Page 69 - Journal of Special Operations Medicine - Spring 2017

The pediatric neck is shorter than the adult neck and prevention of hypothermia is warranted in a pediatric
the combination of a larger head with shorter neck in- trauma patient. Hypothermia has deleterious effects on
creases the risk for high cervical spine injuries (C2–4). the coagulation system; it can result in increased rates
3
This combination can also precipitate airway difficul- of coagulopathy and subsequent hemorrhage. These ef-
ties during transport. When lying supine, the pediatric fects translate into longer hospital stays and, ultimately,
occiput forces the neck into flexion, which causes the to increased mortality. Wade et al. retrospectively re-
9
anterior airway to buckle and close. This is even more viewed hypo- and hyperthermia data from the National
evident when transporting on an adult litter, particularly Trauma Data Bank, three civilian Level I trauma cen-
when the proper shoulder support is not used. ters, and military CSHs, and concluded that both hypo-
and hyperthermia were associated with poor outcomes.
The pediatric airway between 2 and 8 years of age poses Hypothermia was defined as a temperature below 36°C
a unique set of anatomic characteristics. Children of and hyperthermia as temperature above 38°C. Civilian
these ages demonstrate appreciable, predictable differ- casualties were compared with military casualties. Irre-
ences when compared with the adult patient, and antici- spective of the groups, extreme deviations from these
pation of these differences will make successful airway temperatures resulted in increased mortality. 9
management more likely. As mentioned, the proportion-
ally larger head and occiput cause increased flexion of Greater SA:V also predisposes the patient to exposure
the neck when lying flat on a hard surface; this flex- of greater force per square inch of body. The pediatric
ion tends to obstruct the upper and middle airway. The musculoskeletal system is much more pliable, which in-
small mandible, larger tongue, and enlarged tonsils and creases the likelihood for internal organ damage with-
adenoids of children may also contribute to obstruction; out the presence of bony fractures. Patients with blunt
6
this is especially true in an obtunded or paralyzed pa- chest trauma may have significant lung and cardiac in-
tient. The pediatric larynx is more superior than that jury with intact ribs and sternum, due to a relatively
6
of the adult patient and the pediatric airway is seated larger energy transfer through the chest wall and into
more anteriorly. The combination of these factors con- the vital organs. Pediatric patients must be evaluated
5,6
tributes to poor visualization and greater risk of compli- with a high index of suspicion for internal injuries when
cations like failed visualization or intubation attempts, they have a concerning mechanism, even if they do not
prolonged intubation attempts, and airway edema and have significant external signs of trauma.
hypoxia due to prolonged airway manipulation. The pe-
diatric subglottic space represents the narrowest portion In addition to lacking a rigid, protective bony structure,
of the child’s airway and often represents the greatest there is less fatty tissue surrounding their closely situated
resistance to passing an endotracheal tube; this is espe- internal organs. This naked proximity of organs also
cially true in the setting of increased edema from mul- contributes to the risk of multiorgan trauma. Trauma
tiple or prolonged intubation attempts. Readers should to the abdominal cavity more commonly will result in
note that the cricoid cartilage and cricoid membrane liver, spleen, and bowel injury, because of limited cover-
are also much smaller in the pediatric patient; these can age by the bony rib cage and decreased abdominal wall
present significant difficulty if an emergent cricothyrot- muscle mass. 7,8
omy is attempted. 6,7
Pediatric patients suffering from blunt abdominal
For these reasons, translaryngeal or transtracheal jet trauma and who are hemodynamically stable are fre-
ventilation is recommended in lieu of cricothyrotomy quently successfully managed nonoperatively and are
for patients younger than 10 years when intubation at- initially observed for a time. It is especially important
tempts have failed and other devices (e.g., a bag-valve during this time to recognize differences in compensa-
mask [BVM] or laryngeal mask airway) are either not tory mechanisms that operate in children. Smaller pe-
available, are inappropriate for the situation, or have diatric lungs and decreased functional residual capacity
failed. When using BVM ventilation on a child, there is offer decreased oxygen reserves that, in combination
a greater risk of overinflation of the stomach because with their increased metabolic rate, lead to rapid oxy-
children have a relatively larger stomach, lower gastro- gen consumption. Children can compensate for this
esophageal sphincter tone, and relatively smaller lungs. increased consumption of oxygen by increasing their
minute ventilation and cardiac output (i.e., respiratory
It is important to recognize the pediatric body surface rate, heart rate, and stroke volume). Early in trauma,
area to volume ratio (SA:V). An infant’s SA:V is three these compensatory mechanisms, along with vaso-
times that of an adult, and a toddler’s SA:V is two times constriction of the skin and other nonvital areas, may
that of an adult. This can result in greater heat loss disguise the presence of impending shock. The factors
8
and eventual hypothermia, even when the ambient tem- contributing to a decreased physiologic reserve also
perature is warm. A more aggressive approach to the precipitate a propensity to decompensate quickly once

Pediatric Trauma in an Austere Environment 47