Navigating the Challenges of Managing Pediatric Trauma: Current Trends, Evidence, and Practical Pathways
Daniel Scheese MD1; Travis Sullivan, MD1; Jeffrey Haynes, MD2; Edgar Rodas, MD1
1Virginia Commonwealth University Health System, 2Childrens Hospital of Richmond
Corresponding author:
Edgar B. Rodas, MD, Associate Professor, Division of Trauma/Critical Care and Emergency Surgery, Department of Surgery, Virginia Commonwealth University School of Medicine
1201 E. Clay St. Richmond, VA 23298
Email: [email protected]
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Abstract
Background: Pediatric trauma care is shifting toward physiology-first, outcome-focused management that balances rapid hemorrhage control with judicious diagnostics across resource settings.
Objectives: To synthesize contemporary evidence and provide practical guidance on hemostatic resuscitation, radiation stewardship and vascular screening, abdominal trauma pathways and operative strategy, traumatic brain injury (TBI) care, and system-level readiness.
Methods: Narrative review of recent guidelines, consensus statements, and pivotal studies in pediatric trauma, emphasizing practices with demonstrable outcome benefit and de-implementation of low-value care.
Major Findings: Hemostatic resuscitation should prioritize early recognition of hemorrhagic shock, rapid access to blood, and preferential use of low-titer group O whole blood; when unavailable, employ balanced component therapy approximating a 1:1:1 ratio. Monitor and correct ionized calcium during large-volume transfusion. Evidence for tranexamic acid is mixed, supporting selective use and viscoelastic guidance with thromboelastography/rotational thromboelastometry. Radiation stewardship favors age-sensitive rules: clinical clearance with the Pediatric Emergency Care Applied Research Network (PECARN) cervical-spine criteria when risk is very low, magnetic resonance imaging for suspected ligamentous injury in younger children, and chest computed tomography only when results will change management. For blunt cerebrovascular injury, the Utah and McGovern scores support selective CT angiography with grade-tailored antithrombotic therapy. Abdominal trauma pathways combine serial examinations, screening laboratories, and focused assessment with sonography for trauma (FAST) to guide selective imaging and admission; American Pediatric Surgical Association guidance prioritizes hemodynamics over CT grade, encourages early mobilization, and favors symptom-driven follow-up. Operative strategy includes indications for damage-control surgery and the open abdomen with planned re-look and timely fascial closure. For TBI, 2019 Brain Trauma Foundation guidance emphasizes stepwise intracranial pressure control, age-appropriate cerebral perfusion pressure targets, early nutrition, seizure prophylaxis, and avoidance of secondary insults. Greater pediatric readiness at the hospital and system level is associated with improved survival.
Conclusions: A physiology-first, evidence-aligned approach that prioritizes interventions with measurable benefit and de-implements low-value care can improve outcomes for injured children across diverse clinical environments.
Keywords: Pediatric trauma, whole blood, damage-control resuscitation, imaging stewardship, TBI, pediatric readiness