Happy Monday. This month we will be discussing all things associated with Pediatric Trauma. It is the leading cause of death and disability in children. In the United States, greater than 12,000 children die annually from intentional and unintentional injuries. First responders are an integral part of what we call the “Golden Hour, which occurs in the first hour after injury and largely determines a critically injured person’s chances of survival. 

A standardized approach to the initial management of trauma patients has been disseminated by the American College of Surgeons through the Advanced Trauma Life Support (ATLS ) program. The protocols are based on the concept of this Trimodal Death Distribution.

Consider the possibility of serious injury if any of the following are present in children:

• Significant mechanism of injury regardless of obvious injuries

• Altered mental status or the patient is behaving inappropriately

• There is evidence of poor systemic perfusion

• Use the Pediatric Assessment Triangle to visually assess the patient and determine their current physiological status

The Pediatric Assessment Triangle (PAT) functions as a rapid, initial assessment to determine whether a child is sick. This assessment should take 30 seconds or less. It should not delay your ABCDEs. It can be utilized for serial assessments of patients to track their response to therapy. It considers the child’s appearance, work of breathing, and circulation. 

Below is a list of some common high and lower-risk mechanisms of injury:

High-Risk Mechanisms of Injury

• Motor Vehicle Crashes (Unrestrained passenger, Pedestrian hit by a car)

• Moderate (5-15ft) and high falls (15ft +)

• Diving Injuries

• Bicycle crashes while not wearing a helmet

Lower-Risk Mechanisms of Injury

• Motor Vehicle Accidents (Property restrained passengers)

• Low falls (~ this is age dependent 2- 4 ft)

• Helmeted bicycle accidents

Next week, we will discuss treatment priorities during a trauma. Thank you for all that you do for our pediatric patients. Keep up the great work. Please do not hesitate to reach out with any questions. Have a great week everyone. 

Sincerely, 

Regina Yaskey, MD

Pediatric Trauma Part 2 - April 10, 2023

Happy Monday, everyone. This week, we will be discussing treatment priorities during a trauma. 

In any pediatric trauma (just like in adult traumas), your ABCs are a top priority. The most critical interventions are:

• Airway Management

• Cervical Spine Precautions

• Supplemental high oxygen concentration

• Assisted ventilation

Remember, if you have a pediatric patient with signs of hypoperfusion, but no obvious external bleeding, presume that the child has additional injuries (i.e., internal bleeding). In that case, continue to assess and reassess, maintain airway and support breathing, and transport the patient as soon as possible.

Any child showing signs of hypoperfusion, where the only obvious injury is head trauma, can be presumed to have other injuries. A well-appearing patient who has experienced a high-risk mechanism of injury should be treated as potentially unstable due to the risk of serious internal injuries. It is important that you quickly start your assessment, repeat your assessments frequently and ensure you are ready if the child’s condition worsens.

In every pediatric trauma, comprehension of cervical spinal injuries is key. They are rare, but you must take precautions and understand the reasons. As I mentioned earlier, cervical spinal injuries are rare. They cover less than 2% of injured children. They are most commonly due to motor vehicle accidents:

• Cervical vertebrae subluxation or distraction injury

• Children have large heads and weaker necks, small necks

Significantly injured children have cervical vertebral injury until proven otherwise. Therefore, do not perform any head tilt maneuvers on these patients. In-line cervical stabilization is essential throughout the intubation attempt. A cervical collar must be applied prior to moving the patient. Make sure to hold manual stabilization prior to applying the collar. When immobilizing these patients, make allowance for the child’s relatively large head compared to the torso (remember this anatomical difference forces the child’s neck into the position of flexion).

During your examination, please be sure to check the back of the neck for crepitus (crunchiness), muscle spasms, and tenderness. Perform c-spine precautions if the child has a high-risk mechanism for head or neck injury, altered mental status, and evidence of head or neck injury on brief examination. Quickly assess for mental status, muscle tone and body position, visible breathing movement, breathing effort, skin color, and obvious severe injuries.

Do the following during Spinal Immobilization:

1. Grasp the patient’s head and shoulders from a position at the head of the bed, physically keeping the spine aligned with the head.

2. While maintaining spinal alignment, have your colleague apply a cervical collar without lifting the head off the bed.

3. Prepare to roll the patient by having one or two assistants place hands on the far side of the patient across their shoulder, hip, and knee, crossing their arms at the waist.

4. While maintaining cervical alignment from the head of the bed, the individual maintaining spinal alignment should count to three, at which time the assistant(s) roll the patient toward themselves, while another assistant quickly examines the back and then places the backboard under the patient. The patient is then rolled back onto the backboard.

5. Center the patient on the board while maintaining cervical alignment.

6. Secure the upper torso with straps first.

7. Secure the chest, pelvis, and upper legs with straps.

8. Secure the patient’s head by using a commercial immobilization device or rolled towels.

9. Place tape across the patient’s forehead and fasten the edges to the edges of the board.

10. Check all straps and readjust as needed. Reassess distal functions in all extremities.

Many pediatric immobilization devices are out there, and the American College of Surgeons has not endorsed any one product. It is important that we immobilize the patients properly and effectively on whatever device we are using. 

Thank you for all your hard work and dedication to caring for our pediatric patients. Have a great week. 

Sincerely, 

Regina Yaskey, MD

Pediatric Trauma Part 3 - April 17, 2023

Happy Monday! Our month of Pediatric Trauma continues this week by discussing some of the fundamental anatomic and physiologic differences between children and adults. Remember that children are not just little adults; they are different from adults in anatomy and physiology. It makes them more vulnerable during traumas. Knowledge of and attention paid to these differences could be lifesaving for our pediatric patients. 

Let us start with the pediatric airway. Compared to adults, a child's airway is shaped more like a cone than a tube, with the cricoid cartilage being the narrowest portion. It makes visualization of the airway a bit more difficult. Compared to adults, a child's epiglottis is floppy and angled posteriorly, while the larynx is placed more anteriorly. It is why a straight-bladed laryngoscope (e.g., Miller) is better suited to "lift up" the epiglottis during endotracheal intubation in small children. Switch to the Mac blade in teens. 

Remember that newborns, neonates, infants, and (to an extent) toddlers are obligatory nose-breathers. It means that their brain only recognizes that their nares, not their oral cavity, are a means to inhale and exhale. Thus, when blood or a nasal deformity from facial trauma is present, it may effectively block their airway. Proper lateral positioning and suctioning should resolve any presenting signs of airway obstruction or poor ventilation. If using a bulb syringe, be sure to squeeze it before insertion. 

Infants have prominent occiput, which puts their heads in a “sniffing” position when they lie down. Airway structures in children are proportionately “larger” (tongue, tonsils, and adenoids). It is important to roll a towel under their shoulders to help alleviate upper airway obstruction. 

Indications for Endotracheal Intubation prior to transport include: 

• Respiratory arrest/failure         

• Actual/potential airway obstruction  

• Glasgow Coma Scale 8 or less   

• No gag – can’t protect the airway   

• Decompensated shock 

• Intrathoracic or other severe/multiple injuries  

• Your clinical impression 



When assessing a patient and there is no air movement:  

• Open the airway using a modified jaw thrust while stabilizing c-spine 

• Check for foreign bodies and other matter in the mouth and nose (~ teeth, secretions, emesis, blood, and fluid). 

• Remove foreign bodies that can be visualized and provide gentle suctioning if necessary.  

• Give high-concentration oxygen before and after suctioning 

Re-check for air movement immediately after the airway is cleared. Any head, face, or neck trauma with associated altered mental status is a dangerous situation. Manage the pediatric airway immediately, as these patients cannot effectively protect the upper airway. The concomitant depressed gag reflex can allow the patient to aspirate and create a lower airway compromise. 

Bag Mask Ventilation

Breathing 

A child’s ribs are positioned horizontally. Consequently, during inspiration, the ribs only move up, not up and out, like an adult rib cage. This lack of expansion reduces the pediatric patients’ ability to increase tidal volume effectively. Any type of chest injury will likely exacerbate this limitation, and as such, assisted ventilation (even with what seems minor trauma) may be necessary. 

For these patients, first, maintain cervical spine stabilization. Then make sure to assess for respiratory effort, breath sounds, breathing rate, pattern and depth, skin tone at the lips and tongue, and finally, evaluate the chest wall for life- threatening injuries. 

Administer high-concentration oxygen using a non-rebreather mask if: 

• The child shows signs of respiratory distress 

• Breathing is normal, but the mechanism of injury was significant 

• You need to assist ventilations with a bag-valve-mask and high-concentration oxygen if the child shows signs of respiratory failure. 

Circulation 

A human’s total blood volume is 80 -90ml/kg. Tachycardia is the earliest and most reliable indicator of shock. Remember that in children, a small amount of external blood loss is very significant. For example, a 50ml hemorrhage in a 5kg child is approximately 10% of their total blood volume. 

In your initial assessment: 

• Look for active bleeding and apply sterile compresses using direct pressure over bleeding sites 

• Check for the presence of central and peripheral pulses and compare their strength 

• Check skin color and temperature as well as capillary refill time 

• Make sure to repeat your initial assessment frequently 

• Be aware of changes in mental state, skin color, breathing effort, and rate 

• If there are signs of hypoperfusion 

• Tachycardia 

• Poor skin perfusion 

• Compare trunk to extremities: 

• Skin color 

• Temperature 

• 
  

External hemorrhage = Immediate Management 

• Direct pressure 

• Tourniquets 

• Hemostatic agents 

Disability

Glasgow Coma Scale

Exposure 

A child’s body surface area to body mass ratio, compared to adults, is much higher. Coupled with faster ventilation rates, they expel body heat proportionally faster. With any amount of volume loss, acceleration of heat loss is also inevitable. As such, all pediatric trauma patients have a high risk of developing hypothermia, even on the warmest of days. If left unchecked, concomitant arrhythmias, coagulation abnormalities, and acidosis worsen their condition. 

That’s it for this week. I’ll be back next week to continue our discussion. Stay safe, enjoy the warm weather, and keep up the good work. 

Sincerely, 

Regina Yaskey, MD

Pediatric Chest Trauma - April 24, 2023

Happy Monday. This is our final week discussing Pediatric Trauma, which focuses on blunt chest trauma. A pediatric rib cage is more pliable, with a proportionally lesser amount of subcutaneous fat and chest muscle mass. As a result, kinetic energy associated with blunt chest trauma has far less resistance passing into a child’s body compared to an adult. Pulmonary contusion (the most common intrathoracic injury), tension pneumothorax, and hemothorax could likely happen with minor chest trauma. Keep in mind that any of these injuries can cause a ventilation/perfusion mismatch. Management of imminent hypoxemia and hypoxia will be at a premium when evaluating these patients. Blunt chest trauma may also result in a higher incidence of cardiac tamponade with pediatric trauma patients due to the anatomical difference explained above.

Commotio Cordis (an instantaneous cardiac arrest produced by a non-penetrating blow to the chest) may be the origin of a pediatric trauma call. Typically, this occurs from blunt impact to the left chest about the third to fifth intercostal space by an object traveling at least 30 miles per hour. The object can be anything from a fist punch, a line drive from a baseball, the heel of a hockey stick, or leading with the helmet during a football tackle.

Abdominal trauma is the most common cause of unrecognized fatal injury in children. Children have proportionally larger solid organs, less subcutaneous fat, and less protective abdominal musculature than adults. As a result, they suffer relatively more solid organ injury from both blunt and penetrating mechanisms. Bicycle handlebars are a common cause of blunt abdominal trauma, with the spleen being the most injured organ. Consider this the case during an assessment if you discover:

• Trauma to left thorax or abdomen

• Signs or symptoms of shock      

• Complaint of left shoulder pain after abdominal trauma

• Noted lower rib fractures

Approximately one-third of children will have significant intra-peritoneal injuries from blunt abdominal trauma related to motor vehicle crashes. Typically, inappropriate seatbelt use is a major factor, causing lumbar vertebral, bowel, stomach, pancreatic, and mesenteric injuries. These can occur with a lap belt alone or with a three-point restraint. Termed seatbelt syndrome, many children are predisposed because their feet do not reach the floorboard, and they tend to slouch. Additionally, due to their height, the lap belt improperly crosses over the abdomen at their umbilicus rather than the iliac crests of the pelvis. During a frontal MVC, upon impact, the seat belt locks and pulls a patient backward at the navel region. The resultant excessive flexion of the spine causes a Chance Fracture in the lumbar region. As the patient bends forward, it is very likely he or she also hits their head on the back of the front seat, possibly causing a cervical spine injury. If they are in the front seat, injuries are likely from contact with the airbag.

Massive Hemorrhage is defined as bleeding requiring > 40mL/kg or 10 units of blood products in a 24-hour period. Approximately 5-15% of pediatric trauma patients will meet this criterion. Heart rate, blood pressure, and respiratory rate are neither sensitive nor specific for hemorrhagic shock in a child. Young, healthy patients may not be significantly tachycardic or hypotensive until they have lost 30% of their blood volume. Management involves stopping the bleeding. Start vascular access for fluid resuscitation. Start with 20mL/kg of crystalloid (Normal Saline). Tranexamic Acid is a clotting promoter. It is used in pediatric trauma patients who are at risk or have significant bleeding. It should be administered within the first hour but can be given up to 3 hours from the time of injury for the bolus and continuous infusion. Children less than 16 years of age can receive tranexamic acid. You must call medical command to get it approved for usage.

In summary, remember to reassess your patients frequently:

• Children with life-threatening injuries may initially present with a healthy appearance.

• Frequent reassessments are necessary. 

• Blunt and penetrating injuries can cause multisystem trauma in children. 

• Remember that children and adults differ in their anatomy and physiology. 

• Pay specific attention to this during their assessment and management.

Thank you so much for the honor of covering Pediatric Trauma in the month of April. Have a great year, and do not hesitate to reach out with any questions. Thank you for all the work that you do.

Sincerely,

Regina Yaskey, MD