From
StayCurrentMD
ATLS 2021 Pediatric Surgery Update
With Dr. Rich Falcone · hosted by Dr. Rod Gerardo & Dr. Todd Ponsky & Dr. Ellen Encisco
Part of
Hemorrhagic Shock 4 items
Chapter 3 of 6 · Acute Management
Airway management
Airway Management in Pediatric Trauma
Cued at 6:57 · press play
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
The priorities when evaluating a small child with multi-system trauma are the same as for an adult patient: airway, breathing, circulation (ABCs).
Pediatric patients have more pliable chests so ribs don't necessarily break, but they can have a lot of pulmonary contusions and other injuries.
Pediatric patients have a more mobile mediastinum that will shift more easily in response to tension pneumothorax compared to older patients.
Airway management should follow a stepwise approach starting with simple maneuvers like jaw thrust before progressing to more invasive interventions.
Pediatric patients have big tongues and big heads; when laid on a backboard, the large occiput flexes the head forward and can obstruct the airway.
Some pediatric backboards have a cutout for the head or a bump to keep the torso higher and maintain ear-in-line-with-shoulder positioning.
ATLS guidelines recommend needle cricothyroidotomy for patients under 10 years old and surgical cricothyroidotomy for patients over 10.
Provider comfort level matters in cricothyroidotomy choice; saving a life with potential tracheal damage is better than death from inaction.
Pediatric blood volume can be calculated as weight in kilograms times 80 mL.
A 12 kg child's entire blood volume is approximately one liter; a 25 kg child has approximately 2 liters.
Massive transfusion protocols have been proven to help, with more data in adults but also data supporting use in pediatrics.
Once a massive transfusion protocol is activated, blood products continue to arrive automatically until the protocol is stopped; providers must remember to deactivate it.
Thromboelastography (TEG) can guide transfusion management if readily available at the institution.
Glasgow Coma Scale can be assessed in nonverbal children; they should not automatically receive a low verbal score just because they cannot talk.
For nonverbal children, if babbling or saying nonsense is normal for their age, they receive full verbal score; if irritable and crying, they get a 4; if moaning, a 2; if doing nothing, that is most concerning.
A young child who does not cry in response to IV stick or IO placement, or who stops crying suddenly, is most concerning from a neurostatus perspective.
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 big heads, soft skulls, and tendency to fall on their heads.
Trauma and trauma-related injuries are the number one killer of pediatric patients.
MIST stands for mechanism of injury, injuries identified, signs and symptoms, and treatments.
Cricothyroidotomy is not a definitive airway; it buys time to get to the OR for formal tracheostomy.
For needle cricothyroidotomy, a 10 mL syringe with IV catheter can connect to an Ambu bag for ventilation.
Intraosseous (IO) access can be placed in the tibia, humeral head, or distal femur.
The old ATLS protocol was to give 20 cc/kg crystalloid bolus, assess response, give another 20 cc/kg, and only then use blood products.
Updated ATLS guidelines recommend one crystalloid bolus at 20 cc/kg, and if there is transient or no response, proceed directly to blood products at 10 cc/kg.
For a child to start showing signs of hemorrhagic shock, they would have to lose about 50% of their total blood volume.
Over 75% of pediatric trauma deaths are due to head injuries.
Validated algorithms exist to determine when head CT is not needed in pediatric trauma, with different criteria for children younger than 2 versus older than 2.
For children younger than 2, head CT may not be needed if the child is not acting different per parents, has no skull fracture, and meets other criteria.
For children older than 2, additional head CT decision criteria include history of vomiting and signs of basilar skull fracture.
A multi-institutional algorithm for blunt abdominal trauma uses criteria including abdominal pain, abdominal wall trauma/tenderness/distension, abnormal chest X-ray, AST greater than 200, and abnormal pancreatic enzymes.
If all blunt abdominal trauma algorithm criteria are negative (approximately 35% of patients), the risk of intraabdominal injury is very low at 0.6%, with 0.0% requiring intervention.
Having one positive criterion on the blunt abdominal trauma algorithm does not mandate CT but increases risk; multiple positive criteria further increase risk.