Pediatric trauma considerations

👶 Core Concept & Pathophysiology - Little Bodies, Big Problems

• Anatomical Vulnerabilities:
  • Large head-to-body ratio → ↑ head & C-spine injury risk.
  • Pliable skeleton → Internal organ damage without overlying fractures.
  • Less protective fat/muscle → ↑ solid organ (liver, spleen) vulnerability.
• Physiological Challenges:
  • ↑ Body Surface Area (BSA) to mass ratio → Rapid hypothermia.
  • ↑ Metabolic rate → Quicker desaturation.
  • Smaller blood volume (~$80$ mL/kg) → Small losses are significant.

⭐ Hypotension is a LATE and ominous sign of shock in children. They compensate with tachycardia until cardiovascular collapse is imminent.

🕵️ Clinical Manifestations - Telltale Trauma Signs

• Non-Accidental Trauma (NAT) Red Flags:
  • Skin: Bruises in various healing stages, patterned injuries (belt, hand, cigarette), or any bruise on a non-mobile infant (<4 months).
  • Head: Retinal hemorrhages, subdural hematoma (shaken baby).
  • Skeletal: Posterior rib fractures, metaphyseal corner/bucket-handle fractures, multiple fractures at different healing stages.
  • Abdominal: Duodenal hematoma, pancreatic injury without history of high-impact trauma (e.g., MVC).

⭐ Posterior rib fractures are highly specific for NAT. The mechanism involves forceful squeezing of the chest.

📌 TEN-4 FACES-P: High-risk bruising on Torso, Ears, Neck in child <4 yrs, or anywhere in infant <4 mos. Also Frenulum, Auricle, Cheek, Eyelids, Sclera, Patterned.

🩺 Diagnosis - Sizing Up The Situation

• Primary Survey (ATLS/PALS): A systematic approach is critical.
  • 📌 Use Broselow Tape for weight-based dosing & equipment sizing.
  • C-Spine: Immobilize until cleared; higher injury fulcrum (C2-C3).
  • Circulation: Initial fluid bolus is $20 \text{ mL/kg}$ isotonic crystalloid. Repeat up to 2-3 times before blood products.

⭐ Hypotension is a LATE, ominous sign of shock. Tachycardia and poor perfusion (delayed capillary refill >2 sec, cool extremities, weak pulses) are earlier indicators.

• Secondary Survey: Head-to-toe exam after stabilization.
• Imaging:
  • FAST exam: Useful for detecting free fluid (hemoperitoneum).
  • CT scans: Use selectively due to radiation risk (ALARA). Consider Pan-scan for high-energy trauma.

🩹 Management - Fixing The Future

• Fluid Resuscitation:
  • Initial bolus: 20 mL/kg isotonic crystalloid.
  • For hemorrhage: 10 mL/kg pRBCs.
• Hypothermia Prevention: Aggressive warming is critical due to high surface area-to-mass ratio causing rapid heat loss.
• Non-Operative Management (NOM): Preferred for hemodynamically stable solid organ injuries (liver, spleen).
• 💡 Use Broselow Tape for rapid, weight-based equipment sizing and drug dosing.

⭐ Unrecognized hemorrhage is the most common cause of preventable death in pediatric trauma.

⚠️ Complications - Post-Trauma Pitfalls

• Growth Plate (Physeal) Injury:
  • Salter-Harris classification (I-V) predicts prognosis.
  • Risks: growth arrest, limb length discrepancy, angular deformity.
  • Requires long-term orthopedic follow-up.
• Missed Injuries:
  • Non-Accidental Trauma (NAT): Maintain high suspicion with inconsistent history or specific fracture patterns (e.g., posterior ribs).
  • Abdominal Compartment Syndrome (ACS): Can develop post-resuscitation.

⭐ A compliant chest wall in children can mask severe underlying injury; pulmonary contusions can exist without rib fractures.

⚡ Biggest Takeaways

• Head injury is the leading cause of pediatric trauma death due to a large head-to-body ratio.
• Pulmonary contusions can occur without rib fractures because of a highly compliant chest wall.
• Liver and spleen are the most injured abdominal organs; non-operative management is often successful.
• Children compensate for shock with tachycardia; hypotension is a late, pre-arrest finding.
• Initial fluid resuscitation is a 20 mL/kg crystalloid bolus; use Broselow tape for sizing.
• Always consider Non-Accidental Trauma (NAT), especially with posterior rib or metaphyseal fractures.