Pediatric Trauma

Aka: Pediatric Trauma, Trauma in Children

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II. Epidemiology

  1. Head Injury is the leading cause of Traumatic death in children
  2. Splenic Rupture and Liver Laceration are the most common blunt abdominal injuries in children

III. History

  1. See Trauma History
  2. Review with parents and EMS which restraints were present at the scene (e.g. MVA)
    1. Improper Car Restraint use (e.g. premature transition from Booster Seat) is associated with greater injury risk

IV. Precautions: Pitfalls in childhood Trauma assessment

  1. General
    1. Children are higher risk for multiple injuries (compact collection of vital organs)
    2. Rapid deterioration follows compensated shock with normal Blood Pressure
      1. Children compensate with initial Vasoconstriction and often relatively mild Tachycardia
      2. Hypotension (and rapid deterioration) may not occur until 50% of blood loss has occurred
    3. Rapid heat loss with Secondary Hypothermia (due to large BSA to Mass ratio)
    4. Waddell triad (child pedestrian struck by car)
      1. Closed Head Injury
      2. Intra-Abdominal Trauma
      3. Midshaft Femur Fracture
  2. Airway
    1. See Advanced Airway for airway related precautions in children
    2. Higher risk of soft tissue upper airway obstruction (small, narrow funnel shaped upper airway)
  3. Head and Neck
    1. See Pediatric Head Injury Algorithm (PECARN)
    2. MVAs are the most common cause of neck Trauma in Children
    3. Proportionally larger head predisposes to higher risk of Head Injury and Cervical Spine Injury
      1. Upper Cervical Spine is more susceptible to restraint related injury in children <8 years old
      2. Younger children are prone to spinal Ligamentous Injury (see SCIWORA below)
        1. Older children experience Vertebral Fractures
      3. Center of gravity lowers as children grow >8-10 years old
    4. Car Restraints significantly reduce the risk of injury and death, but must be used properly
      1. Car Seats should be used up to age 4 years old (rear facing until age 2 years)
      2. Booster Seats should be used from age 4-8 years old (until height >=57 inches)
        1. Premature use of the adult Shoulder-Lap belt risks neck extension and flexion injuries
        2. See Seat Belt Syndrome
    5. Young children have more severe spine injuries associated with permanent deficits
      1. Mortality rates are higher in young children (30% in some series)
      2. Kokaska (2001) J Pediatr Surg 36(1): 100-5 [PubMed]
    6. Risk of SCIWORA (esp. young children)
      1. Occult spinous injury despite negative XRay or CT spine (spinal ligamentous laxity)
      2. Trauma is unlikely in an asymptomatic child with normal Neurologic Exam
        1. Imaging should not be based solely on mechanism
    7. Neck Bruising
      1. See Neck Vascular Injury in Blunt Force Trauma
      2. Increases risk of vascular injury
      3. Consider CT angiography of neck
  4. Chest
    1. Higher risk for pulmonary injury (thin, pliable chest wall transmits impact to lungs)
    2. Pneumothorax
      1. See Needle Decompression of Thorax, Small Calibre Chest Tube and Chest Tube
      2. Tension Pneumothorax poorly tolerated (mobile mediastinum)
      3. Avoid discharging children with Chest Tube (higher risk of displacement)
    3. Chest XRay is preferred initial chest imaging modality
      1. Blunt aortic injury is uncommon in children (esp. as an isolated injury)
      2. Rib Fractures are rare in children (if present, they suggest serious injury mechanism)
    4. Avoid CT chest as initial imaging in children (consider discussing with Pediatric Trauma surgeon)
      1. Seat Belt Sign in a child is not an indication for chest CT
      2. Aortic injury is rare in children with non-penetrating Chest Trauma (contrast with adults)
      3. Consider if suspected high mechanism injury
        1. Pulmonary Contusion or obvious Rib Fracture (high mechanism injury)
        2. However, observation is a reasonable alternative, as complications will manifest clinically
  5. Abdomen
    1. See Seat Belt Syndrome
    2. See Pediatric Blunt Abdominal Trauma
    3. See Pediatric Blunt Abdominal Trauma Decision Rule
    4. Higher risk of intra-Abdominal Injury (abdominal organs are more anterior)
    5. Spleen is the most commonly injured organ in Pediatric Trauma (esp. boys)
  6. Extremities
    1. Higher risk for incomplete, buckle, or occult Fractures (due to soft bones with thick periostium)
    2. Growth Plate is the weakest part of the bone (weaker than ligaments) and prone to Epiphyseal Fracture

V. Imaging

  1. Asymptomatic children with a normal exam and Vital Signs are unlikely to have abnormal imaging
    1. Avoid imaging based solely on high mechanism
    2. Contrast with adults, where high mechanism injury is often associated with worse injuries

VI. Management: Hemorrhage

  1. See Hemorrhagic Shock
  2. Precautions
    1. Hypotension in children is an ominous sign portending imminent hemodynamic collapse and death
    2. Many shock when child is tachycardic (do not wait for Hypotension)
    3. Permissive Hypotension as used in adult Trauma does not apply to children
  3. Blood Transfusion
    1. Each RBC transfusion is dosed 10 ml/kg
    2. Massive Transfusion is defined as cummulative transfusion volume of 40 ml/kg (50% of circulating volume)
  4. Tranexamic Acid (TXA)
    1. Dose
      1. Bolus: 15 mg/kg up to 1000 mg over 10 minutes
      2. Infusion: 2 mg/kg/h for 8 hours or until bleeding stops
    2. Some studies show TXA to be Safe and effective in children
      1. Eckert (2014) J Trauma Acute Care Surg 77(6): 852-8 +PMID:25423534 [PubMed]
    3. Other studies call for high quality evaluation of TXA in children that is lacking as of 2024
      1. Borgman (2023) J Trauma Acute Care Surg 94(1S Suppl 1):S36-S40 +PMID: 36044459 [PubMed]
      2. Kornelsen (2022) Am J Emerg Med 55:103-110 +PMID: 35305468 [PubMed]

VII. References

  1. Orman and Horezcko (2017) EM:Rap 17(7): 12-3
  2. Claudius, Deane and Keeley (2024) Pediatric Pearls: Pediatric Trauma, EM:Rap, accessed 3/4/2024
  3. Claudius, Behar and Benjamin in Herbert (2016) EM:Rap 16(5): 4-5
  4. Fuchs and Yamamoto (2012) APLS, Jones and Bartlett, Burlington, p. 208
  5. McClung and Ruttan (2019) Crit Dec Emerg Med 33(3): 3-11

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