Epidemiology Trauma is most common cause of death in children > 1 years old Epidemiology mortality rate is approximately 20% CNS injuries have highest overall morbidity and mortality spine fractures have highest morbidity/mortality among musculoskeletal injuries cervical spine injuries more common in children <8-years-old due to fact that restraints do not fit young children Etiology Pathophysiology falls and motor vehicle accidents most common Transport Occipital cut-out needed in spine board when transporting children <8 y.o. larger head size can flex unstable cervical spine leading to injury during transport Help tips Broselow tape = estimate medication doses, size of equipment, shock voltage for defibrillator ETT = (age/4) + 4 or (age+16)/4 = uncuffed BP = 80 + (age x 2) chest tube = 4 x ETT blood volume = 75 mL/kg Intraosseous lines commonly needed due to difficulty obtaining venous access children may remain hemodynamically stable even after significant blood loss hypovolemic shock may result from inadequate fluid resuscitation "triad of death" reflects inadequate resusitation and is characterized by: acidosis hypothermia coagulopathy ATLS with Children Overview should follow ATLS protocol Airway Breathing Circulation Disability Exposure Airway Smaller airway greater risk of airway obstruction with foreign bodies small amounts of swelling will result in a relatively greater reduction in airway diameter Larger tongue, floppy epiglottis Larger occiput flexes the head forward when placed supine on a flat surface to achieve a neutral position, it may be necessary to lift the chin or place a pad under the torso of the infant (or head cut out) Larynx is higher and more anterior sits at the level of the C2-C3 vertebrae body in the young child, compared with C6-C7 in the adult. positioning of the larynx makes its visualisation in the paediatric airway more difficult than in the adult. Breathing Most common cause of cardiorespiratory arrest is hypoventilation Ribs positioned more horizontally with inspiration the ribs only move up, and not up-and-out, like the adult rib cage. limits the capacity to increase tidal volumes Diaphragmatic breathing Fewer Type 1 fibres in respiratory muscles smaller number of fatigue-resistant, Type I fibres in their respiratory muscles exhaust more quickly than adults Respiratory rate varies with age higher oxygen demand = higher respiratory rates Circulation Initial bolus = 20ml/kg NS After two boluses = 10ml/kg of PRBC’s Blood volume is relatively larger, but absolute volume is smaller small volumes of blood will constitute significant blood loss in small children example = 100ml hemorrhage experienced by a 5 kg child represents the loss of approximately 26.7% of their total blood volume assuming a blood volume of 75ml/kg Systemic vascular resistance is lower increases from birth to adulthood Hypotension is a late sign remain normotensive until they are losing large intravascular volumes 25-30% of blood volume before signs of shock Smaller vessels / more subcutaneous tissue difficult to obtain vascular access due to small veins and increased subcutaneous tissue IV access more difficult – consider intraosseus Disability Risk factors for head injury Open sutures, presence of fontanelle Thinner cranial bones thinner cranial bones of children do not afford as much protection to the brain tissue Head relatively larger higher center of gravity = higher incidence of head and neck trauma Exposure Relatively small size large head and organs Higher BMR and surface area greater consumption of oxygen and other metabolites higher respiratory and heart rates larger surface-area to body-mass ratio results in greater heat loss Increased glucose requirements but decreased glycogen stores higher metabolic rate small glycogen stores Pediatric Scoring Systems Pediatric trauma score (PTS) PTS<0=100% mortality PTS of 1-4=40% mortality PTS of 5-8=7% mortality PTS less than or equal to 8 should be sent to designated peds trauma center Pediatric Galsgow Coma Scale GCS<8 correlates with a higher rate of mortality O2 sat at presentation and GCS 72hrs post-injury are both prognostic of long-term neurologic recovery Injuries Head and neck Most common injury associated with all-terrain vehicle injuries is traumatic brain injury ICP can be elevated by pain it is possible to decrease ICP by fracture fixation heterotopic ossification is more common following traumatic brain injury increased serum alkaline phosphatase heralds onset of HO NSAID prophylaxis is indicated in these situations Peripheral nerve injuries most common in closed fractures obtain EMG if no return of function 2-3 months after injury Multiorgan failure occurs early after admission and affects all organ systems