Pediatric TraumaSkills Lab

Natalie Wynn RN, BSN

Valley Hospital Medical Center
Emergency Room

Objectives
Review epidemiological data specific to pediatric
trauma
Review the differences between pediatrics and adult
patients
Review the mechanism of injury
Outline a general approach to the pediatric trauma
patient
Discuss specific considerations for the following
injuries:
Head trauma
Chest and abdominal trauma
Burns
Non-accidental trauma

Pediatric Thorax, Abdomen

and Pelvis

Key Differences From Adults

Airway
Anatomic differences
Larger head and tongue
Special attention to positioning
Potential for airway obstruction
Place in sniffing position
Shorter trachea
Danger of main stem intubation
Conical shaped trachea
Uncuffed endotracheal tubes
Breathing
Respiratory complications

Pediatric Airway Versus

Adult Airway

Signs of Respiratory
Distress in Infants

Respiratory Distress

Begin immediate positive pressure ventilations

Begin immediate positive pressure

ventilations

Altered mental status

Bradycardia
Hypotension
Irregular breathing pattern

Severe Respiratory Distress is a

Medical Emergency Requires
IMMEDIATE INTERVENTIONS!!!
The signs listed here occur late in a respiratory emergency and are
an indication that you must immediately intervene and begin positive
pressure ventilations:
Altered mental status
Bradycardia
Hypotension
Extremely fast, slow, or irregular breathing pattern
Cyanosis to the mucous membranes and body core (late sign)
Loss of muscle tone (limp appearance)
Diminished or absent breath sounds
Head bobbing
Grunting
See-saw or rocky breathing
Decreased response to pain
Inadequate tidal volume

Key Differences Continued

Circulation
Pediatric patients compensate well but
deteriorate quickly.

Less body fat, increased elasticity of

connective tissue, and close proximity of
organs to the body surface impair dissipation
of energy applied.
Incomplete calcification of bones and active
growth centers limit absorption of energy
and can increase potential for injury.

Key Differences
Most pediatric injuries do
not cause immediate
exsanguination.
Blood pressure is a poor
indicator of blood loss and
peripheral perfusion.
Children remain in
compensated shock longer
than adults, but decline
very rapidly.

Mechanisms of Injury

Lateral Impact Collisions (T

bone)
Rear Impact Collisions
Rollover Mechanism
Open Vehicle or
Motorcycle/Moped
Pedestrian Vs. Car
Penetrating Injury (Guns vs.
Knives)

Head Trauma

Head Trauma
Key Differences from Adults
Communication barrier
Delay in care and identification of injury
Different injury types
Skull fractures are more clinically significant than adults
More distendable bony skull
Larger head proportionally
Children have fewer intracranial injuries BUT more edema
than adults
In children < 20 years of age who deteriorate, 39% have brain
swelling only
Children can experience hypovolemic hypotension due to head
trauma
Consider non-accidental trauma in young children (<2 years of age)
Nearly 25% of head injured children <2 years
Up to 66% of head injured children < 1 year

Head Trauma
Assessment (Disability)

Pupillary responsiveness
Corneal reflexes
Gag or cough reflex
Spontaneous motor movements
GCS modified scales
Mental status changes

How to Hold Cervical Spine Immobolization

To hold a pediatric in cervical spine immobolization, you will need
at least three people. One to hold the patients neck in central
position, the second to hold one hand on the patients should and
the other on the hip and the thirds to check for posterior injuries.
The person at the head counts prior to rolling and is in control of
the cervical spine and the others follow directions.

Cervical Spine
Immobolization

Immobolize the
cervical spine with
what you have. Two
towel rolls are a
good modifier if
nothing is available.

Maintain in-line spine stabilization

Suction as necessary
Provide OXYGEN
Provide complete spine immobilization

Jaw Thrust Maneuver

Place two or three fingers of each hand at the angle of the jaw to
lift it up and forward while the other fingers guide the movement.
Insert an airway adjunct if the jaw thrust does not open the
airway.

Head Trauma
Increased intracranial pressure

Low GCS
Pupil decreased reactivity and/or inequality
Disconjugate gaze movements
Vomiting
Vital signs
Irregular breathing and heart rate
Widened pulse pressure
This is known as Cushing Triad.

Minor head injury

More pronounced signs and symptoms
Increased incidence of post-impact seizures and
vision loss

Head Trauma
High Risk: Cat Scan Recommended for All
Decreased mental status
Focal neurologic findings
Signs of depressed or basilar skull fractures
Acute skull fracture by clinical examination or skull
radiographs (if already obtained)
Irritability
Bulging fontanel
Seizure
Vomiting (5 or more times)
Age <3 months
LOC >1 min

Head Trauma
Intermediate Risk

Cat Scan scan or observation recommended 3 or 4 episodes

of vomiting
Transient LOC (less than1 min)
History of lethargy or irritability, now resolved
Behavior not at baseline
Nonacute skull fracture (injury more than 24 hr old)

Either CT or Skull Radiograph or observation

recommended High-force mechanism
Fall onto a hard surface
Scalp hematoma
Unwitnessed trauma
Vague history with physical signs of trauma
Low Risk: Observation Recommended

Low-energy mechanism with no signs and symptoms 2 hr

after trauma

Head Trauma
COMMON SYMPTOMS AND SIGNS OF INCREASED
INTRACRANIAL PRESSURE IN INFANTS

Full fontanel
Split sutures
Altered state of consciousness
Paradoxical irritability
Persistent emesis
Setting sun sign

Signs and Symptoms of Head

Trauma
Headache
Stiff neck
Photophobia
Altered state of consciousness

Persistent emesis
Cranial nerve involvement
Papilledema
Hypertension, bradycardia, and hypoventilation
Decorticate or decerebrate posturing

Pediatric Glascow Coma Scale

Motor

Voice

Eyes

6- obeys commands
5- localizes, clearly pushing
away painful stimulus

5- appropriate for age, fixes,

follows, social smile

4- withdrawal normal
flexion/ withdrawal away from
pain

4- cries, consolable

4- open spontaneously

3- abnormal flexion
decorticate, arms flexed and
legs extended

3- persistently irritable

3- opens to voice

2- abnormal extension
decerebrate, extension of
arms and legs

2- restless, lethargic

2- opens to pain

1- flaccid

1- none

1- does not open

Over 4 years of age, consider using adult Glascow

Coma Scale

Chest Trauma
Epidemiology
Most serious injuries are from blunt trauma
Motor vehicle accidents
Rarely an isolated chest injury
Common blunt chest injuries
Pulmonary contusions (50%)
Pneumothorax (20%), hemothorax (10%)

Penetrating trauma 15% of pediatric chest trauma

Overall increasing incidence of firearm injuries
Majority are criminal acts
Some secondary to poor supervision

Chest Trauma
Key Differences from Adults
Respiratory compromise
Adults use thoracic wall muscles to pull ribs
anteriorly
Expanding the chest wall

Children cannot change chest wall circumference

Decreased vital capacity
Increased respiratory rate

Hidden injuries
Compliant rib cage dissipates force of impact
Less bony injury
Less external signs of trauma
Multiple rib fractures are a sign of serious injury
Consider child abuse

Mobile mediastinum
Rapid development of cardiovascular
compromise

Chest Trauma
Pneumothroax
Types
Open
pneumothorax
Bi-directional
airflow
Tension
pneumothorax
One-directional
airflow
Hemopneumothorax
Blood into the
pleural cavity

Chest Trauma
Assessment for a pneumothorax
Childrens smaller thoracic cavity allows easy
transmission of lung sounds to opposite side
Listen in the axilla
Appearance and work of breathing

Management
Tension pneumothorax
Large bore IV at the second intercostal space,
midclavicular line
OVER the rib

Open pneumothroax
Three way occlusive dressing, or Vaseline dressing
One way valve

Hemothorax
Chest tube placement

Pneumothorax Management
Second Intercostal Space
Midclavicular Line

Find Location, After

Insertion, Cover with
Occlusive Dressing

Abdominal Trauma
Third leading cause of traumatic death behind head and
thoracic injuries
Most common unrecognized fatal injury in children
Blunt trauma related to MVCs causes over 50% of abdominal
trauma
The most lethal mechanism of injury
5-10% of children suffer from seat belt injuries
Small bowel injury
Chance fracture
Bicycle (handlebar injuries) are also common
Duodenal hematoma or pancreatic injury
May have delay in presenting signs and symptoms
Sport related injuries
Spleen, kidney, intestinal injury
Approximately 5% of abdominal injuries occur from child abuse
Second most common cause of death in child abuse

Abdominal Trauma
Pediatric Abdominal Anatomy

Larger solid organs

Less subcutaneous fat
Less protective musculature
Larger kidneys
Flexible cartilaginous rib cage
Compression of internal organs

More solid organ injury

Liver and spleen

Pediatric Burns
Assessment
Airway, Breathing, Circulation, Disability,
Exposure, Focus history
Assess for inhalation injury

Hoarseness
Black sputum or singed facial hair
Facial burns
Accident in closed area

Intubate early to avoid progression of edema

Consider other interventions
Cricothyrotomy

 General
functions
Mental status
changes

Back to Objectives

Depth of Burns
Burn Assessment
Depth
1st degree: Sunburn (epidermis)
2nd degree: Partial or full thickness (dermis)
3rd degree: Nerve damage (beyond dermis)

Burn Assessment

1st degree

Pink or red

Dry

Painful

Days

Superficial 2nd
degree

Pink, clear
blisters

Moist

Painful

1421 days

Deep 2nd degree

Pink,
hemorrhagic
blisters, red

Moist

Painful

Weeks, or may
progress to 3rd
degree and
require graft

3rd degree

White, brown

Dry, leathery

Insensate

Requires excision

4th degree

Brown, charred

Dry

Insensate

Requires excision

The Rule of Nines

Cause use palm of patients

hand size ~1% BSA

Burns
Burn Care

Rinse with warm water

Wrap with Saran wrap
Provide warm blankets
Pain management
Frequent re-dosing
Fentanyl greater than Morphine

Resuscitation
Parkland Formula (greater than 30 kiligrams)
Volume = (percent total body surface area burned) x (Body Mass
kiligrams) x (4 militers/LR)

volume over 1st 8 hours

volume over next 16 hours
Add maintenance fluids with glucose source

Monitoring
Urine output: 1cc/kiligram/hour

Child Abuse
For all pediatric trauma patients
Do a thorough examination
Make sure they are undressed
Gather a careful history if possible
Ask who lives with the child
Gather every detail about the event
History of other injuries
Be alarmed if story is inconsistent

Child Abuse and Neglect

Key Points to Remember!!

Pediatric patients are not the same as adults

Use a systematic approach
Pediatric vital signs do not change like adults
Use proper technique in C-spine
immobilization and airway management
Dont forget about the IO when obtaining
vascular access
Be on the lookout for child abuse

References
Emergency Care (12th ed.). (2012). Brady. Dickensen, E.,
Grant, H., Limmer, D., Murray, B., OKeefe, M.
http://handbook.muh.ie/trauma/Chest/TensionPneumothor
ax.html
http://newmexico.inetgiant.com/alamogordo/addetails/2child-bike-helmet---free/3324985
http://medicineworld.org/news/news-archives/Pediatricnews/March-16-2006.html
http://reference.medscape.com/features/slideshow/intraos
seous-access
TNCC: Trauma Nursing Core Course (6th ed.). (2007). Park
Ridge, Ill.: Emergency Nurses Association.