No scenario demands more rapid, high-stakes decision-making than pediatric trauma—the leading cause of death for children—where timely interventions significantly influence outcomes.^1,2 Despite trauma care advancements, disparities in practice, resources, and training persist, impacting survival and recovery.^3-6 While pediatric trauma centers (PTCs) provide specialized care, 43 percent of children live more than 30 miles from one, and over 80 percent receive initial treatment in non-pediatric facilities. Emergency physicians—who may rarely encounter severe pediatric trauma—are often the first to stabilize.^2-4 Emergency department (ED) pediatric readiness varies widely, and lower readiness scores correlate with higher pediatric mortality.^4,7-9 National organizations recommend having pediatric emergency care coordinators (PECCs) to improve readiness.¹⁰ Standardizing evidence-based care ensures that every child, regardless of where they present, receives optimal initial resuscitative care.

Emergency physicians need to make fast-paced decisions regarding imaging to evaluate for serious injuries. A common screening and diagnostic imaging modality used in trauma is computed topography (CT), with rates of use increasing in pediatrics.^11,12 It is important to limit the development and cancer risks of radiation on children while effectively screening for serious and potentially life-threatening injuries.^13,14 Several guidelines have been developed to guide decision-making around imaging for pediatric trauma.

Traumatic Brain Injury

Imaging for pediatric head trauma patients should follow the Pediatric Emergency Care Applied Research Network (PECARN) pediatric injury/trauma algorithm.^15-17 PECARN guidelines stratify head trauma imaging based on age:

• Less than 2 years: CT if Glasgow Coma Scale (GCS) less than or equal to 14, palpable skull fracture, or altered mental status. Observation for occipital, parietal or temporal scalp hematoma, history of loss of consciousness (LOC) (5 seconds), severe mechanism of injury, or not acting normally.
• Greater than or equal to 2 years: CT if GCS less than or equal to 14 or other altered mental status, or signs of basilar skull fracture. Observation for LOC, vomiting, severe headache, or severe mechanism.

CT is not recommended without these risk factors.

Cervical Spine

Pediatric cervical spine injury (CSI) is rare (less than 1 percent) but can cause severe deficits or death.¹⁸ There are validated prediction rules for CT use in adult CSI, such as National Emergency X-Radiography Utilization Study (NEXUS) and Canadian C-spine rule.^19,20 Pediatric-specific CSI imaging criteria were lacking until 2024, when PECARN developed and validated a three-tiered risk stratification rule in a multicenter prospective observational study of 22,430 children with blunt trauma across 18 EDs, achieving 94 percent sensitivity and 99.9 percent negative predictive value.^21,22

Children with a GCS score of 3-8 or unresponsive on the Alert, Verbal, Pain, Unresponsive (AVPU) level of consciousness scale; had abnormal airway, breathing or circulation; or focal neurologic deficits including paresthesia, numbness or weakness were considered high-risk for CSI and a CT scan should be considered (12.1 percent risk of CSI). For patients with GCS 9-14; V or P on AVPU scale or other signs of altered mental status; self-reported neck pain or neck tenderness on examination; or with substantial head or torso injury, x-rays should be considered (2.8 percent risk of CSI). For those with no risk factors, clinical clearance should be considered (0.2 percent risk of CSI).²¹ This PECARN C-Spine rule effectively enhances risk stratification, minimizing unnecessary imaging (decreasing CT use by 10 percent and radiograph use by 5 percent) while ensuring accurate identification of clinically significant injuries.^21,22

Abdomen

Children with blunt abdominal trauma within 24 hours of injury should be evaluated using the PECARN Pediatric Intra-Abdominal Injury Algorithm.²³ If there is abdominal wall trauma or seatbelt sign, or a GCS score of  less than 14 with blunt abdominal trauma, there is a 5.4 percent risk of intraabdominal injury (IAI) requiring acute intervention or causing death, and CT abdomen should be considered. For patients without the above symptoms but with abdominal tenderness, there is 1.4 percent risk of IAI and CT abdomen should be considered. For patients with thoracic wall trauma, complaints of abdominal pain, decreased breath sounds, or vomiting, there is a 0.7 percent of IAI, and CT abdomen should be considered. For patients without any of these symptoms, CT abdomen should be deferred.^16,23,24

Resources for Emergency Physicians

There are several resources that consolidate these imaging guidelines for easy accessibility, including MDCalc and the Pediatric Education and Advocacy Kit (PEAK) on multisystem trauma.²⁵ PEAK: Multisystem Trauma, developed by the Emergency Medical Services for Children (EMSC) program, provides a free, open-access resource to enhance trauma care. This toolkit distills current best practices, integrates clinical decision support, and gives high-yield trauma management strategies for use in real-time (e.g., Hemorrhagic Shock and Massive Transfusion Protocol). There are multiple podcasts in PEAK that also review best practice imaging guidelines in pediatric trauma including two that focus specifically on cervical spine imaging. SimBox, a free PEAK simulation resource, enhances pediatric readinessin community EDs through hands-on, in-situ training that allows teams to apply trauma principles in realistic drills.²⁶

Pediatric trauma care demands precision, adaptability, and rapid decision-making. Incorporating these evidence-based guidelines and resources into practice will decrease unnecessary imaging and improve pediatric outcomes and trauma care.

Dr. Cheng is an assistant professor of emergency medicine at David Geffen School of Medicine and an attending pediatric emergency medicine, emergency medicine, and EMS physician with Harbor-UCLA Medical Center.

Dr. Tsao is an assistant professor of pediatric emergency medicine at the University of Texas Southwestern Medical Center and an attending pediatric emergency medicine physician at Children’s Medical Center Dallas, Children’s Health.

References

1. Coalition for National Trauma Research (CNTR). Trauma Statistics and Facts. Accessed 02/01/2025. Available from: [55](https://www.nattrauma.org/trauma-statistics-facts/).

2. US Government Accountability Office (GAO). Pediatric Trauma Centers: Availability, Outcomes, and Federal Support Related to Pediatric Trauma Care. 2017: Report to Congressional Requesters. GAO-17-334. Available from: [56](https://www.gao.gov/products/GAO-17-334).
3. Melhado CG, Yorkgitis BK, Remick K, et al. Pediatric Readiness and Trauma Centers: History, Relevance, and Practical Application. Current Trauma Reports. 2023/12/01;9(4):132-139. .
4. Newgard CD, Lin A, Olson LM, et al. Evaluation of Emergency Department Pediatric Readiness and Outcomes Among US Trauma Centers. JAMA Pediatr. Sep 01 2021;175(9):947-956.
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10. Physician Oversight of Pediatric Care in Emergency Medical Services. Prehosp Emerg Care. 2017;21(1):88.
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17. Schonfeld D, Bressan S, Da Dalt L, Henien MN, Winnett JA, Nigrovic LE. Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Arch Dis Child. May 2014;99(5):427-31.
18. Leonard JR, Jaffe DM, Kuppermann N, Olsen CS, Leonard JC, Group PECARNPCSS. Cervical spine injury patterns in children. Pediatrics. May 2014;133(5):e1179-88.
19. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. Jul 13 2000;343(2):94-9.
20. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. Oct 17 2001;286(15):1841-8.
21. Leonard JC, Harding M, Cook LJ, et al. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child Adolesc Health. Jul 2024;8(7):482-490.
22. Ren D. SGEM #467: Send me on my way…without Cervical Spine Imaging. Accessed February 14, 2025. Available from: [57](https://thesgem.com/2025/02/sgem-467-send-me-on-my-way-without-cervical-spine-imaging/).
23. Holmes JF, Lillis K, Monroe D, et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med. Aug 2013;62(2):107-116.e2.
24. Springer E, Frazier SB, Arnold DH, Vukovic AA. External validation of a clinical prediction rule for very low risk pediatric blunt abdominal trauma. Am J Emerg Med. Sep 2019;37(9):1643-1648.
25. Clinical decision support for medical professionals. MDCalc. Accessed February 12, 2024. Available from: [58](https://www.mdcalc.com).
26. SimBox+/TeleSimBox: Pediatric Trauma (ED) Simulation. Updated 2022/01. Available from: [59](https://www.emergencysimbox.com/pediatric-trauma).