Trauma (peds)

This page is for pediatric patients. For adult patients, see: Trauma (main).

Background

• Key is to recognize and treat shock early (before blood pressure decreases),
  • once child has signs and symptoms of shock, may have lost 25% of blood volume
• BP not usually helpful sign of blood loss in pediatric patients
  • Can have high, low, or normal BP in shock
  • pulse pressure is helpful
• 80% of pediatric trauma deaths associated with neurological injury (see pediatric head trauma)

Locations of Possible Life-Threatening Bleeding

• External
• Internal
  • Thoracic cavity
  • Peritoneal cavity
  • Retroperitoneal space (i.e. pelvic fracture)
  • Femur fracture (into muscle/subcutaneous tissue)

Classes of hemorrhagic shock

Class	I	II	III	IV
Approximate blood loss	<15%	15-30%	30-40%	>40%
Heart rate	↔	↔/↑	↑	↑↑
Blood pressure	↔	↔	↔/↓	↓
Pulse Pressure (mmHg)	↔	↓	↓	↓
Respiratory Rate (per min)	↔	↔	↔/↑	↑
Urine Output (mL/hr)	↔	↔	↓	↓↓
Glasgow coma scale score	↔	↔	↓	↓
Base deficit^	0 to -2 mEq/L	-2 to -6 mEq/L	-6 to -10 mEq/L	-10 or less mEq/L
Need for blood products	Monitor	Possible	Yes	Massive transfusion protocol

^Base excess is the quantity of base (HCO3-, in mEq/L) that is above or below the normal range in the body. A negative number is called a base deficit and indicates metabolic acidosis.

Pediatric car seat rules

Age	Type of Car Seat	Position	Comments
<2 years old	Infant-only or convertible car seat	Back seat, rear-facing	If child height or weight > seat limit (usually ~40-65lbs), go to next age up
2-8 years old	Convertible or combination car seat	Back seat, forward-facing	If child height or weight > seat limit, go to next age up
8-12 years old	Booster seat	Back seat, forward-facing	If child height or weight > seat limit (usually 4' 9"), go to next age up
12-13 years old	Lap and shoulder seat belt	Front or back seat, forward-facing

Clinical Features

• Peds assessment triad: appearance, work of breathing & circulation (skin color)
• Child's size allows for distribution of injuries
  • multi-system trauma is common
  • internal organs more susceptible to injury due to anterior placement of liver and spleen (as well as less protective muscle & fat)
  • Kidneys also less well protected and more mobile, prone to decelleration injury
• Wadell Triad in auto vs. pedestrian child= femoral shaft fracture, intraabdominal/intrathoracic injury, and contralateral head injury

Differential Diagnosis

• Standard trauma injuries plus:
• Child abuse
• SCIWORA
• Chance fracture

Evaluation

• FAST exam
• Consider as indicated:
  • CBC, coags, T&S, LFTs for abdominal trauma
  • Plain films
  • CT head, cervical spine clearance clinically or with imaging
  • CT abdomen/pelvis
    • Significant intra-abdominal injury after blunt torso trauma highly unlikely (0.1%) if all of the following are true:
      • Glasgow coma scale ≥14
      • No evidence of abdominal wall trauma or seat belt sign
      • No abdominal tenderness, abdominal pain, or vomiting
      • No thoracic wall trauma or decreased breath sounds

Management

• ATLS
• In ED give IVF at 20cc/kg, if unresponsive after 40cc/kg give PRBCs at 10cc/kg (can start with PRBC if presents in decompensated shock & multiple injuries suspected)

Disposition

• Depends on underlying injury

See Also

• Pediatric head trauma
• Trauma (main)

External Links

• Pediatric Emergency Playbook Podcast -- Multisystem Trauma in Children Part One: Airway, Chest Tubes, and Resuscitative Thoracotomy
• Pediatric Emergency Playbook Podcast -- Multisystem Trauma in Children Part Two: Massive Transfusion, Trauma Imaging, and Resuscitative Pearls