Epidemiology and Unique Characteristics Injury is the leading cause of death and disability in children, surpassing all major diseases. While management priorities (ABCDEs) mirror those of adults, pediatric care requires adjustments for unique anatomy and physiology. Children have a smaller body mass, meaning impact forces are applied per smaller unit of body area, often damaging multiple organs. Their skeletons are incompletely calcified and pliable; consequently, internal organ damage, such as pulmonary contusion, can occur without overlying bone fractures. Additionally, a child's disproportionately large head increases the frequency of blunt brain injuries. The high ratio of body surface area to mass makes children highly susceptible to hypothermia, which can complicate resuscitation.

Airway and Breathing Anatomical differences dictate airway management. The large occiput causes passive flexion of the cervical spine, potentially buckling the airway; therefore, the midface must be maintained parallel to the spine board (neutral position) rather than the "sniffing" position used in adults. Because the infant trachea is short (approx. 5 cm), tube dislodgment and right mainstem intubation are significant risks. Clinicians should use the mnemonic "Don't be a DOPE" (Dislodgment, Obstruction, Pneumothorax, Equipment failure) to troubleshoot deterioration in intubated patients. In breathing assessment, the mobility of mediastinal structures makes children particularly prone to tension pneumothorax.

Circulation and Shock Recognizing shock in children is challenging due to their increased physiologic reserve. A child can maintain a normal systolic blood pressure despite losing up to 30% of their circulating blood volume. Hypotension is a late, ominous sign of decompensated shock involving >45% volume loss. Early signs of hypovolemia include tachycardia, skin mottling, and weakened peripheral pulses rather than blood pressure drops.

Fluid resuscitation is weight-based. If weight is unknown, a length-based resuscitation tape (e.g., Broselow) is essential for estimating medication doses and equipment sizes. Venous access can be difficult; if peripheral attempts fail, intraosseous (IO) infusion is the preferred alternative. Current protocols suggest an initial bolus of 20 mL/kg of warmed isotonic crystalloid. However, strategies are shifting toward "damage control resuscitation" using balanced blood products early for those with severe hemorrhagic shock.

Head, Spine, and Abdomen Children are susceptible to secondary brain injury caused by hypovolemia and hypoxia. However, because of the long-term cancer risks associated with ionizing radiation, CT scans should be used selectively, guided by clinical decision rules like PECARN, rather than routinely. Regarding the spine, "SCIWORA" (Spinal Cord Injury Without Radiographic Abnormalities) is common; a normal x-ray does not rule out spinal cord injury. In abdominal trauma, gastric decompression is critical as swallowed air can mimic distension. Most hemodynamically normal children with solid organ injuries are managed non-operatively.

Maltreatment Non-accidental trauma is a leading cause of infant homicide. Clinicians must identify red flags, such as history inconsistent with the injury, delays in seeking care, retinal hemorrhages, or fractures in children too young to walk.

Analogy: Think of a child's cardiovascular system like a modern lithium-ion battery, while an adult's is like an old flashlight battery. An old flashlight battery dims gradually as it loses power (adults show dropping blood pressure as they lose blood). A lithium battery provides consistent, strong output until it is nearly empty, then shuts down abruptly and completely.