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INTRODUCTION

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Trauma is the most common cause of death in children older than 1 year. Differences in anatomy and physiology mandate modifications to trauma evaluation and management in children.

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CLINICAL FEATURES

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Head trauma is the most frequent pediatric injury resulting in death. Overall, motor vehicle crash is the most common mechanism, and it is the leading mechanism of traumatic death in children older than 1 year.

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Airway: Airway management in children can be challenging. Anatomic differences include a large occiput, large tongue, and cephalad location of the larynx.

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Breathing: Observe the rate, depth, pattern, and work of breathing as well as symmetry of rise and fall of the chest wall. Agitation or somnolence could be a result of hypoxia or hypercapnea, respectively. Children experience oxygen desaturation more quickly due to high oxygen demand and small lungs.

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Circulation: Recognize early signs of circulatory shock including tachycardia, mental status changes, and color and perfusion abnormalities, because hypotension is typically a terminal event in children. Estimate normal systolic blood pressure in children 1 to 10 years of age using the following formula: 90 + (2 × age) mm Hg; hypotension can be estimated as systolic blood pressure less than 70 + (2 × age) mm Hg.

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Disability: In younger children, the Modified Pediatric Glasgow Coma Scale (Table 157-1) should be used. This mirrors the Glasgow Coma Scale for eye opening and motor responses, but incorporates age-appropriate modifications for verbal responses. Perform a pupillary examination and basic assessment of tone and strength.

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Table Graphic Jump Location
Table 157-1

Modified Pediatric Glasgow Coma Scale

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Exposure: Disrobe and expose the child to completely assess for injuries. However, the ratio of surface area to mass is greater in children, putting them at greater risk for hypothermia. Care should be taken to maintain normothermia.

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DIAGNOSIS AND DIFFERENTIAL

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Head Injury

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Infants and neonates are at the highest risk of significant intracranial injury. Mental status assessment should account for developmental stage and patient anxiety. Parietal and occipital skull fractures are frequently associated with intracranial bleeding. Noncontrast CT is the imaging modality of choice for intracranial injury in children. Scalp injuries, particularly in neonates, may result in significant blood loss and shock. Please see Chapter 160 for a discussion on CT imaging in head trauma.

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Spine Injuries

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Young children with spinal cord injuries often do not have associated fractures since the ligaments are relatively elastic. “Clearing the cervical spine” in children is challenging as there is little evidence to guide practice. Multisystem ...

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