Pediatric Trauma

Introduction

• Traumatic injury related to motor vehicle collision is the leading cause of pediatric death and disability globally and is the cause of 50% of pediatric deaths.
• Until recently, TBI from motor vehicle crashes was the most common cause of pediatric mortality in the United States but has now been surpassed by firearm injury; other causes include drowning, domestic fires, homicide, and falls.
• Exsanguination and failure of proper airway management (oxygenation and ventilation) are the most common causes of preventable death in pediatric trauma.¹
• Advanced Trauma Life Support guidelines now prioritize exsanguinating hemorrhage over the remainder of the primary assessment, modifying the familiar mnemonic “ABCDE” to “X-ABCDE”.
• Given their small stature and larger head-to-body ratio, blunt mechanism of injury often results in both TBI and multi-organ system injury. See the OA summary “Pediatric Traumatic Brain Injury” for more details. Link

Pediatric Primary Trauma Survey

• The primary survey aims to deal with immediate life-threatening injuries and prioritize resuscitation of the unstable patient.² See the OA summary “Initial Evaluation of Trauma Patients” for more details. Link
• eXsanguination: Address severe hemorrhage with tourniquets and dressings
• Airway and Breathing: secure the airway, oxygenate and ventilate, address tension pneumothorax or hemothorax.
• Circulation: maintain or restore cardiac output, give volume if needed, send blood for type and cross, alert blood bank if massive transfusion likely
• Disability: assess level of consciousness using the modified Glasgow Coma Scale (GCS), check for lateralizing signs, and examine the pupils
• Exposure: Inspect body to look for burns, chemical contamination, occult injuries and treat temperature dysregulation

Secondary Trauma Survey

• This is a rapid, thorough head-to-toe physical examination to identify injuries not identified during the primary assessment. It also includes a consolidation of the past medical history, consideration of the mechanism of injury, and, ultimately, diagnostic and therapeutic interventions.

Physical Examination

• Remove clothing for thoroughness (with an attempt to maintain age-appropriate patient modesty and avoid major heat loss in smaller children and infants)
• Intermittent vital signs
• Head and face: scalp hematoma, skull fractures, fontanelles, pupils.
• Neck: c-spine immobilization, airway hematomas, vascular injury
• Chest: crepitus, flail chest, asymmetric breath sounds, endotracheal airway (if intubated)
• Abdomen: distension, seatbelt sign (internal injury), swallowed air
• Genitals and Anus: rectal, anal, perineal injury, sphincter tone
• Extremities: bony deformity, fractures, neurovascular injury, compartment syndrome
• Skin: burns, contamination, infection, hypothermia
• The child should be prepared and stabilized for necessary imaging and diagnostics, such as chest, pelvis, and spine radiographs; computed tomography (CT) of the chest, abdomen, and pelvis and head; extended Focused Assessment with Sonography in Trauma (eFAST) exam; and diagnostic peritoneal lavage (DPL). Conscious pediatric patients will likely be very distressed and uncooperative and will often require a secured airway and sedating medications dosed to achieve immobility and safety for imaging and other procedures.
• Upper abdominal distension from swallowed air may be managed with orogastric tube decompression, which will facilitate ventilation and lung expansion.
• The PECARN Head Injury guidelines can help score the necessity of CT head imaging in pediatric trauma patients (children are at greater risk of adult malignancy with significant doses of iatrogenic radiation exposure).
• In suspected cervical spine injury, appropriately sized cervical collars should be used, and patients should be moved with caution.
• Manual In-Line Stabilization (MILS) may be preferred for management of the infant airway when there is concern for C-spine injury to optimize ergonomics.
• Children suffer spinal cord injury without radiologic abnormality (SCIWORA) more often than adults and thus should have precautions taken when clinical suspicion is high.

Major Pediatric Injuries

Thoracic and Abdominal Trauma

• Chest wall compliance allows the transfer of blunt-force energy to the lung parenchyma; the presence of rib fractures and mediastinal injury indicates a high-energy mechanism.
• Mediastinal structure mobility puts children at greater risk for tension pneumothorax (an immediately life-threatening injury).
• Unlike in adults, chest injuries can often be diagnosed with standard screening radiographs and do not require advanced imaging.
• Thoracotomy is rarely required; supportive care and chest tube placement are preferred.
• Upper abdominal distention in a crying child may be due to enterically trapped air, which can be vented with an orogastric tube.
• An examination revealing shoulder or laparotomy belt markings should raise suspicion of intra-abdominal injury, particularly when combined with hemodynamic instability or peritoneal free fluid.
• The eFAST examination can identify free fluid in the abdomen and pelvis in hemodynamically unstable patients, thereby informing the decision to proceed with surgical exploration.
• DPL is rare in children but can be used in hemodynamically unstable children when eFAST and/or safe transport to CT are not possible.
• Abdominal injuries related to bicycle handlebars, lap belt car seats, blunt pancreatic injury, and bladder rupture are all considerations more likely in the pediatric patient than the adult.

TBI

• Signs of TBI include a loss of consciousness any time after a traumatic event, as well as episodes of emesis.
• Children are at greater risk for TBI due to large head size, less myelination, and thinner cranial bones.
• For school-age children and younger, car bumper height corresponds to the level of the thorax and head, increasing the risk of TBI from pedestrian and motor-vehicle collisions.
• A modified GCS is used to assess children under the age of five, with nonverbal vocalizations and cries used in place of speech (Table 1).
• At a GCS of 8 or less, a child should be intubated, and neurosurgery consulted for assessment and possible placement of intracranial pressure (ICP) monitoring.
• Mechanical ventilation can be used to titrate PaCO₂, cerebral blood flow, and manage ICP. Caution is warranted, given that cerebral autoregulation is often impaired in TBI.
• Blood pressure titration and continuous ICP monitoring can be combined to estimate an age-appropriate cerebral perfusion pressure greater than 40 mmHg in 0–5 year olds, greater than 50 mmHg in ages 6-17, and greater than 60 mmHg in ages 18 and up.
• Proper oxygenation and ventilation are essential to keep pace with the greater cerebral metabolic rate compared to adults in order to avoid hypoxic brain injury.
• Cerebral contusions and intracranial bleeds can be diagnosed by a head CT.
• Close monitoring of the quality and quantity of urine output can help diagnose the development of diabetes insipidus and syndrome of inappropriate antidiuretic hormone secretion.
• Hyperglycemia with blood glucose levels greater than 250 mg/dL has been associated with poor outcomes following pediatric TBI.³

Burn Injuries

• Scald injuries are the most common burn in children, followed by open flame and contact chemical burns (70% of pediatric burns are associated with hot liquids).
• Carbon monoxide and cyanide poisoning should be considered in burns secondary to fires involving smoke inhalation and combustible plastics.
• Children should be transferred to a regional burn center for management after initial resuscitation per the criteria from the American Burn Association.
• Prognosis and survival after a burn improve with increasing age.
• Body surface area (BSA) burn estimation should account for the infant and child head being 18% BSA vs. the adult 9% (reference age-appropriate pediatric Lund and Browder chart). See the OA summary “Burn Injuries: Initial Evaluation and Management” for more details. Link
• Large volume blood and insensible volume loss can occur with exposed and damaged capillary beds, resulting in unanticipated severe hypovolemia.
• The Cincinnati and Galveston fluid resuscitation formulas are designed to meet the needs of children (especially those below 30 kg) with the inclusion of dextrose and consideration of insensible losses and maintenance needs (Table 2).
• Fluid resuscitation is clinically targeted to a urinary output of 0.5-1.0 cc/kg/hr., with regular assessment of need and other clinical signs.
• Analgesic and anxiolytic medications should be dosed to clinical effect in the setting of acute metabolic changes and fluid shifts in the perioperative burn care environment; required effective doses are often increased.

Special Considerations in Pediatric Population

Vascular Access

• Intravenous (IV) Access will likely be difficult in the hypovolemic or acutely distressed child.
• Antecubital and saphenous veins are preferred landmark percutaneous targets, but if available, ultrasound should be quickly employed to locate deeper veins.
• The compliant pediatric arterial system increases the risk of inadvertent arterial cannulation and misidentification of venous structures, particularly in shock.
• Intraosseous (IO) access is acceptable and can be obtained at the proximal or distal tibia, the distal femur, and the proximal humerus, with caution for inadvertent infiltration, growth plate injury, incorrect placement, and correct needle size selection (18G IO in infants and 15G in young children).
• IO placement is contraindicated in an extremity with a confirmed or suspected fracture, and at the site of recent IO insertion or surgical intervention.⁴
• Lower limb IO access should be reconsidered if inferior vena cava injury is suspected.
• Multiple practitioners should simultaneously attempt to obtain access, with a low threshold for escalation to IO or femoral and jugular central venous access, with expeditious prioritization over patient comfort, topicalization, and other standards of pediatric care in low-acuity settings.
• Intramuscular or intranasal ketamine and/or midazolam can be effective agents to increase patient comfort and compliance with essential lines and access.

Volume Resuscitation and Hemorrhage Control

• The Pediatric Adjusted Shock Index (SIPA) accounts for age-related changes in normal heart rate (HR) and systolic blood pressure (SBP) to establish age-specific maximum cutoffs for the shock index (maximum normal HR/minimum normal SBP).
• Children have robust sympathetic compensation, with hypotension being a late sign of decompensated shock after prolonged tachycardia to maintain cardiac output.
• Infants have a less compliant myocardium with cardiac output dependent upon HR, with very high HRs (more than 180 bpm) causing worsening filling time.
• Normotension can be maintained with up to 40% loss of intravascular volume.
• In contrast to adults, infants with open fontanelles and unfused cranial bones will have a compliant intracranial compartment into which they can hemorrhage large volumes.
• Body weight estimation is critical for appropriate resuscitation and can be quickly approximated using tools such as the Broselow pediatric emergency tape or the formula [(2 × age in years) + 8] = weight in kilograms.
• Immediate resuscitation with a bolus of warmed isotonic crystalloid at 20 cc/kg and/or balanced blood product administration (1:1:1 Red Blood Cells: Fresh Frozen Plasma: Platelets) at 10-20 cc/kg (a pediatric “unit” of product) should be prioritized.
• A warmer should be used for all blood products, with detailed accounting of multiple “units” given from a single bag. A rapid transfusion device like the Belmont will often be impractical and dangerous in small patients.
• A stopcock with a 10, 20, or 50 cc syringe in line with the product warmer is a practical way to titrate and account for exact blood volumes and “units” of product administered (Figure 2).
• Hypocalcemia is common with ongoing transfusion; for every 20 cc/kg of blood product, the patient should receive 5-10 mg/kg calcium chloride or 15-30 mg/kg calcium gluconate (calcium chloride should be given only via central access to avoid catastrophic extravasation injury).
• Emerging evidence and practice trends suggest that use of low titer o whole blood may be a preferred product for balanced transfusion in pediatric trauma resuscitation and a logistically easier alternative to 1:1:1 component therapy, with ongoing clinical trials for efficacy (see the MATIC-2 trial).⁵ See the OA summary “Whole Blood Transfusions in Pediatric Anesthesia” for more details. Link
• Tranexamic acid should be considered as an antifibrinolytic for any pediatric trauma with risk for ongoing bleeding or hemorrhagic shock at a bolus dose of 10-40 mg/kg, followed by an infusion at 5-10 mg/kg/hour.
• Pediatric massive transfusion is defined as the administration of more than 40 cc/kg of products within 24 hours.

Thermoregulation

• Healthy pediatric patients are at greater risk of hypothermia and temperature dysregulation under general anesthesia, with an additive risk in the setting of trauma and burns.
• Temperatures can be labile and rapidly responsive to forced air warming techniques and overhead convection heat lamps.
• Heat loss can be mitigated by pre-warming the operating room, using warm blankets and fluids, forced-air warm blankets, and a humidified anesthetic circuit.

Pain Management

• Hemodynamically stable anesthetic agents (e.g., ketamine, midazolam) and weight-based dosing can be utilized in infants and small children to provide amnesia and avoid clinical decompensation (episodic memory formation is not thought to begin until approximately age 3-4).
• In neonates, a combination of high-dose opioid and paralytic is a proven, effective, and hemodynamically stable approach (i.e., fentanyl and rocuronium).
• Pediatric patients may require regular wound care in the postop period with repeated dressing changes that may precipitate worsening pain and anticipatory anxiety.
• Repeated exposure to opioid analgesics may result in rapid development of tolerance, requiring the use of a multimodal strategy to include acetaminophen, ketamine, and regional techniques with local anesthetics.
• Nonsteroidal anti-inflammatory drugs should generally be avoided to prevent increased bleeding and renal injury in the trauma setting.
• Weight-based dosing values should be referenced and confirmed with multiple practitioners, especially when the team is unfamiliar with pediatric anesthetic care.

Nonaccidental Trauma (NAT)

• Children with traumatic injuries related to abuse have a mortality rate six times greater than those with unintentional injuries.
• In children less than 12 months old, TBI from NAT is a leading cause of death.⁶
• Thorough history and evaluation are essential to prevent harm in the postoperative period, particularly in children under 2 years.
• Factors suspicious for NAT include⁷
  • Discrepancy between the medical history provided and the degree of physical injury.
  • Long interval between injury and presentation for care
  • History of repeat visit for the same traumatic mechanism
  • Discrepant history between parents or caregivers
  • An injury that is unlikely given the developmental stage
  • Multiple bruises in different stages of healing
  • Genital/perianal/perioral injuries
  • Retinal hemorrhage
  • Long bone fractures in children less than 3
  • Skull/rib fractures in children less than 2
• Caring for the child with suspected NAT can be very emotionally distressing for both the parent/caregiver and the clinician and should proceed in collaboration with a dedicated specialist team that can escalate and investigate appropriately.
• Most clinicians are mandated reporters, meaning that they are bound by law to report incidents of abuse to government authorities (even if only suspected).

Systems Considerations and Family-Centered Care

• Some evidence suggests reduced morbidity, mortality, and imaging burden when a pediatric patient is treated at a dedicated pediatric trauma center compared with an adult trauma center.⁸
• Most children will be initially assessed and cared for in a facility with limited pediatric resources, and an adult trauma team must be ready to provide knowledge of local and regional resources, basic pediatric airway management, skill with pediatric vascular and IO access, fluid resuscitation, proper equipment sizes, early involvement, and access to a surgeon with pediatric expertise.
• Children in need of complete trauma care, including prevention and rehabilitation, should be transferred to a Level I center with greater minimum numbers of pediatric admissions and thus greater staff and team experience (see Table 3).
• As clinically appropriate, parental presence or involvement, or the involvement of child life specialists, can help create a more comfortable environment for a developmentally aware and anxious child by using toys and distraction technologies such as notebooks and interactive games, though this will not be practical in an emergent setting.
• Early administration of amnestic and anxiolytic medications can be helpful in calming a frightened pediatric patient and reducing parental distress, with intranasal and intramuscular routes preferred when IV access is not yet available.