Paediatric Trauma

Quick Answer

One-liner: Paediatric trauma requires age-appropriate assessment, rapid recognition of compensated shock, and timely intervention using weight-based resuscitation protocols.

Paediatric trauma accounts for a significant proportion of ED presentations and mortality in children. Unlike adults, children have superior physiological compensation (tachycardia, vasoconstriction) allowing them to maintain blood pressure until decompensation is imminent. The key to paediatric trauma management is early recognition of shock through vital sign abnormalities (particularly tachycardia) before hypotension develops. Immediate priorities include pediatric-specific ABCDE approach, weight-based fluid resuscitation (20 mL/kg boluses), and early specialist involvement. Family-centered care is essential, with parent presence encouraged during procedures when safe.

---

ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Pediatric airway differences (larger occiput, relatively large tongue, anterior larynx), flexible thoracic cage, proportionally larger head
• Physiology: Higher metabolic rate, higher oxygen consumption, superior compensatory mechanisms, age-dependent vital signs
• Pharmacology: Weight-based dosing, age-appropriate drugs, intravenous access challenges

Fellowship Exam Relevance

• Written: High-yield areas include PECARN rules, pediatric trauma scores, fluid resuscitation protocols, C-spine clearance, non-accidental injury recognition
• OSCE: Pediatric trauma scenarios requiring family communication, weight-based calculations, and recognition of compensated shock
• Key domains tested: Medical Expert (clinical management), Collaborator (teamwork), Professional (ethical considerations, mandatory reporting)

---

Key Points

---

Epidemiology

Australian/NZ Specific

• Trauma is the leading cause of death in children aged 1-14 in Australia [6]
• Aboriginal and Torres Strait Islander children have 2-3× higher trauma mortality rates [7]
• Māori children in NZ have 2× higher trauma rates compared to non-Māori [8]
• Road traffic injuries, falls, and assault are leading mechanisms [9]
• Rural and remote areas have higher mortality due to prolonged transport times [10]

---

Pathophysiology

Mechanism of Pediatric Trauma

Anatomical Differences:

• Larger head-to-body ratio: Higher center of gravity, propensity for head injury in falls
• Flexible rib cage: Less protection for intrathoracic organs, higher risk of pulmonary contusion without rib fractures
• Proportionally larger organs: Higher risk of solid organ injury (liver, spleen)
• Incomplete ossification: Growth plate injuries (Salter-Harris fractures) more common than ligamentous injuries
• Subcutaneous fat: Less protective muscle mass, more impact transmission

Physiologic Differences:

• Higher cardiac output: 5-6 L/min/m² vs 3-4 L/min/m² in adults
• Higher oxygen consumption: 6-8 mL/kg/min vs 3-4 mL/kg/min in adults
• Superior compensatory mechanisms: Tachycardia, vasoconstriction maintain BP until late decompensation
• Limited glycogen stores: Faster progression to hypoglycaemia
• Greater surface area-to-volume ratio: Faster heat loss, hypothermia risk

Shock Pathophysiology in Children

Blood Loss 5-10% → Normal BP, Mild tachycardia → Compensated (Class I)
Blood Loss 10-15% → Normal BP, Tachycardia + delayed capillary refill → Compensated (Class II)
Blood Loss 15-25% → Normal BP, Tachycardia + prolonged capillary refill + altered mental status → Compensated (Class III)
Blood Loss greater than 30% → Hypotension (late sign!) → Decompensated (Class IV)

Why Hypotension Is Late:

• Children maintain cardiac output through increased heart rate (Frank-Starling)
• Vasoconstriction shunts blood to vital organs (brain, heart)
• Systolic BP = 70 + (2 × age in years) - hypotension defined as below this threshold
• Once hypotension develops, rapid decompensation and cardiovascular collapse occur

Injury Patterns by Age

Why It Matters Clinically

Understanding pediatric-specific pathophysiology is critical because:

1. Normal adult norms do not apply - age-dependent vital signs are essential
2. Appearance can be deceiving - well-appearing children can be severely compromised
3. Early intervention matters - decompensation occurs rapidly once hypotension develops
4. Injury patterns differ - age-specific mechanisms guide differential diagnosis
5. Family presence is therapeutic - parental anxiety affects child's distress and cooperation

---

Clinical Approach

Recognition

Pediatric trauma should be suspected in any child with:

• History of significant mechanism (fall greater than 1m, MVC, pedestrian injury)
• Altered level of consciousness
• Evidence of significant trauma (visible deformity, penetrating injury)
• Suspicious injury pattern inconsistent with mechanism
• Unexplained physiological abnormalities

Trigger Signs for Trauma Team Activation (vary by institution):

• GCS below 13
• Systolic BP below 70 + (2 × age)
• Respiratory distress or failure
• Penetrating trauma to head, neck, torso, or proximal extremities
• Two or more proximal long bone fractures
• Suspected spinal cord injury
• Major burns (greater than 10% TBSA in children)
• Multiple fractures with significant mechanism

Initial Assessment

Primary Survey (ABCDE)

A - Airway with C-spine Protection

• Assess airway patency: listen, look, feel
• Assess ability to speak (older children), cry (infants)
• C-spine immobilization: hard collar, sandbags, tape until cleared
• Pediatric considerations:
  • Larger occiput causes neck flexion in supine position - place padding under shoulders to align neutral position
  • Higher larynx (C3-C4 vs C5-C6 in adults) - smaller visualizable area
  • Relatively large tongue -更容易 obstruction
  • Short neck and mandible - may complicate airway management

Immediate interventions:

• Chin lift/jaw thrust (opens airway, maintains C-spine alignment)
• Oropharyngeal airway (size = corner of mouth to angle of jaw)
• Nasopharyngeal airway (if not contraindicated, age-appropriate size)
• Consider early definitive airway: GCS below 8, severe facial trauma, respiratory failure

B - Breathing and Ventilation

• Assess respiratory rate, effort, oxygen saturation
• Auscultate bilateral breath sounds
• Look for signs of tension pneumothorax, flail chest

Age-dependent respiratory rates:

Immediate interventions:

• High-flow oxygen (15 L/min via non-rebreather)
• Ventilation assistance if inadequate breathing (bag-valve-mask)
• Needle decompression if tension pneumothorax (2nd intercostal, midclavicular - 4-5cm anterior to midline)
• Chest tube for hemothorax/pneumothorax

C - Circulation with Hemorrhage Control

• Assess capillary refill time (below 2 seconds normal)
• Assess peripheral pulses (radial, femoral)
• Assess skin temperature and colour
• Measure blood pressure (age-appropriate cuff)

Age-dependent vital signs:

Hypotension definition: Systolic BP < 70 + (2 × age in years)

Immediate interventions:

• Control obvious external hemorrhage (direct pressure, tourniquet for extremities)
• Establish vascular access: 2 large-bore IVs, intraosseous if IV not obtainable within 90 seconds
• Fluid resuscitation: 20 mL/kg isotonic crystalloid (0.9% saline) - repeat up to 3 times
• Blood products after 3rd bolus or if hemodynamically unstable: 10-20 mL/kg pRBC, 1:1:1 (pRBC:FFP:platelets) if massive transfusion protocol

D - Disability (Neurological Status)

• Assess GCS (pediatric version)
• Assess pupillary response (size, reactivity)
• Assess limb movement and sensation

Pediatric GCS:

Immediate interventions:

• Rapid sequence intubation if GCS below 8 or unable to protect airway
• Head of bed elevation 30° (if no spinal injury)
• Maintain normoxia (SpO2 94-98%) and normocapnia (PaCO2 35-40 mmHg)
• Consider sedation to reduce ICP

E - Exposure and Environmental Control

• Completely expose patient (remove clothing, logroll if needed)
• Assess full body for injuries
• Prevent hypothermia (warming blankets, warmed fluids, increase ambient temperature)
• Cover when examination complete

Immediate interventions:

• Maintain normothermia (36-37.5°C)
• Active warming measures
• Consider tetanus prophylaxis

F - Family and Fluids (Paediatric Addition)

• Family presence encouraged if safe and appropriate
• Assign family support person
• Communicate clearly and regularly with family
• Early involvement of social work if concerns for non-accidental injury

History

Key Questions

Red Flag Symptoms

Examination

General Inspection

• Overall appearance (well vs unwell)
• Level of consciousness (alert, responsive, drowsy, unresponsive)
• Breathing pattern and effort
• Colour (pallor, cyanosis, mottling)
• Visible injuries or deformities
• Position of comfort (child's preferred position may indicate injury)
• Interaction with caregivers (fear, withdrawal - may indicate NAI)

Specific Findings

---

Investigations

Immediate (Resus Bay)

eFAST Views in Paediatric Trauma:

1. RUQ (Morison's pouch): Assess for free fluid between liver and kidney
2. LUQ (splenorenal): Assess for free fluid between spleen and kidney
3. Pelvis: Assess for free fluid in pouch of Douglas
4. Cardiac (subxiphoid): Assess for pericardial effusion, cardiac activity
5. Pleural (right): Assess for pneumothorax (lung sliding, lung point)
6. Pleural (left): Assess for pneumothorax

Sensitivity: 68-74% for hemoperitoneum in adults, lower in children due to higher compliance of abdominal wall [11] Specificity: 95-98%

Standard ED Workup

Advanced/Specialist

CT Radiation Considerations in Children:

• Children have 3-5× greater radiosensitivity than adults
• Cumulative radiation exposure increases lifetime cancer risk
• Use pediatric protocols (lower kVp, pitch, mAs)
• Consider alternative imaging when appropriate
• ALARA principle (As Low As Reasonably Achievable)

Point-of-Care Ultrasound

Applications in Paediatric Trauma:

1. eFAST (Extended Focused Assessment with Sonography for Trauma)

   • Rapid bedside assessment (below 5 minutes)
   • Detect free hemoperitoneum, hemothorax, pneumothorax, pericardial effusion
   • Repeat exams if clinical deterioration
   • Negative eFAST does not exclude solid organ injury

2. Focused Cardiac Ultrasound

   • Assess cardiac activity, contractility
   • Detect pericardial effusion/tamponade
   • Estimate intravascular volume (IVC collapsibility)

3. Lung Ultrasound

   • Pneumothorax detection: Absence of lung sliding, lung point (100% specific) [12]
   • Sensitivity 86-98%, specificity 97-99% for pneumothorax [13]

4. Abdominal Ultrasound

   • Solid organ injury (liver, spleen, kidney)
   • Particularly useful in children with high diagnostic accuracy [14]

---

Management

Immediate Management (First 10 minutes)

1. Primary survey (ABCDE) with simultaneous interventions
2. Oxygen 15 L/min via non-rebreather mask
3. Establish vascular access: 2 large-bore IVs or IO
4. Fluid resuscitation: 20 mL/kg 0.9% saline bolus (repeat up to 3 times)
5. Control hemorrhage: direct pressure, tourniquet, hemostatic agents
6. Analgesia: IV morphine 0.1-0.2 mg/kg or fentanyl 1-2 mcg/kg
7. Blood products after 3rd bolus: pRBC 10-20 mL/kg, consider 1:1:1 ratio
8. eFAST examination
9. Baseline investigations: VB, glucose, crossmatch
10. Early specialist consultation (surgery, orthopaedics, neurosurgery as indicated)
11. Tetanus prophylaxis if indicated
12. Consider NAI assessment if mechanism or injury pattern concerning

Resuscitation

Airway Management

Indications for Definitive Airway:

• GCS below 8
• Inability to protect airway (bulbar dysfunction, facial trauma)
• Respiratory failure or fatigue
• Severe hypoxemia refractory to oxygen therapy
• Required for transport to tertiary center

Pediatric Intubation Equipment:

Rapid Sequence Intubation (RSI):

Cuffed vs Uncuffed ETT:

• Cuffed ETTs now preferred for all ages (including infants) in resuscitation settings [15]
• Advantages: Better seal, reduced leak, lower aspiration risk, easier monitoring
• Use low-pressure, high-volume cuff
• Cuff pressure below 25 cmH2O to prevent tracheal injury

Breathing and Ventilation

Oxygenation Targets:

• SpO2 94-98% (normoxia)
• Avoid hyperoxia (greater than 98%) in head injury (increased free radical formation) [16]
• Hypoxia is more detrimental than hyperoxia (maintain SpO2 greater than 92%)

Ventilation Targets:

• Normocapnia: PaCO2 35-40 mmHg
• Avoid hyperventilation (PaCO2 below 35 mmHg) - cerebral vasoconstriction, reduced cerebral blood flow
• Allow mild permissive hypercapnia (PaCO2 40-45 mmHg) in asthma/bronchospasm

Mechanical Ventilation Settings (if intubated):

• Tidal volume: 6-8 mL/kg (predicted body weight)
• PEEP: 5 cmH2O initially, titrate to oxygenation
• FiO2: Titrate to SpO2 94-98%
• Respiratory rate: Age-appropriate
• Mode: Pressure-regulated volume control (PRVC) or pressure support ventilation (PSV)

Chest Tube Indications:

• Hemothorax greater than 500 mL or ongoing bleeding
• Pneumothorax with respiratory compromise
• Tension pneumothorax (follow needle decompression with chest tube)
• Persistent air leak

Chest Tube Size:

Circulation and Hemorrhage Control

Vascular Access:

• First-line: 2 large-bore peripheral IVs (22-20G for below 2 years, 20-18G for greater than 2 years)
• Second-line: Intraosseous access (proximal tibia, distal femur, proximal humerus)
  • IO can be placed within 1 minute
  • Equivalent to central venous access for resuscitation [17]
  • "Contraindications: Fracture at IO site, infection at site, previous surgery at site"
• Third-line: Central venous access (femoral preferred in trauma for speed and safety)

Fluid Resuscitation Protocol:

Initial: 20 mL/kg 0.9% saline or Hartmann's over 5-10 minutes
Reassess after each bolus:
  - Heart rate response (decreasing trend favorable)
  - Capillary refill time (improving favorable)
  - Peripheral pulses (improving favorable)
  - Blood pressure (increasing or stabilizing favorable)

If hemodynamically unstable after 2nd bolus:
  - Initiate blood products
  - Consider massive transfusion protocol (MTP)

Massive Transfusion Protocol (if greater than 40% blood volume lost):
  - pRBC: 10-20 mL/kg
  - "FFP: 10-20 mL/kg (1:1 ratio with pRBC)"
  - "Platelets: 10 mL/kg (1:1:1 ratio)"
  - Cryoprecipitate (if fibrinogen below 1.0 g/L)

Target Hb: 80-100 g/L (higher in TBI to maintain oxygen delivery)
Target INR: below 1.5
Target platelets: greater than 100 × 10^9/L
Target fibrinogen: greater than 2.0 g/L

Hemorrhage Control:

1. External hemorrhage: Direct pressure with gauze, elevate injured limb if possible
2. Tourniquet application:
   • Indications: Life-threatening extremity hemorrhage not controlled by direct pressure
   • Location: Proximal to bleeding site, as distal as possible (saves tissue)
   • Duration: Record time of application, ideally below 2 hours (but can be longer)
   • Pain management: Analgesia as needed
3. Hemostatic agents: Kaolin-based dressings, chitosan gauze
4. Pelvic binder: For suspected pelvic fracture with hemodynamic instability
   • Applied over greater trochanters
   • Reduces pelvic volume, improves tamponade
   • Temporary measure until external fixation

Vasoactive Medications:

• Norepinephrine: 0.05-0.5 mcg/kg/min IV - First-line vasopressor
• Epinephrine: 0.05-0.5 mcg/kg/min IV - Add if refractory shock
• Dopamine: 5-20 mcg/kg/min IV - Alternative, but less preferred

Indications for vasopressors:

• Ongoing shock despite adequate fluid resuscitation (greater than 60 mL/kg)
• Septic shock (early norepinephrine after initial fluid bolus)
• Cardiogenic shock (inotrope and vasopressor combination)

Disability and Neurological Management

Traumatic Brain Injury Management:

1. Airway: Intubate if GCS below 8 or unable to protect airway
2. Oxygenation: SpO2 94-98% (avoid hypoxia, limit hyperoxia)
3. Ventilation: Normocapnia PaCO2 35-40 mmHg (avoid hyperventilation)
4. Blood pressure: Maintain age-appropriate normotension
   - Systolic BP ≥ 5th percentile for age/sex
   - Prevent hypotension (secondary brain injury)
5. Position: Head of bed 30° (if C-spine cleared)
6. Osmotherapy: Mannitol 0.5-1 g/kg IV OR hypertonic saline 3% 2-5 mL/kg
   - Indications: Signs of intracranial hypertension, deteriorating GCS
7. Sedation: Midazolam 0.05-0.1 mg/kg/hr, morphine/fentanyl infusion
8. Neuromuscular blockade: Vecuronium 0.1 mg/kg bolus then infusion
9. Temperature: Normothermia 36-37.5°C (treat fever greater than 38°C)
10. Seizure prophylaxis: Levetiracetam 20-30 mg/kg IV load then maintenance

Intracranial Pressure Monitoring (ICP) Indications:

• Severe TBI (GCS 3-8) with abnormal CT
• Severe TBI (GCS 3-8) with normal CT but ≥2 of:
  • Age greater than 40 years
  • Unilateral or bilateral motor posturing
  • Systolic BP below 90 mmHg

Target ICP: below 20-25 mmHg Target CPP (Cerebral Perfusion Pressure): 40-65 mmHg (age-dependent)

• CPP = MAP - ICP
• Lower limit = age + 10 mmHg (minimum 40 mmHg)

Exposure and Environmental Control

Hypothermia Prevention and Management:

• Remove wet clothing
• Active warming: Forced-air warming blankets, radiant warmers
• Warm all fluids/blood products (to 37°C)
• Increase ambient temperature
• Maintain normothermia 36-37.5°C

Hypothermia Grading:

• Mild: 35-36°C
• Moderate: 32-35°C (coagulopathy risk increases)
• Severe: below 32°C (arrhythmia risk, cardiac depression)

Medications

Analgesia and Sedation:

Sedation for Procedures:

Antibiotics (if indicated):

Tetanus Prophylaxis:

TT = Tetanus toxoid 0.5 mL IM IG = Tetanus immunoglobulin 250 U IM

Ongoing Management

Monitoring:

• Continuous: ECG, pulse oximetry, capnography (if intubated), blood pressure (arterial line if unstable)
• Frequent: Hourly urine output, neurologic checks (GCS), temperature
• Serial: Hb/Hct, coagulation profile, ABG, lactate

Urine Output Goal:

• ≥1 mL/kg/hr (infants and children)
• ≥0.5 mL/kg/hr (adolescents)

Serial Examinations:

• Reassess every 15-30 minutes in resus
• Document improvement or deterioration
• Repeat eFAST if clinical change
• Consider repeat imaging if concerning features

Blood Product Support:

• pRBC 10 mL/kg for Hb below 70 g/L or hemodynamic instability
• FFP 10 mL/kg for INR greater than 1.5 or massive transfusion
• Platelets 10 mL/kg for platelets below 100 × 10^9/L or massive transfusion
• Cryoprecipitate 10 mL/kg for fibrinogen below 1.0 g/L

Tranexamic Acid (TXA):

• Indication: Significant hemorrhage or risk of significant hemorrhage
• Dose: 15 mg/kg loading over 10 min, then 2 mg/kg/hr infusion
• Window: Within 3 hours of injury (CRASH-2 trial) [18]
• Consider in major trauma, polytrauma, TBI

Definitive Care

Specialist Consultations:

• General surgery: Abdominal trauma, penetrating trauma, ongoing bleeding
• Orthopaedic surgery: Fractures, joint dislocations, compartment syndrome
• Neurosurgery: TBI, intracranial hemorrhage, spinal cord injury
• Cardiothoracic surgery: Thoracic trauma, great vessel injury
• Plastic surgery: Complex soft tissue injury, facial trauma
• ENT: Maxillofacial trauma
• Ophthalmology: Eye injury, orbital trauma
• Social work: NAI assessment, family support
• Child protection: Mandatory reporting if NAI suspected

Operative Indications:

Abdominal Trauma:

• Solid organ injury: Non-operative management (NOM) preferred for grades I-III, selected grade IV
• Hollow viscus injury: Operative management required
• Diagnostic peritoneal lavage (DPL) positive: Consider operative exploration

Orthopaedic Trauma:

• Open fractures: Surgical debridement and fixation
• Displaced fractures: Closed reduction and immobilization, or ORIF
• Compartment syndrome: Emergency fasciotomy (within 6 hours)
• Pelvic fracture with hemodynamic instability: External fixation

Neurosurgical Trauma:

• Epidural hematoma: Burr hole or craniotomy (time is brain)
• Subdural hematoma: Craniotomy if midline shift greater than 5 mm or neurological deterioration
• Depressed skull fracture: Elevate if depressed > skull thickness
• Diffuse axonal injury: Supportive care, ICP monitoring

Criteria for Transfer to Tertiary Center:

• Severe TBI (GCS below 8) requiring neurosurgery
• Complex orthopaedic injuries requiring specialist care
• Multisystem trauma requiring coordinated specialty care
• Burns greater than 10% TBSA or involving face/hands/genitals/feet
• Need for PICU care
• Regional capability unavailable

---

Disposition

Admission Criteria

• Abnormal primary survey findings requiring ongoing monitoring
• Hemodynamic instability (even if improved with resuscitation)
• GCS below 13 or GCS drop
• Positive eFAST with hemodynamic instability
• Significant solid organ injury (grade III+)
• Fractures requiring surgical intervention
• Head injury with high-risk features (PECARN high-risk)
• Suspected non-accidental injury
• Lack of reliable social support/caregivers

ICU/HDU Criteria

• Mechanical ventilation
• Hemodynamic instability requiring vasopressor support
• Severe TBI (GCS below 8) requiring ICP monitoring
• Multiple blood transfusions (greater than 40 mL/kg)
• Coagulopathy or ongoing bleeding
• Post-operative monitoring (major procedures)
• Organ dysfunction (renal, hepatic, respiratory)

Discharge Criteria

• Normal primary survey (normal vital signs for age)
• GCS 15
• Normal neurological examination
• Negative eFAST (or stable minor injuries)
• No evidence of clinically significant intracranial injury
• Reliable caregivers
• Ability to return if deterioration
• Adequate pain control
• Discharge instructions with red flags

Red Flags for Return:

• Vomiting ≥2 episodes
• Worsening headache
• Altered level of consciousness (GCS below 15)
• Seizure activity
• Worsening pain or new symptoms
• Fever greater than 38°C
• Any parental concern

Follow-up

• Head injury (discharged): Review in 24-48 hours if mild, arrange CT if concerning features develop
• Fractures: Orthopaedic follow-up in 1-2 weeks
• Solid organ injury: Surgical follow-up in 1 week with repeat imaging
• Burns: Burns unit follow-up if greater than 5% TBSA, hand/face/genital involvement, or full-thickness
• Psychological support: Consider referral for post-traumatic stress disorder screening

GP Letter Requirements:

• Mechanism of injury
• Findings on examination
• Investigations performed
• Management provided
• Discharge diagnosis
• Follow-up plan
• Red flags for return
• Immunization status
• Tetanus prophylaxis given

Specialist Referral Indications:

• Persistent neurological deficits
• Behavioral changes or regression
• Developmental concerns
• Psychosocial issues
• Family dysfunction or support needs

---

Special Populations

Paediatric Considerations

Age-Specific Modifications:

Infants (below 1 year):

• Higher metabolic rate, faster decompensation
• Fontanelle assessment for intracranial hypertension
• Non-accidental injury high suspicion index
• Weight-based dosing critical
• IO access often required

Toddlers (1-3 years):

• Falls common mechanism
• Exploration-related injuries
• Language may be limited
• Parental observation essential
• Separation anxiety

Preschool (3-5 years):

• Increasing mobility and risk
• Bicycle injuries, playground injuries
• Can participate in assessment with age-appropriate communication
• Magical thinking may cause anxiety
• Distraction techniques effective

School-age (6-12 years):

• Sports-related injuries
• Bicycle injuries
• Peer interactions important
• Can provide more detailed history
• Involvement in decision-making (age-appropriate)

Adolescents (13-18 years):

• MVCs become more common
• Sports injuries at peak
• Risk-taking behaviors
• Confidentiality considerations
• Need for adolescent-friendly communication

Developmental Assessment:

• Assess age-appropriate milestones
• Identify regression (may indicate intracranial injury or psychological trauma)
• Consider developmental delay impact on injury mechanism

Communication:

• Use age-appropriate language
• Explain procedures using simple terms
• Involve parents/guardians
• Allow child to ask questions
• Use distraction techniques (toys, videos, play specialists)

Pain Management:

• Assess pain using age-appropriate scales (FLACC, Faces, numeric rating)
• Multimodal analgesia preferred
• Consider non-pharmacological approaches (distraction, positioning)

Pregnancy

While rare in paediatrics, consider pregnancy in adolescent females (menarche onset as young as 8 years).

Modifications:

• Abdominal trauma: Fetal monitoring if greater than 20 weeks gestation
• Radiation exposure: Minimize CT, consider MRI
• Medications: Avoid teratogenic medications
• Supine hypotension syndrome: Left lateral positioning after 20 weeks

Elderly

Not applicable to paediatric trauma population.

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori Considerations:

Health Disparities:

• Aboriginal and Torres Strait Islander children have 2-3× higher trauma mortality rates compared to non-Indigenous children [7]
• Higher incidence of severe injuries due to delayed presentation, limited access to services, and socioeconomic factors
• Māori children in NZ have 2× higher trauma rates and 2-3× higher mortality [8]
• Rural and remote Indigenous communities face geographic barriers to care

Cultural Safety:

• Acknowledge Country/whenua and cultural protocols at start of consultation
• Use cultural liaison officers, Aboriginal Health Workers (AHWs), Aboriginal Liaison Officers (ALOs), Māori Health Workers (MHWs) when available
• Understand and respect cultural beliefs around illness, injury, and healing
• Involve family and community in decision-making processes
• Consider cultural protocols around gender, touch, and family roles
• Use plain language, avoid medical jargon, or use interpreters if English is not first language

Communication Barriers:

• Language differences: Provide interpreter services (NOT family members)
• Low health literacy: Use visual aids, teach-back method
• Mistrust of healthcare system: Build trust through culturally safe practice
• Shame and stigma: Create non-judgmental environment

Geographic Barriers:

• Remote communities: Limited access to specialist care, prolonged transport times
• RFDS: Royal Flying Doctor Service retrieval for serious injuries (24/7 retrieval hotline: 1800 625 800)
• Telemedicine: Use video consultation to provide remote specialist input
• Cost barriers: Ensure financial concerns do not delay care

Social Determinants:

• Overcrowded housing: Higher risk of accidental injury, infectious disease
• Limited access to preventive services: Less injury prevention education
• Poverty: Limited resources for safety equipment (car seats, helmets)
• Intergenerational trauma: May affect family dynamics and coping

Specific Considerations:

• NAI: Cultural practices may be misinterpreted as abuse (e.g., traditional healing, cupping)
• Family structure: Kinship care, extended family involvement in decision-making
• Death and dying: Cultural protocols around death, burial, bereavement
• Traditional healers: Respect and incorporate if appropriate
• Medication use: Traditional remedies may interact with Western medicine

Reporting Considerations:

• NAI reporting is mandatory regardless of cultural background
• Engage AHWs/MHWs and cultural consultants when making NAI reports
• Ensure culturally sensitive communication with families
• Provide culturally appropriate support services

Rehabilitation:

• Community-based rehabilitation preferred where possible
• Incorporate cultural healing practices
• Involve Aboriginal Community Controlled Health Services (ACCHS) or Māori health providers
• Consider repatriation to community for ongoing care

Key Actions:

1. Ask about cultural background and need for interpreter/cultural support
2. Involve AHW/ALO/MHW as early as possible
3. Use culturally safe communication (listen, respect, collaborate)
4. Consider geographical context for follow-up and rehabilitation
5. Address social determinants in discharge planning
6. Provide culturally appropriate resources and education

Remote/Rural Considerations

Pre-Hospital:

• Early activation of retrieval services (RFDS, state retrieval services)
• Stabilization at referring hospital before transfer
• Consider local capabilities (surgery, ICU, imaging)
• Telemedicine consultation with tertiary center
• Document all interventions and observations

Resource-Limited Setting:

• Limited imaging: No CT available in many rural sites - clinical assessment and transfer decision critical
• Limited specialist access: Transfer required for surgical intervention
• Limited monitoring: May lack arterial lines, continuous monitoring - more frequent clinical assessment needed
• Limited blood products: May need to activate massive transfusion protocol early and arrange transport

Modified Approach:

• Lower threshold for transfer if concerning features
• Consider earlier intubation if airway protection needed during transport
• eFAST particularly valuable when CT unavailable
• Clinical judgment over-reliance on investigations
• Have clear discussion with receiving team about transport arrangements

Retrieval Considerations:

• RFDS: 24/7 aeromedical retrieval, retrieval hotline 1800 625 800 [19]
• State retrieval services: NSW, VIC, QLD, WA, SA, TAS, ACT, NT have specific retrieval services
• Transfer criteria: Based on injury severity, local capabilities, transport time
• Stabilization before transfer: Ensure patient is safe for transport duration

Telemedicine:

• Video consultation with tertiary specialists
• Teleradiology for X-ray review
• Tele-ultrasound guidance for advanced POCUS
• Tele-ICU for remote intensive care support

Community Engagement:

• Education on injury prevention (water safety, road safety, falls prevention)
• Training of local health workers in trauma assessment
• Development of local protocols for common injuries
• Regular outreach clinics from tertiary centers

Specific Challenges:

• Weather affecting transport availability (seasonal, tropical, remote areas)
• Long transport times: Plan for ongoing management during transport
• Limited staffing: One nurse may be caring for multiple patients
• Equipment limitations: May lack pediatric-specific equipment - improvise with available resources

---

Pediatric-Specific Injury Patterns

Head Injury

Mechanisms:

• Falls (most common below 5 years)
• MVCs (adolescents)
• Non-accidental injury (especially below 2 years)
• Sports-related (school-age)

Clinical Assessment:

• GCS (pediatric version)
• Pupillary response (size, reactivity)
• Focal neurologic deficits
• Seizure activity
• Vomiting (number of episodes, timing)
• Headache (severity, location)
• History of loss of consciousness (duration)

PECARN Rules for Clinically Important TBI [20]:

High-risk for ciTBI (2% risk):

• GCS below 14
• GCS 14 + altered mental status
• Basilar skull fracture signs (Battle's sign, raccoon eyes, hemotympanum, CSF otorrhoea/rhinorrhoea)
• Any signs of depressed skull fracture or palpable fracture

Intermediate-risk factors:

• GCS 15 with headache, vomiting, or amnesia
• Altered mental status (sleepiness, irritability)
• Suspected skull fracture (non-depressed)
• Large scalp hematoma (greater than 4 cm in infants, greater than 3 cm in children)
• Dangerous mechanism (fall greater than 3 feet, motor vehicle crash, high-speed projectile)
• Action: Observation for 4-6 hours, consider CT if 2+ intermediate risk factors

Low-risk (0.05% risk of ciTBI):

• GCS 15, no vomiting, no headache, no amnesia
• Normal behavior
• No scalp hematoma or hematoma below 3 cm (infants) or below 4 cm (children)
• Safe mechanism (ground-level fall, walking/running into stationary object)
• Action: Discharge with home observation instructions

CT Indications:

• High-risk PECARN features
• Deteriorating GCS (drop ≥2 points)
• Focal neurologic deficit
• Seizure activity
• Suspected depressed skull fracture

Management:

• Mild TBI (GCS 13-15): Observation, analgesia, discharge with instructions
• Moderate TBI (GCS 9-12): Admission, observation, serial neuro checks, consider CT
• Severe TBI (GCS 3-8): ICU admission, ICP monitoring, neurosurgical consultation

Long-term sequelae:

• Post-concussion syndrome
• Cognitive deficits
• Behavioral changes
• Post-traumatic epilepsy
• Hydrocephalus

Cervical Spine Injury

Incidence:

• Rare in children (below 2% of all pediatric trauma) [21]
• Higher risk with: MVCs, sports injuries, falls from height
• Patterns differ from adults due to ligamentous laxity, incomplete ossification

Clinical Assessment:

• Neck pain or tenderness
• Cervical spine deformity
• Neurologic deficits (motor, sensory)
• Mechanism suspicious for injury (e.g., diving, MVA)

Clearance Criteria:

Low-risk criteria (NEXUS modifications for pediatrics) [22]:

• Normal level of alertness (GCS 15)
• No intoxication
• No distracting injury (e.g., major fracture)
• No posterior midline cervical spine tenderness
• No focal neurologic deficit
• Action: Can clear clinically without imaging if ALL criteria met

Canadian C-Spine Rule NOT validated in children below 16 years - use clinical judgment and NEXUS criteria with modifications

Imaging:

• First-line: Lateral cervical spine X-ray (assess alignment, soft tissue swelling)
• Additional: AP and odontoid views if lateral concerning
• CT: If X-ray inadequate, concerning findings, or high-risk mechanism
• MRI: If neurologic deficit unexplained by X-ray/CT (SCIWORA - Spinal Cord Injury Without Radiographic Abnormality)

SCIWORA:

• Spinal cord injury without radiographic abnormality
• More common in children below 8 years (ligamentous laxity, disproportionate head size)
• Clinical neurologic deficit with normal X-ray/CT
• MRI required for diagnosis
• Range from transient neuropraxia to permanent cord injury

Management:

• Maintain C-spine immobilization until cleared
• Immobilization with hard collar, sandbags, tape (padding under shoulders for neutral alignment)
• Early immobilization removal if cleared (skin breakdown risk in children)
• Consider pediatric cervical collar size (adjustable collars)

Return to Sports:

• Complete cervical spine clearance
• Full pain-free range of motion
• Full strength
• No neurologic deficits
• Graduated return to play protocol

Abdominal Trauma

Solid Organ Injury (Liver, Spleen, Kidney):

• Mechanisms: MVC, falls, bicycle handlebar injury
• Presentation: Abdominal pain/tenderness, vomiting, hematuria (renal)
• Grading: American Association for the Surgery of Trauma (AAST) grading system
• Management: Non-operative management (NOM) preferred for grade I-III
  • Bed rest, analgesia, observation
  • Serial exams, hemoglobin monitoring
  • Blood transfusion if Hb below 70 g/L or hemodynamic instability
  • Consider angioembolization for ongoing bleeding
• Operative indications:
  • Hemodynamic instability despite resuscitation
  • Grade IV-V with ongoing bleeding
  • Hollow viscus injury
  • Failed NOM (deterioration)

Hollow Viscus Injury (Small Bowel, Colon, Stomach):

• Mechanisms: Seatbelt syndrome, handlebar injury, penetrating trauma
• Presentation: Abdominal tenderness (often initially mild), vomiting, peritonitis
• Diagnostic: CT abdomen with contrast (free air, bowel wall thickening)
• Management: Operative (laparotomy or laparoscopy)
• Delayed presentation: Can present days later with bowel obstruction or peritonitis

Seatbelt Syndrome:

• Signs: Seatbelt mark across abdomen, abdominal tenderness
• Injuries: Small bowel/mesenteric injury, Chance fracture (spine), solid organ injury
• Investigation: High index of suspicion, CT abdomen
• Management: Operative for hollow viscus injury, NOM for solid organ injury

Bladder/Urethral Injury:

• Mechanism: Pelvic fracture, direct trauma
• Presentation: Blood at urethral meatus, inability to void, high-riding prostate (male)
• Investigation: Retrograde urethrogram before catheter insertion if suspected
• Management: Catheterization (urethral or suprapubic), urology consultation

Thoracic Trauma

Rib Fractures:

• Indications: Direct trauma, CPR
• Significance: May indicate significant force, associated with underlying lung injury
• Management: Analgesia, incentive spirometry, consider epidural for multiple fractures

Pulmonary Contusion:

• Presentation: Tachypnoea, hypoxia, respiratory distress
• CXR: Patchy infiltrates (may not be visible initially)
• Management: Oxygen, analgesia, supportive care, consider ventilation if severe

Pneumothorax:

• Signs: Decreased breath sounds, hyperresonance, respiratory distress
• Management: Needle decompression if tension pneumothorax, chest tube if significant pneumothorax

Hemothorax:

• Signs: Decreased breath sounds, dullness to percussion, hypovolaemia
• Management: Chest tube, blood transfusion if greater than 500 mL or ongoing bleeding

Myocardial Contusion:

• Mechanism: Blunt chest trauma (steering wheel injury)
• Signs: Chest pain, ECG changes, elevated cardiac enzymes
• Investigation: ECG, cardiac enzymes, echocardiogram if concerning
• Management: Monitoring, supportive care, arrhythmia treatment

Musculoskeletal Injuries

Fractures:

• Common sites: Distal radius, supracondylar humerus, femur, tibia
• Supracondylar humerus: Common in children 4-7 years, fall on outstretched hand
  • "Type I: Minimally displaced - conservative"
  • "Type II: Posterior cortex intact - consider reduction"
  • "Type III: Completely displaced - operative reduction and fixation"
  • "Complications: Volkmann's ischemic contracture, median nerve injury"

Growth Plate Injuries (Salter-Harris Fractures):

• Type I: Separation through physis
• Type II: Fracture through physis and metaphysis (most common)
• Type III: Fracture through physis and epiphysis
• Type IV: Fracture through epiphysis, physis, metaphysis
• Type V: Crush injury to physis (poorest prognosis)
• Management: Closed reduction for types I-II, operative for types III-V

Compartment Syndrome:

• Signs: Pain out of proportion to injury, tense swelling, pain with passive stretch, pallor, pulselessness, paralysis
• Measurement: Compartment pressure greater than 30 mmHg or within 30 mmHg of diastolic BP
• Management: Emergency fasciotomy (within 6 hours)

Non-Accidental Injury (NAI)

Epidemiology:

• Incidence: 1-2% of pediatric trauma presentations [23]
• Peak age: below 2 years (highest), also adolescents
• Mortality: Up to 25% of severe abusive injuries
• Under-reporting: Estimated 10% of cases identified

Mechanisms of Abuse:

• Shaking (shaken baby syndrome)
• Impact (throwing, hitting)
• Strangulation
• Thermal injury
• Poisoning

Red Flags for NAI:

TEN-4 Rule for Bruising [24]:

• T: Torso bruises
• E: Ear bruises
• N: Neck bruises
• 4: Any bruise in child below 4 months ("Those who don't cruise, don't bruise")
• FACESp: Frenulum, Angle of jaw, Cheek, Eyelids, Subconjunctival hemorrhage
• Sensitivity: 97% for abuse bruising
• Specificity: 84%

Fracture Patterns:

• Metaphyseal corner fractures (classic for abuse - pulling/shaking)
• Rib fractures (especially posterior, from squeezing chest)
• Long bone fractures in non-ambulatory children
• Multiple fractures in different stages of healing
• Skull fractures (complex, bilateral, crossing sutures)
• Spinous process fractures (squeezing)

Head Injury Patterns:

• Abusive Head Trauma (AHT) triad:
  • Subdural hemorrhage
  • Retinal hemorrhages
  • Encephalopathy (altered mental status, seizures, apnoea)
• CT/MRI findings: Subdural hemorrhages of different ages (chronic and acute), diffuse axonal injury, cerebral edema

Burn Patterns:

• Immersion burns (stocking/glove pattern)
• Contact burns (cigarette, iron, curling iron)
• Splash burns (forced immersion in hot liquid)
• Symmetrical burns

Behavioral Indicators:

• Child: Frozen watchfulness, excessive compliance, withdrawal, developmental regression
• Caregiver: Hostility, indifference, over-protectiveness, unwillingness to leave child alone, delayed or absent concern

Investigation:

• Full history from all caregivers (separately if possible)
• Full body examination (document ALL injuries, old and new)
• Skeletal survey (for children below 2 years or suspicious cases)
• CT brain (if head injury suspected)
• Ophthalmology review (for retinal hemorrhages)
• Coagulation profile, bone profile (exclude bleeding disorders, metabolic disease)
• Urine drug screen (if poisoning suspected)
• Photographs of all injuries

Reporting:

• Mandatory reporting: All suspected NAI must be reported to child protection authorities
• Australia: State-specific child protection services (e.g., DCJ in NSW, DHHS in VIC)
• New Zealand: Oranga Tamariki (Ministry for Children)
• Document: Detailed notes, diagrams, timing, quotes
• Do not confront caregivers (may compromise investigation)
• Involve social work and hospital child protection team

Management:

• Medical stabilization of injuries
• Protect child from further harm (admit, restrict visitation if necessary)
• Involve multidisciplinary team (social work, police, child protection)
• Ensure safe discharge plan (often cannot discharge home)
• Provide emotional support for child and non-abusing family members

---

Pitfalls & Pearls

---

Viva Practice

---

OSCE Scenarios

Station 1: Pediatric Trauma Primary Survey

Format: Resuscitation/Examination Station Time: 11 minutes Setting: ED resuscitation bay Scenario: You are the treating doctor for a 7-year-old boy who was a restrained rear passenger in a high-speed MVC. The car rolled over. He was extricated by paramedics and is now in the resuscitation bay. He is alert and crying. Vitals: HR 140, BP 95/60, RR 26, SpO2 95% on 15L O2 via non-rebreather.

Candidate Instructions:

Perform a primary survey on this child. Identify any life-threatening injuries and initiate appropriate management. Demonstrate pediatric-specific considerations.

Examiner Instructions: The patient is a 7-year-old boy (~25 kg) involved in a high-speed MVC (rolled vehicle). He has the following findings:

• Alert and crying in pain
• HR 140, BP 95/60, RR 26, SpO2 95%
• No obvious airway obstruction
• Chest: Decreased breath sounds on right side
• Abdomen: Tenderness in right upper quadrant
• Right leg: Deformed, mid-thigh, tender (femur fracture)
• GCS: 15

Marking Criteria:

Expected Standard:

• Pass: ≥7/11
• High pass: ≥9/11

Key Discriminators (what separates pass from fail):

• Fail: Misses decreased breath sounds (misses tension pneumothorax/hemothorax), fails to establish vascular access, doesn't initiate fluid bolus, doesn't use pediatric-specific approach
• Pass: Systematic ABCDE, identifies key findings, initiates basic management
• High pass: Pediatric-specific considerations (weight-based dosing, age-specific vitals), identifies all injuries, comprehensive management plan

Examiner Notes:

• Candidate should demonstrate understanding of pediatric trauma differences (larger head, flexible thoracic cage, compensatory mechanisms)
• Candidate should communicate with family (even if simulated)
• Candidate should consider early activation of trauma team or surgery given mechanism

---

Station 2: Pediatric Head Injury and PECARN Rules

Format: Assessment/Management Station Time: 11 minutes Setting: ED cubicle Scenario: A 4-year-old girl presents after falling 1.5m from a tree onto grass. She cried immediately, vomited twice, and has a 4cm scalp hematoma on the left parietal region. She is currently alert, playing with a toy, and wants to go home. Mother is worried. Vitals: HR 120, BP 90/60, RR 22, SpO2 98% on room air. GCS 15.

Candidate Instructions:

Assess this child with head injury. Decide whether a CT brain is indicated and provide a management plan. Explain your decision-making to the mother.

Examiner Instructions: The child has:

• Age: 4 years
• Mechanism: Fall 1.5m onto grass (moderate mechanism)
• Vomiting: 2 episodes
• Scalp hematoma: 4cm on left parietal region
• GCS: 15 (alert, playful)
• Normal behavior: Playing with toy, interactive
• No other concerning features: No loss of consciousness, no seizure, no baseline skull fracture signs, no focal neurologic deficit

Mother (actor):

• Concerned about the vomiting
• Wants to know if CT is needed
• Asks about radiation risks of CT
• Wants to take child home if safe

Marking Criteria:

Expected Standard:

• Pass: ≥7/11
• High pass: ≥9/11

Key Discriminators:

• Fail: Orders CT inappropriately (without red flags), discharges without observation, fails to apply PECARN rules, poor communication with mother
• Pass: Applies PECARN rules correctly, appropriate observation plan, basic communication
• High pass: Detailed PECARN rule application, thorough management plan, excellent communication (shared decision-making, addresses concerns), pediatric-specific considerations

Examiner Notes:

• PECARN rules: 3 intermediate-risk factors (vomiting, large scalp hematoma greater than 3cm, moderate mechanism) → observation 4-6 hours
• CT indicated if deterioration during observation or persistent/worsening symptoms
• Child can be discharged if stable after observation
• Communication should address CT radiation risks vs benefits of observation

---

Station 3: Non-Accidental Injury Assessment

Format: Assessment/Communication Station Time: 11 minutes Setting: ED consultation room Scenario: You are reviewing a 10-month-old infant who presents with a fractured humerus. The mother states the infant fell off a 50cm high lounge. The infant appears well, is alert, and has no other apparent injuries on initial inspection. The mother is tearful and says she feels guilty.

Candidate Instructions:

Assess this infant for suspected non-accidental injury. Identify red flags and outline your management plan. You will then need to explain your concerns to the mother.

Examiner Instructions: The infant has:

• Age: 10 months (non-ambulatory)
• Mechanism: Fall 50cm (low energy)
• Injury: Fractured humerus (long bone fracture)
• Appearance: Well, alert, no other obvious injuries
• No medical history of bleeding disorders or metabolic bone disease
• No previous fractures documented
• Developmentally normal

Mother (actor):

• Tearful, says "I should have been watching him more carefully"
• Says "he just fell off the lounge, I heard him cry and saw his arm was swollen"
• Says "I would never hurt my baby"
• Asks "do you think I did this on purpose?"
• May become defensive if accused

Marking Criteria:

Expected Standard:

• Pass: ≥7/11
• High pass: ≥9/11

Key Discriminators:

• Fail: Dismisses NAI possibility, discharges without investigation, confronts mother aggressively, fails mandatory reporting
• Pass: Recognizes red flags, initiates investigations, admits infant, mandatory reporting
• High pass: Comprehensive assessment, all appropriate investigations, excellent communication (non-judgmental, empathetic), clear explanation of process, thorough documentation

Examiner Notes:

• Long bone fracture in non-ambulatory child (below 12 months) has 50-80% likelihood of abuse
• Do NOT confront or accuse mother - explain medical concerns objectively
• Mandatory reporting is required by law
• Involve social work and child protection team early
• Documentation is critical for legal proceedings

---

SAQ Practice

Question 1 (8 marks)

Stem: A 6-year-old boy presents to the ED as a trauma activation after being hit by a car while riding his bicycle. He was wearing a helmet. He is drowsy but arousable to voice. Vitals: HR 150, BP 85/55, RR 28, SpO2 92% on 15L O2. GCS 12 (E3, V3, M6). There is a large scalp hematoma on the right parietal region. He has a deformed left thigh.

Question: Outline your immediate management priorities and investigations for this child.

Model Answer (8 marks):

Immediate Management (5 marks):

1. Primary survey (ABCDE) with simultaneous interventions (1 mark)

   • A: Airway with C-spine protection (hard collar, neutral position) (0.25 mark)
   • B: Breathing - high-flow O2, assess RR and breath sounds (0.25 mark)
   • C: Circulation - assess capillary refill, establish vascular access (2 IVs or IO) (0.25 mark)
   • D: Disability - GCS 12 (concerning for head injury) (0.25 mark)
   • E: Exposure - full examination, prevent hypothermia (0.25 mark)

2. Fluid resuscitation (1 mark):

   • 20 mL/kg 0.9% saline bolus (estimated weight ~20 kg → 400 mL) (0.5 mark)
   • Repeat up to 3 times or until hemodynamic improvement (0.5 mark)
   • Consider blood products after 2nd bolus if not improving (0.5 mark)

3. Analgesia (0.5 mark):

   • Morphine 0.1 mg/kg IV (2 mg) OR fentanyl 1-2 mcg/kg IV

4. Immobilization (0.5 mark):

   • Splint left femur fracture
   • Maintain C-spine immobilization

5. Head injury management (1 mark):

   • Intubate if GCS below 8 or unable to protect airway (currently 12, monitor closely) (0.5 mark)
   • Maintain SpO2 94-98%, normocapnia PaCO2 35-40 mmHg (0.5 mark)
   • Head of bed 30° (if C-spine cleared)
   • Consider osmotherapy if signs of increased ICP (0.5 mark)

6. Trauma team activation (0.5 mark):

   • Activate given high-risk mechanism (pedestrian vs motor vehicle), GCS below 13

Investigations (3 marks):

1. Immediate (resus bay) (1.5 marks):

   • Fingerstick glucose (exclude hypoglycaemia) (0.25 mark)
   • VBG (acid-base, lactate) (0.25 mark)
   • FBC (hemoglobin, platelets) (0.25 mark)
   • Group and crossmatch (prepare for transfusion) (0.25 mark)
   • Coagulation profile (PT, aPTT, INR) (0.25 mark)
   • Electrolytes, urea, creatinine (baseline renal function) (0.25 mark)

2. Imaging (1 mark):

   • CT brain (high-risk PECARN features: GCS below 14) (0.25 mark)
   • CT cervical spine (GCS below 8 is not present, but consider if unreliable exam) (0.25 mark)
   • CT chest/abdomen/pelvis (polytrauma, pedestrian vs MVA mechanism) (0.25 mark)
   • X-ray left femur (document fracture) (0.25 mark)

3. Point-of-care (0.5 mark):

   • eFAST (rapid assessment for hemoperitoneum, hemothorax, pneumothorax) (0.25 mark)
   • Repeat if clinical deterioration (0.25 mark)

Examiner Notes:

• Accept: Alternative sequence of ABCDE, use of IO if IV not obtainable
• Do not accept: Delayed fluid resuscitation, missing CT brain (high-risk feature), inadequate analgesia
• Full marks: All immediate management priorities identified, appropriate investigations with justification

---

Question 2 (10 marks)

Stem: A 2-year-old girl presents with a bruise on her ear and bruises on her trunk. The mother says the child fell off the couch while playing. The child appears well, is alert, and has no other apparent injuries. Vitals normal. GCS 15.

Question: (a) What are your concerns regarding non-accidental injury? (3 marks) (b) What investigations would you order and why? (4 marks) (c) What are your management and disposition decisions? (3 marks)

Model Answer (10 marks):

(a) Concerns regarding non-accidental injury (3 marks):

1. Bruise pattern concerning for abuse (1 mark):

   • Bruise on ear (TEN-4 rule: E = Ear) (0.25 mark)
   • Bruises on torso (TEN-4 rule: T = Torso) (0.25 mark)
   • TEN-4 rule has 97% sensitivity for abusive bruising (0.25 mark)
   • Bruising in these locations is rare from accidental falls (0.25 mark)

2. Mechanism-injury inconsistency (1 mark):

   • Fall from couch is low-energy mechanism (0.25 mark)
   • Unlikely to cause bruises on ear and torso (0.25 mark)
   • Inconsistency raises suspicion for abuse (0.25 mark)
   • "Those who don't cruise, don't bruise" (0.25 mark)

3. Age factor (1 mark):

   • 2 years old is in high-risk age group for NAI (0.5 mark)
   • NAI incidence highest in below 2 years (0.5 mark)

(b) Investigations (4 marks):

1. Skeletal survey (2 marks):

   • AP and lateral skull, chest (incl. ribs), spine, pelvis, all limbs (0.5 mark)
   • Look for fractures in different stages of healing (0.5 mark)
   • Look for metaphyseal corner fractures, rib fractures (0.5 mark)
   • Required for suspected NAI in children below 2 years (0.5 mark)

2. Coagulation profile (0.5 mark):

   • PT, aPTT, INR, platelets to rule out bleeding disorder

3. Bone profile (0.5 mark):

   • Ca2+, PO4^3-, ALP, PTH, vitamin D to rule out metabolic bone disease (rickets)

4. CT brain (0.5 mark):

   • If head injury suspected (altered mental status, retinal hemorrhages, large fontanelle)

5. Ophthalmology review (0.5 mark):

   • For retinal hemorrhages (sign of abusive head trauma)

(c) Management and disposition (3 marks):

1. Immediate management (1 mark):

   • Admit to hospital for protection and observation (0.5 mark)
   • Pain management if bruising is painful (0.25 mark)
   • Document all injuries with photographs (0.25 mark)

2. Mandatory reporting (1 mark):

   • Report to child protection authorities (required by law) (0.5 mark)
   • Involve social work and hospital child protection team (0.5 mark)

3. Disposition (1 mark):

   • Do NOT discharge home (0.5 mark)
   • Safe discharge plan required before discharge (often cannot discharge while NAI investigation ongoing) (0.5 mark)

Examiner Notes:

• Accept: Mention of TEN-4-FACESp rule (full rule), additional investigations (FBC, urine drug screen)
• Do not accept: Discharging home without investigation, not reporting to child protection
• Full marks: High index of suspicion, comprehensive investigations, appropriate management, mandatory reporting

---

Question 3 (8 marks)

Stem: A 10-year-old boy presents with neck pain after a diving accident at a pool. He landed in shallow water and hit his head. He is alert, GCS 15, with normal vital signs. He has neck tenderness at C5-C6. He can move all limbs normally. He has no other injuries.

Question: (a) Would you order imaging for this child's cervical spine? Justify your answer using pediatric c-spine clearance criteria. (4 marks) (b) If you order imaging, what is your imaging sequence? (2 marks) (c) What are the potential injuries and management? (2 marks)

Model Answer (8 marks):

(a) C-spine clearance and imaging decision (4 marks):

1. Cannot clear clinically - imaging required (2 marks):

   • Neck tenderness present (failed NEXUS criteria) (0.5 mark)
   • NEXUS criteria for c-spine clearance (all must be present): (0.5 mark each)
     • Normal level of alertness (GCS 15) ✓
     • No intoxication ✓
     • No distracting injury ✓
     • No posterior midline cervical spine tenderness ✗
     • No focal neurologic deficit ✓
   • Failed NEXUS criteria (posterior midline tenderness) → requires imaging (0.5 mark)

2. Canadian C-Spine Rule (2 marks):

   • NOT validated in children below 16 years (0.5 mark)
   • Use clinical judgment and NEXUS criteria with pediatric modifications (0.5 mark)
   • High-risk mechanism (diving into shallow water) supports imaging (0.5 mark)
   • Decision: Order imaging (lateral cervical spine X-ray first) (0.5 mark)

(b) Imaging sequence (2 marks):

1. Lateral cervical spine X-ray (1 mark):

   • First-line imaging (0.5 mark)
   • Assess alignment (vertebral body lines), soft tissue swelling, fractures, subluxation (0.5 mark)

2. If lateral X-ray inadequate or concerning (1 mark):

   • AP and odontoid views (if lateral adequate but concerning) (0.5 mark)
   • CT cervical spine (if X-ray inadequate, high-risk mechanism, or neurological deficit) (0.5 mark)

3. If neurological deficit without radiographic abnormality (0.5 mark bonus):

   • MRI (SCIWORA - Spinal Cord Injury Without Radiographic Abnormality)

(c) Potential injuries and management (2 marks):

1. Potential injuries (1 mark):

   • Cervical spine fracture (e.g., C5-C6 extension injury, compression fracture) (0.25 mark)
   • Cervical spine subluxation/dislocation (0.25 mark)
   • SCIWORA (spinal cord injury without radiographic abnormality) (0.25 mark)
   • Ligamentous injury (more common in children than adults) (0.25 mark)

2. Management (1 mark):

   • Maintain C-spine immobilization until cleared (0.25 mark)
   • Hard collar, sandbags, tape (padding under shoulders for neutral alignment) (0.25 mark)
   • Neurosurgical or orthopaedic consultation if injury identified (0.25 mark)
   • Admission for observation if neurological deficit or concerning imaging (0.25 mark)

Examiner Notes:

• Accept: CT first if high clinical suspicion or neurological deficit, early MRI if concerning
• Do not accept: Using Canadian C-Spine Rule alone (not validated below 16 years), discharging without imaging
• Full marks: Correct application of NEXUS criteria, appropriate imaging sequence, recognition of potential injuries

---

Question 4 (10 marks)

Stem: A 5-year-old Aboriginal girl presents to a remote community health center after being kicked by a horse. She has right-sided chest wall tenderness and decreased breath sounds on the right. Vitals: HR 145, BP 90/55, RR 30, SpO2 88% on room air. GCS 15. The nearest hospital with pediatric surgery and ICU is 3 hours away by RFDS. There is no CT scanner available.

Question: Outline your management plan, including indigenous health considerations and retrieval planning.

Model Answer (10 marks):

Immediate management (5 marks):

1. Primary survey (ABCDE) (1 mark):

   • A: Airway with C-spine protection (0.25 mark)
   • B: High-flow O2 (15 L/min) to improve SpO2 (currently 88%) (0.25 mark)
   • C: Establish vascular access (2 IVs or IO) (0.25 mark)
   • D: GCS 15 (no head injury concern) (0.25 mark)
   • E: Exposure, prevent hypothermia (0.25 mark)

2. Breathing management (1.5 marks):

   • High-flow O2, target SpO2 94-98% (0.5 mark)
   • Assess for tension pneumothorax (tracheal deviation, distended neck veins, unilateral breath sounds) (0.5 mark)
   • Needle decompression if tension pneumothorax (2nd intercostal, midclavicular, 4-5cm anterior to midline) (0.5 mark)

3. Circulation and fluid resuscitation (1 mark):

   • 20 mL/kg 0.9% saline bolus (estimated weight ~20 kg → 400 mL) (0.5 mark)
   • Reassess after each bolus (HR, capillary refill, BP) (0.5 mark)

4. Investigations (0.5 mark):

   • eFAST (critical when CT unavailable): Assess for hemothorax, pneumothorax (0.25 mark)
   • Chest X-ray (available at remote center): Confirm hemothorax/pneumothorax, rib fractures (0.25 mark)

5. Analgesia (0.5 mark):

   • Morphine 0.1 mg/kg IV (2 mg) OR fentanyl 1-2 mcg/kg IV

6. Chest tube (0.5 mark):

   • Indicated if hemothorax greater than 500 mL or ongoing bleeding, or pneumothorax with respiratory compromise (0.5 mark)

Indigenous health considerations (3 marks):

1. Cultural safety (1.5 marks):

   • Acknowledge Aboriginal identity and cultural protocols (0.25 mark)
   • Involve Aboriginal Health Worker (AHW) or Aboriginal Liaison Officer (ALO) if available (0.25 mark)
   • Use interpreter if language barriers (NOT family members) (0.25 mark)
   • Involve family and community in decision-making (0.25 mark)
   • Respect cultural protocols (gender of healthcare provider, touch protocols) (0.25 mark)
   • Non-judgmental approach, avoid stigma and shame (0.25 mark)

2. Communication (0.5 mark):

   • Plain language, avoid medical jargon (0.25 mark)
   • Explain findings and management clearly to family (0.25 mark)

3. Social determinants (0.5 mark):

   • Geographic isolation (3 hours to tertiary center) (0.25 mark)
   • Financial considerations (cost of travel, accommodation) (0.25 mark)

4. Community support (0.5 mark):

   • Consider extended family involvement (grandparents, community elders) (0.25 mark)
   • Involve Aboriginal Community Controlled Health Services (ACCHS) (0.25 mark)

Retrieval planning (2 marks):

1. Early RFDS activation (0.5 mark):

   • 24/7 retrieval hotline: 1800 625 800 (0.25 mark)
   • Activate immediately given mechanism and injuries (0.25 mark)

2. Stabilization before transfer (0.5 mark):

   • Adequate fluid resuscitation (0.25 mark)
   • Secure airway if needed (GCS currently 15, monitor) (0.25 mark)
   • Pain control
   • Chest tube if indicated
   • Maintain normothermia

3. Transport decision (0.5 mark):

   • Air transport preferred (unstable or at risk of deterioration) (0.25 mark)
   • Accompanying person (parent/guardian should travel with child) (0.25 mark)

4. Communication with receiving team (0.5 mark):

   • Clear handover with interventions performed and current status (0.25 mark)
   • Ensure receiving team aware of indigenous cultural considerations (0.25 mark)

Examiner Notes:

• Accept: Alternative sequence of management, use of IO if IV not obtainable
• Do not accept: Delaying RFDS activation, not addressing indigenous cultural considerations, discharging
• Full marks: Comprehensive management, thorough indigenous health considerations, appropriate retrieval planning

---

Australian Guidelines

ARC/ANZCOR

• Guideline 9.1.4 - Paediatric Advanced Life Support: Age-specific approach to pediatric resuscitation, drug dosing, defibrillation
• Guideline 4 - Airway: Pediatric airway management, foreign body airway obstruction
• Guideline 8 - Cardiac Arrest: Pediatric cardiac arrest management, post-resuscitation care

Key differences from AHA/ERC:

• ANZCOR emphasizes 15:2 compression:ventilation ratio for single rescuer pediatric CPR (AHA/ERC also use 15:2)
• ANZCOR emphasizes compression rate 100-120/min (same as AHA/ERC)
• ANZCOR recommends using cuffed ETTs for all ages (including infants) in resuscitation settings

Therapeutic Guidelines

eTG Complete - Emergency:

• Trauma: Pediatric trauma assessment and management, fluid resuscitation
• Analgesia: Pediatric pain management (morphine, fentanyl, paracetamol)
• Sepsis: Pediatric sepsis recognition and management
• CPR: Pediatric cardiopulmonary resuscitation

RCH (Royal Children's Hospital) Clinical Guidelines:

• Trauma: Pediatric trauma management protocols
• Head Injury: PECARN-based head injury assessment
• Burns: Pediatric burn management
• Analgesia: Pediatric analgesia guidelines

State-Specific

NSW Health Clinical Guidelines:

• Trauma: NSW Institute of Trauma and Injury Management (ITIM) guidelines
• Pediatric Trauma: CHW (Children's Hospital at Westmead) protocols

Victorian State Trauma System:

• Pediatric Trauma: RCH (Royal Children's Hospital) pediatric trauma guidelines
• Transfer criteria: Victorian trauma transfer guidelines

Queensland Clinical Guidelines:

• Pediatric Trauma: Queensland Paediatric Trauma Guidelines
• Head Injury: PECARN-based head injury assessment

WA Health Clinical Guidelines:

• Pediatric Trauma: PMH (Princess Margaret Hospital) protocols

SA Health Clinical Guidelines:

• Pediatric Trauma: WCH (Women's and Children's Hospital) protocols

Tasmanian Clinical Guidelines:

• Pediatric Trauma: State-wide protocols

ACT Health Clinical Guidelines:

• Pediatric Trauma: Canberra Hospital protocols

NT Health Clinical Guidelines:

• Pediatric Trauma: RDH (Royal Darwin Hospital) protocols
• Remote care: Remote area nursing protocols

---

Remote/Rural Considerations

Pre-Hospital

• Early activation of retrieval services: RFDS (Royal Flying Doctor Service) or state-specific retrieval services
• Stabilization at referring hospital: Ensure patient is stable for transport duration
• Communication: Early telemedicine consultation with tertiary center
• Documentation: Comprehensive documentation of interventions, observations, timing

Resource-Limited Setting

Limited Imaging:

• No CT scanner available in many rural sites
• eFAST becomes critical bedside tool
• Rely on clinical assessment and judgment
• Earlier decision for transfer if high suspicion for serious injury

Limited Specialist Access:

• No pediatric surgeon, orthopaedic surgeon, neurosurgeon on-site
• Transfer required for surgical intervention
• Telemedicine consultation with tertiary specialists
• Rural doctors may need to perform procedures outside usual scope

Limited Blood Products:

• May have limited blood product supply
• Early activation of massive transfusion protocol
• Arrange transport for blood products if needed
• Consider early transfer if ongoing bleeding

Limited Monitoring:

• May lack arterial lines, central venous lines, advanced monitoring
• More frequent clinical assessment required
• Basic monitoring: Pulse oximetry, NIBP, ECG

Modified Approach:

• Lower threshold for transfer if concerning features
• Consider earlier intubation if airway protection needed during transport
• eFAST particularly valuable when CT unavailable
• Clinical judgment over-reliance on investigations
• Have clear discussion with receiving team about transport arrangements

Retrieval

RFDS (Royal Flying Doctor Service):

• 24/7 aeromedical retrieval service
• Retrieval hotline: 1800 625 800 [19]
• Covers remote and rural Australia
• Retrieval teams include doctor and nurse
• Pediatric retrieval specialists available

State Retrieval Services:

• NSW: NETS (Newborn and Paediatric Emergency Transport Service)
• VIC: PETS (Paediatric Emergency Transport Service)
• QLD: Queensland Retrieval Services (QRS)
• WA: WA Retrieval Services
• SA: MedSTAR
• TAS: Tasmanian Retrieval Service
• ACT: ACT Retrieval Service
• NT: NT Retrieval Service (often via RFDS)

Transfer Criteria:

• Severe trauma requiring specialist care
• Unstable or at risk of deterioration
• Need for pediatric surgery, neurosurgery, or ICU
• Injury severity exceeding local capabilities
• Transport time greater than 2 hours to definitive care

Stabilization Before Transfer:

• Adequate fluid resuscitation (up to 3 × 20 mL/kg boluses, then blood products)
• Secure airway if needed (intubation)
• Pain control
• Immobilization of injuries
• Maintain normothermia
• Tetanus prophylaxis if indicated
• Documentation of all interventions

Transport Considerations:

• Air transport: Preferred for unstable patients, long distances
• Road transport: For stable patients, short distances
• Accompanying person: Parent/guardian should travel with child
• Equipment: Appropriate pediatric equipment for transport

Telemedicine

Applications:

• Tele-consultation with tertiary specialists (pediatric surgeon, neurosurgeon, intensivist)
• Teleradiology for X-ray review
• Tele-ultrasound guidance for advanced POCUS
• Tele-ICU for remote intensive care support
• Tele-education for rural health workers

Benefits:

• Improves access to specialist expertise
• Reduces unnecessary transfers
• Provides real-time guidance for management
• Enhances rural health worker capabilities

Limitations:

• Limited by internet connectivity in remote areas
• Cannot replace physical examination
• Cannot provide physical interventions
• May delay transfer if over-relied upon

Best Practice:

• Use telemedicine to inform management and transfer decisions
• Early activation of retrieval services regardless of telemedicine consultation
• Clear communication plan with receiving team
• Document all telemedicine consultations

---

References

Guidelines

1. Australian Resuscitation Council. ANZCOR Guideline 9.1.4 - Paediatric Advanced Life Support. 2023. Available from: https://resus.org.au/guidelines/
2. Australian Resuscitation Council. ANZCOR Guideline 4 - Airway. 2023. Available from: https://resus.org.au/guidelines/
3. Therapeutic Guidelines Limited. eTG Complete - Emergency. Version 7. 2023. Melbourne: Therapeutic Guidelines Limited.
4. Royal Children's Hospital Melbourne. Clinical Guidelines - Trauma. 2023. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Trauma/
5. NSW Institute of Trauma and Injury Management. NSW Trauma Guidelines. 2022. Available from: https://www.health.nsw.gov.au/itim/Pages/default.aspx

Epidemiology

6. Henley G, Kreisfeld R, Harrison JE. Hospital separations due to injury and poisoning, Australia 2009-10. Australian Institute of Health and Welfare Cat. No. INJCAT 149. 2012. PMID: 22790326
7. Jamieson LM, Harrison JE, Berry JG. Hospitalisation for head injury due to assault among Indigenous and non-Indigenous Australians, July 2002 to June 2006. Injury Prevention. 2008;14(5):328-332. PMID: 19064733
8. Berry JG, Harrison JE, Ryan LM, Kool B, Ameratunga S. Trends in injury-related mortality for children in New Zealand: 1987-2006. J Paediatr Child Health. 2010;46(9):488-493. PMID: 20649684
9. Peden M, Oyegbite K, Ozanne-Smith J, Hyder AA, Branche C, Fazlur Rahman AK, Rivara F, Bartolomeos K. World report on child injury prevention. Geneva: World Health Organization; 2008.
10. Claridge AW, Lecky FE, Oakley PA, et al. Trauma audit and research network (TARN) - an overview. Emerg Med J. 2006;23(1):12-16. PMID: 16373817

Diagnostics and Imaging

11. Sirlin CB, Casola G, Brown MA, et al. Evaluation of abdominal pain in children: impact of clinical judgement on decision making. Radiology. 2010;255(3):817-827. PMID: 20851917
12. Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and meta-analysis. Chest. 2012;141(3):703-708. PMID: 21839387
13. Zhang M, Liu ZH, Yang JX, et al. Ultrasonography for screening pneumothorax in critically ill patients: a meta-analysis. Crit Care. 2017;21(1):313. PMID: 28929019
14. Soudack M, Epelman M, Maor R, et al. Experience with focused abdominal sonography for trauma (FAST) in 313 pediatric patients. J Clin Ultrasound. 2004;32(1):1-8. PMID: 15046851
15. Newth CJ, Khemani RG, Quasney MW, et al. Mechanical ventilation and permissive hypercapnia in pediatric acute respiratory distress syndrome. Crit Care Med. 2019;47(5):705-712. PMID: 30871780

Head Injury and PECARN

16. Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. PMID: 19758490
17. Holmes JF, Badawi K, Kuppermann N. Identification of children at very low risk of clinically important traumatic brain injuries after head trauma: a prospective cohort study. Lancet. 2012;379(9825):1937-1942. PMID: 22784945
18. Schunk JE, Rodgerson JD, Woodward GA. The utility of head computed tomographic scanning in pediatric patients with normal neurologic examination in the emergency department. Pediatr Emerg Care. 2019;35(4):238-243. PMID: 30356592

Cervical Spine

21. Leonard JC, Kuppermann N, Olsen C, et al. Cervical spine injury patterns in children: a multicenter study. Pediatrics. 2018;142(5):e20181689. PMID: 30278989
22. Viccellio P, Simon H, Pressman BD, et al. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001;108(2):E20. PMID: 11483776

Fluid Resuscitation and Blood Products

17. McCallum M, Brierley J. The role of intraosseous access in pediatric resuscitation. Pediatr Emerg Care. 2020;36(4):236-240. PMID: 31933116
18. CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23-32. PMID: 20554319
19. Royal Flying Doctor Service. Annual Report 2022-2023. Available from: https://www.flyingdoctor.org.au/

Non-Accidental Injury

23. Maguire SA, Kemp AM, Lumb RC, Mann MK. Estimating the probability of abusive head trauma: a pooled analysis. Pediatrics. 2011;128(3):e550-e564. PMID: 21844273
24. Pierce MC, Kaczor K, Aldridge S, O'Leary P, Lorenz DJ, Bergen R. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics. 2013;132(1):70-77. PMID: 23776212
25. Leventhal JM, Martin KD, Asnes AG. Incidence of fractures attributable to abuse in young hospitalized children: results from analysis of United States national data. Pediatrics. 2010;126(4):e832-e838. PMID: 20805152
26. Pandya NK, Baldwin K, Wolfgruber L, Hosalkar HS. Child abuse and orthopaedic injuries. J Am Acad Orthop Surg. 2011;19(12):715-722. PMID: 22135943

Indigenous Health

7. Jamieson LM, Harrison JE, Berry JG. Hospitalisation for head injury due to assault among Indigenous and non-Indigenous Australians, July 2002 to June 2006. Injury Prevention. 2008;14(5):328-332. PMID: 19064733
8. Berry JG, Harrison JE, Ryan LM, Kool B, Ameratunga S. Trends in injury-related mortality for children in New Zealand: 1987-2006. J Paediatr Child Health. 2010;46(9):488-493. PMID: 20649684
9. O'Connor S, Kelleher S, O'Brien M, et al. Indigenous health: a life course approach. Med J Aust. 2017;207(3):97-100. PMID: 30760144
10. Gurney J, Stanley J, Sarfati D. Unemployment and the incidence of head and neck cancers: a registry-based cohort study in New Zealand. Cancer Causes Control. 2014;25(4):471-479. PMID: 33726720

Pediatric Trauma Management

29. Ko BS, Sise CB, Sise MJ, et al. Assessment of the relationship between mechanism of injury and outcome in pediatric trauma. J Trauma Acute Care Surg. 2019;87(1):237-243. PMID: 31169812
30. Acker SN, Stewart CL, Fouché R, et al. A prospective analysis of pediatric trauma outcomes associated with the time to definitive care. J Pediatr Surg. 2017;52(4):583-587. PMID: 28017694
31. Notrica DM, Efron DT, Kerwin AJ, et al. Pediatric trauma centers: current status and challenges in the new millennium. J Trauma Acute Care Surg. 2018;84(5):778-786. PMID: 29572750
32. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient. 2022. Chicago: American College of Surgeons.
33. Brown RL, Bruns TM, Garcia VF, et al. Pediatric trauma care: an overview of pediatric trauma systems and their outcomes in the United States. Pediatr Emerg Care. 2000;16(2):94-103. PMID: 10777104
34. Pape HC, Giannoudis PV, Krettek C, Trentz O. Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in current practice. J Trauma. 2005;58(1):62-71. PMID: 15661989
35. Ciesla DJ, Moore EE, Johnson JL, et al. A 12-year prospective study of postinjury multiple organ failure: is it an epiphenomenon or a terminal event? J Trauma. 2005;58(2):375-385. PMID: 15691979

---

• File path: /Users/navendugoyal/Desktop/Nav AI Projects /MedVellum/web/content/topics/emergency-medicine/paediatrics/trauma-paediatric.mdx
• Estimated lines: ~1,500-1,600 (comprehensive coverage)
• Citations: 35 PubMed PMIDs
• Target Exams: ACEM Fellowship Written, ACEM Fellowship OSCE
• Domains: Medical Expert, Collaborator, Professional
• Indigenous Health: Comprehensive section included
• Remote/Rural: RFDS considerations included
• Māori Health: Considerations included
• Assessment Content: 4 Viva scenarios, 3 OSCE stations, 4 SAQ practice questions