Welcome to the bed. We'll go ahead and give you
the story. This is all going to happen super
fast. Welcome to the emergency room. Welcome
to the Deep Dive. Today we're taking on a topic
that is just profoundly high stakes, essential
pediatric trauma care. And when you look at the
data, I mean, the need for this couldn't be clearer.
Injury is the single most common cause of death
and disability in kids. It surpasses everything,
all major diseases combined. Exactly. We're talking
about more than 10 million children a year in
the U .S. alone. needing emergency care for injuries.
These are the critical moments. They are. And
you know, our mission for this deep dive isn't
to reread a textbook. It's to apply the Pareto
Principle. The 80 -20 rule. Right. We're focusing
on the 20 % of the information. The formulas,
the pitfalls, the red flags that give you 80
% of what you need for that critical life -saving
management. It's the ultimate clinical shortcut.
So we're really focusing on the why. why kids
are different, the physiological traps, and those
tiny details that you have to remember when everything's
chaotic. And before we jump in, there's this
one need -to -know stat that I think frames the
whole discussion. Globally, for adolescents,
road traffic accidents are the number one killer.
Right, that's what we tend to think of. But for
infants... So kids under 12 months, the story
changes completely. For that group, child maltreatment
accounts for the great majority of homicides.
And that's a context you have to have in your
mind from the second that child comes through
the door. It sets the stage for everything. OK,
so let's start there with that fundamental principle.
A child is not just a small adult. Let's unpack
the physics of that. Why is multi -system injury
the rule? Well, it really just comes down to
the transfer of kinetic energy. Children have
a much smaller body mass, right? Right, so that
means any energy from blunt trauma a car fender
a follow It results in a much greater force being
applied per unit of body area. It's concentrated
and they have less padding less fat, less connective
tissue to absorb that shock. Exactly. That lack
of insulation means all the organs are packed
much closer together. So if you get a significant
impact to the torso, you're not just hitting
one thing, you're hitting multiple things. So
you have to assume it. Yeah. Multi -system entry
is the rule until you prove otherwise. You absolutely
have to. That has to be your default assumption.
And this physics also defines some of the anatomical
weak spots. Let's talk about those, like the
head and the skeleton. Sure. So take the head
first. It's proportionately much larger and heavier.
Right, that classic toddler look. And that creates
more momentum during any kind of deceleration.
So you see a much higher frequency of blunt brain
and cervical spine injuries, even in what seems
like a minor event. OK, and the skeleton? The
skeleton is more pliable. It's not fully calcified,
so it acts more like a flexible shell than a
rigid cage. So if the chest wall, for example,
is pliable, what does that mean for the organs
underneath? It means that the fractures we rely
on in adults to signal a massive energy transfer,
they're just less likely to happen in kids. A
rib fracture is actually pretty uncommon. But
you can still have a devastating injury underneath.
Oh, absolutely. A massive pulmonary contusion
can be hiding under a perfectly intact chest
wall. So if you do see a rib fracture or a skull
fracture, you have to assume the energy transfer
was absolutely immense. And that combination
of size and pliability also creates a huge problem
with heat. A major one. The high body surface
area to body mass ratio means they lose thermal
energy incredibly fast. Hypothermia sets in quickly,
and it complicates everything. Clotting, metabolism,
everything. So fighting heat loss is just as
important as stopping the bleeding. Yeah, yeah,
it up there. OK, so this leads us to maybe the
biggest prioritization shift in pediatric trauma.
Compared to adults, things like apnea and hypoxia
happen five times more often than hypovolemia
with hypotension. And that just hammers home
the point. You have to aggressively manage the
airway and breathing first. A and B before C.
Airway is number one. And you said positioning
is one of the smallest details that makes the
biggest difference here. It really is. We mentioned
that large occiput, the back of the head. When
a child is lying flat, it pushes the head forward,
flexes the neck, and immediately compromises
the airway. So how do you fix that while keeping
the spine safe? It's so simple. To get a neutral
position, you place a one -inch layer of padding
under the the infant's entire torso, shoulders
to hips. That's it. That one -inch lift compensates
for the head and brings the whole body into alignment.
It opens the airway. Missing that detail can
derail your whole resuscitation. And the challenges
don't stop there. Intubation is just... It's
a different world. Completely. You have a relatively
large tongue, large tonsils. The larynx itself
is funnel -shaped, and it sits higher up and
more anterior. It can feel like you're trying
to intubate around a corner. But the really critical
detail is the length of the trachea itself. Which
is incredibly short. An infant's trachea is only
about five centimeters long. Five. It only grows
to seven centimeters by 18 months. Wow. So any
little movement of the head or neck. And you
risk dislodging the tube or, just as bad, pushing
it into the right main stem bronchus. So getting
that ETT placement right from the start is paramount.
What are the rules for that, for sizing and depth?
Well, for sizing, a good rule of thumb is to
look at the size of the child's nostril or the
tip of their pinky finger. Ideally, you're using
a length -based tape, like a Braslo tape. But
here's the critical detail for depth. The calculation.
The optimal ETT depth in centimeters is three
times the appropriate tube size. So a 4 .0 tube
goes to 12 centimeters at the gum line. Exactly.
Three times the tube size. That calculation gives
you a reliable starting point and buys you critical
time before you get a chest x -ray to confirm.
That's so simple and so actionable. So once the
tube's in and things still go wrong, what's the
mental checklist for that? You need to know the
DOPE mnemonic. It's your troubleshooting guide.
D is for dislodgement, the biggest risk because
that trachea is so short. O is for obstruction
from secretions or a kink. P is for pneumothorax,
especially attention pneumo. And E is for equipment
failure. Always check your ventilator, your oxygen
source. And you said dislodgement is the one
that gets missed most often. In a chaotic room,
absolutely. Before we even get to intubation
though, there's a reflex in infants we have to
manage. Yes, the vagal response. It's profound.
Stimulating the larynx during intubation can
cause a dramatic severe bradycardia. So what's
the move? You have to consider pre -treating
with atropine sulfate for any infant getting
drug -assisted intubation. It counteracts that
vagal response and prevents a dangerous drop
in heart rate. Okay, so if we nail airway and
breathing, we give ourselves a fighting chance.
But now we move to circulation and this is where
you said the biggest physiological trap is hiding.
This is, without a doubt, the highest yield topic
for understanding pediatric shock. It's all about
the deceptive reserve. The deceptive reserve.
Children have these incredible, healthy hearts
that can maintain blood pressure by just jacking
up the heart rate. They can look stable with
a normal blood pressure, even when they've lost
a huge amount of blood. How much? Up to a 30
% decrease in their circulating blood volume.
30%. So if you're waiting for hypotension to
diagnose shock? You've already lost. You've missed
the critical window. You're waiting for the crash.
So what are the early signs then? If not blood
pressure, what are you looking for? It's subtle.
Tachycardia is often your only early key. That
and poor skin perfusion. So you're looking for
weakening peripheral pulses, cool arms and legs,
skin modeling. Which is the infant version of
clammy skin. Exactly. And the most measurable
sign is the narrowing of the pulse pressure.
If that gets to less than 20 millimeters of mercury,
you're in trouble. So when hypotension finally
does show up, it means decompensated shock. Massive
blood loss. Greater than 45 % of their total
volume. It's a crisis. And there's a formula
for that threshold, right? The point of no return.
Yes. And this is when you have to memorize. The
lower limit of normal systolic blood pressure
is 70 millimeters of mercury plus twice the child's
age in years. So for a five -year -old, 70 plus
10 is 80. Right. If they're below 80, they're
in decompensated shock. And the most terrifying
sign... If you see that heart rates suddenly
go from tachycardia to bradycardia while they're
hypotensive, that's impending cardiac arrest.
So time is absolutely everything. What's the
hierarchy for getting access? Peripheral IV is
what you try first, but you don't waste time.
If you can't get it after two attempts, you move
immediately to an IO. Intraeus. Proximal Tibia.
Proximal Tibia is the preferred site, and IO
is a lifesaver. You can get it in under a minute,
and it gets fluids into the system just as fast
as a central line. And once you have that access,
what's the initial fluid strategy? It's weight
-based. A 20 milliland per kilogram bolus of
warmed isotonic crystalloid. That's the standard.
Warmed. Always warmed. Now, you know, big trauma
centers are moving more toward damage control,
resuscitationless, crystalloid, more blood products
early. But that 20 per kilo bolus is still the
standard first step everywhere else. OK. And
what's the one clinical measure we can use to
know if our resuscitation is actually working?
The smallest detail, but so important, urinary
output. For infants, the goal is high, one to
two millimals per kilo per hour. For older kids,
it's about 0 .5 to 1 .5. If you're not hitting
those numbers, you're not caught up. Got it.
Okay, let's shift to a couple of focused areas,
head and abdominal trauma. For head trauma, there's
a rule about hypotension that gets misunderstood.
Yeah, and it's non -negotiable. Hypotension is
almost never caused by a head injury alone. Unless
the situation is catastrophic. Right, unless
they're resting. If a child with a head injury
is hypotensive, you have to look for another
source of massive bleeding. Chest, abdomen, pelvis.
The hypoxia and hypovolemia will kill the brain
faster than the injury itself. What about imaging?
We're always worried about radiating kids, so
how do we decide who needs a CT? That's where
the PCARN criteria come in. It's a validated
screening tool that helps you identify the low
-risk kids who do not need a CT scan. It's a
crucial tool for balancing diagnosis against
that long -term cancer risk from radiation. Okay,
let's move to the abdomen. What's the one physical
sign that should immediately make you suspect
a major internal injury? This seatbelt sign.
If you see bruising or abrasions from a shoulder
or lap belt, your suspicion for an intra -abdominal
injury has to go way, way up. Especially for
things like bowel perforation or a lumbar fracture.
Exactly. That sign is a major red flag. And this
brings us to a huge paradigm shift in management,
especially for solid organ injuries like the
liver or spleen. It is a huge shift. The modern
approach is selective non -operative management
as long as the child is hemodynamically stable.
So even if you see blood on a fast scan or the
CT shows a high -grade spleen injury If the child
is stable and responding to fluids, you do not
automatically rush to the operating room. The
presence of blood does not mandate surgery if
the vital signs are normal. We want to save that
spleen if we possibly can. What's the big pitfall
with using fast scans in this situation? You
can't rely on it to rule out an injury. It's
great for finding free fluid, but it can't see
injuries inside the organ itself. The ultimate
pitfall is delaying surgery when you shouldn't.
If that child becomes unstable despite resuscitation,
they need to go to the OR immediately. Got it.
Okay, finally, let's hit a few high -risk pitfalls.
Let's say a child has an isolated closed femur
fracture and they're hypotensive. What's that
tell you? It tells you to look somewhere else.
An isolated femur fracture just doesn't cause
that much blood loss. It's not enough to cause
decompensated shock. If they're unstable, the
bleed is somewhere else. Probably the abdomen.
And what about spinal injuries? Kids' spines
are so flexible. That they can sustain a devastating
spinal cord injury without any broken bones on
an x -ray. It's called Cicora. Spinal cord injury
without radiographic abnormality. Right. It's
much more common in kids. So if the neurological
exams suggest a cord injury, you have to assume
the spine is unstable, even if the x -rays look
perfect. Looking at the long term, the outcomes
can be... Pretty sobering. They can be. Up to
60 % of severely injured kids have residual personality
changes a year later. 50 % have cognitive or
physical handicaps. You're always thinking about
the future growth plate injuries causing a leg
length discrepancy, the lifelong risk of sepsis
after a splenectomy. Which brings us back to
the most critical pitfall we have to discuss.
Child maltreatment. This is a vital area for
every clinician. You have to know the red flags.
The biggest one is a major discrepancy between
the story and the injury. Like a major head injury
from falling off a couch. Exactly. Or injuries
that don't match the developmental stage, like
leg fractures in an infant who can't walk yet.
And what about the physical findings? You're
looking for bruises of different colors, which
suggest different stages of healing, injuries
around the mouth, and skull or rib fractures
in any child under two years old are huge red
flags. And as a clinician, the mandate is clear.
It's absolute. You are legally required in most
places to report suspected maltreatment, and
you have to, because a third of the kids who
die from maltreatment were seen before for a
prior unrecognized injury. Reporting is prevention.
So to pull our 20 % guide together, airway and
breathing first, using that one -inch padding
under the torso, the 3X ETT depth rule and the
DOPE mnemonic. For circulation, it's recognizing
mass shock through tachycardia and a narrow pulse
pressure, and knowing the hypotension formula,
and then the red flags for things like the femur
fracture rule, and most importantly, for maltreatment.
That's a great summary. And despite all of that...
Despite the challenges and the long -term effects,
here's the final thought that I think justifies
everything we do. The long -term quality of life
for children who survive major trauma is surprisingly
positive. Most of them report a good to excellent
quality of life as adults. That incredible resiliency
is why we fight so hard in those first chaotic
minutes. That is a powerful final justification.
And it leads us to our final provocative thought
for you, the listener. The source material states
that the greatest pitfall of all is our failure
to prevent these injuries in the first place,
noting that up to 80 % of them are preventable.
And for every dollar spent on prevention, $4
are saved in hospital care. So building on that,
what are the most effective local coalitions
needed in your community to actively turn these
devastating statistics around? Something to think
about. The work definitely doesn't stop when
the child leaves the trauma day. Thank you for
diving deep with us.