Primary Survey and Early Management

Use a systematic approach based on the ABCDE survey to assess and treat the acutely injured child. The goal is to identify and manage any immediate threat to life and to identify any potential threats.
The following vital signs should be utilised to identify a need for escalation in patient management and further consultation regarding management.
AGE0 – 3 Months4-11 Months1-4 Years5-11 Years12 + Years
 RR (breaths/min)>60>50>40>30>30
HR (beats/min)<100 or >180<100 or >180<90 or >160<80 or >140<60 or >130
BP sys (mmHg)<50<60<70<80<90
SpO2 (%)<90<90<90<90<90

The heart rate, respiration rate, blood pressure and oxygen saturation should be recorded at 15 minute intervals or more frequently if indicated. Monitoring of peripheral perfusion and temperature should also be undertaken.
To measure blood pressure correctly, the cuff should be two-thirds of the length of the medial aspect of the upper arm. A cuff that is too narrow will overestimate, and a cuff that is too wide will underestimate the blood pressure.
All monitoring should be maintained until the retrieval team arrives.

 Airway with cervical spine protection

Continuous monitoring of airway patency is essential throughout management. Deterioration can be sudden: it is essential to have emergency airway equipment always available.
Assess the airway while protecting the cervical spine.  Children have a head which is disproportionately larger than their neck and bodies.  When placed flat on a firm surface the size of the head tends to force the neck into flexion losing the desired neutral spine position and potentially obstructing the airway.  A towel or thoracic elevation device should be placed under the shoulders to raise them 2-4cm and rest the head in a neutral position.  This should be on the hospital bed prior to moving from the ambulance trolley.
(see section on cervical spine management or Royal Children’s Hospital Cervical Spine Clinical Practice Guideline

Assess for airway stability

If the child is stable and the airway is patent, continue to provide oxygen via a non-rebreather mask at 10 L/min.

If the child is unstable, examine for signs of possible airway obstruction (use of accessory muscles, cyanosis, visible swelling of the tongue/pharynx or neck, facial trauma, any obvious foreign bodies in the oral cavity).

Listen for any upper-airway noises such as stridor. 

Attempt simple airway manoeuvres if required

Open the airway using jaw thrust (NOT chin lift/head tilt)

Suction the airway under direct visualisation if excessive secretions are present. Remove any visible foreign bodies from the mouth and pharynx with gentle suction. Do not attempt to remove foreign bodies lodged in the laryngeal inlet with a finger swipe, as this may push the foreign body distally, causing complete obstruction.

Insert an appropriately sized oropharyngeal airway (OPA) if required; remove it if the child gags on insertion. Size by measuring from angle of mandible to level of the central incisors.
For all children: Insert OPA under direct vision, concave side down, using a tongue depressor.

Do NOT use NPA in trauma.
Sizing a guedel
Image used with permission from Royal Childrens Hospital


 Secure the airway if necessary (treat airway obstruction as a medical emergency)

Consider intubation early if any of the following apply:
  • ongoing airway obstruction is present despite OPA
  • adequate ventilation using a bag valve mask is not possible
  • an inhalation injury
  • neurologically flaccid, decerebrate/decorticate posturing
  • a requirement for definitive airway protection
  • unresponsive to pain OR GCS < 8

Consider use of LMA or 2-person bag/mask ventilation if ventilation is difficult.

Only an experienced clinician should attempt intubation in a young child, unless the procedure is required to save life.

Prior to attempting intubation, always have a plan for managing a difficult airway or failed intubation. Verbalise this plan to the trauma team.

Ketamine is the most appropriate anaesthetic agent in the context of trauma to maintain BP and cerebral perfusion pressure (CPP) during induction.10

Apnoeic oxygenation should be used during intubation11.

Endotracheal insertion MUST be verified by CO2 detection, either by capnography (preferably) or a colour change method.  Once CO2 detection is confirmed, capnography (end-tidal CO2) should be monitored continuously during transport.

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If you are unable to intubate a child whose airway is inadequate:

  • Send urgently for expert help – an ICU consultant or most senior registrar, ENT surgeon or anaesthetist or anaesthetic registrar if available.
  • Use a jaw thrust (NOT chin lift/head tilt) and gentle oropharyngeal suction to clear the airway using airway adjuncts, such as an OPA.
  • Give oxygen via a facemask and monitor its effect.

If the child has inhaled a foreign body, or has a partly transected trachea or larynx, and is breathing adequately while partly obstructed, DO NOT try to intubate (which may fail and/or worsen the condition) but give oxygen by mask.12 Allow the child to stay in the most comfortable position to breathe (sitting if necessary). Any child with a significant neck injury will have concerns regarding spinal trauma but airway management takes precedence, so the distressed child must be allowed to maintain position of comfort.
Reassure the child and family and stay with the child until expert help arrives.
If the airway is completely inadequate (SaO2 persistently <80 or patient arrested and definitive airway otherwise impossible), consider:

  • needle cricothyroidotomy (may be used to gain time prior to surgical cricothyroidotomy)
  • surgical cricothyroidotomy (need expert assistance)

See RCH trauma manual for detailed instructions

Maintain full spinal precautions if indicated

Suspect spinal injuries in all multi-trauma patients. In-line immobilisation should be followed by the rapid and gentle application of a properly fitted one-piece collar. If this is not possible (infants/distressed patients), manual in-line stabilization may be preferred in these circumstances. Patients who are distressed/agitated should not be forced into a collar. Gentle reassurance is preferred with application of rolled towels adjacent to the head. Do not use blocks/tape in children. Children with traumatic torticollis should be managed in a position of comfort and no effort should be made to move the neck. 

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 Breathing and ventilation

The chest wall in a child is very elastic; significant internal injury may be present in the absence of any obvious, external injuries.

Administer high-flow oxygen

Apply a face mask with 10 L/min of oxygen via a non-rebreather mask. Titrate to maintain saturations 94-98%

Assess the chest

Measure the respiratory rate and work of breathing.

Look for any intercostal recession, accessory muscle use or nasal flaring. Observe the chest movement. Note: infants are mainly diaphragmatic breathers. They do not move their chest walls significantly during normal adequate breathing. Seek urgent assistance if a patient has severe increased work of breathing in the context of trauma.

Listen for any expiratory ‘grunting’.

Auscultate the chest for air entry/ breath sounds. Ensure the conscious child takes a deep breath when auscultating.

If breathing is inadequate first clinically exclude a tension pneumothorax (progressive accumulation of air in the pleural space under pressure, compressing the lung on the side of the pneumothorax, but also on the contralateral side.)
Tension pneumothorax diagnosis:

  • Hypoxia.
  • Severe respiratory distress.
  • Shift in mediastinum or trachea to contralateral side.
  • Distended neck veins.
  • Absent or decreased breath sounds.
  • Hyper-resonance to percussion.
  • Tachycardia with peripheral vasoconstriction and in hypotensive shock.

Treatment requires urgent needle thoracocentesis in the 2nd intercostal space-mid-clavicular line -on the same side as the pneumothorax. For instructions on how to perform see RCH trauma manual.

Commence positive pressure ventilation using an anaesthetic T-piece circuit if the patient is spontaneously ventilating.

In children, a spontaneously ventilating patient is not able to be adequately oxygenated with a standard Laerdal bag due to inability to overcome the lip valve. Laerdal self-inflating bags do not deliver positive pressure ventilation and should only be used if the patient is apneic or bradypnoeic. Give oxygen via a non-rebreather if required.

Insert a large oro-gastric tube (NOT naso-gastric tube) to treat gastric dilatation early.
Consider intubation by skilled operator.

For critical chest injuries (open pneumothorax/flail segment/pulmonary contusions requiring first aid) see RCH trauma guidelines.

Record the oxygen saturation (SpO2)

Measure saturation and maintain it between 94-98%.

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 Circulation with haemorrhage control

Blood pressure in children and adolescents is maintained until late in haemorrhagic shock due to their vigorous sympathetic and vasoconstrictive response.13 In isolation, blood pressure is not an adequate measure of perfusion.

Assess circulation and perfusion

Measure the heart rate, central capillary refill time and blood pressure and observe the child’s skin colour.

Consider a low or high respiration rate or deteriorating mental state as a marker of inadequate circulation.

Insert two peripheral intravenous (IV) cannulas as large as practicable

As the IV is inserted take blood for glucose, full blood exam, cross-match, urea electrolytes and creatinine, lipase, liver function tests and blood gas if available. Troponin should also be performed if any signs of chest trauma.

If intravenous access is difficult, obtain intraosseous access. Bone marrow aspirated from the IO can be used to cross match blood and test BSL. Inform the laboratory that the specimen is taken from an IO. All medications and blood products can be safely administered through the IO line. Monitor IO continuously for signs of subcutaneous extravasation of fluids (“tissuing”) or failure of any kind. If this occurs, cease IO fluid administration and assess for compartment syndrome.

If circulation is inadequate (capillary refill time (CRT) >3secs, tachycardic, hypotensive, cool peripheries etc.) administer a fluid bolus of 20 mL/kg of 0.9% normal saline.14

Inspect for any signs of haemorrhage and apply direct pressure to any bleeding wounds. Consider the potential for significant internal bleeding related to the mechanism of injury.

If circulation continues to be unstable, repeat the fluid bolus using 20 mL/kg normal saline. If the response is inadequate, administer a bolus of packed red blood cells of 20 mL/kg. Preference is given to fully cross-matched blood, but if it is not available then use type-specific blood. O-negative blood should only be used for exsanguinating haemorrhage. Arrange fresh frozen plasma and platelets if the anticipated loss is greater than 40 mL/kg.

Consent should be obtained from caregiver where possible.

Contact PIPER immediately if giving blood.

Arrange early reassessment and surgical review.

Local blood supply times will vary depending on services available. Minimise the delay in blood provision by contacting the local laboratory early in the trauma presentation.

Minimum cross-match requirements for major trauma patients are:

                Infants:                                2 units
                Small child:                         4 units
                Large child:                         6 units

Contact with PIPER, if not already done, should be initiated at this stage.

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Consider the possible cause of hypovolaemia not responsive to fluid therapy.
Stop sources of bleeding:

Preventing further blood loss
by splinting the pelvis
Image used with permission from Royal Childrens Hospital
  • Bleeding wounds: Utilise external compression (beware compression of infant head wounds may raise intracranial pressure if excessive)

  • Displaced femur fracture: Utilise splinting
  • Pelvic fracture: Utilise a pelvic binder (sheet or towel wrapped tightly around the entire pelvis and clamped to “close the book”).

Maintenance fluid: If the child is stable after initial resuscitation, then the recommended fluid is 0.9% sodium chloride + 5% dextrose.
Use the following formulae to calculate normal daily fluid requirements in children up to 30kgs:

  • Up to 10kgs – 100ml/kg/day.
  • 10-20 kgs – 1000mls plus 50ml/kg/day for each kg over 10kgs.
  • 20-30 kgs – 1500mls plus 20ml/kg/day for each kg over 20kgs.

Hypoglycaemia may be present in injured infants. Correct this with 5 mL/kg of 10% dextrose (0.5g/kg) IV, followed by a glucose infusion, (NaCl + 5% dextrose) at ‘maintenance’ rates. Never give large volume infusions of 5% or 10% dextrose in water, as hyponatremia may occur.

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 Disability: neurological status

Avoid secondary brain injury by treating and preventing hypoxia and hypotension.

Assess level of consciousness

Perform an initial AVPU assessment (Alert, responds to Voice, responds to Pain, Unresponsive).

Assess the child’s mental state by observing their best response to a parent/caregiver. Frightened children may not respond to an unfamiliar adult. If no response, assess response to pain by squeezing one ear lobe hard and observing the best response to that stimulus. Particularly, note their posture looking for signs of decerebrate or decorticate posturing.

Check the pupillary response to light. Note the initial assessment findings and the time, as well as whether the child was moving all limbs. This is critical information for the treating neurosurgeon at the MTS.

Test blood sugar levels

Monitor glucose regularly to ensure that any alterations in level of consciousness are not related to a metabolic cause. Refer to the Traumatic Brain Injury guideline in the case of a child with a traumatic head injury.

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 Exposure/environmental control

Remove all clothing from the child and assess to ensure there are no other obvious, life-threatening injuries present. A log roll can be considered at this stage or be left until the secondary survey.

Hypothermia is common among injured children and may result in acidosis, hypoglycaemia, increased oxygen consumption and decreased oxygen delivery, coagulopathy and haemodynamic instability.

Monitor the child’s temperature via repeated tympanic/axillary measurements. Rectal monitoring is only necessary in intubated patients with a hypothermic injury (i.e. cold water drowning).

Keep the patient normothermic by means of external warming, passive re-warming with blankets and a warm environment. If available, the use of a forced air-warming machine is recommended.

Maintain modesty where possible (cover with sheet etc.)

X-rays form part of the primary survey and should not be delayed. FAST scan can be considered but is not usually necessary in children and should not delay assessment.

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