Objectives

1. Understand the physiologic differences between pediatric and adult trauma victims
2. Perform a rapid primary survey focusing on ABCDEF
3. Discuss the secondary survey
   1. Pediatric considerations for head trauma
   2. Pediatric considerations for cervical spine injuries
   3. Pediatric considerations for chest trauma
   4. Pediatric considerations for abdominal trauma

Please see the “Approach to Trauma” article for an overview of adult traumatic injury.  This article will focus on the approach to trauma in a pediatric patient.

Initial Actions

How should you initially evaluate a child who has had a traumatic injury?

1. Always start with the primary survey
2. Address any problems found before moving on with your evaluation
3. Log roll the patient and get them off the backboard when able
4. Secondary survey with FAST exam and x-rays
5. If the patient begins to deteriorate, reassess the patient and restart your evaluation with the ABC’s
6. Remember this is likely a very terrified child and this can alter your exam. When able, always include family members to help calm and comfort the child.
   

Primary Survey

The initial assessment and survey is not significantly different from adults.  However, children have a unique physiologic response to trauma, creating challenges in their management.  Start with the primary survey as with adult patients.  You will evaluate and address problems with one system before moving to the next.  In reality, this is often done simultaneously. Always have a consistent, systematic approach in the evaluation of a patient with traumatic injuries (i.e. Advanced Trauma Life Support or ATLS).

A – Airway with cervical spine protection

B – Breathing

C – Circulation

D – Disability: neurologic assessment

E – Environment/Exposure

F – Family

Airway

The first priority is determining if the airway is open and patent.

• Is the child speaking?
• If they are non-verbal, are they crying?
• This is a frightening experience for most young children so be wary of the silent child

Pediatric airways have similar complications to adult airways that may lead to loss of a patent airway and a difficult intubation.

• Foreign body in airway
• Facial fractures and bleeding
• Tracheal injuries
• Expanding hematomas
• Depressed level of consciousness and inability to protect airway

If a child does not have a patent airway or is at risk of losing their airway, act quickly.

• Always maintain C-spine immobilization
• Use simple airway manipulations (jaw thrust, nasopharyngeal airway, or an oropharyngeal airway) or bag-valve mask ventilations if these seem ineffective.
• Rapid sequence intubation (RSI) may be required to stabilize a lost airway or protect a tenuous one
• Children with significant airway edema, abnormal anatomy, foreign body, or significant maxillofacial injuries may require cricothyroidotomy (surgical or needle)
• Generally, children less than 8 years old are not candidates for cricothyroidotomy and may require transtracheal ventilation (jet ventilation)

The pediatric airway has both anatomic and physiologic differences that set it apart from an adult airway.

• Prominent occiput – forces flexion of the neck in the supine position potentially obstructing the airway making intubation difficult
• Larger tongue
• Larger adenoid tissue
• Floppy, omega shaped epiglottis
• Larynx is more cephalad and anterior
• Cricoid ring, not the vocal cords, is the narrowest portion of the airway
• Shorter tracheal length
  

 Breathing

Once you have evaluated and stabilized the airway, it’s time to evaluate the patient’s breathing.  As with adults, you will need to look, feel, and listen to the chest in children.

• Inspect – Look for tracheal deviation, accessory muscle use, chest wall injury, and paradoxical breathing (chest wall moves inward with inspiration and outward with expiration)
• Palpate– Feel for crepitus and point tenderness, paradoxical movements with observed paradoxical breathing, or percuss for hyper-resonance or dullness
• Auscultate – Listen for signs of upper airway obstruction (stridor) or signs of pneumothorax (absent breath sounds) or hemothorax (diminished breath sounds)
• Auscultation, especially in small children, is the least reliable evaluation of breathing. In small children, you can hear lung sounds from the adjacent lung even if there is a pneumothorax in the lung that is auscultated.

If a child has a patent airway but your evaluation reveals poor breathing, ventilating the child is your next priority.

• Bag-valve mask (BVM) ventilation is a temporizing method to ventilate a child, and a very important skill!
• A child can be BMV ventilated until an advanced airway can be placed
• Select a proper sized bag with a pop-off valve to reduce barotrauma
• Each breath should be just enough to make the chest rise, avoiding excessive pressure which can cause an iatrogenic pneumothorax
• An oral airway can greatly assist ventilation in children with macroglossia or any other upper airway obstruction
• Again, BVM ventilation is one of the most important life-saving skills you need to learn and master!

Pediatric specific considerations when evaluating breathing in a traumatic injury

• The respiratory rate is age dependent. A rate of 15 may be fine for a 12 year old but would not be for a 6 month old.

• Children have increased vagal tone and a tendency to become bradycardic with laryngoscope blade manipulation
• Lower respiratory reserve
• Higher metabolic demand and a lower functional residual capacity leads to quicker onset of hypoxia with apnea during (shorter apnea time)
• Fatigue easily because of their compliant chest wall aids less in breathing and they rely more on the diaphragm
• Hyperextension of the neck while positioning may lead to airway obstruction

Children also have anatomic differences in their rib cage to consider in pediatric blunt trauma:

• Higher compliance
• Less propensity to fracture ribs and release the force from the trauma
• Increased transmission of blunt force to the underlying lung parenchyma
• Increased incidence of pulmonary contusion vs rib fracture and subsequent pneumothorax/hemothorax (Please see the Approach to Trauma article for an overview of pneumothorax and hemothroax for a review)
• Fewer external signs of trauma
  

Circulation

Children have a remarkable ability to maintain their blood pressure even with significant volume loss (25-30% blood volume loss).  Since children compensate so well (compensated shock), the blood pressure is not as accurate a reflection of circulatory status as it is in adults.

• Feel for central and peripheral pulses (tachycardia is common)
• Skin color
• Capillary refill
• Though it is less helpful during the initial survey, urine output is one of your best indicators of volume status (>1-2 ml/kg/h)

Pediatrics covers a wide range of ages and it is important to know or have a resource available that lists normal heart rate and blood pressure values for a given age

• A good rule of thumb to remember is that the 50th % systolic blood pressure is 90 + (2 x age in years) up to 10 years old and then it is 110 mm Hg similar to an adult

Progression to decompensated shock will quickly lead to complete cardiopulmonary failure. Shock is a reflection that end organs are inadequately perfused and oxygenated.  It must be identified and treated quickly.

• Three types of shock include hemorrhagic, cardiogenic, and distributive
• Hemorrhagic shock is the most common etiology of shock in the setting of a traumatic injury
• Intravenous access is essential: obtain 2 large bore intravenous catheters
• If peripheral intravenous access is difficult or taking too much time, rapid placement of an intraosseous (IO) needle can be life-saving
• Initially give 20ml/kg of isotonic fluids (typically normal saline)
• Fluids should be given rapidly using either a pressure bag or via the 3-way stopcock “pull- push” method
• If a child has not had an adequate response after 2 boluses, consider giving 10ml/kg of packed red blood cells
• Continue to fluid resuscitate the child during the ongoing evaluation and treatment of specific injuries
  

Disability: Neurologic Assessment

Similar to adults, the disability examinations should rapidly assess a child for neurologic deficits.

The American Heart Association Pediatric Advanced Life Support (PALS) program recommends the use of the mnemonic AVPU in children as well.

• Alert – fully alert
• Voice – responds to voice
• Pain – responds to pain
• Unresponsive – is completely unresponsive

This can quickly be assessed while doing a gross motor/sensory examination.  The simplest way is to ask an appropriately aged child to wiggle their fingers or toes and see how they respond.  Infants and younger children require more direct observation and interaction but can still be quickly assessed in the trauma bay. This does not replace the need for a thorough neurologic exam and will be performed during the secondary survey.

A quick pupillary examination is typically done at this time as well.  You are assessing for size, symmetry, and reactivity. Unresponsive and dilated pupils are worrisome for uncal herniation and emergent intervention will be needed.

PALS also recommends the use of the validated Modified Glasgow Coma Scale for Infants and Children to quickly evaluate mental status.  The best possible score is 15 and the lowest is 3.

A rapid bedside glucose should be checked as well.  Children have smaller glycogen stores as well as a higher metabolic demand and can become hypoglycemic.  Hypoglycemia will have a profound effect on a child’s mental status and will require emergent interventions (typically a bolus of intravenous dextrose).

Finally, you should logroll the child while maintaining cervical spine immobilization and palpate the spine for tenderness and step-offs.  You should remove the backboard at this time as well.  Logrolling is a carefully orchestrated maneuver in an effort to maintain inline cervical spine immobilization.

Environment/Exposure

All children must be fully undressed and examined thoroughly for hidden injuries.  The metabolic needs of children are increased by hypothermia and maintenance of normothermia is paramount.  This is accomplished with the use of warm blankets, warmed intravenous fluids, and a warm ambient temperature in the trauma bay.

Family

The emergency department trauma bay can be loud and frightening for young children, impacting the assessment of a child.  Allowing family members to comfort and guide child during the evaluation can provide a more accurate evaluation.  A child life specialist can be invaluable if a family member cannot be present.

It has been shown that family presence during a resuscitation is beneficial to the grieving process as well.  However, one specific person (child life, chaplain, social worker) should be the point person who can answer all of their questions during this experience.  Surprisingly, the largest barrier to implementing this practice has been due to the medical providers.

Secondary Survey

The secondary survey is a head to toe examination that only begins once all problems identified on the primary survey have been addressed and the child is stable.

History

This is when you should obtain a focused history if the child is able to give it or there is a caregiver present. 

This is best obtained using the AMPLE mnemonic:

• A = Allergies
• M = Medications
• P = Past medical history
• L = Last meal
• E = Environments and events associated with injury
  

Physical Exam

Head Trauma

Head injury is the leading cause of death and disability in children.

The relative size of a child’s head compared to their trunk is larger which places more torque on the cervical spine. Children are also more susceptible to shear injury because their brains are less myelinated. Severe head injury is the leading cause of death in children 1-18 years. Always consider non-accidental trauma (NAT) when evaluating a child with head trauma

As a result, the head exam must be thorough and systematic in children.

• Inspect and palpate the skull for step-offs or lacerations
• Battle’s sign (bruising behind the ear), raccoon eyes (periorbital bruising without swelling), and/or hemotympanum (blood behind the ear drum) are worrisome for a basilar skull fracture
• Scalp hematomas, particularly non-frontal are worrisome
• Feel for the anterior fontanelle in a child under 1 year
• An age appropriate neurologic examination to assess motor and sensory function as well as cranial nerves (a caregiver may notice a subtle abnormality)
• Attempt to limit radiation and unnecessary head CT scans by following the PECARN head injury guidelines (http://www.ncbi.nlm.nih.gov/pubmed/19758692 & http://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm/)
• The dental exam can easily be overlooked but should be performed especially looking for injuries that may damage underlying permanent teeth (e.g. impacted tooth)
  

Neck and Spine Trauma

Cervical spine injuries in children vary from adults due to anatomic differences.

• Larger head size with greater flexion and extension
• Weaker paraspinal musculature
• Increased spinal ligament laxity
• Infant spinal column can lengthen without rupture
• Immature vertebral joints
• Lack of uncinated processes until about 10 years of age

Always assume a child has had a C-spine injury until proven otherwise.

• Most patients will arrive to the ED with pre-hospital C-spine immobilization
• Maintain immobilization until an injury has been ruled-out
• If a child is too small for a cervical collar, sandbags on either side of their head and tape are an alternative
• While maintaining C-spine immobilization with a second provider, palpate for midline deformities or tenderness along C-spine
• Thorough motor and sensory examination (isolated sensory complaints more common)
• Many children are asymptomatic or too uncooperative to provide an adequate examination (Use family and child life specialist liberally)
• The typical C-spine decision rules (NEXUS and Canadian) must be used with caution because children were under-represented in their study populations
  

Chest Trauma

Children have thoracic anatomic and physiologic differences from adults

• Compliant chest wall
• Fewer rib fractures
• Compliance can mask underlying injuries and minimize external signs of trauma
• Though increased compliance leads to fewer rib fractures, it also leads to increased pulmonary contusion
• Mediastinum is more mobile

The physical exam evaluating the chest is similar in children compared to adults.

• Inspection: nasal flaring, chest wall injuries, bruising, seat belt sign (shoulder belt), paradoxical chest wall movement
• Palpation: crepitus and/or tenderness
• Auscultation: muffled heart sounds, abnormal lung sounds (absent, muffled); least reliable finding of the three

Isolated thoracic injury is uncommon in children. It is more likely to result with a significant injury causing concomitant injuries. Children will have injuries similar to adults.

• Pneumothorax
• Hemothorax
• Pulmonary contusion
  • Responsible for ~ 10% of all pediatric trauma admissions
  • Mild to severe hypoxia depending on the extent of contused lung
  • Always be vigilant because it can worsen over time as contusion evolves
  • CXR findings may lag behind injury but if abnormal, represents a significant injury
• Flail chest: results from two or more fractures in contiguous ribs (paradoxical chest movement)
• Rib fractures
• Traumatic asphyxiation: due to increased compliance of the pediatric chest wall. Occurs after direct compression of the chest and deep inspiration against a closed glottis with a crush injury.  This increases pressure in the superior and inferior vena cava and leads to facial/neck hemorrhage, cyanosis, and facial swelling.  Treat by addressing associated injuries and elevating the head of the bed.
• Commotio cordis: Almost solely a pediatric traumatic injury. This is a combination of direct anterior chest injury leading to ventricular fibrillation and sudden cardiac death.  Treatment consists of rapid recognition and use of an automated external defibrillator by by-standers or first responders.
  

Abdominal Trauma

Children have specific anatomic differences that protect them from some injuries but place them at greater risk for others.

• Larger solid organs
• Less subcutaneous fat
• Less protective abdominal wall musculature
• Larger kidneys
• Flexible rib cage allowing for excursion of the chest wall and abdominal organ compression

The abdominal exam for children consists of:

• Inspection: vital signs (hypotension, tachycardia, or tachypnea are worrisome), completely undress children, bruising (seat belt sign, periumbilical, flank), or tire tracks may be seen.
• Auscultation: hypoactive bowel sounds
• Palpation: point tenderness, rebound, guarding
• Percussion: diffuse dullness is a sign of peritoneal injury

FAST or Focuses Assessment Sonography in Trauma is a quick and non-invasive ultrasonographic evaluation of the abdomen looking for free fluid. Specific areas are visualized: Morrison’s Pouch (hepato-renal), perisplenic (spleno-renal), bladder, and subxiphoid cardiac view. A positive FAST indicates free fluid and should prompt further evaluation. If the patient is unstable, they should go directly to the OR, otherwise an abdominal CT with intravenous contrast should be obtained. A negative FAST does not rule out serious intra-abdominal injury and further evaluation may still be warranted.

Pelvic Trauma

Pelvic injuries are uncommon in children. Children should still be inspected and palpated for signs of pain or pelvic instability. If there is concern, pelvic films should still be ordered. If there is concern for instability and a pelvic fracture, compression with a wrapped sheet or a pelvic binder should still be placed.

Genital, Perineal, and Rectal Trauma

Any signs of genital hematomas, blood at the urethral meatus, or lacerations should be evaluated further.  If there is concern for blood, a rectal exam should still be performed.  Often times, visualized rectal tone (anal wink) is sufficient unless neurologic injury (spinal shock) is a concern and then a digital rectal exam should be performed.

Musculoskeletal Trauma

A thorough extremity exam is always needed.  Evaluate the neurovascular status. Patients with a gross deformity or point tenderness will need x-rays to evaluate for fracture. Splint deformed extremities to help prevent further injury and alleviate pain.

Differential Diagnosis

The differential diagnosis for a child with a traumatic injury can be large.  Remember that children have unique anatomy and physiology.  Though you perform the same systematic evaluation that you use with every adult, their specific needs and injury patterns will may be different. 

The most life threatening diagnoses that will need emergent intervention include:

• Traumatic brain injury with increased ICP and impending herniation
• Airway obstruction
• Respiratory failure
• Tension pneumothorax
• Massive hemothorax
• Large pulmonary contusion
• Commotio Cordis
• Blunt abdominal trauma with active hemorrhage
  

References

1. American Academy of Pediatrics and Pediatric Othopaedic Society of North America.  Management of Pediatric Trauma.  Pediatrics. 2008 Apr;121(4); 849-854.
2. Avarello, Jahn, Cantor, Richard.  Pediatric Major Trauma: An Approach to Evaluation and Management.  Emerg Med Clin N Am. 2007 Aug;25(3):803-36.
3. Fleming, S., et. al.  “Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies”. Lancet 2011;377(9770):1011–8.
4. Hoffman, Robert J. “Pulmonary Contusion.” Fleisher & Ludwig’s 5-minute Pediatric Emergency Medicine Consult. Philadelphia, Pa.: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2012. Print.
5. Kenefake, Mary, Swarm, Matthew, Walthall, Jennifer.  Nuances in Pediatric Trauma. Emerg Med Clin N Am. 2013 Aug;31(3):627-52
6. Pediatric Advanced Life Support (PALS).  Available at: https://www.heart.org/HEARTORG/CPRAndECC/HealthcareProviders/Pediatrics/Pediatric-Advanced-Life-Support-PALS_UCM_303705_Article.jsp.  Accessed 7/7/15
7. Yanchar, Natalie, Woo, Kenneth, et al.  Chest x-ray as a screening tool for blunt thoracic trauma in children. J Trauma Acute Care Surg. 2013 Oct;75(4):613-9.