Pediatric Multisystem Trauma

Trauma is the leading cause of morbidity and mortality in children.¹ Children have unique injury patterns and substantial differences in their response to trauma when compared with adults; special consideration is required when assessing and managing pediatric trauma. For acute management of a pediatric trauma patient, refer to TREKK’s Pediatric Multisystem Trauma Algorithm.

ANATOMICAL

• Small body mass with large surface area results in increased heat loss and greater external force per body unit area.
• Proportionally larger and less protected solid organs increase chance of intra-abdominal injury (IAI).
• Pliable ribcage/mobile mediastinum leads to major thoracic injury without obvious external signs of trauma.
• Larger head-to-body ratio results in a higher proportion of head injuries and age-related differences in cervical spine injury patterns.

PHYSIOLOGICAL

• Higher metabolic rate leads to increased oxygen and glucose demands, respiratory rate and insensible fluid losses.
• Compensated shock is prevalent and often unrecognized as circulating blood volumes can be very small and blood pressure remains normal until rapid decompensation and cardiac arrest.

DEVELOPMENTAL

• Normal curiosity in young children and increased risk-taking amongst adolescents increases risk of injury.
• Children are often fearful during trauma assessments. Providers may have difficulty with communication and examination, especially in young, preverbal children.

CATASTROPHIC EXTERNAL HEMORRHAGE

• Control bleeding by direct pressure, wound closure with staples as needed, or use of tourniquets for extremity hemorrhage not responsive to pressure.

AIRWAY WITH SPINAL MOTION RESTRICTION

• Have pediatric airway equipment available (1/2 size bigger and smaller for age).
• Manual in-line stabilization or blocks/sandbags with tape across forehead are better than an ill-fitting cervical collar.

BREATHING

• Bag mask ventilation (BVM) with the provision of good mask fit, continuous positive airway pressure and ventilation is a key skill for managing pediatric trauma, and often more valuable than tracheal intubation.
• Children have short tracheas and are often intubated too deeply. Endotracheal tubes are easily dislodged in transport. Secure equipment well. Minimize flexion/extension of neck.
• Internal thoracic injury can occur without external or radiological signs of chest wall trauma.
• Children desaturate quickly. Use modified rapid sequence/drug-assisted intubation protocols and/or apneic oxygenation to avoid hypoxia.
• Insert NG/OG tube to improve respiratory status by relieving abdominal distention that impairs breathing. Avoid NG tube in patients with facial injuries or significant head trauma.

CIRCULATION

• Beware of tachycardia and signs of peripheral vasoconstriction (delayed capillary refill, cool extremities, thready peripheral pulses) as early signs of shock. DO NOT wait for hypotension. Compensated shock can quickly lead to rapid decompensation/cardiac arrest.
• Place intraosseous (IO) lines early if no IV access after 2 attempts or immediately in traumatic arrest/peri-arrest. Consider proximal humeral IOs in hemodynamically unstable patients, especially if concern for IAI, pelvic fracture or hemorrhage.
• If compensated shock, minimize crystalloid (only give 10-20 mL/kg IV warmed isotonic fluids (NS or RL) rapid bolus), then warmed uncrossmatched PRBCs 10-20 mL/kg IV.
• If active bleeding/hypotension, transfuse uncrossmatched PRBCs 10-20 mL/kg STAT.² Repeat prn. If ongoing need for blood after 20 mL/kg PRBCs, activate local massive hemorrhage protocol if available, and arrange transport ASAP.
• If child requires transfusion and within 3 hours of injury, consider administering tranexamic acid.
• If hemodynamically unstable, use eFAST to identify potentially reversible causes (e.g., pericardial effusion, pneumo/ hemothorax, abdominal free fluid).
• Hemorrhage control is critical and should be addressed immediately. Direct pressure, tourniquets, pelvic binders, and splinting long bones should be rapidly completed.

DISABILITY

• Use the Pediatric Glasgow Coma Scale to assess/describe mental status. AVPU can also be used as a baseline assessment.
• Assess pupil size, symmetry, and reactivity. Assess power in all extremities.
• Check blood glucose if decreased LOC and in infants/young children to rule out hypoglycemia.
• Treat pain (with analgesia and non-pharmacologic measures) and distress (with family presence, distraction techniques, and calm person at head of bed). Refer to TREKK’s Pain Treatment Bottom Line Recommendations.

EXPOSURE

• Document temperature and keep warm using warm blankets, overhead heaters, forced air warmers (e.g., Bair Hugger®) and warmed intravenous fluids (+/- PRBCs).
• Ensure full exposure and careful examination including anogenital region.

FAMILY PRESENCE

• Option for family presence is standard of care in Pediatric Trauma Centers across North America to reduce patient/caregiver stress and enhance communication without compromising medical care or team dynamics.
• Have a dedicated support person remain with family if they choose to be present for the resuscitation.
• Assess the family’s preference, the availability of a support person, and the potential for exposure to invasive/distressing medical interventions. Serially reassess whether this option remains appropriate/desirable.

IMAGING PRIOR TO TRANSPORT

• AP Chest x-ray: Obtain in all patients.
• Cervical spine x-ray: No. If unable to clinically clear, defer imaging and maintain spinal motion restriction for transport.
• Pelvic x-ray: Obtain if concern for pelvic fracture, signs of abdominal trauma, femur fracture, hematuria OR hemodynamic instability.
• CT Imaging: Should not delay transport; usually best to allow Pediatric Trauma Center to perform CT imaging.

UTILITY OF EXTENDED FOCUSED ASSESSMENT WITH SONOGRAPHY IN TRAUMA (eFAST)

• eFAST scans have limited sensitivity. May potentially impact management if positive but are not adequate to rule out IAI. If concern for clinically important IAI, abdominal CT scan is necessary and best obtained at Pediatric Trauma Centre.
• Use of eFAST in combination with clinical factors (e.g., physical exam, laboratory tests, and serial assessments) increases sensitivity. Future pediatric trauma guidelines may incorporate this clinical strategy.
• eFAST evaluation with an adequately trained user is sensitive for detecting pneumo- and/or hemothorax.

• Refer to TREKK’s Pediatric Multisystem Trauma Checklist.
• Life-threatening injuries identified and addressed.
• Early communication with receiving Pediatric Trauma Center.
• Airway controlled & equipment well-secured.
• IV or IO access in place and secured.
• Ongoing analgesia, sedation +/- paralysis plan as needed.
• Depending on mode of transport (land/air), discuss need for chest tube placement for pneumothorax prior to transport with Transport Team.
• Communicate key clinical information including patient status, weight (can be estimated with Broselow tape), age, identified injuries, interventions performed, and estimated time of arrival.
• Splint fractures, administer antibiotics and tetanus prophylaxis for open fractures as indicated.
• Gastric tubes & urinary catheters secured as needed.
• Imaging, lab results & paperwork available to Transport Team.

Thank you to the following content experts who led the development of the Pediatric Multisystem Trauma Bottom Line Recommendations, Algorithm and Order Set:

Sue Beno, MD Pediatric Emergency Physician, Division of Emergency Medicine, The Hospital for Sick Children Associate Professor of Pediatrics and Emergency Medicine, University of Toronto.

Joe Nemeth, MD, FCFP, EM, CCFP, Emergency Medicine Physician/Trauma Team Leader, MUHC, Director, Trauma Fellowship  for the Emergency Medicine Physician, Montreal Children’s Hospital.  development

Thank you to the TREKK Editorial Committee, and the following people who supported the of this resource:

Pharmacy review: Danica Irwin (CHEO, Ottawa) & Tracy Furst (HSC, Winnipeg)
TREKK Project Coordinator: Mateja Carevic (University of Manitoba)
TREKK Editorial Lead: Sarah Reid (CHEO, University of Ottawa)

To see our resource development process please visit our website here.

(as cited in the Pediatric Multisystem Trauma Bottom Line Recommendations):

1. Yanchar NL, Warda LJ, Fuselli P. Canadian Pediatric Society Injury Prevention Committee. Child and youth injury prevention; a  public health approach. Paediatr Child Health. 2012;17(9):511.
2. ATLS Subcommittee, American College of Surgeons’ Committee on Trauma, International ATLS Working Group. Advanced  trauma life support (ATLS^®): the tenth edition. 2018. 78-0-9968262-3-5.
3. Mikrogianakis A, Grant V. The Kids Are Alright: Pediatric Trauma Pearls. Emerg Med Clin North Am. 2018;36(1):237-257.
4. Lee L, Farell C. Trauma management: Approach to the unstable child. 2023. UpToDate.

For a complete list of the evidence that informed the creation of the Pediatric Multisystem Trauma Bottom Line Recommendations see the Evidence Repository here.

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of community acquired pneumonia in children in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use