In this section
differ from adults anatomically, physiologically, cognitively and
psychologically. The aim of this chapter is to outline these differences, and
how they influence the assessment and management of traumatic injury in
childhood. These differences will be discussed with regard to their impact on:
is the greatest contributor to childhood mortality[i]. Childhood
activities and the changing levels of maturity of children expose them to
different risks to adults. Children are more likely to fall from playground
equipment, suffer sporting and playground accidents than be involved in motor
vehicle or industrial accidents like their parents. They are, therefore, at risk in proportion to their
level of cognitive, physical and social development.[ii]
Older children and adolescents
consciously engage in risk-taking behaviours, there is an increase in road
traffic accidents, assault, intentional self-harm and intoxication.
[i] Australian Institute of Health and Welfare. 2016. Leading causes of death (AIHW). [ONLINE] Available at: http://www.aihw.gov.au/deaths/leading-causes-of-death/#leading-age. [Accessed 08 March 16].
[ii] Australian Institute of Health and Welfare. 2014. Hospitalised injury in children and young people 2011-12: Injury Research and Statistics Series No.91. [ONLINE] Available at: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129549323. [Accessed 08 March 16].
When involved in the same kind of accident as adults, children may suffer quite different injuries because of their different size, anatomy and physiology.
Infants and small children have
smaller airways – minor injuries and slight swelling can rapidly compromise
their ability to breath. A similar
injury in different aged children can raise different concerns, and have
varying consequences. For example, nasal fractures are common in
adolescents (especially in those playing contact sports) and rarely need
immediate intervention. However, the
same injury in an infant, who is an obligate nose breather, may require immediate
assistance. Such injuries are rare in small
children – given their limited mobility and smaller, more protected noses, so
if present, a nasal injury in these age groups should raise the suspicion of
Thoracic injuries are a
significant cause of mortality in paediatric trauma. The lack of complete ossification of the ribs
and sternum mean the underlying structures are less well protected – leading to the potential for pulmonary / mediastinal injury to occur without significant signs of external injury. Children also have a relative lack of physiological reserve and higher metabolic rate can
lead to rapid desaturation in children.
As with their thorax, the abdominal contents of children are relatively unprotected due to a thin abdominal wall with less fat and underdeveloped musculature. The liver and spleen are less protected by the rib cage and are thus at greater risk from blunt abdominal trauma. Common mechanisms of injury include motor vehicle accidents and handlebar injuries. Any bruising of the abdomen - in particular the "seat belt" sign - signifies an increased risk of intra-abdominal injury. However, the compliance of the abdominal wall means significant injury can exist with only non-specific or subtle external signs.
Young children, with relatively
large heads and underdeveloped musculature sustain higher proportions of isolated
head injuries than older children.[i] Traumatic Brain Injury is the leading cause
of death in paediatric trauma patients. Young children are also more likely
to injure their upper C-spine region (as opposed to the lower C-spine in
adults) for the same reason - however due to the types of accidents they have cervical spine injury is rare in childen. Spinal cord injuries are
relatively uncommon in the paediatric trauma patient – however, children less
than 8 may be susceptible to SCIWORA (spinal cord injury without radiological
Blunt trauma may result
in bone fractures in the adult population, while the cartilaginous nature of
children’s bones tends to prevent them from fracturing. However, lack of a
fracture does not mean absence of injury. Protective equipment and
clothing can be harder to obtain for children compared to adults. The varying and
constantly changing sizes of growing children make correct sizing of helmets,
car restraints and so on difficult and expensive for families. Older children may succumb to peer group
pressure and refuse to use protective wear such as knee splints, wrist guards
and helmets. Finally, the larger surface area /
volume ratio puts children at greater risk of hypothermia following their
Suspicion may be aroused
is important to remember that age is one of the most important risk factors in
non-accidental injury – with the majority of abusive fractures being seen in
children <12 months.
injury patterns are more suggestive of a non-accidental injury:
non-accidental injury is suspected, local policies must be followed. This typically involves consultation with a
senior clinician, social worker and forensic medical service. Where there are immediate safety concerns Child
Protection Services need to be contacted to ensure the safety of that child or
[i] Bayreuther J et al. Paediatric trauma: injury pattern and mortality in the UK. Arch Dis Child Educ Pract Ed 2009. 94(2):37-41
Given the wide spectrum of injuries sustained by children and
their range of developmental stages, health care practitioners need to be
skilled at obtaining a history from parents, care-givers, children and other
health-care providers. Consideration
should always be given to whether the mechanism of injury described is
consistent with the child’s developmental age.
AMPLE is an acronym used for gathering a brief history of
patient and event in the context of a minor injury.
A Allergies – in children
this may be unknown
M Medications - typically fewer than in the adult population
medical history - Children are generally healthy and don’t usually present with
complex medical histories. However, practitioners should ask about previous
injuries – a history of recurrent presentations with injuries may raise
suspicion for NAI.
ate - important if procedural sedation is
required or the patient needs to go to theatre
Immunisation and birth history are also important elements of the history which need to be documented:
are more severely injured, they may arrive at hospital via the emergency
services. It is common in this situation to use a
formal handover tool such as the IMIST - AMBO tool. This acronym stands for:
The function of the
Primary Survey is to rapidly identify and manage immediate life threats. It focuses on the following:
Paediatric airway is smaller
Relatively larger tongue and smaller oral
Infants have a relatively larger
Infants are nose breathers.
Trachea is more cartilaginous and soft
Larynx is higher and more anterior.
Only an experienced clinician should
attempt intubation in the young child.
Shape of the epiglottis
Cricoid ring is the narrowest point in the
The trachea is short
Ribs positioned more horizontally
Adult chest x-ray showing arched ribs:
Neonate chest x-ray showing flattened ribs:
Thin chest wall
Fewer Type 1 fibres in respiratory muscles
Respiratory rate varies with age
Blood volume is relatively larger, but absolute volume is smaller
Systemic vascular resistance is lower
Hypotension is a late sign
Smaller vessels / more subcutaneous tissue
Open sutures, presence of fontanelle
Thinner cranial bones
Head relatively larger
Cognitive and psychological development varies with
Relatively small size
Higher BMR and surface area
Increased glucose requirements but decreased glycogen
Chest wall is more compliant.
Increased mobility of the mediastinal
Relatively thin abdominal wall
Abdominal organ proportions and placement
Diaphragm is more horizontal
Growth plates not fused
Children and infants differ, both anatomically and physiologically, from adults. These differences will have an impact on the assessment and management of paediatric trauma. However it is important to recognise that the basic principles of trauma care
- airway, breathing and circulation - remain the same, regardless of the age of the patient.
Normal paediatric vital signs by age group
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