This page is for pediatric patients. For adult patients, see: Trauma (main)
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)
Locations of Possible Life-Threatening Bleeding
Pediatric car seat rules[1]
| Age
|
Type of Car Seat
|
Position
|
Comments
|
| <2 years old |
Infant-only or convertible car seat |
Back seat, rear-facing |
If child height or weight > seat limit (usually ~40-65lbs), go to next age up
|
| 2-8 years old |
Convertible or combination car seat |
Back seat, forward-facing |
If child height or weight > seat limit, go to next age up
|
| 8-12 years old |
Booster seat |
Back seat, forward-facing |
If child height or weight > seat limit (usually 4' 9"), go to next age up
|
| 12-13 years old |
Lap and shoulder seat belt |
Front 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
Calculators
PECARN Pediatric Head Injury
PECARN — Pediatric Head CT Decision Rule
| Age Group
|
Select One
|
| Patient Age
|
1 <2 years ≥2 years
|
Age <2 Years — Risk Factors
| Criteria
|
No
|
Yes
|
| GCS <15 (altered mental status)
|
1
|
|
| Palpable skull fracture
|
1
|
|
| Occipital/parietal/temporal scalp hematoma
|
1
|
|
| Loss of consciousness ≥5 seconds
|
1
|
|
| Not acting normally per parent
|
1
|
|
| Severe mechanism of injury (MVC with ejection/rollover/fatality, pedestrian/cyclist without helmet struck by motorized vehicle, fall >3 feet, head struck by high-impact object)
|
1
|
|
| Risk Factors (<2y)
|
/ 6
|
Age ≥2 Years — Risk Factors
| Criteria
|
No
|
Yes
|
| GCS <15 (altered mental status)
|
1
|
|
| Signs of basilar skull fracture (hemotympanum, raccoon eyes, Battle sign, CSF otorrhea/rhinorrhea)
|
1
|
|
| Vomiting
|
1
|
|
| Loss of consciousness
|
1
|
|
| Severe headache
|
1
|
|
| Severe mechanism of injury (MVC with ejection/rollover/fatality, pedestrian/cyclist without helmet struck by motorized vehicle, fall >5 feet, head struck by high-impact object)
|
1
|
|
| Risk Factors (≥2y)
|
/ 6
|
| Interpretation (for selected age group)
|
| 0
|
Very low risk — ciTBI risk <0.02% (<2y) or <0.05% (≥2y). CT not recommended.
|
| 1 (intermediate*)
|
Low risk — ciTBI risk ~0.9% (<2y) or ~0.8% (≥2y). Observation vs. CT. *Only if GCS=15 and no skull fracture/AMS. Consider observation for 4-6 hours.
|
| GCS<15 or skull fx
|
High risk — ciTBI risk 4.4% (<2y) or 4.3% (≥2y). CT recommended.
|
| References
|
- Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374:1160-1170. PMID 19758692.
|
External Links
References
