Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 10 n Pediatric Trauma
for other organ system injury, as more than twothirds
of children with chest injury have multiple
injuries. The mechanism of injury and anatomy of
a child’s chest are responsible for the spectrum of
injuries seen.
The vast majority of chest injuries in childhood are
due to blunt mechanisms, most commonly caused
by motor vehicle injury or falls. The pliability, or
compliance, of a child’s chest wall allows kinetic
energy to be transmitted to the underlying pulmonary
parenchyma, causing pulmonary contusion. Rib
fractures and mediastinal injuries are not common; if
present, they indicate a severe impacting force. Specific
injuries caused by thoracic trauma in children are
similar to those encountered in adults, although the
frequencies of these injuries differ.
The mobility of mediastinal structures makes children
more susceptible to tension pneumothorax, the
most common immediately life-threatening injury in
children. Pneumomediastinum is rare and benign in the
overwhelming majority of cases. Diaphragmatic rupture,
aortic transection, major tracheobronchial
tears, flail chest, and cardiac contusions are also
uncommon in pediatric trauma patients. When
identified, treatment for these injuries is the same
as for adults. Significant injuries in children rarely
occur alone and are frequently a component of major
multisystem injury.
The incidence of penetrating thoracic injury increases
after 10 years of age. Penetrating trauma to the chest
in children is managed the same way as for adults.
Unlike in adult patients, most chest injuries in
children can be identified with standard screening
chest radiographs. Cross-sectional imaging is
rarely required in the evaluation of blunt injuries
to the chest in children and should be reserved
for those whose findings cannot be explained by
standard radiographs.
Most pediatric thoracic injuries can be successfully
managed using an appropriate combination of
supportive care and tube thoracostomy. Thoracotomy
is not generally needed in children. (Also
see Chapter 4: Thoracic Trauma, and Appendix G:
Breathing Skills.)
Abdominal Trauma
Most pediatric abdominal injuries result from blunt
trauma that primarily involves motor vehicles and
falls. Serious intra-abdominal injuries warrant prompt
involvement by a surgeon, and hypotensive children
who sustain blunt or penetrating abdominal trauma
require prompt operative intervention.
Assessment
Conscious infants and young children are generally
frightened by the traumatic events, which can
complicate the abdominal examination. While talking
quietly and calmly to the child, ask questions about
the presence of abdominal pain and gently assess the
tone of the abdominal musculature. Do not apply deep,
painful palpation when beginning the examination;
this may cause voluntary guarding that can confuse
the findings.
Most infants and young children who are stressed
and crying will swallow large amounts of air. If the
upper abdomen is distended on examination, insert a
gastric tube to decompress the stomach as part of the
resuscitation phase. Orogastric tube decompression
is preferred in infants.
The presence of shoulder- and/or lap-belt marks
increases the likelihood that intra-abdominal injuries
are present, especially in the presence of lumbar
fracture, intraperitoneal fluid, or persistent tachycardia.
Abdominal examination in unconscious patients
does not vary greatly with age. Decompression of the
urinary bladder facilitates abdominal evaluation.
Since gastric dilation and a distended urinary bladder
can both cause abdominal tenderness, interpret this
finding with caution, unless these organs have been
fully decompressed.
Diagnostic Adjuncts
Diagnostic adjuncts for assessing abdominal trauma
in children include CT, focused assessment with
sonography for trauma (FAST), and diagnostic
peritoneal lavage (DPL).
Computed Tomography
Helical CT scanning allows for the rapid and precise
identification of injuries. CT scanning is often used
to evaluate the abdomens of children who have sustained
blunt trauma and have no hemodynamic
abnormalities. It should be immediately available and
performed early in treatment, although its use must
not delay definitive treatment. CT of the abdomen
should routinely be performed with IV contrast agents
according to local practice.
Identifying intra-abdominal injuries by CT in pediatric
patients with no hemodynamic abnormalities can
allow for nonoperative management by the surgeon.
Early involvement of a surgeon is essential to establish
a baseline that allows him or her to determine whether
and when operation is indicated. Centers that lack
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