Approach to trauma (pediatrics): Clinical sciences

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Introduction 0:00–0:35

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.

Acute Management/Primary survey 0:35–5:54

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.

Secondary survey 5:54–7:19

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.
Now let’s begin our secondary survey by assessing for head trauma. You may notice scalp or facial lacerations, or a skull depression or irregularity, which suggests a fracture.

Head 7:19–8:13

Patients with ocular injury may demonstrate posterior displacement of the globe, or enophthalmos, which suggests an orbital floor fracture.
You might also see signs indicating a dental injury, such as bleeding gums or loose teeth. Any of these findings should make you consider a head injury.
If the extent of the injury is unclear, obtain a skull X-ray or a CT scan of the head. Radiographs might confirm a skull fracture, or a dental injury, like tooth luxation, or root or crown fracture; while the CT scan might also show a skull fracture, intracranial hemorrhage, or an orbital injury or rupture.
Any one of these findings confirms a head injury. Once the head assessment is complete, assess for cervical spine trauma.

Cervical spine 8:13–9:10

If your patient has peripheral weakness, abnormal sensation, midline cervical tenderness, or a focal neurologic deficit, consider a cervical spine injury.
Next, obtain a cervical spine X-ray, possibly in combination with a CT scan, and review the images. Findings such as vertebral fracture, dislocation, or subluxation confirm the presence of a cervical spine injury.
Remember, when compared with adults, children have relatively larger occiputs and weaker cervical musculature, so they have an increased risk of spinal cord injury.
Additionally, because a child’s vertebral column is more elastic than an adult’s, spinal cord injury may occur without radiological abnormality.
For this reason, consider ordering an MRI if you suspect spinal cord injury, even if radiographs appear normal. Once the cervical spine assessment is complete, assess for thoracic trauma.

Thoracic 9:10–10:06

Your patient might have dyspnea or chest pain; and the exam may reveal chest wall bruising, tenderness or crepitus; muffled heart sounds; or decreased breath sounds.
If you identify any of these, consider a thoracic injury and next to the abdominal X-ray, get a CT scan as well. Because children have a compliant chest wall, they can sustain significant internal thoracic injury without external signs of trauma, so have a low threshold for ordering imaging!
Thoracic imaging might reveal rib fractures; vascular injury, such as aortic disruption; tracheobronchial or diaphragmatic injury; pneumothorax, hemothorax, or pulmonary contusions; or esophageal rupture.
Any of these findings confirms a thoracic injury. When the thoracic assessment is complete, it’s time to assess for abdominal trauma.

Abdomen 10:06–10:51

The exam might demonstrate abdominal tenderness, distension, rebound or guarding. If trauma was related to a motor vehicle crash, you might identify the “seat belt sign”, which refers to bruising over the abdomen and thorax in the distribution of a seatbelt.
If you find intraperitoneal bleeding on FAST exam, consider abdominal injury and obtain an abdominal CT scan. Imaging might identify free air under the diaphragm; a hematoma; or injury involving the spleen, kidney, liver, or pancreas; which confirms an abdominal injury.
jNow that the abdominal assessment is complete, you should assess for pelvic or genitourinary trauma. If your patient demonstrates pelvic tenderness, bruising, or instability; bleeding from the urethral meatus; or gross hematuria; consider a pelvic or genitourinary injury.

Pelvis / Genitourinary 10:51–11:24

Then, obtain CT scan for suspected genitourinary injury. The pelvic X-ray might identify a pelvic fracture, while the CT scan may reveal an injury involving the upper or lower urinary tract, which confirms a pelvic or genitourinary injury.
Finally, once your pelvic and genitourinary assessment is complete, assess for musculoskeletal trauma. A bone or joint deformity; or any bruising, swelling, or tenderness; should make you consider a musculoskeletal injury, such as an extremity fracture or dislocation.

Musculoskeletal 11:24–12:34

Next, obtain an X-ray of the injured bone or joint. Radiographs may reveal a long bone fracture or dislocation, which confirms a musculoskeletal injury.
One last clinical pearl! Open fractures may visibly protrude through the skin, but some recede beneath an open wound.
If you notice an open wound with crepitus, excessive bleeding, or blood with visible fat globules, suspect an open fracture, and obtain urgent orthopedic consultation, since open fractures are a surgical emergency.
Fractures that cause neurovascular compromise also require emergent surgical intervention, so whenever you suspect a fracture, remember to assess your patient’s sensation, motor function, capillary refill, and distal pulses for evidence of neurovascular dysfunction.
Alright, once the musculoskeletal assessment is complete and you’ve identified all of the injuries related to trauma, move on to management.

Management 12:34–13:14

Obtain an immediate subspecialty consultation to evaluate your patient’s injuries, and perform surgical intervention, if needed.
Then, monitor your patient’s vital signs and urine output, and provide ongoing management, including fluid resuscitation or blood transfusion if needed; as well as wound care; fracture stabilization; and analgesia.
Also, consider beginning antibiotics and administering a tetanus vaccine, if indicated. Finally, consider transferring your patient to a pediatric trauma center.
Alright, here’s a quick recap… When a pediatric patient presents with trauma, perform a primary survey to identify and manage life-threatening injuries.

Review 13:14–13:41

Then, perform a secondary survey, which includes a head-to-toe exam of the head, cervical spine, thorax, pelvis and genitourinary region, and extremities.
Then, obtain immediate subspecialty evaluation, provide ongoing management, and consider transfer to a pediatric trauma center.
Approach to trauma (pediatrics): Video and Causes | Osmosis