Trauma (peds)

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

  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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