Major trauma and paediatric trauma systems — formative SAQs

1. First 60 seconds

"This child is critically injured with abnormal appearance, circulation to skin and a high-energy mechanism. I confirm the trauma team is activated with named roles, take a structured handover, and run <C>ABCDE treating each threat as it is found. Stabilisation comes before the full diagnosis." The principle is recognise and call for help, control catastrophic haemorrhage first, then proceed in order, because exsanguination kills before airway problems in this child. [6] [8]

2. Team-led primary survey

<C> — Catastrophic haemorrhage. Apply direct pressure to the open femoral fracture, apply a tourniquet proximal to the bleeding if it is exsanguinating, and apply a pelvic binder for the unstable pelvis before airway work. [5]

A — Airway with cervical spine control. Maintain manual in-line stabilisation, assess patency, clear blood or vomit, and summon airway expertise early; the cervical spine is protected throughout. [6]

B — Breathing. Give high-flow oxygen in failure, assess rate, effort, air entry and symmetry, and decompress a tension pneumothorax clinically rather than waiting for imaging. [6]

C — Circulation. Confirm shock from the whole picture despite a non-hypotensive blood pressure, gain intravenous or intraosseous access, control ongoing loss, and give weight-based aliquots with early blood for haemorrhagic shock. [8]

D — Disability. Screen with AVPU and convert to a paediatric Glasgow Coma Scale, check pupils and bedside glucose, and treat seizure or a dangerous low glucose immediately. [1]

E — Exposure. Expose fully but briefly, look for every wound, then warm actively and run safeguarding documentation in parallel. [11]

3. Fluid and blood strategy

"I give balanced crystalloid in weight-based aliquots of 10 to 20 mL per kilogram, reassessing after each, but I minimise the total crystalloid because it worsens the lethal triad of hypothermia, acidosis and coagulopathy. In confirmed haemorrhagic shock I move to balanced blood products early at a ratio near 1 to 1 to 1 of red cells to plasma to platelets, give tranexamic acid within 3 hours, keep the core temperature above 35 degrees Celsius, and arrange surgical or interventional control of the source." The fixed volume is a ceiling, not a target; the goal is to stop the bleeding and break the triad, not to chase a number. [5] [4]

4. Reassessment, escalation and handover

After every action I return to the top and check whether the expected change occurred; I record benefit, harm and unresolved threat. Because this injury exceeds a regional service, I activate retrieval and paediatric trauma centre referral in parallel with resuscitation. The structured handover transfers identity and working weight, mechanism, current physiology and trend, timed actions and response, the prioritised differential and pending tests, local limits, family and safeguarding information, and the next contingency with its named owner. [6] [11]

1. Blood pressure does not exclude shock

Children compensate for hypovolaemia by raising heart rate and vascular tone, so blood pressure is maintained until relatively late. This child already shows poor perfusion with a raised heart rate, prolonged refill and a metabolic acidosis, which is compensated shock in evolution. Hypotension in the trauma bay is an independent predictor of death, so waiting for it to diagnose shock is a classic and dangerous error. Shock is a whole-circulation diagnosis, never a single blood-pressure number. [8] [6]

2. Base deficit and raised international normalised ratio

A base deficit signals tissue hypoperfusion from ongoing bleeding or shock, and a raised international normalised ratio signals traumatic coagulopathy, which is part of the lethal triad. Together they show that the child is sicker than her blood pressure suggests and that resuscitation must move from crystalloid to early blood products, active warming, and tranexamic acid within 3 hours, with surgical control of the source. They also raise the risk of large-volume transfusion, so I crossmatch early, reassess haemoglobin, coagulation, calcium and acid-base throughout, and escalate to definitive haemorrhage control. [5] [8]

3. Imaging decisions and safety of moving the child

I name the question before I order any scan. A focused assessment with sonography in trauma, within operator competence, answers whether there is free intra-abdominal fluid or a pericardial effusion in an unstable child and can direct her to theatre rather than scanning. For a low-risk head or cervical spine concern I apply the PECARN rules, which identify children in whom computed tomography can be safely avoided. Computed tomography is appropriate for the stable child with significant mechanism, but only with a safe transfer plan, monitoring and escort; an unstable child belongs in theatre or being resuscitated, not in a scanner. I do not scan an unstable child. [1] [2]

4. Retrieval and disposition

I call retrieval and the paediatric trauma centre in parallel with resuscitation, before local support is exceeded. I agree the destination, the treatment to continue en route, the escort, the monitoring and blood plan, the contingency for deterioration, and the plan if transfer is delayed. I keep the family informed and document objectively. My structured handover transfers identity and weight, mechanism, physiology and trend, timed actions and response, the prioritised differential and pending tests, local limits, and the next contingency with its named owner. A defensible disposition requires sustained stability, an executed imaging and surgical plan, and a usable safety net. [6] [11]