Pediatric Trauma Anesthesia

Pediatric Trauma Anesthesia: Unique Physiology - Tiny Titans, Big Challenges

• Airway: Obligate nose breathers (infants); large occiput (shoulder roll needed); anterior/cephalad larynx; narrowest at cricoid (infants).
• Respiratory: High O₂ consumption (6-8 mL/kg/min); low FRC (rapid desaturation); diaphragmatic breathing, fatigue-prone.
• Cardiovascular: CO primarily HR-dependent. Blood volume: Neonates $\approx \textbf{80-90}$ mL/kg, Children $\approx \textbf{70-80}$ mL/kg.
  • ⭐ > Hypotension is a LATE, ominous shock sign. Resuscitate on poor perfusion signs (tachycardia, ↓cap refill), not just BP.
• Thermoregulation: Large surface area-to-volume ratio → ↑ heat loss, high hypothermia risk.
• Drug Metabolism: Immature hepatic/renal function → altered drug pharmacokinetics/dynamics; prolonged effects.

Pediatric Trauma Anesthesia: Resuscitation Essentials - ABCs & Fluid Fixes

Pediatric ATLS: ABCDE approach, age-specific modifications.

• Airway & C-spine: Secure, immobilize.
• Breathing: Assess, ventilate.
• Circulation: Control hemorrhage, assess perfusion.
  • Vascular Access: IV attempts; rapid IO if IV fails (<60-90s). Sites: proximal tibia, distal femur.
  • 📌 Broselow-Luten tape for drug/equipment sizing.
  • Fluid Resuscitation: Initial crystalloid $20 \text{ mL/kg}$ (repeat up to $40-60 \text{ mL/kg}$).
  • Blood Products (ongoing shock):

    Product	Dose (mL/kg)	Key Indication
    PRBCs	10-15	↑ O₂ capacity, Hb <7-8 g/dL
    FFP	10-15	Coagulopathy, MTP
    Platelets	5-10 (or 1U/10kg)	Thrombocytopenia <50k, bleeding

    • MTP: Aim 1:1:1 (PRBCs:FFP:Platelets).
• Disability: AVPU, GCS.
• Exposure: Prevent hypothermia.

⭐ For children in hemorrhagic shock, after initial crystalloid boluses, early administration of blood products in a balanced ratio (e.g., 1:1:1 of PRBCs:FFP:Platelets) is crucial and improves outcomes.

Pediatric Trauma Anesthesia: Airway & Anesthesia - Breathing Easy, Sleeping Safe

• Airway Assessment:
  • Pediatric anatomy: Large occiput/tongue, anterior/cephalad larynx, narrow cricoid.
  • Adapt LEMON score.
• Equipment:
  • Blades: Miller (straight) for infants.
  • ETT (cuffed preferred): Uncuffed: $(\text{age in years}/4) + 4$; Cuffed: $(\text{age in years}/4) + 3.5$.
  • LMA as rescue.
• Rapid Sequence Intubation (RSI):
  • Preoxygenate; cricoid pressure.
  • Drugs (age/weight-based):
    • Atropine: 0.02 mg/kg (<1yr or <5yr with SCh).
    • Induction: Ketamine 1-2 mg/kg IV; Etomidate 0.2-0.3 mg/kg IV.
    • Paralysis: SCh (Infants 1-2 mg/kg IV, Child 1 mg/kg IV); Roc 0.9-1.2 mg/kg IV.
• Anesthesia:
  • Agents: Ketamine, Propofol; Sevoflurane. Avoid N2O.
• Monitoring: ECG, SpO2, EtCO2 (key), NIBP, Temp.
• 📌 DOPE: Dislodgement, Obstruction, Pneumothorax, Equipment.

⭐ Atropine (0.02 mg/kg) for infants (<1yr) & children <5yr with SCh prevents bradycardia in RSI.

Pediatric Trauma Anesthesia: Key Injuries & Pain - Ouchie Fixers, Big Hurts

• TBI: Avoid hypotension/hypoxia; maintain CPP; GCS assessment crucial.
• Thoracic Trauma: Tension pneumothorax (needle decompression); chest tube for hemothorax/pneumothorax.
• Abdominal Trauma: FAST scan utility for diagnosis; consider non-operative management.
• Burns: Airway priority; Parkland formula for fluid resuscitation: $4 \text{ mL} \times \text{Body Weight (kg)} \times % \text{TBSA burned}$; aggressive temperature control.
• Pain Assessment: Use age-appropriate scales: FLACC, Wong-Baker FACES, Numeric Rating Scale.
• Multimodal Analgesia: Opioids (careful titration); regional (caudal/epidural, PNBs); non-opioids (paracetamol, ketamine).

⭐ The 'lethal triad' (hypothermia, acidosis, coagulopathy) is particularly detrimental in pediatric patients and requires aggressive preventative and corrective measures.

High‑Yield Points - ⚡ Biggest Takeaways

• Airway management is paramount; cuffed ETTs preferred for aspiration protection.
• Aggressively prevent/treat hypothermia to avoid coagulopathy and acidosis.
• Fluid resuscitation: initial 20 ml/kg crystalloid, then 10-15 ml/kg PRBCs for hemorrhage.
• Permissive hypotension is generally contraindicated in pediatric TBI.
• Employ multimodal analgesia; titrate opioids cautiously.
• Maintain C-spine immobilization until injury is ruled out.
• Crucial: age-specific physiology, vitals, drug doses, and equipment_._