What is the basic assessment for a pediatric patient after a motor vehicle accident (MVA)?

Basic Assessment for Pediatric Patients After Motor Vehicle Accident

Immediately perform a systematic primary survey focusing on airway, breathing, circulation, disability (neurologic status), and exposure while maintaining manual spinal immobilization until injury is excluded. 1

Scene Safety and Initial Stabilization

• Ensure scene safety before approaching the child and activate emergency medical services if not already done 2
• Assume cervical spine injury in all pediatric MVA victims until proven otherwise, given the mechanism of injury 2, 1
• Maintain manual head and neck stabilization to minimize motion of the cervical spine—do not use immobilization devices unless specifically trained, as they may cause harm 2
• Use jaw thrust without head tilt to open the airway if the child is unconscious; if jaw thrust fails to open the airway, use head tilt-chin lift because a patent airway takes priority 2

Primary Survey (ABCDE Approach)

Airway Assessment

• Check for airway patency and anticipate obstruction from blood, dental fragments, or other debris 2
• Have suction immediately available 2
• In unconscious children, active airway support is required to maintain patency 2

Breathing Assessment

• Assess respiratory rate, pattern, and work of breathing 2
• Look for chest and abdominal movement, listen for breath sounds at the mouth/nose, and feel for expired air movement 2
• Auscultate lungs bilaterally for air entry and abnormal sounds 2
• Measure oxygen saturation 2, 3

Circulation Assessment

• Check pulse rate and quality—use the brachial pulse in infants (inside of upper arm) and carotid or femoral pulse in older children 2
• Assess skin color, temperature, and capillary refill 2
• Stop any external bleeding with direct pressure 2
• Measure blood pressure 2, 3

Disability (Neurologic) Assessment

• Determine level of consciousness using the Glasgow Coma Scale (GCS) 2
• Assess pupillary size, equality, and reaction to light 2
• Check for focal neurologic deficits including motor function and sensation 2
• Evaluate mental status for any alteration or confusion 2

Exposure

• Remove clothing to perform a complete examination while preventing hypothermia 2
• Inspect the entire body for bruising, abrasions, lacerations, deformities, or other signs of injury 2

Secondary Survey (Head-to-Toe Examination)

Head and Face

• Palpate the entire skull for step-offs, depressions, or tenderness 2
• Examine fontanelles in infants for tension or bulging 2
• Look for signs of basilar skull fracture: Battle's sign (mastoid ecchymosis), raccoon eyes (periorbital ecchymosis), hemotympanum, or cerebrospinal fluid otorrhea/rhinorrhea 2
• Check pupils for size, symmetry, and reactivity 2
• Examine conjunctivae for hemorrhage 2
• Inspect ears for blood or CSF drainage and assess tympanic membranes 2
• Check nose for blood or CSF drainage 2
• Examine oral cavity for blood, torn frenulum (concerning for abuse), or dental trauma 2

Neck

• Palpate the cervical spine for midline tenderness while maintaining immobilization 2
• Assess neck mobility only after cervical spine injury has been excluded 2

Chest

• Inspect for bruising, abrasions, or seatbelt marks 2
• Palpate ribs for tenderness, crepitus, or irregularities 2
• Auscultate heart for rate, rhythm, and murmurs 2

Abdomen

• Inspect for bruising, distention, or seatbelt marks 2
• Palpate all quadrants for tenderness, guarding, rigidity, or organomegaly 2
• Assess for signs of intra-abdominal injury which may indicate need for CT imaging 2

Pelvis and Genitourinary

• Palpate pelvis for stability and tenderness 2
• Examine external genitalia for any abnormalities or injury 2

Extremities

• Inspect for deformities, swelling, bruising, or lacerations 2
• Palpate long bones for tenderness, crepitus, or abnormal mobility 2
• Assess distal pulses, capillary refill, sensation, and motor function in all extremities 2
• Check for limb deformities consistent with fracture 2

Neurologic

• Assess alertness and responsiveness to environment 2
• Test response to sound and visual stimuli 2
• Evaluate muscle tone and symmetry of movement 2
• Check for presence and symmetry of reflexes 2
• Observe gait if the child is ambulatory 3

Skin

• Perform a complete skin examination for color, perfusion, bruising, abrasions, lacerations, or patterned injuries 2
• Document all injuries with precise location and characteristics, as this is forensically important if abuse is suspected 2

Vital Signs Documentation

• Record temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation 2, 3
• Measure and document Glasgow Coma Scale score 2

Critical Red Flags Requiring Immediate Imaging or Intervention

High-Risk Features for Head CT (if any present)

• GCS ≤14 or any altered mental status 2, 4
• Signs of basilar skull fracture 2, 4
• Post-traumatic seizure 2, 4
• Focal neurologic deficit 2, 4
• Palpable skull fracture (in children <2 years) 2, 4

Cervical Spine Imaging Indications

• Altered mental status or GCS <14 2
• Focal neurologic deficit 2
• Neck pain or midline cervical tenderness 2
• High-risk mechanism (high-speed MVA, ejection from vehicle, rollover) 2
• Age <3 years with any concerning mechanism 2

Chest/Abdomen CT Indications

• Abdominal pain, distention, or bruising 2
• Abnormal liver or pancreatic enzymes 2
• Hemodynamic instability 2
• Seatbelt sign or significant thoracic trauma 2

Common Pitfalls to Avoid

• Do not assume stability based on initial presentation—children can deteriorate rapidly due to their physiologic reserve 2, 1
• Do not remove spinal immobilization until cervical spine injury is definitively excluded by clinical criteria or imaging 2, 1
• Do not rely on skull radiographs—they miss up to 50% of intracranial injuries and provide no information about brain parenchyma 2, 4
• Do not perform routine whole-body "pan-scan" CT—use selective, region-specific imaging based on clinical findings and mechanism 2
• Do not miss occult injuries in young children—they cannot reliably communicate symptoms, requiring lower threshold for imaging 2
• Do not overlook signs of non-accidental trauma—look for injuries inconsistent with mechanism, multiple injuries in different stages of healing, or delay in seeking care 2
• Do not discharge without clear return precautions—instruct caregivers to return immediately for persistent vomiting, excessive somnolence, seizures, worsening headache, unsteady gait, or unequal pupils 4

Disposition Considerations

• Transfer to a pediatric trauma center is indicated for children with serious injuries, as specialized pediatric care reduces morbidity and mortality 2, 1
• Avoid obtaining advanced imaging at referring centers unless performed in consultation with the receiving pediatric trauma center 2
• Children meeting very low-risk criteria (GCS 15, normal mental status, no loss of consciousness, no vomiting, no severe mechanism, no severe headache, no signs of basilar skull fracture) may be safely observed without imaging 2, 4