Good Morning Everyone,
Given our new pediatric trauma protocols at MMC Main, I am providing key differences in the pediatric trauma assessment compared to adults (note: this is not a comprehensive review of pediatric ATLS). While there is significant overlap in the evaluation of adult and pediatric traumatic injuries, there are a few key differences in physiology and anatomy that must be understood to properly evaluate and stabilize a pediatric trauma patient.
Major Differences between Adult and Pediatric Trauma
Weight-based dosing: Utilize Broslow tape (located in Resus 51) to ensure efficient medication dosing and delivery
Allow parents at the bedside during resuscitation to allow for patient comfort and provide explanation of the resuscitation
Consider non-accidental trauma when history is vague or inconsistent
*Pedi STAT is a mobile application providing information on normal vitals, RSI meds, ETT sizing, agitation, burns, PALS, fluid/blood resuscitation, pressors, seizure, GCS, pain management, etc. Great for quick reference!
Airway
If there is a concern for airway stability, below is a diagram detailing the differences in pediatric airway anatomy.
How to Optimize: The anatomical differences are adjusted for by elevating the shoulders and backs of young infants/children with a rolled towel or sheet for optimal alignment.
Cricothyrotomy: If indicated, needle cricothyrotomy is for children <10-12 years due to small size of the cricothyroid membrane. Children older than 10-12 years may have an open cricothyrotomy.
Laryngoscope sizing:
0-2 years: Miller/Mac 1
2-8 years: Miller/Mac 2
> 8 years: Miller/Mac 3
Endotracheal Tube Sizing: Cuffed = (age / 4) + 3.5; Uncuffed = (age / 4) + 4
Endotracheal Tube Advancement: Endotracheal tube size x 3 = Lip Line location
Breathing
Pediatric patients have shorter safe apnea times and more sharp O2 desaturations due to differences in physiologic reserve and oxygen consumption.
Oxygenation / Ventilation
Non-rebreather
<2 year old: 4L/min
2-12 year old: 6L/min
>12: 8L/min
Bag-valve mask ventilation can cause gastric insufflation in children which can quickly compromise ventilation- NG/OG tube should be placed quickly
NG tube size = uncuffed endotracheal tube size x 2
What to do for pediatric Tension Pneumothorax:
ATLS recommends Needle decompression in 2nd intercostal space at midclavicular line (differs from adults)
Chest tube size = 3-4 x uncuffed endotracheal tube size
Circulation
Hemorrhagic shock: Hypotension is a late finding in pediatric hypovolemic shock. Rely on tachycardia or clinical signs of poor perfusion to direct resuscitation.
Lower end of normal systolic BP for various age ranges:
0-28 days: <60
28 days - 1 year: <70
1 year - 10 years: 70 + (age x 2)
> 10 years: 90
IO Access: Optimal locations include anterior tibia, distal femur, and medial malleolus if IV access unsuccessful
Disability
Consider using GCS or AVPU score to assess for disability
AVPU: Alert, Verbal, Painful, Unresponsive
A score of V or lower correlates to GCS </= 9
Exposure
Pediatric patients have higher risk of hypothermia and coagulopathy due to high metabolic demand and surface area: volume ratio. External warming matters!
Laboratory Studies
Not always indicated in children
For patients who are unstable or with severe injuries: Type and Screen, VBG, CBC, BMP, LFT, coagulation factors
Consider BGM for AMS, pregnancy test for females of reproductive age, UA for hematuria
ECG and troponin if concern for blunt cardiac injury
Imaging Indications
E-FAST is recommended in evaluation of an unstable child following trauma
CXR / Pelvic XRs only indicated if clinical concern for pulmonary or pelvic injuries
CT Scans should be ordered with discretion due to portended malignancy risk from radiation. Consider utilizing risk stratification tools such as PECARN for head trauma. Consult with the peds ED, trauma team and/or PICU colleagues if questions arise.
Summary of formulas (can also be found in Pedi STAT):
Laryngoscope sizing:
0-2 years: Miller/Mac 1
2-8 years: Miller/Mac 2
> 8 years: Miller/Mac 3
Endotracheal Tube Sizing: Cuffed = (age / 4) + 3.5; Uncuffed = (age / 4) + 4
Endotracheal Tube Advancement (lip line) = uncuffed endotracheal tube size x 3
Chest tube size = uncuffed endotracheal tube size x 4
NG tube size = uncuffed endotracheal tube size x 2
Lower end of normal systolic BP for various age ranges:
0-28 days: <60
28 days - 1 year: <70
1 year - 10 years: 70 + (age x 2)
> 10 years: 90
I hope this review was helpful! Any additional pearls / thoughts are welcome as we continue to transition to our new pediatric ED protocols.
Best,
Lekha Reddy