Pediatric Trauma in the Field

Why this matters

A 4-year-old can look acceptable after a high-speed crash because the blood pressure is still in an adult normal range. The child can then deteriorate during transport. Children compensate for a long time, then they fail quickly. Adult blood-pressure cutoffs do not clear them.

First, compare the heart rate and capillary refill with the child's age. Check whether the child is quiet. Do not wait for a low blood pressure, and do not give a large adult-style saline bolus. ACS 2021 field triage uses pediatric physiologic criteria for this reason. A fast heart rate and delayed capillary refill show up before the blood pressure falls.

Clinical sequence

1. Use a length-based tape for weight and equipment. Do not guess.
2. Keep the child warm. Do not leave the child on cold wet sheets. Cold plus bleeding is dangerous.
3. Treat a quiet child after trauma as a warning sign. A fast heart rate and delayed capillary refill mean shock before the blood pressure falls.
4. Give oxygen. Protect the blood pressure, especially in a head injury. Do not give a large adult-style saline bolus. Give blood only if your program carries it and the child is in hemorrhagic shock. Treat pain per protocol. Go to a pediatric-capable trauma center when the system has one.

Teaching points

• Children compensate, then deteriorate quickly. A fast heart rate and delayed capillary refill appear before low blood pressure. Do not wait for adult blood-pressure cutoffs. Low blood pressure is late.
• Field triage: an abnormal pediatric Glasgow Coma Scale score or abnormal pediatric vital signs, penetrating injury to the torso, head, or neck, chest-wall instability, or two or more long-bone fractures goes to the highest-level pediatric trauma center available.
• Airway: a large occiput, the back of the head, needs padding under the shoulders, not a large pad under the head. Use modest ventilation volumes. See the pediatric airway lesson.
• Family: one calm parent can help if that keeps the airway safer. Do not let a chaotic scene replace the primary survey.
• NAEMSP 2025 pediatric trauma themes: use modest crystalloid, give blood for hemorrhagic shock when it is available, prevent low oxygen and low blood pressure especially in traumatic brain injury, treat pain, and use a pediatric trauma center. Your protocol owns fluids and milligrams.

Common errors

• Using adult blood-pressure cutoffs and calling a child stable.
• Treating a quiet child as a well child. Crying can be reassuring. A quiet child is more concerning.
• Leaving a bleeding child on cold wet sheets.

Practice

Related: Trauma triage, Pediatric airway.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

• NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; your protocol decides
• ACS/CDC 2021 Field Triage Guidelines — pediatric physiologic and anatomic criteria
• NAEMSP 2025 — Pediatric Severe and Inflicted Trauma — modest crystalloid, blood if available, prevent hypoxia and hypotension (especially TBI), treat pain, pediatric trauma center