A 6 year old was struck by a car. He responds to painful stimuli. The abdomen is rigid with bruising to the upper quadrants. Vital signs show BP 74/40, P 130, R 8 and shallow. What should you do first?

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The priority here is securing and improving ventilation in a pediatric trauma patient. The child is not breathing effectively—rate is very low and breaths are shallow—which risks hypoxia and worsened shock from poor oxygen delivery. Using a bag-valve-mask to assist ventilations delivers adequate tidal volumes and oxygen, addressing the immediate problem of insufficient breathing. Once effective ventilation is established, you can continue with airway management as needed, provide high-flow oxygen, and move toward vascular access and rapid transport. Opening the airway or suctioning are important steps, but they don’t directly correct the inadequate ventilation the patient is currently experiencing as effectively as assisted ventilation with a BVM.