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.
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. There are many manifestations and consequences of trauma unique to pediatric patients that should be addressed in the primary survey (Table 157-1).
Table 157-1 Primary Survey Goals |Favorite Table|Download (.pdf)
Table 157-1 Primary Survey Goals
|Inadequate airway||Securing and protection of airway|
|Cervical spine injury||Stabilization of cervical spine|
- Tension pneumothorax
- Massive hemothorax
- Open pneumothorax
Positive pressure ventilation
Supplemental oxygen administration
Needle decompression, tube thoracostomy
Occlusive dressing, tube thoracostomy
- Hypovolemic shock
- Pericardial tamponade
- Cardiac arrest
Fluid bolus, blood products
Fluid bolus, pericardiocentesis, thoracotomy
Chest compressions (CPR)
ED thoracotomy if penetrating trauma
- Spinal cord injury
- Cerebral herniation
Mild hyperventilation, mannitol
- Exsanguinating hemorrhage
Warmed fluids, external warming
Direct pressure, air splints
Airway: Airway management in children can be challenging. Anatomic differences include a large occiput, large tongue, and cephalad location of the larynx.
Breathing: Infants younger than 6 months are nose breathers and facial trauma may cause respiratory distress. Tachypnea is often the first sign of dyspnea (Table 157-2).
Table 157-2 Signs of Hypoxemia and Inadequate Ventilation |Favorite Table|Download (.pdf)
Table 157-2 Signs of Hypoxemia and Inadequate Ventilation
Signs of hypoxemia
- Poor capillary refill
- Desaturation measured by pulse oximetry
Signs of inadequate ventilation
- Nasal flaring
- Stridor or wheezing
Circulation: Children with compensated shock from hemorrhage have normal blood pressure and tachycardia. Other signs of shock include cap refill >3 seconds, cool extremities, weak peripheral pulses, and altered mental status. Hypotension is a prearrest finding in children.
Disability: In younger children, an age-specific adaptation of the Glasgow Coma Scale should be used. A bulging anterior fontanelle may indicate elevated intracranial pressure.
Exposure: 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.
Infants and neonates are at the highest risk of significant intracranial injury (Table 157-3). Mental status may be difficult to assess due to frequent developmental changes 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.