Historical Development

In North America, improvements to trauma care began in the 1960s and 1970s (Trunkey, 1983; Haller, 1995; Mullins, 1999; Morrison et al., 2002). Pediatric trauma systems did not develop in isolation but in concert with adult care. Trauma care was advanced in both the Korean and Vietnam wars, with the military experiences of treating injured soldiers. A report by Howard (1966) highlighted the enormity of the injury problem and stressed its significance as a neglected public health problem. Furthermore, a series of “preventable death studies” was published that provided fodder for community and political support of coordinated care for injured patients. Funding for emergency medical services first became available in 1966 with the National Highway Safety Act, and further support followed with the Emergency Medical Services System Act in 1973 (Mullins, 1999). In 1968, Cook County hospital in Chicago (for adult care) and Kings County hospital in Brooklyn (for pediatrics) were recognized as the first specialized centers for civilian trauma care in the United States. In 1969, the University of Maryland and the Maryland State police developed a coordinated transport system for injured patients to preferentially take them to a hospital with specific interest in caring for injured patients (Cowley et al., 1973; Cowley and Scanlan, 1979). Illinois is credited as the first state to develop a comprehensive state-wide trauma system that included categorization of trauma hospitals and the establishment of a communication system and a trauma registry (Boyd et al., 1973). In 1984, the Department of Health and Human Services, in conjunction with the National Highway Traffic Safety Administration, began the Emergency Medical Services for Children Program in the United States. This funding has been a critical resource for developing programs and research to improve emergency service systems for children.

The American College of Surgeons Committee on Trauma (ACSCOT) has also strived to improve trauma care in North America. This has been accomplished through the publication of standards for trauma systems, the creation of educational courses for health care professionals, and the establishment of and verification programs to ensure published standards are met. In 1976, the first version of the Optimal Resources for Care of Seriously Injured was released (Committee on Trauma: American College of Surgeons, 1999). The most recent version of this publication (2006) is currently in use and has been retitled “Resources for the Optimal Care of Injured Patient.” It remains a dynamic and important document. This publication established criteria for defining levels of trauma centers (I through III) and trauma systems (I and II), and it defined resource requirements for prehospital care through discharge, as well as specific pediatric needs. Level I centers offer the widest range of services for the most severely injured patient, whereas level III centers allow for stabilization and triage. With respect to trauma system development, eight criteria were defined and have become accepted benchmarks for trauma care (Boxes 30-1 and 30-2). Recently, designation of a level IV trauma center has occurred in some states where the resources do not exist for a level III trauma center. Level IV trauma centers are able to provide initial evaluation, stabilization, preliminary diagnoses, and transportation to a center with a higher level of care. These centers may also provide surgery and critical care services (as defined in the scope of services of trauma care). A trained trauma nurse and physicians are available on the patients’ arrival to the emergency department.

In 1986, the ACSCOT established its consultation and verification program to ensure that these standards were being met. At present in North America, there are 94 verified level I centers for adult care and 46 level I centers for pediatrics.

Another valuable contribution by the ACSCOT is the Advanced Trauma Life Support course (ATLS). First released in 1979, the course is now taught all over the world (American College of Surgeons Committee on Trauma, 1997). The first pediatric chapter was introduced in 1983. Although initially designed for surgeons, a wide variety of health care professionals involved in trauma care participate today. The ATLS course provides a common language, framework, and approach to injured patients that facilitate communication between health care professionals in order to optimize and prioritize care. Regular recertification is mandated to keep physicians current with new advances in trauma management. Similar to other ACSCOT programs, the ATLS course is constantly evolving. The current version is the seventh edition.

Trauma System Components

A trauma system is not simply an isolated hospital that cares for injured patients but a broad coalition of participants that includes an integrated approach to trauma. This includes prevention, prehospital care, and hospital care through rehabilitation (Ehrlich et al., 2001, 2002).

A primary step in developing an effective trauma system is a needs assessment of the community that it serves. For example, rural trauma systems differ from those in urban settings—each have different mortality rates, injury patterns, geographic areas, available resources, and expertise (Rogers et al., 1999; Ehrlich et al., 2004). Community responsibility and involvement (particularly with injury prevention) are essential for political support and funding. Studies support the concept that community-based injury-prevention programs play a substantial role in reducing morbidity and mortality (Hulka et al., 1997; Nathens et al., 2000).

A second important consideration in developing a regional trauma system is to understand that all facilities have a role in treating injured patients. A tiered approach (e.g., Levels I through IV) with specific hospitals designated to care for the varied complexity of injured patients is essential. Level I hospitals are tertiary or quaternary centers, with levels II and III centers having fewer capabilities and resources. Level IV hospitals are distinct because of their remote nature (rural trauma). A list of recommended requirements for each level of care can be found in the ACSCOT publication Resources for the Optimal Care of the Injured patient: 2006 (Committee on Trauma: American College of Surgeons, 1999). A basic tenet and overarching requirement for this tiered system is a central communication (central command) structure and a well-developed triage system so that the most severely injured patients go first to the appropriately designated hospital. In addition, a trauma registry system is essential for outcomes analysis and quality-assurance programs.

A third point is that a trauma system is not an isolated surgical program but a multidisciplinary team of physicians, nurses, technicians, and allied health professions. A large trauma program uses a significant percentage of hospital resources for everything from the blood bank to social work. Regular meetings of all stakeholders are needed to solve problems and respond to changing injury patterns and community needs.

Anesthesiologists play a variety of roles in trauma response. These roles span from assisting as primary responders in airway management and vascular access to coordinating operating-room resources to ensure that patients are treated in a timely and effective fashion. A pediatric anesthesiologist is an invaluable resource when treating injured children. A 1993 report from the Institute of Medicine identified specific pediatric emergency medical service deficiencies in rural states (Institute of Medicine, 1993), including the pediatric airway management, vascular access, and special resuscitation needs of injured children. Airway control is a primary tenet of trauma care, and proper endotracheal intubation (ETI) is recognized as a definitive method to achieve airway control. ETI, however, in injured children is required less often than in adults; hence, maintaining skills can be difficult for health care providers (Baker et al., 2009). Several studies have looked at airway management in pediatric trauma and examined significant aspects, including how success and complication rates of ETI vary by location (e.g., field, transferring hospital, or trauma center) and personnel, whether bag-mask ventilation is effective with respect to oxygenation and ventilation before ETI, and whether multiple attempts at intubation adversely affect patient care or outcomes (Cooper et al., 1992; Gausche et al., 2000; Glaeser, 2000; Ehrlich et al., 2004). These studies have demonstrated that field intubation success rates are poor. Successful pediatric intubations relate to the skill of the person performing the intubation, and anesthesiologists’ airway management skills are considered superior to those of all other health care professionals. Failed attempts at ETI appear to produce a spiral effect that results in multiple failed attempts and delayed transfer to definitive care. Complications resulting from ETI seem far more common when the intubation is attempted in the field and the risk of complication is exacerbated with each attempt. Increased complication rates do impact patient recovery, as shown by longer durations of hospitalization (Cooper et al., 1992; Gausche et al., 2000; Glaeser, 2000).

Triage Scores: Where Is the Injured Child Best Treated?

An ideal triage scoring system would have few data points, be easy to apply, have limited subjective assessments, and have a high sensitivity and specificity. Unfortunately, no triage score accomplishes all of these tasks, but each system does have strengths and limitations. For example, studies have shown that assessments made in the field by paramedics are less accurate and reliable for pediatric trauma patients when compared with adults (Engum, 2000). Alternatively, comparisons between adult and pediatric trauma triage scores have not shown that a pediatric specific trauma score provides a significant advantage over the original adult measure.

Glasgow Coma Scale

In 1974, Teasdale and Jennett first introduced the GCS. A lower score reflects a lower level of consciousness and therefore a potentially more serious head injury. Scores can range from 3 to a maximum of 15 (normal). The GCS measures three specific components of consciousness (eye movement, verbal, and motor responses) with higher scores (up to 5) given to the best response. A patient with a GCS of 13 to 14 is considered to have a mild head injury; 9 to 12 indicates a moderate injury; and a score of 8 or lower indicates a severe insult. Adaptations of the GCS for the pediatric population have occurred, and a Pediatric GCS is now widely used (Table 30-1).

GCS scores determined in the field are less predictive of outcome than those generated at a hospital (Meredith et al., 1995). When each individual component of the GCS is evaluated, the motor component is the strongest predictor of outcome.

Revised Trauma Score

The revised trauma score (RTS) is a physiologic-based triage score (Table 30-2). The RTS was derived from two earlier versions of a triage scores, the Triage Index and the Trauma Score (Champion et al., 1980, 1981, 1989). The RTS has three variables—respiratory rate, systolic blood pressure, and GCS. The RTS is the sum of each variable multiplied by a weighted coefficient.

TABLE 30-2 Revised Trauma Score*

* The Revised Trauma score is the sum of the weighted variables (see formula in text). The higher the score, the better the prognosis.

From Centers for Disease Control and Prevention: Traumatic brain injury in the United States: a report to Congress, Atlanta, 1999, Department of Health and Human Services National Center for Injury Control and Prevention.

where GCS is the Glasgow Coma Scale; SBP is systolic blood pressure; and RR is respiratory rate. These variables were determined to correlate statistically with survival and mortality. A higher RTS is associated with a better chance of survival. An injured patient with a RTS score of 11 or lower is recommended to be treated at a designated trauma center. Eichelberger established and developed pediatric coefficients for the RTS that was then validated in the pediatric population (Engum et al., 2000). The RTS is also recommended as one of the triage tools in the American College of Surgeons trauma guidelines, Resources for the Optimal Care of the Injured Patient (Committee on Trauma: American College of Surgeons, 1999).

Alert, Verbal, Painful, or Unresponsive Scale

This is a simple scale that categorizes a patient’s condition as alert, verbal, painful, or unresponsive (APVU). No numeric scores are given, but an injured child with a P or U should be taken to the designated trauma center. Subjective interpretation is inherent in this score, so it is best used as a component of the triage process, especially for children in whom the age and development of the child can impact the response. There is a significant risk of undertriaging patients when using this score.

Pediatric Trauma Score

The Pediatric Trauma Score (PTS) was first introduced by Tepas in 1987 (Tepas et al., 1987; Nayduch et al., 1991). Its design was thought to be more reflective of pediatric injuries (Table 30-3). Six variables comprise both physiologic and injury attributes. After a number for each variable is totaled, a score of 8 or lower is considered to be a marker for children requiring care at a designated trauma center. A limitation of the PTS is that some variables are subjectively scored, particularly the central nervous system (CNS) assessment. Therefore, there is a risk of interrater and intrarater variability. The PTS has been compared with the RTS with surprisingly few apparent differences or inherent advantages (Tepas et al., 1987, 1988; Nayduch et al., 1991).

TABLE 30-3 Pediatric Trauma Score

* A total score of 8 or less suggests care at a designated trauma center.

Data from Tepas JJ III, Mollitt DL, Talbert JL, et al: The pediatric trauma score as a predictor of injury severity in the injured child, J Pediatr Surg 22:14–18, 1987; Tobias JD, Ross AK: Intraosseous infusions: a review for the anesthesiologist with a focus on pediatric use, Anesth Analg 110:391–401, 2010.

Age-Specific PTS

The most recent proposed triage score is the Age Specific PTS (Table 30-4). First described by Potoka et al. in 2001, the main addition is the use of age-specific physiologic variables. To date, long-term data are lacking and only a single study suggests that it is better than traditional adult scores; therefore, the clinical utility as a triage score still remains to be proven. This score is, however, a pediatric-specific tool that addresses areas where other adult scores become less accurate (e.g., extremes of age).

Abbreviated Injury Scale

The Abbreviated Injury Scale (AIS) emerged from the automotive industry in 1969 (JAMA, 1971; Association for the Advancement of Automotive Medicine, 1990). It was initially designed as an epidemiologic tool to describe motorvehicle crashes but has been adapted to all types of trauma (JAMA, 1971; Association for the Advancement of Automotive Medicine, 1990). Revised and updated several times over the years, the first version published was the AIS-90 (for the year 1990) in 1998 (Association for the Advancement of Automotive Medicine, 1990). This score evaluates nine body regions. A scale from 1 to 6 is used to define injuries (1, minor; 2, moderate; 3, serious; 4, severe; 5, critical; and 6, maximal.) The underlying premise is an association of injury with threat to life. A body region with a score of 6 is considered an unsurvivable injury. The scores are determined retrospectively and based primarily on ICD-9-CM codes. A significant amount of expertise is required to assign these ratings, and interrater and intrarater variability is common. To help limit this phenomenon, software has been developed to convert the ICD-9-CM codes directly to an AIS score. Unfortunately, ICD-9-CM coding itself is inherently variable (MacKenzie et al., 1985, 1989).

Injury Severity Score

The Injury Severity Score (ISS) is one of the most widely used scoring systems in the trauma literature. It correlates well with several important trauma outcomes such as mortality and duration of hospitalization. Developed in 1974, the ISS is a method of characterizing the trauma patient with multiple injuries (Baker et al., 1974; Baker and O’Neill, 1976). The ISS is based on the AIS, which describes the severity of injury to different body regions (see the previous section). For example:

The above formula shows AIS scores of the three most injured of the following body regions: A, the head, neck, and face; B, the thorax and abdomen, and C, the extremities (including the external pelvis). The ISS takes scores from 0 to 75 (i.e., AIS scores of 5 for each category). However, if any of the three scores is a 6, the score is automatically set at 75, because a score of 6 indicates that an injury is unsurvivable.

Two modifications have been reported to the ISS score—the modified ISS (MISS) incorporating the GCS, and the New ISS, focusing on injuries over body regions. However, evaluations of both the MISS and new ISS have not shown advantages over the standard ISS; therefore, in many centers and registries the AIS-90 still remains the standard severity of injury scoring system.

Survival Probability: Trauma Score and Injury Severity Score

The Trauma Score and Injury Severity Score (TRISS) is not a score but rather a method of predicting mortality. It was first proposed in 1987 and combines the physiologic variables of the RTS with the anatomic severity-of-injury scores generated by the ISS (Boyd et al., 1987). The final result is that a probability of survival (Ps) is generated.

Where e is the base of the natural log 2.72183, and b is derived from the following formula:

The age factor is 0 for those younger than 55 years of age, and 1 for those who are 55 years of age. The variables b0, b1, b2, and b3 are blunt and penetrating trauma coefficients for adult and pediatric populations (Eichelberger et al., 1993).

TRISS is the most widely used predictor of survival in the trauma literature. As with other statistical processes, limitations exist. These are specifically noted in patients older than 55 years of age (extremes of age), and with trauma patients whose ISS is greater than 25. In fact, some authors suggest that because of the TRISS deficiencies, this method of calculating survival probabilities should be abandoned completely, particularly in urban centers (Cayten et al., 1991; Demetriades et al., 1998).

A Severity Characterization of Trauma Score

A Severity Characterization of Trauma (ASCOT) score is an attempt to revise and fix the limitations found using TRISS methodology (i.e., severely injured patients and extremes of age) (Champion et al., 1990b). ASCOT uses individual components of the RTS (not totaled) and incorporates a modification of AIS entitled The Anatomic Profile. Furthermore, it excludes those patients with either very severe or nonserious injuries (a maximum AIS score of less than 2 and an RTS score of greater than 0; an AIS score of 6 and an RTS score equal to 0). The Anatomic Profile categorizes the AIS scores that are greater than 2 into three groups: head, brain, and spinal cord injuries; thorax or neck injuries; and all other serious injuries. A comparison of ASCOT vs. TRISS with a pediatric population did not provide more reliable or accurate scoring over the TRISS.

Pediatric Age-Adjusted TRISS

This is a recent tool used to describe mortality that applies the pediatric-specific, age-adjusted PTS. Although it may be a more promising predictor of mortality, its data are limited and it has not been validated by other investigators (Schall et al., 2002).

The multitude of scoring systems reflect the reality that no single approach addresses all aspects of pediatric trauma accurately or provides the necessary tools to effectively answer all research questions. Many scoring systems suffer from inherent inaccuracies of coding (e.g., related to discharge diagnoses, ICD-9-CD diagnoses, and data on death certificates). Although physiologic variables generally seem to outperform anatomic variables in these systems, codification requires experience and training. Finally, certain elements of the laboratory data have been shown to be a strong predictor of mortality, yet these variables are not included in the prediction models.

Airway

The first step in trauma resuscitation is to assess the airway and then secure it when necessary to assure respirations. Indications for ETI include inability to oxygenate and ventilate and the need to protect the airway against aspiration. Appropriate management of the airway may be challenging or difficult without proper preparation and familiarity with the unique characteristics of the pediatric airway. In a young child or infant, the tongue is relatively large and the larynx and glottic opening are more anterior. A child’s airway has a smaller diameter and a shorter length. Airway edema occurring in an already small airway results in significant changes in the internal diameter of the airway and in increased resistance to airflow. The short length of the trachea makes right mainstem intubations more likely and increases the likelihood of extubation from small positional changes of the ET tube. Because the pediatric mid-face is small compared with the tongue, airway obstruction is common. Blood, vomit, teeth, and foreign bodies are common causes of airway obstruction. In addition, children are often placed in cervical collars that may be too large for them. This can make it hard see a child’s face and can present a challenge to identifying an airway obstruction. The first step to making the obstructed airway patent (while keeping the cervical collar on) is a jaw thrust with suction. Oral or nasal airways may be required if a jaw thrust is unsuccessful. If the airway is still not patent after these maneuvers, there should be consideration of a possible airway foreign body.

The initial management of the pediatric airway involves bag-valve-mask ventilation with a jaw-thrust maneuver. Intubation is indicated in patients with respiratory or cardiac compromise or an altered level of consciousness. All pediatric trauma patients should be considered to have a full stomach and possible cervical spine injury. See related video online at www.expertconsult.com.Because of this, the airway should be secured after a rapid-sequence induction (RSI) (that may include cricoid pressure) with manual inline stabilization and an oral ETI. Nasotracheal intubation may be suboptimal and difficult because of the small size and acute angle of the nasopharynx and the more anterior and cephalad position of the glottic opening.

The RSI for pediatric trauma patients can be accomplished with an induction agent that is immediately followed by a muscle relaxant. Standard induction agents for trauma patients include etomidate (0.2 to 0.3 mg/kg) and ketamine (2 to 4 mg/kg) or the combination of fentanyl (2 to 3 mcg/kg), midazolam (0.05 to 0.1 mg/kg) with lidocaine (1 mg/kg). Sodium thiopental (STP) and propofol should be reserved for patients who are not hemodynamically unstable. STP is an ideal induction agent for patients with head trauma, provided they are not hypovolemic. Ketamine is relatively contraindicated in patients with increased intracranial pressure (ICP). Although etomidate provides hemodynamic stability in trauma patients who are hypovolemic, it may decrease survival in patients with sepsis secondary to adrenal suppression (Annane et al., 2002). Muscle relaxation can be achieved with rocuronium (0.8 to 1.2 mg/kg) or succinylcholine (1 to 1.5 mg/kg). Succinylcholine is contraindicated in crush injuries, long-bone fractures, and patients susceptible to malignant hyperthermia. In patients who are hemodynamically stable, the combination of propofol (4 mg/kg) and remifentanil (3 mcg/kg) can be used for rapid-sequence intubation and has an onset and offset similar to propofol and succinylcholine (1 mg/kg) (Crawford et al., 2005).

ETIs have been deemphasized in the prehospital setting, because they are often unsuccessful. Gausche and others (2000) reported a success rate of only 57%. All intubated trauma patients that come to the emergency department should have the placement of their endotracheal tubes (ETTs) confirmed with either end-tidal carbon dioxide (CO₂) or direct laryngoscopy.

If initial intubation attempts are unsuccessful after an RSI, the patient should be ventilated with bag-mask ventilation. If a patient cannot be ventilated or if it is very difficult, a laryngeal mask airway (LMA) can be placed to facilitate ventilation and subsequent intubation. However, it must be recognized that the LMA does not protect the airway from aspiration and must be replaced by an ETT as soon as skilled personnel become available. The stomach should be decompressed with a nasogastric or orogastic tube after intubation, and a chest x-ray should be obtained to verify the ETT position (Fig. 30-2).

FIGURE 30-2 Gastric dilation often occurs after crying or positive-pressure ventilation by gas and mask.

Depending on the nature of the underlying injury, securing the airway in a patient who has sustained multiple injuries or even isolated facial injuries can be extremely complicated, as illustrated in Figure 30-3. The management of such cases calls upon the resourcefulness and skills of the anesthesiologist and requires careful consideration of damage to surrounding structures such as major blood vessels and the airway structures themselves. The ability to maintain a patent airway via face mask, and the potential for an expanding hematoma that may subsequently compromise an airway that may be patent at the current time, must be anticipated. Additional considerations include the risks of increased ICP with concomitant head trauma, exacerbating an existing cervical spine injury, and aspiration during airway manipulation. The presence of rhinorrhea, otorrhea, or ecchymoses around the eyes should raise suspicion about a possible basilar skull fracture, and any instrumentation of the nasal passages, including passage of a nasal ETT or an N/G tube, should be avoided. Similarly, crepitus at the neck may herald the presence of a tracheal disruption, and intubation under direct vision using a fiberoptic scope should be considered to avoid false passage of the ETT. See related video online at www.expertconsult.com.

FIGURE 30-3 An 11-year-old girl fell 10 to 15 feet while sliding down the school banisters onto a plant supported by a thick wooden pole. She eventually was intubated orally with direct laryngoscopy.

(From Melillo EP, et al: Difficult airway management of a child impaled through the neck, Paediatr Anaesth 11:615, 2001.)

In cases in which airway difficulty is anticipated, it may be prudent to transport the child to the operating room with an anesthesiologist and otolaryngologist once the child has been stabilized hemodynamically and additional injuries have been ruled out. The airway may then be secured with preparations to perform an emergent tracheostomy in case of failed laryngoscopy. An inhalational induction may be tolerated by the patient who has been volume resuscitated. This permits direct laryngoscopy or flexible fiberoptic intubation while the patient is breathing spontaneously. In patients who have suffered loss of consciousness or head injury, there should be a high index of suspicion for cervical spine injury, even with the absence of radiologic evidence. When performing laryngoscopy, inline axial stabilization must be performed (Fig. 30-4). Inline axial stabilization is performed by an assistant during laryngoscopy. The assistant should place both arms on either side of the patient’s head while gripping the patient’s shoulders. The assistant’s function is to maintain the patient in a neutral position during laryngoscopy, avoiding flexion, extension, or rotation of the cervical spine. The use of muscle relaxants is best avoided until the airway is secured. If intravenous agents are required to induce anesthesia, it is preferable to use short-acting agents such as propofol and remifentanil that effectively blunt ICP responses to direct laryngoscopy yet permit return of spontaneous respiration in case of failed intubation.

FIGURE 30-4 Manual axial inline stabilization during direct laryngoscopy.

Breathing

Assuring adequate ventilation is the next task after securing the airway. Breathing is best assessed by auscultation and observation of chest motion. During the primary assessment the patient should be assessed for the presence or absence of breathing, respiratory rate, and work of breathing. The chest should also be observed for symmetry of chest motion and breath sounds. The chest wall should also be observed for evidence of direct chest trauma resulting in abrasions, penetration, or chest-wall instability. The back needs to be assessed as well for posterior chest wall trauma. Although there are no concrete recommendations to guide intubation, pediatric patients with increased work of breathing or life-threatening injuries (head injuries) may require ETI. Immediately after ETT placement, the position should be confirmed with end-tidal CO₂. Patients in cardiac arrest or very small patients may require direct laryngoscopy. A portable chest x-ray and arterial blood gas should be obtained before leaving the trauma bay to determine the position of the ETT and its adequate delivery of oxygenation and ventilation. Continuous end-tidal CO₂ monitoring and pulse oximetry are useful adjuncts. Many injuries that impair respiration include simple, tension, and open pneumothorax; massive hemothorax; flail chest; and pulmonary contusion. A sudden change in the respiratory status after successful intubation should prompt an immediate evaluation for a reversible cause. An enlarged pneumothorax or development of a tension pneumothorax can occur after converting from spontaneous ventilation to positive pressure ventilation. Other causes for a decline in respiratory status include a displaced ETT (e.g., extubation or right mainstem intubation), obstruction in the ETT (e.g., blood or secretions), and equipment failure.

Circulation and Access

Children who sustain multiple injuries often arrive in hypovolemic or hemorrhagic shock that must be promptly recognized and treated. Unlike adults, children maintain an almost normal blood pressure until 25% to 35% of their circulating blood volume is lost (Fig. 30-5). This is likely because of their high sympathetic tone that causes peripheral vasoconstriction in an effort to maintain blood pressure in the face of a diminished blood volume. Therefore, tachycardia is an earlier sign of impending shock than hypotension. Additionally, signs of poor peripheral perfusion such as delayed capillary refill (more than 2 seconds), weak or thready pulses, mottling or cyanosis of the skin, and impaired consciousness are earlier indicators of shock than low blood pressure. The presence of hypotension as a result of hypovolemia should be considered an ominous sign that usually heralds impending cardiovascular collapse. Table 30-5 describes the stages of pediatric shock and clinical signs seen at these stages.

FIGURE 30-5 Increase in systemic vascular resistance in response to hypovolemia preserves blood pressure until 25% of blood volume is lost. Hypotension is a late sign of hypovolemia.

(From Rasmussen GE, Grandes CM: Blood, fluids, and electrolytes in the pediatric trauma patient, Int Anesthesiol Clin 32:79, 1994.)

TABLE 30-5 Stages of Pediatric Blood Volume Loss (Shock) and Associated Clinical Signs

CV, Cardiovascular; CNS, central nervous system.

From Rasmussen GE, Grandes CM: Blood, fluids, and electrolytes in the pediatric trauma patient, Int Anesthesiol Clin 32:79-101, 1994.

It is imperative to rapidly assess the pediatric trauma patient for signs of shock upon arrival in the trauma center and at regular intervals thereafter. The initial fluid bolus administered in the trauma setting is warmed isotonic crystalloid (lactated Ringer’s solution or normal saline) in a bolus of 20 mL/kg, IV (see Fig. 30-1). The pulse, capillary refill, and blood pressure are reassessed. A second bolus of 20 mL/kg is administered if there is no significant response or only a transient improvement in these parameters. A third crystalloid bolus may be given if necessary to maintain appropriate vital signs and circulation. Blood (10 mL/kg) should be administered next if additional fluid resuscitation is required. The need for blood transfusion initially is uncommon and usually signals surgical bleeding that may require an operation.

If shock persists and fails to respond to fluid therapy, other causes should be sought. Such causes may include long bone or pelvic fractures. Pericardial effusion and tamponade are less common occurrences in blunt trauma compared with penetrating injuries. The classic clinical signs of cardiac tamponade are shock, muffled heart sounds, pulses paradoxus, electrical alternans, and distended neck veins. Treatment requires immediate pericardiocentesis.

Pneumothorax is a common complication of blunt chest injury in children, with nearly one fourth of pneumothoraces under tension (Nakayama et al., 1992). Unilateral or bilateral tension pneumothoraces may produce hypotension and hypoxemia. The classic signs of tension pneumothorax are ipsilateral tympany, shift of the trachea to the contralateral side, and distended neck veins.

Significant occult blood loss may be overlooked on the initial examination of the small child and infant. Because the absolute blood volume of a child is small, the significance of external blood loss may be underestimated. In addition, blood accumulation in the infant’s large, expandable head and open fontanels can produce shock. Careful assessment of the abdomen is also central in the evaluation of the injured patient in shock.

Adequate large-bore IV access must be established as early as possible in the course of the resuscitation. Although peripheral routes offer the most rapidly accessible sites, such access may be difficult or impossible to obtain in the child with depleted intravascular volume or shock and resultant peripheral vasoconstriction. In such cases, a central venous catheter may be placed in the femoral or neck vessels if personnel with the necessary skills are available. Delays in establishing vascular access may be lifethreatening; therefore, if the above routes fail, intraosseous (IO) access should be rapidly initiated to expedite the administration of volume expanders and necessary pharmacologic agents. Once the child has been resuscitated, additional vascular access should be obtained.

IO access is placed in the medial surface of the proximal tibia 1 to 3 cm below the tibial tuberosity or the distal femoral metaphysis. IO has been used as a lifesaving measure to establish short-term vascular access in critically ill or injured children (Fig. 30-6).

FIGURE 30-6 Appropriate placement of the IO infusion needle on the medial surface, distal to tibial tuberosity.

(From Ellemunter H: Intraosseous lines in preterm and full-term neonates, Arch Dis Child Fetal Neonatal Ed 80:74F, 1999.)

The use of IO infusions in the algorithm of trauma and cardiopulmonary resuscitation has evolved over the years and now takes a more prominent role for providing vascular access to children. The subject of IO has been reviewed by Tobias and Ross (2010).

Access needles for IOs include manual devices such as butterfly needles, spinal needles, bone marrow biopsy needle such as Susfast (Cook Critical Care; Bloomington, Indiana) and the basic Jamshidi needle (Baxter Healthcare Corporation; Deerfield, Illinois). More recently, automated devices have been marketed (Fig. 30-7). The EZ-IO (Vidacare; San Antonio, Texas) functions like a battery-powered drill, with a beveled drill and a preset depth. It is designed to be used in the tibia. The Bone Injection Gun (BIG; Waismed; Kansas City, Missouri) is a spring-locked device also designed to be used in the tibia. It comes in a range of sizes for use in infants, small children, and adults. A device specifically designed for entry into the bone marrow of the sternum is the FAST1 (First Access for Shock and Trauma, PYN6 Medical Corporation; Vancouver, British Columbia). It is approved for patients ages 12 and older. Table 30-6 summarizes these devices. Details regarding instructions on the use of these devices can be viewed on the manufacturers’ websites.

FIGURE 30-7 Automated devices. A, EZ-IO. B, Bone Injection Gun.

(A, Courtesy Vidacare, San Antonio, TX; B, Courtesy Waismed, Kansas City, Mo.)

A review of the use of IO access in pediatric trauma patients up to 10 years of age reported successful placement of access in 28 out of 32 attempts in the prehospital setting and in the trauma care center (Guy et al., 1993). In this study, IO access was placed successfully by paramedics, nurses, and physicians with only one incident of minor extravasation of fluid and no long-term complications in the survivors. The commonest complication of IO access is subperiosteal infiltration that in most cases resolves spontaneously without further problems. The most feared complication—osteomyelitis—occurs in 0.6% cases (Rosetti et al., 1985). Other rare complications include fractures and emboli. Although few complications have been reported with this technique, it must be recognized that the high mortality in patients who require IO access prevents the assessment of long-term complications.

Disability (Neurologic Assessment)

A brief rapid neurologic evaluation is performed as part of the primary survey. It should include assessment of the patient’s level of consciousness and pupillary function. The AVPU method or the more detailed GCS should be performed. If AVPU is selected, the GCS calculation is performed during the secondary survey with a detailed neurologic examination. Periodic reassessment of the level of consciousness is necessary to detect neurologic deterioration caused by progression of traumatic brain injury (TBI), hypoxemia, or hypovolemia. Changes in mental status require prompt reevaluation of the ABCs. If they are adequately managed, then deterioration in mental status should be considered to be a result of TBI, prompting further brain imaging and consultation with a neurosurgeon.

Exposure

Exposure involves removing the trauma patient’s garments, usually with shears, to allow detailed physical examination and detect injuries. Rolling the patient, while maintaining cervical spine precautions, is necessary to identify injuries to the dorsal surface of the body that would otherwise be occult. Padding should be placed on the backboard at this time to prevent decubitus ulcer formation. This assessment should be rapid, and the patient should be covered in warmed blankets or with a warming device to prevent hypothermia. In addition, IV fluids should be warmed, and the room temperature should be raised. This is especially important in small children, who are more prone to hypothermia because of their larger surface area-to-volume ratio.

Secondary Survey