Pediatric Trauma and Surgical Critical Care
Anatomy drives the physiology
Children have a compliant chest wall, so pulmonary contusion occurs without rib fractures; a large head and surface area; and a spleen that is the most commonly injured solid organ. Head injury remains the leading cause of traumatic death.
The primary survey follows catastrophic haemorrhage control, airway with cervical spine protection, breathing, circulation, disability and exposure. Hypotension is a late sign: a child maintains blood pressure through tachycardia and vasoconstriction until roughly 30-40% blood loss. Give crystalloid boluses of 10-20 mL/kg and reassess, moving early to blood products in massive haemorrhage. FAST is useful but a negative scan does not exclude retroperitoneal or hollow viscus injury; CT remains the standard in the stable child.
Traps
Cushing triad (hypertension, bradycardia, irregular respiration) is a late sign of raised intracranial pressure - do not wait for it, and do not hyperventilate routinely. Non-accidental trauma must be recognised: mechanism inconsistent with the injury, delayed presentation, sentinel injuries and bruising in non-mobile infants all mandate reporting. In burns, the Parkland formula (4 mL/kg/% total body surface area over 24 hours, half in the first eight hours) excludes superficial partial-thickness burns, and circumferential full-thickness burns need escharotomy.
Worked example
A 20 kg child needs maintenance fluid. Using 4-2-1: 4 mL/kg for the first 10 kg (40), 2 mL/kg for the next 10 kg (20), 1 mL/kg thereafter (0) gives 60 mL/hour. Rule of thumb: 4-2-1 for maintenance, 10 mL/kg per bolus for shock with reassessment after each.