EMERGENCY PAEDIATRIC REFRESHER COURSE 2013

TRAUMA & ORTHOPEDIC EMERGENCIES

Sebastian van As

TRAUMA UNIT

RED CROSS CHILDREN’S HOSPITAL UNIVERSITY OF CAPE TOWN

Not all is what it seems!

South Africa

• Approximately 52 million people

• Approximately 20 million children

Childhood Deaths

WHO TRAUMA NUMBER 1 KILLER IN 2020

Child Injuries

Trauma a leading cause childhood deaths Approximately 1 million deaths annually

1. Road traffic accidents

-Pedestrian (80%)

-Passengers (20%)

2. Drowning

3. Burns

Ratio Adults/Children

Age

18

Statistics

• Annually 8000 children die as a result of unintentional injuries

• Mainly motor vehicle accidents, burns and drowning

• Child in SA 25 times more chance to end up in hospital as compared to the UK

0

5

10

15

20

25

30

35

40

45

Ger

man

y

Japan

Aus

tral

ia

USA

Bra

zil

Kor

ea

Chi

na

Vie

tnam

Sou

th A

fric

a

Polytrauma • Very common in children & adolescents

• Represent often clinical decision problems Some of the reasons:

• Relative large head • Many organ systems densely packed together • Exploring the world • Risk behaviour • Dangerous sports

Trauma Team Approach

Doctors

Nurses

Support Staff

Polytrauma very common in young people

Polytrauma •Require a fine balance of numerous specialists:

• Trauma surgeons • Radiologists

• Neurosurgeons • Thoracic surgeons

• Orthopaedic surgeons • Paediatric surgeons • Plastic Surgeons • Hand surgeons • ENT surgeons

• Maxillo-facial surgeons • Urologists • ICU doctors

Polytrauma

Require often also numerous paramedics:

• Social workers

• Physiotherapist

• Dieticians

• Occupational therapist

• Counseller

Polytrauma

Resuscitation room = Flight Control Room

Leading Trauma Doctor = Flight Commander

Initial Phase

Resuscitation:

Airway & Cervical spine stabilization

Breathing

Circulation

– CGS 13-14/15

– Bp 80/40

– Pulse Rate 140, feeble

– Resp Rate 54

– Hb 10 Gram%

– Cyanotic, distressed

– No scalp wounds

– Left Chest > Right Chest

– Decreased Air Entry Left

– Abdomen soft, scaphoid

– Pelvis clinically fractured

– Near total amputation left leg

Second Phase

“Management frenzy”

All (sub) specialist want to be first on the list!

Often various interventions/investigations still on the go

Delay in diagnostic procedures due to specialist interfering

If patients needs to have imaging outside the resusc room this is even more complicated

Not always easy to find all pathology; often camouflaged!

Which teams to call?

Guiding principle: ABC

Airway & Breathing compromise

Thoracic Surgeons

Circulation compromise

Pediatric Surgeons

– CGS 13-14/15

– Bp 80/40

– Pulse Rate 140, feeble

– Resp Rate 54

– Hb 10 Gram%

– Cyanotic, distressed

– No scalp wounds

– Left Chest > Right Chest

– Decreased Air Entry Left

– Abdomen soft, scaphoid

– Pelvis clinically fractured

– Near total amputation left leg

Triad of Death

Bloody Vicious Cycle of Polytrauma:

Acidosis

Hypothermia

Coagulopathy

Damage Control

First Phase (Operating theatre)

Control hemorrhage

Alleviate contamination

Packing

Fracture immobilization

Second phase (ICU)

Rewarming

Correction coagulopathy

Reversing Acidosis

Team Management

We all know what to do; ABCDE

Main problem, nearly ALL hospitals:

Trauma Doctor the MOST junior one around

They don’t have experience

They often call the wrong specialist

They lack authority

Solutions to this problem:

Senior Specialist on close stand-by!

Always have experienced nursing staff on duty with junior doctors!

Change of staff gradually:

New teams / change over:

Make a sure there is a “critical mass”

of experience

Don’t change more than 2 members of the team at one time

(doctors/nurses/support staff)

Family management

Trauma surgeon often little time

Make sure the family is not left alone:

Family friends

Experienced nursing staff

Social worker

Pastor support

Conclusive remarks

•Each case represents a new challenge

•All cases are different

•Highly complex management

•Require experience and compassion

•Often an evolving management plan is the best (The situation is RARELY static)

•Open communication with all stake holders is crucial

Thank you!

Not all what it seems…