The burden of paediatric trauma is greatest in low- and middle-income countries where more than 95% of all injury deaths occur. Paediatric injuries are a growing global public health problem with trauma due to falls, road traffic accidents and burns being important causes. Many of these injuries are preventable. The survival of children who sustain major trauma depends on pre-hospital care and early resuscitation.
Assessment[edit | edit source]
The principles in managing trauma in children are the same as for adults: Primary Survey (ABCDE).
Assessment of Weight[edit | edit source]
Immediately assess the child's weight, either by asking the child’s parent, using a formula or a method such as the Broselow paediatric measuring tape.
Accurate dosing of medications and fluids is essential.
Primary Survey: Specific Considerations in Paediatric Trauma[edit | edit source]
- The relatively larger head, especially the occiput, and tongue
- Small babies rely on nose breathing
- The jaw is smaller, the larynx is higher and the epiglottis is proportionally bigger and more “U”-shaped
- The cricoid is the narrowest part of the airway which limits the size of the ET tube
- By puberty, the larynx has grown and the narrowest part is at the cords
- The trachea in the full-term new-born is about 4 cm long and will admit a 3.0 or 3.5 mm diameter endotracheal tube (ETT) (the adult trachea is about 12 cm long)
- Gastric distension is common following resuscitation, and a naso-gastric tube is useful to decompress the stomach
- If using a cuffed ETT, avoid high cuff pressures to minimise subglottic swelling and ulceration
- Oral intubation is easier than nasal for infants and young children
Assessment of Circulation[edit | edit source]
Cardiac Output and Pulses[edit | edit source]
Cardiac output in paediatric patients is primarily determined by heart rate.
The femoral artery in the groin and the brachial artery in the antecubital fossa are the best sites to palpate pulses in the child. If the child is pulseless, cardiopulmonary resuscitation must be commenced. Survival from paediatric cardiac arrest following trauma is very low.
Shock[edit | edit source]
Signs of shock in paediatric patients include:
- Tachycardia
- Weak or Absent Peripheral Pulses
- Capillary Refill > 2 seconds
- Tachypnoea
- Agitation
Children have increased blood loss associated with long bone and pelvic fractures compared with adults; therefore, early splinting and stabilisation are even more
important.
Children have tremendous reserves to compensate for hypovolaemia, so when they start to show signs of shock it may already be at an advanced stage. Children initially compensate for hypovolaemia with tachycardia and may not drop their blood pressure until they have lost 45% of their circulating volume.
Intraosseous Access[edit | edit source]
This is a relatively safe and very effective method of fluid administration. If an intraosseous needle or bone marrow needle is not available then a large spinal needle can be used. The best site is on the anteromedial aspect of the tibia below the tibial tuberosity, aiming slightly downwards away from the epiphyseal growth plate.
The clinical technique of intraosseous access will be demonstrated on one of the skill stations.
Fluid Replacement in Children[edit | edit source]
An initial bolus of 20 ml/kg body weight of Normal Saline may be given.
If no response is obtained after a second bolus then 20 ml/kg type specific blood or (10 ml/kg) packed red blood cells should be administered; O Rh negative products can be used if type specific blood is not available. Consider giving 5ml/kg of 10% dextrose if severely malnourished.
Aim to produce a urine output of 1–2 ml/kg/hour for the infant, and 0.5–1 ml/kg/hour in the adolescent.
Disability and Exposure: Specific Considerations in Paediatric Trauma[edit | edit source]
The clinical examination is of the utmost importance because radiographs are difficult to interpret and spinal cord injuries may not be apparent on X-Ray.
Hypothermia is a major problem in children because of their relatively large surface area to volume ratio. They lose proportionally more heat through the head. Fluids should be warmed.
Exposure of the child is necessary for assessment but consider covering as soon as possible
Consider early transfer to a paediatric trauma centre.
Support[edit | edit source]
Children should be kept warm and close to family if at all possible
Paediatric Physiological Values[edit | edit source]
Weight Formulae[edit | edit source]
A formula for estimated weight (kg) of a child between 1-5 years is:
(2 x age in years ) + 8
and between 6-12 years it is:
(3 x age in years) + 7
Normal Physiological Ranges[edit | edit source]
| Variable | New Born | 6 Months | 12 Months | 5 Years | Adult |
|---|---|---|---|---|---|
| Respiratory Rate (Breaths/Minute) | 50 +/- 10 | 30 +/- 5 | 24 +/- 6 | 23 +/- 5 | 12 +/- 3 |
| Tidal Volume (ml) | 21 | 45 | 78 | 270 | 575 |
| Minute Ventilation (L/Minute) | 1.05 | 1.35 | 1.78 | 5.5 | 6.4 |
| Haematocrit | 55 +/- 7 | 37 +/- 3 | 35 +/- 2.5 | 40 +/- 2 | 43-48 |
| Arterial pH | 7.3-7.4 | 7.35-7.45 | 7.35-7.45 |
| Age | Heart Rate - Range
(Beats/Minute) |
Systolic Blood Pressure
(mmHg) |
|---|---|---|
| 0-1 Year | 100-160 | 60-90 |
| 1 Year | 100-170 | 70-90 |
| 2 Years | 90-150 | 80-100 |
| 6 Years | 70-120 | 85-110 |
| 10 Years | 70-110 | 90-110 |
| 14 Years | 60-100 | 90-110 |
| Adult | 60-100 | 90-120 |
| Age | Weight
(Kg) |
Respiratory Rate
(Breaths/Minute) |
ETT Size | ETT at Lip
(cm) |
ETT at Nose
(cm) |
|---|---|---|---|---|---|
| Newborn | 1.0-3.0 | 40-50 | 3.0 | 5.5-8.5 | 7.0-10.50 |
| Newborn | 3.5 | 40-50 | 3.5 | 9.0 | 11.0 |
| 3 Months | 6.0 | 30-50 | 3.5 | 10.0 | 12.0 |
| 1 Year | 10.0 | 20-30 | 4.0 | 11.0 | 14.0 |
| 2 Years | 12.0 | 20-30 | 4.5 | 12.0 | 15.0 |
| 3 Years | 14.0 | 20-30 | 4.5 | 13.0 | 16.0 |
| 4 Years | 16.0 | 15-25 | 5.0 | 14.0 | 17.0 |
| 6 Years | 20.0 | 15-25 | 5.5 | 15.0 | 19.0 |
| 8 Years | 24.0 | 10-20 | 6.0 | 16.0 | 20.0 |
| 10 Years | 30.0 | 10-20 | 6.5 | 17.0 | 21.0 |
| 12 Years | 38.0 | 10-20 | 7.0 | 18.0 | 22.0 |