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The European Trauma Course Manual

Edition 4.0
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11.
Trauma in children
Learning outcomes
Following this part of the course you will be able to demonstrate competence in:
QHow to prepare to receive a paediatric patient with major trauma

QHow to assess a paediatric patient with major trauma

QUnderstanding the differences between adult and paediatric trauma victims

QRecognizing the common injuries that children sustain

QRecognizing the signs of non-accidental injury in children

Introduction QUncontrolled haemorrhage is the leading cause of

preventable death from trauma in children;
Although major trauma is relatively rare in children, it Qsolid abdominal organs in small children are less

is a leading cause of death above the age of one year protected by the ribcage than in bigger children
and 10% of all trauma fatalities occur in children of and are more prone to injury;
less than 16 years. Given the low frequency of major Qthe elasticity of bones makes organ injuries possible

trauma, a methodical approach to the management of without overlying fractures;

the injured child is essential and trauma teams should Qpelvic fractures are rare in children and cause less

receive continuous training and rehearse regularly to blood loss than in adults;
enable all team members to fulfill their roles. Q90% of all solid organ injuries in children are treated

Planning and preparation
for receiving a paediatric
trauma patient
Hospitals that receive paediatric trauma should have
a set of specific guidelines, protocols and standard
operating procedures describing the pathway for
seriously injured children within their institution. As a
conservatively;
Qspinal immobilization should only be applied in
cooperative or unconscious patients; enforcing it
could cause further damage;
Qchildren have a greater reserve to compensate
initially for blood loss, followed by sudden
decompensation. Hypotension is a late sign in
shock and precedes decompensation, hypotensive
resuscitation should therefore not be applied in
children;
Qchildren have a high body surface area/volume

minimum there must be: ratio causing small children to be very prone to
Qimmediate availability of staff with paediatric hypothermia;
expertise; Qthose aged 10 years or older should be assessed

Qpaediatric airway and vascular access equipment; and resuscitated as small adults.
Qpaediatric monitoring;

Qvisual aids or approved phone apps for all paediatric
calculations and drug preparation in order to avoid
drug errors.
Injury patterns are age dependent, however the
following points apply to all children:
Qtraumatic brain injury is the leading cause of death
and disability in all age groups followed by chest
injuries;
The trauma alert and team briefing
The alert and briefing follow the same principles
as discussed in chapter 2 (figure 2.1) with only a few
differences for the paediatric patient:
QFollow the ATMIST communication between the
team leader and pre-hospital team. If the child’s age
is known, their weight can then be approximated
to enable the relevant equipment, drugs and fluids
to be prepared in advance (table 11.1).

CHAPTER 11 TRAUMA IN CHILDREN | 143

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QEnsure that the room is as warm as possible and
avoid further heat loss after arrival by having
appropriate equipment readily available e.g.
forced air warming, warm fluids and blankets.
QDuring the briefing, acknowledge the fact that
some team members may be anxious but use
reassurance emphasising that the system is
exactly the same as for an adult patient.
QBrief a team member to remain with the family
at all times to explain what is happening in the
resuscitation room and provide a conduit for an
AMPLE history. This person can be a doctor or a
Trauma Support Practitioner (TSP).
QBrief the airway person to communicate with
and reassure the child. Keeping children as calm
as possible enables procedures to be carried out
with minimal distress and allows assessment of
their neurological status.
QRecognize the potential for difficulties with
immobilising the cervical spine in distressed and
uncooperative patients. A more pragmatic approach
is required to optimise cervical immobilization.
QEnsure early access to analgesia, don’t forget the
intranasal route (IN). This will improve the child’s
cooperation and reassure distressed parents.
QEnsure there is senior support available.
TABLE 11.1
Calculation of child’s weight
1-12 months (0.5 x age in months) + 4
1-5 years (2 x age in years) + 8
6-12 years (3 x age in years) + 7
The primary survey
Paediatric trauma patients are assessed (figure 2.2)
and managed (figure 2.3) using the same system as
described in chapter 2 and follows the cABC principle.
Factors relevant to the primary survey in children are:
Airway personnel
Start by talking to the child, introduce themselves,
explain what is happening and, if appropriate,
comfort them. This allows airway patency and level
of consciousness to be assessed. Following this, and
depending on the response:
QGive high flow oxygen if the SpO is below 95% in
2
rest (ensure the mask is the right size and place it
so the child receives maximum oxygen without
unnecessary distress).
QIf there is any sign of airway obstruction, provide
basic airway management bearing in mind the
specific characteristics of a child’s airway (table 11.2).
Whilst carrying out simple airway manoeuvres in
a young child, ensure that the soft tissues are not
compressed resulting in airway compromise. An
144 | EUROPEAN TRAUMA COURSE
oropharyngeal airway of the appropriate size
can help to maintain a patent airway. It must be
inserted carefully to avoid damage to palate and
subsequent bleeding.
QIf indicated, suction should be performed with
a large bore soft catheter to avoid mucosal
lacerations. Care is required to avoid too deep
insertion with stimulation of the gag reflex and
vomiting.
QIn children who arrive with a tracheal tube in
place, confirm correct tube position and size
immediately by auscultation and capnography.
TABLE 11.2
Structural characteristics of the paediatric airway
Anatomical feature: Effect:
Large occiput (<3 years), Head and neck flex
short neck
Infants (<6 months) breath Complete airway obstruction
via the nose may occur if blocked by blood,
oedema, tubes
Relatively large tongue, Obscures view of glottis
floppy epiglottis
Relatively short trachea Risk of right main bronchus
intubation
Smallest diameter below Pass glottis but cannot pass
glottic level subglottis with ET
QChildren are at greater risk of regurgitation and
aspiration from swallowing air (aerophagy); a naso-
or oro-gastric tube should be used to decompress
the stomach if the distension is excessive. An
unconscious child requiring ventilatory support
should also have a gastric tube inserted to vent the
stomach and reduce the risk of aspiration.
QIf a child requires intubation, it should be
undertaken by an anaesthetist. General
anaesthesia is required to avoid increases
in intracranial pressure and trauma during
attempted intubation from coughing, gagging
and vomiting. The team leader needs to allocate
tasks as described in chapter 2. Indications
for intubation and ventilation are outlined in
table 11.3. Equipment and planning for failed
intubation must be in place e.g. supraglottic
airway devices. Remember, almost all children
can be oxygenated adequately using a good
technique with a bag-mask while expert help
is obtained. Surgical airways in children are
technically difficult and should only be attempted
by appropriately trained clinicians.
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TABLE 11.3
Indications for intubation and ventilation
Q Inability to provide adequate oxygenation
Q Obvious need for prolonged control of the airway e.g. multiple
injuries
Q Decreased level of consciousness e.g. head injury
Q Inadequate ventilation e.g. flail chest, exhaustion
Q Persisting circulatory failure
Q Potential airway compromise e.g. burns, inhalational injury
Q Each child that needs sustained airway support requires ETI
QIf a surgical airway is required, needle
cricothyroidotomy using a 14-18g cannula is an
option if the landmarks can be identified. This is
described in chapter 3. However, in children a surgical
airway or needle cricothyroidotomy is hardly ever
required; the practitioner should concentrate on
optimising his basic airway technique, maintain PEEP,
use a supraglottic airway and call for an anaesthetist
before proceeding to a surgical airway. During
ventilation through a face mask or a supraglottic
airway air can escape into the stomach and inflate
the stomach (diaphragmatic splinting), which makes
ventilation more difficult and can cause hypoxaemia.
To treat diaphragmatic splinting, a large bore suction
catheter can be inserted into the stomach and can
be left in place; a modern face mask usually seals well
around a suction catheter. Using this method high
ventilation pressures can be delivered; air insufflated
into the stomach escapes easily through the suction
catheter, which prevents gastric distention.
QMonitoring should be attached. Oxygen saturation
is the most important parameter to be monitored
and a pulse oximeter should be applied immediately.
In the haemodynamically compromised child the
signal can be weak and the readings unreliable.
Capnography is essential in the intubated patient.
QEnsure adequate immobilization of the cervical
spine until a spinal injury is ruled out. Up to 75%
of cervical spinal cord lesions are incomplete at
presentation with the potential for deterioration
if handled incorrectly. If in doubt, assume cervical
spinal injury. There is no evidence to support the
use of cervical collars for immobilisation in children.
Immobilisation of the cervical spine should be
maintained with manual in-line stabilisation.
Alternatively, children a vacuum splint can be used
to immobilise the whole child, including head and
neck. Involving the parents or carers may enable
better immobilization. Forced immobilisation is
likely to cause harm and should not be applied. If
a C-spine injury is suspected MILS or head-blocks
should be applied if tolerated by the child.
QProvide analgesia after discussion with the
team leader. This should be given at the earliest
opportunity to allow a more effective assessment
of the child. The IV route is the most appropriate
in major trauma, but if this fails, the intranasal
route can be used. Intranasal Fentany is ideal to
provide rapid analgesia and sedation if there is no
IV access in place. The choice of drug will depend
on local protocols; examples are given in table 11.4.
TABLE 11.4
Analgesic drugs and doses used in children
Drug Dose Comments
Morphine 0.03-0.1 mg/kg Must be diluted (usu-
IV/kg IV ally to 1mg in 10ml,
100microgram/ml)
Fentanyl 0.5-1microgram/kg IV Must be diluted
(usually to 100mi-
crogram in 10ml,
10microgram/ml)
2microgram/kg
intranasal
Ketamine 0.2-0.5mg/kg IV Excessive doses
will cause loss of
consciousness
3mg/kg intranasal
2mg/kg
intramuscular
Reduce doses by 50% when using S-Ketamine
Paracetamol 15mg/kg IV Opiate sparing
Whichever drug is used, the dose must be checked to
ensure an accurate and safe dose is given. In order to
avoid dosing errors we recommend the use of local
guidelines, visual aids and approved smart-phone
apps. The child’s pain should be re-assessed at regular
intervals using a suitable tool and further doses
given as required. Other methods such as distraction
techniques, regional nerve blocks, splintage and
immobilization will be applicable to some patients.
QCheck the AMPLE.
QThe airwary personnel carries out the neurological
assessment, which is mainly based on the social
interaction of the child with its environment and
the child's response to external stimuli. This can be
difficult at times, especially in autistic children or
children with a low pain threshold. The presence
of a parent is helpful to calm the child and to help
interpreting the child's behavior. The neurological
assessment consists of: the paediatric GCS (table
11.6), pupillary response to light, and assessment
of the motor response between all four quadrants.
This is of particular importance if the child is
to be anaesthetised, which makes a through
neurological assessment impossible.
Breathing personnel
Q Assess breathing pattern. This can be difficult if the
child is crying but with reassurance and analgesia
a more accurate assessment is possible. It is
important to assess the respiratory rate, symmetry
of movement, work of breathing (whether there is
any accessory muscle use) and if it is effective.
CHAPTER 11 TRAUMA IN CHILDREN | 145
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QEnsure ECG and SpO2 monitors are attached, if
not already done so. It can be difficult at times to
assess pulse oximetry if the child is unsettled or
upset but usually with persistence and reassurance
an accurate reading is possible. The ECG leads are
usually tolerated well.
QInspect, palpate, percuss and auscultate the chest.
Despite minimal external evidence of injury, there
can still be significant internal injury. Pulmonary
contusions are the commonest thoracic injury in
children, and can be present even in the absence
of hypoxia and hypoventilation. Most significant
contusions will be seen on the initial chest x-ray
but may be delayed and only seen after 48 hours.
QInspect and palpate the neck.
QPerform lateral thoracostomy and chest tube
insertion as necessary. The indications are the
same as in adults.
QSupport other team members if no chest
intervention is required.
Circulation personnel
QStem any overt haemorrhage. In infants scalp
lacerations can occasionally cause significant
blood loss.
QEstablish IV access, take appropriate blood samples.
Venous access is a high priority in the child with
severe injury and should be delegated to the
most appropriate person. The optimal sites are the
veins on the dorsum of the hand or foot and the
saphenous vein anterior to the medial malleolus.
Two short, wide bore IV cannulas are the ideal, the
size dictated by the size of the child. If vascular
access is difficult the intraosseous route is preferred
using an electrical powered drill, e.g. EZ-iO®.
Consider the use of IN analgesia before IO insertion.
QStart monitoring, if not already done attach ECG,
measure pulse rate, capillary refill time and blood
pressure. Children are often tachycardic because
of anxiety or pain and not just fluid loss. As they
have a lower absolute circulating blood volume
than adults, the loss of relatively small volumes can
result in a significant haemodynamic compromise.
However, they compensate very effectively by
increasing their peripheral resistance and heart rate
until they suddenly decompensate. Bradycardia in
a shocked child usually heralds cardiac arrest. It can
be difficult to get an accurate blood pressure in a
restless and conscious child. If it is easy, this may
be an indicator as to how unwell the child is. Non-
invasive blood pressure monitoring in shock can
give false readings of both systolic and diastolic
pressures, whereas the mean pressure better
reflects invasive BP readings. It is important to use
an adequately sized cuff to avoid over- or under-
estimation of the BP. Early consideration should be
given to inserting an arterial line as this will also
provide information on volume status and repeated
arterial blood gas sampling. The normal ranges of
vital signs in children vary with age (table 11.5).
QStart fluid resuscitation. If there are signs of ongoing
and uncontrolled blood loss activate the massive
146 | EUROPEAN TRAUMA COURSE
haemorrhage protocol (MHP). The use of crystalloids
and colloids should be limited to avoid dilution of
clotting factors and aggravation of trauma induced
coagulopathy (TIC). As in adults, PRBC, platelets and
FFP should be transfused in a ratio of 1:1:1. in 1-10 ml/kg
aliquots depending on the severity of hemodynamic
instability. TXA and factor concentrates should be
given according to local protocol.
QAim for normal blood pressure. The compensatory
mechanisms for blood loss in children are different
from adults. Children respond with tachycardia and
massive vasoconstriction, allowing them to keep
their bloodpressure relativley stable until abrupt
circulatory collapse ensues (Fig 11.1). Hypotensive
Resuscitation is therefore not applicable in children.
The principles of damage control resuscitation in
children are outlined in Fig. 11.2.
QE xamine the abdomen, pelvis and long bones
even if there is little external evidence of injury.
The pelvis needs assessing only once to determine
pain or instability. The perineum should also be
inspected but rectal and vaginal examinations are
not indicated in children at this point.
QApply the correct sized pelvic binder if indicated
by the history/mechanism/findings. Children
are less likely to suffer major haemorrhage from
pelvic fractures; in children that have not reached
puberty the haematoma remains contained within
the strong periostum. Again there can be minimal
evidence of the damage externally.
QIf competent and indicated, perform sonography
(eFAST). As in adults, ultrasound is an extemely
valuable tool to guide resuscitation in children. Due
to the relatively higher resolution and penetration
of ultrasound, image quality is usually better
in children than in adults. However, negative
sonography does not rule out significant abdominal
injury. A CT scan of the abdomen is or sometimes a
diagnostic laparoscopy (in stable patients) are the
preferred investigations if intrabdominal injuries are
suspected. An uncooperative child may need to be
anaesthetised for a scan.
QInsert a urinary catheter if clinically indicated and
no signs of urethral injury.
Figure 11.1 The cardiovascular response to blood loss in children
is different to the adult response; a significant decreases in blood
pressure occurs only immediately before decompensation. The
vertical red lines indicate the decompensation threshold. (HR
Heart-Rate; BP Blood-Pressure)
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Paediatric Major Trauma?

Paediatric Major Haemorrhage? Then...

Tranexamic Acid QIf not administered already:

T Q15 mg/kg bolus (max 1g), followed by

Q2 mg/kg/hr over 8 hours (max 125mg/hr)

Resuscitation QActivate MHP & consider:

QRapid infuser

R QCell salvage

QNo hypotensive resuscitation (unless post-pubertal)

QPelvic binder / splint #s / tourniquet

QLimit crystalloid and colloid use

Avoid Hypothermia QTarget temperature > 36°C

A QRemove wet clothing and sheets

QWarm fluids

QWarming blanket / mattress

Unstable? QIf unstable, coagulopathic, hypothermic or acidotic,

Damage Control perform damage control surgery

U Surgery
QAim surgery time < 90 minutes

QHaemorrhage control, decompression, decontamination

and splintage

Metabolic QAvoid acidosis

QBase excess guides resuscitation

M QIf lactate > 5mmol/L or rising, consider stopping surgery,

splint and transfer to ICU

QMonitor blood glucose

Avoid Q Inappropriate use of vasoconstrictors doubles mortality

A Vasoconstrictors Q However, use may be required in cases of spinal cord or

traumatic brain injury

Test Clotting QConsider TEG

Check clotting every 15ml PRBC / kg BW

T
Q

QAim platelets > 75x109/L

QAim INR & aPTTR ) 1.5

QAim fibrinogen > 1.5g/L

Imaging QConsider:
Supine CXR and e-FAST

I
Q

QC T: Most severely injured / haemodynamically unstable

patients gain most from CT

QInterventional radiology

Calcium QMaintain ionised Ca2+ > 1.0 mmol/L

C QAdminister 0.2ml/kg 10% Calcium Chloride over 10 mins

as required
QGive routinely after MHP Pack One

Figure 11.2 Massive Haemorrhage Protocol for children

Copyright: L May, A Kelly, M Wyse, K Thies, T Newton. Contact: lauraflower@doctors.org.uk

CHAPTER 11 TRAUMA IN CHILDREN | 147

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TABLE 11.5
TABLE 11.5
Normal vital signs in children
Normal vital signs in children
Age Weight Pulse Respiratory rate Systolic BP
Age Weight Pulse Respiratory rate Systolic BP
(kg) (beats/min) (breaths/min) (mmHg)
(kg) (beats/min) (breaths/min) (mmHg)
3-6 months 5-7 100-160Q  30-40 70-90
3-6 months 5-7 100-160QQ 30-40 70-90
10

1 year 10 100-160 30-40 70-90
1 year 100-160 30-40 70-90
2 years 12 95-140 25-30 80-100
2 years 12 95-140 25-30 80-100
3-4 years 14-16 95-140 25-30 80-100
3-4 years 14-16 95-140 25-30 80-100
5-8 years 18-24 80-120 20-25 90-110
5-8 years 18-24 80-120 20-25 90-110
10 years 30 80-100 15-20 90-110
10 years 30 80-100 15-20 90-110
12 years 40 60-100 12-20 100-120
12 years 40 60-100 12-20 100-120

skills 125)
Intraosseous needle (see page section)
TABLE
TABLE 11.6
Intraosseous
11.6 needle (see page 125) Trauma Support
Support Practitioner
Practitioner
TABLE 11.6
11.6 Trauma
TABLE
KEY POINTS
Glasgow Coma Scale - Age <4 years TThe
Trauma
Q
Q he TSP
TSP have aa crucial
Support
have crucial role in
Practitioner
role in the
the resuscitation
resuscitation of
QThe TSP have a crucial role in the resuscitation of
of
KEY POINTS
Glasgow Coma Scale - Age <4 years
Glasgow Coma Scale
Indications:
Glasgow Coma Scale -- Age
inabilityAge <4 years
years
to cannulate
<4 a peripheral vein, Q Tchildren.
children.
children.
he TSP haveTheya are
They
They
are
are
often
crucial
often
often
able
roleable
able
in theto resuscitation
to
to
establish good
establish
establish
good
good of
Eye
Eye opening:
Indications:
opening: inability to cannulate a peripheral vein,
Eye opening: lack of time or expertise to insert a contact with
children.
contact with
They the
thearechild
child
oftenandable
and to support
to support
to relatives
establish
relatives
good at
at
Spontaneously
Eye opening:
Spontaneously lack of time or expertise to insert a44 contact with the child and to support relatives at
Spontaneously central venous cannula 4 the same
same
contact
the time,
with
time, thewhilst
whilst
child the
and medical
to support team relatives
members at
Spontaneously
To central venous cannula 343 the same time, whilst the medical team members
To speech
speech
Procedure: insertion of intraosseous needle are same
the
are focused
focused time, onwhilst
on the resuscitation.
the resuscitation.
the medical team Engaging
Engaging with
members
with
To speech
Procedure: insertion of intraosseous needle 233 are focused on the resuscitation. Engaging with
To pain
To speech 2 the awake
are
the awake child
focused child
on is important;
is
the important; it helps
resuscitation.
it helps to establish
Engaging
to establish
with
To pain
Complications: failure to enter marrow cavity, infection, the awake child is important; it helps to establish
Complications:
To pain failure to enter marrow cavity, infection, 2 confidence and can
can secure cooperation,
cooperation, which in in
No
To response
pain
No response compartment syndrome 112 the
confidence
awake child
confidence and
and is important;
can secure
secure it helps to establish
cooperation, which
which in
No response compartment syndrome 1 turn facilitates
facilitates fast and goal directed treatment.
treatment.
No response
Common
Verbal 1
delay in use, inserted distally to fracture turn
confidence and fast
can and
secure
goalcooperation,
directed
turn facilitates fast and goal directed treatment. which in
Verbal response:
Common response: delay in use, inserted distally to fracture Children develop hypothermia much faster
faster than
pitfalls:response: clogged cannula
Verbal turn
Children
Childrenfacilitates
develop
develop fasthypothermia
hypothermia
and goal directedmuch
much treatment.
faster than
than
Alert, babbles,
Verbal babbles,
pitfalls:
Alert, response:words
words to usual
usual
clogged
to ability
cannula
ability 55 adults. Forced-air-warming
Forced-air-warming
Alert, babbles, words to usual ability 5 Children
adults. develop hypothermia or
adults. Forced-air-warming or warmed blankets warmed
much faster
blankets
than
Alert,
Less babbles,
Less than
than usualwords
usual words,tospontaneous
words, usual abilityirritable
spontaneous irritable cry
cry 445 shouldbe
adults.
should be appliedto toprevent
Forced-air-warming
applied preventandand treat
or treat
treat
warmedhypothermia.
hypothermia.
blankets
Less than usual words, spontaneous irritable cry 4 should be applied to prevent and hypothermia.
Less
Criesthan
Cries only usual
only to words, spontaneous irritable cry
to pain
pain 343 The further
should
The further
be tasks of
applied
tasks of
to the TSP
the TSP are
prevent are largely
and largely
treat the same
same as
hypothermia.
the as
TABLE 11.6
Cries only to pain 3
The further tasks of the TSP are largely the same as
TABLE
Cries 11.6 outlined
The
outlined
furtherin chapter
in chapter
tasks of 2.
2.
the TSP are largely the same as
Moansonly
Moans to to pain
to pain
pain 232 outlined in chapter 2.
Moans to pain
Glasgow Coma Scale - Age <4 years 2 outlined in chapter 2.
Moans
No
Glasgow to pain
No response
response to
to pain
Coma Scale - Age <4 years
pain 112
No response to pain 1 Ensure that
Ensure that the the child’s
child’s temperature
temperature is is
Eye
Motor
No opening:
response:
response to pain 1 Ensure that the child’s temperature is
Motor
Eye response:
opening: maintained
Ensure
maintained that and
andthe hypothermia
child’s
hypothermia is prevented.
prevented.
temperature
is is
Motor response:
Spontaneously
Motor response: 46 maintained and hypothermia is prevented.
Obeys verbal
Spontaneously command
Obeys verbal command 46 This is
maintained
This is achieved
achieved by having
and hypothermia
by having aa warm
is prevented.warm
warm
Obeys
To speechverbal command 36 This is achieved by having a
Obeys
To verbal
Localises
speech to
Localises to paincommand
pain 3556 resuscitation
This is
resuscitation area and
achieved
area and bytasking
having
tasking a TSP
a TSPa towarm
to keep
keep
Localises to pain
resuscitation area and tasking a TSP to keep
To pain to
Localises pain 25 the patient
patient covered
resuscitation
the covered
area and with
with a blanket
blanket
tasking
a a TSPorto
or hot air
keep
hot air
Flexion
pain (withdraws)
Flexion
To (withdraws) to
to pain
pain 2445 the patient covered with a blanket or hot air
Flexion
No (withdraws) to pain
response 14 warming
the patient
warming device
covered
device at all
at all times
with a
times and to
blanket
and toorwarm
warmhot all
air
all
Flexion
Abnormal
No (withdraws)
response
Abnormal flexion to to
flexion to painpain
pain (decorticate)
(decorticate) 1343 warming device at all times and to warm all
Abnormal flexion to pain (decorticate) 3 fluids given.
fluids
warming given.
device at all times and to warm all
Verbal
Extension
Abnormal response:
to pain
pain to
flexion (decerebrate)
pain (decorticate) 322 fluids given.
Extension
Verbal to
response: (decerebrate) fluids given.
Extension to pain
Alert, babbles, (decerebrate)
words to usual ability 25
Extension
No
No response
response
Alert, to pain
babbles, (decerebrate)
words to usual ability 5112
No
Less response
than usual words, spontaneous irritable cry 41
No response
Less than usual words, spontaneous irritable cry 41 One of
One of the
the key
key roles
roles of of the
the team
team leader
leader is is to
to supervise
supervise
One of the key roles of the team leader is to supervise
Cries only to pain 3 and guide
One
and guide
of the the
key
the team
roles
team members
of the
members team whilst
leader
whilst theisresuscitation
the resuscitation
to supervise
Cries only to pain 3 and guide the team members whilst the resuscitation
is ongoing.
and
is ongoing.
guide theIn Inteam
In a paediatric
paediatric traumatheititresuscitation
is essential
essential
Moans to pain
Moans to pain 2
2 is ongoing. members whilst
aa paediatric trauma
trauma it isis essential
that
is
that the child
ongoing.
the childInisis akept
kept as peaceful
paediatric
as peacefultraumaas possible
as possible
it is so they
they
essential
so
No response to pain 1 that the child is kept as peaceful as possible so they
No response to pain 1 understand
that the
understand child what
whatis is happening
kept
is happening
as peaceful but
as
but without so
possible
without scaring
they
scaring
Motor response: understand what is happening but without scaring
them. This
understand
them. This can
can
what be done
be done by having
is happening
by having aa calmcalm resuscitation
Motor response: them. This can be done by havingbut without
a calm scaring
resuscitation
resuscitation
Obeys verbal command 6 room, This
them.
room, distracting
can
distracting be the child
done
the child
by in aa variety
having
in variety
a calm of ways
ways and
resuscitation
of and
Obeys verbal command 6 room, distracting the child in a variety of ways and
Localises to pain 5 havingdistracting
room,
having the parent/carer
the parent/carerthe child
close in a
by. variety of ways and
Localises to pain 5 having the parent/carer close by.
Flexion (withdraws) to pain 4 having the parent/carer close by.
Flexion (withdraws) to pain 4 There is is the
the misconception
misconception that that sometimes
sometimes keeping keeping
Abnormal flexion to pain (decorticate) 3 There
There is the misconception that sometimes keeping
Abnormal flexion to pain (decorticate) 3 the child
There
the child
is theinmisconception
in blissful ignorance
blissful ignorancethat or providing
providing
sometimes
or false
keeping
false
Extension to pain (decerebrate) 2 the child in blissful ignorance or providing false
Extension to pain (decerebrate) 2 reassurance
the child
reassurance in isblissful
is preferable
preferable whereasorin
ignorance
whereas in providing
reality children
reality children
false
No response 1
reassurance is preferable whereas in reality children
No response 1 deal veryvery well
reassurance
deal well with the
is preferable
with the majority
majority
whereas of in reality
of situations. children
It is
is
deal very well with the majority situations. It
important
deal
important very to explain
well
to explain
with the
to majority
the of
parents/carerssituations.
to It
remain is
important to explain to the parents/carers to remain
calm as
important
calm as children
children
to reactto
explain
react and
and follow
the their lead.
parents/carers
follow their lead. IfIftoaaremain
child is
child is
calm as children react and follow their lead. If a child is
cooperative
calm as
cooperative it is
children
it is react
muchand
much easier
easier to manage
follow
to manage
their lead.their
theirIf a injuries.
child
injuries.is
cooperative it is much easier to manage their injuries.
It is
is essential
essentialitto
cooperative
It to tell
tell them the truth
truth at all
all times
times because
It is essential toistell
muchthem
them easier
the
the to manage
truth at
at theirbecause
all times injuries.
because
if you
It
if you
is lose their
essential
lose their
to trust
tell
trust it is
them
it is often
often
the impossible
truth at all
impossible timesto regain
to regain
because it.
it.
if you lose their trust it is often impossible to regain it.
if you lose their trust it is often impossible to regain it.

148 | EUROPEAN TRAUMA COURSE

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Imaging in the paediatric trauma patient

Imagingtoinradiation
Exposure the paediatric
should betrauma patient
minimised in children. Specific injuries in children
Exposure
There mustto radiation
be a clear should be minimised
indication for each in children.
imaging
There must
request and be a clear indication
therefore the standard for each C-spine,imaging
CXR Traumatic brain injury
request
and pelvicand XR therefore
as part of the standardsurvey,
the primary C-spine, are CXR
not Over half of all severely injured children suffer isolated
and pelvic XROnly
appropriate. as part
if theof the primary
injuries cannot survey,
be are not
cleared head injuries. This is the leading cause of death and
appropriate.
clinically
TIPVME,
Only aif the cervicalinjuriesspinecan XR notand be cleared
a CXR permanent disability in paediatric trauma. Survivors
clinically,
be a cervical
obtained. A negative spine chestXR X-ray
and avirtually
CXR shouldrules outbe of traumatic brain injury exhibit functional difficulties
obtained.
any majorAthoracic
negativeinjury
chestin X-ray virtually
a child withrules out any
no obvious persisting beyond childhood. Common findings
major thoracic
clinical signs ofinjury in a child
a chest injury.
with
Theno use obviousof clinical
whole include poor school performance, employment
signs of CT-scan
body a chest injury. iscontroversial because of the difficulties, poor quality of life, and increased mental
The use ofexposure
significant whole to body CT-scanA is
radiation. controversial
CT-scan should health problems. The best outcome after head
because
only beofrequested
the significant if the exposure to radiation.
mechanism andA CT-the injury is achieved by rapid access to definitive care
Specific injuries in children
scan should
physical only be requested
examination suggests if the
an mechanism
injury, andanda and minimisation of ‘secondary injury’, including
the physical
change of examination
managementsuggests is to anbeinjury, and a
expected. avoidance of hypoxaemia, hypotension, and hypo-
Traumatic
change
The thyroid brain
of managementglandinjury is toparticularly
be expected. susceptible or hypercapnia. Twenty percent of all children with
The
Overradiation
to half
thyroid
of all and
gland
severely isinjured
given particularly
the children susceptible
low incidence suffer isolated
of to
C- traumatic brain injuries require emergency craniotomy
radiation
head injuries.
spine and This
injuries givenis the
theleading
conventional low incidence
cause
X-ray of of deathC-spine
diagnosticand for evacuation of sub- or extradural haematoma.
injuries
permanent
should conventional
takedisability
priorityinX-raypaediatric
over diagnostic
trauma.
CT-scanning. should
Survivors
Onlytakeif This should be undertaken as fast possible, with a
priority
of traumatic
there is over brain
CT-scanning.
a strong injury
suggestionexhibit
Onlyoffunctional
ifathere
C-spine isdifficulties
ainjury
stronga maximum acceptable time target of 4 hours from the
suggestion
persisting should
CT-scan beyond
of a C-spine
bechildhood.
injury a Common
considered. CT-scan should
findings
Consideration be injury.
considered.
include be
should poor Consideration
school
given as performance,
to should
whether be itemployment
given as to
is justified
whether
difficulties,
depending it is
poor
onjustified
quality
the depending
of life, and
mechanism onincreased
of the mechanism
injury mental
and the Thoracic trauma
of
health
injuryclinical
child’s problems.
and thecondition
child’s
The best clinical
or outcome
condition
can after
be focused or can head
be
on Serious chest injuries in children are rare, but can present
focused
injury isbody
specific on
achieved
specific
regions.by
body rapidregions.
access to definitive care without visible external signs and are associated with
and minimisation of ‘secondary injury’, including significant morbidity and mortality. The high flexibility
Planning
avoidance Round of hypoxaemia, hypotension, and hypo- of the paediatric ribcage explains why even fatal chest
or hypercapnia.
The primary survey Twenty percent of
concludes withall the
children
planning
with injuries can occur without any bony lesions. Rib fractures
traumatic
round, the brain
the purposeinjuries
purpose of require
which
of which isemergency
to collate
is to all craniotomy
findings,
collate all occur only if exceptional force is involved and if present
review
for evacuation
findings, allreview
measuresofallsub-
taken
measuresor soextradural
far, and so
taken haematoma.
establish
far, andan should raise suspicion regarding further underlying
individual
This should
establish patient
an be undertaken
pathway
individual (figure
patient as fast 2.5).possible,
pathway Depending
(GJgurewith ona
2.). serious injuries. A chest x-ray is the first imaging
maximum
the local infrastructure
Depending acceptable
on the local timethe target
majorityof 4 of
infrastructure hours
the from
the severely
the
majority modality for thoracic trauma in children, but if there is
injury.
injured
of children injured
the severely will need to be will
children transferred
need totobea suspicion of an intra-thoracic injury a chest CT should be
children’s trauma
transferred to a centre.
children’s trauma centre. obtained. As in adults, the majority of thoracic injuries in
Thoracic trauma children rarely require surgical intervention, apart from
Serious chest injuries in children are rare, but can present placing a chest tube for a pneumothorax.
Secondary survey
without visible external signs and are associated with
significant morbidity and mortality. The high flexibility Abdominal injury and pelvic fracture
A secondary
ofQthe paediatric ribcage
survey is explains
performed why even
in anfatalidentical
chest Abdominal injuries are the third most frequent injuries
injuries
waycan to an
occuradultwithout
with any
a detailed
bony lesions.
‘headRib to fractures
toe’ and after head and extremity trauma in children and are
occur‘frontonlytoif back’
exceptional
examination.
force is involved and if present the primary cause of circulatory shock. The history and
QWhilst
should raisecarrying
suspicion out regarding
the examination,
further remember,
underlying understanding the mechanism of injury are both key
serious
eveninjuries.minimalA external
chest x-ray marking
is the mayfirst imaging
indicate in diagnosing abdominal injuries. The solid organs are
modality
significant for thoracic
injury internally.
trauma in Make children,
a detailed
but if there
recordis proportionally larger and the abdominal wall is thin,
suspicion
including of andiagrams
intra-thoracic
and photographs.
injury a chest CT should be offering relatively little protection. The diaphragm is
QIt is extremely
obtained. As in adults,
raretheto perform
majorityaofrectal
thoracic
examination
injuries in more horizontal than in adults, causing the liver and
children
in a child.
rarely Ifrequire
it is indicated,
surgical intervention,
it must be done apart from
by a spleen to lie lower and more anteriorly. In addition the
placing
paediatric
a chestsurgeon
tube forand a pneumothorax.
not repeated. ribs, being very elastic, offer less protection to these
QDuring the examination, although complete organs. This exposure leads to a higher incidence of
Abdominal
exposure is injury and pelvic
necessary, fracture
it is essential to keep the spleen and liver injuries than in adults. Fortunately,
Abdominal
child as injuries
warm as arepossible.
the third most
Children
frequent
cool injuries
quickly 90% of these injuries can be managed conservatively
afterand headinfants
andevenextremity
more rapidly.
trauma in children and are or with interventional radiology alone. The bladder is
QR
the primary
equest causeany further
of circulatory
investigations
shock.or Theinterventions
history and intra-abdominal, rather than pelvic, and is therefore
understanding
as needed. the mechanism of injury are both key more exposed when full. Respiratory compromise
Review all abdominal
inQdiagnosing patient documentation;
injuries. The solid it isorgans
essential
are can complicate abdominal injury as a result of
proportionally
to be as accurate larger and as possible.
the abdominalThis is wall
evenismore
thin, diaphragmatic splinting/irritation.
offering
significant relatively
in child
littleprotection
protection. cases.
The diaphragm is
QMaintain
more horizontal than indialogue
ongoing adults, causing
with the the liver and
parents/
spleen
carers, to lielisten
lowertoand more
their anteriorly.
concerns andIn addition the
information
ribs,theybeing canvery elastic, offer less protection to these
provide.
organs. This exposure leads to a higher incidence of
spleen and liver injuries than in adults. Fortunately,
CHAPTER 11 TRAUMA IN CHILDREN | 149
90% of these injuries can be managed conservatively
or with interventional radiology alone. The bladder is
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Road traffic collisions often involve rapid decelerations
which cause abdominal compression. This can result in
damage to the liver, spleen and kidneys and rupture of
the duodenum at the duodenojejunal flexure; direct
blows can readily injure the same solid organs. Injuries
to the pancreas or duodenum are a classic sequel of
bicycle handlebar trauma.
Fractures of the elastic immature pelvis are relatively
rare in children, and generally have a good prognosis.
However, if they are associated with other serious
injuries (head injury, long bone fractures, intra-
abdominal injuries), mortality can increase to 15%.
Most pelvic fractures in children can be treated
conservatively. In adolescents, fractures of the pelvic
ring can lead to severe life-threatening retroperitoneal
haemorrhage, which requires external splinting in the
Emergency Department.
Vertebral column and spinal cord injuries
In children under eight years, the upper three cervical
vertebrae are most often injured, compared with
adults when it is usually lower cervical vertebrae.
The low incidence of bony injury is explained by
the greater mobility of the cervical spine in children
which dissipates applied forces over more segments.
Remember that on plain cervical spine x-rays, 9% of
children can have pseudosubluxation of C2 on C3 and
of C3 on C4. Injuries to the thoracic and lumbar spine
are rare but are most common in the multiply injured
child. In the 2nd decade of life, 44% of reported injuries
to the vertebral column and/or spinal cord result from
sporting and other recreational activities. When an
injury does occur, multiple levels are often involved as
the force is dissipated; the most common mechanism
of injury is hyperflexion.
Spinal cord injury without radiographic abnormality
(SCIWORA) is said to have occurred if the spinal cord
has been injured without an obvious injury to the
vertebral column. The cervical spine is more frequently
affected because it has the greatest mobility.
Limb injuries
The mortality of isolated limb injuries in children and
adolescents is low. If associated with trauma to other
organ systems, the mortality seems to depend on these
injuries rather than on the extremity. In the context
of damage control resuscitation, definitive repair is
postponed until the patient is fully stabilised. However,
temporary stabilisation of long bone fractures is part of
the resuscitative efforts because it reduces blood loss,
pain and the incidence of multiple organ dysfunction
syndrome. Temporary measures include external
fixation or casting for more distal fractures.
Crush injuries need early debridement. Reconstructive
surgery is often staged and tailored to the patient’s
condition. Vascular injuries are relatively rare and
150 | EUROPEAN TRAUMA COURSE
present with absent pulses and pallor of the affected
limb. They are easily overlooked in the polytrauma
patient and they must be actively searched for in order
to save the limb.
Non-accidental injuries
It is important when dealing with any child to have an
awareness of non-accidental injury. There are clues
in the history; an unexplained delay in presentation,
injury incompatible with history or a change in the
story over time. In the resuscitation room there are
sometimes indicators of possible concern revealed
by watching the interaction of the parents with the
child and the parents’ behaviour. Occasionally the
appearance of the child can be cause for concern
or the child may disclose physical abuse if given the
opportunity.
During the examination, certain injuries should raise
suspicion; rib fractures in an infant, long bone fractures
in a non-mobile child, or metaphyseal or epiphyseal
injuries, which are often multiple. Sometimes suspicion
is only raised following imaging, when old fractures are
identified or there is evidence of healing. It is important
when examining burns or scalds to ensure that the
injury distribution is compatible with the mechanism.
Non-Accidental Injuries often show a typical pattern
(figure 11.3).
Non–accidental injuries must be considered but it is
important to put all the factors together carefully to
avoid any unnecessary distress for the family with
an inappropriate accusation. However, if there are
concerns, it is vital that they are explored, to ensure
the well-being and safety of the child that is being
treated, and any siblings still at home. Please familiarise
yourself with your local safeguarding protocols.
Injury Pattern
Non-Accidental Injury Accidental Injury
Figure 11.3 Non-Accidental Injuries often exhibit a typical pattern.
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Summary
The paediatric trauma patient can be managed
effectively and competently following the
system outlined above and need not be feared.
It is essential to focus on communication with the
child and the family, to enable the most accurate
assessment and treatment. The mechanism will
give an indication of the likely injury, particularly
if the child is unable to localise it and the external
evidence is minimal. Preparation of equipment,
drugs, and fluids before arrival alleviates some
of the stress when faced with a distressed child
and helps to prevent mistakes and ensure timely
assessment and management. Early analgesia
is imperative and improves the assessment and
experience for the child. It is important when
dealing with any child to have an awareness of
non-accidental injury. Certain injuries should
raise suspicion such as rib fractures in an infant,
long bone fractures in a non-mobile child, or an
injury inconsistent with the history.

Having worked through this chapter you are now

ready to apply the following knowledge in the
paediatric trauma workshop:
Qhow to prepare to receive a paediatric patient

with major trauma;

Qunderstand the differences between adult and

paediatric trauma victims;

Qhow to conduct a primary survey in a paediatric

patient with major trauma;

Qrecognize the common injuries that children

sustain;
Qrecognize the signs of non-accidental injury in

children.

These cognitive abilities will be integrated with

the practical skills during the course workshops.

CHAPTER 11 TRAUMA IN CHILDREN | 151

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Trauma in children – skills

Insertion of intraosseous needle
Indications:
Qinability to obtain vascular access;

Qlack of time or expertise to insert a central venous

cannula.

Procedure:
QThe most common sites used for intraosseous

access in children is 2-3cm below the tibial

tuberosity on the flattened medial aspect of
the tibia, alternatively the anterolateral surface
of the femur (figure 11.4), 3cm above the lateral Figure 11.4 Insertion of an IO needle into the proximal tibia
condyle, the proximal humerus (figure 5.7), or
the medial malleolus. The major tubercle of
the humerus can also be used as in adults but
it can be difficult to identify in infants. Fractured
bones should be avoided particularly those with
fractures proximal to the site of entry.
QIf a tibial IO is inserted, a pillow should support

the knee and proximal lower leg. The skin should

be cleaned.
QIn a conscious child, infiltrate the area and

underlying periosteum with 3–5ml 1%

lignocaine.
QThe needle is inserted 90° to the skin and

advanced until the bone is reached.

QThe drill is then activated and gentle pressure

applied until a ‘give’ is felt as the cortex is

penetrated.
QRemove the trocar and attach a syringe via a short

extension. Correct placement is confirmed by

aspiration of marrow content and easy infusion
of fluid. The aspirated sample can be sent to
the laboratory for routine bloods and used for
bedside glucose estimation.
QInject a small volume of local anaesthetic to ease

the pain caused by injection.

QFlush the system with 20ml saline to clear any

debris or clot.
QFluids need to be given in boluses. This is easiest

to achieve using a syringe and three-way tap.

The flow rates under gravity alone are not high
enough for resuscitation.
QIntraosseous lines need to be replaced by venous

cannulation as soon as possible.

Complications:
Qextravasation;

Qsubperiosteal infusion;

Qfat and bone marrow embolism;

Qosteomyelitis;

Qdamage to the growth plate and cortex;

Qpain and subcutaneous oedema;

Qcompartment syndrome.

152 | EUROPEAN TRAUMA COURSE