16.2 Pediatric Multisystem Trauma: Primary/Secondary Survey, Damage Control & Hemorrhage Control
Key Takeaways
Use xABCDE and treat threats as the team identifies them. Control exsanguinating external bleeding, decompress suspected tension pneumothorax promptly in an unstable child and prevent heat loss.
Use rapid IV or IO access, early blood and urgent source control for traumatic hemorrhagic shock. Consider early tranexamic acid under the local pediatric hemorrhage protocol.
Persistent motor or sensory deficits after trauma need urgent spinal cord evaluation even with normal CT. Maintain motion restriction and obtain specialist-directed MRI.
An abdominal seat-belt mark raises concern for bowel or mesenteric injury and a thoracolumbar flexion-distraction injury. Unexplained free fluid and tenderness require urgent surgical review and serial assessment.
For blunt liver or spleen injury, use the response to resuscitation and evidence of ongoing bleeding to guide monitoring and intervention. Stable children can usually be managed nonoperatively.
Pediatric Multisystem Trauma
Quick Answer: Treat life threats as they are recognized. Control catastrophic external bleeding, protect the airway and decompress suspected tension pneumothorax immediately when the child is unstable. Obtain rapid IV or IO access, give early blood for hemorrhagic shock and mobilize source control. Reassess perfusion, neurologic status and response throughout the survey.
Primary Survey and Immediate Interventions
The current ACS ATLS edition uses xABCDE, with the added x emphasizing early control of exsanguinating external hemorrhage. The priorities organize team work. Several actions can occur in parallel and the survey is repeated after interventions or deterioration. ACS ATLS 11 · Pediatric trauma survey
| Step | Findings and actions |
|---|---|
| x — External hemorrhage | Control severe external bleeding immediately. Use direct pressure and a properly fitting tourniquet for life-threatening limb bleeding when indicated. Record application time. |
| A — Airway and spine | Assess patency and ability to protect the airway. Use jaw thrust, suction and manual in-line stabilization as appropriate. A young child's prominent occiput can flex the neck when supine. Pad under the torso as needed to achieve neutral alignment. Give assisted ventilation or intubate when indicated. |
| B — Breathing | Assess air entry, chest movement, oxygenation and ventilation. A compliant pediatric chest can transmit enough force to injure the lungs without visible rib fractures. Unilateral markedly reduced breath sounds plus severe respiratory or circulatory compromise suggests tension pneumothorax. Decompress immediately without waiting for imaging, then arrange definitive chest drainage and reassess. Choose the decompression technique and equipment for the child and local trauma protocol. |
| C — Circulation | Assess pulses, capillary refill, mental status and pressure. Children can have shock before hypotension appears. Look for bleeding in the chest, abdomen, pelvis, long bones and externally. Obtain rapid IV access or use IO if IV access would delay resuscitation. |
| D — Disability | Record pediatric GCS components, pupils and lateralizing findings. A post-resuscitation GCS of 3–8 suggests severe TBI. Assess airway protection and ventilation and involve the neurotrauma team early. A new fixed dilated pupil or rapidly falling GCS raises concern for herniation. |
| E — Exposure and environment | Inspect for hidden injuries, then cover and actively prevent heat loss. Monitor temperature and use warmed blood products during major hemorrhage when feasible. |
Thoracic trauma guidance · Pediatric chest trauma cohort · AHA/Red Cross bleeding control
GCS example. A school-aged child who opens their eyes to voice (3), makes incomprehensible sounds (2) and withdraws from pressure (4) has a GCS of 9. Record each component and whether sedation or intubation limits the exam. Repeat the assessment after stabilization. Pediatric trauma GCS table
Hemostatic Resuscitation and Brain Protection
For suspected traumatic hemorrhagic shock, prioritize blood when available and arrange urgent hemorrhage control. A limited isotonic crystalloid bolus may bridge a delay when blood is unavailable. Activate the local pediatric massive hemorrhage protocol based on physiology and expected need. Low-titer group O whole blood is a protocol option. If using components, the pediatric consensus suggests high plasma-to-red-cell and platelet-to-red-cell ratios, with weight-based dosing and local product definitions. Follow perfusion, temperature, acid–base status, coagulation and ionized calcium. Reassess for ongoing blood loss or another cause of shock if the response is transient. Pediatric hemorrhagic shock consensus · 2025 AHA/AAP PALS
Avoid deliberate hypotension in injured children with hemorrhagic shock. In suspected TBI, prevent hypoxemia and hypotension while controlling bleeding. For intracranial hypertension in severe pediatric TBI, the Brain Trauma Foundation recommends an IV 3% saline bolus of 2–5 mL/kg over 10–20 minutes. Escalate rapidly with the neurotrauma team for signs of herniation. Monitor neurologic status and do not use routine prophylactic hyperventilation. Pediatric severe-TBI guideline
Consider tranexamic acid (TXA) within three hours in a child with traumatic hemorrhagic shock according to the local protocol. This pediatric recommendation is conditional and based on very low-certainty evidence. The pediatric TIC-TOC pilot tested feasibility and cannot establish a mortality benefit. Adult CRASH-3 results do not establish routine use in isolated pediatric TBI. Discuss an isolated head injury with the local neurotrauma pathway. TXA is an adjunct to blood and source control. Pediatric pilot trial · Adult CRASH-3 trial
Secondary Survey and Occult Injury
After immediate threats are addressed, obtain the mechanism, restraint use, timeline, history and treatments already given. Perform a head-to-toe examination and document reassessment. Recheck neurologic status and perfusion and repeat the primary survey if the child deteriorates. Imaging follows stability, examination and the suspected injury.
Spinal cord injury despite normal radiographs or CT
In children the more flexible spine can deform transiently without a persistent bony abnormality. A motor or sensory deficit after trauma with normal radiographs or CT can reflect spinal cord injury without radiographic abnormality (SCIWORA), using the traditional term for normal conventional imaging. MRI may show cord edema, hemorrhage or compression, or may be normal. Maintain spinal motion restriction and arrange urgent specialist-directed MRI. The sensory level, mechanism and other findings guide the extent of imaging. A 4-year-old with paralysis and a T4 sensory level needs cord evaluation even when the CT report shows no fracture. Original pediatric SCIWORA series · Pediatric spine imaging evidence · PECARN cervical spine study
Seat-belt sign, FAST and abdominal imaging
An abdominal seat-belt mark after a crash raises concern for bowel or mesenteric injury and a thoracolumbar flexion-distraction injury (Chance-type). In a PECARN subgroup, gastrointestinal injuries occurred in 11% versus 1% of definitively tested children with and without a seat-belt sign. Even without initial abdominal pain or tenderness, 11/194 (5.7%) with a mark and GCS 14–15 had an intra-abdominal injury. Use this sign to guide evaluation, even if the first exam seems reassuring. PECARN seat-belt study
FAST can rapidly identify free fluid during shock evaluation. A negative FAST cannot exclude abdominal injury. Routine FAST did not improve care in a randomized trial of hemodynamically stable children. In a stable child, combine mechanism, exam and a pediatric risk assessment to decide on observation or CT. A positive risk factor in the PECARN rule takes the child out of its very-low-risk group. It does not by itself require CT. Unexplained fluid on CT plus a seat-belt sign and tenderness warrants pediatric surgical review, serial exams and further imaging or intervention as findings evolve. Free fluid alone does not establish perforation. An unstable child needs immediate resuscitation and a hemorrhage-control plan before transport to CT. Pediatric FAST trial · Prospective PECARN validation
Blunt liver or spleen injury
Under APSA guidance, disposition follows vital signs after resuscitation. Persistent abnormalities or transient response warrant intensive monitoring and evaluation for ongoing bleeding. Stable children can usually receive ward care and nonoperative management, even when anatomic injury grade is high. Ongoing hemorrhage requires prompt evaluation for operative control or angioembolization as appropriate. Avoid waiting for a fixed cumulative transfusion volume. Discharge depends on clinical condition. APSA retains activity restriction of injury grade plus two weeks and reserves follow-up imaging for symptomatic patients. APSA guideline · APSA full guideline
Possible inflicted injury
A history inconsistent with development, concerning bruises or fractures, or unexplained neurologic findings should prompt a child protection evaluation after stabilization. Posterior rib fractures, classic metaphyseal lesions and extensive multilayer retinal hemorrhages raise concern in the appropriate context. No single finding establishes the cause. The workup may include a skeletal survey in children under 24 months, urgent noncontrast head CT for acute neurologic findings, and ophthalmology and child abuse pediatrics consultation. Document objectively and follow applicable reporting requirements. AAP technical report · ACR suspected physical abuse update
A 4-year-old has flaccid paralysis and loss of sensation below T4 after a high-speed rollover. CT of the spine shows no fracture or malalignment. After immediate life threats have been addressed, what is the best next step?
Clear the spine based on the CT result and arrange outpatient neurologic follow-up.
Obtain flexion-extension radiographs before contacting the spine team.
Attribute the findings to a peripheral nerve injury and order outpatient nerve conduction studies.
Maintain spinal motion restriction and obtain urgent spine consultation and MRI for suspected spinal cord injury.
A 7-year-old in a lap belt has a transverse abdominal bruise, lower abdominal tenderness and mid-back pain after a crash. He remains hemodynamically stable. Contrast-enhanced CT shows unexplained pelvic free fluid without visible liver or spleen injury. Which injury pattern and next step best fit?
Suspect bowel or mesenteric injury and a thoracolumbar flexion-distraction injury. Obtain urgent pediatric surgical assessment, evaluate the spine and perform serial abdominal exams.
Treat this as an abdominal wall contusion and discharge because CT shows no solid-organ injury.
Assume occult splenic hemorrhage and proceed to splenectomy solely on the basis of the free fluid.
Treat the lumbar pain as an isolated strain and defer reassessment of the abdominal tenderness until outpatient follow-up.
A 10-year-old after blunt abdominal trauma has heart rate 148 beats/min, blood pressure 84/52 mmHg, delayed capillary refill, and deteriorating mentation. FAST shows free fluid in the splenorenal recess. Blood products are available. What is the most appropriate next action?
Continue serial crystalloid boluses before requesting blood and wait for CT grading to decide whether to call surgery.
Prioritize blood products and activate the pediatric hemorrhage protocol as indicated. Arrange urgent surgical evaluation for ongoing bleeding.
Start a vasopressor as the primary treatment and defer blood while checking serial perfusion measurements.
Transport for immediate splenic embolization based on FAST alone, before beginning blood resuscitation.
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