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)

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
  • PECARN head trauma rule
• Trauma (main)

Calculators

PECARN Pediatric Head Injury

PECARN — Pediatric Head CT Decision Rule

Age Group	Select One
Patient Age	1 <2 years    ≥2 years

Age <2 Years — Risk Factors

Criteria	No	Yes
GCS <15 (altered mental status)	1
Palpable skull fracture	1
Occipital/parietal/temporal scalp hematoma	1
Loss of consciousness ≥5 seconds	1
Not acting normally per parent	1
Severe mechanism of injury (MVC with ejection/rollover/fatality, pedestrian/cyclist without helmet struck by motorized vehicle, fall >3 feet, head struck by high-impact object)	1
Risk Factors (<2y)	/ 6

Age ≥2 Years — Risk Factors

Criteria	No	Yes
GCS <15 (altered mental status)	1
Signs of basilar skull fracture (hemotympanum, raccoon eyes, Battle sign, CSF otorrhea/rhinorrhea)	1
Vomiting	1
Loss of consciousness	1
Severe headache	1
Severe mechanism of injury (MVC with ejection/rollover/fatality, pedestrian/cyclist without helmet struck by motorized vehicle, fall >5 feet, head struck by high-impact object)	1
Risk Factors (≥2y)	/ 6

Interpretation (for selected age group)
0	Very low risk — ciTBI risk <0.02% (<2y) or <0.05% (≥2y). CT not recommended.
1 (intermediate*)	Low risk — ciTBI risk ~0.9% (<2y) or ~0.8% (≥2y). Observation vs. CT. *Only if GCS=15 and no skull fracture/AMS. Consider observation for 4-6 hours.
GCS<15 or skull fx	High risk — ciTBI risk 4.4% (<2y) or 4.3% (≥2y). CT recommended.

References
Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374:1160-1170. PMID 19758692.

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