Control bleeding by direct pressure, wound closure with staples as needed, or use of tourniquets for extremity hemorrhage not responsive to pressure.

Have pediatric airway equipment available (1/2 size bigger and smaller for age).
Manual in-line stabilization or blocks/sandbags with tape across forehead are better than an ill-fitting cervical collar.

Bag mask ventilation (BVM) with the provision of good mask fit, continuous positive airway pressure and ventilation is a key skill for managing pediatric trauma, and often more valuable than tracheal intubation.
Children have short tracheas and are often intubated too deeply. Endotracheal tubes are easily dislodged in transport. Secure equipment well. Minimize flexion/extension of neck.
Internal thoracic injury can occur without external or radiological signs of chest wall trauma.
Children desaturate quickly. Use modified rapid sequence/drug-assisted intubation protocols and/or apneic oxygenation to avoid hypoxia.
Insert NG/OG tube to improve respiratory status by relieving abdominal distention that impairs breathing. Avoid NG tube in patients with facial injuries or significant head trauma.

Beware of tachycardia and signs of peripheral vasoconstriction (delayed capillary refill, cool extremities, thready peripheral pulses) as early signs of shock. DO NOT wait for hypotension. Compensated shock can quickly lead to rapid decompensation/cardiac arrest.
Place intraosseous (IO) lines early if no IV access after 2 attempts or immediately in traumatic arrest/peri-arrest. Consider proximal humeral IOs in hemodynamically unstable patients, especially if concern for IAI, pelvic fracture or hemorrhage.
If compensated shock, minimize crystalloid (only give 10-20 mL/kg IV warmed isotonic fluids (NS or RL) rapid bolus), then warmed uncrossmatched PRBCs 10-20 mL/kg IV.
If active bleeding/hypotension, transfuse uncrossmatched PRBCs 10-20 mL/kg STAT.² Repeat prn. If ongoing need for blood after 20 mL/kg PRBCs, activate local massive hemorrhage protocol if available, and arrange transport ASAP.
If child requires transfusion and within 3 hours of injury, consider administering tranexamic acid.
If hemodynamically unstable, use eFAST to identify potentially reversible causes (e.g., pericardial effusion, pneumo/ hemothorax, abdominal free fluid).
Hemorrhage control is critical and should be addressed immediately. Direct pressure, tourniquets, pelvic binders, and splinting long bones should be rapidly completed.

Use the Pediatric Glasgow Coma Scale to assess/describe mental status. AVPU can also be used as a baseline assessment.
Assess pupil size, symmetry, and reactivity. Assess power in all extremities.
Check blood glucose if decreased LOC and in infants/young children to rule out hypoglycemia.
Treat pain (with analgesia and non-pharmacologic measures) and distress (with family presence, distraction techniques, and calm person at head of bed). Refer to TREKK’s Pain Treatment Bottom Line Recommendations.

Document temperature and keep warm using warm blankets, overhead heaters, forced air warmers (e.g., Bair Hugger®) and warmed intravenous fluids (+/- PRBCs).
Ensure full exposure and careful examination including anogenital region.

Option for family presence is standard of care in Pediatric Trauma Centers across North America to reduce patient/caregiver stress and enhance communication without compromising medical care or team dynamics.
Have a dedicated support person remain with family if they choose to be present for the resuscitation.
Assess the family’s preference, the availability of a support person, and the potential for exposure to invasive/distressing medical interventions. Serially reassess whether this option remains appropriate/desirable.