27th – 28th 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 3rd 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, cajoleExplain

Full examination History :

AllergiesMedicationPast medical historyLast mealEnvironment – 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 decompressionUrinary 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 -1

Airway Normal Maintainable Unmaintainable

CNS Awake Obtunded Coma

Body weight (kg)

>20 10-20 <10

Systolic Blood pressure (mmHg)

>90 50-90 <50

Open wound None Minor Major

Skeletal injury None Closed fracture

Open/multiple fractures

Score >8 – Minor traumaScore <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 splenectomyOverwhelming post splenectomy infectionLifetime risk 5%

Post op vaccines against: -Strep pneumoniae- Haemophilus influenzae

Type B- Neisseria meningitidis

Oral penicillin prophylaxis until 18 yrs

Grade of injury

ICU stay Ward stay

House Arrest

Contact activity Restriction

Grade I None 1 day 1 week 1 month

Grade II None 2 days 2 weeks 2 months

Grade III and above

1 day 3 days 3 weeks 3 months

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