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

Disclaimer

The notes provided on Pediatime are generated from online resources and AI sources and have been carefully checked for accuracy. However, these notes are not intended to replace standard textbooks. They are designed to serve as a quick review and revision tool for medical students and professionals, and to aid in theory exam preparation. For comprehensive learning, please refer to recommended textbooks and guidelines.