Trauma in pregnancy, children and older adults

• Trauma is a leading cause of death in young and middle-aged adults; in pregnancy it is the leading cause of non-obstetric maternal death, and both mother and fetus are at risk. In children the mechanisms are different and injuries are easily missed; in older adults a fall from standing height is the dominant mechanism and can still be life-threatening.
• The ATLS primary survey still applies to every patient, but its clues fail in predictable ways: a pregnant woman is hypovolaemic only after large losses because her blood volume is expanded; a child may keep a normal blood pressure until sudden collapse; an older adult may never develop tachycardia.
• Pregnancy: control catastrophic bleeding, protect the airway, tilt the patient 15 degrees to the left to keep the uterus off the inferior vena cava, monitor the fetus when it is viable (about 23 weeks or more), give RhD immunoglobulin to every RhD-negative patient, and consider perimortem caesarean section if resuscitation fails. ^[2]
• Children: estimate weight before dosing, using a length-based tape or a validated formula; use intraosseous access early if peripheral access will be difficult; and limit first-line computed tomography.
• Older adults: lower the threshold for shock. A systolic pressure of 110 mmHg can be hypotension in an older trauma patient, and an age-adjusted shock index over 50 points to occult shock.

By the end of this page you should be able to:

1. Apply the ATLS xABCDE primary survey to a pregnant patient, a child and an older adult, and state the adjustment each group needs.
2. Explain the physiological changes of pregnancy that alter trauma assessment, and perform left uterine displacement.
3. State when to monitor the fetus, when to give RhD immunoglobulin and when to perform perimortem caesarean section.
4. Estimate a child's weight using a length-based tape or an age-based formula, and select the imaging and vascular access appropriate to age.
5. Recognise occult shock in older adults using blood pressure, heart rate, lactate and base excess, and account for beta-blockers and anticoagulants.
6. Tailor a trauma plan for low-resource and regional differences using the notes provided.

The core problem of trauma in special populations is not that the injuries are different in kind; it is that the same injury produces a different physiological response, and the usual bedside clues are therefore unreliable. A fit 25-year-old with haemorrhage becomes tachycardic and hypotensive early. A pregnant patient may lose a large volume before her pressure falls because her circulating volume is expanded. A child may remain compensated, with a normal pressure, and then decompensate abruptly. An older adult may be taking a beta-blocker or may have chronic hypertension, so neither tachycardia nor a "normal" pressure can be trusted.

The ATLS (Advanced Trauma Life Support) primary survey therefore remains the backbone: exsanguinating haemorrhage is controlled first, then airway with cervical spine protection, breathing, circulation, disability and exposure, repeated whenever the patient changes. ^{[1] [2]} The notes below are the adjustments that those principles need in pregnancy, childhood and old age. NICE NG39 applies to children under 16 years and adults 16 years or over unless a recommendation states otherwise. ^[1]

These principles hold for all three groups and are taken as read by the adjustments above. The team works in parallel only when the patient is peri-arrest; otherwise each step is completed before the next. Exsanguinating external bleeding is controlled by direct pressure, wound packing or tourniquet before airway work ends. ^{[1] [2]}

• Treat as you go. An abnormality found in one step is treated before the survey moves on, and the survey is repeated after every intervention.
• Reassess. Deterioration means going back to the beginning and looking for a new tension pneumothorax, re-bleeding or a missed injury.
• Protect the neck. Until cleared, a dangerous mechanism, neck pain or an altered level of consciousness means manual in-line stabilisation and jaw thrust rather than head tilt.
• Keep warm. Untreated hypothermia is part of the lethal triad of trauma and worsens coagulopathy. ^[1]
• Definitive airway. Airway protection is needed when a patient cannot maintain or protect the airway, or has inadequate oxygenation or ventilation despite initial measures, including a falling level of consciousness. ^[1]
• Transfer early. Start the process when the patient needs something the hospital cannot deliver; keep resuscitating while they move. ^[1]

The three groups below are described for what is added or changed.

Fetal outcome follows maternal outcome. ATLS puts it plainly: the best initial treatment for the fetus is the best resuscitation of the mother. ^[2] Direct maternal trauma is still the commonest cause of fetal death. Approximately 7% of pregnancies are complicated by some trauma, 4 in 1000 require admission, it increases with gestational age, and just over half occurs in the third trimester. Fetal mortality has been quoted as high as 61% in major trauma and as high as 80% when maternal shock is present. ^[2]

A fetus is considered viable at about 23 to 24 weeks of gestation. ^{[3] [2]} Special positioning, monitoring and the possibility of perimortem caesarean section all depend on that threshold.

Pregnancy changes almost every measurement the trauma team uses. ^[3]

• Blood volume expands from about the 6th week of gestation and peaks at approximately the 32nd week; the volume may increase to roughly 6 litres. Because of this expansion it can take up to 50% more volume loss before the blood pressure changes in resuscitation. ^[3]
• Pulse rises by 5 to 15 beats per minute. ^[3]
• Blood pressure in the second trimester runs 5 to 10 mmHg below the pre-pregnancy baseline. ^[3]
• Haemoglobin concentration may fall by about 5 g/L from plasma dilution. ^[3]
• Clotting factors and fibrinogen increase, producing a hypercoagulable state and a higher risk of thromboembolism. ^[3]
• Leucocytosis and a raised erythrocyte sedimentation rate are normal in pregnancy and cannot be used to diagnose infection or bleeding. ^[3]
• The diaphragm is pushed up by the uterus, so a chest drain may need to be placed 1 to 2 intercostal spaces above the usual level if one is required. ^[3]
• Oxygen demand rises markedly; maintain oxygen saturation above 95% in every pregnant trauma patient. ^[3]

After mid-pregnancy the gravid uterus compresses the inferior vena cava and aorta when the patient lies flat, and cardiac output can fall by 30%. ^[3] This is why a pregnant trauma patient develops supine hypotension, and why blood pressure and heart rate must be interpreted with it in mind.

Two manoeuvres prevent it. The first is to tilt the whole patient about 15 degrees to the left. The second, when she must remain flat for spinal protection or airway control, is manual displacement of the uterus to the left. ^{[2] [3]} Tilt the patient on a long board or manually, and do not let a pelvic binder or spinal board compress the uterus.

The uterus also changes the anatomy of the abdomen. Pelvic and retroperitoneal vessels are hypertrophied and blood flow to the uterus is high, so retroperitoneal haemorrhage is both more likely and harder to see. A FAST examination will find intraperitoneal fluid but will not exclude retroperitoneal bleeding. ^[3]

• Viable fetus: about 23 to 24 weeks of gestation. ^{[3] [2]}
• Cardiotocographic (CTG) monitoring: all pregnant women beyond 20 weeks of gestation who suffer trauma should have CTG monitoring for at least 6 hours. It should continue and further evaluation should follow if there are contractions, a non-reassuring fetal heart rate pattern, vaginal bleeding, significant uterine tenderness or irritability, serious maternal injury, or rupture of the membranes. ^[2]
• If no conventional continuous monitoring is available: intermittent Doppler or bedside ultrasound fetal heart rate checks are an acceptable temporary substitute. ^[3]
• Rupture of membranes and fetal heart rate: any patient with a viable fetus beyond 23 weeks should have fetal monitoring, and emergent caesarean section may be considered in serious trauma with a non-reassuring rhythm after 24 weeks. ^{[3] [2]}

Fetomaternal haemorrhage can occur in up to 30% of pregnant patients after trauma, and it is the mechanism by which an RhD-negative woman becomes sensitised to her fetus. ^[3] Because of this, ACOG recommends Kleihauer-Betke testing for all RhD-negative pregnant trauma patients, and the haemorrhage is the reason RhD immunoglobulin is given after trauma. ^{[3] [2]}

Practical points:

• ACOG recommends Kleihauer-Betke testing from 4 weeks of pregnancy because of alloimmunisation concerns. ^[3]
• The EAST guideline recommends Kleihauer-Betke analysis in all pregnant patients beyond 12 weeks of gestation. ^[2]
• The EAST guideline also recommends RhD immunoglobulin in unsensitised RhD-negative pregnant patients with obstetric haemorrhage or abdominal trauma at 13 weeks or more, and individualises it in significant abdominal trauma when circumstances differ. ^[2]
• The purpose of the Kleihauer-Betke test is to restrict RhD immunoglobulin to those who need it and to identify the rare patient in whom the standard dose is insufficient. An alternative in practice is to give RhD immunoglobulin to all unsensitised RhD-negative pregnant patients with suspected blunt uterine trauma, then guide additional dosing by the test result. ^[2]
• The window for protection is 72 hours after fetomaternal haemorrhage. ^[2]
• When it is needed, the dose is 300 mcg of RhD immunoglobulin per 30 mL of fetomaternal haemorrhage (10 mL of fetal whole blood contains 5 mL of fetal red cells). ^[2]
• If no Kleihauer-Betke testing is available, it is reasonable to give RhD immunoglobulin to all RhD-negative pregnant patients with significant trauma, and to repeat the dose if bleeding or trauma continues.

Perimortem caesarean section (resuscitative hysterotomy) is the rescue procedure when maternal resuscitation is failing. ACOG supports considering it from about 24 weeks of gestation, and EAST supports consideration in any moribund pregnant woman of 24 weeks or more. ^{[2] [3]}

• Start as soon as possible. The EAST guideline gives a 4-minute ideal target from maternal arrest, and delivery should occur within 20 minutes of maternal death. ^[2]
• Other reviews phrase the trigger as within 5 minutes of maternal haemodynamic instability with failed resuscitation. ^[3]
• In practice the two statements agree: begin immediately, aim to deliver within minutes, and do not delay for staff or equipment that has not arrived; maternal resuscitation continues throughout.
• The best chance of a neurologically intact child falls with every minute after arrest.

Diagnostic imaging is not withheld for fetal reasons when the mother's life or limb is threatened, but it is ordered judiciously. ^{[2] [3]}

• Exposure of less than 5 rad (50 mGy) to the fetus has not been associated with an increase in fetal anomalies or pregnancy loss and is regarded as safe at any point in gestation. ^[2]
• Fetal dose without shielding is about 30% of the maternal dose; shield the fetus for all studies except pelvic and lumbar spine views. ^[2]
• CT of the abdomen delivers a higher fetal dose than a plain radiograph, so abdomen and pelvis CT in particular should be justified and performed rather than duplicated. ^{[2] [3]}
• Ultrasound and MRI involve no ionising radiation; MRI is not recommended in the first trimester until more data are available. ^[2]
• Teratogenic risk is highest during organogenesis at 5 to 10 weeks; after 10 weeks radiation is more likely to affect growth or the central nervous system, and fetuses are unlikely to be affected after 15 weeks. ^[3]
• Intravenous iodinated contrast is an FDA category B agent and can be used when it changes management. ^[3]

Children compensate for blood loss better than adults and can maintain a normal blood pressure until they suddenly decompensate, so normal observations in a child do not exclude shock. Their head is large relative to body, the airway is more easily obstructed, and oxygen consumption is high, meaning hypoxia develops quickly. Head injury is proportionally more common than in adults. ^{[1] [4]}

Most paediatric trauma is blunt. Falls, road traffic collisions and non-accidental injury dominate; penetrating trauma is less common in most regions. Keep a low threshold for safeguarding concerns whenever the mechanism and the injuries do not match.

Before giving any drug or selecting any tube or binder size, the child needs an estimated weight because weighing is impractical in the resuscitation room. ^[4]

Length-based tape. The Broselow tape is the most widely used length-based tool. It is a colour-coded tape in 9 zones, intended for children up to 12 years, weighing 3 to 36 kg and measuring 47 to 143 cm; each zone also gives recommended equipment sizes. ^[4] It is quick and works even when age is unknown, but it is a proprietary product and may not be available everywhere. ^[4]

Age-based formulas. Where a tape is not available, the formulas recommended by the Advanced Paediatric Life Support (APLS) course, developed for children from 1 month to 12 years, are a practical fallback. ^[4]

• Body-habitus tapes. The Paediatric Advanced Weight Prediction in the Emergency Room (PAWPER) tape adds a simple habitus score to length and has been more accurate than length alone or age alone in several studies; the Dose-by-Growth tape is a similar colour-coded alternative. ^[4]
• Equipment sizes. Length-based tapes give airway, tube and drug dose information directly. Where they are not available, use weight estimates plus standard paediatric dosing references and a local checklist rather than memory.

• Peripheral intravenous access is the usual route. In children under 16, if peripheral access is anticipated to be difficult, consider intraosseous access as first-line access rather than delay resuscitation. ^[1]
• In active bleeding, do not flood with crystalloid. In children, plasma and red cells are replaced in a ratio of 1 part to 1 part, with the volume based on the child's weight. ^[1]
• Tranexamic acid should be given as soon as possible in major trauma with active or suspected active bleeding, and not more than 3 hours after injury unless there is evidence of hyperfibrinolysis. ^[1]
• Reverse anticoagulation rapidly when bleeding is active; consult a haematologist immediately for children who may need reversal. ^[1]
• A pelvic binder is applied in the same way as in adults when pelvic fracture and bleeding are suspected: centred over the greater trochanters, as early as possible, as a temporary measure. ^[1]

• NICE NG39 recommends chest X-ray or ultrasound, not routine CT, as first-line imaging to assess chest trauma in children under 16. ^[1]
• Whole-body CT is not routinely used to image children under 16; clinical judgement limits it to the body areas where it is needed. ^[1]
• Radiation doses are lower than adult doses where a CT is necessary, and weighing the child improves dosing accuracy. Shield and avoid duplicate scans. ^[3]

Children cannot always give a history. A discrepancy between the stated mechanism and the injuries, multiple bruises of different ages, or an injury incompatible with the development stage should trigger a child protection referral. Major trauma in a child should also activate the hospital's designated safeguarding lead.

A fall from standing height is the dominant mechanism, but it is not trivial: major trauma in older adults is increasing worldwide. Patients over 65 make up a growing share of trauma admissions, and one large international review found that 65 years is the most common age threshold for defining an older trauma patient. ^[5] Comorbidity and medication do most of the harm.

The three traps are these. First, bleeding may not trigger tachycardia. Second, the blood pressure that looks acceptable for a 30-year-old may be profound hypotension for someone whose baseline is 160 mmHg. Third, a normal brain may have been abnormal before the injury: dementia, previous strokes and eye disease make neurological assessment unreliable.

Unrecognised haemorrhage and hypoperfusion are common in older trauma patients and are a major cause of preventable death. About one third of older trauma patients have occult hypoperfusion with a systolic pressure below 90 mmHg as judged by lactate and base deficit, and occult or unrecognised haemorrhage is estimated in about 20%. ^[5]

Practical thresholds: ^[5]

• Systolic blood pressure (SBP): 110 mmHg is the inflection point at which mortality begins to rise. Treat 110 mmHg as suspicious in an older trauma patient, not 90. ^[5]
• Heart rate: mortality rises above 90 beats per minute. Tachycardia may be masked by beta-blockers, so its absence does not reassure. ^[5]
• Age-adjusted shock index: (heart rate divided by systolic blood pressure) multiplied by age. A value above 50 is suspicious for occult shock.
• Lactate: above 4 mmol/L, or a base excess below minus 6 mEq/L, has been associated with a 40% mortality rate. ^[5]

• Beta-blockers and fixed pacemakers: these patients may be unable to mount a tachycardia at all. Rely on perfusion markers, skin temperature, capillary refill, urine output and trend, not on heart rate alone.

A history of congestive heart failure, cerebrovascular disease, liver, kidney or malignant disease is associated with early mortality even in initially stable patients, so comorbidity itself is a risk factor and should be recorded. ^[5]

Beta-blockers have been associated with increased mortality in injured older patients without head injury. ^[5] Warfarin and other anticoagulants are strongly associated with intracranial haemorrhage and mortality. ^[5] Many older patients take both an antiplatelet and an anticoagulant, which compounds the risk.

Management implications:

• Anticoagulation is rapidly reversed in major trauma with active haemorrhage; hospital trusts that admit major trauma must have a protocol for identifying it and reversing it. ^[1]
• Vitamin K antagonist reversal in adults uses prothrombin complex concentrate immediately; plasma is not used to reverse it. ^[1]
• For direct oral anticoagulants or other agents, consult a haematologist immediately. ^[1]
• A detailed medication history, including over-the-counter and herbal products, should accompany every handover.
• Always inspect for head injury and intracranial bleeding in patients on anticoagulants, even after a minor fall.

Falls account for roughly 60% of severe traumatic injury and death in older adults. ^[5] Low-energy mechanisms produce severe injury when bone quality, muscle mass and vision are impaired. Rib fractures are associated with increased mortality in this group, and blunt aortic injuries are three times more common after road traffic collisions. ^[5]

• Frailty is an independent predictor of mortality and should be assessed, but it should not be used to deny access to a major trauma centre or appropriate surgery. ^[5]
• Delayed presentation is common: carers and relatives may adopt a "wait and see" approach after a fall. A thorough handover from the scene is essential. ^[5]
• Hypothermia declares earlier and faster in older adults, from reduced body fat and metabolic reserve. Minimise heat loss and anticipate coagulopathy. ^[5]
• Delirium is common and undertreated pain is one of its triggers. Adequate analgesia is therefore part of neurological care, and benzodiazepines are avoided where possible. ^[5]
• Non-conveyance and refusal are more common than in younger patients. One in ten older adults assessed after an incident is not transported. Document capacity carefully and arrange follow-up. ^[5]
• A GCS drop from 15 to 14 after injury is associated with increased mortality and higher risk of traumatic brain injury in older patients, more so than in younger patients. A drop of this size should prompt transfer. ^[5]

• Use a lower threshold for transfer and investigation. Major trauma centre criteria and activation based on age alone are debated, but older patients under-triage easily. ^[5]
• Investigations are not changed by age; the population that benefits from CT still needs it. Avoid labels such as "frail so do less," and focus on the patient's wishes, functional recovery and likely outcome.
• Rib fractures are common, serious and undertriaged: adequate analgesia (often regional blockade), incentive spirometry and close respiratory monitoring matter.

ATLS principles are the framework the three sections above modify. NICE NG39 provides the evidence for the haemorrhage, airway, chest and documentation steps, and applies to children under 16 and adults 16 or over unless a recommendation specifies age. ^[1] ACOG's trauma guidance is widely quoted for pregnancy and was the source behind the 5 rad and perimortem caesarean thresholds above, reported through the EAST review and the pregnancy trauma literature. ^{[2] [3]}

A few regional notes:

• North America (NICE not local, ATLS as standard): trauma centres follow ATLS with ACS TQIP guidance. Geriatric teams and trauma-specific frailty screening are increasingly standard.
• United Kingdom and Europe: NICE NG39 standards, with major trauma centre networks and prehospital doctor teams. Anticoagulant reversal protocols are expected in every trauma-receiving hospital.
• Low-resource settings: the whole primary survey can be done with hands, a stethoscope and a cloth pelvic binder. Oxygen, two large-bore IV lines, warmth and blood when it is available change survival more than imaging. Left uterine tilt and RhD immunoglobulin are cheap and effective; ultrasound, when available, is the main imaging tool. CT and whole-body scanning are reserved for patients whose haemodynamic status allows and whose management will change because of it. ^[3]
• East and Southern Africa: obstetric trauma is managed in referral hospitals alongside maternity units where possible. When cardiotocography and Kleihauer-Betke testing are unavailable, give RhD immunoglobulin to all RhD-negative pregnant patients with significant trauma and monitor the fetus with intermittent Doppler. Older patients are managed with the same lower thresholds, but lactate and base excess may not be available at the bedside; heart rate trends and conscious level become even more important.
• Geriatric volume: the rise in older trauma is global, and undertriage starts at the scene. Recording a medication list and a baseline cognitive and functional state belongs to every handover.

• Initial trauma assessment: the primary survey
• Haemorrhagic shock and damage-control resuscitation
• Thoracic trauma
• Head and spinal injury in trauma
• Paediatric resuscitation and the sick child
• Anticoagulant and antithrombotic drugs
• Major trauma service delivery and NICE NG39-40
• Falls prevention and frailty
• Obstetric haemorrhage and major obstetric emergency protocols