Direct pressure application is the first-line management technique for external hemorrhage.

A hemostatic dressing is a useful adjunct to direct pressure and frees up personnel who
would otherwise need to maintain pressure for a prolonged period.

Tourniquets are useful tools when hemorrhage is life-threatening, but they carry the risk of
limb loss.
Autologous transfusion can be considered in any patient with exsanguinating hemorrhage,
although it is most often indicated in patients with massive hemothorax (defined as blood
loss of one-third of the circulating blood volume or more).

It entails collection of blood from a patient’s body cavity into a collection bag containing
citrate and later reinfusing it through a filter back into the circulation through peripheral or
central venous access.

Contraindications include gross contamination (often external hemorrhage), known infection,
or presence of malignancy.
Open chest wounds should be covered with an occlusive dressing secured on three sides to
prevent air from entering the pleural space during inspiration and to allow air to exit during
If urethral injury is suspected in boys, a retrograde urethrogram is the initial procedure of

The inability to void, unstable pelvic fracture, blood at the urethral meatus, scrotal
hematoma, perineal ecchymosis, or a high-riding prostate on rectal examination are all
indications for a retrograde urethrogram to confirm an intact urethra before the insertion of a
urinary catheter.

If there is suspicion of significant pelvic vascular injury or if pelvic angiography is a
consideration, then the retrograde urethrogram is not done initially.

In girls, possible urethral injury is an indication for urology consultation, and urethrography is
not needed due to lack of a firm attachment of urethra to the pubic bone and a significantly
shorter urethral length that is susceptible to injury.
Uretheral Injuries
Penetrating wound - need (eFAST) to evaluate for pericardial effusion, pneumothorax or
hemothorax, and intraperitoneal bleeding.

If diaphragmatic injury is suspected,NG or OG tube should be placed to decompress the
stomach and bowel contents, and use of a chest tube should be avoided if possible.
Thoracoabdominal Trauma
Suspected in any child with a significant blunt-force injury who has a low oxygen saturation,
tachypnea, abnormal lung auscultation

Initial anteroposterior chest radiograph is only 30% to 50% sensitive for pulmonary

There could be associated rib fractures, hemothorax or pneumothorax.

Associated Injuries in rib fractures are vascular and cervical spine (first and second ribs),
intrathoracic (upper ribs), and intra-abdominal (lower ribs) injuries.
Pulmonary Contusion
Abdominal Trauma
Kehr sign - left-shoulder pain caused by referred diaphragmatic irritation caused by a
splenic laceration.

A duodenal hematoma usually presents later with signs and symptoms of bowel obstruction
and may be associated with thoracic or lumbar fractures, with ecchymosis or abrasions in a
lap belt distribution.

A pancreatic laceration would also have a delayed presentation with fever, abdominal pain
and vomiting. Amylase and lipase lack sensitivity when used in the initial workup of the
patient. Normal CT does not rule out pancreatic Injury.

A liver laceration can present with right shoulder pain.

Trauma to the inferior vena cava, hepatic vein, and abdominal aorta usually result in
hypotension caused by intra-abdominal hemorrhage.

An elevated aspartate aminotransferase (>200 U/L) or an elevated alanine aminotransferase
(>125 U/L) are suggestive of significant blunt abdominal trauma.

Lap belt sign or a flexion/extension fracture ( chance fracture ) of the lumbar spine must
lead to further evaluation for an occult gastrointestinal tract injury.
Imaging in Head Trauma
Computed tomography (CT) remains the primary modality for imaging blunt head trauma to
look for clinically important injuries.

Magnetic resonance imaging has a limited role in acute evaluation of blunt head trauma,
but is very useful for detecting vascular injury, diffuse axonal injury, or differentiating old
and new hematoma in abusive head trauma.