Pediatric Trauma Management Guidelines
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Muhammed ElgasimPediatric Trauma Management Guidelines
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Muhammed ElgasimStructured Approach to the Seriously Injured Child
Pre-Arrival Preparation
• Receive trauma alert using ATMISTER mnemonic:
o Age/Sex
o Time of incident
o Mechanism of injury
o Injuries suspected
o Signs (vital signs, GCS)
o Treatment given
o ETA
o Requirements (e.g. bloods, CT, specialist support)
• Brief trauma team using STEP UP:
o Self-prepare
o Team roles clarified
o Environment set up
o Patient/Primary survey focus
o Update with current status
o Plan ahead (imaging, procedures, transfer)
• Activate Paediatric Trauma Team and assign clear roles (airway, primary survey, scribe, etc.)
• Prepare paediatric equipment, blood products, and warming devices
PRIMARY SURVEY & RESUSCITATION
<c> Catastrophic External Haemorrhage
• Apply direct pressure, tourniquet, or haemostatic dressings
• Suspect bleeding in "floor + 5 Bs":
o Breast (thorax) o Bone (femur)
o Belly (abdomen) o Brain (scalp/head, esp. infants)
o Buttock (pelvis)
• Apply pelvic binder if instability suspected
• Administer Tranexamic Acid 15 mg/kg IV (max 1g) within 3 hours
A – Airway with Cervical Spine Protection
• Manual in-line stabilisation (MILS) if spinal injury suspected
• Remove foreign bodies, suction secretions
• Use jaw thrust (avoid head tilt)
• Insert oropharyngeal/nasopharyngeal airway if needed
• Prepare for intubation if GCS ≤8 or airway threat
• Avoid spinal boards—use vacuum mattress
B – Breathing
• Assess: Effort, Efficacy, Effects on other systems
• Look: chest rise, flail chest, asymmetry
• Listen: breath sounds, crackles, silence
• Feel: tracheal deviation, crepitus, percussion
• Identify & treat:
1. Tension pneumothorax
2. Open pneumothorax
3. Flail chest
4. Massive haemothorax
5. Aspiration or airway obstruction
• Ventilate if hypoxic, prepare for intubation
C – Circulation with Haemorrhage Control
• Check: HR, pulse volume, cap refill, BP, temperature
• Establish 2 large-bore IV lines or IO access
• Take bloods: crossmatch, gas, lactate, clotting
• If shocked:
o Give 10 mL/kg warmed blood (or crystalloid if unavailable)
o Repeat x1 if ongoing signs of shock
o Activate Massive Haemorrhage Protocol
• Administer:
o Platelets, cryoprecipitate, calcium gluconate
• Apply pelvic binder and splint long bones
• Monitor lactate, Hb, coagulation, electrolytes
D – Disability (Neurological Status)
• Assess AVPU or GCS
• Check pupil size/reactivity
• Suspect raised ICP: GCS <8, posturing, unequal pupils
• Immediate interventions:
o Oxygen @15 L/min
o 20° head elevation
o Controlled ventilation (target ETCO₂ 4.5–5.0 kPa)
o Hypertonic saline or mannitol
o Antipyretics and anticonvulsants if needed
• Prepare for neurosurgical referral and CT brain
• Consider TXA if traumatic brain injury and <3 hrs from injury
E – Exposure & Environmental Control
• Fully expose for hidden injuries (log roll for back)
• Maintain temperature >36°C
• Use warming blankets, warmed IV fluids
• Look for:
o Rashes, bruising, tyre marks
o Penetrating wounds (esp. perineum, axilla, groin)
o Non-accidental injury signs
• Maintain modesty and privacy
SECONDARY SURVEY & EMERGENCY TREATMENT
AMPLE History
• Allergies
• Medications
• Past medical history
• Last meal
• Events/Environment (mechanism, location)
Systematic Head-to-Toe Exam
• Surface: scalp, skin, bruises, abrasions
• Orifices: nose, ears, eyes, mouth, genitals
• Cavities: chest, abdomen, pelvis (inspect and palpate)
• Extremities: pulses, limb deformities, movement
Emergency Interventions
• Insert nasogastric/orogastric tube
• Provide analgesia (after resuscitation)
• Start antibiotics/tetanus prophylaxis for open wounds
• Imaging: CT/trauma series per clinical need
FURTHER STABILISATION & DEFINITIVE CARE
System Reassessments
• Respiration: ABG, ETCO₂, ETT position
• Circulation: ECG, BP (invasive if possible), Hb, lactate
• Neurology: GCS, pupils, ICP if monitored
• Metabolism: Electrolytes, glucose, renal/hepatic function
• Host Defence: Antibiotics, wound care, prevent pressure injury
Monitoring & Transfers
• Continuous reassessment and charting of vital signs
• Urinary catheter if output monitoring needed (1–2 mL/kg/h target)
• Prepare for CT imaging, surgery, or transfer
• Document clearly using trauma proforma
• Consider tertiary survey to detect missed injuries
Common questions
Powered by AIThe secondary survey in pediatric trauma care provides a thorough examination after primary life-threatening conditions have been managed. It involves taking a detailed AMPLE history (Allergies, Medications, Past medical history, Last meal, Events/Environment) and a systematic head-to-toe exam that includes checking for surface, orifices, cavities, and extremities. This process differs from the primary survey, which focuses on immediate life-threatening conditions following the ABCDE protocol .
To ensure airway safety when a spinal injury is suspected, manual in-line stabilization (MILS) should be performed. This entails avoiding head tilts and potentially requiring the use of jaw thrust techniques. If needed, an oropharyngeal or nasopharyngeal airway can be inserted, and preparation for intubation should be made if the patient's GCS is ≤8 or there is an airway threat .
Maintaining environmental control involves fully exposing the patient to identify hidden injuries while using warming devices to keep body temperature above 36°C. It includes observing for rashes, bruising, and signs of non-accidental injuries, while also maintaining the patient's modesty and privacy .
The ATMISTER mnemonic helps ensure structured communication and preparation before the arrival of a seriously injured child by capturing critical information. It includes Age/Sex, Time of incident, Mechanism of injury, Injuries suspected, Signs (vital signs, GCS), Treatment given, ETA, and Requirements (e.g., bloods, CT, specialist support).
The Massive Hemorrhage Protocol involves administering blood products like platelets and cryoprecipitate to manage severe blood loss. Benefits include rapid restoration of hemodynamic stability. Protocol procedures include checking heart rate, pulse, blood pressure, and establishing IV lines for blood or crystalloid fluid administration which is repeated if signs of shock persist .
Tranexamic Acid (TXA) is used in pediatric trauma to manage bleeding effectively. Administering TXA within 3 hours of injury at a dosage of 15 mg/kg IV (max 1g) is critical to its effectiveness. It is particularly recommended when traumatic brain injury is present, as it helps stabilize fibrin clots and reduce bleeding .
The trauma team plays a crucial role in the resuscitation and stabilization of pediatric patients by functioning cohesively with clearly assigned roles such as handling the airway or primary survey. Using the STEP UP guide ensures self-preparation, team role clarification, and environment setup. Updating with current status and planning ahead for imaging or procedures is critical for efficient teamwork and management of trauma .
Interventions for managing raised ICP include administering oxygen at 15 L/min, elevating the head to 20 degrees, controlled ventilation (targeting ETCO₂ 4.5–5.0 kPa), and medication with hypertonic saline or mannitol. These are necessitated by conditions such as GCS <8, posturing, or unequal pupils, indicating potential severe neurological compromise .
A tertiary survey in pediatric trauma care is significant for detecting any missed injuries that might not have been apparent during the initial and secondary surveys. It involves a thorough re-evaluation and examination, crucial for comprehensive care and ensuring no overlooked injuries hinder recovery .
The structured approach involves applying direct pressure, a tourniquet, or haemostatic dressings to control bleeding. Clinicians suspect bleeding in areas referred to as 'floor + 5 Bs': thorax, abdomen, pelvis, femur, and head. Use of a pelvic binder is recommended if instability is suspected. Tranexamic Acid is administered at 15 mg/kg IV (up to a maximum of 1g) within 3 hours of the injury .