Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 10 n Pediatric Trauma
treating surgeon must make the decision to perform
angioembolization.
Nonoperative management of confirmed solid organ
injuries is a surgical decision made by surgeons, just as
is the decision to operate. Therefore, the surgeon must
supervise the treatment of pediatric trauma patients.
Specific Visceral Injuries
A number of abdominal visceral injuries are more
common in children than in adults. Injuries such as
those caused by a bicycle handlebar, an elbow striking a
child in the right upper quadrant, and lap-belt injuries
are common and result when the visceral contents are
forcibly compressed between the blow on the anterior
abdominal wall and the spine posteriorly. This type
of injury also may be caused by child maltreatment.
Blunt pancreatic injuries occur from similar mechanisms,
and their treatment is dependent on the extent
of injury. Small bowel perforations at or near the
ligament of Treitz are more common in children than
in adults, as are mesenteric and small bowel avulsion
injuries. These particular injuries are often diagnosed
late because of the vague early symptoms.
Bladder rupture is also more common in children
than in adults, because of the shallow depth of the
child’s pelvis.
Children who are restrained by a lap belt only are at
particular risk for enteric disruption, especially if they
Pitfall
Delay in transfer in
order to obtain CT
scan
Delayed identification
of hollow
visceral injury
Delayed
laparotomy
prevention
• Recognize that children who
will be transferred to a trauma
center are not likely to benefit
from imaging at the receiving
hospital.
• Recognize that the risk of
hollow viscus injury is based
on the mechanism of injury.
• Perform frequent reassessments
to identify changes
in clinical exam findings as
quickly as possible.
• Recognize that early involvement
of a surgeon is necessary.
• Recognize that persistent
hemodynamic instability in a
child with abdominal injury
mandates laparotomy.
have a lap-belt mark on the abdominal wall or sustain
a flexion-distraction (Chance) fracture of the lumbar
spine. Any patient with this mechanism of injury and
these findings should be presumed to have a high
likelihood of injury to the gastrointestinal tract, until
proven otherwise.
Penetrating injuries of the perineum, or straddle
injuries, may occur with falls onto a prominent object
and result in intraperitoneal injuries due to the
proximity of the peritoneum to the perineum. Rupture
of a hollow viscus requires early operative intervention.
(Also see Chapter 5: Abdominal and Pelvic Trauma.)
HEAD Trauma
The information provided in Chapter 6: Head Trauma
also applies to pediatric patients. This section emphasizes
information that is specific to children.
Most head injuries in the pediatric population
are the result of motor vehicle crashes, child
maltreatment, bicycle crashes, and falls. Data from
national pediatric trauma data repositories indicate
that an understanding of the interaction between the
CNS and extracranial injuries is imperative, because
hypotension and hypoxia from associated injuries
adversely affect the outcome from intracranial injury.
Lack of attention to the ABCDE’s and associated
injuries can significantly increase mortality from
head injury. As in adults, hypotension is infrequently
caused by head injury alone, and other explanations
for this finding should be investigated aggressively.
A child’s brain is anatomically different from that
of an adult. It doubles in size in the first 6 months
of life and achieves 80% of the adult brain size by
2 years of age. The subarachnoid space is relatively
smaller, offering less protection to the brain because
there is less buoyancy. Thus, head momentum is more
likely to impart parenchymal structural damage.
Normal cerebral blood flow increases progressively
to nearly twice that of adult levels by the age of 5
years and then decreases. This accounts in part for
children’s significant susceptibility to cerebral hypoxia
and hypercarbia.
Assessment
Children and adults can differ in their response to head
trauma, which influences the evaluation of injured
children. Following are the principal differences:
1. The outcome in children who suffer severe brain
injury is better than that in adults. However,
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