PEDIATRIC TRAUMA

EARLY MANAGEMENT
RESUSCITATION
OF SEVERELY INJURED CHILD

EDWIN BASYAR
 Trauma  the leading cause of death and
disability in children
 Over all mortality rate for children with
trauma : 2,5%
 More than 90% injuries in children: result

of blunt mechanism
 NPTR (1997): multiple trauma 48%

 Majority of injured children to ER: do not

have life threatening injuries

 10 – 15%  truly life threatening injuries
 NPTR develop Pediatric Trauma Score
 most predictive of death and disability
 Score range from +12 (no or minor
injury) to -6 (fatal injury)
 Trimodel of traumatic death :
• First peak : injured patient die very soon
after the injury ( seconds or minutes ) :
CNS, central vasculature
• Second peak : occurs minutes or hours
after the injury ( epidural hematoma,
solid organ injury, fluid in pleural /
pericardial space )  require rapid
identification and treatment during
the “golden hour”
• Third peak : injury mortality occurs days
and weeks  result of complication of
injury
 The priorities and the protocol of trauma
management in children : the same as in
adult
 Injured children are not small-injured

adult
 Anatomy and physiology in children

require special considerations

 Children : small, less fat and elastic

connective tissue, multiple organs in

close proximity to a very pliable skeleton
 Smaller body mass : transmitted injury is
distributed all over the body  multi-
system injury
 In children :

• most seriously injury  multiple organ injury

( including CNS )
• thoracic injury are unusual ( significant cause
for mortality )
• vulnerable for intraabdominal organ injury
(very pliable ribs  injury to the liver and
spleen; pelvis fails to protect the bladder)
 Initial assessment of the injured child:
• ABCDEs of the primary survey (guarantee
the airway, ensure breathing, restore
circulation and control hemorrhage,
assessment of neurologic status and
disability
• Resuscitation phase ( ECG monitoring,
urinary and gastric catheters, blood and
urine studies )
• Secondary survey ( a thorough head to toe
evaluation )
 Assessment of circulatory status in
children :
evaluation of pulse, HR, perfusion, skin color,
capillary refill and blood pressure.
 In children : BP is maintain until
hypovolemia is quite severe
• Significant hemorrhagic injury may present
with a normal blood pressure (reflex
tachycardia and increase peripheral
vasoconstriction )
• Children compensate 25 – 30% of circulating
volume blood loss with minimal initial
external signs
• 40% blood volume loss  ability of vascular
constriction is totally lost  BP rapidly falls
 progressive bradycardia
 Vascular access in injured children :
• Percutaneous peripheral
• Intraosseus access (< 6 years old )
• Venous cut-down
• Percutaneous ( femoral, subclavian, jugular
vein )
 Initial fluid resuscitation in children with
circulatory failure
• Warmed isotonic crystalloid solution (RL, NS)
bolus 20 ml / Kg ( may repeat 2 or 3 times )
• PRC 10 ml / kg
• Hemodynamic respons (-)  OR
• Hemodynamic respons (+)  observation
• Organs primary important in hypovolemic
shock : heart, brain, kidneys and skin
 Indication of effective volume
resuscitation :
• Slowing hearth rate (< 130 bpm) with
improvement other physiologic signs
• Increase in pulse pressure
• Return of normal skin color
• Increase extremity warmth
• Clearing of sensorium
• Increase in systolic BP (> 80 mmHg)
• Increase in urine output (1 to 2 ml/ Kg / hrs)
 Abdominal injury
• Abdominal wall in children is quite thin
 minor force result in serious compression
and disrupting injury
• Little protection for the upper abdominal
viscera  high incidence splenic and hepatic
injury
• 90% of abdominal injury in children :
result of blunt trauma
• Non operative management  80 - 90%
success rate and has become the standard of
care in the treatment of blunt abdominal
injury in children
• Hemodynamic stable children with isolated
solid organ injury  tolerate Hb to 7 gr%
(without blood transfusion)
• CT  preferred imaging technique for
hemodynamic stable injured children
• FAST  gaining acceptance reliable method
for evaluation trauma patient ( unstable )
• DPL  potentially a major procedure for
children, but infrequently necessary
• Indication for operation in blunt abdominal
trauma:
 Hemodynamic instability
 Suspected associated injury

 Excessive transfusion requirement ( > 0,5 BV )

 Summary :
• Resuscitation in severely injured children
should be aggressive to avoid irreversible
shock
• Non operative management has become the
clear standard of care for pediatric blunt
trauma