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Pediatric Snowboarding Severe Abdominal Trauma: Report of Our Experience

Pediatric Snowboarding Severe Abdominal Trauma: Report of Our Experience. Zampieri Nicola, Trabucchi Elia, Trabucchi Gabriele, Romagnoli Carlo 1 Department of Surgery-Paediatric Surgical Unit- Woman and Child Hospital-University of Verona-Italy;

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Pediatric Snowboarding Severe Abdominal Trauma: Report of Our Experience

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  1. Pediatric Snowboarding Severe Abdominal Trauma: Report of Our Experience Zampieri Nicola, Trabucchi Elia, Trabucchi Gabriele, Romagnoli Carlo 1Department of Surgery-Paediatric Surgical Unit- Woman and Child Hospital-University of Verona-Italy; 2Orthopedics and Traumatology, Trauma Clinic, Livigno- Italy

  2. No conflict for all Authors(III level Hospital)

  3. Introduction Alpine skiing and snowboarding are popular winter sports and they are associated with a high risk of injurythe type of injuries related to these sports have changed over time as the equipment and slope-grooming technologies have evolvedMusculoskeletal injuries in snowboarding are common and the types of injiuries varies. Hand, wrist, shoulder and ankle injiuries are the most commonon the other hand, snowboarding injiuries are different respect to the type of trauma: collisions vs falls have different trauma energy with different results-rails-wood-stationary objects

  4. Introduction Snowboarding injuries have increased and blunt abdominal trauma is frequentAlpine rescue team is essential in high mountain especially with severe trauma and essential is the first management of these cases

  5. Introduction DATA ARCHIVES: Livigno more than 800.000 tourists (November –May)STATISTICS DATA: more than 600 cases per season (paediatric trauma more than 70/y)Nationality: CZ, Denmark, Poland, Sweden, Russia, Italy, UK, other 11 Deaths into the slopes: from 2005 November to 2017 May only adults: trauma and cardiac arrest Type of trauma : 1-joint distortion 2- bone fractures 3- blunt abdominal/thoracic/head trauma 3- joint dislocations 4- skin lesions 5- medical problems (stroke, cardiac arrest, AF/VF/VT/AT, head-hake, high pressure, panic attack).Team Organization: Mountain rescue team: 1 doctor + 4 rescuers specialized for alpine rescueEquipment: snow moto/ski/rescue sled(Toboggans) vacuum mattress/vacuum splint/femoral traction splint/pelvic slings braces/spine boards/back boards/cervical collars defibrillator/drugs/ oxygen/first aid kit (suture, surgical instruments) thermo blanketWorkplace temperature: -25°C to 10°C- 2700 mt-3200 mt

  6. Introduction Livigno snowpark: is the biggest in Europe“BIG MAMA” Jump

  7. Materials and Methods We retrospectively review medical charts of patients aged 6-18 yrs treated in the ski area in high mountain (2700-3200 mt) between December 2008 and December 2016; inclusions and exclusions criteria were created. data were analyzed focusing on type of injury and type of management. The rescue team worked with helicopter support when necessary due to the difficulty to treat these patients in a locum first-aid centre.Exclusion criteria: patients lost to follow-up or repatriated for treatment.PATIENT STABLE without acute urgencies go to Trauma clinic for considerationPATIENT stable/unstable with acute urgencies: transferred after stabilization by helicopter (from 6 to 20 minutes after call) to Acute Trauma Centre (III level Hospital) Distance: 6-15 min by helicopter 2h by ambulance

  8. Materials and Methods All patients were treated using the ISS score before hospitalization

  9. Materials and Methods All subjects had Helmets as reguired by Italian legislator Alcohol and drugs involved were recorededPatients treatment: a) 1 rescue man start immediately after call and localization into the sky area (mean 3,7 minutes); b) after evaluation he asks for advanced treatment (mean 3,3 minutes); c) team organization and starting with materials (mean 4,2 minutes); d) diagnosis, prepare patients and decision (mean 5,4 minutes)When helicopter support was impossible into 20 minutes, patients were stabilized in the ski area and secured at the Trauma Clinic while helicopter coming. All patients were stabilized in the ski area with peripheral venous cannulation, fluids and pain-killer infusion, thermo blanket, oxygen, braces and vacuum devices as indicated.

  10. Results During the study period 32patients were treated. 30 were male and 2 female (p<0.05)18 (56%) had an associated head trauma with concussion and neurocognitive deficits: other 5 cases had head trauma without deficits One patients required oral intubation (ISS 32) median emergency medical services transport time of 44 minutesOne patients had thoracic spine injury associated with complete spine injuryPatients characteristics: 20 were injuried in a fall (13 after a jump)10 collided with a stationary object2 cases unclear (alcohol involved)

  11. Results Statistical considerations:19 cases had single organ injury (18 spleen and 1 kidney)5 cases had spleen and kidney6 cases had liver and spleen injury2 cases had spleen, liver and pancreatic injury (collision with rail)Snowboarders respect to skiers had higher frequencies of injury to the lumbar spinemanagement: 2 patients underwent splenectomy and nephrectomy while only one patients had splenectomy aloneall other cases were treated conservatively without morbidityHYPOTHERMIA: 24% of accidents had mild hypothermia

  12. Results Statistical considerations:Liver trauma: grade II-IIISpleen trauma: grade II-IVKidney trauma: grade II-IVPancreatic trauma: grade 3 Symptoms: 1- tachicardia 2- confusion 3- abdominal tenderness Abdominal stiffness 4- vomit 5- flank hematoma 6- Breathing difficulty

  13. Results Statistical considerations:patients older than 15 years were more likely to have multiple organ injuries (p<0.05) patients older than 15 years were more likely to have injuries against stationary objects (p<0.05)patients younger than 10 years were more likely to have skeletal fractures associated (p<0.05)Weather and trauma correlation:Big trauma where more common in March and April (sunny) and after important snowfalls (> 48 hours) (p<0.05)abdominal trauma associated with skeletal fractures were more common in “winter” and associated with falls

  14. Results Statistical considerations:the mean ISS value was 15 (range 9-30) subjects older than 13 were more likely to have ISS between 18 and 27 (p<0.05)the ISS value was statistically correlated with weather and type of trauma (collision vs falls)patients with trauma outside slopes (free riders) where more likely to have hypothermia (mild)(p<0.05)ISS value increased after important show like the famous “nine knights”

  15. Discussion this is the unique organized and certified rescue team in the Alpen zone in Italy From a clinical point of view some questions are necessary:1. Are a significant number of people treated by personnel that are not knowledgeable, or not equipped with current technology? 2-have these patients treated using the corrected equipment?3- which is the “correct time” in high mountain to understand, without first aid, the clinical situation of patient?Rescuers have an important role in the first aid medical treatment of victims …Nobody is dead until warm and dead…

  16. Discussion There are some differences in the overall injury patterns between skiers and snowboarderswhile skiers have usually trauma of legs and arms and spine, snowboarders had also important abdominal traumathese patients, with the recent opening of snowparks are prone to injury with stationary objects with serious consequencesabdominal trauma could be associated with morbidity even if at present many of abdominal trauma are treated conservatively (hospitalization mean 18 days range 6-32)the difference between trauma and organ injuries could be in the type of equipment used …Nobody is dead until warm and dead…

  17. Discussion Accidental hypothermia is defined as an unintentional drop in core body temperature below 35◦C.Hypothermic cardiac arrest is defined as cessation of circulation caused by hypothermia, including ventricular fibrillation (VF), ventricular tachycardia without pulse (VT), pulseless electric activity (PEA) and asystole (AS). Hypothermia is classified as mild (32–35◦C), moderate(28–32◦C), severe (20–28◦C) and profound (<20◦C)Treatment of hypothermia starts in the field. Many rescuers and first-aid providers do not have equipment to institute rewarming with warm, humidified oxygen, and warm IV-fluids, although these methods should be initiated to help prevent (core) temperature afterdropThe most important phase of treatment is the prevention of post-rescue collapse during the first 30 minutes following rescue, and during transportation to a Hospital…Nobody is dead until warm and dead…

  18. Discussion Young male snowboarders are at risk for having multiple organ injuries In the slopes and in extreme conditions there are no clear signs of intraabdominal organ failure but undestanding the dynamicity of traumas could be useful to suspect them it is essential to understand also the kinetic power of trauma as soon as possible to avoid morbidityAbdominal trauma especially after collision with stationary object are at risk for severe organ failure…Nobody is dead until warm and dead…

  19. CONTACT: • Prof. Nicola Zampieri MD, PhD • Women and Child Hospital • AOUI Verona • E mail: dr.zampieri@libero.it

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