Unlike the adult population, attaining two peripheral IVs can be an enormous challenge in some children, and central access may be technically easier. Have your best IV personnel (usually nurses and/or anesthesia providers) ready for any incoming pediatric casualties. Remember the scalp veins may be the easiest access in a baby. If this fails, then you have three options – central line, venous cutdown (usually saphenous vein ), or intraosseous line. Current combat teaching is that an intraosseous placement is a safe and reliable method for access in children of all ages and should not take longer than 10 s to achieve. This maneuver is a standard part of pre-deployment war surgery courses. Don’t blow it off. Know how and where to insert an IO. Intraosseous sites in infants and toddlers include the anterior tibia below the tuberosity, distal femur, proximal humerus, iliac crest, and the sternum. The anterior tibia should be your first choice in children and the technique is shown in Fig. 31.2. If that fails, then try the anterior distal femur next. There are now several excellent military kits available for both children and adults, including the EZ-IO (Vidacare Corp.) system that uses a power drill for placement (Fig. 31.3). If an intraosseous catheter kit is not available, a strong (18-gauge) short spinal needle may be substituted. You can use this catheter as you would any central line, but it should be removed within 24–48 h.

Femoral, subclavian, or jugular percutaneous access can be safely placed and act as longer-term access after the resuscitation. The use of ultrasound guidance has made central access technically easier and more reliable. In the emergency setting, the subclavian or femoral veins are easiest to access. However, it is true for all lines that the smaller the child, the higher the complication rates in the form of misplacement, pneumothorax, and hemothorax. In children less than 2 years old, you should avoid the femoral area if possible due to the risk of vein obstruction or devastating injury to the femoral artery. After all, misadventures in vascular access and an occluded SFA are the last things you need to be dealing with. Another good option in an emergency situation is a direct cutdown, but remember that these sound easier than they are. You need good lighting and exposure and wear magnifying loupes if you have them. Saphenous cutdown in the ankle is technically easier and faster than in the groin in children (Fig. 31.4), but both can be effectively used. Either EJ or IJ cutdowns are excellent options as long as the neck is available during the trauma resuscitation. Remember to remove the cervical spine collar if they don’t have a mechanism that warrants having one in place – it just makes everything harder.

Technical considerations to enhance success at IV access include proper-sized angiocatheters, knowing the anatomy of the venous architecture, and knowing the developmental changes that occur throughout childhood. The use of predetermined-size algorithms to determine appropriate equipment sizes (Broselow^© tapes ) in the trauma bay is invaluable during a pediatric trauma resuscitation. Either too small (24 gauge in a child over 2 years of age) or too large (20 gauge in children under 1 year) will lead to failure and frustration. When in doubt, 22-gauge IV will be adequate for the distal saphenous vein of most toddlers and full-term infants. When dealing with percutaneous central venous access, there are several technical considerations to remember. The standard j-tip guide wires may not pass into the vein easily, and reversing the wire to use the straight end carries a risk of perforation. In these cases, the 0.018″ floppy-tipped wires and 20G introducer needles found in the 5Fr arterial access micropuncture kits are the perfect solution because they are essentially the same kits that are used for pediatric central venous access. The external jugular vein can be an excellent access point and requires only a superficial cutdown and careful placement technique. The most important advice with placement of these central lines is to use very slow and gentle motion of the needle to access the vein; otherwise, you will go through the back wall. For subclavian lines, make your skin puncture site more medial than you would for an adult, and direct the needle through the space between the clavicle and first rib. You will hit the larger subclavian/jugular junction or innominate vein much more reliably than trying for the mid or distal subclavian vein (Fig. 31.5). Small, rugged point-of-care ultrasound machines can be found in virtually every downrange medical treatment facility. They will prove to be an invaluable adjunct in vascular access.

The overall triage, evaluation, and resuscitation priorities are the same in children as they are in adults, but there are a few major anatomic and physiologic differences that need to be appreciated. Children have large heads and tongues as well as foreshortened airways. This makes airway occlusion due to the tongue a much larger issue in the pediatric patient population. Bradycardia during intubation in children is well described, and you should either administer atropine (0.1–0.5 mg IV) during induction or have it standing by. The trachea is very short, making right mainstem intubation and inadvertent extubation very common events. Verify the correct position of the tube, and then SECURE it tightly. For children that have been crying or receiving bag-mask ventilation, while en route, the surgeon should be keenly aware of gastric distention and its cardiopulmonary effects. In a chaotic prehospital environment, there is risk of inappropriate ventilation (too fast and too much volume) by the providers that will distend the stomach and reduce the functional residual capacity. The resulting hypoxia and bradycardia may lead to a viscous cycle of more aggressive ventilation and cardiac arrest. In these situations, be mindful that gastric decompression may be a lifesaving maneuver – especially when things are going downhill in the trauma bay and not really making sense.

While the head and airway presents the most important anatomic consideration, the most important physiologic issue concerns estimating the degree of shock. Children are able to maintain blood pressure while significantly dropping cardiac output due to an enhanced heart rate affect and the tremendous elasticity/reactivity of their peripheral vessels. The result is that they will not drop their blood pressure until the last possible moment before cardiovascular collapse. Bradycardia is an ominous sign and usually indicates severe hypoxia or that arrest is imminent.

Evaluating the abdomen in a pediatric patient can be quite challenging, and supplemental imaging and/or surgical exploration should be performed when indicated in all trauma patients. Ultrasound images are typically excellent in children but may be compromised by gastric or bowel distension and patient motion. In adults, the FAST exam is used to identify hemoperitoneum or pericardial fluid in the hypotensive patient to guide the next step in management. Given the ability to maintain vascular tone, the absence of hypotension doesn’t mean that pediatric patients don’t have a surgical abdomen. Consider an initial FAST exam even if they seem “metastable” and then decide on surgery versus additional imaging (CT) or observation. CT is the gold standard for identifying abdominal injuries and should be used liberally if there has been abdominal trauma. Discuss a protocol with your radiologist to minimize radiation exposure while still obtaining adequate images. A missed injury is much more of a concern than a theoretical increase in cancer risk decades later. Screaming children will usually have significant gastric distension which can mimic an acute abdomen. If you haven’t already done it, place an NG tube and repeat your exam.

The management of pneumo- and hemothorax is similar to adults, with two additional challenges. The first is selecting an appropriate-sized chest tube. Very small tubes are fine if you only have air to evacuate, but larger tubes (at least 20 French) should be used to evacuate blood. The second challenge in placement is tube location. For infants and small children, it is physically impossible to put your finger or even a Kelley or tonsil clamp into the pleural space to assist in directing the tube during insertion. Most small tubes come with malleable trocars with a sharp chamfered tip to assist in placement; I recommend removing the trocar if you are not familiar and comfortable with it. If using the trocar, a cutdown technique is still advisable as most surgeons are far more familiar with that method than the percutaneous chest tube placement. To assist with accurate placement, pull the trocar back 1 cm so that the sharp point is located within the tube and then perform cutdown on top of the rib as normal. The trocar now functions as a stylet and adds rigidity and can then be used as a steering mechanism to guide the tube into any part of the thoracic space desired. Keep in mind that it is still possible to injure the lung or mediastinal structures during tube placement.