Approach to trauma (pediatrics): Clinical sciences

Trauma refers to any physical injury that is caused by an external force or impact, such as an accident or violence. When compared with adults, infants and children have unique anatomical and physiological differences that influence trauma evaluation and management. During a pediatric trauma evaluation, the goal of the primary survey is to recognize and treat life-threatening injuries, while the secondary survey serves to identify any additional injuries.

When a pediatric patient presents with trauma, first perform a primary survey. This should be done using the ABCDE assessment to determine if your patient is stable or unstable.

A stands for Airway. While maintaining cervical spine precautions, suction the oropharynx and assess for signs indicating airway obstruction, like stridor or a visible foreign body. Remember that patients who can speak clearly do not have airway obstruction. You may need to intubate your patient to secure their airway, so keep in mind that children's airways are shorter and narrower than an adult’s; their tongues are relatively larger; and they have a more flexible and floppier epiglottis. For this reason, children often require differently sized laryngoscope blades.

Here’s a high-yield fact! During the primary survey, you can use Broselow emergency tape to quickly estimate a child’s weight, endotracheal tube or laryngeal mask size, and medication dosing.

Next up is B for Breathing. Now that the airway is secure, it’s time to assess your patient’s oxygenation and ventilation. Remember that infants are obligatory nose breathers, and nasal obstruction can interfere with an infant’s ventilation, so be careful not to obstruct the nares during your evaluation! Check oxygen saturation with pulse oximetry and provide supplemental oxygen if needed. Look for signs of respiratory distress, like accessory muscle use, tachypnea, or grunting. If your patient has poor respiratory effort or respiratory distress, they may require support with bag-mask or mechanical ventilation. During the primary survey you’ll need to quickly identify and treat life-threatening conditions like tension pneumothorax or a massive hemothorax, both of which cause profound respiratory compromise.

Let’s move on to C for Circulation. To evaluate your patient’s circulatory status, assess their pulses, capillary refill, and blood pressure; and look for sources of hemorrhage. Then, apply pressure to areas of active bleeding, or add a tourniquet if there is arterial hemorrhage from an extremity. Also, obtain IV or IO access with two large-bore catheters, begin fluid resuscitation, and consider blood transfusion. Remember, when compared to adults, children have more effective hemodynamic compensation mechanisms, so hypotension is a late sign of shock. During the primary survey you’ll need to quickly identify and treat life-threatening conditions like massive hemothorax and cardiac tamponade, both of which cause critical impairment of circulation.

Now, let’s discuss D for Disability. After evaluating the ABCs, you should perform a brief neurologic assessment. This can be accomplished by using the Glasgow Coma Scale, or GCS, for older patients; or the Pediatric GCS for preverbal children. The GCS is scored using 3 components, which measure eye-opening responses, verbal, and, motor, with a maximum score of 15, and a minimum score of 3. Children with a GCS score of 12 or less require head imaging, and those with a score of 8 or less also require intubation.

Regardless of the GCS score, you should obtain a CT scan of the head if your patient reports a severe headache, if they lost consciousness, or if you suspect a basilar skull fracture. In this case, imaging might demonstrate a severe brain injury such as intracranial hemorrhage or brain herniation. Remember, a child’s brain is not completely myelinated, and their cranial bones are thinner than an adult’s, so they have an increased risk of serious head injury. Additionally, infants have open fontanelles, so they usually don’t exhibit overt signs of increased intracranial pressure, like bradycardia or widened pulse pressure.

Time for a clinical pearl! The AVPU scale is another tool that can be used to assess a young child’s level of consciousness. AVPU stands for Alert; Verbally responsive; Painfully responsive; and Unresponsive. Alert children are at their mental baseline, while Verbally responsive children do not open their eyes spontaneously but react and open their eyes to a verbal stimulus. Those who are Painfully responsive will only respond and open their eyes to painful stimuli. Finally, Unresponsive patients do not respond or open their eyes spontaneously or to any stimulus.

Finally, let’s discuss E for Exposure. You’ll need to remove all clothing to obtain a thorough examination, but be careful not to let your patient become hypothermic. Because a child’s body surface area-to-mass ratio is higher than an adult’s, they can lose body heat quickly. To prevent hypothermia, you can provide warm intravenous fluids, blankets, and ambient heat. Additionally, consider placing a gastric tube to decompress the stomach and a urinary catheter to monitor urinary output.

Now, if your patient is unstable, you will need to move on to emergent intervention of the injury that is causing their instability.

Once life-saving measures are underway and the patient has been stabilized, begin the secondary survey. Use the mnemonic AMPLE to remember the key elements of the history and ask about your patient’s Allergies; Medications; Past medical history; the Last time they ate; and any Events related to the trauma, which include the mechanism of trauma and interventions received in the field. Then, conduct a thorough head-to-toe exam, to evaluate any injuries that weren’t addressed during the primary survey.

Useful imaging studies include chest and pelvic X-rays and any relevant CT scans that might narrow down your differential. Another important test is a Focused Abdominal Sonography in Trauma, or FAST exam, which is a bedside ultrasound that quickly scans the pericardium, hepatorenal space on the right, splenorenal space on the left, and pelvis for evidence of free fluid which could be from bleeding or hollow viscus injury.

Here’s a high-yield fact! As part of any trauma evaluation, you should also order lab work, including a CBC, blood type, ABG, CMP, and coagulation studies. Some other labs to consider include a blood alcohol level, as well as a urinalysis, urine pregnancy test, and urine toxicology screen.