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PHTLS_ Prehospital Trauma Life Support 8TH

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PHTLS_ Prehospital Trauma Life Support 8TH

PHTLS_ Prehospital Trauma Life Support 8TH


Analgesia Patients with electrical burns should ideally be transported with
a urinary catheter in place. Patients with myoglobinuria require
Burns are extremely painful and, as such, require appropri- aggressive fluid administration to maintain a urine output of
ate attention to pain relief beginning in the prehospital setting. greater than 100 ml/hour in adults or 1 mUkg/hour in children to
Narcotic analgesics such as fentanyl (1 mcg per kg body weight) avoid acute kidney iitjury. Sodium bicarbonate is administered
or morphine (0.1 mg per kg body weight) in adequate dosages in some cases to make the myoglobin more soluble in urine and
will be required to control pain. reduce the likelihood of renal iitjury; however, its actual benefit
in preventing acute kidney iitjury remains a topic of debate.
Special Considerations
The electrical burn patient may have associated mechanical
Electrical Burns iitjuries as well. Approximately 15% of patients with electrical
iitjuries will also have traumatic iitjuries. This rate is twice that
Electrical iitjuries are devastating iitjuries that can easily be seen in patients burned by other mechanisms.19 Tympanic mem-
underappreciated. In many cases the extent of apparent tissue branes may rupture, resulting in hearing difficulties. Intense
damage does not accurately reflect the magnitude of the actual and sustained muscle contraction (tetany) can result in shoul-
iitjury. Tissue destruction and necrosis are much greater than the der dislocations and compression fractures of multiple levels
visually apparent trauma because most of the destruction occurs of the spine as well as long bones, and for this reason patients
internally as the electricity is conducted through the patient. The with electrical iitjury should have their spine immobilized. Long-
patient will have external burns at the points of contact with the bone fractures should be splinted when detected or suspected.
electrical source as well as grounding points (Figure 15-20). As the Intracranial bleeds and cardiac dysrhythmias may also occur.
electricitycourses through the patient's body, deep layers oftissue
are destroyed despite seemingly minor iitjuries on the surface.

Electrical and crush injuries share many similarities. In
both iitjuries, there is massive destruction of large muscle
groups with resultant release of both potassium and myoglobin
(see the Musculoskeletal Trauma chapter). The release of mus-
cle potassium causes a significant increase in the serum level,
which can result in cardiac dysrhythmias. Elevated potassium
levels can make administration of the depolarizing muscle
relaxant succinylcholine prohibitively dangerous.18 If chemical
paralysis of the patient is required, such as for rapid sequence
intubation, nondepolarizing agents such as vecuronium or
rocuronium may be used. Myoglobin is a molecule found in
the muscle that assists the muscle tissue in transportation of
oxygen. When released into the bloodstream in considerable
amounts, the myoglobin is toxic to the kidneys and can cause
kidney failure. This condition, myoglobinuria, is evidenced by
tea- or cola-colored urine (Figure 15-21).

Prehospital care providers are commonly called upon to pro-
vide interhospital transfers of patients after electrical iitjuries.

Figure 15-20 Patient after electrical injury from high-tension wires. Figure 15-21 Urine of patient after electrical injury from high-tension
wires. The patient has myoglobinuria after extensive muscle destruction.
Source: Courtesy of Jeffrey Guy, MD.
Source:© Suphatthra China/ShutterStock, Inc.

CHAPTER 15 Burn Injuries 419

Electrical flash burns are the result of superheated air. soot in the sputum are at risk for a smoke-inhalation irtjucy; how-
Nevertheless, because of the catastrophic and occult nature of ever, the absence of these signs does not exclude the diagnosis
conduction irtjmies, it is imperative that providers maintain a high of a toxic inhalation (Figure 15-23). Maintaining a high index of
index ofsuspicionfor the presence ofa transmission type ofirtjucy. suspicion is vitally important because signs and symptoms may
not manifest for days after the exposure.
Circumferential Burns
There are three elements ofsmoke inhalation: thermal irtjucy,
Circumferential burns of the trunk or limbs are capable of asphyxiation, and delayed toxin-induced lung iajucy. Dry air is a
producing a life- or limb-threatening condition as a result of the poor conductor of heat; the inhalation of heated air associated
thick, inelastic escharthat is formed. Circumferential bums ofthe with a structure fire rarely induces thermal irtjury to the airways
chest can constrict the chest wall to such a degree that the patient below the level of the vocal cords. The large surface area of the
suffocates from the inability to inhale. Circumferential burns of nasopharynx acts effectively as a heat exchanger and cools the
the extremities create a tourniquet-like effect that can render an inhaled, heated air to about body temperature by the time the air
arm or leg pulseless. Therefore, all circumferential burns should reaches the level ofthe vocal cords. When heated dry air at 300°C
be handled as an emergency and patients transported to a burn (572°F) is inhaled, the air is cooled to 50°C (122°F) by the time it
center or to the local trauma center, if a burn center is not avail- is at the level of the trachea.20 The vocal cords provide additional
able. As discussed previously, escharotomies are surgical inci- protection by reflexively moving into an adducted or closed posi-
sions made through the burn eschar to allow expansion of the tion.21 The exception to this is the inhalation of steam. Steam has
deeper tissues and decompression ofpreviously compressed and 4,000 times the heat-carrying capacity of dry air and is capable of
often occluded vascular structures (Figure 15-22). burning the distal airways and bronchioles when inhaled.20

Smoke Inhalation Injuries Asphyxiants

The leading cause of death in fires is not thermal irtjucy but the Two gaseous products that are clinically important as asphyx-
inhalation oftoxic smoke. Any patient with a history ofexposure iants are carbon monoxide and cyanide gas. Both molecules are
to smoke in an enclosed space should be considered to be at risk classified as asphyxiants and, thus, cause cell death by cellular
of having an inhalation irtjucy. Victims with burns to the face or hypoxia or asphyxia. Patients with asphyxia from smoke con-
taining one or both of these compounds will have inadequate
delivery ofoxygen to tissues despite an adequate blood pressure
or pulse oximeter reading.

Carbon monoxide binds to hemoglobin with much greater
affinity than oxygen does. The symptoms of carbon monoxide
inhalation depend on the duration or severity of exposure and
the resultant serum levels. Symptoms can range from mild head-
ache to coma and death (Figure 15-24). Traditional teaching is

Figure 15-24

Figure 15-22 Escharotomies are performed to release the • Mild
constricting effect of circumferential burns. • Headache
Source: Courtesy of Jeffrey Guy, MD. • Fatigue
• Nausea
Figure 15-23
• Moderate
• Burn in a confined space • Severe headache
• Confusion or agitation • Vomiting
• Burns to face or chest • Confusion
• Singeing of eyebrows or nasal hair • Drowsiness/sleepiness
• Soot in the sputum • Increased heart rate and ventilatory rate
• Hoarseness, loss of voice, or stridor
• Severe
• Seizures
• Coma
• Cardiorespiratory arrest
• Death


that patients poisoned with carbon monoxide develop "classic" extremely difficult. Therefore, in the majority of cases, bypass-
cherry-red skin coloration. Unfortunately, this is often a late sign ing a burn or trauma center in favor of a facility with a hyper-
and should not be relied upon when considering the diagnosis. baric chamber is not warranted.

Portable pulse carbon monoxide monitors that Cyanide gas is produced from the burning of plastics
noninvasively measure the amount of carbon monoxide in the or polyurethane. Cyanide poisons the cellular processes of energy
bloodstream are available for use in the prehospital settings production, preventing the body's cells from using oxygen. The
(Figure 15-25). These monitors look and work similar to pulse patient can die from asphyxia despite having adequate amounts
oximeters. Patients will generally complain of mild symptoms of oxygen available in the blood. Symptoms of cyanide toxicity
with levels of 10-20% carboxyhemoglobin. As the level of car- include altered level of consciousness, dizziness, headache, and
bon monoxide in the blood further increases, symptoms pro- tachycardia or tachypnea. Patients with carbon monoxide tox-
gressively get worse. As levels exceed 50-60%, seizures, coma, icity from a structure fire should also be considered to be at risk
and death result. for cyanide poisoning. The treatment of cyanide poisoning is the
rapid administration of antidote. The preferred antidote for cya-
Pulse oximeters cannot be used to guide recognition or nide poisoning is a medication that directly binds to the cyanide
treatment. Pulse oximetry will give a falsely normal or elevated molecule, rendering it harmless. Hydroxocobalamin (Cyanokit)
reading because the detection of oxyhemoglobin depends on the detoxifies the cyanide by directly binding to it and forming cyano-
colorimetric analysis performed by the oximeter and that analy- cobalamin (vitamin B1;l, which is nontoxic. Hydroxocobalamin is
sis is fooled by the similar color of carboxyhemoglobim. available for prehospital use in Europe and in the United States.
A second chelating agent that has been used in Europe for cyanide
Treatment of carbon monoxide toxicity is removal of the poisoning is dicobalt edetate; however, ifthis medication is admin-
patient from the source and administration of oxygen. When istered in the absence ofcyanide poisoning, cobalt toxicity is a risk
breathing room air (21% oxygen), the body will eliminate half
the carbon monoxide in 250 minutes.22 When the patient is The "Lilly kit" or "Pasadena kit" has been the traditional cya-
placed on 1000...6 oxygen, the half-life of the carbon monoxide- nide antidote kit used in the United States and may still be utilized
hemoglobin complex is reduced to 40 to 60 minutes.23 For many in some settings. This method of treating cyanide poisoning was
years, hyperbaric oxygen has been considered the treatment developed in the 1930s and found to be effective in detoxifying
of choice for moderate or severe carbon monoxide poisoning. animals poisoned with 21 times the lethal dose of cyanide.25 The
The use of hyperbaric oxygen reduces the half-life of carbon goal of this antidote therapy is to induce the formation of a sec-
monoxide to 20 to 30 minutes and has been thought to decrease ond poison (methemoglobin) in the patient's blood. This thera-
the incidence of long-term sequelae from the carbon monoxide peutically induced poison binds with the cyanide and allows the
exposure. Recently, the benefit of hyperbaric oxygen treatment body to slowly detoxify and excrete the cyanide.
over standard 100% oxygen therapy has been questioned.24 In
addition, ifthe patient has significant burn injuries or other trau- The Lilly kit contains three medications. The first medi-
matic injuries, providing needed care in a hyperbaric chamberis cation to be administered for victims of cyanide poisoning is
a nitrate, either amyl nitrate or sodium nitrate, both of which
Figure 15-25 Masimo prehospital carbon monoxide monitor, Rad-57. are provided in the kit. Amyl nitrate comes in an ampule that is
broken open, releasing fumes that the patient inhales; sodium
Source: Courtesy of Masimo Corporation. nitrate, which is given IV, is the preferred method of adminis-
tration as it is a more efficient delivery modality and avoids
exposure of healthcare providers to amyl nitrate fumes. The
nitrate medications change some of the patient's hemoglobin
into a form called methemoglobin, which attracts the cya-
nide away from the site of toxic action in the mitochondria
of the cell. Once the cyanide binds with the methemoglobin,
the mitochondria can once again begin to produce energy for
the cell. Unfortunately, methemoglobin is toxic because it does
not carry oxygen to cells as well as hemoglobin does. This
decrease in oxygen delivery can exacerbate the tissue hypoxia
associated with increased carbon monoxide levels that the
victim may also have as a result of smoke inhalation.26•27

The third medication in the kit is sodium thiosulfate, which
is given IV after the nitrate. The thiosulfate and cyanide from the
methemoglobin are metabolized to thiocyanate, which is safely
excreted in the patient's urine.

Because of the toxicity of methemoglobin and the time
needed to administer the full Lilly kit, hydroxocobalamin has
become the preferred antidote for the treatment of cyanide

CHAPTER 15 Burn Injuries 421

Toxin-Induced Lung Injury The most common form of bum child abuse is forcible
immersion. These injuries typically occur when an adult places
The thermal and asphyxiant components of an inhalation injury a child in hot water, often as a punishment related to toilet
are usually apparent at the time of the rescue. In contrast, the training.36 Factors that determine the severity of injury include
signs and symptoms of toxin-induced lung injury typically do not age of the patient, temperature of the water, and duration of
manifest themselves for several days. The first several days after exposure. The child may sustain deep second- or third-degree
a smoke inhalationinjury are often described as the "honeymoon bums of the hands or feet in a glove-like or stocking-like
period." During this period, the patient may appear deceptively pattern. Such findings are especially suspicious when the bums
stable with little or no pulmonary dysfunction. The severity of are symmetric and lack splash pattems37 (Figures 15-26 and
this lung injury is largely dependent on two factors: the composi- 15-27). In cases of intentional scalding, the child will tightly
tion of the smoke and the duration of exposure.28 flex the arms and legs into a defensive posture because of
fear or pain. The resultant bum pattern will spare the ftexion
In simplified terms, smoke is the product of incomplete creases of the popliteal fossa (knees), the antecubital fossa
combustion-that is, chemical dust. The chemicals in the (elbows), and the groin. Sharp lines of demarcation will also
smoke react with the lining of the trachea and lungs and dam- be seen between burned and unburned tissue, essentially indi-
age the cells lining the airways and lungs.29-31 Compounds cating a dip38•39 (Figure 15-28).
such as ammonia, hydrogen chloride, and sulfur dioxide form
corrosive acids and alkalis when they are inhaled and react
with water.32 These poisons cause necrosis of the cells lining
the trachea and bronchioles. Normally, these cells have tiny
hairlike structures called cilia. On these cilia is a blanket of
mucus that captures and transports normally inhaled debris
to the oropharynx, where the debris is swallowed into the GI
tract. Several days after an inhalation injury, these cells die.
The debris from these necrotic cells and the debris these cells
typically capture accumulate instead of being removed. The
result is an increase in secretions, plugging of the airways with
mucus and cellular debris, and an increased rate of life-threat-
ening pneumonia.

Prehospital Management

The initial and most important element of caring for a patient
with smoke exposure is determining the need for orotra-
cheal intubation. Continuous re-evaluation of airway patency
is required in order to recognize developing signs of airway
obstruction. Change in the character of the voice, difficulty han-
dling secretions, or drooling are signs ofimpending airway occlu-
sion. Whenever patency of the patient's airway is in doubt, the
prehospital care provider can proceed with securing the airway
using orotracheal intubation.33.:w In some cases, rapid sequence
intubation may be necessary, if allowed, to manage the airway.
In the event of long transport times, rendezvous with an agency
capable of providing definitive airway management should be

Patients with smoke inhalation should be transported to
bum centers even in the absence of surface burns. Bum centers
treat a greater volume of patients with smoke inhalation and
offer unique modes of mechanical ventilation.

Child Abuse Figure 15-26 The straight lines of the burn pattern and absence of

Approximately 200;6 of all child abuse is the result of intentional splash marks indicate that this burn is the result of abuse.
burning. The majority of the children intentionally burned are
1 to 2 years of age.35 Many jurisdictions require health care pro- Source: Courtesy of Jeffrey Guy, MD.
viders to report cases of susp ected child abuse.


Contact Burns

Contact burns are the second most common mechanism of burn
injury in children, whether accidental or intentional. All body
smfaces have some degree of curvature. When an accidental
contact burn occurs, the burning agent makes contact with the
curved body smface area. The burning instrument is deflected
off the curved smface, or the victim withdraws from the hot
object. The resultant injury has an irregular burn edge and depth.
When a child receives an intentional contact burn, the inflicting
implement is pressed onto the child's skin. The resultant injury
has sharp lines of demarcation between burned and unburned
tissue and uniform depth.39 Common objects involved in contact
burns include curling irons, steam irons, radiators, and hot pots
and pans.

Figure 15-27 The sparing of the areas of flexion and the sharp lines Radiation Burns
of demarcation between burned and unburned skin indicate that this
child was in a tightly flexed, defensive position before injury. Such a The severity of burns produced from various forms of radi-
posture indicates that the scald is not accidental. ation is a product of the amount of energy absorbed by the
Source: Courtesy of Jeffrey Guy, MD. target tissue. The various forms of radiation include elec-
tromagnetic radiation, x-rays, gamma rays, and particulate
Figure 15-28 The stocking-type scald of the child's foot indicates radiation. The different forms of radiation are able to transfer
intentional immersion burn injury consistent with chi ld abuse. varying degrees of energy to tissue. Additionally, some forms
Source: Courtesy of Jeffrey Guy, MD. of radiation (e.g., electromagnetic) can pass through tissue or
an individual, resulting in no damage. In contrast, other forms
In accidental scald injuries, the burns will have variable of radiation (e.g., neutron exposure) are absorbed by the tar-
burn depth, irregular margins, and smaller burns remote from get tissue and result in significant injury. It is the absorption
the large burns, indicating splash.40 ofthe radiation that results in damage to the absorbing tissue.
The absorption capacity of the radiation is more damaging
than the actual dose of radiation. Equivalent doses of different
forms of radiation will have dramatically different effects on
an individual.

The typical exposure to radiation occurs in the setting ofan
industrial or occupational incident. However, with the increasing
threat of global terrorism, the detonation of a "dirty bomb" or
radiation dispersal device (conventional explosive with radioac-
tive material added) or a small, improvised nuclear device (i.e.,
"dirty nuke") is a possibility. (See the Explosions and Weapons of
Mass Destruction chapter for more detail.)

The detonation of a dirty bomb is designed to spread radio-
active material over a large area. While the explosion itselfwould
likely injure or kill individuals in close proximity to the blast, the
risk from the radioactive material is, in reality, relatively small.
There is little likelihood ofabsorbing a large enough dose ofradi-
ation to produce clinical illness.

The detonation of a nuclear weapon in a metropolitan area,
on the other hand, would injure and kill many people by three
mechanisms: thermal burns from the initial firestorm, super-
sonic destructive blast causing blunt and penetrating trauma,
and production of radiation. Mortality from a combination of
thermal and radiation burns is greater than that from either ther-
mal or radiation burns alone of equal magnitude. The combina-
tion of thermal and radiation burns has a synergistic effect on

CHAPTER 15 Burn Injuries 4 2 3

Radiation is a hazardous material, and many of the initial After a nuclear event, IV supplies, infusion pumps, and
priorities are the same as for any patient exposed to a hazardous receiving medical facilities may be in short supply. If the
material. The initial priorities are to utilize appropriate personal prehospital care provider is unable to provide the patient with
protective equipment, remove the patient from the source of IV resuscitation, the patient can be resuscitated with oral flu-
contamination, remove contaminated clothing, and irrigate the ids. A cooperative patient should be encouraged to drink a bal-
patient with water. Remember that any removed clothing should anced salt solution to maintain a large urine output; alternatively,
be considered contaminated and should be handledwith caution. fluids can be delivered by nasogastric or nasoenteric tubes. Oral
Irrigation is done carefully to remove any radioactive debris or balanced salt solutions include Moyer's solution (4 grams sodium
particles from contaminated areas without spreading the iajury chloride [0.5 teaspoon ofsalt] and 1.5 grams sodium bicarbonate
to uncontaminated body surfaces. Irrigation should continue [0.5 teaspoon baking soda] in 1 liter water) and World Health
until contamination has been minimized to a steady state, as Organization oral rehydration solution (WHO ORS). Animal
determined by a full-body survey with a Geiger counter.42 research has shown encouraging results with such resuscita-
tion strategies in patients with burns as large as 40% TBSA.
The exception to this approach is the patient who has sus- Administration of balanced salt solution to the GI tract at a rate
tained major trauma in addition to their radiation iajury. In these of 20 ml/kg provided resuscitation equivalent to standard IV fluid
cases, clothing should beremoved immediately, then the traumatic resuscitation.43
iajury is dealt with and the patient stabilized. Patients with burns
should undergo fluid resuscitation similar to any other patient with Chemical Burns
burn iajury. Irradiated patients may experience vomiting and diar-
rhea, which will necessitate an increase in resuscitation fluids. All prehospital care providers need to be familiar with the basics of
treating chemical iajuries. Prehospital care providers in urban set-
The physiologic consequences of whole-body radiation are tings may be called to a chemical incident at an industrial setting,
termed acute radiation syndrome (ARS). The initial symptoms whereas a rural prehospital care provider may be summoned to an
ofARS typically appear within hours ofexposure. The cells ofthe incident involving agents used in agriculture. Tons of hazardous
body that are most sensitive to the effects of radiation are those materials are transportedthrough urban and rural settings dailyby
that typically undergo rapid division. These rapidly dividing cells both highways and rail systems. Military prehospital care provid-
are found in the skin, GI tract, and bone marrow; therefore, these ers may treat casualties of chemical burns caused by weapons or
tissues manifest the first signs of ARS. Within a few h ours after incendiary devices, chemicals used to fuel or maintain equipment,
significant radiation exposure, the patient will experience nau- or chemical spills after damage to civilian installations.
sea, vomiting, and cramping abdominal pain. Aggressive fluid
management is required to prevent the development of renal lajuries from chemicals are often the result of prolonged
failure. Over the following days, the patient may develop bloody exposure to the offending agent, in contrast to thermal iajuries,
diarrhea, ischemia of the bowel, and overwhelming infection, which usually involve a very brief exposure duration. The sever-
and may die. Bone marrow is extremely sensitive to the effects ity of chemical iajury is determined by four factors: nature of
of radiation and will stop production ofwhite blood cells needed the chemical, concentration ofthe chemical, duration of contact,
to fight infections and platelets needed to make b lood clots. The and mechanism of action of the chemical.
resultant infections and bleeding complications are often fatal.

OK"" 0

I _ ..-...:.


...__ _,[_ )

0 234 5 6789 10 11 12 13 14

t(10°MW) Vi1J t tfTM~+> t tMilk of (ct '"T"'1
Battery Gr?~efruit Milk Blood Baking Lye Drain cleaner
acid JUICe Black Magnesia
coffee Saliva soda Ammonia Bleach

Figure 15-29 Chemical agents are classified as acid, neutral, or base, depending upon t he amount of hydrogen or hydroxide ions. Many
household items will be acid or base and require care in handling.

Source: © Jones & Bartlett Learning.


Chemical agents are classified as acid, base, organic, or inor-
ganic. Acids are chemicals with a pH between 7 (neutral) and 0
(strong acid). Bases are agents with a pH between 7 and 14 (strong
base) (Figure 15-29). Acids damage tissue by a process called
coagulative necrosis; the damaged tissue coagulates and trans-
forms into a barrierthatprevents deeperpenetration ofthe acid. In
contrast, alkali bums destroy the tissue by liquefaction necrosis;
the base liquefies the tissue, allowing the chemical to penetrate
more deeply and cause increasingly deeper tissue damage.

Prehospital Management

The greatestpriorityinthe care ofa patientexposedto chemicalagents Figure 15-30 Eyes t hat have sustained a chemical injury require
is personal and scene safety. As in an emergency, the prehospital care prompt irrigation with copious amounts of sa line. A Morgan lens can
provider should always be protected first. Ifthere is any possibility of be placed on t he eye to provide appropriate ocular irrigation.
exposure to a chemical hazard, ensure scene safety and determine if
any special gannent orbreathing apparatus is required. Avoid contam- Source: Courtesy of Jeffrey Guy, MD.
ination ofequipment and emergency vehicles; a contaminatedvehicle
creates an exposure risk to all others in its path. Attempt to obtain
identification ofthe chemical agent as soon as possible.

Remove all clothing from the patient, as it may be contami-
nated with the c hemical agent in either liquid or powder form. The
contaminated clothing needs to be discarded with care. Ifany par-
ticulate substance is on the skin, it should be brushed away. Next,
wash (l,avage) the patient with copious amounts of water. Lavage
will dilute the concentration of the ir\jurious agent and wash away
any remaining reagent The key to lavage is to use large amounts of
the water. A common error is to rinse 1 or 2 liters of water across
the patient, then stop the lavage process once the water starts to
pool and accumulate on the floor. When lavaged with only small
amounts offluid, the offending agent is spread across the patient's
body surface area and not flushed away.44,45

Failure to provide adequate runoff and drainage of lavage
fluid may cause ir\jury to previously unexposed and unir\jured
areas of the patient's body as the contaminated lavage accumu-
lates beneath the patient. One simple way ofpromoting runoff in
a prehospital setting is to place the patient on a backboard and
then tilt it with cribbing or other means to elevate the head. At
the lower end of the board, tuck a large plastic garbage bag to
capture the contaminated runoff.

Neutralizing agents for chemical burns are typically avoided.
Often in the neutralizing process the neutralizing agents give
off heat in an exothermic reaction. Therefore, a well-meaning
prehospital care provider may create a thermal bum in addition
to the chemical bum. Most commercially available decontami-
nation solutions are made for the purpose of decontaminating
equipment, not people.

Chemical Burns to the Eye attached to IV tubing and an IV bag. Application of an ophthalmic
local anesthetic such as proparacaine will simplify the patient's
Irtjuries to the eye caused by exposure to alkali may be encoun- care for the prehospital care provider.
tered. A small exposure to the eye can result in a vision-threatening
ir\jury. The eyes should be inunediatelyirrigatedwithlarge amounts Specific Chemical Exposures
of irrigation fluid. Ifpossible, ocular decontamination with contin-
uous irrigation using a Morgan lens is performed (Figure 15-30). Cement is an alkali that may be retained on the clothing or
If a Morgan lens is not available, continuous irrigation may be in the footwear of individuals . The powdered cement will
accomplished manually with handheld IV tubing or, if both eyes react with the victim's sweat in a reaction that gives off heat
are involved, a nasal cannula placed on the bridge of the nose and

CHAPTER 15 Burn Injuries 4 2 5

and excessively dries, or desiccates, the skin.46 This exposure the lungs and the eyes. After exposure, patients will complain of
typically presents with a bum injury hours or the day after con- a burning sensation in the throat and eyes. The skin involvement
tact with the cement. The initial treatment includes brushing develops several hours later as redness is followed by blistering
the cem ent powder away followed by copious irrigation. in the exposed or contaminated areas. After intense exposure,
victims will develop full-thickness necrosis and respiratory fail-
Fuels such as gasoline and kerosene can cause contact burns ure.4rM1The principal treatment in the field is decontamination to
after prolonged exposure. These organic hydrocarbons can dis- prevent inadvertent cross-contamination.
solve cell membranes, resulting in skin necrosis.47 Decontamination
of the patient covered with fuel is accomplished by irrigation with In caring for victims of vesicant exposure, prehospital care
large volumes of water. Gasoline contact exposure can lead to providers must wear appropriate gloves, garments, and breath-
full-thickness tissue injury. An exposure of sufficient duration or ing equipment (Figure 15-31). The patients must be decontam-
severity also may result in systemic toxicity. Severe cardiovascular, inated and irrigated with water or saline. Other agents used to
renal, pulmonary, neurologic, and hepatic complications may fol- decontaminate victims, used by specially trained personnel,
low absorption through the topical wounds. In cases of suspected include dilute hypochlorite solution and Fuller's earth powder,
systemic toxicity, prompt surgical debridement may be warranted which is available commercially and functions as an absorbent
ifthere is concernfor ongoing absorption oftoxins from the wound. agent. Additional specialized treatment is required when the
patient arrives at a burn center.
Hydrofluoric acid is a dangerous substance widely used in
domestic, industrial, and military settings. It is primarily found in Figure 15-31
the manufacturing of refrigerants but is also used when making
herbicides, pharmaceuticals, high-octane gasoline, aluminum, plas- To limit the spread of a hazardous material, the National
tics, electrical compon ents, and fluorescent light bulbs. In addition, Institute of Occupational Safety and Health (NIOSH),
it is used to etch glass and metal and is found in rust removers and the Occupational Safety and Health Administration
automobile wheel cleaners. The real danger of this chemical is the (OSHA), the U.S. Coast Guard, and the Environmental
fluoride ion, which produces profound alterations of electrolytes, Protection Agency (EPA) have developed and advocated
especially calcium and magnesium.48 Even small amounts ofhydro- the use of control zones. 52 The objective of this concept
fluoric acid can lead to profound, and potentially lethal, hypocalce- is to perform specific activities in specific zones. By
mia (low serum calcium level). Left untreated, hydrofluoric acid adherence to such principles, the likelihood of spread
will liquefy tissues and leach calcium from the patient's bones. of contamination and injury to emergency response
Initial treatment for hydrofluoric acid exposure is irrigation with personnel and bystanders is reduced.
water, followed by application ofcalcium gluconate gel at an emer-
gency department. Patients with hydrofluoric acid burns should be The zones are three concentric circles. The innermost
promptly transferred to a burn center for additional treatment. zone is the hot zone. This is the region immediately
involved with and adjacent to the hazardous materials
Injuries from phosphorus are often seen in military settings. incident. Personnel entering this area must be fully
White phosphorus (WP) is a powerful incendiary agent used in protected, in most cases using Level A personal protective
the production of munitions. Itburns violently when exposed to equipment (PPE), against the potential hazard (see the
air, producing brilliant flames and dense smoke. It will continue Explosions and Weapons of Mass Destruction chapter).
to bum until all of the agent has been consumed or is deprived of The task of rescuers in the hot zone is to evacuate injured
oxygen. When in contact with skin, WP will produce deep chem- patients before decontamination or patient care. The
ical and thermal burns. next zone is the warm zone, where decontamination
of patients, personnel, and equipment occurs, again by
The initial treatment is to deprive the WP of access to oxy- personnel using appropriate protective equipment. In
gen. All clothing needs to be rapidly removed because it may this zone, the only patient care administered is a primary
contain some retained phosphorus particles that could ignite the assessment and spine immobilization, as indicated. The
clothing. Keep the affected areas immersed in water or saline- outermost zone is the cold zone, where equipment and
soaked dressings, and remoisten the dressings during transport. personnel are staged. Once the patient is evacuated to
If the dressings dry out, any retained WP will reignite and could the cold zone, providers can then deliver definitive care
ignite the dressings and bum the patient. without the need for chemical PPE.

Hypochlorite solutions are often used to produce house- If a patient arrives to your hospital or aid station
hold bleaches and industrial cleaners. These solutions are strong from a hazardous materials scene and has not been
alkalis; the commonly available solutions are 4% to 6% and are decontaminated, you should follow the concepts of
not usually lethal unless large areas of the body are exposed to these hazardous materials zones.
the chemical. In greater concentrations, however, small volumes
are potentially lethal. About 30 ml of a 15%solution is considered
a life-threatening exposure.

Sulfur and nitrogen mustards are compounds that are
classified as vesicants or blister agents. These agents have
been used as ch emical weapons and are recognized as a threat
in chemical terrorism. These chemicals will bum and blisterskin
on exposure. Theyare irritants to the skin and cause irritation to


Tear gas and similar chemicals are known as riot control duration of the irritation typically lasts 30 to 60 minutes.
agents. A riot c ontrol agent will rapidly and briefly disable Treatment consists of removing those exposed to the riot
those exposed to it by causing irritation to the skin, mucous control agent from the source of the exposure, remov-
membranes, lungs, and eyes. The extent of the injury is ing contaminated clothing, and irrigating the patients' s kin
determined by the magnitude of exposure to the agent. The and eyes.

• All burns are serious, regardless of their size.
• Potentially life-threatening burns include large thermal burns, electrical injuries, and chemical burns.
• Unlike in mechanical trauma (e.g., penetrating, blunt), the body has little to no adaptive mechanisms t o

survive a burn injury.
• Burn injuries are not isolated to the skin; these are systemic injuries of unparalleled magnitude. Patients

with major burn injury will experience dysfunction of the cardiovascular, pulmonary, gastrointestinal, renal,
and immune systems.
• Failure to provide appropriate fluid resuscitation will lead to refractory shock, multiorgan dysfunction, and
even deepening of the burns. The role of the prehospital care provider is, therefore, crucial in optimizing
survival after a burn injury.
• Although complicated and dangerous, burns are rarely rapidly fatal. A patient with severe smoke inhalation
and large thermal burns may take several hours or days to die. Patients with burns also are likely to have
other mechanical trauma.
• Dramatic burns may focus the prehospital care provider's attention away from other, potentially life-
threatening injuries. Performing primary and secondary assessments will reduce the likelihood of missing
these injuries (e.g., pneumothorax, pericardia! tamponade, splenic rupture).
• Constant vigilance is required to avoid becoming a victim. Often the injuring agent still poses a risk for
injuring the prehospital care providers.
• Even small burns in areas of high function (hands, face, joints, perineum) may result in long-term impair-
ment from scar formation.
• Familiarity with burn center transport criteria will help ensure that all patients can achieve maximal func-
tion recovery after burn injury.
• The leading cause of death in patients with burns is complications from smoke inhalation: asphyxiation,
thermal injury, and delayed toxic-induced lung injury. Frequently, patients do not develop symptoms of
respiratory failure for 48 hours or longer. Even without burns to the skin, victims ofsmoke inhalation should
be transported to burn centers.
• Victims of burn injury from hazardous materials, such as chemicals or radioactive agents, should undergo
decontamination to avoid inadvertent spread of the material to prehospital and health care providers.

You are called to a residential structure fire. When your unit arrives, you witness a two-story house that is fully involved with fire and
thick, black smoke pouring out of the roof and windows. You are directed to a victim who is being cared for by EMRs. They tell you
that the patient re-entered the burning building in an attempt to rescue his dog, and he was carried out unconscious by fi re fighters.

Your patient is a man who appears to be in his thirties. The majority of his clothes have been burned off. He has obvious burns to
his face, and his hair has been singed. He is unconscious; he is breathing spontaneously, but with snoring respirations. The EMRs have
placed the patient on high-flow oxygen with a nonrebreather mask. On physical examination, his airway is patent with manual assistance
Gaw thrust); he ventilates easily. The sleeves of his shirt have been burned off. His arms have circumferential burns, but his radial pulse is
easily palpable. His heart rate is 118 beats/minute, blood pressure is 148/94 mm Hg, ventilatory rate is 22 breaths/minute, and oxygen
saturation (Spo2), taken by pulse oximeter, is 92%. On physical examination, you determine that the patient is burned on his entire head
and has blistering of the anterior chest and abdomen, along with full-thickness burns of his entire right and left arm and hand.

• What is the extent of burns for this patient?
• What are the initial steps for managing this patient?
• How does the prehospital care provider recognize an inhalation injury?

CHAPTER 15 Burn Injuries 427

The patient has sustained critical injuries. Given that the patient was found collapsed in a burned building with burns to the face and
labored respirations, you must be concerned that the patient has inhaled a large amount of smoke.

Evaluate and re-evaluate for airway edema and an inhalation injury. Airway patency needs to be a concern; however, the patient
currently is managing his own airway. Keeping in mind that often the best person to manage an airway is the patient, you need to
balance the time required to transport the patient with the difficulties of airway management in a patient with an edematous airway.
If transport will be prolonged or delayed, secure the airway by tracheal intubation. The patient clearly needs 100% oxygen given the
exposure to smoke and concerns about asphyxiants. If you elect to intubate this patient, be careful to secure the ET tube. Anchor t he
tube securely. A portable carbon monoxide monitor placed on the patient reports a carboxyhemoglobin level of 16%, which is already
being treated since the patient is on 100% oxygen. You consult the local protocol regarding management of smoke inhalation with
potential cyanide poisoning.

Both upper extremities have deep, full-thickness burns. You are not able to identify any veins to establish an IV line. Neither leg is
burned, nor is there evidence of any fractures. An 10 line is started in the left tibia, and an infusion of lactated Ringer's is begun.

The patient is burned on the entire head, both upper extremities, and the anterior trunk. Each limb is approximately 9% of TBSA,
the anterior trunk is 18%, and the head is approximately 9%. Therefore, the estimated TBSA burned is approximately 45%. The patient
weighs approximately 175 pounds, or 80 kg. Estimate the patient's fluid needs using the Parkland formula, as follows:

45% TBSA burned x 80 kg x 4 ml/kg/TBSA burned = 14,400 ml to be administered in first 24 hours

Half this fluid total is administered in the first 8 hours after injury. Therefore, the hourly rate for the first 8 hours is:

14,400 ml/2 = 7,200 ml to be administered in first 8 hours

Calculate the hourly fluid rate:

7,200 ml/8 = 900 ml per hour for hours 0 to 8

References 10. Jandera V, Hudson DA, de Wet PM, Innes PM, Rode H. Cooling
the burn wound: evaluation of different modalities. Burns.
1. Tredget EE, Shankowsky HA, Taerwn TV, et al. The role of inha- 2000;26:265-270.
lation injury in burn trauma: a Canadian experience. Ann Surg.
1990;212:720. 11. Sawada Y, Urushidate S, Yotsuyanagi T, Ishita K. Is prolonged
and excessive cooling of a scalded wound effective? Burns.
2. Herndon D, Rutan R, Rutan T. Management of the pediatric patient 1977;23(1):5558.
with bums. J Burn Care Rehabil. 1993;14(1):3.
12. Venter TH, Karpelowsky JS, Rode H. Cooling of the burn wound: the
3. Rossignal A, Locke J, Burke J. Pediatric burn irtjuries in ideal temperature of the coolant. Burns. 2007;33:917-922.
New England, USA. Burns. 1990;16(1):41.
13. Dunn K, Edwards-Jones VT. The role of Acticoat with
4. Mortiz AR, Henrique FC Jr. Studies of thermal injury: the relative nanocrystal-line silver in the management of bums. Burns.
importance of time and surface temperature in the causation of 2004;30(s uppl):S1.
cutaneous burn injury. Am J Pathol. 1947;23:695.
14. Wright JB, Lam K, Burrell RE. Wound management in an era of
5. Robinson MC, Del Becarro EJ. Increasing dermal perfusion after increasing bacterial antibiotic resistance: a role for topical silver
burning by decreasing thromboxane production. J Trauma. treatments. Am J I nfect Control. 1998;26:572.
15. Ym HQ, Langford R, Burrell RE. Comparative evaluation ofthe anti-
6. Heggers JP, Ko F, Robson MC, et al. Evaluation of burn blister fluid. microbial activity of Acticoat antimicrobial dressing. J Burn Care
Pl,a,st Reconstr Surg. 1980;65:798. Rehabil. 1999;20:195.

7. Rossiter ND, Chapman P, Haywood IA. How big is a hand? Burns. 16. Chung KK, Salinas J, Renz EM, et al. Simple derivation of the
1996;22(3):230-231. initial fluid rate for the resuscitation of severely burned adult
combat casualties: in silico validation of the rule of 10. J Trauma.
8. Berry MG, Evison D, Roberts AH. The influence ofbody mass index
on burn surface area estimated from the area of the hand. Burns. 2010;69:84~54.
17. Navar PD, Saffle JR, Warden GD. Effect of inhalation injury on
9. de Camara DL, Robinson MC. Ultrastructure aspects of cooled fluid resuscitation requirements after thermal injury. Am J Surg.
thermal injury. J Trauma. 1981;21:911-919. 1985;150:716.


18. RxList. Anectine: warnings. Child Abuse. 2001.
wamings-precautions.htm Reviewed January 31, 2011. Accessed Accessed December 17, 2013.
September 1, 2013. 37. Chadwick DL. The diagnosis of inflicted iltjury in infants and young
children. Pediatr Ann. 1992;21:477.
19. Layton TR, McMurty JM, McClain EJ, Kraus DR, Reimer BL. 38. Adronicus M, Oates RK, Peat J, et al. Nonaccidental burns in chil-
Multiple spine fractures from electrical iltjuries. J Burn Care dren. Burns. 1998;24:552.
Rehabil. 1984;5:373--375. 39. Purdue GF, Hunt JL, Prescott PR. Child abuse by burning: an index
of suspicion. J Trauma. 1988;28:221.
20. Moritz AR, Henriques FC, McClean R. The effects of inhaled heat on 40. Lenoski EF, Hunter KA. Specific patterns of inflicted burn iltjuries.
the air passages and lungs. Am J Pa/Jwl. 1945;21:311. J Trauma. 1977;17:842.
41. Brooks JW, Evans EI, Ham WT, Reid JD. The influence of exter-
21. Peters WJ. Inhalation iltjury caused by the products of combustion. nal body radiation on mortality from thermal burns. Ann Surg.
Can Med Assoc J. 1981;125:249. 1953;136:533.
42. American Burn Association (ABA). Radiation iltjury. In: Advanced
22. Forbes WH, Sargent F, Roughton FJW. The rate of carbon monoxide Burn Life Support Course. Chicago, IL: ABA; 1999:66.
uptake by normal men. Am J Physiol. 1945;143:594. 43. Michell MW, Oliveira HM, Vaid SU, et al. Enteral resuscitation of
burn shock using intestinal infusion of World Health Organization
23. Mellins RB, Park S. Respiratory complications of smoke inhalation oral rehydration solution (WHO ORS): a potential treatment for
in victims of fires. J Pediatr. 1975;87:1. mass casualty care. J Burn Care Rehabil. 2004;25:848.
44. Bromberg BF, Song IC, Walden RH. Hydrotherapy of chemical
24. Buckley NA, Juurlink DN, Isbister G, Bennett MH, Lavonas EJ. burns. Plast Reconstr Surg. 1965;35:85.
Cochrane Summaries. There is insufficient evidence to support 45. Leonard LG, Scheulen JJ, Munster AM. Chemical burns: effect of
the use of hyperbaric oxygen for treatment of patients with carbon prompt first aid. J Trauma. 1982;22:420.
monoxide poisoning. 46. Alam M, Moynagh M, Orr DS, Lawlor C. Cement burns-the Dublin
Published April 13, 2011. Accessed September 1, 2013 national burns experience. J Burns Wounds. 2007;7:33--38.
47. Mozingo DW, Smith AD, McManus WF, et al. Chemical burns.
25. Chen KK, Rose CL, Clowes GH. Comparative values of several anti- J 'Prauma. 1998;28:64.
dotes in cyanide poisoning. Am J Med Sci. 1934;188:767. 48. Mistry D, Wainwright D. Hydrofluoric acid burns. Am Fam
Physician. 1992;45:1748.
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50. Papirmeister B, Feister AJ, Robinson SI, et al. The sulfur mus-
27. Vogel SN, Sultan TR. Cyanide poisoning. Clin Toxicol. 1981;18:367. tard iltjury: description of lesions and resulting incapacitation.
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29. Herndon DN, Traber DL, Niehaus GD, et al. The pathophysiology of Defense Against M ustard Gas. Boca Raton, FL: CRC Press;
smoke inhalation in a sheep model. J 'Prauma. 1984;24:1044. 51. Sidell FR, Takaiitji ET, Franz DR. Medical Aspects of Chemical
30. Till GO, Johnson KJ, Kunkel R, et al. Intravascular activation of and Biological War.fare. Washington, DC: Office of the Surgeon
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Physiol Respir Environ Exerc Physiol. 1984;56:966.
32. Trunkey DD. Inhalation iltjury. Surg Clin North Am. 1978;58:1133.
33. Haponik E, Summer W. Respiratory complications in the burned
patient: diagnosis and management of inhalation iltjury. J Grit Care.
34. Cahalane M, Demling R. Early respiratory abnormalities from
smoke inhalation. JAMA. 1984;251:771.
35. Hight DW, Bakalar HR, Lloyd JR. Inflicted burns in children: recog-
nition and treatment. JAMA. 1979;242:517.
36. U.S. Department of Justice, Office of Justice Programs, Office of
Juvenile Justice and Delinquency Prevention. Burn I njuries in

At the completion of this chapter, the reader will be able to do the following:

• Identify the anatomic and physiologic differences • Demonstrate an understanding of management
in children that account for unique pediatric techniques for the various injuries found in
injury patterns. pediatric patients.

• Demonstrate an understanding of the special • Calculate the Pediatric Trauma Score.
importance of managing the airway and restoring
adequate tissue oxygenation in pediatric patients. • Describe the signs of pediatric trauma suggestive
of nonaccidental trauma.
• Identify the quantitative vital signs for pediatric


You are called to t he scene of a motor vehicle crash on a heavily traveled highway. Two vehicles have been involved in a fronta l offset
collision. One of the vehicle's occupants is a child improperly restrained in a child booster seat. No weather-related factors are involved
on this spring afternoon.

On arrival at the scene, you see that the police have secured and blocked traffic from the area around the crash. As your partner
and the other arriving crew are assessing the other patients, you approach the child. You see a young boy, approximately 2 years of age,
sitting in the booster seat, which is slightly turned at an angle; there is blood on the back of the headrest of the seat in front of him.
Despite numerous abrasions and minor bleeding from the head, face, and neck, the child appears very calm.

Your primary and secondary assessments reveal a 2-year-old boy who weakly repeats "ma-ma, ma-ma." His pulse rate is 180 beats/
minute, with the radial pulses weaker than the carotid; his blood pressure is 50 millimeters of mercury (mm Hg) by palpation. His ven-
tilatory rate is 18 breaths/minute, slightly irregular, but w ithout abnormal sounds. As you continue to assess him, you note that he has
stopped saying "ma-ma" and seems to just stare into space. You also not e t hat his pupils are slightly dilated, and his skin is pale and
sweaty. A woman who identifies herself as the family's nanny tells you that the mother is en route and that you should wait for her.

• What are the management priorities for this patient?
• What are the most likely injuries in this child?
• Where is the most appropriate destination for this child?

~ Introduction The Child as Trauma
Annual data reporting from the Centers for
Disease Control and Prevention (CDC) contin- Demographics of Pediatric Trauma
ues to show that , although the leading cause
of death continues to vary by age group, injury is the most com- The unique needs and characteristics of pediatric patients
mon cause of death for children in the United States. More than require special attention when assessing the acutely injured
8.5 million children are injured annually, with approximately child. The incidence ofblunt (versus penetrating) trauma is high-
one child death from injuries every 30 minutes.1•2 Tragically, as est in the pediatric population. The National Pediatric Trauma
many as 800,6 of these deaths may be avoidable, either by effec- Registry (NPTR), the National Trauma Data Bank (NTDB) of the
tive injury-prevention strategies or by ensuring proper care in American College of Surgeons (ACS), continues to identify blunt
the acute injury phase.3 trauma as the most common mechanism of injury, with pene-
As with all aspects of pediatric care, proper assessment and trating injury accounting for only 10% of pediatric cases. While
management of an injured child require a thorough understand- penetrating trauma will often result in injury to one body system,
ing of not only the unique characteristics of childhood growth blunt trauma mechanisms have a greater propensity for multi-
and development (including their immature anatomy and devel- system injury.
oping physiology) but also their unique mechanisms of injury.
The adage holds true that "children are not just little adults." Falls, pedestrians struck by automobiles, and occupant
Children have distinct, reproducible patterns of injury, differ- injury as a result of motor vehicle crashes are the most common
ent physiologic responses, and special treatment needs, based causes of pediatric injury in the United States, with falls alone
on their physical and psychosocial development at the time of accounting for more than 2.5 million injuries a year.2 Worldwide,
injury. the World Health Organization estimates that approximately
This chapter first describes the special characteristics ofthe 950,000 children die from trauma and tens of millions are hos-
pediatric trauma patient, then reviews optimal trauma manage- pitalized with nonfatal injuries.4 As in the United States, traffic-
ment and its rationale. Although the unique charact eristics of related accidents are the most common cause of death, with
pediatric injury are important for the prehospital care provider burns, homicide, and falls the next most common.
to understand, the fundamental basic and advanced life support
treatment approach using the primary and secondary assess- For a variety of reasons, to be discussed throughout this
ments is the same for every patient, regardless of age or size. chapter, multisystem involvement is the rule rather than the
exception in major pediatric trauma Although there may only
be minimal external evidence of injury present, potentially

CHAPTER 16 Pediatric Trauma 431

life-threatening internal injury may still exist and must be evalu- blunt pediatric trauma involving closed head injury results in
ated for at an appropriate trauma center. apnea, hypoventilation, and hypoxia much more commonly than
hypovolemia and hypotension. Therefore, clinical care guidelines
Kinematics of Pediatric Trauma for pediatric trauma patients should include greater emphasis on
focused management of the airway and breathing.
A child's size produces a smaller target to which forces from
fenders, bumpers, and falls are applied. Minimal cushioning from Thermal Homeostasis
body fat, increased elasticity of connective tissues, and proxim-
ity ofthe viscera to the surface of the body limit children's ability The ratio between a child's body surface area and body mass
to dissipate these forces as in the adult; therefore, energy is more is highest at birth and diminishes throughout infancy and
readily transmitted to underlying organs. Additionally, the skel- childhood. Consequently, more surface area exists through
eton of a child is incompletely calcified, contains multiple active which heat can quickly be lost, not only providing additional
growth centers, and is more resilient than that of an adult. As a stress to the child but also altering the child's physiologic
result, there may be significant internal injuries without obvious responses to metabolic derangements and shock. Profound
evidence of external trauma. hypothermia can result in severe coagulopathy and potentially
irreversible cardiovascular collapse. In addition, many of the
Common Patterns of Injury clinical signs of hypothermia are similar to those of impending
decompensated shock, thereby potentially muddying the prehos-
The unique anatomic and physiologic characteristics ofthe pediat- pital care provider's clinical assessment.
ric patient, combined with the age-specific common mechanisms
of injury, produce distinct, but predictable, patterns of injury Psychosocial Issues
(Figure 16-1). Improper seat belt usage or front seat placement
in the vehicle with resulting air bag impact can lead to significant The psychological ramifications for an injured child can also
injury in the pediatric patient (Figure 16-2). Traumais frequently a present a major challenge. Particularly with a very young child,
time-critical illness, and familiarity with these patterns will assist regressive psychological behavior may result when stress,
the prehospital care provider in optimizing management deci- pain, or other perceived threats impair the child's ability to
sions for the injured child in an expeditious manner. For example, process frightening events. Unfamiliar individuals in strange

Figure 16-1 • . .. .. .• . ...

Type of Trauma Patterns of Injury

Motor vehicle crash (child is passenger) Unrestrained: Multisystem trauma (including chest and abdomen), head and neck
injuries, scalp and facial lacerations

Restrained: Chest and abdomen injuries, lower spine fractures
Side impact: Head, neck, and chest injuries; extremity fracture
Deployed air bag: Head, face, chest injuries; upper extremity fractures

Motor vehicle crash (child is pedestrian) Low speed: Lower extremity fractures
High speed: Multisystem trauma (including chest and abdomen), head and neck

injuries, lower extremity fractures

Fall from a height Low: Upper extremity fractures
Medium: Head and neck injuries, upper and lower extremity fractures
High: Multisystem trauma (including chest and abdomen), head and neck

injuries, upper and lower extremity fractures

Fall from bicycle Without helmet Head and neck lacerations, scalp and facial lacerations, upper
extremity fractures

With helmet: Upper extremity fractures
Striking handlebar: Internal abdominal injuries

Source: Modified from American College of Surgeons Committee on Trauma: Pediatric t rauma. In ACS Committee on Trauma: Advanced trauma life support for doctors,
student course manual, ed 9, Chicago, 2012, A CS.


Figure 16-2

Despite laws in all 50 states requiring the use of car safety of injured children having an abdominal wall bruise from
seats or child restraint devices for young children, in almost the seat belt, and only 13% of those with bruising having
half of motor vehicle crashes, the child is not restrained or intestinal injury.9 It is reasonable to assume that any child
is improperly restrained.5 Furthermore, if a child is the front- found restrained by a lap belt with abdominal wall bruising
seat occupant in a vehicle with a passenger-side air bag, after a motor vehicle crash has an intra-abdominal injury
the child is just as likely to sustain serious injury whether until proved otherwise.
appropriately restrained or not.6 A child exposed to a
passenger-side air bag is twice as likely to sustain significant Approximately 1% of all motor vehicle crashes involving
injury as a front-seat passenger without an air bag.7 children also resulted in exposure of the child to a deployed
passenger air bag. Of these children, 14% suffered serious
Children w ith lap belt or inappropriate seat belt injury, compared with 7.5% of restrained front-seat
placement are thought to be at increased risk for bowel passengers not exposed to an air bag. Overall risk of any
injury in motor vehicle crashes. The incidence is difficult injury was 86% versus 55% in the control group of patients
to determine. In one study, 20% of injured children had (those not exposed to an air bag).7 Minor air bag injury
a visible seat belt bruise, and 50% of these children had included minor upper torso and facial burns and lacerations.
significant intra-abdominal injuries; almost 25% of these Major air bag injury consisted of significant chest, neck,
children had intestinal perforation.8 Others have shown face, and upper extremity injuryrn There has been a
documented decapitation of a child by a passenger air bag.2
an increased risk, but not to this extent, with only 5%

surroundings can limit a child's ability to fully cooperate with recover from the injury but also continue normal growth. The
history taking, physical examination, and treatment. An under- effect ofinjury on this process, especially in terms of permanent
standing of these characteristics and a willingness to soothe disability, growth deformity, or subsequent abnormal develop-
and comfort an injured child are frequently the most effective ment, cannot be overestimated. Children sustaining even minor
means ofachieving good rapport and obtaining a comprehensive traumatic brain injury (TBI) may have prolonged disability in
assessment of the child's physiologic state. cerebral function, psychological adjustment, or other regulated
organ systems. As many as 600Ai of children who have sustained
The child's parents, or caregivers, also frequently have unique severe multiple trauma have personality changes, with 500Ai hav-
needs and issues, such as information about the child's injuries ing subtle cognitive or physical handicaps. These disabilities can
and planned treatment orreassurance about the child's condition, have a substantial effect on siblings and parents, resulting in a
that, ifaddressed, may assist the prehospital care provider in car- high incidence offamily dysfunction, including divorce.
ing for the child successfully; however, if ignored, these needs
and issues can cause parents to become angry or aggressive and The effects of inadequate or suboptimal care in the acute
presentsignificant obstacles to effective care. Whenever a child is injury phase may have far-reaching consequences not only on the
sick orinjured, the caregivers are also affected and should be con- child's immediate survival but also, perhaps more importantly, on
sidered to be patients as well. The treatment ofall patients begins the long-term quality of the child's life. Therefore, it is extremely
with effective communication, but communication becomes even important to maintain a high index of suspicion for injury and to
more important when dealing with these "parent patients." It may use clinical "common sense" when caring and making transport
only consist of simple words of compassion, or great lengths of decisions for the acutely injured child.
patience, but you cannot be an effective prehospital care pro-
vider for the pediatric patient if you are ignorant of the parents'/ Pathophysiology
caregivers' needs. When you include the parents/caregivers in the
process, they can often act as functional members oftheir child's The final outcome for the injured child may be determined by the
emergency care team. Furthermore, parental engagement will quality of care rendered in the first moments following an injury.
be a signal to the child that you are endorsed as a "safe" person, During this critical period, a coordinated, systematic primary
increasing the likelihood ofthe child's cooperation. assessment is the best strategy to avoid unnecessary morbidity and
preventoverlooking a potentiallyfatal injury. As in the adultpatient,
Recovery and Rehabilitation the three most common causes ofimmediate death in the child are
hypoxia, massive hemorrhage, and overwhelming central nervous
Also unique to the pediatric trauma patient is the effect that system (CNS) trauma Expedient triage, stabilizing emergency
even minor injury may have on subsequent growth and develop- medical treatment, and transport to the most appropriate center for
ment. Unlike an anatomically mature adult, a child must not only treatment can optimize the potential for a meaningful recovery.

CHAPTER 16 Pediatric Trauma 4 3 3

Hypoxia A narrowing pulse pressure and increasing tachycardia may be
the first subtle signs of impending shock.
The first priority in prehospital care is always to maintain
a patent airway, whether by basic supportive measures or Furthermore, the prehospital care provider must pay close
through advanced techniques. Confirming that a child has attention to signs of ineffective organ perfusion as evidenced
an open and functioning airway does not preclude the need by alterations in respiratory efforts, decreased LOC, and dimin-
for supplemental oxygen and assisted ventilation, especially ished skin perfusion (decreased temperature, poor color, and
when CNS injury, hypoventilation, or hypoperfusion is pres- prolonged capillary refill). Unlike in the adult, these early signs
ent. Well-appearing, injured children can rapidly deterio- of hemorrhage in the child may be subtle and difficult to iden-
rate from mild tachypnea to a state of total exhaustion and tify, leading to a delayed recognition of shock. Jf the prehospital
apnea. Once an airway is established, the rate and depth of care provider misses these early signs, a child may lose enough
ventilation should be carefully evaluated to confirm adequate circulating blood volume that compensatory mechanisms fail.
ventilation. If ventilation is inadequate, merely providing an When this happens, cardiac output plummets, organ perfusion
excessive c oncentration of oxygen will not prevent ongoing or decreases, and the child can rapidly decompensate, often lead-
worsening hypoxia. ing to irreversible, fatal hypotension and shock. Therefore, every
child who sustains blunt trauma should be carefully monitored
The effects of even transient (brief) hypoxia on the trau- to detect these subtle signs that might signal that there is ongo-
matically injured brain deserve special attention. A child may ing hemorrhage, long before frank vital sign abnormalities.
have significant alteration in level of consciousness (LOC), yet
retain an excellent potential for a complete functional recovery A major reason for the rapid transition to decompensated
if cerebral hypoxia is avoided. shock is the loss of red blood cells (RBCs) and their correspond-
ing oxygen-carrying capacity. Restoration of lost intravascu-
Pediatric patients who require aggressive airway manage- lar volume with crystalloid solutions will provide a transient
ment should be preoxygenated before attempting to place an increase in blood pressure, but circulating volume will dissipate
advanced airway device. This simple maneuver may not only quickly as the fluid shifts across capillary membranes. It is gen-
begin the reversal of existing hypoxia but also provide sufficient erally thought that when replacing the intravascular volume with
reserves to improve the margin of safety when placement of an isotonic crystalloid solutions, a 3:1 ratio of crystalloid to the sus-
advanced airway is performed. A period of hypoxia during mul- pected blood loss is needed to compensate for this fluid shift. As
tiple or prolonged attempts at placing an advanced airway may blood is lost and intravascular volume is replaced with crystal-
be more detrimental to the child than simply ventilating the child loids, the remaining RBCs are diluted in the bloodstream, reduc-
with a bag-mask and rapidly transporting.11-13 In light of recent ing the blood's ability to carry oxygen to the tissues. Therefore,
data, attempting advanced airway management is unnecessary it should be assumed that any child who requires more than one
and potentially harmful if the child is adequately ventilated and 20 milliliter per kilogram (ml/kg) bolus of crystalloid solution
oxygenated using good basic life support skills, such as bag- may be rapidly deteriorating and not only needs intravascular
mask ventilation. volume resuscitation with crystalloid solution but will likely also
require a transfusion of RBCs so that oxygen-delivery capacity is
Hemorrhage restored in parallel to the intravascular volume.

Most pediatric injuries do not cause immediate exsanguination. However, once vascular access has been secured, there is a
However, children who sustain injuries that result in major blood tendency to inadvertently over-resuscitate an injured child who
loss frequently die within moments of the injury or shortly after is not in frank shock. In the child with moderate bleeding, no
arrival at a receiving facility. These fatalities frequently result evidence of end-organ hypoperfusion, and normal vital signs,
from multiple injured internal organs, with at least one signifi- fluid resuscitation should be limited to no more than one or two
cant injury causing acute blood loss. This bleeding may be minor, normal saline boluses of 20 ml/kg. The intravascular component
such as a simple laceration or contusion, or may be a life-threat- of one bolus represents approximately 25% of a child's blood
ening hemorrhage, such as a ruptured spleen, lacerated liver, or volume. Therefore, if more than two boluses are required, the
avulsed kidney. prehospital care provider must take care to reassess the child for
sources of previously undetected ongoing bleeding.
As in adults, the injured child compensates for hemorrhage
by increasing systemic vascular resistance; however, this is at In the child with TBI, fluid resuscitation should be given to
the expense of peripheral perfusion. Children are physiologically prevent hypotension, a known and preventable secondary insult
more adept at this response because pediatric vasoconstriction is to head injury. 14•15 The cerebral perfusion pressure is the differ-
not limited by pre-existing peripheral vascular disease. Utilizing ence between the intracranial pressure (the pressure inside the
blood pressure measurements alone is an inadequate strategy to skull) and the mean arterial pressure (the pressure driving blood
identify the early signs of shock. Tachycardia, although it may into the skull). Traumatic brain injury can cause an increase in
be the result of fear or pain, should be considered to be sec- intracranial pressure, therefore even though blood may be ade-
ondary to hemorrhage or hypovolemia until proven otherwise. quately oxygenated, if the systemic blood pressure is low, oxy-
genated blood may not perfuse the brain; thus, hypoxic brain
injury can still occur. Although over-resuscitation should be


avoided to prevent an iatrogenic cerebral edema, hypotension consciousnessis one ofthe most importantprognosticindicators
must be prevented or quickly treated with fluid resuscitation, ofpotential CNS injury and should be recorded for every case. In
as a single episode of hypotension can increase mortality by as the event that the injury was not witnessed, amnesia to the event
much as 150<>A>.16 Careful assessments of the child's vital signs is commonly used as a surrogate for a loss of consciousness.
and frequent re-evaluation aftertherapeutic interventions should Further, complete documentation of baseline neurologic status
guide ongoing management decisions. is important, including the following:

Isotonic crystalloid solutions should be the fluid of choice 1. Glasgow Coma Scale score (modified for pediatrics)
for resuscitation of the child with TBI, because hypotonic crys- 2. Pupillary reaction
talloid solutions (e.g., dextrose in water) are lmown to increase 3. Response to sensory stimulation
cerebral edema. Furthermore, although hypertonic crystalloid 4. Motor function
solutions (e.g., hypertonic saline) may be useful for treatment of
cerebral edema in the pediatric intensive care unit where there These are essential steps in the initial pediatric trauma
is extensive monitoring, evidence to date has not demonstrated assessment for neurologic injury. The absence of an adequate
improved outcomes of pediatric trauma patients when adminis- baseline assessment makes ongoing follow-up and evaluation of
tered in the field. interventions extremely difficult.

Central Nervous System Injury Attention to detail in history taking is especially important
in pediatric patients with possible cervical spine injury. A child's
The pathophysiologic changes after CNS trauma begin within skeleton is incompletely calcified with multiple active growth
minutes. Early and adequate resuscitation is the key to increased centers, often preventing radiographic diagnosis of injury from
survival of children with CNS trauma. Although some CNS inju- a mechanism causing a stretching, contusion, or blunt injury to
ries are overwhelmingly fatal, many children with the appear- the spinal cord. This condition is called spinal cord injury with-
ance of a devastating neurologic injury go on to a complete and out radiographic abnormality, or SCIWORA. A transient neu-
functional recovery after deliberate coordinated efforts to pre- rologic deficit that resolves prior to facility arrival may be the
vent secondary injury. These recoveries are achieved through the only indicator of a significant spinal cord injury. Despite quick
prevention of subsequent episodes of hypoperfusion, hypoventi- symptom resolution, children with SCIWORA can develop spinal
lation, hyperventilation, and ischemia. Adequate ventilation and cord edema up to 4 days after the initial injury, with devastating
oxygenation (while avoiding hyperventilation) are as critical in neurologic disabilities if left untreated.
the management of TBis as the avoidance of hypotension.15
For given degrees of CNS injury severity, children have
lower mortality and a higher potential for survival than their Primary Assessment
adult counterparts. However, the addition of injuries outside the
brain lessens the child's chances offavorable outcome, illustrating The small and variable size of the pediatric patient (Figure 16-3),
the potentially negative effect ofshock from associated injuries. the diminished caliber and size of the blood vessels and circulat-
ing volume, and the unique anatomic characteristics of the air-
Children with TBI frequently present with an alteration in way frequently make the standard procedures used in basic life
consciousness, possibly sustaining a period of unconsciousness
not witnessed during the initial evaluation. A history of loss of

Newborn Birth to 6 weeks 51 to63(20to25) 4 to 5 (8 to 11)
Infant 6 weeks to 1 year 56 to 80 (22 to 31) 4 to 11 (8 to 24)
Toddler 77 to 91 (30 to 36) 11 to 14 (24 to 31 )
Preschooler 1 to 2 years 91 to 122 (36 to 48) 14to25 (31 to55)
School-age child 2 to 6 years 122 to 165 (48 to 65) 25 to 63 (55 to 139)
Adolescent 6 to 13 years 165 to 182 (65 to 72) 62 to 80 (139 to 176)
13 to 16 years

CHAPTER 16 Pediatric Trauma 4 3 5

support extremely challenging and technically difficult. Effective
pediatric trauma resuscitation mandates the availability ofappro-
priately sized airways, laryngoscope blades, endotracheal (ET)
tubes, nasogastric tubes, blood pressure cuffs, oxygen masks,
bag-mask devices, and associated equipment. Attempting to
place an overly large intravenous (IV) catheter or an inappropri-
ately sized airway can do more harm than good, not only because
of the potential physical damage to the patient, but also because
it may delay transport to the appropriate facility. Color-coded,
length-based resuscitation guides (discussed later in the chapter)
provide practical medication and equipment references.17

Airway Figure 16-4 Compared to an adult (A), a child has a larger occiput
and less shoulder muscu lature. When placed on a f lat surface, t hese
As in the injured adult, the immediate priority and focus in factors result in flexion of t he neck (B).
the acutely injured child are on airway management. However,
there are several anatomic differences that complicate the care Source: A. ©Jones & Bartlett Learning . Phot ographed by Darren Stahlman.
ofthe injured child. Children have a relatively large occiput and
tongue and have an anteriorly positioned airway. Additionally, Figure 16-5 Sniffing position.
the smaller the child, the greater the size discrepancy between In comparison to that of the adult, the child's larynx is
the cranium and the midface. Therefore, the relatively large
occiputforces passivefl.exion ofthe cervical spine (Figure 16-4). smaller in size and is slightly more anterior and cephalad (for-
These factors all predispose children to a higher risk of ana- ward and toward the head), making it more difficult to visual-
tomic airway obstruction than adults. In the absence of ize the vocal cords during intubation attempts (Figure 16-6).
trauma, the pediatric patient's airway is best protected by a Endotracheal intubation, despite being the most reliable means
slightly superior-anterior position of the midface, known as
the sniffing position (Figure 16-5). In the presence of trauma,
however, the neutral position best protects the cervical spine
by keeping it immobilized to prevent the fl.exion at the fifth
and sixth cervical vertebrae (C5 to C6) and the extension at Cl
to C2 that occurs with the sniffing position. In this position, a
jaw-thrust maneuver can be used to facilitate airway opening
if needed.

Manual stabilization of the cervical spine is done during air-
way management and maintained until the child is immobilized
with an appropriate cervical immobilization device, whether it is
commercially purchased or a simple solution such as towel rolls.
Additionally, placing a pad or blanket of 2 to 3 centimeters (cm;
about 1 inch) in thickness under an infant's torso can lessen the
acute fl.exion of the neck and help keep the airway patent.

Bag-mask ventilation with high-fl.ow (at least 15 liters
per minute) 100% oxygen probably represents the best choice
when the injured child requires assisted ventilation.11 If the
child is unconscious, an oropharyngeal airway may be consid-
ered, but due t o risk of vomiting, it should not be used in the
child with an intact gag reflex. This is also true of the laryngeal
mask and King LT airways, both of which are supraglottic air-
ways; when sized appropriately, these devices can be consid-
ered for airway management in pediatric trauma patients who
cannot be ventilated by simple bag-mask device. In very young
children, especially those weighing less than 20 kg, these
devices can cause iatrogenic upper airway obstruction by
causing the relatively larger pediatric epiglottis to fold into the


of ventilation in the child with airway compromise, should be Breathing
reserved for those situations in which bag-mask ventilation is
ineffective and nonvisualized advanced airway devices have As in all trauma patients, a significantly traumatized child typ-
failed. Nasotracheal intubation is generally not recommended ically needs an oxygen concentration of 85% to 100% (fraction
in young children. This technique requires a spontaneously of inspired oxygen [Fi02] of 0.85 to 1.0). This concentration is
breathing patient, involves blind passage around the relatively maintained by the use ofsupplementaloxygen and an appropri-
acute posterior nasopharyngeal angle, and can cause more ately sized clear plastic pediatric mask. When hypoxia occurs
severe bleeding in children. Additionally, in the patient with a in the small child, the body compensates by increasing the
basilar skull fracture, it can even inadvertently penetrate the ventilatoryrate (tachypnea) and by a strenuous increase in ven-
cranial vault. tilatory effort, including increased thoracic excursion efforts
and the use of accessory muscles in the neck and abdomen.
If unable to receive effective bag-mask ventilation, a child This increased metabolic demand can produce severe fatigue
with craniofacial injuries causing upper airway obstruction may and result in ventilatory failure, as an increasing percentage of
be considered for percutaneous transtracheal jet ventilation the patient's cardiac output becomes devoted to maintaining
with a large angiocatheter. This should be performed only by this respiratory effort. Ventilatory distress can rapidly prog-
those skilled in the procedure, as the thin and malleable pediat- ress from a compensated ventilatory effort to ventilatory fail-
ric trachea can be easily damaged, resulting in permanent iatro- ure, then respiratory arrest, and ultimately a hypoxic cardiac
genic airway loss. This procedure is only a temporary measure to arrest. Central (rather than peripheral) cyanosis is a fairly late
improve oxygenation and does not provide adequate ventilation. and often inconsistent sign of respiratory failure and should
Increasing hypercarbia dictates that a more definitive airway be not be depended on to recognize impending respiratory failure.
established as soon as safely possible. Surgical cricothyroidot-
omy is usually not indicated in the care of the pediatric trauma Evaluation of the child's ventilatory status with early rec-
patient, though it may be considered in the larger child (usually ognition of the signs of distress and the provision of ventilatory
at the age of 12 years). 18 assistance are key elements in the management of the pediatric
trauma patient. The normal ventilatory rate of infants and chil-
dren younger than 4 years is typically two to three times that of
adults (Figure 16-7).

Tachypnea with signs ofincreased effort or difficulty may be
the first manifestations of respiratory distress and shock. As dis-
tress increases, additional signs and symptoms include shallow
breathing or minimal chest movement. Breath sounds may be
weak or infrequent, and air exchange at the nose or mouth may
be reduced or minimal. Ventilatory effort becomes more labored
and may include the following:

Figure 16-6 Comparison of the adult and child airways. • Head bobbing with each breath
• Gasping or grunting
• F1ared nostrils

Newborn Birth to 6 weeks 30 to 50 < 30 or> 50
Infant 6 weeks to 1 year 20 to 30 < 20 or> 30
Toddler 20 to 30 < 20 or> 30
Preschooler 1 to 2 years 20 to 30 < 20 or> 30
School-age child 2 to 6 years 12 to 25 <12or>25
Adolescent 6 to 13 years 12 to 20 <12or>20
13 to 16 years

CHAPTER 16 Pediatric Trauma 4 3 7

• Stridor or snoring respirations Use of the correct-sized bag-mask is essential for obtain-
ing a proper mask seal, providing the proper tidal volume, and
• Suprastemal, supraclavicular, subcostal, or intercostal ensuring that the risks of hyperinflation and barotrauma are
retractions minimized. Ventilating a child too forcefully or with too large
of a tidal volume can lead to gastric distension. In tum, gastric
• Use of accessory muscles, such as neck and abdominal distension can result in regurgitation, aspiration, or prevention
wall muscles of adequate ventilation by limiting diaphragmatic excursion.
Hyperinflation can lead to a tension pneumothorax that can
• Distension of the abdomen when the chest falls (see- result in both severe respiratory distress and sudden cardiovas-
saw effect between the chest and abdomen) cular collapse, as the mediastinum is more mobile in the child.
This mobility protects the child from traumatic aortic injuries
The effectiveness of a child's ventilation should be evalu- but increases the susceptibility to tension pneumothorax. The
ated using the following indicators: more mobile mediastinum compresses easily, allowing for ear-
lier respiratory compromise and cardiovascular collapse than
• Rate and depth (minute volume) and effort indicate occurs in an adult.
adequacy of ventilation.
Changes in a child's ventilatory status can be subtle, but
• Pink skin may indicate adequate ventilation. ventilatory effort can rapidly deteriorate until ventilation is
• Dusky, gray, cyanotic, or mottled skin indicates insuffi- inadequate and hypoxia ensues. The patient's breathing should
be evaluated as part of the primary assessment and carefully
dent oxygenation and perfusion. and periodically reassessed to ensure its continued adequacy.
Pulse oximetry should also be monitored, and efforts should be
• Anxiety, restlessness, and combativeness can be early made to keep oxygen saturation (Sp02) at greater than 95% (at
signs of hypoxia. sea level).

• Lethargy, depressed LOC, and unconsciousness are Whenever a child is manually ventilated, it is important to
probably advanced signs of hypoxia. carefully control the rate at which ventilations are being admin-
istered. It is relatively easy to inadvertently hyperventilate the
• Breath sounds indicate the depth of exchange. patient, which will decrease the carbon dioxide level in the blood
and cause cerebral vasoconstriction. This can lead to poorer out-
• Wheezing, rales, or rhonchi may indicate inefficient comes in patients with TBI. Furthermore, excessive ventilation
oxygenation. pressures can lead to gastric insuffl.ation. The distended stomach
can subsequently push up into the more pliable pediatric thorax
• Declining pulse oximetry and/or declining capnography and limit tidal volume capacity.
indicate respiratory failure.
A rapid evaluation of ventilation includes assessment of the
patient's ventilatory rate (particularly tachypnea), ventilatory The survival rate from immediate exsanguinating injury is low
effort (degree of labor, nostril flaring, accessory muscle use, in the pediatric population. Fortunately, the incidence of this
retraction, and seesaw movement), auscultation (air exchange, type ofinjury is also low. External hemorrhage should be quickly
bilateral symmetry, and pathologic sounds), skin color, and men- identified and controlled by direct manual pressure during the
tal status. primary assessment. Injured children usually present with at
least some circulating blood volume and should respond appro-
In the child initially presenting with tachypnea and priately to volume replacement.
increased ventilatory effort, normalization of the ventilatory rate
and apparent lessening of the respiratory effort should not be As in the assessment of the airway, a single measurement
immediately interpreted as a sign of improvement as it may indi- of heart rate or blood pressure does not equate with physiologic
cate exhaustion or impending respiratory failure. As with any stability. Serial measurements and changing trends ofvital signs
change in the patient's clinical status, frequent reassessment is are critical in gauging a child's evolving hemodynamic state in
necessary to determine ifthis is an improvement or deterioration the acute injury phase. Close monitoring of vital signs is abso-
in physiologic status. lutely essential to recognizing the signs of impending shock,
enabling the appropriate interventions to be performed to pre-
Ventilatory assistance should be given to those children in vent clinical deterioration. Figures 16-8 and 16-9 provide the
acute ventilatory distress. Because the main problem is one of normal ranges for pulse rate and blood pressure by pediatric
inspired volume rather than concentration of oxygen, assisted age groups.
ventilation is best given by use of a bag-mask device, supple-
mented with an oxygen reservoir attached to high-concentra- If the primary assessment suggests hypotension, the most
tion oxygen (Fi02 of 0.85 to 1.0). Because a child's airway is likely cause is blood loss through a major external wound that
so small, it is prone to obstruction from increased secretions, is readily observable (e.g., large scalp laceration, open femur
blood, body fluids, and foreign materials; therefore, early and fracture), an intrathoracic injury (identifiable by diminished
periodic suctioning may be necessary. In infants, who are
obligate nose breathers, the nostrils should also be suctioned.

When obtaining a mask seal in infants, caution should be
exercised to avoid compressing the soft tissues underneath the
chin because doing so pushes the tongue against the soft pal-
ate and increases the risk of occluding the airway. Pressure on
the uncalcified, soft trachea should also be avoided. One or two
hands can be used to obtain a mask seal, depending on the size
and age of the child.


Figure 16-8 . .... Pulse Rate (beats/minute) That
Indicates a Possible Serious Problem*
Group Age Pulse Rate (beats/minute)
< 100 or> 160
Newborn Birth to 6 weeks 120 to 160 < 80 or> 150
80 to 140 < 60 or> 140
Infant 6 weeks to 1 year 80 to 130 < 60 or> 130
80 to 120 < 60 or> 120
Toddler 1 to 2 years 60 to 110 < 60 or> 100
60 to 100
Preschooler 2 to 6 years

School-age child 6 to 13 years

Adolescent 13 to 16 years

*Bradycardia or tachycardia.

...Figure 16-9 . ... . .... ....

Group Age Expected BP Range (mm Hg}* Lower Limit of Systolic BP (mm Hg)
> 60
Newborn Birth to 6 weeks 74 to 100 > 70
50 to 68 > 70
> 75
Infant 6 weeks to 1 year 84 to 106 > 80
56 to 70 > 90

Toddler 1 to 2 years 98 to 106
50 to 70

Preschooler 2 to 6 years 98 to 112
64 to 70

School-age child 6 to 13 years 104 to 124
64 to 80

Adolescent 13 to 16 yea rs 118 to 132
70 to 82

*Top numbers represent systolic range; bottom numbers represent diastolic range.

ventilatory mechanics and auscultatory findings), or a major tachycardia may be from hypovolemia, psychological stress,
intra-abdominal injury. Because blood is not a compressible pain, or fear can also increase the heart rate. All injured children
medium, blood loss from a major intra-abdominal injury can should have their heart rate, ventilatory rate, and overall CNS
produce abdominal distension and increasing abdominal girth. status monitored closely. An accurate blood pressure reading
However, increased abdominal girth in the young pediatric may be difficult to obtain in the prehospital setting, and focus
trauma patient can also commonly be caused by gastric disten- should be placed on other signs ofperfusion. A pediatric patient's
sion from crying and air swallowing. Gastric decompression systolic blood pressure, if measured, may seem alarmingly low
through a nasogastric or orogastric tube can help to distinguish when compared to that of an adult, but may be within the normal
between these causes ofdistension, although it is best to assume range for a healthy child.
that a distended abdomen is a sign of potentially significant
abdominal injury. A child with hemorrhagic injury can maintain adequate cir-
culating volume by increasing peripheral vascular resistance
A major consideration in the assessment of a pediatric to maintain mean arterial pressure. Clinical evidence of this
patient is compensated shock. Because of their increased phys- compensatory mechanism includes prolonged capillary refill,
iologic reserve, children with hemorrhagic injury frequently peripheral pallor or mottling, cool peripheral skin tempera-
present with only slightly abnormal vital signs. Although initial ture, and decreased intensity of the peripheral pulses. In the

CHAPTER 16 Pediatric Trauma 4 3 9

child, signs of significant hypotension develop with the loss of examination to identify other injuries is complete, the pediatric
approximately 309i> of the circulating volume. If initial resusci- patient should be covered to preserve body heat and prevent fur-
tation is inadequate, increased peripheral vascular resistance ther heat loss.
will not be able to compensate for loss of circulating volume
and the b lood pressure will fall. The concept of evolving shock Pediatric Trauma Score
must be of paramount concern in the initial management of
an injured child and is a major indication for transport to an The decision as to which child requires what level of care must
appropriate trauma facility for expeditious evaluation and proceed from a careful and rapid evaluation of the entire child.
treatment. Overlooking potential organ system injury and inadequately
managing the pediatric patient are two common problems, both
Disability in the field and in the hospital. For this reason, the Pediatric
Trauma Score (PTS) was developed to provide a reliable and
After assessment of airway, breathing, and circulation, the pri- simple protocol for assessment that is predictive of outcome;
mary assessment must include an assessment of neurologic however, the PTS is not used in the CDC's field triage algorithm
status. Although the AVPU scale (Alert, responds to Verbal stim- as the physiologic, anatomic, and mechanistic considerations in
ulus, responds to Painful stimulus, Unresponsive) remains a the field triage algorithm have been considered adequate for the
simple, rapid assessment tool for the child's neurologic status, it initial field assessment (Figure 16-11).
remains less informative than the Glasgow Coma Scale (GCS). It
should be combined with a careful examination of the pupils to To calculate the PTS, six components of pediatric injury are
determine whether they are equal, round, and reactive to light. graded and then added together to produce a score predictive of
As in adults, the GCS provides a more thorough assessment of injury severity and potential for mortality. The six components
neurologic status and should be calculated for each pediatric are the pediatric patient's size, airway, LOC, systolic blood pres-
trauma patient. The scoring for the verbal section for children sure, presence of fractures, and skin condition. The system is
younger than 4 years of age must be modified because of devel- based on an analysis of pediatric injury patterns and is designed
oping communication skills in this age group, and the child's to provide a protocol checklist to ensure that all the major injury
behavior should be observed carefully (Figure 16-10). factors related to injury outcome are considered in the initial
evaluation of the child. The PTS is different than the Revised
The GCS score should be repeated frequently and used to Trauma Score (RTS), which considers only the blood pressure,
document progression or improvement of neurologic status ventilatory rate, and GCS score.
during the postinjury period (refer to the Scene Assessment and
the Shock chapters for a review of the GCS). A more thorough Size is the first component because it is readily observed
assessment of motor and sensory function should be performed and is a major consideration in the infant/toddler group. The air-
in the secondary assessment if time permits. way is assessed next, because the functional status and the level
ofcare required to provide adequate ventilation and oxygenation
Expose/Environment must be considered.

Childrenshould be examinedfor otherpotentiallylife-threatening The most important historical factor in primary assessment
injuries; however, they may be frightened at attempts to remove of the CNS is loss of consciousness (LOC). Because children
their clothes. In addition, because ofchildren's high body surface frequently sustain transient LOC during an injury, the obtunded
area, they are more prone to developing hypothermia. Once the grade (+1) is applied to any child with loss of consciousness, no
matter how fleeting. This grade identifies children at higher risk
Figure 16-10 Verbal Score of developing potentially fatal, yet frequently treatable, intracra-
5 nial injuries that may lead to secondary brain injury.
Verbal Response
Appropriate words or social 4 Systolic blood pressure (SBP) is used to identify children in
3 whom evolving preventable shock may occur (SBP 51 to 90 mm
smile; fixes and follows 2 Hg; +1). Regardless ofsize, a child whose SBP is less than 50 mm
Crying but consolable Hg (- 1) is in obvious jeopardy (Figure 16-12). A child whose SBP
Persistently irritable exceeds 90 mm Hg (+2) falls into a better outcome category. If
Restless, agitated the appropriately sized blood pressure cuff is not available, SBP
No response is assessed as +2 if the radial or pedal pulse is palpable, +1 if
only the carotid or femoral pulse is palpable, and -1 if no pulse
is palpable.

Because of the high incidence of skeletal injury in the
pediatric population and its potential contribution to mortality
and disability, the presence of a long-bone fracture is included
in the PTS as a component. Finally, the skin is assessed for open
wounds and penetrating injury.


Figure 16-11

Component +2 +1 -1
Size Child/adolescent >20 kg Toddler 11-20 kg Infant <1 O kg
Airway Normal Assisted : 0 2 mask, cannula Intubated: ETI,
Consciousness Awake Obtunded, lost consciousness Coma, unresponsive
Systolic blood 51-90 mm Hg <50 mm Hg
90 mm Hg Carotid, femora l pulse palpable Weak or no pulses
pressure Good peripheral pulses,
Single closed fracture anywhere Open or multiple fractures
Fracture perfusion

None seen or suspected

Cutaneous No visible injury Contusion, abrasion, laceration Tissue loss, any gun shot wound or stab
<7 cm not through fascia through fascia

Note: The Pediatric Trauma Score (PTS) is primarily designed to f unction as a checklist. Each component can be assessed by basic physical
examination. Airway evaluation is designed to reflect intervention required for effective care. An open fracture is graded -1 for fracture and -1 for
cutaneous injury. As clinical observation and diagnostic evaluation continue, further definition and reassessment will establish a trend t hat predicts
severity of injury and potential outcome.

Figure 16-12

The term pediatric or child includes a vast range of physical 16-9 can aid in evaluating vital signs in pediatric patients.
development, emotional maturity, and body sizes. The These tables present statistically common ranges into which
approach to the patient and the implications of many most children in these age groups will fall.
injuries vary greatly between an infant and an adolescent.
Several commercially available items serve as rapid
In most anatomic and therapeutic dosage considerations, reference guides for pediatric vital signs and equipment
a child's weight (or specific height or length) serves as size. These include the length-based resuscitation tape and
a more accurate indicator than exact chronologic age.17 several slide-rule-type plastic scales.
Figure 16-3 lists the average height and weight for healthy
children of varying ages. The following guideline formulas can also be used to
estimate the expected finding for ages 1 to 10 years:
The acceptable ranges of vital signs vary for the different
ages within the pediatric population. Adult norms cannot Weight (kg) = 8 + (2 x Child's age [years])
be used as guidelines in smaller children. An adult
ventilatory rate of 30 breaths/minute is tachypneic, and Lowest acceptable SBP (mm Hg) = 70
an adult heart rate of 120 beats/minute is tachycardic.
Both are considered alarmingly high in an adult and are + (2 x Child's age [years])
significant pathologic findings. However, the same findings
in an infant may be within the normal ranges. Total vascular blood volume (ml) = 80 ml

Normal ranges of vital signs for different age groups x Child's weight (kg)
may not be consistent across all pediatric references. In
an injured child without a previous history of normal vital Quantitative vital signs in children, although important, are
signs, borderline vital signs may be viewed as pathologic, only one piece of information used in making an assessment.
even though the signs may be physiologically acceptable in A child with a normal set of vital signs can rapidly deteriorate
that specific child. The guidelines in Figures 16-8, 16-8, and into either critical ventilatory difficulty or decompensated
shock. Vital signs should be considered along with
mechanism of injury and other clinical findings.

CHAPTER 16 Pediatric Trauma 441

By nature ofits design, the PTS serves as a straightforward Management
checklist that ensures that all of the components necessary to
identify a critically injured pediatric patient are considered. The keys to pediatric patient survival from a traumatic injury are
As a predictor of injury, the PTS has a statistically signifi- rapid cardiopulmonary assessment, age-appropriate aggressive
cant, direct linear relationship with the Injury Severity Score management, and transport to a facility capable of managing
(ISS) and an inverse linear relationship with patient mortality. pediatric trauma. A color-coded, length-based resuscitation tape
There is a threshold score of 8, below which injured pediatric was devised t.o serve as a guide that allows for rapid identifica-
patients should be taken to an appropriate pediatric trauma tion of a patient's height with a correlated estimation of weight,
center because they have the greatest potential for prevent- the size of equipment to be used, and appropriate dosages of
able mortality and morbidity. Although research has shown potential resuscitative drugs. In addition, most prehospital sys-
that other scores, such as the RTS, the unresponsive element tems have a guideline for selecting appropriate destination facil-
(U) of the AVPU score, and a best motor response of 1 from ities for pediatric trauma patients.
the GCS, predict mortality at least as well as the PTS, the PTS
remains the only score that includes size, s keletal injury, and Airway
open wounds. Although the PTS is a readily available assess-
ment and triage tool, it has not been universally accepted. Ventilation, oxygenation, and perfusion are as essential to an
Other methods oftriage are used, and it is the prehospital care injured child as to an adult. Thus, the primary goal of the ini-
provider's responsibility to be well versed in local protocols tial resuscitation of an injured child is restoration of adequate
and procedures. tissue oxygenation as quickly as possible. The first priority of
assessment and resuscitation is the establishment of a patent
Secondary Assessment (Detailed airway.
Physical Examination}
A patent airway should be ensured and maintained with
The secondary assessment of the pediatric patient should suctioning, manual maneuvers, and airway adjuncts. As in the
follow the primaryassessment only after life-threatening conditions adult, initial management in the pediatric patient includes in-line
have been identified and managed. The head and neck should cervical spine stabilization. Unless a specialized pediatric spine
be examined for obvious deformities, contusions, abrasions, board that has a depression at the head is used, adequate pad-
punctures, burns, tenderness, lacerations, or swellings. The ding (2 t.o 3 cm [about 1 inch]) should be placed under the t.orso
thorax should be re-examined. Potential pulmonary contusions of the small child so that the cervical spine is maintained in a
may become evident after volume resuscitation, manifested by straight line rather than forced into slight flexion because of the
respiratory distress or abnormal lung sounds. Trauma patients disproportionately large occiput (Figure 16-13). When adjusting
are infrequently nil per os (NPO [fasting]) at the time of their and maintaining airway positioning, compressing the soft tissues
injuries, so insertion of a nasogastric or orogastric tube may be ofthe neck and trachea should be avoided.
indicated, if local prot.ocols allow. This protocol is especially
important for children who are obtunded or who have post-trau- Once manual control of the airway is achieved, an oro-
matic seizure activity. pharyngeal airway can be placed if no gag reflex is present.
The device should be inserted carefully and gently, parallel
Examination of the abdomen should focus on distension, t.o the course of the tongue rather than turned 90 or 180 degrees
tenderness, discoloration, ecchymoses, and presence of a mass. in the posterior oropharynx as in the adult. Use of a tongue blade
Careful palpation of the iliac crests may suggest an unstable t.o depress the t.ongue can be helpful in pediatric patients.
pelvic fracture and increase the suspicion for possible retroper-
it.oneal or urogenital injury as well as increased risk for hidden Endotracheal intubation under direct visualization of the
blood loss. An unstable pelvis should be noted, but repeated trachea may be indicated for long transports (Figure 16-14).
examinations of the pelvis should not be performed, as this may However, this should only be initiated by experienced personnel
result in further injury and increased blood loss. The pediatric and when adequate oxygenation cannot be maintained by a bag-
patient should be appropriately immobilized on a longboard and mask device. Importantly, there are no data to show improved
prepared for transfer t.o a pediatric trauma facility. survival or neurologic outcome in pediatric trauma patients intu-
bated early in the field versus those who underwent bag-mask
Each extremity should be inspected and palpated t.o rule ventilation. In fact, there is some evidence suggesting worse
out tenderness, deformity, diminished vascular supply, and neu- outcomes.16 A more recent study in a rural setting found that
rologic deficit. A child's incompletely calcified skeleton, with its multiple prehospital intubation attempts were associated with
multiple growth centers, increases the possibility of epiphyseal significant complications (Figure 16-15).19•20
(growth plate) disruption. Accordingly, any area of edema, pain,
tenderness, or diminished range of motion should be treated as Although the Combitube has been a proven rescue airway
if it were fractured until evaluated by radiographic examination. device for adult trauma victims,21·2"2 its large size and the lack
In children, as in adults, a missed orthopedic injury in an extrem- of smaller sizes make it inadequate as a rescue device for small
ity may have little effect on mortality but may lead to long-term children (under 4 feet [1.2 m] in height). The laryngeal mask air-
deformity and disability. way and now the smaller sizes of the King LT airways provide an
alternate airway device choice in older children (> 8 years of age,
when the airway is more similar to that of adults) and are reason-
able alternatives to endotracheal intubation in certain situations.23


For pediatric patients, the risks may outweigh the benefits of deterioration from mild hypoxia to ventilatory arrest, ventilation
endotracheal intubation and must be carefully considered before should be assisted if dyspnea and increased ventilatory effort are
attempting the procedure, especially in the pediatric patient in observed. A properly sized bag-mask device with a reservoir and
whom bag-mask ventilation is providing adequate ventilation high-flow oxygen to provide an oxygen concentration of between
and oxygenation. Consideration of the risks associated with 85% and l OOoA> (Fi02 of0.85 to LO) should be used. Continuous pulse
endotracheal intubation is increasingly important as additional oximetry serves as an acijunct for ongoing assessment ofairway and
nonvisualized advanced airway devices become available and breathing. The Sp0 should be keptat greater than 95%(atsealevel).
added into the prehospital care provider's practice.
In the intubated pediatric patient with a closed head injury,
The pediatric patient's minute volume and ventilatory effort ET tube placement should be confirmed in multiple fashions,
should be evaluated carefully. Because of the potential for rapid including directly visualizing the ET tube pass through the vocal
folds, listening for the presence of equal bilateral breath sounds,
and listening for the absence of sounds over the epigastrium


Figure 16- 13 Provide adequate padding under the chi ld's torso or use a spine board w ith a cutout for t he child's occiput.

Figure 16-14

Endotracheal intubation of a pediatric patient should pliable, and overzealous cricoid pressure may completely
include careful attention to cervical spine immobilization. occlude the airway.
One prehospital care provider should maintain the
pediatric patient's spine in a neutral position while another A common error that occurs during the intubation
prehospital care provider intubates. of pediatric patients under emergency circumstances is
aggressive advancement of the ET tube resulting in its
The narrowest portion of the pediatric airway is the placement into the right main bronchus. The ET tube
cricoid ring, creating a "physiologic cuff." Although should never be advanced more than three times the ET
uncuffed ET tubes were previously used in pediatric patients tube size (in centimeters). For example, a 3.0-cm ET tube
due to this difference, newer recommendations endorse should rest at a depth no greater than 9 cm.
the use of cuffed tubes in all ages. The cuffed tube allows
prehospital care providers to inflate the cuff fully, partially, The chest and epigastrium should always be auscultated
or not at all, depending on the strength of the seal. To
prevent iatrogenic tracheal injury, cuff pressures should not after the ET tube is placed and end-tidal carbon dioxide
exceed 25 centimeters of water (cm Hp). The appropriate (ETCO) capnometry used when available. ET tube
size for a cuffed ET tube can be estimated by using the placement should be frequently reassessed, especially after
diameter of the child's fifth finger or the external nares, or any movement of the patient. In addition to confirming ET
by using the formula age/4 + 3.5. tube placement, auscultation may rule out the possibility
of other pulmonary injury. The pediatric patient w ith a
A slight amount of cricoid pressure frequently brings the compromised airway and a pulmonary injury who has been
anterior structures of the child's larynx into better view. successfully intubated may be in greater jeopardy for the
However, pediatric tracheal rings are relatively soft and development of a tension pneumothorax as a result of
positive-pressure ventilation .

CHAPTER 16 Pediatric Trauma 4 4 3

Figure 16-15

It would almost seem intuitive that providing an ET tube ventilation following intubation in patients transported to
as early as possible in the management of the pediatric the trauma center. 13
patient with TBI would be of benefit. A retrospective review
showed improved survival in adult patients with TBI who Data supporting prehospital pediatric endotracheal
were intubated prior to arrival at the receiving hospital.24 intubation are limited and ambiguous. In the spontaneously
Subsequent studies evaluated rapid-sequence intubation breathing child, endotracheal intubation with or
(RSI), demonstrating its improved efficiency and success without pharmacologic assistance is not recommended.
rate in intubation of adults and children.25·26 However, many Emergency medical services programs that perform
retrospective and prospective case-control studies found that pediatric prehospital intubation should include at least the
prehospital intubation compared with bag-mask ventilation following: 29
did not improve survival or neurologic outcome and even
might have been detrimental.12•27•28 A prospective randomized 1. Close medical direction and supervision
trial in children comparing endotracheal intubation to bag- 2. Training and continuing education, including hands-
mask ventilation in an urban area with short transport times
demonstrated no difference in survival or neurologic outcome on operating room experience
between the two groups but an increased incidence of 3. Resources for patient monitoring, drug storage, and
complications in the intubated group.11
ET tube placement confirmation
Prolonged periods of hypoxia are often associated with 4. Standardized RSI protocols
the intubation process, as well as periods of overaggressive 5. Availability of an alternate airway such as a

laryngeal mask airway or King LT airway
6. Intensive continuing quality assurance/quality

control and performance review program

when ventilated. Continuous end-tidal carbon dioxide (ETC02) Careful reassessment of the patient's airway and respiratory
monitoring should be used to document continuing appropriate status is needed to distinguish these subtle differences in the
ET tube placement and avoid extremes of hypercarbia and hypo- presentation.
carbia, both of which can be just as detrimental to recovery from
a closed head irtjury as hypoxia. ETC02 should be targeted at 30 Needle decompression is performed using the same land-
to 40 mm Hg.13 marks as in the adult, but it is often more immediately effective
in the child because the mediastinum rapidly shifts back to its
Tension Pneumothorax normal position and venous return is quickly restored.

Children are more susceptible than adults to acute cardiovas- Circulation
cular collapse from a tension pneumothorax. Most children
with tension pneumothoraces will present with acute cardiac Once the pediatric patient's external hemorrhage is controlled,
decompensation secondary to decreased venous return before perfusion should be evaluated. Controlling external hemorrhage
any detectable changes in oxygenation and ventilation have involves applying direct manual pressure on the bleeding point,
occurred. Any child who acutely decompensates, especially after the use of advanced hemostatic dressings, and the selective use
initiation of positive-pressure ventilation by bag-mask device or of tourniquets in extreme cases in which other measures have
advanced airway placement, should be emergently assessed for failed. Managing an external hemorrhage is not just a matter of
tension pneumothorax. covering the bleeding site with layer after layer of absorbent
dressing. If the initial dressing becomes saturated in blood, it is
Jugular venous distension may be difficult to determine best to add an additional dressing rather than to replace it, as
because an extrication collar has been applied or because of the the removal may dislodge any clot that has begun to form, while
presence of hypovolemia from hemorrhage. Tracheal shift is a at the same time performing additional interventions to stop the
late sign of tension pneumothorax and may only be determined ongoing hemorrhage.
by palpating the trachea in the jugular notch. In these pediat-
ric patients, unilateral absent breath sounds, in association with The pediatric vascular system is usually able to maintain a
cardiovascular compromise, represent an indication for emer- normal blood pressure until severe collapse occurs, at which point
gency needle decompression. In the intubated pediatric patient, it is often unresponsive to resuscitation. F1uid resuscitation should
diminished sounds on the left may indicate a right main bron- be started whenever signs of compensated hypovolemic shock
chus intubation, but when associated with acute cardiac decom- are present and must be started immediately in pediatric patients
pensation, these sounds may represent tension pneumothorax. who present with decompensated shock. Lactated Ringer's (LR)
or normal saline (NS) solution in 20-ml/kg boluses should be used.


For pediatric trauma patients who display any signs of The determination of which pediatric patients should have
hemorrhagic shock or hypovolemia, key factors to survival are intravascular access depends on the severity of injury, the expe-
appropriate volume resuscitation and rapid initiation of trans- rience of the involved prehospital care providers, and transport
port to a suitable facility. Transport should not be delayed to times, among other factors. If uncertainty exists as to which
obtain vascular access or administer IV fluid. pediatric patients need intravascular access, or if fluid replace-
ment is needed during transport, online medical direction should
Vascular Access be obtained.

Fluid replacement in a pediatric patient with severe hypotension Fluid Therapy
or signs of shock must deliver adequate fluid volume to the right
atrium to avoid further reduction in cardiac preload. The most Lactated Ringer's solution, or NS solution if LR solution is
unavailable, is the initial resuscitation fluid of choice for a hypo-
appropriate initial sites for IV access are the antecubital f ossa volemic pediatric patient. As discussed in the Shock chapter, the
time that a crystalloid fluid remains in the intravascular space
(anterior aspect of the forearm at the elbow) and the saphe- is relatively short, which is why a 3:1 ratio of crystalloid fluid to
nous vein at the ankle. Access through the external jugular vein blood lost has been recommended.
is another possibility, but airway management takes priority in
An initial fluid bolus for a pediatric patient is 20 ml/kg, which
such a small space and spinal immobilization makes the neck is approximately 25% of the normal circulating blood volume of
poorly accessible. the child. As much as 40 to 60 ml/kg may be required to achieve
adequate and rapid initial replacement in response to signifi-
In the unstable or potentially unstable pediatric patient, cant blood loss. Any pediatric patient who does not show at
attempts at peripheral access s hould be limited to two in 90 sec- least a minor improvement in hemodynamic status with the first
onds. If peripheral access is unsuccessful, intraosseous access 20-ml/kg fluid bolus and stabilization after the second 20-ml/kg
should be established (Figure 16-16). bolus should receive a blood transfusion. The crystalloid bolus
may temporarily restore cardiovascular stability as it transiently
Placement of a subclavian or internal jugular catheter in a
pediatric patient should be performed only under the most con-
trolled circumstances within the hospital; this should not be
attempted in the prehospital environment.

Figure 16-16

lntraosseous (10) infusion can provide an excellent Evidence that the needle is adequately with in the marrow
alternative site for resuscitative volume replacement in includes the following:
injured children of all ages. This is an effective route for
infusion of medications, blood, or high-volume fluid 1. A soft "pop" is heard and no resistance is felt after
administ ra t i o n . the needle has passed through the cortex.

The most accessible site for 10 infusion is the anterior 2. Bone marrow aspirates into the needle.
t ibia just inferior and medial to the tibial tuberosity. After 3. Fluid flows freely into the marrow without evidence
preparing the skin antiseptically and securing the leg
adequately, a site is chosen on the anterior portion of the of subcutaneous infiltration.
t ibia, 1 to 2 cm (0.4 to 0.8 inches) below and medial to the 4. The needle is secure and does not appear loose or
tibial tuberosity. Specially manufactured 10 infusion needles
are optimal for the procedure, but spinal or bone marrow wobbly.
needles may also be used. Spinal needles that are 18- to 10 infusion should be considered during initial
20-gauge work well because they have a trocar to prevent resuscitation if percutaneous venous cannulation
the needle from being obstructed as it passes through the (venous IV insertion) has been unsuccessful.
bony cortex into the marrow. Any 14- to 20-gauge needle Because the flow rate is limited by the bone marrow
can be used in an emergency. cavity, the administration of fluids and medications
should normally be done under pressure, and the
There are a variety of commercially available devices 10 route alone will seldom be sufficient after initial
that ease the difficulty of placing an 10 needle, using resuscitation.
various mechanical devices. For example, one device uses Proper location of the insertion site is extremely
a high-speed drill to insert a specially designed 10 needle, important in the pediatric patient. Failure to properly
and another uses a spring-loaded mechanism. The needle identify landmarks could lead to misplacement of the
is placed at a 90-degree angle to the bone and advanced 10 device and damage of the epiphyseal plate (growth
firmly through the cortex into the marrow. center) of the bone, which, in turn, can result in
growth problems of the bone and unequal extremity

CHAPTER 16 Pediatric Trauma 4 4 5

fills and then leaks from the circulatory system. However, until transported to the nearest appropriate hospital capable of
circulating RBCs are replaced and oxygen transport is restored, caring for trauma victims, according to local prehospital triage
hypoxic injury can continue. guidelines.

Pain Management Aeromedical transport may be considered in rural areas
to expedite transport. There is little evidence that aero-
As with adults, pain management should be considered for chil- medical transport provides any benefit in urban areas in which
dren in the prehospital setting. Indications for analgesia include ground transport to a pediatric trauma centeris almost as quick.32
isolated limb irtjury and suspected spinal fracture. Small doses It is becoming increasingly evident that utilizing aeromedical
of a narcotic analgesia that are appropriately titrated will not transport exposes both the patient and the crew to a significant
compromise the neurologic or abdominal examination. Both amount of risk. These concerns must be carefully weighed when
morphine and fentanyl are acceptable choices, but they should deciding whether to utilize this resource.
be administered only according to written prehospital care
guidelines or with orders from online medical control. Because Review of more than 15,000 records in the NPTR indicates
of the side effects of hypotension and hypoventilation, all pedi- that 25% of the pediatric patients were injured severely enough
atric patients receiving IV narcotics should be monitored with to require triage to a designated pediatric trauma center. Use of
pulse oximetry and serial vital signs. In general, benzodiaze- the PJ'S can help with appropriate triage. Many EMS and trauma
pines should not be administered in combination with narcotics systems use other pediatric triage criteria, which may be dic-
because of their synergistic effects on respiratory depression or tated by state, regional, or local guidelines. All prehospital care
even respiratory arrest. providers need to be familiar with the triage protocols in place
within their own systems.
Unfortunately, the trendto undertreatpediatricpainremains
an issue in emergency medical services (EMS). In one study of Specific Injuries
children with long-bone fractures, only 1()0;6 received any analge-
sia while en route to the hospital.00 Traumatic Brain Injury

Transport Traumatic brain injury (TBI) is the most common cause of death
in the pediatric population. Of the fatalities included in the first
Because timely arrival at the most appropriate facility may be the 40,000 patients in the NPTR, 89% had a CNS injury as either the
key element in the pediatric patient's survival, triage is an import- primary or the secondarycontributorto mortality. Although many
ant consideration in the management of a pediatric patient. of the most severe injuries are treatable only by prevention, ini-
tial resuscitative measures may minimize secondary brain injury
The tragedy of preventable pediatric traumatic death has and, consequently, the severity of the pediatric patient's injury.
been documented in multiple studies reported over the past three Adequate ventilation, oxygenation, and perfusion are needed to
decades. It is estimated that as many as 80% of pediatric trauma prevent secondary morbidity. While the recovery of pediatric
deaths can be classified as preventable or potentially prevent- patients sustaining severe TBI is typically considered to be bet-
able. These statistics have been one of the primary motivations ter than in adults, growing evidence indicates that a wide vari-
for the development of regionalized pediatric trauma centers, ety of impairments persist, including functional, cognitive, and
where continuous, coordinated, high-quality, sophisticated care behavioral abnormalities.
can be provided.
The results of the initial neurologic assessment are useful
Many urban areas have both pediatric trauma centers and for prognosis. Even with a normal initial neurologic evaluation,
adult trauma centers. Ideally, the pediatric multisystem trauma however, any child who sustains a significant head injury may
patient will benefit from the initial resuscitation capability and be susceptible to cerebral edema, hypoperfusion, and second-
definitive care available at a pediatric trauma center because ary insults (Figure 16-17). Furthermore, victims of nonaccidental
of its specialization in treating traumatized children. It may be trauma may have very little external evidence oftrauma, yet may
appropriate to bypass an adult trauma center in favor of trans- have sustained considerable intracranial injury. A baseline GCS
port to a pediatric-capable trauma center. For many communi- score should be assessed and frequently repeated during trans-
ties, however, the nearest specialized pediatric trauma center port. Supplemental oxygen should be administered, and if pos-
may be hours away. In these cases, the seriously traumatized sible, pulse oximetry should be monitored. Although vomiting
child should be transported to the nearest adult trauma center is common after a concussion, persistent or forceful projectile
because early resuscitation and evaluation before transport to a vomiting is of concern and requires further evaluation.
pediatric facility may improve the pediatric patient's chances of
survival.31 As with hypoxia, hypovolemia may dramatically worsen
the original TBI. External hemorrhage must be controlled and
In areas where no specialized pediatric trauma center the pediatric patient's fractured extremities immobilized to limit
is nearby, personnel working in adult trauma centers should internal blood loss associated with these injuries. An attempt
be experienced in the resuscitation and treatment of both should be made to keep these pediatric patients in a euvolemic
adult and pediatric trauma patients. In areas where neither (normal volume) state with IV volume resuscitation. On rare
facility is readily close, the seriously injured child should be occasions, infants younger than about 6 months of age may


Figure 16-17

The issue of concussion in pediatric patients, particularly a variety of symptoms and complaints, including headache,
those engaged in sports activities, has become a topic of nausea, balance problems, feeling dazed or stunned,
great importance.33 In the past, when a pediatric athlete confusion, and asking questions slow ly or repetitively. It is
sustained a concussion, the child was kept out of the game recommended that medical personnel present at a sporting
for a short time and was allowed to return to play as soon event have a formal method for assessing pediatric athletes
as he or she felt able to play again. More recently, it has for concussion using a standard sideline assessment tool as
been recognized that repeated blows to the head and well as a neurologic examination.
brain lead to long-term difficulties with cognition, behavior,
and function. It is now recommended that any pediatric Full recovery from a concussion may take a week
athlete who has sustained a concussion be removed from or longer-in some cases, months. Until the pediatric
play and not be permitted to participate for the duration athlete has fully recovered from the concussion and is
of the event. asymptomatic, the child should not be allowed to return to
play. Once the pediatric athlete is asymptomatic, he or she
The recognition of concussion is of key importance. may be returned to activity and play in a graded, structured
Where it was once thought that concussion involved a brief format with repeat evaluations to assess for relapse of
loss of consciousness with a return to normal function, symptoms. Return of symptoms indicates incomplete
it is now understood that loss of consciousness is not recovery, and the pediatric athlete should refrain from
necessary to make the diagnosis. Concussion may involve participation in sports until improvement has occurred.

become hypovolemic as a result of intracranial bleeding because During prolonged transports, small doses of mannitol (0.5 to
they have open cranial s utures and fontanelles. An infant with 1 g/kg body weight) may benefit pediatric patients with evidence
of intracranial hypertension, if local pr otocols permit . However,
an open fontanelle may better tolerate an expanding intracranial use of mannitol in the setting of insufficient volume resuscita-
hematoma and thus not become symptomatic until rapid expan- tion may result in hypovolemia and worsening shock. Mannitol
should not be given in the field without discussing this option
sion occurs. An infant with a bulging fontanelle should be con- with online medical control, unless permitted by standing orders
sidered to have a more severe TBI. or protocol.

For pediatric patients with a GCS score of eight or less, ade- Brief seizures may occur soon after TBI and, aside from
quate oxygenation and ventilation should be the goal at all times, ensuring patient safety, oxygenation, and ventilation, often
not the placement of an ET tube. Prolonged attempts at secur- do not require specific treatment by prehospital care provid-
ing an endotrach eal airway may increase periods of hypoxia and ers. However, recurrent seizure activity is worrisome and may
delay transport to an appropriate facility. The best airway for a require IV boluses of a benzodiazepine, such as diazepam (0.1
pediatric patient is the one that is both safest and most effec- to 0.2 mg/kg/dose) . Depending on local protocols, midazolam or
tive. Ventilation with a bag-mask device while being prepared to lorazepam may also be used, but all benzodiazepines should be
su ction emesis, should it occur, is often the best airway for the used with extreme caution because of the potential side effects
pediatric patient with TBI. 11·13 ofventilatory depression and hypotension, as well as their ability
to cloud the neurologic examination.
A pediatric patient with signs and symptoms of intracranial
hypertension or increased intracranial pressure, such as a slug- Spinal Trauma
gishly reactive or nonreactive pupil, systemic hypertension, bra-
dycardia, and abnormal breathing patterns, may benefit from The indication for spinal immobilization in a pediatric patient
temporary mild hyperventilation to lower intracranial pressure. is based on the mechanism of i.Itjury and physical findings; the
However, this effect of hyperventilation is transient and also presence of other i.Itjuries that suggest violent or sudden move-
decreases overall oxygen delivery to the CNS, actually causing ment ofthe head, neck, or torso; or the presence ofspecific signs
additional secondary brain i.Itjury.34 It is strongly recommended of spine i.Itjury, such as deformity, pain, or a neurologic deficit .
that this strategy not be used unless the pediatric patient is exhib- As with adult patients, the correct prehospital management of a
iting signs of active herniation or lawralizing signs (distal neu- suspected spine i.Itjury is in-line manual stabilization followed by
rologic abnormalities such as weakness on one side from i.Itjury the use of a properly fitting cervical collar and immobilization
of the pediatric patient to an appropriate device so that the
to an area of the brain). ETC02 monitoring should guide manage- head, n eck, torso, pelvis, and legs are maintained in a neutral
ment in the intubated pediatric patient, with the target range about in-line position. This should be achieved without impairing the

35 mm Hg. Hyperventilation to an ETC02 of less than 25 mm Hg
has been associated with worse neurologic outcome.13 If capnog-
raphy is not available, a ventilation rate of 25 breaths/minute for
children and 30 breaths/minute for infants should be used.35

CHAPTER 16 Pediatric Trauma 4 4 7

pediatric patient's ventilation or ability to open the mouth or dis- or hemothorax. Although rib fractures are rare in childhood,
rupting any other resuscitative efforts. they are associated with a high risk of intrathoracic injury when
present. Crepitus may be appreciated on examination and may
The threshold for perfomting spinal immobilization is lower be a sign of pneumothorax. The risk of mortality increases with
in young children because of their inability to communicate or the number ofribs fractured. A high index ofsuspicion is the key
otherwise participate in their own assessment. No studies have to identifying these injuries. Every pediatric patient who sustains
validated the safety of clinically clearing a pediatric patient's trauma to the chest and torso should be carefully monitored for
spine in the field. The same immaturity previously discussed also signs of respiratory distress and shock. Abrasions or contusions
contributes to children's fear and lack of cooperation with immo- over the pediatric patient's torso after blunt force trauma may be
bilization. A child who strongly fights attempts at immobilization the only clues to the prehospital care provider that the child has
may be at increased risk of worsening any existing spinal inju- suffered thoracic trauma.
ries. It may be valid to decide not to restrain such a pediatric
patientifthe childcan be persuaded to lie quietly withoutrestraints. Additionally, when transporting a pediatric patient who
However, any decision to stop immobilization attempts in the inter- has sustained a high-impact blunt thoracic injury, the pediatric
est of patient safety must be supported by careful and thorough patient's cardiac rhythm should be monitored once en route to a
documented reasoning as well as serial assessment of neurologic medical facility. In all cases, the key items in managing thoracic
status during and immediately after transport. Ideally, this decision trauma involve careful attention to ventilation, oxygenation, and
would be made in concert with online medical control. timely transport to an appropriate facility.

When most small children are placed on a rigid surface, the Abdominal Injuries
relatively larger size of the child's occiput will result in passive
neck fl.exion. Unless using a specialized pediatric spine board The presence of blunt trauma to the abdomen, an unstable pel-
that has a depression at the head to accommodate the occiput, vis, post-traumatic abdominal distension, rigidity or tenderness,
sufficient padding (2 to 3 cm [about 1 inch]) should be placed or otherwise unexplained shock can be associated with possible
under the pediatric patient's torso to elevate it and allow the intra-abdominal hemorrhage. A "seat belt sign" (or mark) across
head to be in a neutral position. The padding should be contin- the abdomen of a pediatric patient is often an indicator of seri-
uous and from the shoulders to the pelvis and extend to the ous internal injuries (Figure 16-18).
lateral margins of the torso to ensure that the thoracic, lumbar,
and sacral spine are on a, stable platform without the possi- The key prehospital elements in management of abdom-
bility of anterior-posterior movement. Padding should also be inal injuries include fluid resuscitation, supplemental high-
placed between the lateral sides of the pediatric patient and the concentration oxygen, and rapid transport to an appropriate
edges of the board to ensure that no lateral movement occurs facility with continued careful monitoring en route. There are
when the board is moved or if the pediatric patient and board really no definitive interventions that prehospital care provid-
need to be rotated to the side to avoid aspiration during vomiting ers can offer to pediatric patients with intra-abdominal inju-
episodes. ries, and, as such, there should be every effort to transport
pediatric patients rapidly to the closest, most appropriate
Various new pediatric immobilization devices are available. facility.
The prehospital care provider needs to regularly practice and be
familiar with any specialized equipment used in the prehospital
care provider's system as well as the required adjustments nec-
essary when irrunobilizing a pediatric patient using adult-sized
equipment. If a vest-type device is used on a pediatric patient,
adequate immobilization while at the same time preventing
respiratory compromise must be ensured. In the past, it was
recommended that an infant or young child be irrunobilized in a
car safety seat if that is where they were found.36•37 The National
Highway Traffic Safety Administration now recommends that

it is better to transport the pediatric patient immobilized in an
appropriately sized pediatric irrunobilization device instead of
the car seat. Keeping the injured child in an upright position in
the car seat increases the axial load placed on the spine by the
patient's head; therefore, standard immobilization techniques
are preferred to the car seat.38

Thoracic Injuries Figure 16-18 "Seat belt sign" in a 6-year-old patient who was
found to have a ruptured spleen. Seat belt signs are often associated
The extremely resilient rib cage of a child often results in less with serious intra-abdominal injuries.
injury to the bony structure ofthe thorax, but there is still risk for
pulmonary injury, such as pulmonary contusion, pneumothorax, Source: Courtesy of Jeffrey Guy, MD.


Extremity Trauma directly related to soft-tissue burns but are secondary to smoke
inhalation. When children are trapped in a structure fire, they
Compared with the adult skeleton, the child's skeleton is often hide from the fire under beds or in closets. These children
actively growing and consists of a large proportion of cartilagi- frequently die, and their recovered bodies often have no burns;
nous tissue and metabolically active growth plates. The ligamen- they die from carbon monoxide or hydrogen cyanide toxicity and
tous structures that hold the skeleton together are frequently hypoxia More than 50% of children younger than 9 years old in
stronger and better able to withstand mechanical disruption structure fires have some degree of smoke-inhalation injury.
than the bones to which they are attached. As a result, children
with skeletal trauma frequently sustain major traumatic forces Thermally induced edema of the airway is always a concern
before developing long-bone fractures, dislocations, or deformi- in patients with bums, but especially in pediatric patients. The
ties. Incomplete ("greenstick") fractures are common and may smaller diameter of the pediatric trachea means that 1 mm of
be indicated only by bony tenderness and pain on use of the edema will produce a greater magnitude of airway obstruction
affected extremity. than in an adult with a larger-diameter airway. A pediatric patient
with an edematous airway may be sitting forward and drooling,
Primary joint disruption from injury other than penetrating or complaining ofhoarseness or voice changes. These symptoms
injury is uncommon compared with disruption of the diaphy- should prompt rapid preparations for and initiation of transport
seal (shaft) or epiphyseal (end) segments of bone. Fractures to the hospital. While en route, supplemental oxygen is adminis-
that involve the growth plate are unique in that they must be tered and preparations made for airway intervention should the
carefully identified and managed in the acute injury phase to not symptoms progress or the pediatric patient develop respiratory
only ensure adequate healing, but also prevent subsequent dis- or cardiac arrest.
placement or deformity as the child continues to develop. The
association of neurovascular injuries with orthopedic injuries If an ET tube is placed, it needs to be protected against
in children should always be considered, and the distal vascu- inadvertent dislodgement or removal. If the pediatric patient
lar and neurologic examination should be carefully evaluated. accidentally becomes extubated, the prehospital care provider
Often, the presence of a potentially debilitating injury can be may not be able to intubate the pediatric patient again due to
determined only by radiologic study or, when the slightest sug- progressive edema, and the results could be disastrous. Securing
gestion of a decrease in distal perfusion exists, by arteriography an ET tube in a pediatric patient who has peeling facial skin and
(x-ray study of a blood vessel that has been injected with radio- moist wounds is difficult. Securing the ET tube to the face with
opaque contrast material). adhesive tape should not be attempted in a pediatric patient with
facial bums. The ET tube should be secured with two pieces of
The apparent gross deformity sometimes associated with umbilical tape, with one piece draped above the ear and the sec-
extremity injury should not distract focus from potentially ond piece placed below the ear. An effective alternative to umbil-
life-threatening injuries. Uncontrolled hemorrhage represents ical tape is IV tubing. Ifthese supplies are not available but extra
the most life-threatening consequence of extremity trauma In hands are, designate a prehospital care provider to be solely
multisystem pediatric and adult trauma patients alike, the initi- responsible for holding the airway in place.
ation of transport to an appropriate facility without delay after
completion of the primary assessment, resuscitation, and rapid Fluid Resuscitation
packaging remains paramount in reducing mortality. If basic
splinting can be provided en route without detracting from the Rapid establishment of intravascular access is vital to prevent
pediatric patient's resuscitation, it will help to minimize bleeding the development of shock. Delayed fluid resuscitation in pediat-
and pain from long-bone fractures, but attention to life-threaten- ric patients has been associated with significantly worse clinical
ing injuries should always remain the primary focus. outcomes and an increased mortality rate, especially in burned
Thermal Injuries
After securing an airway, providing adequate ventilation and
Following motor vehicle crashes and drowning, burns rate third oxygenation, it is critical that venous access be obtained quickly.
as a cause of pediatric trauma deaths.1 Caring for an injured Children have a relatively small intravascular volume, and a
child always poses significant physical and emotional challenges delay in fluid resuscitation may lead to the rapid development
to the prehospital care provider, and these difficulties are only of hypovolemic shock. To provide the large volumes of IV fluids
amplified when caring for the pediatric patient with burns. The required in critical bums, such pediatric patients usually require
pediatric patient with burns may have an edematous (swollen) two peripheral IV catheters to achieve the required IV flow rates.
airway, IV access may be complicated by burns ofthe extremity, The insertion of a single large-bore IV catheter is often challeng-
and the pediatric patient may be hysterical from pain. ing, so two IV catheters is all the more so. Burns on the extrem-
ities may make it difficult to impossible to establish enough
The primary assessment should be followed as in other access for an appropriate fluid resuscitation.
causes of pediatric trauma, but every step of the primary assess-
ment may be more complicated than in a pediatric patient with- In pediatric patients with burns, as in adult patients with
out thermal injuries. Most deaths related to structure fires are not burns, fluid needs are calculated from the time of the injury, so
even a delay of 30 minutes to the beginning of fluid resuscitation

CHAPTER 16 Pediatric Trauma 4 4 9

can result in hypovolemic shock. Excessive fluids can result in Abuse

respiratory complications as well as excessive edema, which can

complicate burn care. Each year approximately 1.5 million children are abused by

The amount of fluids typically given to a patient with burns burning, accounting for 20% of all incidents of child abuse.21,39

is calculated based on the estimated percentage of body sur- Approximately 20% to 25% of children admitted to a pediatric
face area burned using the "rule of nines," a rapid and in1pre- burn center are victims of child abuse.40·41 An increased aware-

cise method of estimating resuscitative fluid needs based on ness of this problem among prehospital care providers can

adult battlefield burn casualties. The premise of this method improve detection of this cause ofpediatric trauma. Careful doc-

of burn size estimation is that major regions of the adult body umentation of the situation surrounding the iajury, as well as of

(e.g., head, arm, anterior torso) each comprise 9% of the total the iajury patterns themselves, can aid officials in the prosecu-
body surface area Children's anatomic regions are proportion- tion of the offenders.42

ally different than those in adults; children have larger heads The two most common mechanisms by which these chil-

and smaller limbs. Therefore, estimation of pediatric burn size dren receive burns are scalds and contact burns. Scalds are the

should use diagrams that are age specific, such as the Lund- most common source of nonaccidental burns. Scalding iajuries

Browder chart, and not the rule of nines. If charts and diagrams typically are inflicted on children of toilet-training age. The usual

are not available, the "rule of palms" may be utilized. Using this scenario is that children soil themselves and are subsequently

method, the size of the pediatric patient's palm plus fingers rep- inlmersed in a tub of scalding water. These scald burns are char-

resents approximately 1% of the body surface area. (See the acterized by a pattern ofsharp demarcation between burned and

Burn Injuries chapter for further discussion of these burn esti- unburned tissue and sparing of flexion creases, as the child will

mation methods.) frequently draw his or her legs up to avoid the scalding water

Based on the percentage of body surface area burned, (see the Burn Injuries chapter).

the volume of IV fluids needed for resuscitation is determined Contact burns are the second most common mechanism

(see the Burn Iajuries chapter). Two important pediatric con- of abuse burns. Common items used to inflict contact burns

siderations merit mention. First, small children have a limited are curling irons, clothing irons, and cigarettes. Cigarette burns

reserve of glycogen. Glycogen is essentially glucose molecules appear as round wounds measuring slightly over 1 cm in diame-

strung together and is used for carbohydrate storage purposes. ter (typically 1.3 cm). To conceal these iajuries, the abuser may

These glycogen molecules can then be mobilized in times of place the burns in areas usually covered by clothing, above the
stress. If these limited glycogen stores become depleted, the hairline in the scalp, or even in the axillae.

child may rapidly develop hypoglycemia. Second, children have All the surfaces of the human body have some degree of

a large volume-to-surface area ratio; the general shape of an curvature; a hot item that falls onto the body surface will have

adult is a cylinder, whereas children resemble a sphere. The an initial point of contact and will then deflect from the point of

clinical implication is that a child will require more IV fluids. contact. The resultant accidental contact burns will have irreg-

To address both of these issues, in addition to the calculated ular borders and uneven depths. In contrast, when a hot item is
resuscitative fluids, maintenance fluids containing 5% dextrose deliberately used to burn someone, the item is pressed onto the

are administered. In prolonged transports of a pediatric patient region of the body. The burn will have a pattern with a sharp

with a Foley catheter, the fluids should be titrated to ensure a regular outline and uniform burn depth (see the Burn Injuries

urine output of 1 ml/kg/hour. Ifthe urine output is not adequate, chapter).

a fluid bolus of 20 ml/kg is administered, and the rate of admin- A high index of suspicion for abuse is important, and all

istration of the resuscitative fluids is increased to achieve the cases of suspected abuse should be reported. Make meticulous

desired urine output. observations of the surroundings, such as tlle position of vari-

Once peripheral IV access has been obtained, provisions ous pieces of furniture, presence of curling irons, and depth of

must be made to ensure that the IV line is not inadvertently bath water. Record the names of the individuals present at the

removed or dislodged. The usual techniques used to secure scene. Any pediatric patient suspected of being abused by burns,

IV lines are often ineffective when a line is placed in or adjacent regardless of the size of the burns, needs to be cared for at a

to a burn because adllesive tape and dressings may not adhere center experienced in pediatric burn care.

to burned tissue. If possible, the IV line is secured with a Kerlix Child abuse and neglect are further discussed later in this

dressing, though circumferential dressings must be frequently chapter.

monitored as edema develops, to prevent tissue damage from

the dressing becoming a constricting band.

When peripheral venous access cannot be obtained, M a t a r Vehicle Injury

intraosseous catheters should be used for the unstable and/

Preventionor unconscious pediatric patient. Although previously advo-

cated only for pediatric patients younger than 3 years of age, The American Academy of Pediatrics (AAP) has defined optimal
restraint for children in motor vehicles. The AAP recommends
intraosseous infusions are now used in older children as well that children should always ride in the rear seat and face the rear
as adults.


of the seat until 2 years of age. Children should be in child safety procedures vary, so prehospital care providers should be familiar
seats until 4 years ofage, and then graduate into a belt-positioning with the appropriate agencies that handle child abuse cases in their
booster seat until they are 8 to 10 years old. At that time, the stan- location. The need to report abuse is emphasized by data suggesting
dard three-point (seat belt-shoulder harness combination) adult thatup to 5(1>;0ofmaltreated children are released back to their abus-
restraint can be used. The lap belt alone should never be used. ers because abuse was not suspected or reported (Figure 16-20).

Suboptimal restraint is defined as the lack of use of a child Prolonged Transport
safety seat or booster seat for anyone younger than 8 years of
age, and lack of a three-point restraint for a child older than Occasionally a situation arises as a result ofpatient location, tri-
8 years (see Figure 16-2).43 In a recent review, when these guide- age decisions, or environmental considerations in which trans-
lines were observed, the risk of abdominal injury in children port will be prolonged or delayed and prehospital personnel
appropriately restrained was 3.5 times less than in the subopti- need to manage the ongoing resuscitation of a pediatric patient.
mally restrained pediatric population.44 The protective benefit of Even though this may be suboptimal because of the lack of field
the rear-seatposition is such that risk ofdeath is decreased by at resources (e.g., blood) and the inability to perform diagnostic
least 30<>A>, even if restrained with a lap belt only in the rear seat and therapeutic interventions, by applying the principles dis-
versus three-point restraint in the front seat.45 cussed in this chapter in an organized fashion, the pediatric
patient can be safely managed until arrival at a trauma center. If
Child Abuse and radio or cell phone contact with the receiving facility is possible,
Neglect constant communication and feedback are crucial for both pre-
hospital and hospital-based members of the trauma team.
Child abuse (maltreatmentornonaccidental trauma) is a significant
cause of childhood injury. As m entioned previously, almost 20% of Management consists of continued serial evaluation of the
all bums in pediatric patients involve either child abuse or child components of the primary assessment. The pediatric patient
neglect.42 Prehospital care providers must always consider the should be securely stabilized on a backboard with spinal pre-
possibility of child abuse when circumstances warrant. cautions. The board should be padded as well as possible to
prevent pressure sores. If the airway is tenuous and the crew is
Prehospital care providers should suspect abuse or neglect well trained in pediatric airway management, including endotra-
if they note any ofthe following scenarios: cheal intubation, then airway management should be performed.
Otherwise, conscientious bag-mask ventilation is still an accept-
• Discrepancy between the history and the degree of able management strategy, assuming it provides adequate oxy-
physical injury, or frequent changes in the reported genation and ventilation.
Pulse oximetry should be monitored and preferably ETC02
• Inappropriate response from the family. as well, especially in the pediatric patient with a head injury. If
signs of shock exist, 20-ml/kg boluses of LR or NS solution are
• Prolonged interval between time of injury and call for administered until the pediatric patient improves or is trans-
medical care. ferred to definitive care.

• History ofthe injury inconsistent with the developmental The GCS score should be calculated early and followed
level of the child. For example, a history indicating that serially. Assessment for other injuries should continue, and all
a newborn rolled offa bedwouldbe suspectbecause new- efforts to keep the pediatric patient normothermic should be
borns are developmentally unable to roll over. standard practice. Fractures should be splinted and stabilized
with serial neurovascular assessments. This cycle of continued
Certain types of injury also suggest abuse, such as the fol- assessment of the primary assessment should be repeated until
lowing (Figure 16-19): the pediatric patient can be safely transported or transferred to
definitive care.
• Multiple bruises invarying stages ofresolution (exclud-
ing the palms, forearms, tibial areas, and the forehead Any change or decompensation in the pediatric patient's
in ambulatory children, who are frequently injured in condition requires immediate reassessment of the primary
normal falls). Accidental bruises usually occur over assessment. For example, if Sp02 begins to decline, is the ET
bony prominences. tube still secure and in the airway? Ifso, has the pediatric patient
developed a tension pneumothorax? Is the ET tube now in the
• Bizarre injuries such as bites, cigarette burns, rope right main bronchus? If the pediatric patient has received what
marks, or any pattern injury. was thought to be sufficient fluid and is still in shock, is there
now cardiac tamponade, severe cardiac contusion, or perhaps
• Sharply demarcated burns or scald injuries in unusual an occult source of bleeding, such as intra-abdominal injury or
areas (see the Burn Injuries chapter). missed scalp laceration? Has the GCS score changed? Are there
now lateralizing signs suggesting progressive head injury and
In many jurisdictions, prehospital care providers are legally
mandated reportersifthey identify potential child abuse. Generally,
prehospital care providers who act in good faith and in the best
interests of the child are protected from legal action. Reporting

CHAPTER 16 Pediatric Trauma 451

Figure 16-19 Indicators of possible nonaccidental trauma. A. "Raccoon eyes," or periorbital bruising, a possible indicat ion of anterior fossa
skull fracture. B. Mongolian blue spots, shown here on the trunk and buttocks of a newborn Asian infant, which can be easily confused
with bruising. C. Well-circumscribed lesions with blistering, seen here as a result of a cigarette burn. D. Fingertip burns caused by having the
hand held forcibly against an electric stove burner. The burns are confined to the t ips because the chi ld t ried to prevent her hand from being
flattened against the burner. E. Abrasion caused by a ligature. F. Facial bruising from a slap to the face. The handprint can just be identified.

Source: Taylor S, Raffles A: Diagnosis in color: Pediatrics, London, 1997, Mosby-Wolfe.


Figure 16-20

Prehospital care providers may be the only medical 4. Collect significant items. Preserving the potential
responders to a potential crime scene involving mechanism of injury is vital to verifying a suspect's
nonaccidental (abuse) trauma. Although prehospital care history.
providers are under intense pressure at an emergency
scene, they are in a unique position to collect items of 5. Identify and record t he child's age and
evidentiary importance that may assist in determining the developmental stage.
mechanism of injury and identifying the abuser.
6. Recogn ize and document the signs of abuse and
The prehospital care provider's response to a "child neglect.
in need of assistance" call should ideally involve 10 a. Signs of physical abuse: unexplained fractures,
fundamental actions: bruises, black eyes, cuts, burns, and w elts;
pattern injuries and bite marks; antisocial
1. Document all adults and children present. behavior; fear of adults; signs of apathy,
2. Document all statements and the demeanors depression, host ility, or stress; eating disorders
b. Signs of sexual abuse: difficulty walking
of all persons present. As recorders of "scene" o r sitting, overcompliance, excessive
statements, prehospital care providers must be aggressiveness, nightmares, bed-wetting, drastic
familiar with the general requirements that allow change in appetite, inappropriate interest or
certain statements to be used in court. knowledge of sexual acts, fea r of a particular
a. Identify and document the maker of the person

statement. c. Signs of neglect: unsuitable clothing; unbathed/
b. Record all statements in the official report.
dirty; severe body odor; severe diaper rash;
c. Record verbatim content, using quotation marks underweight; lack of food, formula, or toys;
parent or child use of drugs or alcohol;
when appropriate. apparent lack of supervision; unsuitable living
d. Document the t ime when the statement was conditions
7. Assess other children present.
made. 8. Evaluate children and adults with disabilities.
e. Record the speaker's demeanor. 9. Adhere to mandatory reporting requirements and
f. Explain the prehospital care provider's procedures.
10. Interact with the mult idisciplinary team (MDT).
responsibilities as necessary. Nonaccidental pediatric trauma and neglect cases are
g. Ask open-ended, nonleading follow-up fraught with difficult issues. Holding abusers responsible for
t heir acts requ ires meticulous documentation; thoroug h,
questions, but do not become exposed to risk if coordinated investigations; and teamwork. Prehospital care
aggression occurs during further questioning. providers are uniquely positioned to observe and document
h. Record the question. The content of an answ er vital information when assessing the possibility of child
can often be understood only by knowi ng the abuse.
question that was asked.
i. List all persons present who heard the statement.
3. Document the environment. Prehospital care
providers may arrive before caregivers clean up,
modify, or destroy evidence.

Source: M odified from Rogers LL: Emergency medical professionals: assisting in identifying and documenting child abuse and neglect. NCPCA Update Newslett
17(7): 1, 2004.

requiring more aggressive treatments? Is the circulation and neu- By paying attention to the basics and continually reas-
rologic function of the extremities still intact? Is the pediatric sessing your pediatric patient, adequate resuscitation can be
patient normothermic? If radio contact is available, continued performed until the pediatric patient can be transferred to defin-
advice and guidance should be sought throughout the resuscita- itive care.
tion and transport.

CHAPTER 16 Pediatric Trauma 4 5 3

• The primary assessment and management of the pediatric patient in the prehospital setting require applica-
tion ofstandard trauma life support principles modified to account for the unique characteristics ofpediatric

• Traumatic brain injury is the leading cause of death from trauma, as well as the most common injury for
which pediatric patients require airway management.

• Children have the ability to compensate for volume loss longer than adults, but when they decompensate,
they deteriorate suddenly and severely.

• Significant underlying organ and vascular injury can occur with few or no obvious signs of external injury.
• Pediatric patients with the following signs are unstable and should be transported without delay to an appro-

priate facility, ideally a pediatric trauma center:
• Respiratory compromise
• Signs of shock or circulatory instability
• Any period of postinjury unconsciousness
• Significant blunt trauma to the head, thorax, or abdomen
• Fractured ribs
• Pelvic fracture
• Always consider the possibility of abuse or nonaccidental trauma when the history of the injury does not
match the presentation of the patient.

You are called to the scene of a motor vehicle crash on a heavily traveled highway. Two vehicles have been involved in a frontal offset
collision. One of the vehicle's occupants is a child improperly restrained in a child booster seat. No weather-related factors are involved
on this spring afternoon.

On arrival at t he scene, you see that the police have secured and blocked traffic from the area around the crash. As your partner
and the other arriving crew are assessing the other patients, you approach the child. You see a young boy, approximately 2 years of age,
sitti ng in the booster seat, wh ich is slightly turned at an angle; there is blood on the back of the headrest of the seat in front of him.
Despite numerous abrasions and minor bleeding from the head, face, and neck, the child appears very calm.

Your primary and secondary assessments reveal a 2-year-old boy who weakly repeats "ma-ma, ma-ma." His pulse rate is 180 beats/
minute, w ith the radial pulses weaker than the carotid; his blood pressure is 50 mm Hg by palpation. His ventilatory rate is 18 breaths/
minute, slightly irregular, but without abnormal sounds. As you continue to assess him, you note that he has stopped saying "ma-ma"
and seems to just stare into space. You also note that his pupils are slightly dilated, and his skin is pale and sweaty. A woman who iden-
tifies herself as the family's nanny tells you that the mother is en route and that you should wait for her.

• What are the management priorities for this patient?
• What are the most likely injuries in this child?
• W here is the most appropriate destination for th is ch ild?


You correctly identify this child as a victim of multisystem trauma who is in shock and critically injured. Because of the probable traumatic @
brain injury combined with the change in mentation, you have to determine the greatest threat to his survival-the brain injury and
other injuries not yet identified. You correctly identify hypotension and tachycardia, w hich you assume are related to hypovolemic shock,
probably the result of an unrecognized intra-abdominal injury.

Initially, the patient's breathing is supported with high-concentration oxygen through a nonrebreathing mask. You realize t hat his
ventilatory rate is low for a child of his age and are prepared to provide more aggressive airway control with a bag-mask if his condition
deteriorates. As you consider options for airway management, you ask your partner to hold manual stabilization of the head and neck.

Because of the nature of the ch ild's injuries, you consult with online medical control, who agrees t hat helicopter transport to the
closest pediatric trauma center is more appropriate than ground tra nsport to a nearby community hospital that has no pediat ric criti-
cal care, neurosurgical, or orthopedic resources. Brief efforts at peripheral venous access are successful. You begin crystalloid infusion
through the IV line. The ped iatric patient's mother arrives just as you are transferring care to the helicopter crew.

References 13. Davis DP, Dunford JV, Poste JC, et al. The impact of hypoxia and
hyperventilation on outcome after paramedic rapid sequence intu-
1. Centers for Disease Control and Prevention, National Center bation of severely head-injured patients. J Trauma Injury Infect
for htjury Prevention and Control, Web-Based htjury Statistics Grit Care. 2004;57(1):1.
Query and Reporting System (WISQARS). Leading causes of death
reports, 2010. O_us 14. York J, Arrillaga A, Graham R, Miller R. Fluid resuscitation of
.html. Accessed January 5, 2014. patients with multiple injuries and severe closed-head injury: expe-
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2. Centers for Disease Control and Prevention, Web-Based Injury Injury Infect Orit Care. 2000;48(3):376.
Statistics Query and Reporting System (WISQARS). Leading causes
of nonfatal injury reports, 2012. 15. Manley G, Knudson MM, Morabito D, et al. Hypotension, hypoxia,
ncipc/nfilead2001.html. Accessed January 5, 2014. and head injury: frequency, duration, and consequences. Arch Surg.
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Care Med. 2002;30(11 suppl):S416. 16. Chesnut RM, Marshall LF, IQauber MR, et al. The role of second-
ary brain injury in determining outcome from severe head injury.
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h t t p : / / wh q l i b d o c . w h o . i n t / p u b l i c a t i o n s/ 2 0 0 8/ 9 7892415635 74_ 17. Luten R. Error and time delay in pediatric trauma resuscitation:
eng.pdf. Accessed September 4, 2013. addressing the problem with color-coded resuscitation aids.
5. Winston FK, Durbin DR, Kallan MJ, Moll EK The danger of pre- Surg Clin North Am . 2002;82(2):303.
mature graduation to seat belts for young children. Pediatrics.
2000;105(6):1179. 18. American College of Surgeons (ACS) Committee on Trauma.
6. Grisoni ER, Pillai SB, Volsko TA, et al. Pediatric airbag injuries: the Pediatric trauma. In: ACS Committee on Trauma. Advanced
Ohio experience. J Pediatr Surg. 2000;35(2):160. Trauma Life Support for Doctors, Student Course Manual. 8th ed.
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blunt trauma. J Trauma Injury Infect Orit Care. 1998;45(1):69. rural pediatric trauma patients. J Pediatr Surg. 2004;39:1376.
10. Durbin DR, Kallan M, Elliott M, et al. Risk of injury to restrained
children from passenger air bags. Annu Proc Assoc Adv Auto Med. 21. Heins M. The "battered child" revisited. JAMA. 1984;251:3295.
2002;46:15. 22. Davis DP, Valentine C, Ochs M, et al. The Combitube as a salvage
11. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital
pediatric endotracheal intubation on survival and neurological out- airway device for paramedic rapid sequence intubation. Ann Emerg
come: a controlled clinical trial. JAMA. 2000;283(6):783. Med. 2003;42(5):697.
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brain injury. J Trauma Injury Infec Grit Care. 2003;54(3):444. Infect Grit Care. 1999;47(2):352.
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improves survival in patients with severe head injury. Arch Surg.
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romuscular blockade improves prehospital intubation success in

CHAPTER 16 Pediatric Trauma 4 5 5

severely head-injured patients. J Trauma Injury Infect Grit Care. 36. De Lorenzo RA. A review of spinal immobilization techniques.
2003;55(4):713. J Emerg Med. 1996;14(5):603.
26. Pearson S. Comparison of intubation attempts and completion
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27. Stockinger ZT, McSwain NE Jr. Prehospital endotracheal intubation 38. U.S. Department ofTransportation, National Highway Traffic Safety
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28. Murray JA, Demetriades D, Berne TV, et al. Prehospital intubation lances. DOT HS 811 677. September 2012.
in patients with severe head injury. J Trauma Injury Infect Grit
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31. Larson JT, Dietrich AM, Abdessalam SF, Werman HA Effective use 41. Montrey JS, Barcia PJ. Nonaccidental burns in child abuse. South
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Prehosp Emerg Care. 2004;8(4):343.

At the completion of this chapter, the reader will be able to do the following:

• Discuss the epidemiology of trauma in the elderly • Compare and contrast the assessment techniques
population. and considerations used in the elderly population
with those used in younger populations.
• Describe the anatomic and physiologic effects
of aging as a factor in causes of geriatric trauma • Demonstrate modifications in spinal
and as a factor in the pathophysiology of trauma. immobilization techniques for safe and effective
spinal immobilization of the elderly patient with
• Explain the interaction of various pre-existing the highest degree of comfort possible.
medical problems with traumatic injuries in
geriatric patients and how these interactions • Compare and contrast the management of the
produce differences in the pathophysiology and elderly trauma patient with that of the younger
manifestations of trauma. trauma patient.

• Discuss the physiologic effects of specific • Assess the scene and elderly patients for signs
common classes of medications on the and symptoms of abuse and neglect.
pathophysiology and manifestations of geriatric

CHAPTER 17 Geriatric Trauma 457

Your unit is dispatched to the home of a 78-year-old woman who has fallen down a flight of stairs. Her daughter states that they had
spoken on the telephone just 15 minutes earlier and that she w as coming to her mother's house to do some shopping. When she got
to the house, she found her mother on the floor and called for an ambulance.

Upon initial contact, you find the patient lying at the bottom of a flight of stairs. You note that the patient is an elderly w oma n
whose appearance matches her reported age. While maintaining in-line stabilization of the spine, you note that the patient is unrespon-
sive to your commands. She has a visible laceration of the forehead and an obvious deformity of the left wrist. She is w earing a Medic
Alert bracelet that indicates that she is diabetic.

• Did the fall cause the change in mental status, or was there an antecedent event?
• How do the patient's age, medical history, and medications interact with the injuries received to make the pathophysiology and

manifestations different from those in younger patients?
• Should advanced age alone be used as an additional criterion for transport to a trauma center?

~ Introduction age to be just under 800 million today (representing 11% of the
world population) and projects that it will increase to just over
~ -"'/ The elderly population represents the fastest- 2 billion in 2050 (representing 22% of the world population).3

growing age group in the United States. The injured elderly present unique challenges in prehospital
(and hospital) care management, second only to those encoun-
Gerontologists (medical specialists who study tered with infants. Sudden illness and trauma in elderly patients
present a different prehospital care dimension than in younger
and care for elderly patients) divide the term elderly into three patients. Some of the earliest data looking at the effect of age
on outcome are from the Major Trauma Outcome Study by the
specific categories, as follows: American College of Surgeons Committee on Trauma.4 Data
from more than 3,800 patients aged 65 years and older were com-
• Middle age: 50 to 64 years ofage pared to almost 43,000 patients younger than 65 years of age.
• Late age: 65 to 79 years ofage Mortality increased in ages 45 to 55 years and doubled by age 75
• Older age: 80 years of age and older years. The age-adjusted risk of death occurs across the spectrum
of injury severity, suggesting that injuries that could be easily
Although such definitions are important for epidemio- tolerated by younger patients may result in mortality in those of
logic data, it is also important to recognize that the physiologic advanced age.
changes of aging occur along the entire age spectrum and vary
among individuals. Recovery from closed head injury starts to Because older persons are more susceptible to critical ill-
decline beginning in the mid-20s age group, and overall survival ness and trauma than the rest of the population, a wider range of
from trauma starts to decline in the late 30s. In addition, increas- difficulties in patient assessment and management needs to be
ing age is often associated with multiple pre-existing medical considered. Because elderly patients often access medical care
conditions, which further complicate the recovery from trauma. through emergency systems (e.g., 9-1-1), rendering care is differ-
The approach to the elderly patient includes recognition of this ent than for younger patients. The range of disabilities experi-
fact, although younger patients with comorbidities may share enced by elderly patients is enormous, and field assessment may
similar attributes. take longer than with younger patients. Difficulties in assessment
can be expected as a result of age-related sensory impairments
Over 41 million Americans (13.3% of the U.S. population) in hearing and vision, senility, and physiologic changes.
are 65 years of age or older, and the size of this group has risen
dramatically during the last 100 years. 1 At the same time, fertil- Advances in medicine and an increasing awareness of
ity rates have dropped, meaning that there will be fewer people healthier lifestyles during the last several decades have resulted
under 65 years of age to support the costs of health care and in a significant increase in the percentage of the population
living expenses of those over 65 years of age. By the year 2050, over 65 years of age. Although trauma occurs most frequently
nearly 25% of Americans will be eligible for Medicare, and the in young people, and geriatric emergencies are most often med-
population over 85 years of age will have grown from 5.5 million ical problems, a growing number of geriatric calls result from
to 19 million p eople.2 The United Nations Population Division
estimates the worldwide number of those older than 60 years of


or include trauma. Trauma is the fourth leading cause of death organ systems have achieved maturation, and a turning point
in persons aged 55 to 64 years and is the ninth highest cause of in physiologic growth has been reached. The body gradually
death in those aged 65 years and older.5 Approximately 15% of loses its ability to maintain homeostasis (the state of relative
ir\jury-related deaths in elderly patients are classified as homi- constancy of the body's internal environment), and viability
cide. Trauma deaths in this age group account for 25% of all declines over a period of years until death occurs.
trauma deaths nationwide.6
The fundamental process of aging occurs at the cellular
Specific patterns of ir\jury are also unique to the geriatric level and is reflected in both anatomic structure and physiologic
population.7 Although motor vehicle crashes are the leading function. The period of "old age" is generally characterized by
cause of death from trauma overall, falls are the predominant frailty, slower cognitive processes, impairment of psycholog-
cause of traumatic death in patients over 75 years ofage. As with ical functions, diminished energy, the appearance of chronic
small children (age younger than 5 years), scald ir\juries account and degenerative diseases, and a decline in sensory acuity.
for a greater percentage of bums in those over 65 years. Functional abilities are lessened, and the well-known external
signs and symptoms of older age appear, such as skin wrinkling,
Progress in recent years has not only increased adult life changes in hair color and quantity, osteoarthritis, and slowness
expectancy but has also affected the quality of life and, there- in reaction time and reflexes (Figure 17-1).
fore, the range of physical activities performed at older ages. As
more people live longer and enjoy better health in their older Influence of Chronic Medical
years, more of them travel, drive, and continue active physical Problems
pursuits that can result in an associated increase in geriatric
trauma. Many who could retire now continue to work despite a As people age, they experience the normal physiologic changes
health problem or advancing age. of advancing years and can also experience more medical prob-
lems. Although some individuals can reach an advanced age
Recent social changes have increased the number of older without any serious medical problems, statistically an older
people living in independent housing, retirement communities, person is more likely to have one or more significant medical
and other assisted-living facilities compared with those in nurs- conditions (Figure 17-2). Seniors presently consume more than
ing homes or other, more guarded and limited environments. one-third of health care resources in the United States.8 Usually,
This shift in home environment suggests a probable increase proper medical care can control these conditions, helping to
in the incidence of simple household trauma, such as falls, in avoid or minimize exacerbations from becoming repeated acute
elderly persons. The past few years have also seen an increase and often life-threatening episodes.
in geriatric victims of crime in the home and on the streets.
Older people are often singled out as "easy marks" and can sus- Some older individuals have reached advanced age with
tain substantial trauma from crimes of seemingly limited vio- minimal medical problems, whereas others may live with chronic
lence, such as purse snatching, when they are struck, knocked
down, or fall. tBrain mass Diminished hearing
tDepth perception
With the growing awareness of this expanding popula- J Sense of smell and
tion at risk, the prehospital care provider must understand Discrimination J T taste
the unique needs of an elderly trauma patient. Specifically, the of colors T
aging process and the effects of coexisting medical problems t Saliva production
on an elderly patient's response to trauma and trauma manage- tPupillary response
ment must be understood. The special considerations outlined t Esophageal activity
in this chapter should be included in the assessment and man-
agement of any trauma patient who is 65 years of age or older,
physically appears elderly, or is middle-aged and has any of
the significant medical problems typically associated with the
elderly population.

Anatomy and Respiratory J I. Cardiac stroke
Physiology of Aging vital capacity T T volume and rate

The aging process causes changes in physical structure, body tRenal function t Gastric secretions
composition, and organ function, and it can create unique prob-
lems during prehospital care. The aging process influences mor- 2- to 3-inch loss J Number of
tality and morbidity rates. in height T body cells
J Elasticity of skin
Aging, or senescence, is a natural biologic process and Degeneration T Thinning of epidermis
is sometimes referred to as a process of "biologic reversal" of the joints J 15%-30%
that begins during the years of early adulthood. At this time, T body fat
tTotal body water

Figure 17-1 Changes caused by aging.

CHAPTER 17 Geriatric Trauma 459

Figure 17-2 Figure 17-4

Age (years} PED (%}

13-39 3.5
65-74 11 .6 PED Number PED Total Mortality
of Present {%} Rate{%}

29.4 Patients {%}

75-84 34.7 Hypertension 597 47.9 7.7 10.2

85+ 37.3 Pulmonary 286 23 3.7 8.4


illnesses and depend on modem medical means to swvive. Thislat- Cardiac 223 17.9 2.9 18.4
ter group can deteriorate more rapidly in an emergency situation. disease
198 15.9 2.5 12.1
Repeated acute episodes of a medical problem or even the Diabetes 167 13.4 2.1 4.8
single occurrence of a significant episode can result in chronic 80 6.4 20
residual effects on the body. A patient who has previously had an Obesity 45 3.6 0.6 13.3
acute myocardial infarction sustains permanent heart damage.
The resultant reduced cardiac capacity continues for the rest of Malignancy 40 3.2 0.5 37.5
the patient's life, affecting the heart and, because of the ensuing Neurologic 41 3.3 0.5 12.2
chronic impairment of circulation, other organs as well.
As a person's age advances, additional medical problems
can occur. None is truly isolated because the effect on the body Renal disease
is cumulative. The total influence on the body usually is greater
than the sum of each individual effect. As each condition pro- Hepatic
gresses and reduces the quality of the body's vital functions, the disease
individual's ability to withstand even modest anatomic or physi-
ologic insults is greatly diminished. higher mortality rate because of the way in which they interfere
with an elderly patient's ability to respond to trauma (Figure 17-4).9
Regardless of whether the patient is pediatric, middle-aged,
or elderly, the priorities, intervention needs, and life-threatening Ears, Nose, and Throat
conditions that usually result from serious trauma are the same.
However, because of these pre-existing physical conditions, Tooth decay, gum disease, and iltjury to teeth result in the need
elderly patients often die from less severe iltjuries and die sooner for various dental prostheses. The brittle nature of capped teeth,
than younger patients. Data support that pre-existing conditions fixed bridges, or loose, removable bridges and dentures poses a
playa role in the mortality ofan elderly trauma patient and that the special problem; these foreign bodies can be easily broken and
more conditions a trauma patient has, the higher his or her mor- aspirated and can subsequently obstruct the airway.
tality rate (Figure 17-3). Certain conditions are associated with a
Changes in the contours of the face result from resorption
Figure 17-3 Numoer. of of the mandible, in part because of the absence of teeth (eden-
Diseases (P.EDs) anCJ P.atier.iit tulism). This resorption causes a characteristic look ofan infold-
Outcome After. rauma ing and shrinking mouth. These changes can adversely affect the
ability to create an effective seal with a bag-mask device and to
Number of Survived Died Mortality sufficiently visualize the airway during endotracheal intubation.
PEDs 6341 211 Rate{%}
The nasopharyngeal tissues become increasingly fragile
0 3.2 with age. In addition to the risk this change poses during the ini-
tial trauma, interventions such as insertion of nasopharyngeal
tubes may induce profuse bleeding ifnot performed with care.

868 56 6.1 Respiratory System

2 197 36 15.5 Ventilatory function declines in the elderly person partly as a

3 or more 67 22 24.7 result of the decreased ability of the chest wall to expand and
contract and partly from stiffening of the airway. The increased

stiffness in the chest wall is associated with a reduction in


expansion ofthe chest wall and a stiffening of cartilaginous con- reliance on diaphragmatic activity to breathe. This increased
nections of the ribs. As a result of these changes, the chest cage reliance on the diaphragm makes an older person especially
is less pliable. With declines in the efficiency of the respiratory sensitive to changes in intra-abdominal pressure. Thus, a supine
system, the elderly person requires more work to breathe and position or a full stomach from a large meal can provoke venti-
greater exertion to carry out daily activities. latory insufficiency. Obesity can also play a part in diaphragm
movement restriction, especially when fat distribution tends to
The alveolar surface area in the lungs decreases with age; be central.
it is estimated to decrease by 4% for each decade after 30 years
of age. A 70-year-old person, for example, would have a 16% Cardiovascular System
reduction in alveolar surface area. Any alteration ofthe already-
reduced alveolar surface decreases oxygen uptake. Additionally, Diseases of the cardiovascular system are the primary cause of
as the body ages, its ability to saturate hemoglobin with oxy- death in the elderly population. Cardiovascular disease accounts
gen decreases, leading to lower baseline oxygen saturation as for more than 3,000 deaths per 100,000 persons over 65 years of
a normal finding and less oxygen reserve available. 10 Because of age. In 2010, myocardial infarction accounted for 27% of deaths
impaired mechanical ventilation and diminished surface for gas in the United States, with an additional 6% caused by stroke.5
exchange, the elderly trauma patient is less capable of compen-
sating for physiologic losses associated with trauma. Age-related decreases in arterial elasticity lead to increased
peripheral vascular resistance. The myocardium and blood ves-
Changes in the airway and lungs of elderly persons may sels rely on their elastic, contractile, and distensible (stretch-
not always be related to senescence alone. Cumulative chronic able) properties to function properly. With aging, these properties
exposure to environmental toxins over the course of their lives decline, and the cardiovascular system becomes less efficient at
may be caused by occupational hazards or tobacco smoke. moving circulatory fluids around the body. The cardiac output
Impaired cough and gag reflexes, along with poor cough strength diminishes by approximately 50% from 20 to 80 years of age.
and diminished esophageal sphincter tone, result in an increased Among patients over 75 years of age, as many as lOOAi will have
risk of aspiration pneumonitis. A reduction in the number of some degree of overt congestive heart failure.
cilia (hair-like projections of the cells in the respiratory tract
that propel foreign particles and mucus from the bronchi) pre- Atherosclerosis is a narrowing of the blood vessels, a con-
disposes the elderly person to problems caused by inhaled par- dition in which the inner layer of the artery wall thickens as fatty
ticulate matter. deposits build up within the artery. These deposits, calledplaque,
protrude above the surface of the inner layer and decrease the
Another factor that affects the respiratory system is a diameter of the internal channel of the vessel. The same luminal
change in the spinal curvature. Curvature changes, primarily narrowing occurs in the coronary vessels. Almost 50% of the U.S.
increasing kyphosis, accompanied by an anteroposterior hump population has coronary artery stenosis by age 65 years.5
(as seen in osteoporosis patients) often lead to additional venti-
latory difficulty (Figure 17-5). One result of this narrowing is hypertension, a condition
that affects one ofsix adults in the United States. Calcification of
Changes that affect the diaphragm can also contribute to the arterial wall reduces the ability of the vessels to change size
ventilatory problems. Stiffening of the rib cage can cause more in response to endocrine and central nervous system stimuli.
The decrease in circulation can adversely affect any of the vital
liJ organs and is a common cause of heart disease. Of particular
Alveoli concern is that the baseline normal blood pressure of the elderly
trauma patient may be higher than in younger patients. What
Figure 17-5 Spinal curvature can lead to an anteroposterior hump, would otherwise be accepted as normotension may indicate
which can cause ventilatory difficulties. Reduction in the alveolar profound hypovolemic shock in the patient with pre-existing
surface area can also reduce the amount of oxygen that is exchanged hypertension.
in the lungs.
With age, the heart itself shows an increase in fibrous tissue
and size (myocardial hypertrophy). Atrophy of the cells of the
conduction system results in the increased incidence of cardiac
dysrhythmias. In particular, the normal reflexes in the heart that
respond to hypotension diminish with age, resulting in the inabil-
ity of elderly patients to increase their heart rate appropriately to
compensate adequately for a low blood pressure. Maximal heart
rate also begins to decrease starting at age 40 years, estimated
by the formula 220 minus the age in years. Patients with a per-
manent pacemaker have a fixed heart rate and cardiac output
that cannot meet the demands of increased myocardial oxygen
consumption accompanying the stress of trauma. Patients with
hypertension taking beta blocker medications may also not have
an increase in heart rate to compensate for hypovolemia.

CHAPTER 17 Geriatric Trauma 461

In the elderly trauma patient, this reduced circulation con- structure of the brain may be involved in mental impairment. As
tributes to cellular hypoxia. The result is cardiac dysrhythmia, changes occur in the brain, memory can be affected, and person-
acute heart failure, and even sudden death. The body's ability ality changes and other reductions in brain function can occur.
to compensate for blood loss or other causes of shock is sig- These changes may involve the need for some form of mental
nificantly lowered in the elderly person because of a diminished health service. About 10% to 15% of elderly persons require pro-
inotropic (cardiac contraction) response to catecholamines. fessional mental health services. However, when assessing an
In addition, total circulating blood volume decreases, creating elderly trauma patient, any impairment in mentation should be
less physiologic reserve for blood loss from trauma. Diastolic assumed to be the result of an acute traumatic insult, such as
dysfunction makes the patient more dependent on atrial filling shock, hypoxia, or brain injury.
to augment cardiac output, which is diminished in hypovolemic
states. Sensory Changes

The reduced circulation and circulatory-defense responses, Vision and Hearing
coupled with increasing cardiac failure, produce a significant
problem in managing shock in the elderly trauma patient. Fluid Overall, approximately 28% of elderly persons have hearing
resuscitation needs to be carefully monitored because of the impairment, and approximately 13% have visual impairment.
reduced compliance of the cardiovascular system and the often Men tend to be more likely to have hearing difficulties, whereas
"stiff' right ventricle. As the patient ages, cardiac muscle loses both genders have a similar incidence of eye-related impairment.
its elastic properties and becomes "stiffer." As a result, its abil-
ity to compensate for a sudden increase in circulating volume Loss of vision is challenging at any age, and it may be even
is limited. Care must be taken when treating hypotension and more problematic for the elderly person. The inability to read
shock to avoid causing volume overloading with aggressive fluid directions (e.g., on a prescription label) can lead to a disastrous
resuscitation. 11 effect. In addition, elderly persons experience decreases in
visual acuity, ability to differentiate colors, and night vision.
Nervous System
The cells of the lens of the eye are incapable of restoration
As individuals age, brain weight and the number of neurons to their original molecular structure. One of the destructive
(nerve cells) decrease. The weight of the brain reaches its peak agents over years ofexposure is ultraviolet radiation. Eventually,
(1.4 kilogram, or 3 pounds) at approximately 20 years of age. the lens loses its capability to increase in thickness and curva-
By 80 years of age, the brain has lost about 1()0;6 of its weight, ture. The result is almost universal farsightedness (presbyopia)
with progressive cerebral atrophy. 12 The body compensates for in persons over 40 years of age, requiring glasses for reading.
the loss of size with increased cerebrospinal fluid. Although this
additional space around the brain can protect it from contusion, As a result of changes to the various structures of the eye,
it also allows for more brain movement in response to acceler- elderly persons have more difficulty seeing in dimly lit environ-
ation/deceleration injuries. The increased space in the cranial ments. Decreased tear production leads to dry eyes-itching
vault also explains why the elderly patient may have significant and burning-and the inability to keep the eyes open for long
volumes of blood accumulate around the brain with minimal or periods.
no symptoms.
With age, the lens of the eye begins to become cloudy and
The speed with which nerve impulses are conducted along impenetrable to light. This gradual process results in a cataract,
certain nerves also decreases. These decreases result in only or a milky lens that blocks and distorts light that enters the eye
small effects on behavior and thinking. Reflexes are slower, and blurs vision. Some degree ofcataract formation is present in
but not to a significant degree. Compensatory functions can 95% of elderly persons. This deterioration of vision increases the
be impaired, particularly in patients with diseases such as risk ofa motor vehicle crash, particularly when driving at night.13
Parkinson's disease, resulting in an increased incidence of falls.
The peripheral nervous system is also affected by the slowing of A gradual decline in hearing (presbycusis) is also charac-
nerve impulses, resulting in tremors and an unsteady gait. teristic of aging. Presbycusis is usually caused by loss of con-
duction of sound into the inner ear; the use of hearing aids can
General information and vocabulary abilities increase or are compensate for this loss to some degree. This hearing loss is most
maintained, whereas skills requiring mental and muscular activ- pronounced when the person attempts to discriminate complex
ity (psychomotor ability) may decline. The intellectual functions sounds, such as when many people are speaking at once, or with
that involve verbal comprehension, arithmetic ability, fluency loud, ambient noise present, such as the wailing of sirens.
of ideas, experiential evaluation, and general knowledge tend
to increase after 60 years of age in those who continue learn- Pain Perception
ing activities. Exceptions are those who develop senile dementia
and other disorders such as Alzheimer's disease. Because of the aging process and the presence of diseases such
as diabetes, elderly persons may not perceive pain normally,
The normal biologic aging of the brain is not a predictor placing them at increased risk of injury from excesses in heat
for diseases of the brain. However, decreases in the cortical and cold exposure. Many elderly persons have conditions such
as arthritis that result in chronic pain. Living with daily pain


can cause an increased tolerance to pain, which may result in a
patient's failure to identify areas of injury. In evaluating patients,
especially those who usually "hurt all over" or who appear to have
a high tolerance to pain, areas in which the pain has increased
or in which the painful area has enlarged should be located. It
is also important to note whether the pain's characteristics or
exacerbating factors have changed since the trauma occurred.

Renal System

Changes common with aging include reduced levels of filtration
by the kidneys and a reduced excretory capacity. These changes
should be considered when administering drugs normally
cleared by the kidneys. Chronic renal inhibition typically affects
elderly persons and contributes to a reduction in a patient's over-
all health status and ability to withstand trauma. For example,
renal dysfunction may be one cause of chronic anemia, which
would lower a patient's physiologic reserve.

Musculoskeletal System

Bone loses mineral as it ages. The loss of bone (osteoporosis) Figure 17-6 Kyphosis, typically caused by osteoporosis. Because of
is unequal among the genders. During young adulthood, bone the elderly person's tendency to flex the legs, t he arms appear longer.
mass is greater in women than in men. However, bone loss is
more rapid in women and accelerates after menopause. With this Source:© Dr. P. MarazzVScience Source.
higher incidence of osteoporosis, older women have a greater
probability of fractures, particularly of the neck of the femur Deficits that relate to the musculoskeletal system (e.g.,
(hip). Causes of osteoporosis include loss of estrogen levels, inability to flex the hip or knee adequately with changes in
increased periods of inactivity, and inadequate intake and inef- terrain) predispose the elderly person to falls. Muscle fatigue
ficient use of calcium. can cause many problems that affect movement, especially falls.
Changes in the body's normal posture are common, and changes
Osteoporosis contributes significantly to hip fractures and in the spine make the curvature become more acute with aging.
spontaneous compression fractures of the vertebral bodies. The Some degree of osteoporosis is universal with aging. Because
incidence approaches 1% per year for men and 2% for women of this progressive bone resorption, the bones become less pli-
over age 85 years. 14 ant, more brittle, and more easily broken. The decrease in bone
strength, coupled with reduced muscle strength caused by less
Older persons are sometimes shorter than they were active exercise, can result in multiple fractures with only mild or
in young adulthood because of dehydration of the vertebral moderate force. The most common sites oflong-bone fracture in
discs. As the discs flatten, a loss of approximately 2 inches elderly persons include the proximal femur, hip, humerus, and
(5 centimeters) in height occurs between 20 and 70 years of wrist. The increased incidence of falls as a mechanism of injury
age. Kyphosis (curvature of the spine) in the thoracic region results in Colles' fractures of the distal radius, as the dorsiflexed
can also contribute to height loss and is often caused by oste- hand is outstretched in an effort to break the fall.
oporosis (Figure 17-6). As the bones become more porous and
fragile, erosion occurs anteriorly, and compression fractures of The entire vertebral column changes with age, primarily
the vertebrae may develop. As the thoracic spine becomes more because of the effects of osteoporosis, osteophytosis (bone
curved, the head and shoulders appear to be pushed forward. spurs), and calcification of the supporting ligaments. This calcifi-
If chronic obstructive pulmonary disease (COPD), particularly cation results in decreased range of motion and narrowing of the
emphysema, is present, the kyphosis may be more pronounced spinal canal. The narrowed canal and progressive osteophytic
because of the increased development of the accessory muscles disease put these patients at high risk for spinal cord injury with
of breathing.

Absolute levels of growth hormones decrease with aging,
in cor\junction with a decline in responsiveness to anabolic hor-
mones. The combined effect is a reduction in muscle mass of
about 4% per decade after age 25 years until age 50 years, when
the process accelerates to between 10% and 35% per decade.
Muscle loss is measured microscopically by both absolute num-
ber of muscle cells and reduction in cell size.

CHAPTER 17 Geriatric Trauma 4 6 3

even minor trauma. The narrowing of the spinal canal is called cell-mediated and humoral responses to infection also results.
spinal stenosis and increases the likelihood of cord compres- Coupled with any pre-existing nutritional problems common
sion without any actual break in the bony cervical spine. The in the elderly population, there is an increased susceptibility to
thoracic and lumbar spine degenerate progressively as well, and infection. Sepsis is a common cause of late death after severe or
the combined forces of osteoporosis and posture changes lead even insignificant trauma in the elderly patient.
to increased falls. A high level of suspicion for spinal iajury is
needed during patient assessment because more than 500A> ofver- Assessment
tebral compression fractures are asymptomatic.15

Skin Prehospital assessment of the elderly patient is based on the
same method used for all trauma patients. Although the meth-
Significant changes in the skin and connective tissues are associ- odology is unchanged, the process may be altered in elderly
ated with aging and result in difficulties with response to trauma patients. As with all trauma patients, however, the mechanism
as well as direct wound healing. Cell numbers decrease, tissue ofiajury should be considered first. This section discusses some
strength is lost, and the skin has impaired functional status. As special considerations in assessing an elderly trauma patient.
the skin ages, sweat and sebaceous glands are lost. Loss ofsweat
glands reduces the body's ability to regulate temperature. Loss Kinematics
of sebaceous glands, which produce oil, makes the skin dry and
flaky. Production of melanin, the pigment that gives color to skin Falls
and hair, declines, causing an aging pallor. The skin thins and
appears translucent, primarily because of changes in underlying Falls are the leading cause of trauma death and disability in
connective tissue, and therefore is more prone to sustaining dam- those over 75 years of age. Approximately one-third of commu-
age from relatively minor trauma. The thinning and drying ofthe nity-dwelling people over 65 years of age fall each year, increas-
skin also reduce its resistance to minor iajury and microorgan- ing to 50% by 80 years of age. Men and women fall with equal
isms, resulting in an increased infection rate from open wounds. frequency, but women are more than twice as likely to sustain a
As elasticity is lost, the skin stretches and falls into wrinkles and serious iajury because of more pronounced osteoporosis. Falls
folds, especially in areas of heavy use, such as those overlying in the elderly, even those that occur from a standing position, can
the facial muscles ofexpression. Thinning of the skin also results result in serious iajury and life-threatening trauma.
in the potential for significant tissue loss and iajury in response
to relatively low-energy transfers. Most falls result from the inherent nature of aging, with
the changes in posture and gait.16 Declining visual acuity from
Loss offatty tissue can predisposethe elderlyperson to hypo- cataracts, glaucoma, and loss of night vision contributes to the
thermia. The loss ofup to 200A> ofdermal thickness with advanced loss of visual clues used by elderly persons to navigate safely.
age and an associated loss in vascularity are also responsible for Diseases of the central and peripheral nervous systems and the
impaired thermoregulatory dysfunction. However, hypothermia vascular instability of cardiovascular disease further precipitate
should also suggest the possibility of occult sepsis, hypothyroid- falls. Not only do pre-existing conditions predispose the geriat-
ism, or phenothiazine overdose in the elderly population. This ric patients to more serious complications, but also the use of
loss of fatty tissue also leads to less padding over bony promi- medications to treat these conditions, such as anticoagulants
nences, such as the head, shoulders, spine, buttocks, hips, and and beta blockers, interferes with the normal physiologic and
heels. Prolonged immobilization without additional padding can compensatory responses to trauma. However, the most import-
result in tissue necrosis and ulceration as well as increased pain ant variables contributing to falls in elderly persons are physi-
and discomfort during treatment and transport. cal barriers in their environment, such as slippery floors, throw
rugs, stairs, poorly fitting shoes, and poor lighting.
Nutrition and the Immune System
Long-bone fractures account for the majority of iajuries,
With aging, a reduction in lean body mass and decreases in met- with fractures of the hip resulting in the greatest mortality and
abolic rate cause a reduction in caloric needs. However, because morbidity rates. The mortality rate from hip fractures is 20% at
ofinefficient utilization mechanisms, protein needs may actually 1 year after the iajury and rises to 33% at 2 years. Mortality is
increase. These competing changes often result in pre-existing most often secondary to pulmonary embolus and the effects of
malnutrition in the elderly trauma patient. The financial status of decreased mobility.
retired individuals may also affect their choices of and access to
quality nutrition. Vehicular Trauma

The ability of the immune system to function decreases as Motor vehicle crashes are the leading cause of trauma death
it ages. Grossly, organs associated with the immune response in the geriatric population between 65 and 74 years of age. An
(thymus, liver, and spleen) all decrease in size. A decrease in elderly patient is five times more likely to be fatally iajured in a
motorvehicle crash than a younger driver, even though excessive


speed is rarely a causative factor in the older age group.17 For pain perception can result in more significant burns. Thinning of
many reasons, elderly persons are often involved in collisions dermal elements may result in a deeper thickness of burns.
during daylight hours, during good weather, and close to their
domicile (Figure 17-7). The presence ofpre-existing medical conditions, such as car-
diovascular disease and diabetes, results in poor tolerance to the
These high fatality rates have been attributed to certain resuscitative care of burns. Vascular collapse and infection are
physiologic changes. In particular, subtle changes in memory the most common causes ofdeath from burns in elderly patients.
and judgment together with impaired visual and auditory acuity
can result in delayed reaction time. A common finding at crash Traumatic Brain Injury
investigations is that the elderly driver failed to yield to oncom-
ing traffic. The brain has undergone a 100,1, reduction in mass by 70 years of
age. The dura mater adheres more closely to the skull, resulting
Figure 17-7 in a loss of some brain volume. The dural bridging veins become
more stretched and, thus, susceptible to tearing. This results in a
The National Highway Traffic Safety Administration has lower frequency of epidural hemorrhage and a higher frequency
produced a CD-ROM program to assist physicians in of subdural hemorrhage. Because of brain atrophy, a fairly large
assessing and counseling older drivers. subdural hemorrhage can exist with minimal clinical findings.
The combination of head trauma and hypovolemic shock yields
Alcohol is rarely involved, unlike with motor vehicle crashes a greater fatality rate. Pre-existing medical conditions or their
in younger persons. Only 5% offatally injured elderly persons are treatmentmaybe a cause ofaltered mentationin elderlypatients.
intoxicated, compared with 25% for all other age categories.17 When in doubt as to whether confusion represents an acute or a
chronic process, the injured patient should be assumed to have
Elderly pedestrians represent more than 20% of all pedes- sustained a traumatic brain injury and preferentially transported
trian fatalities. Because of slower walking speeds, the time to a trauma center for evaluation when possible.
allowed by traffic signals may be too short for the elderly person
to traverse the crosswalk safely. This may explain the observa- Primary Assessment
tion that more than 45% of all elderly pedestrian fatalities occur
near a crosswalk. Airway

Assault and Domestic Abuse Evaluation of the elderly patient begins with assessment of the
airway. Changes in mentation may be associated with the tongue
blocking the airway. The oral cavity should be examined for
foreign bodies, such as dentures or fractured teeth that have
become dislodged.

Abuse is defined as willful infliction of injury, unreasonable con- Breathing
finement, intimidation, or cruel punishment resulting in physical
or psychological harm or pain, or the withholding of services Elderly patients who breathe at a rate of less than 10 or greater
that would prevent these conditions. The elderly are highly than 30 breaths/minute, similar to any other adult, will not have
vulnerable to this crime. Violent assaults have been estimated adequate minute volume and will require positive-pressure
to account for more than 100,f> of trauma admissions in elderly assisted ventilations. In most adults, a ventilatory rate between
patients. The need for chronic care because of debilitation may 12 and 20 breaths/minute is normal and confirms that an ade-
predispose an elderly person to abuse or neglect from his or her quate minute volume is present. However, in an elderly patient,
caregivers. It is estimated that only about 15% of cases of geriat- reduced tidal volume capacity and pulmonary function may
ric abuse are reported to the proper authorities18•19 (see the later result in an inadequate minute volume, even at rates of 12 to 20
discussion on Elder Maltreatment). breaths/minute. Breath sounds should be immediately assessed
ifthe ventilatory rate is abnormal; however, these sounds may be
Burns harder to hear because of smaller tidal volumes.

Elderly patients represent 200Ai of burn unit admissions, with an An elderly patient's vital capacity is diminished by 500Ai.
estimated 1,500 fire-related deaths per year. Burn fatalities in Kyphotic changes ofthe spine (anteroposterior) result in a venti-
elderly patients occur from burns of smaller size and severity lation-perfusion mismatch at rest. Hypoxia is much more likely
compared with other age groups. Fatality rates are seven times to be a consequence of shock than in younger patients. Elderly
those ofyounger burn victims. patientsalso have a decreased abilityfor chestexcursions. Lower
tidal volumes and lower minute volumes are typical. Reductions
Because ofimpairments in visual and auditory acuity, elderly in capillary oxygen and carbon dioxide exchange are significant.
persons may have delayed recognition of house fires. Decreased Hypoxemia tends to be progressive.

CHAPTER 17 Geriatric Trauma 465

Circulation year may not indicate disorientation but only a lack of"calendar"
importance in the structure of their lives.
Some findings can only be interpreted properly by lmowing the
individual patient's pre-event, or "baseline," status. Expected Similarly, people who no longer drive pay less attention to
ranges of vital signs and other findings usually accepted as nor- roads, town borders, locations, and maps. Although normally
mal are not "normal" in every individual, and deviation is much oriented, they may not be able to identify their present location.
more common in the elderly patient. Although the typical ranges Confusion or the inability to recall events and details long past
are broad enough to include most individual adult differences, may be more indicative of how long ago the events occurred
an individual ofany age may vary beyond these norms; therefore, rather than how forgetful the individual is. Likewise, the repeated
such variation in elderly patients should be expected. retelling of events long past and more attention paid to the far
past than the immediate past often simply represent a nostalgic
Medication may contribute to these changes. For example, lingering on years and events. Such social and psychological
in the average adult, a systolic blood pressure of 120 millimeters compensations should not be considered as signs of senility or a
of mercury (mm Hg) is considered normal and generally unim- diminished mental capacity.
pressive. However, in the chronically hypertensive patient who
normally has a systolic blood pressure of 150 mm Hg or higher, Expose/Environment
a pressure of 120 mm Hg would be a concern, suggestive of hid-
den bleeding (or some other mechanism causing hypotension) Elderly persons are more susceptible to ambient environmental
of such a degree that decompensation has occurred. Likewise, changes. They have a decreased ability to respond to tempera-
heart rate is a poor indicator of trauma in elderly patients ture changes, decreased heat production, and a decreased ability
because of the effects of medications such as beta blockers to rid the body of excessive heat. Thermoregulatory problems
and the heart's poor response to circulating catecholamines are related to an imbalance of electrolytes (e.g., potassium deple-
(epinephrine). Quantitative information or signs should not be tion, hypothyroidism, diabetes mellitus). Other factors include a
used in isolation from other findings. However, failing to recog- decreased basal metabolic rate, decreased ability to shiver, arte-
nize that such a change occurred or that itis a serious pathologic riosclerosis, and effects of drugs and alcohol. Hypertherrnia may
finding in a particular patient can produce a poor outcome for result from cerebrovascular accidents (strokes) and adminis-
the patient. tration of diuretics, antihistamines, and antiparkinsonian drugs.
Hypothermiais often associated with decreased metabolism, less
Delayed capillary refilling time is common in the elderly fat, less efficient peripheral vasoconstriction, and poor nutrition.
because of less efficient circulation (peripheral arterial disease);
therefore, it is a poor indicator of acute circulatory changes in Secondary Assessment (Detailed
these patients. Some degree of decreased distal motor, sensory, History and Physical Examination)
and circulatory ability in the extremities represents a common
normal finding in elderly patients. The secondary assessment of the elderly trauma victim is
performed in the same manner as for younger patients and
Disability after urgent life-threatening conditions have been addressed.
However, a number of factors may complicate assessment of the
All findings should be viewed collectively to maintain an geriatric patient, meaning prehospital care providers may need
increased level of suspicion for neurologic injury in the elderly to take more than the average amount of time when assessing
patient. Wide differences in mentation, memory, and orientation elderly patients.
(to the past and present) can exist in elderly persons. Significant
neurologic trauma should be identified in light of the individu- Communication Challenges
al's preinjury, normal status. Unless someone on the scene can
describe this status, it should be assumed that the patient has Many factors come into play when communicating with geriatric
a neurologic injury, hypoxia, or both. The ability to distinguish patients, from the normal biologic effects ofthe aging process to
between a patient's chronic status and acute changes is an generational expectations of the provider-patient relationship.
essential factor to prevent underreaction or overreaction to the Understanding how best to communicate with individuals in this
patient's present neurologic status when evaluating his or her age group will help the prehospital care provider deliver prompt,
overall condition. However, unconsciousness remains a serious efficient care.
sign in all cases.
• Additional patience may be needed because of the
The elderly patient's orientation to time and place should be elderly patient's hearing or visual impai rments.
assessed by careful and complete questioning. People who work Empathy and compassion are essential. A patient's
5 days a week with weekends off usually lmow the day of the intelligence should not be underestimated merely
week. Ifthey do not, it can be assumed that they have some level because communication may be difficult or absent.
of disorientation. For those who no longer work a traditional
job and who are often surrounded by others who do not, a lack
of distinction b etween days of the week or even months of the


Ifthe patient has close associates or relatives, they may • Be respectful and avoid language that m ay be inter-

participate in giving information or may stay nearby preted as condescending. The patient should be add-

to help validate information. However, not all elderly ressed by his or her last name, unless otherwise

patients have significant deficits. Speaking in a louder instructed by the patient. Use of a patient's first name

tone or slower cadence to the elderly patient may be without his or her permission or use ofpet names such

unnecessary and insulting. as "honey" may insult the patient and make him or her

• Assessment of the elderly patient requires different a less willing participant. Phrases such as, "Now, now,

questioning tactics. The patient should be asked for you'll be fine," which may be considered patronizing or

specific versus general information because elderly dismissive, should be avoided.

persons often respond "yes" to all questions during the

assessment process. Asking open-ended questions is a Physiologic Changes
useful tool in evaluating most patients, including the

elderly. When dealing with a problem, however, provid- The prehospital care provider must be prepared for the physio-

ing specific details from which to choose can be help- logic distinctions often encountered in the geriatric age group.

ful. For example, instead of saying, "Describe the pain

in your hip," the prehospital care provider can ask, "Is • The body may not respond the same as in younger
the pain in your hip s harp, stabbing, or dull?" or "On a patients. Typical findings of serious illness, such as

scale of 1 to 10, with 10 being the most intense pain, fever, pain, or tenderness, may take longer to develop

how would you rate the pain?" and, thus, make it more difficult to evaluate the elderly

• A signij'icant other may need to be involved. With the patient. In addition, many medications will alter the

patient's permission, involving the caregiver or spouse body's response. Often a prehospital care provider will

may be necessary to gather valid information. It is have to depend on the patient's history alone.

important, however, to not approach elderly patients • Altered comprehension or neurologic disorders are a

as if they are small children. A common mistake by signij'icant problem for many elderly patients. These

health care providers in both prehospital and emer- impairments can range from confusion to senile demen-

gency department settings is to treat the elderly in this tia ofthe type associated with Alzheimer's disease. Not

way. Often, well-meaning relatives are so aggressive in only may these patients have difficulty in communicat-

reporting the events for an elderly loved one that they ing, but they may also be unable to comprehend or help

take over as the respondent to all inquiries. In such a sit- in the assessment. They may be restless and sometimes

uation, theprehospital care provider can easily overlook combative.

that the clinical impression and history are from some- • Elderly patients may rwt be properly rwurished or

one other than the patient and may not be correct. Not hydrated. Shake the patient's hand to feel for grip

only does this increase the danger of obtaining incom- strength, skin turgor, and body temperature. Look at

plete or inaccurate information through a third party's the patient's state of nourishment. Does the patient

impressions and interpretation of what is transpiring, appear to be well, thin, or emaciated? Elderly patients

butit also discounts the patient as a mature adult. have a decreased thirst response, and they also have a

Some elderlypatients may be reluctant to give infor- decreased amount of body fat (15% to 30%) and total

mation without the assistance of a relative or support body water.

person. However, the elderly patient may not want any • Elderly patients have a decrease in skeletal muscle
otherperson presentfor many reasons, including abuse weight, widening and weakening of bones, degen-

problems. The elderly patient may fear punishment for eration of joints, and osteoporosis. They have an

telling someone, in the presence of the abuser, why he increased probability of fractures with minor injuries

or she has multiple bruise marks. Also, some problems and a greatly increased risk of fractures to the verte-

may embarrass the elderly patient, and the person may brae, hip, and ribs. The ease of rising or sitting should

not want any family members to lmow about them. be observed as it provides clues as to muscle strength.
• Pay attention to impaired hearing, sight, compre- • Elderly patients have degeneration of heart muscle

hension, and mobility capabilities. Eye contact cells and fewer pacemaker cells. Elderly persons are

should be made with the patient. The patient may be prone to dysrhythmia as a result of a loss of elastic-

hearing impaired and depend on watching your lips ity of the heart and major arteries. Widespread use of

and other facial movements. Noise, distractions, and beta blockers, calcium channel blockers, and diuretics

interruptions should be minimized. Fluency in speech, further complicates this problem. Often after injury,

an involuntary movement, cranial nerve dysfunction, elderly patients present with low cardiac output with

or difficulty breathing should be noted. Is the patient's hypoxia and have no lung injury. Cardiac stroke volume

movement easy, unsteady, or unbalanced? and rate decrease, as does cardiac reserve, all leading

CHAPTER 17 Geriatric Trauma 467

to morbidity and mortality in the elderly trauma patient. caused injury, affect mentation, and may make blood
An elderly patient with a systolic blood pressure of glucose therapy difficult if their use is unrecognized.
120 mm Hg or lower should be considered to be in • Over-the-counter medications, including herbal prepa-
hypovolemic shock until proved otherwise. rations and supplements, are frequently used by elderly
persons. Their inclusion in the list of medications is
Environmental Factors often omitted by patients, who should be specifically
questioned about their use. These preparations are
The environment in which the patient is found can tell you a lot unregulated and, thus, have unpredictable dose effects
about the patient's well-being. and possible drug interactions. Complications of these
agents include bleeding (garlic) and myocardial infarc-
• Look for behavioral problems or manifestations that tion (ephedrine/ma huang).
do not fit the scene. Look at the patient's physical
appearance and grooming. Are the patient's attire and Assessing the elderly trauma patient's medication list can
grooming appropriate for where and how the patient prove challenging if, for example, the patient has lost conscious-
was found? Is the patient able to care for him- or her- ness or is struggling to recount an extensive list of medications
self? Is the living environment clean and well-kept? Is with difficult names. In some communities, emergency medi-
there the potential for elder abuse or neglect? cal services (EMS) agencies have promoted programs such as
the File of Life Project ( In this program, the
Detailed History patient's detailed medical history is placed in a common location
Medications in any house: the refrigerator door. The patient completes a med-
ical history form that is then placed into a magnetic holder that
Knowledge of a patient's medications can provide key infor- is applied to the refrigerator, alerting prehospital care providers
mation in determining prehospital care. Pre-existing disease in to the File of Life (Figure 17-8).
the elderly trauma patient is a significant finding. The follow-
ing classes of drugs are of particular interest because of their Because geriatric patients are often taking numerous
frequent use by elderly persons and their potential to affect the medications, the possibility of drug interactions or inadver-
assessment and care of the trauma patient: tent overdose must be considered as a possible cause of the
patient's trauma, altered mental status, or changes in vital

• Beta blockers (e.g., propranolol, metoprolol) may Medical Conditions
account for a patient's absolute or relative bradycardia. Numerous medical conditions may predispose individuals to

In this situation, an increasing tachycardia as a sign traumatic events, especially those that result in an alteration in

of developing shock may not occur. The drug's inhibi- the level of consciousness or other neurologic deficit. Common

tion of the body's normal sympathetic compensatory examples include seizure disorders, insulin shock from diabetes

mechanisms can mask the true level of the patient's mellitus, syncopal episodes from antihypertensive medication,
circulatory deterioration. Such patients can rapidly cardiac dysrhythmia from an acute coronary syndrome, and

decompensate, seemingly without warning. cerebrovascular accidents. Because the incidence of chronic

• Calcium channel blockers (e.g., verapamil) may pre- medical conditions increases with age, geriatric patients are
vent peripheral vasoconstriction and accelerate hypo- more prone to suffering trauma as the result of such a medical

volemic shock. problem than are younger victims. The astute prehospital care

• Nonsteroidal anti-inflammatory agents (e.g., ibuprofen) provideralways keepsthis conceptin mind during the assessment
may contribute to platelet dysfunction and increase and notes clues from the primary and secondary assessments

bleeding. that may point to a medical problem that precipitated the injury,

• Anticoagulants (e.g., clopidogrel, aspirin, warfarin) such as the following:
may increase blood loss. Data suggest that use of

warfarin increases the risk of isolated head injury and • Observations made by bystanders that a victim

adverse outcome. Any bleeding from trauma will be appeared unconscious prior to a crash

more brisk and difficult to control when a patient is • A Medic Alert bracelet that indicates the patient has an

taking an anticoagulant. More importantly, internal underlying condition such as diabetes

bleeding can progress rapidly, leading to shock and • An irregular heartbeat or cardiac dysrhythmia seen

death. during electrocardiogram monitoring

• Hypoglycemic agents (e.g., insulin, metformin, rosigl-

itazone) may be causally related to the events that This key information is passed on to the receiving facility.

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