The goal of any person providing trauma care to anyone—especially to children—should be not only to provide efficient and effective care but also to minimize the need for such care. If one is a true patient advocate, then one should be active in identifying and addressing situations, structures, and products that pose a significant level of risk of serious injury and make efforts to control these risks through one of the “three Es of injury prevention”: engineering, education, and enforcement.1 Unfortunately, a major hindrance to injury prevention efforts is individuals who view injuries as “accidents” and therefore as unavoidable. Great strides can be made with properly directed effort, but the point that accidents do not just happen must be driven home.

Kids Are Different

Providers tend to underestimate the frequency of pediatric injury. Trauma is the most common cause of death in children over the age of 1 year. According to the Centers for Disease Control and Prevention, in 2007 (the most recent year for which full statistics have been made available) there were 182,749 deaths due to trauma with 11,039 of those occurring in children under the age of 18. For 2009, there were 8,021,631 nonfatal injuries to children that resulted in hospital visits in the United States. These occurred at a time when the population in question numbered 74,548,215.2 This means for every nine children in the country, there will be one trauma-related hospital visit.

Most fatal injuries are due to motor vehicle collisions, and, even among nonfatal injuries, transportation-related injuries are very common and, in some age groups, predominate the statistics, but falls, burns, drowning, intentional injuries (abuse and violence), and unintentional incidents involving firearms are responsible for the vast majority of pediatric trauma. Penetrating trauma accounts for only 20% of cases in most populations, although it is more common in certain subsets that have a greater exposure to violence.3

Behavioral factors and lack of experience, lower muscle mass, a less well-calcified skeleton, a smaller surface area, a larger head in proportion to body size, less well-developed ligaments in the spinal column, and less well-secured organs in the abdominal cavity make children more vulnerable to injury.

The behavioral factors contributing to the increased injury rate in children are often due to their inherent desire to learn and explore. This, coupled with the poor judgment that comes with a lack of experience, leads to what I describe as the “curiosity killed the cat” issue in injury. The less well-developed reflexes and sense of balance demonstrated by many children also play a role. As the patient population ages toward adolescence, the poor judgment factor becomes a larger issue as a result of peer pressure and the desire to establish a social standing based on accomplishment, as well as the increased frequency of drug and alcohol use.

Less muscle mass and lower muscle tone in children also tend to increase the frequency and severity of musculoskeletal injuries and internal organ injuries. It also predisposes to spinal injury due to less structural support of the vertebral column. The frequency of internal organ injury is the result of having less tissue in which forces can be dissipated before reaching the internal organs. Musculoskeletal injuries are a result of a lack of stabilization of the joints and a lack of protective “padding” for the skeleton. This can lead to increased incidence of dislocations and fractures, although the less-calcified nature of the pediatric skeleton tends to offset the fracture risk and change the nature of the fractures that do occur.

The lower level of calcification tends to result in a “bend but not break” tendency. This causes the incidence of “greenstick” fractures of the long bones,4 wherein the bone bends and only partially breaks; avulsive fractures at joint surfaces—especially those associated with epiphyseal plates (growth plates)5—and, in the case of the ribs and sternum, less protection for the heart and lungs.6 The rib cages of children, especially those of infants and toddlers, are exceptionally pliable compared to those of an adult. This is one reason why the presence of a rib or sternal fracture in a child is often a portent of serious injury. The forces are more directly transmitted to the heart and lungs and can cause severe injury. In a child struck a serious blow to the chest, widespread pulmonary contusions are extremely common.

When dealing with blunt trauma in children, it is important to keep in mind that multisystem and multiorgan injuries are proportionally greater in children than in adults. In other words, the application of a given force (for example, the impact of a bumper from a car striking a pedestrian) covers a much greater area of the body relative to the whole in a child than in an adult. This often leads to having a patient with injuries to multiple regions of the body.

The head of a child constitutes a much larger portion of the body mass than it does in adults, which plays a role in trauma epidemiology in two primary ways. The first is that in vertical falls, children tend to impact in either a flat (“belly flop” or “skydiver”) or head-first orientation. In adults, the most common orientation is a feet-first impact. This causes a difference in the distribution of injuries: Children tend to have a higher incidence of head and cervical spine injuries; adults tend to have more injuries to the feet and legs as well as lumbar and thoracic spine fractures, normally compressive in nature.7-10

The comparatively large mass of a child’s head, coupled with the lower level of muscular development of the neck and the lower tensile strength of the pediatric cervical spine ligaments, predisposes children to an increased risk of injury to the spinal cord. This injury is most often in the form of subluxation (a form of dislocation), which may be transient in nature; by the time the patient reaches the hospital, the vertebrae may have self-reduced back to their normal positions, potentially resulting in spinal cord injury without radiographic abnormality (SCIWORA). The initial injury may be overlooked in up to nearly a quarter of all cases if aggressive imaging searches to rule out such injuries are not performed.11

The issue of less firmly anchored abdominal organs primarily is seen with the kidneys, which are less firmly anchored in the retroperitoneum, which increases the risk of injuries to the vascular pedicle. This is primarily a result of deceleration—trauma cases such as motor-vehicle collisions and falls where the child manages to land in either a sitting or standing position.

Splenic and hepatic injuries are also frequently seen in children. This is largely due to the greater relative area occupied by these organs and the greater relative surface anatomy—they have a much greater exposure relative to the skin surface of the abdomen and are less well protected by the less protective flexible rib cage.

The final major factor in pediatric trauma epidemiology is the effect of the size of the child relative to the front of a motor vehicle. Whereas adults and older children will often go over the top of the hood of a vehicle that strikes them, younger children will be struck and knocked to the ground, resulting in them being literally run over. The areas of the body directly impacted will determine the organs injured. In adults, as an example, it is not uncommon to see fractures of the tibia and fibula from the bumper striking the lower legs. In older children, the bumper may impact the child at the level of the femur, and in very young children, the impact can be at the level of the pelvis or even the abdomen.

Managing the Airway

Pediatric trauma frequently involves injury to the face and head, which can result in difficulties in airway management. This complicates the issues already associated with pediatric injury management simply because of the differences in pediatric airways (see Table 1) and the infrequency with which most personnel deal with children in need of aggressive airway management. Given that few things will kill a trauma patient as quickly and surely as the inability to establish and maintain an airway, however, providers must be prepared to intubate or perform a surgical airway to maintain adequate ventilation and oxygenation as necessary.

When dealing with the pediatric airway, one must walk a fine line between being excessively aggressive—which could potentially add the unnecessary risk of complications—and being overly cautious—which may further harm the patient through the development of hypoxia and hypercarbia. While one should never hesitate to secure a tenuous airway, maintaining the airway and securing adequate ventilation and oxygenation are the goal. The goal is not intubation, and protracted attempts at endotracheal tube placement should be avoided whenever possible. If difficulty is encountered, serious consideration should be given to utilizing alternative airway devices such as a laryngeal mask airway.

The option of surgical airways in pediatric patients is rather limited, mostly due to the small size of the cricothyroid space, which rules out surgical cricothyrotomy in small children. A formal tracheotomy is a possibility but should be performed only by a surgeon well versed and recently experienced in the procedure. Needle cricothyrotomy is a stopgap measure at best, since it allows for oxygenation but not ventilation. The other major limitations—making the procedure less than an optimal choice for anything other than an in extremis case—are the lack of airway protection associated with it and the need for specialized equipment.

To compound the respiratory issues inherent with pediatric trauma patients, the frequency of pulmonary contusions associated with chest trauma and the propensity toward the development of pulmonary edema in children (due to lower levels of collagen and other elastic tissues in the lungs) can produce ventilation and oxygenation issues. Children tend to have much lower respiratory reserves due to less well-developed accessory muscles, which means that the need for intervention will tend to present earlier in these cases and can often arise abruptly as the patient tires and starts to decompensate.

The thinner chest wall of children—especially infants and preschool age children—can make localization of breath sounds more difficult than in older patients. The sounds from one side or one lobe will carry over to another area or even the opposite side of the chest much more frequently than in other patients. This makes the presence or absence of breath sounds a relatively poorly sensitive indicator of the presence of pneumothorax.

Cardiovascular compensation in children is in the form of tachycardia and vasoconstriction. The pediatric heart is less compliant and less contractile than an adult’s heart. This is one of the primary reasons a tachycardic child is assumed to have significant injuries—especially if there are signs of diminished peripheral circulation (mottled skin, pale extremities, cyanosis, etc)—until absolutely proven otherwise. Never assume the tachycardic response is simply the result of pain, fear, or anxiety.

This compensation can be maintained until 20% to 30% of the total blood volume has been lost. Once that threshold is reached, the resulting decompensation can be swift and dramatic. Hypotension is a late sign of hypovolemic shock in children, and its absence should not be relied upon to rule out serious trauma.12 The onset of bradycardia in a pediatric patient is normally a sign of hypoxia and is normally a very ominous portent, as cardiac output is significantly dependent—sometimes nearly completely—upon heart rate until the heart has reached the normal adult size.4 Providers commonly overestimate the blood volume. One common mistake providers make with regard to pediatric patients is an overestimation of the blood volume. A good rule of thumb for this is to assume 70 to 100 mL of blood per kilogram of body weight based on age. Neonates up to 1 month of age tend to be toward the higher end of the scale with children up to 2 years of age being around the 80 mL/kg range and older children and adults having volumes around the lower end of the range.13 A seemingly small amount of blood loss in a small child can be fatal. Aggressive searches for and efforts to control bleeding, both internal and external (see Table 2), are particularly important in children.

Caution must be used in utilizing higher airway pressures, both peak inspiratory and PEEP, in children with known or suspected hypovolemia due to the risk of decreasing the return to the lower pressure right side of the heart and thereby worsening the cardiac output by diminishing ventricular filling rates. The differential diagnosis of a sudden onset of hypotension associated with a patient receiving assisted ventilation must include the possibility that the ventilatory efforts are responsible for or at least contributory to the issue.

Often overlooked is the ease with which children develop hypothermia due to their higher surface area relative to their mass and the lower amount of body fat (in most children) compared to adults. Infants cannot generate body heat by shivering until approximately 3 months of age.15 The act of shivering or the catabolism of body fat in an effort to produce heat can be sufficient to induce hypoxia in critically ill children. Other results of hypothermia in children include metabolic acidosis, coagulopathic states, hypoglycemia, and respiratory depression. Therefore, it is direly important to prevent hypothermia from developing during resuscitation and to treat preexisting low body temperatures as soon as they are noted. Repeated measurements of body temperature along with the other vital signs should be a standard practice. The warming of the resuscitation room to a much higher temperature than normal should also be considered. The guide that I use in my presentations on the topic is to remind participants that if the room is comfortable for them to work in, it is probably too cold for a naked and critically ill child.

Conclusion

The goals of pediatric trauma resuscitation are to establish and maintain an airway, establish vascular access, and adequately fluid resuscitate patients (especially those with head injuries); maintain spinal precautions until the presence of an injury has been definitively ruled out; identify and treat immediately life-threatening injuries (both internal and external); and continue to look for serious injuries—even after one or more are found—that may provide an explanation for the findings with which the patient presents. If one follows the steps necessary to achieve these goals, keeps the aforementioned issues in mind, and works proactively, it is possible to effectively and appropriately manage a pediatric trauma patient.

Stephen L. Richey, CRT, is flight respiratory therapist, Grace on Wings Air Ambulance and injury prevention researcher, Kolibri Aviation Safety Research, Indianapolis. For further information, contact [email protected].

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