Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Trauma management: Approach to the unstable child

Lois K Lee, MD, MPH
Gary R Fleisher, MD
Section Editor
Richard G Bachur, MD
Deputy Editor
James F Wiley, II, MD, MPH


In the United States, over 17,000 children and adolescents die annually of unintentional and intentional injuries, making trauma the leading cause of death for this population [1]. It is also the leading cause of emergency department (ED) visits, comprising up to one-third of all visits for children less than 15 years of age [2-4].

Blunt injury accounts for approximately 90 percent of all pediatric trauma. When blunt force is applied to a child's small body, multisystem trauma occurs frequently. Although the majority of injuries are mild to moderate in severity, the clinician caring for children should be prepared to rapidly evaluate and manage those patients with serious and life threatening trauma. In addition, children have differing anatomy and physiology from adults that require specific attention during advanced trauma care. (See "Trauma management: Unique pediatric considerations".)

The initial approach to the management of the unstable child with major traumatic injuries is presented here. The approach to the initially stable child with traumatic injury and the classification of trauma in the injured child are discussed separately. (See "Approach to the initially stable child with blunt or penetrating injury" and "Classification of trauma in children".)


A standardized approach to the initial management of trauma patients has been disseminated by the American College of Surgeons through the Advanced Trauma Life Support (ATLS) program (figure 1 and table 1). The ATLS protocols are based on the concept of the Trimodal Death Distribution [5]:

The first peak of death occurs in the seconds to minutes immediately after injury and only prevention can impact this mortality.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Aug 15, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. http://www.cdc.gov/ncipc/wisqars (Accessed on August 11, 2016).
  2. Krauss BS, Harakal T, Fleisher GR. The spectrum and frequency of illness presenting to a pediatric emergency department. Pediatr Emerg Care 1991; 7:67.
  3. Krauss BS, Harakal T, Fleisher GR. General trauma in a pediatric emergency department: spectrum and consultation patterns. Pediatr Emerg Care 1993; 9:134.
  4. Freid VM, Makuc DM, Rooks RN. Ambulatory health care visits by children: principal diagnosis and place of visit. Vital Health Stat 13 1998; :1.
  5. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 9th ed, American College of Surgeons, Chicago 2012.
  6. Waltzman ML, Mooney DP. Major trauma. In: Textbook of Pediatric Emergency Medicine, 5th, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.1349.
  7. Perno JF, Schunk JE, Hansen KW, Furnival RA. Significant reduction in delayed diagnosis of injury with implementation of a pediatric trauma service. Pediatr Emerg Care 2005; 21:367.
  8. Vernon DD, Furnival RA, Hansen KW, et al. Effect of a pediatric trauma response team on emergency department treatment time and mortality of pediatric trauma victims. Pediatrics 1999; 103:20.
  9. Stafford PW, Blinman TA, Nance ML. Practical points in evaluation and resuscitation of the injured child. Surg Clin North Am 2002; 82:273.
  10. Dormans JP. Evaluation of children with suspected cervical spine injury. J Bone Joint Surg Am 2002; 84-A:124.
  11. Cantor RM, Leaming JM. Evaluation and management of pediatric major trauma. Emerg Med Clin North Am 1998; 16:229.
  12. Lee LK, Fleisher G. An approach to the injured child. In: Textbook of Pediatric Emergency Medicine, 6th, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2010. p.1233.
  13. Schafermeyer R. Pediatric trauma. Emerg Med Clin North Am 1993; 11:187.
  14. Jaffe D, Wesson D. Emergency management of blunt trauma in children. N Engl J Med 1991; 324:1477.
  15. Management of shock. In: Pediatric Advanced Life Support Provider Manual, Chameides L, Samson RA, Schexnayder SM, Hazinski MF (Eds), American Heart Association, Subcommittee on Pediatric Resuscitation, Dallas 2011. p.85.
  16. Eckert MJ, Wertin TM, Tyner SD, et al. Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg 2014; 77:852.
  17. American College of Surgeons Committee on Trauma. Pediatric Trauma. In: Advanced Trauma Life Support (ATLS) Student Course Manual, 9th ed, American College of Surgeons, Chicago 2012. p.246.
  18. Chidester SJ, Williams N, Wang W, Groner JI. A pediatric massive transfusion protocol. J Trauma Acute Care Surg 2012; 73:1273.
  19. Neff LP, Cannon JW, Morrison JJ, et al. Clearly defining pediatric massive transfusion: cutting through the fog and friction with combat data. J Trauma Acute Care Surg 2015; 78:22.
  20. Hendrickson JE, Shaz BH, Pereira G, et al. Coagulopathy is prevalent and associated with adverse outcomes in transfused pediatric trauma patients. J Pediatr 2012; 160:204.
  21. Strumwasser A, Speer AL, Inaba K, et al. The impact of acute coagulopathy on mortality in pediatric trauma patients. J Trauma Acute Care Surg 2016; 81:312.
  22. Holmes JF, Palchak MJ, MacFarlane T, Kuppermann N. Performance of the pediatric glasgow coma scale in children with blunt head trauma. Acad Emerg Med 2005; 12:814.
  23. Capraro AJ, Mooney D, Waltzman ML. The use of routine laboratory studies as screening tools in pediatric abdominal trauma. Pediatr Emerg Care 2006; 22:480.
  24. Holmes JF, Sokolove PE, Brant WE, et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med 2002; 39:500.
  25. Rees MJ, Aickin R, Kolbe A, Teele RL. The screening pelvic radiograph in pediatric trauma. Pediatr Radiol 2001; 31:497.
  26. Melniker LA, Leibner E, McKenney MG, et al. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Ann Emerg Med 2006; 48:227.
  27. Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg 2007; 42:1588.
  28. Holmes JF, Brant WE, Bond WF, et al. Emergency department ultrasonography in the evaluation of hypotensive and normotensive children with blunt abdominal trauma. J Pediatr Surg 2001; 36:968.
  29. Eppich WJ, Zonfrillo MR. Emergency department evaluation and management of blunt abdominal trauma in children. Curr Opin Pediatr 2007; 19:265.
  30. Levy JA, Bachur RG. Bedside ultrasound in the pediatric emergency department. Curr Opin Pediatr 2008; 20:235.
  31. Slack SE, Clancy MJ. Clearing the cervical spine of paediatric trauma patients. Emerg Med J 2004; 21:189.
  32. Sokolove PE, Kuppermann N, Holmes JF. Association between the "seat belt sign" and intra-abdominal injury in children with blunt torso trauma. Acad Emerg Med 2005; 12:808.
  33. Shlamovitz GZ, Mower WR, Bergman J, et al. Poor test characteristics for the digital rectal examination in trauma patients. Ann Emerg Med 2007; 50:25.
  34. Shlamovitz GZ, Mower WR, Bergman J, et al. Lack of evidence to support routine digital rectal examination in pediatric trauma patients. Pediatr Emerg Care 2007; 23:537.
  35. Cervical spine immobilization before admission to the hospital. Neurosurgery 2002; 50:S7.
  36. Blackwell CD, Gorelick M, Holmes JF, et al. Pediatric head trauma: changes in use of computed tomography in emergency departments in the United States over time. Ann Emerg Med 2007; 49:320.
  37. Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 2001; 176:289.
  38. Frush DP, Donnelly LF, Rosen NS. Computed tomography and radiation risks: what pediatric health care providers should know. Pediatrics 2003; 112:951.
  39. Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med 2007; 357:2277.
  40. Palchak MJ, Holmes JF, Vance CW, et al. A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med 2003; 42:492.
  41. Feliz A, Shultz B, McKenna C, Gaines BA. Diagnostic and therapeutic laparoscopy in pediatric abdominal trauma. J Pediatr Surg 2006; 41:72.
  42. Bachman, D, Santora, S. Orthopedic trauma. In: Textbook of Pediatric Emergency Medicine, 5th, Fleisher, GR, Ludwig, S, Henretig, FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.1525.
  43. Bowman SM, Zimmerman FJ, Christakis DA, et al. Hospital characteristics associated with the management of pediatric splenic injuries. JAMA 2005; 294:2611.
  44. Mooney DP, Rothstein DH, Forbes PW. Variation in the management of pediatric splenic injuries in the United States. J Trauma 2006; 61:330.
  45. Ochoa C, Chokshi N, Upperman JS, et al. Prior studies comparing outcomes from trauma care at children's hospitals versus adult hospitals. J Trauma 2007; 63:S87.
  46. Stylianos S, Nathens AB. Comparing processes of pediatric trauma care at children's hospitals versus adult hospitals. J Trauma 2007; 63:S96.
  47. Segui-Gomez M, Chang DC, Paidas CN, et al. Pediatric trauma care: an overview of pediatric trauma systems and their practices in 18 US states. J Pediatr Surg 2003; 38:1162.
  48. Potoka DA, Schall LC, Gardner MJ, et al. Impact of pediatric trauma centers on mortality in a statewide system. J Trauma 2000; 49:237.
  50. Sasser SM, Hunt RC, Sullivent EE, et al. Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage. MMWR Recomm Rep 2009; 58:1.
  51. Sathya C, Alali AS, Wales PW, et al. Mortality Among Injured Children Treated at Different Trauma Center Types. JAMA Surg 2015; 150:874.
  52. Densmore JC, Lim HJ, Oldham KT, Guice KS. Outcomes and delivery of care in pediatric injury. J Pediatr Surg 2006; 41:92.
  53. Webman RB, Carter EA, Mittal S, et al. Association Between Trauma Center Type and Mortality Among Injured Adolescent Patients. JAMA Pediatr 2016; 170:780.
  54. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient. American College of Surgeons Chicago, IL 2006, p. 55.
Topic Outline