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History
Mechanism and context
Injury context
Time of injury
Location and environment
Witnessed event
Prehospital care
Immobilization used
Bleeding control used
Mechanism specific details
Mechanism details
Motor vehicle collision
Restraint use
Airbag deployment
Intrusion
Ejection
Rollover
Pedestrian or cyclist
Vehicle speed estimate
Run over
Fall
Height estimate
Landing surface
Sports
Collision
Axial load
Penetrating
Object type
Distance
Symptoms and OPQRST for pain
Pain OPQRST
Onset
Immediate
Delayed
Provocation and palliation
Worse with movement
Better with immobilization
Quality
Sharp
Dull
Burning
Region and radiation
Primary location
Radiation pattern
Severity
Child reported scale
Caregiver observed severity
Timing
Constant
Intermittent
Associated symptoms
Loss of consciousness
Amnesia
Seizure
Vomiting
Headache
Neck pain
Chest pain
Dyspnea
Abdominal pain
Weakness
Numbness
Baseline and prior episodes
Baseline status
Baseline neurodevelopment
Baseline mobility
Baseline communication
Baseline vision and hearing
Baseline behavior
Prior similar injuries
Alarm Features
First 5 minutes critical workflow
Immediate triggers
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
Medications
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
Diet
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
Review of Systems
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
Collateral History and Family History
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
Risk Factors
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
Differential Diagnosis
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
Past Medical History
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
Physical Exam
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
Lab Studies
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
Imaging
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
Special Tests
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
ECG
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
Assessment
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
Plan
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
Disposition
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
Discharge Instructions
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
References
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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.