Accidents and Accidents and PoisonsPoisons
Dr D. BarryDr D. Barry
POISONINGPOISONING
PoisoningPoisoning
Accidental;Accidental; pre-school age ( pre-school age (♂ > ♀)♂ > ♀)
Intentional;Intentional; > 9 years ( > 9 years (♀ > ♂)♀ > ♂)
Factitious / MFactitious / Münchausen by proxy ünchausen by proxy (rare)(rare)
IathrogenicIathrogenic
StatisticsStatistics
Accidental poisoning preventable Accidental poisoning preventable cause of morbidity and mortalitycause of morbidity and mortality
Ireland:Ireland: 3,000 annual poisons and 1,000 3,000 annual poisons and 1,000
admissions annually (1-4 yrs)admissions annually (1-4 yrs) 12 deaths 2001-200312 deaths 2001-2003
PoisoningPoisoning
National Poisons centre-Beaumount HospNational Poisons centre-Beaumount Hosp 20062006
Children<10yrs: Children<10yrs: 4466 enquiries/4726 4466 enquiries/4726 products.products.
Drugs, Household, Chemical Drugs, Household, Chemical products(cosmetic and personal hygiene)products(cosmetic and personal hygiene)
Adolescents10-19 yrs: Adolescents10-19 yrs: 899 899 enquiries/1490 products. Drugs, enquiries/1490 products. Drugs, industrial and household products industrial and household products (analgesics, anti-inflammatory)(analgesics, anti-inflammatory)
Accidental PoisoningAccidental Poisoning Infants and young children will drink or Infants and young children will drink or
eat ANYTHING!eat ANYTHING! If it looks interesting / smells good/ has a If it looks interesting / smells good/ has a
bright colour ----- They will eat / drink itbright colour ----- They will eat / drink it Substances taken are Medicines & Substances taken are Medicines &
Household Products; detergents, garden Household Products; detergents, garden agents, pesticidesagents, pesticides
Most are not taken in sufficient quantity to Most are not taken in sufficient quantity to cause harm cause harm
Children still die every year due to Children still die every year due to poisoningpoisoning
What age do children pick up What age do children pick up tablets?tablets?
What age can children open What age can children open doors/presses?doors/presses?
What age can children open What age can children open containers?containers?
Prevention: Safety Prevention: Safety InformationInformation
Child resistant containersChild resistant containers Out of reachOut of reach Lock up household substancesLock up household substances No chemicals under the kitchen sinkNo chemicals under the kitchen sink Childminders/Visitors as aboveChildminders/Visitors as above Dispose of out of date medsDispose of out of date meds Know what meds/products are in Know what meds/products are in
your houseyour house
PresentationsPresentations
Ingestion known/suspected Ingestion known/suspected Eg. toddler found by carer playing with tablets Eg. toddler found by carer playing with tablets
/ missing tablets from open container etc. / missing tablets from open container etc. Disclosure by teenager / family etcDisclosure by teenager / family etc
Symptomatic;Symptomatic; Reduced ConsciousnessReduced Consciousness Metabolic acidosis (high anion gap)Metabolic acidosis (high anion gap) ArrhythmiaArrhythmia GI upset (vomiting / abdo pain / anorexia etc)GI upset (vomiting / abdo pain / anorexia etc) SeizuresSeizures
HistoryHistory
What toxin/medication was takenWhat toxin/medication was taken Who was the witnessWho was the witness How much was takenHow much was taken What time was it takenWhat time was it taken What other medications or toxic What other medications or toxic
substance was available to the child substance was available to the child
Physical ExaminationPhysical Examination
Toxic syndromesToxic syndromes Anticholinergics Anticholinergics hot as a hare, dry as hot as a hare, dry as
a bone (dry mouth), red as a beet, blind a bone (dry mouth), red as a beet, blind as a bat (dilated pupils), mad as a as a bat (dilated pupils), mad as a hatter (delirium)hatter (delirium)
Organophosphates (cholinergic) Organophosphates (cholinergic) diarrhoea, diaphoresis, miosis, diarrhoea, diaphoresis, miosis, bradycardia, bronchosecretions, emesis, bradycardia, bronchosecretions, emesis, lacrimation, salivationlacrimation, salivation
Physical ExaminationPhysical Examination
Toxic syndromesToxic syndromes Cocaine/amphetamines Cocaine/amphetamines
(sympathomimetic) (sympathomimetic) mydriasis, mydriasis, tachycardia, hypertension, tachycardia, hypertension, hyperthermia, seizureshyperthermia, seizures
Narcotics Narcotics miosis, bradycardia, miosis, bradycardia, hypotension, hypoventilation, comahypotension, hypoventilation, coma
ManagementManagement
ManagementManagement
1)1) Stabilise patient / ResusStabilise patient / Resus2)2) Accurate history & calculate Accurate history & calculate
ingestioningestion3)3) Initial work-upInitial work-up4)4) Gastric Gastric
elimination/decontaminationelimination/decontamination5)5) Monitoring, levels, nomograms - Monitoring, levels, nomograms -
Discuss with Toxicology centreDiscuss with Toxicology centre6)6) Antidote etc.Antidote etc.7)7) Why / How did it happen follow-upWhy / How did it happen follow-up
1) Resuscitation1) Resuscitation AirwayAirway BreathingBreathing CirculationCirculation Cornerstone of management of acute Cornerstone of management of acute
poisoning is supportive carepoisoning is supportive care
2) Investigations2) Investigations
Full blood countFull blood count Urea, creatinine, electrolytesUrea, creatinine, electrolytes Blood glucoseBlood glucose Blood gasBlood gas Serum and urine for toxicologySerum and urine for toxicology
3) History3) History
What toxin/medication was takenWhat toxin/medication was taken Who was the witnessWho was the witness How much was takenHow much was taken What time was it takenWhat time was it taken What other medications or toxic What other medications or toxic
substance was available to the child substance was available to the child ((Who’s in the house & what meds Who’s in the house & what meds are they on?)are they on?)
4) Gastric 4) Gastric DecontaminationDecontamination
Gastric evacuationGastric evacuation Induction of emesisInduction of emesis Gastric lavageGastric lavage
Chemical decontaminationChemical decontamination Activated charcoalActivated charcoal CatharticsCathartics Whole bowel irrigationWhole bowel irrigation
NB NB – corrosive substances are – corrosive substances are particularly dangerous – seek expert particularly dangerous – seek expert advice first!advice first!
Induction of EmesisInduction of Emesis
Rarely done anymoreRarely done anymore Syrup of ipecac most commonly usedSyrup of ipecac most commonly used Induces vomiting in 20 - 60 minutesInduces vomiting in 20 - 60 minutes Contraindicated in:Contraindicated in:
infants less than 6 monthsinfants less than 6 months poor conscious statepoor conscious state diminished gag reflexdiminished gag reflex hydrocarbons, acids, alkalishydrocarbons, acids, alkalis
Gastric LavageGastric Lavage Large bore orogastric tube with Large bore orogastric tube with
normal saline irrigationnormal saline irrigation If conscious state is depressed, airway If conscious state is depressed, airway
protection with an endotracheal tube protection with an endotracheal tube prior to lavage is recommendedprior to lavage is recommended
Contraindicated in hydrocarbons, Contraindicated in hydrocarbons, acids and alkalis (risk of aspiration)acids and alkalis (risk of aspiration)
Most effective within 1 hour of Most effective within 1 hour of ingestion,ingestion,
Removes up to 40% of ingested toxinRemoves up to 40% of ingested toxin
Activated CharcoalActivated Charcoal Complex Molecule with large surface area; binds many Complex Molecule with large surface area; binds many
poisonspoisons Not indicatedNot indicated in heavy metal poisoning ( in heavy metal poisoning (iron,iron, lithium) lithium)
or ingestion of or ingestion of acid or alkaliacid or alkali where endoscopy may be where endoscopy may be required or required or alcohol ingestionalcohol ingestion
Promotes reabsorption from circulation into bowel & Promotes reabsorption from circulation into bowel & interrupt entero-hepatic circulation of some drugs interrupt entero-hepatic circulation of some drugs (aspirin, barbituates)(aspirin, barbituates)
Very unpalatable => give via NG / lavage tube (25-50g)Very unpalatable => give via NG / lavage tube (25-50g) typical dose SE; severe lung damage if aspiratedtypical dose SE; severe lung damage if aspirated Patient must be conscious or airway protectedPatient must be conscious or airway protected Window of opportunity; 1 hour Window of opportunity; 1 hour (↑ with salicylates)(↑ with salicylates)
Multidose charcoal-controversial Multidose charcoal-controversial
5) Monitoring, levels, 5) Monitoring, levels, nomograms nomograms
You will not know the toxicity of You will not know the toxicity of every substance / drugevery substance / drug
Poisons Information Centre provide Poisons Information Centre provide invaluable help and advice 24 hours invaluable help and advice 24 hours a daya day
Blood levels (often at 4 hours)Blood levels (often at 4 hours) May have nomogramMay have nomogram
6) Antidotes6) Antidotes
BenzodiazepinesBenzodiazepines
IronIron OpiatesOpiates ParacetamolParacetamol ββ-blockers-blockers DigoxinDigoxin
>> FlumazenilFlumazenil
>> DesfuroximineDesfuroximine
>> NaloxoneNaloxone
>> N-acetylcystineN-acetylcystine
>> Glucagon / Glucagon / AdrenalineAdrenaline
>> Fab antibodiesFab antibodies
Some Potentially Harmful Some Potentially Harmful PoisonsPoisons
ParacetamolParacetamol IronIron Aspirin (salicylates)Aspirin (salicylates) Substance abuse; Alcohol, Ecstasy, Cocaine, Substance abuse; Alcohol, Ecstasy, Cocaine,
etc.etc. Digoxin/ Antiarrhythmics/ Any Cardiac DrugDigoxin/ Antiarrhythmics/ Any Cardiac Drug Tricyclic AntidepressantsTricyclic Antidepressants BenzodiazepinesBenzodiazepines OpiatesOpiates Ethylene glycolEthylene glycol (anti-freeze/de-icer) (anti-freeze/de-icer)
ParacetamolParacetamol
Paracetamol IngestionParacetamol Ingestion Most widely available and commonly Most widely available and commonly
ingested Medicineingested Medicine Infants almost never drink enough to Infants almost never drink enough to
require Blood levels to be tested!!!require Blood levels to be tested!!! Increasing incidence of deliberate Increasing incidence of deliberate
ingestioningestion Mostly girls > 9 years oldMostly girls > 9 years old Assess Assess quantity and timingquantity and timing of ingestion of ingestion Do not trust information given; if large or Do not trust information given; if large or
unknown ingestion------ Treat as overdoseunknown ingestion------ Treat as overdose
Paracetamol ingestion; Paracetamol ingestion; symptomssymptoms
Initially asymptomatic (? Nausea)Initially asymptomatic (? Nausea)
36 hours later; 36 hours later; hepatic necrosishepatic necrosis (? (? Right subcostal pain) +/- liver Right subcostal pain) +/- liver decompensationdecompensation
Renal Failure (ATN) may occurRenal Failure (ATN) may occur
Paracetamol Overdose Paracetamol Overdose ManagementManagement
Activated Charcoal (gastric lavage not Activated Charcoal (gastric lavage not helpful) in < 1 – 4 hourhelpful) in < 1 – 4 hour
Check level at 4 hours post ingestionCheck level at 4 hours post ingestion Map on NomogramMap on Nomogram N-AcetylcysteineN-Acetylcysteine IV IV
if > treatment line on normogram (*? if > treatment line on normogram (*? High risk pt.?)High risk pt.?)
Monitor LFTs, Coag, U&E, blood levelMonitor LFTs, Coag, U&E, blood level
Iron IngestionIron Ingestion
> 20mg/kg iron ingestion; toxicity possible> 20mg/kg iron ingestion; toxicity possible > 60mg/kg – serious toxicity> 60mg/kg – serious toxicity > 150mg/kg – fatal!> 150mg/kg – fatal! Calculate Iron content of tabs & possible Calculate Iron content of tabs & possible
intakeintake Tests; Tests;
PFAPFA FBC, G&X, glucose, VBGFBC, G&X, glucose, VBG serum iron (@ 4 hours)serum iron (@ 4 hours)
Iron Ingestion; Iron Ingestion; SymptomsSymptoms
Stage 1; (30mins – 6 hours) abdo pain, Stage 1; (30mins – 6 hours) abdo pain, vomiting, diarrhoea (+/- bloody; ie. vomiting, diarrhoea (+/- bloody; ie. haemorrhagehaemorrhage
Stage 2 (10 hours – 30 hours); silent phaseStage 2 (10 hours – 30 hours); silent phase (iron absorbs & accumulates in tissues, mitochondria (iron absorbs & accumulates in tissues, mitochondria
etc.)etc.) Stage 3; cellular & mitochondrial damage;Stage 3; cellular & mitochondrial damage;
shock, encephalopathy, liver shock, encephalopathy, liver decompensationdecompensation
Hypoglycaemia, lactic acidosisHypoglycaemia, lactic acidosis Stage 4; (weeks later); Stage 4; (weeks later); GI stricturesGI strictures & &
obstruction, liver failureobstruction, liver failure
Iron Ingestion; Iron Ingestion; ManagementManagement
Stabilise; A B CStabilise; A B C
Gastric Lavage in < 1 hour Gastric Lavage in < 1 hour
Charcoal not helpfulCharcoal not helpful
Desferrioxamine (iron chelator) Desferrioxamine (iron chelator) ?PO (controversial) ?PO (controversial) IVIV
Salicylate (Aspirin)Salicylate (Aspirin)
Induces Gastric stasis!Induces Gastric stasis! Also slow/sustained release Also slow/sustained release
preparationspreparations => may be recoverable up to 12 hours => may be recoverable up to 12 hours
post ingestionpost ingestion Gastric lavage up to 4 hoursGastric lavage up to 4 hours ? Repeated charcoal doses? Repeated charcoal doses Serial blood levels (as levels can ↑ > 6 Serial blood levels (as levels can ↑ > 6
hours)hours)
Salicylate Poisoning; Salicylate Poisoning; SymptomsSymptoms
Phase 1;Phase 1; (0-12 hours)(0-12 hours) Anxiety, sweating, Anxiety, sweating, fever, tachycardia, fever, tachycardia, hyperventilationhyperventilation with with
Resp Alkalosis! Resp Alkalosis! => compensatory alkaline urine with loss of HCO=> compensatory alkaline urine with loss of HCO33
--, K, K++
Phase 2;Phase 2; (may be immediate in young (may be immediate in young children)children)
↓ ↓ K+K+ (& paradoxic aciduria) (& paradoxic aciduria) Phase 3;Phase 3; (up to 24 hours)(up to 24 hours) dehydration, dehydration, acidosis acidosis
predominates, pulmonary oedema, resp failurepredominates, pulmonary oedema, resp failure
Specific managementSpecific management
Alkalisation of Urine to aid drug Alkalisation of Urine to aid drug excretionexcretion Sodium BicarbonateSodium Bicarbonate
Fluids & K+ replacementFluids & K+ replacement Serial levels & ongoing monitoringSerial levels & ongoing monitoring Resp support!Resp support!
Ethylene GlycolEthylene Glycol Tastes sweetTastes sweet In Anti-Freeze, De-icer fluid etcIn Anti-Freeze, De-icer fluid etc Causes metabolic acidosis (high anion gap)Causes metabolic acidosis (high anion gap) Widespread cellular damage (esp. Kidneys) Widespread cellular damage (esp. Kidneys)
Haemodialysis may be neededHaemodialysis may be needed Activated Charcoal doesn’t work!Activated Charcoal doesn’t work! Metabolised by Alcohol Dehydrogenase into Metabolised by Alcohol Dehydrogenase into
toxic by-productstoxic by-products Ethanol (40%) is competitive inhibitor of Ethanol (40%) is competitive inhibitor of
Alcohol Dehydrogenase & may be used Alcohol Dehydrogenase & may be used Co-factors; thiamine, pyridoxine etc.Co-factors; thiamine, pyridoxine etc.
Caustic IngestionsCaustic Ingestions
Eg. Acids / alkalis / batteriesEg. Acids / alkalis / batteries Burns in mouthBurns in mouth necrosis of oesophagus necrosis of oesophagus strictures commonstrictures common Lung damage when aspiratedLung damage when aspirated
No emesis / lavage / charcoal etc. No emesis / lavage / charcoal etc.
7) Follow-up of Poison 7) Follow-up of Poison IngestionIngestion
Must consider; why did this happen?Must consider; why did this happen? NB – social historyNB – social history
Carers? Carers? Supervision concern / Neglect?Supervision concern / Neglect? Housing etc. Housing etc. Child-proofing the homeChild-proofing the home
Social Worker InvolvementSocial Worker Involvement Psyche involvement if deliberatePsyche involvement if deliberate
Possible Metabolic Possible Metabolic abnormalitiesabnormalities
Metabolic acidosis Metabolic acidosis
(high anion gap)(high anion gap) SalicylatesSalicylates IronIron Ethanol, methanol, Ethanol, methanol,
ethylene glycolethylene glycol IronIron
HypoglycaemiaHypoglycaemia Iron poisoningIron poisoning Alcohol poisoningAlcohol poisoning
HypokalaemiaHypokalaemia SalicylatesSalicylates ΒΒ-blockers-blockers
HyperkalaemiaHyperkalaemia digoxindigoxin
Childhood Childhood AccidentsAccidents
Dr. D BarryDr. D Barry
Childhood accidentsChildhood accidents Leading cause of death and disability in Leading cause of death and disability in
children and young adultschildren and young adults
More than 5 million deaths per year More than 5 million deaths per year worldwideworldwide
Lack of global attention to childhood Lack of global attention to childhood injuriesinjuries
Leading cause of death in children over 1 Leading cause of death in children over 1 yearyear
Childhood Mortality by Childhood Mortality by AgeAge
0%
5%
10%
15%
20%
25%
30%
< 1 year 1 - 4 years > 5 years
SIDSCongenital anomalyInfectonNeoplasmsAccidents
Accident typesAccident types
FallsFalls DrowningDrowning BurnsBurns ChokingChoking RTARTA
*****NB – when to consider *****NB – when to consider NAINAI **********
FALLSFALLS
Children Fall all the timeChildren Fall all the time Toddlers ( 1 – 3 Years) especiallyToddlers ( 1 – 3 Years) especially Babies roll over, fall off beds , climb Babies roll over, fall off beds , climb
out of cots, fall out of high chairs out of cots, fall out of high chairs etc.etc.
Fractures are uncommonFractures are uncommon Detailed HistoryDetailed History Detailed Detailed FULL FULL ExaminationExamination
FallsFalls
Clinical assessment will direct further Clinical assessment will direct further investigations ( if any)investigations ( if any)
Many children < 1 Year with a head Many children < 1 Year with a head injury are observed as inpatients to injury are observed as inpatients to ensure they remain wellensure they remain well
All are referred to social work All are referred to social work > 99% are > 99% are Genuine AccidentsGenuine Accidents But be Vigilant; ? NAI / safety But be Vigilant; ? NAI / safety
concernsconcerns
Fractures in ChildrenFractures in Children
Signs;Signs; tenderness, tenderness, swelling, swelling, deformity, deformity, ↓ ↓ use use etc.etc.
Consider;Consider; does the history fit the injury? NAIdoes the history fit the injury? NAI Underlying condition predisposing bone Underlying condition predisposing bone
to #to #
ManagementManagement
X-ray (AP / lateral)X-ray (AP / lateral)
RestRest Immobilise & ProtectImmobilise & Protect AnalgesiaAnalgesia PhysiotherapyPhysiotherapy
Consider – antibiotics / tetanus etc. Consider – antibiotics / tetanus etc.
What’s this?What’s this?
Salter-Harris #Salter-Harris #
Growth Plates – vulnerable to # Growth Plates – vulnerable to # Joint capsule, surrounding ligaments Joint capsule, surrounding ligaments
tendons etc stronger than cartilaginous tendons etc stronger than cartilaginous growth plategrowth plate
Shearing / Avulsion therefore possibleShearing / Avulsion therefore possible Types 1 - 5Types 1 - 5
Salter-Harris FractureSalter-Harris Fracture
What’s going to happen What’s going to happen here?here?
Pulled elbowPulled elbow
‘‘nursemaid’s’ elbownursemaid’s’ elbow Sudden pull on hand with elbow Sudden pull on hand with elbow
extendedextended Radial head subluxesRadial head subluxes Child holds forearm unwilling to move itChild holds forearm unwilling to move it Reduced simply by supinating forearm, Reduced simply by supinating forearm,
then flex!then flex! Immediate recovery!Immediate recovery!
Pulled elbowPulled elbow
What’s this?What’s this?
Toddler’s fractureToddler’s fracture
Shaft of tibiaShaft of tibia 9 months – 3 years9 months – 3 years Low –energy forcesLow –energy forces Spiral appearance, non-displacedSpiral appearance, non-displaced Limp / not weight bearingLimp / not weight bearing
DrowningDrowning
Leading cause of Accidental Death Leading cause of Accidental Death worldwide < 15 yr worldwide < 15 yr
2% mortality < 4 yr olds2% mortality < 4 yr olds ““the process of experiencing respiratory the process of experiencing respiratory
impairment from submersion/immersion impairment from submersion/immersion in liquid”in liquid”
PREVENTION;PREVENTION; Water Safety, Life Guards etc.Water Safety, Life Guards etc. Supervision while swimming and in the bath Supervision while swimming and in the bath Known epileptics – must be supervisedKnown epileptics – must be supervised
Drowning PathologyDrowning Pathology Upon submersion; apnoea, bradycardiaUpon submersion; apnoea, bradycardia Hypoxia, Acidosis (due to apnoea) -> Hypoxia, Acidosis (due to apnoea) ->
tachyc.tachyc. 20 secs – 5 mins; fluid inhaled20 secs – 5 mins; fluid inhaled Laryngeal spasm (as fluid hits glottis)Laryngeal spasm (as fluid hits glottis) AlvoelitisAlvoelitis Pulmonary oedema (up to 12-24 hours Pulmonary oedema (up to 12-24 hours
later)later) Hypothermia common* Hypothermia common* +/- injuries incurred (esp. C-spine injury)+/- injuries incurred (esp. C-spine injury)
Drowning; What type Drowning; What type water?water?
Salt water; pulls fluid into air spaces by Salt water; pulls fluid into air spaces by osmotic gradient => this washes away osmotic gradient => this washes away surfactantsurfactant
Freshwater; disrupts alveolar surfactant Freshwater; disrupts alveolar surfactant => alveoli collapse. Fluid transudes into => alveoli collapse. Fluid transudes into air spacesair spaces
Dirty/Contaminated? – consider what Dirty/Contaminated? – consider what antibiotic choiceantibiotic choice
Burns / ScaldsBurns / Scalds
Burns / ScaldsBurns / Scalds
Most common less than 5 years oldMost common less than 5 years old Major source of morbidity & Major source of morbidity &
mortalitymortality Scalds most commonly from cups of Scalds most commonly from cups of
tea, bath water etc.tea, bath water etc.
Burns / ScaldsBurns / Scalds
Prevention through practical Prevention through practical household measures and Public household measures and Public Health Campaigns are the most Health Campaigns are the most important factorsimportant factors
Management of Burns / Scalds----Management of Burns / Scalds----
(covered by Mr. Orr)(covered by Mr. Orr)
Choking/ Strangulation/ Choking/ Strangulation/ SuffocationSuffocation
Toddlers & young children particularly at Toddlers & young children particularly at riskrisk
Choking on aspirated food/ small toysChoking on aspirated food/ small toys Accidental strangulation of infants– Accidental strangulation of infants–
entangled inentangled in any cord/ telephone wire etc.any cord/ telephone wire etc.
Increasing incidence of both accidental Increasing incidence of both accidental and intentional hanging in teenage boysand intentional hanging in teenage boys
Choking/ Strangulation/ Choking/ Strangulation/ SuffocationSuffocation
PreventionPrevention
Public Health CampaignsPublic Health Campaigns
Parent & Child EducationParent & Child Education
Choking; ManagementChoking; Management
Back blows x 5Back blows x 5 Chest thrusts x 5Chest thrusts x 5 Check mouthCheck mouth Mouth to MouthMouth to Mouth Back blows x 5Back blows x 5 Abdominal thrusts x 5 (not < 1 year)Abdominal thrusts x 5 (not < 1 year) Heimlich manouvre (older child)Heimlich manouvre (older child)
Foreign bodiesForeign bodies
Road Traffic AccidentsRoad Traffic Accidents
Most common cause of accidental Most common cause of accidental death in Childrendeath in Children
4 out of 5 children who die in RTA s 4 out of 5 children who die in RTA s are not properly restrainedare not properly restrained
Booster Seats
Road Traffic AccidentsRoad Traffic AccidentsPedestrians & CyclistsPedestrians & Cyclists
Speed in school and residential areas Speed in school and residential areas major factormajor factor
Greatest risk; Boys 5 -10 years old;Greatest risk; Boys 5 -10 years old; Unable to judge car speed and lack of Unable to judge car speed and lack of
danger awarenessdanger awareness Seat Belt Laws Need to be enforced Seat Belt Laws Need to be enforced
more strictlymore strictly Ongoing campaign has improved Ongoing campaign has improved
compliancecompliance
PreventionPrevention
School / Residential Zone speed limit School / Residential Zone speed limit reduction and reduction and enforcementenforcement
Supervision & Education of ChildrenSupervision & Education of Children
Helmets and cycle lanes for Helmets and cycle lanes for cyclists------------ Not useful if cyclists cyclists------------ Not useful if cyclists are ignored by motoristsare ignored by motorists
Questions?Questions?
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