ATLS APPROACH TO PEDIATRIC TRAUMA

PREPARE
 Room and equipment
 Staff: nursing, radiology, lab, RTs
 Discuss case/interventions
 Paramedic report

PRIMARY SURVEY (Assessment and Management)

 Airway
 Breathing
 Circulation
 Disability
 Exposure
 Full vitals

ADJUNCTS TO PRIMARY SURVEY

 Pulsox, cardiac monitors, BP monitor, CO2 monitor
 NG tube
 Foley
 ECG
 Xrays: Cspine, CXR, pelvis
 Trauma blood work
 ABG
 DPL/ABUS if appropriate

SECONDARY SURVEY
 AMPLE history
 H/N
 Chest
 Abd
 U/G
 Neuro
 Msk
 Roll pt

ADJUNCTS TO SECONDARY SURVEY

 Xrays
 CT head, chest, pelvis, abd, spine
 ABUS
 DPL
 Contrast studies
 Endoscopy
 Angiography
 Esophagoscopy
 Bronchoscopy
PRIMARY SURVEY
 Airway and C-spine
 LOOK
- level of consciousness, agitated, cyanosis, retractions, AMU,
evidence of facial or laryngeal injury, evidence of UAW burn
(carbenaceous sputum, singed hairs, soot around mouth)
 LISTEN
- speech clear, stridor, gurgling, hoarseness
 FEEL
- facial/neck trauma, trachea midline, crepitus, subQ emphysema
 MANAGE
- put on C - collar
- maneuvers: jaw thrust, suction, foreign body removal
- devices: oropharyngeal airway, nasopharyngeal airway
- definitive airways: endotracheal intubation, jet insufflation,
cricothyroidotomy, tracheostomy (nasotracheal intubation
discouraged in peds)
 Breathing and Ventilation
 LOOK
- RR, depth of respirations, chest mvmts, flail segments
 LISTEN
- breath sounds, heart sounds, bowel sounds in chest
 FEEL
- subQ emphysema, trachea midline, percussion, chest wall injury
 MANAGE
- 100% 02: face mask with NRB at 10 - 12 L/min
- pulsoximeter, end tidal C02
- ventilation as necessary
- thoracentesis for pneumo, chest tube for hemo/pneumo, seal
open chest wounds with three sided dressing
- problems with intubated pt: Disloged, Distended stomach,
Obstructed tube, Pneumothorax, Equipment failure
 Circulation and Hemorrhage
 LOOK
- identify external bleeding, skin color, diaphoresis, JVD, femur #s
 LISTEN
- muffled heart sounds, murmur
 FEEL
- pulse rate, pulse quality, BP, cool/clammy skin
 MANAGE
- cardiac monitor, BP monitor
- two large bore IVs, send blood for trauma panel and ABG
- intraosseous catheter or venous cutdown if can’t get peripherals
- bolus 20 cc/kg NS or RL for hypotension
- packed rbcs 10 cc/kg if >2 boluses required
- direct pressure to bleeding sites; no clamping
- identify cause of hypotension: chest, belly, pelvis, external, SCI,
MSK, head (rare): CXR and pelvic Xray should be done ASAP
- abdomenal ultrasound, DPL, thoracotomy, surgical consult prn
 Disability
 PUPILS + GCS
 Manage: may include RSI intubation, hyperventilation/mannitol for herniation
 Exposure/Environment: Full exposure and prevent hypothermia with warmed solutions and
blankets
 Full Vitals: Repeat vitals including core temp; are you stuck on primary survey b/c of poor
 vitals??
ADJUNCTS TO PRIMARY SURVEY
 Most should already be done
 Monitors: Pulsox, BP and cardiac monitor, ET CO2 monitor
 Xrays: C-spine, CXR, and pelvic Xrays (TRY to get CXR and pelvis early; C-spine can
wait until secondary survey)
 DPL, ABUS
 NG and urinary tubes if not contraindicated (foley after rectal)

SECONDARY SURVEY
 AMPLE history and details of accident including condition of vehicle, ejection, other
injured passengers, seat belts, blood loss at seen, vitals on route, interventions on route,
etc
 Head and Neck
 Head: lacerations, contusions, fractures, burns
 Face: maxillofacial fractures, racoon eyes, battle signs, look in mouth,
burns, carbenaceous sputum, soot, singed hairs, nose for CSF leak
 Eyes: pupil size and reactivity, EOM, visual acuity, hemorrhage, racoon
eyes
 Ears: battle signs, hemotympanum, CSF leak
 Cranial nerves: II - XII if not already tested; occulocephalics and
occulovestibular reflexes, corneal reflex, gag reflex
 Neck: inspect for blunt injury, penetrating injury, tracheal deviation,
accessory muscle use; palpate for deformity, tenderness, swelling, subQ
emphysema, tracheal deviation, symmetry of pulses; listen to carotids,
palpate C-spine.
 Chest
 Look: blunt or penetrating trauma, acc muscle use, chest expansion, JVD
 Listen: breath sounds and heart sounds
 Feel: tenderness (AP and lateral compression), rib tenderness,
crepitation, subcutaneous emphysema, percuss for hyperresonance or
dullness
 Abdomen
 Look: blunt or penetrating trauma (look closely at sides re hepatic and
splenic injury may be suspected by lower rib cage lateral abrasion)
 Listen: bowel sounds
 Feel: palpate for tenderness, guarding, rebound; percuss for tenderness
 DPL, ABUS, ABCT, pelvic Xrays as appropriate
 Urogenital
 Look: contusions, lacerations, urethral/vaginal/rectal bleeding
 Rectal: prostate position, bone fragments, wall integrity, sphincter tone,
blood
 Vaginal: laceration, blood, bone fragments
 MSK
 Look, feel, move all joints of upper and lower limb looking for lacerations,
contusions, deformities, crepitus, possible fractures
 Compress pelvis AP and lateral
 Assess limb pulses and neuro status distal to suspected fractures
 Obtain Xrays of injured parts
 Neuro
 Mental status and GCS
  Cranial nerves
 Strength, Reflexes, Sensation, Coordination
 Roll Pt
 Look, feel for any injuries, lacerations, contusions, spine tenderness,
rectal

PEDIATRIC VS ADULT TRAUMA

PATHOPHYSIOLOGY
 Smaller body mass of children thus the energy force per unit body areas is much higher
in pediatrics than in adults resulting in more severe injuries
 Incomplete calcification of skeleton and growth plates make children more susceptible
 Internal organ damage without obvious overlying external fractures b/c of pliable
skeleton: severe pulmonary contusions without rib fractures is an example
 Large surface area to body volume thus hypothermia more of a concern
 Increased physiological reserve allows near normal maintenance of vital signs even in
the presence of severe shock: hypotension is a LATE sign of shock; kids crash quickly
and LATE
 MUST keep in mind child abuse as a mechanism of injury

MANAGEMENT ISSUES
 Fluid boluses: 20 cc/kg (compared to 2L in adults)
 Blood transfusion: 10 cc/kg
 Braslow tape essential equipment
 Intraosseous or venous cutdown if can’t get iv access (3Xs or 90sec)
 Increased emphasis on gastric decompression re poor ventilation and vagal stimulation
 Hypothermia bigger issues in kids: make sure iv fluids warmed, blankets, etc

AIRWAY MANAGEMENT
 Oral Airways: do not put in backwards and rotate 180 degrees; put straight in with
depressor
 Orotracheal intubation: preferred route of definitive airway management; RSI preferred
 Nasotracheal intubation: not recommended b/c of increased risk of pharyngeal/adenoid
bleeding and relatively acute angle of the posterior nasopharynx
 Cricothryoidotomy: rarely indicated, should only be done by surgeon, TTJV preferred
 TransTracheal Jet Ventilation (needle cricothyroidotomy): preferred over surgical cric

AIRWAY EQUIPMENT
 Cuffed tubes
 NO cuffs < 8yo b/c of narrow cricoid ring provides “functional cuff”
 Uncuffed tubes should have small air lead @ peak inflation pressure
(30mmHg)
 ETT sizes
 Age/4 + 4
 Size of pinky or nostril
 Have size above and size below available
 Blade sizes
  Premie Miller 0
 0-2 Miller 1
 2 - 10 Miller/Mac 2
 > 10 Mac 3
 Depth
 ETT size (i.d.) X 3
 Age/2 +12
 Vocal cord marker

AIRWAY AND VENTILATION: ANATOMY/PATHOPHYSIOLOGY

 Head/Mouth/Pharynx
 Large head with prominent occiput: causes passive flexion of neck and
airway obstruction (AWO) to poor position
 Large tongue which easily obstructs airway; also makes laryngoscopy
more difficult b/c of large tongue in the way
 Loose teeth can easily be dislodged and cause AWO
 Relative poor tone of pharyngeal musculature thus passive AWO
 Relative prominence of adenoids: nasopharyngeal intubation not
recommended
 Large, floppy epiglottis that doesn’t lift up as well with the curved blade
thus the use of the straight blade to raise the epiglottis
 Larynx/Trachea/Bronchial tree/Lungs
 Anterior larynx: harder to visualize; anterior larynx position makes the
angle between the base of the tongue and glottic opening more acute
thus the straight blades create a more direct visual plane from the mouth
to the glottis
 Cricoid ring is the narrowest part of airway (compared to vocal cords in
adults) and it forms a natural seal with the ETT hence uncuffed tubes < 8
yo; cuffed tubes risk pressure necrosis
 Short trachea: very easy to intubate the right mainstem bronchus
 Short airway: very easy to dislodge tube; minimal movement will dislodge
ETT
 Narrow lumen: means using smaller ETTs which get blocked more easily
with secretions, blood, etc
 Narrow lumen: small amounts of edema, bleeding, etc will cause
obstruction
 Resistence varies with 1/radius^4 (any decreased radius increases
resistence to the fourth power)
 High compliance of pediatric airway makes it very susceptible to dynamic
collapse in presence of AWO: trachea will collapse in presence of upper
airway obstruction like croup or epiglotitis
 Small lung volumes, especially in neonates/infants thus aggressive
ventilation can easily cause pneumothoraces (most common cause of
pediatric pneumos)
 Chest Wall
 Cartilaginous ribs very compliant thus chest retraction during respiratory
distress decreases the ability to maintain FRC, prevents increase in tidal
volume and increases work of breathing
 Any compromise of diaphragmatic excursion can increase respiratory
distress due to reduced effectiveness of horizontal diaphragm
contractions (gastric distension, abdominal masses, etc)
DETERIORATION OF INTUBATED PATIENT
 Displaced tube: listen, ETCO2, laryngoscopy to look, “if in doubt, pull it out”
 Distension: gastric distension can reduces ventilation and cause vagal response; NG/OG
tube
 Obstruction: secretions, blood blocking the tube; pull tube
 Pneumothorax: listen to chest, CXR
 Equipment: check ventilator, bag, BVM, seal, hoses etc; d/c ventilator and bag,
?improvement

CHEST TRAUMA
 Same injuries as adult but different frequencies
 Injuries
 Rib fractures 50%
 Pneumothorax 20%
 Hemothorax 10%
 Pathophysiology
 Chest wall is less protective and transmits traumatic forces to the lung
parenchyma and mediastinal structures; mediastinal structures are more
mobile than in adults
 Children are diaphragmatic breathers
 Injury Patterns as a result of compliant chess wall
 Pulmonary contusion is more common
 Pulmonary contusion can occur without rib fractures
 Intrapulmonary hemorrhage more common in kids
 Tension pneumothorax more common in peds b/c mobility of mediastinum
means that less pressure is required to compress and shift the
mediastinal structures and contralateral lung
 Gastric distension easily compresses the lungs
 Diaphragmatic injury as profound affect on ventilation
 Less common injuries in pediatrics
 Bony chest injury: rib fractures less common b/c chest wall compliance
 Other: aortic disruption, diaphragmatic hernia, major tracheobronchial
tears, flail chest, cardiac contusion
 Pneumothorax
 May not hear decreased BS b/c of easily transmitted sounds from other
side
 See braslow for tube sizes
 Occult pneumos require chest tubes
 Signs of tension pneumothorax are often subltle: can’t see tracheal
deviation b/c of short neck, may still have bilateral breath sounds heard,
hypotension late
 Hemothorax
 Indication for OR thoracotomy = initial drainage > 15 - 20 ml/kg or ongoing
drainage > 5 ml/kg/hr or continued air leak
 Emergency Room Thoracotomy
  Indications the same as adults
 Rarely needed but should be done if indicated
 Indicated in penetrating trauma only (NOT blunt)
- penetrating trauma + loss of vitals at scene
- penetrating trauma + loss of vital on transport
- penetrating trauma + loss of vitals in ED
- note: NOT indicated if NO vital signs at the scene
 Commotio cordis = myocardial concussion
 Sudden cardiac collapse after chest impact
 Results in brief dysrythmia, hypotension, or LOC
 NO lasting pathological changes
 May result in asystole or VF
 Explains sudden cardiac death after blow to chesst in which no
hitolopathological changes are present on autopsy
 CASE: baseball to chest then Vfib arrest
ABDOMINAL TRAUMA
 Injuries
 Spleen is MC
 Liver is 2nd MC
 Pathophysiology
 Less abdominal wall musculature protection
 Less abdominal fat protection
 Larger spleen and liver
 Large mobile kidneys
 Compliant lower chest wall thus easy compression of spleen and liver
 Patterns of injury
 Prone to liver and splenic injury
 Increased importance of gastric decompression (NG or OG tube) because
of reduced effectiveness of ventilation and potential vagal response
 Duodenal hematomas, traumatic pancreatitis, duodenal/jejunal
perforations, mesenteric and small bowel avulsion injuries are all more
common in pediatrics: less developed abdominal musculature and
common mechanism of injury (bike handles, epigastric blow, etc)
 Bladder rupture more common due to shallowness of pelvis
 Specific injuries
 Diaphragmatic rupture: common with lap belts
 Splenic injury: most common, evaluate with CT, delayed rupture also
occurs, remember left shoulder tip pain
 Liver injury: 2nd most common injury, MOST COMMON cause of lethal
hemorrhage in pediatrics,
 Renal: deceleration and vascular injuries
 Lap belt injuries in children
 Chance fracture
 Small bowel perf
 Mesenteric artery
 Pancreatic injuries
 Diaphragmatic rupture
 Similar approach to patient
 Generally emphasis is on non-surgical mx
 Clinical indication for laparotomy: to OR
 NO clinical indicator for laparotomy: abdominal investigation
-stable: CT scanning preferred

-unstable: ultrasound or DPL (DPL in pediatrics should only be

done by surgeon according to ATLS)