Editor’s note: This post represents the second in a series led by Drs. Ashley Lubberdink and Kaif Pardhan translating the pediatric guidelines that have been developed by TREKK (TRanslating Emergency Knowledge for Kids). For more information and further pediatric emergency medicine guidelines, please visit the TREKK website.
It is a hot summer day in July. A 10-year-old boy is brought into the Pediatric ED after he has been in a collision on an ATV. He was riding on a trail at approximately 40 km/hr and hit a large wood telephone pole. He comes into the ED via EMS with vitals as follows: T 36.8 HR 140, BP 90/60, RR 25, SpO2 98% RA. He is moaning out in pain. His obvious injuries on primary assessment include bruising to the anterior chest wall, a deformed left wrist (closed), and tenderness to palpation over the abdominal area.
What are some specific considerations unique to pediatric patients in trauma?
Airway (pediatric airway is smaller)
- Larger occiput- causes flexion of airway, especially when on a flat backboard
- Infants are obligate nasal breathers
- Relatively larger tongue and smaller oral cavity
- Floppy epiglottis (omega shaped)
- Larynx is superior and anterior (C3-C4)
- Cricoid is narrowest point in the airway
- Shorter trachea
- Trachea more cartilaginous and soft
- High basal metabolic rate (BMR), high O2 demand
- Smaller functional residual capacity (FRC), desaturate more quickly than adults
- Extremely pliable and compliant chest wall- allows for significant internal injury without external signs of trauma
- Hypotension is a late (ominous) sign- can indicate pre-arrest!
- To increase cardiac output (CO), infants are heart rate (HR) dependent
- More difficult to obtain IV access due to smaller vessels, small gauge IV or IO often necessary
- Thoracic skeleton and abdominal musculature not as developed or protective- more damage to internal organs
- Compartments of bleeding similar to adults: thorax, abdomen, retroperitoneum, long bones (less severe), head (infants), “the street”
- Signs of increased intracranial pressure (ICP) in peds important especially for nonverbal- decreasing level of consciousness, Cushing’s triad (hypertension, bradycardia, irregular respiratory rate), irritability, and bulging anterior fontanelles (open sutures, anterior fontanelle until 12-18 months)
- Thinner cranial bones- increased likelihood of skull fractures
- Decreased myelinization and increased cerebral water content- higher risk of diffuse axonal injury, less amenable to operative intervention
- High BMR, high body surface area dissipates heat quicker
- Mechanism of injury differs due to child’s smaller size- more likely to suffer polytrauma
- Increased glucose requirements
The Broselow Tape:
The Broselow Tape relates a child’s height as measured by the tape to his/her weight to provide medical instructions including medication dosages, the size of the equipment that should be used, and the level of shock voltage when using a defibrillator. Particular to children is the need to calculate all these therapies for each child individually. In an emergency, the time required to do this detracts from valuable time needed to evaluate, initiate, and monitor patient treatment. The Broselow Tape is designed for children up to approximately 12 years of age who have a maximum weight of roughly 36 kg (80 pounds). The Broselow Tape is recognized in most medical textbooks and publications as a standard for the emergency treatment of children.
Some Quick Calculations for Pediatric Resuscitation:
|Endotracheal tube (ETT) size||Age / 4 + 4 (uncuffed) – 0.5 size if cuffed|
|OG/NG size||2 x ETT size|
|Foley size||3 x ETT size|
|Chest tube size||4 x ETT size|
|Weight (age < 7)||Age x 2 + 8|
|Weight (age >=&)||Age x 3 + 7|
*A really good app that can be downloaded is Pedi STAT. For a small fee, it can give you age/ weight/ length based resuscitation calculations, drug doses, etc. that can be very useful for the ED, wards, etc!
What are some key considerations in the Pediatric ATLS Assessment?
- Airway and C-spine control: It is important to have a Broselow tape, and have pediatric airway equipment available, also equipment that is a half size bigger and smaller than intended. The use of cuffed vs. uncuffed ETT in children < 8 is still not without controversy, however in 2010 the AHA updated its guidelines and said that cuffed ETT’s were appropriate in this age group3. Surgical airway (cricothyrotomy) can be used in older children but is not currently recommended in ATLS for children < 11, and would be an exceedingly rare clinical circumstance. If blocks or sandbags are available, use these with tape across the forehead, as they may be of more utility than a poor-fitting C-collar.
- Breathing: Children can desaturate quickly, and modified RSI protocols might be necessary to avoid hypoxia. Using a NG/OG tube to deflate the stomach may dramatically improve respiratory status and ventilation by relieving abdominal distension.
- Circulation: Tachycardia, delayed capillary refill, cool extremities, and thready peripheral pulses are all things to be wary of. Warmed isotonic fluids (NS or RL) should be given at bolus doses of 20 cc/kg. Between 1-2 boluses, if hemodynamic status remains compromised, consider giving uncrossmatched blood (O-negative). In the adult literature, there’s been a move away from using crystalloid in trauma and going straight to addressing hypovolemic blood loss with blood directly. To date, there is a paucity of evidence in the pediatrics literature recommending this strategy at this time, but it may be something to consider in the trauma room if obvious bleeding is present. Place IO lines if no IV can be established > 90 seconds or after 2 attempts (1-2 skilled providers).
- Disability: If the child can’t talk yet, try using the Pediatric Glasgow Coma Scale (see below). A blood glucose should be checked to ensure hypoglycemia is not contributing to altered mental status. Pain should be addressed early in pediatric patients, and if possible family members’ presence may help in alleviating anxiety.
- Exposure: Warm blankets, Bair huggers, overhead heaters, and warmed fluids +/- blood should be utilized.
- Non accidental trauma(NAT): ALWAYS consider NAT in paediatric trauma, especially in infants, when the presentation is delayed, and when mechanism does not correlate with injury patterns.
Weight Based Analgesia
|Name||Initial IV dose||Duration|
|Morphine||0.1-0.2 mg/kg||3-4 hour|
|Hydromorphone (IV/IO)||0.015 mg/kg||2-4 hour|
|Fentanyl (IV/ IO/ IM/ SQ)||1-3 mcg/kg (use 2-3 mcg/kg if <3years and 1-2 mcg/kg if >=3years||0.5-1.5 hour|
|Fentanyl (intranasal)||2 mcg/kg (doses > 50 mcg should be divided between nares)||1 hour|
Common Places for IO Insertion in Pediatrics
- Proximal tibia: With slight external rotation of leg, identify the tibial tuberosity, move 1-2 cm medial and inferior. The flat anteromedial surface of the bone is the insertion site.
- Distal tibia: Identify the medial malleolus, the flat part of distal tibia 1-2 cm superior to medial malleolus is the insertion site.
- Proximal humerus: Position the patient so their hand is resting on their abdomen and their elbow is adducted, palpate up the humerus to greater tubercle approx. 1 cm superior to surgical neck of the humerus.
- Distal femur: Identify patella by palpation, the insertion site is just proximal to patella (max 1 cm) and approximately 1-2 cm medial to the midline. Remember to displace the soft tissue when doing these in the femur, either laterally or medially!
Pediatric Glasgow Coma Score
Remember the Pediatric GCS is age based. This chart was adapted from Rosen’s Emergency Medicine textbook, 8th ed.1
Radiography in Blunt Pediatric Trauma
- CXR: Recommended
- C- spine X-rays or CT imaging of neck: Not warranted for all patients. May be done if not able to clinically clear the C-spine or mechanism. Luckily, C-spine injuries are significantly less common in kids compared to adults. A child’s C-spine fulcrum is around C2 (adult fulcrum~ C7). For C-spine X-rays <8 years, use AP and lateral neck views, once >=8 years inclusion of the odontoid view is recommended.
- Pelvic X-Rays: Can be omitted if low risk for fracture with a normal GCS and hemodynamic status, and NONE of 1) signs of abdominal trauma, 2) abnormalities on pelvic exam, 3) associated femur fracture or hematuria. Should be included if suspicion of pelvic fracture or hemodynamic instability
- CT imaging: should not delay transport to trauma center. For CT head use clinical decision rules and consider on a case by case basis
The FAST Scan in Pediatric Trauma
There has been emerging evidence on this topic in the last few years with increased POCUS training and accessibility and use of ultrasound in the ED. A study published in the Journal of Pediatric Surgery in 2013 looked at 536 children arriving to a level 1 pediatric trauma center in the U/S in which all TTL’s were formally trained to do FAST exams4. The sensitivity, specificity, PPV and NVP in detecting pathologic free fluid in this population were 50%, 85%, 53.8%, and 87.9%. In this study, conclusions relayed true positive FAST exams are rare and would unlikely direct patient management. Although a negative FAST may potentially reduce CT scans due to reassurance, it may be unwarranted due to the tests low specificity.
Resuscitative Thoracotomy in Children?
Allen et al. did a review of the literature for Pediatric ED thoracotomy and found a survival rate of 10.2% in penetrating trauma, which a much lower survival rate of 1.6% in blunt pediatric arrest2. Adolescents had more penetrating injuries whereas children had more blunt trauma. Indications for penetrating trauma are signs of life within 10-15 minutes of arrival.
The Pediatric Trauma Score (PTS)
Trauma triage scores are developed to predict which children require care at a trauma centre. The PTS is a tool that predicts mortality in paediatric trauma patients. As a general guide, the score recommends that all children with a PTS < 8 (high risk or worrisome) should be transferred to a paediatric trauma centre.
|Weight||Weight >20 kg||10-20 kg||<10kg|
|Airway||Normal||Oral or nasal airway, oxygen||Intubated, cricothyroidotomy, or tracheostomy|
|Systolic Blood Pressure||>90 mm Hg, good peripheral pulses and perfusion||50-90 mm Hg, carotid/femoral pulses palpable||<50 mm Hg, weak or no pulses|
|Level of Consciousness||Awake||Obtunded or any loss of consciousness||Coma, unresponsive|
|Fracture||None seen or suspected||Single, closed||Open or multiple|
|Cutaneous||None visible||Contusion, abrasion, laceration <7 cm not through fascia||Tissue loss, any gunshot wound or stab wound through fascia|
|Adapted with permission from Tepas JJ, Molitt DL, Talbert JL, et al: The pediatric trauma score as a predictor of injury severity in the injured child. Journal of Pediatric Surgery. 1987;22(1)15.5|
Pitfalls of inadequate resuscitation
- Failure of managing A’s and B’s
- Failure of recognizing intra-abdominal hemorrhage (C)
- Failure of managing the A,B,C’s in children with traumatic brain injury, contributing to secondary brain injury
- Failure to involve family members within the resuscitation room
- Failure to treat the pediatric patients’ pain, especially nonverbal children or those with developmental delay.
Back to the Case
The patient was brought into the Trauma Bay and connected to monitors. A Broselow tape estimated his body weight at approximately 35 kg. The primary survey indicated his airway was patent and protected (vocalizing) and C-collar was left in place. The patients’ parents were allowed into the room to provide comfort and were accompanied by a social worker. After 2 failed IV attempts by a senior nurse, the EZ-IO gun was prepared, the proximal tibia was cleaned with chlorhexidine, lidocaine was used to freeze the site of contact, and an IO line was obtained within seconds. A 700 cc bolus (20 cc/kg) of NS was given through IV tubing and syringe attached to a 3-way stopcock (to push fluids quickly). 70 mcg of intranasal fentanyl was given for pain.
The chest and lungs were auscultated and were clear, there was no crepitus to the chest area and the trachea was midline. The abdomen was diffusely tender to palpation. A FAST exam was performed and was negative. There was no pelvic instability or obvious long bone injuries. The left wrist had normal neurovascular status. The team ordered trauma labs (Hb 100), an ECG (sinus tachycardia), a CXR (unremarkable), Pelvic X-rays (unremarkable), and a left wrist Xray which showed a Salter Harris II injury of the distal radius complicated by associated fracture of the distal ulna.
After the first 700 cc NS bolus was complete, repeat vital signs were: T 36.8 HR 90, BP 110/70, RR 22, SpO2 99% RA. A 20 gauge IV was obtained in the right antecubital fossa. The left wrist was splinted for comfort. The patient was deemed stable and was transported to the CT scanner to rule out abdominal injuries. There was a liver laceration that had led to approximately 100 cc of bleeding within the abdomen, and the child was admitted to the inpatient unit for further monitoring.
- Follow the same general principles of ATLS when resuscitating children
- Always consider the unique anatomical and physiological differences between children and adults
- Consider NAT in all cases of pediatric blunt multisystem trauma so that it is not missed
Reviewing with the Staff
This summary nicely illustrates the most important take home message when it comes to managing pediatric trauma – the principles, approach and goals of resuscitation are the same in children as they are in adults, but there are pediatric nuances that clinicians need to be aware of!
Wide differences in pediatric anatomy, physiology and developmental maturation account for specific injury patterns in children that are not seen in adults, and for high energy mechanisms, polytrauma is the rule. Traumatic brain injury is the leading cause of injury-related death in children, as in adults, and mitigating secondary brain injury from hypoxia and hypotension through careful attention to airway, breathing and circulatory support is key. Abdominal injuries are common, and can be lethal if secondary signs of inadequate perfusion/shock are not recognized or addressed. The flip side is that children rarely require operative intervention for abdominal trauma, and for solid organ injuries conservative management is standard. The optimal approach to reduced crystalloid, balanced transfusion management and hemostatic agents like TXA in pediatric trauma is actively being explored; definitive and standardized modifications to clinical guidelines have not yet mirrored the practice changes that have occurred in adult trauma. Lastly, family presence is a unique component of pediatric resuscitations, and the ability to offer it with proper support provides benefits not only for the child and family, but also for the clinical team.
Diagnostic imaging is a changing and moving target in pediatric trauma! While important to identify injuries, the radiation exposure from CT scanning cannot be underappreciated in this young, radiosensitive population. Clinical decision rules exist to help guide physicians in their decisions to obtain CT scans, and the principle of ALARA (as low as reasonably achievable) should be applied to each CT scan for each child. CT imaging should not delay transfers, and should rather occur at the trauma center. EFAST is a valuable rapid bedside tool that does not incur radiation, but at present FAST or even formal abdominal ultrasonography, is not sensitive enough to rule out intraabdominal bleeding on its own.
As mentioned in the summary, it is vital that non accidental trauma is considered particularly in infants, when there is a delay in presenting to care, and when the stated mechanism does not correlate with the identified injuries. Finally, without doubt the best way to improve outcomes in pediatric trauma is to prevent its occurrence in the first place! Injury prevention counselling in the ED is an important component of our work, and evidence shows it makes a difference.