Approach to a Child with Road Traffic Accident (RTA)

Initial Triage and Categorization

• A child presenting to the emergency room with severe trauma from a road traffic accident (RTA) is categorized under Level 1 (Resuscitation) in the triage acuity classification, denoting a life-threatening condition that requires immediate, aggressive medical intervention within 1 to 5 minutes.

Primary Assessment and Stabilization (The ABCDE Approach)

• Airway with Cervical Spine Protection:
  • In any child with a history of RTA or trauma, a cervical spine injury must be strongly suspected, and the cervical spine must be manually stabilized and immobilized immediately.
  • The airway should be opened utilizing the jaw thrust maneuver, and the head tilt-chin lift maneuver must be strictly avoided as it can exacerbate cervical spine injuries.
  • Endotracheal intubation, preferably using a cerebroprotective rapid sequence intubation (RSI) technique, is indicated if the child has a Glasgow Coma Scale (GCS) score $\le$ 8, abnormal breathing patterns due to cervical spine or chest wall injury, or a loss of protective airway reflexes.
• Breathing and Ventilation:
  • Administer 100% supplemental oxygen via a non-rebreathing face mask or provide bag-valve-mask ventilation if respiratory efforts are poor, targeting an oxygen saturation (SpO2) of > 94%.
  • The clinician must urgently look for life-threatening thoracic trauma such as tension pneumothorax, pulmonary contusion, or rib fractures, which often present with chest pain, respiratory distress, and unequal chest rise.
  • If a tension pneumothorax is suspected clinically, an immediate needle thoracotomy must be performed in the second intercostal space in the midclavicular line.
• Circulation and Hemorrhage Control:
  • RTAs frequently cause significant external or internal hemorrhage (e.g., in the chest, abdomen, retroperitoneum, or scalp), leading to hypovolemic/hemorrhagic shock.
  • Establish two large-bore intravenous lines immediately; if peripheral access is unsuccessful within 90 seconds or 3 attempts, an intraosseous (IO) line must be secured.
  • Control any obvious external bleeding with direct pressure.
  • For hemorrhagic shock, "damage control resuscitation" or "hemostatic resuscitation" is recommended, which emphasizes the early use of blood products (plasma, platelets, and packed red blood cells in a 1:1:1 or 1:1:2 ratio) rather than large volumes of crystalloids, to minimize hemodilution and resuscitation-induced coagulopathy.
  • "Permissive hypotension" may be considered in trauma, which involves restricting fluid administration until the hemorrhage is surgically controlled, accepting a brief period of suboptimal end-organ perfusion to prevent re-bleeding from recently clotted vessels.
• Disability (Neurological Evaluation):
  • Traumatic Brain Injury (TBI) is the most common cause of raised intracranial pressure (ICP) in children.
  • Assess the depth of coma using the Modified Glasgow Coma Scale (mGCS) and check for pupillary size, shape, symmetry, and reaction to light to identify signs of brainstem herniation.
  • If raised ICP is suspected, initiate first-tier therapies: keep the head in the midline with 30-degree elevation, avoid noxious stimuli, maintain normothermia and euglycemia, and administer osmotherapy (3% hypertonic saline or 20% mannitol).
  • Prophylactic antiseizure drugs (phenytoin or levetiracetam) are indicated for children at high risk of seizures due to parenchymal injuries, severe TBI, or depressed skull fractures.
• Exposure and Environment:
  • The child must be completely undressed to perform a thorough head-to-toe examination to identify hidden injuries, lacerations, ecchymoses, or deformities.
  • Strict measures must be taken to maintain normothermia, as hypothermia exacerbates trauma-induced coagulopathy and shock.

Classification of Hemorrhagic Shock in Trauma

• The severity of hemorrhagic shock in trauma is classified into four classes based on the volume of blood lost, which guides ongoing resuscitation efforts.

Secondary Survey and Investigations

• Focused Assessment Sonography for Trauma (FAST): Ultrasonography is a critical bedside tool used to rapidly evaluate the intraperitoneal cavity and pleural spaces for accidental trauma, helping to detect occult internal bleeding or organ injury.
• Neuroimaging: A non-contrast Computed Tomography (NCCT) of the head and cervical spine is the primary imaging modality of choice to assess for epidural hematoma, subdural hematoma, intracranial hemorrhage, and cerebral edema.
• Radiography: Plain radiographs of the chest and pelvis should be obtained to identify concomitant injuries such as pulmonary contusions, rib fractures, or pelvic fractures.
• Laboratory Investigations: Send critical samples including a complete blood count, blood grouping and cross-matching, arterial blood gas, lactate, and a coagulation profile (PT/aPTT) to monitor for disseminated intravascular coagulation (DIC) or massive transfusion needs.