Trauma management: Overview of unique pediatric considerations

INTRODUCTION — Children have unique anatomy and physiology compared with adults, which must be taken into consideration when managing pediatric trauma patients [1]. This review will cover the specific anatomical and physiologic differences between children and adults that affect medical care.

The approach to the seriously injured child is discussed separately. (See "Trauma management: Approach to the unstable child" and "Approach to the initially stable child with blunt or penetrating injury".)

PEDIATRIC ANATOMY

Airway — Several features of the airway in infants and young children can make airway management challenging in patients with major trauma [2]:

●The relatively large occiput in the infant or child naturally flexes the neck in the supine position, potentially causing airway obstruction (picture 1) in children with altered mental status as well as potentially exacerbating any unstable cervical spine injury unless addressed during cervical spine motion restriction (figure 1). (See "Pediatric cervical spinal motion restriction", section on 'Neutral spine position'.)

●Small oral cavities, relatively large tongues and, in children 3 to 10 years old, tonsillar hypertrophy [3] make upper airway obstruction more likely, especially in children with altered mental status. These anatomic features can also hamper airway visualization during laryngoscopy and endotracheal tube delivery. (See "Emergency airway management in children: Unique pediatric considerations", section on 'Anatomic considerations'.)

●The larynx is more cephalad and anterior in infants and children compared with adults, making adequate visualization during endotracheal intubation more difficult (figure 2). Other factors to consider include the short trachea and the relatively large, floppy epiglottis in infants and young children. (See "Emergency airway management in children: Unique pediatric considerations", section on 'Anatomic considerations'.)

●A narrow tracheal diameter, a small distance between the tracheal rings, and a cricothyroid membrane that is not easily palpated combine to make needle cricothyroidotomy and percutaneous transtracheal ventilation a difficult procedure in infants and children. (See "The difficult pediatric airway for emergency medicine" and "Needle cricothyroidotomy with percutaneous transtracheal ventilation".)

●With the short trachea (5 cm long in infants, 7 cm long in 18-month-old children), there is a higher risk for initial mainstem bronchus intubation or subsequent accidental tube dislodgement with any motion of the head. (See "Emergency airway management in children: Unique pediatric considerations", section on 'Anatomic considerations'.)

Taken together, these factors make securing and maintaining the airway of pediatric trauma patients different and potentially more difficult than in adults, especially in children <3 years of age.

Head — Infants and young children <8 years of age have heads that are disproportionately large relative to the rest of their body and weak neck musculature. As a result, head trauma commonly occurs during blunt trauma and is the leading cause of mortality in critically injured children. (See "Severe traumatic brain injury (TBI) in children: Initial evaluation and management".)

In addition, burns to the face and scalp in children potentially involve a larger proportion of body surface area (up to 19 percent in young infants) compared with adults (up to 9 percent) (table 1 and figure 3). This difference is important to properly calculate the extent of burns in children during initial evaluation. (See "Moderate and severe thermal burns in children: Emergency management", section on 'Evaluation of burn injury'.)

Brain — Infants have skulls with open sutures, and their brains have a larger subarachnoid space and extracellular space. Thus, they can tolerate an expanding intracranial hematoma to a greater extent than older children or adults before demonstrating classic signs of increased intracranial pressure (ICP). For this reason, infants with head trauma need careful assessment for a bulging fontanelle, diastatic cranial sutures, or increasing head circumference [2]. Also, infants with intracranial hemorrhage or bleeding into the subgalea can infrequently develop hemorrhagic shock.

The infant brain is less myelinated, and their cranium is thinner and less protective. Therefore, mild forces may still result in skull fractures and/or significant parenchymal injury in up to 10 percent of infants with minor blunt head trauma. (See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'Skull fractures'.)

In addition, the possibility of abusive head injury in infants and young children must be pursued when they present with altered mental status. Abusive head trauma can result in severe traumatic head injury (TBI) on head computed tomography (CT) without obvious external signs of trauma. (See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Physical examination'.)

Spinal cord and spine — Infants and children have several anatomic features that permit the spinal column to stretch farther without bony injury than the spinal cord can tolerate. These features are most prevalent in children <8 years old and make them predisposed to high cervical spine and spinal cord injuries and spinal cord injury without plain radiographic or CT bony abnormality (SCIWORA). (See "Spinal cord injury without radiographic abnormality (SCIWORA) in children", section on 'Pertinent anatomy'.)

The majority of children with SCIWORA have clear findings of spinal cord injury on initial examination. However, up to one-quarter of patients with SCIWORA have transient neurologic symptoms (eg, extremity paresthesias and/or weakness) by history or that are resolving during emergency department evaluation; however, they can also develop delayed onset of neurologic deficits hours to days after injury. Children with clinical findings suggesting spinal cord injury but with normal plain radiographic or CT imaging of the spine should undergo magnetic resonance imaging (MRI) [4]. (See "Spinal cord injury without radiographic abnormality (SCIWORA) in children", section on 'Clinical features and diagnosis'.)

Chest — Injury patterns after blunt thoracic trauma in children also differ from adults (see "Thoracic trauma in children: Initial stabilization and evaluation"):

●The chest wall of a child is more compliant than that of an adult because the bones are less ossified and contain more cartilage. Therefore, serious intrathoracic injury such as pulmonary or myocardial contusion can occur without evidence of chest wall trauma. (See "Pulmonary contusion in children" and "Overview of intrathoracic injuries in children".)

●In children, rib fractures require significant force and are often indicators of underlying organ injury. Rib fractures with no explanation or an implausible history is concerning for physical child abuse. (See "Physical child abuse: Recognition", section on 'Fractures' and "Orthopedic aspects of child abuse", section on 'Rib fractures'.)

●In children, the mediastinal structures are more freely mobile and make them more prone to tension pneumothorax.

Abdomen — Especially in infants and toddlers, the liver, spleen, and pancreas are less protected by the rib cage and are more prone to direct injury and hemorrhage after blunt trauma. (See "Liver, spleen, and pancreas injury in children with blunt abdominal trauma", section on 'Pertinent anatomy'.)

Musculoskeletal system — Children have immature bones with growth plates that are more pliable than skeletally mature patients. These anatomic features predispose children to fractures of the physes (growth plates) (figure 4) and to greenstick (figure 5 and image 1) and buckle fractures (image 2). (See "General principles of fracture management: Fracture patterns and description in children".)

In children, blood loss associated with an isolated fracture, including long bone fractures, is proportionately less than in adults and does not explain shock in pediatric trauma patients. Such patients require evaluation for other causes of hemodynamic instability such as intraabdominal injury. (See "Femoral shaft fractures in children", section on 'Epidemiology'.)

Vascular system — Vascular access for fluid resuscitation is often more difficult to achieve in children than in adults. Infant and pediatric intraosseous needles are available and can be employed when intravascular (IV) access is unsuccessful in injured children with hemodynamic compromise. (See "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies" and "Intraosseous infusion".)

PEDIATRIC PHYSIOLOGY

Vital signs — Normal vital signs change with age in children (table 2). In general, heart and respiratory rates are higher than in adults and blood pressure is lower. The 5th percentile systolic blood pressure for age can be approximated by the following formula for children 1 to 10 years of age:

Metabolism — Children are prone to hypothermia and insensible fluid losses because of their large body surface area to weight ratio and higher metabolic rate. Hypothermia can complicate an already critical situation as it may worsen metabolic acidosis and exert a negative inotropic effect on the heart. (See "Hypothermia in children: Clinical manifestations and diagnosis", section on 'Pediatric considerations'.)

Breathing and ventilation — Hypoxia is the most common cause of cardiac arrest in children. Adequate oxygenation is essential, as is adequate ventilation to maintain acid-base balance. Because of limited functional residual capacity and increased oxygen utilization, infants and children become hypoxemic much more quickly than adults when ventilation is inadequate. Infants and young children also have smaller tidal volumes (6 to 8 mL/kg) and are at greater risk for iatrogenic barotrauma and pneumothorax with overly positive pressure ventilation. (See "Emergency airway management in children: Unique pediatric considerations", section on 'Physiologic considerations'.)

Shock — Tachycardia followed by poor skin perfusion are the initial signs of circulatory failure in children (table 3). Their increased physiologic reserve allows children to maintain their blood pressure despite a loss of 30 to 45 percent of total blood volume. Thus, hypotension with uncompensated shock is a late and sudden finding that requires an immediate response. (See "Initial evaluation of shock in children" and "Trauma management: Approach to the unstable child".)

In infants, uncompensated shock with hypotension in the early stages is accompanied by tachycardia, which can progress to bradycardia if blood loss continues unchecked. (See "Pediatric advanced life support (PALS)", section on 'Shock'.)

SUMMARY AND RECOMMENDATIONS

●Unique pediatric anatomy and physiology – Although the goals and approach to the critically ill pediatric trauma patient are the same as for adults, unique pediatric anatomy and physiologic features create specific challenges in assessment and management. (See 'Pediatric anatomy' above and 'Pediatric physiology' above.)

●Pediatric anatomy

•Airway – Securing and maintaining the airway of a pediatric trauma patient is affected by the relatively large occiput, small oral cavity, tonsillar hypertrophy in pre-school and school age children, and laryngeal location (figure 2). (See 'Airway' above.)

•Head and brain – Head trauma and traumatic brain injury (TBI) commonly occur after blunt injury because a child's head is disproportionately large compared with the rest of the body, and the neck musculature is weak. Subgaleal or intracranial bleeding in infants and young children can infrequently cause shock. (See 'Head' above and 'Brain' above.)

•Spinal cord injury – Spinal cord injury without plain radiographic or CT abnormality (SCIWORA) is more common in children younger than eight years of age. Children with clinical findings suggesting spinal cord injury but normal plain radiographic or CT imaging of the spine should undergo MRI [4]. (See 'Spinal cord and spine' above.)

•Chest – Children are more prone to develop pulmonary contusion in the absence of rib fracture and/or tension pneumothorax. Rib fractures require significant force and, in children without a plausible history, should raise concern for non-accidental trauma. (See 'Chest' above.)

•Abdomen – The liver and spleen are more prone to direct injury and hemorrhage after blunt trauma as they are less protected by the ribcage, especially in infants and toddlers. (See 'Abdomen' above.)

•Musculoskeletal system – Children have immature bones with growth plates that are more pliable than skeletally mature patients. These anatomic features predispose children to physeal (figure 4), greenstick (figure 5 and image 1), and buckle fractures (image 2). Blood loss associated with an isolated fracture, including long bone fractures, is proportionately less than in adults and does not explain shock in pediatric trauma patients. (See 'Musculoskeletal system' above.)

•Vascular system – Peripheral venous access for fluid resuscitation may be more difficult to achieve; intraosseous cannula placement provides a rapidly available alternative route. (See 'Vascular system' above and "Intraosseous infusion".)

●Pediatric physiology

•Vital signs – Normal vital signs change with age in children (table 2). For children 1 to 10 years of age, the 5th percentile systolic blood pressure for age can be approximated by the following formula (see 'Vital signs' above):

Systolic pressure (5th percentile) = 70 mmHg + 2 X (age in years)

•Breathing and ventilation – Because of their smaller lung volumes and greater metabolic demand, infants and children become hypoxemic much more quickly than adults when breathing is inadequate or absent. Infants and young children also have smaller tidal volumes (6 to 8 mL/kg) and are at greater risk for iatrogenic barotrauma with overly aggressive artificial ventilation. (See 'Breathing and ventilation' above.)

•Metabolism – Children are prone to hypothermia and increased insensible fluid losses. (See 'Metabolism' above.)

•Signs of shock – Tachycardia and poor skin perfusion are the initial signs of circulatory failure in children, which should be recognized early and managed with fluid resuscitation and close monitoring (table 3). Hypotension with uncompensated shock is a late and sudden finding that requires an immediate medical response. (See 'Shock' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Gary R Fleisher, MD, who contributed to earlier versions of this topic review.