Important guidelines, formulae and injury patterns

Principles of Paediatric Trauma

Introduction

Trauma is commonest cause of death and disability in children over one year of age, and the second leading cause of death in children over ten years old

Key Differences Between Adult and Paediatric Trauma

Anatomical Differences

• Proportionally larger head relative to body size increases susceptibility to head injury.

• Smaller airway calibre and a more anterior larynx make airway compromise more likely.

• More elastic chest wall may mask underlying thoracic injury despite normal clinical appearance.

• Higher body surface area-to-mass ratio predisposes to hypothermia.

• Open growth plates are vulnerable to injury, with potential for long-term deformity.

Physiological Differences

• Higher baseline heart rate and respiratory rate.

• Greater physiological reserve, yet children may compensate until sudden decompensation occurs.

• Smaller circulating blood volume (approximately 80 mL/kg).

• Different pharmacokinetics and metabolism, necessitating weight-based dosing of medications

  
  

Initial Assessment and Resuscitation

Pre-Hospital Care and the SAFE Approach

In the field, first responders should adopt the SAFE approach:

• Shout for help

• Approach with care

• Free from danger

• Evaluate the child

In hospital

Team Formation and Allocation

Trauma resuscitation is a team effort requiring a clear leader and well-defined roles:

• Leader coordinates resuscitation

• Roles include catastrophic haemorrhage control, cervical spine control, airway, breathing, circulation, scribe, and runner

• “Somebody means nobody”: all tasks must be allocated explicitly

  
  

Structured Handover

Use the ATMIST mnemonic when handing over to the emergency department team:

• Age of the child

• Time of injury

• Mechanism of injury

• Injuries found

• Signs and symptoms

• Treatment given

Primary Survey in the Resuscitation Room

Paediatric trauma resuscitation follows a modified C–C–A–B–C–D–E–F–G sequence:

1. Cervical Spine Control

   • Manual in-line stabilisation preferred over collars.

   • Gentle, less threatening; allows jaw thrust and communication

2. Catastrophic Haemorrhage Control

   • Direct pressure, splints, tourniquets as needed

3. Airway

   • Position, open, clear, and maintain airway

   • Prepare for adjuncts or intubation if compromised

4. Breathing

   • Assess chest movement (adequacy, symmetry)

   • Manage pneumothorax, haemothorax, and respiratory compromise promptly

5. Circulation

   • Check pulse, capillary refill, and blood pressure.

   • Insert two large-bore IV/IO lines.

   • Activate massive transfusion protocol (MTP) as needed:

     • Signs of hypovolaemia/hypotension →  MTP

     • 40 mL/kg loss → MTP + urgent radiology or theatre

6. Disability

   • Pupils, AVPU score, and early assessment of neurological status

7. Exposure and Temperature Control

   • Fully expose the child while maintaining warmth (hypothermia prevention)

   • Inspect the back

8. Don’t Ever Forget Glucose

   • Check blood glucose early; hypoglycaemia can mimic or worsen injury

9. Reassessment

   • Continuous monitoring and cycle repetition

Once half the volume of blood has been replaced, need to decide whether child is stable enough to go to radiology or need to go to theatre for damage control surgery

Damage Control Surgery

Principles

In unstable paediatric trauma patients, damage control surgery is life-saving:

• Rapid entry (usually midline laparotomy).

• Control of bleeding and contamination

• Quadrant packing and temporary abdominal closure (laparostomy)

• Transfer to PICU for stabilisation, investigation, and multidisciplinary planning

• “Second look” laparotomy typically performed after 48 hours when stable

• Definitive surgery deferred until physiology normalises

  
  

Traumatic Brain Injury

Primary brain injury occurs at the moment of trauma and cannot be reversed. Preventing secondary brain injury is paramount:

• Avoid hypo and hyper (thermia, glycemia, tension)

• Control seizures, pain, and anxiety

• Optimise oxygenation, ventilation (CO₂), and fluid status

Non-Accidental Injury

Clinicians must always be vigilant for signs of abuse:

• Injury patterns inconsistent with history

• Delayed presentation or repeated attendances

• Inappropriate parental responses or differing accounts between caregivers

Prompt safeguarding referral is essential when non-accidental injury is suspected

Trauma Prevention

Most childhood injuries are predictable and preventable. Effective prevention involves:

• Environmental changes (safer roads, playgrounds).

• Legislation (seatbelt, helmet laws).

• Education and early intervention targeting parents, schools, and communities.

  
  

Summary Points

• Trauma is the leading cause of death and disability in children beyond infancy

• Anatomical and physiological differences between children and adults profoundly influence trauma care

• A structured, team-based approach to resuscitation improves outcomes

• Damage control principles are essential in the unstable child

• Non-accidental injury must always be considered

• Prevention strategies remain the most effective means of reducing the burden of paediatric trauma

Page edited by Prof. Ashok Daya Ram MBBS, FRCS, FRCPS, FEBPS, FRCS (Paed Surgery), Consultant Paediatric and Neonatal Surgeon, Norfolk and Norwich University Hospital, Norwich, UK. October 2025

Updated APSA Blunt Liver/Spleen Injury Guidelines 2019

Admission

ICU Admission Indicators:

• Abnormal vital signs after initial volume resuscitation

ICU:

• Activity: Bed rest until vital signs are normal

• Labs: CBC every 6 hours until vital signs are stable

• Diet: NPO (nothing by mouth) until vital signs and hemoglobin are stable

Ward:

• Activity: No restrictions

• Labs: CBC on admission and/or 6 hours after injury

• Diet: Regular diet

  
  

Procedures

Transfusion:

• Unstable vital signs after 20 cc/kg bolus of isotonic IVF

• Hemoglobin <7

• Signs of ongoing or recent bleeding

Angioembolization:

• Indicated for signs of ongoing bleeding despite pRBC transfusion

• Not indicated for contrast blush on admission CT without unstable vital signs

Operative Exploration with Control of Bleeding:

• Consider if vitals remain unstable despite pRBC transfusion

• Consider massive transfusion protocol

  
  

Set Free

• Discharge based on clinical condition, not injury severity (grade)

• Tolerating a diet

• Minimal abdominal pain

• Normal vital signs

  
  

Aftercare

• Activity Restriction:

  • Safe to restrict activity to grade plus 2 weeks

  • Shorter restrictions may be safe but lack sufficient data

• Follow-up Imaging:

  • Low risk of delayed complications in spleen and liver injuries

  • Consider imaging for symptomatic patients with prior high-grade injuries

Waddell triad

Child hit by car

1. Ipsilateral femur fracture

2. Ipsilateral intrathoracic or intraabdominal injury

3. Contralateral head injury

Seat belt injury

1. Vertebral fracture - T12-L1 (chance fracture

2. Liver laceration/bruising on abdominal wall

3. Bowel injury e.g bucket handle

Shock

Hypotension = Systolic < (70 + age x2)

Shock index = max heart rate/lowest systolic BP

Cut offs:

>1.22 age 4-6

>1 age 7-12

>0.9 age 13+

Normal is <0.9

Use to predict need for transfusion

Blood volume in neonates:

Approx 85ml/kg

Blood volume in children/adults

Approx 70ml/kg

Paediatric Glasgow Coma Scale

References

https://apsapedsurg.org/wp-content/uploads/2020/10/APSA_Solid-Organ-Injury-Guidelines-2019-2.pdf

Holcomb and Ashcraft’s Pediatric Surgery, 7th edition, 2020, Chapter 14 Early Assessment and Management of Trauma

Sinniah, D. (2012). Shock in children. International e-Journal of Science, Medicine & Education.

Borgialli DA, Mahajan P, Hoyle JD Jr, Powell EC, Nadel FM, Tunik MG, Foerster A, Dong L, Miskin M, Dayan PS, Holmes JF, Kuppermann N; Pediatric Emergency Care Applied Research Network (PECARN). Performance of the Pediatric Glasgow Coma Scale Score in the Evaluation of Children With Blunt Head Trauma. Acad Emerg Med. 2016 Aug;23(8):878-84. doi: 10.1111/acem.13014. Epub 2016 Aug 1. PMID: 27197686.