Pediatric Trauma Resuscitation

Fig. 9.1

Broselow Pediatric Emergency Resuscitation Tape

9.4.2 Normal Pediatric Vital Signs

Pediatric vital signs vary by age (Table 9.1). Children are able to maintain normal blood pressures until late hemorrhagic shock (>30 % blood loss), and therefore subtle changes in heart rate and respiratory rate must be noted. As a general rule, the lower limit of acceptable systolic blood pressure (SBP) = (Age × 2) + 70 mmHg. For newborns, acceptable SBP is 60 mmHg or greater (Table 9.1).

Table 9.1

Pediatric vital signs

	Pulse (beats/min)	Systolic blood pressure (mmHg)	Respiration (breaths/min)
Newborn (<1 month)	95–145	60–90	30–60
Infant (1 month–1 year)	125–170	75–100	30–60
Toddler (1–2 years)	100–160	80–110	24–40
Preschool (3–4 years)	70–110	80–110	22–34
School age (4–12 years)	70–110	85–120	18–30
Adolescent (>12 years)	55–100	95–120	12–16

9.4.3 A = Airway (C-Spine Immobilization)

Cardiac arrest in a child is most often of respiratory etiology. An injured child who is obtunded, unresponsive, or combative may need to be intubated. An uncooperative child who needs radiologic imaging may also need to be intubated. Intubation must be performed with the jaw thrust technique to maintain in-line cervical stabilization. Keep in mind these key anatomic differences for intubation in children: larger tongue, more anterior/superior glottis, and shorter trachea. You may find that a straight Miller blade is easier than the curved one because the epiglottis is floppy (less cartilaginous). The appropriate size of endotracheal tube (ETT) can be estimated by the size of the pinkie finger (or the formula = [age + 16]/4). The Broselow Pediatric Emergency Resuscitation Tape is also a useful tool to estimate ETT (and other device) size and medication doses, given a child’s height or weight. Use an uncuffed ETT in a young child (<8 years old or approximately 60 lbs), because the subglottic trachea is narrowed and provides a sufficient seal. However, cuffed ETT may be used (except in newborns), if appropriate cuff pressures are used. Rapid sequence intubation (RSI) is similar to adults, including preoxygenation with 100 % FiO₂, medication administration (Table 9.2), cricoid pressure, cervical spine stabilization, laryngoscopy, and advancement of tube to an appropriate distance beyond the cords. Confirm exhaled CO₂ and secure the tube. In the rare event of acute airway obstruction, needle cricothyroidotomy with a 14 g catheter is preferential to open cricothyroidotomy because of the increased incidence of subglottic stenosis.

Table 9.2

Common emergency medication doses in children

Medication	Dose
Adenosine	0.1 mg/kg IV first dose (max 6 mg) rapid push 0.2 mg/kg IV second dose (max 12 mg)
Amiodarone (VF/VT arrest)	5 mg/kg IV (max 15 mg/kg/day)
Atropine sulfate	0.02 mg/kg IV (min 0.1 mg, max 0.5 mg) 0.04 mg/kg IV for second dose
Calcium chloride (10 %)	10–20 mg/kg IV
Calcium gluconate (10 %)	15–60 mg/kg IV
Diazepam	0.5–1.0 mg/kg IV
Dobutamine	2–20 mcg/kg/min IV
Dopamine	2–5 mcg/kg/min IV (>15 mcg/kg/min for alpha effect)
Epinephrine (asystole/PEA arrest)	0.01 mg/kg IV first dose (repeat Q3–5 min during CPR)
Epinephrine infusion	0.1 mcg/kg/min IV, then titrate (range: 0.1–1 mcg/kg/min)
Lidocaine	1 mg/kg IV push 20–50 mcg/kg/min IV
Magnesium sulfate	25–50 mcg/kg IV over 10–20 min (max 2g)
Morphine sulfate	0.1 mg/kg IV
Midazolam	0.1 mg/kg IV (max 5 mg)
Naloxone	0.1 mg/kg IV (if less than 5 years old or 20 kg) 2 mg IV (if greater than 5 years or 20 kg)
Pancuronium	0.1–0.2 mg/kg IV
Sodium bicarbonate	1–4 mEq/kg IV
Succinylcholine	2.0 mg/kg (if < 10kg) 1.0–1.5 mg/kg (if > 10 kg)
Thiopental	4–6 mg/kg IV
Vecuronium	0.2 mg/kg IV

VF ventricular fibrillation, VT ventricular tachycardia, PEA pulseless electrical activity

9.4.4 B = Breathing

Assess for potential life-threatening thoracic injuries: pneumothorax (open chest wound or tension pneumothorax), hemothorax, flail chest/pulmonary contusions, and rib fractures with splinted breathing. The mediastinum of a child is very compliant and can lead to rapid decline from a tension pneumothorax. Children are diaphragmatic breathers, and therefore gastric distension can be an unrecognized contributor to respiratory distress, especially in the young child who is distended from swallowing air while crying. When concerned about gastric distension, like this, a nasogastric tube should be placed to decompress the stomach. (Use an orogastric tube in very young children who are obligate nose-breathers.)

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