Residency · Residency · Pediatrics
Pediatric Trauma and the Primary Survey
Introduction
Trauma remains the leading cause of death in children aged 1 to 18 years in the United States. The anatomic and physiologic differences between children and adults necessitate a tailored approach to trauma assessment and management. Children have proportionally larger heads, more compliant chest walls, and solid organs that are less protected by the rib cage and musculature. The primary survey follows the systematic ABCDE approach but must account for age-specific variations in vital signs, anatomy, and injury patterns.
Anatomic and Physiologic Considerations
Key Differences from Adults
The larger head-to-body ratio in children increases the risk of head injury, making the head the most commonly injured body region in pediatric trauma. The compliant chest wall means that significant pulmonary contusion can occur without rib fractures; conversely, rib fractures in young children suggest massive force and should raise concern for non-accidental trauma. Proportionally larger solid organs (liver and spleen) are less protected, making blunt abdominal trauma more consequential. A higher body surface area-to-mass ratio creates greater susceptibility to hypothermia. Children have substantial physiologic reserve and compensate effectively through tachycardia and vasoconstriction, potentially not showing hypotension until 25-30% of blood volume is lost. Blood volume is estimated at approximately 80 mL/kg in infants and 70 mL/kg in older children.
<image>Anatomical comparison diagram showing a child versus adult body highlighting key differences relevant to trauma: proportionally larger head, more anterior and higher airway, compliant chest wall, relatively larger abdominal organs, and unfused growth plates in long bones</image>
The Primary Survey: ABCDE
A -- Airway with Cervical Spine Protection
Cervical spine immobilization should be applied in all trauma patients until cleared, using an appropriately sized collar. Pediatric airway differences include a larger tongue, higher and more anterior larynx (C3-C4 versus C5-C6 in adults), shorter trachea, and the narrowest point at the cricoid ring (subglottic) in children under 8 years. The jaw thrust maneuver is preferred over head-tilt chin-lift to maintain cervical spine alignment. Endotracheal tube sizing uses the formula (age/4) + 4 for uncuffed tubes or (age/4) + 3.5 for cuffed tubes. The Broselow tape provides rapid weight estimation and equipment sizing in the resuscitation bay.
B -- Breathing and Ventilation
Assessment includes respiratory rate, chest wall movement symmetry, breath sounds, and oxygen saturation. Tension pneumothorax requires needle decompression at the 2nd intercostal space (midclavicular line) or the 4th-5th intercostal space (anterior axillary line), followed by chest tube placement. Open pneumothorax is managed with a three-sided occlusive dressing followed by a chest tube. Flail chest is rare in children due to chest wall compliance, but when present indicates severe force. Ventilation with bag-valve-mask should avoid hyperventilation, targeting an ETCO2 of 35-40 mmHg.
C -- Circulation and Hemorrhage Control
Direct pressure is applied for external hemorrhage, with tourniquets used for life-threatening extremity bleeding. Perfusion is assessed through heart rate, pulse quality, capillary refill, skin color, and mental status. Two large-bore IV access sites should be obtained; if unsuccessful within 90 seconds, an intraosseous (IO) needle is placed (proximal tibia is the preferred site in children). Fluid resuscitation begins with 20 mL/kg isotonic crystalloid boluses, reassessing between each, and repeating up to 3 boluses. If there is no improvement after 40-60 mL/kg of crystalloid, blood product transfusion (10 mL/kg pRBCs) is initiated. A massive transfusion protocol uses a 1:1:1 ratio of pRBCs, FFP, and platelets in severe hemorrhage. Permissive hypotension is not well-studied in pediatrics, so age-appropriate blood pressure should be maintained.
D -- Disability (Neurologic Assessment)
The Glasgow Coma Scale (GCS) is assessed using the pediatric modification for preverbal children. Pupil size and reactivity are checked. A GCS of 8 or less indicates the need for definitive airway management. A brief motor assessment of all four extremities is performed. The PECARN head injury decision rules are an evidence-based tool to guide CT imaging decisions in minor head trauma, reducing unnecessary radiation exposure.
E -- Exposure and Environmental Control
The patient is completely undressed for thorough examination. A log-roll with cervical spine precautions is performed to examine the back. Hypothermia must be prevented aggressively using warmed fluids, Bair Hugger, overhead warmers, and increased room temperature. Children lose heat rapidly, and hypothermia worsens coagulopathy and acidosis, contributing to the lethal triad of hypothermia, acidosis, and coagulopathy.
<image>Illustration of the primary survey ABCDE approach in a pediatric trauma resuscitation bay, showing proper cervical spine immobilization, jaw thrust technique, bilateral IV access, Broselow tape measurement, and warming devices, with a trauma team positioned around the patient</image>
Secondary Survey
The secondary survey is performed only after the primary survey is complete and life-threatening injuries are addressed. It consists of a head-to-toe examination with a detailed history using the AMPLE framework (Allergies, Medications, Past medical history, Last meal, Events surrounding injury). The FAST examination (Focused Assessment with Sonography in Trauma) evaluates for free fluid in the abdomen and pericardium, though FAST has lower sensitivity in children compared to adults, so CT abdomen may still be needed if clinical concern is high. Occult injuries should be evaluated, including the lap-belt complex (flexion-distraction lumbar spine fractures with bowel injury) and handlebar injuries (duodenal hematoma, pancreatic injury).
Specific Injury Patterns
Traumatic Brain Injury (TBI)
TBI is the most common cause of trauma mortality in children. Epidural hematoma classically presents with a "lucid interval" followed by rapid deterioration and is often associated with temporal bone fracture and middle meningeal artery injury. Subdural hematoma is common in non-accidental trauma in infants and associated with retinal hemorrhages. Management focuses on maintaining cerebral perfusion pressure while avoiding hypotension and hypoxia, with neurosurgical consultation.
Abdominal Trauma
Solid organ injuries to the spleen, liver, and kidney are most common. Non-operative management is the standard of care for hemodynamically stable solid organ injuries in children, with serial abdominal examinations and hemoglobin monitoring. Operative intervention is indicated for hemodynamic instability despite resuscitation or hollow viscus injury.
Musculoskeletal Trauma
| Salter-Harris Type | Description | Prognosis |
|---|---|---|
| I | Fracture through physis only | Excellent; may have normal X-ray |
| II | Through physis + metaphyseal fragment | Good (most common type) |
| III | Through physis + epiphyseal fragment | Fair; intra-articular involvement |
| IV | Through metaphysis, physis, and epiphysis | Guarded; crosses growth plate |
| V | Crush injury to physis | Poor; growth arrest risk |
Growth plate (physis) injuries are classified by the Salter-Harris classification (Types I-V). Greenstick and torus fractures are unique to pediatric bone, which is more porous and flexible. Compartment syndrome requires a high index of clinical suspicion in displaced fractures, as the "5 P's" (pain, pallor, pulselessness, paresthesias, paralysis) are late findings.
<image>Flowchart showing the PECARN head injury decision algorithm for children under 2 years and children 2 years and older, with clinical criteria at each decision node leading to CT recommendation, observation, or discharge</image>
Clinical Pearls
Children compensate for hemorrhage by increasing heart rate and SVR, and hypotension indicates loss of 25-30% of blood volume with impending cardiovascular collapse. The Broselow tape is an essential tool for rapid weight-based medication dosing and equipment sizing in pediatric emergencies. Rib fractures in infants and toddlers are highly suspicious for non-accidental trauma. Non-operative management is the standard for hemodynamically stable solid organ injuries in children. Hypothermia prevention is critical because children have a high body surface area-to-mass ratio and lose heat rapidly. PECARN criteria should be used to reduce unnecessary head CT scans in children with minor head injuries.
References
- American College of Surgeons. Advanced Trauma Life Support (ATLS) Student Course Manual. 10th Edition. 2018.
- Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study (PECARN). Lancet. 2009;374(9696):1160-1170.
- Notrica DM, Eubanks JW 3rd, Tuggle DW, et al. Nonoperative management of blunt liver and spleen injury in children: evaluation of the ATOMAC guideline using GRADE. Journal of Trauma and Acute Care Surgery. 2015;79(4):683-693.
- Densmore JC, Lim HJ, Oldham KT, Guice KS. Outcomes and delivery of care in pediatric injury. Journal of Pediatric Surgery. 2006;41(1):92-98.
