Pediatric Trauma Resuscitation

Abstract

Care of the injured child differs in important ways from that of the injured adult. The pediatric trauma surgeon must account for these differences when crafting a plan of care. Pediatric patients differ from adults in measurable, distinct biomechanical ways: less mineralization of bone means that the skeleton offers less protection to structures in the CNS, thorax, and abdomen; decreased muscle strength per unit volume means not only diminished protection of the cervical spine and abdomen, but decreased Starling effect in the heart; increased surface area relative to body mass means dramatically increased vulnerability to radiative and evaporative loss of heat and fluid; and scaling of energetics means that babies require three times the energy per kilogram of body mass than adults and have far less reserve.

Appendices

Summary Points

The patterns of injury in children are different those commonly seen in adults.

Children are more likely to develop spinal cord injury without radiographic abnormality (SCIWORA), internal injuries without bone fractures, and airway compromise with minimal change in the diameter due to edema or compression.

The physiologic response of children to injury is different than that of adults.

Children increase cardiac output in response to hypovolemia by increasing heart rate. Any degree of hypotension suggests massive hypovolemia and impending shock.

The role of the pediatric trauma surgeon is to protect the child by keeping the trauma bay focused on the plan and destination, preventing iatrogenic injury, and managing surgical injuries (either operatively of non-operatively).

All procedures performed in the field or during transport (endotracheal intubation, intravenous access, cervical spine immobilization) should be confirmed to be appropriate in the trauma bay – never assume they were done properly.

Digital rectal examination is rarely useful and should be performed only when absolutely necessary.

Except for a single AP CXR, routine radiographic imaging of the pelvis, abdomen or spine is usually unnecessary.

Most children can have their cervical spine cleared on the basis of physical examination and a single lateral cervical spine X-ray.

Editor’s Comment

The standardization of trauma care for adults and children with incorporation of science-based protocols is one of the most significant advances in medical science of the twentieth century. Modern pediatric trauma systems are examples of the benefits of teamwork and the practical application of evidence-based diagnostic and therapeutic concepts. The trauma bay should have one recognized leader who nevertheless welcomes input from any member of the team. The leader should use a gentle but firm voice without shouting or bullying. Every finding and intervention should be carefully recorded on paper and videotaped for later review and as part of a formal quality assurance program. Parents should be allowed to be present and every aspect explained to them by an experienced observer at their side. The child should be kept warm and comfortable, with narcotics and anxiolytics if necessary, and everything should be explained in an age-appropriate manner. All procedures should be done by experienced personnel or residents in training, but never by a “first-timer” – the stakes are too high and the teaching value overrated.

In pediatric trauma, there is a tendency for exaggerated personal emotional reaction and heavy-handedness in the delivery of care: over-hydration, over-exposure to cold and radiation, over-protection (incomplete physical examination, tubes and catheters that are too small), superfluous laboratory studies, excessive concern about medical liability, and failing to use the proper size implements. In every aspect of the injured child’s care, one should strive for a “just-right” approach based on scientific evidence and experience.

Diagnostic Studies

Thorough primary, secondary, and tertiary physical examinations.

Anterior-posterior chest radiograph on admission.

Cervical spine X-rays (lateral ± AP ± odontoid) when there is any sign of injury to the head or neck.

FAST/abdominal US (indications in children still unknown).

Diagnostic peritoneal lavage (used only in very unusual circumstances).

Flexion-extension cervical X-rays.

Plain X-rays at all sites that are clearly injured or tender.

Computed tomography of the head, neck, chest, or abdomen when indicated.

Head and/or spine MRI when diffuse axonal injury of brain or SCIWORA is suspected.

CT-angiography when major vascular injury is suspected.

CT-cystogram if bladder injury is suspected.

Parenteral Preparation

Your child is being treated according to well-­established and scientifically-based protocols and by experienced and caring individuals.

We need to be thorough but we will be gentle and thoughtful at every step.

Technical Points

Intravenous access can be difficult in young children, making the intra-osseous catheter an excellent option in many cases.

In children, endotracheal intubation can be challenging and dangerous. In the emergency setting children should be intubated by the most experienced clinician using appropriate rapid induction techniques.

Gastric distension can compromise ventilation and sometimes causes bradycardia and hypotension – consider placing a naso- or orogastric tube to decompress the stomach.

Foley catheters are not routinely placed except in critically injured children, in which case an appropriate size catheter should be placed with gentle technique to prevent urethral injury and subsequent stricture.