›Trauma team activation criteria local protocol dependent
›Airway compromise or impending obstruction
›Respiratory distress or hypoxemia
›Signs of shock
›Major external hemorrhage
›Altered mental status
›Seizure after trauma
Vital sign danger patterns
›High risk vital patterns
›Hypotension for age
›Tachycardia out of proportion to pain
›Bradypnea or apnea
›Persistent hypoxemia on oxygen
›Hypothermia
High risk findings
›High risk exam findings
›Stridor or facial burns
›Tracheal deviation
›Asymmetric breath sounds
›Unstable chest wall
›Abdominal distension with guarding
›Pelvic instability with hypotension
›Open fracture with bleeding
›Neuro deficit
Non accidental trauma concern
›Safeguarding red flags
›History inconsistent with injury
›Delay in presentation
›Multiple injuries in different healing stages
›Sentinel bruising in non mobile child
›Patterned injuries
03Medications/meds32
Home and recent medications
›Current exposures
›Prescription medications
›Over the counter medications
›Supplements and herbals
›Recent medication changes
›Adherence concerns
Anticoagulant and antiplatelet exposure
›Bleeding risk medications
›Warfarin
›Direct oral anticoagulants
›Heparins
›Antiplatelet agents
ED analgesia and sedation options
›Analgesia options weight based
›Acetaminophen
›15 mg per kg per dose oral or rectal
›Maximum 1000 mg per dose
›Ibuprofen
›10 mg per kg per dose oral
›Maximum 600 mg per dose
›Fentanyl intranasal
›1.5 micrograms per kg
›Repeat 0.5 to 1 microgram per kg after 10 minutes if needed
›Morphine IV
›0.05 mg per kg
›Repeat 0.05 mg per kg every 5 to 10 minutes to effect
›Ketamine analgesic dose IV
›0.1 to 0.3 mg per kg
›Avoid in uncontrolled hypertension
›Procedural sedation considerations
›NPO status context dependent
›Airway risk features
›Continuous capnography when available
›Age appropriate resuscitation equipment
04Diet/diet9
Recent intake and aspiration risk
›Intake status
›Time of last oral intake
›Liquids versus solids
›Vomiting episodes
›Aspiration risk factors
Hydration and energy exposures
›Fluid related context
›Poor intake since injury
›Diarrhea before injury
›Caffeine or energy drinks in older child
05Review of Systems/ros27
Neurologic
›Neuro symptoms
›Headache
›Confusion
›Irritability
›Lethargy
›Seizure
›Vision change
Cardiopulmonary
›Chest symptoms
›Dyspnea
›Chest pain
›Palpitations
›Cough
›Hemoptysis
Gastrointestinal and genitourinary
›Abdominal and GU symptoms
›Abdominal pain
›Vomiting
›Hematemesis
›Blood per rectum
›Hematuria
›Flank pain
Musculoskeletal and skin
›MSK and skin symptoms
›Limb pain
›Refusal to bear weight
›Back pain
›Neck pain
›Wounds
›Burns
06Collateral History and Family History/chafh16
Source and reliability
›Collateral
›Caregiver present
›EMS report
›Bystander report
›Video or scene photos
Family history relevant to trauma care
›Family conditions
›Bleeding disorders
›Hemophilia
›Von Willebrand disease
›Cardiac channelopathies
›Long QT syndrome
›Brugada syndrome
Social support and supervision
›Support reliability
›Safe discharge supervision
›Transportation access
›Ability to return if worse
07Risk Factors/rf16
Patient factors increasing injury risk
›High risk patient factors
›Infancy
›Neurodevelopmental delay
›Seizure disorder
›Bleeding disorder
›Anticoagulant exposure
Environmental and exposure risks
›Context risks
›High speed roadway exposure
›Water exposure and possible drowning
›Cold exposure
›Fire and smoke exposure
Procedure and device related risks
›Devices and prior procedures
›Ventriculoperitoneal shunt
›Tracheostomy
›Gastrostomy tube
›Implanted cardiac device
08Differential Diagnosis/ddx60
Life threatening
›Cannot miss diagnoses
›Traumatic brain injury with mass effect
›Progressive decreased consciousness
›Unequal pupils
›Cervical spine injury
›Neuro deficit
›Midline neck tenderness
›Airway burn or inhalation injury
›Hoarseness
›Soot in mouth
›Tension pneumothorax
›Severe respiratory distress
›Hemodynamic compromise
›Massive hemothorax
›Shock with decreased breath sounds
›Dullness to percussion
›Cardiac tamponade
›Shock with muffled heart sounds
›Distended neck veins
›Intraabdominal hemorrhage
›Abdominal tenderness
›Hypotension
›Pelvic fracture with hemorrhage
›Pelvic instability
›Shock
›Sepsis mimicking trauma decompensation
›Fever
›Toxic appearance
Common
›Common trauma diagnoses
›Concussion mild traumatic brain injury (S06.0X0)
›Headache
›Dizziness
›Skull fracture (S02.0)
›Scalp hematoma
›Palpable step off
›Extremity fracture (S42 to S92)
›Deformity
›Point tenderness
›Sprain and strain
›Pain with range of motion
›Normal radiographs
›Pulmonary contusion (S27.3)
›Hypoxemia
›Chest wall tenderness
›Abdominal solid organ injury (S36)
›Abdominal tenderness
›Seat belt sign
Less common and mimics
›Less common and mimics
›Spinal cord injury without radiographic abnormality
›Neuro symptoms with normal CT
›MRI abnormality
›Occult bowel injury
›Worsening pain over time
›Free fluid without solid organ injury
›Blunt cardiac injury
›Chest trauma with arrhythmia
›Troponin elevation
›Compartment syndrome (T79.A)
›Pain out of proportion
›Pain with passive stretch
09Past Medical History/pmh15
Chronic conditions affecting trauma care
›Comorbidities
›Congenital heart disease
›Chronic lung disease
›Neuromuscular disease
›Diabetes mellitus (E10 to E11)
›Sickle cell disease (D57)
Surgical history and devices
›Prior procedures
›Neurosurgery
›Orthopedic surgery
›Abdominal surgery
›Implanted shunts
Prior injury and baseline function
›Baseline function
›Baseline mobility
›Baseline speech and cognition
›Baseline feeding and swallowing
10Physical Exam/exam51
Primary survey and resuscitation exam
›ABCDE
›Airway
›Patency
›Stridor
›Blood and secretions
›Facial trauma
›Breathing
›Work of breathing
›Symmetry of chest rise
›Breath sounds
›Chest wall tenderness
›Circulation
›Pulses
›Capillary refill
›Skin perfusion
›External hemorrhage
›Disability
›GCS appropriate for age
›Pupils
›Focal deficits
›Exposure
›Full skin inspection
›Temperature control
Secondary survey head to toe
›Head and neck
›Scalp hematoma
›Skull step off
›Battle sign
›Racoon eyes
›Hemotympanum
›C spine midline tenderness
›Chest and back
›Seat belt marks
›Crepitus
›Rib tenderness
›Spine tenderness
›Abdomen and pelvis
›Distension
›Tenderness
›Guarding
›Pelvic stability
›Extremities and neurovascular
›Deformity
›Range of motion limitation
›Distal pulses
›Capillary refill distal to injury
›Sensation
›Motor function
Subtle findings and pitfalls
›Common missed findings
›Occult intraabdominal injury with minimal early tenderness
›Non accidental trauma patterns
›Compartment syndrome evolving over hours
11Lab Studies/labs29
Core trauma labs when indicated
›Basic labs
›CBC
›Baseline hemoglobin trend
›Platelet count
›Electrolytes and renal function
›Sodium
›Potassium
›Creatinine
›Liver enzymes
›AST
›ALT
›Coagulation studies
›INR
›aPTT
›Type and screen
›Massive transfusion planning
›Rh status
Point of care and perfusion assessment
›Shock markers
›Lactate
›Venous blood gas
›Glucose
Targeted tests by scenario
›Scenario specific tests
›Urinalysis for hematuria
›Creatine kinase for crush injury
›Troponin for suspected blunt cardiac injury
›Pregnancy test in post menarchal patient
Limitations and interpretation pearls
›Pitfalls
›Normal early hemoglobin does not exclude hemorrhage
›Isolated mild transaminase elevation not diagnostic without clinical context
12Imaging/img48
Scoring Systems
›Decision tools for imaging selection
›PECARN pediatric head trauma rule
›Age under 2 years pathway
›Age 2 years and older pathway
›High risk features for clinically important TBI
›Intermediate risk features and observation option
›Pediatric blunt abdominal trauma risk rule
›Abdominal wall trauma or seat belt sign
›GCS under 14
›Abdominal tenderness
›Thoracic wall trauma
›Abdominal pain complaint
›Decreased breath sounds
›Vomiting
›Cervical spine clearance tools local protocol dependent
›NEXUS criteria limitations in young children
›Canadian C spine rule not validated for pediatrics
MRI
›MRI indications
›Suspected spinal cord injury without radiographic abnormality
›Persistent neuro deficit with normal CT
›Ligamentous cervical spine injury concern
›MRI considerations
›Need for sedation in younger children
›Implanted device compatibility
›Time sensitivity versus CT
CT
›CT head
›High risk head injury features
›Anticoagulant exposure
›Worsening neuro status during observation
›CT cervical spine
›Neuro deficit
›Persistent midline tenderness
›High risk mechanism with unreliable exam
›CT chest abdomen pelvis
›Hemodynamic stability required
›High risk mechanism with concerning exam
›FAST positive with concern for operative injury
›CT cautions
›Radiation exposure risk higher in children
›Contrast nephropathy risk context dependent
Ultrasound
›POCUS applications
›eFAST local protocol dependent
›Cardiac view for tamponade
›Lung views for pneumothorax
›FAST interpretation pitfalls
›Lower sensitivity for isolated hollow viscus injury
›Small volume hemoperitoneum may be missed early
›Free fluid may be physiologic in adolescent females
13Special Tests/spec14
Bedside neurologic and cognitive testing
›Neuro bedside tools
›Age appropriate GCS scoring
›Pupillary reactivity
›Serial neuro checks interval based
›Concussion symptom screen
Orthopedic and neurovascular maneuvers
›Limb assessment maneuvers
›Joint stability testing when safe
›Passive stretch pain for compartment syndrome
›Two point discrimination when feasible
›Doppler pulses if weak pulses
Procedural diagnostics
›Procedure guided diagnostics
›Wound exploration for foreign body
›Saline load test local protocol dependent
›Arthrocentesis if septic joint mimic
14ECG/ecg13
Indications after trauma
›When ECG is useful
›Chest trauma with arrhythmia symptoms
›Suspected blunt cardiac injury
›Syncope preceding trauma
›Electrical injury
High risk patterns
›Concerning ECG findings
›New conduction delay
›ST segment changes
›Ventricular ectopy
›High grade AV block
Serial testing logic
›Monitoring strategy
›Abnormal ECG with troponin elevation
›Normal ECG and normal troponin lowers blunt cardiac injury risk
15Assessment/ax16
Severity and risk stratification
›Trauma severity summary
›Hemodynamic status
›Respiratory status
›Neuro status
›Suspected bleeding source
›Need for airway intervention
Working problem list
›Problem oriented assessment
›Head injury risk category
›C spine injury risk category
›Thoracic injury risk category
›Abdominal injury risk category
›Extremity injury risk category
Diagnostic uncertainty and alternatives
›Mimics and alternative explanations
›Medical event preceding injury
›Non accidental trauma
›Intoxication exposure in adolescent
16Plan/plan28
Immediate stabilization priorities
›Resuscitation priorities
›Oxygen for hypoxemia
›Bag mask ventilation if inadequate respirations
›Two IV or IO access if shock
›Balanced warmed fluids for initial resuscitation local protocol dependent
›Early blood products for hemorrhagic shock local protocol dependent
Hemorrhage control and transfusion
›Bleeding control
›Direct pressure and tourniquet when appropriate
›Pelvic binder for suspected unstable pelvic fracture with shock
›Tranexamic acid local protocol dependent
›15 mg per kg IV loading dose
›Maximum 1000 mg loading dose
›Infusion 2 mg per kg per hour for 8 hours
Airway and ventilation strategy
›Airway plan
›Anticipated difficult airway features
›C spine protection during airway management
›RSI medication selection local protocol dependent
Diagnostic sequencing and reassessment loop
›Reassessment loop
›Repeat vitals every 5 to 15 minutes in unstable patient
›Repeat neuro checks at defined intervals
›Repeat exam after analgesia
›Repeat FAST if evolving shock local protocol dependent
Consultations
›Consultation triggers
›Trauma surgery
›Neurosurgery for intracranial injury
›Orthopedics for open fracture or neurovascular compromise
›Child protection team for non accidental trauma concern
›Transfer center for higher level pediatric trauma care
17Disposition/dispo27
Level of care criteria
›ICU level care
›Ongoing respiratory support
›Persistent shock or vasopressors
›Severe traumatic brain injury
›Ongoing bleeding requiring transfusion
›Inpatient admission
›Moderate traumatic brain injury
›Solid organ injury requiring observation
›Uncontrolled pain requiring IV opioids
›High risk fractures needing operative management
Observation pathway
›ED or short stay observation
›Intermediate risk head injury with serial neuro checks
›Persistent vomiting with normal neuro exam
›Abdominal pain with reassuring initial evaluation
Transfer criteria
›Transfer to pediatric trauma center
›Airway intervention requirement
›Suspected intracranial hemorrhage
›Unstable thoracic injury
›Hemorrhagic shock
›Complex multisystem trauma
Discharge criteria
›Safe discharge features
›Normal mental status baseline
›Stable vitals for age
›Pain controlled on oral medications
›Normal neurovascular exam distal to injury
›Reliable caregiver observation
›Clear return precautions understood
18Discharge Instructions/di28
Copy discharge instructions
›Summary
›Injury evaluation today did not show life threatening injuries
›Symptoms can change in the next 24 to 48 hours
›Medications
›Acetaminophen as directed for pain
›Ibuprofen as directed for pain if no kidney disease and no bleeding risk
›Avoid aspirin unless prescribed
›Activity
›No sports or high risk activity until cleared if head injury symptoms
›Splint or sling use as directed if provided
›Elevation and ice for swelling in first 24 to 48 hours
›Follow up
›Primary care or clinic follow up in 1 to 3 days
›Fracture clinic follow up timing as instructed
›Concussion follow up if symptoms persist beyond 48 hours
›Return to emergency care now
›Increasing sleepiness or hard to wake
›Worsening headache
›Repeated vomiting
›Confusion or behavior change
›Seizure
›Weakness or numbness
›Trouble breathing
›Chest pain
›Abdominal pain worsening
›Fainting
›Bleeding that will not stop
›Blue or cold fingers or toes beyond an injury
19References/r8
Guidelines and decision tools
›Evidence sources
›American College of Surgeons ATLS Student Course Manual 2023
›Advanced Trauma Life Support for Doctors ATLS 10th edition 2018
›Pediatric Advanced Life Support PALS Provider Manual 2020
›PECARN head trauma clinical decision rule study 2009
›PECARN blunt abdominal trauma prediction rule study 2013
›NICE head injury assessment and early management guideline 2023
›EAST trauma practice management guidelines pediatric trauma topics various years local protocol dependent
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.