ANESTHESIOLOGISTS COMMONLY PROVIDE CARE TO CHILDREN who have suffered traumatic injuries. These injuries vary in complexity, and patients range from the healthy older child with an isolated elbow fracture to the infant with a life-threatening epidural hematoma. The anesthesiologist should view the management of children with traumatic injuries as a continuum of care that may originate in the prehospital setting with emergency medical services (EMS), progress to the emergency department (ED), and continue through the operating room, the postanesthesia care unit, and the intensive care unit. Anesthesiologists may become involved in all phases of care of the traumatically injured child, with the possible exception of the prehospital setting. The care required is often complex but can be effectively accomplished in a collaborative environment incorporating a standardized process for initial evaluation and management.1 Anesthesiologists should be familiar with these processes to effectively continue this care in the perioperative setting.
Anesthesiologists are essential participants in many capacities during the care of injured children. Operative interventions demand full involvement of the anesthesiologist. In many institutions, anesthesiologists also provide emergency airway and critical care management. From the perspectives of airway control, ventilation, hemodynamic resuscitation, metabolic management, and effective control of pain, anesthesiologists can play a central role in the care of the injured child. Common diseases of childhood are now better understood and more effectively treated, which has resulted in more cures, better outcomes, and an improved quality of life. Despite major reductions in the overall mortality rate for pediatric trauma in recent years, unintentional injuries remain the leading cause of death and disability in the pediatric population of the United States.2 Injury has also emerged as the most common public health threat to children around the world.3
This chapter reviews the key principles of anesthesia management of traumatic injuries to children. This discussion is intended to augment the principles established in the widely accepted Advanced Trauma Life Support (ATLS) program, which is produced by the American College of Surgeons Committee on Trauma.4 Additional resources for the management of the pediatric trauma patient include the Advanced Pediatric Life Support (APLS) course administered by the American Academy of Pediatrics and the American College of Emergency Physicians.5 Many of the topics discussed in this chapter are being investigated to determine the most effective strategy, including volume resuscitation, evaluation of the cervical spine, and prehospital tracheal intubation.
Traumatic injuries are the most common cause of death within the United States for children older than 1 year of age.6 Approximately 20,000 deaths of children occur annually as a result of trauma. Most traumatic injuries in children are a result of motor vehicle accidents (the leading cause of death), falls, nonaccidental trauma (Fig. 38-1), drowning, or extremes of temperature.
FIGURE 38-1 Fatalities by age group from child abuse and neglect in 2010. Most of these children are 3 years of age or younger. (Data from the U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth, and Families, Children’s Bureau; Child Maltreatment 2010. Available at
www.acf.hhs.gov/programs/cb/pubs/cm10/cm10.pdf#page=70 [accessed September 2012]).
The epidemiology of trauma reflects its continued growth as a significant health risk for children of the world. Table 38-1 illustrates the recent incidence of injury types per 100,000 U.S. children.2 Motor vehicle trauma is a major threat to the health of children in the United States, which has spurred research to identify methods to improve their protection.7–9
Pediatric and adult injury patterns and treatment protocols are different.10 Head injuries are the leading cause of death in children. One explanation for this is the proportionately large head of children compared with adults. Thoracic injuries are the second leading cause of death for pediatric trauma patients. Due to increased rib cage pliability from a lack of bony calcification and the flexible cartilaginous component, severe internal injury can occur in children without obvious external signs such as rib fractures. Blunt abdominal trauma frequently can be treated with close observation, avoiding operative intervention. Penetrating abdominal trauma usually requires surgical exploration. However, diagnostic laparoscopy is being used in lieu of exploratory laparotomy in hemodynamically stable children to evaluate and repair many types of abdominal injuries.11
Nonaccidental trauma, also referred to as shaken baby syndrome or child abuse, is an epidemic that continues to grow in virtually all parts of the world. Although 3 million reports of nonaccidental trauma are filed every year in the United States, most experts believe that this represents less than one third of the actual cases.12,13 Every state has stringent laws for reporting nonaccidental trauma. These laws are designed to assist the health care provider who suspects mistreatment and to punish health care providers who do not appropriately report potential neglect. It is the responsibility of every physician involved, including the anesthesiologist, to be aware of the potential for nonaccidental trauma in all infants and children and to report all suspicious observations accurately to the appropriate authorities.
Characteristics of nonaccidental trauma include a history inconsistent with the character and extent of the injuries and a delay in seeking medical assistance.14,15 Nonaccidental trauma should be considered when the history appears improbable. Funduscopic examination may disclose retinal hemorrhages or papilledema, which may suggest forceful shaking of the head or increased intracranial pressure (ICP), respectively. Examination of the skin may show bruises, burns, or other injuries in several stages of healing (Fig. 38-2). A skeletal survey may reveal multiple fractures of various ages occurring typically at the metaphyses of long bones. Occasionally, a child who has previously been silent in the company of the parents or caregiver tells operating room or recovery room personnel about the events surrounding his or her injuries. These reports should be carefully documented and relayed to the appropriate personnel. Maltreated children are often terrified of painful procedures, and the need for sensitivity and reassurance in these settings cannot be overemphasized.
FIGURE 38-2 Common examples of child abuse, also referred to as nonaccidental trauma, are shown. A, Typical areas on children where bruising can be caused by daily living activities. The blue areas indicate regions where normal bruising may occur. The black areas are regions of unusual bruising. Any bruise in the black areas must be considered for possible child abuse. Cutaneous manifestations of child abuse vary. B, A child with obvious facial trauma. C, A whipping injury from a belt plus additional bruises. FIGURE 38-2, cont’d D, A cigarette burn. E, An immersion burn; notice sparing of the popliteal fossa, which is typical of this type of child abuse injury. F and G, Facial bruises. H, Whipping injury from an electrical cord. I, Unusual finger injuries in an infant.
(Photographs courtesy of several child advocates from several institutions who asked to remain anonymous.)
The anesthesiologist encountering a potential victim of nonaccidental trauma may provide the first impartial assessment of the child’s status.16 Physicians, nurses, and other professionals who provide initial resuscitation may be preoccupied with the small child’s acute and potentially life-threatening injuries. Historical data associated with the event may be inaccurate or fictitious at the time of initial presentation. An objective evaluation by the anesthesiologist in preparation for operative intervention may reveal the first objective evidence of nonaccidental trauma. Indications of mistreatment may be subtle, ranging from lack of parental availability for perioperative counseling and consent to irrational refusal of permission for a necessary operative intervention.17,18
The evolution of pediatric trauma systems has significantly improved outcomes and quality of life for trauma victims.19,20 Countries such as the United States have a trauma system philosophy more in line with the military approach. in which prehospital personnel such as paramedics are the initial team to make rapid assessments, initiate efforts at stabilization, obtain radio contact with the medical facility, and transport the child to the trauma center as rapidly as possible.21 This philosophy of minimizing the time on the scene and emphasizing prompt transport to the closest trauma center is called scoop and run.
In parts of Canada and several European countries, initial resuscitation of injured children is commonly performed by physicians who are charged with evaluating the child at the scene, securing the airway, initiating resuscitative measures to maintain hemodynamic stability, and transporting the child to an appropriate trauma center (Fig. 38-3). Instituting these management procedures may result in additional time on the scene. This approach has been called stay and play. Many aspects of this system are being integrated into existing American trauma systems as part of mass casualty disaster management plans.22,23
FIGURE 38-3 Management of pediatric trauma patients. The primary goals are delivery of oxygen, appropriate ventilation, perfusion to vital organs, maintenance of normothermia to mild hypothermia, stability of renal and neurologic function, correction of coagulopathies, avoidance of overhydration, and meticulous management of metabolic demands.
(Modified from Todres ID, Fugate JH, editors. Critical care of infants and children. Boston: Little, Brown; 1996, p. 17.)
Developing a systematic approach to the care of the pediatric trauma patient is crucial. This includes acquiring age- and size-appropriate equipment. Luten and Broselow developed a system that provides immediate guidance for the identification of appropriate equipment and drug doses based on the child’s length.24–27 This system assigns a specific color based on the child’s body length. A corresponding color-coded, length-based wristband can then be placed onto the child, which designates drug doses and devices that match the assigned color. The system is designed to minimize delays, medication miscalculations, and equipment errors.
Over the past 2 decades, there have been dramatic advances in the capability of prehospital providers to recognize the need for and initiate resuscitation of pediatric trauma patients. Part of this progression has been attributed to the development of trauma systems and the commitment of trauma centers to provide more effective medical direction to prehospital providers. Effective management of the continuum of care for trauma patients is optimized if the prehospital personnel communicate the details regarding the child’s injuries directly to the hospital personnel. This information may include details about the mechanism of injury, forces involved, time elapsed from the event, loss of consciousness, estimated blood loss, treatment given, and a summary of suspected injuries.
As trauma systems have evolved and EDs have become overwhelmed by larger patient volumes, effective triage for the pediatric trauma patient has become increasingly important. Care of traumatically injured children requires the use of significant personnel and resources from many services, including the operating room and ancillary services such as diagnostic imaging and transfusion services.28 Inappropriate triage may waste precious resources and potentially limit access to patients most in need if every patient with traumatic injuries, regardless of their severity, is sent to a trauma center. Conversely, not recognizing that a child must be brought to a trauma center may increase morbidity and result in preventable deaths.29,30
The Glasgow Coma Scale (GCS) (E-Table 38-1) and the modified GCS for children (Table 38-2) are the most common scales used to estimate the severity of neurologic injury. The GCS assigns a total score with a range of 3 to 15 that quantifies eye opening, verbal, and motor functions. The Pediatric Trauma Score (PTS) was developed to facilitate the initial assessment and triage of injured children (Table 38-3). As trauma systems have matured and prehospital providers have become more experienced with assessment and field management, the GCS and PTS have emerged as effective tools for determination of appropriate direct transfer to a trauma center.31,32
Effective airway management in the prehospital environment has many challenges, including poor access to the child, lack of use of pharmacologic agents, inclement weather conditions, trauma to the face, and providing care in challenging environments such as an ambulance. Several studies of adult patients undergoing tracheal intubation in the prehospital setting have reported an increased incidence of difficult tracheal intubation,33 need for multiple attempts,34 and undiagnosed esophageal intubation. These events have been reported by all levels of providers, including anesthesiologists.35 However, anesthesiologists have increased success rates and lower complication rates during tracheal intubation compared with other providers.36–38
Unsuccessful prehospital airway management in children may be due to a combination of training, experience, equipment, and environmental issues. A significant proportion of the unsuccessful prehospital tracheal intubations result from ineffective operator training and lack of professional experience. Most prehospital providers, such as paramedics, receive minimal dedicated training in pediatric airway management, including tracheal intubation.39 These providers may not have an opportunity to use their skills on a routine basis. Over time, the psychomotor skills required for pediatric tracheal intubation decay, which likely contributes to the increased complication and failure rates associated with tracheal intubation in children.
Guidelines have proposed that avoidance of airway instrumentation in the prehospital setting may be just as effective as tracheal intubation for pediatric trauma patients. For example, the American Heart Association Pediatric Advanced Life Support (PALS) guidelines state, “Bag-mask ventilation can be as effective as ventilation through an endotracheal tube for short periods and may be safer.”40 The 2010 PALS guidelines state, “In the prehospital setting, ventilate and oxygenate infants and children with a bag-mask device, especially if transport time is short.”40 As a result, many EMS personnel have developed policies containing a scoop and run philosophy for pediatric trauma patients that avoid definitive airway management if the transport time is brief and bag-mask ventilation is effective. Several investigators have also questioned whether prehospital tracheal intubation is the best approach in children who require positive-pressure ventilation. The infrequent need for tracheal intubation in pediatric trauma patients has created obstacles for members of the emergency medical teams to maintain their skills. Multiple studies have demonstrated an increased mortality rate or worsening neurologic outcomes for adult patients who received prehospital tracheal intubation compared with those who received standard bag-mask ventilation.41,42 Several studies that focused on children also reported increased complication rates associated with prehospital tracheal intubation.43–46
There is a trend for using alternative airway devices in the field in adult and pediatric trauma patients. Among the devices that have found favor, supraglottic airway devices have proved easy to use and reliable in the field. Although these devices do not protect the airway from regurgitation and aspiration, they may prevent airway obstruction during transport. One meta-analysis of prehospital alternative airway devices in adults and children indicated that LMAs were very successful in the hands of anesthesiologists and nonphysician flight crews (success rate of 96%) and slightly less successful in the hands of nonphysician clinicians (83%).47 However, there is a dearth of evidence to support a role for the LMA in pediatric trauma.
Anesthesiologists should familiarize themselves with the initial management of pediatric trauma patients in the ED because they may be asked to assist in emergency airway management and intraoperative care. Rapid establishment of provisional diagnoses and priorities of care is essential in the ED management of trauma victims.48 Most trauma centers use a multilayered assessment system consisting of a primary survey with resuscitation, a secondary survey, and definitive management.1
Anesthesiologists can provide more effective intraoperative management if they understand the care of pediatric trauma patients commonly used in the ED. During initial resuscitation, a team member should attempt to obtain a history from the parents, the prehospital personnel, and perhaps the child. It should include the usual questions about drug allergies, medications, and past illnesses and inquiries about loss of consciousness, estimated blood loss, and treatment rendered before arrival at the ED.
Based on the ATLS course, evaluation of the trauma patient occurs in three progressive steps: primary survey, secondary survey, and definitive care.4 The initial evaluation of all trauma patients is the primary survey. The sequence of the primary survey can be remembered as “ABCDE”: airway (A), breathing (B), circulation (C), disability (D), and exposure or environment (E). Many trauma centers have the personnel and resources to simultaneously perform several activities and have prepared trauma rooms, usually in the ED. A trauma cart should be maintained daily in the trauma room and be prepared with all necessary equipment to resuscitate a child (E-Fig. 38-1 and E-Table 38-2). In this circumstance, it would be acceptable for the primary and secondary surveys to occur simultaneously—that is, the primary survey (e.g., volume resuscitation) can occur as a part of the secondary survey (e.g., drawing blood samples).
The airway (A) should be evaluated for patency and opened using a jaw-thrust technique if obstruction is encountered. Immobilization of the cervical spine should be maintained. The child’s breathing (B) and ventilation should be evaluated, and immediate intervention should take place if they are inadequate. Circulation (C) is evaluated by palpation of peripheral pulses, blood pressure, sensorium, and skin turgor. Control of external hemorrhage by the application of direct pressure is also part of the circulation phase. Disability (D) is evaluated by examining the child for neurologic injuries. A GCS score of 8 or less implies severe neurologic injury (see Table 38-2), and immediate intubation (with in-line neck stabilization if indicated) is strongly recommended. Exposure (E) of the whole child is essential for a complete examination. The environment (E) should consist of a heated treatment area that is ideally prepared in advance of the child’s arrival.
E-FIGURE 38-1 Trauma cart. This shelving system, devised in 1984 by Robert Luten, MD, remains the most effective and efficient way to store age- and weight-based resuscitation equipment and to ensure that all compartments are always stocked.
The importance of an adequate and secure airway cannot be overemphasized. All trauma patients should initially receive 100% supplemental oxygen. Tracheal intubation of most children with major trauma occurs by using a rapid-sequence induction (RSI) with appropriate medications or, in some situations, while the child remains awake. When increased ICP is suspected, measures to prevent further increases during tracheal intubation should be undertaken. Regardless of site or mode of tracheal intubation, proper position and patency of the tracheal tube must be confirmed as soon as the child arrives in the ED.49 Techniques to verify correct tracheal tube position may initially include auscultation, direct laryngoscopy, and determination of the tracheal tube length from the lips and the detection of end-tidal carbon dioxide (E-Fig. 38-2). All children should be monitored with frequent blood pressure measurements and continuous electrocardiography and pulse oximetry.
E-FIGURE 38-2 Appropriate endotracheal intubation is best confirmed by a measurement of exhaled carbon dioxide. When a capnograph is unavailable, portable products, such as the Easy Cap II (Mallinckrodt, Inc., Pleasanton, Calif.), which has a dead space of 25 mL and usually is indicated for patients weighing less than 15 kg, or the PediCap, which has a dead space of 3 mL and is designed for children who weigh 1 to 15 kg, may be used.
In trauma patients, shock is most commonly the result of hypovolemia. Cardiogenic shock, although rare in children, may be associated with chest trauma or preexisting cardiovascular disease. Attempts should be made to place two large-bore intravenous lines that are appropriate for age. One strategy for a child who has hypotension is to administer an initial bolus of 20 mL/kg of an isotonic crystalloid solution such as lactated Ringer’s solution or normal saline. Fluid administration may be repeated with additional boluses of isotonic crystalloid as required to stabilize the blood pressure into the normal range. Blood products should be considered when the volume of isotonic crystalloid surpasses 40 to 60 mL/kg and the blood pressure remains unstable. Glucose-containing solutions usually should not be administered because they may produce unacceptable hyperglycemia and worsen the neurologic outcome.
For traumatic injuries that are primarily located in the abdomen, attempts should be made to place intravenous access in the upper extremities. Traumatic injuries that are located in the chest should have vascular access placed in the upper and lower extremities to account for disruption of a major vessel above or below the right atrium. If vascular access cannot be obtained promptly, femoral venous or intraosseous access should be strongly considered (see Fig. 48-6, A-D, and E-Fig. 48-1, A-E).50
When the primary survey and initial resuscitation have been completed, a secondary survey is initiated. The secondary survey is a complete head-to-toe examination designed to identify additional injuries not recognized during the primary survey. Frequent reassessment of the vital signs is critical during this phase. If clinical deterioration occurs, the primary survey and initial resuscitation should be repeated. Head examination should include visual inspection, palpation, assessment of pupillary size and reactivity, and a funduscopic examination. The cervical spine, chest, and abdomen should be evaluated in detail. Chest examination should involve inspection for wounds, palpation for tenderness and crepitance, and auscultation for bilateral breath sounds. The abdomen should also be examined carefully. In children, the physical signs of intraabdominal injuries can be subtle, especially in sedated or neurologically depressed children. The extremities should be inspected for tenderness, bruising, deformities, and vascular insufficiency.
Diagnostic testing is completed during the secondary survey.51,52 Imaging studies, including computed tomography (CT) scans of the brain, neck, chest, abdomen, and pelvis, may be obtained, along with a bedside focused abdominal sonography for trauma (FAST) examination, which is used to detect intraperitoneal free fluid. Standard radiographs of the chest and extremities may also be obtained during the secondary survey. Laboratory studies, including blood count, electrolytes, and blood product crossmatching, are completed during the secondary survey. If the child remains unstable despite aggressive resuscitation, the patient should be considered for emergent transfer to the operating room for surgical intervention. After the child has been stabilized and all injuries have been identified, plans for definitive care can be made. This may include admission to the intensive care unit, an acute care bed, or an observation unit; discharge home with outpatient follow-up and consultation with specialists; or transfer to the operating room.
Anesthesiologists, surgeons, and other personnel should work as a coordinated team when managing children with trauma. This collaborative approach can optimize the prompt and reliable identification of suspected injuries so that the anesthesiologist can more effectively anticipate the magnitude of bleeding, physiologic effects, and nature of the surgical procedures. By understanding the appropriate evaluation and initial management of the pediatric trauma patient, the anesthesiologist can recognize injuries that might have been undiagnosed and anticipate the resultant effects intraoperatively.53
The approach to diagnosis and treatment for the pediatric trauma patient is dictated by the degree of urgency (see Fig. 38-3). For critically ill and hypotensive children who need immediate surgical intervention, resuscitation and the administration of anesthesia may need to be provided simultaneously. Basic principles are applied in this circumstance, including establishment and protection of the airway, maintenance of adequate ventilation, and support of hemodynamics with fluids, blood products, and vasoactive medications. Establishment of generous vascular access is recommended in the critically injured child; this may necessitate a vascular cutdown or placement of an intraosseous needle for volume resuscitation. Anesthetic medications should be cautiously administered in this situation by carefully titrating the dose of the medication to the child’s hemodynamic status.
For the child who requires emergent transfer to the operating room, does not have a secure airway in place, and is not anticipated to have a difficult airway, induction of anesthesia should begin with preoxygenation and be followed by intravenous RSI. If the child is thought to be hypovolemic, a preoperative fluid bolus of balanced salt solution (20 mL/kg) should be administered before induction of anesthesia and drugs selected that maintain circulatory homeostasis. If concern exists regarding a possible cervical spine injury, which applies to most trauma patients, the practitioner should also incorporate in-line immobilization of the cervical spine during airway management and all transfers (Fig. 38-4).54 Arterial and central venous line placements should be selected on a case-by-case basis. The anesthesiologist should be vigilant for the development of undiagnosed traumatic injuries that may manifest in the operating room. For a child who is critically ill, surgery should proceed without delay, and monitoring may initially include only a blood pressure cuff, pulse oximeter, and electrocardiogram.
FIGURE 38-4 Cervical spine control must be maintained during intubation. The child with a cervical spine injury requiring a definitive airway should be intubated under controlled circumstances. A neurosurgeon or the primary trauma physician should stabilize the head and neck during intubation. Oral intubation is the preferred route. In-line stabilization before attempts at laryngoscopy should be made so that the head is stabilized and prevented from rotating from side to side and from flexion and extension. No traction should be placed on the cervical spine because it is associated with increased neurologic deficits in patients with proven cervical fractures.
As conditions permit, hemodynamic monitoring with arterial and central venous catheters may be established. Arterial catheters for trauma patients may be helpful in some situations, including concern about the adequacy of ventilation and need to frequently sample arterial blood gases, the need for frequent and repeated blood sampling (i.e., severe hemorrhage or metabolic derangements), hemodynamic instability; and the need to alter the blood pressure rapidly. In a setting with significant actual or anticipated blood loss, establishment of large-bore venous access is of much greater priority than obtaining arterial access. Establishment of central venous access may be delayed until hemodynamic stability is established, because peripheral venous lines typically can be obtained quickly and provide effective volume resuscitation. Rotating the neck to place an internal jugular central line in a trauma patient with a possible cervical spine injury should be avoided.
After oxygenation, ventilation, and circulation have been stabilized, the anesthesiologist may need to address other concerns. If it has not been possible to administer acceptable doses of anesthetic medications, they are administered in stepwise increments after hemodynamic stability has been achieved. Evidence from adult victims of major trauma indicates that recall is more common in these cases. It is reasonable to assume that a similar risk holds true in children.55–57 An intravenous dose of midazolam is strongly recommended,58