The Approach to the Pediatric Trauma Patient
Joshua P. Parreco
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Unintentional injury is the leading cause of morbidity and mortality in children in the United States.
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Injuries related to motor vehicles are the leading cause of death in children, whereas injuries from falls are the leading cause of nonfatal injury.1
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In the 1970s and 1980s, J Alex Haller of Johns Hopkins University first developed, implemented, and championed a modern trauma system for pediatric patients.4
TRAUMA RESUSCITATION
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The resuscitation of the pediatric trauma patient is guided by fundamental advanced trauma life support (ATLS) principles, including the primary (ABCDE), secondary (AMPLE), and tertiary surveys.
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With acute blood loss, children will maintain a normal central blood pressure longer than adults.
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Shock in children is manifested as tachycardia, delayed capillary refill, altered mental status, decreased urine output, and tachypnea.
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Normal values for heart rate (beats per minute), blood pressure (mm Hg), and respiratory rate (breaths per minute), respectively5:
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Hypovolemia should be treated with a bolus of 20 mL/kg of an isotonic crystalloid solution. Failure to improve should result in a second bolus. Continued failure should then result in transfusion of packed red blood cells followed by fresh frozen plasma and platelets.6
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The Broselow Pediatric Emergency Tape is a widely used color-coded tape measure that relates a child’s height to weight and provides instructions regarding medication dosages and other equipment sizes. The colors typically correspond to a colored pouch in a resuscitation kit or colored drawer in the pediatric resuscitation cart.
PRIMARY SURVEY
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Airway
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Protect airway and stabilize C-spine manually or with a collar.
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In small children, avoid passive flexion of the neck that can result in anterior buckling of the pharynx owing to a larger occiput.
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Indications for endotracheal intubation include inadequate ventilation, inability to protect airway, or respiratory failure that is anticipated.
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Newborns require an uncuffed endotracheal tube to avoid pressure-induced damage. Traditionally an uncuffed tube was recommended for all children younger than 8 years of age; however, modern tubes that support low pressures with high volumes are safe.
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The diameter of a child’s fifth finger can serve as an approximate tube diameter.
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Surgical cricothyrotomy is contraindicated below the age of 12 years owing to potential laryngeal injury or stenosis. Needle cricothyroidotomy can be safely performed on patients of any age.
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