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An introduction to … Paediatric Trauma

An introduction to … Paediatric Trauma. Dr Matt Harvey ST7 PICM, RHC Glasgow Paediatric Retrieval Fellow, ScotSTAR. Objectives. Who What Where When How Why. Is Paediatric Major Trauma Common??. NO <10% of major trauma Severe morbidity and mortality Road traffic collisions

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An introduction to … Paediatric Trauma

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  1. An introduction to…Paediatric Trauma Dr Matt Harvey ST7 PICM, RHC Glasgow Paediatric Retrieval Fellow, ScotSTAR

  2. Objectives • Who • What • Where • When • How • Why

  3. Is Paediatric Major Trauma Common?? NO <10% of major trauma • Severe morbidity and mortality • Road traffic collisions • Head injuries

  4. Who sees Paediatric Trauma?(Where does it present?) 89% of traumatically injured children did not present to a MTC 26% of traumatically injured children are driven/ take public transport to ED

  5. WHAT • What injuries? • What severity? • What mechanism?

  6. Age predicts mechanism…mechanism predicts injury

  7. Age predicts mechanism…mechanism predicts injury Under 1 – HEAD 1 – 5 = EXTREMITIES Older…

  8. WHEN will these children present? i.e. out-of-hours, but rarely late PM/ early AM

  9. HOW • How to manage the injured child? • How to image the child? • How have the guidelines changed? • How to transfer the critically injured child?

  10. Guidelines • APLS • ATLS • Royal College of Radiologists • Others • RCH Melbourne

  11. The trauma approach • MILS • Cervical collars??? • Blocks & tapes • VacMat • Spinal board vs. scoop mattress???

  12. The Patronising Page • Airway • Breathing • Circulation • Disability • Exposure • Don’t ever forget Glucose

  13. But I can’t get access!! • Another operator • External jugular** • IO • Femoral • Cut-down **Consider saphenous & scalp where appropriate

  14. Resuscitation fluids • Blood (if available) • Blood/ Platelets/ FFP (if available) - 1:1:1 ratio • Other • 10ml/kg bolus • Reassess frequently

  15. Not just blood for bleeding Tranexamic acid • Adults: CRASH-2 study • Paeds: Cardiac/ scoliosis/ craniofacial • Pragmatic dosage schedule – 15mg/kg loading dose (max 1g) over 10 minutes • Infusion of 2mg/kg per hour

  16. D is for disability • GCS??

  17. D is for disability • GCS • AVPU • AVPainU

  18. Neurology • Log roll no more - 20 degree tilt • Normothermia • Remember Glucose

  19. Imaging the injured child • APLS vs. RCR • XR Chest & C-spine (if indicated) • Pan-scan CT?? • ALARA • “FAST scan” US??

  20. “The (routine) use of adult protocols and in particular the "whole body" CT trauma survey is not appropriate as a routine investigation in childhood”

  21. BRAIN = CT • NICE/Dept. guidelines • THORAX • Plain films • Penetrating = CT • C-SPINE • Plain film • PEG views difficult • Cord = MRI • ABDOMEN • CT with contrast • SPINE • Plain films • MRI • CT for complex # • PELVIS • CT abdo/pelvis with contrast • EXTREMITIES • Plain films • CT for complex #

  22. What else is in? • Pelvic splints • Thomas splints • Kendrick splints

  23. HOW to transfer the injured child • Team • Transport • Road • Air • Fixed wing • Rotary

  24. HOW to transfer the (critically) injured child

  25. Before you move • Tertiary survey • What have we missed?

  26. WHY don’t we talk about..

  27. The elephant in the room Of 14 845 children: 769 as SCA (5.2%, CI 4.8%-5.5%) Suspected child abuse 751 of 769 (97.7%) in the age group of 0– 5 years 76.3% under ONE year of age Suspected victims of abuse Higher overall injury severity scores Higher proportion of head injury THREEfold higher mortality rate (7.6% vs. 2.6%) TARN DATA Jan 2004 – Dec 2013

  28. Non-accidental injury Remember • NAI • Involve the right people • Recognise potential risk to others

  29. Thank you • Panel discussion & Questions

  30. Resources • ScotSTAR website http://www.snprs.scot.nhs.uk/ • RCR Trauma Imaging https://www.rcr.ac.uk/sites/default/files/publication/BFCR%2814%298_paeds_trauma.pdf • APLS Guidelines http://www.alsg.org/en/files/apls_chapter_13_2015.pdf • NICE CG176 https://pathways.nice.org.uk/pathways/head-injury • RCH Melbourne http://www.rch.org.au/paed_trauma/manual/Paediatric_Trauma_Manual/

  31. Question 1 • What are Kendrick splints? • Immobilisation device for isolated femoral fractures • Contraindicated if assoc. ankle # http://www.tamingthesru.com/blog/acmc/traction-splints-applying-the-ktd-traction-splint

  32. Question 4 • Use of external jugular cannula • Generally safe • Short term use advised • Patient in head down position (transiently) might facilitate insertion

  33. Question 2 • Can you scan through a vac mat? • Device-dependent • Valve causes most degradation of the image – patient positioning important

  34. Question 3 • Analgesia options in the context of low incidence and general medical and nursing practitioners • Simple analgesia • Parental presence • IM/IV opiates • Intranasal – diamorphine/ fentanyl

  35. Question 4 • What type of fluid to use? • Major haemorrhage – products as discussed • Other • 0.9% NaCl OK initially • Large volumes can => hyperchloraemic metabolic acidosis • 5% Albumin • Dextrose – not for volume resuscitation

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