Pediatric Trauma

Pediatric Trauma: Anatomical Vulnerabilities and Epidemiology

Trauma is the leading cause of death and disability in children aged 1–18 years in the United States.^[1] Pediatric trauma patients require a specialized approach due to distinct anatomical, physiological, and developmental differences compared to adults. High-yield exam topics include the pediatric trauma triad of death, weight-based medication dosing, and age-appropriate vital sign norms. Mastery of these concepts is critical for the Certified Emergency Nurse (CEN) exam and safe clinical practice.

Key Anatomical and Physiological Differences

Large head-to-body ratio – increases risk of head injury and cervical spine trauma.^[2]
Smaller, more compliant chest wall – forces transmitted directly to underlying organs, leading to pulmonary contusions without rib fractures.^[2]
Relatively larger liver and spleen – less protected by the rib cage; prone to blunt abdominal injury.^[2]
Higher body surface area (BSA)-to-weight ratio – accelerates heat loss; hypothermia worsens coagulopathy and acidosis.
Developing skeletal system – ligamentous laxity can cause spinal cord injury without radiographic abnormality (SCIWORA).^[3]
Thinner skin and less subcutaneous fat – increases vulnerability to burns and degloving injuries.

Epidemiology and Mechanism

Blunt trauma (e.g., motor vehicle collisions, falls) accounts for >85% of pediatric trauma.^[1]
Penetrating trauma (e.g., gunshot wounds, stabbings) is less common but carries high mortality.
Non-accidental trauma (child abuse) must be considered in children <2 years presenting with injuries inconsistent with the reported mechanism.^[4]

Systematic Assessment and Resuscitation in Pediatric Trauma

Primary Survey (ABC-DE) with Pediatric Modifications

Use a systematic ATLS-based approach.^[5] Age-adjusted vital signs guide the recognition of shock (see Table 1).

A – Airway and cervical spine immobilization: Open airway with jaw‑thrust maneuver; use appropriately sized oral or nasal airways. Maintain in-line immobilization.
B – Breathing and ventilation: Assess respiratory rate, effort, and breath sounds. Needle decompression for tension pneumothorax (2nd intercostal space, midclavicular line; use catheter appropriate for chest wall thickness).^[6]
C – Circulation with hemorrhage control: Evaluate pulses, skin color, capillary refill. Obtain immediate vascular access (IV/IO). Apply direct pressure to external bleeding. The first sign of shock in children is tachycardia; hypotension is a late and ominous finding.^[7]
D – Disability (neurologic status): Use the age-appropriate Glasgow Coma Scale (GCS). Assess pupil size and reactivity.
E – Exposure and environmental control: Fully undress the patient, then warm the environment, use warm blankets, overhead radiant warmers, and warm IV fluids.^[5]

Table 1: Age-Adjusted Vital Signs (Normal Ranges for Triage)

Age	Heart Rate (beats/min)	Systolic BP (mmHg)	Respiratory Rate (breaths/min)
Infant (0–1 yr)	100–160	70–100	30–60
Toddler (1–3 yr)	90–150	80–110	24–40
Preschool (3–6 yr)	80–140	80–110	22–34
School‑age (6–12 yr)	70–120	90–120	18–30
Adolescent (12–18 yr)	60–100	100–130	12–20

Adapted from: American Heart Association PALS Guidelines^[7] and ATLS Student Course Manual.^[5]

Weight Estimation and Equipment Selection

Broselow™ tape estimates weight from height/length; provides color‑coded equipment sizes and drug doses.^[5]
Alternative: Age‑based formula (for children 1–10 years): weight (kg) = (age in years × 2) + 8.
Use a pediatric drug reference or code card to avoid dosing errors.

Secondary Survey and Diagnostic Workup

After primary survey and resuscitation, perform a head‑to‑toe examination and obtain adjuncts:

Imaging: Focused Assessment with Sonography for Trauma (FAST) is useful for detecting intra‑abdominal fluid; CT is the gold standard for stable patients. C‑spine X‑ray (3 views) or CT when indicated.
Laboratory studies: CBC, coagulation profile, type and crossmatch, arterial blood gas, lactate, and serum glucose.
Scoring tools: Pediatric Trauma Score (PTS) predicts injury severity and mortality (higher score = better prognosis); GCS ≤8 indicates severe traumatic brain injury.^[8]

Clinical Presentations: Shock, TBI, and Organ Injury

Shock States

Compensated shock: Tachycardia, cool extremities, delayed capillary refill (>2 sec), narrowed pulse pressure, normal blood pressure. This is the window for early intervention.^[7]
Decompensated shock: Hypotension, bradycardia (preterminal), altered consciousness, absent peripheral pulses. Requires immediate aggressive resuscitation.
Hemorrhagic shock class (pediatric modification): Even 20–25% blood volume loss can cause tachycardia and delayed capillary refill without hypotension.

Traumatic Brain Injury (TBI)

Signs of increased intracranial pressure (ICP): Cushing's triad (hypertension, bradycardia, irregular respirations), pupillary asymmetry, posturing (decorticate/decerebrate), bulging fontanelle (infants).^[6]
Seizures, persistent vomiting, or lethargy warrant immediate CT.
Elevate head of bed 30° (after c‑spine clearance), maintain normocapnia, avoid hypotension (MAP >50–60 mmHg depending on age).

Thoracic Injuries

Pulmonary contusion: The most common blunt thoracic injury; may deteriorate over hours. Hypoxia, tachypnea, and decreased breath sounds.
Tension pneumothorax: Distended neck veins (may be absent in hypovolemia), tracheal deviation (late), hyper‑resonance, absent breath sounds. Immediate needle decompression.
Cardiac tamponade: Muffled heart sounds, distended neck veins, hypotension (Beck's triad). FAST shows pericardial fluid; treatment is pericardiocentesis or surgical window.^[9]

Abdominal Injuries

Solid organ injury: Liver and spleen are most common (blunt trauma). Signs: abdominal tenderness, distension, Kehr's sign (left shoulder pain in splenic injury), Cullen sign (periumbilical ecchymosis – late).
Hollow viscus perforation: Less common but may present with peritonitis after a delay. Consider in handlebar injuries or seatbelt marks.

Diagnostic Workup and Imaging Priorities

Primary Survey – Fast Assessment

A: Look, listen, feel for airway patency; provide jaw‑thrust, suction, OPA/NPA.
B: Auscultate for equal breath sounds, assess oxygen saturation, apply high‑flow oxygen.
C: Palpate pulses (central vs peripheral), assess skin color and temperature, obtain IV/IO access.

Laboratory and Imaging Pearls

Monitor serial lactate and base deficit to guide resuscitation adequacy.
Elevated liver enzymes may indicate hepatic injury; microscopic hematuria suggests renal or bladder trauma.
CT with contrast is the diagnostic standard for stable patients; FAST may miss solid organ injuries without free fluid.^[10]

Resuscitation Protocols and Operative Management

Resuscitation

Airway management: Early intubation if GCS ≤8, airway obstruction, apnea, or impending respiratory failure. Use rapid sequence intubation (RSI) with appropriate pediatrics agents (e.g., etomidate, rocuronium).^[6]
Hemorrhage control: Direct pressure, tourniquet for life‑threatening extremity bleeding. Pelvic binder for unstable pelvic fractures.
Fluid resuscitation: Start with warm isotonic crystalloid (0.9% NaCl or Lactated Ringer’s) 20 mL/kg bolus; reassess. If still in shock, repeat up to 40–60 mL/kg. Persistent shock requires blood products (10 mL/kg PRBC, 10–20 mL/kg FFP/platelets).^[5]
Massive transfusion protocol: Initiate early if hemorrhagic shock is refractory; aim for 1:1:1 ratio (PRBC:FFP:platelets) in older children. Use calcium replacement (citrate binding).^[7]
Hypothermia prevention: Warm IV fluids, high‑flow warm humidified oxygen, bear hugger or forced air warmer, overhead heat lamps.

Operative vs Non‑Operative Management

Solid organ injury (liver/spleen): Most are managed non‑operatively with monitoring, serial hemoglobin, and ICU care. Surgery indicated for hemodynamic instability despite adequate resuscitation or ongoing transfusion needs.
Damage‑control surgery: Consider in unstable patients with multiple injuries; abbreviated laparotomy, temporary closure, ICU resuscitation, then definitive repair.

Pain Management

Titrate opioids (e.g., morphine 0.1 mg/kg IV) while monitoring respiratory status. Use ketamine for procedures or if hemodynamically unstable.
Avoid NSAIDs in suspected bleeding or renal injury.

Preventing Hypothermia, Over-Resuscitation, and Missed Abuse

Hypothermia: Aggressive warming needed – avoid excessive exposure. Hypothermia exacerbates coagulopathy and acidosis.^[5]
Fluid overload: Over‑resuscitation with crystalloid can worsen lung injury (ARDS), coagulopathy, and abdominal compartment syndrome. Use blood products early.
Missed non‑accidental trauma: Inconsistent history, delay in seeking care, retinal hemorrhages, spiral femur fracture in non‑ambulatory child – mandatory reporting.
Cervical spine injury: Immobilize until cleared with radiographs and/or CT. Children have less neck muscle tone; increased risk of SCIWORA.
Late decompensation: Children maintain normal blood pressure until ≥40% blood loss – falling BP indicates imminent arrest.^[7]

Essential Concepts for CEN Exam Mastery

Memorize age‑adjusted vital sign tables. The CEN exam frequently tests recognition of tachycardia as early shock vs normal variant.
Broselow tape is the preferred weight estimation method in pediatric trauma – know its colored zones.
Pediatric Trauma Score (PTS): Components: weight, airway status, systolic BP, central nervous system, open wound, skeletal injury. Score −6 to +6; <8 strongly associated with mortality.^[8]
Needle decompression in children: Use a 14–16 gauge catheter, length 1.25–2 inches depending on patient size; longer needle may be needed in adolescents.
Three highest‑yield exam questions often revolve around: (1) earliest sign of shock, (2) weight‑based dosing, (3) hypotension as a late sign.
Remember the “rule of 3’s” for traumatic brain herniation: Cushing’s triad (hypertension, bradycardia, irregular respirations).
For penetrating trauma, document wound location, number of wounds, and exit sites – anticipate internal injuries even if external wound appears small.