Pediatric Trauma Patients

Trauma in the pediatric population is more challenging to both assess and manage, limited communication skills in combination with a variety of anatomical and physiological differences create a potentially dangerous situation, especially if care is delivered without considering several of the aftermentioned differences. This section will review some of the specific differences that affect patients in the EMS setting and a specialized assessment tool, the Pediatric Assessment Triangle (PAT).

Special Considerations in Pediatric Trauma

• HEAD: EMS providers should recognize that pediatric patients have heavy heads with weak neck muscles, increasing their risk of cervical spine injury and predisposing them to brain trauma induced by coup-contrecoup forces such as in shaken-baby syndrome. 

Since an infant's head is larger than the rest of their body, placing padding under their shoulders will help to maintain a neutral position.  For children < 4 years of age, padding under the shoulders to the upper torso will render the sniffing position. 

• CHEST: The increased chest wall flexibility in pediatric patients increases the chances of flail chest in the presence of significant chest trauma.
• RESPIRATORY RATE: Normal respiratory rates in pediatric trauma patients vary with age, what is normal for an adult may be fatal for an infant. Forgetting this can lead to under-treating respiratory distress. Signs of increased work of breathing are generally more visible in pediatric patients due to their small size.
• BLOOD PRESSURE: Normal blood pressure may be present in pediatric patients even during the later stages of shock, they tend to decompensate suddenly and without warning. Rapid and regular reassessment is vital to the care of these patients.
• HEART RATE: Bradycardia may represent hypoxia in pediatric patients, heart rates below 60 can be fatal for neonatal patients, and heart rates in the normal adult range are generally too low for extremely young pediatric patients. Bradycardic pediatric patients should be ventilated as hypoxemia is one of the most common causes of pediatric bradycardia.
• IMMOBILIZATION: To prevent flexion of the neck during cervical immobilization, EMS providers should pad beneath the pediatric patient from the shoulders to the hips. This is required due to the increased flexibility of the pediatric spine.
• INCREASED VULNERABILITY: EMS providers should understand that pediatric patients are more susceptible to trauma from vehicle crashes, pedestrian versus vehicle collisions, drownings, burns, falls, and penetrating trauma. Due to both their smaller size and their decreased awareness of the environment and its various hazards. 

Pediatric Assessment Triangle (PAT)

The PAT is a tool similar to the ABCs that focuses on the three key signs that are vital in the assessment of a pediatric patient. Appearance, work of breathing, and circulation to the skin. 

Appearance: children in traumatic situations should appear stressed, panicked, tearful, and hyperactive or hyperaware. Fatigued-appearing, lethargic, or unresponsive children should prompt significant concern.

Work of Breathing: Nasal flaring, grunting, and intercostal retractions are easy to see in children who are in respiratory distress. The presence of these are also signs of impending respiratory collapse, the small size of children and their increased need for oxygen relative to their size makes decompensation a rapid process when it occurs.

Circulation to the Skin: The final element of the PAT, the presence of cyanosis, cold extremities, or mottled skin are reliable signs that sufficient circulation or oxygenation is not occurring. If a pulse is to be checked in a pediatric patient, the most reliable site is the brachial pulse, which is best felt on the medial aspect of the bicep 2/3 of the way up the upper arm. Blood pressure can be unreliable in young patients, hence the use of circulatory signs as a key part of the PAT.