EM Command Center / Pediatrics & Obstetrics • 3 min read • 3 sections

Pediatric Trauma & Neonatal Crises

Critical emergency reference for pediatric trauma and high-stakes neonatal crises. Details the PECARN pediatric head injury algorithm for infants and children, the TEN-4-FACES bruising rule for child abuse / non-accidental trauma, the low-risk criteria for Brief Resolved Unexplained Events (BRUE), and recognizing duct-dependent congenital heart disease with emergency prostaglandin E1 (alprostadil) administration.

Resuscitation Quick Ribbon (First 2 Minutes)

High-Acuity

PECARN CT Head Rule:Age < 2 years vs. >= 2 years; identifies children with < 0.05% risk of clinically important traumatic brain injury (ciTBI) who do not need CT imaging.

Suspected Child Abuse:TEN-4-FACES rule: Bruising on Torso, Ears, or Neck in child < 4 years, Frenulum tear, or ANY bruise on an infant < 4 months; mandatory full skeletal survey and reporting.

Duct-Dependent Neonatal Shock:Start Alprostadil (PGE1) 0.05-0.1 mcg/kg/min IV; anticipation of apnea is mandatory (have endotracheal tube ready at bedside).

Hyperoxia Test:Administer 100% O2 for 10 min. If PaO2 remains < 150 mmHg -> Cyanotic Congenital Heart Defect (right-to-left shunt) rather than primary pulmonary disease.

Pediatric Blood Transfusion:PRBC 10-20 mL/kg; Platelets 10 mL/kg; FFP 10-20 mL/kg; Cryoprecipitate 5-10 mL/kg.

Bottom-Line Clinical Pearl

In a neonate presenting in the first 2-3 weeks of life with sudden cyanosis, respiratory distress, or unexplained shock, suspect closure of the ductus arteriosus in duct-dependent congenital heart disease. Immediately administer IV Alprostadil (PGE1) 0.05-0.1 mcg/kg/min to reopen the ductus and prepare for apnea.

1. PECARN Pediatric Head Injury Decision Rules

The Pediatric Emergency Care Applied Research Network (PECARN) rule identifies children at very low risk of clinically important traumatic brain injury (ciTBI: death, neurosurgery, intubation > 24h, or hospital admission >= 2 nights):

Age Group	High Risk (CT Head Recommended, ciTBI ~4.4%)	Intermediate Risk (Observe vs. CT, ciTBI ~0.9%)	Low Risk (NO CT Recommended, ciTBI < 0.05%)
Children < 2 Years	1. GCS <= 14 or other signs of altered mental status 2. Palpable skull fracture	1. Non-frontal scalp hematoma (occipital, parietal, temporal) 2. Loss of consciousness >= 5 seconds 3. Severe mechanism of injury (fall > 3 ft, MVC ejection, bike/ped) 4. Not acting normally according to parent	Absence of all 6 criteria -> CT NOT recommended.
Children >= 2 Years	1. GCS <= 14 or other signs of altered mental status 2. Signs of basilar skull fracture (Battle sign, raccoon eyes, CSF rhinorrhea/otorrhea, hemotympanum)	1. Any history of loss of consciousness 2. History of vomiting 3. Severe headache 4. Severe mechanism of injury (fall > 5 ft, high-speed MVC, rollover)	Absence of all 6 criteria -> CT NOT recommended.

2. Non-Accidental Trauma & The TEN-4-FACES Bruising Rule

Bruising is the most common early manifestation of physical child abuse, yet frequently overlooked prior to fatal head or abdominal trauma:

Mnemonic Component	High-Risk Finding for Abuse	Clinical Specifics
T - Torso	Bruising anywhere on chest, abdomen, back, buttocks	Rare in accidental cruising/falls (which occur on bony prominences: shins, forehead).
E - Ears	Bruising on the pinna, earlobe, or behind ear	Strongly predictive of direct blunt impact or pinching/pulling abuse.
N - Neck	Bruising or petechiae on neck	Sign of strangulation, choking, or forceful restraint.
4 - 4 Years / 4 Months	Any bruising in a child < 4 years old in the TEN regions OR ANY bruising on an infant < 4 months old ('Those who don't cruise rarely bruise')	Infants < 4 months cannot roll or crawl; bruising is 99% predictive of non-accidental trauma.
FACES	Frenulum, Auricular, Cheeks, Eyes, Sclera	Torn labial or lingual frenulum indicates forced bottle/pacifier insertion or blunt blow to mouth.

3. Duct-Dependent Congenital Heart Disease & Prostaglandin E1

Lesion Category	Anatomic Congenital Anomalies	Clinical Presentation as Ductus Closes (Days 3-14)	Emergency Pharmacotherapy
Duct-Dependent Pulmonary Flow (Cyanotic)	Tetralogy of Fallot with severe PS, Pulmonary Atresia, Tricuspid Atresia	Severe central cyanosis unresponsive to 100% O2 (PaO2 < 50-100 on hyperoxia test); minimal respiratory distress	Alprostadil (PGE1) 0.05 - 0.1 mcg/kg/min IV infusion. Side Effects: APNEA (occurs in 10-20% within 1 hour; prepare for intubation), severe hypotension, fever, flushing.
Duct-Dependent Systemic Flow (Shock / Collapse)	Coarctation of the Aorta, Hypoplastic Left Heart Syndrome (HLHS), Critical Aortic Stenosis, Interrupted Aortic Arch	Cardiogenic shock, differential cyanosis / pulse deficit (strong right brachial pulse, absent femoral pulses), pallor, severe metabolic acidosis	Alprostadil (PGE1) 0.05 - 0.1 mcg/kg/min IV infusion to restore retrograde systemic perfusion via PDA. Minimal supplemental O2 (high O2 accelerates ductal closure).

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