in the Extremes of Age
Injury is the most common cause of death & disability in children.
Children with multi-system injury deteriorate rapidly and develop
Children have unique anatomy / physiology:
- most serious paediatric trauma is blunt trauma involving the brain
- apnoea, hypoventilation and hypoxia are 5x as common than
hypovolaemia with hypotension.
--> aggressive A&B control is paramount in management.
More force is applied per unit body area.
Less fat, less CT, more proximity to vital organs.
--> higher multiple organ injuries
Greater brain injury.
More pliable and has growth centres.
Ratio of surface area to body V is highest at birth then diminishes.
hermal energy loss is significant.
--> preempt hypothermia.
A significant challenge
Cooperative manipulation is extremely difficult.
May easily be upset / aggressive.
Also injury can upset future growth/development.
- don't underestimate these physiological and psychological results.
- 60% show personality change at 1 yr
- 50% show cognitive / physiological handicap
- QOL can be impaired by growth plate damage, splenectomy etc.
Need different sizes.
Midface size small relative to cranium.
- c-spine is liable to flex
--> keep head in sniffing position (plane of face parallel to spinal
Place padding between torsoand spinal board
Larynx visualisation is more difficult due to soft tissues in the
- secretions accumulate in the retropharyngeal area.
Trachea is ~5cm in an infant, 7cm by 18mo.
--> don't intubate the R mainstem bronchus.
Optimise by sniffing position with neutral c-spine position.
Chin lift, jaw thrust, inline immobilisation.
Clear secretions, O2 very well before mechanical airway control.
Only when unconscious else will vomit.
Do not insert backwards then rotate (risk trauma to oropharynx)
For severe brain injury, airway / ventilatory failure or requires
operative intervention for hypovolaemia.
Used uncuffed tube of appropriate size (fragile airway) if <9
Gauge size by matching diametre to external nares or child's little
- 3-3.5 tube in newborns
- 4 by 6-9mo
- then 4+(age/4) for uncuffed
- and 3+(age/4) for cuffed
- insert to tube size x 3 or if >2yrs to (Age/2)+12
- If intubation not possible, bag-mask until definitive airway
- avoid nasotracheal intubation in children >9yrs (anatomy
makes it difficult and easy to cause damage)
- position tube 2-3cm below vocal cords and carefully secure
- ausculaate both hemithoraces and axillae to preclude R mainstem
- get a CXR
Rapid sequence intubation for a child
ii) atropine sulphate 01.-0.5mg
iii) sedation (midazolam HCL 0.1mg/kg if hypovolaemic; midazolam
0.3mg/kg if normovolaemic)
iv) cricoid pressure
v) paralysis (succinylcholine chloride <10kg: 2mg/kg; >10kg:
vi) intubate, check tube position
vii) release cricoid pressure.
Preferred method before surgical airway
Needle jet insufflation is an appropriate temporising technique.
Do not damage airway / alveoli with vigorous bag masking.
Hypoxia is the most common cause of cardiac arrees in a child.
- a relatively normal pH should be maintained (acidosis preceeds
arrest) with adequate ventilation / perfusion
- caution: do not simply
correct hypercarbia with bicarbonate(!)
Manage thoracic injuries / tube thoracostomy as required
- use an appropriate sized-tube, insert at same site: 5th ICS.
- 10-14 for newborns
- 12-18 to 6mo
- 14-20 to 1yr
- 14-24 to 3yrs
- 20-32 to 7 yrs
- 28-38 to 10 yrs
Children have greater reserve and subtle manifestations
- tachycardia and poor skin perfusion are the only keys to early
- more subtle signs are loss of peripheral pulses, narrowing pulse
pressure (<20mmHg), skin mottling, cool extremities, decreased LOC,
dulled pain response
- 30% blood V reduction is required to manifest a change in vital signs.
- drop in urinary output will follow
- hypotension marks uncompensated shock and blood loss >45%, may
- early surgical assessment is
Note tachycardia will also accompany fear, pain and stress.
Rapidly replace circulating volume
- estimated at 80ml/kg
Used warmed 20ml/kg bolus when shock suspected.
Absent peripheral pulses
Weak thready central p.
dull to pain.
long cap refill
long cap refill
- would represent 25% of blood volume if stayed in circulation
- may need 3 boluses if 25% loss (3:1 rule)
Consider Packed RBCs if 3rd bolus started
- bolus 10ml/kg of type-specific / O-neg
Normal Indicated by:
Slowing HR (age dependent)
Peripheral pulses returning
Skin colour returning
Increasing BP (90mmHg + 2xAge)
Increased PP (>20mmHg)
Urine 1-2ml/kg/hr (age dependent)
- stabilise on crystalloid
- deteriorate after fluid/blood
- do not stabilise
--> operate on latter two.
Percutaenous peripheral (2 attempts)
Venous cutdown (saphenous, ankle)
Percutaneous placement (ext jugular)
Note: IV access in the child
<6 is perplexing and challenging.
- intraosseous is safe efficaceous and quick.
Excellent measure of adeuquacy of volume
- 2ml/kg/hr in the infant
- 1.5ml/kg/hr in the toddler
- 1ml/kg/hr in the child/adolescent.
Straight catheter for children <15kg.
8% child injuries
2/3 associated with other organ injuries.
Principally blunt eg MVAs
Internal organs may be damaged without bony #.
Rib #s suggest massive energy transfer and major multiple serious
Specific injuries are same as for adult
- however mediastinal mobility makes tension pneumo and flails more
- pulmonary contusionsa are more common
- diaphragm, aortic, major tracheobronchial, flail injuries rare in
Manage as per adult chest trauma.
Mainly blunt, MVAs
- penetrating injury dictates prompt surgical involvement especially if
Be gentle and calm to aid palpation
Decompress stomach as children swallow air (12Fr)
- and urinary bladder
CT for stable kids if
immediate, early and does not delay Rx (may need sedation)
DPL is used in hypotensive
children when FAST not available.
- same as adult DPL; to be performed by
- blood does not mean mandatory laparotomy if child stable /
responding, but leukocytes, foreign matter does.
FAST is yet to be studied in children, but is used.
Bleeding from an injured liver, spleen, kidney is often self-limiting
- if child cannot be normalised and if blood in abdo suggested, prompt
- else manage nonoperatively in a capable facility
- frequent reevaluation is required
Surgeon must manage the child.
All hollow viscus ruptures need early repair.
Duodenal haematoma from
strikes to RUQ (low abdo tone)
- NG tube and parenteral nutrition
Small bowel perforations at
lig of Treit
Mesenteric small bowel perfs
- often diagnosed late due to vague symptoms
Bladder rupture (shallow
Perineum injuries (near
surface) from straddles.
Lap belts relate to enteric
Spleen, liver kidney disruption from blunt force
- often present hypovolaemic and respond
- CT and ICU monitoring
- delayed splenic haemorrhage is less common.
Common in children: MVAs, falls, bikes.
Hypotension and hpoxia worsen outcome
of intracranial injury.
- ABCDEs and hypotension warrant aggressive attention.
- hypotension is the worst single factor
Need early ET use and O2.
Brains of children are
1. Increased H20, plasticity, incomplete myelinisation, vast
neurochemical change, smaller subarachnoid space (less protective)
- thus head damage produces more parenchymal damage.
- outcome is better than adults, but worse if <3.
2. Cerebral blood flow is twice adult level by 5 then decreases
- severe susceptibility to hypoxia
3. Rarely infants may be hypotensive from blood loss into epidural
space / subgaleal space
- treat hypovolaemia rapidly.
4. More tolerant of expanding mass lesions if young (open fontanelles,
- treat a child without coma and bulging fontanelles cautiously and get
an early neurosurg consult.
5. Vomiting and amnesia are common and don't necessariliy relate to
- persistent vomiting demands CT
- gastric decompression is warranted.
6. Seizures are more common and usually self limited
- investigate recurrent siezures with CT
7. Mass lesions less common, but elevated ICP / brain swelling more
- replace blood volume rapidly or worse secondary brain injury worsens
- emergency CT those with possible surgical need.
8. Modify verbal score of GCS
9. Early surgical consult for ICP monitoring if:
- GCS <8 or motor scores 1-2.
- multiple inuries and brain injury with major volume resuscitation or
- abnormal CT
10 Adjust meds
- phenobarbital: 10-20mg/kg/dose
- diazepam 0.1-0.2 mg/kg/dose slow IV
- phenytoin 15-20mg/kg at 0.5-1.5 ml/kg/min loading then 4-7mg/kg/day
- mannitol (rarely needed; may worsen hypovolaemia): 0.5-1g/kg
Spinal cord injury
Uncommon, 5% of spinal injuries are in children.
- mostly MVAs, sports.
See spine XR notes
Spinal cord injury without radiogaphic abnormality is more common in
- 2/3 of children with spinal cord injury have a normal spine series
Spinal XRs do not exclude significant
spinal cord injury
Similar to adult except:
1. Concerns for growth plates
- history is more important
- epiphysial injury retards growth, especially difficult-to-recognise
2. Proportionally less blood loss with isolated #s eg femur
3. Buckle #s common
4. More vascular injury eg supracondylar elbow/knee #s.
5. Simple splinting is adequate until definitive orthopaedic evaluation
- a single attempt at # reduction is OK.
Suspect abuse if:
- injury does not fit mechanism
- if prolonged interval before advice sought
- if repeat trauma, different EDs
- parents inappropriate, negligent
- history murky / changes.
- multiple subdurals, esp without fresh skull #
- retinal haemorrhages
- perioral injuries
- rupture viscera, without major blunt trauma
- genital / perineal trauma
- frequent injuries with old scar / healed #s
- long bone #s in children <3
- bizarre injuries
- sharply demarcated burns, unusual places.
Drs are bound by law to report incidences of abuse.
- 50% of children presenting dead from abuse have presented before, so
Newborn - minutes to hours
Neonate - <28 days
Infant - <1 yr
Child - 1-8 yrs
>12 yrs 15-20
>12 yrs 60-100
- changes are late.
>12 yrs 100-120
Other Organ Systems
Trauma is 7th leading cause of death in the elderly.
Falls (40% of deaths), MVAs and burns most common.
- physical impairments, physiological changes and comorbidities
Supplemental O2 is important early.
Intubation should be considered early due to low cardiopulmonary
Dentition, nasopharynx fragility, macroglossia and microstomia and
cervical arthitis can make airway difficult.
- keep intact well-fitting dentures in place to facilitate bag-masking
- place nasal tubes with great care.
Comorbidities speed physiological decline in respiratory reserve.
Careful respiratory monitoring is essential
Caution with O2 if COPD suspected.
- but do not allow hypoxia; if CO2 necessarily rising, intubate in
discussion with senior ICU staff.
Simple pneumo/haemothorax are poorly tolerated.
- adequate pain control is importat
Complications eg pneumonia occur frequently
Overzealous fluid infusion should be avoided.
Heart loses reserve rapidly with age and CAD becomes common.
- total blood volume decreases, circulation time increases, myocardium
stiffens, conduction slows, and cell mass reduces.
- the endogenous catecholamine release with stress is less responsive
- diastolic dysfunction makes heart more dependent on atrial filling to
increase cardiac output.
- kidney loses mass rapidly after 50 yrs, with decreased GFR &
renal blood flow; max concentration ability drops to 70% of a
220-age = max typical HR
A common pitfall is a mistaken pressure of normal BP and HR indicate
- blood pressure often increases with age and 120 may be low.
- onset may be delayed, and chronic high afterload state may limit
cardiac output and ultimately end-organ perfusion.
- the elderly hypertensives on diuretics may have a low vascular volume
and K+ anyway.
Severely injured hypotensive pts with metabolic acidosis almost always
die due to low reserve.
Ringer's lactate is the initial fluid of choice: give 1-2L and closely
Some say maintain >100 Hb level
Assess for blood loss quickly, including rapid FAST (and DPL)
Little role for nonoperative management of blunt abdo solid-viscus
Retroperitoneal exsanguinating haemorrhage is not uncommon in the
- negative FAST/DPL and ongoing hypotension with pelvic/lumbar # should
prompt angiography and transcatheter embolisation.
33% of pts who die do so late from sequential organ failure reflecting
early unsuspected states of hypoperfusion.
Impaired cardiac performance may supervene.
- hypovolaemic and cardiogenic shock may coexist.
Atrophy and CSF reduction occur with aging.
Dura becomes tightly adherant
--> bridging veins stretched and subdural more common, with
surprising volumes possible.
Blood flow reduces by 20% over 70, atheroma may make this worse.
Intervertebral disc dehydration changes loads and spinal stenosis
places cord at greater risk, esp if osteoporotic.
Higher incidence of subdurals, brain haemorrhage, less severe cerebral
- gradual onset neuro decline is possible with subdurals.
- liberal use of CT is encouraged
C-spine injury is more common
- more occult and harder to diagnose due to age changes.
- MRI is useful.
Dermis loses thickness, loss of vascularity occurs, and less thermal
regulatory ability follows.
Less barrier to infection.
Protect from hypothermia
- think of occult disease also, ep sepsis, pancreatitis.
Other Organ Systems
Aging stiffens body tissues
Deterioration of tendons, ligaments and capsules means injury easier.
Less muscle mass due to less response to anabolic hormones.
Osteoporosis decreases normal bone with consequent strenth loss and
less resistance to #s.
Immobility predisposes to pulmonary morbidity and mortality.
Undertake the least invasive, most
definitive procedure that allows early mobilisation.
Caloric needs decline, but protein needs may increase
Poor nutrition is common anyway, and increases complications.
--> early support
Immune response declines with age.
- less ability to respond to bacteria / viruses.
Infections and mortality higher.
Drugs may impair physiological responses.
- beta blockers limit chronotropic activity
- Ca channel blockers prevent peripheral vasoconstriction
- NSAIDs promote bleeding
- steroids reduce stress response
- diuretics dehydrate and give electrolyte abN
- diabetics take hypoglycaemics
- psychotropics can be problematic if stopped suddenly
- tetanus is infrequently not up-to-date.
Doctor, family and patient may choose supportive care in certain
- eg extensive burns with unprecedented survival rates
Seek existence of a living vill, advance directives etc.
- self-determination is paramount
- medical intervention is only appropriate when in the pt's best
- medical therapy must outweight consequences