ATLS 2021 Pediatric Surgery Update

The priorities for evaluating a small child with multi-system trauma are the same as for an adult patient - airway, breathing, and circulation.

Pediatric patients have more pliable chests, so ribs don't necessarily break, but they can have significant pulmonary contusions and other injuries without obvious chest wall findings.

Pediatric patients are more susceptible to tension pneumothorax because their mediastinum is more mobile and shifts more easily in response to tension.

Pediatric patients have large tongues and large heads; when laid on a backboard, the large occiput flexes the head forward and can obstruct the airway.

True pediatric backboards have a cutout for the head or a built-in bump to keep the torso higher and maintain ear-in-line-with-shoulder alignment.

ATLS recommends needle cricothyroidotomy for children under 10 years old and surgical cricothyroidotomy for those over 10.

The choice between needle and surgical cricothyroidotomy depends partly on what the provider is most comfortable with; saving the child's life with potential tracheal damage is better than death from inaction.

Cricothyroidotomy (needle or surgical) is not a definitive airway; it buys time to get to the OR for formal tracheostomy.

A 10 mL syringe with IV catheter can be used for needle cricothyroidotomy and connects directly to an Ambu bag.

When performing needle cricothyroidotomy, you must allow for exhalation, not just continuous insufflation.

The old ATLS protocol was to give two 20 mL/kg crystalloid boluses before considering blood products.

Current ATLS teaching is to give one 20 mL/kg crystalloid bolus, and if there is transient or no response, move directly to blood products (10 mL/kg).

Pediatric blood volume is calculated as weight in kilograms times 80 mL (infants differ slightly).

A 12 kg child has a total blood volume of approximately 1 liter; a 25 kg child has approximately 2 liters.

Massive transfusion protocols have been proven to help in adults and there is data supporting their use in pediatrics as well.

Once a massive transfusion protocol is activated, blood products continue to arrive automatically until the protocol is deactivated; the key is remembering to call and stop it.

Glasgow Coma Scale can be performed in nonverbal children; they do not automatically receive zero or low verbal scores if they cannot talk normally for their age.

For nonverbal children on GCS verbal assessment: babbling/nonsense appropriate for age receives full score, irritable crying scores 4, moaning scores 2, and no response is most concerning.

The most concerning neurological sign in a young trauma patient is a child who does not cry or respond to painful stimuli like IV or IO placement, or a child who stops crying suddenly.

Children have more diffuse brain injuries in general than adults.

Child abuse is the most common cause of severe head injury in children less than 2 years old.

Children are more at risk for head injury because of large heads, soft skulls, and tendency to fall on their heads, leading to diffuse rather than focal injuries.

A multi-institutional algorithm for blunt abdominal trauma identifies approximately 35% of patients at very low risk (0.6%) of intraabdominal injury if they have no abdominal pain, no abdominal wall trauma/tenderness/distension, normal chest X-ray, AST less than 200, and normal pancreatic enzymes.

Having one positive criterion on the abdominal trauma algorithm does not mandate CT but stratifies risk; having multiple positive criteria increases risk further.