EM · Paediatric trauma
Paediatric trauma — the modified approach
Also known as Paediatric trauma · Child trauma · Injured child
Paediatric trauma — the different injury patterns (the larger head, the compliant chest, the less-protected abdominal organs), the physiological differences (the smaller blood volume, the faster desaturation, the higher surface-area-to-mass), the weight-based drug dosing (the Broselow tape, the formula weight equals age plus 4 times 2), the paediatric assessment triangle, the fluid bolus of 10 to 20 mL per kilogram, and the non-accidental injury consideration. ACEM-primary, globally tagged.
Checked against its sources on 3 Sept 2026
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Red flags
- The injured child has a different physiology — a smaller blood volume, a faster desaturation, and a higher surface-area-to-mass ratio that accelerates the hypothermia
- The paediatric assessment triangle (the appearance, the work of breathing, the circulation to the skin) identifies the sick child before the vital signs are taken
- The weight is estimated with the Broselow tape or the formula weight equals age plus 4 times 2 — every drug dose is weight-based
- An intra-osseous needle is placed early if the intravenous access is difficult after two attempts or 90 seconds — the child's veins are small and they collapse in the shock
- A history inconsistent with the injury, a delayed presentation, or a pattern of injuries inconsistent with the developmental stage raises the suspicion of the non-accidental injury
Meet the patient
A 4-year-old is dragged into resus after a reversing vehicle rolled over him in the driveway. He is crying but clingy, his left thigh is grossly deformed by a closed femur fracture, and his abdomen is tense and distended. The numbers that matter: heart rate 165, capillary refill 4 seconds, blood pressure 92/58.[1]
Hold that child. His blood pressure looks fine, and he is quietly losing a fifth of his circulating volume into his thigh and his peritoneum. The question this whole topic answers is the one his resuscitation turns on: how do I dose, fluid and access a child whose weight I do not yet know, and whose shock my blood pressure cannot see?[1]
References15ShowHide
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- [2]Hannon MM, Middelberg LK, Lee LK The Initial Approach to the Multisystem Pediatric Trauma Patient Pediatr Emerg Care, 2022.PMID 35639432
- [3]Lubitz DS, Seidel JS, Chameides L, et al. A rapid method for estimating weight and resuscitation drug dosages from length in the pediatric age group Ann Emerg Med, 1988.PMID 3377285
- [4]Borland M, Milsom S, Esson A Equivalency of two concentrations of fentanyl administered by the intranasal route for acute analgesia in children in a paediatric emergency department: a randomized controlled trial Emerg Med Australas, 2011.PMID 21489168
- [5]Pierce MC, Kaczor K, Lorenz DJ, et al. Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics JAMA Netw Open, 2021.PMID 33852003
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- [7]Kochanek PM, Tasker RC, Carney N, Totten AM, et al. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines. Pediatr Crit Care Med, 2019.PMID 30829890
- [8]Holcomb JB, Tilley BC, Baraniuk S, Fox EE, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA, 2015.PMID 25647203
- [9]CRASH-3 trial collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet, 2019.PMID 31623894
- [10]Hutchison JS, Ward RE, Lacroix J, Hébert PC, et al. Hypothermia therapy after traumatic brain injury in children. N Engl J Med, 2008.PMID 18525042
- [11]Weiser G, Hoffmann Y, Galbraith R, Shavit I. Current advances in intraosseous infusion - a systematic review. Resuscitation, 2012.PMID 21871243
- [12]Wells M, Goldstein LN, Bentley A, Basnett S, et al. The accuracy of the Broselow tape as a weight estimation tool and a drug-dosing guide - A systematic review and meta-analysis. Resuscitation, 2017.PMID 28958796
- [13]Wells M, Goldstein LN, Bentley A. Development and validation of a method to estimate body weight in critically ill children using length and mid-arm circumference measurements: The PAWPER XL-MAC system. S Afr Med J, 2017.PMID 29262946
- [14]Maitland K, Kiguli S, Opoka RO, Engoru C, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med, 2011.PMID 21615299
- [15]Holmes JF, Lillis K, Monroe D, Borgialli D, et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med, 2013.PMID 23375510