Paediatric Major Trauma is unpredictable, unique and challenging resuscitation. An unidentified 8-month-old girl was brought in after a car-trailer head-to-head collision with an unknown mechanism of injury had massive open abdominal wound with bowel evisceration, decompensated hypovolaemic shock, head injury , bilateral hip bruises complicated withcoagulopathy and transaminitis. Her parents died at the scene. A multidisciplinary team was activated. She was semi-conscious with respiratory distress requiring manual in-line stabilization and direct intubation. Her initial vitals were GCS 8/15, BP 60/15(40)mmHg, HR 190bpm, RR 60bpm and SpO2 100% pre and post intubation. Within 4 hours, the eviscerated bowels wereprotected, covered by sterile plastic with sterile tape at border to secure haemostasis in catastrophic external haemorrhage. She received early inotropic support to preserve cerebral perfusion, infusion morphine and midazolam, antibiotics coverage and massive blood transfusions (packed cell, fresh frozen plasma, cryoprecipitate) including haemostatic agents(tranexamic acid, vitamin K). Extensive normal saline and sterofundin boluses were administered to expedite resolution of acidosis and shock. She was successfully resuscitated, referred and safely transferred to tertiary centre for intensive, post-trauma care and definitive surgery . Case highlights the challenges of managing paediatric major trauma in a ruralhospital setting with limited resources. To improve emergency care, it emphasizes on preparedness emergency team with early activation of paediatric trauma and massive transfusion protocols, effective team approach and communication skills with telemedicine. Itis made benchmark in guiding local policy-making to optimizing workforce teams, to reduce morbidity and mortality in paediatric trauma and improve rural emergency services.