Question 17

Outline  the  differences  in  management of  multi-trauma  occurring in  a  6-year-old child, compared with management of multi-trauma occurring in an adult.

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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.


•    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


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.


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Schalamon, Johannes, et al. "Multiple trauma in pediatric patients." Pediatric surgery international 19.6 (2003): 417-423.

Magin, M. N., et al. "Multiple Trauma in Children-Patterns of Injury-Treatment Strategy-Outcome." European journal of pediatric surgery 9.05 (1999): 316-324.

Reichmann, I., et al. "Comparison of multiple trauma in children and adults." Der Unfallchirurg 101.12 (1998): 919-927.

Reichmann, I., et al. "Comparison of multiple trauma in children and adults." Journal of Orthopaedic Trauma 13.3 (1999): 232.

Avarello, Jahn T., and Richard M. Cantor. "Pediatric major trauma: an approach to evaluation and management." Emergency medicine clinics of North America 25.3 (2007): 803-836.

Adelson, P. David, et al. "Phase II clinical trial of moderate hypothermia after severe traumatic brain injury in children." Neurosurgery 56.4 (2005): 740-754.

Coley, Brian D., et al. "Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma." Journal of Trauma and Acute Care Surgery 48.5 (2000): 902-906.