This series is a collaboration with the EMS for Children Innovation and Improvement Center (EIIC) and will be part of the pre-hospital resources for its Pediatric Education and Advocacy Kit (PEAK) for multisystem trauma. Click on the link to learn more! https://emscimprovement.center/education-and-resources/peak/. 

In this episode we kick off a multipart series on pediatric trauma just in time for summer and trauma season. Join your two hosts as they tackle the prehospital management of pediatric trauma. Everything from head to toe and the pathophysiology that makes pediatric trauma unique from the adult population. Below are the episode talking points you don't want to miss. 

Objectives

• Assess the current landscape of pediatric trauma.
• Recognize the physiologic differences between adults and children in trauma.
• Evaluate how the mechanism of injury informs the management.
• Analyze how to approach a pediatric trauma patient.
• Summary and take-home points.

Brought to you by The National Association of EMS Physicians (NAEMSP) and Missouri Emergency Medical Services for Children (MO-EMSC).

Hosts: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney

Website: https://sites.libsyn.com/414020 

GET CEU CREDIT THROUGH PRODIGY EMS 

Content Experts: Joelle Donofrio-Odmann, DO and Joseph Finney, MD

Pediatric Assessment Triangle

 

The Changing Landscape of Traumatic Pediatric Death

 

Goldstick, 2022

Trimodal Distribution of Death

From McLaughlin et al, 2017:

74% of pediatric deaths age 1-14y were in first 24 hours. Of children who die from traumatic injuries, most die within 24 hours of arriving to the hospital. When compared to adult trauma patients, children are more likely to die in the emergency department (ED) rather than surviving long enough for hospital admission or transfer to the operating room.

Where you are treated matters

Theodorou et al in 2021 reviewed over 7000 pediatric trauma admissions and found, of the 134 patients who died, Traumatic brain injury was the most common cause of death (66%), followed by anoxia (9.7%) and hemorrhage (8%).  54% died in the ED. More likely to die if suffered penetrating trauma. 

Pediatric Trauma: ATC vs PTC

The United States Government Accountability Office found 57 percent of the nation's 74 million children lived within 30 miles of a pediatric trauma center that can treat pediatric injuries, regardless of severity. 

The presence of pediatric trauma centers was associated with lower rates of MVC death in children. Adult level 1/2 trauma centers appear to offer comparable risk reduction. Where population differences in pediatric trauma mortality are observed, addressing disparities in county-level access to pediatric trauma care may serve as a viable target for system-level improvement.

Pediatric patients <14yo do better at Pediatric Trauma centers likely related to management in the ED, avoiding the second peak of mortality. 

Why Does All This Matter: Anatomic and Physiologic Differences in Pediatric Trauma

A Case

A 5-year-old boy injured while crossing the street when he was struck by a vehicle at city speeds (w50 km/h). He is crying and pale, with a hematoma to the right forehead; bruising to the left side of the upper abdomen; and an obvious, closed, deformity of his femur. His vital signs are heart rate (HR), 135 beats/min, respiration rate (RR), 30 breaths/min; blood pressure (BP), 95/65 mm Hg; and O2 saturations of 91% on room air, which improve to 97% with supplemental O2

Factors to Consider when approaching pediatric trauma:

Head and Neck

•       Large head on short weak neck with fulcrum out away from the center of gravity

•       Traumatic brain injury likely present and must be investigated.

•       80% of pediatric multisystem trauma involves the head.

•       Remember TBI is a major cause of trauma mortality. 

•       Heavy head compared to body, often first impact point so affected by rapid acceleration deceleration forces. Also, higher risk of axonal injury from shearing forces given limited myelin development. Prehospital management focused on H bombs.

Airway

•       Airway is crowded and easily obstructed.

•       Use a shoulder roll anytime you are managing a pediatric airway under 8 years.

•       Intubation is for your ego; SGA is for your patient 

•       Cuffed tubes are both safe and effective for pediatric patients.

Pediatric Airway Considerations:

Head: In the supine position, a young child's head will cause a natural flexion of the neck due to its large size. This neck flexion can create a potential airway obstruction. Patients usually benefit from a towel to elevate the shoulders as well as someone to assist to help hold the head, as it can be floppy.

Nose: <4mo are obligate nose breathers and this means nasal congestion can cause significant respiratory distress. 

Tongue: A child's tongue is proportionally larger in the oropharynx when compared to adults, and it may obstruct the airway due to this size.

Larynx: Located opposite C2—C3, a child's larynx is higher up than in an adult, creating a more anterior location that often results in difficulty when a provider attempts to visualize a child's airway. HARDER TO INTUBATE.

Epiglottis: The adult epiglottis is flat and flexible, while a child's is U-shaped, shorter and stiffer. This makes it more difficult to manipulate and is a common reason providers can't visualize an airway with a curved blade in a pediatric patient.

Vocal cords: The anterior attachment of a pediatric patient's vocal cords is lower than the posterior attachment, which creates an upward slant, whereas in adults, the vocal cords are horizontal. This concave shape may affect ventilation, and it's important for providers to use a jaw-lift maneuver to open the arytenoids.

Trachea: The trachea is shorter in pediatric patients, which increases the likelihood of right mainstem intubation and of the tube becoming dislodged. At birth, 1/3 the diameter