What is the initial evaluation and management approach for a child involved in a road traffic accident (RTA)?

Initial Evaluation and Management of a Child Involved in a Road Traffic Accident

Begin with the systematic ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach for immediate assessment and treatment, as this priority-based method is applicable to all critically ill or injured children and focuses on the most life-threatening problems first. 1, 2

Immediate Primary Survey: The ABCDE Approach

The ABCDE approach must be performed systematically, addressing each component before moving to the next 2:

A - Airway Assessment and Management

• Assess airway patency while maintaining cervical spine stabilization in all trauma patients 1
• Look for signs of airway obstruction: abnormal breath sounds, stridor, inability to speak, drooling, or altered mental status 2
• Immediately secure the airway if compromised, using age-appropriate equipment (note: the Broselow system provides useful information for pediatric resuscitation equipment sizing) 1
• Maintain in-line cervical spine immobilization until injury is ruled out 1

B - Breathing Assessment

• Evaluate respiratory rate, work of breathing, chest wall movement symmetry, and oxygen saturation 2
• Auscultate all lung fields for decreased or absent breath sounds 2
• Look for signs of tension pneumothorax, flail chest, or open chest wounds 2
• Provide supplemental oxygen immediately to all trauma patients during initial assessment 2

C - Circulation Assessment

• Assess perfusion status: capillary refill time (>2 seconds abnormal), skin color and temperature, pulse quality and rate 2
• Measure blood pressure - this is critical as elevated blood pressure may be the first symptom of childhood traumatic stress 1
• Control any external hemorrhage with direct pressure 2
• Establish vascular access and initiate fluid resuscitation if signs of shock present 1

D - Disability (Neurological Assessment)

• Assess level of consciousness using AVPU (Alert, Voice responsive, Pain responsive, Unresponsive) or Glasgow Coma Scale 2
• Document duration of any loss of consciousness - loss of consciousness >24 hours is an independent predictor of poor outcome 3
• Check pupil size and reactivity 2
• Assess for focal neurological deficits 2

E - Exposure and Environmental Control

• Completely undress the child to identify all injuries, examining front and back 2
• Look specifically for signs of abuse or neglect, as all providers must remain vigilant for non-accidental trauma 1
• Prevent hypothermia by covering the child after examination and maintaining warm environment 1

Critical Risk Stratification

Immediately identify high-risk factors that predict poor outcomes 3:

• Spinal injury (independent predictor of poor outcome) 3
• Multiple trauma (independent predictor of poor outcome) 3
• Loss of consciousness >24 hours (independent predictor of poor outcome) 3
• Need for mechanical ventilation (independent predictor of poor outcome) 3
• Presence of underlying disease (independent predictor of poor outcome) 3
• Increased Injury Severity Score (ISS) (independent predictor of poor outcome) 3

Diagnostic Imaging Considerations

• Minimize radiation exposure - this is of primary importance in pediatric trauma due to cumulative radiation dose concerns 1
• Use pediatric-specific imaging protocols when available 1
• Balance diagnostic necessity against radiation risk 1

Disposition and Transfer Decisions

Transfer to a pediatric trauma center is indicated for younger and more severely injured children, as they have improved outcomes at specialized facilities 1:

• Children's hospital trauma centers or trauma centers integrating pediatric services show lower pediatric injury mortality rates 1
• Stabilize before transfer if immediate transport not feasible 1
• Use pediatric critical care transport teams when available for interfacility transfers 1
• Approximately 17.4 million children lack access to pediatric trauma centers within 60 minutes, making initial stabilization at community hospitals critical 1

Psychosocial Assessment

Screen for acute stress reactions and evaluate for potential abuse 1:

• All injured children and families should be evaluated for stress reactions related to injury 1
• Mandatory screening for child abuse using established protocols - providers must know state reporting requirements 1
• Look for injury patterns inconsistent with reported mechanism 1

Essential Ancillary Assessments

• Pain management should be addressed early in the evaluation 1
• Family presence during resuscitation should be facilitated when possible 1
• Engage child life specialists if available 1
• Monitor fluid and electrolyte balance carefully in pediatric patients 1

Common Pitfalls to Avoid

• Do not skip steps in the ABCDE sequence - adherence to systematic approach varies from 18-84% in clinical practice, but team leader presence and training improve adherence 4
• Do not delay hearing assessment in children with head trauma or ear injuries, as trauma is a risk factor for delayed-onset hearing loss 5
• Do not overlook secondary stressors - assess both the traumatic event and current life circumstances, as symptoms may relate to either 6
• Do not provide false reassurance to families about outcomes until complete evaluation is performed 6
• Do not forget to provide direct feedback to prehospital providers - this is essential for continuous quality improvement 1

Performance Improvement

• All cases should undergo systematic review through trauma registry processes 1
• Benchmark outcomes against national databases 1
• Provide constructive feedback to referring facilities and prehospital providers 1