27 th – 28 th April 2009 MIME Mediterranean Conference Centre Valletta Malta

Ms. J. Galea MD MRCS Ed. Paediatric Surgical Unit Mater Dei Hospital Malta

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

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

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

Blunt (80%) vs penetrating Most common causes – MVA, handlebar injury Battered child

Airway + C-spine immobilization Breathing Circulation Disability (AVPU) Exposure

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

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

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

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

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

Variables+2+1 AirwayNormalMaintainableUnmaintainable CNSAwakeObtundedComa Body weight (kg) > <10 Systolic Blood pressure (mmHg) > <50 Open woundNoneMinorMajor Skeletal injuryNoneClosed fractureOpen/multiple fractures Score >8 – Minor trauma Score <0 – high mortality

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

- 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

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)

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

Grade of injury ICU stayWard stayHouse Arrest Contact activity Restriction Grade INone1 day1 week1 month Grade IINone2 days2 weeks2 months Grade III and above 1 day3 days3 weeks3 months

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