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IntroductionChildren differ from adults anatomically, physiologically, cognitively and psychologically. The aim of this chapter is to outline these differences, and how they influence the assessment and management of traumatic injury in childhood. These differences will be discussed with regard to their impact on:
Different mechanism of injuryTrauma is the greatest contributor to childhood mortality[i]. Childhood activities and the changing levels of maturity of children expose them to different risks to adults. Children are more likely to fall from playground equipment, suffer sporting and playground accidents than be involved in motor vehicle or industrial accidents like their parents. They are, therefore, at risk in proportion to their level of cognitive, physical and social development.[ii]
Different patterns of injuryWhen involved in the same kind of accident as adults, children may suffer quite different injuries because of their different size, anatomy and physiology. Airway injuriesInfants and small children have smaller airways – minor injuries and slight swelling can rapidly compromise their ability to breath. A similar injury in different aged children can raise different concerns, and have varying consequences. For example, nasal fractures are common in adolescents (especially in those playing contact sports) and rarely need immediate intervention. However, the same injury in an infant, who is an obligate nose breather, may require immediate assistance. Such injuries are rare in small children – given their limited mobility and smaller, more protected noses, so if present, a nasal injury in these age groups should raise the suspicion of non-accidental injury. Chest injuriesThoracic injuries are a significant cause of mortality in paediatric trauma. The lack of complete ossification of the ribs and sternum mean the underlying structures are less well protected – leading to the potential for pulmonary / mediastinal injury to occur without significant signs of external injury. Children also have a relative lack of physiological reserve and higher metabolic rate can lead to rapid desaturation in children. Abdominal injuriesAs with their thorax, the abdominal contents of children are relatively unprotected due to a thin abdominal wall with less fat and underdeveloped musculature. The liver and spleen are less protected by the rib cage and are thus at greater risk from blunt abdominal trauma. Common mechanisms of injury include motor vehicle accidents and handlebar injuries. Any bruising of the abdomen - in particular the "seat belt" sign - signifies an increased risk of intra-abdominal injury. However, the compliance of the abdominal wall means significant injury can exist with only non-specific or subtle external signs. Head and neck injuriesYoung children, with relatively large heads and underdeveloped musculature sustain higher proportions of isolated head injuries than older children.[i] Traumatic Brain Injury is the leading cause of death in paediatric trauma patients. Young children are also more likely to injure their upper C-spine region (as opposed to the lower C-spine in adults) for the same reason - however due to the types of accidents they have cervical spine injury is rare in childen. Spinal cord injuries are relatively uncommon in the paediatric trauma patient – however, children less than 8 may be susceptible to SCIWORA (spinal cord injury without radiological abnormality). Extremities and ExposureBlunt trauma may result in bone fractures in the adult population, while the cartilaginous nature of children’s bones tends to prevent them from fracturing. However, lack of a fracture does not mean absence of injury. Protective equipment and clothing can be harder to obtain for children compared to adults. The varying and constantly changing sizes of growing children make correct sizing of helmets, car restraints and so on difficult and expensive for families. Older children may succumb to peer group pressure and refuse to use protective wear such as knee splints, wrist guards and helmets. Finally, the larger surface area / volume ratio puts children at greater risk of hypothermia following their trauma. Non-accidental injuriesSuspicion may be aroused by:
It is important to remember that age is one of the most important risk factors in non-accidental injury – with the majority of abusive fractures being seen in children <12 months. Some injury patterns are more suggestive of a non-accidental injury:
Where non-accidental injury is suspected, local policies must be followed. This typically involves consultation with a senior clinician, social worker and forensic medical service. Where there are immediate safety concerns Child Protection Services need to be contacted to ensure the safety of that child or their siblings. [i] Bayreuther J et al. Paediatric trauma: injury pattern and mortality in the UK. Arch Dis Child Educ Pract Ed 2009. 94(2):37-41 Differences in taking a historyGiven the wide spectrum of injuries sustained by children and their range of developmental stages, health care practitioners need to be skilled at obtaining a history from parents, care-givers, children and other health-care providers. Consideration should always be given to whether the mechanism of injury described is consistent with the child’s developmental age. AMPLE is an acronym used for gathering a brief history of patient and event in the context of a minor injury. A Allergies – in children this may be unknown M Medications - typically fewer than in the adult population P Past medical history - Children are generally healthy and don’t usually present with complex medical histories. However, practitioners should ask about previous injuries – a history of recurrent presentations with injuries may raise suspicion for NAI. L Last ate - important if procedural sedation is required or the patient needs to go to theatre E Event - what happened? Immunisation and birth history are also important elements of the history which need to be documented:
Where children are more severely injured, they may arrive at hospital via the emergency services. It is common in this situation to use a formal handover tool such as the IMIST - AMBO tool. This acronym stands for:
Examination and managementPrimary surveyThe function of the Primary Survey is to rapidly identify and manage immediate life threats. It focuses on the following:
AirwayPaediatric airway is smaller
Relatively larger tongue and smaller oral cavity
Infants have a relatively larger occiput
Infants are nose breathers.
Trachea is more cartilaginous and soft
Larynx is higher and more anterior.
Only an experienced clinician should attempt intubation in the young child. Shape of the epiglottis
Cricoid ring is the narrowest point in the airway
The trachea is short
Cervical Spine
Breathing Ribs positioned more horizontally
Adult chest x-ray showing arched ribs:
Neonate chest x-ray showing flattened ribs:
Thin chest wall
Diaphragmatic breathing
Intercostal retraction:
Fewer Type 1 fibres in respiratory muscles
Respiratory rate varies with age
Heart rate
CirculationBlood volume is relatively larger, but absolute volume is smaller
Systemic vascular resistance is lower
Hypotension is a late sign
Fixed-stroke volume
Smaller vessels / more subcutaneous tissue
Disability - Central Nervous System (CNS)Open sutures, presence of fontanelle
Thinner cranial bones
Head relatively larger
Cognitive and psychological development varies with age
ExposureRelatively small size
Higher BMR and surface area
Increased glucose requirements but decreased glycogen stores
Secondary surveyChestChest wall is more compliant.
Increased mobility of the mediastinal structure
AbdomenRelatively thin abdominal wall
Abdominal organ proportions and placement
Diaphragm is more horizontal
MusculoskeletalGrowth plates not fused
Cartilaginous bones
ConclusionChildren and infants differ, both anatomically and physiologically, from adults. These differences will have an impact on the assessment and management of paediatric trauma. However it is important to recognise that the basic principles of trauma care - airway, breathing and circulation - remain the same, regardless of the age of the patient. Appendix 1Normal paediatric vital signs by age group
Reference ListAdvanced Life Support Group. (1997). Advanced Paediatric Life Support. (2 ed.). London: BMJ Publishing Group. Ojanen Thomas, D. (1988). The ABC's of Pediatric Triage. Journal of Emergency Nursing, 14(3), 154 - 159. Soud, T. (1992). Airway, breathing, circulation, and disability: what is different about kids? Journal of Emergency Nursing., 18(2), 107-16. When assessing a 7 year old child which activity would the nurse expect the child to perform?According to Piaget, what behavior should the nurse expect to find in a 7-year-old child? The child classifies and sorts facts to solve problems.
Which finding indicates an 8 year old is a latchkey child?Which finding indicates an 8-year-old is a latchkey child? The child is unsupervised at home after school.
Which age group of children enjoys finger foods and exhibits dawdling and regression select all that apply?(Dawdling and regression behaviors are common in preschoolers and toddlers. These children also enjoy finger foods. The age range of a toddler is 1 - 3 years and the age range of a preschooler is 3 -6 years.
Which stage of moral development is indicated when a child says I must follow the rules otherwise I will be punished?Stage 1: (Punishment and Obedience Orientation).
(“I must follow the rules otherwise I will be punished”).
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