ATLS 2021 Pediatric Surgery Update

The priorities for evaluating a small child with multi-system trauma are the same as for an adult patient - ensure airway, breathing, and circulation.

Pediatric patients have more pliable chests, so ribs don't necessarily break, but they can have significant pulmonary contusions and other injuries without obvious chest wall findings.

Pediatric patients are more susceptible to tension pneumothorax because their mediastinum is more mobile and shifts more easily in response to tension.

Children have large tongues and large heads; when placed on a backboard, the large occiput flexes the head forward and can obstruct the airway.

Pediatric backboards should have a cutout for the head or a bump to keep the torso higher, maintaining the ear in line with the shoulder to prevent airway obstruction.

ATLS recommends needle cricothyroidotomy for children under 10 years and surgical cricothyroidotomy for those over 10 years.

A needle or surgical cricothyroidotomy is not a definitive airway; it buys time to get to the OR for a formal tracheostomy.

For needle cricothyroidotomy, a 10 mL syringe with IV catheter can be used, and the IV catheter connects directly to an Ambu bag.

The updated ATLS guideline recommends giving one 20 cc/kg crystalloid bolus, and if the patient shows transient or no response, proceeding directly to blood products (10 cc/kg) rather than giving a second crystalloid bolus.

Pediatric blood volume is calculated as weight in kilograms times 80 mL.

Massive transfusion protocols have been proven to help, with more data in adults but also supporting data in pediatrics.

Glasgow Coma Scale can be assessed in nonverbal children; if a child cannot talk normally for their age, they do not lose verbal points. A normally babbling infant receives full verbal score; irritable crying scores 4; moaning scores 2; no response scores lowest.

The most concerning neurologic sign in a young trauma patient is a child who does not cry or respond to painful stimuli like IV or IO placement, or a child who stops crying suddenly.

Children have more diffuse brain injuries in general than adults.

Child abuse is the most common cause of severe head injury in children less than 2 years old.

Children are more at risk for head injury because of large heads, soft skulls, and tendency to fall on their heads, resulting in diffuse rather than focal injuries.

For blunt abdominal trauma, a validated multi-institutional algorithm uses five criteria: abdominal pain, abdominal wall trauma/tenderness/distension, abnormal chest X-ray, AST greater than 200, or abnormal pancreatic enzymes. Patients with none of these criteria (about 35% of the population) have 0.6% risk of intra-abdominal injury and 0.0% risk of requiring intervention.

Having more than one positive criterion on the abdominal trauma algorithm increases risk of intra-abdominal injury; having all four criteria confers even higher risk.