This course is designed to give an overview of the initial assessment and management of the pediatric trauma patient. Focus will be placed on frequent causes of pediatric trauma as well as common injuries that pediatric trauma patients sustain. Determining the extent of injury by proper interpretation of the Pediatric Trauma Score and the Pediatric Glasgow Coma Scale will also be presented. Primary nursing assessment and intervention when caring for the pediatric trauma patient will also be discussed. Special considerations when assessing pediatric trauma patients and possible complications that may result from pediatric trauma will be the final focus of this course.
Course Objectives
Upon completion of this course the student will be able to:
Describe common causes of pediatric trauma.
Have a better understanding of the extent of injury using the Pediatric Trauma Score.
Explain neurological findings based on the Pediatric Glasgow Coma Scale scoring system.
Differentiate between the Pediatric Glasgow Coma Scale used for infants and children as well as the modified scale for infants under the age of two years old.
Discuss the specific features when attaining the primary assessment for a pediatric trauma patient.
Describe special considerations when assessing injury of the pediatric patient.
List 3 potential complications associated with pediatric trauma.
Introduction:
Approximately 80% to 90% of all pediatric injuries result from blunt trauma. Caring for the injured child requires specialized knowledge, management and great attention to detail. Because they respond differently to medications, fluid resuscitation, blood losses, respiratory difficulties and the mending of growing bones; it is imperative that these children not be viewed by healthcare workers as “little adults”.
Common Pediatric Trauma Causes and Injuries:
The most common mechanisms of injury for pediatric trauma include; motor vehicle accidents, pedestrian vs. motor vehicle accidents, bicycle vs. motor vehicle accidents and falls from heights.
The leading cause of death with pediatric patients who sustain a head trauma is failure to manage the airway.
Unrestrained pediatric patients most common sustain head and neck injuries (due to the fact that the pediatric patient has a proportionally larger head then an adult, and the neck muscles and supporting structures are weaker).
If the pediatric patient was restrained, blunt trauma from the seat belt or harness is a common injury (especially if the patient was restrained improperly).
If the child was involved in a bicycle vs. automobile accident, the most common injuries are noted to be to the head, spine and abdomen (what ever part of the body is closest to the bumper of the car).
If the child is involved in a pedestrian vs. automobile accident, the most common injuries are to the head, chest and lower extremities.
Head or cervical injuries are most commonly seen with diving accidents.
If a child falls more the 2.5 times his/her height, head and/or cervical injuries should be suspected.
Inhalation of gases or products of combustion causes greater injuries in infants and children then adults (due to a smaller trachea and greater impact of swelling).
Pediatric Trauma Score:
The Pediatric Trauma Score (PTS) is a scoring tool that assists clinicians in determining the severity of injury that a pediatric patient has sustained. The PTS has been adjusted to take into consideration the physiologic and anatomical differences that are unique to pediatric patients. The PTS consists of six parameters that are common factors in determining the condition of an injured pediatric patient. Each component is initially assessed and a number value is given to the assessment finding. When the assessment is complete, the scores are tabulated and based on the total score, a degree of recovery or survival is determined or predicted. The following is an example of the PTS.
Pediatric Trauma Score Sheet
Assessment
+2
+1
-1
Score
Weight
Greater than 20 kgs. (44 lbs.)
10 to 20 kgs. (22 to 44 lbs.)
Less then 10 kgs. (less then 22 lbs.)
Airway
Airway is patent with no assistance required.
Airway is maintainable and protected by patient, monitoring required.
Airway is not maintainable, requires adjunct therapy such as suctioning, OPA or intubation.
Systolic B/P & Pulses
Systolic B/P is greater then 90 mmHg with palpable radial pulse.
Systolic B/P is between 50-90 mmHg with palpable carotid pulse.
Systolic B/P is less then 50 mmHg with no palpable pulse.
CNS
Awake and Alert.
Positive LOC (may have been temporary).
Unresponsive
Fractures
None
Suspected or closed fractures.
Multiple fractures either open or closed.
Wounds
None
Minor wounds (abrasions, lacerations or burns that cover less then 10% of the body that do not include burns of the hands, face, feet or genitalia).
Penetrating, major avulsions, lacerations, burns that cover greater then 10% or burns involving the hands, face, feet of genitalia.
Total Score
Pediatric Trauma Scoring System:
9-12 – Minor trauma
6-8 – Potentially life threatening trauma
0-5 – Clearly a life threatening trauma
Less then 0 – Usually a fatal injury
Pediatric Glasgow Coma Scale:
The Pediatric Glasgow Coma Scale (PGCS) is equivalent to the adult version of the GSC and is used to assess the mental status of the pediatric patient. Although it is not recommended in most cases to use the same assessment tool as an adult, the PGCS has been slightly modified to be effective in the pediatric population. The PGCS is comprised of three tests which include; eye, verbal and motor responses. Both individual values and the sum of the three values are considered with a sum of 3 or less meaning deep coma or death, while the highest possible score (15) means the pediatric patient is fully awake, alert and oriented. The following chart will help the nurse assess the pediatric patient’s mental status in an organized fashion (Note: This PGCS is recommended for infants/children over the age of 2).
Pediatric Glasgow Coma Scale
Activity
Infants
Children
Score
Eye Opening
Spontaneous
Spontaneous
4
To Speech or Sound
To Speech or Sound
3
To Painful Stimuli
To Painful Stimuli
2
None
None
1
Verbal Response
Appropriate Words, Sounds, Social Smile, Fixes and Follows
Oriented
5
Cries, but is consolable
Confused
4
Persistently Irritable
Uses Inappropriate Words
3
Restless and Agitated
Makes Incomprehensible Sounds
2
None
None
1
Motor Response
Spontaneous Movement
Obeys Commands
6
Localizes To Pain
Localizes To Pain
5
Withdraws To Pain
Withdraws To Pain
4
Abnormal Flexion (Decorticate Posturing)
Abnormal Flexion (Decorticate Posturing)
3
Abnormal Extension (Decerebrate Posturing)
Abnormal Extension (Decerebrate Posturing)
2
None
None
1
Total Score
Pediatric Glasgow Coma Scale Scoring:
13-15 – Minor Head Injury
9-12 – Moderate Head Injury
Less then or equal to 8 – Severe Head Injury
Pediatric Glasgow Coma Scale
(For Infants Two Years of Age and Under)
Activity
Assessment
Score
Eye Opening
Spontaneous
4
To Speech or Sound
3
To Painful Stimuli
2
None
1
Verbal Response
Coos and/or Babbles
5
Irritable Cry
4
Cries to Pain
3
Moans to Pain
2
None
1
Motor Response
Spontaneous Movement
6
Withdraws to Touch
5
Withdraws to Pain
4
Abnormal Flexion
3
Abnormal Extension
2
None
1
Total Score
Pediatric Glasgow Coma Scale Scoring (infants less then 2 yrs. old):
More pediatric trauma “preventable deaths” are related to improper stabilization of the airway rather than improper c-spine precautions or multiple traumatic injuries. The following assessment is considered to be the “primary survey” assessment of a pediatric trauma patient.
Airway and Protective Airway Reflexes (asses for signs of airway obstruction and/or respiratory distress):
Cyanosis
Intercostal retraction
Stridor
Absent Breath Sounds
Drooling
Bradycardia/Tachycardia
Nasal Flaring
Apnea
Bradypnea/Tachypnea
Chocking
Grunting
Irritability
Lethargy
Provide Basic Airway/Spinal Immobilization (open airway using a jaw thrust and chin lift method until spinal injury is ruled out):
Assess breathing (rate, depth, chest symmetry)
Suspect pneumo/hemothorax in cases of increased respiratory distress or diminishing lung sounds.
Consider placement of OPA if unconscious
Suction PRN/Pulse Oximetry/100% O2 if required
If cervical trauma is suspected, immobilize neck with appropriate device.
Infants and small children may require an under the shoulder supportive device to keep the head in a neutral position.
Oxygen Therapy:
Use nasopharyngeal or oropharyngeal airway, mask or blow by oxygen as tolerated.
If the child is unresponsive, begin hyperventilation immediately (hyperventilation will help reduce cerebral edema)
Assist ventilation if needed (if chest rise is inadequate, consider the following):
Repositioning the airway
Foreign body obstruction
Inadequate bag volume or activated pop-off valve
Rescue breathing (using a bag/valve/mask device)
Intubation and mechanical ventilation is often required with Glasgow Coma Scores of 8 or less.
Evaluation of Circulation includes:
Heart rate (quality of pulse).
Mental status (pediatric Glasgow Coma Scale).
Skin (Pale, cool, moist skin and delayed capillary refill are due to peripheral vasoconstriction).
Capillary refill (less then a 3 second return).
Blood pressure (not always a reliable assessment in pediatric patients).
Check for external injuries causing excessive bleeding.
If circulation (systemic perfusion) is compromised use IV/IO isotonic crystalloids (bolus 20ml/kg). Start two large bore IV’s.
Increased/decreased heart rate may be sign of shock or head/spinal trauma.
Neurological Assessment (Any of the following can be signs of head injury in the pediatric trauma patient):
Restlessness, Agitation, Lethargy (can be due to hypoxia or decreased cerebral perfusion).
Altered LOC (can also be due to hypoxia, decreased cerebral perfusion or shock).
Metabolic disorders can also cause neurological changes.
Use PTS and PGCS for complete neurologic assessment.
Special Considerations for Pediatric Trauma Victims:
Overall Size – because pediatric patient are smaller in size, they are more susceptible to wide range of injuries. The mechanism of injury should be based on the relative size of the patient and appropriate equipment must be selected.
Head Size – the pediatric patient has a larger head in proportion to the rest of the body, so head and spinal immobilization techniques may need to be modified to assure that there is proper alignment. The use of additional padding may be needed under the shoulders.
Tongue Size – the pediatric patient has a larger tongue size (proportionally) and therefore has an increased risk for airway obstruction.
Metabolic – the pediatric patient has a more rapid metabolic system (quicker then most adults) that can cause an increased use of oxygen and glucose.
Connective Tissue – the pediatric patient has greater elasticity of connective tissue which can cause greater stretching and tearing injuries, to the extend that a pediatric patient can have a serious spinal cord injury with no apparent visible signs. For any sign of deficit, the pediatric patient should be considered to have a spinal injury and appropriate precautions should be initiated.
Compact Organs – the pediatric patient has compact organs (smaller torso) which can mean greater injury to multiple organs during a traumatic injury. Pediatric patients with multiple organ injury may initially look uninjured, but then deteriorate rapidly. This requires frequent assessment and reassessment to recognize serious injury.
Less Rigid Skeletal Structure – because the pediatric patient still has many active growth centers and a skeletal system that is not fully calcified; they can usually tolerate or withstand a more severe force without breaking bones. Therefore the lack of outward injury should not be confused with the possibility of severe internal injury.
Less Body Fat – the pediatric patient has less body fat and a larger surface area in relation to body weight which can cause them to lose heat very quickly. Maintaining body heat and observing for hypothermia assessment and intervention priorities. Interventions to decrease hypothermia include; removing wet clothing, increase room temperature, warming lights, warmed IV fluids and routine monitoring of temperature.
Total Circulating Volume – the pediatric patient has a total circulating volume that (per unit of body weight) is 25% greater then an adult. Estimated blood loss is significantly related to body weight. For example; a blood loss of 150 ml in a 25 kg patient equals approximately 10% of the patient’s total circulating volume. Therefore; smaller body fluid losses can more quickly compromise the patient’s circulation.
Pain Assessment – for pediatric patients between the ages of 3 and 12, the FACES pain scale is usually effective. The FLACC pain scale can also be used if the patient is unable to use other scales. Note that pediatric patients often respond differently to pain and may not be able to express or demonstrate where they are feeling pain so look for behavioral cues such as crying, grimacing, decreased activity, altered sleeping patterns as possible signs of pain.
Blood Pressure – blood pressure in the pediatric patient is not a reliable indicator of shock.
Potential Complications of Pediatric Trauma:
Hypovolemic Shock
Septic Shock
Neurogenic Shock
Respiratory Distress Syndromes
Atelectasis
Increased Intracranial Pressure (ICP)
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Diabetes Insipidus
Compartment Syndrome
GI Bleed
Meningitis
Tension Pneumothorax
Hemothorax
Pulmonary Emboli
Skin Breakdown
Peritonitis
Pneumonia
Disseminated Intravascular Coagulation (DIC)
References
Alterman, D., M.D. (2006). Considerations in pediatric trauma. Retrieved on March 10, 2007 at:
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