Pediatric Trauma

Pediatric Trauma Overview - Little Patients, Unique Risks

• Unique Vulnerabilities:
  • Anatomy: Large head, pliable bones, compliant chest wall.
  • Physiology: ↑ Surface Area to Volume ratio (hypothermia risk), single kidney often unprotected, ↑ metabolic rate (rapid O₂ desaturation).
• Epidemiology (Leading death cause >1 yr):
  • Mechanisms: Falls (commonest), Motor Vehicle Accidents (MVA, highest mortality), pedestrian, bicycle, Non-Accidental Trauma (NAT).
• Trauma Patterns:
  • Blunt > Penetrating.
  • Polytrauma is the rule, not the exception.
• Key Principle:
  • Tri-modal death distribution underscores that prevention is key.

⭐ The 'Rule of Nines' for burns is modified in children (Lund-Browder chart is more accurate) due to different body proportions.

Primary Survey & Resuscitation - Kid-Sized ATLS

• Airway: Smaller, anterior larynx; narrowest at cricoid (uncuffed ETT <8yrs). Sniffing position. RSI considerations.
• Breathing: ↑RR, diaphragmatic. Pliable chest (occult pneumo/hemothorax). Needle thoracostomy: 2nd ICS MCL or 4th/5th ICS AAL.
• Circulation: Tachycardia = early shock. Hypotension = LATE. BP formula: $(Age \text{ in yrs} \times 2) + 70$ (systolic lower limit). Fluid: 20ml/kg crystalloid bolus (up to 3x), then 10-20ml/kg PRBCs. IO access vital. Broselow tape.
• Disability: Pediatric GCS (or AVPU). Glucose check (hypoglycemia risk).
• Exposure: Prevent hypothermia (high risk, large surface area).

⭐ In children, hypotension is a late sign of shock; tachycardia, altered mental status, and poor peripheral perfusion are earlier indicators.

Specific Injuries Part 1 - Head, Chest & Abdomen

• Head Trauma:
  • Most common cause of pediatric trauma death.
  • GCS <8: intubate.
  • PECARN for CT use in minor head trauma.
    • 
  • Diffuse Axonal Injury (DAI) common.
  • Cushing's triad (bradycardia, hypertension, irregular respirations): late sign.
• Chest Trauma:
  • Rib fractures rare; indicate severe force.
    • Multiple in infant: consider Non-Accidental Trauma (NAT).
  • Pulmonary contusion: most common chest injury.
  • Tension pneumothorax: clinical diagnosis, immediate needle decompression.
• Abdominal Trauma:
  • Spleen (most common), liver, kidney.
  • Non-Operative Management (NOM) highly successful.
  • Specific injuries: Duodenal hematoma (handlebar injury), pancreatic injury.
  • FAST scan for initial assessment.
  • ⭐

    The presence of a 'seatbelt sign' (abdominal wall bruising) after an MVA significantly increases suspicion for intra-abdominal injuries, particularly hollow viscus perforation and lumbar spine fractures.

Specific Injuries Part 2 - MSK & NAT Alerts

• MSK Trauma:
  • Growth Plate Injuries: Salter-Harris 📌 SALTER: I-Slipped, II-Above, III-Lower, IV-Through, V-ERasure/cRush.
  • Supracondylar Humerus Fx: Neurovascular compromise risk (Volkmann's).
  • Femur Fx: Significant blood loss. Rx: spica/traction/ORIF (age-dependent).
  • Compartment Syndrome: Pain out of proportion.
• Non-Accidental Trauma (NAT):
  • Suspect: Inconsistent history, delay, specific patterns.
  • Fractures: Posterior ribs, metaphyseal (corner/bucket-handle), sternal, scapular, spinous process; multiple, varied healing.
  • Shaken Baby: Subdural hematoma, retinal hemorrhages, DAI.
  • Burns: Stocking/glove, cigarette.
  • Mandatory reporting.

⭐ Metaphyseal corner fractures and posterior rib fractures are highly specific indicators of non-accidental trauma in infants.

High‑Yield Points - ⚡ Biggest Takeaways

• Blunt trauma is the leading injury mechanism in children.
• Head injury is the primary cause of pediatric traumatic death.
• Suspect Non-Accidental Injury (NAI) with inconsistent history or specific patterns.
• Spleen is the most commonly injured abdominal organ in blunt trauma.
• Initial fluid: 20 mL/kg isotonic crystalloid; use Broselow tape for drug dosing.
• Unique pediatric physiology (e.g., ↑SA:V ratio) impacts trauma management.
• Consider SCIWORA (Spinal Cord Injury Without Radiographic Abnormality).