FRCA Notes

Paediatric Trauma

Resources

  • Children are at higher risk of trauma due to their lack of experience and awareness of danger, and trauma is the leading cause of death in children >1yr old
  • Although most often blunt trauma, the mechanisms of traumatic injury vary with age:
    • Infant - NAI is most common
    • Toddlers - falls
    • Older children: RTCs and sports injuries
  • Difficulties in the paediatric trauma patient include:
    • Inability of patient to describe symptoms or cooperate with assessment, investigation or management
    • Subtle changes in vital signs with age
    • Increased physiological reserve leading to maintenance of normal vital signs until extremely shocked

  • It should be presumed that a paediatric trauma patient has multisystem injury until proven otherwise
    • There is greater force applied per unit body area owing to smaller body mass
    • The paediatric patient has less fat/connective tissue and their major organs are in closer proximity
    • The incompletely calcified skeleton means fractures are less likely even when there is internal organ damage and high energies
    • The presence of skull and/or rib fractures represents a massive amount of energy transferred

  • Trimodal distribution of mortality:
    • 50% at scene from severe TBI or major haemorrhage
    • 30% within the first few hours from head injury, haemorrhage or airway emergencies
    • Late deaths due to organ failure and sepsis, possibly due to inadequate initial resuscitation

  • Catastrophic haemorrhage should be managed as in adults; pressure, tourniquets and if necessary urgent surgical intervention

C-spine

  • If C-spine protection is considered necessary, start with MILS
    • If MILS isn't possible use blocks/tape
    • Rigid immobilisation of the head risks increasing leverage on the neck as the child struggles hence spinal collars are no longer routinely used in paediatric patients

  • C-spine injury is uncommon (<2% of paediatric trauma) in relation to the higher incidence of TBI
  • If they do occur, however, higher cord injuries (C1-3) are more likely in young children due to underdeveloped neck musculature and disproportionately large head
  • SCIWORA is more common in children <8yrs old and reported in 10-20% of paediatric patients with spinal cord injury

Airway

  • Airway issues are the commonest cause of preventable trauma death in children
  • The commonest cause of airway occlusion is from the tongue in the unconscious head-injured child
  • Airway management as per ATLS e.g. avoid head-tilt/chin-lift, use jaw thrust, simple adjuncts, intubation
  • Indications for invasive ventilation are similar to adults:
Indications for invasive ventilation
Actual, or impending, airway compromise
Ventilatory failure ± need for neuroprotective ventilation
Reduced GCS
Combative or agitated patients (especially after TBI)
Humanitarian for analgesia e.g. severe burns, traumatic amputation
Anticipated clinical course requiring intubation e.g. CT, theatre, inter-hospital transfer

  • The choice of drugs for induction is typically:
    • Ketamine 0.5 - 2mg/kg
    • Rocuronium 1mg/kg
  • Ongoing anaesthesia is maintained with:
    • Propofol 2-5mg/kg/hr if earlier wake-up is anticipated
    • Midazolam 20-80mcg/kg/hr if anticipate long period of ventilation
    • Morphine 20-80mcg/kg/hr
    • Further 1mg/kg boluses of rocuronium as required

  • Thoracic injuries occur in 3% of children with blunt trauma
    • Pulmonary contusion, pneumothorax and haemothorax are the most common
    • Blunt tracheobronchial tree, diaphragmatic and cardiovascular (cardiac, aorta) injuries are rare
    • Significant injury may be present even in the absence of rib fractures; if rib fractures are present it indicates a significant injury mechanism/energy transfer

  • Children are already predisposed to hypoxia owing to higher oxygen consumption, smaller FRC, increased chest wall compliance and a greater reliance on diaphragmatic breathing
  • They thus tolerate thoracic injuries poorly; certainly any compromise of diaphragmatic excursion significantly limits a child's ability to ventilate
  • Management is as in adults; thoracostomies, chest drains, invasive ventilation

  • Evaluate circulation as in adults; HR, CRT, peripheral perfusion, blood pressure, mentation ± urine output
  • Paediatric patients compensate well; hypotension is a late sign of decompensated shock and may be rapidly followed by bradycardia and arrest

  • Obtain vascular access, with early IO access if IV access attempts have failed
  • Send blood for VBG, Group and cross-match, FBC, U&E, clotting inc. fibrinogen

  • Fluid resuscitation initially with 10ml/kg boluses of warmed crystalloid
  • Consider permissive hypotension to a systolic BP of 80-90mmHg or a palpable radial pulse until haemorrhage is curtailed

  • Give TXA 15mg/kg as a bolus as soon as possible, within 3hrs of injury
  • Then infused 2mg/kg/hr for either 8hrs or until bleeding stops

Major haemorrhage and transfusion

  • Activate paediatric major haemorrhage protocol
  • Early use of warmed blood products instead of vasopressors

  • 10ml/kg warmed O-negative or cross-matched pRBC
  • Octaplas (FFP96) 5-10ml/kg boluses in a 1:1 ratio with pRBC

  • Give platelets 10ml/kg (if under 15kg) or 1 adult pack (if >15kg) if either:
    • 20ml/kg pRBCs have been transfused
    • Platelet count <75 x x109/L

  • Cryoprecipitate 10ml/kg if either:
    • Fibrinogen <1g/L
    • 40ml/kg of blood products have been administered

  • Aim ionised calcium >1mmol/L
    • Give 0.1ml/kg 10% calcium chloride after every 20ml/kg transfused products or if ionised calcium <1
    • Alternatively use 0.5ml/kg 10% calcium gluconate

  • Treat transfusion-associated hyperkalaemia, targetting a potassium <6mmol/L
    • Give 0.1units/kg insulin actrapid in 10ml/kg 10% dextrose

  • Monitor temperature and target 36'C
    • High body surface area to mass ratio means hypothermia develops quickly; steps to prevent hypothermia should be undertaken
    • Use oesophageal temperature probe in the unconscious child
    • Warm fluids e.g. Ranger, Belmont
    • Warm, humidified breathing circuits e.g. use HME
    • Under-mattress or forced-air warmers

Factor Target Intervention
Hb >80g/L RBC transfusion
Platelets >75 x 109/L Platelet transfusion
Fibrinogen >2g/L Cryoprecipitate | PCC | FFP
Prothrombin time (INR) & APTTr <15s (<1.5) FFP
Ionised calcium >1mmol/L IV calcium
Temperature >35°C Active warming
pH >7.2 Resuscitation | I&V
Lactate <4 Resuscitation


  • Assess conscious level with AVPU or paediatric GCS
  • Check pupils
  • Check glucose (target >3mmol/L)
  • Ensure adequate analgesia e.g. morphine 0.1 - 0.2mg/kg IV/IO

Paediatric GCS

Score Eyes Voice Motor
1 No opening No response No response
2 To pain Inconsolable or agitated Abnormal extension (decerebrate)
3 To speech Moaning, partially consolable Abnormal flexion (decorticate)
4 Spontaneously open Cries but consolable, inappropriate interactions Withdraw from pain
5 Appropriate interactions, smiles, fixes & follows Withdraw from touch
6 Moves spontaneously or purposefully


  • Aim UO 1- 2ml/kg/hr
  • Consider prophylactic antibiotics if penetrating injury inc. need for emergency thoracostomy - choice depends on nature of injuries
  • Ongoing temperature management as in Circulation
  • Address other life-threatening problems, but children are more likely than adults to require secondary transfer to a dedicated paediatric centre

Abdominal trauma

  • Accounts for 10% of trauma in children
  • Second most frequent cause of preventable trauma death in children
  • The abdominal organs are more vulnerable due to the pliability of the ribs and the failure of the pelvic bones to protect the bladder
  • Splenic injury is most common, followed by hepatic, renal, intestinal and pancreatic injuries
  • Indications for emergency laparotomy include:
    • Haemodynamic instability despite resuscitation with distended abdomen
    • Pneumoperitoneum
    • Renal vascular injury

Limb trauma

  • Skeletal injury occurs in 10-15%
  • Uncommonly life-threatening although open long bone fractures can cause significant haemorrhage and shock
  • Pelvic fractures are rare

Further management

  • Transfer to tertiary paediatric centre
  • Secondary survey
  • Admit all major trauma to PICU