ATLS Module 10 - Pediatric Trauma
10 yo male arrives at ED after bicycle crash. He is complaining of upper abdominal pain.
vitals: HR 115 & BP 100/65. CT scan of abdomen shows large splenic laceration with
contrast extravasation. As he returns to ED from radiology, HR increases to 150 and BP
drops to 70/45. What are the most appropriate next steps in management? - ANS-condition
has rapidly deteriorated to shock state, and he needs resuscitation en route to the operating
room.
administer 20mL/kg isotonic fluid bolus and 10 mL/kg type specific or O- pRBCs.
pt should have emergent laparotomy/splenectomy
(angioembolization is not appropriate, unless he responds to resuscitation and interventional
radiology is immediately available)
\10 yo male struck head while diving into the swimming pool. On exams, he demonstrates
weakness in all extremities. Cervical spine films reveal no fractures. The best next step in
management should be:
a. obtain urgent spine surgery consult
b. flexion-extension films
c. CT of cervical spine
d. high dose steroids - ANS-A
CT & MRI will likely be required, but a neurosurgical/spine surgeon should be involved
\6 month old infant is brought to ED after fall onto hard floor. she is crying and appropriately
interactive. her eyes are open. she is moving all extremities. there is a laceration on scalp,
and anterior fontanelle is firm and bulging. what is the next most appropriate step in
management?
a. skull series plain films
b. CT of head
c. family reassurance & discharge
d. laceration repair and observation - ANS-b
\7 yo male is struck by car while riding bike. at ED, he is tachycardic, hypotensive, and
hypoxic. He has diminished breath sounds and a large contusion on the right side. the most
appropriate next step in management:
a. vascular access & fluid resuscitation
b. endotracheal intubation
c. perform immediate needle thoracostomy to right chest
d. perform tube thoracostomy of right chest - ANS-c
although rare, tension pneumothorax is more common in children than adults.
decompression should be performed immediately before any other interventions
\a 5 year old boy is struck by an automobile and brought to ED. He is lethargic but withdraws
from painful stimuli.
vitals: BP 90, HR 160, RR 40, oxygen sat 85%.
The best option for establishing vascular access after experienced nurses have failed to
obtain peripheral IV access on 2 attempts is: - ANS-placement of intraosseous device
\a child's primary response to hypovolemia is tachycardia... which could also be caused by
pain, fear, psychological stress... what are the other more subtle signs of blood loss in
children? - ANS--progressive weakening of pulses
, -narrowing pulse pressure to <20mmHg
-skin mottling
-cool extremities compared to torso
-decrease in level of consciousness with dulled response to pain
\an infants trachea is ~5 cm long and grows to 7 cm by about 18 months... what can failure
to appreciate this short length result in? - ANS-intubation of right mainstem bronchus,
inadequate ventilation, accidental tube dislodgement, and/or mechanical barotrauma
\children can sustain spinal cord injury without radiographic abnormalities (SCIWORA)... a
normal c spine series may be found in 2/3 of children with spinal cord injury... how do you
avoid missing this? - ANS-if injury is suspected on history & exam, normal x-ray doesnt
exclude significant spinal cord injury
*when in doubt about integrity of c spine or spinal cord, assume unstable injury exists, limit
spinal motion and obtain appropriate consultation
(red text)
\CT scanning doesn't come without risk... 1/1000 kids can develop fatal cancers...When CT
scan is necessary, radiation must be kept As Low As Reasonable Achievable (ALARA)...
how do you achieve the lowest dose possible? - ANS-perform only when medically
necessary, scan only when results will change management, scan only the area of interest,
and use lowest radiation dose possible
red text
\does vomiting and amnesia imply increased intracranial pressure in children? - ANS-not
necessarily... vomiting and amnesia are common after brain injury in children... however, if
vomiting is/becomes persistent... that becomes more frequent concern and mandates CT of
head
\FAST exam is used in children as extension of abdominal exam.... why should it no be
relied upon as the sole dx test? - ANS-it is incapable of identifying isolated intraparenchymal
injuries which account for 1/3 of solid organ injuries in children... & significant abdominal
injuries may be present in the absence of any free intraperitoneal fluid
\following successful intubation of obtunded 2 yo male involved in MVC, he is transported to
CT scanner. during transport, there is sudden deterioration of oxygen saturation. what is the
most likely cause of deterioration? - ANS-dislodgement of tube
\how do you estimate a child age >3 years old blood volume? - ANS-70 mL/kg
\how do you estimate a child age 1-3 years old blood volume? - ANS-75 mL/kg
\how do you estimate the infant's blood volume? - ANS-80mL/kg
\how does the blood loss a/w longbone/pelvic fx differ in kids than aduts? - ANS-blood loss is
proportionately less in children
*if isolated closed femur fx is treated appropriately, the average fall in hematocrit is not
enough to cause shock... therefore, if hemodynamic instability was present in isolated femur
fx, prompt eval for other sources of blood loss is necessary
\how does the pliability or compliance of a child's chest wall effect them with chest traumas?
- ANS-it allows kinetic energy to be transmitted to underlying pulmonary parenchyma,
causing pulmonary contusion
*mobility of mediastinal structures make children more susceptible ot tension
pneumothorax.... the MC immediately life threatening injury in kids (red text)
\how does the respiratory rate in children change with age? - ANS-*decreases with age
infant breaths 30-40 times/minute
older child breaths 15-20 times/minute
10 yo male arrives at ED after bicycle crash. He is complaining of upper abdominal pain.
vitals: HR 115 & BP 100/65. CT scan of abdomen shows large splenic laceration with
contrast extravasation. As he returns to ED from radiology, HR increases to 150 and BP
drops to 70/45. What are the most appropriate next steps in management? - ANS-condition
has rapidly deteriorated to shock state, and he needs resuscitation en route to the operating
room.
administer 20mL/kg isotonic fluid bolus and 10 mL/kg type specific or O- pRBCs.
pt should have emergent laparotomy/splenectomy
(angioembolization is not appropriate, unless he responds to resuscitation and interventional
radiology is immediately available)
\10 yo male struck head while diving into the swimming pool. On exams, he demonstrates
weakness in all extremities. Cervical spine films reveal no fractures. The best next step in
management should be:
a. obtain urgent spine surgery consult
b. flexion-extension films
c. CT of cervical spine
d. high dose steroids - ANS-A
CT & MRI will likely be required, but a neurosurgical/spine surgeon should be involved
\6 month old infant is brought to ED after fall onto hard floor. she is crying and appropriately
interactive. her eyes are open. she is moving all extremities. there is a laceration on scalp,
and anterior fontanelle is firm and bulging. what is the next most appropriate step in
management?
a. skull series plain films
b. CT of head
c. family reassurance & discharge
d. laceration repair and observation - ANS-b
\7 yo male is struck by car while riding bike. at ED, he is tachycardic, hypotensive, and
hypoxic. He has diminished breath sounds and a large contusion on the right side. the most
appropriate next step in management:
a. vascular access & fluid resuscitation
b. endotracheal intubation
c. perform immediate needle thoracostomy to right chest
d. perform tube thoracostomy of right chest - ANS-c
although rare, tension pneumothorax is more common in children than adults.
decompression should be performed immediately before any other interventions
\a 5 year old boy is struck by an automobile and brought to ED. He is lethargic but withdraws
from painful stimuli.
vitals: BP 90, HR 160, RR 40, oxygen sat 85%.
The best option for establishing vascular access after experienced nurses have failed to
obtain peripheral IV access on 2 attempts is: - ANS-placement of intraosseous device
\a child's primary response to hypovolemia is tachycardia... which could also be caused by
pain, fear, psychological stress... what are the other more subtle signs of blood loss in
children? - ANS--progressive weakening of pulses
, -narrowing pulse pressure to <20mmHg
-skin mottling
-cool extremities compared to torso
-decrease in level of consciousness with dulled response to pain
\an infants trachea is ~5 cm long and grows to 7 cm by about 18 months... what can failure
to appreciate this short length result in? - ANS-intubation of right mainstem bronchus,
inadequate ventilation, accidental tube dislodgement, and/or mechanical barotrauma
\children can sustain spinal cord injury without radiographic abnormalities (SCIWORA)... a
normal c spine series may be found in 2/3 of children with spinal cord injury... how do you
avoid missing this? - ANS-if injury is suspected on history & exam, normal x-ray doesnt
exclude significant spinal cord injury
*when in doubt about integrity of c spine or spinal cord, assume unstable injury exists, limit
spinal motion and obtain appropriate consultation
(red text)
\CT scanning doesn't come without risk... 1/1000 kids can develop fatal cancers...When CT
scan is necessary, radiation must be kept As Low As Reasonable Achievable (ALARA)...
how do you achieve the lowest dose possible? - ANS-perform only when medically
necessary, scan only when results will change management, scan only the area of interest,
and use lowest radiation dose possible
red text
\does vomiting and amnesia imply increased intracranial pressure in children? - ANS-not
necessarily... vomiting and amnesia are common after brain injury in children... however, if
vomiting is/becomes persistent... that becomes more frequent concern and mandates CT of
head
\FAST exam is used in children as extension of abdominal exam.... why should it no be
relied upon as the sole dx test? - ANS-it is incapable of identifying isolated intraparenchymal
injuries which account for 1/3 of solid organ injuries in children... & significant abdominal
injuries may be present in the absence of any free intraperitoneal fluid
\following successful intubation of obtunded 2 yo male involved in MVC, he is transported to
CT scanner. during transport, there is sudden deterioration of oxygen saturation. what is the
most likely cause of deterioration? - ANS-dislodgement of tube
\how do you estimate a child age >3 years old blood volume? - ANS-70 mL/kg
\how do you estimate a child age 1-3 years old blood volume? - ANS-75 mL/kg
\how do you estimate the infant's blood volume? - ANS-80mL/kg
\how does the blood loss a/w longbone/pelvic fx differ in kids than aduts? - ANS-blood loss is
proportionately less in children
*if isolated closed femur fx is treated appropriately, the average fall in hematocrit is not
enough to cause shock... therefore, if hemodynamic instability was present in isolated femur
fx, prompt eval for other sources of blood loss is necessary
\how does the pliability or compliance of a child's chest wall effect them with chest traumas?
- ANS-it allows kinetic energy to be transmitted to underlying pulmonary parenchyma,
causing pulmonary contusion
*mobility of mediastinal structures make children more susceptible ot tension
pneumothorax.... the MC immediately life threatening injury in kids (red text)
\how does the respiratory rate in children change with age? - ANS-*decreases with age
infant breaths 30-40 times/minute
older child breaths 15-20 times/minute
