Chapter 38. The injured child
Differences between children and adults
Children differ from adults in the following ways:
• Size – smaller size means that a child sustains more injuries than an adult would sustain from the same force
• Shape – the child’s relatively large head means that more forces may be applied through the neck during deceleration. A falling child tends to land head first
• Skeleton – the skeleton in children is very elastic, the child may sustain internal organ damage without overlying fracture; lung contusion may occur without overlying rib fracture because the ribs are more pliable
• Surface area – the larger surface area relative to body size in children means more rapid heat loss can occur.
Psychological problems
A careful and gentle approach is needed to the assessment and treatment of a frightened child who is in pain. Children almost invariably find the presence of a parent calming and although they may not understand what is said, continuous quiet speech is also reassuring. Under stressful circumstances, the child may regress to a younger age and may not behave as might be expected for the chronological age.
Equipment
Appropriately sized and designed equipment must be available in order to allow appropriate treatment.
Specific differences
Airway
• Relatively large tongue and easily damaged soft palate. This is why oropharyngeal airways are inserted the right way up instead of rotating them during insertion
• Relatively large epiglottis which should be picked up directly by the laryngoscope blade to allow better visualisation of the vocal cords
• Relatively short trachea. When inserted, the black vocal cord marker near the tip of the endotracheal tube should be placed at the level of the cords. After placement it is essential that intubation of the right main bronchus has been excluded
• The narrowest part of the upper airway is below the level of the cords at the level of the cricoid, cuffed ET tubes should be avoided to avoid necrosis of the wall of the trachea
• The larynx is more difficult to visualise
• Surgical cricothyroidotomy should not be performed in children; only needle cricothyroidotomy is appropriate.
Breathing
• Children have low oxygen reserves and their metabolism uses oxygen very quickly, so if ventilation is impaired, cyanosis rapidly ensues
• Children breathe rapidly, if ventilatory support is needed, then the rate of ventilation should be around 20 breaths/minute for a child and 40 breaths per minute for an infant. The volume of the ventilation is best judged by watching the child’s chest move
• Children do not tolerate tension pneumothorax well. This is because the mediastinum is very mobile and it can be pushed across to compress the other lung by the increased pressure within the injured hemithorax. Repeated assessment of air entry in the ventilated child and early needle cricothyrotomy are therefore of paramount importance.
Circulation
• The heart rate in children is faster than in adults
• In children under 1 year old, the minimum acceptable normal systolic pressure is 70 mmHg
• In children older than 1 year, the expected systolic pressure can be worked out by the formula:
• The circulating blood volume of a child is approximately 80 mL/kg, which means that the total blood volume of a neonate is likely to be around 240 mL
• A child’s first response to a decrease in blood volume is a tachycardia. The next response is usually cool skin at the peripheries, with a drop in blood pressure as a late sign. The absence of low blood pressure does not exclude the diagnosis of shock
• In the majority of cases, immediate evacuation to hospital for fluid therapy and possible surgical intervention is the most appropriate course of action. In cases of prolonged transfer or entrapment, however, prehospital fluid administration may be required
• Try the antecubital fossa or in a child under 1 year old, the dorsum of the hand or foot and have a low threshold for switching to intraosseous access.
Disability (neurological status)
• Children frequently sustain head injuries because of the relatively large size of their head. Vomiting once or twice after head injury is common and does not necessarily imply increased intracranial pressure, however persistent vomiting will require admission for observation and possible investigation
• As with adult head injuries periods of hypoxia or hypovolaemia must be avoided
• Infants can lose a large proportion of their circulating volume from scalp lacerations or into haematomas within the scalp. Head injuries do not otherwise cause hypotension
• The key to optimum management is the prevention of secondary brain injury by paying attention to the airway, breathing and circulation. This, combined with rapid evacuation to definitive care, is far more important than attempts at neurological assessment
• The AVPU assessment can be used in children but the Glasgow Coma Scale has to be modified for children younger than 4 years of age.
Non-accidental injury
Healthcare professionals have a responsibility for the protection of children. It is important that a child who is being deliberately abused is identified and protected from further injury. All healthcare professionals need to be aware of the features of non-accidental injury. Suspicion should be aroused by:
• A history that does not fit the apparent injuries
• A delay in seeking help
• An inappropriate response from the child or carers
• Inconsistent history of the injury.
Injuries that are especially associated with a non-accidental cause include:
• Injuries around the mouth
• Injuries around the genital area
• Long-bone fractures in children under 3 years old
• Bizarre injuries such as cigarette burns or rope burns.
It is important that prehospital personnel pass on any suspicions to the healthcare professionals to whom the case is handed on at the hospital.
For further information, see Ch. 38 in Emergency Care: A Textbook for Paramedics.
