18.3 Neonatal and Pediatric Trauma and Medical Care
Key Takeaways
- Waddell's triad is the pedestrian child: femur or pelvis, torso, and contralateral head; non-accidental injury is the history that does not match the injury.
- Pediatric airway starts with a large occiput—pad the shoulders—and every drug and fluid is weight-based; Broselow is a start, not a measured weight.
- Distinguish bronchiolitis, asthma, and croup by age and noise; septic children get 20 mL/kg boluses with a hard reassess, not a firehose into a closing duct.
- Neonates die of cold and low sugar; ductal-dependent lesions need prostaglandin with an apnea plan; abdominal-wall and neural-tube defects are cover-and-fluid problems.
- Choose an isolette versus a vacuum mattress on purpose; noise, vibration, and a parent in the cabin are operational facts, not extras.
Trauma: Waddell's triad and non-accidental injury
Waddell's triad is the child pedestrian pattern: bumper to the femur or pelvis, hood to the torso, then the contralateral head hits the ground or windshield. Do not clear the belly because the femur is obvious. Package for multi-system trauma and fly to a pediatric trauma center when the map allows.
Non-accidental injury (NAI) is a history problem as much as a bruise problem. Red flags:
- Injury that does not match developmental age (a six-week-old who "rolled off the couch").
- Delay in seeking care, or a story that changes when the caregiver is separated.
- Patterned burns, cigarette marks, or immersion lines.
- Bruising on a non-mobile infant, ears, or neck.
- Posterior rib fractures, metaphyseal corner fractures, or subdural hemorrhage paired with retinal hemorrhages.
You are not the forensic interviewer. Write the words you were given. Do not coach a cleaner story. Treat the injuries. Tell the receiving team.
Airway anatomy and weight-based everything
The pediatric airway fails for geometric reasons. The occiput is large, so a flat stretcher flexes the neck and obstructs; pad the shoulders, not a stack of towels under the head. The tongue is large. The larynx is more cephalad and anterior. Classic teaching still treats the cricoid as the narrowest point of the infant larynx. The trachea is short, so a slightly deeper tube becomes a right-mainstem or an extubation on the first roll.
Every drug, joule estimate, and fluid bolus is weight-based. A measured kilogram weight wins. Broselow (or another length-based tape) is a start when you cannot weigh the child—not a substitute for a stated weight from a sending neonatal intensive care unit (NICU).
Respiratory medical: croup, bronchiolitis, asthma
Age and the noise tell you the disease more reliably than a single wheeze in a loud cabin.
| Disease | Typical patient | Cabin job |
|---|---|---|
| Croup | Toddler, barky cough, inspiratory stridor | Keep calm, oxygen, racemic or nebulized epinephrine if protocol; do not poke the airway |
| Bronchiolitis | Infant, viral season, copious secretions | Suction, oxygen or high-flow; bronchodilators and steroids are not routine |
| Asthma | Older child, recurrent wheeze | Bronchodilators, steroids, magnesium if protocol; watch for the quiet chest |
A wheezy three-month-old is bronchiolitis until the story is clearly something else. An eight-year-old who speaks in two-word sentences is asthma. Croup that becomes silent and exhausted is an airway, not a "more nebs" problem.
Shock, sepsis, and the heart that is not sepsis
Septic children get 20 mL/kg isotonic crystalloid boluses with a hard reassess after each one. Repeat while perfusion is still poor and the lungs are still dry. This is not a single polite adult bag. It is also not a firehose into a congenital heart.
Mixing lesions versus closing-duct shock
Congenital heart disease can look like sepsis. A gray, poorly perfused neonate whose duct is closing (coarctation, hypoplastic left heart) is obstructive shock, not hypovolemia. A blue infant who does not pink on oxygen may be a mixing or right-heart lesion, or persistent pulmonary hypertension. Flooding either child with 60 mL/kg of saline can finish the ventricle. If the sending story is a ductal-dependent lesion, start prostaglandin E1 per protocol (apnea risk—section 18.4), keep the child warm, and do not chase a normal adult saturation.
Neonates: heat, sugar, abdominal wall, neural tube
Hypothermia kills neonates. They have a huge surface-area-to-mass ratio, almost no shiver, and a wet head. Dry, hat, chemical warmer or isolette, and a cabin that is not an unplanned freezer. Check glucose. A jittery or limp neonate is hypoglycemic until you prove otherwise.
Omphalocele is a membrane-covered midline defect, often with other anomalies. Gastroschisis is bowel without a membrane, usually to the right of the umbilicus, with large fluid and heat loss. Cover (moist sterile dressings or a bowel bag), do not try to reduce the viscera on the ramp, decompress the stomach, and give fluids. Neural-tube defects (myelomeningocele) get a moist cover, a position that does not crush the sac (prone or side), and latex caution in many programs.
Cabin packaging: isolette, mattress, family
Choose the box on purpose:
- Isolette (transport incubator) for the neonate who needs heat, humidity, and a closed space. It does not make the aircraft quiet.
- Vacuum mattress for the injured child who needs spinal motion restriction and a molded surface that will not rattle fractures apart.
Noise and vibration steal auscultation and temperature control. Trust end-tidal carbon dioxide (ETCO2), pulse oximetry, and a temperature probe. A parent in the cabin is a program and weight-and-balance decision, not a courtesy you invent after the door closes. If a parent flies, brief seats, sterile cockpit, and what they will see if you have to work.
A 6-year-old pedestrian is struck. There is a mid-shaft femur deformity, abdominal bruising, and a contralateral scalp hematoma. What is the correct pattern and plan?
A 2-day-old gray neonate has poor pulses. The sending team suspects coarctation with a closing duct. What is the correct cabin plan?
A 4-month-old in viral season has copious secretions, tachypnea, and hypoxia without a long asthma history. What is the correct flight treatment idea?