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Multisystem Trauma in Children Part One: Airway, Chest Tubes, and Resuscitative Thoracotomy

Traumatized children need your full attention.

Protocols work well for adults, but trauma in children requires that we exercise our clinical muscles just a bit more.

Two main reasons:

  1.  Children have specific injury patterns.

  2.  Their physiologic response to trauma is unique.

Crash course in pediatric anatomy and physiology in trauma

When you think of trauma in children, think of Charlie Brown. Large head, no neck, his chest and abdomen form an underdeveloped, amorphous shape.

Alternatively, think of children as apples – they are rounder than they are tall, with a large increased surface area. Apples don’t have a hard shell or thick rind to protect them. If you drop them, you may not see any evidence of damage to the outside, but there can be considerable bruising just under the surface.

  • A child has thin skin, less subcutaneous deposits than an adult, and a non-calcified, pliable thorax that deforms more than it protects or shields.
  • The child’s abdominal muscles are not yet developed. There is less peritoneal fat to cushion a blow, and so traumatic forces transmit readily into internal organs, often without external bruising.
  • The child’s large surface area also causes him to dissipate heat more quickly. He may be wet from urine or blood, and in a major trauma, this faster cool-down predisposes him to coagulopathy.


A 5-year-old boy who was playing with his older brother in front of their home when the ball rolled into the street. He ran after it, and was struck by a sedan going approximately 30 mph.

This is the so-called Wadell’s triad  that occurs in a collision of auto versus pedestrian or auto versus bicycle. The initial impact is the greatest, and will vary depending on the child’s height and what part of his body reaches up to the bumper of the car. Depending on the height of the child and the height of the car, the initial impact will cause a femur fracture, a pelvic fracture, or direct abdominal trauma. The second impact happens as the child is flung onto the grill or the hood of the car, causing usually thoracic trauma. The third impact can be the coup de grâce – to add insult to major injury, the child is then propelled forward, worsening the two previous impacts’ injuries and adding a third – severe blunt head trauma.

Intubation Pearl #1:

If your patient has any subtle change in mental status, intubate early. In pediatric trauma, we need to be proactive. Hypoxia is our enemy.

Intubation Pearl #2:

Thankfully cervical spine injuries in children are uncommon, and when they do occur, they typically occur at the child’s fulcrum, which is at C2. Compare this with an adult’s injury pattern with our fulcrum at C7. Be careful and minimize manipulation of the cervical spine, but do what you must to visualize the chords and place the tube. Keep the neck midline, and realize that the child’s usual decrease respiratory reserve is even more affected by trauma. Preoxygenate and pass that tube quickly.

Chest Tube Pearl #1:

Chest tube sizing in pediatrics is straightforward if we remember that the traditional chest tube size is 4 x the ETT size.

Chest Tube Pearl #2:

Try using a pigtail catheter.

Safety Triangle

  • Lateral edge of the pectoral muscle
  • Lateral edge of the latisimus dorsi
  • Line along the fifth intercostal space at the level of the nipple.

It’s roughly where you would put on a generous dose of deodorant. Insertion here minimizes the risk of damage to nerves, vessels and organs.

Resuscitative Thoracotomy in Children

In a 40-year review of ED thoracotomy, Moore et al. analyzed 1,691 patients who received ED thoracotomy. Overall all-cause adult survival was 6.1%. In children ? 15 years of age, overall all-cause survival was considerably less, at 3.4%.

In a large case series and review of the literature for pediatric ED thoracotomy, Allen et al. found a survival rate in penetrating trauma of 10.2%, with a much lower survival rate in blunt pediatric arrest, at 1.6%. Adolescents had more penetrating injuries, and younger children had more blunt trauma.

To synthesize, the rarity of ED thoracotomy in children is due to the fact that:

  1. Traumatic full arrest in children is uncommon.
  2. It is most often blunt trauma.
  3. Blunt traumatic arrest in children is mostly non-survivable.


If you have access to resuscitative endovascular balloon occlusion of the aorta or REBOA, this may be an option to temporize the child to get him to the relative control of the operating room. REBOA involves accessing the common femoral artery, passing a vascular sheath, floating a balloon catheter to the appropriate section of the aorta, and inflating the balloon to occlude blood flow.

Brenner et al. described a case series of 6 patients from two Level I trauma centers. They used REBOA for refractory hemorrhagic shock due to either blunt or penetrating injury. After balloon occlusion, blood pressure improved sufficiently to take the patient either to interventional radiology or to the OR. Four patients lived, two died. The AORTA trial is underway to investigate its use in trauma.


  1. Children are like Charlie Brown – large head, no neck, amorphous, underdeveloped and unprotected thorax and abdomen. Or, if you like, they’re like, apples – they have a large surface area and are easily internally bruised, often without overt signs of external bruising.
  2. Chest tubes for children are very similar to the adult procedure – the traditional chest tube size is 4 x the child’s ETT size. Try to use smaller pigtail catheters, available in commercial kits, whenever possible. They’re easy, safe, and effective.
  3. Resuscitative thoracotomy is for penetrating trauma with signs of life wthin 10-15 minutes of arrival. Find the correctable surgical cause of the arrest. Resuscitative thoracotomy for blunt trauma has a dismal prognosis in children.

Selected References

Allen CJ, Valle EJ, Thorson CM, Hogan AR, Perez EA, Namias N, Zakrison TL, Neville HL, Sola JE. Pediatric emergency department thoracotomy: a large case series and systematic review. J Pediatr Surg. 2015 Jan;50(1):177-81.

American College of Surgeons Committee on Trauma; American College of Emergency Physicians Pediatric Emergency Medicine Committee; National Association of Ems Physicians; American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Fallat ME. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Pediatrics. 2014 Apr;133(4):e1104-16.

Holscher CM, Faulk LW, Moore EE, Cothren Burlew C, Moore HB, Stewart CL, Pieracci FM, Barnett CC, Bensard DD. Chest computed tomography imaging for blunt pediatric trauma: not worth the radiation risk. J Surg Res. 2013 Sep;184(1):352-7.

Moore HB, Moore EE, Bensard DD. Pediatric emergency department thoracotomy: A 40-year review. J Pediatr Surg. 2015 Oct 19.

Scaife ER, Rollins MD, Barnhart DC, Downey EC, Black RE, Meyers RL, Stevens MH, Gordon S, Prince JS, Battaglia D, Fenton SJ, Plumb J, Metzger RR. The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. J Pediatr Surg. 2013 Jun;48(6):1377-83.

Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011 Dec;71(6):1869-72.


Pediatric Trauma on WikEM


This post and podcast are dedicated to Dr Al Sacchetti, MD, FACEP. Thank you for promoting the emergency care of children and for spreading the message that you don’t need subspecialty training to take good care of acutely ill and injured children.

Powered by #FOAMed — Tim Horeczko, MD, MSCR, FACEP, FAAP

Pediatric; Emergency Medicine; Pediatric Emergency Medicine; Podcast; Pediatric Podcast; Emergency Medicine Podcast; Horeczko; Harbor-UCLA; Presentation Skills; #FOAMed #FOAMped #MedEd

  • DGM

    Fantastic podcast! What do you think about FAST scanning in kids? Also – I saw an article on this ( and ) a couple of months ago, and it looks awesome!

    • Tim Horeczko

      Thank you!

      I love where you’re going with this! We’ll go over the FAST in next month’s episode, “Multisystem Trauma in Children, Part Two: Massive Transfusion, Trauma Imaging, and Resuscitative Pearls”

      Not to wait until then, the short answer is that FAST is specific, but very insensitive in children. We can’t use it like we do in adults (blunt trauma, unstable –>OR). Most blunt trauma in children is managed non-operatively; to do that, good CT imaging is needed. FAST in children is a “nice to have”, but not essential. Having said that, it is mostly helpful for something you will react to in the ED: otherwise unrecognized hemopericardium, pneumothorax. We just need more anatomic and parenchymal 3-D fidelity to manage them (hopefully) non-op.

      Thanks for the link on the hemostatic foam — something used in the military currently, likely to be more commercially available soon — I have seen demos only — and it is very impressive and safe. If I find out more, I’ll share with the community. Thanks for listening!

  • Zaf Qasim

    Tim – great post and podcast – really appreciate this information to help improve our management of something most us thankfully don’t see too often! Particularly enjoyed the alligator description for open cardiac compressions!

    I am glad you touched on REBOA, a topic I’m particularly interested in. Thus far the current available (and approved) equipment to allow REBOA is too large for use in the pediatric population, in particular the 12 French sheath. The large sheath really almost completely occludes the common femoral artery in adults. The current studies from the US have primarily been in adults, and several centers (including ours when I put together our protocol) currently put children on the exclusion list for use for these reasons.

    At Shock Trauma in Baltimore, the youngest patient that has gotten REBOA was 18. I could see it being used in someone in their late teens who is “adult size” though I would ensure there is clear collaboration with your trauma and even vascular surgical colleagues before continuing.

    Once the newer catheter becomes more readily available, this may all evolve and change which would be great news, and as ever, we would all benefit from great outcomes data regarding use in this population.

    I look forward to hearing part 2 – thanks for all your efforts!


    • Tim Horeczko


      Thank you so much for your comments and for listening!

      Yes, REBOA in children is very rare — then again, it’s not quite used very often now in adults — your experience is really helpful to the community!

      I am thinking about the up-and-coming commercial ER-REBOA, which is a soft catheter, available down to 7 French (so not as traumatic to vessels either).

      I see REBOA in the PED as a school-age phenomenon at first, with potential broadening of the age range.

      Thanks so much, Zaf, for sharing your considerable experience — so great to know you, and thanks again for your kind support!


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