The Approach to the Pediatric Trauma Patient
Joshua P. Parreco
Unintentional injury is the leading cause of morbidity and mortality in children in the United States.
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
In high-income countries, the annual rate of physical abuse is 4% to 16% of children,2 and children with abuse-related fractures are missed by physicians in 20% of first visits.3
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
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.
With acute blood loss, children will maintain a normal central blood pressure longer than adults.
Shock in children is manifested as tachycardia, delayed capillary refill, altered mental status, decreased urine output, and tachypnea.
Normal values for heart rate (beats per minute), blood pressure (mm Hg), and respiratory rate (breaths per minute), respectively5:
<1 year: <160, >60, <60
1 to 2 years: <150, >70, <40
3 to 5 years: <140, >75, <35
6 to 12 years: <120, >80, <30
>12 years: <100, >90, <30
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
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
Airway
Protect airway and stabilize C-spine manually or with a collar.
In small children, avoid passive flexion of the neck that can result in anterior buckling of the pharynx owing to a larger occiput.
Indications for endotracheal intubation include inadequate ventilation, inability to protect airway, or respiratory failure that is anticipated.
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.
The diameter of a child’s fifth finger can serve as an approximate tube diameter.
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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