Paediatric trauma considerations

Question 1

What are the mechanism of injury considerations?

Answer 1

• Slipping through gaps in safety structures
• Falls from playground equipment
• Burns: pulling things off counters, lack of understanding of consequences. Face, upper chest and arms more likely to be accidental.
• React differently to dangers and so may have different injury patterns
• Sporting injuries
• Child may sustain different injury patterns to adults due to their size and response to danger.
• EG car bonnets can be at head height, more likely to be thrown by the car. Chest and limb injury patterns also. More likely to be pulled under the vehicle, especially by big ones, as more of their body is lower down.
• Response to danger is different – deer in headlights response. Turn towards oncoming danger and freeze, leads to frontal injuries.

Question 2

How are children likely to be affected by traumatic injuries?

Answer 2

• Airway more likely to be occluded in cases of minor swelling caused by trauma.
• Neck/face trauma, more prone to airway obstruction
• Airways more difficult to manage if this happens
• Need support under the shoulders to rest the head in a neutral position,
• Big head, weak muscles, more prone to isolated head injuries as they cannot support/protect the head as well.
• Chest wall is more elastic, bends more than it breaks. Evidence of injury such as broken ribs, crepitus, flail segment and bruising will not be so evident. Underlying structures have still experienced huge force.
• Rib cage does not protect as much of the abdomen as it does in an adult. The ribs are higher up and more horizontal. Liver and spleen are not protected in infants but are in adults.
• Bladder sits higher up in the abdomen, descends until adulthood when it is sat in the pelvis and protected.
• Abdomen has a much thinner abdomen wall, less fat in the area, and less developed muscles. Adds up to less protection.

Question 3

What are the physiological considerations of managing a paediatric trauma patient?

Answer 3

• Smaller lungs: any damage/increase in need for oxygen is harder to compensate for. More likely to become hypoxic/respiratory failure.
• Smaller blood volume: more likely to go into shock earlier. Small amount of blood loss could be a life-threatening haemorrhage.
• Effective CV compensatory mechanisms. Can undertake very extreme and effective vasoconstriction. May hide the fact that a child will be going in to shock. Compensate until they drop off a cliff.
• Large surface area to volume area: get cold quickly, which impedes coagulation. Trauma triad.
• Cold leads to vasoconstriction in extremities, leading to anaerobic respiration, leading to acidosis. This disrupts the coagulation cascade. It is very sensitive to temperature and pH.
• Smaller glycogen stores, higher metabolic rate. Will burn through these reserves quickly. Cold and compensatory mechanisms take a lot of energy.

Question 4

How do you tailor the approach to paediatrics?

Answer 4

• Cat Haem approach is the same
• Neutral alignment, raise shoulders if needed. OPAs inserted without invert. Smaller things can block smaller airways.
• Shorter neck makes tracheal deviation harder to see in short, chubby necks. Surgical emphysema may not be as visibly obvious in infants.
• Belly breathers. Signs of recession. Can increase their rate but not very able to increase depth. Young children breath irregularly. May do a full minute resp rate. Still 15L o2.
• Brachial for infants. Central and peripheral capillary refill. Cold may affect vasoconstriction. BP difficult to get
• Temp and BM are very important. Paediatric GCS. AVPU.
• Expose. This may distress the child. Use judgement.

Question 5

How should c-spine be approached in children?

Answer 5

• Spinal injuries are very rare in children but may be very difficult to exclude
• Immobilisation can be extremely distressing especially if they can no longer see their parent. Manual immobilisation may be less distressing.
• Consider immobilising in car seat if extraction for full examination is not possible.
• Can place blanket/padding on scoop to raise shoulders.

Question 6

How can head injuries present differently under 18 months?

Answer 6

In children under 12-18 months, head injury may not cause neuro deficit as brain can expand a bit through the fontanelle. Bulging fontanelle can indicate injury.