Pediatric trauma remains the leading cause of death in children and presents unique clinical and ethical challenges, particularly in mass casualty incidents (MCIs) and austere environments. In a recent presentation at FDNY 2025, Dr. Mark Piehl, pediatric intensivist at WakeMed Health Children’s and Founder & Chief Medical Officer of 410 Medical, shared real world insights and evidence-based strategies for improving pediatric trauma care when resources are limited.
Dr. Piehl emphasized a re-prioritization of traditional trauma algorithms for pediatric patients to emphasize a circulation first approach to care. In resource-constrained settings where hypoxia, hypovolemia, and airway compromise often occur simultaneously, rapid control of hemorrhage and restoration of perfusion prior to advanced airway management are essential to improved outcomes.
Through a series of patient case studies, including a 6-year-old with TBI and hemorrhagic shock from an MVC and a 2-year-old badly injured by a dog, Dr. Piehl highlighted how pediatric physiology, vulnerability, and amazing potential for recovery demand rapid application of basic resuscitation skills. He demonstrated that timely interventions such as intraosseous (IO) access, delivery of warmed low-titer O whole blood (LTOWB), basic airway management techniques, and adequate analgesia can stabilize severely injured children prior to transport to definitive care.
Key Takeaways:
- Pediatric trauma patients deteriorate quickly but can respond to simple strategies including femoral IO placement, field blood administration, and basic airway management techniques such as positioning and suction
- For traumatic injury with hemorrhagic shock, a “Circulation-first” approach is preferred over the classic ABC approach
- Devices and protocols should be adapted to pediatric anatomy, including size-appropriate tourniquets and oral airways
- In preparation for MCI’s where children may be involved, emotional and ethical triage challenges can be addressed through simulation and training on basic pediatric resuscitation techniques
- The RAMP triage method is simpler and probably allows faster decision-making and reduced under-triage compared to traditional JumpSTART triage
Dr. Piehl called for broader adoption of pediatric-focused education in EMS, disaster planning, and military medicine. This can result in a trauma system that is not only capable of managing children during MCIs but optimized to ensure the best possible outcomes, even when care is delayed and resources are limited.
For more information on pediatric trauma resuscitation, view this Prodigy webinar: Circulation First! Resuscitation in Pediatric Trauma presented by Dr. Mark Piehl and Dr. Peter Antevy.
To request access to the full slide deck from the FDNY 2025 presentation, contact Dr. Piehl at mpiehl@wakemed.org.