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  • Injury is the leading cause of death of children in the United States.

  • Orotracheal intubation is the most reliable means of securing an airway.

  • Hypovolemic shock is caused by blood loss, which makes up 8% to 9% of the body weight of a child. Determining the extent of volume depletion and shock requires evaluation of multiple parameters.

  • Attempt vascular access en route.

  • Intraosseous (IO) access should be obtained for immediate fluid resuscitation if attempts at intravenous (IV) cannulation are unsuccessful after 3 attempts or within 90 seconds.

  • For shock, give a rapid initial infusion of 20 mL/kg of crystalloid solution.

  • Unique characteristics of the pediatric cervical spine (C-spine) predispose it to ligamentous disruption and dislocation injuries without radiographic evidence of bone injury.

  • Radiographs to be obtained as soon as possible in the setting of major blunt trauma include lateral cervical spine, antero-posterior (AP) chest, and AP pelvis views.

Injury is the leading cause of deaths in children in the United States, representing almost 40% of all pediatric fatalities.1 Approximately 20,000 children die as a result of injury per year. For every child that dies from an injury, 40 others are hospitalized and 1120 are treated in EDs.2 Up to 70% of pediatric patients die prior to arrival at a center capable of providing care.3

Mortality data alone does not reveal the profound impact of trauma. For children less than 19 years of age, injuries are the leading cause of visits to EDs, numbering 9 million, accounting for more than 225,000 admissions, and resulting in nearly $87 billion in health care and societal costs.1 Even minor injuries can have lasting effects, causing physical or cognitive functional impairment and affecting quality of life years after the acute traumatic event. Therefore, the physical, emotional, and psychological needs of the child and family must be considered.

Early recognition and treatment of life-threatening airway obstruction, inadequate breathing, and intra-abdominal and intra-cranial hemorrhage significantly increases survival rate following major trauma. The initial assessment and management of the injured child follows the same ATLS® sequence as adults: primary survey and resuscitation, followed by secondary survey.4 Pain evaluation and control as well as constant reassessment ensures quality of care.


Blunt trauma is the predominant mechanism of injury in children, with only 10% to 20% suffering penetrating injury.2 Boys are injured twice as frequently as girls. Motor vehicle crashes (MVCs) account for more than half of all childhood trauma deaths.1 Other major causes of death are falls, drowning, poisoning, and fire-related injuries, with the relative incidence for each injury type varying by age group (Table 23-1).5

TABLE 23-1Leading Causes of Fatal Injury in Children by Age Group in 20151

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