Gareth Hosie Consultant Paediatric Surgeon 17th April 2015 Childhood trauma Gareth Hosie Consultant Paediatric Surgeon 17th April 2015

Trauma Commonest cause of death in children > 1 yr

Causes of death Head injury

Children Relatively large head Elastic thoracic cage Tend to bounce

Abdominal trauma - penetrating

Blunt abdominal trauma

Blunt abdominal trauma

Blunt abdominal trauma

How often is surgical intervention required?

31.1.15 9 year old girl 12.30 fell 12 – 15 ft from top of playground slide Walked home 14.00 felt faint, 2 episodes of “shaking” Mum brought her to A&E – arrived 15.30

Examination P 150 , BP 130/70 Pale, cool peripheries Normal neurology Tender L side of abdomen and flank

10ml /kg 0.9% NaCl

CT BP ↓ 65mm Hg systolic 2nd bolus NaCl – BP 102 mmHg

Hb 8.3g/dl Blood given

But … Continued to ↓ Hb

21.7.12 11 year old boy Riding BMX bike, doing jumps on skate park Fell sidewards approx 1m Handlebar injury to abdomen

Examination Haemodynamically stable Abrasion on epigastrium Tender upper abdomen

Serum amylase 298 u/l

CT guided insertion of abdominal drain

Following month Continued drain output

11.11.09 5 year old boy Chest and abdomen crushed by large marble fireplace

1 week post trauma Laparoscopic insertion abdominal drain 2 litres of old blood / bilious fluid aspirated

2 years post trauma

What about a ruptured spleen?

Ruptured spleen--when to operate? J Pediatr Surg. 1981 Jun;16(3):324-6. Wesson DE, Filler RM, Ein SH, Shandling B, Simpson JS, Stephens CA. Abstract Sixty-three patients with splenic injuries were treated during a 5-yr period from 1974-1979. The decision to operate was based on the patient's clinical course, not on the presence of splenic injury alone. Those who were stable on admission or after initial resuscitation were treated nonoperatively. This consisted of strict bed rest, nasogastric suction, and i.v. fluids--including blood--as required. Those who bled massively were operated on promptly. At operation, the spleen was repaired if possible or excised if damaged beyond repair. Forty patients were treated nonoperatively. Sixteen of these required blood transfusions (mean 31.2 +/- 5.3 ml/kg). One patient in this group developed a large defect on spleen scan at 3 wk post injury. There was no other morbidity and no mortality following nonoperative treatment. Nineteen required operation all within 16 hr of admission. Fifteen underwent splenectomy, 2 partial splenectomy, and 1 splenorrhaphy. In 1 the bleeding had stopped. All required blood before operation (mean 80.4 +/- 10.1 ml/kg). Seven in this group died (6 from head injuries and 1 from bleeding). Thus surgery was avoided in 2 out of 3 and the spleen saved in 3 out of 4 patients with documented splenic injuries. We believe that where adequate facilities exist nonoperative treatment of splenic injuries is both safe and effective. When bleeding is massive from the beginning or replacement requirements exceed 40 ml/kg, operation is indicated

Take home messages Children are resilient Abdominal surgery rarely needed – and almost never in the early stages of trauma management