ITLS Pediatric Trauma Considerations 3 — Questions and Answers

Question 1: A 6-year-old pedestrian struck by a car typically sustains a predictable pattern of injuries known as Waddell's triad. What injuries comprise this pattern?

Head injury, rib fractures, and liver laceration
Femur or tibia fracture (bumper height), trunk injury (hood/fender), and head injury (ground impact) (Correct answer)
Bilateral arm fractures and facial injury
Spinal cord injury, pelvic fracture, and abdominal injury

Correct answer: Femur or tibia fracture (bumper height), trunk injury (hood/fender), and head injury (ground impact)

Waddell's triad describes the classic pediatric pedestrian injury pattern: lower extremity fracture from bumper impact, thoracic/abdominal injury from being thrown onto the hood, and head injury from subsequent ground impact.

Waddell's triad occurs because a child's body proportions interact differently with a vehicle than an adult's. The sequence: (1) The bumper strikes at or above the child's center of gravity (femur or pelvis level for a small child, tibia for a larger child), fracturing the lower extremity. (2) The child is scooped onto the hood or struck by the fender, sustaining thoracic or abdominal injuries (rib fractures, organ lacerations, pulmonary contusion). (3) The child is thrown or falls from the vehicle and strikes the ground head-first (the large, heavy pediatric head leads), causing head injury (concussion, skull fracture, intracranial hemorrhage). Adults, being taller, are typically struck below their center of gravity and rotate over the vehicle differently. ITLS teaches that auto-pedestrian mechanisms in children mandate a rapid trauma survey specifically looking for all three injury components. Even if one component appears minor, the others must be actively sought. Lower extremity fractures at bumper height are a red flag for the associated trunk and head injuries that may be less immediately apparent.

Question 2: How does the Broselow tape assist ITLS providers in pediatric trauma resuscitation?

It measures the severity of injuries
It provides a length-based estimate of weight and corresponding equipment sizes, drug doses, and fluid volumes coded by color zones (Correct answer)
It is used to measure tourniquet tension
It replaces the need for patient assessment

Correct answer: It provides a length-based estimate of weight and corresponding equipment sizes, drug doses, and fluid volumes coded by color zones

The Broselow tape uses the child's length to estimate weight, then provides color-coded zones that correspond to pre-calculated drug doses, fluid volumes, and appropriately sized equipment (ETT, blade, etc.).

The Broselow-Luten tape is an essential pediatric resuscitation tool that addresses the challenge of weight-based dosing in emergencies where the child's weight is unknown. The tape is placed beside the supine child from head to heel. The child's length falls within a color zone (grey, pink, red, purple, yellow, white, blue, orange, green), each corresponding to an estimated weight range. Each color zone provides: endotracheal tube size, laryngoscope blade size, BVM size, blood pressure cuff size, suction catheter size, IV catheter gauge, IO needle size, fluid bolus volumes (20 mL/kg pre-calculated), drug doses (epinephrine, atropine, etc. pre-calculated), defibrillation energy, and cardioversion energy. This eliminates the need for mental math under pressure—a leading source of pediatric medication errors. The tape is accurate for children up to approximately 36 kg. For larger children, standard adult dosing methods apply. ITLS providers should be familiar with the Broselow system and have the tape readily accessible in the pediatric equipment kit.

Question 3: A 2-year-old has symmetric bilateral rib fractures in various stages of healing along with retinal hemorrhages. What should the ITLS provider consider?

The child has brittle bone disease
Non-accidental trauma (child abuse) should be strongly suspected based on the injury pattern inconsistent with a single accidental event (Correct answer)
These are normal findings in active toddlers
The child was in a car seat during a single accident

Correct answer: Non-accidental trauma (child abuse) should be strongly suspected based on the injury pattern inconsistent with a single accidental event

Bilateral rib fractures in various stages of healing indicate repetitive trauma over time, and retinal hemorrhages are strongly associated with abusive head trauma. This injury pattern is inconsistent with any single accidental mechanism.

Non-accidental trauma (NAT/child abuse) is an important diagnosis for ITLS providers to recognize. Red flags in this scenario: (1) Bilateral symmetric rib fractures—occur from squeezing the chest, not from single-incident mechanisms. (2) Fractures in various stages of healing—indicate repetitive trauma over days to weeks, impossible from a single event. (3) Retinal hemorrhages—strongly associated with shaking injuries (abusive head trauma), with a positive predictive value >90% for abuse. (4) Age 2 years—pre-verbal children cannot report abuse. Additional abuse indicators: injuries inconsistent with developmental capabilities (femur fracture in a non-walking infant), delay in seeking care, history that changes between retellings, injuries in protected areas (back, buttocks, inner thighs), patterned injuries (loop marks, cigarette burns), and caregiver behavior (lack of concern, overly detailed explanations). ITLS providers are mandated reporters. Documentation should be objective and detailed. Photograph injuries when possible. Report concerns to the receiving hospital and child protective services. The child's safety takes priority—never confront the caregiver on scene, as this may endanger the child.

Question 4: When positioning a pediatric patient on a backboard for spinal immobilization, why is padding needed under the torso rather than under the head?

Children have smaller torsos that need elevation
The child's proportionally larger occiput forces the cervical spine into flexion on a flat surface; padding the torso brings the spine to neutral alignment (Correct answer)
To make the child more comfortable
Torso padding prevents rolling off the board

Correct answer: The child's proportionally larger occiput forces the cervical spine into flexion on a flat surface; padding the torso brings the spine to neutral alignment

Children's disproportionately large occiput (back of the head) causes cervical flexion when placed on a flat backboard. Placing padding (1-2 inches) under the torso elevates it to match the occiput's height, achieving neutral cervical alignment.

This is one of the most important pediatric immobilization concepts in ITLS. In children under 8, the occiput is proportionally much larger than in adults. When placed supine on a flat surface, the prominent occiput pushes the head forward, flexing the cervical spine. Cervical flexion in a potential spinal injury patient can worsen cord compression. Two solutions: (1) Use a backboard with an occipital recess (cut-out for the head). (2) Place 1-2 inches of padding (folded towel/blanket) under the torso from shoulders to pelvis, effectively raising the body to the level where the cervical spine achieves neutral alignment. This is the OPPOSITE of adult positioning, where padding may be needed under the head. The correct position is confirmed when the external auditory meatus (ear canal) is aligned with the anterior shoulder—the standard landmark for neutral cervical positioning in children. Additionally, pediatric cervical collars must be properly sized; adult collars can hyperextend the pediatric cervical spine. If a proper-size collar is unavailable, towel rolls and tape may provide better immobilization.

Question 5: A 10-year-old falls from a tree (15 feet) and is complaining of abdominal pain. Vitals show HR 140, BP 90/60, RR 28. What does the tachycardia and borderline blood pressure indicate in this pediatric patient?

Normal vital signs for an anxious 10-year-old
Significant hemorrhage with decompensating shock—children maintain blood pressure until they have lost 30-40% of blood volume, so hypotension indicates a critical state (Correct answer)
Mild hypovolemia that will resolve without treatment
Pain-related tachycardia with no hemodynamic significance

Correct answer: Significant hemorrhage with decompensating shock—children maintain blood pressure until they have lost 30-40% of blood volume, so hypotension indicates a critical state

In children, blood pressure is maintained until very late in shock (30-40% volume loss). A BP of 90/60 with tachycardia in a 10-year-old with abdominal pain after a significant fall indicates decompensating hemorrhagic shock requiring immediate aggressive intervention.

This case represents a pediatric trauma emergency. Normal BP for a 10-year-old is approximately 100-110/60-70 mmHg. A BP of 90/60 with HR 140 in the context of a 15-foot fall with abdominal pain indicates decompensating hemorrhagic shock from likely intra-abdominal solid organ injury (spleen or liver). Children have robust cardiovascular compensation: intense vasoconstriction and tachycardia maintain blood pressure effectively even with significant blood loss (up to 30-40% of volume). When blood pressure finally falls, the child is on the edge of cardiovascular collapse—the 'cliff effect.' This child has likely lost >25-30% of blood volume. The fall height (15 feet = significant mechanism for a child) and abdominal pain further raise concern. ITLS management: rapid 20 mL/kg crystalloid bolus, prepare for possible second bolus, continuous reassessment, early ALS intercept, and rapid transport to a pediatric trauma center. This patient needs surgical evaluation. Hypotension in a child is a pre-arrest warning sign—the next step down is cardiovascular collapse.

Question 6: What is the appropriate size endotracheal tube for a 6-year-old child, and how is it calculated?

Always use a 3.0 mm tube for children
Use the formula (age/4) + 4 for uncuffed tubes, giving a 5.5 mm tube; or (age/4) + 3.5 for cuffed tubes, giving a 5.0 mm cuffed tube (Correct answer)
Use the same size as the child's little finger diameter
All children under 8 get a 4.0 mm tube

Correct answer: Use the formula (age/4) + 4 for uncuffed tubes, giving a 5.5 mm tube; or (age/4) + 3.5 for cuffed tubes, giving a 5.0 mm cuffed tube

ETT size is calculated using (age/4) + 4 for uncuffed tubes or (age/4) + 3.5 for cuffed tubes. For a 6-year-old: (6/4) + 4 = 5.5 mm uncuffed, or (6/4) + 3.5 = 5.0 mm cuffed.

Proper ETT sizing is critical in pediatric airway management because the pediatric airway is narrow and a tube that is too large causes subglottic injury, while one too small provides inadequate ventilation and allows aspiration around the tube. The standard formulas: Uncuffed ETT: (age in years/4) + 4 = internal diameter in mm. Cuffed ETT: (age in years/4) + 3.5. For a 6-year-old: uncuffed = (6/4) + 4 = 5.5 mm; cuffed = (6/4) + 3.5 = 5.0 mm. Current practice increasingly favors cuffed tubes even in young children (properly sized and with cuff pressure monitoring <20-25 cmH2O), as they reduce the need for tube changes and improve ventilation reliability. Always have one size larger and one size smaller available. Insertion depth can be estimated by (ETT size × 3) at the lip: 5.0 mm tube × 3 = 15 cm at the teeth. Confirm placement with waveform capnography, bilateral breath sounds, and chest rise. The Broselow tape provides pre-calculated ETT sizes that are often more convenient in the resuscitation setting.

ITLS Pediatric Trauma Considerations 3

A 6-year-old pedestrian struck by a car typically sustains a predictable pattern of injuries known as Waddell's triad.
What injuries comprise this pattern?