Paediatric Trauma

Quick Answer

What makes paediatric trauma different from adult trauma?

Paediatric trauma requires understanding of age-specific physiology, different injury patterns, and the highest index of suspicion for non-accidental injury. Key principles:

1. Blood volume - 80 mL/kg (neonate) to 70 mL/kg (older child); hypovolaemic shock manifests late
2. TBI management - Age-specific GCS, higher tolerance for hypotension but avoid hypoxia at all costs
3. Hypotensive resuscitation - Systolic BP targets: 70 + (2 × age in years) mmHg
4. Massive transfusion - Ratios extrapolated from adult data; warm all fluids
5. Non-accidental injury - 10-25% of paediatric trauma; mandatory reporting obligations

Clinical Pearl: Children compensate for hypovolaemia remarkably well - they maintain BP until 30-40% blood loss. When the BP drops, it drops catastrophically. Don't wait for hypotension to recognise shock.

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Clinical Overview

Epidemiology

Burden of paediatric trauma:

Mechanism by age:

Injury Patterns

Unique paediatric anatomy affects injury patterns:

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Physiological Considerations

Blood Volume and Haemorrhage

Age-specific blood volumes:

Shock classification (paediatric adaptation):

Critical concept: Children maintain BP through vasoconstriction and tachycardia until 30-40% blood loss. A "normal" BP in a tachycardic child does NOT mean they are not in shock.

Cardiovascular Response

Compensatory mechanisms:

1. Tachycardia - Primary response (earliest sign)
2. Vasoconstriction - Maintains BP despite volume loss
3. Increased contractility - Maximal in first hours

Decompensation signs (ominous):

• Bradycardia (late sign, pre-arrest)
• Hypotension (indicates severe shock)
• Altered consciousness
• Decreased urine output

Age-specific BP targets:

Pulse pressure:

• Narrowing indicates early shock (diastolic maintained, systolic falling)
• Difference <20 mmHg concerning

Respiratory Considerations

Age-specific differences:

Implications:

• Higher oxygen demand + smaller reserves = rapid desaturation
• Fatigue occurs earlier (type I muscle fibres less developed)
• Small airways obstruct easily (post-traumatic oedema critical)

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Primary Survey (ABCDE)

A - Airway

Considerations:

• Large tongue relative to oropharynx (obstruction risk)
• High anterior larynx
• Cricoid is narrowest point (cuffed vs uncuffed ETT debate)

Management:

Cervical spine:

• Immobilise in neutral position (child's neck more flexible, injury at higher level)
• "Sniffing position" in infants = neutral (large occiput)
• Hard collar + blocks + tape

B - Breathing

Assessment:

• Rate, depth, symmetry, work of breathing
• Palpate for chest wall tenderness, crepitus
• Percussion for dullness (haemothorax) or hyperresonance (pneumothorax)

Life-threatening injuries:

Clinical Pearl: Children have compliant chest walls - severe intrathoracic injury can occur WITHOUT rib fractures. Don't be falsely reassured by intact ribs on X-ray.

C - Circulation

Haemorrhage control:

• Direct pressure for external bleeding
• Tourniquet for extremity haemorrhage (time-stamped)
• Pelvic binder for suspected pelvic fracture

Access:

Intraosseous access:

• Any age (formerly <6 years, now accepted in all ages)
• Sites: Proximal tibia, distal tibia, distal femur, humeral head
• All medications and fluids can be given IO
• Complications: Compartment syndrome, extravasation, osteomyelitis (rare)

D - Disability

Paediatric GCS (age-appropriate):

Pupils:

• Size, symmetry, reaction
• Fixed dilated = urgent neurosurgical consultation
• Unilateral dilated = expanding mass lesion

AVPU scale (simpler alternative):

• Alert
• Verbal response
• Pain response
• Unresponsive

E - Exposure

Complete examination:

• Log roll maintaining C-spine immobilisation
• Check back, perineum, between skin folds
• Remove all clothing
• Prevent hypothermia (warm blankets, warmed fluids, ambient temperature)

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Traumatic Brain Injury (TBI)

Pathophysiology

Primary injury:

• Occurs at moment of impact
• Not reversible
• Includes: Contusions, lacerations, diffuse axonal injury, haematomas

Secondary injury:

• Occurs minutes to days after trauma
• Potentially preventable
• Mechanisms:
  • Hypoxia (SaO2 <90% doubles mortality) [3]
  • Hypotension (systolic BP <90 mmHg doubles mortality) [4]
  • Hyper/hypocapnia
  • Hyperthermia
  • Seizures
  • Intracranial hypertension

Management Priorities

The "sacred triad" - avoid at all costs:

Specific targets:

Intracranial Hypertension

Signs of raised ICP:

Management of raised ICP:

Clinical Pearl: Hyperventilation is a double-edged sword. It reduces ICP acutely but causes cerebral vasoconstriction and may worsen ischaemia. Use only as bridge to definitive therapy.

Imaging

Indications for CT head:

C-spine clearance:

• Clinical clearance if:
  • Alert, no midline tenderness, no distracting injury, no intoxication, no neurological deficit
  • If not meeting criteria: CT C-spine or MRI

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Fluid Resuscitation and Blood Products

Initial Resuscitation

Balanced crystalloid:

• 20 mL/kg boluses (warm to 37°C)
• Reassess after each bolus
• Typical requirement: 40-60 mL/kg for moderate shock

Blood products:

• If haemodynamically unstable after 40-60 mL/kg crystalloid
• O-negative if crossmatch not available
• Warm all blood products

Permissive Hypotension

Rationale:

• Avoids "popping the clot" in uncontrolled bleeding
• Reduces dilutional coagulopathy
• Adult data supports improved outcomes

Paediatric targets:

Contraindications:

• TBI (cerebral perfusion dependent on MAP)
• Spinal cord injury
• Isolated head injury

Massive Transfusion Protocol (MTP)

Definition:

• Transfusion of ≥50% blood volume in 3 hours
• Or ≥100% blood volume in 24 hours

Paediatric blood volume estimates:

MTP ratio (extrapolated from adult data):

Adjuncts:

• Calcium: Maintain ionised Ca >1.1 mmol/L (citrate binding)
• Tranexamic acid: 15 mg/kg IV over 10 min (if <3 hours from injury) [5]
• Fibrinogen: Maintain >1.5-2.0 g/L (cryoprecipitate or fibrinogen concentrate)
• pH: Avoid acidosis (reduces coagulation factor activity)
• Temperature: Maintain >35°C

Clinical Pearl: Hypothermia, acidosis, and hypocalcaemia form the "lethal triad" of coagulopathy. Address all three aggressively in massive transfusion.

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Anaesthetic Management

Induction

Principles:

• Ketamine is neuroprotective and maintains BP (excellent for trauma)
• Avoid propofol in hypovolaemic patients (vasodilation, myocardial depression)
• Etomidate acceptable (stable hemodynamics) but adrenal suppression
• Opioids - titrate carefully (reduced dose in hypovolaemia)

RSI technique:

• Standard unless difficult airway predicted
• Cricoid pressure (controversial, but often used)
• In-line stabilisation if C-spine not cleared

Induction drugs:

Maintenance

Balanced technique:

• Ketamine infusion (optional) or low-dose volatile
• Opioid infusion (fentanyl 1-3 mcg/kg/hr)
• Muscle relaxation (atracurium or rocuronium)

Ventilation:

• Protective lung strategy
• Avoid hypocapnia in TBI (cerebral vasoconstriction)
• PEEP appropriate (helps prevent atelectasis)

Monitoring

Procedures Under Anaesthesia

Diagnostic imaging:

• CT head/chest/abdomen/pelvis ("pan-scan")
• May require intubation for uncooperative/injured child
• Minimise transport risks

Interventional radiology:

• Embolisation for active bleeding
• Sedation/anaesthesia required
• Same monitoring standards as OR

Emergency surgery:

• Damage control surgery prioritised
• Haemorrhage control before definitive repair
• Return to ICU for rewarming, correction of coagulopathy

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Non-Accidental Injury (NAI) / Child Abuse

Recognition

Epidemiology:

• 10-25% of paediatric trauma admissions [6]
• <1 year: Up to 50% of fractures are inflicted [7]
• Mortality from abuse: 20-40% for severe head injury [8]

Red flags:

Specific injuries highly suggestive of abuse:

Mandatory Reporting

Legal obligations:

• All Australian states/territories: Mandatory reporting by doctors
• New Zealand: Mandatory reporting under Oranga Tamariki Act
• Suspicion alone (not proof) is sufficient to report
• Protection of reporter (good faith reporting protected)

Process:

1. Document thoroughly - Photographs, diagrams, verbatim quotes
2. Consult - Social work, child protection team, senior colleagues
3. Report - State child protection services, police if criminal
4. Safety - Ensure child not discharged to unsafe environment
5. Follow-up - Ensure investigation occurs

The "differential diagnosis" approach:

• Don't confront parents with accusation
• Frame as "we need to rule out..."
• Medical workup for bleeding disorders, bone fragility (Osteogenesis imperfecta), rickets
• Skeletal survey (<2 years), ophthalmology exam

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Indigenous Health Considerations

Aboriginal and Torres Strait Islander Children

Disproportionate trauma burden:

Contributing factors:

• Geographic isolation (limited trauma services)
• Higher rates of socio-economic disadvantage
• Overcrowding housing (burns, falls)
• Limited water safety infrastructure in remote areas
• Higher rates of domestic violence (NAI risk)

Cultural considerations in trauma care:

1. Communication in emergency:

   • Use Aboriginal Liaison Officers immediately
   • Family decision-making processes
   • May need to contact extended family for consent
   • Language barriers in high-stress situations

2. Child abuse recognition:

   • Higher baseline rates of injury in some communities
   • Don't dismiss injuries as "cultural practices"
   • Same high index of suspicion required
   • Mandatory reporting applies regardless of ethnicity

3. Remote and rural challenges:

   • Distance to trauma centres
   • RFDS/retrieval delays
   • Need for primary hospital stabilisation
   • Telemedicine support from tertiary centres

4. Post-trauma support:

   • Rehabilitation services limited in remote areas
   • Psychological support may be culturally inappropriate
   • Connection to Country important for healing

Māori Children (Aotearoa New Zealand)

Health disparities:

• Higher injury mortality rates than European children
• Higher rates of intentional injury
• Geographic barriers similar to Aboriginal children

Whānau involvement:

• Trauma affects whole whānau
• Decision-making involves extended family
• Respect for tikanga around serious illness/injury
• Whānau may wish to karakia (pray) at bedside

Oranga Tamariki:

• Child protection services
• Māori children over-represented in system
• Cultural considerations in assessments
• Māori-led services preferred where available

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ANZCA Professional Standards

Relevant Guidelines

Trauma-Specific Requirements

Personnel:

• Trauma-trained anaesthetist
• Paediatric airway skills
• Experience with massive transfusion
• Child protection training (recognition of NAI)

Equipment:

• Age-appropriate airway equipment
• Warming devices (forced air, fluid warmers)
• Rapid infuser
• Blood products immediately available
• IO access equipment

Environment:

• Trauma bay with resuscitation capability
• Operating theatre immediately available
• Paediatric ICU
• Child protection protocols in place

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Assessment Content

Short Answer Questions (SAQs)

SAQ 1: Paediatric Shock Recognition (20 marks)

Question:

A 5-year-old child (weight 20 kg) is brought to the emergency department after a motor vehicle crash. On arrival: HR 150, BP 90/60, RR 30, capillary refill 4 seconds, cool peripheries. Describe the assessment of haemorrhagic shock in children and outline your initial resuscitation. (20 marks)

Model Answer:

Shock Assessment (8 marks):

Clinical signs (4 marks):

• HR 150 (tachycardic for age - normal 80-120)
• BP 90/60 = MAP 70 (within normal range for age)
• Narrow pulse pressure (30 mmHg) suggests early shock
• Capillary refill 4 seconds (>2 seconds = abnormal)
• Cool peripheries (vasoconstriction)
• RR 30 (mild tachypnoea, compensatory)

Interpretation (2 marks):

• Class II shock (15-25% blood loss, compensated)
• Child maintaining BP through vasoconstriction and tachycardia
• Blood volume for 20 kg = 1.4-1.5 L
• 15-25% loss = 210-375 mL blood loss
• BP normal does NOT mean not in shock

Age-specific considerations (2 marks):

• BP maintained until 30-40% blood loss in children
• Tachycardia is earliest sign of shock
• Delayed capillary refill and cool peripheries confirm peripheral vasoconstriction

Resuscitation (12 marks):

Immediate (4 marks):

• 100% O2 via non-rebreather mask
• Two large peripheral IVs (20-22G)
• C-spine immobilisation (MVC mechanism)
• Full primary survey (ABCDE)
• Blood gas, FBC, crossmatch, coagulation

Fluid resuscitation (4 marks):

• Warmed crystalloid (0.9% NaCl or balanced solution)
• 20 mL/kg boluses (400 mL for 20 kg)
• Reassess after each bolus
• Target: HR <120, capillary refill <2 seconds, warm peripheries
• If no response after 40-60 mL/kg → blood products

Blood products (2 marks):

• PRBC 10-15 mL/kg if ongoing bleeding
• Permissive hypotension (SBP target 70 + 2×age = 80 mmHg)
• Warm all products
• Consider tranexamic acid (15 mg/kg) if <3 hours from injury

Monitoring (2 marks):

• Continuous pulse oximetry, ECG, BP
• Urine output (target >1 mL/kg/hr)
• Temperature (prevent hypothermia)
• Serial blood gases (lactate, Hb)
• Consider arterial line

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SAQ 2: Traumatic Brain Injury (20 marks)

Question:

An 8-year-old child presents with severe traumatic brain injury following a fall. GCS is 7 (E2, V1, M4). Discuss the principles of preventing secondary brain injury and the specific targets for physiological parameters. (20 marks)

Model Answer:

Secondary Brain Injury Prevention (8 marks):

Concept (2 marks):

• Primary injury occurs at moment of impact and is irreversible
• Secondary injury occurs minutes to days later and is preventable
• Goal is to prevent secondary insults that worsen outcome

Key mechanisms (3 marks):

• Hypoxia (cerebral ischaemia)
• Hypotension (reduced cerebral perfusion)
• Hyper/hypocapnia (cerebral blood flow dysregulation)
• Hyperthermia (increased metabolic demand)
• Seizures (increased metabolic demand)
• Intracranial hypertension (reduced perfusion)

Evidence (3 marks):

• Hypoxia (SaO2 <90%) doubles mortality
• Hypotension (SBP <5th percentile) doubles mortality
• Each secondary insult worsens functional outcome
• Prevention is cornerstone of neuroprotective strategy

Physiological Targets (12 marks):

Airway and breathing (3 marks):

• Intubate if GCS ≤8 (protect airway, optimise ventilation)
• SpO2 >95% (avoid hypoxia at all costs)
• PaO2 >100 mmHg (adequate oxygenation)
• PaCO2 35-40 mmHg (avoid hypocapnia - causes vasoconstriction)
• PEEP appropriate (prevents atelectasis, doesn't worsen ICP if euvolaemic)

Circulation (3 marks):

• Systolic BP >5th percentile for age:
  • Age 8: 70 + (2×8) = 86 mmHg minimum
  • Target 90-100 mmHg ( CPP = MAP - ICP, target CPP 50-70)
• Maintain euvolaemia (avoid fluid overload or dehydration)
• MAP >65-70 mmHg typically required

Other parameters (3 marks):

• Temperature 36-37°C (avoid fever, maintain normothermia)
• Head position 30° elevation (improves venous drainage)
• Head midline (no neck rotation)
• Normoglycaemia (avoid hyper/hypoglycaemia)

ICP management if raised (3 marks):

• First-line: Head elevation, sedation, head midline
• Mannitol 0.25-0.5 g/kg (osmotherapy)
• 3% hypertonic saline 3-5 mL/kg (alternative osmotherapy)
• CSF drainage via EVD if available
• Hyperventilation only as bridge (causes vasoconstriction)
• Decompressive craniectomy for refractory ICP

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SAQ 3: Non-Accidental Injury (20 marks)

Question:

A 10-month-old infant presents with a skull fracture and bilateral retinal haemorrhages after a reported "fall from couch." The parents report the child fell while learning to walk. Describe the features suggestive of non-accidental injury and your management obligations. (20 marks)

Model Answer:

Features Suggestive of NAI (10 marks):

Historical red flags (4 marks):

• Developmental inconsistency: 10-month-old not walking independently (developmentally inappropriate)
• Mechanism doesn't match injury: Simple fall from couch unlikely to cause complex skull fracture + bilateral retinal haemorrhages
• Delayed presentation: Time lag between injury and seeking care
• History changes: Inconsistent accounts from different caregivers
• Unwitnessed injury: No one saw the "fall"

Injury pattern (4 marks):

• Bilateral retinal haemorrhages: Highly suggestive of shaking (acceleration-deceleration injury)
• Complex skull fracture: More force than simple short fall
• Pattern injuries: Consider other bruises/marks (handprints, belt marks, loop marks)
• Multiple injuries: Check for fractures in different stages of healing (skeletal survey)
• Visceral injuries: Unexplained abdominal trauma

Behavioural observations (2 marks):

• Child's behaviour: Fearful of parents, frozen watchfulness, indiscriminate attachment
• Parental behaviour: Hostile, blaming, avoiding eye contact, minimizing injury
• Inappropriate affect: Parent not distressed given severity of injury

Management Obligations (10 marks):

Medical assessment (3 marks):

• Full physical examination (log roll, check back, perineum)
• Document all injuries: Photographs, diagrams, measurements
• Skeletal survey (mandatory <2 years with suspected abuse)
• Ophthalmology examination (indirect ophthalmoscopy for retinal haemorrhages)
• Head CT (acute injury) and MRI (subacute/chronic injuries)
• Consider bleeding disorder workup (differential diagnosis)

Documentation (2 marks):

• Verbatim quotes from caregivers (history, explanations)
• Detailed description of injuries (location, pattern, colour, age)
• Photographs with consent or clinical indication
• Diagrams marking injuries
• No definitive statements about intent ("findings concerning for...")

Mandatory reporting (3 marks):

• All Australian states: Doctors must report suspicion of child abuse
• New Zealand: Mandatory reporting under Oranga Tamariki Act
• Report to child protection services (not police directly unless immediate danger)
• Suspicion alone is sufficient (no proof required)
• Good faith reporting is protected

Child safety (2 marks):

• Do not discharge to unsafe environment
• Consult social work, child protection team
• Liaison with child protection services before discharge
• Ensure child is safe or admitted under protective custody if needed

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Viva Voce Scenarios

Viva 1: Severe Haemorrhagic Shock (15 marks)

Scenario: A 3-year-old child (15 kg) is brought in after being hit by a car. HR 180, BP 60/40, unresponsive, cool peripheries, capillary refill 5 seconds.

Examiner Questions:

Q1: "What class of shock is this and what is the estimated blood loss?" (5 marks)

Model Answer:

• Class III/IV shock (severe, decompensated)
• BP 60/40 is profoundly hypotensive for age
  • Normal SBP for 3 years: 70 + (2×3) = 76 mmHg
  • 60 mmHg is severe hypotension
• HR 180 (severe tachycardia)
• Altered consciousness (GCS reduced)
• Cool peripheries, capillary refill 5 seconds

Blood volume: 15 kg × 70-75 mL/kg = 1,050-1,125 mL Estimated loss: >40% = >420-450 mL This is life-threatening haemorrhage

Q2: "What is your immediate management?" (5 marks)

Model Answer:

• Call for help (trauma team, blood bank, surgeon)
• 100% O2 via non-rebreather
• Two large IVs or intraosseous access if no IV in 60 seconds
• Fluid resuscitation:
  • Warmed crystalloid 20 mL/kg bolus (300 mL)
  • If no response → blood products immediately
  • O-negative blood if crossmatch not ready
• Blood products:
  • PRBC 10-15 mL/kg (150-225 mL)
  • FFP and platelets if massive transfusion
  • Warm all products
• Monitoring:
  • ECG, pulse oximetry, BP (arterial line when possible)
  • Temperature, urine output
• Treat reversible causes:
  • Tension pneumothorax? (needle decompression)
  • Cardiac tamponade? (pericardiocentesis)
  • External haemorrhage control

Q3: "What are the targets for blood pressure in this child?" (5 marks)

Model Answer:

• Age-specific target: 70 + (2 × age) = 76 mmHg minimum

• Permissive hypotension: 70-80 mmHg systolic acceptable in this scenario

  • Rationale: Avoid "popping the clot" in uncontrolled bleeding
  • Reduce dilutional coagulopathy
  • Adult trauma data supports improved outcomes

• However: If TBI present, need higher MAP for cerebral perfusion

  • CPP = MAP - ICP
  • Target CPP 50-60 in children
  • If ICP elevated, need MAP 60-70 minimum

• Individualise: Based on:

  • Presence/absence of TBI
  • Response to fluid
  • Urine output (>1 mL/kg/hr)
  • Mental status

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Viva 2: Traumatic Brain Injury Crisis (15 marks)

Scenario: You are anaesthetising a 6-year-old with severe TBI (GCS 6) for emergency craniotomy. During induction, the pupil on the side of the lesion becomes dilated and non-reactive.

Examiner Questions:

Q1: "What is happening and why?" (5 marks)

Model Answer:

• Unilateral dilated pupil = expanding intracranial mass lesion on that side
• Mechanism: Transtentorial (uncal) herniation
  • Temporal lobe uncus herniates through tentorial incisura
  • Compresses ipsilateral CN III (oculomotor nerve)
  • Parasympathetic fibres on outer surface of nerve affected first
  • Loss of parasympathetic input → unopposed sympathetic → mydriasis
• Critical sign: Indicates brainstem compression, life-threatening
• Requires: Immediate action to reduce ICP

Q2: "What are your immediate management steps?" (5 marks)

Model Answer:

• Immediate ICP reduction measures:

  1. Head position: Elevate head 30° (if not already)
  2. Mannitol: 0.5 g/kg IV bolus (or 3% saline 5 mL/kg)
  3. Hyperventilation: Acutely to PaCO2 30-35 mmHg (temporary measure only)
  4. Sedation/paralysis: Ensure adequate (prevent coughing, straining)
  5. CSF drainage: If EVD in situ

• Surgical urgency:

  • Expedite craniotomy
  • Communicate with surgeon (herniation occurring)
  • Prepare for possible decompressive craniectomy

• Haemodynamic support:

  • Maintain MAP (cerebral perfusion)
  • Avoid hypotension at all costs

Q3: "What is the evidence regarding hyperventilation in TBI?" (5 marks)

Model Answer:

• Effect: Hyperventilation → ↓ PaCO2 → cerebral vasoconstriction → ↓ cerebral blood volume → ↓ ICP (acute effect)

• Risks:

  • Cerebral vasoconstriction reduces cerebral blood flow
  • Risk of cerebral ischaemia (especially in injured brain)
  • Rebound hyperaemia when normalised
  • Worse outcomes if prolonged

• Current recommendations:

  • Avoid routine prophylactic hyperventilation
  • Use only as temporary bridge (e.g., herniation syndrome)
  • Target PaCO2 35-40 mmHg normally
  • If hyperventilating, consider jugular venous oxygen monitoring or brain tissue oxygen monitoring
  • Normalise as soon as possible (e.g., after surgical decompression)

• Alternative: Hypertonic saline preferred for ICP reduction (no vasoconstriction risk)

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