Pediatric Trauma and Pediatric Shock from the ATLS

The source for the following is the 9th edition of the Advanced Trauma Life Support Student Course Manual.*

Airway and Breathing:

“Endotracheal intubation is indicated for injured children in a variety of situations, including:

  • a child with severe brain injury who requires controlled ventilation
  • a child in whom an airway cannot be maintained
  • a child who exhibits signs of ventilatory failure
  • a child who has suffered significant hypovolemia who has a depressed sensorium or who requires operative intervention.”

“Orotracheal intubation is the most reliable means of establishing an airway and administering ventilation to a child.”

“Preoxygenation should be performed in children who require an endotracheal tube for airway conotrol.”

“When airway maintenance and control cannot be accomplished by bag-mask ventilation or orotracheal intubation, a rescue airway with either laryngeal mask LMA, intubating LMA, or needle cricothyroidotomyis necessary. Needle-jet insufflation via the cricothyroid membrane is an appropriate measure for oxygenation but it does not provide adequate ventilation and progressive hypercarbia will occur. Laryngeal mask airways are appropriate adjunct airways for infants and children, but their placement requires experience, and the airway may distend if ventilation is overly vigorous. LMA sizes range from 1 (appropriate for infants <6.5 kg),1.5 (for 5 to 10 kg), 2 (for 10 to 20 kg), 2.5 (for 20 to 30 kg), and 3 for between 30 and 70 kg);in patients over 70 kg, adult sizing is appropriate.”

“Surgical cricothyroidotomy is rarely indicated for infants or small children. It can be performed in older children in whom the cricothyroid membrane is easily palpable (usually by age of 12 years).”

“Normal spontaneous tidal volumes vary from 4 to 6 mL/kg for infants and children, although slightly larger volumes of 6 to 8 mL/kg, and occasionally as high as 10 mL/kg, may be required during assisted ventilation.”


A child can be in shock even with a normal blood pressure because a child’s main response to hypovolemia is tachycardia (although pain and fear can also cause tachycardia).

“The mean normal systolic blood pressure for children is 90 mm Hg plus twice the child’s age in years. The lower limit of normal systolic blood pressure in children is 70 mm Hg plus twice the child’s age in years.”*

Hypotension is a very late sign of shock in children.

Hypotension in a child represents a state of decompensated shock and indicates severe blood loss of greater than 45% of the circulating blood volume[emphasis added] .” This child needs immediate ABCs and immediate surgical consultation and possible operation. The child needs airway support (and C-spine stabilization if indicated). The patient usually needs immediate endotracheal intubation and ventilatory and oxygen support to guard airway and reduce metabolic demand by reducing work of breathing. The patient needs vigorous fluid bolus and often pRBCs.

Systemic Response to Blood Loss In Children, ATLS Table 10.4
Cardiovascular Increased heart rate; weak, thready peripheral pulses; normal systolic blood pressure (80-90 + 2 x age in years); normal pulse pressure Markedly increased heart rate; weak, thready central pulses; absent peripheral pulses; low normal systolic blood pressure (70-80 + 2 x age in years); narrowed pulse pressure (1) Tachycardia followed by bradycardia; very weak or absent central pulses; absent peripheral pulses; hpotension (70 + 2 x age in years); narrowed pulse pressure (or undetectable diastolic blood pressure)
Central Nervous System Anxious; irritable; confused Lethargic; dulled response to pain (2) Comatose
Skin Cool, mottled; prolonged cappillary refill Cyanotic; markedly prolonged capillary refill Pale and cold
Urine Output(3) Low to very low Minimal
  1. A narrowed pulse pressure in pediatrics is less than 20 mm Hg.
  2. The child’s dulled response to pain with this degree of blood loss (30%-45%) may be indicated by IV catheter insertion.
  3. After initial decompression by urinary catheter. Low normal is 2 ml/kg/hr (infant), 1.5 ml/kg/hr (younger child), 1 ml/kg/hr (older child), and 0.5 ml/kg/hr (older child), and 0.5 ml/kg/hr (adolescent). IV contrast can falsely elevate urinary output.

As noted above , tachycardia is the child ‘s primary response to hypovolemia. And we want to recognize shock due to hypovolemia (or any cause) as soon as possible. “Other more subtle signs of blood loss in children include progressive weakening of peripheral pulses, a narrowing of pulse pressure to less than 20 mm Hg, skin mottling (which substitutes for clammy skin in infants and young children), cool extremities compared with the torso skin, and a dulled response to pain.”

“The goal of fluid resuscitation is to rapidly replace the [lost] circulating volume. An infant’s blood volume can be estimated at 80 mL/kg, and a child’s at 70 mL/kg. When shock is suspected, a bolus of 20 mL/kg of warmed isotonic crystalloid is needed.”

Failure to improve hemodynamic abnormalities following the first bolus of reesuscitation fluid raises the suspicion of continuing hemorrage, prompts the need for administration of a second and perhaps a third 20 ml/kg bolus of isotonic crystall0id fluid, and requires the prompt involvement of a surgeon. When starting an additional bolus of isotonic crystalloid fluid or if at any point during volume resuscitation the child’s condition deteriorates, consideration must be given to the early use of 10 mL/kg of type specific or O-negative warmed pRBCs.”

The best way to estimate the weight of a child is to ask the child’s caregiver if you can. Next you can use the Broselow length based tape to determine weight. And finally you can estimate the weight in kilograms by the formula : Wt (in kg) = (2 x age) + 10.

Look For A Favorable Response to Fluid Resuscitation

“Injured children should be monitored carefully for response to fluid resuscitation and adequacy of organ perfusion. A return toward hemodynamic normality is indicated by:

  • Slowing of the heart rate (<130 beats/min,with improvement of other physiologic signs; this response is age dependent)
  • Clearing of the sensorium
  • Return of peripheral pulses
  • Return of normal skin color
  • Increased warmth of extremities
  • Increased systolic blood pressure (normal is approximately 90 mm Hg plus twice the age in years)
  • Increased pulse pressure (>20 mm Hg)
  • Urinary output of 1 to 2 mL/kg/hr (age-dependent)
Pediatric Vital Functions ATLS, Table 10.5
Infant 0-12 months 0-10 <160 >60 <60 2
Toddler 1-2 years 10-14` <150 >70 <40 1.5
Preschool 3-5 years 14-18 <140 >75 <35 1
School Age 6-12 years 36-70 <120 >80 <30 1
Adolescent> or = 13 years 36-70 <100 >90 <30 0.5

An Important Cause of Pediatric Hypotension to Consider

Mobility of mediastinal structurres makes the child more susceptible to tension pneumothorax, the most common immediately life threatening injury in children.”

Blood Loss From Pediatric Musculoskeletal Trauma

“Blood loss associated with long-bone and pelvic fractures is proportionately less in children than in adults. Blood loss related to an isolated closed femur fracture is associated with an average fall in hematocrit of 4 percentage points, which is not enough to cause shock. Hemodynamic instability in the presence of an isolated femur fracture should prompt evaluation for other sources of blood loss, which usually be found within the abdomen.

*American College of Surgeons,Chapter 10: Pediatric Trauma. 9th ed, 2012. pp. 272—284.






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