What are the initial management steps for a child with trauma?

Initial Management of Pediatric Trauma

All injured children require immediate stabilization following the ABCDE sequence, with providers ensuring basic competency in pediatric trauma care and early transfer of severely injured children to designated pediatric trauma centers to reduce mortality. 1

Primary Survey and Resuscitation (ABCDE Sequence)

The initial approach must follow a systematic algorithm prioritizing life-threatening conditions:

A - Airway with Cervical Spine Protection

• Establish and maintain a patent airway while simultaneously immobilizing the cervical spine using bimanual stabilization and cervical collar placement 2, 3
• Use the Broselow system for weight-based equipment sizing and medication dosing during early resuscitation 1

B - Breathing and Ventilation

• Evaluate breathing, ventilation, and oxygenation immediately 2
• Recognize and treat tension pneumothorax, open pneumothorax, and massive hemothorax on identification 2, 3

C - Circulation and Hemorrhage Control

• Assess for circulatory compromise and shock, with immediate hemorrhage control 2, 3
• Address massive blood loss as a primary cause of early cardiorespiratory arrest in trauma 3

D - Disability and Neurologic Status

• Assess for signs of increased intracranial pressure and impending cerebral herniation 2, 3
• Evaluate for severe brain damage that may precipitate early arrest 3

E - Exposure with Temperature Control

• Expose the patient completely for full assessment while actively preventing hypothermia 2, 3
• Hypothermia is a recognized cause of delayed cardiorespiratory arrest in trauma 3

Critical Pediatric-Specific Considerations

Imaging and Radiation Safety

• Minimize diagnostic radiation exposure by using pediatric-specific protocols for imaging 1
• In hemodynamically unstable patients, prioritize radiological and ultrasound examinations over CT 4
• Whole-body CT is appropriate for hemodynamically stable polytrauma patients to avoid missing injuries 4

Fluid and Blood Management

• Address fluid and electrolyte management carefully, as disturbances can cause delayed arrest 1, 3
• Blood transfusion protocols should follow pediatric-specific guidelines 1

Mandatory Child Abuse Screening

• Screen every injured child for signs of potential child abuse and report concerns to appropriate authorities immediately 1, 5
• This is a mandatory reporting requirement in all jurisdictions 1

Transfer and Destination Decisions

When to Transfer

• Transfer the youngest and most severely injured children to designated pediatric trauma centers 1, 5
• Younger children and those with serious injuries have improved outcomes at pediatric trauma centers or integrated pediatric-adult trauma services 1
• Stabilize at regional referral centers before transport to tertiary facilities when necessary 1

Transport Considerations

• Use pediatric critical care transport teams for transfers of seriously injured children 1
• Effective stabilization and timely, safe transport are vital to reduce further injury 6

Common Pitfalls to Avoid

• Do not delay resuscitation for diagnostic imaging - hemodynamic stability takes absolute priority 5
• Do not miss child abuse - maintain high vigilance as perineal and other injuries warrant mandatory reporting 1, 5
• Do not overlook psychological needs - evaluate all injured children and families for stress reactions and provide referrals 1, 5
• Do not forget family presence - allow family presence during resuscitation as part of comprehensive pediatric care 1

Secondary Survey

After completing the primary survey and achieving stabilization:

• Perform sequential head-to-toe physical examination 3
• Obtain focused history (mechanism of injury, time of injury, prehospital interventions) 3
• Order complementary investigations based on examination findings 3

Post-Stabilization Care

• Admit to pediatric intensive care units when available, as PICU bed availability improves survival in pediatric trauma 1
• Initiate early rehabilitation planning, especially for neurologic injuries 1
• Provide child life specialists, traumatic stress counseling, and substance abuse counseling as needed 1