Dr. K.M. Abul Hasan, M.S., M.Ch.,
Childhood Accidents Accidents are the most common cause of death among children aged 1 to 14 years. Accidents cause a third of deaths of children aged between 10 and 14 years. Accidents result in about 10,000 children being permanently disabled annually. Accidents cause one child in five to attend an accident and emergency department every year. Accidents lead to one fifth of all hospital paediatric admissions.
CAUSE OF DEATH IN 1-14 YEAR OLD AGE GROUP Cause % Accidents 52 Cancer 10 Congenital Anomalies 5 Others 33
ACCIDENTS Vehicular Accidents Fall from a height Burns Drowning Snake & Insect Bites Poisoning / FB Ingestion Birth Trauma
Kids aren’t small adults! Characteristic Result Large BSA Hypothermia Poor neck musculature Flex/ext injury Large blood vol in head Cerebral edema Dec alveolar surf area Rapid desats High metabolic rate Rapid desats Small airway Inc airway resistance Heart high in chest Injury/tamponade Small pericardial sac Injury/tamponade Compliant skeleton Fractures less common Thin walled, small abd Organs not protected Poorly dev renal fnx Risk renal failure
Need specific supplies Central lines Monitors Urinary catheters ETT NGT/OGT Laryngoscopes Resuscitation drugs Bronchoscopes Resuscitation devices IV IO trocars
Paediatric trauma score + 2 + 1 - 1 Wt > 20 kg 10-20 kg < 10 kg Airway Patent Maintain Unmaint SBP > 90 50-90 < 50 Pulses Radial Carotid Nonpalp CNS Awake + LOC Unresp Frx None Closed Mult/op Wounds None Minor Major Total -6 to +12
Initial management Primary survey Evaluate life-threatening conditions Immediate intervention Secondary survey Evaluate other injuries requiring treatment Paediatric trauma score May be useful for triage 9-12 Minor trauma 6-8 Potentially life threatening 0-5 Life threatening < 0 Usually fatal
Primary survey Cornerstone of trauma care Life threatening conditions Evaluate Stabilize Treat Moves forward on all fronts by team Often listed sequentially ABCDE
Paediatric airway Narrow oropharynx Large tongue Stiff, short epiglottis Larynx anterior and cephalad Cord view is difficult Trachea shorter Mainstem intubation more common Extubation more common
Paediatric intubation view Larynx Anterior Cephalad C 4 level Epiglottis long & U shaped Trachea short Neonates → 2 cm cords to carina Cricoid → Narrowest point until 10 yo
Resuscitation Give first priority of treating to life – threatening problems, identify during primary survey. Pt with cardiorespiratory compromise should be provided with high – flow oxygen Endotracheal intubation and ventilation are required if O 2 is inadequate in child with severe head injury or to control flail chest. Pneumothorax & haemothorax are best treated by chest tube drainage. Two large peripheral IV canulae require in severely injured children. Central venous access should only be assess by expert.
Resuscitation Overextension of the neck during the maintenance of airway result in respiratory compromisation (short neck and relatively larger tongue) Circulation is evaluated from vital signs, capillary refill time, skin color, temperature and mental status. Systolic BP is normal until 25% of circulatory volume has been lost. Intraosseous vascular assess is helpful in children Cervical spine injury can be present without radiological signs, after major trauma cervical spine injury should be assumed until it can be excluded by full neurological assessment, the neck must be immobilized.
Secondary Survey & Emergency Management When pt become stable, the secondary survey attempt to identify all injuries in a systemic way by detailed clinical examination and appropriate investigation. Emergency treatment involve 1- Treatment of chest injuries 2- Treatment of abdominal injuries.
Chest injuries Mediastinum less well affixed Compliant chest wall Fractures less common PTX Pulmonary contusion Hemothorax
Pneumothorax Symptoms Not Moving Chest wall Tracheal shift Cardiac shift Air entry absent Treat Intercostal Drainage
Pulmonary contusion Worsening oxygenation & ventilation Decreasing pulmonary compliance Progressively more aggressive vent strategy Increase FiO 2 Increase vent pressures and PEEP Volutrauma typically avoided with plateau pressures < 40. Hemodynamic compromise possible with increasing vent pressures
Circulation Control blood loss Vascular access Apparent Early vascular access Hidden Supradiaphragmatic Long bone fractures Alternatives to PIV Pelvic fractures Central Hemothorax Hemoperitoneum Surgical cutdown ICH (prior to fontanelle Intraosseous closure) Consider A-line Tissue perfusion Shock symptoms
Cardiac Tamponade Cardiac tamponade may follow blunt or penetrating chest injury. It requires emergency needle “pericardiocentesis”.
Emergency Management Of Abdominal Trauma Blunt abdominal trauma is generally more common than penetrating injury. In children more vulnerable organs are liver and spleen because less protected by pliable rib cage. Intra-abdominal or intra-thoracic bleeding is likely in shock child with no obvious source of hemorrhage. The abdomen must be carefully inspected for sign of patterned bruising which indicate forceful compression against rigid skeleton.
Investigations used In Abdominal Trauma The definitive radiological investigation of major abdominal trauma in haemodynamically stable child is CT – scan with IV – contrast. Expert ultrasound scanning is readily available it can demonstrate free abdominal fluid and solid organ injuries but it is not valuable as CT Diagnostic peritoneal lavage is obsolete in children because modern imaging is superior Laprotomy is indicated for bowl perforation and penetrating trauma.
Non-operative Management Of Isolated Splenic or Liver Injuries Haemodynamic stability after resuscitation with fluid not more than 40 – 60 ml/kg. Good quality of CT-scan. No evidences of hollow visceral injury. Frequent careful monitoring and immediate availability of necessary surgical expertise.
Children With Intra-abdominal Bleeding Child with ongoing intra-abdominal bleeding require laparotomy. Preliminary angiography and arterial embolization can be useful in some cases of hepatic trauma. Bile leak is uncommon and managed with radiological techniques
INJURY TO THE EXTERNAL GENITALIA • Penile Trauma • Zipper Injuries • Degloving Injuries • Strangulation Injuries • Scrotum & Testis • Avulsion of scorted skin • Hematocele
Electr Electrocution in ocution in Childr Children en Rare but life threatening – more common in the west. Ventilation (1) Quickens Stabilization (2) Prevents Neurological sequalae
33% of children died of Electrocution are < 5 Years 80% are injured at Home Source: Child Accident Prevention Foundation of Australia 86% of Electrocution Injuries involve 1-4 Years Old Highest frequency at meal time Insertion of keys, hairpins into the outlets common types CPSC – Consumer Product Safety Commission
Prevention Children A dangerous mix Water & Electricity
Drowning Death from asphyxia associated with submersion in a fluid Near Drowning If there is any recovery following a submersion incident
Epidemiology 3 rd most common cause of death in U.K. Swimming pools, Garden ponds & inland water ways. SUBMERSION IN A SUMP
Pathophysiology Submersion Diving reflex 20 Seconds Apnoea Bradycardia Hypoxia - Acidosis 20 Sec. to 2.5 Mts Breathing Occurs Fluid is Inhaled Laryngospasm, Secondary Apnoea Water, Mud, Debris enter the lung Bradycardia Cardiac Arrest Death
Primary Survey & Ressuscitation Protect Spine Protect Airway & Ventilation. Empty the stomach. Deep Body Temp Resusscitation at temp < 30 0 c is useless
Rewarming If core temp > 32 0 c – External Warming If core temp < 32 0 c – Core Rewarming - Arrhythmias
External Rewarming Remove cold, wet clothing Warm Blankets Infrared radiant lamp Heating blanket
Core Rewarming Warm intravenous fluids to 39 0 c Warm ventilator gases to 42 0 c Gastric or bladder lavage with normal saline at 42 0 c Peritoneal lavage with potassium free dialysate Pleural or Pericardia lavage Extracorporeal blood rewarming
Out Come 70% survive – if resuscitations is done water side 40% survive – if not done quickly 25% with sequalae
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