2. INTRODUCTION
• The priorities & principals of assessment &
management of injuries in Children are same as in
adults.
• Unique Anatomical & Physiologival characteristics of
the Children & different mechanisms of Injury
results in MultiSystem Injury being the Rule rather
than the exception in Children . So, Aggressive
management accordingly is to be done.
• Many injuries can be managed initially in a general
hospital ED, but care of the most seriously injured
children requires prompt triage and transportation
to a designated pediatric trauma center
3. Unique Characteristics of Pediatric
patienets related to Trauma
1. SIZE & SHAPE :
SMALLER BODY MASS in the children , the energy
imparted from the trauma results in a greater force
applied per unit of body surface area.
This more intense energey is transmitted to a body
having LESS FAT, LESS CONNECTIVE TISSUE, & CLOSE
PROXIMITY to MULTIPLE ORGANS , resulting in severe &
multi-system injuries in children.
Head in proportionately larger than the body , so high
frequency of Blunt Brain injuries is there.
4. • 2. SKELETON
Incomplete calcification
Multiple active growth centres
More pliable
Internal organ damage is frequent without
external skeletal damage.
If bony injury (e.g skull/rib # ) present : must have
underlying severe organ injury (e.g blunt brain
injury/ pulonary contusion etc.)
Diagnostic difficulty by Radiography
5. 3. SURFACE AREA
(Child’s body surface area : Blood volume ) ratio is
Highest @ Birth & decreases with Age.
Thermal energy loss & thereby Hypothermia
develops quickly in children with
Hypovolemia/hypotension
4. PSYCHOLOGICAL STATUS :
• emotional unstability
• Regressive behaviour with pain/ stress
• Naturally more fear & Stranger anxiety
Difficulty in CLINICAL ASSESSMENT
6. PRINCIPLES of Pediatric Trauma Care
• Prehospital Care
• TRIAGE
• PRIMARY SURVEY (A/B/C/D/E)
• RESUSCITAION
• SECONDARY SURVEY
• POSTRESUSCITAION MONITORING & RE-
EVALUATION
• DEFINITIVE CARE
7. Prehospital Care
prehospital interventions should focus on
airway and respiratory management ,
spinal immobilization
recognition of shock,
rapid transport to an appropriate facility based
upon the predicted severity of injury as soon as
possible
Shortening the time interval between injury and
definitive care remains a priority, and interventions
beyond lifesaving measures can be performed en
route to the hospital.
Don’t delay in transport for ET intubation/ IV access
9. AIRWAY EVALUATION & MANAGEMANT
• inability to maintain a Patent airway asssoc
with lack of oxygenation & Ventilation is
the most common cause of cardiac arrest
in children .
• So, children’s airway is a priority.
• Assess for Obstruction due to , POSITION,
INJURY, BLOOD, TEETH, FOREIGN BODY,
VOMITUS,
10. Pediatric Anatomy Potential Implications Airway Maneuvers
Large head and occiput May push head forward, occluding
airway
Shoulder roll may be required
to align airway axes
Large tongue May occlude upper airway in
obtunded or paralyzed patient
Jaw thrust, oral or
nasopharyngeal airway, Miller
(straight) laryngoscope blade
Superior larynx and
anterior cords
May make visualization of cords
difficult
Shoulder roll may be required
to align airway axes, straight
laryngoscope blade to lift
epiglottis
Cricoid narrowing Subglottic space is narrowest
portion of the pediatric airway,
prone to inflammation and upper
airway obstruction
Monitor cuff insufflation
pressures in small children
Large adenoids and tonsils May cause upper airway
obstruction; may bleed with nasal
intubation
Avoid blind nasal intubation in
young children
Small cricoid cartilage Makes open cricothyrotomy
technically difficult
Needle cricothyrotomy
preferred in young children
Large stomach, low
gastroesophageal sphincter
tone, relatively small lungs
Insufflation of stomach with bag-
valve mask ventilation or swallowed
air, children are prone to vomiting
Consider early placement of
orogastric or nasogastric tube
to deflate stomach when using
positive pressure ventilation
12. Airway management
NON-INVASIVE
• Indication :
Spontaneously Breathing
Child with Partially
Obstructed airway
Methods :
1. Neutral Position
2. Jaw-thrust + Bi-manual In-
line stabilisation
3. Suction of Secretion
/vomitus /Blood
4. Bag-Mask Ventilation +/-
Oral Airway
INVASIVE
• Indication
1. Unconscious/ GCS <9
2. Lack of Patent airway
3. Impending loss of patent
airway
4. Inability to Oxygenate/
Ventilate
5. Full/Impending Cardiac
Arrest
PRE-REQUISITE : Fully Pre-
Oxygenation
13. Invasive Definitive Airway
ENDO-TRACHEAL INTUBATION
• Most reliable Method of
establishing definitive
Airway & administering
ventilation in a child
• Orotracheal Intubation
under direct Laryngoscopic
visualisation along with
Adequate immobilisation &
protection of C-Spine is
preffered
• Naso-tracheal route is NOT
PREFFERED in children
• Method : DAI (RSI )
CRICOTHYROIDOTOMY
• When Airway maintenance
/control can’t be achieved
by Bag-Mask Ventilation /
Orotracheal Intubation
• Needle Cricothyroidotomy
preferred over Surgical
Cricothyroidotomy (≤8yrs)
• Caution :
1. Temporary Technique
2. Inadequate ventilation
progressive Hypercarbia
15. Age
Et tube(mm
Internal Diameter)
Blade Size & shape
Premature 2.5 Uncuffed* 0 Straight
Newborn 3.0 Uncuffed* 1.0 Straight
1–6 mo 3.5 Uncuffed* 1.0–1.5 Straight
6–12 mo 4.0 Uncuffed* 1.5 Straight
1–2 y 4.5 Uncuffed* 1.5 Straight
3–4 y 5.0 Uncuffed* 1.5–2.0 Straight or
curved
5–6 y 5.5 Uncuffed* 2.0 Straight or
curved
7–8 y 6.0 Cuffed 2.0 Straight or
curved
9–10 y 6.5 Cuffed 2.0 Straight or
curved
11 y 7.0 Cuffed 3.0 Straight or
curved
Age-Based Airway Equipment Size
2-10yrs
UNCUFFED ETT SIZE
AGE(yrs)/4 + 4
CUFFED ETT SIZE
AGE (yrs)/4 + 3.5
Weight based
ET Tsize
< 1kg : 2.5 mm
1-2kg : 3 mm
2-3kg : 3.5 mm
>3kg : 3.5-4.0
mm
16. Cervical Spine Immobilization
• Criteria:
• spinal pain or tenderness,
• significant multisystem trauma,
• severe head or facial trauma,
• neurologic deficit in any extremity,
• loss of consciousness,
• significant distracting injury,
• altered mental status
• METHOD ( Immobilize C-Spine until such injury excluded)
• A properly fitting rigid Cervical collar should be used.
• Head should be secured to the spine board using towel rolls
• padding may be necessary behind the shoulders
• Secure the child's body to the board by straps or wide cloth tape
• prevent lateral movement of the child during log-rolling
17. BREATHING
• ASSESSMENT
1. RATE
2. CHEST WALL MOVEMENT ( PARADOXICAL
BREATHING/ FLAIL SEGMENT)
3. TRACHEAL DEVIATION
4. OPEN WOUNDS
5. OXYGEN STATUS
6. PERCUSSION NOTE
7. CREPITUS
18. Signs of hypoxemia
Cyanosis
Agitation
Poor capillary refill
Bradycardia
Desaturation measured by pulse oximetry
Signs of inadequate ventilation
Tachypnea
Nasal flaring
Grunting
Retractions
Stridor or wheezing
19. MANAGEMENT Of BREATHING &
VENTILATION
• WARM HUMIDIFIED O2
• GASTRIC DECOMPRESSION (To prevent Aspiration)
• Appropriate Mechanical Ventilation ( avoid
Barotrauma & Volutrauma )
• NEEDLE/ TUBE THORACOSTOMY (
pneumo/hemo/hemo-pneumothorax)
avoid using long 14-18 g over-the-needle catheters for
needle thoracostomy ( 2nd ICS, MCL)
Chest tubes (small size) inserted by Tunneling , site
same as adult ( 5TH ICS, JUST ANT to MAL )
20. CIRCULATION & SHOCK
• Child’s Increased Physiologic Reserve : allows
for maintenance of normal SBP even in shock
• Upto 30% diminuation in circulatory blood
volume may be required to manifest a
Decrease in Child’s SBP
• TACHYCARDIA & POOR SKIN PERFUSION are
often the Only Early recognising features for
hypovolemia
27. DISABILITY
• Level of consciousness can be assessed using
either the Glasgow Coma Scale (GCS) or the
AVPU system
• GCS <8 : prompt endotracheal intubation in
trauma patients
• In children, GCS < 5 : poor outcome.
• Examination of cranial nerves
• pupillary responsiveness
• motor strength of each limb
28. EXPOSURE
• to identify important injuries and to detect
and correct hypothermia.
• Control bleeding by direct pressure, using air
splints on the extremities if needed
• A rectal temperature should be obtained
• Whenever possible, keep the child covered
and use external warming devices
• Consider warming fluids to 40°C (104°F) if
large amounts of IV fluids or blood products
are used.
30. Secondary Survey
• to identify all other injuries in the patient
• The presence of family may often be helpful to
calm and console frightened and injured
children
• complete history ( “AMPLE” (allergies,
medications, past medical history, time of last
meal, and events leading up to the injury )
• Imaging, diagnostic, and laboratory studies
31. Stabilization
• stabilized sufficiently to allow transfer of the child to
the radiology suite or inpatient unit, or safe transfer
to HIGHER CENTRE
• Continual reassessment is crucial
• Endotracheal tube dislodgment,
• development of a pneumothorax,
• regurgitation of stomach contents,
• occult hemorrhage causing shock,
• Worsening neurologic function
• Careful monitoring of fluid administration,
• Analgesics and sedatives
32. Referral to a HIGHER Pediatric Center
• Use of trauma triage scores : identify a child
whose care requires a more experienced team
• commonly used systems
1. Pediatric Trauma Score
2. Revised Trauma Score .
• Higher numbers : greater likelihood of survival
and thus a reduced need for trauma center
care
• A child with a Revised Trauma Score of <12 or
a Pediatric Trauma Score of <8 should be
transferred to a trauma center.
33. Pediatric Trauma Score
–1 +1 +2
Size (kg) <10 10–20 >20
Airway Unmaintained Maintained Normal
Systolic blood
pressure (mm
Hg)
<50 50–90 >90
Level of
consciousness
Comatose Altered Awake
Wounds Major open Minor open None
Skeletal
trauma
Open/multiple Closed None
35. Indications for Transfer to a Pediatric
Trauma Center
Mechanism of injury Ejection from motor vehicle
Fall from a height
Motor vehicle collision with prolonged
extrication
Motor vehicle collision with death of
another vehicle occupant
Anatomic injury Multiple severe trauma
More than three long-bone fractures
Spinal fractures or spinal cord injury
Amputations
Severe head or facial trauma
Penetrating head, chest, or abdominal
trauma
38. PEDIATRIC HEAD TRAUMA
• Head trauma consists of INJURY to Bony Skeleton,
Soft Tissue , & IntraCranial Contents
• Traumatic Brain injury is the leading cause of death
due to pediatric trauma
• Concussion is term for mild traumatic brain injury
with trauma-induced alteration in mental status,
often manifested with amnesia / confusion
• Children are more susceptible to secondary brain
injury , triggered by hypovolemia, decreased CPP,
Hypoxia, Hyperthermia, Seizures. So, adequate &
early restoration of circulating blood volume &
avoidig hypoxia is necessary
40. Pediatric considerations in Assessment
1. Infants & Young Child having Open fontanelle
& Mobile cranial sutures , more tolerant to
increasing IC SOL / Brain Edema. So even in a
Conscious child with bulging fontanelle/
suture diastasis indicate severe brain injury
Early neurosurgical intervention is essential.
2. Vomiting & Amnesia are common in children
after head injury , doesn’t necessarily imply
increased ICP. But, Persistant /more frequent
Vomiting is a concern & mandates CT HEAD
41. 3. Impact Seizures is more common in Children &
usually self-limited, but REQUIRES CT Head(Only
50% of children with post-traumatic seizures
have abnormal findings on CT scan) least likely
to result in long-term sequelae.
4. Raised ICP due to Cerebral edema is more
common than focal mass lesions in children, so
early ICP Monitoring indicated with
GCS <8 or MOTOR SCORE 1 or 2
Co-existent Multiple Organ injuries requiring
major volume resuscitation
Cerebral haemorrrhage/ edema & brain
herniation in CT HEAD
42. RADIOLOGIC EVALUATION
• primary goal : to identify traumatic brain
injury and to detect intracranial injuries that
require surgical intervention
• No clinical criteria can reliably predict the
presence of an intracranial injury
• CT and MRI are necessary . CT is the imaging
modality of choice.
• Indications are different acc to age
43. 0 to 2 Years of Age
• INDICATIONS
(1) any neurologic abnormality,
(2) any altered mental status,
(3) any scalp abnormalities (contusion, abrasion,
laceration, cephalohematoma),
(4) Persistent vomiting
• Maintain a lower threshold for imaging young infants
BECAUSE serious head injuries can produce findings
that are nonspecific and difficult to appreciate
• Children <2 years of age who have low-energy
mechanisms of injury and who have not experienced
signs or symptoms lasting >2 hours after injury may be
managed by observation alone
44. >2 Years of Age
Defined as applicable for patients aged 2–20 y, previously healthy, with isolated head injury
A child with a minor closed head injury is defined as a child with normal mental status, normal
findings on neurologic examination, and no signs suggestive of skull fracture
46. MANAGEMENT
• RAPID , EARLY ASSESSMENT & MANAGEMENT of
ABCDE
• NEUROSURGICAL CONSULTATION (from the beginning )
• Children in the negligible or low risk categories with
normal evaluation findings can be safely discharged
home (assuming there are no home-related risks) with
24-hour observation and follow-up with the primary
care provider. Discharge instructions should clearly
state the need to return to the ED if any symptoms in
the moderate-risk category occur
49. • ANTI-CONVULSANTS
• Children who experience two or more seizures, or seizures lasting
longer than a few minutes, should receive anticonvulsant therapy
• Prophylactic anticonvulsant therapy should also be strongly
considered in a child with a GCS score of <8, even if no seizures
have yet occurred, because the risk of developing acute post-
traumatic seizures is high, and many of these children already
have high intracranial pressures that will increase further with a
seizure
• MANNITOL
• Rarely indicated
• Diuresis may worsen hypovolemia
• Should be withheld during resuscitation unless there is signs of
Transtentorial herniation
• IV mannitol in a dose of 0.5 to 1.0 gram/kg can be used to lower
intracranial pressure, but the effect is temporary (a few hours
50. SPINAL TRAUMA
• Spinal trauma is relatively uncommon in young
children and is more commonly seen in adolescents
• Motor vehicle crashes (most common cause) , falls
and sports mishaps.
• 50% of spinal injuries and 67% of cervical spinal
injuries in children <12 years of age occur between
the occiput and C2
• Due to increased flexibility of the spine and spinal
column in younger children spinal cord injury
without radiographic abnormality (SCIWORA) can
occur
51. Anatomic differences of the Spinal Column in Children
and adults
Underdevelopment of supporting muscles
Partially ossified vertebrae
Wedge-shaped vertebrae
Horizontal facet joints
Higher fulcrum of flexion
Unstable atlanto-occipital joint
Children with spinal cord trauma have a higher mortality rate than
adults, and the mortality is frequently due to concomitant traumatic
brain injury
Because most spinal injuries fail to improve substantially, even in
children, the most important factor in prognosis is the initial neurologic
status
52. Assessment
1. Clinical Findings
1. Vertebral fractures
pain, tenderness, or overlying soft tissue injury
2. spinal cord injuries (with or without fracture)
paresthesias, paralysis, and other findings based
upon the level or type of spinal cord injury
3. SCIWORA
•In >50% of children onset of paralysis is delayed,
sometimes up to 4 days
•Many of these children have transient
paresthesias, numbness, or weakness at the time of
or shortly after the injury.
53. 2. Radiography
• Considerations for Cervical Spine Imaging in
Children
• Moderate- or high-risk head injury
• Multiple trauma
• Signs or symptoms of spinal injury
• Direct mechanism for spinal injury
• Altered mental status or focal neurologic findings
• Distracting painful injury
• Agitation with possible mechanism for spinal
injury
54. • . Plain radiography ( remains a useful tool for
initial imaging of the child with a possible spinal
column injury)
• Plain radiographic imaging of the cervical spine
should include at a minimum three views:
lateral, anteroposterior, and odontoid
• if there is any doubt : CT scan
• CT scanning without plain radiographic imaging
of the cervical spine is also an acceptable
alternative if a head CT scan is also being
obtained,
• SCIWORA : MRI
55. Spinal Cord Injury without Radiographic
Abnormality (SCIWORA)
• Up to 66% of spinal cord injuries
• In children who have experienced transient or
persistent symptoms such as paresthesias or
weakness, with objective signs OF spinal injury , spinal
column imaging must be performed
• If findings on all radiographs are negative but the child
has signs or symptoms of a spinal cord injury, then MRI
should be performed emergently
• Any time the diagnosis of SCIWORA is considered, the
child requires a neurosurgical consultation in the ED
and admission to the hospital.
• Cervical spine immobilization should be maintained
throughout this entire procedure
56. MANAGEMENT
• prehospital and ED settings
immobilization,
diagnosis of the specific injury,
possibly, steroid administration.(Steroid therapy
should be considered if there is evidence of a
neurologic deficit,Though Debate continues )
• immediate neurosurgical consultation.
• If a spinal fracture is also present, a pediatric
orthopedist should be consulted .
57. CHEST TRAUMA
• 80% all Pediatric injuries
• Marker for other organ injury ( >2/3rd Pediatric Chest
Injuries assoc with Multiple Injuries)
• Mechanism : mainly, Blunt Trauma (penetrating trauma
more common after 10yrs)
• Rib # , Mediastinal Injuries , Diaphragmatic injury are
Uncommon,
• Mobility of mediastinal structures : more susceptible to
Tension Pneumothorax
• Treatment : Supportive Care +/- Thoracostomy+
Adequate Ventilation ( like Adults)
58. ABDOMINAL TRAUMA
• Mechanism : blunt trauma mainly,
• More susceptible to
Solid organ Avulsion (liver, spleen,
Kidney)
Bladder Injury
Duodenal Hematoma
Blunt Pancreatic injury
Small Bowel perforation @/near the
ligament of Treitz, Avulsion, Mesenteric Avulsion
more common in Children
59. Clinical Examination
Clincal assessment becomes difficult @ times
Frightened, Crying Conscious
infants/ young children having Voluntary
guarding
Upper Abdominal Distension due to
Aerophagia
Tenderness due to Gastric dilatation & Bladder
Distension
60. Diagnostic adjuncts
1. Abdominal CECT
• Gold Standard for Abdominal organ Injuries
even for Children
• Abdominal CT SCAN should be IMMEDIATELY
available , performed Early & Must Not delay
further treatment , & Should be accompanied by
Doctor skilled in Pediatric airway management &
vascular access.
• Indications : abdominal tenderness, abdominal
distention, abdominal bruising, hematuria,
vomiting, neurologic obtundation, falling or low
hematocrit, and absent bowel sounds
61. 2. FAST
Advantage :
• Rapid
• Non-invasive
• Can be Repeated
• Can detect small-amount
of blood
Disadvantage:
Not Consistent to diagnose
Isolated Parenchymal
injury In Children (>1/3rd
solid organ injuries in
children)
• May be used in hemodynamically
unstable children with abdominal
trauma if CT/FAST not readily available
or who can’t be safely transported to
CT,
• By ONLY THE SURGEON who will care
for the child
In Children , Uncertain
Utility
Advantage :
Can be peformed by attending
doctor @ bedside
Disadvantage :
Invasive
•Uncontrolled penetration may
produce iatrogenic organ injury
•Retroperitoneal bleeding can’t be
assessed
•DPL interferes with subsequent
clinical examination
3. DPL
62. Abdominal trauma management
OPERATIVE
• PRESENCE of INTRAPERITONEAL
BLOOD, DOES NOT MANDATE
LAPAROTOMY in CHILDREN
• Indication :
1. Hemodynamically unstable even
after resuscitative efforts &
Diagnostics (+) for blood
2. Hemodynamically Stable but
transfusion requirement is >1/2
Child’s Blood Volume , or
>40ml/kg during 24hrs after
injury
3. HVP , most of the cases (DPL +
for feces/bile/vegetable
fibres/leococytosis)
NON-OPERATIVE
• Selective cases
• Decision taken by the Surgeon
only
• MUST be UNDER CONTINUOUS
MONITORING by SURGEONS
• Indication
1. Hemodynamically Stable ,
without requiring massive
transfusion
63. Pelvic and GU Trauma
• GU injuries are uncommon in children
• Trauma to the GU tract should be considered
in all children with multiple trauma, a pelvic
fracture, or injury to the flank, back, or groin
• Children are less likely to die of hemorrhage
from a pelvic fracture than are adults
64. CLINICAL ASSESSMENT
• often nonspecific
• back pain,
• abdominal pain,
• hypotension,
• abdominal wall trauma
• Pelvic fractures, particularly anterior ring fractures,
(associated with urethral and bladder injury)
• Hematuria is considered the hallmark finding in GU
trauma, although it is a nonspecific sign
• The degree of hematuria does not correlate with
the severity of injury, because renal pedicle
disruption can be associated with no hematuria
and minor injuries can be associated with gross
hematuria
65. RADIOGRAPHY
• based on clinical
presentation
• Asymptomatic microscopic
hematuria in children with
blunt trauma and no
apparent injuries is a low-
yield indication for emergent
abdominal CT
• Cystourethrography
all patients with suspected
lower urinary tract injuries
(blood at the urethral meatus
or severe anterior pelvic
fracture)
Treatment of spinal cord injuries in the prehospital and ED settings consists of immobilization, diagnosis of the specific injury, and, possibly, steroid administration. Steroid therapy should be considered if there is evidence of a neurologic deficit. Debate continues regarding the benefit of steroid administration in spinal cord injury
Because most morbidity and mortality in pediatric trauma is due to traumatic brain injury, prehospital interventions should focus on airway and respiratory management, recognition of shock, spinal immobilization, and rapid transport to an appropriate facility based upon the predicted severity of injury
Shortening the time interval between injury and definitive care remains a priority; minimizing on-scene time is an important issue in prehospital management. Transport to the hospital should be initiated as soon as possible, and interventions beyond lifesaving measures can be performed en route to the hospital.
Although establishment of IV access may be the prehospital ALS intervention that is most often performed, the beneficial effects of this intervention remain in doubt for the majority of pediatric trauma patients. Although airway management is crucial to prevent hypoxia, prehospital endotracheal intubation requires specialized skills and training, and it is not associated with better outcomes in children than is bag-valve mask ventilation.
Injuries and conditions that require immediate lifesaving intervention should be identified and treated during the primary survey , The priorities in the management of children with traumatic injuries do not differ from those in the management of injured adults
The most important step in trauma care for children is airway intervention
Statistically validated criteria to predict which children require immobilization have not been developedCompleting the primary survey takes precedence over clearance of the child's cervical spine by clinical or radiographic methods.
Signs of shock include tachycardia, cool extremities, altered level of consciousness, weak distal pulses, low urine output, and capillary refill time of >3 seconds. Measure capillary refill in children at the head or chest to minimize the influence of environmental factors. For shock, give rapid crystalloid fluid boluses of 20 mL/kg. If three boluses of crystalloid fail to correct signs of shock, then blood [packed red blood cells (RBCs)] should be given using 10 mL/kg boluses
IO 18G INFANTS, 15 G YOUNG CHILD
, because some injuries may only be manifested over time and complications from therapeutic interventions can occur
Children with any loss of consciousness or any symptoms after head injuries from sports should be kept out of athletic activities for 1 week and reevaluated before return to athletic activities
Furosemide (1.0 milligram/kg) may decrease edema as well. To date, no studies have shown steroid therapy to be helpful
A single lateral cervical spine radiograph has been shown to miss fractures and result in a delay in diagnosis.
The role of flexion and extension lateral cervical spine radiographs is controversial. Flexion-extension images should not be obtained if there are neurologic signs or symptoms
In children, the need to limit exposure to ionizing radiation, immature development of the cervical spine, and uncooperative behavior of the child all affect the usefulness and diagnostic ability of radiographic imaging
Up to 66% of spinal cord injuries in children produce no abnormal radiographic findings and thus fall under the umbrella of SCIWORA