Assessment | Management |
0 up to 5 minutes | |
Mobilize trauma resources | Immobilize cervical spine |
Assess vital signs | |
Airway – Identify: | |
Obstruction | Open airway; suction secretions |
Administer 100% O2 | |
Midface fracture/difficult airway or Direct airway injury | Surgical airway |
Breathing – Identify: | |
Tension pneumothorax | Needle decompression; place chest tube or pigtail catheter |
Massive hemothorax | Place chest tube |
Open pneumothorax | Apply 3-sided occlusive dressing |
Flail chest | Perform bag-valve-mask ventilation |
Impaired oxygenation/ventilation | Rapid sequence endotracheal intubation |
Circulation – Identify: | |
Absent circulation | Cardiac compressions, thoracotomy if witnessed arrest |
External hemorrhage | Control external hemorrhage |
Signs of shock | Secure IV access; obtain laboratory studies |
Fluid resuscitation* | |
Cardiac tamponade | Pericardiocentesis followed by thoracotomy |
Pelvic fracture | Wrap or bind pelvis |
Disability – Identify: | |
Level of consciousness (GCS) | Endotracheal intubation for rapidly declining GCS, GCS ≤8 or herniation¶ |
Pupillary response | Elevate head of bed to 30° if no signs of shock |
Signs of spinal cord injury | |
Signs of impending herniation | Moderate hyperventilation (pCO2 30 to 35) |
Neurosurgical consultation | |
Administer osmotic agents if normotensive | |
Exposure – Identify: | |
Hypothermia | Remove clothing |
Initiate rewarming | |
5 up to 15 minutes | |
Repeat vital signs every 5 minutes | Continue care of airway, breathing, circulation, and disability |
Reassess response to interventions | Proceed to intraosseous or central venous access if peripheral IV access unsuccessful |
Intubated patients: | |
Monitor end-tidal CO2 | Gastric tube placement |
Obtain blood gas | Perform thoracotomy in patients who lose vital signs during resuscitation |
Persistently hypotensive patients: | |
FAST examination, if available | |
15 up to 20 minutes | |
Reassess response to interventions | Continue care of airway, breathing, circulation, and disability |
Reassess level of consciousness | Logroll patient and remove spine board |
Examine head, neck, chest, abdomen, pelvis, and extremities | Provide analgesia |
Place urinary catheter if no signs of urethral disruption | |
Obtain screening radiographs, as indicated | Operative management for patients who remain hemodynamically unstable despite rapid blood infusion per trauma surgeon |
20 up to 60 minutes | |
Reassess response to interventions | Provide analgesia |
Splint fractures | |
Reassess level of consciousness | Update tetanus immunization, as needed |
Perform complete PE (secondary survey) | Antibiotics for open fracture, contaminated wounds, or suspected bowel perforation |
Repeat selected laboratory studies (eg, hematocrit, blood gas, glucose) | Determine need for emergency life- or limb-saving operative procedures |
CT of head, neck, chest, abdomen, or pelvis, as indicated by clinical findings | Transition to definitive care at a regional pediatric trauma center |
O2: oxygen; CO2: carbon dioxide; GCS: Glasgow coma scale; pCO2: partial pressure of carbon dioxide; IV: intravenous; FAST: focused abdominal sonography for trauma; PE: physical examination; CT: computed tomography.
* Administer 20 mL/kg of warmed normal saline or Ringer's lactate as rapidly as possible using a rapid infuser or the push/pull method via stopcock. In children with severe head injury, the aim is to ensure normal, but not excessive, circulating volume.
¶ Signs of herniation include coma, unilateral pupillary dilation with outward eye deviation followed by hemiplegia, hyperventilation, Cheyne-Stokes respirations, and/or decerebrate or decorticate posturing. Refer to UpToDate topics on severe traumatic brain injury in children for more specific guidance.Do you want to add Medilib to your home screen?