College Answer

Many candidates missed multiple aspects of management, usually because they did not follow a systematic approach (eg. according to EMST guidelines). Basic principles of management

according to EMST guidelines are the same – ie primary survey (ABCDE), resuscitation, secondary survey, re-evaluation, definitive care. However, candidates need to recognise and accommodate the different characteristics of the 6 year old trauma patient:

Mechanism of injury: falls and assaults more likely

Patterns of injury: more likely blunt trauma with multiorgan injury and head injury common

Physiologic and anatomic differences:

•    Different airway anatomy

•    Large body surface area/volume ratio – implications for exposure and heat loss

•    Different normal physiologic values

•    Increased cardiovascular reserve – 30% blood volume may be lost before vital signs change; hypotension indicates >45% loss

•    Immature skeleton – Incomplete skeletal calcification, with more flexible bones– eg pulmonary contusions without rib fractures common; ligament flexibility and increased head mass makes cervical spine injuries above C4 more likely and Spinal Cord Injury Without Obvious Radiological Abnormality (SCIWORA) may occur.

Assessment:

•    History – may be difficult to obtain

•    Examination – may need to modify for age - eg modified GCS, but a 6 year old can be scored as per an adult

•    Investigations – may require modification – eg uncooperative child may require GA for CT

•    Treatment:

•    Airway: uncuffed tube, size estimated from age, cervical precautions

•    Breathing

•    Circulation: IV access may be difficult, consider intraosseous needle. Fluid boluses calculated according to weight (20ml/kg) as are maintenance requirements

•    Disability: modified GCS

•    Exposure: care to maintain body temperature

•    Drug doses calculated according to weight (average 6 year old 20kg)

•    Equipment sizes (eg chest drains, urinary catheters, nasogastric) appropriate for size – Broselow tape useful

Other specific issues:

•    Psychological issues – patient and parents

•    Consent issues

•    Potential child abuse

•    Consider transfer to a specialist paediatric centre

Discussion

The examiners complained that a systematic approach needed to be followed, but the college answer also fails to use such an approach. Typicaly, trauma management follows an "ABCDE" system. The summary below offers a brief systematic discussion of the differences between adult and paediatric trauma, following the ATLS system of 

• Airway: 
  • More difficult anatomy; cricothyroidotomy is challenging
  • Breathing:
  • Tension pneumothorax is harder to identify. 
  • Ribs rarely fracture (cartilaginous): force is transmitted to the lungs, causing more pulmonary contusions. Hypoxia is of more rapid onset.
• ​Circulation:
  • Increased reserve of compensation: more blood may be lost before manifestations of shock are seen.
• Disability:
  • Modified GCS must be used. Greater risk of raised ICP because of anatomical differences (bigger brain, smaller skull). C-spine injury is usually much higher (C1-C3) and is possible without radiological evidence (SCIWORA).
• Exposure:
  • Hypothermia is more likely (mass:BSA ratio)
• Family and social issues:
  • ​very important: family is the "F" in "ABCDEF" of paediatric trauma
  • counselling of carer
  • Guilt, blame, etc
• Abdominal issues:
  • Organs are unprotected by rib cage
  • Spleen and liver are often lacerated
  • Shallow pelvis fails to protect the bladder
  • Kidneys are more mobile and less defended
  • Laparotomy is rarely indicated
• Metabolic problems:
  • Hyperglycaemia and glycogen reserve depletion is more rapid; hypercatabolism develops early
• Injury patterns as compared with adults:
  • more multiple injuries (force is transmitted to more of the body)
  • improved survival from trauma
  • shorter ICU stay, fewer complications
  • need to consider non-accidental causes
  • Burns are of a different pattern : more head/face from falling pots, more hands from grabbing hot objects

More detail is available in the chapter on Trauma in Children. When preparing for such a low-yield topic, one has got to keep in mind the relative value of storing this information versus the revision of more frequently examined topics.