before they can be safely transferred to a pediatric trauma center for ongoing definitive care and rehabilitation.
Key points
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Initial resuscitation and stabilization of pediatric patients with trauma is of critical importance.
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There are special differences to consider in the ABCs (airway, breathing, circulation) of pediatric trauma care.
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Clinicians should know the goals of pediatric trauma resuscitation.
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Common injury patterns, physiologic differences, and treatment approaches used in pediatric trauma centers may differ from those in adult trauma practices.
Introduction
Pediatric patients with trauma pose unique challenges, both practical and cognitive, to front-line care providers. Emergency physicians are already skilled at resuscitating and stabilizing patients with trauma. The initial resuscitation of a traumatized child should follow the same Advanced Trauma Life Support (ATLS) principles used with adult trauma resuscitations. Therefore, trained emergency physicians have all the skills and competencies required to manage acutely injured children. What is sometimes lacking is the confidence and experience required to understand the common injury patterns, physiologic differences, and treatment approaches used in pediatric trauma centers, which may differ from adult trauma practices.
Children have anatomic, physiologic, and metabolic differences that are well described in textbooks and the medical literature. It is the combination of these factors that leads to unique injury patterns with different approaches and responses to treatment compared with adults. A similar traumatic mechanism can lead to slightly different internal injuries with unique management and treatment strategies between the two groups.
This article is intended for community, nonpediatric trauma center, emergency physicians who are frequently called on to assess, resuscitate, and stabilize injured children before they can be safely transferred to a pediatric trauma center for ongoing definitive care and rehabilitation.
This article focuses on the most common and practical pointers regarding pediatric patients with trauma with a blunt mechanism of injury. It does not focus on penetrating traumatic injuries. Most pediatric patients with blunt trauma are not rushed to the operating room (OR) for emergency surgery. Most pediatric patients with trauma with a blunt mechanism of injury respond and stabilize with an appropriate initial medical resuscitation. Well-resuscitated and stabilized patients are then able to be transported safely to a pediatric trauma center for ongoing definitive care and rehabilitation.
Typical Emergency Medical Services Patch Call
A 5-year-old boy, injured while crossing the street when he was struck by a vehicle at city speeds (∼50 km/h). He is crying and pale, with a hematoma to the left forehead; bruising to the left side of the upper abdomen; and an obvious, closed, deformity of his left tibia and fibula. His vital signs are heart rate (HR), 135 beats/min, respiration rate (RR), 30 breaths/min; blood pressure (BP), 95/65 mm Hg; and O 2 saturations of 91% on room air, which improve to 97% with supplemental O 2 .
Key issues to focus on:
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Based on their anatomy, children respond to external forces like bobble-head figurines. They have a large cranium on a short, weak, neck. There is usually some component of head injury (mild, moderate or severe) that needs to be managed. Supportive therapy for traumatic brain injury (TBI) is the mainstay of treatment. Ongoing, active assessment for signs and symptoms of increased intracranial pressure (ICP) is required. Clinical signs of increased ICP necessitate active treatments focused on reducing ICP.
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Cervical spine (C-spine) injuries are rare but C-spine protection and assessment are important. Be concerned about young, nonverbal children who do not move their necks. Be reassured but cautious with young, nonverbal children who freely turn their heads while crying.
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Pulmonary contusions are the most common intrathoracic injuries. Pneumothorax and hemothorax occur less frequently than in adults because of the flexibility of the bones in the rib cage and the transmission of blunt force to the organs and tissues underneath.
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Intra-abdominal injuries most commonly involve bleeding of the large solid organs (ie, spleen and liver).
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Orthopedic injuries and pain management are also common considerations in pediatric patients with multitrauma. Be concerned when children are lying still and not freely moving an extremity. Be reassured when children are spontaneously moving their arms and legs, because they are less likely to have a significant fracture in that limb. Pain and hypovolemia are both common causes of tachycardia, so they need to be addressed in the initial approach to the patient.
Primary survey
ATLS principles for initial assessment are the same in pediatric patients as in adult patients with trauma. The ABCDE (airway, breathing, circulation, disability, expose) cognitive model is organized to identify and treat life-threatening issues as soon as possible. A Broselow tape and color-coded pediatric resuscitation equipment system (eg, cart, bags) should be readily available so that unnecessary challenges and delays in locating the proper-sized equipment can be minimized. Continuous monitoring of vital signs is essential for ongoing assessment of response to interventions. A vigilant algorithm of assess, reassess, and reassess again must be maintained to accurately follow a patient’s positive trajectory toward improvement and stabilization, or to quickly recognize and respond to a patient’s deterioration, which would require more aggressive resuscitation and treatment. Call for assistance as early as necessary. Mobilize transport teams and obtain clinical support and advice from pediatric experts as early as possible. There is no shame in calling for advice. Pediatric experts are always willing to assist, advise, and accept patients in transfer. Pediatric trauma centers do not put up obstacles to patient transfer and should always be there to assist their community partners.
Pediatric Primary Survey: Airway, Breathing, Circulation, Disability, Exposure
A talking or crying child has a patent airway, is breathing spontaneously, and has sufficient BP to maintain cerebral perfusion and could be considered stable initially. In contrast, a quiet, nonvocalizing child with an altered level of consciousness (LOC) likely has severe, multisystem injuries. Emergency departments (EDs) should be equipped with a quick and accessible reference for age-specific vital signs as well as tips for key numbers to remember or cutoffs to keep in mind. Check vital signs, temperature, and glucose level immediately. On initiating assessment of the ABCDEs, make sure to oxygenate, start intravenous lines, and begin fluid resuscitation.
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Airway with C-spine protection:
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Clear secretions, and assess patency and need for immediate tracheal intubation
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Indications for early intubation include :
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Airway obstruction, unrelieved by simple maneuvers.
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Apnea.
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Cardiac arrest.
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Decreasing LOC (airway protection and control of CO 2 ).
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Severe maxillofacial trauma.
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Inhalation injury.
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Focus on oxygenation. Always be prepared to support pediatric patients with good quality bag-valve-mask (BVM) ventilation. BVM maintains oxygenation and compensates for poor respiratory effort while providing time to smoothly and properly prepare for a pediatric intubation in the adult ED ( Fig. 1 ).
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