Treating a child who has experienced trauma is different from managing injuries in an adult, requiring specialized knowledge of their unique anatomy and physiology. Understanding the correct principles for assessment and intervention helps avoid common misconceptions. This article breaks down established facts across the main domains of pediatric trauma care.
Anatomical and Physiological Distinctions
A young child’s disproportionately large and heavy head creates a high center of gravity, increasing the likelihood of head and neck injuries. The fulcrum of cervical spine movement is higher, at the C2-C3 level, making this area more vulnerable. Weaker neck muscles and elastic ligaments also contribute to a distinct pattern of spinal injuries.
A child’s rib cage is more pliable, offering less protection to the organs beneath. This elasticity means severe internal injuries, like pulmonary contusions, can occur without rib fractures. The abdominal organs, such as the liver and spleen, are proportionally larger and less shielded by a thinner abdominal wall.
Children’s bones are more porous and flexible, leading to different fracture patterns like “greenstick” or buckle fractures. An injury to the growth plates (epiphyseal plates) at the ends of long bones can affect the bone’s future growth.
Critical Assessment and Vital Signs Interpretation
Initial evaluation uses the Pediatric Assessment Triangle (PAT), a rapid, hands-off observation tool. The PAT provides a general impression by evaluating three components: Appearance, Work of Breathing, and Circulation to the Skin. This assessment is performed in 30 to 60 seconds using only visual and auditory clues.
The Appearance component assesses nervous system function using the TICLS mnemonic:
- Tone
- Interactiveness
- Consolability
- Look/gaze
- Speech/cry
Work of Breathing is evaluated by listening for abnormal sounds and looking for increased effort, such as nasal flaring. Circulation to the Skin is observed by checking for pallor, mottling, or cyanosis. The PAT helps categorize the child’s physiological state and guides the urgency of interventions.
A hands-on assessment includes checking vital signs, but interpretation depends on the child’s age, as normal ranges vary significantly. For example, a heart rate of 150 is normal for an infant but indicates distress in a school-aged child. Tachycardia (an elevated heart rate) is the earliest indicator of shock in a pediatric patient.
Shock and Fluid Resuscitation Principles
Children have effective compensatory mechanisms that can mask the severity of shock. A child’s body can maintain normal blood pressure for a prolonged period by increasing heart rate and constricting blood vessels. This effective response can be misleading during an assessment.
A drop in blood pressure (hypotension) is a late sign of decompensated shock, indicating a child has exhausted their reserves and is nearing cardiopulmonary arrest. Treatment must be initiated based on earlier signs of inadequate perfusion, such as:
- Persistent tachycardia
- Delayed capillary refill
- Cool extremities
- Altered mental status
Initial management is rapid fluid resuscitation with a bolus of 20 mL/kg of an isotonic crystalloid solution, like Normal Saline, given over 5 to 10 minutes. After each bolus, the patient is reassessed for improvement to guide further fluid administration.
If crystalloid boluses do not stabilize a patient in hemorrhagic shock, packed red blood cells (PRBCs) are indicated at a dose of 10 mL/kg. This is used when ongoing blood loss is the suspected cause of shock.
Airway and Breathing Management Priorities
The pediatric airway’s anatomy presents unique challenges. A child’s tongue is large relative to their oral cavity, making it a common source of obstruction. The larynx is located higher and more anteriorly, and the epiglottis is longer, which can make intubation more difficult.
Proper positioning is a primary step in managing the airway. Due to a child’s large occiput, lying flat can cause neck flexion and obstruct the airway. Placing the head in a neutral or “sniffing” position aligns the airway axes, often achieved by putting a small towel under the shoulders.
Children have smaller oxygen reserves and a higher metabolic rate, making them susceptible to rapid oxygen desaturation. During assisted ventilation, avoid overly aggressive breaths, which can cause gastric distention. This distention can push on the diaphragm and impede lung inflation.
Neurological and Environmental Considerations
Neurological Assessment
Assessing neurological status requires age-appropriate tools. The Glasgow Coma Scale (GCS) is modified for preverbal children, using responses like crying or spontaneous movements instead of verbal answers.
In infants with open fontanelles (soft spots), a bulging fontanelle can indicate increased intracranial pressure. A sunken fontanelle may suggest dehydration.
Environmental Control
Children are vulnerable to hypothermia due to their large body surface area-to-mass ratio and less subcutaneous fat. Hypothermia can worsen outcomes by causing metabolic acidosis and interfering with blood clotting (coagulopathy).
Environmental control is an active part of resuscitation. Remove wet clothing and cover the child with warm, dry blankets to prevent heat loss. Maintaining normothermia supports the body’s ability to respond to treatment.