Blunt force is responsible for the majority of serious injuries in children. High energy impact produces more multisystem injuries, related to patient size and momentum. Age-based differences in cognition, size and vital signs present special challenges.
Priorities of pediatric evaluation and stabilization are identical to those in adults except for the following important differences which include airway management, vascular access, definition and recognition of shock, fluid requirements, medication dosages, equipment needs and importance of the family unit.
Evaluation of a young patient unable to describe pain and localize symptoms requires patience and experience. An injured child is frightened and often separated from parental support. Emotional trauma may create more long-term morbidity than cognitive or physical impairment.
Pediatric vital signs are age dependent. Resuscitation fluids and drug dosages can be calculated prior to the patient's arrival in the trauma center by estimating weight based on patient age. The child also has a faster metabolic rate and higher relative body surface area, with increased thermal loss.
Priorities of Pediatric Evaluation and Stabilization
Relative to the adult, the child's larynx is anterior and the trachea is short. Endotracheal tube size is determined by the diameter of the fifth finger or nares, and cricothyroidotomy is rarely indicated. In small children, gastric decompression may improve ventilation dramatically.
A smaller blood volume makes blood loss more significant. Children maintain blood pressure with tachycardia and vasoconstriction, and when this compensation is exhausted, severe shock develops rapidly. Expeditious vascular access is obtained by peripheral venous or intraosseous routes.
Shock is treated with 20 ml/kg lactated ringers infused rapidly and repeated once if necessary. If the patient continues to deteriorate, 10 ml/kg packed cells is given as a bolus. A normal pulse rate, blood pressure over 80 and urinary output of 1 ml/kg/hr usually signifies adequate fluid resuscitation.
Rib fractures are present with only half of significant pediatric thoracic injuries. Continuous non-invasive monitoring with pulse oximetry and transcutaneous C02 monitoring detects early respiratory failure. Chest tubes are placed through a subcutaneous tunnel to prevent air leak.
Abdominal solid organ injuries are frequent, are well demonstrated by double-contrasted computed tomography, and rarely require operative intervention. Intestinal or pancreatic injury is uncommon, and without a history of focal impact to the upper abdomen, should raise suspicion of abuse.
Pediatric head injuries are more often diffuse than focal, are often associated with transient seizures, and may produce apnea. In contrast to adults and children, intracranial bleeding can produce shock in infants. The Glasgow Coma Score is modified for preverbal children. Spinal cord injury is rare.
Extremity fractures are common, and repeated evaluation for compartment syndrome is crucial. Infants and toddlers have pliable skeletons, resulting in unique greenstick and buckle fractures, and requiring significant, often nonaccidental, force to produce breaks. Growth plate injury may impair subsequent limb growth.
Child abuse must be considered when there is a delay in medical care, doctor shopping, incomplete immunizations, and a vague, inconsistent history incompatible with physical exam findings. The parent may be preoccupied, hostile or defensive, while the child is often sad, withdrawn or frightened. Poor hygiene, inappropriate clothes, failure to thrive, developmental delay, and injuries in various stages of healing are visible clues. Bruises in unusual locations, fractures in infants and toddlers, brain injury under 2 years of age, abdominal hollow organ injury, perineal injury and burns are suspicious for abuse.
Pediatric trauma affects the entire family. Children require explanations in language they can understand. Play therapy and pediatric rehabilitation are important facets of trauma care. Comprehensive care of the injured child is best provided by an organized trauma system with treatment supervised by a pediatric surgeon.
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