Pediatric Trauma: xABCDE per ATLS 11th Edition (2025)

x — Exsanguinating hemorrhage control

• Scan for massive external bleeding before anything else. Apply direct pressure, wound packing with hemostatic gauze, a properly size-appropriate tourniquet (many adult tourniquets are too wide/stiff for small limbs — pediatric-specific tourniquets or improvised narrow tourniquets placed correctly are emphasized), and pelvic binders sized for a child's smaller pelvis.
• This step is done in parallel with, not instead of, calling for help and beginning monitoring.

A — Airway with cervical spine protection

• Relatively large occiput (causes neck flexion when lying flat — needs a shoulder roll or padding under the torso, not the head, to keep the airway neutral)
• Large tongue, prominent tonsils/adenoids, and a short, anteriorly positioned, more cephalad larynx that predispose to obstruction (Miller's Anesthesia, 10e, "Pediatric Trauma Patients")
• The airway is funnel-shaped with the cricoid ring as the narrowest point in younger children (classic teaching, still relevant for uncuffed vs cuffed ETT selection)
• Assume a full stomach regardless of last meal time — rapid sequence intubation is preferred when definitive airway is needed (Barash, Cullen & Stoelting's Clinical Anesthesia, 9e)
• Indications for definitive airway mirror adults: obstruction, respiratory distress/poor effort, inability to protect airway, deteriorating mental status, GCS <8, penetrating neck trauma with airway compromise (Sabiston Textbook of Surgery)
• C-spine protection uses age/size-appropriate immobilization; ATLS 11 has also revised spine motion restriction guidance toward more selective, less blanket immobilization (JournalFeed).

B — Breathing

• Higher baseline respiratory rates and lower functional reserve than adults; a compliant chest wall means underlying lung/mediastinal injury (pulmonary contusion, tension pneumothorax) can occur without rib fractures.
• The mediastinum is more mobile, so tension pneumothorax and mediastinal shift develop faster and are less well tolerated.
• Needle/finger decompression and chest tube sizing must be weight- and age-adjusted.

C — Circulation with hemorrhage control

• Children compensate well: tachycardia and vasoconstriction can maintain a normal blood pressure until 30-40% of circulating volume is lost. Hypotension is a late and ominous sign in a child, not an early one — do not wait for it.
• Estimated blood volume is ~80 mL/kg. Fluid/blood resuscitation is weight-based, typically guided by a length-based tool (e.g., Broselow tape) rather than adult fixed-volume boluses.
• ATLS 11's emphasis on damage control resuscitation (early blood products, reduced crystalloid, balanced transfusion) extends to pediatrics, though permissive hypotension targets used in adults are applied more cautiously in children given their narrow compensatory window (JournalFeed).
• Vascular access can be difficult in small children — intraosseous access is used early if IV access fails.

D — Disability (neurologic status)

• Use AVPU or a pediatric-adjusted GCS (verbal scoring modified for pre-verbal children).
• Check point-of-care glucose early — children have lower glycogen reserves and become hypoglycemic quickly under physiologic stress, which can mimic or worsen neurologic depression.
• Pupillary exam and gross motor/sensory screening as in adults.

E — Exposure/Environment

• Children have a much higher body-surface-area-to-mass ratio, so they lose heat far faster than adults — hypothermia worsens coagulopathy in an already bleeding patient.
• Fully expose to find all injuries but actively warm (warmed fluids/blood, warming blankets, keep room warm) immediately after exposure — this is emphasized more strongly given ATLS 11's broader focus on coagulopathy prevention.

Additional ATLS 11 themes relevant to pediatric care

• Structured team communication, defined roles, and checklists during resuscitation (reduces missed injuries — a real problem in pediatric trauma per recent literature: missed-injury rates remain a documented challenge in pediatric trauma centers, PMID 40063092).
• Trauma-informed, family-centered care is now formally incorporated, which matters especially for children (allowing caregiver presence when feasible, minimizing psychological trauma during resuscitation).
• A mandatory secondary/tertiary survey to catch injuries missed on the primary survey, which is disproportionately important in children who can't always localize or verbalize symptoms.

Trauma in Pregnancy: xABCDE per ATLS 11th Edition (2025)

x — Exsanguinating hemorrhage control

• Control massive external bleeding immediately, exactly as in non-pregnant patients (direct pressure, wound packing, tourniquet).
• If uncontrolled hemorrhage is present, the primary survey is explicitly re-prioritized to xABCDE(F) before proceeding further (Washington State DOH Trauma Resuscitation Guideline, Dec 2025, based on ATLS 11).

A — Airway with spinal motion restriction

• Pregnancy causes airway edema, friable mucosa, and reduced functional residual capacity — anticipate a difficult airway.
• A smaller endotracheal tube (6.5-7.0 mm) than usual may be needed due to airway edema.
• Maintain cervical spine stabilization per mechanism, using a neutral spine position (avoid hyperextension).

B — Breathing and ventilation

• Supplemental oxygen to keep maternal SpO2 >95% — the fetus tolerates maternal hypoxia poorly.
• Pregnancy reduces functional residual capacity and increases oxygen consumption, so desaturation happens rapidly — have a low threshold to support ventilation.
• Remember that mild tachypnea/hyperventilation is physiologic in pregnancy, not necessarily distress.

C — Circulation with hemorrhage control

• Maternal blood volume increases ~30-50% by term, so tachycardia and hypotension are delayed signs — the mother can lose up to ~30% of blood volume before showing classic shock signs, while the fetus may already be hypoperfused (Sabiston Textbook of Surgery; Mulholland and Greenfield's Surgery, 7e).
• Mild tachycardia and relative hyperventilation are normal in pregnancy and should not be over-interpreted as shock, but conversely, do not be falsely reassured by "normal" vitals — treat presumptively and resuscitate early and aggressively.
• After ~20 weeks gestation, place the patient in left lateral decubitus (or manually displace the uterus leftward) to relieve aortocaval compression from the gravid uterus and restore venous return/cardiac output. If spinal injury is suspected, secure to a backboard and tilt the whole board left rather than repositioning the patient alone.
• Early blood product transfusion and reduced crystalloid use (consistent with ATLS 11's broader damage-control resuscitation philosophy) apply here too, since occult abruption/fetomaternal hemorrhage can cause significant blood loss without obvious external bleeding.

D — Disability (neurologic status)

• Standard GCS and pupillary exam; AVPU as a rapid screen.
• No pregnancy-specific modification to GCS scoring itself, but be alert that eclampsia/pre-eclampsia can also alter mental status and must be considered in the differential for a pregnant trauma patient with altered consciousness.

E — Exposure and environmental control

• Fully expose the patient while preventing hypothermia (coagulopathy risk is compounded by pregnancy-related hypercoagulable/hemorrhagic physiology).
• Specifically assess for obstetric injury: uterine tenderness, fundal height, vaginal bleeding, and fluid leakage (rupture of membranes) — these findings screen for placental abruption, uterine rupture, and preterm labor.

Secondary survey additions specific to pregnancy (G — "Get monitoring/comfort," per the ATLS 11-aligned framework)

• Continuous maternal cardiac/BP monitoring.
• <20 weeks gestation: fetal heart rate by Doppler ultrasound.
• >20 weeks gestation: cardiotocographic (CTG) monitoring — generally recommended for a minimum of 4-6 hours (up to 24 hours if there are risk factors) given the risk of abruption presenting hours after the initial injury.
• FAST/eFAST is safe and preferred as initial imaging (detects hemoperitoneum and can assess fetal viability); standard plain radiography and CT should not be withheld out of fetal radiation concern when clinically indicated — maternal evaluation takes priority, with reasonable shielding/dose-minimization where feasible.
• Early, even pre-arrival, obstetric team notification/involvement is emphasized as part of the multidisciplinary, team-based approach that ATLS 11 broadly stresses (Mulholland and Greenfield's Surgery, 7e, "Team Approach to Trauma in the Pregnant Patient").
• Indications for emergency laparotomy are unchanged from non-pregnant patients — do not withhold surgery for fear of fetal compromise (Tintinalli's Emergency Medicine).
• Universal screening for intimate partner violence (IPV) is recommended, since pregnancy is a recognized risk period for IPV-related trauma.

Recent evidence context