Initial management and stabilization of
pediatric trauma patients

ROBERT M. ARENSMAN, MD
MARY BETH MADONNA, MD

aFall 1997

TRAUMATIC INJURY IS  the leading cause of death in children of all ages. In fact, injuries, accidents and violence account for more childhood death and disabilities than all other causes combined. Approximately 27 of every 100 children seek medical attention for an injury in any given year. This means that about 16,614,000 children are injured each year in the United States, with adolescents having the highest proportion and severity of injuries. Records show that 44% of the injuries occur at home, and an additional 19% occur at school.¹ Of those children sustaining severe traumatic injuries, 55% are disabled one year after injury.² Children with head injuries have the slowest recovery from their injuries. Furthermore, traumatic injury in children dramatically affects the economy because of expenses for medical care and rehabilitation and costs related to the inability of the children to function independently in society. Therefore, injury prevention should be a priority for everyone.

However, when children are injured, good initial management is essential, as is their transfer to a pediatric trauma center when needed. Hall and associates³ from Cook County Hospital found that children with serious blunt traumatic injuries had better outcomes at pediatric trauma centers than at adult centers, while children with penetrating injuries fared the same in either center.

FIGURE 1. Algorithm: Initial Management of Pediatric Trauma Patient

The treatment priorities in children who sustain serious trauma are similar to those in adults—the stabilization of the child and management of life-threatening injuries.^4,5 Using the "ABC's" as outlined in the Advanced Trauma Life Support Manual⁶ (Airway, Breathing and Circulation), teams of professionals found in many hospitals manage these initial priorities simultaneously (see Figure 1). Obviously, though, supplies that are suitable for all ages and sizes must be on hand if children are received: these include multiple-sized endotracheal tubes and laryngoscopes; large to small intravenous catheters, including intraosseous trocar access; and urinary catheters and nasogastric tubes from little to big. In addition, resuscitation medications must be easily accessible in the appropriate doses. In the adult trauma center, it is often helpful to have a chart posted on the wall of the trauma room that indicates medication doses for a variety of weights and ages.

An airway for normal breathing is your first priority

As in all injured patients, your first priority as an emergency room physician is to maintain an intact airway. You do this while you maintain cervical spine immobilization. Keep in mind the anatomic differences in children that affect airway management.⁴ Infants and small children have proportionately larger heads than do adults, and when a child is lying supine, flexion of the neck can occur to the point of airway obstruction. By placing small children in the "sniffing position," midface slightly anterior and superior, you can prevent this problem. Also, because a child's tongue is proportionately larger relative to the mouth than in an adult and may cause obstruction, lift the chin to move the tongue forward. Nasotracheal intubation is not recommended due to the small nasal passages in young children. Infants are obligate nose breathers, so take special attention to suction the nasal passages free from debris. The larynx in children is more anterior and cephalad than in adults, which makes identifying the vocal cords more difficult. The trachea is also much shorter, so you must take care to avoid right mainstem bronchial intubation.

Depending on the status of the child, you may use various measures to maintain a patent airway. In a spontaneously breathing and crying child, you can use an oral airway to keep the tongue from occluding the posterior pharynx. Insert the appropriate size airway while maintaining C-spine control. (However, do not insert it and then rotate it 180°; doing so can lead to trauma to the teeth, soft tissues of the mouth and the tonsils, which are often enlarged in children.) By adding a mask, you can give additional oxygen to a child with a patent airway. For optimal results, be sure you have a tight seal.

For children who cannot maintain an airway, you must perform endotracheal intubation. You may also decide to intubate at-risk children before they are transported. Proper preparation is an important aspect of intubation; make sure that suction equipment is ready for use, and select the proper endotracheal tube (ETT). (Experienced physicians can estimate the correct size by noting the size of the child's nares or little finger. A formula is also helpful to estimate size [Internal Diameter mm = (age+16)/4]⁵ .)

Just before intubation, hyperventilate the child with the mask, and while visualizing the vocal cords, maintain cervical spine immobilization. After you have inserted the ETT past the cords, advance it only an additional two to three centimeters to prevent right mainstem intubation. Check placement by auscultating breath sounds. When you have the tube secured, confirm placement with a chest radiograph.

When children have severe facial trauma or if intubation attempts have been unsuccessful, you'll have to consider a surgical airway. Remember, however, that the cricoid cartilage is the only circumferential support of the airway in children under 12 years of age, so in these children you do not perform a surgical cricothyroidotomy. An acceptable temporary solution is a needle cricothyroidotomy. Using a 12- or 14-gauge angiocatheter, puncture the cricoid membrane, advance the plastic tubing and then withdraw the needle. Connect the catheter to IV tubing and deliver oxygen intermittently. This is only a temporary solution because CO₂ retention occurs with time. The permanent surgical airway is a tracheostomy, and you perform it in much the same fashion as you do in an adult, taking care to avoid any removal of cartilage.

After you have a secure airway in the traumatized child, adequate oxygenation and ventilation should be assured. Auscultate to assess for equal breath sounds. In small infants, breath sounds may be transmitted from the contralateral side so an early chest radiograph is important. In addition to listening for equal breath sounds, observe the child for grunting, nasal flaring and the use of accessory muscles; all are signs of impending respiratory distress. Monitor the respiratory rate; tachypnea is based on the normal respiratory rate for the child's age.

In these very early moments of the child's care, you should be alert for two life-threatening thoracic injuries—tension pneumothorax and pericardial tamponade. Tension pneumothorax: Tension pneumothorax can occur in the absence of external signs of thoracic trauma because children have a very compliant chest wall. Also, a simple pneumothorax can progress to a tension pneumothorax after the child is intubated and on positive-pressure ventilation. Signs of tension pneumothorax include absent breath sounds on the affected side, hypotension, tracheal deviation, jugular venous distention and possible electromechanical dissociation (EMD). If a tension pneumothorax is diagnosed, the child needs an immediate needle thoracostomy. You do this by inserting an angiocatheter high and anterior on the chest wall so that the air may be released. After the child is stabilized, the definitive tube thoracostomy is done.

Pericardial tamponade: Pericardial tamponade is another problem that you must address immediately. Signs of tamponade include muffled heart tones, hypotension, jugular venous distention and possible EMD. This condition calls for an immediate pericardiocentesis. To do this, you insert a needle attached to a syringe, and if possible an electrode, into the subxyphoid space and direct the needle toward the left shoulder at a 15° to 30° downward angle. You advance the needle while withdrawing on it until there is blood return. If an electrode is present, a flip in the waveform indicates that the heart has been punctured. If blood or air are found in the pericardial space, you connect the syringe to a stopcock for repeated aspiration. At the same time, prepare for an emergency thoracotomy or sternotomy.

Assess the child's hemodynamic status and circulation

With the airway open and the child's breathing assured, the next step is to assess the child's hemodynamic status, control hemorrhage and make sure you have intravenous access.

Assess for shock

Shock is a state of insufficient delivery of oxygen to the cells. The most common form of shock in a child who has sustained trauma is hemorrhagic shock from excessive blood loss. Acidosis occurs due to the accumulation of lactic acid, a byproduct of anaerobic metabolism. The child's respiratory rate increases to correct the pH. Tachycardia also occurs, although this is not a specific sign. Heart contractility increases in the older child but is not a mechanism readily available to the infant and small child. In addition, an increase in vasomotor tone shunts the blood to the essential organs. This results in decreased capillary refill. To check capillary refill, compress the nail bed or hypothenar eminence and watch for immediate blanching. The time to return to normal color is the capillary refill time. Normally this is less than two seconds; a longer time indicates decreased perfusion. Late signs of hemorrhagic shock include hypotension and initial agitation and then decreased mental status and oliguria.

Control hemorrhage

To control ongoing hemorrhage, identify the external sites and use direct pressure and elevation techniques. Occasionally pneumatic splints can be used to assist in controlling bleeding, although the pneumatic antishock garment is no longer routinely used. If it has been placed on the child at another emergency facility, slowly decompress one compartment at a time to avoid severe shock due to large blood-volume shifts.

Get lines in

To begin volume replacement, you must establish intravenous access; your ideal goal is to insert two peripheral intravenous lines in different uninjured extremities. This can be problematic in children, however, and fortunately other alternatives are available. For example, intraosseous access is particularly appropriate in some small children. You can use a bone marrow aspiration needle or a commercially available kit. The tibia is the most accessible site. Insert the needle with a screwing motion one to two centimeters below the tibial tuberosity until resistance gives way, and aspirate the marrow to confirm placement. In addition to replacing fluids with this site, you can use it for drawing laboratory samples for testing and for giving medications.

Another alternative is a cutdown, which can be done over the saphenous vein at the ankle or at the cephalic vein at the elbow. The saphenous vein is preferable if a leg is uninjured because it is more superficial and is not near nerves or arteries.

For central access you can use the subclavian or femoral veins. Femoral catheterization is easy to learn and has few complications in the acute period. To prevent infectious complications, replace all of the emergently placed access devices with more permanent access after the child is stabilized.

Once access is established, begin volume replacement. Give a fluid bolus of 20 ml/kg of lactated Ringer's solution or 0.9% normal saline, and monitor the child's response. The bolus can be repeated twice if complete response is not obtained initially. If shock is still present, transfuse the child with blood. Give type-specific packed red blood cells (PRBC's) at 10 ml/kg. If the child does not respond to this, assess the child for continued blood loss, especially from internal sites. If the child is unstable, you can use uncrossmatched, O-negative blood initially.

Assess the child's potential disabilities

Next you can turn your attention to the child's neurologic status. Assess the size and symmetry of the pupils and the child's level of consciousness. A guideline to use for this is the Glasgow Coma Scale (GCS) or the modified scale available for small children. A simpler technique is to use the AVPU mnemonic. The child is Alert, responsive to Verbal stimuli, responsive to Painful stimuli only or Unresponsive. Note focal neurologic deficits; if there are any, further work-up is needed.

Do a full exposure so you don't miss anything

To avoid missing any injuries, expose the child completely so you can do a full head-to-toe examination. Roll the child to look at the back, and also do a rectal exam to assess tone and bleeding. Insert a nasogastric tube to prevent gastric dilatation or aspiration from vomiting. Place a urinary catheter to monitor urine output and to check for the presence of blood. If a boy has blood in the scrotum or at the urethral meatus, or if there is a high-riding prostate, do a retrograde urethrogram before catheter insertion.

After the exam is complete, cover the child again to prevent hypothermia. In addition to warm blankets, consider the use of a radiant heat lamp, a Bearhugger^® and warm fluids. To warm the fluids, a commercially available warmer can be used, but if this is not available, a microwave can warm a liter of crystalloid fluid from room temperature to 34°C in two minutes.⁴

Look for specific injuries

After the initial stabilization is complete, turn your attention to assessing the child for specific injuries to various organ systems. Although a complete discussion of this topic is beyond the scope of this article, some brief highlights are addressed here.

Central Nervous System: Pediatric head trauma is common and is the leading cause of death in injured children. Unlike adults who suffer focal injuries, children are more likely to have diffuse injury. As a result, they are prone to elevations in intracranial pressure. This part of your assessment begins with the neurologic examination; any at-risk children should then undergo computerized tomography (CT). The goal in children with head injuries is to reduce intracranial pressure and maintain cerebral perfusion pressure. Hyperventilation can acutely decrease the intracranial pressure. Fluid resuscitation, as previously discussed, can help maintain blood pressure to increase the cerebral perfusion. Before beginning further therapy such as diuretics, consult a pediatric neurosurgeon. In addition, consider the transfer of these patients to a pediatric trauma center, where they are the most likely to have improved outcomes.³

Cervical spine injury is a rare event in children, but if it's unrecognized, it can lead to severe morbidity. Therefore, keep the child immobilized until the appropriate radiographs are evaluated. Furthermore, children can have spinal cord injury without radiographic abnormalities (SCIWORA). Therefore, even if radiographs are normal, the child is to remain immobilized if there are any neurologic abnormalities or tenderness over the spine. In addition, get a pediatric neurosurgical consultation in these children. Magnetic resonance imaging (MRI) might be necessary to help assess the spinal cord in these children.

Thoracic trauma: As stated before, a child can have significant injury to the chest cavity even when external signs are absent. If rib fractures are present, significant trauma has occurred. In addition to the life-threatening injuries already discussed, other serious injuries are likely, such as an open pneumothorax from a penetrating wound to the chest. If the thoracic wall wound is larger than 2/3 the diameter of the trachea, adequate ventilation cannot occur because air preferentially exits the wound, the path of least resistance. Close the wound temporarily with a flutter-type of dressing secured on three sides. When the child breathes in, the dressing is sucked in and occludes. When the child exhales, the air can exit and a tension pneumothorax is prevented. In addition, a massive hemothorax can occur and is usually the result of injury to the great vessels or heart. Evacuation of blood using a tube thoracostomy is a short-term measure; a significant portion of these children will require surgical intervention. If multiple ribs are fractured, a flail chest may occur and you see paradoxical respiratory motion. In addition to the external trauma seen in these children, there is usually significant pulmonary contusion that contributes to hypoxia. Supplemental oxygen, chest physiotherapy and adequate pain control are mandatory in the management of these children.

Abdominal and Pelvic Trauma: Unstable vital signs after proper resuscitation and evaluation of the thoracic cavity can be a sign of significant intraabdominal or pelvic injury. Assess stable patients for tenderness or distention of the abdomen. If you suspect any injury, the choice for evaluation is the CT. However, if a peritoneal lavage is performed in a child, the volume of fluid infused is 10 ml/kg of buffered saline or lactated Ringer's. Even if there is free blood in the peritoneum, a laparotomy is not always necessary. Many children with liver and splenic injuries can be managed non-operatively, even with the presence of other significant injuries. ⁷ Pelvic injuries in children are not common but can occur; therefore, a routine pelvic radiograph is done in the child with multiple injuries. When pelvic fractures do occur, they are usually not as severe as in adults and therefore do not tend to lead to exsanguination and death.⁸

Burns: Major burns contribute to a substantial percentage of the mortality in children.⁵ Airway management is important and elective intubation is considered if you find inhalation injury, facial burns, singed eyebrows or nasal hair, or carbonaceous sputum. Assess the percentage of the body surface area (BSA) burned but do not follow the "rule of 9's" in children; a chart can be useful for this determination. Provide volume resuscitation initially as you would in all trauma patients but after you have assessed the area of burn, the fluid replacement recommended is lactated Ringer's at 3–4 ml/kg/%BSA in addition to maintenance fluids. Infuse this volume over the first 24 hours, with half going in during the initial eight hours. After all the clothing is removed, clean the burns with sterile saline and apply a moist non-occlusive dressing. Transfer children to a burn center if any of the following are present: partial or full thickness burns over 10% of the BSA; full thickness burns over 5% of the BSA; burns to the face, hands, feet, genitalia, perineum or major joints; circumferential burns; electrical or chemical burns; burns associated with inhalation injury.

Be attuned to the possibility of abuse

Whenever you treat children with traumatic injuries, you must be attuned to the possibility of abuse. Many types of injury can be the result of an abusive family member or friend. Clues to abuse include a history that is not consistent with the injury, a delay in seeking treatment, injuries in different phases of healing and multiple healed fractures on radiographs. Because your goal is to ensure the safety and well being of the children you treat, thoroughly investigate any suspicious circumstances and, if needed, report your findings to the appropriate authorities.

Always consider transport

As previously noted, children with serious blunt trauma, especially with associated head injury, have better outcomes at a pediatric trauma center. Therefore, after you have stabilized the severely injured child, consider transport to one of these centers. Often the receiving institution supplies a transport team. The pediatric center possesses all of the proper equipment needed for a variety of childhood age groups. Of course, the referring physician should readily communicate with physicians at the receiving hospital to prepare them for the extent of injuries in the child. By law, you must send complete medical records and include all lab tests and, if possible, any radiographs to prevent the cost and time of repetitive testing.

In summary, the pediatric trauma patient is evaluated following the same principles used for managing an adult trauma patient with the exceptions outlined in this article. The goal is to stabilize injured children by thoroughly assessing them for injuries, appropriately treating these injuries and transferring them to a tertiary care center when appropriate. In addition, education of parents, teachers and children about injury prevention should be a priority because of its value in saving countless lives and money.

REFERENCES

1. Scheidt PC, Harel Y, Trumble AC, Jones DH, Overpeck MD, Bijur PE: The epidemiology of nonfatal injuries among US children and youth. Am J Public Health 1995;85(7):932-938.

2. Hu X, Wesson DE, Logsetty S, Spence LJ: Functional limitations and recovery in children with severe trauma: A one-year follow-up. J Trauma 1994;37(2):209–213.

3. Hall JR, Reyes HM, Meller JL, Loeff DS, Dembek R: The outcome for children with blunt trauma is best at a pediatric trauma center. J Pediatr Surg 1996;31(1):72–77.

4. Glynn L, Statter MB: The ABC's of pediatric trauma. In Arensman RM(ed.): Pediatric trauma: Initial care of the injured child. New York: Raven Press, 1995:7–18.

5. Graneto JW, Soglin DF: Transport and stabilization of the pediatric trauma patient. Pediatr Clinics NA 1993;40(2):365–380.

6. American College of Surgeons Committee on Trauma: Advanced Trauma Life Support Manual for Physicians. Chicago, 1990.

7. Coburn MC, Pfeifer J, DeLuca FG: Nonoperative management of splenic and hepatic trauma in the multiply injured pediatric and adolescent patient. Arch Surg 1995;130:332–338.

8. Ismail N, Bellemare JF, Molitt DL, DiScala C, Koeppel B, Tepas III, JJ. Death from pelvic fractures: Children are different. J Pediatr Surg 1996;31(1):82–85.

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