The primary survey, as defined by Advanced Trauma Life Support, is a prioritized evaluation and management protocol focused on identifying and treating the most life-threatening injuries first. This framework is unique to trauma care.
Pediatric trauma patients with respiratory failure can be considered the most seriously injured. One should expect them to behave as such despite potentially having “normal” heart rate or blood pressure. Having awareness of basic pediatric airways skills, including bag-mask, is crucial. The most effective, objective, and rapid steps in evaluating breathing and adequate ventilation are auscultation of the chest, application of a pulse oximeter for measurement of oxygen saturation, and assessment of respiratory rate.
The greater physiologic reserve of children makes early identification of cardiovascular compromise more challenging than in adults.
Of the three main components of the Glasgow Coma Scale, the motor score has been shown to be the best predictor of outcome after injury.
When intravenous access is challenging, moving quickly to placing intraosseous access can be lifesaving.
Trauma is the leading cause of death and acquired disability in children and adolescents, resulting in more deaths in children than all other causes combined. , Because children with severe injuries can rapidly deteriorate, resources for rapidly identifying and treating injuries are needed immediately on arrival at the receiving hospital. The initial evaluation of injured children in the emergency department (trauma resuscitation) has two main goals: (1) identify and immediately treat potentially life-threatening injuries and (2) determine disposition after the trauma resuscitation on the basis of known or suspected injuries. The trauma team must stabilize the child, determine the extent of the injury, and develop an initial treatment plan for the child’s hospitalization.
Advanced Trauma Life Support (ATLS) is a framework and series of protocols developed to standardize the initial evaluation and management of injured patients and avoid omission of potentially lifesaving interventions. After 4 decades of refinement, ATLS serves as the standard for the initial management of injured patients and is now taught to providers around the world. The impact of ATLS on reducing morbidity and mortality after injury has been affirmed in several studies. , ATLS training is mainly focused on treating the injured adult but includes modules that emphasize the anatomic, physiologic, and psychologic features that make management of the injured child unique. The basic algorithms of assessing and addressing life-threatening injuries first are the same for children as they are for adults.
The first phase of ATLS is the primary survey, a rapid evaluation focused on identifying life-threatening injuries. The steps include evaluation and treatment of the airway (A , airway ) followed by evaluation of respiratory dynamics (B , breathing ), evaluation of the patient’s hemodynamic status (C , circulation ), followed by a neurologic assessment (D , disability ). The final phase of the primary survey (E , exposure/environment ) includes removing the patient’s clothing to identify concealed injuries and ensuring that the patient is protected from environmental heat loss. The primary survey is then followed by the secondary survey, a detailed head-to-toe evaluation that identifies other injuries. The steps within the primary survey are repeated as needed if the patient’s status changes and to monitor the response to therapeutic interventions. The initial management of injured adults has been the domain of trauma surgeons; the jurisdiction of care for the injured child is not as well defined at many centers. Frequently, pediatricians, anesthesiologists, and emergency department physicians have an active role in the initial management and treatment of injured children. Although formal ATLS training is not needed for most pediatric providers, this training should be mandatory for those actively involved in the initial evaluation of injured children. The goal of this chapter is to provide a focused introduction to the initial resuscitation of injured children. This chapter does not serve as a replacement for ATLS training but will instead highlight aspects of the resuscitation that are unique to injured children or may not be emphasized in the ATLS curriculum.
Prehospital care and trauma team activation
Initial field care, appropriate triage, and rapid transport are all aspects of prehospital care that can have an important impact on the outcome in pediatric trauma. Cities and regions have developed trauma systems that coordinate these aspects of care by creating networks of prehospital and hospital providers. The most severely injured children are triaged to the centers within each trauma system that have the personnel, facilities, and equipment to manage these patients. Equally important, minimally injured patients can be directed to nontrauma hospitals to avoid burdening pediatric trauma centers with these patients. Field triage is based on several components, including physiologic criteria, anatomic injury, mechanism of injury, and underlying medical conditions. Triage criteria are designed to minimize inappropriate transport of severely injured patients to nontrauma hospitals (undertriage) but achieve this goal at the cost of directing some patients to trauma centers who are only minimally injured (overtriage). Due to the limited time and resources available for evaluation in the prehospital setting, overtriage is an unavoidable aspect of current trauma systems. Injured children who have met criteria for transport to high-level trauma centers by current criteria may be minimally injured and require no specific interventions before discharge from the emergency department. A key aspect of the initial management of the injured child in the emergency department is effectively continuing the care started in the field while avoiding unneeded care for those with minimal injuries.
One approach that has been used in many centers to address the problem of overtriage is the use of a tiered team response in the emergency department. On the basis of prehospital criteria, patients who are identified as being most at risk for severe injury are met by a full team upon arrival, including a trauma surgeon, emergency department physicians, critical care physicians, anesthesiologists, nurses, and radiology technicians. Patients with a lower likelihood of severe injury are initially met by a smaller team with the option of summoning a larger team if the initial evaluation suggests a severe injury. Centers that have used this approach for team activation have significantly reduced the expenditure of resources on minimally injured patients without any impact on the care received for more severely injured patients.
Trauma resuscitations are among the most resource-intensive and time-pressured events in any hospital. The severity of the patient’s injuries, number of team members required, and number of simultaneous evaluation and management steps needed contribute to the complexity of the environment. To manage the complexity of trauma resuscitation, a systematic team-based and process-focused approach is needed to rapidly identify and treat life-threatening injuries and minimize team errors.
Designating a specific room and team for trauma resuscitations helps ensure that the needed resources are immediately available. A single location ensures that supplies (i.e., emergency airway kits, chest tube and thoracotomy trays, cervical collars, and central or intraosseous vascular access kits) are available and that team members know to gather at a specific site. Physicians, nurses, radiography technicians, respiratory therapists, and other hospital personnel needed for trauma resuscitation are identified in advance as trauma team members assemble and assume their roles in the resuscitation area upon arrival of the injured child. These seemingly simple preparations ensure that the arriving patient has the maximal resources available at the receiving hospital. It is especially helpful to have a resuscitation room equipped with pediatric age- and size-specific equipment. Special carts, with color-coded drawers matching the Broselow measuring device, are helpful to organize size-specific equipment. The trauma resuscitation room should be warmed in preparation for patient arrival as an effort to prevent hypothermia.
Before arrival at the hospital, prehospital providers transmit information to hospital providers regarding the mechanism of injury, status of the patient, and initial treatments or interventions that have been provided. This information can alert the team to prepare specific equipment or resources or to summon other essential personnel. Before the patient arrives, it is good practice for the team to review prehospital information to ensure that all team members are aware of the patient’s status and anticipated needs. On arrival at the emergency department, an additional and final exchange of information between the prehospital providers and trauma team occurs. A “time out,” or quiet period, facilitates this information transfer. Essential elements that should be obtained in this report include details about the injury event, vital signs obtained at the scene and during transport, pertinent physical findings, and the initial treatments administered and response to these treatments. Allowing the prehospital providers to give their report before starting the patient evaluation or even transferring the patient to the emergency department gurney improves information exchange and prevents repetitive questions later in the resuscitation.
The primary survey, as defined by ATLS, is a prioritized evaluation and management protocol focused on identifying and treating the most life-threatening injuries first. This approach is different from the traditional initial evaluation in a patient in which an extensive history and physical examination are performed before diagnosis and treatment. The classic steps of the primary survey are taught in the ATLS course as a sequence, with evaluation and treatment by one provider of “A” followed by “B,” and so forth. In actual practice, most centers have a team of providers allowing the evaluation and management steps to proceed forward in parallel. A designated team leader stands at the foot of the bed, receives information reported by the team, and provides higher-level direction of the conduct of the resuscitation. While the steps of the primary survey provide the framework for the initial assessment, new information may be obtained in later phases or a patient’s status may change, requiring iterative performance of each step. It is often a challenge to ensure that the team retains its focus on the underlying prioritization scheme of the primary survey and does not omit or minimize steps in this process ( Fig. 117.1 ). When resuscitations are evaluated, compliance with ATLS protocols is often low, mandating continued training and retraining to ensure that the well-established benefits of this protocol are realized. The use of a checklist by the trauma team leader has been associated with greater ATLS task performance and with increased frequency and speed of primary and secondary survey task completion. ,
Establish an airway with cervical spine stabilization (A)
Establishment of a patent airway with cervical spine stabilization is the first step of the primary survey. All patients should immediately receive oxygen as the evaluation is begun. After oxygen is placed, evaluation of the airway can proceed. Injured children who present to the emergency department can be placed into three categories with respect to initial airway management: (1) those with a patent airway requiring no manipulation, (2) those who have undergone intervention in the field or at another hospital to establish a patent airway, and (3) those who will need an intervention to establish a patent airway. Most children evaluated by the trauma team are in the first group. For these patients, evaluation should consist of several simple steps, including asking the patient’s name, inspection for craniofacial injuries, assessment for voice changes, and listening for obvious stridor. These steps can be performed easily and rapidly in most children. A simple statement that “the airway is patent” will communicate to the team that these confirmatory steps have been accomplished. Because most injured children will not require any specific airway management, omission of elements of the airway assessment is common in pediatric trauma resuscitation. Although the patency of the airway may seem “obvious” in many patients, subtle and early signs of pending airway compromise will be missed if a formal airway evaluation is not completed ( Table 117.1 ).
|Errors Identified||N (%)|
|Airway and Breathing|
|Delay in oxygen therapy||60 (67)|
|Chest not auscultated||40 (44)|
|Oxygen saturation not measured||33 (37)|
|Neck not adequately examined||71 (79)|
|No head stabilization on transfer||18 (20)|
|Inappropriate intravenous access||18 (20)|
|Pulse not assessed||37 (41)|
|Central capillary refill not assessed||59 (66)|
|Blood pressure not measured||28 (31)|
|Fluid bolus not warmed||33 (89)|
|Perineum not examined||41 (45)|
|Head not examined||13 (15)|
|Ears not examined||16 (18)|
|Mouth not examined||41 (45)|
|Back not examined||13 (15)|
|Chest not examined||3 (3)|
|Abdomen not examined||2 (2)|
The second category is children with an airway already established in the field or other hospital, usually by endotracheal intubation. Airway interventions performed before a patient’s arrival should not be interpreted as an adequate airway; additional steps should be performed to assess airway patency, especially in light of the relative tenuous nature of pediatric airways placed under emergency situations. The key steps to evaluating an endotracheal tube placed outside the emergency department are assessing the appropriateness of tube size, evaluating tube depth, assessing adequacy of ventilation by auscultation and inspection of the chest, measurement of end-tidal carbon dioxide (CO 2 ), and confirmation of tube position with a chest radiograph. The appropriate tube size can be evaluated using age-specific formulas and charts or by comparing the tube with the child’s fifth (little) finger. Inadvertent deep placement of an endotracheal tube in a prehospital setting is common, especially among younger children. The short airway in pediatric patients increases the likelihood that an endotracheal tube will migrate from the proper position during transport. An easy rule for rapidly assessing tube depth is that the length of the tube at the teeth should be three times the tube size (internal diameter measured in millimeters). Age-specific formulas for evaluating endotracheal tube depth are also available. An adequate airway is confirmed through auscultation of bilateral breath sounds, inspection for chest wall movement, and measurement of end-tidal CO 2 . Because of a shorter airway and relatively less margin for movement of an endotracheal tube in younger children, correct endotracheal tube position cannot be reliably confirmed by auscultation of bilateral breath sounds alone. Final confirmation of endotracheal tube position requires a chest radiograph.
The final category of injured children undergoing airway evaluation is those who present with airway compromise requiring intervention. Because this category of injured children is least common, clearly defined personnel and procedures are needed to prepare the team to efficiently and safely establish an airway. Indications for endotracheal intubation in pediatric trauma include apnea, inability to maintain a patent airway by other means, a need to protect the lower airway from aspiration of blood or vomitus, impending or potential compromise of the airway, presence of a closed head injury with a Glasgow Coma Scale (GCS) score ≤8, and inability to maintain adequate oxygenation with supplemental face-mask oxygen. An altered level of consciousness, usually due to an intracranial injury, is the most commonly observed reason for emergency airway intervention in the acutely injured child. Although a neurologic assessment is performed later in the primary survey, early recognition of children requiring a formal airway because of an altered level of consciousness is essential.
Once the trauma team has confirmed the need to establish an airway, the least invasive method for achieving this goal should be chosen. A chin lift and jaw thrust may be sufficient for initially opening the airway in some patients. These are simple and rapid steps that can facilitate bag-valve-mask ventilation. In the presence of a suspected cervical spine injury, only a jaw thrust should be used in order to protect the cervical spine from manipulation. These maneuvers, however, are not sufficient for long-term airway management. Small children on a flat spine board may have a partially occluded airway because their proportionately large head forces the neck into a kyphotic (flexed) position, resulting in upper airway obstruction. Simple manipulation of the young child’s head to maintain the plane of the face parallel with the plane of the spine board can improve airway patency.
When a more definitive airway is necessary, the preferred method for establishing an airway in pediatric trauma is orotracheal intubation. A rapid-sequence technique is preferred. During endotracheal intubation, steps should be taken to account for the short length and narrow diameter of the trachea, including choosing an appropriately sized endotracheal tube and confirming tube position. Nasotracheal intubation can be used for airway control in trauma but is contraindicated in patients with facial trauma, cerebrospinal fluid leaks, or suggestions of basilar skull fractures because these injuries suggest the possibility of a disruption between the cranial vault and the nasopharynx. , The laryngeal mask airway (LMA) is also an option for emergency airway management in situations in which endotracheal intubation cannot be accomplished. However, as the LMA does not protect against aspiration and cannot be used effectively to provide positive-pressure ventilation in patients with altered respiratory compliance or resistance, it should be used only as a rescue technique if the patient’s trachea cannot be intubated.
Less than 1% of all adult patients who require an emergency airway in the emergency department require a surgical airway. The percentage of children requiring an emergency airway after injury is likely to be even smaller. Among injured children with a compromised airway, endotracheal intubation may not be possible because of significant craniofacial injuries; massive bleeding from the nasopharynx or oropharynx; or preexisting anatomic features, such as a short neck, micrognathia, or small mouth that make intubation more difficult. In this “cannot intubate/cannot ventilate” subset, a systematic approach is necessary to rapidly secure a patent airway ( Fig. 117.2 ).
If bag-valve-mask ventilation is successful, the team has time to find alternative routes of securing an airway. Examples include bringing a more experienced physician to the trauma bay to assist with establishing an airway or using alternative techniques such as indirect laryngoscopy or fiberoptic intubation. If bag-valve-mask ventilation is not successful, an appropriate invasive procedure may be required. Among injured children, appropriate options include surgical or needle cricothyrotomy, depending on the child’s size. Among children with a larger airway whose cricothyroid membrane is easily palpated, a surgical cricothyrotomy is preferred. If small neck size or other anatomic features preclude the safe placement of a cricothyrotomy, a needle cricothyrotomy with insufflation of oxygen into the airway has been recommended. As a general rule of thumb, patients under the age of 12 years have a more pediatric-shaped airway and needle cricothyroidotomy should preformed. Over the age of 12 years, patients tend to have a more adult-shaped airway and surgical cricothyroidotomy is the best option.
Surgical cricothyrotomy should be performed by members of the team with experience with this technique and, generally, only in children 12 years or older with an easily palpated cricothyroid membrane. This procedure has four main steps: (1) identification of the cricothyroid membrane, (2) making an incision through the skin and cricothyroid membrane, (3) stabilization of the larynx with a tracheal hook at the inferior aspect of the ostomy, and (4) placement of a tube in the trachea.
Needle cricothyrotomy is performed by inserting a large-bore (12- to 18-gauge) angiocatheter in a caudal direction at a 30- to 45-degree angle through the cricothyroid membrane. During needle advancement, constant negative pressure is applied to the plunger of the syringe to aspirate air and confirm its endotracheal position. After confirmation of endotracheal placement, the syringe and stylet are removed, and the cannula is connected to an oxygen source. Another option is to place a needle tracheostomy where the needle is placed at roughly the second tracheal ring and bypassing the small larynx in children. There are numerous methods for delivering oxygen via the angiocatheter but CO 2 removal is limited. Thus, needle-based airway procedures are considered useful for emergent oxygenation, not a long-term ventilation strategy. While pediatric evidence is limited, a flow of 25 to 35 psi from a standard regulator set at 10 to 12 L/min for most children has been recommended. Standard intravenous (IV) tubing can be connected to the cannula, and a Y-connector can be placed between the IV tubing and oxygen tubing. Intermittent occlusion for 1 second and release of the Y-connector for 4 to 5 seconds provides some passive ventilation. Improving oxygen saturations over the first minute after placement confirms correct deployment. A needle cricothyrotomy is a highly tenuous airway. It should be carefully secured after placement and managed by a single person in charge of maintaining the cannula and applying ventilation. Needle cricothyroidotomy should be converted to a more stable airway as soon as possible. Prolonged used of this technique will result in progressive respiratory acidosis from underventilation. Because surgical airway management is rarely performed in pediatric patients, centers that manage injured children should have the equipment and adequately trained personnel for performing these procedures when needed.
Cervical spine stabilization should be viewed as part of the “A” step and is included as part of airway management in ATLS. Endotracheal intubation in the trauma bay should proceed with the assumption that a cervical spine injury is present until this type of injury has been formally ruled out. This step is needed in patients with any mechanism of injury that can be associated with cervical spine trauma. Many injured children present to the emergency department with a cervical collar that was placed in the field because of the mechanism of injury. The initial evaluation of the airway should be immediately followed or simultaneously performed with an assessment of the proper size and fitting of the cervical collar or placement of a cervical collar when one is not present. When endotracheal intubation is required, in-line cervical spine stabilization must be used. A member of the team holds the neck on each side with hands and forearms maintaining the stability of the spine during airway manipulation. While cervical spine stabilization is important, it is also important to remember not to force children into ill-fitting collars, especially for mechanisms of injury in which spine injury is unlikely.
Establishment of a patent airway is an important initial step but is not sufficient to ensure oxygenation and ventilation. The breathing (B) step of the primary survey is the immediate assessment of air movement into the lungs and performance of measures to establish adequate air movement if it is compromised. The three most effective, objective, and rapid steps in evaluating this are auscultation of the chest, application of a pulse oximeter for measuring oxygen saturation, assessment of respiratory rate, and assessment of end tidal CO 2 . Because patients are supine during the primary survey, auscultation is limited to the anterior and lateral chest. Auscultation should be performed in both of these areas to obtain the most accurate evaluation of ventilation. Localizing abnormal auscultatory findings to a specific region of the chest can be more difficult in younger children because of smaller chest size and the usual supine position of the injured patient during the primary survey. However, in most children, auscultation can be used to identify significant compromise in aeration requiring lifesaving intervention. These steps can be supplemented by a subjective evaluation of the adequacy and symmetry of chest wall movement and an evaluation for evidence of chest wall trauma. Because of the pliability of the chest wall of younger children, significant chest injury may be present even in the absence of any chest wall deformity. The measurement of end tidal CO 2 in an intubated patient can allow optimization of Pa co 2 . This is paramount in the traumatic brain injury (TBI) patient, as hypocarbia or hypocarbia has been correlated with decreased survival.
The “B” phase of the primary survey is when thoracic injuries that can significantly impair ventilation may be identified and immediately treated. These include tension pneumothorax, open pneumothorax, flail chest with pulmonary contusion, and massive hemothorax. The diagnosis of a tension pneumothorax should be made on clinical criteria, including tracheal deviation, unilateral absence of breath sounds, neck vein distention, tachycardia, hypotension, and respiratory distress. Delaying treatment to obtain a confirmatory chest radiograph should be avoided because of the time delay associated with processing and interpreting this study, with the risk for a decompensation in clinical status. When the clinical diagnosis of a tension pneumothorax is made, the chest should immediately be decompressed by placing a 14- to 18-gauge angiocatheter needle into the second intercostal space at the midclavicular line. The needle should be sufficiently long to penetrate the chest wall and enter the pleural space. Once the angiocatheter is in place, the needle should be removed to prevent further trauma. Beware that aggressive insertion of a needle into the chest can also create a pneumothorax where one did not previously exist. A minimum length of 5 cm is recommended in older children and adults, but shorter needles may suffice in infants and younger children. Proper intrathoracic placement of the needle can be partly confirmed by an audible rush of air when entering the chest. Because needle decompression will convert a tension pneumothorax into a simple pneumothorax, a chest tube will be necessary regardless of the response to needle decompression. If a child arrives after needle decompression, tube thoracostomy placement will most likely be necessary for definitive treatment. If later in the workup an occult pneumothorax is identified on computed tomography (CT) imaging but is not visible on a plain radiograph, it is not likely to require treatment but should be followed with an interval chest radiograph to ensure that it does not enlarge.
An open pneumothorax or “sucking chest wound” occurs when the size of a chest wall injury approaches two-thirds the area of the tracheal lumen, causing a preferential pull of air into the pleural space through the wound. This injury can lead to mediastinal shift, decreased venous return, and eventual cardiopulmonary collapse. Open pneumothorax is rare in children and is usually the result of a penetrating injury. Airflow through the wound will be audible or can be visualized by bubbling of blood at the wound. A semi-occlusive rectangular petroleum jelly/gauze dressing that is occlusive on three sides beyond the wound edge will produce a one-way valve effect that will allow air to escape on expiration but inhibit air from entering the thoracic cavity on inspiration.
Flail chest occurs when a segment of the chest wall has lost continuity with the movement of the thoracic cage, occurring when two or more adjacent ribs are fractured in two or more places. The pediatric thoracic cage is more compliant than adults, and rib fractures are not always present when parenchymal injuries exist. When occurring in infants and young children, rib fractures suggest a significant amount of blunt force to the chest and the possibility of an underlying pulmonary contusion as well as hepatic or splenic injury. Because fractured ribs can lead to direct lung injury, the presence of a flail chest segment should raise the suspicion of a pneumothorax and hemothorax. Due to compromised ventilatory function and underlying pulmonary injury, management of flail chest is focused on providing temporary ventilatory support until the injury heals. Intubation may be immediately necessary in the emergency department when ventilation is significantly compromised by this injury. Surgical fixation of multiple displaced rib fractures has been shown to reduce the hospital length of stay, reduce the need for ICU admission, and reduce the overall mortality in adult trauma patients. Thus, it should be considered after patient stabilization. ,
Significant bleeding may occur with thoracic trauma from intercostal vessels, internal mammary vessels, lung parenchyma, or cardiopulmonary vessels, leading to massive hemothorax. Children with this injury will present with decreased breath sounds and dullness to percussion on the affected side. Eliciting the finding of dullness to percussion can be difficult in a noisy trauma resuscitation area but is a diagnostic feature that can be used to distinguish this injury from a pneumothorax. While the diagnosis is optimally made with a chest radiograph, the team should proceed with immediate chest tube placement if clinical evidence suggests the presence of a large amount of intrathoracic blood. When a massive hemothorax is present, fluid resuscitation or blood transfusion will often be necessary. After chest tube placement, the amount of blood initially obtained and the rate of continued bleeding from the tube should be evaluated. A thoracotomy for controlling bleeding from the chest wall, lung, or heart may be indicated if the initial volume exceeds 20% to 25% of estimated blood volume, bleeding continues at a rate exceeding 2 to 4 mL/kg per hour, the rate of bleeding is increasing, or the pleural space cannot be drained of blood and clots. The latter three criteria may be observed after the child is initially stabilized and has been admitted to the hospital.
About 75% of traumatic chest injuries can be treated expectantly or with placement of a chest tube and volume resuscitation. Although placement of a chest tube in an injured child is similar to placement in other settings, additional steps should be considered in the injured child. When placing a chest tube for trauma, the tube should be directed posteriorly to allow for adequate drainage of blood in a supine patient. Although insertion of a large chest tube (28F) for a traumatic hemothorax was previously thought to be necessary to allow adequate evacuation, emergent insertion of a 20 Fr to 22 Fr chest tube has been shown to have equal efficacy of drainage, rate of complications, and need for additional invasive procedures. The fifth intercostal space (nipple level) in the anterior midaxillary line is ideal in most patients to prevent placement of the tube through the diaphragm or abdomen but allows sufficient length in the chest for drainage and avoiding later dislodgement. Confirmation of tube placement in the pleural space can be confirmed in infants and smaller children by the egress of air or blood after placement. Proper tube placement in the thoracic cavity can also be evaluated by observing air condensation on the internal surface of the tube and movement of fluid in the water-seal chamber in time with the patient’s respirations when connected to a pressure-regulated collection device. A chest radiograph should be performed to verify placement of the tube before leaving the resuscitation area.
The circulation (C) step of the primary survey is the assessment, recognition, and management of shock. Because of greater physiologic reserve, early identification of cardiovascular compromise can be more difficult in children than adults ( Table 117.2 ). Objective assessment of circulation starts with measuring the heart rate and blood pressure and assessing pulses and capillary refill. Tachycardia after injury can indicate shock, pain, fear, or other psychologic stress. Therefore, tachycardia cannot be used as the sole criterion for diagnosing cardiovascular compromise. Blood pressure should be measured using the appropriately sized cuff on arrival to the resuscitation area. Periodic reassessment of heart rate and blood pressure should continue throughout the resuscitation period to allow continuous reassessment of the patient’s hemodynamic status. Pediatric patients in the early stages of shock will often maintain blood pressure and cardiac output by increasing their heart rate. Hypotension in a child manifests at later stages of shock, an ominous sign of impending circulatory collapse. Palpation of central and peripheral pulses is a rapid method for detecting hypotension and often can be accomplished before a cuff blood pressure is obtained. In teenagers, pulses are most likely to be lost in progressive hypotension in the wrist or feet followed by the groin and then by the neck. Palpation for pulses in each of these areas can provide a crude estimate of the level of hypotension. This, however, cannot be relied on in younger children. Assessment of capillary refill in addition to a visual evaluation of skin color can also be used to quickly gauge peripheral perfusion.