Combined blunt mechanisms (Child with **multiple blunt injuries** from one or sequential mechanisms (MVC + ground strike, fall + impact against object, assault with multiple blows) — treat greatest life threat first per ATLS sequence; do not be distracted by obvious extremity injury while missing chest/abdomen/head (ATLS pediatric, WHO))
Sequential system assessment (After ABCDE stabilization: **head** (GCS, pupils) → **c-spine** → **chest** (breath sounds, CXR if indicated) → **abdomen** (tenderness, FAST) → **pelvis** → **extremities** → **exposure** for occult injury; reassess after each intervention (ATLS pediatric))
First-line therapy
ATLS ABCDE — treat greatest life threat first • procedure
Duration: ED / observation · Simultaneous assessment and treatment · address airway/ventilation/hemorrhage before detailed extremity exam · **FAST** when circulation addressed · serial exams — occult injury may evolve (ATLS pediatric, ERC)
• **A — Airway:** clear obstruction; jaw thrust; intubate if GCS ≤8 or failing ventilation; protect c-spine during airway maneuvers (ATLS).
• **B — Breathing:** inspect, palpate, auscultate; treat pneumothorax, flail segment, hemothorax; O₂ for hypoxia — see **chest_trauma** for details (ATLS).
• **C — Circulation:** control external hemorrhage; 10–20 mL/kg crystalloid with reassessment; blood products for shock; FAST for occult abdominal bleeding — see **abdominal_trauma** (ATLS, PALS).
• **D — Disability:** GCS, pupils, glucose; assume **head_trauma** if mechanism fits — prioritize if expanding hematoma or declining GCS (ATLS, AAP).
• **E — Exposure:** identify all injuries; prevent hypothermia; log roll with c-spine care; complete secondary survey only when primary stable (ATLS pediatric).
System-specific escalation per findings • procedure
Duration: As indicated · Activate consultants and imaging per injured systems — CT head/c-spine/chest/abdomen as indicated; trauma team for multi-system blunt injury (ATLS, AAP)
• **Reassessment:** repeat primary survey after every intervention and before transfer — combined blunt injuries may unmask occult bleeding (ATLS pediatric).
Clinical notes
• Combined blunt trauma: treat greatest life threat first — ABCDE simultaneously; obvious extremity deformity must not delay assessment of chest, abdomen, head (ATLS pediatric, WHO).
• Sequential system review after stabilization: head/GCS → c-spine → chest → abdomen/FAST → pelvis → extremities → full exposure (ATLS).
• Occult injury vigilance: delayed hemothorax, solid-organ laceration, epidural hematoma — serial exams and reassess after interventions (ATLS, AAP).
• Primary care role: recognize multi-system injury, initiate ABCDE, activate EMS/trauma team, do not delay transfer for complete workup if unstable (ATLS, WHO).
• ATLS — Primary and secondary survey in pediatric polytrauma (2024)
• WHO — Emergency trauma care for children (multi-injury) (2022)
