Trauma assessment in children

Primary Survey (ABCDE) - First Things First

• A: Airway with C-Spine Protection
  • Assess patency; clear secretions/foreign bodies.
  • Use jaw-thrust, not head-tilt.
  • Immobilize cervical spine (collar, blocks).
• B: Breathing & Ventilation
  • Check respiratory rate, effort, chest rise, SpO₂.
  • Provide high-flow O₂; assist ventilation if needed.
• C: Circulation & Hemorrhage Control
  • Assess HR, BP, capillary refill (<2 sec), pulses.
  • Control bleeding; secure IV/IO access.
  • Give 20 mL/kg isotonic crystalloid bolus for shock.
• D: Disability (Neurologic Status)
  • Use AVPU (Alert, Verbal, Pain, Unresponsive) or GCS.
  • Check pupil size and reactivity.
• E: Exposure & Environment
  • Completely undress to find all injuries.
  • Prevent hypothermia (warm blankets/fluids).

⭐ The Broselow Tape provides pre-calculated drug doses and equipment sizes based on a child's length, crucial in time-sensitive emergencies.

Secondary Survey - The Full Picture

• A complete head-to-toe examination performed after the primary survey and initial stabilization. Aims to identify all injuries.
• History (📌 AMPLE):
  • Allergies
  • Medications
  • Past medical history/Pregnancy
  • Last meal
  • Events leading to injury
• Comprehensive Physical Exam:
  • Head & Face: Check for lacerations, fractures, raccoon eyes, Battle's sign.
  • Neck: Palpate for tenderness, maintain C-spine immobilization.
  • Chest & Abdomen: Inspect for bruising, auscultate, palpate for tenderness.
  • Pelvis & Limbs: Assess for stability, fractures, and distal pulses.
  • Back: Log-roll to inspect the entire spine.

⭐ The standard Glasgow Coma Scale (GCS) is modified for pre-verbal children (Pediatric GCS), as motor and verbal responses differ. A score < 8 often indicates the need for intubation.

Pediatric Pearls - Little People, Big Differences

• Airway: Large occiput & tongue; anterior/cephalad larynx (C3-C4). Prone to obstruction.
• Breathing: Compliant chest wall → significant internal injury (pulmonary contusion) without rib fractures.
• Circulation: Excellent compensation; hypotension is a LATE sign of shock.
  • Estimated Blood Volume: 80 ml/kg.
• Disability: Open fontanelles/sutures can mask early signs of rising ICP. Use age-appropriate GCS.
• Exposure: High surface area-to-volume ratio → rapid heat loss & hypothermia.

⭐ Hypotension is a sign of decompensated shock in children, often representing >30-45% blood volume loss. Intervene before it appears.

Trauma Scoring - The Numbers Game

• Pediatric Trauma Score (PTS): Predicts injury severity and mortality. A score < 8 indicates a major trauma requiring a specialized center.

  • Components are scored +2, +1, or -1: Weight, Airway, SBP, CNS status, Open Wounds, and Fractures.

• Pediatric Glasgow Coma Scale (pGCS): Crucial for assessing neurologic status, modified for pre-verbal children.

  • Eye (E): Spontaneous (4), To sound (3), To pain (2), None (1).
  • Verbal (V): Coos/babbles (5), Irritable cry (4), Cries to pain (3), Moans to pain (2), None (1).
  • Motor (M): Normal/spontaneous (6), Withdraws to touch (5), Withdraws to pain (4).

⭐ A GCS score of ≤ 8 is a key indication for endotracheal intubation to protect the airway.

High‑Yield Points - ⚡ Biggest Takeaways

• The pediatric airway is prone to obstruction due to a larger occiput; use a padded backboard.
• Tachycardia and poor perfusion are early signs of shock; hypotension is a late, ominous finding.
• Assess neurological status using the Pediatric Glasgow Coma Scale (pGCS).
• Children have a larger body surface area, leading to a significant risk of hypothermia.
• Head trauma is the most common cause of mortality in pediatric trauma.
• Pulmonary contusions can occur without overlying rib fractures due to a compliant chest wall.