Bedside Snapshot
- Recognize
- Mechanism plus perfusion and mental status. Capillary refill, heart rate and GCS trend matter more than blood pressure. A normal BP does not exclude shock.
- Red Flags
- Capillary refill above 2 s or cool, mottled skin
- Any fall in GCS
- New unequal or fixed pupil, or posturing
- First Actions
- ABCDE. Stop bleeding; limit crystalloid to one 20 mL/kg bolus, then blood early; prevent hypoxia and hypotension; 0.9% saline in TBI.
- Key Doses
- 3% saline 2–5 mL/kg IV over 10–20 min (ICP)
Calcium chloride 20 mg/kg (max 2 g)
TXA: 15 mg/kg IV/IO (max 1 g) over 10–20 min, then 2 mg/kg/hr (max 1 g); protocol-dependent - Don't Miss
- Abusive head trauma when the injury does not fit the history; hypoglycemia as the cause of altered mental status; hemorrhage with a normal blood pressure.
- Escalate & Transport
- Pediatric trauma center per protocol. Neurocritical care for ICP. Child protection for an injury that does not fit the history.
Overview & Pediatric Differences
Injured kids look fine for longer than injured adults. Their reserves and chest walls work differently, so the early signs of shock and brain injury are quiet. This page covers recognizing and resuscitating the injured child with hemorrhage, the imaging calls for head and cervical spine injury, and the care of traumatic brain injury (TBI). Burns, detailed chest or belly injury and child protection each have their own pages.
Why Kids Are Different
- Compensation hides shock: a young child can lose significant blood and still look stable. The pressure holds, then falls late. A normal blood pressure does not rule out hemorrhagic shock.
- Smaller reserves: functional residual capacity, blood volume, and chest wall and spinal soft-tissue mobility all differ from adults. That makes children more prone to hypoxemia.
- Compliant chest wall: a pliable chest passes force straight into the lungs and heart. Serious lung or heart injury can happen with no rib fractures at all.
- Brain injury is fragile: hypoxia and hypotension after TBI pile onto the injury already there. Oxygenation and perfusion come first.
- Infants cannot give a history: check the mechanism against the child's age and mobility. The child maltreatment page covers the rest.
Scope: these decision rules are for blunt injury in children. They screen and triage. A child who misses a rule still gets a full clinical assessment.
Recognition & Severity
Read the vitals and the mental status together. Compensated shock shows up first as tachycardia, slow capillary refill, cool skin and a narrowing pulse pressure. Blood pressure is the late sign. Use these canonical thresholds. Systolic hypotension is below 60 mmHg in a neonate (0–28 days), below 70 mmHg in an infant (1–12 months), below 70 + 2 × age for ages 1–10 years, and below 90 mmHg over 10 years. Capillary refill is normal at 2 seconds or less. For heart and respiratory rates, use the age-based vital signs.
| Feature | Mild or Compensated | Moderate | Severe or Decompensated |
|---|---|---|---|
| Heart rate | Tachycardia for age with normal blood pressure | Tachycardia with prolonged capillary refill | Bradycardia below 60/min with poor perfusion |
| Capillary refill | 2 s or less | More than 2 s | More than 2 s with cool or mottled skin |
| Systolic BP | Normal for age | Normal, with a falling pulse pressure | Below 60 mmHg (neonate); below 70 mmHg (infant); below 70 + 2 × age (1–10 years); below 90 mmHg (over 10 years) |
| Mental status | GCS 15, behaving normally | GCS 9–14 or altered (a PECARN spine risk factor) | GCS 3–8 or unresponsive (a PECARN spine risk factor) |
| Airway and breathing | Normal work of breathing | Increased work of breathing | Abnormal airway, breathing or circulation |
Age-Specific Presentation
- Infant: irritability or lethargy, poor feeding, a bulging fontanelle, or a bruise on the head, ears or frenulum. Any of these is a reason to look for an injury that does not fit the history.
- Toddler and preschool child: crying that will not settle, a limp that suggests a fracture, and vomiting after head injury.
- School-age child and adolescent: the injury pattern looks more like adult trauma. Assess and treat as an adult, with pediatric dosing and vital-sign limits.
Pediatric Glasgow Coma Scale
The adult GCS is hard to apply in children under about 5 years. The paediatric version, validated in clinical use, scores eye, verbal and motor responses against age-expected responses. Verbal scoring is age-adjusted. So trend serial scores, and don't rely on one.
Red flags: any fall in GCS. A new unequal or fixed pupil. Posturing. A falling level of consciousness with bradycardia. Hypotension at any age. Treat every one of these as an emergency, then move to the management section for the injury.
Differential Diagnosis
Several conditions look like trauma, or hide alongside it. Check for each one before you blame a change in mental status on the injury.
| Condition | Distinguishing Features | Key Test or Finding |
|---|---|---|
| Abusive head trauma | Injury that does not fit the history or development; sentinel bruising | Full skin examination; child maltreatment page |
| Hypoglycemia | Altered mental status with no clear injury, or a seizure | Point-of-care glucose in every altered child |
| Seizure | Witnessed convulsion or post-event confusion | Ask about events; treat per the seizure protocol |
| Hemorrhagic shock | Tachycardia, cool skin, prolonged capillary refill with a normal blood pressure | Serial capillary refill and heart rate; hemoglobin |
| Intoxication or opioid toxicity | Depressed breathing or pinpoint pupils with altered mental status | Respiratory rate and pupils; naloxone per the weight-based dosing page |
Management by Type: Hemorrhagic Shock
- Stop the bleeding: direct pressure, tourniquet and hemorrhage control per local protocol. For pelvic bleeding, a pelvic binder per protocol (Pelvic Binder). See Hemorrhage Control.
- Prevent hypothermia: remove wet clothing, cover the child, and use warmed fluid and a blood warmer where stocked. Cold makes the coagulopathy worse.
- Decompress the chest if indicated: for suspected tension pneumothorax with shock, needle decompression per protocol (Needle Decompression).
- Limit crystalloid: one 20 mL/kg bolus of crystalloid before blood, at most. Balanced crystalloid is the better choice over 0.9% saline when both are on hand. Run the bolus over 5–20 min, and reassess after each one.
- Start blood early: red cells and plasma, plus platelets per protocol, go in a balanced ratio. Pediatric multicenter studies tied a higher plasma-to-red-cell ratio to better survival.
- Use whole blood where stocked: low-titer group O whole blood is linked to better survival in kids with life-threatening bleeding. Plenty of pediatric centers hand out RhD-negative units to girls and women who could become pregnant.
- Give tranexamic acid early: the pooled pediatric data on TXA are observational. That is 10 studies, 1 randomized trial and 34,144 children. Fewer children died (odds ratio 0.58, 95% CI 0.38–0.89). The best results came from a subgroup given a 1 g first dose, and that dose was not adjusted for weight. In the same analysis, seizures ran slightly higher with TXA. Get it in within 3 hours of injury. Dose by weight, per protocol. The Tranexamic Acid page has the details.
- Check ionized calcium: during rapid transfusion, replace calcium per protocol. See Calcium Chloride below.
- Transport: to a pediatric trauma center per protocol. Field triage runs on the CDC field triage criteria and local protocol (Trauma Assessment). The NAEMSP 2025 position statement recommends blood for hemorrhagic shock when you have it, along with judicious crystalloid.
Do not wait for hypotension: by the time a bleeding child's pressure drops, that child is near circulatory collapse. Base the resuscitation on perfusion and mechanism.
Protocol-dependent: each system and blood bank sets its own prehospital blood, whole blood and tranexamic acid use, and its own pediatric product volumes. Work from local protocols and medical direction.
Management by Type: Traumatic Brain Injury
Prevent Secondary Injury
- Oxygen and blood pressure first: hypoxia and hypotension make outcome worse after TBI. Prevent both.
- Isotonic fluid only: 0.9% saline is the crystalloid of choice in TBI. Avoid hypotonic fluid.
- Check glucose and treat seizures: per protocol, in every child with altered mental status. Early seizure prophylaxis follows protocol, and the agent and duration vary by center.
- Steroids and prophylactic hypothermia: neither one is a way to improve outcome after TBI. Do not give corticosteroids or start prophylactic hypothermia for that (BTF pediatric guidance).
Airway, Ventilation and Blood Pressure
- Oxygen: keep SpO₂ at 94–99%. Avoid hypoxia.
- Ventilation: target normocapnia, with PaCO₂ about 35–40 mmHg. In the field you will usually measure EtCO₂, and it reads a few mmHg below PaCO₂.
- Avoid prophylactic hyperventilation: do not push PaCO₂ below 30 mmHg. Brief, mild hyperventilation is a stopgap for signs of herniation only. Then return to normocapnia (BTF pediatric guidance).
- Head position: head of bed 30 degrees with the head midline, when the spine allows.
- Blood pressure: hold systolic at or above the age-based target, which the BTF pediatric threshold sets at the 5th percentile for age. Treat any systolic below the age-based hypotension threshold (see Recognition & Severity).
- Intubation: plan the RSI with a hemodynamic check before induction, and avoid hypotension and hypoxia during and after intubation (RSI).
Raised ICP and Herniation
A falling GCS, a new dilated or fixed pupil, or posturing means raised intracranial pressure (ICP) or herniation. The pediatric guideline targets ICP below 20 mmHg. Cerebral perfusion pressure (CPP) sits at an age-specific target, and this page uses 40 mmHg as the floor. The neurocritical care protocol sets the age band.
- Hypertonic saline 3% bolus: 2–5 mL/kg IV over 10–20 min for intracranial hypertension (BTF 2019 pediatric recommendation). Recheck sodium and repeat per ICP.
- Continuous 3% infusion: 0.1–1.0 mL/kg/hr on a sliding scale, at the minimum dose that keeps ICP below 20 mmHg.
- 23.4% for refractory ICP: 0.5 mL/kg, maximum 30 mL, through a central line under neurocritical care protocol. The source here is institutional practice, not the BTF guideline.
- Sodium ceiling (neurocritical care protocol): avoid sustained serum sodium above 170 mEq/L for more than 72 hr.
- Mannitol: the fallback if hypertonic saline can't be given. Hold it for hypotension. Neurocritical care protocol sets the pediatric dose.
Prehospital: the Brain Trauma Foundation prehospital guideline (3rd edition, 2023) was derived from adults, and its hyperosmolar wording has not been confirmed for children. If herniation is in play, hypertonic saline goes in under protocol and medical direction.
Imaging Decision: PECARN Head Rule (GCS 14–15)
Derivation and validation of the PECARN head rules used a combined sample of 42,412 children with blunt head trauma, a GCS of 14–15, and presentation within 24 hours. Clinically important TBI occurred in 0.9%, and neurosurgery in 0.1%. Meet every item in the age-matched row and the child is at very low risk, so CT can be avoided. Below a GCS of 14, the rules don't apply.
| Age | Items Present |
|---|---|
| Under 2 years | Normal mental status; no scalp hematoma except frontal; no loss of consciousness or less than 5 s; non-severe injury mechanism; no palpable skull fracture; acting normally per parents |
| 2 years and older | Normal mental status; no loss of consciousness; no vomiting; non-severe injury mechanism; no signs of basilar skull fracture; no severe headache |
Severe mechanism is any one of these. A motor vehicle crash with ejection, death of another passenger or rollover. A pedestrian or bicyclist without a helmet struck by a motorized vehicle. A fall of more than 0.9 m (3 ft) for a child under 2 years, or more than 1.5 m (5 ft) for a child 2 years and older. A head struck by a high-impact object. The non-severe-mechanism item counts as met only if none of these apply.
Intermediate risk (not very low risk) is a middle tier. It is not a CT rule. The rule does not settle CT versus observation. That call rests on clinician experience, parental preference, and features such as multiple findings or worsening symptoms.
Any item missing: the child is not in the very-low-risk group. Bring in a clinician who can make the CT call. Don't let the rule be the reason to delay transport or care.
Cervical Spine Imaging: PECARN 2024 Rule
The 2024 PECARN cervical spine rule was derived and validated in 22,430 children with blunt trauma. In the validation cohort, it reached 94.3% sensitivity, 60.4% specificity and 99.9% negative predictive value. The authors' algorithm recommends CT for high-risk factors. Plain radiographs cover the other factors.
- High-risk factors: GCS 3–8 or unresponsive on AVPU; abnormal airway, breathing or circulation; or a focal neurologic deficit (paresthesia, numbness or weakness). One is enough for CT of the cervical spine.
- Other factors: neck pain; altered mental status (GCS 9–14, AVPU verbal or pain, or other signs); substantial head injury; substantial torso injury; or midline neck tenderness. One is enough for plain radiographs of the neck.
- No factors: the negative predictive value was 99.9%. Local protocol governs imaging and clearance.
Do not clear the spine on examination alone in an altered child. Altered mental status (GCS below 15 or AVPU other than alert) is a risk factor the rule counts.
Medications & Dosing: Hemorrhage and Resuscitation
| Drug | Dose & Route | Max | Notes |
|---|---|---|---|
| Red cells (pRBC) or whole blood | 10–20 mL/kg IV/IO per unit size and blood bank protocol | None established; reassess after each unit | Balanced ratio with plasma; ionized calcium per protocol. Low-titer group O whole blood where stocked (Whole Blood). |
| Plasma | About 15 mL/kg IV/IO (actual weight) guided by INR, fibrinogen or viscoelastic results | None established | Balanced with red cells. Pediatric MTP ratio per the local dose book (Blood Products). |
| 0.9% saline or lactated Ringer's | 10–20 mL/kg IV/IO over 5–20 min reassess after each bolus | One 20 mL/kg bolus before blood in hemorrhage | Stop for overload. Use 0.9% saline in TBI. Balanced crystalloid is preferred for other shock (Normal Saline). |
| Tranexamic acid | Pediatric (protocol-dependent, off-label): 15 mg/kg IV/IO over 10–20 min, then 2 mg/kg/hr Adult: 1 g over 10 min, then 1 g over 8 hr (not for children) | Pediatric: 1 g load, 1 g infusion; adult total 2 g; start within 3 hr of injury | Off-label for trauma in the US. Pediatric evidence is observational; seizures were slightly more frequent in the pooled analysis (Tranexamic Acid). |
| Calcium chloride 10% | 20 mg/kg IV/IO slowly (0.2 mL/kg of 10%) repeat per ionized calcium | 2 g | Central or IO access preferred. Give for citrate-related hypocalcemia during massive transfusion (Calcium Chloride). |
Adult fixed doses in children: Adult fixed amounts are a common trauma error. Stop using them. Work out tranexamic acid, calcium and blood products from the child's measured weight and the protocol.
Doses vary by protocol; follow local protocols and medical direction. Blood is ordered by component. Think units and ratios, not milligrams.
Medications & Dosing: Brain Injury and Analgesia
| Drug | Dose & Route | Max | Notes |
|---|---|---|---|
| Hypertonic saline 3% High-alert | 2–5 mL/kg IV over 10–20 min (3% = 30 mg/mL, 513 mEq/L Na⁺) | Adult: 100–150 mL per bolus (no pediatric volume cap; use the mL/kg dose) | Intracranial hypertension bolus (BTF 2019 pediatric recommendation). Recheck sodium after each bolus; avoid sustained sodium above 170 mEq/L (Hypertonic Saline 3%). |
| Hypertonic saline 3%, continuous High-alert | 0.1–1.0 mL/kg/hr IV infusion, sliding scale | Titrate to ICP below 20 mmHg; no fixed max | Lowest dose that keeps ICP below 20 mmHg. Avoid sustained sodium above 170 mEq/L. |
| Hypertonic saline 23.4% High-alert | 0.5 mL/kg IV bolus (central line) | 30 mL per bolus | Refractory ICP only, under neurocritical care protocol (institutional practice, not a BTF guideline dose). Not for peripheral IV. |
| Mannitol | Adult: 0.5–1 g/kg IV over 15–30 min Pediatric: 0.25–1 g/kg IV over 20–30 min per neurocritical care protocol | No fixed max; hold for hypotension | Alternative when hypertonic saline cannot be given. Adult rate cap: not to exceed 0.1 g/kg/min (Mannitol). |
| Fentanyl High-alert | 1 mcg/kg IV/IO, slow push over 1–2 min (50 mcg/mL) | Initial dose max 100 mcg; repeat per protocol | Analgesia for injury; intranasal fentanyl is preferred for children without IV access under the NAEMSP 2023 pain guideline (Fentanyl). |
Hypertonic saline is dosed in mL/kg for children: Run the adult number and a 100 mL bolus lands at 10 mL/kg in a 10 kg child. That is two to five times the pediatric range. Get the volume from the weight. Then have a second clinician check the concentration and the volume.
The ISMP lists hypertonic saline and fentanyl as high-alert drugs. Doses vary by protocol; follow local protocols and medical direction.
Monitoring, Reassessment & Disposition
| Parameter | Target | Notes |
|---|---|---|
| SpO₂ | 94–99% | Avoid hypoxia after TBI and hemorrhage |
| Blood pressure | At or above the age threshold | SBP below the age-based hypotension threshold (see Recognition & Severity); avoid hypotension in TBI |
| ICP | Below 20 mmHg | Pediatric guideline threshold; treat sustained elevation |
| Cerebral perfusion pressure | Age-specific; floor 40 mmHg | Pediatric guideline; age band per neurocritical care protocol |
| PaCO₂ (EtCO₂ proxy) | PaCO₂ 35–40 mmHg (EtCO₂ reads a few mmHg lower) | Avoid prophylactic hyperventilation (PaCO₂ below 30 mmHg); brief hyperventilation only for herniation |
| Serum sodium | Avoid above 170 mEq/L | Sustained above 170 mEq/L for more than 72 hr is the limit; check after each bolus |
| Temperature | Normothermia | Prevent fever and hypothermia |
- Labs: hemoglobin, ionized calcium, coagulation studies and fibrinogen when bleeding or transfusing; sodium after each hypertonic bolus; glucose.
- Reassessment: after each bolus, unit of blood and neurologic check; neurologic checks per local protocol.
- Disposition: pediatric ICU or pediatric trauma center for hemorrhage, a GCS below 15 with any decline, or a positive CT.
Pitfalls & Safety Checks
| Pitfall | Consequence | Prevention |
|---|---|---|
| Normal blood pressure taken as no shock | Late collapse | Use capillary refill, heart rate and mental status; trend vitals |
| Adult fixed volume in a child | Hypertonic overdose or wrong tranexamic acid dose | Calculate from measured weight; second check |
| Crystalloid before blood | Dilution and worse coagulopathy | One 20 mL/kg bolus at most before blood |
| Hypotonic fluid in TBI | Worsens brain swelling | 0.9% saline in TBI |
| Spine cleared on examination in an altered child | Missed cervical injury | PECARN factors; imaging per algorithm |
| CT decision without the rule | Unneeded radiation or a missed injury | Apply PECARN head rules only at GCS 14–15 |
| Hypoglycemia missed as TBI | Untreated cause of altered mental status | Point-of-care glucose in every altered child |
| Prophylactic hyperventilation after TBI | Cerebral ischemia from low PaCO₂ | Target normocapnia; brief hyperventilation only for herniation |
| Hypotension during intubation | Secondary brain injury | Plan the RSI; treat hypotension and hypoxia at induction |
| Inflicted injury missed | Repeat injury | Full skin examination; child protection per state law |
Most catastrophic error: dosing hypertonic saline by the bag instead of by kilograms. Work in mL/kg. Read the concentration off the label before the bolus goes in.
Special Populations
Infants and Young Children
- History: the child can't tell you what happened. Write down the caregiver's account word for word, then check it against the injury.
- Imaging: under 2 years, the PECARN head rule carries its own items. Use them only at GCS 14–15.
- Abuse screen: see child maltreatment.
Adolescents
- Protocol switch: switch to adult protocols at 40 kg or more, or when the child is beyond the length-based tape. Each service should run one rule.
Children on Hyperosmolar Therapy
- Sodium: check after each bolus and avoid sustained sodium above 170 mEq/L.
- Central access: 23.4% saline goes in through a central line only.
Suspected Abuse
- Report: child protection and reporting follow state law. Don't confront the caregiver in the field. The child maltreatment page covers the detail.
Prehospital & Transport Considerations
| Level | Typical Role in This Topic |
|---|---|
| EMT | Airway, hemorrhage control, cervical spine precautions, vital signs and GCS, transport to a pediatric trauma center |
| AEMT | IV or IO access and analgesia per protocol |
| Paramedic | Blood products where stocked, tranexamic acid and weight-based analgesia per protocol |
| RN (ED/ICU) | Hypertonic saline boluses and infusions, sodium checks, ICP and cerebral perfusion monitoring |
| Critical care transport | Ventilation, pumps and concentrations, blood on board where carried, and the handoff |
- Equipment and preparation: length-based tape, pre-drawn or colour-coded doses, and size-appropriate collars and restraints.
- Restraint: size-appropriate on the stretcher. Never a caregiver's lap.
- Destination: a pediatric trauma center per protocol, with pediatric-capable ICU and neurosurgery. Field triage runs on the CDC field triage criteria and local protocol.
- Handoff: a structured report such as IMIST-AMBO or MIST, with the mechanism, GCS trend, vital-sign trend, blood given and times.
Clinical Pearls
Blood pressure is the last thing to fall: Don't take a normal pressure in a bleeding child at face value. Compensation holds the number up until the reserve is gone. Once it finally falls to the hypotension threshold, the child is close to collapse. Act on capillary refill, heart rate and mental status well before that.
A negative PECARN rule answers one question: The head and neck rules find the children at very low risk. They do not prove a child is well. A child who fails any item still needs a clinician's decision. An altered child still needs a neck decision before the collar comes off.
Weigh the saline, not the bag: Pediatric hypertonic saline is dosed in mL/kg. The 100 mL adult bag is a volume built for an adult. Write the dose in mL/kg and the volume in mL on the run sheet. That is the simplest way to catch the error before it reaches the line.
References
- Kochanek PM, Tasker RC, Carney N, et al. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines. Pediatr Crit Care Med. 2019;20(3 suppl 1). https://doi.org/10.1097/PCC.0000000000001735
- Kuppermann N, Holmes JF, Dayan PS, et al; Pediatric Emergency Care Applied Research Network. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study (landmark trial). Lancet. 2009;374(9696):1160-1170. https://doi.org/10.1016/S0140-6736(09)61558-0
- Leonard JC, Harding M, Cook LJ, et al. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child Adolesc Health. 2024;8(7):482-490. https://doi.org/10.1016/S2352-4642(24)00104-4
- Cicero MX, Adelgais K, Funaro MC, et al. Prehospital Trauma Compendium: Pediatric Severe and Inflicted Trauma - A Position Statement and Resource Document of NAEMSP. Prehosp Emerg Care. 2025. https://doi.org/10.1080/10903127.2025.2457141
- Morgan KM, Leeper CM, Yazer MH, Spinella PC, Gaines BA. Resuscitative practices and the use of low-titer group O whole blood in pediatric trauma. J Trauma Acute Care Surg. 2023;94(1S suppl 1):S29-S35. https://doi.org/10.1097/TA.0000000000003801
- Lin YC, Wang TH, Kang YN, Chiu HH. Effect of tranexamic acid on children with traumatic bleeding: a systematic review and meta-analysis. Am J Emerg Med. 2025;97:65-71. https://doi.org/10.1016/j.ajem.2025.07.008
- Emergency department implementation of the Brain Trauma Foundation pediatric severe brain injury guideline recommendations. Pediatr Emerg Care. 2020 Apr;e239-e241. https://doi.org/10.1097/PEC.0000000000001903
- Reilly PL, Simpson DA, Sprod R, Thomas L. Assessing the conscious level in infants and young children: a paediatric version of the Glasgow Coma Scale. Childs Nerv Syst. 1988;4(1):30-33. https://doi.org/10.1007/BF00274080
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- For Educational Purposes Only: This content is intended for educational reference and should not be used for clinical decision-making.
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