Trauma management: Approach to the unstable child
- Lois K Lee, MD, MPH
Lois K Lee, MD, MPH
- Assistant Professor of Pediatrics
- Harvard Medical School
- Gary R Fleisher, MD
Gary R Fleisher, MD
- Editor-in-Chief — Adult and Pediatric Emergency Medicine
- Section Editor — Pediatric Signs and Symptoms
- Egan Family Foundation Professor
- Harvard Medical School
- Section Editor
- Richard G Bachur, MD
Richard G Bachur, MD
- Section Editor — Pediatric Trauma
- Professor of Pediatrics and Emergency Medicine
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
In the United States, over 12,000 children and adolescents die annually of unintentional and intentional injuries, making trauma the leading cause of death for this population . Injury and poisoning is also the leading cause of emergency department (ED) visits, accounting for over 7 million ED visits in 2010, which is over one quarter of the 25.5 million ED visits for children less than 18 years of age .
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 :
●The first peak of death occurs in the seconds to minutes immediately after injury and only prevention can impact this mortality.
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- INJURY CLASSIFICATION
- Injury extent
- Injury type
- Injury severity
- INITIAL APPROACH
- PRIMARY SURVEY
- - Hemorrhage control
- Persistent hemorrhage
- - IV access
- - Fluid resuscitation
- Blood products
- - Massive transfusion protocol
- - Controlled hypotension
- - Vasoactive pressor medications
- - Advanced procedures
- - Neurologic assessment
- - Disability management
- Exposure and environment
- Adjuncts to the primary survey
- - Laboratory studies
- - Screening radiographs
- - FAST (Focused Assessment with Sonography for Trauma)
- - Urinary catheter
- - Gastric tube
- SECONDARY SURVEY
- Physical examination and management
- - Head
- - Cervical spine and neck
- - Chest
- - Abdomen
- - Perineum
- - Musculoskeletal
- - Neurologic
- Adjuncts to the secondary survey
- - Radiographs
- - Head CT
- - Neck CT
- - Abdominal CT
- - Laparoscopy
- - Orthopedic management
- Definitive care
- SUMMARY AND RECOMMENDATIONS