Approach to pediatric trauma: A comprehensive review

Adarsh Nath

Consultant-Emergency Medicine, Kauvery Hospital, Bangalore

Introduction

Trauma is a leading cause of morbidity and mortality in children. The Advanced Trauma Life Support (ATLS) protocol provides a structured approach that is still the cornerstone of early trauma management. Pediatric patients, due to unique anatomical and physiological differences, require tailored evaluation and resuscitation.

Three Peaks of Death in trauma

Peaks	Timeframe	Characteristics
Immediate	Seconds–Minutes	Deaths often occur at the scene; prevention is key.
Early	Minutes–Hours	“Golden hour”—focus on timely intervention.
Late	Days–Weeks	Often due to infections or multi-organ dysfunction syndrome (MODS).

Classification of trauma

Extent	Type	Severity
Polytrauma = Injury to ≥2 body areas	Blunt or penetrating	Based on mechanism, vital signs, Glasgow Coma Scale (GCS), trauma score

Initial Approach

Primary Survey: Rapid primary evaluation with resuscitation of vital functions using the xABCDE approach.
Secondary Survey: Comprehensive assessment and continued post-resuscitation monitoring.
Transition: Use adjuncts to secondary survey and continue to definitive care.

Two Key Principles

Assessment and management occur simultaneously during the primary survey.
Any identified physiologic threat to life must be rapidly treated before moving on to the next priority. If deterioration occurs, repeat the primary survey and address new problems before definitive care.

Detailed components

Exsanguination

Immediate control of external bleeding using direct pressure, homeostatic dressings, pelvic binders, and scalp clips.

Airway

Address airway obstruction due to foreign bodies or fractures.
Maintain cervical spine immobilisation in suspected injury cases.

Indications for C-spine motion restriction

Indication	Description
Anatomic predisposition to neck injury	Conditions like Down syndrome, prior neck injury
History of cervical spine surgery	Previous surgical interventions on cervical spine
GCS <15 or intoxication	Glasgow Coma Scale less than 15 or intoxicated state
Neck pain, torticollis, and/or guarding of the neck	Pain, abnormal neck position, and protective response
Neurologic deficit	Impairment in neurological function
Distracting injuries	Other significant injuries that may mask neck injury

Breathing

Look for tracheal deviation, abnormal chest movement, accessory muscle use, thoracic contusions/lacerations.
Use bedside ultrasound if available.
Manage with high-concentration oxygen, ventilation support, and chest tube placement as indicated.

Circulation

Assess for compensated or hypotensive shock.
Children may maintain blood pressure despite significant blood loss.
Consider shock in any child with cool extremities and tachycardia.

Hemorrhage control and IV access

Interventions	Details
External hemorrhage control	Manual compression, figure-of-eight sutures, scalp clips, pelvic binders
IV Access	Two large bore IVs (upper extremities preferred), 22-24 gauge for infants, 18-20 gauge for older children
Fluid resuscitation	20 mL/kg NS/RL bolus over 10–15 min, up to 3 boluses (60 mL/kg total)
Blood transfusion	10 mL/kg PRBC if no improvement post fluids
Massive Transfusion Protocol	Weight-based volume triggers for initiating MTP

Massive Transfusion Protocol Volume Triggers

Weight Category	Volume Trigger (mL/kg)
<5 kg (Neonate)	55
5–25 kg (Infant)	50
25–50 kg (Child)	45
>50 kg (Adolescent)	40 or 6 units PRBC

Disability

GCS < 12 requires airway management and controlled ventilation.
Maintain cerebral perfusion with rapid fluid resuscitation.
Use IV Mannitol or hypertonic saline for signs of cerebral herniation.

Exposure

Perform full body exposure for injury identification.
Log roll.
Prevent hypothermia.

Secondary Survey

SAMPLE History: Signs/Symptoms, Allergies, Medications, Past history, Last meal, Events.
Full Physical Exam: Complete head to toe including perineum.

Adjuncts	Purpose
The Gs: EKG, CBG, ABG	Cardiac and metabolic status
Blood work (CBC, coagulation, LFT, RFT)	Comprehensive laboratory assessment
Type and cross-match	For resuscitation, MTP, compatibility
Imaging	To identify internal injuries and guide interventions

Conclusion

The xABCDE approach provides a structured, prioritised framework essential for managing pediatric trauma efficiently. Prompt identification of life-threatening conditions and simultaneous resuscitation significantly influence outcomes during the critical golden hour. With a tailored strategy that respects the pediatric population’s unique characteristics, clinicians can not only save lives but also reduce long-term morbidity. A disciplined, protocol-driven response is not just best practice—it is a duty of care in pediatric emergency medicine.

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Approach to pediatric trauma: A comprehensive review