Pediatric Trauma

ABCs

1. Airway
1. Anatomy
• the large occiput in small children (<3) causes passive flexion of the cervical spine when on a spine board. This leads to the posterior pharynx buckling anteriorly (sniffing position). To keep the cervical spine neutral, a 1-inch thick layer of padding should be placed under the child’s entire torso.
• the tongue and tonsils are relatively large, which may make visualization of the larynx difficult
• the larynx and vocal cords are more cephalad and anterior, making visualization during intubation more difficult
• the trachea is short in infants. This can result in right mainstem intubations, inadequate ventilation, accidental tube dislodgement. Optimal ETT depth is 3 times the appropriate tube size.


2. Management
1. Clearing the airway
• maintain neutral alignment of the spine (padding under torso of toddlers)
• jaw thrust maneuver to open the airway
• clear the mouth and oropharynx of secretions and debris


2. Oral airway
• should only be inserted if child is unconscious (gag reflex → vomiting)
• don’t insert the airway backward and then rotate it into position - this can result in hemorrhage from the soft tissues in the oropharynx
• directly insert the airway, using a tongue blade to depress the tongue


3. Orotracheal Intubation
• most reliable means of establishing an airway
• anatomic limitations preclude nasotracheal intubation
• must protect the c-spine
• correct ETT size can be determined by using a tube the same size as the external nares or tip of the 5th finger
• preoxygenate before intubating
• infants should be pretreated with atropine to prevent bradycardia from direct laryngeal stimulation
• sedation may be provided with midazolam or etomidate
• succinylcholine is used for temporary paralysis
• correct depth is 3 times the ETT size at the gums
• correct positioning should be confirmed byend-tidal CO2 detection, clinical exam, and CXR
• because of the short length of the trachea, tube dislodgement occurs easily


4. Rescue Airways
• LMA, intubating LMA, or needle cricothyroidotomy may be necessary if orotracheal intubation is unsuccessful and airway maintenance and control cannot be maintained by bag-mask ventilation
• surgical cricothyroidotomy is rarely indicated for infants or small children. It can be performed in older children if the cricothyroid membrane can be easily palpated (usually by 12 years of age)


2. Breathing and Ventilation
• hypoxia is the most common cause of cardiac arrest in children
• prior to arrest, hypoventilation causes respiratory acidosis, which is the most common acid-base disorder in injured children
• needle decompression of a tension pneumothorax is accomplished over the top of the third rib in the midclavicular line
• chest tubes are inserted in the fifth intercostal space, just anterior to the midaxillary line


3. Circulation and Shock
1. Recognition of Shock
• child’s increased physiologic reserve allows for maintenance of blood pressure in the normal range, even in the presence of shock
• mean SBP in children is 90 mm Hg plus twice the child’s age in years
• lower limit of normal SBP is 70 mm Hg plus twice the child’s age
• DBP should be about two-thirds of the SBP
• loss of 30% of blood volume may be required to register a decrease in systolic blood pressure
• hypotension in a child represents decompensated shock and indicates a blood loss of > 45% of the circulating blood volume
• tachycardia and poor skin perfusion are often the only early signs of hypovolemia
• however, tachycardia may also be caused by pain, fear, stress
• more subtle signs of blood loss in children include weak peripheral pulses, narrowed pulse pressure (<20 mm Hg), cool extremities, decreased level of consciousness, poor urine output


2. Determining a Child’s Weight
• necessary for determining fluid volumes and drug dosages
• ask parent or caregiver if available
• length-based resuscitation tape can be very helpful
• calculate: ((2 x age) + 10) in kgs


3. Circulating Blood Volume
• infant’s blood volume is 80 mL/kg
• child’s blood volume is 70 mL/kg
• bolus of 20 mL/kg represents 25% of a child’s blood volume


4. Venous Access
• preferred sites:
• percutaneous peripheral: antecubital fossae, saphenous vein at ankle
• intraosseous: anteromedial tibia, distal femur
• percutaneous: femoral veins
• percutaneous: external jugular
• venous cutdown: saphenous vein at the ankle


1. Intraosseous Infusion
• should be discontinued once suitable venous access has been established
• should not be done in an extremity with a fracture
• complications include cellulitis, osteomyelitis, compartment syndrome, and iatrogenic fracture


5. Fluid Resuscitation
• based on child’s weight
• initial fluid bolus of 20 mL/kg
• PRBCs are given as a bolus of 10 mL/kg
• as in the adult population, there is a move towards restricting fluid resuscitation in favor of the balanced use of PRBCS, FFP, and platelets
• nonresponders to fluid and blood boluses likely need an operation


6. Urine Output
• goal for infants < 1 year old is 2 mL/kg/hr
• goal for younger children is 1.5 mL/kg/hr
• goal for older children is 1.0 mL/kg/hr


4. Thermoregulation
• high body surface area to body mass in children increases heat exchange with the environment, directly affecting the body’s ability to regulate core temperature
• increased metabolic rates, thin skin, and lack of subcutaneous fat also increase heat loss and caloric expenditure
• hypothermia prolongs coagulation times and adversely affects CNS function
• child must be kept warm during the primary survey and resuscitation: warm room, thermal blankets, warm IV fluids and blood products