Paeds · acute-care-resuscitation-and-toxicology
Major trauma and paediatric trauma systems
Also known as Paediatric major trauma · Paediatric trauma primary survey · Trauma team and team activation · Paediatric trauma system and retrieval · Damage control resuscitation in children
A fellowship approach to the injured child within an organised paediatric trauma system. Run a trauma primary survey that controls catastrophic haemorrhage first and protects the cervical spine, lead a structured trauma team with defined roles, use weight-based fluid and early blood for haemorrhagic shock, avoid the lethal triad, apply paediatric imaging decision rules, escalate to a paediatric trauma centre before local support is exceeded, and reassess after every intervention.
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Target exams
Red flags
- Uncontrolled external or junctional haemorrhage: stop the bleed with direct pressure or a tourniquet before airway work
- A threatened airway in a child with possible cervical spine injury: maintain manual in-line stabilisation and call airway expertise early
- Shock with a normal blood pressure: children compensate then collapse; hypotension is a late and dangerous sign
- Mechanism suggesting major haemorrhage, a base deficit or abnormal INR, or a falling haemoglobin: move from crystalloid to blood early
- Glasgow Coma Scale below 9, asymmetric or unreactive pupils, or a witnessed deterioration: treat as a threatened brain and prepare for definitive airway and neurosurgery
- Injury severity or age beyond local capability: activate the trauma system and arrange paediatric retrieval in parallel with resuscitation
- Inconsistent injury history, delay in presentation, or patterned injury in a non-mobile infant: run safeguarding in parallel
Life stages
Care settings
Clinical exam formats
Board mappings
- Acute Care
- Current 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young person
- Current 2026 PREP curriculum — Learning Objective 2.2.3: Perform acute resuscitation and advanced life support
- Current 2026 PREP curriculum — Learning Objective 2.4.4: Assess and manage infants, children and young people with potential cardiac, respiratory or neurological emergencies or acute sepsis
- Current 2026 PREP curriculum — Learning Objective 2.4.5: Manage transfer of an unwell newborn, infant, child or young person
- Renewed curriculum for first-year trainees from 2027 — Learning goal 11: Acute care and procedures
- Renewed curriculum for first-year trainees from 2027 — Learning goal 17: Acute care
- Clinical Applications
- Medical Sciences
- Long Cases
- Short Cases
- 3. Professional skills and knowledge: Clinical procedures
- 4. Professional skills and knowledge: Patient management
- 6. Leadership and team working
- 7. Patient safety, including safe prescribing
- General Paediatrics: Resuscitates, stabilises and treats extremely unwell babies, children and young people, liaising with specialist teams, as necessary
- General Paediatrics: Assumes the role of Acute Paediatric Team Leader
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- Video
- General Pediatrics Content Outline — Domain 7: Emergency and Critical Care
- General Pediatrics Content Outline — Universal Task 1: Physiology and Pathophysiology
- General Pediatrics Content Outline — Universal Task 3: Diagnosis
- General Pediatrics Content Outline — Universal Task 4: Management and Treatment
- General Pediatrics EPA 7: Recognizing a Severely Ill Patient, Providing Initial Management, and Mobilizing Resources Needed for Continued Care
- Patient Care 3: Organize and Prioritize Patient Care
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Patient Management
- Systems-Based Practice 1: Patient Safety
- Interpersonal and Communication Skills 2: Interprofessional and Team Communication
- Medical Expert
- Pediatrics: Foundations EPA #1 — Recognizing deteriorating and/or critically ill patients and initiating stabilization and management
- Pediatrics: Core EPA #2 — Resuscitating and stabilizing critically ill patients
Overview & Definition
Major trauma means serious injury that carries a threat to life, limb or function, and in children it is managed by a system rather than by a single clinician. That system has three moving parts: pre-hospital triage that sends the right child to the right place, a hospital trauma team that runs a structured primary survey, and a retrieval and definitive-care network that catches the child when local resources are exceeded. Your job at the bedside is the middle layer, but you must understand the whole system because your decisions feed into it. [6] [11]
The paediatric primary survey is the ABCDE method adapted for trauma. The adaptation matters: a child who is bleeding to death exsanguinates before an airway problem kills them, so many services teach <C>ABCDE, controlling catastrophic external haemorrhage first, then proceeding through airway with cervical spine control, breathing, circulation, disability and exposure. You treat each life threat the moment you find it, then you return to the start and reassess. This treat-as-found, reassess-from-the-top discipline is what separates a trauma team from a crowd of clinicians around a trolley. [6] [8]
[6] [11]Trauma resuscitation is damage control, not definitive repair. The first goal is to stop the bleeding, restore perfusion, prevent hypothermia, acidosis and coagulopathy, and keep the brain perfused and oxygenated. Definitive surgery, imaging for every injury, and the full secondary survey come after the child is stable, and some of them come after transfer to a centre that can deliver them. Ordering a scan on an unstable child is a classic and dangerous error. [5] [8]
The first five minutes of a paediatric trauma call
- 1
Pre-arrival and team
Receive a pre-alert, confirm the trauma team is activated with named roles, and prepare age- and weight-appropriate airway, access and warming equipment.
- 2
Handover and <C>A
Take a structured pre-hospital handover, then control catastrophic haemorrhage with direct pressure or a tourniquet before airway work.
- 3
A to E, treat as found
Run airway with cervical spine control, breathing, circulation, disability and exposure in order, treating each threat the moment it is found.
- 4
Reassess and escalate
Return to the top after every intervention; if injury severity exceeds local capability, activate retrieval and paediatric trauma centre referral in parallel.
- 5
Secondary survey
Once the child is stable, take an AMPLE history, perform a head-to-toe secondary survey, apply imaging decision rules, and re-evaluate.
References12ShowHide
- [1]Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study Lancet (London, England), 2009.PMID 19758692
- [2]Leonard JC, Harding M, Cook LJ, et al. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study The Lancet Child and Adolescent Health, 2024.PMID 38843852
- [3]Davis AL, Wales PW, Malik T, et al. The BIG Score and Prediction of Mortality in Pediatric Blunt Trauma The Journal of pediatrics, 2015.PMID 26118931
- [4]Noland DK, Apelt N, Greenwell C, et al. Massive transfusion in pediatric trauma: An ATOMAC perspective Journal of pediatric surgery, 2019.PMID 30389149
- [5]Russell, Russell T Damage-control resuscitation in pediatric trauma: What you need to know The journal of trauma and acute care surgery, 2023.PMID 37314396
- [6]Galvagno SM Jr, Nahmias JT, Young DA Advanced Trauma Life Support Update 2019: Management and Applications for Adults and Special Populations Anesthesiology clinics, 2019.PMID 30711226
- [7]Mora MC, Veras L, Burke RV, et al. Pediatric trauma triage: A Pediatric Trauma Society Research Committee systematic review The journal of trauma and acute care surgery, 2020.PMID 32301877
- [8]Leeper CM, McKenna C, Gaines BA Too little too late: Hypotension and blood transfusion in the trauma bay are independent predictors of death in injured children The journal of trauma and acute care surgery, 2018.PMID 29389838
- [9]Nishijima DK, VanBuren JM, Linakis SW, et al. Traumatic injury clinical trial evaluating tranexamic acid in children (TIC-TOC): A pilot randomized trial Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2022.PMID 35266589
- [10]Herren A, Palmer CS, Landolt MA, et al. Pediatric Trauma and Trauma Team Activation in a Swiss Pediatric Emergency Department: An Observational Cohort Study Children (Basel), 2023.PMID 37628376
- [11]Ciorba MC, Maegele M Polytrauma in Children—Epidemiology, Acute Diagnostic Evaluation, and Treatment Deutsches Arzteblatt international, 2024.PMID 38471125
- [12]Russell K, Biswas S Pediatric trauma center vs. adult trauma center: which is better? Current opinion in anaesthesiology, 2023.PMID 36745064