Acute Care of Multiple Trauma in Pediatrics

Topic Name Introduction Primary Survey Secondary Survey Specific Injuries Resuscitation Principles Trauma Imaging Critical Procedures Monitoring & Documentation

Introduction to Pediatric Trauma Care

Trauma remains a leading cause of morbidity and mortality in children. Understanding the unique anatomical and physiological differences in children is crucial for optimal trauma care.

Anatomical Considerations

• Head:
  • Larger head-to-body ratio
  • Higher center of gravity
  • Unfused sutures until age 2
  • Thinner cranial bones
• Airway:
  • More cephalad larynx
  • Shorter trachea
  • Larger tongue relative to oral cavity
  • Narrowest point at cricoid ring
• Chest:
  • More compliant chest wall
  • Internal injury possible without external signs
  • Mediastinal mobility
  • Limited respiratory reserve
• Abdomen:
  • Less protected organs
  • Thinner abdominal wall
  • More exposed liver and spleen
  • Higher risk of multiple organ injury

Physiological Response to Trauma

• Cardiovascular:
  • Maintenance of BP until 30-40% blood volume loss
  • Rapid decompensation once reserves depleted
  • Tachycardia primary sign of shock
  • Limited cardiac contractile reserve
• Respiratory:
  • Higher metabolic rate and oxygen consumption
  • Lower functional residual capacity
  • Rapid desaturation
  • Early respiratory failure

Primary Survey in Pediatric Trauma

Airway and Cervical Spine

• Initial Assessment:
  • Look: For chest/abdominal movement
  • Listen: For stridor/gurgling
  • Feel: For air movement
  • Assess: Voice/cry quality
• Immediate Actions:
  • Manual in-line stabilization
  • Jaw thrust maneuver
  • Suction as needed
  • Appropriate sizing of equipment

Breathing and Ventilation

• Assessment Parameters:
  • Respiratory rate and effort
  • Chest wall movement
  • Breath sounds
  • Oxygen saturation
  • Capnography when available
• Life-Threatening Conditions:
  • Tension pneumothorax
  • Open pneumothorax
  • Massive hemothorax
  • Flail chest

Circulation and Hemorrhage Control

• Assessment:
  • Heart rate (age-specific)
  • Pulse quality (central and peripheral)
  • Capillary refill time
  • Blood pressure
  • Skin color and temperature
• Shock Classification:

  Class	Blood Loss	HR	BP	Signs
  I	<15%	Normal	Normal	Minimal
  II	15-30%	↑	Normal	Mild anxiety
  III	30-40%	↑↑	↓	Confusion
  IV	>40%	↑↑↑	↓↓	Lethargy

Disability

• Neurological Assessment:
  • AVPU Scale
  • Pediatric Glasgow Coma Scale
  • Pupillary response
  • Posturing
• Signs of Raised ICP:
  • Cushing's triad
  • Pupillary changes
  • Focal neurological signs
  • Level of consciousness changes

Exposure and Environment

• Complete exposure with temperature control
• Look for hidden injuries
• Prevent hypothermia
• Log roll when appropriate

Secondary Survey

History (AMPLE)

• Allergies: Medications and environmental
• Medications: Current medications and timing
• Past Medical History: Relevant conditions
• Last Meal: Timing and content
• Events/Environment: Mechanism of injury

Mechanism of Injury Assessment

• Motor Vehicle Collisions:
  • Position in vehicle
  • Restraint use
  • Vehicle damage
  • Ejection status
  • Airbag deployment
• Falls:
  • Height of fall
  • Landing surface
  • Position on landing
  • Loss of consciousness

Systematic Examination

• Head and Face:
  • Scalp lacerations/hematomas
  • Facial symmetry
  • CSF leakage
  • Dental injury
• Neck:
  • Tracheal position
  • JVD
  • Step deformities
  • Subcutaneous emphysema
• Chest:
  • Chest wall stability
  • Breath sounds
  • Heart sounds
  • Subcutaneous emphysema
• Abdomen:
  • Tenderness
  • Distension
  • Organ enlargement
  • Seat belt sign
• Pelvis:
  • Stability
  • Bleeding
  • Urethral injury signs
• Extremities:
  • Deformities
  • Pulses
  • Motor function
  • Sensory function

Specific Injury Patterns

Head Trauma

• Assessment Priorities:
  • Level of consciousness changes
  • Pupillary response
  • Focal neurological signs
  • Signs of basilar skull fracture
• Management Principles:
  • Maintain cerebral perfusion pressure
  • Control intracranial pressure
  • Prevent secondary injury
  • Early neurosurgical consultation

Chest Trauma

• Common Injuries:
  • Pulmonary contusion
  • Pneumothorax
  • Hemothorax
  • Cardiac contusion
• Management:
  • Early tube thoracostomy when indicated
  • Pain control for rib fractures
  • Selective ventilatory support
  • Regular reassessment

Abdominal Trauma

• Solid Organ Injury:
  • Splenic injury grading
  • Liver injury assessment
  • Kidney injury evaluation
  • Non-operative management criteria
• Hollow Viscus Injury:
  • Signs and symptoms
  • Diagnostic challenges
  • Surgical indications
  • Monitoring requirements

Resuscitation Principles

Fluid Resuscitation

• Initial Approach:
  • Crystalloid bolus: 20mL/kg
  • Reassess after each bolus
  • Maximum 40-60mL/kg before blood
  • Consider early blood products in severe trauma
• Blood Product Administration:

  Product	Initial Dose	Indications
  PRBCs	10-15mL/kg	Ongoing bleeding, shock
  FFP	10-15mL/kg	Coagulopathy, massive transfusion
  Platelets	10mL/kg	Count <50k in active bleeding
  Cryoprecipitate	5mL/kg	Fibrinogen <100mg/dL

Massive Transfusion Protocol

• Activation Criteria:
  • Shock with poor response to initial fluids
  • Active bleeding with hemodynamic instability
  • Anticipated need for multiple blood products
  • Severe multisystem trauma
• Protocol Components:
  • PRBC:FFP:Platelets ratio of 1:1:1
  • Early calcium supplementation
  • Temperature management
  • Coagulation monitoring

Trauma Imaging

Initial Imaging

• Chest X-ray:
  • Mandatory in major trauma
  • AP supine initially
  • Assess ETT position
  • Look for pneumothorax/hemothorax
• Pelvic X-ray:
  • Required in blunt trauma
  • Assessment of stability
  • Guide fluid resuscitation
• FAST Exam:
  • Four standard views
  • Repeat with clinical changes
  • Limited by subcutaneous air
  • Lower sensitivity in children

CT Imaging

• Head CT Indications:
  • GCS <14
  • Focal neurological signs
  • Loss of consciousness
  • Severe mechanism
  • Clinical deterioration
• C-Spine CT Criteria:
  • Altered mental status
  • Neurological symptoms
  • High-risk mechanism
  • Neck pain/tenderness
• Body CT Considerations:
  • Radiation dose adjustment
  • Contrast timing
  • Positioning challenges
  • Motion artifact reduction

Critical Procedures

Airway Management

• RSI Medications:

  Drug	Dose	Comments
  Etomidate	0.3mg/kg	Hemodynamically stable
  Ketamine	1-2mg/kg	Preferred in shock
  Rocuronium	1mg/kg	Longer duration
  Succinylcholine	1-2mg/kg	Contraindications apply

Chest Procedures

• Needle Decompression:
  • 2nd/3rd intercostal space
  • Midclavicular line
  • Catheter length considerations
  • Convert to chest tube if positive
• Chest Tube Placement:
  • 4th/5th intercostal space
  • Anterior axillary line
  • Size selection by age
  • Secure fixation technique

Monitoring and Documentation

Clinical Monitoring

• Vital Signs Frequency:
  • Q5min during resuscitation
  • Q15min if stabilizing
  • Q30-60min when stable
  • More frequent with concerns
• Neurological Checks:
  • GCS trending
  • Pupillary response
  • Motor function
  • Hourly in TBI

Laboratory Monitoring

• Initial Labs:
  • Blood gas analysis
  • Complete blood count
  • Coagulation profile
  • Basic metabolic panel
  • Type and cross
• Ongoing Monitoring:
  • Hemoglobin/Hematocrit
  • Coagulation parameters
  • Lactate trending
  • Base deficit
  • Electrolytes

Documentation Requirements

• Essential Elements:
  • Timing of events
  • Physical findings
  • Interventions performed
  • Response to treatment
  • Team communications
• Quality Metrics:
  • Time to critical interventions
  • Fluid administration volumes
  • Temperature management
  • Pain control adequacy
  • Family communication