5 Pediatric Trauma

How childhood affects injury patterns

Children are not simply smaller adults. Age-related anatomy and physiology affect injury patterns, vital signs, and how quickly a child can deteriorate.

A relatively large head makes head injury more likely, especially in younger children. A flexible chest wall can transmit force to the lungs and other structures without obvious rib fractures or bruising. A thinner abdominal wall and relatively exposed liver and spleen increase the risk of internal injury after blunt impact. Children also lose body heat quickly when exposed, and normal vital signs vary with age.

Use the mechanism without ruling injuries out

Use the mechanism of injury to guide suspicion, not to rule injuries in or out. A child struck in the chest may have significant lung injury despite little external evidence. Abdominal bruising from a seat belt or handlebar impact should raise concern for internal injury.

Consider possible inflicted injury when the history does not fit the child’s developmental abilities, the injuries, or the timing of care. Do not assume a cause before a careful assessment.

Organize the initial assessment

Activate an appropriate trauma response for a seriously injured child. When possible, prepare age- and weight-appropriate equipment and medication, assign team roles, and obtain a brief pre-arrival handover. Assess and treat threats as they are found; team members may address several priorities at once.

The c-ABCDE sequence organizes the initial assessment. Treat immediate threats as they are identified rather than waiting to complete every step.

Control bleeding and assess airway and breathing

Control immediately life-threatening external bleeding with firm direct pressure. Use a tourniquet for life-threatening limb bleeding when indicated and trained, and do not remove an embedded object. Also suspect hidden blood loss in the chest, abdomen, pelvis, long bones, or scalp.

Check whether the child can speak or cry, listen for obstruction, and look for blood, vomit, facial injury, or reduced alertness. Open and maintain the airway while limiting neck movement when injury is suspected. Airway management takes priority over immobilization; when possible, keep a distressed child in a position that supports breathing.

Assess respiratory effort, rate, chest movement, oxygenation, and breath sounds. Treat immediately life-threatening chest problems based on clinical findings. Do not wait for imaging to treat a suspected tension pneumothorax, and remember that a normal-looking chest wall does not exclude internal injury.

Assess circulation and disability

Check heart rate, pulses, skin temperature and color, capillary refill, mental status, and blood pressure. Control bleeding, obtain vascular access, and prepare for blood-product resuscitation and definitive hemorrhage control when shock is suspected.

For traumatic hypotensive hemorrhagic shock, 2025 AHA/AAP guidance considers blood products reasonable instead of crystalloid for ongoing volume resuscitation when available. Follow local protocols.

Quickly assess alertness, for example with AVPU: Alert, responds to Voice, responds to Pain, or Unresponsive. Check pupils and movement, and check glucose when indicated. Preventing low oxygen and low blood pressure helps limit secondary brain injury.

Expose carefully and prevent heat loss

Expose enough of the child to find injuries, including on the back when safe. Then cover the child and actively prevent heat loss. Record temperature and preserve the child’s dignity.

Recognize shock before blood pressure falls

A child may maintain blood pressure through compensation even while perfusion worsens. Hypotension is a late and dangerous sign; its absence is not reassurance.

Watch for trends such as increasing heart rate, cool or mottled skin, delayed capillary refill, weak pulses, altered behavior or alertness, and decreasing urine output. Interpret heart rate, respiratory rate, and blood pressure using age-appropriate ranges. Reassess after every intervention and whenever the child’s condition changes.

Continue with a focused secondary assessment

After immediate threats are treated, perform a systematic head-to-toe examination and obtain a focused history using SAMPLE. Include the event, symptoms, allergies, medications, relevant medical history, last intake, and events since the injury. Recheck vital signs and repeat the primary survey.

Look for injuries that may be subtle in preverbal children. Use imaging and laboratory tests selectively according to clinical findings and local protocols. A negative FAST examination does not reliably exclude abdominal injury in children, and it should not delay resuscitation or further assessment when concern remains.

For example, after a high-impact collision, a child may be pale, restless, and tachycardic while blood pressure is normal and no major wound is visible. Do not dismiss shock because the pressure is normal. Continue c-ABCDE, look for concealed bleeding, keep the child warm, and escalate resuscitation and trauma-team evaluation.

Maintain priorities through reassessment

Prioritize catastrophic bleeding, airway and breathing problems, early recognition of shock, protection of the brain and spine as appropriate, and prevention of heat loss. Use age-adjusted observations, consider the mechanism alongside examination findings, and repeat assessments often because a child can worsen before hypotension appears.

• Pediatric shock