Pediatric Trauma

Pediatric Trauma - Tiny Terrors, Big Trouble

• Unique Anatomy & Physiology: Larger head-to-body ratio, thinner chest wall, pliable bones (greenstick fractures), ↑surface area (hypothermia risk).
• Airway: Large occiput, anterior/cephalad larynx, narrowest at cricoid.
• Breathing: Diaphragmatic breathers, susceptible to fatigue.
• Circulation: Compensate well initially, then rapid decompensation. Hypotension is a LATE sign. Tachycardia is an early sign.
  • Estimated blood volume: 80 ml/kg.
• Disability: Glasgow Coma Scale (GCS) modified for children.
• Exposure/Environment: Prevent hypothermia.
• Common Injuries: Head trauma (most common cause of death), abdominal trauma (liver/spleen), fractures.
• Non-Accidental Trauma (NAT): Consider if injury pattern inconsistent with history. 📌 TEN-4 FACES P (Torso, Ears, Neck, Frenulum, Auricular, Cheek, Eyelid, Subconjunctival hemorrhage, Patterned bruising).

⭐ Waddell's Triad (vehicle vs. pedestrian): 1. Femur fracture, 2. Intra-abdominal/Intrathoracic injury, 3. Contralateral head injury. Indicates severe trauma and high mortality risk in pediatric pedestrian injuries by motor vehicles.

• Fluid Resuscitation: Isotonic crystalloids 20 ml/kg bolus, repeat up to 2-3 times. Then packed RBCs 10-15 ml/kg if no response.
• Damage Control Resuscitation: Early blood product use in severe trauma (1:1:1 PRBC:FFP:Platelets).

Initial Assessment - ABCs for Small Fries

• Primary Survey (ABCDE): Rapidly identify & manage life-threats.
  • 📌 PAT: Appearance, Work of Breathing, Circulation (skin). (Initial visual)

• A - Airway & C-Spine:
  • Immobilize C-spine.
  • Jaw thrust.
  • ETI (uncuffed): $(Age/4) + 4$; (cuffed): $(Age/4) + 3.5$.
• B - Breathing:
  • High-flow O2.
  • Assess: RR, effort, SpO2.
  • Needle for tension pneumothorax: 2nd ICS MCL / 5th ICS AAL.
• C - Circulation:
  • IV/IO access (IO if IV > 90s).
  • Fluid: 20 mL/kg isotonic crystalloid bolus (max 60 mL/kg pre-blood).
  • Control bleeding.

  ⭐ Hypotension: LATE, ominous shock sign in children. Compensatory mechanisms mask it.

Key Injury Patterns - Ouchie Hotspots

• Head Trauma:
  • Leading cause of trauma death.
  • Infants: Assess fontanelles. Ping-pong, growing skull fractures.
  • ↑Risk diffuse axonal injury (DAI) due to large head, weak neck.
• Thoracic Trauma:
  • Rib fractures rare (pliable ribs) but indicate severe force.
  • Pulmonary contusion: Most common chest injury.
• Abdominal Trauma:
  • Spleen & liver: Most injured solid organs.
  • Handlebar injury → duodenal hematoma, pancreatic injury.
  • Non-operative management (NOM) often preferred.
• Musculoskeletal Trauma:
  • Physeal (growth plate) injuries: Salter-Harris classification.
  • NAT indicators: 📌 Multiple fractures (varied healing), posterior ribs, corner fractures.
• Spinal Trauma:
  • Upper C-spine (C1-C3) injuries common. Pseudosubluxation.
  • SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) more frequent.

⭐ Waddell's Triad (pedestrian vs. vehicle): 1. Femur fracture, 2. Thoracic/abdominal injuries, 3. Contralateral head injury.

Scoring & Special Scenarios - Numbers & Nuances

• Pediatric Trauma Score (PTS):
  • Components (each +2, +1, or -1): Weight, Airway, SBP, CNS, Open Wound, Skeletal Fx.
  • Range: -6 to +12.
  • Mortality: ↑ if PTS < 0; Survival good if PTS > 8.
• Pediatric Glasgow Coma Scale (pGCS):
  • Modified for pre-verbal children (Eye opening, Verbal response, Motor response).
  • Score: 3 (min) to 15 (max).
  • Severe TBI: pGCS ≤ 8.
• Non-Accidental Trauma (NAT):
  • Suspect: Inconsistent history, delayed presentation.
  • Key injuries: Retinal hemorrhages, posterior rib #, metaphyseal #, subdural hematoma.

  ⭐ Posterior rib fractures and metaphyseal corner fractures are highly suggestive of NAT.

• Waddell's Triad (Pedestrian vs. Vehicle): 📌 HCL
  • Contralateral Head injury, Thoraco-abdominal injury, Femur #.

High‑Yield Points - ⚡ Biggest Takeaways

• Pediatric airway is distinct: smaller, anterior, larger tongue; prioritize patency.
• C-spine injuries often involve upper vertebrae; consider SCIWORA even with normal X-rays.
• Blunt abdominal trauma commonly affects liver and spleen; non-operative management is frequent.
• Head trauma is the primary cause of death; assess with Pediatric GCS.
• Initial fluid bolus: 20 ml/kg isotonic crystalloid.
• High risk of hypothermia due to larger surface area to mass ratio.
• Pulmonary contusions can occur without rib fractures due to chest wall compliance.