Pediatric trauma considerations

Primary Survey - Little People, Big Differences

• Airway: Larger occiput/tongue → place shoulder roll for neutral alignment. Uncuffed ETT size formula: $(Age/4) + 4$.
• Breathing: Pliable chest wall means significant internal injury can occur without rib fractures.
• Circulation: Tachycardia is the earliest sign of shock. Obtain Intraosseous (IO) access if IV attempts fail.
• Disability: Assess using the Pediatric Glasgow Coma Scale (pGCS).
• Exposure: High surface-area-to-mass ratio ↑ risk of hypothermia; use aggressive warming measures.

⭐ Hypotension is a late, ominous sign, often heralding imminent cardiac arrest.

Head & Spine Trauma - Protecting the Noggin

• Anatomical Risks: Large head-to-body ratio & weak neck muscles ↑ risk for high cervical spine (C1-C2) injuries.
  • Open fontanelles can temporarily compensate for rising intracranial pressure (ICP), masking early signs.
• Unique Injury Patterns: Be vigilant for Spinal Cord Injury Without Radiographic Abnormality (SCIWORA).
  • Assess consciousness with the Pediatric Glasgow Coma Scale (GCS).
  • Cushing's triad (hypertension, bradycardia, irregular respirations) is a late and ominous sign of ↑ ICP.

⭐ A child with neurological signs of spinal injury but normal X-ray/CT scans is characteristic of SCIWORA; MRI is required for diagnosis.

Thoracic & Abdominal Trauma - Insides & Out

• Pliable Thorax: Compliant chest wall often means significant internal injury (e.g., pulmonary contusion, diaphragmatic rupture) without overlying rib fractures.
  • Mobile mediastinum ↑ risk of rapid decompensation from tension pneumothorax.
• Abdominal Focus: Solid organs are more vulnerable than hollow viscera.
  • Non-operative management is the standard for hemodynamically stable liver or spleen lacerations.
  • Serial exams are crucial; peritonitis suggests hollow viscus injury.

⭐ The spleen is the most commonly injured organ in pediatric blunt abdominal trauma, followed by the liver.

Musculoskeletal Trauma - Bendy Bones & Breaks

• Pediatric bones are more porous and pliable with a thick, metabolically active periosteum, leading to unique fracture patterns and faster healing.
• Common Types:
  • Greenstick: Incomplete fracture; cortex breaks on one side, bends on the other.
  • Torus (Buckle): Compression failure of the cortex, often at the metaphysis.
  • Plastic Bowing: Bending without a visible cortical break.
• Physeal (Growth Plate) Fractures: Classified by the Salter-Harris system.
  • 📌 SALTER Mnemonic:
  • I: Straight across
  • II: Above
  • III: Lower
  • IV: Through
  • V: ERasure (crush)

⭐ Salter-Harris Type II is the most common type, typically involving the distal radius. Prognosis is generally excellent as it spares the germinal layer of the physis.

Non-Accidental Trauma - Hidden Clues

• History: Vague, inconsistent with injury severity, or significant delay in seeking care.
• Fractures: High-specificity patterns like metaphyseal corner fractures, posterior rib fractures, or multiple fractures in various stages of healing.
• Bruising: 📌 TEN-4 mnemonic: Bruising on Torso, Ears, or Neck in a child < 4 years old. Patterned bruises are a major red flag.

⭐ Retinal hemorrhages are a hallmark of abusive head trauma (shaken baby syndrome) and are often found on fundoscopic exam.

• Children have unique injury patterns due to anatomical differences; head trauma is more common.
• The pediatric airway is smaller and anterior; consider uncuffed ET tubes in young children.
• High risk of hypothermia due to a larger body surface area-to-mass ratio.
• Fluid resuscitation is weight-based (20 mL/kg crystalloid); the Broselow tape is a key tool.
• Tachycardia, not hypotension, is the earliest reliable sign of shock.
• Always maintain a high index of suspicion for non-accidental trauma (NAT).
• C-spine injuries may present as SCIWORA (Spinal Cord Injury Without Radiographic Abnormality).