Trauma in Children

• Trauma is the leading cause of death in all children
• Most common surgical problem affecting children
• Proper treatment can prevent death and life-long disability
• Infants and children differ from adults in significant physiological and anatomical ways
  - smaller physiological reserves
  - increased risk of:
  • dehydration
  • hypoglycaemia
  • hypothermia

Airway

Breathing

Circulation

Disability

Exposure of child without losing heat

Principles of managing paediatric trauma patients are essentially same as for adult

MANAGING THE AIRWAY IN A CHILD WITH OBSTRUCTED BREATHING

MANAGING THE AIRWAY IN A CHILD WITH SUSPECTED NECK TRAUMA

STABILIZE SUSPECTED NECK TRAUMA

LOGROLL IN SUSPECTED NECK TRAUMA

• Avoid rotation, extremes of flexion and extension of neck
• One person should assume responsibility for neck:
  • Stand at top of patient and hold head
  • Place fingers at edge of mandible with palm over ears
  • Maintain gentle traction to keep neck straight and in line with body

BREATHING

If child not breathing, ventilate with self-inflating bag and mask Connect mask to oxygen if available Must have correct size and position of facemask to prevent leakage

OROPHARYNGEAL AIRWAYS

Can improve airway opening Come in different sizes Appropriate sized airway goes from centre of teeth (incisors) to angle of jaw when laid on face with raised curved (convex) side up Take particular care in children because of possibility of soft tissue damage

INSERTION OF OROPHARYNGEAL AIRWAY

• Select appropriate sized airway
• Position child to open airway
• Use tongue depressor, insert airway
  • Convex side up in infant
  • Concave side up in older child until tip reaches soft palate, then rotate 180Ëš and slide back over tongue
• Recheck airway opening, use different size or reposition if necessary
• Give oxygen

HOW TO GIVE OXYGEN

CIRCULATION

• The radial pulse at the wrist should be felt.
• If strong and not obviously fast, pulse is adequate
• If radial pulse is difficult to find, try brachial pulse in middle of upper arm

INTRAVENOUS ACCESS IN CHILDREN

Select suitable vein to place 22 or 24 gauge cannula Have assistant keep limb steady, use rubber glove or tubing as tourniquet Clean surrounding skin with antiseptic solution Introduce cannula into vein and fix securely with tape Apply a splint with elbow extended, wrist slightly flexed.

INTRAOSSEOUS ACCESS

Intraosseous puncture provides quick access to circulation in shocked child if venous cannulation impossible Fluids, blood, medicines may be given Fluids may need to be given under pressure If intraosseous needles unavailable, use spinal or bone marrow biopsy needle

TRAUMA IN CHILDREN

Most sensitive indicator of fluid status in a child is urine output Infants are unable to concentrate urine as well as adults, thus more susceptible to electrolyte abnormalities Dosage calculation (based on weight), for fluids, transfusions, drugs is crucial to correct management

Normal Urine output: (ml/kg/hour) Infants 1-2   ml/kg/h Children 1   ml/kg/h Adults 0.5   ml/kg/h How much urine would you expect a 20 kg child to produce in 24 hours?

• Monitor fluid status, electrolytes, haemoglobin diligently
• Maintenance fluid requirements must be supplemented to compensate for all losses
• Tachycardia is an earlier sign than hypotension
• Events happen quickly in babies; monitor closely
• Malnutrition can impair response of children to injury, ability to heal and recover
• Good nutrition promotes healing - poor nutrition prevents it
• Avoid hypothermia. Infants and young children, especially those with little subcutaneous fat, are unable to maintain normal body temperature when there are wide variations in ambient temperature or when anaesthetized

SHOCK RESUSCITATION PROTOCOL IN CHILDREN

TRAUMA IN THE ELDERLY

• Injury risk increases due to slower reflexes, reduced visual acuity, diminished strength
• Even though appearing minor, injuries should be given higher severity scores simply based on age
• Clinician's index of suspicion should be increased