Trauma Resuscitation Clinical Pathway — Emergency Department

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Resuscitation Patient Meeting Trauma Activation Criteria

Modified from Advanced Trauma Life Support (ATLS)- Protocol for pediatric trauma

Prior to Patient Arrival
Determine Trauma Activation Level Trauma Activation Communication

Pre-Notification
Via Emergency Medical Services (EMS)		ED Medical Command Physician (MCP) notifies transport of level
Transferred from Outside Hospital		Transport center calls ED MCP and trauma fellow who determine activation level

No Notification
Via EMS or private vehicle		ED clinician notifies Transfer Center with activation level

**Special Considerations for Transfer**
Assign	Trauma Resuscitation Team Roles Implement Crowd Control

Patient arrival to ED

0 min

Primary Survey: Organized Evaluation to identify life threats and Intervene

**Life-threatening Injury**
Respiratory
Altered mental status due to neurologic/circulatory etiologies Airway Obstruction Direct Airway Trauma Tension Pneumothorax Suspected Pneumothorax Pulmonary Contusion Smoke Inhalation
Circulatory
Hemorrhagic Shock Blunt Trauma Penetrating Trauma Pelvic Fracture Long Bone Fracture Vascular Injury Massive Hemothorax Cardiac Tamponade
Neurologic
Head/Intracranial Injury Spinal Cord Trauma Spinal Shock

		Interventions
C	Catastrophic Hemorrhage	Identify and control active exsanguination
A	Airway, C-Spine	Oxygen, Suction C-Spine Immobilization, Clearance
B	Breathing	Assess Indications for Intubation Medications, Procedure Ventilation, Monitoring
C	Circulation	Vascular Access, Escalation, Large Bore Access x2 Trauma Labs Rapid Fluid Administration Consider massive transfusion protocol See Massive Transfusion Protocol Procedure
D	Disability, Dextrose	Neurologic Assessment, GCS Score, AVPU Treat Brain Injury For suspected herniation: Modest hyperventilation 3% NS bolus If Signs of spinal cord injury: Spine immobilization Evaluate for signs of Spinal Shock
E	Exposure	Ensure full exposure (remove all clothing) Environmental support, Maintain Normothermia

Log Roll: Immediately after primary survey completion

Secondary Survey: Organized Evaluation to identify all injuries

Imaging Considerations	Per Trauma Attending/Fellow, ED Attending/Fellow - Prioritize triaging imaging
Plain films X-ray	C-Spine, chest, pelvis, injured extremities
Computerized tomography (CT)	Non-contrast Head CT (consider C1-C2) abdominal CT IV contrast, chest CT IV contrast
Considerations for Pediatric eFAST Nasogastric/orogastric tube, foley

Ongoing Care: Stabilization and Considerations for Disposition

Consults	Neurosurgery, Orthopedics, Plastics, Oral and Maxillofacial Surgery, ENT, Vascular, Urology, Social Work As clinically indicated, Contact Numbers
Other Considerations	Continued attention to ABCDs Analgesia, temperature, antibiotics, tetanus Review laboratory/radiology results
Communication	CT, Blood Bank, OR, Anesthesia, PICU Contact numbers

20 min

Disposition

Prepare patient for transport with equipment and medications Proceed to Radiology as clinically indicated

Medical Examiner

ECPR

PICU

Med/Surg

ED Exam Room

Discharge Home

Reviewed by Children's Hospital of Philadelphia Trauma Committee: November 2019
Posted: January 2020
Revised: February 2023
Authors: H. McCorkle, CRNP; D. Perks, CRNP; S. Meyers, MD; G. Nace, MD; S. Fesnak, MD; MK. Abbadessa, ACCNS-P;
J. Connelly, CRNP; S. Gaines, RN; J. Lavelle, MD

Evidence

CHOP Programs

Educational Media

Pediatric Trauma: Differences in Care

Related Links

ATLS, American College of Surgeons

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

Emergency Department Clinical Pathway for Children Meeting Trauma Activation Criteria

Evidence

CHOP Programs

Educational Media

Related Links