Paediatric Nursing Update

1. Paediatric Nursing Update 27th – 28th April 2009 MIME Mediterranean Conference Centre Valletta Malta

2. Abdominal trauma in children Ms. J. Galea MD MRCS Ed. Paediatric Surgical Unit Mater Dei Hospital Malta

3. Trauma – leading cause of morbidity and mortality in children • Mortality 8.5% • Abdomen is the 3rd most common site of injury – 8-10% of all trauma admissions • Most common site of initially unrecognized fatal injury.....

4. The paediatric abdomen • Thinner musculature • Lower fat and connective tissue content • More elastic attachments - renal and intestinal trauma • More flexible ribs – less likely to fracture BUT less effective at energy dissipation – liver and splenic trauma • Solid organs comparatively larger

5. Other paediatric characteristics • Shallow pelvis – bladder trauma • Use of lap belt – flexion-distraction injury lumbar spine (Chance fracture) – potentially disrupted GIT • Larger body surface , less thermoregulation • Unique compensatory mechanisms – hypotension is late sign in hypovolaemic child

6. Causes of abdominal trauma • Blunt (80%) vs penetrating • Most common causes – MVA, handlebar injury • Battered child

7. Management

8. Assessment • Airway + C-spine immobilization • Breathing • Circulation • Disability (AVPU) • Exposure

9. Paediatric measurements • Weight : (age +4) x 2 • Energy: 4 J/kg • Tube: age(years) +4 4 • Fluids: 20mls/kg ( up to 2 boluses – then RCC 15ml/kg + 10ml/kg crystalloid solution at body temp) • Adrenaline: 10ug/kg – iv/io 100ug/kg – tracheal route • Glucose: 5-10ml/kg 10% dextrose

11. Remember • Conscious child - scared because of events - surrounded by strangers - in pain Be patient and calm – joke, encourage, cajole Explain

12. Secondary Survey • Full examination • History : Allergies Medication Past medical history Last meal Environment – nature of accident / mechanism, etc

13. Assessing the abdomen • Inspection: movement with respiration, distension, bruising patterns, scaphoid abdomen, perineal and genital areas • Palpation: signs of tenderness, guarding • Auscultation NB. Consider : (NOT routine) Crying child swallows large amount of air - NGT for gastric decompression Urinary retention due to pain, strange environment – catheter for urinary decompression

17. Investigations • Blood: CBC, U&Es, Creat, amylase, glucose, xmatch • Urine analysis • Radiology: – CXR, Pelvis Xray, C-spine xray, AXR - Ultrasound – free fluid, organ damage - CT – gold standard in haemodynamically stable child DPL in children – not reliable, paediatric surgeon needed

20. Paediatric Trauma Score Score >8 – Minor trauma Score <0 – high mortality

21. Non-operative: - most common approach - solid organ bleeds are self limiting – delayed ruptures rare - requires an institution which has: ITU service paediatric surgical team paediatric nursing (on wards, in theatre) paediatric anaesthesia paediatric radiology

22. Treatment - parameter monitoring must be regular and obsessive – pulse blood pressure level of consciousness urine output temperature - repeated clinical examinations - deviation from expected clinical course – immediate surgical input, immediate reimaging

23. Treatment • Operative if: - penetrating injury (immediate) - perforated viscus / hollow organ injury (delayed presentation) NB Does not include duodenal haematoma – treated nonoperatively by NGT decompression +/- feeding beyond the haematoma until swelling diminishes - refractory hypovolaemic shock (in spite of resuscitation)

25. Rarely splenectomy • Overwhelming post splenectomy infection • Lifetime risk 5% • Post op vaccines against: -Strep pneumoniae - Haemophilus influenzae Type B - Neisseria meningitidis • Oral penicillin prophylaxis until 18 yrs

27. Clinical pathway for Solid organ injury

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