Trauma (peds)

Background
  • Key is to recognize and treat shock early (before blood pressure decreases),
    • once child has signs and symptoms of shock, may have lost 25% of blood volume
  • BP not usually helpful sign of blood loss in pediatric patients
    • Can have high, low, or normal BP in shock
    • pulse pressure is helpful
  • 80% of pediatric trauma deaths associated with neurological injury (see pediatric head trauma)

Pediatric car seat rules[1]
Age Type of Car Seat Position Comments
<2 years oldInfant-only or convertible car seatBack seat, rear-facingIf child height or weight > seat limit (usually ~40-65lbs), go to next age up
2-8 years oldConvertible or combination car seatBack seat, forward-facingIf child height or weight > seat limit, go to next age up
8-12 years oldBooster seatBack seat, forward-facingIf child height or weight > seat limit (usually 4' 9"), go to next age up
12-13 years oldLap and shoulder seat beltFront or back seat, forward-facing

Clinical Features
  • Peds assessment triad: appearance, work of breathing & circulation (skin color)
  • Child's size allows for distribution of injuries
    • multi-system trauma is common
    • internal organs more susceptible to injury due to anterior placement of liver and spleen (as well as less protective muscle & fat)
    • Kidneys also less well protected and more mobile, prone to decelleration injury
  • Wadell Triad in auto vs. pedestrian child= femoral shaft fracture, intraabdominal/intrathoracic injury, and contralateral head injury

Differential Diagnosis

Evaluation
  • FAST exam
  • Consider as indicated:
    • CBC, coags, T&S, LFTs for abdominal trauma[2]
    • Plain films
    • CT head, cervical spine clearance clinically or with imaging
    • CT abdomen/pelvis[3]
      • Significant intra-abdominal injury after blunt torso trauma highly unlikely (0.1%) if all of the following are true:
        • Glasgow coma scale ≥14
        • No evidence of abdominal wall trauma or seat belt sign
        • No abdominal tenderness, abdominal pain, or vomiting
        • No thoracic wall trauma or decreased breath sounds

Management
  • ATLS
  • In ED give IVF at 20cc/kg, if unresponsive after 40cc/kg give PRBCs at 10cc/kg (can start with PRBC if presents in decompensated shock & multiple injuries suspected)

Disposition
  • Depends on underlying injury

See Also

References
  1. AAP 2011. http://pediatrics.aappublications.org/content/pediatrics/early/2011/03/21/peds.2011-0213.full.pdf
  2. The Utility of Laboratory Testing in Pediatric Trauma: A Primer from TAMING OF THE SRU Dec 13, 2019 available at http://www.tamingthesru.com/blog/grand-rounds/diagnostics/labs-in-peds-trauma
  3. Holmes JF et al. Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries. Ann Emerg Med. 2013
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