1. Paediatric Trauma The Basic Principles Emergency Medicine Department ARI / RACH FY/ST Teaching Programme

2. Aims To teach you to have a Structured Approach Highlight the recent changes in APLS algorithms

3. Background Paediatric Injuries are Common Paediatric Major Trauma is Rare Trauma and Injuries are leading cause of death in the developed world after the first year of life.

4. Children are Different Anatomy – Injury Patterns – Compliant Skeleton Physiology Psychology Complicated by the fact that there is such a variance across the age ranges from infancy to puberty…

5. Simple Structure Preparation Primary Survey Resuscitation Secondary Survey Definite Care Reassess

6. Preparation Simulation Teaching PLS / APLS / EPLS

7. Preparation Team – Ensure all aware and present – ? Code Red – Role allocation Equipment – ABC – Drugs – WETFLAG Cards Calculations Weight - 3 x Calcluations Energy - 4J / Kg Tube - Age / 4 + 4 Fluids -10mls / kg boluses -(20ml / kg Medical, 5ml / kg Cardiac) Lorazepam - 0.1mg/kg Adrenaline - 0.1ml/kg of 1:10,000 Glucose - 2ml/kg of 10% + Infusion

8. Primary Survey CCatastrophic Haemorrhage Control AAirway with C-Spine Control BBreathing with Ventilatory Support CCirculation DDisability with Prevention of Secondary Insult EExposure with Temperature Control TREAT AS YOU PROGRESS… CONTINUALLY REASSES

9. Catastrophic Haemorrhage Control Turn off the tap – No point resuscitating when just going in and out onto the floor – The ‘First Clot is the Best Clot’ Dressing / Pressure Splintage of Long Bone # / Pelvic #

10. Airway Ensure patency, if not your in trouble! Airway takes priority over C-Spine – But be careful – Jaw Thrust (no head tilt) C-Spine – MILS – Collars not recommended, but can be used – Block and Tapes – Preference depends on compliance If in doubt then MILS Blocks and Tapes when Anaesthetised to alert people to the risk

11. Breathing All trauma victims need O2 – High Flow Identify the LIFE THREATENING CHEST INJURIES A T O M F C Treat as you find them – or patient will die!

12. Breathing Airway Compromise Shoulda Noticed Earlier! Patients Dead – Go Have Coffee Tension Pneumothorax Needle Thoracocentesis and Chest Drain Open Pneumothorax Occlusive Dressing Massive Haemothorax IV Access / IVI and Chest Drain Flail Chest Analgesics +/- +ve Pressure Ventilation Cardiac Tamponade Needle Thoracocentesis

13. Circulation 2 x IV Access Bloods inc XM / Major Haemhorrage Pelvic Binder Assess all cavities for blood loss – Chest / Abdo / Pelvis/ Long Bones and the Floor – Patient has a Front and a Back!

14. Circulation Fluid Resuscitation – Used to be 10ml/kg + 10ml/kg Boluses Call Surgeons 10ml/kg + 10ml/kg Boluses After 40ml/kg give blood at 10ml/kg boluses – But now 30-50% of Circulating Volume replaced with salty water – Now simple 10ml/kg boluses If they are losing blood, give blood!! Likley to have 1 x Nacl whilst get O –ve / Type Specific

15. Disability AVPU GCS Pupils, Tone and Posture Prevent secondary insult – Reduce ICP – Reduce metabolic demands

16. Exposure Expose to identify other potentially significant injuries… Observe temperature

17. Disposal Theatre CT Scan PICU Ward Discharge This will be situational and decided case by case

18. Secondary Survey Once Primary Survey and Resuscitation complete You may get stuck at the Resuscitation Phase – Secondary Survey not completed – Document in notes Toes to toe examination to identify additional injuries Includes Log-roll and Spinal Assessment Imaging – Trauma Series – Others: FAST, CT Adjuncts – Catheter – NG

19. Tertiary Survey Completed after the acute phase for identification of subtle injuries

20. After a Resus Case Hot Debrief Potential later Case Review or Debrief – Formal – Clinical Governance All team members inputs are valued and if you have any discussion points, questions, uncertainties – please ask!

21. Questions

22. Summary of changes: C – ABC C-Spine Immobilisation Fluid Resuscitation Preparation Primary Survey with Resus – ABCDE Approach Secondary Survey if possible