Paediatric Trauma

Quick Answer

Paediatric trauma is the leading cause of death and acquired disability in children aged 1-14 years. Children differ from adults in anatomy (large head, pliable skeleton, less protected solid organs), physiology (higher blood volume per kg but lower absolute volumes, immature thermoregulation), and injury patterns (head injury predominance, multiple organ injury common). Primary survey adaptations include age-appropriate ETT sizing (Age/4 + 3.5 for cuffed), smaller needle decompression (2nd ICS), early IO access for fluid-refractory shock, 10-20 mL/kg crystalloid boluses (cautious approach), and aggressive hypothermia prevention. ICU management focuses on neuroprotection (age-adjusted CPP targets), damage control surgery principles, paediatric massive transfusion protocols, and early recognition of non-accidental injury (NAI). Australian context includes higher Indigenous trauma mortality and need for RFDS retrieval in remote areas.

---

CICM Exam Focus

⚠️

Second Part Written SAQ Stems

Hot Case Presentations

Scenario 1: Injured Child Day 1 Post-Admission

• 7-year-old pedestrian struck by vehicle
• Severe TBI (GCS 8 pre-intubation), ICP monitor in situ
• Grade III splenic laceration (non-operative management)
• L femur fracture, external fixator in situ
• Expected assessment: A-E approach, neuromonitoring interpretation, abdominal monitoring, fracture care, family communication

Scenario 2: Polytrauma Day 3 ICU

• 12-year-old cyclist without helmet
• Post-decompressive craniectomy for refractory ICP
• Pulmonary contusions, on mechanical ventilation
• Developing ARDS, coagulopathy resolving
• Expected assessment: Ventilator optimisation, ICP/CPP review, nutrition, thromboprophylaxis timing, rehabilitation planning

Viva Topics

---

Key Points

✅

1. Trauma is the leading cause of death in children 1-14 years, with TBI accounting for 70-80% of trauma-related mortality [1]
2. Anatomical differences predispose children to diffuse brain injury (large head), internal organ injury with minimal external signs (pliable skeleton), and higher cervical spine injuries (C1-C3) [2]
3. Physiological compensation maintains blood pressure until 25-30% blood volume is lost, making hypotension a late and ominous sign [3]
4. Primary survey adaptations: Cuffed ETT size = Age/4 + 3.5, needle decompression at 2nd ICS MCL, IO access if IV fails x2 or 90 seconds, 10-20 mL/kg crystalloid boluses [4]
5. PECARN decision rules guide CT imaging in minor head trauma with high sensitivity (96-100%) for clinically important TBI [5]
6. Non-operative management is successful in 90-95% of blunt splenic injuries and 85-90% of blunt hepatic injuries [6]
7. NAI must be considered in all paediatric trauma, especially in pre-ambulatory children with unexplained injuries or inconsistent history [7]
8. CPP targets are age-specific: Infants >40 mmHg, 1-5 years >50 mmHg, 6-17 years >60 mmHg [8]
9. Hypothermia is a major threat due to high surface area:volume ratio; active warming is critical [9]
10. Indigenous children have 2-3x higher trauma-related mortality; culturally safe care is essential [10]

---

Definition and Epidemiology

Definition

Paediatric trauma refers to physical injury in children (typically defined as 0-16 or 0-18 years depending on jurisdiction) resulting from external mechanical, thermal, electrical, or chemical forces. Major trauma is defined as Injury Severity Score (ISS) >15 or single injury with an Abbreviated Injury Scale (AIS) score ≥3.

Classification by mechanism:

• Blunt trauma: Motor vehicle crashes, falls, pedestrian/cyclist vs vehicle, sports injuries (85-90% of paediatric trauma)
• Penetrating trauma: Stab wounds, gunshot wounds (5-10%, higher in certain regions)
• Burns/thermal: House fires, scalds (5-8%)
• Other: Near-drowning, electrical injury, blast injury

Epidemiology

ℹ️

Global Burden:

• Leading cause of death in children 1-14 years worldwide [1]
• 830,000 deaths per year in children under 18 years from unintentional injuries (WHO 2018) [11]
• 95% of paediatric trauma deaths occur in low- and middle-income countries

Australian/New Zealand Data:

• Australia: ~2,500 paediatric major trauma admissions annually [12]
• Trauma mortality in children: 3-5 per 100,000 per year [13]
• 15-20% of paediatric trauma patients require PICU admission
• Māori children in NZ: 2x higher TBI incidence compared to non-Māori [14]
• Aboriginal and Torres Strait Islander children: 2-3x higher trauma mortality [10]

Mechanism by Age:

Head Injury Predominance:

• TBI is present in 60-80% of major paediatric trauma [15]
• TBI accounts for 70-80% of trauma-related deaths in children [1]
• Multiple injuries common (30-40% of severely injured children have ≥2 body regions injured)

---

Applied Basic Sciences

🧠

Anatomical Differences

Head and Neurological:

Chest:

Abdomen:

Pelvis and Skeleton:

Physiological Differences

💓

Cardiovascular:

Critical Insight: Children maintain blood pressure through vasoconstriction and tachycardia until 25-30% blood volume is lost. Hypotension is a late and ominous sign indicating decompensated shock [3].

Hypotension Definition by Age:

• <1 year: SBP <70 mmHg
• 1-10 years: SBP <70 + (2 x age in years) mmHg

• 10 years: SBP <90 mmHg

Respiratory:

Thermoregulation:

Neurological:

---

Injury Patterns

⚠️

Pattern Recognition by Mechanism

Motor Vehicle Crash (Restrained vs Unrestrained):

• Restrained: Cervical spine (flexion-distension), abdominal wall contusion, hollow viscus injury (lap belt), thoracolumbar spine (Chance fracture)
• Unrestrained: TBI (impact with interior), multi-system injury, ejection injuries

Pedestrian vs Vehicle (Waddell's Triad):

1. Lower extremity fracture (bumper impact)
2. Chest/abdominal injury (bonnet/hood impact)
3. Head injury (windscreen/ground impact)

Falls:

• <3 metres: Low energy, usually isolated injury

• 3 metres: High energy, consider multi-system injury

• Fall onto point (e.g., playground equipment): Internal organ injury with minimal external signs

Bicycle:

• Helmeted: Lower TBI severity
• Unhelmeted: Severe TBI common
• Handlebar injury: Liver, spleen, pancreas, duodenum

---

Primary Survey Adaptations

⚡

A - Airway (with Cervical Spine Protection)

Anatomical Considerations:

• Large occiput: Neutral position may require shoulder roll (not head ring in infants)
• Large tongue relative to oral cavity: More easily obstructs
• High, anterior larynx (C3-4 in infant vs C5-6 in adult)
• Floppy, omega-shaped epiglottis
• Subglottic narrowing (cricoid ring is narrowest point)

ETT Sizing:

• Cuffed ETT (preferred): (Age/4) + 3.5 mm ID
• Uncuffed ETT: (Age/4) + 4 mm ID
• Depth (oral): (Age/2) + 12 cm OR (ETT size x 3)

RSI Drugs:

Cervical Spine Protection:

• Manual in-line stabilisation (MILS) during intubation
• Cervical collar sized appropriately (paediatric sizes)
• Higher cervical injuries (C1-C3) due to high fulcrum
• SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) more common in children <8 years [17]

B - Breathing

Assessment:

• Work of breathing, respiratory rate, chest expansion
• Auscultation (decreased air entry, wheeze, crackles)
• SpO2 (target 94-98%, avoid hyperoxia in TBI)
• Palpate for crepitus, flail segments

Key Interventions:

Tension Pneumothorax:

• Clinical diagnosis: Tachycardia, hypotension, decreased breath sounds, tracheal deviation (late)
• Needle decompression: 2nd intercostal space, mid-clavicular line (adult: often 4th-5th ICS AAL)
• Needle size: 18-20G, 4.5-5 cm length (shorter than adult)
• Definitive: Chest drain (tube thoracostomy)

Chest Drain Sizing:

• Neonate: 10-12 Fr
• Infant: 12-16 Fr
• Child 1-5 years: 16-20 Fr
• Child 6-10 years: 20-24 Fr
• Adolescent: 24-32 Fr

Initial Ventilation Settings (Post-Intubation):

C - Circulation

❤️

Signs of Shock in Children:

Vascular Access:

IO Access Details:

• Proximal tibia: 1-2 cm below tibial tuberosity, anteromedial surface
• Distal tibia: 1-2 cm above medial malleolus
• Distal femur: 2-3 cm above lateral condyle
• Contraindications: Fracture in that bone, previous IO in same bone (24h), prosthesis/surgical hardware

Fluid Resuscitation:

Critical Alert: Modern Paediatric Trauma Resuscitation Principles:

• Damage Control Resuscitation (DCR): Permissive hypotension (except TBI), haemostatic resuscitation, limit crystalloid
• NOT aggressive crystalloid loading (cf. historical teaching)
• Target: Palpable central pulses, improving mental status, adequate urine output

Surviving Sepsis Campaign Paediatric 2020 recommends 10-20 mL/kg boluses with frequent reassessment, avoiding excessive crystalloid which dilutes clotting factors and worsens coagulopathy [18].

Paediatric Massive Transfusion Protocol (MTP):

Activation criteria (any of):

• Estimated blood loss >40 mL/kg
• Ongoing haemorrhage requiring surgical intervention

• 2 units pRBC in first hour and ongoing haemorrhage

• Shocked child unresponsive to 40 mL/kg crystalloid

Paediatric MTP Ratios:

Evidence for 1:1:1 ratios extrapolated from adult PROPPR trial [19]; paediatric-specific data limited but similar ratios generally recommended [20].

Tranexamic Acid (TXA):

• Dose: 15 mg/kg IV bolus (max 1g), then 2 mg/kg/hr for 8 hours
• Give within 3 hours of injury (no benefit after 3 hours, possible harm)
• CRASH-2 evidence extrapolated to paediatrics [21]
• TXA-Paediatric studies ongoing [22]

D - Disability

GCS Assessment:

Pupil Examination:

• Size: Normal 2-4 mm
• Reactivity: Brisk, sluggish, fixed
• Asymmetry: >1 mm difference concerning for herniation
• Bilateral fixed dilated pupils: Poor prognosis but NOT irreversible in children [23]

Blood Glucose:

• Check in ALL altered consciousness/seizures
• Hypoglycaemia more common in infants (limited glycogen stores)
• Target: 5-10 mmol/L

E - Exposure and Environment

🛡️

Hypothermia Prevention is CRITICAL:

• Children lose heat rapidly (high surface area:volume ratio)
• Target: Normothermia (36.5-37.5°C)
• Active warming: Warm IV fluids (37-40°C), forced air warming (Bair Hugger), overhead radiant heaters
• Passive warming: Warm blankets, head covering, minimise exposure time

Full Exposure:

• Log roll with cervical spine protection
• Inspect front and back
• Palpate spine for tenderness, step-off
• Examine perineum (urethral blood, high-riding prostate, anal tone in suspected spinal injury)

---

Specific Injuries

Head Injury (Leading Cause of Mortality)

🧠

Epidemiology:

• Present in 60-80% of major paediatric trauma [15]
• 70-80% of trauma deaths due to TBI [1]
• Falls: Leading mechanism <5 years
• MVC/pedestrian: Leading mechanism >5 years

Pathophysiology of Paediatric TBI:

• Higher brain water content: More susceptible to diffuse cerebral oedema
• Incomplete myelination: Increased vulnerability to axonal shearing
• Developing autoregulation: Narrower CPP tolerance range
• Open fontanelles (infants): Some accommodation but also delays ICP rise presentation

PECARN Clinical Decision Rules:

For children <2 years with minor head trauma (GCS 14-15):

For children ≥2 years:

Sensitivity 96-100% for clinically important TBI [5].

Severe TBI Management (See related topic: Paediatric TBI):

Hypertonic Saline for Raised ICP:

• 3% NaCl: 2-5 mL/kg bolus over 10-20 minutes
• 23.4% NaCl: 0.5-1 mL/kg (severe refractory ICP)
• Target serum Na: <160 mmol/L, osmolality <320 mOsm/kg

Cervical Spine Injury

Epidemiology:

• 1-2% of paediatric trauma patients
• Higher cervical (C1-C3) injuries more common in children <8 years [24]
• Lower cervical (C5-C7) more common in older children/adolescents

SCIWORA (Spinal Cord Injury Without Radiographic Abnormality):

• 20-30% of paediatric spinal cord injuries [17]
• Due to ligamentous laxity and cartilaginous vertebrae
• MRI is diagnostic modality of choice
• May have delayed presentation (up to 4 days)

Clearance Protocol:

• Canadian C-spine Rule (modified for children)
• NEXUS criteria applicable >3 years
• CT if high risk; MRI for suspected ligamentous/spinal cord injury
• Collar immobilisation until cleared clinically or radiologically

Chest Trauma

Key Principles:

• Rib fractures UNCOMMON due to compliant chest wall
• Rib fractures indicate MASSIVE force (often associated with other injuries, mortality >25%) [25]
• Consider NAI if rib fractures in infant without high-energy mechanism
• Pulmonary contusion common WITHOUT rib fractures

Specific Injuries:

Abdominal Trauma

⚠️

Key Principles:

• Solid organs (spleen, liver) less protected by rib cage
• Multi-organ injury in 25-30% of abdominal trauma
• Non-operative management (NOM) is standard for isolated solid organ injury

FAST (Focused Assessment with Sonography for Trauma):

• Sensitivity lower in children (60-70%) compared to adults [26]
• Useful for identifying free fluid
• Cannot grade solid organ injury
• Negative FAST does not rule out significant injury

Splenic Injury:

NOM Success Rate: 90-95% for blunt splenic injury [6]

Failure Criteria (requiring surgery):

• Haemodynamic instability despite resuscitation

• 40 mL/kg transfusion requirement

• Peritonitis
• Hollow viscus injury

Hepatic Injury:

NOM Success Rate: 85-90% for blunt hepatic injury [6]

Hollow Viscus Injury:

• Lap belt (seatbelt) sign: Abdominal wall bruising
• Consider duodenal haematoma, bowel perforation
• CT with oral contrast or serial abdominal examination
• Free air = operative management

Pancreatic Injury:

• Handlebar injury classic mechanism
• Delayed presentation (12-48 hours)
• Elevated lipase/amylase
• CT/MRI for grading, ERCP for ductal injury

Pelvic Fractures

🦴

Key Principles:

• Less common in children (cartilaginous, flexible pelvis)
• When present, indicates HIGH-ENERGY mechanism
• Associated injuries in 50-70% (head, abdominal, thoracic)
• Massive haemorrhage risk (retroperitoneal space can accommodate entire blood volume)

Classification:

• Tile Classification (A, B, C based on stability)
• Young-Burgess (LC, APC, VS, combined)

Management:

• Pelvic binder (sheet if no commercial binder): Apply at level of greater trochanters
• Resuscitation: MTP activation, damage control principles
• Angioembolisation: For arterial bleeding refractory to resuscitation
• External fixation or internal fixation: Based on fracture pattern

Bladder/Urethral Injury:

• More common in children (bladder intra-abdominal)
• Blood at urethral meatus, high-riding prostate
• Retrograde urethrogram before catheterisation if suspected

---

Non-Accidental Injury (NAI)

🛡️

Overview

Importance:

• NAI accounts for 10-25% of TBI in infants <1 year [7]
• Most common cause of death from NAI is head injury
• Delayed recognition leads to re-injury and death

Red Flags for NAI

Critical Alert: History Inconsistent with Injury:

• Mechanism does not explain severity/type of injury
• Changing or inconsistent account between caregivers/over time
• Delay in seeking medical attention
• History provided differs from child's developmental capability

Injury Patterns:

• Injuries at different stages of healing
• Injuries to non-ambulatory children (especially bruising)
• Patterned injuries (hand, belt, cord marks)
• Bruising in unusual locations (ears, neck, trunk, buttocks in pre-mobile infant)
• Multiple fractures (especially ribs, metaphyseal "corner" fractures)
• Subdural haematoma with retinal haemorrhages (abusive head trauma)

High-Risk Injuries:

• Rib fractures (especially posterior) without high-energy mechanism
• Metaphyseal "bucket-handle" or "corner" fractures
• Spiral long bone fractures in non-ambulatory child
• Multiple skull fractures
• Subdural haematoma + retinal haemorrhages + encephalopathy (Shaken Baby/Abusive Head Trauma)

Abusive Head Trauma (AHT)

Previously termed "Shaken Baby Syndrome"

Classic Triad:

1. Subdural haematoma (often bilateral, interhemispheric)
2. Retinal haemorrhages (often extensive, multilayered)
3. Encephalopathy

Additional Findings:

• Rib fractures (posterior, from squeezing)
• Long bone fractures (metaphyseal)
• Bruising (grip marks on chest, arms)
• Lack of external head trauma (cf. accidental TBI)

Retinal Haemorrhage:

• Ophthalmology examination MANDATORY in suspected AHT
• Extensive, multilayered haemorrhages highly specific for AHT
• Document and photograph

Mandatory Reporting

Australia:

• Mandatory reporters: Doctors, nurses, teachers, police (varies by state)
• Report to state/territory child protection authority
• ACT: Care and Protection Services
• NSW: Family and Community Services (Child Protection Helpline)
• VIC: Department of Families, Fairness and Housing
• QLD: Department of Children, Youth Justice and Multicultural Affairs
• WA: Department of Communities
• SA: Department for Child Protection
• TAS: Child Safety Services
• NT: Territory Families

New Zealand:

• Report to Oranga Tamariki (Ministry for Children)
• Any person can report; professionals have moral (not always legal) obligation

Legal Considerations:

• Immunity from liability when reporting in good faith
• Failure to report may constitute professional misconduct
• Document concerns objectively in medical record
• Preserve evidence (photographs, specimens)
• Involve hospital child protection team/social work

Forensic Considerations

• Detailed documentation (contemporaneous notes, diagrams, photographs)
• Chain of custody for specimens (blood, urine, clothing)
• Skeletal survey if suspected NAI in children <2 years
• Consider bone scan or MRI for subtle fractures
• Ophthalmology examination for retinal haemorrhages
• Multidisciplinary approach (child protection, forensic paediatrician, social work, police)

---

ICU Management

Admission Criteria

• GCS ≤12 or requiring intubation
• Haemodynamic instability requiring ongoing resuscitation
• Respiratory failure requiring mechanical ventilation
• Multi-organ injury requiring close monitoring
• Post-operative monitoring (neurosurgery, damage control surgery)
• Ongoing MTP requirement
• TBI with ICP monitoring

TBI Protocol (Age-Adjusted)

Tier 0: Prevention (Baseline):

• Head of bed 30 degrees
• Neck neutral (avoid jugular compression)
• Normoxia (SpO2 94-98%)
• Normocapnia (PaCO2 35-40 mmHg)
• Normothermia (36.5-37.5°C)
• Analgesia and sedation optimisation
• Euvolaemia

Tier 1: First-Line (ICP 20-25 mmHg):

• Sedation optimisation (target RASS -3 to -4)
• Neuromuscular blockade
• CSF drainage (if EVD)
• Maintain age-appropriate CPP

Tier 2: Second-Line (ICP >25 mmHg):

• Hypertonic saline (3% NaCl 2-5 mL/kg)
• Temporary hyperventilation (PaCO2 30-35 mmHg) for acute spikes
• Barbiturate coma (thiopental 3-5 mg/kg bolus, 1-5 mg/kg/hr)
• Decompressive craniectomy (refractory ICP >30 mmHg)

CPP Targets by Age:

Evidence: Brain Trauma Foundation Paediatric Guidelines 2019 [8]

Damage Control Surgery

Principles:

• Abbreviated initial surgery: Stop haemorrhage, control contamination
• Resuscitate in ICU: Correct coagulopathy, hypothermia, acidosis (lethal triad)
• Definitive surgery: When patient stabilised (24-72 hours)

Damage Control Laparotomy:

• Splenectomy/packing for splenic injury
• Hepatorrhaphy/packing for liver injury
• Resection without anastomosis, stapled ends (bowel)
• Temporary abdominal closure (VAC, Bogota bag)

Damage Control Orthopaedics:

• External fixation for long bone fractures
• Pelvic external fixation/binder
• Definitive fixation delayed until stable

Massive Transfusion (Paediatric)

Activation Criteria:

• Estimated blood loss >40 mL/kg

• 2 units pRBC in first hour with ongoing haemorrhage

• Predicted need for ongoing blood products

Protocol:

Targets:

• Haemoglobin >70-80 g/L (higher in TBI)
• Platelets >50 x 10^9/L (>100 in TBI or ongoing haemorrhage)
• Fibrinogen >1.5 g/L
• INR <1.5
• pH >7.2
• Temperature >35°C
• Ionised calcium >1.0 mmol/L

Adjuncts:

• TXA: 15 mg/kg bolus (max 1g), 2 mg/kg/hr for 8 hours [21]
• Calcium chloride: 10-20 mg/kg (0.1-0.2 mL/kg of 10%) to maintain iCa >1.0 mmol/L
• Fibrinogen concentrate: 50-70 mg/kg if fibrinogen <1.5 g/L

Analgesia and Sedation

PRIS (Propofol Infusion Syndrome):

• Avoid propofol infusion >48 hours or >4 mg/kg/hr in children [27]
• Risk: Metabolic acidosis, rhabdomyolysis, cardiac failure
• Monitor lactate, CK, triglycerides

Nutrition

• Initiate enteral nutrition within 24-48 hours
• Target 1.5-2.0 x resting energy expenditure
• Protein: 1.5-2.5 g/kg/day
• Early nutrition associated with improved outcomes [28]

Thromboprophylaxis

• Challenging balance: VTE risk vs bleeding risk
• Generally delayed until 24-48 hours post-injury and haemostasis confirmed
• Mechanical prophylaxis (SCDs) if pharmacological contraindicated
• LMWH (enoxaparin 0.5 mg/kg BD) or UFH once safe

---

Australian/New Zealand Context

Indigenous Health Considerations

👥

Aboriginal and Torres Strait Islander Children:

• 2-3x higher trauma incidence [10]
• 3x higher trauma-related mortality
• Contributing factors: Geographic isolation, delayed presentation, socioeconomic disadvantage, higher rates of MVC/pedestrian injury

Māori Children (New Zealand):

• 2x higher TBI incidence [14]
• Higher representation in severe trauma
• Contributing factors: Similar to above, plus higher rates of unintentional injury in home environment

Cultural Safety in Trauma Care:

Remote and Rural Considerations

Retrieval Services:

• RFDS (Royal Flying Doctor Service): 24/7, 1800 625 800
• NETS (NSW/ACT): Neonatal and paediatric retrieval
• PIPER (VIC): Paediatric Infant Perinatal Emergency Retrieval
• RSQ (QLD): Retrieval Services Queensland
• MEDSTAR (SA): Medical Emergency Retrieval Service

Telemedicine:

• Early consultation with tertiary paediatric trauma centre
• Real-time guidance for resuscitation, imaging interpretation
• Assists with decision for retrieval vs local management

Stabilisation Priorities Before Retrieval:

• Airway secured (intubate if GCS ≤8 or deteriorating)
• Ventilation optimised (PaCO2 35-40 mmHg)
• Haemorrhage controlled (external, chest drains, pelvic binder)
• Circulation stabilised (MTP if needed)
• Hypothermia prevented (active warming)
• Documentation and imaging prepared for handover

State-Specific Guidelines

---

Prognosis and Outcomes

Mortality Predictors

Functional Outcomes

Paediatric Glasgow Outcome Scale-Extended (GOS-E Peds):

1. Death
2. Vegetative state
3. Lower severe disability (totally dependent)
4. Upper severe disability (dependent for daily activities)
5. Lower moderate disability (independent but disabled)
6. Upper moderate disability (minor residual deficits)
7. Lower good recovery (minor problems)
8. Upper good recovery (returned to normal)

Outcomes at 12 months (Major Paediatric Trauma):

• Favourable outcome (GOS-E Peds 5-8): 60-70%
• Unfavourable outcome (GOS-E Peds 2-4): 25-35%
• Mortality: 5-10% [30]

Neurological Recovery

Paediatric TBI-Specific Outcomes:

• Better recovery potential than adults for equivalent injury
• BUT: Infants may have worse outcomes than older children [31]
• Cognitive deficits: 20-30% at long-term follow-up
• Behavioural problems: 15-25%
• Educational support required: 10-20%
• Persistent motor deficits: 10-15%

Rehabilitation

Acute Phase (ICU/PICU):

• Early mobilisation as tolerated
• Physiotherapy: ROM, positioning
• Occupational therapy: Sensory stimulation
• Speech pathology: Swallow assessment

Subacute Phase (Inpatient Rehabilitation):

• Multidisciplinary team
• Structured rehabilitation program
• Family education and involvement

Long-Term (Community):

• Outpatient rehabilitation
• School reintegration
• Neuropsychological assessment
• Behavioural management
• Family support services

---

SAQ Practice Questions

SAQ 1: Polytrauma with TBI

📝

Question:

A 5-year-old male is brought to your regional Emergency Department after being an unrestrained rear passenger in a motor vehicle crash. On arrival, his GCS is 7 (E1V2M4), heart rate 150 bpm, blood pressure 70/40 mmHg, and SpO2 92% on high-flow oxygen. CT brain shows a right-sided acute subdural haematoma with 8 mm midline shift and effacement of basal cisterns.

a) Outline your immediate management priorities in the first 15 minutes. (6 marks)

b) Describe your approach to fluid resuscitation and blood product administration in this child. Include activation criteria for massive transfusion protocol and target ratios. (6 marks)

c) The child is now intubated and ventilated with ICP monitor showing ICP 28 mmHg. Outline your tiered approach to managing raised ICP, including age-appropriate CPP targets. (5 marks)

d) Discuss three considerations specific to communicating with the family of this critically injured child. (3 marks)

Model Answer:

a) Immediate Management Priorities (6 marks)

Airway and Cervical Spine (2 marks):

• Immediate RSI for GCS 7: Pre-oxygenate, fentanyl 1 mcg/kg (cautious in hypotension), ketamine 1-2 mg/kg (haemodynamically stable), rocuronium 1.2 mg/kg
• Cuffed ETT size: (5/4) + 3.5 = 4.75 mm, use 4.5 mm
• Manual in-line stabilisation, cervical collar post-intubation
• Target SpO2 94-98%, PaCO2 35-40 mmHg (avoid hyperventilation prophylactically)

Breathing (1 mark):

• Confirm bilateral air entry
• Ventilator settings: Vt 6-8 mL/kg, rate 20/min, PEEP 5, FiO2 to achieve SpO2 94-98%
• Consider chest trauma (pulmonary contusion, pneumothorax)

Circulation (2 marks):

• Blood pressure 70/40 mmHg indicates hypotension in 5-year-old (threshold = 70 + 2x5 = 80 mmHg)
• Obtain IV access x2 (or IO if IV fails within 90 seconds)
• Crystalloid bolus 10-20 mL/kg (balanced crystalloid or 0.9% NaCl)
• Activate MTP if haemodynamic instability persists after 40 mL/kg crystalloid
• Target: Palpable central pulses, improving heart rate, mental status (post-sedation)

Disability and Exposure (1 mark):

• Document GCS pre-intubation, pupil size/reactivity
• Expose fully, log roll with C-spine protection
• Active warming: Warm fluids, forced air warmer, radiant heater (prevent hypothermia)

b) Fluid Resuscitation and Blood Products (6 marks)

Initial Crystalloid (2 marks):

• 10-20 mL/kg balanced crystalloid (Hartmann's/Plasmalyte) or 0.9% NaCl
• Maximum 40-60 mL/kg before transition to blood products
• Modern DCR approach: Limit crystalloid, early blood products

MTP Activation Criteria (1 mark):

• Estimated blood loss >40 mL/kg
• Ongoing haemorrhage requiring surgical intervention

• 2 units pRBC in first hour with ongoing haemorrhage

• Shocked child unresponsive to 40 mL/kg crystalloid
• This child meets criteria (hypotensive despite fluid resuscitation)

MTP Ratios (2 marks):

• Target 1:1:1 ratio (pRBC:FFP:Platelets)
• Initial pack: 20 mL/kg pRBC, 20 mL/kg FFP, 20 mL/kg platelets
• Adjuncts: TXA 15 mg/kg bolus (max 1g), then 2 mg/kg/hr for 8h (if <3h from injury)
• Calcium chloride to maintain iCa >1.0 mmol/L
• Cryoprecipitate 5-10 mL/kg if fibrinogen <1.5 g/L

Targets (1 mark):

• Hb >80 g/L (higher in TBI)
• Platelets >100 x 10^9/L (TBI)
• Fibrinogen >1.5 g/L
• INR <1.5
• Ionised calcium >1.0 mmol/L

c) Tiered ICP Management (5 marks)

Age-Appropriate CPP Target (1 mark):

• 5-year-old falls in 6-17 year age group
• Target CPP >60 mmHg
• CPP = MAP - ICP; with ICP 28, need MAP >88 mmHg

Tier 0: Prevention (1 mark):

• Head of bed 30 degrees
• Neck neutral (avoid jugular compression)
• Normocapnia (PaCO2 35-40 mmHg)
• Normothermia (36.5-37.5°C)
• Analgesia and sedation optimisation

Tier 1: First-Line (ICP 20-25 mmHg) (1 mark):

• Deepen sedation (target RASS -4)
• Neuromuscular blockade (rocuronium infusion)
• CSF drainage if EVD in situ (drain when ICP >20)
• Optimise MAP for CPP target

Tier 2: Second-Line (ICP >25 mmHg - this patient) (2 marks):

• Hypertonic saline 3%: 2-5 mL/kg bolus over 10-20 min
• Temporary hyperventilation (PaCO2 30-35 mmHg) for acute spike/impending herniation
• Barbiturate coma: Thiopental 3-5 mg/kg bolus, then 1-5 mg/kg/hr infusion
• Consider decompressive craniectomy if ICP refractory >30 mmHg

Neurosurgical Consultation:

• SDH with 8 mm midline shift and effaced cisterns = likely surgical candidate
• Urgent neurosurgical evaluation for evacuation vs decompressive craniectomy

d) Family Communication (3 marks)

Three Considerations (1 mark each):

1. Honesty with compassion: Explain critical nature of injuries, uncertain prognosis. Avoid false reassurance but also avoid removing all hope. Children can have remarkable recovery.

2. Family-centred approach: Involve family in bedside care as appropriate. Allow parents to be present during procedures when safe. Acknowledge their distress and provide support resources (social work, chaplaincy).

3. Cultural considerations: If Indigenous family, involve Aboriginal Health Worker/Liaison Officer. Facilitate extended family presence for decision-making. Respect cultural protocols regarding head injury, end-of-life discussions.

---

SAQ 2: Abdominal Trauma Management

Question:

An 8-year-old female is brought to the Emergency Department after a bicycle vs car collision. She was hit by the handlebar upon impact. She is alert (GCS 15) but has abdominal pain and tenderness. Her heart rate is 130 bpm, blood pressure 100/65 mmHg, and haemoglobin 95 g/L. FAST scan shows free fluid in Morison's pouch and the pelvis. CT abdomen reveals a Grade III splenic laceration with moderate haemoperitoneum.

a) Describe your approach to non-operative management (NOM) of this splenic injury, including monitoring parameters and bed rest protocols. (6 marks)

b) List five criteria that would indicate failure of NOM and need for surgical intervention. (5 marks)

c) Discuss the advantages and disadvantages of non-operative versus operative management for paediatric splenic injuries. (5 marks)

d) If this child were Aboriginal and presented to a remote hospital in the Northern Territory, describe two specific considerations for her management and retrieval. (4 marks)

Model Answer:

a) Non-Operative Management Approach (6 marks)

Initial Stabilisation (1 mark):

• IV access x2, blood typed and crossed (4 units pRBC available)
• Crystalloid resuscitation to maintain adequate perfusion
• Continuous monitoring: HR, BP, SpO2, UO

Monitoring Parameters (2 marks):

• Vital signs: q1h for first 24h, then q2-4h
• Serial abdominal examination: q2-4h for first 24-48h
• Serial haemoglobin: q4-6h for first 24h, then q12-24h
• Haematocrit trend more important than absolute value
• Urine output: Target >1 mL/kg/hr
• Mental status, capillary refill

Bed Rest and Activity Restriction (2 marks):

• Strict bed rest for first 24-48 hours
• Clear fluids initially, advance diet as tolerated
• Gradual mobilisation from Day 2-3 if haemodynamically stable
• No contact sports or strenuous activity for 4-6 weeks (Grade III)
• Follow-up imaging: Repeat ultrasound at 48-72h, consider CT before discharge

Transfusion Threshold (1 mark):

• Transfuse if Hb <70 g/L or ongoing haemodynamic instability
• Target Hb 80-100 g/L
• Track transfusion requirements (>40 mL/kg = NOM failure)

b) NOM Failure Criteria (5 marks, 1 mark each)

1. Haemodynamic instability despite resuscitation: Persistent hypotension (SBP <90 mmHg or <70 + 2×age), tachycardia unresponsive to 40 mL/kg fluid/blood

2. Transfusion requirement >40 mL/kg: Ongoing need for blood products indicates uncontrolled haemorrhage

3. Peritonitis on examination: Increasing abdominal tenderness, guarding, rigidity (suggests hollow viscus injury or ongoing haemorrhage)

4. Declining haemoglobin despite transfusion: Haemoglobin drop >20 g/L over 24 hours with transfusion support

5. Evidence of hollow viscus injury: Free air on imaging, bilious/feculent aspirate from NG tube, clinical deterioration

c) NOM vs Operative Management (5 marks)

Advantages of NOM (2.5 marks):

Disadvantages of NOM (1.5 marks):

Advantages of Operative Management (0.5 marks):

• Definitive haemorrhage control
• May be necessary for Grade IV-V injuries or haemodynamic instability

Disadvantages of Operative Management (0.5 marks):

• Splenectomy: Lifelong infection risk (OPSS), vaccination requirement, antibiotic prophylaxis
• Surgical complications: Bleeding, infection, adhesions
• Psychological impact of surgery

d) Remote/Indigenous Considerations (4 marks, 2 marks each)

Consideration 1: Retrieval and Transfer:

• Contact RFDS/retrieval services early (before patient deteriorates)
• Stabilise before transfer: IV access, fluid resuscitation, blood available
• Telemedicine consultation with paediatric surgical centre for decision-making
• Weather and distance considerations (prolonged transfer time in NT)
• Ensure blood products available for transfer if needed
• Handover all documentation and imaging to retrieval team

Consideration 2: Cultural Safety:

• Involve Aboriginal Health Worker (AHW) from presentation
• Extended family involvement in decision-making (may need time for family to gather)
• Clear explanation of condition and management plan (avoid jargon)
• Respect cultural protocols regarding children and medical procedures
• Consider whether family can accompany child on retrieval (often possible with RFDS)
• If transfer to Darwin or Adelaide, arrange accommodation/support for family
• Awareness of Sorry Business or other cultural obligations that may affect family availability

---

Viva Practice Scenarios

Viva 1: Massive Transfusion in Paediatric Trauma

⚠️

Examiner: A 4-year-old child is brought to your trauma centre after a pedestrian vs vehicle accident. He has an open pelvic fracture with active bleeding. Heart rate 190 bpm, blood pressure 55/30 mmHg, and he is obtunded. How would you manage this child?

Candidate: This is a 4-year-old in haemorrhagic shock with an open pelvic fracture. My immediate priorities follow the <C>ABCDE approach with massive haemorrhage control being paramount.

Catastrophic haemorrhage control:

• Apply pelvic binder at the level of the greater trochanters to reduce pelvic volume and tamponade bleeding
• For a 4-year-old, a paediatric pelvic binder or folded sheet tied around the pelvis is appropriate
• Apply direct pressure to any external bleeding wounds

Airway:

• This child is obtunded, so I need to assess airway patency and consider early intubation
• With GCS likely <8 given the description, I would proceed with RSI using ketamine 2 mg/kg for haemodynamic stability and rocuronium 1.2 mg/kg

Examiner: What vascular access would you obtain and what fluids would you give?

Candidate: For vascular access:

• Attempt large-bore IV x2 (antecubital, saphenous)
• If IV access fails within 90 seconds or 2 attempts, I would immediately place an IO needle
• Proximal tibia is my preferred site in a 4-year-old

For fluids:

• I would activate the massive transfusion protocol immediately given:
  • Haemorrhagic shock with BP 55/30 (hypotensive for age)
  • Open pelvic fracture with ongoing haemorrhage
  • This will require surgical intervention

Initial resuscitation:

• Start with 10-20 mL/kg of uncrossmatched O-negative blood if available, or balanced crystalloid while waiting
• Target 1:1:1 ratio of pRBC:FFP:Platelets
• In a 4-year-old (approximately 18 kg), MTP pack would be approximately:
  • pRBC: 360 mL (20 mL/kg)
  • "FFP: 360 mL (20 mL/kg)"
  • "Platelets: 360 mL (20 mL/kg)"

Adjuncts:

• TXA 15 mg/kg bolus (270 mg) within 3 hours of injury, then 2 mg/kg/hr infusion
• Calcium chloride to maintain ionised calcium >1.0 mmol/L

Examiner: What are your transfusion targets in this child with massive haemorrhage?

Candidate: My targets for massive transfusion are:

• Haemoglobin >70-80 g/L
• Platelets >50 x 10^9/L (>100 if ongoing bleeding or TBI)
• Fibrinogen >1.5 g/L
• INR <1.5
• Ionised calcium >1.0 mmol/L
• pH >7.2
• Temperature >35°C (normothermia is critical)
• Avoid the lethal triad: Hypothermia, acidosis, coagulopathy

Examiner: The pelvic binder is in place but bleeding continues. What are your surgical options?

Candidate: For ongoing haemorrhage despite pelvic binder:

Damage control surgery approach:

1. Preperitoneal pelvic packing - surgeons can access the retroperitoneal space and pack around the pelvis to tamponade venous bleeding (most pelvic bleeding is venous)

2. External fixation - stabilises the pelvic ring and reduces pelvic volume

3. Angioembolisation - if the child is stabilised enough for transfer to interventional radiology, angioembolisation can control arterial bleeding (10-15% of pelvic bleeding is arterial)

4. REBOA (Resuscitative Endovascular Balloon Occlusion of Aorta) - can be considered as a bridge in extremis, though paediatric experience is limited

The decision would be made in collaboration with paediatric surgeons, orthopaedics, and interventional radiology if available.

Examiner: This child's mother is Aboriginal and speaks limited English. How would you communicate with her during this emergency?

Candidate: This is challenging but essential. I would:

1. Involve Aboriginal Health Worker/Liaison Officer immediately - they can assist with communication, cultural protocols, and family support

2. Use interpreter services - if Aboriginal language interpreter is not immediately available, phone interpreter services (TIS National 131 450) can provide immediate support

3. Clear, simple communication - avoid medical jargon, explain the severity of the situation and what we are doing to help her child

4. Allow family presence when safe - if the mother wishes to be present and it's safe, this may provide comfort

5. Extended family notification - in Aboriginal culture, extended family (aunties, uncles, grandparents) are often involved in decision-making. Facilitate their involvement if possible and if time permits

6. Acknowledge distress - express empathy and provide emotional support through social work/chaplaincy

7. Regular updates - even brief updates during resuscitation help families feel involved

---

Viva 2: Non-Accidental Injury Recognition

Examiner: A 6-month-old infant is brought to the Emergency Department by parents reporting a "fall from the couch." The infant is lethargic with a bulging fontanelle. What are your concerns?

Candidate: This presentation is highly concerning for non-accidental injury (NAI)/abusive head trauma.

My concerns are:

1. Inconsistent mechanism: A 6-month-old falling from a couch (typically <1 metre) should not cause significant intracranial injury. Lethargy and bulging fontanelle suggest raised ICP from intracranial pathology.

2. Age group: Infants <1 year are at highest risk for NAI. They are non-verbal, cannot provide history, and are vulnerable.

3. Clinical signs of raised ICP: Bulging fontanelle indicates increased intracranial pressure, consistent with intracranial haemorrhage.

Examiner: What specific injuries would you look for to support or refute NAI?

Candidate: I would perform a thorough head-to-toe examination looking for:

Head and Neurological:

• Subdural haematoma (CT brain) - especially if bilateral or interhemispheric
• Retinal haemorrhages (ophthalmology examination mandatory) - extensive, multilayered haemorrhages highly specific for AHT
• Skull fractures - especially multiple or complex fractures
• Scalp swelling or bruising (may be subtle)

Skin:

• Bruising in unusual locations: Ears, neck, trunk, buttocks (TEN-4 rule: Torso, Ears, Neck in child <4 years)
• Patterned bruising: Hand marks, belt marks, bite marks
• Bruising at different stages of healing
• Bruising in a non-ambulatory infant is highly suspicious (infants don't bruise themselves)

Skeletal:

• Rib fractures (especially posterior) - classic for NAI, from squeezing
• Metaphyseal "bucket-handle" or "corner" fractures
• Spiral fractures of long bones in non-ambulatory child
• Multiple fractures at different stages of healing

Other:

• Intra-abdominal injury without adequate mechanism
• Burns in suspicious pattern (cigarette, immersion)
• Genital injuries

Examiner: The CT brain shows bilateral subdural haematomas. What would you do next?

Candidate:

Immediate clinical priorities:

1. Stabilise the infant: Manage raised ICP (positioning, consider hypertonic saline if GCS deteriorating)
2. Neurosurgical consultation for potential surgical intervention

NAI investigation:

1. Ophthalmology examination - urgent dilated fundoscopy for retinal haemorrhages
2. Skeletal survey - full radiographic skeletal survey to identify occult fractures
3. Blood tests - FBC, coagulation studies (exclude bleeding disorder), liver function, lipase (exclude abdominal injury)
4. MRI brain - when stable, to better characterise injury timing and pattern

Child protection:

1. Notify child protection team/social work - mandatory reporting obligation
2. Document findings meticulously - clinical notes, diagrams, photographs with consent
3. Secure environment - ensure infant's safety (may require hospital admission under child protection order)
4. Separate caregiver histories - interview parents separately to identify inconsistencies
5. Police notification - work with child protection team; this is a potential crime

Examiner: The parents deny any trauma. How do you handle this conversation?

Candidate: This is a sensitive but essential conversation:

Approach:

1. Non-accusatory but clear: "We have found serious injuries that do not match the history provided. We are concerned about how these injuries occurred."

2. Focus on the child's wellbeing: "Our primary concern is your baby's health and safety. We need to understand what happened so we can provide the best care."

3. Explain the process: "When children have unexplained injuries, we are legally required to involve child protection services. This is to ensure your child's safety."

4. Offer support: "This is a difficult situation for everyone. We can provide social work support for your family."

5. Document carefully: Note exact quotes, parental demeanour, any inconsistencies

6. Multidisciplinary team: Involve forensic paediatrician, child protection team, social work. Do not attempt to "investigate" alone.

Legal obligations:

• I have a mandatory reporting obligation as a doctor
• I must report to state child protection authority
• I have immunity from liability when reporting in good faith
• I cannot promise confidentiality to parents regarding child safety concerns

Examiner: What if the family wants to take the baby home?

Candidate: The infant should NOT be discharged home until:

1. Medical stability ensured - the infant requires treatment for intracranial injury

2. Child protection assessment completed - risk assessment by child protection services

3. Safety plan in place - if concerns exist about returning to the home environment

If the family attempts to leave against medical advice:

1. Escalate immediately - notify nursing unit manager, hospital administration, child protection

2. Invoke emergency child protection powers - in most Australian jurisdictions, hospitals can apply for an emergency care and protection order to prevent discharge

3. Contact police - if parents attempt to forcibly remove the child and there are reasonable concerns for safety

4. Document everything - detailed notes of conversation, concerns, and actions taken

The child's safety is the paramount concern and overrides parental wishes in this situation.

---

ZICS Paediatric Study Group Guidelines, State trauma system guidelines (ACI NSW, Trauma Victoria)

47. Q: Hypertonic saline dosing for raised ICP in children? A: 3% NaCl 2-5 mL/kg bolus over 10-20 minutes

48. Q: What is the evidence for barbiturate coma in refractory paediatric ICP? A: Case series show ICP reduction in 60-70% of refractory cases; use limited to refractory situations

49. Q: Indigenous trauma mortality disparity in Australia? A: Aboriginal and Torres Strait Islander children have 2-3x higher trauma mortality

50. Q: Mandatory reporting obligation for NAI in Australia? A: Doctors are mandatory reporters in all states/territories; report to state child protection authority

---

References

1. Maas AIR, Menon DK, Manley GT, et al. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol. 2022;21(11):1004-1060. PMID: 36183712

2. Araki T, Yokota H, Morita A. Pediatric traumatic brain injury: characteristic features, diagnosis, and management. Neurol Med Chir (Tokyo). 2017;57(2):82-93. PMID: 28111406

3. Suttipongkaset P, Jitpratoom P, Auewarakul C, et al. Blood pressure thresholds and mortality outcomes in paediatric trauma. Emerg Med J. 2019;36(4):239-244. PMID: 30670527

4. American College of Surgeons. Advanced Trauma Life Support Student Course Manual. 10th ed. Chicago: ACS; 2018.

5. Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. PMID: 19758692

6. Notrica DM, Eubanks JW III, Tuggle DW, et al. Nonoperative management of blunt liver and spleen injury in children: Evaluation of the ATOMAC guideline using GRADE. J Trauma Acute Care Surg. 2015;79(4):683-693. PMID: 26402544

7. Keenan HT, Runyan DK, Marshall SW, et al. A population-based study of inflicted traumatic brain injury in young children. JAMA. 2003;290(5):621-626. PMID: 12902365

8. Kochanek PM, Tasker RC, Carney N, et al. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines. Pediatr Crit Care Med. 2019;20(3S Suppl 1):S1-S82. PMID: 30829890

9. Tsuei BJ, Kearney PA. Hypothermia in the trauma patient. Injury. 2004;35(1):7-15. PMID: 14728948

10. Australian Institute of Health and Welfare. Injury among young Australians. AIHW Bulletin no. 60. Canberra: AIHW; 2008.

11. World Health Organization. Global status report on road safety 2018. Geneva: WHO; 2018.

12. Trauma Victoria. Victorian State Trauma System Annual Report 2022. Melbourne: Trauma Victoria; 2022.

13. Mitchell RJ, Curtis K, Holland AJA, et al. Acute costs and predictors of higher treatment costs for major paediatric trauma in New South Wales, Australia. J Paediatr Child Health. 2013;49(7):557-563. PMID: 23711224

14. Barker-Collo S, Theadom A, Jones K, et al. Prevalence and patterns of traumatic brain injury among children in New Zealand: findings from the BIONIC study. N Z Med J. 2016;129(1438):39-50. PMID: 27508397

15. Langlois JA, Rutland-Brown W, Thomas KE. The incidence of traumatic brain injury among children in the United States: differences by race. J Head Trauma Rehabil. 2005;20(3):229-238. PMID: 15908823

16. Bar-Joseph G, Guilburd Y, Tamir A, et al. Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension. J Neurosurg Pediatr. 2009;4(1):40-46. PMID: 19569909

17. Pang D, Pollack IF. Spinal cord injury without radiographic abnormality in children--the SCIWORA syndrome. J Trauma. 1989;29(5):654-664. PMID: 2724383

18. Weiss SL, Peters MJ, Alhazzani W, et al. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med. 2020;21(2):e52-e106. PMID: 32032273

19. Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471-482. PMID: 25647203

20. Neff LP, Cannon JW, Morrison JJ, et al. Clearly defining pediatric massive transfusion: cutting through the fog and friction with combat data. J Trauma Acute Care Surg. 2015;78(1):22-28. PMID: 25539199

21. CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23-32. PMID: 20554319

22. Eckert MJ, Wertin TM, Tyner SD, et al. Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg. 2014;77(6):852-858. PMID: 25423531

23. Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993;34(2):216-222. PMID: 8459458

24. Patel JC, Tepas JJ 3rd, Mollitt DL, et al. Pediatric cervical spine injuries: defining the disease. J Pediatr Surg. 2001;36(2):373-376. PMID: 11172441

25. Garcia VF, Gotschall CS, Eichelberger MR, et al. Rib fractures in children: a marker of severe trauma. J Trauma. 1990;30(6):695-700. PMID: 2352298

26. Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg. 2007;42(9):1588-1594. PMID: 17848254

27. Bray RJ. Propofol infusion syndrome in children. Paediatr Anaesth. 1998;8(6):491-499. PMID: 9836214

28. Hartman S, Loughan AR. Pediatric traumatic brain injury and nutrition. Curr Opin Clin Nutr Metab Care. 2022;25(5):358-363. PMID: 35788505

29. Ducrocq SC, Meyer PG, Orliaguet GA, et al. Epidemiology and early predictive factors of mortality and outcome in children with traumatic severe brain injury: experience of a French pediatric trauma center. Pediatr Crit Care Med. 2006;7(5):461-467. PMID: 16885792

30. Potoka DA, Schall LC, Ford HR. Improved functional outcome for severely injured children treated at pediatric trauma centers. J Trauma. 2001;51(5):824-832. PMID: 11706327

31. Agran PF, Anderson C, Winn D, et al. Rates of pediatric injuries by 3-month intervals for children 0 to 3 years of age. Pediatrics. 2003;111(6 Pt 1):e683-e692. PMID: 12777586

32. Holmes JF, Mao A, Awasthi S, et al. Validation of a prediction rule for identifying children with thoracic injuries after blunt torso trauma. Ann Emerg Med. 2009;54(4):528-533. PMID: 19647343

33. Bennett TD, Riva-Cambrin J, Keenan HT, et al. Variation in intracranial pressure monitoring and outcomes in pediatric traumatic brain injury. Arch Pediatr Adolesc Med. 2012;166(7):641-647. PMID: 22751882

34. Tasker RC, Vonberg FW, Ulano ED, et al. Updating evidence for using hypothermia in pediatric severe traumatic brain injury: conventional and Bayesian meta-analytic perspectives. Pediatr Crit Care Med. 2017;18(4):355-362. PMID: 28221227

35. Adelson PD, Wisniewski SR, Beca J, et al. Comparison of hypothermia and normothermia after severe traumatic brain injury in children (Cool Kids): a phase 3, randomised controlled trial. Lancet Neurol. 2013;12(6):546-553. PMID: 23664370

36. Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med. 2007;357(22):2277-2284. PMID: 18046031

37. Osmond MH, Klassen TP, Wells GA, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ. 2010;182(4):341-348. PMID: 20142371

38. Dunning J, Daly JP, Lomas JP, et al. Derivation of the children's head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child. 2006;91(11):885-891. PMID: 17056861

39. Styner JK. The birth of Advanced Trauma Life Support (ATLS). Surgeon. 2006;4(3):163-165. PMID: 16764200

40. Letton RW Jr, Worrell V; APSA Committee on Trauma Blunt Liver Injury Study Group. Delay of operation is not warranted for children with solid organ injuries other than liver. J Trauma Acute Care Surg. 2010;68(6):1297-1301. PMID: 20539170

41. Nance ML, Mahboubi S, Wickstrom M, et al. Pattern of abdominal free fluid following isolated severe blunt hepatic injury in children. J Trauma. 2002;52(1):85-89. PMID: 11791056

42. Lynch JM, Meza MP, Newman B, et al. Computed tomography grade of splenic injury is predictive of the time required for radiographic healing. J Pediatr Surg. 1997;32(7):1093-1095. PMID: 9247239

43. Partrick DA, Bensard DD, Moore EE, et al. Ultrasound is an effective triage tool to evaluate blunt abdominal trauma in the pediatric population. J Trauma. 1998;45(1):57-63. PMID: 9680013

44. Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA. 1999;281(7):621-626. PMID: 10029123

45. Starling SP, Patel S, Burke BL, et al. Analysis of perpetrator admissions to inflicted traumatic brain injury in children. Arch Pediatr Adolesc Med. 2004;158(5):454-458. PMID: 15123478

46. Maguire SA, Kemp AM, Lumb RC, et al. Estimating the probability of abusive head trauma: a pooled analysis. Pediatrics. 2011;128(3):e550-e564. PMID: 21844052

47. Christian CW, Block R; Committee on Child Abuse and Neglect. Abusive head trauma in infants and children. Pediatrics. 2009;123(5):1409-1411. PMID: 19403508

48. Biron D, Bhargava R, Bhargava S. Skeletal survey in child abuse: a review. Br J Radiol. 2022;95(1132):20210647. PMID: 35286150

49. Flaherty EG, Perez-Rossello JM, Levine MA, et al. Evaluating children with fractures for child physical abuse. Pediatrics. 2014;133(2):e477-e489. PMID: 24470643

50. Sheets LK, Leach ME, Koszewski IJ, et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics. 2013;131(4):701-707. PMID: 23478861

51. Australian Institute of Health and Welfare. Child protection Australia 2021-22. Child welfare series no. 77. Canberra: AIHW; 2023.

52. Oranga Tamariki. Working with Maori: He aratohu mo te mahi me te whanau Maori. Wellington: Oranga Tamariki; 2020.

---

Related Topics

• Paediatric Traumatic Brain Injury
• Paediatric Status Epilepticus
• Paediatric Sepsis
• Paediatric Respiratory Failure
• Bronchiolitis
• Neonatal Resuscitation