Important points in the history

Primary survey and emergency management


Cervical spine protection

C-Spine immobilisation

  • Stabilise the child's neck
  • Tape the child's forehead to the sides of a firm board
  • Prevent the neck from moving by supporting the child's head e.g. by using bags of IV fluid on each side
  • If vomiting use log roll to turn onto one side, keeping the head in line with the body


  • Consider the possibility of cardiac tamponade

  • Consider other mediastinal injuries, disruption of great vessels, diaphragmatic rupture etc.

  • Indication for intubation and ventilation:

    • Persistent airway obstruction
    • Predicted airway obstruction (e.g. inhalational burn, severe facial trauma)
    • Loss of airway reflexes/ loss of consciousness
    • Inadequate respiratory effort or increasing fatigue
    • Disrupted ventilator mechanism e.g. flail chest
    • Persistent hypoxia despite oxygen administration
    • Severe traumatic brain injury

    Resources for mechanical ventilation are limited
    A pragmatic approach to intubation and ventilation is needed
    Call for HELP - experienced paediatrician and/ or anesthetist

    Note on the usage of drugs: we use ketamine as an induction agent. In traumatic brain injury the theoretical risk of increasing intracranial pressure is outweighed by the relative haemodynamic stability compared with the use of other induction agents.



    >5 years <5 years
    Obeys commands (6) Normal spontaneous movements (6)
    Localises pain (5) Withdraws to touch (5)
    Withdraws to pain (4) Withdraws to pain (4)
    Flexion to pain (decorticate) (3) Abnormal flexion (decorticate) (3)
    Extension to pain (decerebrate) (2) Abnormal extension (decerebrate) (2)
    No response (1) No response (1)
    Orientated (in person or place or address) (5) Alert, babbles, words or sentences to usual ability (normal) (5)
    Confused (4) Less than usual ability, irritable cry (4)
    Inappropriate words (3) Cries to pain (3)
    Incomprehensible sounds (2) Moans to pain (2)
    No response to pain (1) No response to pain (1)
    Spontaneous (4) Spontaneous (4)
    To voice (3) To voice (3)
    To pain (2) To pain (2)
    None (1) None (1)


    Other procedures & imaging

    Secondary survey after management of ABCDE

    How to position the unconscious child

    No Neck Trauma: Recovery Position
    Turn the child on to their side to reduce the risk of aspiration
    Keep the neck slightly extended and stabilise by placing the cheek on one hand
    Bend one leg to stabilise the body position

    Transfer & further management